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BackgroundRural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users. ObjectiveWe aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time. MethodsThis study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity. ResultsParticipants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor’s degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre–COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence. ConclusionsWe did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

BackgroundThe COVID-19 pandemic has been declared an international public health emergency, and it may have long-lasting effects on people’s mental health. There is a need to identify effective health behaviors to mitigate the negative mental health impact of COVID-19. ObjectiveThe objectives of this study were to (1) examine the regional differences in mental health and COVID-19–related worry, attention to news, and stress, in light of the state-level prevalence of COVID-19 cases; (2) estimate the associations between mental health and COVID-19–related worry, attention to news, and stress and health behavior engagement (ie, physical activity, mindfulness meditation); and (3) explore the mediating effect of health behavior engagement on the associations between mental health and COVID-19–related worry, attention to news, and stress. MethodsA cross-sectional survey was distributed to a sample of US adult paying subscribers to the Calm app (data were collected from April 22 to June 3, 2020). The survey assessed COVID-19–related worry, attention to news, and stress; health behavior engagement; and mental health (ie, perceived stress, posttraumatic stress disorder, and anxiety and depression). Statistical analyses were performed using R software. Differences in COVID-19–related worry, attention to news, and stress and mental health by location were assessed using t tests and chi-square tests. Logistic and ordinary least squares models were used to regress mental health and health behavior on COVID-19–related worry, attention to news, and stress; moreover, causal mediation analysis was used to estimate the significance of the mediation effects. ResultsThe median age of the respondents (N=8392) was 47 years (SD 13.8). Participants in the Mid-Atlantic region (New Jersey, New York, and Pennsylvania) reported higher levels of stress, more severe depression symptoms, greater worry about COVID-19, paying more attention to COVID-19–related news, and more stress related to social distancing recommendations than participants living in other regions. The association between worry about COVID-19 and perceived stress was significantly mediated by changes in physical activity (P

BackgroundMindfulness meditation smartphone apps may improve mental health but lack evidence-based behavioral strategies to encourage their regular use for attaining mental health benefits. In October 2019, the Calm mindfulness meditation app introduced a mood check-in feature, but its effects on participation in meditation have yet to be tested. ObjectiveThe objective of this study was to investigate how a mood check-in feature impacts meditation behavior in Calm app subscribers. MethodsThis was a retrospective longitudinal analysis of mobile app usage data from a random sample of first-time subscribers to the Calm app (n=2600) who joined in summer 2018 or summer 2019. The mood check-in feature allows users to rate their mood using an emoji after completing a meditation session and displays a monthly calendar of their past mood check-ins. Regression analyses were used to compare the rate of change in meditation behavior before and after the introduction of mood check-ins and to estimate how usage of mood check-ins was associated with individuals’ future meditation behavior (ie, intent-to-treat effects). Additional regression models examined the heterogenous effect of mood check-ins between subscribers who were active or inactive users prior to the introduction to mood check-ins (ie, above or below the median number of weeks with any meditation within their cohort). In order to confirm the specific associations between mood check-ins and meditation engagement, we modeled the direct relationship between the use of mood check-ins in previous weeks and subsequent meditation behavior (ie, treatment on the treated effects). ResultsDuring the first 9 months of their subscription, the 2019 cohort completed an average of 0.482 more sessions per week (95% CI 0.309 to 0.655) than the 2018 cohort; however, across both cohorts, average weekly meditation declined (–0.033 sessions per week, 95% CI –0.035 to –0.031). Controlled for trends in meditation before mood check-ins and aggregate differences between the 2018 and 2019 samples, the time trend in the number of weekly meditation sessions increased by 0.045 sessions among the 2019 cohort after the introduction of mood check-ins (95% CI 0.039 to 0.052). This increase in meditation was most pronounced among the inactive subscribers (0.063 sessions, 95% CI 0.052 to 0.074). When controlled for past-week meditation, use of mood check-ins during the previous week was positively associated with the likelihood of meditating the following week (odds ratio 1.132, 95% CI 1.059 to 1.211); however, these associations were not sustained beyond 1 week. ConclusionsUsing mood check-ins increases meditation participation in Calm app subscribers and may be especially beneficial for inactive subscribers. Mobile apps should consider incorporating mood check-ins to help better engage a wider range of users in app-based meditation, but more research is warranted.

BackgroundOver 30% of Americans report regular sleep disturbance, and consumers are increasingly seeking strategies to improve sleep. Self-guided mindfulness mobile apps may help individuals improve their sleep. Despite the recent proliferation of sleep content within commercially available mindfulness apps, there is little research on how consumers are using these apps for sleep. ObjectiveWe conducted a cross-sectional survey among subscribers to Calm, a popular, consumer-based, mindfulness-based meditation app, and described and compared how good sleepers, poor sleepers, and those with self-reported insomnia use the app for sleep. MethodsParticipants who were paying subscribers of Calm and had used a sleep component of Calm in the last 90 days were invited to complete an investigator-developed survey that included questions about sleep disturbance and the use of Calm for sleep. Based on self-reports of sleep disturbances and of insomnia diagnosis, participants were categorized as “good sleepers,” “poor sleepers,” or “those with insomnia diagnosis.” Chi-square tests compared reasons for downloading the app and usage patterns across participants with and without sleep disturbance. ResultsThere was a total of 9868 survey respondents. Approximately 10% of participants (1008/9868, 10.21%) were good sleepers, 78% were poor sleepers (7565/9868, 77.66%), and 11% reported a diagnosis of insomnia (1039/9868, 10.53%). The sample was mostly White (8185/9797, 83.55%), non-Hispanic (8929/9423, 94.76%), and female (8166/9578, 85.26%). The most common reasons for sleep disturbances were racing thoughts (7084/8604, 82.33%), followed by stress or anxiety (6307/8604, 73.30%). Poor sleepers and those with insomnia were more likely than good sleepers to have downloaded Calm to improve sleep (χ22=1548.8, P

BackgroundIn the United States, nearly half (48%) of school-aged children experience sleep disturbance that results in less than the recommended sleep duration, which may negatively impact mental health and behavior. Mindfulness interventions may improve sleep and mental health in youth. However, there are gaps in the literature regarding how children (2-12 years) and adolescents (13-17 years) practice mindfulness and the extent to which they benefit from these practices. ObjectiveThe purpose of this study was to determine parents’ perceptions of their children’s engagement with a consumer-based mindfulness meditation app and the extent to which they believe their children have benefitted from using the app, particularly with regard to sleep. MethodsThis study is a secondary analysis of a cross-sectional survey in adult subscribers (N=11,108) to the mindfulness meditation mobile app Calm. Participants who indicated that they had a child or children younger than 18 years (2944/11,108) who used the Calm app were asked additional questions related to their perceptions of their children’s engagement with Calm. Descriptive statistics were used to assess children’s app engagement, and chi-square tests and binary logistic regression models were used to assess differences in children’s usage based on gender and age. ResultsAmong the survey respondents, approximately half of the parents (1537/2944, 52.21%) reported that their children used Calm. Children used Calm mostly for (1) sleep (1168/1537, 75.99%), (2) stress (491/1537, 31.95%), (3) depression or anxiety (430/1537, 27.98%), and (4) improvement of overall health (215/1537,13.99%). Older children were more likely to begin using Calm to reduce stress, depression, or anxiety, whereas younger children were more likely begin using Calm to improve sleep. Most children used Calm when lying down to go to bed (1113/1529, 72.79%). Children were most likely to use sleep stories at night (1144/1207, 94.78%), followed by music and soundscapes (749/1114, 67.24%), meditations (736/1120, 65.71%), and breathing exercises (610/1092, 55.86%). Nearly all parents believed that using sleep stories was helpful for their children’s sleep (1090/1128, 96.63%), and the majority of parents felt that the other components were also helpful for their children’s sleep (music and soundscapes [570/728, 78.30%], meditations [445/696, 63.94%], and breathing exercises [610/1092, 55.86%]). ConclusionsTo our knowledge, this is the first study to explore parents’ perceptions of how their children or adolescents use a popular consumer-based mindfulness mobile app (ie, Calm). As the majority of children use the app for sleep, mindfulness meditation mobile apps should consider incorporating age-appropriate sleep content to meet the needs of this audience. More research is needed to confirm the feasibility and effectiveness of mindfulness meditation apps for improving sleep and mental health in children and adolescents.

BackgroundSmartphone ownership is becoming ubiquitous among US adults, making the delivery of health interventions via a mobile app (ie, mobile health [mHealth]) attractive to many researchers and clinicians. Meditation interventions have become popular and have been delivered to study participants via mobile apps to improve a range of health outcomes in both healthy adults and those with chronic diseases. However, these meditation mHealth interventions have been limited by a lack of high-quality control groups. More specifically, these studies have lacked consistency in their use of active, time-matched, and attention-matched control groups. ObjectiveThe purpose of this study is to beta test a novel health education podcast control condition delivered via a smartphone app that would be a strong comparator to be used in future studies of app-based meditation interventions. MethodsPatients with myeloproliferative neoplasm (MPN) cancer were recruited nationally. Upon enrollment, participants were informed to download the investigator-developed health education podcast app onto their mobile phone and listen to ~60 min/week of cancer-related educational podcasts for 12 weeks. The benchmarks for feasibility included ≥70% of participants completing ≥70% of the prescribed 60 min/week of podcasts, ≥70% of participants reporting that they were satisfied with the intervention, and ≥70% of participants reporting that they enjoyed the health education podcasts. ResultsA total of 96 patients with MPN were enrolled in the study; however, 19 never began the intervention. Of the 77 patients who participated in the intervention, 39 completed the entire study (ie, sustained participation through the follow-up period). Participation averaged 103.2 (SD 29.5) min/week. For 83.3% (10/12) of the weeks, at least 70% of participants completed at least 70% of their total prescribed use. Almost half of participants reported that they enjoyed the health education podcasts (19/39, 48.7%) and were satisfied with the intervention (17/39, 43.6%). There were no significant changes in cancer-related outcomes from baseline to postintervention. ConclusionsA 12-week, health education podcast mobile app was demanded but not accepted in a sample of patients with cancer. Using the mobile app was not associated with significant changes in cancer-related symptoms. Based on findings from this study, a health education podcast mobile app may be a feasible option as a time- and attention-matched control group for efficacy trials with more extensive formative research for the content of the podcasts and its acceptability by the specific population. Trial RegistrationClinicalTrials.gov NCT03907774; https://clinicaltrials.gov/ct2/show/NCT03907774

BackgroundThere is a need for tools to decrease cancer patients’ and survivors’ long-term symptom burden. Complementary strategies, such as meditation, can accompany pharmacologic therapy to improve symptoms. Although support programs with targeted content have wider reach, higher adherence, and greater impact, there are no consumer-based meditation apps designed specifically for cancer. ObjectiveThis study aimed to gather information to advise the development of a cancer-specific meditation app in a small convenience sample of cancer patients and survivors who currently use the Calm app. MethodsAdult cancer patients and survivors who are Calm users (N=82) were recruited through the Daily Calm Facebook page. Participants completed a Web-based survey related to Calm app use and satisfaction, interest in and ideas for a cancer-specific Calm app, and demographic characteristics. Open-ended responses were inductively coded. ResultsParticipants were aged between 18 and 72 years (mean 48.60 years, SD 15.20), mostly female (77/82, 94%), white (65/79, 82%), and non-Hispanic (70/75, 93%), and reported using Calm at least 5 times per week (49/82, 60%). Although rates of satisfaction with current Calm components were high (between 65/82, 79% and 51/81, 63%), only 49% (40/82) of participants used guided meditations that they felt specifically helped with their cancer-related symptoms and survivorship, and 40% (33/82) would prefer more cancer-related content, with guided meditations for cancer-specific anxieties (eg, fear of recurrence; n=15) and coping with strong emotions (n=12) being the most common suggestions. A majority of participants (51/82, 62%) reported that they would be interested in becoming a member of a Calm cancer community (eg, in-app discussion boards: 41/46, 89%; and social media communities: 35/42, 83%). Almost half of the participants (37/82, 45%) reported that they would benefit from features that tracked symptoms in concurrence with app usage, but respondents were divided on whether this information should be shared with health care providers through the app (49/82, 60% would share). ConclusionsResponses suggest ways in which the current Calm app could be adapted to better fit cancer patients’ and survivors’ needs and preferences, including adding cancer-specific content, increasing the amount of content focusing on coping with strong emotions, developing communities for Calm users who are cancer patients and survivors, and including features that track cancer-related symptoms. Given differences in opinions about which features were desirable or would be useful, there is a clear need for future cancer-specific apps to be customizable (eg, ability to turn different features on or off). Although future research should address these topics in larger, more diverse samples, these data will serve as a starting point for the development of cancer-specific meditation apps and provide a framework for evaluating their effects.

BackgroundMeditation has become increasingly popular due to its health benefits; however, barriers to delivering meditation programs in traditional group-based formats limit the accessibility of these benefits. Smartphone-based meditation may increase the availability of these programs to larger, more diverse audiences; however, research on subscriber characteristics and usage patterns in meditation mobile apps is lacking. ObjectiveThis study aimed to describe the demographics, clinical characteristics, and usage patterns of a convenience sample of Calm subscribers and explore the relationship between self-reported app usage and changes in health, stress, and sleep. MethodsParticipants were 12,151 paying Calm subscribers (response rate=12.08%, 12,151/100,594) who completed an anonymous Web-based survey with 11 quantitative questions related to user engagement, reasons for starting Calm, and changes after using the app. Demographic characteristics, chronic health diagnoses, and sleep difficulties were also assessed. Chi-square tests were used to examine differences in app usage. Logistic regression models were used to examine demographic and health characteristics that may predict changes in health, stress, and sleep. ResultsRespondents were 18-96 years old (mean 48.57 [SD 13.79]), primarily female (79.94%, 8778/10,981), white (81.41%, 8959/11,005), and most reported a chronic health diagnosis (56.86%, 6289/11,061). Mental health diagnoses (41.13%, 4549/11,061) were more common than physical health diagnoses (32.19%, 3560/11,061). Most respondents (76.31%, 8684/11,360) reported difficulties falling or staying asleep. On average, respondents had been using Calm for 11.49 months (SD 10.49), and 60.03% (7281/12,129) used it 5 or more times per week. Meditations (used by 80.02%, 9497/11,841) and Sleep Stories (55.66%, 6591/11,841) were the most popular components. The frequency of using Calm was associated with incremental increases in the likelihood of noticing changes in mental health (χ22=136.8; P

BackgroundCollege students experience high levels of stress. Mindfulness meditation delivered via a mobile app may be an appealing, efficacious way to reduce stress in college students. ObjectiveWe aimed to test the initial efficacy and sustained effects of an 8-week mindfulness meditation mobile app—Calm—compared to a wait-list control on stress, mindfulness, and self-compassion in college students with elevated stress. We also explored the intervention’s effect on health behaviors (ie, sleep disturbance, alcohol consumption [binge drinking], physical activity, and healthy eating [fruit and vegetable consumption]) and the feasibility and acceptability of the app. MethodsThis study was a randomized, wait-list, control trial with assessments at baseline, postintervention (8 weeks), and at follow-up (12 weeks). Participants were eligible if they were current full-time undergraduate students and (1) at least 18 years of age, (2) scored ≥14 points on the Perceived Stress Scale, (3) owned a smartphone, (4) were willing to download the Calm app, (5) were willing to be randomized, and (7) were able to read and understand English. Participants were asked to meditate using Calm at least 10 minutes per day. A P value ≤.05 was considered statistically significant. ResultsA total of 88 participants were included in the analysis. The mean age (SD) was 20.41 (2.31) years for the intervention group and 21.85 (6.3) years for the control group. There were significant differences in all outcomes (stress, mindfulness, and self-compassion) between the intervention and control groups after adjustment for covariates postintervention (all P.19). Similar results were found for mindfulness and self-compassion. Effect sizes ranged from moderate (0.59) to large (1.24) across all outcomes. A significant group×time interaction in models of sleep disturbance was found, but no significant effects were found for other health behaviors. The majority of students in the intervention group reported that Calm was helpful to reduce stress and stated they would use Calm in the future. The majority were satisfied using Calm and likely to recommend it to other college students. The intervention group participated in meditation for an average of 38 minutes/week during the intervention and 20 minutes/week during follow-up. ConclusionsCalm is an effective modality to deliver mindfulness meditation in order to reduce stress and improve mindfulness and self-compassion in stressed college students. Our findings provide important information that can be applied to the design of future studies or mental health resources in university programs. Trial RegistrationClinicalTrials.gov NCT03891810; https://clinicaltrials.gov/ct2/show/NCT03891810

Background: In the United States, 68% of children do not get the recommended nine hours of sleep, which can lead to many negative health outcomes (e.g., mental health). Mindfulness meditation mobile apps may be an option for improving children's sleep and mental health outcomes; however, there is limited research on how children across different ages access these types of apps, the content they prefer, and the benefits they experience. Objective: The purpose of this study was to describe parents' reports of how and why their children use the Calm mindfulness meditation app and how using Calm may impact their sleep and mental well-being across age and gender. Method: This study was a cross-sectional survey of Calm subscribers (N = 2437) with children who used Calm. Participants were asked how their child accessed content, why their child used Calm, and the benefits of Calm for their child's sleep and mental well-being. Results: Approximately half of the parents reported that they used Calm with their child. Older children (13-17 years) were more likely to use Calm independently, preferred content outside of Calm Kids, and were more likely to use Calm to manage emotions. Younger children (2-12 years) most commonly used Calm with their parents and on a parent's device and preferred Calm Kids Sleep Stories. Conclusion: To our knowledge, this is the first study to explore parents' perceptions of children's use of a commercial mindfulness meditation app across ages. Children use Calm differently based on their.

The digital mental health industry has seen remarkable growth in recent years. However, within this crowded landscape, many companies overlook a critical factor for gaining a competitive edge: the integration of science. In this context, "science" refers to the strategic collection and analysis of information (i.e., data) at digital mental health companies, aimed at guiding business decisions and achieving business objectives. This paper demonstrates that science is integral, yet underutilized in the digital mental health industry, with common misconceptions about its role. When science is integrated within a company, it enables them to (1) innovate, (2) understand customers, (3) make informed decisions, and (4) drive revenue. Digital mental health companies recognizing the multifaceted value of science may be better equipped for sustainable growth and success amid the crowded digital health market. [ABSTRACT FROM AUTHOR]

Background: Many school-based recess interventions have been shown to be effective in increasing physical activity but their relative efficiency compared to other school-based programs are unknown. This study examined the cost-effectiveness of Ready for Recess, a program designed to increase students' physical activity in 2 elementary schools. Methods: Standard cost-effectiveness analysis method was used from a program's perspective for this study. Program effectiveness was measured as total metabolic equivalent (MET) hours gained. Program costs included equipment, training, and personnel costs during the 1-year intervention. The cost-effectiveness was measured as the ratio of program costs to total MET-hours gained. Results: Ready for Recess cost $27,643.97 for the 2 schools in the first year of implementation. Physical activity increased by 1.8 MET-hours per day per student. Approximately 32 cents were spent on Ready for Recess to produce an additional MET-hour per student per school day in the 2008-2009 school year. Conclusions: Ready for Recess was cost-effective in its first year of implementation using 35 cents as a benchmark and it was cost-effective relative to other school-based physical activity interventions. The program may be more cost-effective if implemented for a longer time and on a larger scale.

Interventions to manage weight and stress during the interconception period (i.e., time immediately following childbirth to subsequent pregnancy) are needed to promote optimal maternal and infant health outcomes. To address this gap, we summarize the current state of knowledge, critically evaluate the research focused on weight and stress management during the interconception period, and provide future recommendations for research in this area. Evidence supports the importance of weight and stress management during the reproductive years and the impact of weight on maternal and child health outcomes. However, evidence-based treatment models that address postpartum weight loss and manage maternal stress during the interconception period are lacking. This problem is further compounded by inconsistent definitions and measurements of stress. Recommendations for future research include interventions that address weight and stress tailored for women in the interconception period, interventions that address healthcare providers' understanding of the significance of weight and stress management during interconception, and long-term follow-up studies that focus on the public health implications of weight and stress management during interconception. Addressing obesity and stress during the interconception period via a reproductive lens will be a starting point for women and their families to live long and healthy lives., Author(s): Jennifer Huberty [sup.1] , Jenn A. Leiferman [sup.2] , Abbey R. Kruper [sup.3] , Lisette T. Jacobson [sup.4] , Molly E. Waring [sup.5] , Jeni L. Matthews [sup.1] , [...]

State and national organizations recently developed policies focused on increasing physical activity (PA) in afterschool programs (ASPs). These policies emphasize "activity friendly" environment characteristics that, when present, should lead to higher levels of PA and reduce the amount of time children spend sedentary during an ASP. Currently, little is known about the impact of existing PA policies on children's PA and sedentary behaviors in ASPs. A sample of 18 community-based ASPs serving 1,241 children (5-12 years) were audited for environment features outlined in existing PA policies (i.e., presence of a written policy to promote PA, collecting child feedback, staff training to promote PA and the quality of that training, holding parent workshops, use of PA curricula, evaluating PA, allocating time in the schedule for PA opportunities, and providing activities that appeal to both boys and girls). Children's PA and sedentary behavior were measured via accelerometry. Unexpectedly, the presence of a written policy, collecting child feedback, and receiving 1 to 4 hours of staff training for PA was associated with an increase in time spent sedentary and a decrease in PA. Conversely, allocating 50% or more time in an ASP schedule for PA and providing activities that appealed to boys and girls was associated with a decrease of time spent sedentary and an increase in PA. The present state of practice in ASPs suggests that policy environment characteristics are largely unrelated to the amount of PA children accumulate while attending ASPs. (Contains 4 tables.)

The purpose of this study was to determine: (i) the effect of schools' baseline community readiness (CR) on youth physical activity (PA) at recess prior to the Ready for Recess intervention; (ii) if changes in PA due to the intervention were explained by baseline CR and (iii) if specific components of the intervention altered an association between baseline CR and changes in youth PA. Methods that were employed included: six informants from each of 17 schools participated in CR interviews at baseline (N = 101). CR scores were calculated based on the CR model's nine stages. Direct observation was used to measure PA. Poisson models evaluated the association between baseline CR and PA. Results were that seven schools were in denial, eight in vague awareness and two in pre-planning stages. CR marginally predicted pre-intervention PA. When compared with youth at schools in denial, youth at schools in vague awareness and pre-planning demonstrated significant increases in moderate/vigorous PA. Ready for Recess strengthened this association. This is the first study to demonstrate that school CR may explain changes in PA at recess after a school-based PA intervention. Low CR levels may contraindicate interventions. Efforts to increase school CR "a priori" may be critical to increasing PA among youth.