Journal of Physical Activity and Health, 2015, 12, 655 -658 http://dx.doi.org/10.1123/jpah.2013-0527 © 2015 Human Kinetics, Inc.
ORIGINAL RESEARCH
Evaluation of West Virginia’s Healthy Lifestyles Act Physical Education Component Using the YRBSS Courtney Pilkerton and Thomas K. Bias Background: Public health researchers have demonstrated the potential for significant gains in physical activity through public policy. West Virginia passed House Bill 2816, known as the Healthy Lifestyles Act in 2005. This Act amended the code on the requirements of physical education and physical fitness in schools, creating minimum physical education requirements at each grade level. The goal of this policy evaluation was to identify if, 5 years postimplementation, students have increased physical education in schools. Methods: Data from the 2003, 2005, 2007, 2009, and 2011 Youth Risk Behavior Surveillance System surveys were used to examine the time trend of weekly PE participation in WV Schools. Results: There have been no significant changes in participation in physical education classes since before the implementation of the HLA. Conclusions: Simple policy changes by themselves may not effectively create change in physical activity environments, as policy is moderated by strength of language, implementation, and enforcement. Further studies are needed to determine why the HLA has not been successful in increasing physical activity of youth and what changes to the standards and mandates, ways implementation in schools could be improved, and/or the enforcement of these standards are needed for such policies to be successful. Keywords: policy, youth, fitness, schools
In 2012, West Virginia had the nation’s fourth highest prevalence of obesity at 33.8%.1 West Virginia’s rate of obesity is consistently higher than the United States average and has increased an average of 4.6% per year since 1989.2 Similar to adults in West Virginia, childhood obesity is of growing concern with 33.6% of children age 10 to 17 currently overweight or obese,3 ranking eighth worst in the nation.4 This rate in childhood obesity has increased rapidly since the 1970s and contributes to obesity in adulthood and greater risk for chronic disease development.5 Current literature suggests environment, government, and other factors beyond an individual’s control are highly influential on obesity.6,7 Public policy is seen as a way to decrease the rate of obesity, generally through strategies such as junk-food marketing bans, increased nutritional and physical activity standards in schools and policy changes to the built environment and transportation.7–9 Following these ideas, West Virginia passed the Healthy Lifestyles Act in 2005 and began implementation in 2006, which included guidelines and mandates for the sale of healthy beverages and soft drinks, physical education time, fitness testing, the collection of body mass index measurements, and health education instruction and assessment.7,10–12 This type of top-down statewide policy approach has been identified as key to promoting physical activity changes.13 Article 1E of the HLA created the Office of Healthy Lifestyles and set up a partnership to encourage healthy lifestyles.14 Article 2 of the HLA amended Chapter 18 of the West Virginia state code which deals with education. The HLA amended the code on the sale of healthy beverages and soft drinks in schools.14 The HLA also amended the code on the requirements of physical education and physical fitness in schools creating minimum physical education requirements at each grade level, outlines how schools without available staff can develop alternative programs, and requires Pilkerton is with the Dept of Epidemiology and Bias ([email protected]) is with the Dept of Health Policy, Management, and Leadership, West Virginia University, Morgantown, WV.
fitness testing of all students in grades 4 through 8 and body mass index measurement of all students each year.14 Specifically, the act required students to participate in “not less than 1 full period of physical education” for grades K to 5, “not less than 1 full period of physical education” for grades 6 to 8, and “not less than 1 full course credit of physical education” for grades 9 to 12. Implementation of the school components began in August 2006 and are detailed elsewhere.12 During the policy implementation phase, the West Virginia Board of Education Policy 2510 interpreted this as specific PE time requirements, namely requiring 90 minutes of PE per week in elementary schools, 2700 minutes of PE per year in middle school, and 1 full course credit of PE for graduation in high school. The law and resulting policy added specific time requirements that did not exist as state law before passage, and high schools were never before required to offer a lifetime physical activity elective.12 Evaluation of the HLA is necessary to determine policy efficacy and steps to increase policy effectiveness in reducing childhood obesity. Both short-term and long-term assessment is important in monitoring outcomes as well as creating the opportunity to respond to inadequacies, unforeseen consequences, or implementation barriers as soon as they are identified. Policy evaluation and analysis are also essential components if such efforts should be replicated in other states. There have been 2 early short-term evaluations of the HLA, the first in the 2007–08 school year and the second in the 2008–09 school year.12 The first evaluation involved examining survey results from school personnel, students and parents, and health care providers. These surveys found an increased awareness of childhood obesity and the importance of exercise by school personnel, students, and parents and overwhelmingly found positive (> 80%) views of the new HLA regulations.12 The evaluation also identified the main barriers to implementation of the physical education requirements were lack of funding, understaffing, and inadequate facilities. The final recommendation after the first year was to “increase physical activity for all students, with an emphasis on moderate-to-vigorous physical activity”12. The second evaluation found no progress in regards to physical activity and overall student fitness had gotten worse.15 655
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There have been no long-term attempts to examine the outcomes of the HLA physical education components. The goal of this analysis is to identify if high school students have increased amounts of physical education as a result of this Act. Longitudinal evaluation is necessary because of the barriers to implementation reported by the principals and superintendents.15 As solutions are found to such barriers, it should be expected for implementation to increase. In addition, the original evaluation reports relied on primary data collection such as surveys of school administrators to report results. These results were focused largely on process and policy implementation rather than physical education outcomes. Surveys were sent and collected from parents and students as well to understand perceptions and concerns around the Healthy Lifestyles Act. Both the year 1 and year 2 evaluation reports, which were prepared for and funded by the state department of education had specific steps and recommendations expected to be put in place to improve policy implementation. Here, we present a longitudinal secondary data analysis of data collected nationally by the Centers for Disease Control and Prevention to independently identify the impact on physical education across West Virginia. This longer-term evaluation process utilizes standard measures for youth health in the United States to examine the impact of the law.
Methods Data Source and Study Population The Youth Risk Behavior Surveillance System (YRBSS) is a biannually administered national, state, and regional survey collecting information on health risk behaviors among young adults including behaviors that contribute to unintentional injuries and violence, sexual behaviors, tobacco use, alcohol and other drug use, unhealthy dietary behaviors, and physical activity since 1991. West Virginia, with support from the Center for Disease Control and Prevention, interviews a representative sample of public school students in 9th through 12th grades. Detailed descriptions of YRBSS study design and methods are described elsewhere.16 All participants of the 2003, 2005, 2007, 2009, and 2011 YRBSS surveys were eligible for inclusion in our data analyses. Students were excluded if they were missing data on the number of days per week participating in physical education classes, race/ ethnicity, sex, or grade level. The final total study population was 7,541. There were 1453 total students in 2003, 1170 in 2005, 1337 in 2007, 1480 in 2009, and 2101 in 2011.
Variables The main outcome of interest was weekly physical education (PE) participation. The YRBSS asks respondents how many times per week they have a PE class. Students were categorized as having weekly PE participation if they responded that they had at least 1 PE class per week. The main variable of interest is year. Year is the YRBSS year in which the student participated. Demographic covariates included are grade (9th, 10th, 11th, 12th), sex, and race/ ethnicity (non-Hispanic White, Black or African American, Asian, Hispanic/Latino, and Other). Age was excluded because of potential multicollinearity with grade.
Statistical Analysis All statistical analyses were performed with Stata 13 (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). All models were run using survey procedures to account for survey weights and design. Adjusted models controlled for sex, grade, and race/ethnicity. A logistic model was performed to determine time trend of weekly PE participation. Pearson chi square with Rao and Scott correction was performed to test differences between years. Contrast statements were used to test for linear trend in time. Margin statements were used to calculate predicted values at mean values of covariates. Interactions between time and sex, time and race/ethnicity, and time and grade were explored.
Results The final total study population was 7541. There were 1453 total students in 2003, 1170 in 2005, 1337 in 2007, 1480 in 2009, and 2101 in 2011. Overall, 85.9% of students were non-Hispanic white, 46.1% were female, and more were in 9th or 10th grade than senior grades (Table 1). Thirty-five percent of high school students had a PE class at least once per week. There were no significant differences in the odds of having PE weekly between any years in either unadjusted or adjusted models (Table 2). The predicted fraction of students having weekly PE was about 35% for all years (Figure 1). There were no differences over time in having weekly PE classes between grade levels or racial/ ethnic groups. There was a significant interaction between sex and time (Figure 2). Males were significantly more likely to have a weekly PE class, 38%, than females, 29%.
Table 1 Characteristics of Study Population (N = 7541) by YRBSS Year Overall
2003
2005
2007
2009
2011
Grade N (%) 9th 10th 11th 12th
2154 (26.9) 2214 (29.4) 1863 (25.5) 1310 (18.2)
374 (24.6) 521 (35.5) 371 (26.6) 187 (13.3)
379 (30.8) 331 (27.9) 272 (24.2) 188 (17.1)
371 (26.3) 375 (28.5) 403 (30.9) 188 (14.3)
443 (28.2) 418 (28.0) 342 (23.9) 277 (23.6)
587 (25.8) 569 (27.6) 475 (23.1) 470 (23.6)
Sex N, (% Female)
3885 (46.1)
749 (45.3)
589 (45.7)
714 (48.6)
760 (44.7)
1073 (46.1)
Race/ethnicity N, (%) Non-Hispanic White Black/African American Other
6471 (85.9) 423 (5.8) 647 (8.3)
1212 (83.6) 154 (11.1) 87 (5.4)
1052 (89.3) 44 (4.5) 74 (6.2)
1165 (87.9) 59 (3.7) 113 (8.4)
1246 (84.2) 78 (4.3) 156 (10.3)
1796 (85.9) 88 (5.8) 217 (8.3)
Has a weekly PE class N, (%)
2660 (34.9)
801 (35.3)
635 (38.6)
458 (30.8)
643 (32.9)
815 (36.7)
Abbreviations: YRBSS, Youth Risk Behavior Surveillance System. JPAH Vol. 12, No. 5, 2015
WV Healthy Lifestyle PE Policy Evaluation 657
Table 2 Odds of Having at Least 1 Physical Education Class per Week, YRBSS Year
Unadjusted model
Adjusted model*
2003
1.0
1.0
2005
1.15 (0.74, 1.79)
1.16 (0.77, 1.75)
2007
0.81 (0.55, 1.21)
0.86 (0.59, 1.24)
2009
0.90 (0.58, 1.40)
0.91 (0.60, 1.36)
2011
1.06 (0.71, 1.58)
1.16 (0.78, 1.74)
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Abbreviations: YRBSS, Youth Risk Behavior Surveillance System. * Adjusted for sex, grade, and race/ethnicity.
Conclusions There have been no changes in participation in physical education classes during the period before or after the implementation of the HLA. These results are consistent with those seen in earlier evaluation of the HLA which also showed no progress in physical activity or fitness.12,15 The significant finding that boys are more likely to participate in PE classes than girls is also consistent with literature showing that boys participate in more physical activity than girls.17 This study supports the idea that so far the HLA has not yet resulted in improvements in PE participation. Possible reasons for the lack of change seen after the HLA’s implementation are in the wording of the law. While the beverage
Figure 1 — Predicted fraction of high school students who had at least 1 physical education class per week at mean sex, grade, and race/ethnicity by year, Youth Risk Behavior Surveillance System.
Figure 2 — Predicted fraction of high school students who had at least 1 physical education class per week at mean grade and race/ethnicity by year and sex, Youth Risk Behavior Surveillance System. JPAH Vol. 12, No. 5, 2015
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658 Pilkerton and Bias
and physical education requirements hope to address childhood obesity there is concern with the wording of the legislation and its enforcement. For schools without sufficient physical education staff, the HLA allows alternative programs to be developed, but the HLA does not define the parameters of these alternative programs or provide guidelines for approving these programs. Although the HLA provides detailed amounts of time students should be in physical education classes and that they should be ‘active,’ the HLA does not define active or provide information on the activities and intensity of activities that physical education classes should provide. In addition, the HLA only dictated 1 physical education credit through all 4 years of high school. It is possible that the law itself was written with such low standards that it did not increase physical education among high school students while it may have an impact on younger students who had higher standards. Enforcement of these regulations is not discussed in the HLA, although in other areas of policy such as tobacco control enforcement has been a prominent focus.18 It is also possible that barriers to implementation discussed in the first evaluations are contributing to the lack of improvement. Inadequate facilities, understaffing, and a lack of funding in up to 30% of schools12,15 could leave a large number of students without the opportunities to actively participate in PE classes.
Limitations and Strengths The main limitation of this study is the self-report nature of the data, although it seems unlikely that students would report the number of PE classes per week in which they participate so inaccurately as to explain our findings. Another limitation is the possibility that results are biased because students attending the same school are likely to make similar choices in PE classes as the availability would be the same. Much of this cluster effect should be controlled for in the weighting of individuals.16 Schools could potentially have had, in a nonsystematic fashion, internal policies in place dictating physical education credit or time requirements that are unknown to the authors. Therefore, some schools may have demonstrated no changes in student behavior due to the fact policy may not have changed in those specific locales. A final limitation is that YRBS is often conducted in the spring. We would miss counting students who exclusively took physical education in the fall. One strength of this study is the large representative sample of West Virginia students available over time by using YRBSS data. While several limitations exist, the findings support our main conclusion that future policy efforts should be strengthened and developed with the aim to improve population level outcomes. Specifically, issues such as preexisting school level policies or failure to overcome implementation barriers indicates a need for stronger efforts at the policy formation stage. In conclusion, further studies are needed to determine why the HLA has not been successful in increasing physical education of youth and what changes to the standards and mandates in the policy, how it is being implemented, or the enforcement of these standards are needed to be successful. Population level evaluation shows no statistically significant changes since implementation of the HLA began. Implementation of recommendations made in previous evaluations, such as more encouragement of active PE time, increased movement in academic classes, and eliminating barriers to implementation may help to improve the number of students participating in daily PE. Furthermore, lawmakers may want to revisit the amount of physical education required by the law to move toward healthy outcomes for high school students. These findings demonstrate that, while public policy shows promise to
increase physical activity in populations, there are many subtleties and elements of policy such as enforcement and implementation that moderate such effects. Loopholes or alternatives to minimum requirements may also decrease outcomes. In addition, lawmakers need to consider if the mandatory minimums set by statute should be increased to create demonstrable change in health outcomes through policy. Future legislative activities should consider in-depth preliminary assessment to understand current policies in place at the county or school level.
References 1. U.S. Department of Commerce Economics and Statistics Administration U.S. Census Bureau. Census Regions and Divisions of the United States. 2013; http://www2.census.gov/geo/pdfs/maps-data/maps/ reference/us_regdiv.pdf. Accessed July 15, 2015. 2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Annual Survey Data 2013. 3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235–241. PubMed doi:10.1001/jama.2009.2014 4. Data Resource Center for Child and Adolescent Health. 2011/12 National Survey of Children’s Health Data Query. 2012; http://www. childhealthdata.org/browse/survey/results?q=2415&r=50. 5. Paulhus E. Afterschool Programs in West Virginia: Improving the Lives of the State’s Children. West Virginia Center on Budget and Policy. 2012. http://www.wvpolicy.org/afterschool-programs-inwest-virginia-improving-the-lives-of-the-states-children. Accessed July 15, 2015. 6. Burnett D. Fast-food lawsuits and the Cheeseburger Bill: critiquing congress’s response to the obesity epidemic. Va. J. Soc. Pol’y & L. 2006;14:357. 7. Weiss RI, Hayne CL, Smith JA. Legislative approaches to the obesity epidemic. J Public Health Policy. 2004;25(3-4):3–4. PubMed 8. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics. 2006;117(2):417–424. PubMed doi:10.1542/ peds.2005-0058 9. Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Q. 2009;87(1):71–100. PubMed doi:10.1111/j.1468-0009.2009.00548.x 10. West Virginia University Health Research Center. West Virginia Standards for School Nutrition Year One Evaluation Executive Summary. 2010. 11. West Virginia University Health Research Center. West Virginia Standards for School Nutrition Year Two Evaluation Executive Summary. 2011. 12. Harris C, Bradlyn A, O’Hara Tompkins N, Kelley G. West Virginia Healthy Lifestyles Act: Year One Evaluation Report, 2009. 2009. 13. Eyler A, Brownson R, Schmid T, Pratt M. Understanding policies and physical activity: frontiers of knowledge to improve population health. J Phys Act Health. 2010;7:S9. PubMed 14. Healthy Lifestyles Act. HB 28162005. 15. Harris C, Bradlyn A, O’Hara Tompkins N, Kelley G. West Virginia Healthy Lifestyles Act. Year Two Executive Summary; 2010. 16. Brener ND, Eaton DK, Flint KH, et al. Methodology of the youth risk behavior surveillance system—2013. US Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. 17. Patnode CD, Lytle LA, Erickson DJ, Sirard JR, Barr-Anderson D, Story M. The relative influence of demographic, individual, social, and environmental factors on physical activity among boys and girls. Int J Behav Nutr Phys Act. 2010;7:79. PubMed doi:10.1186/14795868-7-79 18. Jacobson PD, Wasserman J. The implementation and enforcement of tobacco control laws: policy implications for activists and the industry. J Health Polit Policy Law. 1999;24(3):567–598. PubMed
JPAH Vol. 12, No. 5, 2015
ORIGINAL RESEARCH
Evaluation of West Virginia’s Healthy Lifestyles Act Physical Education Component Using the YRBSS Courtney Pilkerton and Thomas K. Bias Background: Public health researchers have demonstrated the potential for significant gains in physical activity through public policy. West Virginia passed House Bill 2816, known as the Healthy Lifestyles Act in 2005. This Act amended the code on the requirements of physical education and physical fitness in schools, creating minimum physical education requirements at each grade level. The goal of this policy evaluation was to identify if, 5 years postimplementation, students have increased physical education in schools. Methods: Data from the 2003, 2005, 2007, 2009, and 2011 Youth Risk Behavior Surveillance System surveys were used to examine the time trend of weekly PE participation in WV Schools. Results: There have been no significant changes in participation in physical education classes since before the implementation of the HLA. Conclusions: Simple policy changes by themselves may not effectively create change in physical activity environments, as policy is moderated by strength of language, implementation, and enforcement. Further studies are needed to determine why the HLA has not been successful in increasing physical activity of youth and what changes to the standards and mandates, ways implementation in schools could be improved, and/or the enforcement of these standards are needed for such policies to be successful. Keywords: policy, youth, fitness, schools
In 2012, West Virginia had the nation’s fourth highest prevalence of obesity at 33.8%.1 West Virginia’s rate of obesity is consistently higher than the United States average and has increased an average of 4.6% per year since 1989.2 Similar to adults in West Virginia, childhood obesity is of growing concern with 33.6% of children age 10 to 17 currently overweight or obese,3 ranking eighth worst in the nation.4 This rate in childhood obesity has increased rapidly since the 1970s and contributes to obesity in adulthood and greater risk for chronic disease development.5 Current literature suggests environment, government, and other factors beyond an individual’s control are highly influential on obesity.6,7 Public policy is seen as a way to decrease the rate of obesity, generally through strategies such as junk-food marketing bans, increased nutritional and physical activity standards in schools and policy changes to the built environment and transportation.7–9 Following these ideas, West Virginia passed the Healthy Lifestyles Act in 2005 and began implementation in 2006, which included guidelines and mandates for the sale of healthy beverages and soft drinks, physical education time, fitness testing, the collection of body mass index measurements, and health education instruction and assessment.7,10–12 This type of top-down statewide policy approach has been identified as key to promoting physical activity changes.13 Article 1E of the HLA created the Office of Healthy Lifestyles and set up a partnership to encourage healthy lifestyles.14 Article 2 of the HLA amended Chapter 18 of the West Virginia state code which deals with education. The HLA amended the code on the sale of healthy beverages and soft drinks in schools.14 The HLA also amended the code on the requirements of physical education and physical fitness in schools creating minimum physical education requirements at each grade level, outlines how schools without available staff can develop alternative programs, and requires Pilkerton is with the Dept of Epidemiology and Bias ([email protected]) is with the Dept of Health Policy, Management, and Leadership, West Virginia University, Morgantown, WV.
fitness testing of all students in grades 4 through 8 and body mass index measurement of all students each year.14 Specifically, the act required students to participate in “not less than 1 full period of physical education” for grades K to 5, “not less than 1 full period of physical education” for grades 6 to 8, and “not less than 1 full course credit of physical education” for grades 9 to 12. Implementation of the school components began in August 2006 and are detailed elsewhere.12 During the policy implementation phase, the West Virginia Board of Education Policy 2510 interpreted this as specific PE time requirements, namely requiring 90 minutes of PE per week in elementary schools, 2700 minutes of PE per year in middle school, and 1 full course credit of PE for graduation in high school. The law and resulting policy added specific time requirements that did not exist as state law before passage, and high schools were never before required to offer a lifetime physical activity elective.12 Evaluation of the HLA is necessary to determine policy efficacy and steps to increase policy effectiveness in reducing childhood obesity. Both short-term and long-term assessment is important in monitoring outcomes as well as creating the opportunity to respond to inadequacies, unforeseen consequences, or implementation barriers as soon as they are identified. Policy evaluation and analysis are also essential components if such efforts should be replicated in other states. There have been 2 early short-term evaluations of the HLA, the first in the 2007–08 school year and the second in the 2008–09 school year.12 The first evaluation involved examining survey results from school personnel, students and parents, and health care providers. These surveys found an increased awareness of childhood obesity and the importance of exercise by school personnel, students, and parents and overwhelmingly found positive (> 80%) views of the new HLA regulations.12 The evaluation also identified the main barriers to implementation of the physical education requirements were lack of funding, understaffing, and inadequate facilities. The final recommendation after the first year was to “increase physical activity for all students, with an emphasis on moderate-to-vigorous physical activity”12. The second evaluation found no progress in regards to physical activity and overall student fitness had gotten worse.15 655
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656 Pilkerton and Bias
There have been no long-term attempts to examine the outcomes of the HLA physical education components. The goal of this analysis is to identify if high school students have increased amounts of physical education as a result of this Act. Longitudinal evaluation is necessary because of the barriers to implementation reported by the principals and superintendents.15 As solutions are found to such barriers, it should be expected for implementation to increase. In addition, the original evaluation reports relied on primary data collection such as surveys of school administrators to report results. These results were focused largely on process and policy implementation rather than physical education outcomes. Surveys were sent and collected from parents and students as well to understand perceptions and concerns around the Healthy Lifestyles Act. Both the year 1 and year 2 evaluation reports, which were prepared for and funded by the state department of education had specific steps and recommendations expected to be put in place to improve policy implementation. Here, we present a longitudinal secondary data analysis of data collected nationally by the Centers for Disease Control and Prevention to independently identify the impact on physical education across West Virginia. This longer-term evaluation process utilizes standard measures for youth health in the United States to examine the impact of the law.
Methods Data Source and Study Population The Youth Risk Behavior Surveillance System (YRBSS) is a biannually administered national, state, and regional survey collecting information on health risk behaviors among young adults including behaviors that contribute to unintentional injuries and violence, sexual behaviors, tobacco use, alcohol and other drug use, unhealthy dietary behaviors, and physical activity since 1991. West Virginia, with support from the Center for Disease Control and Prevention, interviews a representative sample of public school students in 9th through 12th grades. Detailed descriptions of YRBSS study design and methods are described elsewhere.16 All participants of the 2003, 2005, 2007, 2009, and 2011 YRBSS surveys were eligible for inclusion in our data analyses. Students were excluded if they were missing data on the number of days per week participating in physical education classes, race/ ethnicity, sex, or grade level. The final total study population was 7,541. There were 1453 total students in 2003, 1170 in 2005, 1337 in 2007, 1480 in 2009, and 2101 in 2011.
Variables The main outcome of interest was weekly physical education (PE) participation. The YRBSS asks respondents how many times per week they have a PE class. Students were categorized as having weekly PE participation if they responded that they had at least 1 PE class per week. The main variable of interest is year. Year is the YRBSS year in which the student participated. Demographic covariates included are grade (9th, 10th, 11th, 12th), sex, and race/ ethnicity (non-Hispanic White, Black or African American, Asian, Hispanic/Latino, and Other). Age was excluded because of potential multicollinearity with grade.
Statistical Analysis All statistical analyses were performed with Stata 13 (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP). All models were run using survey procedures to account for survey weights and design. Adjusted models controlled for sex, grade, and race/ethnicity. A logistic model was performed to determine time trend of weekly PE participation. Pearson chi square with Rao and Scott correction was performed to test differences between years. Contrast statements were used to test for linear trend in time. Margin statements were used to calculate predicted values at mean values of covariates. Interactions between time and sex, time and race/ethnicity, and time and grade were explored.
Results The final total study population was 7541. There were 1453 total students in 2003, 1170 in 2005, 1337 in 2007, 1480 in 2009, and 2101 in 2011. Overall, 85.9% of students were non-Hispanic white, 46.1% were female, and more were in 9th or 10th grade than senior grades (Table 1). Thirty-five percent of high school students had a PE class at least once per week. There were no significant differences in the odds of having PE weekly between any years in either unadjusted or adjusted models (Table 2). The predicted fraction of students having weekly PE was about 35% for all years (Figure 1). There were no differences over time in having weekly PE classes between grade levels or racial/ ethnic groups. There was a significant interaction between sex and time (Figure 2). Males were significantly more likely to have a weekly PE class, 38%, than females, 29%.
Table 1 Characteristics of Study Population (N = 7541) by YRBSS Year Overall
2003
2005
2007
2009
2011
Grade N (%) 9th 10th 11th 12th
2154 (26.9) 2214 (29.4) 1863 (25.5) 1310 (18.2)
374 (24.6) 521 (35.5) 371 (26.6) 187 (13.3)
379 (30.8) 331 (27.9) 272 (24.2) 188 (17.1)
371 (26.3) 375 (28.5) 403 (30.9) 188 (14.3)
443 (28.2) 418 (28.0) 342 (23.9) 277 (23.6)
587 (25.8) 569 (27.6) 475 (23.1) 470 (23.6)
Sex N, (% Female)
3885 (46.1)
749 (45.3)
589 (45.7)
714 (48.6)
760 (44.7)
1073 (46.1)
Race/ethnicity N, (%) Non-Hispanic White Black/African American Other
6471 (85.9) 423 (5.8) 647 (8.3)
1212 (83.6) 154 (11.1) 87 (5.4)
1052 (89.3) 44 (4.5) 74 (6.2)
1165 (87.9) 59 (3.7) 113 (8.4)
1246 (84.2) 78 (4.3) 156 (10.3)
1796 (85.9) 88 (5.8) 217 (8.3)
Has a weekly PE class N, (%)
2660 (34.9)
801 (35.3)
635 (38.6)
458 (30.8)
643 (32.9)
815 (36.7)
Abbreviations: YRBSS, Youth Risk Behavior Surveillance System. JPAH Vol. 12, No. 5, 2015
WV Healthy Lifestyle PE Policy Evaluation 657
Table 2 Odds of Having at Least 1 Physical Education Class per Week, YRBSS Year
Unadjusted model
Adjusted model*
2003
1.0
1.0
2005
1.15 (0.74, 1.79)
1.16 (0.77, 1.75)
2007
0.81 (0.55, 1.21)
0.86 (0.59, 1.24)
2009
0.90 (0.58, 1.40)
0.91 (0.60, 1.36)
2011
1.06 (0.71, 1.58)
1.16 (0.78, 1.74)
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Abbreviations: YRBSS, Youth Risk Behavior Surveillance System. * Adjusted for sex, grade, and race/ethnicity.
Conclusions There have been no changes in participation in physical education classes during the period before or after the implementation of the HLA. These results are consistent with those seen in earlier evaluation of the HLA which also showed no progress in physical activity or fitness.12,15 The significant finding that boys are more likely to participate in PE classes than girls is also consistent with literature showing that boys participate in more physical activity than girls.17 This study supports the idea that so far the HLA has not yet resulted in improvements in PE participation. Possible reasons for the lack of change seen after the HLA’s implementation are in the wording of the law. While the beverage
Figure 1 — Predicted fraction of high school students who had at least 1 physical education class per week at mean sex, grade, and race/ethnicity by year, Youth Risk Behavior Surveillance System.
Figure 2 — Predicted fraction of high school students who had at least 1 physical education class per week at mean grade and race/ethnicity by year and sex, Youth Risk Behavior Surveillance System. JPAH Vol. 12, No. 5, 2015
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658 Pilkerton and Bias
and physical education requirements hope to address childhood obesity there is concern with the wording of the legislation and its enforcement. For schools without sufficient physical education staff, the HLA allows alternative programs to be developed, but the HLA does not define the parameters of these alternative programs or provide guidelines for approving these programs. Although the HLA provides detailed amounts of time students should be in physical education classes and that they should be ‘active,’ the HLA does not define active or provide information on the activities and intensity of activities that physical education classes should provide. In addition, the HLA only dictated 1 physical education credit through all 4 years of high school. It is possible that the law itself was written with such low standards that it did not increase physical education among high school students while it may have an impact on younger students who had higher standards. Enforcement of these regulations is not discussed in the HLA, although in other areas of policy such as tobacco control enforcement has been a prominent focus.18 It is also possible that barriers to implementation discussed in the first evaluations are contributing to the lack of improvement. Inadequate facilities, understaffing, and a lack of funding in up to 30% of schools12,15 could leave a large number of students without the opportunities to actively participate in PE classes.
Limitations and Strengths The main limitation of this study is the self-report nature of the data, although it seems unlikely that students would report the number of PE classes per week in which they participate so inaccurately as to explain our findings. Another limitation is the possibility that results are biased because students attending the same school are likely to make similar choices in PE classes as the availability would be the same. Much of this cluster effect should be controlled for in the weighting of individuals.16 Schools could potentially have had, in a nonsystematic fashion, internal policies in place dictating physical education credit or time requirements that are unknown to the authors. Therefore, some schools may have demonstrated no changes in student behavior due to the fact policy may not have changed in those specific locales. A final limitation is that YRBS is often conducted in the spring. We would miss counting students who exclusively took physical education in the fall. One strength of this study is the large representative sample of West Virginia students available over time by using YRBSS data. While several limitations exist, the findings support our main conclusion that future policy efforts should be strengthened and developed with the aim to improve population level outcomes. Specifically, issues such as preexisting school level policies or failure to overcome implementation barriers indicates a need for stronger efforts at the policy formation stage. In conclusion, further studies are needed to determine why the HLA has not been successful in increasing physical education of youth and what changes to the standards and mandates in the policy, how it is being implemented, or the enforcement of these standards are needed to be successful. Population level evaluation shows no statistically significant changes since implementation of the HLA began. Implementation of recommendations made in previous evaluations, such as more encouragement of active PE time, increased movement in academic classes, and eliminating barriers to implementation may help to improve the number of students participating in daily PE. Furthermore, lawmakers may want to revisit the amount of physical education required by the law to move toward healthy outcomes for high school students. These findings demonstrate that, while public policy shows promise to
increase physical activity in populations, there are many subtleties and elements of policy such as enforcement and implementation that moderate such effects. Loopholes or alternatives to minimum requirements may also decrease outcomes. In addition, lawmakers need to consider if the mandatory minimums set by statute should be increased to create demonstrable change in health outcomes through policy. Future legislative activities should consider in-depth preliminary assessment to understand current policies in place at the county or school level.
References 1. U.S. Department of Commerce Economics and Statistics Administration U.S. Census Bureau. Census Regions and Divisions of the United States. 2013; http://www2.census.gov/geo/pdfs/maps-data/maps/ reference/us_regdiv.pdf. Accessed July 15, 2015. 2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Annual Survey Data 2013. 3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235–241. PubMed doi:10.1001/jama.2009.2014 4. Data Resource Center for Child and Adolescent Health. 2011/12 National Survey of Children’s Health Data Query. 2012; http://www. childhealthdata.org/browse/survey/results?q=2415&r=50. 5. Paulhus E. Afterschool Programs in West Virginia: Improving the Lives of the State’s Children. West Virginia Center on Budget and Policy. 2012. http://www.wvpolicy.org/afterschool-programs-inwest-virginia-improving-the-lives-of-the-states-children. Accessed July 15, 2015. 6. Burnett D. Fast-food lawsuits and the Cheeseburger Bill: critiquing congress’s response to the obesity epidemic. Va. J. Soc. Pol’y & L. 2006;14:357. 7. Weiss RI, Hayne CL, Smith JA. Legislative approaches to the obesity epidemic. J Public Health Policy. 2004;25(3-4):3–4. PubMed 8. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics. 2006;117(2):417–424. PubMed doi:10.1542/ peds.2005-0058 9. Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Q. 2009;87(1):71–100. PubMed doi:10.1111/j.1468-0009.2009.00548.x 10. West Virginia University Health Research Center. West Virginia Standards for School Nutrition Year One Evaluation Executive Summary. 2010. 11. West Virginia University Health Research Center. West Virginia Standards for School Nutrition Year Two Evaluation Executive Summary. 2011. 12. Harris C, Bradlyn A, O’Hara Tompkins N, Kelley G. West Virginia Healthy Lifestyles Act: Year One Evaluation Report, 2009. 2009. 13. Eyler A, Brownson R, Schmid T, Pratt M. Understanding policies and physical activity: frontiers of knowledge to improve population health. J Phys Act Health. 2010;7:S9. PubMed 14. Healthy Lifestyles Act. HB 28162005. 15. Harris C, Bradlyn A, O’Hara Tompkins N, Kelley G. West Virginia Healthy Lifestyles Act. Year Two Executive Summary; 2010. 16. Brener ND, Eaton DK, Flint KH, et al. Methodology of the youth risk behavior surveillance system—2013. US Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. 17. Patnode CD, Lytle LA, Erickson DJ, Sirard JR, Barr-Anderson D, Story M. The relative influence of demographic, individual, social, and environmental factors on physical activity among boys and girls. Int J Behav Nutr Phys Act. 2010;7:79. PubMed doi:10.1186/14795868-7-79 18. Jacobson PD, Wasserman J. The implementation and enforcement of tobacco control laws: policy implications for activists and the industry. J Health Polit Policy Law. 1999;24(3):567–598. PubMed
JPAH Vol. 12, No. 5, 2015
