Impacts of active school design on school-time sedentary behavior and physical activity: A pilot natural experiment.

BACKGROUND: Children spend a significant portion of their days in sedentary behavior (SB) and on average fail to engage in adequate physical activity (PA). The school built environment may influence SB and PA, but research is limited. This natural experiment evaluated whether an elementary school designed to promote movement impacted students' school-time SB and PA. METHODS: Accelerometers measured SB and PA at pre and post time-points in an intervention group who moved to the new school (n = 21) and in a comparison group experiencing no school environmental change (n = 20). Difference-in-difference (DD) analysis examined SB and PA outcomes in these groups. Measures were also collected post-intervention from an independent, grade-matched group of students in the new school (n = 21). RESULTS: As expected, maturational increases in SB were observed. However, DD analysis estimated that the intervention attenuated increase in SB by 81.2 ± 11.4 minutes/day (p<0.001), controlling for time in moderate to vigorous physical activity (MVPA). The intervention was also estimated to increase daily number of breaks from SB by 23.4 ± 2.6 (p < .001) and to increase light physical activity (LPA) by 67.7 ± 10.7 minutes/day (p<0.001). However, the intervention decreased MVPA by 10.3 ± 2.3 minutes/day (p<0.001). Results of grade-matched independent samples analysis were similar, with students in the new vs. old school spending 90.5 ± 16.1 fewer minutes/day in SB, taking 21.1 ± 2.7 more breaks from SB (p<0.001), and spending 64.5 ± 14.8 more minutes in LPA (p<0.001), controlling for time in MVPA. Students in the new school spent 13.1 ± 2.7 fewer minutes in MVPA (p<0.001) than their counterparts in the old school. CONCLUSIONS: This pilot study found that active school design had beneficial effects on SB and LPA, but not on MVPA. Mixed results point to a need for active classroom design strategies to mitigate SB, and quick access from classrooms to areas permissive of high-intensity activities to promote MVPA. Integrating active design with programs/policies to promote PA may yield greatest impact on PA of all intensities.

Innovation and entrepreneurship programs in US medical education: a landscape review and thematic analysis.

BACKGROUND: Training in innovation and entrepreneurship (I&E) in medical education has become increasingly prevalent among medical schools to train students in complex problem solving and solution design. OBJECTIVE: We aim to characterize I&E education in US allopathic medical schools to provide insight into the features and objectives of this growing field. DESIGN: I&E programs were identified in 2016 via structured searches of 158 US allopathic medical school websites. Program characteristics were identified from public program resources and structured phone interviews with program directors. Curricular themes were identified via thematic analysis of program resources, and themes referenced by >50% of programs were analyzed. RESULTS: Thirteen programs were identified. Programs had a median age of four years, and contained a median of 13 students. Programs were led by faculty from diverse professional backgrounds, and all awarded formal recognition to graduates. Nine programs spanned all four years of medical school and ten programs required a capstone project. Thematic analysis revealed seven educational themes (innovation, entrepreneurship, technology, leadership, healthcare systems, business of medicine, and enhanced adaptability) and two teaching method themes (active learning, interdisciplinary teaching) referenced by >50% of programs. CONCLUSIONS: The landscape of medical school I&E programs is rapidly expanding to address newfound skills needed by physicians due to ongoing changes in healthcare, but programs remain relatively few and small compared to class size. This landscape analysis is the first review of I&E in medical education and may contribute to development of a formal educational framework or competency model for current or future programs. ABBREVIATIONS: AAMC: American Association of Medical Colleges; AMA: American Medical Association; I&E: Innovation and entrepreneurship.

Using Green Building As A Model For Making Health Promotion Standard In The Built Environment.

The built environment-the constructed physical parts of the places where people live and work-is a powerful determinant of both individual and population health. Awareness of the link between place and health is growing within the public health sector and among built environment decision makers working in design, construction, policy, and both public and private finance. However, these decision makers lack the knowledge, tools, and capacity to ensure that health and well-being are routinely considered across all sectors of the built environment. The green building industry has successfully established environmental sustainability as a normative part of built environment practice, policy making, and investment. We explore the value of this industry's experience as a template for promoting health and well-being in the built environment.

A design thinking framework for healthcare management and innovation.

The business community has learned the value of design thinking as a way to innovate in addressing people's needs--and health systems could benefit enormously from doing the same. This paper lays out how design thinking applies to healthcare challenges and how systems might utilize this proven and accessible problem-solving process. We show how design thinking can foster new approaches to complex and persistent healthcare problems through human-centered research, collective and diverse teamwork and rapid prototyping. We introduce the core elements of design thinking for a healthcare audience and show how it can supplement current healthcare management, innovation and practice.

Influence of school architecture and design on healthy eating: a review of the evidence.

We examined evidence regarding the influence of school physical environment on healthy-eating outcomes. We applied a systems perspective to examine multiple disciplines' theoretical frameworks and used a mixed-methods systematic narrative review method, considering both qualitative and quantitative sources (published through March 2014) for inclusion. We developed a causal loop diagram from 102 sources identified. We found evidence of the influence of many aspects of a school's physical environment on healthy-eating outcomes. The causal loop diagram highlights multilevel and interrelated factors and elucidates the specific roles of design and architecture in encouraging healthy eating within schools. Our review highlighted the gaps in current evidence and identified areas of research needed to refine and expand school architecture and design strategies for addressing healthy eating.

Building healthy communities: establishing health and wellness metrics for use within the real estate industry.

It is increasingly well recognized that the design and operation of the communities in which people live, work, learn, and play significantly influence their health. However, within the real estate industry, the health impacts of transportation, community development, and other construction projects, both positive and negative, continue to operate largely as economic externalities: unmeasured, unregulated, and for the most part unconsidered. This lack of transparency limits communities' ability to efficiently advocate for real estate investment that best promotes their health and well-being. It also limits market incentives for innovation within the real estate industry by making it more difficult for developers that successfully target health behaviors and outcomes in their projects to differentiate themselves competitively. In this article we outline the need for actionable, community-relevant, practical, and valuable metrics jointly developed by the health care and real estate sectors to better evaluate and optimize the "performance" of real estate development projects from a population health perspective. Potential templates for implementation, including the successful introduction of sustainability metrics by the green building movement, and preliminary data from selected case-study projects are also discussed.

Overcoming legal liability concerns for school-based physical activity promotion.

Schools have been identified as a priority environment for physical activity promotion as a component of efforts to help prevent childhood obesity. A variety of school-based environmental and programmatic strategies have been proven effective in promoting physical activity both on-site and in the surrounding community. However, many schools are deterred by fears of increased risk of legal liability for personal injuries. We examine 3 school-based strategies for promoting physical activity--Safe Routes to School programs, joint use agreements, and playground enhancement--from a tort liability perspective, and describe how schools can substantially minimize any associated liability risk through injury prevention and other strategies. We also recommend approaches to help schools overcome their liability concerns and adopt these critically needed healthy school policies.

Healthy eating design guidelines for school architecture.

We developed a new tool, Healthy Eating Design Guidelines for School Architecture, to provide practitioners in architecture and public health with a practical set of spatially organized and theory-based strategies for making school environments more conducive to learning about and practicing healthy eating by optimizing physical resources and learning spaces. The design guidelines, developed through multidisciplinary collaboration, cover 10 domains of the school food environment (eg, cafeteria, kitchen, garden) and 5 core healthy eating design principles. A school redesign project in Dillwyn, Virginia, used the tool to improve the schools' ability to adopt a healthy nutrition curriculum and promote healthy eating. The new tool, now in a pilot version, is expected to evolve as its components are tested and evaluated through public health and design research.

Built environment and physical activity promotion: place-based obesity prevention strategies.

This paper seeks to encourage continued innovation in translating built environment and transportation-focused physical activity research into practice. Successful strategies, policies, and tools from across the U.S. and globally that demonstrate potential for wider-scale implementation are highlighted. The importance of building practice and translational research partnerships with groups and organizations outside traditional public health spheres, such as those who work in real estate and land-use development, is also discussed.

Engaging physical activity policymakers.

Evidence for the health benefits of physical activity is overwhelming: physical activity is protective against type II diabetes, cardiovascular disease, breast and colon cancer, stroke, osteoporosis, depression, falls in older adults, and many other adverse health outcomes. Research also suggests that widespread physical inactivity exacts a heavy toll on the US economy, as well as on individual health. Researchers have estimated that those who are physically inactive impose greater costs on society than do smokers or problem drinkers. Increasing rates of physical activity may therefore be one of the most cost-effective means to prevent disease, improve health outcomes, and reduce medical expenses - particularly as the US population ages. However, determining the optimal blend of intervention strategies to achieve these population-level goals is challenging. Research suggests that individually-focused efforts alone have thus far failed to sustain shifts to more active lifestyles, fueling calls for an increase in complementary physical activity-related public policy interventions.

Urban sprawl and delayed ambulance arrival in the U.S.

BACKGROUND: Minimizing emergency medical service (EMS) response time is a central objective of prehospital care, yet the potential influence of built environment features such as urban sprawl on EMS system performance is often not considered. PURPOSE: This study measures the association between urban sprawl and EMS response time to test the hypothesis that features of sprawling development increase the probability of delayed ambulance arrival. METHODS: In 2008, EMS response times for 43,424 motor-vehicle crashes were obtained from the Fatal Analysis Reporting System, a national census of crashes involving > or =1 fatality. Sprawl at each crash location was measured using a continuous county-level index previously developed by Ewing et al. The association between sprawl and the probability of a delayed ambulance arrival (> or =8 minutes) was then measured using generalized linear mixed modeling to account for correlation among crashes from the same county. RESULTS: Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival (p=0.03). This probability increases quadratically as the severity of sprawl increases while controlling for nighttime crash occurrence, road conditions, and presence of construction. For example, in sprawling counties (e.g., Fayette County GA), the probability of a delayed ambulance arrival for daytime crashes in dry conditions without construction was 69% (95% CI=66%, 72%) compared with 31% (95% CI=28%, 35%) in counties with prominent smart-growth characteristics (e.g., Delaware County PA). CONCLUSIONS: Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival following motor-vehicle crashes in the U.S. The results of this study suggest that promotion of community design and development that follows smart-growth principles and regulates urban sprawl may improve EMS performance and reliability.

Rear-seat motor vehicle travel in the U.S.: using national data to define a population at risk.

BACKGROUND: Recent studies suggest that the relative protection offered by rear seating in motor vehicle crashes has decreased, potentially reflecting disproportionate advancements in front-seat safety technology. Safe adaptation of advanced front-seat restraint systems for the rear-seat environment will require exposure data that are currently unavailable. PURPOSE: This study uses national data to quantify rear-seat occupancy patterns, restraint use, and annual travel exposure in the U.S. in order to support the development of advanced crash protection systems for rear-seat motor vehicle occupants. METHODS: Data from the 2000-2006 National Automotive Sampling System Crashworthiness Data System and 2001 National Household Transportation Survey were analyzed in 2008 to quantify occupancy patterns (e.g., seat position, restraint use) and annual person-trips for rear-seat passengers in the U.S. RESULTS: The overall proportion of person-trips by rear-seat occupants is relatively low (12.9%); however national at-risk exposure remains significant (approximately 39 billion annual person-trips). Annual rear-seat travel exposure is similar among children < or = 12 years and adults (18.9 vs 19.1 billion person-trips) despite the fact that children are proportionally much more likely to ride in rear positions (79.3% vs 7.4%). Restraint use among adult rear-seat occupants was also much lower than among front-seat occupants (50.4% vs 82.2%). CONCLUSIONS: While rear-seat occupancy is relatively low compared with front-seat occupancy at-risk rear-seat travel by both child and adult passengers in the U.S. remains significant. Restraint use by rear-seat occupants is much lower than that among front-seat passengers, particularly among adults and older children, substantially increasing injury risk. Development of future crash protection systems for rear-seat passengers must account for these exposure patterns to ensure safe and effective integration into production vehicles.

Postmortem computed tomography as an adjunct to autopsy for analyzing fatal motor vehicle crash injuries: results of a pilot study.

BACKGROUND: Detailed fatal injury data after fatal motor vehicle crashes (MVC) are necessary to improve occupant safety and promote injury prevention. Autopsy remains the principle source of detailed fatal injury data. However, procedure rates are declining because of a range of technical, ethical, and religious concerns. Postmortem computed tomography (PMCT) is a potential alternative or adjunct to autopsy which is increasingly used by forensic researchers. However, there are only limited data regarding the utility of PMCT for analysis of fatal MVC injuries. METHODS: We performed whole body PMCT and autopsy on six subjects fatally injured in MVC in a single county in Michigan. All injuries detected by either method were coded using the Abbreviated Injury Scale (AIS). Severe injuries, defined as AIS 3 or higher (AIS 3+), were tallied for each forensic procedure to allow a comparison of relative diagnostic performance. RESULTS: A total of 46 AIS 3+ injuries were identified by autopsy and PMCT for these cases. The addition of PMCT to autopsy increased overall detection of AIS 3+ injuries (all types) by 28%. PMCT detected 27% more AIS 3+ skeletal injuries than autopsy but 25% less soft tissue injuries. CONCLUSIONS: Use of PMCT improves the detection of AIS 3+ injuries after fatal MVC compared with isolated use of autopsy and also produces a highly detailed permanent objective record. PMCT appears to improve detection of skeletal injury compared with autopsy but is less sensitive than autopsy for the detection of AIS 3+ soft tissue injuries. Neither autopsy nor PMCT identified all AIS 3+ injuries revealed by the combination of the two methodologies. This suggests that PMCT should be used as an adjunct to autopsy rather than a replacement whenever feasible.

Injury reporting on local TV news: a prime-time opportunity for prevention.

BACKGROUND: Local television news is America's primary source of information and may be an opportunity to shape public opinion surrounding issues such as injury prevention. OBJECTIVE: This study sought to systematically evaluate unintentional-injury coverage on local television news and to identify frequently interviewed public-service professionals and factors associated with discussion of risk factors and prevention. METHODS: Late news broadcasts from 122 local television stations within the U.S. during October 2002 were analyzed. The main outcomes variables were counts of case-injury stories: motor-vehicle crashes, fires, falls, drowning, poisonings, and sports-recreational injuries; identification of interviewed public service professionals; and discussion of risk factors and prevention. Bivariate and mulitvariate analysis was performed to identify predictors of discussion of prevention measures, risk factors, or both. Data were analyzed in Fall 2006. RESULTS: From 2795 broadcasts, 1748 case-injury stories were identified. Fires and motor-vehicle crashes constituted 84% of the case-injury stories. There were 245 case-injury stories containing an interview with a public service professional. Police officers and firefighters accounted for 82% of these interviews. Interviews with police officers and firefighters were independently associated with discussion of risk factors and prevention measures for motor-vehicle crashes (OR=2.49, CI=1.7-3.6) and fires (OR=2.77, CI=1.2-5.9), respectively. CONCLUSIONS: Motor-vehicle crashes and fires were the most commonly reported injury topics. Police officers and firefighters were most commonly interviewed and, if interviewed, increased the likelihood that risk factors, prevention measures, or both were discussed. Optimizing the messages delivered by public service professionals through public service professional-level and media-level interventions may be an opportunity for disseminating injury-prevention information to the public and to policymakers, and methods to increase the likelihood of media interviews with public service professionals should be explored.

Urban sprawl and miles driven daily by teenagers in the United States.

BACKGROUND: Urban sprawl's association with increased automobile reliance and daily mileage is well established among adults. However, sprawl's specific impact on teen driving exposure is unknown. Teen driver fatality rates per mile driven are significantly higher than adults, making the identification of environmental influences on travel behavior particularly important in this age group. METHODS: Driving and demographic data for 4528 teens (weighted=10.5 million) aged 16-19 years were obtained from the 2001 National Household Transportation Survey (NHTS). County-level sprawl was measured using an index developed by Ewing et al. The association between daily miles driven by teens and sprawl, controlling for demographic characteristics, was modeled using ordinal logistic regression. The predicted probability of driving >20 miles in counties with varying degrees of sprawl also was calculated. RESULTS: Of the surveyed teens, 48% did not drive, 27% drove <20 miles/day, and 25% drove >20 miles/day. Of the 52% of teens who reported driving, the average distance driven was 15.6 miles/day. More-pronounced sprawl was associated with increased daily mileage (p<0.001). Overall, teens in sprawling counties were more than twice as likely to drive >20 miles/day than teens in compact counties. This trend was most prominent among the youngest drivers. For example, the predicted probability of boys aged 16-17 years driving >20 miles per day varied from 9% to 24% in compact versus sprawling counties. CONCLUSIONS: Sprawl is associated with increased daily mileage by teen drivers. Given the stark relationship between driving exposure and fatality risk among teens, increased efforts to understand and modify the effects of sprawl on adolescent driving behavior are necessary.

Comparison of teen driver fatality rates by vehicle type in the United States.

OBJECTIVES: To compare national fatality rates for teen drivers by vehicle type. METHODS: Fatality rates were calculated for 16- to 19-year-old drivers by vehicle type using data from the Fatal Analysis Reporting System (1999-2003) and estimates of miles driven from the National Household Transportation Survey (2001). Relative fatality risks for teen drivers of sports utility vehicles (SUVs) and pickups were calculated using passenger cars as a reference. RESULTS: Per vehicle mile driven, the fatality risk for both male and female teens driving SUVs was decreased relative to passenger car drivers (male teens: relative risk [RR], 0.33 [95% confidence interval [CI] = 0.29 to 0.37]; female teens: RR, 0.45 [95% CI = 0.34 to 0.59]). Fatality rates for male teens driving pickups were also lower per mile driven compared with male passenger car drivers (RR, 0.55 [95% CI = 0.51 to 0.60]). Fatality rates for female teens driving pickups and passenger cars were not statistically different but appear potentially higher for pickups (RR, 1.19 [95% CI = 0.98 to 1.44]). Both SUVs and pickups demonstrated significantly higher rates of fatal rollovers than passenger cars. Female adolescent drivers of SUVs and pickups were at particularly high risk for fatal rollovers per vehicle mile driven compared with passenger cars (SUV: RR, 1.88 [95% CI = 1.19 to 2.96]; pickup: RR, 3.42 [95% CI = 2.29 to 5.10]). CONCLUSIONS: Fatality rates for teen drivers vary significantly by vehicle type. From 1999 to 2003 in the United States, fatal rollovers were significantly more likely per mile driven for teen drivers of both SUVs and pickups compared with passenger cars. However, overall fatality rates (i.e., all crash types) for teen drivers of SUVs and male drivers of pickups were lower per mile driven than for teen drivers of passenger cars. The results of this ecological analysis cannot predict the individual-level fatality risk for teens driving different vehicle types. However, the significant variability in fatality rates among SUVs, pickups, and passenger cars seen at a population level suggests that vehicle choice should be further explored as a potentially modifiable risk factor in interventions to address teen driver safety.

Violence and substance use as risk factors for depressive symptoms among adolescents in an urban emergency department.

Violence and substance use were examined as multiple risk factors for depressive symptoms among 115 adolescents presenting to an urban emergency department. Using a hierarchical multivariate model, significant risk factors for increasing depression symptoms included female gender, increased involvement in substance use and greater exposure to community violence.

Sexual function, quality of life, and severity of anal incontinence after anal sphincteroplasty.

OBJECTIVE: The purpose of this study was to determine the severity of anal incontinence and its impact on quality of life and sexual function in women after anal sphincteroplasty. STUDY DESIGN: Eighty-six women who underwent anal sphincteroplasty during the years 1993 to 2004 were mailed validated survey instruments to evaluate continence status, health-related quality of life, and sexual functioning. Demographic and perioperative data were obtained from patient charts. RESULTS: At a mean follow-up time of 5.6 +/- 3.0 years, 6 women (11%) were totally continent; 8 women (15%) were incontinent of flatus only, and 41 women (75%) were incontinent of liquid and/or solid stool. Sexual function scores were not correlated with continence scores; 24% vs 4% of subjects who had undergone an overlapping sphincteroplasty versus an end-to-end sphincteroplasty reported pain during intercourse (P = .04). CONCLUSION: Anal continence rates 5 years after anal sphincteroplasty are disappointing, adversely impact quality of life, yet do not appear to relate to sexual function.

Intentional injury management and prevention in pediatric practice: results from 1998 and 2003 American Academy of Pediatrics Periodic Surveys.

OBJECTIVE: Intentional injuries are significant causes of pediatric morbidity and mortality in the United States. A 1998 American Academy of Pediatrics (AAP) survey identified child abuse, domestic violence, and community violence as concerns for pediatricians, although the majority of pediatricians also reported feeling unprepared to manage these issues. A second AAP survey in 2003 analyzed trends in pediatrician experience and attitudes related to these issues. METHODS: Surveys were sent to national random samples of AAP members in 1998 (n = 1629) and 2003 (n = 1603); response rates were 62% and 53%, respectively. Surveys measured pediatrician experience in the past 12 months in managing injuries caused by child abuse, domestic violence, and community violence. Attitudes regarding available resources and adequacy of training about intentional injury management were also collected. Trends between surveys were analyzed using chi2 analysis. RESULTS: The proportion of pediatricians who reported treatment of intentional injuries increased between surveys. The percentage of pediatricians who indicated that screening for domestic violence and community violence risk should be included in routine health visits increased from 66% to 72% and 71% to 77%, respectively. Confidence in ability to identify and manage injuries that were caused by domestic violence and community violence increased but remained low, whereas the proportion of pediatricians who expressed confidence in ability to identify child abuse decreased (65% vs 60%). CONCLUSIONS: Despite overall improvement in acceptance of intentional injury prevention in routine care as well as confidence in intentional injury management, pediatrician confidence to identify and manage intentional injuries remains low.