Physical inactivity is a recognized public health concern. Inadequate proportions of children in the U.S, including those of preschool age, are meeting physical activity recommendations. In response to low numbers of preschool children attaining appropriate physical activity levels, combined with the large number of young children who attend preschool, researchers have identified the need to devise interventions to increase physical activity at preschools. However, few multi-component interventions to increase physical activity in preschool children exist. The aims of this study were to observe the effects of a multi-component intervention on physical activity, sedentary behavior, and physical activity energy expenditure in 3-5 year-old children; identify factors that associate with change in those variables; and evaluate the process of implementing the multi-component intervention. The purpose of this manuscript is to describe the study design and intervention protocol.
The overall design of the Study of Health and Activity in Preschool Environments (SHAPES) was a two-year randomized trial (nested cohort design), with two conditions, two measurement occasions, and preschool serving as the unit of analysis. Sixteen schools (eight intervention and eight control) were enrolled. The intervention protocol was based on the social ecological model and included four main components: (a) indoor physical activity (“move inside”), (b) recess (“move outside”), (c) daily lessons (“move to learn”), and (d) social environment. Components were implemented using teacher and administrator trainings and workshops, site support visits, newsletters, and self-monitoring methods. Outcomes included accelerometer assessment of physical activity, sedentary behavior, and physical activity energy expenditure; weight status; and demographic factors; family/home social and physical environment; and parental characteristics. An extensive process evaluation battery was also used to monitor dose delivered by interventionists, completeness of intervention component delivery by teachers, and fidelity of teachers’ implementation.
The study will address important gaps relative to increasing physical activity in preschool children. Few studies to date have incorporated a multi-component approach, rigorous measurement protocol, and thorough evaluation of intervention implementation.
Young children; Policy; Pre-K; School; Childcare
Asthma is characterized by both chronic inflammation and airway remodeling. Remodeling - the structural changes seen in asthmatic airways - is pivotal in the pathogenesis of the disease. Although significant advances have been made recently in understanding the different aspects of airway remodeling, the exact biology governing these changes remains poorly understood. There is broad agreement that, in asthma, increased airway smooth muscle mass, in part due to smooth muscle hyperplasia, is a very significant component of airway remodeling. However, significant debate persists on the origins of these airway smooth muscle cells. In this review article we will explore the natural history of airway remodeling in asthma and we will discuss the possible contribution of progenitors, stem cells and epithelial cells in mesenchymal cell changes, namely airway smooth muscle hyperplasia seen in the asthmatic airways.
Airway remodeling; Airway smooth muscle; Asthma; Fibrocytes; Mesenchymal stem cells
This study reports the results of the “Active by Choice Today” (ACT) trial for increasing moderate-to-vigorous physical activity (MVPA) in low-income and minority adolescents.
The ACT program was a randomized controlled school-based trial testing the efficacy of a motivational plus behavioral skills intervention on increasing MVPA in underserved adolescents. Twenty-four middle schools were matched on school size, percentage minorities, percentage free or reduce lunch, and urban or rural setting before randomization. A total of 1,563 6th grade students (mean age, 11.3 years, 73% African American, 71% free or reduced lunch, 55% female) participated in either a 17-week (over one academic year) intervention or comparison after-school program.
Main Outcome Measure
The primary outcome measure was MVPA based on 7-day accelerometry estimates at 2-weeks postintervention and an intermediate outcome was MVPA at midintervention.
At midintervention students in the intervention condition engaged in 4.87 greater minutes of MVPA per day (95% CI: 1.18 to 8.57) than control students. Students in intervention schools engaged in 9.11 min (95% CI: 5.73 to 12.48) more of MVPA per day than those in control schools during the program time periods; indicating a 27 min per week increase in MVPA. No significant effect of the ACT intervention was found outside of school times or for MVPA at 2-weeks postintervention.
Motivational and behavioral skills programs are effective at increasing MVPA in low-income and minority adolescents during program hours, but further research is needed to address home barriers to youth MVPA.
physical activity; adolescents; minorities; interventions
Rationale: Asthma is characterized by disordered airway physiology as a consequence of increased airway smooth muscle contractility. The underlying cause of this hypercontractility is poorly understood.
Objectives: We sought to investigate whether the burden of oxidative stress in airway smooth muscle in asthma is heightened and mediated by an intrinsic abnormality promoting hypercontractility.
Methods: We examined the oxidative stress burden of airway smooth muscle in bronchial biopsies and primary cells from subjects with asthma and healthy controls. We determined the expression of targets implicated in the control of oxidative stress in airway smooth muscle and their role in contractility.
Measurements and Main Results: We found that the oxidative stress burden in the airway smooth muscle in individuals with asthma is heightened and related to the degree of airflow obstruction and airway hyperresponsiveness. This was independent of the asthmatic environment as in vitro primary airway smooth muscle from individuals with asthma compared with healthy controls demonstrated increased oxidative stress–induced DNA damage together with an increased production of reactive oxygen species. Genome-wide microarray of primary airway smooth muscle identified increased messenger RNA expression in asthma of NADPH oxidase (NOX) subtype 4. This NOX4 overexpression in asthma was supported by quantitative polymerase chain reaction, confirmed at the protein level. Airway smooth muscle from individuals with asthma exhibited increased agonist-induced contraction. This was abrogated by NOX4 small interfering RNA knockdown and the pharmacological inhibitors diphenyleneiodonium and apocynin.
Conclusions: Our findings support a critical role for NOX4 overexpression in asthma in the promotion of oxidative stress and consequent airway smooth muscle hypercontractility. This implicates NOX4 as a potential novel target for asthma therapy.
asthma; airway smooth muscle; airway hyperresponsiveness; NOX4; SOD2
Fibrocytes are bone marrow–derived CD34+ collagen I–positive cells present in peripheral blood that develop α-smooth muscle actin expression and contractile activity in tissue culture. They are implicated in the pathogenesis of tissue remodeling and fibrosis in both patients with asthma and those with idiopathic pulmonary fibrosis. Targeting fibrocyte migration might therefore offer a new approach for the treatment of these diseases. Ion channels play key roles in cell function, but the ion-channel repertoire of human fibrocytes is unknown.
We sought to examine whether human fibrocytes express the KCa3.1 K+ channel and to determine its role in cell differentiation, survival, and migration.
Fibrocytes were cultured from the peripheral blood of healthy subjects and patients with asthma. Whole-cell patch-clamp electrophysiology was used for the measurement of ion currents, whereas mRNA and protein were examined to confirm channel expression. Fibrocyte migration and proliferation assays were performed in the presence of KCa3.1 ion-channel blockers.
Human fibrocytes cultured from the peripheral blood of both healthy control subjects and asthmatic patients expressed robust KCa3.1 ion currents together with KCa3.1 mRNA and protein. Two specific and distinct KCa3.1 blockers (TRAM-34 and ICA-17043) markedly inhibited fibrocyte migration in transwell migration assays. Channel blockers had no effect on fibrocyte growth, apoptosis, or differentiation in cell culture.
The K+ channel KCa3.1 plays a key role in human fibrocyte migration. Currently available KCa3.1-channel blockers might therefore attenuate tissue fibrosis and remodeling in patients with diseases such as idiopathic pulmonary fibrosis and asthma through the inhibition of fibrocyte recruitment.
Pulmonary fibrosis; asthma; fibrocyte; cell migration; ion channel; KCa3.1; patch clamp electrophysiology; 1-EBIO, 1-Ethyl-2-benzimidazolinone; αSMA, α-Smooth muscle actin; ASM, Airway smooth muscle; IPF, Idiopathic pulmonary fibrosis; Kd, Concentration producing 50% block
African Americans are at increased risk for cardiovascular disease and cancer morbidity and mortality. Physical activity and healthy dietary practices can reduce this risk. The church is a promising setting to address health disparities, and community-based participatory research is a preferred approach.
Using a community-based participatory approach and the social ecologic model, the FAN trial aims to increase self-reported moderate-intensity physical activity and fruit and vegetable consumption and reduce blood pressure in African American church members. Secondary aims are to increase objectively measured moderate-intensity physical activity and fiber/whole grain consumption and reduce fat consumption.
FAN is a group randomized trial (GRT) with two levels of clustering: participants (N=1,279; n=316 accelerometer subgroup) within church and church within church cluster. In the first wave, seven clusters including 23 churches were randomized to an immediate intervention or delayed intervention. In subsequent waves, 51 churches were randomized to an immediate or delayed intervention.
Church committee members, pastors, and cooks participate in full-day trainings to learn how to implement physical activity and dietary changes in the church. Monthly mailings and technical assistance calls are delivered over the 15-month intervention. Members complete measurements at baseline and 15-months. A detailed process evaluation is included.
FAN focuses on modifying the social, cultural, and policy environment in a faith-based setting. The use of a community-based participatory research approach, engagement of church leaders, inclusion of a detailed process evaluation, and a formal plan for sustainability and dissemination make FAN unique.
Community-based participatory research; Physical activity; Diet; Nutrition; African American; Faith-based
This cross-sectional study examined relationships between HIV-related stigma, social support, and depression in a sample of 340 HIV-infected African American women living in rural areas of the Southeastern United States. Three aspects of social support (availability of different types of support, sources of support, and satisfaction with support) and two aspects of HIV-related stigma (perceived stigma and internalized stigma) were measured. Perceived availability of support (p < .0001), sources of support (p = .03), satisfaction with support (p = .003), perceived stigma (p < .0001), and internalized stigma (p < .0001) were all significantly correlated with depression. Social support variables were negatively correlated and stigma variables were positively correlated with depression. HIV-related perceived stigma and internalized stigma were found to mediate the effect of sources of available support on depression. Study findings have implications for designing and implementing interventions to increase social support and decrease HIV-related stigma in order to decrease depression among African American women with HIV disease.
African American women; depression; HIV disease; HIV-related stigma; rural; social support
Objective The factorial validity and measurement equivalence/invariance of scales used to measure social-cognitive correlates of physical activity among adolescent girls were examined. Methods Confirmatory factor analysis was applied to questionnaire responses obtained from a multi-ethnic sample (N = 4885) of middle-school girls from six regions of the United States. A cohort of 1893 girls completed the scales in both sixth and eighth grades, allowing longitudinal analysis. Results Theoretically and statistically sound models were developed for each scale, supporting the factorial validity of the scales in all groups. Multi-group and longitudinal invariance was confirmed across race/ethnicity groups, age within grade, BMI categories, and the 2-year period between grades. Conclusions The scores from the scales provide valid assessments of social-cognitive variables that are putative mediators or moderators of change in physical activity. The revised scales can be used in observational studies of change or interventions designed to increase physical activity among girls during early adolescence.
African American; Asian American; confirmatory factor analysis; Hispanic/Latina; measurement equivalence/invariance; mediators; physical activity
The present study was designed to develop an innovative motivational intervention (based on Self-Determination Theory and Social Cognitive Theory) to increase physical activity (PA) in underserved adolescents. Sixty-four adolescents (35 females, 29 males; 50% minority; 65% on reduced lunch program; ages 11–13 yr) participated in either an 8-week motivational intervention after-school (n = 32) or a typical after-school program (n = 32). The conceptual framework for the intervention targeted the social environment (perceived autonomy, perceived social support, participation, fun), cognitive mediators (perceived choice, self-efficacy, and relatedness/belongingness), and motivational orientation (intrinsic motivation, commitment, positive self-concept). Formative evaluation data was collected by staff through daily forms throughout the 8-week program and through observational data completed by independent objective observers during 2 weeks of the program. The major themes that were identified addressed theoretical concepts regarding the intervention and logistical issues in delivering the intervention. The data revealed information regarding the importance of the cognitive appropriateness of the PA and motivational activities, the environmental climate for promoting nurturing relationships, developing specific strategies for increasing intrinsic rather than extrinsic reinforcement, and developing methods for preventing social “cliques” and gender conflicts to maintain an appropriate level of support in the social climate. Themes for training staff included focusing on team building, leadership, and nurturing. This formative evaluation is being used to formalize a randomized trial to test the effects of a student-centered motivational intervention on increasing PA in underserved 6th graders.
Objective To test whether self-efficacy for overcoming barriers to physical activity has direct, indirect (i.e., mediated), or moderating relations with naturally occurring change in perceived social support and declines in physical activity during high school. Methods Latent growth modeling was used with measures completed in the 8th, 9th, and 12th grades by a cohort of 195 Black and White girls. Results Self-efficacy was stable and moderated the relation between changes in physical activity and perceived social support. Girls who maintained a perception of strong social support had less of a decline in physical activity if they also had high self-efficacy. However, girls having high self-efficacy had a greater decline in physical activity if they perceived declines in social support. Conclusions Randomized controlled trials of physical activity interventions based on social cognitive theory should consider that the influence of girls’ perceptions of social support on their physical activity may differ according to their efficacy beliefs about barriers to physical activity.
adolescents; growth curve analysis; health behavior; race/ethnicity
Although school-based behavioral interventions for increasing physical activity (PA) in children and adolescents have been conducted, little evidence suggests that these curriculum-based approaches lead to increases in overall activity outside of program days. The overall goal of the “Active by Choice Today” (ACT) trial is to expand the body of knowledge concerning the factors that influence long-term increases in PA in underserved adolescents (low socioeconmic status, minorities) during their middle school years.
Design and setting:
An overview of the ACT study design, theoretical framework, process evaluation, and primary hypotheses is presented. The trial involves twenty-four middle schools (1560 6th graders) in South Carolina that are randomly assigned to one of two after-school programs (motivational and life skills intervention, or general health education).
The intervention integrates constructs from Self-Determination and Social Cognitive Theories to enhance intrinsic motivation and behavioral skills for PA. The intervention targets skill development for PA outside of program days and the after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) is designed to positively impact cognitive mediators (self-efficacy, perceived competence), and motivational orientation (intrinsic motivation, commitment, positive self-concept).
It is hypothesized that the 17-week motivational and life skills intervention will lead to greater increases in moderate-to-vigorous PA (based on 7-day accelerometry estimates) at post-intervention as compared to the general health education program.
Implications of this innovative school-based trial are discussed.
Physical activity; Minorities; Low income; Adolescents; Intrinsic motivation; Behavioral skills
Research suggests that appropriate medical care for interscholastic athletes is frequently lacking. However, few investigators have examined factors related to care.
To examine medical care provided by interscholastic athletics programs and to identify factors associated with variations in provision of care.
Mailed and e-mailed survey.
Patients or Other Participants:
One hundred sixty-six South Carolina high schools.
The 132-item Appropriate Medical Care Assessment Tool (AMCAT) was developed and pilot tested. It included 119 items assessing medical care based on the Appropriate Medical Care for Secondary School-Age Athletes (AMCSSAA) Consensus Statement and Monograph (test-retest reliability: r = 0.89). Also included were items assessing potential influences on medical care. Presence, source, and number of athletic trainers; school size; distance to nearest medical center; public or private status; sports medicine supply budget; and varsity football regional championships served as explanatory variables, whereas the school setting, region of state, and rate of free or reduced lunch qualifiers served as control variables.
Main Outcome Measure(s):
The Appropriate Care Index (ACI) score from the AMCAT provided a quantitative measure of medical care and served as the response variable. The ACI score was determined based on a school's response to items relating to AMCSSAA guidelines.
Regression analysis revealed associations with ACI score for athletic training services and sports medicine supply budget (both P < .001) when controlling for the setting, region, and rate of free or reduced lunch qualifiers. These 2 variables accounted for 30% of the variance in ACI score (R2 = 0.302). Post hoc analysis showed differences between ACI score based on the source of the athletic trainer and the size of the sports medicine supply budget.
The AMCAT offers an evaluation of medical care provided by interscholastic athletics programs. In South Carolina schools, athletic training services and the sports medicine supply budget were associated with higher levels of medical care. These results offer guidance for improving the medical care provided for interscholastic athletes.
high schools; administration; interscholastic athletes
The purpose of this study was to demonstrate how formative program process evaluation was used to improve dose and fidelity of implementation, as well as reach of the intervention into the target population, in the "Active by Choice Today" (ACT) randomized school-based trial from years 1 to 3 of implementation.
The intervention integrated constructs from Self-Determination Theory and Social Cognitive Theory to enhance intrinsic motivation and behavioral skills for increasing long-term physical activity (PA) behavior in underserved adolescents (low income, minorities). ACT formative process data were examined at the end of each year to provide timely, corrective feedback to keep the intervention "on track".
Between years 1 and 2 and years 2 and 3, three significant changes were made to attempt to increase dose and fidelity rates in the program delivery and participant attendance (reach). These changes included expanding the staff training, reformatting the intervention manual, and developing a tracking system for contacting parents of students who were not attending the after-school programs regularly. Process outcomes suggest that these efforts resulted in notable improvements in attendance, dose, and fidelity of intervention implementation from years 1 to 2 and 2 to 3 of the ACT trial.
Process evaluation methods, particularly implementation monitoring, are useful tools to ensure fidelity in intervention trials and for identifying key best practices for intervention delivery.
Physical activity decreases during childhood and adolescence, and physical activity levels are significantly lower in females than males, particularly during adolescence. Schools are attractive settings in which to implement interventions designed to promote physical activity in girls and young women, but few studies have tested the sustained effects of such interventions.
Cross-sectional. Data were collected in 2002–2003 and analyzed in 2006–2007.
1594 adolescent girls in 22 high schools.
The intervention, Lifestyle Education for Activity Program (LEAP), was designed to increase physical activity in 9th grade girls through two channels: changes in instructional practices and changes in the school environment. This study (LEAP 2) examined the extent to which effects of the intervention were maintained when the girls were in 12th grade.
Main Outcome Measures
Number of 30-minute blocks per day of vigorous physical activity.
Girls in the intervention schools that most fully implemented and maintained the intervention were more likely than girls in the other schools to participate in an average of one or more blocks of vigorous physical activity per day (p=0.04; OR=1.49; 95% CI=1.01, 2.20).
A comprehensive physical activity intervention that is fully implemented and maintained can increase participation in vigorous physical activity by high school girls.
Formative research is used to inform intervention development, but the processes of transmitting results to intervention planners and incorporating information into intervention designs are not well documented. The authors describe how formative research results from the Trial of Activity for Adolescent Girls (TAAG) were transferred to planners to guide intervention development. Methods included providing oral and written reports, prioritizing recommendations, and cross-checking recommendations with intervention objectives and implementation strategies. Formative work influenced the intervention in many ways. For example, results indicated that middle schools offered only coeducational physical education and health education classes, so the TAAG intervention was designed to be appropriate for both sexes, and intervention strategies were developed to directly address girls’ stated preferences (e.g., enjoyable activities, opportunity to socialize) and barriers (e.g., lack of skills, fear of injury) for physical activity. The challenges of using formative research for intervention development are discussed.
formative research; intervention trials; physical activity; adolescents
School and community agency collaboration can potentially increase physical activity opportunities for youth. Few studies have examined the role of community agencies in promoting physical activity, much less in collaboration with schools. This article describes formative research data collection from community agencies to inform the development of the Trial of Activity for Adolescent Girls (TAAG) intervention to provide out-of-school physical activity programs for girls. The community agency survey is designed to assess agency capacity to provide physical activity programs for girls, including resources, programs, and partnerships. Most agency respondents (n = 138) report operations during after-school hours, adequate facilities, and program options for girls, although most are sport oriented. Agency resources and programming vary considerably across the six TAAG field sites. Many agencies report partnerships, some involving schools, although not necessarily related to physical activity. Implications for the TAAG intervention are presented.
physical activity; community agency; school and community collaboration
Health-e-AME was a 3-year intervention designed to promote physical activity at African Methodist Episcopal churches across South Carolina. It is based on a community-participation model designed to disseminate interventions through trained volunteer health directors.
We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate this intervention through interviews with 50 health directors.
Eighty percent of the churches that had a health director trained during the first year of the intervention and 52% of churches that had a health director trained during the second year adopted at least one component of the intervention. Lack of motivation or commitment from the congregation was the most common barrier to adoption. Intervention activities reached middle-aged women mainly. The intervention was moderately well implemented, and adherence to its principles was adequate. Maintenance analyses showed that individual participants in the intervention's physical activity components continued their participation as long as the church offered them, but churches had difficulties continuing to offer physical activity sessions. The effectiveness analysis showed that the intervention produced promising, but not significant, trends in levels of physical activity.
Our use of the RE-AIM framework to evaluate this intervention serves as a model for a comprehensive evaluation of the health effects of community programs to promote health.
Recent public health objectives emphasize the importance of exercise for reducing disability among people with arthritis. Despite the documented benefits of exercise, people with arthritis are less active than those without arthritis. The purpose of this study was to examine the factors that influence exercise participation among insufficiently active individuals with arthritis and to compare these factors with those identified by nonexercisers and regular exercisers with arthritis.
Forty-six individuals with arthritis were recruited from various community-based organizations to participate in seven focus groups segmented by exercise status and education. Trained moderators led each discussion using a standard guide. All focus group discussions were transcribed verbatim and coded.
Pain was the most commonly mentioned barrier to exercise and limited exercise participation for nonexercisers and insufficiently active individuals. Paradoxically, insufficiently active individuals also identified exercise-related reductions in pain as a potential motivation for increasing exercise. Likewise, exercise-related reductions in pain were a motivation to continue exercising for the exerciser groups. Nonexercisers expressed that a reduction in pain was a possible outcome of exercise but were skeptical of its occurrence. Receiving tailored advice from a health care provider was consistently identified as an exercise enabler across the groups.
Findings from this study indicate that potential strategies for increasing exercise participation include incorporating pain management strategies and coping skills into exercise interventions and ensuring that health care providers provide specific exercise advice to their patients with arthritis.