Adapted Motivational Interviewing to Promote Exercise in Adolescents With Congenital Heart Disease: A Pilot Trial.

PURPOSE: To assess a motivational interviewing (MI) intervention to improve moderate-to-vigorous physical activity (MVPA) in adolescents with congenital heart disease. METHODS: Intervention participants received one-on-one telephone-based adapted MI sessions over 3 months. Outcomes were acceptability, change mechanisms (stage of change and self-efficacy), and limited efficacy (physical activity, fitness, and quality of life). RESULTS: Thirty-six participants were randomized. Intervention participants completed 4.2 ± 1.2/6 MI sessions, with no improvements in the high self-efficacy or stage of change observed. Participants accumulated 47.24 ± 16.36 minutes of MVPA/day, and had comparable outcomes to peers without heart disease (except for functional capacity). There was no significant difference in change in any outcome by group. CONCLUSIONS: The intervention was acceptable, but effectiveness could not be determined due to the nature and size of sample. CLINICAL RELEVANCE: Pediatric cardiac rehabilitation remains the sole effective intervention to increase MVPA in this population.

School and classroom effects on Daily Physical Activity (DPA) policy implementation fidelity in Ontario classrooms: a multi-level analysis.

BACKGROUND: This paper examines school and classroom effects on Daily Physical Activity (DPA) policy implementation in classrooms in Ontario, Canada. In 2005 the Ontario Ministry of Education mandated a policy requiring school boards to "ensure that all elementary students, including students with special needs, have a minimum of twenty minutes of sustained MVPA each school day during instructional time". Based on an adaptation of Chaudoir's conceptual framework, this paper contributes to understanding the extent to which school factors (as reported by administrators) and classroom factors (as reported by teachers) are associated with policy implementation fidelity at the classroom level. METHODS: Cross-sectional online surveys were conducted in 2014 with elementary school administrators and teachers, based on representative random samples of schools and classrooms. A measure assessing implementation fidelity was developed from the six required components of the policy and for this paper fidelity at the classroom level is treated as the outcome variable. Several school- and classroom-level measures were also included in the surveys and a number of these were selected for inclusion here. Data from the two surveys were merged and selected variables were included in the multi-level analysis. Two-level logistic regression models were conducted to account for nesting of classrooms within schools and a series of models were conducted to identify factors associated with implementation fidelity. RESULTS: The analytic sample for this study included 170 school administrators and 307 classroom teachers from corresponding schools. Findings from the multi-level logistic regression analyses indicated that only classroom/teacher-level factors were significantly associated with implementation fidelity at the classroom level. None of the school/administrator predictors were significantly related to fidelity. The most parsimonious model included five significant classroom/teacher predictors: teachers' perception of DPA as realistic and achievable; confidence (self-efficacy); scheduling DPA in timetables; lack of space; and lack of time. CONCLUSIONS: Findings from the study indicate the theoretical and practical importance of addressing classroom and teacher factors since they are most proximal to implementation fidelity to the policy. Several of these factors also reflect complex structural and organizational contexts, indicating that a systems approach to understanding and supporting DPA implementation fidelity is warranted.

A Review of Implementation Outcome Measures of School-Based Physical Activity Interventions.

BACKGROUND: Measuring the implementation of school-based physical activity (PA) interventions is an important prerequisite in assessing their impact. Prior to conducting a study to assess the implementation of the daily physical activity (DPA) policy in Ontario, Canada, a literature review was conducted to identify existing survey instruments to measure 5 implementation outcomes: adoption, fidelity, implementation cost, reach, and sustainability. METHODS: A search for survey instruments to assess these implementation outcomes at the teacher and school administrator levels was conducted in 7 bibliographic databases, as well as the gray literature. Each survey instrument was coded as assessing 1 of the 5 implementation outcomes if it included at least 1 item measuring the construct. RESULTS: Twenty-three survey instruments were identified. None of the instruments were specifically developed to measure the implementation outcomes. Fidelity was the most common implementation outcome measured, followed by adoption. The least common implementation outcome measured was sustainability. Thirty-five percent of survey instruments assessed were previously tested for validity and 26% were previously tested for reliability. CONCLUSIONS: Based on this review, a gap in available instruments to measure implementation outcomes of school-based PA programs was identified. An adapted theoretical framework, presented here, has potential application in future implementation studies.

Evaluation of Daily Physical Activity (DPA) policy implementation in Ontario: surveys of elementary school administrators and teachers.

BACKGROUND: School-based structured opportunities for physical activity can provide health-related benefits to children and youth, and contribute to international guidelines recommending 60 min of moderate-to-vigorous physical activity (MVPA) per day. In 2005, the Ministry of Education in Ontario, Canada, released the Daily Physical Activity (DPA) policy requiring school boards to "ensure that all elementary students, including students with special needs, have a minimum of twenty minutes of sustained MVPA each school day during instructional time". This paper reports on the first provincial study evaluating implementation fidelity to the DPA policy in Ontario elementary schools and classrooms. Using an adapted conceptual framework, the study also examined associations between implementation of DPA and a number of predictors in each of these respective settings. METHODS: Separate cross-sectional online surveys were conducted in 2014 with Ontario elementary school administrators and classroom teachers, based on a representative random sample of schools and classrooms. An implementation fidelity score was developed based on six required components of the DPA policy. Other survey items measured potential predictors of implementation at the school and classroom levels. Descriptive analyses included frequency distributions of implementation fidelity and predictor variables. Bivariate analyses examining associations between implementation and predictors included binary logistic regression for school level data and generalized linear mixed models for classroom level data, in order to adjust for school-level clustering effects. RESULTS: Among administrators, 61.4 % reported implementation fidelity to the policy at the school level, while 50.0 % of teachers reported fidelity at the classroom level. Several factors were found to be significantly associated with implementation fidelity in both school and classroom settings including: awareness of policy requirements; scheduling; monitoring; use of resources and supports; perception that the policy is realistic and achievable; and specific barriers to implementation. CONCLUSIONS: Findings from the surveys indicate incomplete policy implementation and a number of factors significantly associated with implementation fidelity. The results indicate a number of important implications for policy, practice and further research, including the need for additional research to monitor implementation and its predictors, and assess the impacts of study recommendations and subsequent outcomes of a reinvigorated DPA moving forward.

The search for healthy schools: A multilevel latent class analysis of schools and their students.

The objective of this study was to establish and investigate a taxonomy of school health among high school students in Ontario, Canada. Data analyzed were based on 3358 9th-12th graders attending 103 high schools who participated in the 2011 Ontario Student Drug Use and Health Survey. Based on 10 health-related indicators, multilevel latent class analysis was used to extract 4 student-level latent classes and 3 school-level latent classes. Unhealthy schools (19% of schools) had the lowest proportion of healthy students (39%) and the highest proportion of substance-using (31%) and unhealthy (18%) students. Healthy schools (66%) contained the highest proportion of healthy students (56%) and smaller proportions of substance-using (22%) and unhealthy students (8%). Distressed schools (15%) were similar to healthy schools in terms of the proportions of healthy and unhealthy students. Distressed schools, however, were characterized by having the largest proportion of distressed students (35%) and the lowest proportion of substance-using students (4%). Meaningful categories of schools with respect to healthy environments can be identified and these categories could be used for focusing interventions and evaluating school health programs.

Ten-year trends in overweight/obesity among Ontario middle and high school students and their use in establishing baseline measures for government reduction targets.

OBJECTIVES: Public health concern about increasing levels of child/youth overweight and obesity has resulted in initiatives to address this issue. In 2012, the Ontario Ministry of Health and Long-Term Care (MOHLTC) established a target to reduce childhood obesity by 20% within five years. In this paper, we examine trends and establish baseline levels of overweight/obesity to assess the impacts of population-level interventions. METHODS: We analyzed 10 years (2003-2013) of data accumulated from six cycles of the Ontario Student Drug Use and Health Survey using logistic regression to assess trends in the prevalence of overweight/obesity among middle and high school students. The 2013 data are used to begin monitoring progress toward achieving the MOHLTC target. RESULTS: From 2003 through 2013, the prevalence of overweight/obesity among middle school students in the province remained stable overall and among all subgroups except 7th-grade females, who showed a significant linear decline. Among high school students, the prevalence of overweight/obesity showed a significant linear increase and an increase among 11th graders, females, and 10th- and 11th-grade females specifically. The prevalence remained stable but elevated among 9th- and 12th-grade females as well as among males in all grades. In 2013 (baseline for the MOHLTC target), 25.1% of students in grades 7-12 were overweight or obese, implying a presumed 2018 target of 20.1%. CONCLUSION: Ten-year trends in overweight/obesity indicate stability among males and significant linear increases in some female subgroups. Also, baseline data (2013) will facilitate the monitoring of future interventions aimed at achieving the 2018 MOHLTC target.

Barriers to accessing and using contraception in highland Guatemala: the development of a family planning self-efficacy scale.

Understanding the persistent inequalities in the prevalence rates of family planning and unmet need for family planning between indigenous and nonindigenous women in Guatemala requires localized explorations of the specific barriers faced by indigenous women. Based on social cognitive theory, elicitation interviews were carried out with a purposive sample of 16 young women, aged 20-24 years, married or in union, from the rural districts of Patzún, Chimaltenango, Guatemala. Content analysis was carried out using the constant-comparison method to identify the major themes. Based on this qualitative study, the following barriers are incorporated into the development of a self-efficacy scale: lack of knowledge about and availability of methods, fear of side effects and infertility, husbands being against family planning (and related fears of marital problems and abandonment), pressure from in-laws and the community, and the belief that using contraception is a sin. This is the first evidence-informed self-efficacy scale developed with young adult, indigenous women that addresses the issue of family planning in Latin America.

Adolescents' self-efficacy to overcome barriers to Physical Activity Scale.

This paper describes a revised measure of self-efficacy to overcome barriers to moderate and vigorous physical activity in a sample of 484 high school students in Toronto, Ontario. The students had a mean age of 15.3 years. Principal axis factoring with oblique rotation yielded five factors: self-efficacy to overcome internal, harassment, physical environment, social environment, and responsibilities barriers. Two problematic items were removed, which resulted in a 22-item measure. Subsequent analyses were conducted on responses to this shortened measure. Confirmatory factor analysis supported the five-factor model and demonstrated age- and sex-invariance. The subscales had good internal consistency reliability. Structural regressions demonstrated a strong relationship between the resulting factors and a physical activity measure (energy expenditure), showing predictive validity.

Clustering of specific health-related behaviours among Toronto adolescents.

PURPOSE: The clustering of specific health-related behaviours was examined among adolescents. METHODS: In 2005, cluster analysis was conducted to identify homogeneous groups of Toronto, Ontario, 14- to 17-year-old adolescents (n=445) with similar behaviour patterns according to self-reported measures of moderate to vigorous physical activity (metabolic equivalent [MET] hours a week of MVPA), sedentary behaviours (viewing television or videos, using a computer/the internet, doing homework, and talking with friends), fruit and vegetable consumption, and alcohol consumption. RESULTS: Three clusters of adolescents were identified: "active, high screen-time users," "active, low screen-time users," and "less active, least frequent drinkers." CONCLUSIONS: Identifying clusters of adolescents with similar health-related behaviour patterns suggests that researchers and practitioners should develop and implement interventions tailored to specific clusters.

School disconnectedness: identifying adolescents at risk in Ontario, Canada.

BACKGROUND: There is strong theoretical and empirical support for school connectedness as an important element of healthy youth development. The primary objective of this study was to replicate previous research identifying factors differentiating youth who do not feel connected to their schools in a sample of adolescents in Ontario, Canada. A secondary objective was to extend this work by assessing whether physical activity was an additional health behavior that differentiated youth who feel connected to their schools from those who do not. METHODS: Data for this study were based on questionnaires from 2243 grade 7 to grade 12 students derived from the 2001 cycle of the Ontario Student Drug Use Survey. Logistic regression analysis was used to examine associations between physical activity, other health risk factors, and school disconnectedness. RESULTS: The odds of feeling disconnected from their schools were substantially greater for female students who perceived their health or academic performance to be poor, engaged in no vigorous physical activity, reported 3 or more physician visits during the past year, and had low extracurricular involvement. None of the sociodemographic factors or substance use measures was significantly associated with school disconnectedness for any students. CONCLUSIONS: Our results highlight sex differences in how school disconnectedness is related to health-compromising behaviors such as physical inactivity. Further research is required to examine how boys and girls perceive, interpret, and internalize the school climate. Increasing school connectedness should be a consideration for academic administrators and health-promotion advocates.

The decline in physical activity among adolescent students: a cross-national comparison.

BACKGROUND: The decline in physical activity during adolescence is a key public health concern. This comparative study assesses whether the age-related decline in physical activity among high school students occurs similarly in the United States (U.S.) and Ontario, whether the decline in physical activity is steady throughout the age range, or whether any declines are age-specific. METHODS: Data are based on self-reports of 9th- to 12th-graders derived from the 2001 Youth Risk Behavior Survey (n=13,503) and the 2001 Ontario Student Drug Use Survey (n=1322). Physical activity is measured by the number of days of vigorous physical activity during the past 7 days. RESULTS: In both samples, there was a dominant and steady decline in physical activity between ages 14 and 18 years. The number of activity days was higher in the U.S. than in Ontario holding constant age and sex. However, a significant sample-by-age interaction showed that the decline in the percentage of U.S. students reporting 3 or more physical activity days was greater than it was in Ontario. CONCLUSIONS: While the pattern of decline was shown to be similar, the decline was stronger among US adolescents. Future research should examine additional factors influencing the decline in activity and the optimal timing of programs to reduce the decline.

The relationship between vigorous physical activity and juvenile delinquency: a mediating role for self-esteem?

Many policy-related reviews of the potential social value of sport and physical activity list the prevention of juvenile delinquency. We examined the relationships among vigorous physical activity, self-esteem, and delinquent behavior among adolescents in a large cross-sectional survey of Ontario adolescents. Data are based on questionnaires from 3,796 students (range 11-20 years) derived from the 2005 Ontario Student Drug Use Survey. Negative binominal regression methods were used to estimate both additive and interactive models predicting delinquent behavior. Vigorous physical activity was positively associated with delinquent behavior; however, this pattern of association was observed only among male adolescents. There was no evidence of a mediating role for self-esteem. Our findings suggest that physical activity is not the solution for reducing juvenile delinquency.

The relationship between sedentary activities and physical inactivity among adolescents: results from the Canadian Community Health Survey.

PURPOSE: To evaluate the relationships between the time spent on sedentary activities (computer usage, video game playing, television viewing, and reading) and physical inactivity in a sample of youth (aged 12-19 years) from the 2000-2001 Canadian Community Health Survey. METHODS: The study sample included 7982 youth (4034 males, 3948 females) across Canada (mean age: 15.61 years, SD: 2.23 years). Weekly time spent on computers, video games, television, and reading during leisure-time was obtained through self-reported questionnaires. Physical inactivity was determined by respondents' daily energy expenditure assessed through a physical activity questionnaire. Multivariate logistic regression analysis was conducted to examine the relationship between sedentary activities and physical inactivity respectively by gender. Sociodemographic variables, health status, and overweight status were controlled in the analysis. RESULTS: A substantial proportion of Canadian youth was inactive: 50.3% of males and 67.8% of females. Controlling for sociodemographic variables, health status, and body mass index, television viewing was significantly associated with physical inactivity for both males and females regardless of their overweight status. However, computer usage was associated with physical activity among males, and reading was associated with physical activity among females. CONCLUSIONS: There is a complex inter-relationship between sedentary behaviors and physical inactivity, highlighting the need for targeted interventions addressing patterns of sedentary behavior engagement. Reducing time spent on television viewing may be one plausible strategy within such interventions in reducing physical inactivity among youth.

A provincial study of opportunities for school-based physical activity in secondary schools.

PURPOSE: Adolescents spend considerable time at school and thus it is important to understand their opportunities for school-based physical activity. This study surveyed Ontario secondary schools to identify the range of structured opportunities and their engagement by students. METHODS: A questionnaire was mailed to key informants in 600 randomly selected secondary schools in Ontario, for which 474 respondents (79%) returned completed questionnaires. RESULTS: Curriculum-based physical education (PE) classes in grade nine were reported to be offered in all schools and these classes in grades 10, 11 and 12 were offered in almost all schools. Student enrollment in PE decreased from grades 9 to 12 (97.9%, 49.6%, 43.3% and 35.9%, respectively). Respondents reported that funding, timetable, facilities and resources made it somewhat difficult to implement the health and physical education curriculum in their schools. About two-thirds (65.5%) of the schools had an intramural program and 15.0% of students participated in it, whereas 97.2% of the schools had an inter-school sports program and 25.0% of students participated in it. Supervision issues made it difficult to provide intramural programs and funding made it difficult to provide inter-school sports programs. CONCLUSIONS: Although provision of physical activity opportunities in Ontario appears satisfactory, actual engagement by students is low. The results suggest that strategies to increase student participation in PE, intramural programs, and inter-school sports programs need further consideration.

Adolescent girls' perceived barriers to participation in physical activity.

Research shows a decline in physical activity levels during adolescence, particularly among girls. This study explored perceived barriers to participation in moderate and vigorous physical activity among adolescent girls who live in a large ethnoracially and socioeconomically diverse city. A total of 73 adolescent girls in Toronto participated in 1 of 7 focus group sessions which were audiotaped and transcribed verbatim, and qualitative software was used to facilitate data analysis. A constant comparison approach was used to inductively develop themes. Participants' perceived barriers to participating in physical activity included: lack of time; involvement in technology-related activities; influence peers, parents and teachers; concern about safety; inaccessibility of facilities and cost of using them; competition; and body-centered issues. The results suggest that strategies to address specific intrapersonal, social-environmental, and physical-environmental barriers to physical activity participation should be used in physical activity promotion programs for adolescent girls.

Relationship of vigorous physical activity to psychologic distress among adolescents.

This article examines the relationship between vigorous physical activity and psychologic distress (by using the General Health Questionnaire-12) among a sample of 2,104 adolescents. Multiple regression analysis revealed a differential relationship between physical activity and dimensions of the General Health Questionnaire-12. Specifically, vigorous physical activity was related significantly to problems with social functioning but not to depression or anxiety.

Male adolescents' reasons for participating in physical activity, barriers to participation, and suggestions for increasing participation.

This study explored male adolescents' reasons for participating in moderate and vigorous physical activity, perceived barriers to moderate and vigorous physical activity, and suggestions as to what can be done to increase participation in physical activity. A total of 26 male 15- and 16-year-old adolescents participated in focus group sessions, which were audiotaped and transcribed verbatim; qualitative software facilitated data analysis. A constant comparison approach was used to inductively develop themes. It was found that participants engaged in physical activity for both intrinsic and extrinsic reasons. Their perceived barriers to physical activity included both internal factors (individual characteristics, lower priority for physical activity, and involvement in technology-related activities) and external factors (the influence of peers and family, lack of time, and inaccessibility and cost of facilities). Participants suggested that physical activity be promoted more in the community and that an environment more supportive of physical activity be developed. Results suggest that a variety of strategies should be used to help male adolescents maintain or increase participation in moderate and vigorous physical activity.

Trends in vigorous physical activity participation among Ontario adolescents, 1997-2001.

OBJECTIVE: This paper examines trends in vigorous physical activity participation among students enrolled in grades 7, 9, 11 and 13 in Ontario between 1997 and 2001. Patterns in participation by gender and grade level are also described. METHODS: Data were derived from the Ontario Student Drug Use Survey for 1997, 1999, and 2001. Three outcomes of vigorous physical activity were included in self-report questionnaires completed by more than 5,000 students over a three-year period. They responded to the survey in classroom groups during school time. Estimates were weighted and variance and statistical tests have been corrected for the complex sample design. RESULTS: Comparisons between 1997 and 2001 indicated that, overall, patterns of vigorous physical activity remained stable. However, there were significant declines in vigorous physical activity participation by females and 11th grade students between 1997 and 2001. INTERPRETATION: The trends for females and 11th graders are disturbing, since they indicate that the normal gender and age differences in vigorous physical activity participation, found in numerous previous studies, are compounded by declining levels over time for these groups.

Teachers' perspective on barriers to implementing physical activity curriculum guidelines for school children in Toronto.

BACKGROUND: Teachers in Ontario are expected to implement the physical activity guidelines in the health and physical education (HPE) curriculum document that was introduced in 1998. This study examined Toronto teachers' perspective on barriers to implementing these guidelines. METHODS: Forty-five teachers from five Toronto elementary schools in which generalist classroom teachers provide physical education classes participated in focus groups. An experienced moderator facilitated each session. Themes were inductively generated from the data. RESULTS: Participants reported that children were not engaged in moderate or vigorous physical activity daily and for the expected duration. Participants identified three categories of barriers to implementing the curriculum guidelines: lower priority for HPE, lack of performance measures for physical activity, and lack of sufficient infrastructure. First, they reported that the new curriculum expectations for other subjects were demanding, which left little time to focus on physical education. They felt that resource support for the HPE curriculum was not sufficient and that physical education specialists were necessary but unavailable to implement the curriculum. Second, participants felt accountable to both government and parents for high student performance on standardized tests in subjects deemed to be of higher priority. Third, participants reported inadequate facilities and equipment, use of portables for classrooms, cancelling physical education to have events in the gymnasium, and unavailability of teachers to supervise off-school physical activity. CONCLUSION: The study suggests that participating teachers perceive physical education to be a low priority in the educational system, making it difficult for them to meet the HPE curriculum expectations.