7
Institutional Strategies for Promoting Physical Activity
After considering policy and community strategies for promoting physical activity, workshop participants turned their attention to institutional strategies, in a session moderated by Linda Meyers. The session included presentations by Allison Nihiser and Nico Pronk, followed by a panel discussion with the speakers.
A key finding in the 2012 Physical Activity Guidelines for Americans Midcourse Report (HHS, 2012), according to Nihiser, is strong evidence for the importance of a multicomponent approach to promoting school physical activity. An essential part of this approach is physical education, the majority of which is spent keeping students active. Nihiser discussed how the recommendations in that report helped inform and strengthen the Comprehensive School Physical Activity Program of the Centers for Disease Control and Prevention (CDC) and SHAPE America—a national framework for addressing physical activity in schools—and how other national initiatives are helping states implement the report’s recommendations. Among other signs of progress, in 2013 CDC provided funding for the first time to all 50 states to support efforts to address physical activity in schools.
Many workplace physical activity programs are quite effective, but their effectiveness depends on design, according to Pronk. He described how the workplace has been changing such that jobs have become more sedentary, creating a great need for physical activity and movement. He then proposed an organizing framework for the implementation of effective
workplace physical activity programs and elaborated on what researchers have learned about the design characteristics of successful programs. He also emphasized that the culture of an organization is a strong predictor of the degree of success of such programs.
EVIDENCE-BASED AND INNOVATIVE STRATEGIES FOR SCHOOL-BASED PHYSICAL ACTIVITY1
A key finding in the Physical Activity Guidelines for Americans Midcourse Report (HHS, 2012), according to Nihiser, is that schools are an important setting for increasing levels of physical activity among youth. More important, she stated, the report presents strong evidence for recommending that schools implement a multicomponent approach to school physical activity and ensure that physical education is one component of that approach. The report emphasizes that schools should ensure not only that enough time during the school day is spent on physical education, but also that the majority of physical education class time is spent keeping students active. Additional key findings are that there is enough evidence to recommend implementing active transportation—that is, walking or biking—to and from school, and emerging evidence to recommend activity breaks (i.e., classroom-based physical activity and recess).
The Comprehensive School Physical Activity Program
The multicomponent approach recommended in the Midcourse report helped inform and strengthen the recommendation of CDC and SHAPE America that schools develop and implement the Comprehensive School Physical Activity Program (CDC, 2013). This program serves as a national framework for addressing physical activity in schools and improving the quality of physical activity and physical education throughout the school day. According to Nihiser, the program is intended to guide schools’ physical activity programming so that students have as many opportunities as possible to be physically active throughout the school day, as well as before and after school, and can achieve the recommended 60 minutes of physical activity daily.
The Comprehensive School Physical Activity Program has five components. The first, and the foundation of the program, is physical education. The others are physical activity during school, physical activity before and after school, staff involvement (i.e., with staff both serving as role models for living healthy lives and helping to implement and energize the program),
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1 This section summarizes information and opinions presented by Allison Nihiser, M.P.H., Centers for Disease Control and Prevention, Atlanta, Georgia.
and family and community engagement (e.g., ensuring that communities are providing additional resources for schools). The process for implementing the program, Nihiser said, involves identifying a champion for physical activity at the school, typically a physical education teacher. That individual then recruits others from the community to lead the school through, first, an assessment of physical activity opportunities throughout the school day, then implementation, and finally evaluation.
Based on national data collected by CDC, in 2012 no state had more than 30 percent of its schools offering the Comprehensive School Physical Activity Program, and only 12 states had 21 to 30 percent of their schools implementing the program. “We really have a lot of work to do in this area,” Nihiser said.
States can help by providing support to schools. In 2012, 49 percent of states provided professional development or offered funding for professional development for physical education teachers on the development, implementation, and evaluation of the Comprehensive School Physical Activity Program.
Additionally, Nihiser listed three innovative national initiatives whose goals are to disseminate and implement the Comprehensive School Physical Activity Program and improve the quality of physical activity and physical education in schools: (1) CDC’s State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health2; (2) Let’s Move! Active Schools3; and (3) the President’s Council on Fitness, Sports and Nutrition’s Presidential Youth Fitness Program.4
As part of the CDC’s State Public Health Actions program, Nihiser said, CDC provided funding to all 50 states for the first time in 2013 to address physical activity in schools. All states are funded to address both physical education and recess policies at the state and district levels; 32 states receive additional funding to work with targeted districts on providing professional development and technical assistance for the Comprehensive School Physical Activity Program.
Let’s Move! Active Schools is working directly with schools to implement the Comprehensive School Physical Activity Program. According to Nihiser, any school can sign up to be a Let’s Move! Active School. The program identifies a physical activity champion at each school and empowers that individual to promote physical activity across the school day. Addi
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2 See http://www.cdc.gov/chronicdisease/about/state-public-health-actions.htm (accessed September 8, 2015).
3 See http://www.letsmove.gov (accessed September 8, 2015).
4 See http://www.pyfp.org (accessed September 8, 2015).
tionally, the program provides a number of free resources, including online tools, professional development, and training.
The purpose of the Presidential Youth Fitness Program is to improve the quality of physical education in schools by improving fitness education. Its three-pronged approach involves, first, schools conducting an assessment using the FITNESSGRAM®. Additionally, schools receive and participate in professional development and training from the program on incorporating fitness education into the curriculum and communicating about the assessment. Finally, schools and students are provided recognition so that they are motivated to continue to improve their levels of fitness. As with Let’s Move! Active Schools, any school can sign up to be part of the Presidential Youth Fitness Program.
A key challenge for the Comprehensive School Physical Activity Program, Nihiser said, is ensuring that schools can implement the program. A common component of all three of the above-described national initiatives is professional development and training, with Let’s Move! Active Schools and the Presidential Youth Fitness Program providing training directly to a school’s physical education teacher or physical activity champion and with the CDC initiative providing training at the state and district levels. Additionally, all three initiatives have comprehensive and rigorous evaluation components. At the time of this workshop, the Presidential Youth Fitness Program had just released its year 1 evaluation results.
Innovative Approaches to School-Based Physical Activity
Nihiser reiterated that physical education is the foundation of the Comprehensive School Physical Activity Program’s five-component approach. She stated that there has been a big push across the country to implement the recommendation in the Midcourse report to ensure not only that adequate time is provided for physical education in the school day, but also that students are active during physical education classes (HHS, 2012). Likewise, efforts are being made nationwide to transform physical education to incorporate what SHAPE America recently identified as the four essential components of physical education (SHAPE America, 2015):
- policy and environment (i.e., by ensuring that time, facilities, and other support are available for physical education so that students can engage in it as they do in any other subject);
- curriculum (i.e., by ensuring that physical education is informed by a curriculum based on national standards);
- appropriate instruction (i.e., by hiring qualified physical education teachers who can keep students active for the majority of class time); and
- student assessment (i.e., by ensuring that students are being assessed for whether they are achieving national standards).
In addition to efforts to transform physical education nationwide, another area of innovation, Nihiser observed, is recess in secondary schools. As students age, they tend to engage in less physical activity. Everyone is familiar with the recommendations around recess in elementary school, Nihiser said. But what about using recess in middle and high schools to add more physical activity time to the school day for older youth? Nihiser called for more research in this area. For example, what is appropriate for recess for middle and secondary school students? How should the students be supervised? How can recess for adolescents be promoted? Does recess in middle and secondary school result in increased physical activity? Does it result in the same increase in academic achievement observed in elementary school students? Nihiser noted that SHAPE America would be issuing a policy statement on recess in grades K-12.
With respect to innovative initiatives promoting physical activity before and after school, again, the Midcourse report states that there is enough evidence to recommend that schools implement active transport to and from school. Nihiser noted that CDC has been working with the Office of the Surgeon General to examine strategies for promoting walking in a number of settings, including educational settings.
In addition to active transport to and from school, more than 10 million youth across the country engage in after-school programs. The impact achieved by targeting these programs could be great, Nihiser said. She noted the Alliance for a Healthier Generation’s Healthy Out-of-School Time Initiative, which gives out-of-school-time providers a science-based framework designed to help create environments where youth are encouraged to eat healthier and move more. The Initiative’s healthy eating and physical activity standards for after-school programs have been adopted by a number of organizations.
Free Resources to Implement the Comprehensive School Physical Activity Program
In conclusion, Nihiser highlighted some free resources that schools, districts, and states can tap to support implementation of the Comprehensive School Physical Activity Program, all of which are available online.5 They include A Guide for Developing Comprehensive School Physical Activity Programs, which provides schools with a template and process for program
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5 See http://www.cdc.gov/healthyschools/physicalactivity/cspap.htm (accessed September 8, 2015).
development, implementation, and evaluation; the School Health Index, which enables schools to assess their health policies and practices across a range of health topics, including physical activity; School Health Guidelines to Promote Healthy Eating and Physical Activity, which includes a number of practices schools can use to implement more opportunities for physical activity throughout the school day; and the Physical Education Curriculum Analysis Tool, which allows districts and schools to assess their physical education curriculum and determine whether it is aligned with national standards. Nisiher noted that the Physical Education Curriculum Analysis Tool was being updated to reflect SHAPE America’s revised national standards.
PHYSICAL ACTIVITY PROMOTION AT THE WORKPLACE: DESIGN MATTERS6
The Changing Workplace
The workplace is a “changing place,” Nico Pronk began. Technology is changing the energy requirements of jobs, and the resulting sedentary job types create positive energy balances. “This is pervasive throughout the contemporary workplace,” Pronk said. Other important shifts in the workplace include changes in the physical locations where people work, with many people working via remote access; an aging and multigenerational workforce, with people working longer before retiring because of financial challenges; and variations in the extent to which media and communication technologies reach different types of workers to promote physical activity.
As an example of how energy requirements in the workplace have changed over time, Pronk cited data from Church and colleagues (2011) showing a dramatic shift in on-the-job energy expenditure over the past 50 years, with jobs requiring moderate energy expenditure decreasing from approximately 50 percent of all jobs in 1960 to approximately 20 percent in 2010 (see Figure 7-1). Over the same time period, the percentages of jobs requiring light or sedentary energy expenditure have increased. This subtle shift over five decades accounts for workers expending roughly 100 fewer calories per day. While that may not sound like much on a daily basis, Pronk said, it accounts for almost 80 percent of the increase in weight among the workforce over the 50-year period. Also over the past three decades, obesity in the workforce has doubled, confirming for Pronk that the changing nature of the workplace has engineered physical activity out of employment (Pronk, 2015).
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6 This section summarizes information and opinions presented by Nico Pronk, Ph.D., HealthPartners, Inc., Minneapolis, Minnesota.
FIGURE 7-1 Change over time in on-the-job energy expenditure in the U.S. private sector, 1960-2010.
NOTE: METS = metabolic equivalents of task.
SOURCE: Presented by Nico Pronk on April 15, 2015 (modified from Church et al., 2011).
Pronk asked, why would employers be interested in physical activity and integrating movement into the workday? He cited several reasons. First, physical activity has been associated with almost 5 percent lower health care costs per active day per week (Pronk et al., 1999). At the same time, low levels of physical activity, or inactivity, have been associated with many negative health outcomes, including overweight and obesity, creating additional health care costs. Anderson and colleagues (2005) found that physical inactivity, overweight, and obesity combined were associated with 23 percent of health plan costs and 27 percent of national health care costs. According to Pronk, these associations between physical activity and health care costs alone suggest that employers should be interested in integrating movement into the workday. However, with the introduction of health care exchanges, Pronk said, that argument may become limited. If so, productivity and work performance will also need to be considered.
In terms of which physical activity interventions provide the greatest return on investment, a systematic review of population-level physical activity interventions (Laine et al., 2014) found that the most cost-efficient programs are those that increase walking and biking. Examples of such programs include community rail-trails ($0.006/metabolic equivalent of task [MET]-h), pedometers ($0.14/MET-h), and school health education ($0.056/MET-h).
Promoting Physical Activity at the Workplace
In Pronk’s opinion, while people can be asked to change their behavior to increase their physical activity, or reduce their physical inactivity, it is difficult to do that by oneself and without support. Policy interventions that change either one’s physical or psychosocial environment can facilitate individual efforts (Pronk and Kottke, 2013). But even with policy interventions, Pronk cautioned, “people still need to change their behavior as well.”
Physical activity can be promoted at the workplace by being built into either the workday or the physical workplace. Ways to build it into the workday include changing the workflow (e.g., identifying natural opportunities to build physical activity or motion into the job itself), implementing physical activity “booster” breaks (e.g., stopping the assembly line for 5 minutes and having everyone on that line participate in some sort of flexing, stretching, or cardiovascular activity), and holding walking meetings. Ways to build physical activity into the physical workplace include encouraging the use of staircases (e.g., using messages or other point-of-decision prompts telling people to use the stairs instead of the elevator), using sit-stand devices (i.e., so that people doing sedentary work can break up the sitting periodically by standing up), and building an activity-friendly campus (e.g., by providing walking paths or bicycles that people can use to ride from one building to another).
In addition to building physical activity into either the workday or the workplace, other ways to promote physical activity among workers include using technology creatively (e.g., using wearable tracking devices such as pedometers so that workers can measure their own physical activity), promoting active commuting (e.g., bicycle-to-work programs that provide incentives for people to buy equipment and clothing), and creating a physical activity–friendly work culture.
Pronk emphasized the role of leadership, at all levels, in changing the cultural norms of an organization with respect to physical activity. While in a corporate setting, leadership at the top level sets the vision, he noted, middle management directors, managers, and supervisors need to be engaged as leaders for the vision to spread. Additionally, frontline leaders need to step up, Pronk said, to “get [the vision] deep into [their] organization.” Pronk observed that in many cases, even though the CEO or other top-level leaders have issued a formal message that it is okay to take a physical activity break, a worker who actually takes such a break is frowned upon. He said, “A frown alone can eliminate an entire program.”
A take-away message from the literature on promotion of physical activity in the workplace, Pronk continued, is that while it is desirable to focus on physical activity, that focus needs to be part of a company’s overall comprehensive multicomponent approach to improving health and
well-being. “These programs need to fit,” he said, “with other things that are going on at the workplace.” While systematic reviews (e.g., Dugdill et al., 2008) reveal that pedometer programs, active travel (biking or walking to and from work), and workplace coaching can increase daily physical activity, a number of barriers to physical activity exist at multiple levels of influence (Edmunds et al., 2013). Because of these barriers, Pronk said, the design of physical activity intervention programs in the workplace should be based on an ecological or multilevel model, as recommended in the National Physical Activity Plan (Pronk, 2009).
A Framework for Designing Physical Activity Interventions in the Workplace
The first step in designing a physical activity intervention in the workplace, Pronk said, is to make sure that physical activity is possible (Pronk, 2009). If workers are confined to an assembly line and the only thing they do is move widgets from one place to the next, or if workers sit in a small cubicle and are on the telephone all day, it may not be possible for them to be active unless some change is made. The next step is to ensure that the intervention is simple. The more complex an intervention is, the less likely it is to be successful. Third, the intervention needs to be socially rewarding. For example, some workers may enjoy the social reward that comes with team-based interventions. Fourth, the intervention needs to be financially rewarding. Fifth, it needs to be personally relevant. If the physical activity does not apply to someone, he or she will not participate. Sixth, the intervention needs to be organizationally relevant so that the business continues to support it. Finally, to be sustainable, the intervention needs to be connected to the community so that when workers go home and then return to work, they engage in the physical activity again.
All of these steps are part of a framework that Pronk (2009) developed for designing physical activity interventions for the workplace (see Figure 7-2). Other components of the framework include level of influence (i.e., individual, interpersonal, or group level; organizational/policy; or environmental/community); customer and user experience; and health, productivity, and return-on-investment outcomes.
Design Principles of Success
To better understand design principles of success, Pronk reviewed 28 scientific and “grey” literature (industry reports, consensus statements) publications on best practices. His search yielded 44 best practices related to successful outcomes (e.g., organizational commitment to a healthy culture, adequate resourcing, meaningful and relevant incentives, wellness
FIGURE 7-2 A translational framework for program design.
NOTE: ROI = return on investment.
SOURCE: Presented by Nico Pronk on April 15, 2015 (reprinted with permission, from Pronk, N. P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6[Suppl. 2]:S220-S235).
champion networks). Rather than presenting all 44 best practices and saying, “This is what you have to do,” Pronk (2014) reorganized them into nine design principles:
- leadership that sets the vision, assigns accountability, ensures structural support and resources, and sets policy;
- relevance to needs and interests that optimizes participation and is tied to long-term engagement;
- partnership with both internal and external stakeholders;
- comprehensiveness, as defined in Healthy People 2010;
- implementation, which involves having a planned, coordinated, and fully executed work plan;
- engagement, including the promotion of respect and trust and of co-ownership, the leveraging of company culture, and the use of incentives that optimize intrinsic motivation;
- a formal communication strategy that is linked to goals and objectives and the use of multiple delivery channels and modes;
- data-driven monitoring and learning; and
- compliance with regulatory standards and requirements.
A Case Study
As a quick case study of a physical activity intervention promoted as part of an overall program for employee well-being, Pronk described an example from IBM (Pronk et al., 2014). IBM created an online physical activity resource, the Virtual Fitness Center (VFC), to serve as an interactive behavior change tool with goal setting, activity logging, team-based campaigns, progress reports, feedback loops, and other features. In the first year, approximately 16,000 employees (12.5 percent) participated. In the second to fourth years, when incentives were added, more than 80,000 employees (63 percent) participated. In terms of outcomes among users, physical activity–related risks decreased by 52 percent. Health perception, life satisfaction, smoking, body weight, and overall risk status improved. Although average annual health care costs among VFC users increased by $291 per year from 2003 to 2005, they increased by $360 per year among nonusers. Additionally, VFC users had significantly lower inpatient hospital costs, heart disease–related costs, and costs to treat diabetes. From a business perspective, Pronk said, “these are pretty powerful results.”
Conclusions
In conclusion, Pronk emphasized that the workplace is a complex and dynamic environment. Activities that promote physical activity and movement enhance worker performance and support positive business outcomes, and promotion of physical activity should be an integral part of an overall well-being strategy. Not only are organizing frameworks and principles for best-practice program design available, Pronk said, but they also increase the chances of success.
Following Nico Pronk’s presentation, he and Nihiser participated in a panel discussion with the audience.
Data on the Comprehensive School Physical Activity Program
An audience member asked Nihiser whether any datasets are now or will be available to help in identifying schools that are implementing the Comprehensive School Physical Activity Program. Nihiser replied that the data she presented showing the percentage of schools in each state that were implementing the program were from 2012 and that data for 2014 would be available later in 2015. The 2012 data points were composite variables based on only some components of the program. The 2014 question-
naire included three additional questions related to assessment, before- and after-school programs, and family engagement. Additionally, according to Nihiser, national school- and classroom-level data from the School Health Policies and Practices Study would be available later in 2015, reflecting responses to a number of questions related to physical activity before, during, and after school.
Nihiser also was asked whether the Comprehensive School Physical Activity Program data can be linked to data from CDC’s Youth Risk Behavior Survey as a way to determine if outcome measures of physical activity are related to whether schools have implemented certain policies. Nihiser replied that the two datasets can indeed be linked, and noted that a couple of relevant manuscripts were in preparation.
Physical Activity Versus Physical Education
An audience member remarked that, based on her experience working with people from schools across the country, many people do not understand the difference between physical education and physical activity. She clarified that physical education, as defined by SHAPE America, provides students with a sequential K-12 standards-based program of curricula and instruction designed to develop motor skills, knowledge, and behaviors for active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence. “That is what physical education is,” she said. “Physical activity is how we practice that.” She encouraged more discussion on the difference between the two when debating policy.
Training the Next Generation of Physical Educators
An audience member asked about efforts to train the next generation of physical educators. Nihiser replied that CDC is providing training-of-trainers on the Comprehensive School Physical Activity Program. For this purpose, CDC is using the Guide for Developing Comprehensive School Physical Activity Programs, a publication she had mentioned during her presentation, and has developed a 1-day workshop that is currently being marketed to state health department grantees. Additionally, CDC has been working with the American Cancer Society, which every few years provides all-day trainings-of-trainers for university staff on CDC tools and resources related to school health. In 2014, for example, Nihiser conducted a training of 20 university staff on CDC’s School Health Guidelines to Promote Healthy Eating and Physical Activity.
Interventions to Reduce Uninterrupted Sitting Time at Work
When asked whether there are any data on interventions to reduce uninterrupted sitting time at work, Pronk replied that an “emerging” set of cross-sectional studies is associating prolonged sitting time with poor health outcomes. Additionally, a small set of intervention studies has begun to examine permissive activity workstation designs, whereby a sedentary worker can either stand up in place, walk in place, or pedal in place to break up uninterrupted sitting time. In Pronk’s opinion, results from the small set of studies completed thus far are promising, but more remains to be learned. For example, some studies examine the use of sit-stand devices by themselves. But when those devices are couched in a workplace-specific context—for example, in the context of training or supervisor or manager support—outcomes can be enhanced and the devices used for longer periods of time. In Pronk’s opinion, researchers need to learn more about how to optimize these interventions.
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