Preventive Medicine 72 (2015) 130–132
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Commentary
Understanding the real value of youth physical activity promotion Michael W. Beets ⁎, Robert G. Weaver, Justin B. Moore University of South Carolina, Arnold School of Public Health
Keywords: Economics Moderate-to-vigorous physical activity Intervention School
Getting youth “up and moving” has been, and will continue to be, an important and challenging public health endeavor. During the past decades of concerted effort on this topic, schools have been the primary setting targeted. The reason for this is clear – most youth (b 18 years) in the United States attend publicly funded elementary and secondary schools – with enrollment numbers for fall 2014 reaching almost 50 million (National Center for Education Statistics, 2014). Such expansive reach provides opportunities to deliver a myriad of health promotion efforts to millions of children, of which physical activity often plays a primary role. The allocation of time for physical education (PE) and recess, as well as, resources for youth sports (both intramural and extramural), classroom physical activity breaks, and before- and afterschool programming are examples of such efforts. Each of these opportunities can provide youth with valuable amounts of moderate-tovigorous physical activity (MVPA) that can contribute to their total daily recommendation of 60 minutes of MVPA (U.S. Department of Health and Human Services, 2008). In an environment where funding for public health efforts is tight, understanding the costs associated with youth physical activity promotion efforts and which represent the “best” investment is critical information to inform policy-related decisions. A study by Babey et al. (2014) pursues this line of inquiry by performing an economic analysis of school-based physical activity promotion. In their analysis, they reviewed four types of programs: extending the regular school day by 1 h for PE, before-school programs, after-school programs, and classroom physical activity breaks. The authors concluded that extending the school day by one additional hour for PE and offering two 10minute physical activity breaks in the classroom are superior to before- and after-school programs in terms of reach and cost per student. While the authors' research question is important and the authors should be commended for their efforts, there are numerous conceptual and cost assumptions that require further explanation. First, the authors propose that extending the school day for an additional hour of PE would cost $264 per child per year with no cost incurred by families (see Table 1 in Babey et al., 2014). This estimate appears to grossly underestimate the true cost of operating a school. ⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ypmed.2014.11.009 0091-7435/© 2014 Elsevier Inc. All rights reserved.
According to the National Center for Education Statistics (2014), in 2010–2011, taking into account all school operating expenses, it costs an average of $10.61 per hour to operate a public school for each student (based on a per pupil expense of $12,608 for a 180 day school year that operates an average of 6.6 h per day). Over the course of one school year, increasing the school day by 1 h would translate into an additional $1910.30 per student. For a single school serving 503 students (national enrollment average), the annual cost of extending each school day by one additional hour would approach $1 million ($961,778). If this policy is adopted nationwide, the education finance budget would require an additional $95 billion in funding. The authors suggest that extending the school day would come at no cost to families, yet their discussion concedes that a barrier to such an approach would be an unwillingness to increase taxes, mostly in the form of increased income, sales, and property taxes — with state and local governments likely shouldering the majority of this tax burden (New American Foundation, 2014). The authors' solution is to have teachers come later or leave earlier — implying that fewer teachers would be present and responsible for the entire student body at some points during the school day. If this does not work, the authors suggest that PE could be held as a one large school-wide session, if an outdoor or indoor space is available. Unfortunately, delivering PE in this form would fundamentally change what constitutes PE and would also undermine the ability of a single (let alone multiple) teacher(s) to get all youth in the school at one time to spend 50% of the hour in MVPA (the goal the authors hypothesize PE can deliver). Further, many schools have limited access to outdoor space at some point throughout the school year due to inclement weather and few schools have indoor facilities that can accommodate the entire student body for physical activity. Even fewer schools provide students from Kindergarten through 12th grade (K-12) with PE each day (Lee et al., 2007). The authors also present economic analyses on programs that occur after the regular school day and indicate that the cost of these programs to families is $2867 per student per year and low reach. There are several fundamental flaws with this analytical approach. First, the definition that the authors use for these programs includes both traditional afterschool programs (Afterschool Alliance, 2014), as well as, clubs, and intramural and extramural (i.e., interscholastic) sports. However, the evidence used to estimate the impact (i.e., MVPA accumulated) and corresponding costs is drawn solely from the traditional afterschool program literature. Traditional afterschool programs are fundamentally different than clubs or intramural and interscholastic sport opportunities. The authors themselves (Babey et al., 2014) reference several sources where a clear distinction is drawn among these types of programs. Thus, what the
M.W. Beets et al. / Preventive Medicine 72 (2015) 130–132
authors present are cost estimates for traditional afterschool programs — leaving club and sport opportunities entirely out of the analysis. Second, the cost presented for traditional afterschool programs is based on the entire duration of the program, typically 3 h per day. Babey et al. did not take into account that physical activity opportunities are one of multiple activities scheduled each day in these programs, with snack, homework assistance, and enrichment activities offered. This is surprising since they recognize this in their article but proceed to provide cost estimations for the entire 3-hour delivery of the program. Afterschool programs schedule an average of 60 min of physical activity opportunities each day (Beets et al., 2013; Brazendale et al., in press). Given that afterschool programs operate every day of the school year, this translates into $15.93 per student per day, or an hourly operating expense per student of $5.31 — half the amount of operating a school for a single hour. With anywhere from 20 to 30 min of MVPA accumulated during this hour of programming (Beets et al., 2014; Trost et al., 2008), the cost per minute of MVPA ranges from $0.18 to $0.27, compared to $0.35 per minute of MVPA during a one hour PE class (if 30 min of MVPA is accumulated during 1 h at $10.61). Third, traditional afterschool programs serve 10.2 million youth annually, with an additional 19.4 million youth wanting to participate if an afterschool program was available (Afterschool Alliance, 2014). If traditional afterschool programs were able to meet the expressed demand, they would serve over 50% of the youth attending public or private K-12 schools. Further, 84% (5 in 6) of the parents favor public funding of afterschool programs, with the majority of the programs (80%) providing opportunities for the youth attending to be physically active each day. The authors do not include sports or clubs as settings where youth accumulate MVPA. With over 44 million youth participating in some form of sport (National Council of Youth Sports, 2008), such a venue is highly relevant to evaluate. A recent study found that youth can accumulate an average of 45 min of MVPA during a single practice session (Leek et al., 2011). This is a substantial amount of activity, but the costs are high as athletic facilities are expensive. Costs for football stadiums alone can reach well over $1 million (Appel Osborne Landscape Architecture, 2014) with some schools willing to invest $60 million for this single sport (The Assocaited Press, 2014). While this is only one example, such investment in athletic facilities is often for the health benefit of only a few students on the team and mostly middle and high school students participate (Lee et al., 2007). Community-based sports are an alternative, yet youth often face “pay to play” participation requirement that limits those from low-income households from being involved (C.S. Mott Children's Hospital, University of Michigan, 2012). The number of youth participating in clubs or other forms of afterschool activity opportunities is less clear; nevertheless, a single study found that other after-school program, such as dance, can contribute almost a third of the girls' daily MVPA (O'Neill et al., 2011), suggesting that such programs help youth outside of the regular school day to be physically active. The authors base the costs associated with PE and classroom activity breaks on hypothetical idealized amounts of activity that “could” be accumulated. For PE, 50% of time spent in MVPA (or 30 min of MVPA within 1 h) is used to estimate cost. While this is a widely recognized benchmark within the PE field, the authors clearly state that few if any PE classes ever achieve this goal. Since current practice fails to deliver MVPA, it is unclear why extending the school day would improve upon this without substantial investment in professional development training. In turn, this investment would need to be included within any economic analysis hoping to achieve this goal. Secondly, the cost estimates for classroom activity breaks hinge on the ability of regular classroom teachers in getting students engaged in MVPA 100% during a 10 minute activity break — teachers must include two of these 10 minute breaks within a day and students accumulate 20 min of MVPA. This would be an impressive accomplishment, especially given that well-trained PE teachers are unable to achieve half of this goal. In
131
fact, suggesting that any allotted length of time could be spent 100% in MVPA is unrealistic (Erwin et al., 2013, 2014) and thus distorts what would most likely occur from the implementation of these strategies. Moreover, these hypothetical scenarios are not applied to the cost estimates for programs occurring after the regular school day. Finally, there is no mention of recess, the amount of MVPA accumulated during recess, and the costs associated with delivery, despite the fact that substantial attention has focused on how to best maximize MVPA during recess (Parrish et al., 2013), and schools allocate an average of 30 min for recess each day (Beyler et al., 2014). Further, the estimates associated with before-school opportunities suggest that if school teachers were paid to supervise a 30 minute session before school, and youth attending accumulated 20 min of MVPA (66% time spent in MVPA — an unlikely result), this would all come at no cost to families. It is clear that any and all physical activity opportunities afforded to youth during the day can make a valuable contribution towards achieving public health goals. How to cost-consciously maximize physical activity during these already allotted opportunities, in turn, will greatly assist the field of youth physical activity promotion. As researchers and practitioners look to establish “whole of school” approaches that span from before- to after-school, and everything in between (Carson et al., 2014), such information can help to direct efforts and funding to those opportunities that best help youth achieve their recommended daily allotment of MVPA. However, these pursuits cannot be done haphazardly. Such efforts should be firmly grounded in the literature and provide estimates based on what practice currently delivers (and what society is likely to support) — not on hypothetical idealized scenarios that are unlikely to be achieved in practice. Once we've established where we are, only then can we create a plan that helps everyone, including youth, move forward. Conflict of interest statement The authors declare that there are no conflicts of interest.
References Afterschool Alliance, 2014. America after 3 PM: a household survey on afterschool in America. http://afterschoolalliance.org/AA3PM/. Appel Osborne Landscape Architecture, 2014. Portfolio of athletic complexes. http:// www.appelosborne.com/portfolio/athletic-complexes/. Babey, S.H., Wu, S., Cohen, D.A., 2014. How can schools help youth increase physical activity? An economic analysis comparing school-based programs. Prev. Med. 69, S55–S60. Beets, M.W., Huberty, J., Beighle, A., Moore, J.B., Webster, C., Ajja, R., Weaver, G., 2013. Impact of policy environment characteristics on physical activity and sedentary behaviors of children attending afterschool programs. Health Educ. Behav. 40, 296–304 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db= PubMed&dopt=Citation&list_uids=23048006. Beets, M.W., Weaver, R.G., Moore, J.B., Turner-McGrievy, G., Pate, R.R., Webster, C., Beighle, A., 2014. From policy to practice: strategies to meet physical activity standards in YMCA afterschool programs. Am. J. Prev. Med. 46, 281–288. Beyler, N., Bleecker, M., James-Burdumy, S., Fortson, J., Benjamin, M., 2014. The impact of Playworks on students' physical activity during recess: findings from a randomized controlled trial. Prev. Med. 69, S20–S26. Brazendale, K., Beets, M.W., Weaver, R.G., Huberty, J.L., Pate, R.R., Beighle, A., 2014. Wasting our time? Allocation versus accumulated physical activity in afterschool programs. J. Phys. Act. Health (in press). C.S. Mott Children's Hospital, University of Michigan, 2012. Pay-to-play sports keeping lower-income kids out of the game. http://www.mottnpch.org/reports-surveys/ pay-play-sports-keeping-lower-income-kids-out-game. Carson, R.L., Castelli, D.M., Beighle, A., Erwin, H., 2014. School-based physical activity promotion: a conceptual framework for research and practice. Child. Obes. 10, 100–106 (bGo to ISIN://WOS:000336892500003). Erwin, H., Koufoudakis, R., Beighle, A., 2013. Children's physical activity levels during indoor recess dance videos. J. Sch. Health 83, 322–327 bGo to ISIN://WOS:000316633900004. Erwin, H.E., Ickes, M., Ahn, S., Fedewa, A., 2014. Impact of recess interventions on children's physical activity—a meta-analysis. Am. J. Health Promot. 28, 159–167 bGo to ISIN://WOS:000331894900012. Lee, S.M., Burgeson, C.R., Fulton, J.E., Spain, C.G., 2007. Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J. Sch. Health 77, 435–463 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db= PubMed&dopt=Citation&list_uids=17908102). Leek, D., Carlson, J.A., Cain, K.L., Henrichon, S., Rosenberg, D., Patrick, K., Sallis, J.F., 2011. Physical activity during youth sports practices. Arch. Pediatr. Adolesc. Med. 165, 294–299 (bGo to ISIN://WOS:000289166200002). National Center for Education Statistics, 2014. Fast facts elementary and secondary. http://nces.ed.gov/fastfacts.
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National Council of Youth Sports, 2008. Report on trends and participation in organized youth sports. http://www.ncys.org/pdfs/2008/2008-ncys-market-research-report. pdf. New American Foundation, 2014. School finance: federal, state, and local K-12 school finance overview. http://febp.newamerica.net/background-analysis/school-finance. O'Neill, J.R., Pate, R.R., Hooker, S.P., 2011. The contribution of dance to daily physical activity among adolescent girls. Int. J. Behav. Nutr. Phys. Act. 8 (bGo to ISIN://WOS: 000294332800002). Parrish, A.M., Okely, A.D., Stanley, R.M., Ridgers, N.D., 2013. The effect of school recess interventions on physical activity a systematic review. Sports Med. 43, 287–299 bGo to ISIN://WOS:000318535400005.
The Assocaited Press, 2014. High school football stadium in Texas, which cost $60 million, closed due to structural problems. http://www.nydailynews.com/sports/60m-highschool-football-stadium-closed-cracks-article-1.1799608. Trost, S.G., Rosenkranz, R.R., Dzewaltowski, D., 2008. Physical activity levels among children attending after-school programs. Med. Sci. Sports Exerc. 40, 622–629 (http://www.ncbi. nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_ uids=18317385). U.S. Department of Health and Human Services, 2008. 2008 Physical Activity Guidelines for Americans.
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Commentary
Understanding the real value of youth physical activity promotion Michael W. Beets ⁎, Robert G. Weaver, Justin B. Moore University of South Carolina, Arnold School of Public Health
Keywords: Economics Moderate-to-vigorous physical activity Intervention School
Getting youth “up and moving” has been, and will continue to be, an important and challenging public health endeavor. During the past decades of concerted effort on this topic, schools have been the primary setting targeted. The reason for this is clear – most youth (b 18 years) in the United States attend publicly funded elementary and secondary schools – with enrollment numbers for fall 2014 reaching almost 50 million (National Center for Education Statistics, 2014). Such expansive reach provides opportunities to deliver a myriad of health promotion efforts to millions of children, of which physical activity often plays a primary role. The allocation of time for physical education (PE) and recess, as well as, resources for youth sports (both intramural and extramural), classroom physical activity breaks, and before- and afterschool programming are examples of such efforts. Each of these opportunities can provide youth with valuable amounts of moderate-tovigorous physical activity (MVPA) that can contribute to their total daily recommendation of 60 minutes of MVPA (U.S. Department of Health and Human Services, 2008). In an environment where funding for public health efforts is tight, understanding the costs associated with youth physical activity promotion efforts and which represent the “best” investment is critical information to inform policy-related decisions. A study by Babey et al. (2014) pursues this line of inquiry by performing an economic analysis of school-based physical activity promotion. In their analysis, they reviewed four types of programs: extending the regular school day by 1 h for PE, before-school programs, after-school programs, and classroom physical activity breaks. The authors concluded that extending the school day by one additional hour for PE and offering two 10minute physical activity breaks in the classroom are superior to before- and after-school programs in terms of reach and cost per student. While the authors' research question is important and the authors should be commended for their efforts, there are numerous conceptual and cost assumptions that require further explanation. First, the authors propose that extending the school day for an additional hour of PE would cost $264 per child per year with no cost incurred by families (see Table 1 in Babey et al., 2014). This estimate appears to grossly underestimate the true cost of operating a school. ⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ypmed.2014.11.009 0091-7435/© 2014 Elsevier Inc. All rights reserved.
According to the National Center for Education Statistics (2014), in 2010–2011, taking into account all school operating expenses, it costs an average of $10.61 per hour to operate a public school for each student (based on a per pupil expense of $12,608 for a 180 day school year that operates an average of 6.6 h per day). Over the course of one school year, increasing the school day by 1 h would translate into an additional $1910.30 per student. For a single school serving 503 students (national enrollment average), the annual cost of extending each school day by one additional hour would approach $1 million ($961,778). If this policy is adopted nationwide, the education finance budget would require an additional $95 billion in funding. The authors suggest that extending the school day would come at no cost to families, yet their discussion concedes that a barrier to such an approach would be an unwillingness to increase taxes, mostly in the form of increased income, sales, and property taxes — with state and local governments likely shouldering the majority of this tax burden (New American Foundation, 2014). The authors' solution is to have teachers come later or leave earlier — implying that fewer teachers would be present and responsible for the entire student body at some points during the school day. If this does not work, the authors suggest that PE could be held as a one large school-wide session, if an outdoor or indoor space is available. Unfortunately, delivering PE in this form would fundamentally change what constitutes PE and would also undermine the ability of a single (let alone multiple) teacher(s) to get all youth in the school at one time to spend 50% of the hour in MVPA (the goal the authors hypothesize PE can deliver). Further, many schools have limited access to outdoor space at some point throughout the school year due to inclement weather and few schools have indoor facilities that can accommodate the entire student body for physical activity. Even fewer schools provide students from Kindergarten through 12th grade (K-12) with PE each day (Lee et al., 2007). The authors also present economic analyses on programs that occur after the regular school day and indicate that the cost of these programs to families is $2867 per student per year and low reach. There are several fundamental flaws with this analytical approach. First, the definition that the authors use for these programs includes both traditional afterschool programs (Afterschool Alliance, 2014), as well as, clubs, and intramural and extramural (i.e., interscholastic) sports. However, the evidence used to estimate the impact (i.e., MVPA accumulated) and corresponding costs is drawn solely from the traditional afterschool program literature. Traditional afterschool programs are fundamentally different than clubs or intramural and interscholastic sport opportunities. The authors themselves (Babey et al., 2014) reference several sources where a clear distinction is drawn among these types of programs. Thus, what the
M.W. Beets et al. / Preventive Medicine 72 (2015) 130–132
authors present are cost estimates for traditional afterschool programs — leaving club and sport opportunities entirely out of the analysis. Second, the cost presented for traditional afterschool programs is based on the entire duration of the program, typically 3 h per day. Babey et al. did not take into account that physical activity opportunities are one of multiple activities scheduled each day in these programs, with snack, homework assistance, and enrichment activities offered. This is surprising since they recognize this in their article but proceed to provide cost estimations for the entire 3-hour delivery of the program. Afterschool programs schedule an average of 60 min of physical activity opportunities each day (Beets et al., 2013; Brazendale et al., in press). Given that afterschool programs operate every day of the school year, this translates into $15.93 per student per day, or an hourly operating expense per student of $5.31 — half the amount of operating a school for a single hour. With anywhere from 20 to 30 min of MVPA accumulated during this hour of programming (Beets et al., 2014; Trost et al., 2008), the cost per minute of MVPA ranges from $0.18 to $0.27, compared to $0.35 per minute of MVPA during a one hour PE class (if 30 min of MVPA is accumulated during 1 h at $10.61). Third, traditional afterschool programs serve 10.2 million youth annually, with an additional 19.4 million youth wanting to participate if an afterschool program was available (Afterschool Alliance, 2014). If traditional afterschool programs were able to meet the expressed demand, they would serve over 50% of the youth attending public or private K-12 schools. Further, 84% (5 in 6) of the parents favor public funding of afterschool programs, with the majority of the programs (80%) providing opportunities for the youth attending to be physically active each day. The authors do not include sports or clubs as settings where youth accumulate MVPA. With over 44 million youth participating in some form of sport (National Council of Youth Sports, 2008), such a venue is highly relevant to evaluate. A recent study found that youth can accumulate an average of 45 min of MVPA during a single practice session (Leek et al., 2011). This is a substantial amount of activity, but the costs are high as athletic facilities are expensive. Costs for football stadiums alone can reach well over $1 million (Appel Osborne Landscape Architecture, 2014) with some schools willing to invest $60 million for this single sport (The Assocaited Press, 2014). While this is only one example, such investment in athletic facilities is often for the health benefit of only a few students on the team and mostly middle and high school students participate (Lee et al., 2007). Community-based sports are an alternative, yet youth often face “pay to play” participation requirement that limits those from low-income households from being involved (C.S. Mott Children's Hospital, University of Michigan, 2012). The number of youth participating in clubs or other forms of afterschool activity opportunities is less clear; nevertheless, a single study found that other after-school program, such as dance, can contribute almost a third of the girls' daily MVPA (O'Neill et al., 2011), suggesting that such programs help youth outside of the regular school day to be physically active. The authors base the costs associated with PE and classroom activity breaks on hypothetical idealized amounts of activity that “could” be accumulated. For PE, 50% of time spent in MVPA (or 30 min of MVPA within 1 h) is used to estimate cost. While this is a widely recognized benchmark within the PE field, the authors clearly state that few if any PE classes ever achieve this goal. Since current practice fails to deliver MVPA, it is unclear why extending the school day would improve upon this without substantial investment in professional development training. In turn, this investment would need to be included within any economic analysis hoping to achieve this goal. Secondly, the cost estimates for classroom activity breaks hinge on the ability of regular classroom teachers in getting students engaged in MVPA 100% during a 10 minute activity break — teachers must include two of these 10 minute breaks within a day and students accumulate 20 min of MVPA. This would be an impressive accomplishment, especially given that well-trained PE teachers are unable to achieve half of this goal. In
131
fact, suggesting that any allotted length of time could be spent 100% in MVPA is unrealistic (Erwin et al., 2013, 2014) and thus distorts what would most likely occur from the implementation of these strategies. Moreover, these hypothetical scenarios are not applied to the cost estimates for programs occurring after the regular school day. Finally, there is no mention of recess, the amount of MVPA accumulated during recess, and the costs associated with delivery, despite the fact that substantial attention has focused on how to best maximize MVPA during recess (Parrish et al., 2013), and schools allocate an average of 30 min for recess each day (Beyler et al., 2014). Further, the estimates associated with before-school opportunities suggest that if school teachers were paid to supervise a 30 minute session before school, and youth attending accumulated 20 min of MVPA (66% time spent in MVPA — an unlikely result), this would all come at no cost to families. It is clear that any and all physical activity opportunities afforded to youth during the day can make a valuable contribution towards achieving public health goals. How to cost-consciously maximize physical activity during these already allotted opportunities, in turn, will greatly assist the field of youth physical activity promotion. As researchers and practitioners look to establish “whole of school” approaches that span from before- to after-school, and everything in between (Carson et al., 2014), such information can help to direct efforts and funding to those opportunities that best help youth achieve their recommended daily allotment of MVPA. However, these pursuits cannot be done haphazardly. Such efforts should be firmly grounded in the literature and provide estimates based on what practice currently delivers (and what society is likely to support) — not on hypothetical idealized scenarios that are unlikely to be achieved in practice. Once we've established where we are, only then can we create a plan that helps everyone, including youth, move forward. Conflict of interest statement The authors declare that there are no conflicts of interest.
References Afterschool Alliance, 2014. America after 3 PM: a household survey on afterschool in America. http://afterschoolalliance.org/AA3PM/. Appel Osborne Landscape Architecture, 2014. Portfolio of athletic complexes. http:// www.appelosborne.com/portfolio/athletic-complexes/. Babey, S.H., Wu, S., Cohen, D.A., 2014. How can schools help youth increase physical activity? An economic analysis comparing school-based programs. Prev. Med. 69, S55–S60. Beets, M.W., Huberty, J., Beighle, A., Moore, J.B., Webster, C., Ajja, R., Weaver, G., 2013. Impact of policy environment characteristics on physical activity and sedentary behaviors of children attending afterschool programs. Health Educ. Behav. 40, 296–304 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db= PubMed&dopt=Citation&list_uids=23048006. Beets, M.W., Weaver, R.G., Moore, J.B., Turner-McGrievy, G., Pate, R.R., Webster, C., Beighle, A., 2014. From policy to practice: strategies to meet physical activity standards in YMCA afterschool programs. Am. J. Prev. Med. 46, 281–288. Beyler, N., Bleecker, M., James-Burdumy, S., Fortson, J., Benjamin, M., 2014. The impact of Playworks on students' physical activity during recess: findings from a randomized controlled trial. Prev. Med. 69, S20–S26. Brazendale, K., Beets, M.W., Weaver, R.G., Huberty, J.L., Pate, R.R., Beighle, A., 2014. Wasting our time? Allocation versus accumulated physical activity in afterschool programs. J. Phys. Act. Health (in press). C.S. Mott Children's Hospital, University of Michigan, 2012. Pay-to-play sports keeping lower-income kids out of the game. http://www.mottnpch.org/reports-surveys/ pay-play-sports-keeping-lower-income-kids-out-game. Carson, R.L., Castelli, D.M., Beighle, A., Erwin, H., 2014. School-based physical activity promotion: a conceptual framework for research and practice. Child. Obes. 10, 100–106 (bGo to ISIN://WOS:000336892500003). Erwin, H., Koufoudakis, R., Beighle, A., 2013. Children's physical activity levels during indoor recess dance videos. J. Sch. Health 83, 322–327 bGo to ISIN://WOS:000316633900004. Erwin, H.E., Ickes, M., Ahn, S., Fedewa, A., 2014. Impact of recess interventions on children's physical activity—a meta-analysis. Am. J. Health Promot. 28, 159–167 bGo to ISIN://WOS:000331894900012. Lee, S.M., Burgeson, C.R., Fulton, J.E., Spain, C.G., 2007. Physical education and physical activity: results from the School Health Policies and Programs Study 2006. J. Sch. Health 77, 435–463 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db= PubMed&dopt=Citation&list_uids=17908102). Leek, D., Carlson, J.A., Cain, K.L., Henrichon, S., Rosenberg, D., Patrick, K., Sallis, J.F., 2011. Physical activity during youth sports practices. Arch. Pediatr. Adolesc. Med. 165, 294–299 (bGo to ISIN://WOS:000289166200002). National Center for Education Statistics, 2014. Fast facts elementary and secondary. http://nces.ed.gov/fastfacts.
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M.W. Beets et al. / Preventive Medicine 72 (2015) 130–132
National Council of Youth Sports, 2008. Report on trends and participation in organized youth sports. http://www.ncys.org/pdfs/2008/2008-ncys-market-research-report. pdf. New American Foundation, 2014. School finance: federal, state, and local K-12 school finance overview. http://febp.newamerica.net/background-analysis/school-finance. O'Neill, J.R., Pate, R.R., Hooker, S.P., 2011. The contribution of dance to daily physical activity among adolescent girls. Int. J. Behav. Nutr. Phys. Act. 8 (bGo to ISIN://WOS: 000294332800002). Parrish, A.M., Okely, A.D., Stanley, R.M., Ridgers, N.D., 2013. The effect of school recess interventions on physical activity a systematic review. Sports Med. 43, 287–299 bGo to ISIN://WOS:000318535400005.
The Assocaited Press, 2014. High school football stadium in Texas, which cost $60 million, closed due to structural problems. http://www.nydailynews.com/sports/60m-highschool-football-stadium-closed-cracks-article-1.1799608. Trost, S.G., Rosenkranz, R.R., Dzewaltowski, D., 2008. Physical activity levels among children attending after-school programs. Med. Sci. Sports Exerc. 40, 622–629 (http://www.ncbi. nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_ uids=18317385). U.S. Department of Health and Human Services, 2008. 2008 Physical Activity Guidelines for Americans.
