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1.  Seasonal variation in musculoskeletal extremity injuries in school children aged 6–12 followed prospectively over 2.5 years: a cohort study 
BMJ Open  2014;4(1):e004165.
Objectives
The type and level of physical activity in children vary over seasons and might thus influence the injury patterns. However, very little information is available on the distribution of injuries over the calendar year. This study aims to describe and analyse the seasonal variation in extremity injuries in children.
Design
Prospective cohort study.
Setting
10 public schools in the municipality of Svendborg, Denmark.
Participants
A total of 1259 school children aged 6–12 years participating in the Childhood Health, Activity, and Motor Performance School Study Denmark.
Methods
School children were surveyed each week during 2.5 school-years. Musculoskeletal injuries were reported by parents answering automated mobile phone text questions (SMS-Track) on a weekly basis and diagnosed by clinicians. Data were analysed for prevalence and incidence rates over time with adjustments for gender and age.
Results
Injuries in the lower extremities were reported most frequently (n=1049). There was a significant seasonal variation in incidence and prevalence for lower extremity injuries and for lower and upper extremity injuries combined (n=1229). For the upper extremities (n=180), seasonal variation had a significant effect on the risk of prevalence. Analysis showed a 46% increase in injury incidence and a 32% increase in injury prevalence during summer relative to winter for lower and upper extremity injuries combined.
Conclusions
There are clear seasonal differences in the occurrence of musculoskeletal extremity injuries among children with almost twice as high injury incidence and prevalence estimates during autumn, summer and spring compared with winter. This suggests further research into the underlying causes for seasonal variation and calls for preventive strategies to be implemented in order to actively prepare and supervise children before and during high-risk periods.
doi:10.1136/bmjopen-2013-004165
PMCID: PMC3902503  PMID: 24401728
Public Health; Sports Medicine
2.  Risk factors for low back pain in a cohort of 1389 Danish school children: an epidemiologic study 
European Spine Journal  1999;8(6):444-450.
This study was designed as a cross-sectional questionnaire-based survey of low back pain (LBP) in 13- to 16-year-old Danish school children. The cohort consisted of 671 boys and 718 girls in eighth and ninth grade in 46 municipal schools in three counties of Sealand. All the pupils filled in a questionnaire with LBP as the main topic and were at the same time examined by the school doctors. The first part of the questionnaire contained questions about leisure time sports activity, TV watching, PC use, job in leisure time and smoking. The second part dealt with LBP in relation to frequency and severity, influence on daily living and use of the health system. The school doctor measured body height and weight, (BMI), degree of hypermobility and the tightness of the hamstring muscles. The results showed a cumulative life-time prevalence of LBP of 58.9%, a 1-year prevalence of 50.8% and an increase in LBP prevalence of 6.4% from 14 to 15 years of age, independent of gender. Fourteen percent (141 F, 54 M) fulfilled the criteria for general hypermobility and 12.2% (45 F, 124 M) had tightness of hamstring muscles of more than 40 °. Recurrent/continuous LBP in a moderate to severe degree was recorded in 19.4% of children (182 F, 88 M). This was positively correlated to female gender, BMI more than 25 kg/m2, competitive sport for boys, poor physical fitness, daily smoking, heavy jobs in leisure time, increased use of the health system and reduced life quality. Stepwise logistic regression analysis indicates that female gender, daily smoking and heavy jobs are important associated factors for severe LBP in adolescents, with an observed probability of 46% if all factors are present. We don’t know yet whether these factors are of any causal importance in the development of severe LBP.
doi:10.1007/s005860050203
PMCID: PMC3611212  PMID: 10664301
Key words Low back pain; Adolescents; Epidemiology; Smoking; Physical activity; Hypermobility
3.  Evaluating the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on children’s quality of life, enjoyment and participation in physical activity 
BMC Public Health  2014;14:164.
Background
An emerging public health strategy is to enhance children’s opportunities to be physically active during school break periods. The aim of this study was to evaluate the effects of the Lunchtime Enjoyment Activity and Play (LEAP) school playground intervention on primary school children’s quality of life (QOL), enjoyment and participation in physical activity (PA).
Methods
This study consisted of a movable/recycled materials intervention that included baseline, a 7-week post-test and an 8-month follow-up data collection phase. Children within an intervention school (n = 123) and a matched control school (n = 152) aged 5-to-12-years-old were recruited for the study. Children’s PA was measured using a combination of pedometers and direct observation (SOPLAY). Quality of life, enjoyment of PA and enjoyment of lunchtime activities were assessed in the 8-12 year children. A multi-level mixed effect linear regression model was applied in STATA (version 12.0) using the xtmixed command to fit linear mixed models to each of the variables to examine whether there was a significant difference (p < 0.05) between the intervention and control school at the three time points (pre, post and follow-up).
Results
Significant overall interaction effects (group × time) were identified for children’s mean steps and distance (pedometers) in the intervention school compared to the control school. Intervention school children also spent significantly higher proportions within specified target areas engaged in higher PA intensities in comparison to the control school at both the 7-week post-test and 8-month follow-up. A short-term treatment effect was revealed after 7-weeks for children’s physical health scale QOL, enjoyment of PA and enjoyment of intra-personal play activities.
Conclusions
Examining the effects of this school playground intervention over a school year suggested that the introduction of movable/recycled materials can have a significant, positive long-term intervention effect on children’s PA. The implications from this simple, low-cost intervention provide impetus for schools to consider introducing the concept of a movable/recycled materials intervention on a wider scale within primary school settings.
Trial registration
Australian and New Zealand Clinical Trials Registration Number: ACTRN12613001155785.
doi:10.1186/1471-2458-14-164
PMCID: PMC3937016  PMID: 24524375
Physical activity; Primary school; Intervention; Lunchtime; Children; Enjoyment; Quality of life; Recess; School playgrounds
4.  Correlates of physical fitness and activity in Taiwanese children 
International nursing review  2008;55(1):81-88.
Aim
This cross-sectional study examined factors related to children’s physical fitness and activity levels in Taiwan.
Methods
A total of 331 Taiwanese children, aged 7 and 8, and their mothers participated in the study. Children performed physical fitness tests, recorded their physical activities during two weekdays and completed self-esteem questionnaires. Research assistants measured the children’s body mass and stature. Mothers completed demographic, parenting style and physical activity questionnaires.
Results
Attending urban school, lower body mass index (BMI), older age and better muscular endurance contributed to the variance in better aerobic capacity, and attending rural school and better aerobic capacity contributed to the variance in better muscular endurance in boys. Attending urban school, lower BMI and better athletic competence contributed to the variance in better aerobic capacity, and younger age, rural school and higher household income contributed to the variance in better flexibility in girls.
Conclusion
Despite the limitations of the study, with many countries and regions, including Taiwan, now emphasizing the importance of improving physical fitness and activity in children, an intervention that is gender-, geographically, and developmentally appropriate can improve the likelihood of successful physical fitness and activity programmes.
doi:10.1111/j.1466-7657.2007.00588.x
PMCID: PMC2883246  PMID: 18275540
Body Mass Index; Children; Chinese; Physical Activity; Physical Fitness; Taiwan
5.  GENDER AND RACE PATTERNS IN THE PATHWAYS FROM SPORTS PARTICIPATION TO SELF-ESTEEM 
Athletics is the most prominent extracurricular activity in U.S. secondary schools in terms of student participation and school budgets. The latter is often justified on the grounds that healthy bodies produce healthy minds, that school sports boost school spirit, and that participation in school-based sports increases students’ self-esteem. In this article we examine the interrelationships among participation in a school-based sport and the benefits assumed to be associated with it. Specifically, we test a model that postulates that school spirit, operationalized as attachment to school, and healthy bodies, operationalized as a sense of physical well-being, mediate the relationship between school sports and self-esteem. Data from the National Longitudinal Study of Adolescent Health on Caucasian and African American girls and boys were employed to test the model. School attachment and physical well-being absorbed the statistical effect of participating in a sport for all four gender-by-race groups. Among Caucasian girls a negative residual effect of sports participation was observed, which suggests that sports participation encapsulates multiple effects with contradictory influences. For African American girls school attachment by itself was not a significant mediator of the effect of sports participation on self-esteem. For all groups a sense of physical well-being was the more powerful mediator.
doi:10.1525/sop.2002.45.4.445
PMCID: PMC3051198  PMID: 21399740
6.  Family Involvement in School-Based Health Promotion: Bringing Nutrition Information Home 
School psychology review  2008;37(4):567-577.
Family-school collaboration related to children’s physical development has become increasingly important as childhood obesity rates continue to rise. The present study described the development and implementation of a literacy-based, family component of a school-based health education program and investigated its viability, acceptability, and effectiveness. Interactive children’s books were the mechanism by which students, parents, and teachers received consistent messages at home and school regarding nutrition information. The home-school intervention served to bridge home and school cultures in an urban population. Preliminary process evaluation results indicated that the interactive children’s books were feasible to implement in the school context. Parents, children, and teachers had positive perceptions of the books. Parents who received the books demonstrated increased knowledge of 5 a Day, the primary nutrition message communicated in the program. Although not statistically significant, after the first and second years of intervention, parents in the experimental group reported that their children were eating 0.54 and 0.36 additional servings of fruit and vegetables per day compared with children in the control group. The program did not seem to impact the availability and accessibility of fruits and vegetables at home.
PMCID: PMC2714582  PMID: 19633724
7.  Relationship Between Body Mass Index at Age 3 Years and Body Composition at Age 11 Years Among Japanese Children: The Shizuoka Population-Based Study 
Journal of Epidemiology  2012;22(5):411-416.
Background
A few studies reported an association between body weight during early childhood and body composition in later life, as measured by dual-energy X-ray absorptiometry (DXA); however, none of those studies investigated an East Asian population. In a Japanese population, we examined the association between body weight at age 3 years and body composition at age 11 years, as measured using DXA.
Methods
The source population was 726 fifth-grade school children enrolled at 3 public schools in Shizuoka Prefecture, Japan from 2008–2010. All children who lived in the study area went to 1 of these 3 schools. DXA was used to obtain data on body composition, and the Maternal and Child Health Handbook was used to calculate body mass index (BMI). The general linear model was used for statistical analysis.
Results
We were able to analyze data on body composition at age 11 years and BMI in early childhood for 550 children. BMI at age 3 and change in BMI z-score from birth to age 3 were positively associated with bone mineral content (BMC), fat-free soft tissue mass (FFSTM), and fat mass (FM) at age 11. After adjusting for confounding factors, mean BMC, FFSTM, and FM were significantly lower among children who were underweight at age 3 and significantly higher among children who were overweight at age 3, as compared with values for normal-weight children at age 3.
Conclusions
Among Japanese children, body weight at age 3 years predicts body composition at age 11 years.
doi:10.2188/jea.JE20110113
PMCID: PMC3798635  PMID: 22672998
body composition; child; development; nutrition
8.  Predicting Adolescent Self-Esteem From Participation in School Sports Among Latino Subgroups 
Data from the in-school survey of the National Longitudinal Study of Adolescent Health on girls and boys who claim a Mexican, Puerto Rican, or Cuban heritage were employed to test two hypotheses: (1) Participating in a school-based sport is associated with self-esteem, and (2) school attachment and a sense of physical well-being mediate this relationship. The first hypothesis was partially confirmed in that participation in school sports was associated with self-esteem among Mexican American adolescent girls and boys, Puerto Rican girls, and Cuban American boys, but not among Cuban American girls nor Puerto Rican boys. The second hypothesis was confirmed in that, where there was a significant relationship between participating in a school sport and self-esteem, school attachment and physical well-being mediated this relationship. The results underscore the need to study psychosocial processes separately among Latino subgroups and to examine gender within each subgroup.
doi:10.1177/0739986302238212
PMCID: PMC3048356  PMID: 21379403
9.  A healthy school start - Parental support to promote healthy dietary habits and physical activity in children: Design and evaluation of a cluster-randomised intervention 
BMC Public Health  2011;11:185.
Background
Childhood obesity is multi-factorial and determined to a large extent by dietary habits, physical activity and sedentary behaviours. Previous research has shown that school-based programmes are effective but that their effectiveness can be improved by including a parental component. At present, there is a lack of effective parental support programmes for improvement of diet and physical activity and prevention of obesity in children.
Methods/Design
This paper describes the rationale and design of a parental support programme to promote healthy dietary habits and physical activity in six-year-old children starting school. The study is performed in close collaboration with the school health care and is designed as a cluster-randomised controlled trial with a mixed methods approach. In total, 14 pre-school classes are included from a municipality in Stockholm county where there is large variation in socio-economic status between the families. The school classes are randomised to intervention (n = 7) and control (n = 7) groups including a total of 242 children. The intervention is based on social cognitive theory and consists of three main components: 1) a health information brochure; 2) two motivational interviewing sessions with the parents; and 3) teacher-led classroom activities with the children. The primary outcomes are physical activity in the children measured objectively by accelerometry, children's dietary and physical activity habits measured with a parent-proxy questionnaire and parents' self-efficacy measured by a questionnaire. Secondary outcomes are height, weight and waist circumference in the children. The duration of the intervention is six months and includes baseline, post intervention and six months follow-up measurements. Linear and logistic regression models will be used to analyse differences between intervention and control groups in the outcome variables. Mediator and moderator analysis will be performed. Participants will be interviewed.
Discussion
The results from this study will show if it is possible to promote a healthy lifestyle and a normal weight development among children from low-income districts with relatively limited efforts involving parents. Hopefully the study will provide new insights to the further development of effective programmes to prevent overweight and obesity in children.
Trial registration
ISRCTN: ISRCTN32750699
doi:10.1186/1471-2458-11-185
PMCID: PMC3071321  PMID: 21439049
10.  Associations between sport and screen-entertainment with mental health problems in 5-year-old children 
Background
Few studies have examined the benefits of regular physical activity, and risks of sedentary behaviour, in young children. This study investigated associations between participation in sports and screen-entertainment (as components of physical activity and sedentary behaviour), and emotional and behavioural problems in this population.
Methods
Cross-sectional analysis of data from 13470 children (50.9% boys) participating in the nationally representative UK Millennium Cohort Study. Time spent participating in sports clubs outside of school, and using screen-entertainment, was reported by the child's mother at child age 5 years, when mental health was also measured using the Strengths and Difficulties Questionnaire.
Results
45% of children did not participate in sport clubs and 61% used screen-entertainment for ≥ 2 hours per day. Children who participated in sport had fewer total difficulties; emotional, conduct, hyperactivity-inattention and peer relationship problems; and more prosocial behaviours. These relationships were similar in boys and girls. Boys and girls who used screen-entertainment for any duration, and participated in sport, had fewer emotional and behavioural problems, and more prosocial behaviours, than children who used screen-entertainment for ≥ 2 hours per day and did not participate in sport.
Conclusions
Longer durations of screen-entertainment usage are not associated with mental health problems in young children. However, our findings suggest an association between sport and better mental health. Further research based on longitudinal data is required to examine causal pathways in these associations and to determine the potential role of this and other forms of physical activity in preventing mental health disorders.
doi:10.1186/1479-5868-7-30
PMCID: PMC2867988  PMID: 20409310
11.  Study protocol: rehabilitation including social and physical activity and education in children and teenagers with cancer (RESPECT) 
BMC Cancer  2013;13:544.
Background
During cancer treatment children have reduced contact with their social network of friends, and have limited participation in education, sports, and leisure activities. During and following cancer treatment, children describe school related problems, reduced physical fitness, and problems related to interaction with peers.
Methods/design
The RESPECT study is a nationwide population-based prospective, controlled, mixed-methods intervention study looking at children aged 6-18 years newly diagnosed with cancer in eastern Denmark (n = 120) and a matched control group in western Denmark (n = 120). RESPECT includes Danish-speaking children diagnosed with cancer and treated at pediatric oncology units in Denmark. Primary endpoints are the level of educational achievement one year after the cessation of first-line cancer therapy, and the value of VO2max one year after the cessation of first-line cancer therapy. Secondary endpoints are quality of life measured by validated questionnaires and interviews, and physical performance. RESPECT includes a multimodal intervention program, including ambassador-facilitated educational, physical, and social interventions. The educational intervention includes an educational program aimed at the child with cancer, the child’s schoolteachers and classmates, and the child’s parents. Children with cancer will each have two ambassadors assigned from their class. The ambassadors visit the child with cancer at the hospital at alternating 2-week intervals and participate in the intervention program. The physical and social intervention examines the effect of early, structured, individualized, and continuous physical activity from diagnosis throughout the treatment period. The patients are tested at diagnosis, at 3 and 6 months after diagnosis, and one year after the cessation of treatment. The study is powered to quantify the impact of the combined educational, physical, and social intervention programs.
Discussion
RESPECT is the first population-based study to examine the effect of early rehabilitation for children with cancer, and to use healthy classmates as ambassadors to facilitate the normalization of social life in the hospital. For children with cancer, RESPECT contributes to expanding knowledge on rehabilitation that can also facilitate rehabilitation of other children undergoing hospitalization for long-term illness.
Trial registration
Clinical Trials.gov: file. NCT01772849 and NCT01772862
doi:10.1186/1471-2407-13-544
PMCID: PMC3832686  PMID: 24229362
Cancer; Pediatric; Children; Rehabilitation; Physical activity; Quality of life; Intervention; Peers; Controlled; School reentry
12.  Prenatal Stress Exposure Related to Maternal Bereavement and Risk of Childhood Overweight 
PLoS ONE  2010;5(7):e11896.
Background
It has been suggested that prenatal stress contributes to the risk of obesity later in life. In a population–based cohort study, we examined whether prenatal stress related to maternal bereavement during pregnancy was associated with the risk of overweight in offspring during school age.
Methodology/Principal Findings
We followed 65,212 children born in Denmark from 1970–1989 who underwent health examinations from 7 to 13 years of age in public or private schools in Copenhagen. We identified 459 children as exposed to prenatal stress, defined by being born to mothers who were bereaved by death of a close family member from one year before pregnancy until birth of the child. We compared the prevalence of overweight between the exposed and the unexposed. Body mass index (BMI) values and prevalence of overweight were higher in the exposed children, but not significantly so until from 10 years of age and onwards, as compared with the unexposed children. For example, the adjusted odds ratio (OR) for overweight was 1.68 (95% confidence interval [CI] 1.08–2.61) at 12 years of age and 1.63 (95% CI 1.00–2.61) at 13 years of age. The highest ORs were observed when the death occurred in the period from 6 to 0 month before pregnancy (OR 3.31, 95% CI 1.71–6.42 at age 12, and OR 2.31, 95% CI 1.08–4.97 at age 13).
Conclusions/Significance
Our results suggest that severe pre-pregnancy stress is associated with an increased risk of overweight in the offspring in later childhood.
doi:10.1371/journal.pone.0011896
PMCID: PMC2912844  PMID: 20689593
13.  Physical environmental characteristics and individual interests as correlates of physical activity in Norwegian secondary schools: The health behaviour in school-aged children study 
Background
The school has been identified as a key arena for physical activity promotion for young people. Effective change of physical activity behaviour requires identification of consistent and modifiable correlates. The study explores students' interests in school physical activity and facilities in the school environment and examines their associations with students' participation in physical activity during recess and their cross-level interaction effect.
Methods
This cross-sectional study was based on a national representative sample of Norwegian secondary schools and grade 8 students who participated in the Health Behaviour in School-aged Children (HBSC) 2005/06 study. The final sample comprised 68 schools and 1347 students. Physical environment characteristics were assessed through questionnaires completed by the principals, and students' physical activity and interests in physical activity were assessed through student self-completion questionnaires.
Results
Most students were interested in more opportunities for physical activity in school. Multilevel logistic regression models demonstrated that students attending schools with many facilities had 4.49 times (95% Confidence Interval (CI) = 1.93–10.44) higher odds of being physically active compared to students in schools with fewer facilities when adjusting for socio-economic status, sex and interests in school physical activity. Also open fields (Odds Ratio (OR) = 4.31, 95% CI = 1.65–11.28), outdoor obstacle course (OR = 1.78, 95% CI = 1.32–2.40), playground equipment (OR = 1.73, 95% CI = 1.24–2.42) and room with cardio and weightlifting equipment (OR = 1.58, 95%CI = 1.18–2.10) were associated with increased participation in physical activity. Both students' overall interests and the physical facilitation of the school environment significantly contributed to the prediction of recess physical activity. The interaction term demonstrated that students' interests might moderate the effect of facilities on recess physical activity.
Conclusion
The findings support the use of an ecological approach and multilevel analyses in the investigation of correlates of physical activity that allows for a broader understanding of the influence of and interaction between factors at multiple levels on physical activity behaviour. In the promotion of physical activity in lower secondary schools, the study suggests that programmes should include a focus on environmental facilitation and incorporate strategies to increase students' interests for school physical activity.
doi:10.1186/1479-5868-5-47
PMCID: PMC2564975  PMID: 18823545
14.  Direct and indirect associations between the family physical activity environment and sports participation among 10–12 year-old European children: testing the EnRG framework in the ENERGY project 
Background
Sport participation makes an important contribution to children’s overall physical activity. Understanding influences on sports participation is important and the family environment is considered key, however few studies have explored the mechanisms by which the family environment influences children’s sport participation. The purpose of this study was to examine whether attitude, perceived behavioural control, health belief and enjoyment mediate associations between the family environment and 10–12 year-old children’s sports participation.
Methods
Children aged 10–12 years ( = 7234) and one of their parents (n = 6002) were recruited from 175 schools in seven European countries in 2010. Children self-reported their weekly duration of sports participation, physical activity equipment items at home and the four potential mediator variables. Parents responded to items on financial, logistic and emotional support, reinforcement, modelling and co-participation in physical activity. Cross-sectional single and multiple mediation analyses were performed for 4952 children with complete data using multi-level regression analyses.
Results
Availability of equipment (OR = 1.16), financial (OR = 1.53), logistic (OR = 1.47) and emotional (OR = 1.51) support, and parental modelling (OR = 1.07) were positively associated with participation in ≥ 30mins/wk of sport. Attitude, beliefs, perceived behavioural control and enjoyment mediated and explained between 21-34% of these associations. Perceived behavioural control contributed the most to the mediated effect for each aspect of the family environment.
Conclusions
Both direct (unmediated) and indirect (mediated) associations were found between most family environment variables and children’s sports participation. Thus, family-based physical activity interventions that focus on enhancing the family environment to support children’s sport participation are warranted.
doi:10.1186/1479-5868-10-15
PMCID: PMC3621808  PMID: 23374374
Sport; Physical activity; Children; Family; Home; Determinants; Mediation; Cognitions
15.  Effects of a Multi-Pronged Intervention on Children’s Activity Levels at Recess: The Aventuras para Niños Study12 
Advances in Nutrition  2011;2(2):171S-176S.
Latino children spend more time in sedentary activities than other American children, and only ~1 in 5 Latino children in public elementary and middle schools meet all 6 fitness standards in statewide fitness testing. Schools that facilitate physical activity (PA) by maintaining playgrounds and providing physical education classes have children who are more active and less overweight. The aims of the present study were to examine the extent to which several social and physical environmental changes in school settings resulted in observed changes in area characteristics and children’s activity levels during recess. Thirteen elementary schools serving predominately Mexican American children were randomized into control or activity and nutrition environmental intervention conditions. Playgrounds and activities were restructured in 6 intervention schools to promote more PA. After 1 y, there were no overall statistical differences between treatment groups in PA or sedentary behavior in these settings and results did not differ by gender. Changing the social and physical environments to promote children’s moderate-to-vigorous PA is important to the design of active and healthy recess environments. The present results are not conclusive as to the link between these interventions and actual behavior, but show sufficient promise for further population and setting specific research.
doi:10.3945/an.111.000380
PMCID: PMC3065761  PMID: 22332049
16.  A participatory and capacity-building approach to healthy eating and physical activity – SCIP-school: a 2-year controlled trial 
Background
Schools can be effective settings for improving eating habits and physical activity, whereas it is more difficult to prevent obesity. A key challenge is the “implementation gap”. Trade-off must be made between expert-driven programmes on the one hand and contextual relevance, flexibility, participation and capacity building on the other. The aim of the Stockholm County Implementation Programme was to improve eating habits, physical activity, self-esteem, and promote a healthy body weight in children aged 6–16 years. We describe the programme, intervention fidelity, impacts and outcomes after two years of intervention.
Methods
Nine out of 18 schools in a middle-class municipality in Sweden agreed to participate whereas the other nine schools served as the comparison group (quasi-experimental study). Tailored action plans were developed by school health teams on the basis of a self-assessment questionnaire called KEY assessing strengths and weaknesses of each school’s health practices and environments. Process evaluation was carried out by the research staff. Impacts at school level were assessed yearly by the KEY. Outcome measures at student level were anthropometry (measured), and health behaviours assessed by a questionnaire, at baseline and after 2 years. All children in grade 2, 4 and 7 were invited to participate (n=1359) of which 59.8% consented. The effect of the intervention on health behaviours, self-esteem, weight status and BMIsds was evaluated by unilevel and multilevel regression analysis adjusted for gender and baseline values.
Results
Programme fidelity was high demonstrating feasibility, but fidelity to school action plans was only 48% after two years. Positive and significant (p<.05) impacts were noted in school health practices and environments after 2 years. At student level no significant intervention effects were seen for the main outcomes.
Conclusions
School staff has the capacity to create their own solutions and make changes at school level on the basis of self-assessment and facilitation by external agents. However these changes were challenging to sustain over time and had little impact on student behaviours or weight status. Better student outcomes could probably be attained by a more focused and evidence-based approach with stepwise implementation of action plans.
doi:10.1186/1479-5868-9-145
PMCID: PMC3545832  PMID: 23245473
Children; Eating habits; Exercise; Fidelity; Health promotion; Obesity prevention; Process evaluation; Quasi-experimental study; Self-esteem
17.  Health-related quality of life for children with rare diagnoses, their parents’ satisfaction with life and the association between the two 
Purpose
To examine children’s health-related quality of life and parents’ satisfaction with life and explore the association between the two in families where a child has a rare disorder.
Methods
We used a cross-sectional study design. A questionnaire was sent to parents of 439 school children (6–18 years) with congenital rare disorders. Children’s health-related quality of life (HRQOL) was examined by Pediatric Quality of Life InventoryTM 4.0 (PedsQL) Norwegian version. Satisfaction with life was examined by Satisfaction with Life Scale (SWLS).
Results
The response rate was 48% (n = 209). The average age of the children was 12 years and 50% were girls. The parents scored their children with reduced physical, emotional, social and school functioning. The reductions were greatest in the physical area. Parents scored average to high on SWLS but significantly lower than the general Norwegian population. There was a positive association between parental SWLS and the children’s social functioning and school functioning.
Conclusion
Children with congenital, rare disorders often require assistance from many parts of the public service system. Caring for their physical needs should not conflict with their educational and social needs. It is important that the children’s school-life is organized so that the diagnosis does not interfere with the children’s education and social life more than necessary.
doi:10.1186/1477-7525-11-152
PMCID: PMC3844436  PMID: 24010895
School children; Disabilities; Rare disorders; Children’s health related quality of life; PedsQL; Parent’s satisfaction of life; SWLS
18.  Association Between Self-Reported Household Practices and Body Mass Index of US Children and Adolescents, 2005 
Introduction
Parents can set household practices that influence children’s behaviors. The objective of this study was to determine whether children (children and adolescents aged 9–18 y) who live in a household that has healthful practices related to behaviors associated with obesity have a lower body mass index (BMI).
Methods
We analyzed data from the 2005 Styles mail panel survey (N = 1,685 parents and children). We used multiple logistic regression to assess associations between 4 household practices and 3 children’s behaviors: watching television, participating in vigorous physical activity, and purchasing sodas and snacks at school.
Results
Children watched more television if they had a television in their bedrooms, were less active as a family, and had no junk food restrictions at home. Children in less active families participated in about half as much VPA as children in more active families. Children purchased more sodas and snacks at school if they had a television in their bedrooms and their family consumed more meals at fast-food restaurants. Children whose families were less active were more likely to have a self-reported BMI at or above the 85th percentile. In addition, children who watched more television were more likely to have a self-reported BMI at or above the 85th percentile.
Conclusion
Household practices were associated with children’s behaviors and self-reported BMI. A household profile that includes being active as a family may counteract the increase in childhood obesity.
doi:10.5888/pcd9.110149
PMCID: PMC3523893  PMID: 23237244
19.  Certified Athletic Trainers in Secondary Schools: Report of the Council on Scientific Affairs, American Medical Association 
Journal of Athletic Training  1999;34(3):272-276.
Background:
In June 1997, the American Academy of Pediatrics introduced a resolution asking the American Medical Association (AMA) to support efforts to place certified athletic trainers in all secondary schools. The AMA Council on Scientific Affairs studied that resolution and presented this report to the AMA House of Delegates in June 1998.
Objective:
To identify the professional responsibilities, educational requirements, and current use of certified athletic trainers in the prevention and care of high school sports injuries.
Data Sources:
MEDLINE and HealthSTAR databases were searched for English-language articles published from 1980 to 1998. Additional references were derived from references in pertinent articles, communication with experts, and the Internet sites of athletic training and sports medicine associations.
Data Synthesis:
One in 5 of approximately 6 million adolescents who participate in high school sports each year sustains a sport-related injury. Most of these injuries are minor and occur during practices rather than competitions. Approximately 1 of every 100000 high school athletes will sustain a catastrophic injury. About 35% of US high schools use the services of a certified athletic trainer, who, under a physician's supervision, is responsible for the prevention and care of athletic injuries and coordination of the school athletic health program.
Conclusions/Recommendations:
Emphasis should be given to ensuring the health, safety, and well-being of participants in high school sports. Whereas most high school sports injuries are minor, adequately trained personnel should be present on site to ensure that such injuries are recognized early, treated immediately, and allowed to heal properly, thereby reducing the risk of more serious injury or reinjury. For such care, team physicians and coaches should have the assistance of a certified athletic trainer.
PMCID: PMC1322922  PMID: 16558576
athletic injuries; athletic training; high school sports; injury prevention; adolescent health
20.  Efficacy of a Text Message-Based Smoking Cessation Intervention for Young People: A Cluster Randomized Controlled Trial 
Background
Smoking prevalence remains high, particularly among adolescents and young adults with lower educational levels, posing a serious public health problem. There is limited evidence of effective smoking cessation interventions in this population.
Objective
To test the efficacy of an individually tailored, fully automated text messaging (short message service, SMS)–based intervention for smoking cessation in young people.
Methods
A 2-arm cluster randomized controlled trial, using school class as the randomization unit, was conducted to test the efficacy of the SMS text messaging intervention compared to an assessment-only control group. Students who smoked were proactively recruited via online screening in vocational school classes. Text messages, tailored to demographic and smoking-related variables, were sent to the participants of the intervention group at least 3 times per week over a period of 3 months. A follow-up assessment was performed 6 months after study inclusion. The primary outcome measure was 7-day smoking abstinence. Secondary outcomes were 4-week smoking abstinence, cigarette consumption, stage of change, and attempts to quit smoking. We used regression models controlling for baseline differences between the study groups to test the efficacy of the intervention. Both complete-case analyses (CCA) and intention-to-treat analyses (ITT) were performed. Subgroup analyses were conducted for occasional and daily smokers.
Results
A total of 2638 students in 178 vocational school classes in Switzerland participated in the online screening. Overall, 1012 persons met the inclusion criteria for study participation, and 755 persons (74.6%) participated in the study (intervention: n=372; control: n=383). Of the 372 program participants, 9 (2.4%) unsubscribed from the program during the intervention period. Six-month follow-up data were obtained for 559 study participants (74.0%). The 7-day smoking abstinence rate at follow-up was 12.5% in the intervention group and 9.6% in the control group (ITT: P=.92). No differences between the study groups were observed in 4-week point prevalence abstinence rates. The decrease in the mean number of cigarettes smoked per day from baseline to follow-up was higher in the intervention group than in the control group (ITT: P=.002). No differences between the groups were observed in stage of change (ITT: P=.82) and quit attempts (ITT: P=.38). The subgroup analyses revealed lower cigarette consumption in both occasional and daily smokers in the intervention group compared to the control group. Occasional smokers in the intervention group made more attempts to quit smoking than occasional smokers in the control group.
Conclusions
This study demonstrated the potential of an SMS text message–based intervention to reach a high proportion of young smokers with low education levels. The intervention did not have statistically significant short-term effects on smoking cessation; however, it resulted in statistically significant lower cigarette consumption. Additionally, it resulted in statistically significant more attempts to quit smoking in occasional smokers.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 19739792; http://www.controlled-trials.com/ISRCTN19739792 (Archived by WebCite at http://webcitation.org/6IGETTHmr).
doi:10.2196/jmir.2636
PMCID: PMC3757913  PMID: 23956024
smoking cessation; text messaging (SMS); young people; school; students
21.  Policies and Opportunities for Physical Activity in Middle School Environments 
The Journal of school health  2007;77(1):41-47.
BACKGROUND
This study examined physical activity opportunities and barriers at 36 geographically diverse middle schools participating in the Trial of Activity for Adolescent Girls.
METHODS
Principals, physical education and health education department heads, and program leaders were interviewed to assess policies and instructional practices that support physical activity.
RESULTS
Schools provided approximately 110 hours per year in physical education instruction. Approximately 20% of students walked or bicycled to school. Eighty-three percent of schools offered interscholastic sports and 69% offered intramural sports. Most schools offered programs for girls, but on average, only 24 girls (~5%) in the schools attended any programs. Only 25% of schools allowed after school free play. An overall score created to assess school environmental support for physical activity indicated that, on average, schools met 6.7 items of 10 items. Free/reduced lunch program participation versus not (p = .04), perceived priority of physical education instruction over coaching (p = .02), and safety for walking/bicycling to school (p = .02) predicted environmental support score.
CONCLUSIONS
Schools have policies and practices that support physical activity, although unfavorable practices exist. Schools must work with community partners and officials to provide environments that optimally support physical activity, especially schools that serve low-income students.
doi:10.1111/j.1746-1561.2007.00161.x
PMCID: PMC2475674  PMID: 17212759
middle schools; physical activity; adolescents; socioeconomic status
22.  Comparison of physical activity between children with autism spectrum disorders and typically developing children 
Regular physical activity is important for promoting health and well-being; however, physical activity behaviors in children with autism spectrum disorders (ASD) have received little attention. We compared physical activity levels among 53 children with ASD and 58 typically developing children ages 3–11 years who participated in the Children's Activity and Meal Patterns Study (CHAMPS). After adjustment for age and sex the amount of time spent daily in moderate and vigorous activity (MVPA) was similar in children with ASD (50.0 minutes/day, and typically developing children 57.1 minutes/day). However, parents reported that children with ASD participated in significantly fewer types of physical activities than did typically developing children (6.9vs.9.6, p < .001) and spent less time annually participating in these activities compared to typically developing children (158 vs. 225 hr/yr, p < 0.0001) after adjusting for age and sex. Although both groups of children engaged in similar levels of moderate and vigorous activity (MVPA) as measured by accelerometry, children with ASD engaged in fewer physical activities and for less time according to parental report, suggesting that some of the activity in children with ASD is not captured by standard questionnaire-based measures.
doi:10.1177/1362361312437416
PMCID: PMC3690470  PMID: 22807562
accelerometry; children; physical activity; autism spectrum disorders
23.  Relations between the school physical environment and school social capital with student physical activity levels 
BMC Public Health  2013;13:1191.
Background
The physical and social environments at schools are related to students’ moderate-to-vigorous physical activity (MVPA) levels. The purpose of this study was to explore the interactive effects of the school physical environment and school social capital on the MVPA of students while at school.
Methods
Data from 18,875 grade 6–10 students from 331 schools who participated in the 2009/10 Canadian Health Behaviour in School-Aged Children survey were analyzed using multi-level regression. Students answered questions on the amount of time they spend in MVPA at school and on their school’s social capital. Administrator reports were used to create a physical activity related physical environment score.
Results
The school physical environment score was positively associated with student MVPA at school (β = 0.040, p < .005). The association between the school social capital and MVPA was also positive (β = 0.074, p < .001). The difference in physical environments equated to about 20 minutes/week of MVPA for students attending schools with the lowest number of physical environment features and about 40 minutes/week for students attending schools with the lowest school social capital scores by comparison to students attending schools with the highest scores.
Conclusions
The findings suggest that school social capital may be a more important factor in increasing students MVPA than the school physical environment. The results of this study may help inform interventions aimed at increasing student physical activity levels.
doi:10.1186/1471-2458-13-1191
PMCID: PMC3882326  PMID: 24341628
Adolescent; Physical activity; School; Built environment; Social capital
24.  Screen-based activities and physical complaints among adolescents from the Nordic countries 
BMC Public Health  2010;10:324.
Background
A positive association between time spent on sedentary screen-based activities and physical complaints has been reported, but the cumulative association between different types of screen-based activities and physical complaints has not been examined thoroughly.
Methods
The cross-sectional association between screen-based activity and physical complaints (backache and headache) among students was examined in a sample of 31022 adolescents from Denmark, Sweden, Norway, Finland, Iceland and Greenland, as part of the Health behaviour in school-aged children 2005/06 (HBSC) study. Daily hours spent on screen-based activities and levels of physical complaints were assessed using self-reports.
Results
Logistic regression analysis indicated that computer use, computer gaming and TV viewing contributed uniquely to prediction of weekly backache and headache. The magnitude of associations was consistent across types of screen based activities, and across gender.
Conclusion
The observed associations indicate that time spent on screen-based activity is a contributing factor to physical complaints among young people, and that effects accumulate across different types of screen-based activities.
doi:10.1186/1471-2458-10-324
PMCID: PMC2904715  PMID: 20534116
25.  Sports drink consumption and diet of children involved in organized sport 
Background
Organized sport provides one option for children to be physically active. However, there is a paucity of information about the relationship between children’s participation in organized sport and their diet, and specifically their sports drink consumption. Therefore, the relationship between sports participation in children and the consumption of sports drinks, sugar-sweetened beverages (SSBs) and other components of diet was examined.
Methods
A cross-sectional descriptive study was conducted using baseline data from the Action Schools! BC Dissemination study cohort (n = 1421; 9.90 (0.58) y; 736 girls, 685 boys). The differences between the dietary behaviours of children participating in organized sport (sport) versus those that did not participate (non-sport) was examined. A modified Physical Activity Questionnaire for Older Children (PAQ-C) was used to measure physical activity levels and participation in organized sport. A Food Frequency Questionnaire (FFQ) and 24-hour dietary recall were used to assess eating behaviour and macronutrient intake (including protein, fat, and carbohydrate as well as sugar, fibre and total calories). Fruit, vegetable and beverage quantities were hand-tallied from the dietary recall. Fruit, vegetable and beverage frequency was assessed using the FFQ. Analysis of covariance (ANCOVA) was used to analyse differences between groups and a chi-square test of association was use to determine if participation in sport was significantly associated with the proportion of children consuming sports drinks and SSBs, and with gender.
Results
Children involved in sport had a lower body mass index (BMI) and were more physically active than children in the non-sport group (p < 0.01). Only a small number (n = 20/1421) of children consumed sports drinks and no difference in consumption of sports drink between sport and non-sport participants (p > .05) was observed. However, children involved in organized sport consumed more total calories, fat, fibre, fruit, vegetables and non-flavoured milk (p < 0.01) than non-sport children.
Conclusions
Children involved in organized sport were more physically active, consumed a healthier diet than non-participants and on average had lower BMI’s despite consuming more calories. As consumption of sports drinks among this age group was low, this may be an ideal time to begin educating children and their parents about the appropriate consumption of sports drinks and the perils of consuming too many SSBs, specifically.
doi:10.1186/1550-2783-10-38
PMCID: PMC3751771  PMID: 23958337
Organized sport; Children; Diet; Physical activity; Sugar-sweetened beverage; Sports drink

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