Abstract
Afterschool programs (3-6
‘. . . afterschool programs . . . have garnered considerable attention as a setting where physical activity can be increased to improve the health outcomes (. . .) of children attending such programs.’
Increasing the amount of time youth spend in health-enhancing physical activity is a foremost public health priority. Historically, the majority of efforts aimed at doing so have focused almost exclusively on changes to the school environment (eg, physical education, recess, health education). Many of the attempts (ie, interventions) have greatly underperformed from initial expectations.1-3 This has led the research community to look toward settings outside the regular school schedule to enhance opportunities for youth to be physically active.
Out-of-school time opportunities include both during the school year (ie, before and after school hours, weekends) and summer programming. Only until recently have these time segments been explored as potential means through which physical activity interventions can be delivered. Of these, afterschool programs (ASPs, defined below) have garnered considerable attention as a setting where physical activity can be increased to improve the health outcomes (eg, physical fitness, weight reduction) of children attending such programs.4,5
Over the past decade, a number of studies examining the impact of physical activity programs/interventions within the ASP setting have been conducted. Within the past several years, 3 comprehensive reviews*— 2 narrative6,7 and 1 quantitative 4 — have synthesized the body of work and concluded such endeavors are meritorious. Nevertheless, substantial work is needed to translate and disseminate existing evidence into routine practice. 8 This is reflected in the low levels of physical activity of children attending ASPs. 9
The purpose of this review is to examine the existing evidence base for physical activity promotion in ASPs and to address the following. First, a definition of ASPs is presented, along with a discussion of the characteristics of children who regularly attend ASPs. There are numerous studies included in comprehensive reviews; however, the definition of “afterschool programs” varies among them making it difficult to know what types of programs the results generalize to. Likewise, we know little about the characteristics of the children that routinely attend ASPs. Second, what do we know about physical activity levels in ASPs and their contributions in increasing physical activity? It is unclear how much physical activity children routinely accumulate while attending an ASP and what child, staff, and/or site characteristics are related to increased/decreased activity. Next, what strategies have been conducted thus far and did contribute to physical activity outcomes? Of the successful interventions, what common set of intervention elements have been included and what do we know about what works best in terms of physical activity outcomes? Finally, what are the changes needed to move ASP research and practice forward? The answers to these will assist in shaping the research agenda for enhancing physical activity opportunities within the ASP setting.
What Is an Afterschool Program?
“Afterschool [after-school] programs” refers to community-based programs that take place immediately after the regular school day (typically 3:00-6:00 . . . a program that a child regularly attends that provides supervised enriching environment in the hours after the school day ends. These programs are usually offered in schools or centers and are different from individual activities, such as sports, special lessons, or hobby clubs.
Afterschool programs that focus solely on a single activity (eg, academic tutoring, music lessons) or are designed specifically to promote physical activity such as clubs (eg, Girls on the Run) or sports teams (eg, intra- and intermurals)12-15 are not considered within this definition and, therefore, not included in this review despite their occurrence immediately after the regular school day and inclusion in prior comprehensive reviews of physical activity interventions within ASPs.4,6,7 In addition, since the focus of this review is on physical activity promotion exclusively, studies evaluating nutrition, academic performance, and/or social/emotional effects of ASPs will not be discussed. Examples of ASPs included are those conducted by the YMCA, Boys and Girls Club, and programs overseen by other nonprofit organizations (eg, Girl’s Inc., www.girlsinc.org) or run independently by a school or community center.
Who Attends Afterschool Programs?
According to the America After 3PM 2009 report, 8.4 million youth attend ASPs for an average of 8.1 hours per week. 11 This represents an increase of approximately 3 million children enrolled in ASPs since 2004. Of these, 70% are of elementary age (second through fifth or sixth grade, ≤12 years old) and 40% are from low-income schools. 11 Although youth in middle and high school attend ASPs, they do so with less frequency (approximately 18% and 12%, respectively, of youth attending ASPs nationwide). Overall, 13.7% of children K-12th enrolled in public and private schools attend an ASP.* For elementary and middle school, approximately 18.9% † attend an ASP. Predominately, youth attending ASPs are Caucasian (60%), followed by Hispanic and African American (14% each), with these proportions varying based on geographic locale.
No national data on the enrollment size of a typical ASP exist. Several reports from nonprofit organizations and state-level Departments of Education (ASP reports were identified through online Google searches using the following keywords: “after school,” “afterschool,” or “after-school.”) that describe common characteristics of preexisting ASPs. Overall, ASPs are quite diverse and serve anywhere from 14 to more than 300 children per program.16,17 Estimates of average enrollment per ASP range anywhere from 53 to 91 for elementary school–age children and 51 to 96 for middle school–age children. A national study on ASPs located and operated within public elementary schools (excludes community-based ASPs such as faith-based or YMCA and Boys and Girls Clubs) reported that of the 49 700 public elementary schools nationwide, 56% operate one or more ASPs. 18 The total enrollment across all programs was more than 4 million children, for an average of 136 children attending each ASP. In South Carolina alone there are more than 1100 ASPs serving more than 82 000 youth (unpublished data provided by the South Carolina Afterschool Alliance). This translates into an average enrollment of 77 children per ASP. In Hawaii, the A+ ASPs (http://doe.k12.hi.us/programs/aplus.htm) serve approximately 25 555 elementary children across the state (~137 children per ASP). In Los Angeles, the LA BEST (http://www.lasbest.org/what/publications/) ASPs serve more than 28 000 youth across 180 sites (~156 youth per ASP).
One specific type of ASP, 21st Century Community Learning Centers, serves more than 1.7 million children in 10 339 ASPs nationwide (average of 174 children per program). 19 These centers are designed to provide academic enrichment activities for children from high-poverty and low-performing schools, in addition to other enrichment and physical activity opportunities. Two thirds of these centers serve elementary students, with more than half serving elementary students solely. Unlike the findings from America After 3PM, one third of the attendees are Hispanic and another 25% are African American.
It is recognized that many ASPs are not represented in the reports identified. Nevertheless, this information indicates preexisting ASPs are numerous, serve a diverse range of children, and have substantial reach and contact time (based on the average enrollment size and weekly attendance) to provide physical activity opportunities. Furthermore, with a high percentage of children from low-income households that are potentially at greater risk for gaining unhealthy levels of body weight and accumulating low levels of physical activity,20-25 ASPs can serve as locations where safe and meaningful amounts of physical activity are accumulated.
Physical Activity Levels of Children Attending Afterschool Programs and Its Influences
A small number of studies have reported the typical (ie, expected and unadulterated—no intervention manipulation) amount of physical activity children accumulate while attending an ASP. Of these, all used high-quality measures. This includes direct observation8,26 (J. L. Huberty, in press), 59 pedometery, 27 and accelerometry.9,28-30 These studies are summarized in Table 1. Based on accelerometry from 2 studies, girls accumulate fewer minutes of moderate-to-vigorous physical activity (MVPA) during an ASP (~13-17 minutes) in comparison with boys (~18.5-23.7 minutes).9,28 This translates into roughly 12% to 16% and 17% to 23% of the total time spent at an ASP for girls and boys, respectively. Girls attending a girls-only ASP that provided culturally tailored dance accumulated approximately 8.8 to 11.4 minutes of MVPA. 30 A study of middle school students attending ASPs reported the accumulation of roughly 9 to 10 minutes of MVPA daily. 29 A recent study of 245 children attending 3 large-scale ASPs reported that children on average accumulated approximately 2800 steps/day within the program, and boys accumulated an average 3200 steps/day versus 2600 steps/day for girls. 27 Direct observation (SOPLAY 31 ) of more than 500 children attending 12 ASPs in Omaha, Nebraska, found that 51.2% of boys and 40.9% of girls were moderately to vigorously physically active during the program (J. L. Huberty, unpublished data). Similarly, direct observation of children attending 40 YMCA and Boys and Girls Club ASPs in Ontario, Canada found that on average 52% to 54% was spent engaged in MVPA. 8 Conversely, direct observation of children attending A+ ASPs in Hawaii found that children spent roughly 16.8 minutes in MVPA, which translates into only 13.3% of program time. 26
Summary of Afterschool Program Studies Reporting Physical Activity Assessments of Children Enrolled
Abbreviations: SD, standard deviation; NA, not applicable; LVPA, light-to-vigorous physical activity; MVPA, moderate-to-vigorous physical activity.
Trost et al 28 report baseline physical activity levels for the HOP’N intervention (refer to Dzewaltowski et al 32 ).
Same study sample reported in both studies.
Baseline values reported.
Site-level estimates reported.
Fewer studies, however, have evaluated ASP characteristics that correspond or contribute to children’s physical activity within these programs. An expected finding is that girls accumulate less overall physical activity and MVPA than boys.9,28,33 The reasons for this are unclear; however, our unpublished observations suggest that the majority of activities offered within ASPs appeal more to boys than to girls (eg, touch football, kickball). Direct observation findings suggest that girls spend more time physically active when ASP staff verbally promote physical activity (eg, encouraging; J. L. Huberty et al, in press). 59 Likewise, the presence of equipment and whether the activity is organized (either by adults or children and has formal or informal rules) are related to increased physical activity (J. L. Huberty et al, in press). 59 A similar relationship is observed with boys for equipment and verbal promotion. When staff are involved in other activities related to their job (eg, cleaning, taking roll, or are not actively supervising the children) activity levels decrease (J. L. Huberty et al, in press). 59 Overweight and obese status (based on BMI [body mass index] age–gender specific percentiles) does not appear to be related to overall physical activity levels.9,28 A single study reported that ethnicity was not related to physical activity, 33 whereas another study found that African American children were more active than their white non-Hispanic peers. 9 Self-efficacy for overcoming barriers and enjoyment of physical activity are marginally related to increased physical activity within the ASPs. 33 This suggests that psychosocial correlates play a small role within this setting.
The limited number of studies (8 in total) and the lack of a wide diversity of sites make it difficult to determine whether the physical activity estimates are reflective of all ASPs. These studies, however, indicate that children engage in modest levels of physical activity while attending ASPs. The consistent finding of gender inequity of activity levels clearly indicates that additional work is required to understand why girls are less active than boys, particularly since “equal” opportunities are to be provided to all children within ASPs. Moreover, work is required that identifies what activities girls would want to participate in within the ASP setting and what gender-specific barriers prevent them from participating. No studies have examined site-level characteristics, such as total enrollment, physical environmental features (eg, indoor/outdoor activity spaces), and the presence/absence of policies governing activity levels (eg, minimum of 30 minutes of MVPA daily) in relation to children’s physical activity in ASPs. Despite this, these studies point to potentially critical elements that should be incorporated into an intervention. Additional descriptive (ie, cross-sectional) studies, including a wide range of ASP types (eg, school, community, faith) and geographic locations are required.
Physical Activity Policies in Afterschool Programs
To address physical activity levels in ASPs, state and national organizations have developed policies to regulate the minimal amount of physical activity children should accumulate while attending an ASP. A comprehensive review of existing policies identified a total of 4 policies that specifically benchmark the number of minutes or percentage of time children should spend being physically active. 34 A sample of existing policies is presented in Table 2. Examples of policies are, California’s each child should accumulate a minimum of 30 minutes of MVPA daily during the ASP, whereas North Carolina’s states that 20% of an ASP’s schedule be devoted to MVPA. All the policies were developed almost exclusively from expert opinion or were adapted from existing physical activity policies from other settings (eg, physical education). Thus, no empirical evidence collected from within the ASP setting was used to inform the benchmarks outlined in the policies. At this time, it is unclear whether any ASP can reasonably meet the identified goals. This last point is of considerable importance in that, although necessary, the policies are yet to be empirically tested to determine if they are feasible to implement and achieve. Furthermore, as discussed below, ASPs have few evidence-based strategies to assist in the successful achievement of policy goals.
Example of Existing Physical Activity Policies a for the Afterschool Program Environment
See Beets et al 34 for full description of existing policies.
A recent study evaluated the extent to which children attending ASPs meet any of the identified policy benchmarks. 9 They found that based on the policy, the percentage of children meeting a benchmark ranged anywhere from 0% (California’s 60 minutes of MVPA daily) to 93% (National Afterschool Association [NAA] chance for 30 minutes of physical activity for every 3-hour time block). With such variability and inconsistency across the policies—not only in the amount of time benchmarked but also in the percentage of children meeting the benchmark—it is difficult to determine which policy is the most “effective” one. Obviously an arbitrarily low (as in the case of the NAA policy) or high (as in the case of California’s 60 minutes of MVPA) benchmark would unnecessarily impede progress toward the ultimate intention of these polices—improvements in the amount of time children are physically active within an ASP. These policy issues must be dealt with to move the ASP field forward toward widespread adoption and implementation of physical activity policies.
An additional consideration is the ability to operationalize and monitor policy benchmarks to monitor progress/achievement. The 2 most developed policies, California and North Carolina, both use MVPA to describe physical activity benchmarks. The ability of ASP staff to accurately monitor MVPA using low-cost devices, however, is severely limited. This issue is critical since the ability to self-monitor progress toward meeting policy goals is an important part of the integration of enhanced activity opportunities into the afterschool setting. To address this, a recent study 27 developed pedometer step count guidelines that correspond to meeting California’s 30 minutes of MVPA daily. They found that 4600 steps per day accurately differentiated between children who met the 30 minutes MVPA daily guideline versus those who failed to accumulate 30 minutes of MVPA. This represents an important step forward in providing afterschool leaders and staff the means by which to ensure they meet policy goals through the ability to self-monitor physical activity levels of children attending their ASP with pedometers.
Intervention Strategies and Efficacy/Effectiveness
To identify interventions and corresponding strategies focused on ASPs and improvements in physical activity, a systematic review was performed. Studies were identified from previous comprehensive narrative6,7 and quantitative 4 reviews, in addition to keyword searches (methodology described in the prior reviews) in PubMed, Web of Science, and Google Scholar. In total, 17 peer-reviewed articles that met the definition of ASPs (presented earlier) were located. Where reported, the following standard characteristics of studies were extracted: the type of evaluation (described below); primary outcomes and findings categorized as either positive changes in treatment group (+), no changes between treatment and control (0), or negative changes in favor of the control group (−); study design; sample size; age group; program duration (hours per day, days per week, and weeks per year), study duration, number of ASP sites, type of site (school based, community locations), average number of staff to student ratio; average number of students per site; who implemented the intervention; and the cost associated with delivering the intervention. The studies are summarized in Table 3 (a majority of these studies and characteristics have been summarized in prior reviews and will not be reviewed in detail here).
Overall, the empirical evidence on promoting physical activity with ASPs was divided into 2 major types of studies:
“Field” studies: evaluations of enhancements to preexisting community-based ASPs
“Laboratory” studies: creation and evaluation of interventions delivered within entirely new ASPs, designed and implemented by researchers solely for the purpose of evaluating the intervention
Description of Published Afterschool Program Physical Activity Intervention Evaluations
Abbreviations: NR, not reported; MVPA, moderate-to-vigorous physical activity; BMI, body mass index; CV fitness, cardiovascular fitness; VG, video games; F&V, fruit and vegetable intake; RCT, randomized controlled trial; QED, quasi-experimental design; ASP, afterschool program; BG, Boys and Girls Club.
New = creation of entirely new afterschool program; Preexisting = evaluation of intervention within preexisting community-based afterschool programs.
“+” indicates change in favor of treatment group; “0” indicates no change between groups; “-” indicates change in favor of control group.
Sample size based on reported total enrollment of afterschool program, where applicable, or the baseline sample size (not the number of children completing the study).
Free of charge reported by Gutin et al 36 ; $558 and $956 reported by Wang et al 49 based on first-year program delivery costs.
Comparisons made among program attendance within intervention programs (<20%, 20% to 39%, 40% to 59%, 60% to 79%, >80%). “+” indicates significant trend for higher attendance with improved outcomes.
Average students per site calculated as sample size of treatment divided by 3 schools.
Comparisons made from single treatment group pretest/posttest design.
Sample size: n = 148 and 125 represent the analytical sample; N = 533 children enrolled in the ASP across 3 years; average students per site calculated as the total number of children across the 3-year study (N = 533) divided by 3 (number of years of study), divided by 7 (number of sites); 1:6 ratio reported by Trost et al. 28
Intervention group increased MVPA by 7%, and control group increased MVPA by 10%.
“Field” studies consist of working within already preexisting ASPs (eg, YMCA, Boys and Girls Clubs, individual school sponsored). These studies integrate physical activity enhancements into existing programs through improvements in program offerings, providing training to enhance the skills and capacity of ASP staff to incorporate and promote physical activity, providing equipment to increase the physical activity of the children attending, and/or the evaluation of curricula developed specifically for the ASP setting to increase physical activity.
Conversely, although “laboratory” evaluations have similar characteristics as do “field” studies, the distinguishing features of this type of evaluation are threefold. First, the ASP was developed to test an intervention’s effectiveness. This indicates that the program did not exist prior to the research study and, therefore, was not an already established part of a community. Second, the intervention was not designed to be integrated within an already preexisting community-based ASP, rather, the intervention itself was designed to serve as an additional ASP option for children to enroll and attend. Finally, the intervention is often implemented by paid professional staff or college students and not by staff from the general public.
Such distinctions are critical because capacity building within preexisting ASPs, of which there are numerous across the nation, serves to enhance already established and embedded programs within communities. Furthermore, it is these preexisting programs that will remain once a grant’s cycle is completed. For instance, following their implementation and evaluation, the Georgia Fit Kid program.35-37,50 and Active Choice Today29,51 are no longer operating (J. B. Moore, personal communication, January 2011; D. King-Wilson, personal communication, April 2011). Thus, although changes in physical activity or fitness were observed (see Table 3), the long-term impact of these programs in the community is nonexistent because they simply no longer exist. Unless translation and dissemination of these programs in some prepackaged commercialized form (such as SPARK or CATCH Kids Club) is planned, their contribution to the ASP field is trivial. In other words, enduring, sustainable programs are needed.
Common issues reported across “laboratory” evaluations are ones that preexisting ASPs routinely deal with as part of their ongoing operations. The logistics related to advertisement (ie, recruitment), enrollment, attendance of children, and transportation are all handled by individuals trained within the profession of afterschool programming. These issues can unnecessarily impede the research process and have a substantial impact on a program’s findings. 4 For instance, transportation is a major hurdle to adequate program attendance (eg, greater than or equal to 40% of program days attended), and thus, exposure to the intervention.30,36 Preexisting programs, as part of their ongoing operations, have transportation to (eg, transporting children from schools and bringing them to an outside of school location) and from (eg, parents picking up children from the ASP) already coordinated within their program design. Preexisting programs also are held in well-established locations. This limits the potential of relocating programs should extraneous events outside the control of the research study arise. 30
The benefits of working within preexisting ASPs are numerous. As mentioned above, changes to programming and the environment are more likely to have a lasting, and thus, sustainable impact. 52 The day-in-day-out logistics associated with operating an ASP are many, are at times complicated, and are largely not directly related to the intervention under evaluation. Thus, resources allocated to run an ASP (eg, transportation costs, staffing) can be funneled into more relevant intervention-related activities. Many preexisting ASPs have some longevity within their respective community. This likely reflects a degree of community support for its (the ASP’s) existence (ie, parents annually enroll their children in the program, thereby sustaining the program). These characteristics can serve to minimize the impact of program attrition and importantly, differential attrition. 36 Existing ASPs also have considerable expertise in doing what they do—operating ASPs. This “local wisdom” can serve to inform intervention development and assist in circumventing potential problems with recruitment. The final benefit, and potentially the most important, the work conducted within preexisting programs is likely to have greater generalizability, since they represent the real-world setting and challenges associated with delivering high-quality physical activity programming. 8 However, the effect sizes from such studies are likely to be smaller than those from more controlled studies, yet would more closely reflect the “true” effect size observed in the population after dissemination. If changes to current practice are the ultimate end product of intervention studies, research that takes place within “real” programs conducted by “real” staff needs greater emphasis.
Despite these benefits, there are drawbacks to working within preexisting ASPs. The primary issue is one of staff turnover. 46 Staff are often hired/employed from schools (eg, classroom or physical education teachers), are non-research-related college-age or high school–age students seeking part-time employment, or volunteers within the community (eg, faith-based setting). Low wages and limited benefits are often the cause for a high turnover rate. With this comes an issue related to intervention fidelity, as longitudinal evaluations could be faced with training new staff on a yearly basis. An intervention that takes time to reach a level of comfort that ensures optimal implementation may unnecessarily suffer in effectiveness because of the limited time that staff have to master the intervention’s content. Nevertheless, the “authenticity” of the setting will provide truer estimates of an intervention’s impact than those gathered under more analogue conditions (ie, laboratory studies). In total, for these reasons the research community should remove itself from the business of operating and managing ASPs and focus efforts at working with preexisting programs within the community to build capacity and eventually sustainable physical activity promotion programs.
Efficacy/Effectiveness of Existing Efforts
According to a comprehensive review, 53 there are roughly 52 programs available to ASPs that are designed to promote physical activity and/or nutrition. How many of these have been empirically tested for effectiveness, however, remains unclear. The lack of evidence of effectiveness makes it difficult to support their widespread dissemination, particularly given the costs associated with the purchase of program curricula materials and corresponding trainings. A meta-analysis of ASPs found that efforts to increase physical activity can lead to a modest impact (effect size 0.44). 4 More recently, 2 laboratory29,30 and 1 field 32 large-scale randomized controlled trials, 1 natural experiment field study, 8 and 1 quasi-experimental study 48 not included within the 3 reviews on ASPs,4,6,7 offer additional evidence on the effectiveness of intervention efforts to improve physical activity within the ASP setting and are now discussed.
The Stanford GEMS was a 2-year randomized controlled trial that evaluated a community (ie, ASP) and family intervention on reducing obesity in low-income African American girls. 30 The ASP consisted of a culturally tailored dance program based on Bandura’s social cognitive model. The program taught 3 types of dance routines (African dance, hip-hop, and step). The classes were led by African American college students or recent graduates from the local community. Physical activity of the girls during the program was measured via accelerometry. At baseline, girls in the intervention accumulated 11.4 minutes of MVPA during the program in comparison with 8.8 minutes of MVPA by the control group. Across the 2 years, both groups reduced their MVPA during the ASPs by an average of 1.9 and 1.2 minutes of MVPA for the intervention and control, respectively.
Active Choices Today (ACT) is an ASP based on self-determination theory and is designed to increase middle school–age children’s motivation and behavioral skills related to participating in physical activity.29,51 The 17-week program focused on developing strategies for children to use to be physically active outside the program, specifically in the home environment. The primary outcome, MVPA, was measured via accelerometry. Overall daily MVPA (inside plus outside the program) did not increase for children exposed to ACT. At midpoint in the intervention children exposed to ACT increased their MVPA within the program by approximately 9.1 minutes (to an average of 17.8 minutes within the ASP).
HOP’N afterschool was based on the social cognitive theory and an ecological development systems model. 32 The physical activity component employed the CATCH Kids Club curriculum box, activity equipment, and included weekly behavioral goals to be physically active during the program for 30 minutes every day. Over the course of 3 repeated cross-sectional years, comparisons across all children showed that the HOP’N ASP resulted in a net gain of 2.1 minutes of MVPA, compared with a net decrease of -4.8 minutes of MVPA for children in the control group. Subgroup analyses indicated that healthy weight children in the treatment condition (<85th BMI percentile) decreased MVPA by 0.8 minutes, whereas children in the control condition decreased their MVPA by 1.9 minutes. For overweight/obese children (385th percentile) children in the treatment condition MVPA increased by 6.0 minutes, whereas overweight/obese children in the control decreased MVPA by 8.5 minutes.
The CATCH Kids Club (CKC), one of the most widely disseminated afterschool physical activity and nutrition curriculum, was recently evaluated within 330 YMCA and Boys and Girls Clubs in Ontario, Canada. 8 This study was a natural experiment with the ASPs initiating the purchase and subsequent implementation of the CKC. Within a subsample of 34 YMCAs and 6 Boys and Girls Clubs research staff collected systematic observation data of children’s physical activity using SOFIT. 54 Comparisons between CKC sites and non-CKC sites 1 year post-CKC implementation indicated that the proportion of time children spent in MVPA in the CKC sites increased by 7.2% (52.1% to 59.3%). The proportion of time spent in MVPA at the non-CKC sites, however, increased by 10.2% (54% to 64.2%).
The YMCA After-School Food and Fitness Project 48 evaluated the effectiveness of an intervention focused on changing routine practice within YMCA ASPs related to physical activity and nutrition. The goal of the intervention was to increase physical activity within the program and at home. The intervention consisted of creating environmental changes, such as increasing scheduled time for physical activity, staff participation in activity, information sent to and involvement from parents, and increasing the number of days that physical activity was offered. A total of 32 YMCAs across 4 geographical regions took part in the evaluation. A total of 16 ASPs received the intervention. Assessments of MVPA were collected in a subsample of children attending the ASPs in the fall and again in the spring during a single school year. Increases in total daily MVPA were observed from baseline to posttest in the intervention ASPs, with an average increase of 10.5 minutes of MVPA per day compared with the control ASPs. Changes in MVPA during the ASPs were not reported, and therefore, it is unclear how much physical activity increased from alterations to routine practice during program time.
The results of these studies, and the conclusions from prior reviews, clearly suggest that further intervention strategies, such as enhanced professional development training and refinement of existing curricula, need to be developed and tested to successfully improve the amount of physical activity accumulated within the ASP setting. Conversely, whether the strategy failed or the study failed cannot be determined; therefore, additional investigations using existing strategies needs to continue. Thus, the question of which strategies work “best” and can serve to inform future interventions is difficult to answer. A review of strategies used within these 17 studies revealed that 8 specific intervention elements were included across studies. The strategies along with an example from a study that used the strategy are summarized in Table 4.
Examples of Strategies Employed in Interventions Designed to Increase Physical Activity Within the Afterschool Program Setting
The strategies included allocating additional time for physical activity,30,36,40,46,48 training of program staff to model appropriate health-related behaviors, how to get children physically active, or deliver program curricula26,30,32,39,40,46,48 health (eg, benefits of physical activity) and/or behavioral change (eg, build self-efficacy, self-monitoring, perceived competency) education,26,29,32,39,41-43,45,46 rewards/incentives,30,32,39,40 cultural tailoring,30,39 modifying or creating a mastery-oriented climate rather than a competitive-oriented climate,30,36 inclusion of parents through family nights, concurrent enrollment in the program, or assistance with program delivery,30,39,41,45,48 and outside organization involvement (eg, Cooperative Extension Services) in delivering intervention-related content.30,32,41,48
Studies often incorporate 2 or more intervention elements making it difficult to discern what strategy is most effective. Furthermore, many of these same strategies have been employed in both successful and unsuccessful interventions. These inconsistencies create a situation where empirical evidence does not support what intuitively appear to be requisite elements to include within an intervention. Based on these studies, at minimum, interventions should incorporate the following: high-quality professional development training, allocating time in the ASP schedule for children to intentionally engage in sufficient amounts of physical activity, and tailoring the intervention in some manner to local conditions, be it cultural or otherwise (eg, all-girl programs, availability of physical activity resources—indoor/outdoor play space). Because all ASPs are unique (eg, number of children enrolled, location), some similar and some different strategies will be required across ASPs to promote physical activity (ie, there is no “one size fits all” approach). 55 Thus, a degree of local tailoring (for each ASP) should occur that is both responsive and adaptive to the characteristics of each ASP site. 56
Unexplored Issues and Future Directions
Even though ASPs are poised to make a substantial and meaningful contribution to children’s physical activity, there are unresolved questions that require attention to ASP practice. First, additional large-scale (ie, large number of ASPs) cross-sectional or prospective nonintervention studies of representative preexisting community-based ASPs are necessary. Additional work needs to examine factors, outside of child characteristics, that facilitate or impeded physical activity. These include staff characteristics and associated behaviors (eg, promoting physical activity), ASP characteristics, such as the presence of policies, physical resources and environmental features (eg, indoor and outdoor space), and equipment availability. Comparisons among these and other features with children’s physical activity will help identify which are the most salient for ASPs and should be targeted for modification.
The afterschool field has numerous prepackaged programs to select from. The extent to which these programs result in improvements in physical activity is unclear. For those “evidence-based” programs widely marketed (SPARK and CATCH Kids Club), limited evidence is available to warrant the substantial upfront investment in materials and professional development training. CATCH Kids Club is a perfect example where the 2 studies evaluating its impact show contradictory findings (one for and one against).8,46 For SPARK, there is no available published peer-reviewed evidence on its effectiveness and a single abstract suggests that the program does not increase physical activity. 57 Despite this, it is advertised as the “most field-tested and researched programs available” (http://www.sparkpe.org). Based on existing evidence, it appears that such claims are premature for the ASP setting, and ASP providers should take this into consideration prior to investing. Additional work should focus on field evaluations and refinements of existing ASP physical activity curricula. Likewise, no studies have specifically pitted 2 or more existing curricula against one another. This would have tremendous merit as it would assist ASP leaders in the decision as to which curriculum is the most effective. For these studies, funding organizations need to place priority on evaluating modifications to preexisting ASPs. This would be a departure from current practice where over half of the studies published to date are evaluations of ASPs run and managed by researchers.
For the general ASP leader making decisions based on existing evidence for allocating resources toward physical activity, information related to “how much is it going to cost me?” is largely unavailable. This is because the cost associated with increasing physical activity in ASPs is not well documented. What little has been reported indicates that it may cost anywhere from $558 to $956 per child attending 49 (see Table 3). Other studies report charging children $100 for attending 42 or completely subsidizing attendance altogether. 29 The price associated with readily available commercialized programs, such as SPARK or the CATCH Kids Club, may be too high for many ASPs running on already limited budgets. For instance, the cost associated with the SPARK training ranges from $2700 to $4700, not including the purchase price of other program-related materials and corresponding equipment (see http://www.sparkpe.org). The CATCH Kids Club activity box currently retails for $195, the equipment kit $1395, and the online training anywhere from $1200 to $1950 (see http://www.flaghouse/com). Such price barriers may unnecessarily impede the uptake of effective strategies. Future studies need to identify low-cost alternatives if widespread use of best practices for facilitating physical activity is to become the norm.
Finally, the advent of state and national policies (see Table 2) to regulate the amount of physical activity children accumulate in ASPs is a relatively recent pursuit. In fact, new standards have just been adopted by the National Afterschool Association (see http://www.niost.org) related to physical activity and nutrition. 58 The extent to which these policies will make or have made any substantial changes is unknown. Based on current evidence, 9 simply asking ASPs to adopt a policy is unlikely to yield any measureable improvements. Future work should inform what addition elements need to be in place (eg, technical support from physical activity experts, staff training, portable equipment, etc) before practice emulates policy goals. Additionally, consideration for the ability to operationalize and measure progress toward and compliance of policy goals is needed. Nevertheless, policies do reflect the next step toward holding ASPs accountable for providing adequate levels of physical activity. The questions remaining are as follows: “What is the most appropriate policy benchmark to adopt?” and “What strategies are effective to bring afterschool programs up to a level where they meet policy goals?” Given the limited effectiveness of existing programs, additional studies are needed to explore alternative means to improve the ASP environment.
Conclusion
In conclusion, ASPs represent a promising approach to increasing physical activity across a wide cross section of the youth population Evidence compiled to date suggests some promising strategies exist, yet there are mixed results or weak findings. Thus, additional work conducted within preexisting community-based ASPs is required. Until investments in this evaluative research are made, current practice within ASPs is unlikely to be able to meet already established physical activity policy goals and will continue to result in suboptimal physical activity levels. Despite these challenges, “quality” ASPs appear to be capable of making substantial contributions toward children’s achieving daily physical activity recommendations.
Footnotes
Acknowledgements
The author would like to thank Dr Bradley Cardinal for his insightful comments on earlier drafts of this article.
*
The purpose of this review is not to exhaustively present information regarding the conclusions from these reviews or to present information regarding individual study findings summarized in these reviews; readers are referred to the following reviews for summaries of the studies: References 4, 6, and 7.
*
Estimate based on the number of children enrolled in preK to 8th grade and 9th to 12th grade during 2009 in public (55.28 million) and private (5.97 million). Source: US Department of Education, National Center for Education Statistics (2011). Digest of Education Statistics, 2010 (NCES 2011-015).
†
Estimate based on children preK to 8th grade enrolled in public elementary schools (34.5 million) and private (4.58 million) and 88% of afterschool program enrollees of elementary and middle school age (7.39 million). Source: US Department of Education, National Center for Education Statistics (2011). Digest of Education Statistics, 2010 (NCES 2011-015).