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Background: Childhood obesity continues to be a global epidemic and many child-based settings (e.g. school, afterschool programs) have great potential to make a positive impact on children's health behaviors. Innovative and time-sensitive methods of gathering health behavior information for the purpose of evaluation and strategically deploying support are needed in these settings., Purpose: The aim is to (1) demonstrate the feasibility of mobile health (mHealth) for monitoring implementation of healthy eating and physical activity (HEPA) standards and, (2) illustrate the utility of mHealth for identifying areas where support is needed, within the afterschool setting., Methods: Site leaders ( N = 175) of afterschool programs (ASPs) were invited to complete an online observation checklist via a mobile web app (Healthy Eating and Physical Activity Mobile, HEPA m ) once per week during ASP operating hours. Auto-generated weekly text reminders were sent to site leaders' mobile devices during spring and fall 2015 and 2016 and spring 2017 school semesters. Data from HEPA m was separated into HEPA variables, and expressed as a percent of checklists where an item was present. A higher percentage for a given item would indicate an afterschool has higher compliance with current HEPA standards., Results: A total of 141 site leaders of ASPs completed 13,960 HEPA m checklists. The average number of checklists completed per ASP was 43 (range 1-220) for healthy eating and 50 (range 1-230) for physical activity. For healthy eating, the most common challenge for ASPs was 'Staff educating children about healthy eating', and for physical activity checklists, 'Girls only physical activity is provided at ASP'., Conclusion: HEPA m was widely used and provided valuable information that can be used to strategically deploy HEPA support to ASPs. This study gives confidence to the adoption of mHealth strategies as a means for public health practitioners to monitor compliance of an initiative or intervention.

Limited information is available on the cost-effectiveness of interventions to achieve healthy eating and physical activity policies in afterschool programs (ASPs). The objective of this study is to present the costs associated with a comprehensive intervention in ASPs. Intervention delivery inputs (IDIs) associated with a group randomized delayed treatment controlled trial involving 20 ASPs serving >1700 children (5-12yrs) were catalogued prospectively across 2-years (2014-2015). IDIs, analyzed 2015, were expressed as increases in per-child per-week enrollment fees based on a 34-week school year in US$. Total IDIs for year-1 were $15,058 (+$0.58/child/week enrollment fee). In year-2, total costs were $13,828 (+$0.52/child/week) for the delayed group and $7916 (+$0.30/child/week) for the immediate group, respectively. Site leader and staff hourly wages represented 11-17% and 45-46% of initial training costs; travel and trainer wages represented 31-42% and 50-58% of booster costs. Overall, a 1% increase in boys and girls, separately, accumulating 30 mins/d of moderate-to-vigorous physical activity ranged from $0.05 to $0.26/child/week, while a one-day increase in serving a fruit/vegetable or water, or not serving sugar-added foods/beverages ranged from $0.16 to $0.87/child/week. Costs associated with implementing the intervention were minimal. Additional efforts to reduce costs and improve intervention effectiveness are necessary., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Across the U.S., afterschool programs (ASPs, 3:00pm-6:00pm) are trying to achieve nationally endorsed nutrition standards (Healthy Eating Standards) calling for fruits/vegetables and water to be served every day, while eliminating sugar-sweetened beverages and foods. The purpose of this study was to evaluate the 2-year changes in the types of foods and beverages served during a community-based intervention designed to achieve the Healthy Eating Standards., Study Design: Randomized delayed treatment trial with an immediate (1-year baseline and 2-year intervention) or delayed (2-year baseline and 1-year intervention) group., Setting/participants: Twenty ASPs serving 1,700 children (aged 5-12 years) were recruited, with baseline occurring spring 2013, and outcome assessment occurring spring 2014 and 2015., Intervention: The multistep intervention, Strategies To Enhance Practice for Healthy Eating, assisted ASP leaders/staff to serve foods/beverages that meet the nutrition standards., Main Outcome Measures: The foods and beverages served for snack were observed directly., Results: Compared with non-intervention years, both the immediate and delayed groups increased the number of days/week that fruits/vegetables (0.6 vs 1.7 days/week and 0.6 vs 4.4 days/week, OR=3.80, 95% CI=1.45, 9.95) and water (2.3 vs 3.7 days/week and 2.7 vs 4.8 days/week, OR=4.65, 95% CI=1.69, 12.79) were served. Sugar-sweetened beverages were almost eliminated by post-assessment (1.2 vs 0.2 days/week and 3.2 vs 0.0 days/week, OR=0.05, 95% CI=0.02, 0.13). Only the immediate group decreased the number of days/week desserts were served (2.9 vs 0.6 days/week, OR=0.10, 95% CI=0.03, 0.33). Implementation barriers for the delayed group included once/month delivery schedules for fruits/vegetables and limited storage space for foods meeting the Healthy Eating Standards., Conclusions: Improvements in the foods/beverages served in ASPs can be made, yet were hindered by structural barriers related to procurement and storage of perishable foods. Additional efforts are needed to support ASPs as they work toward fully achieving the Healthy Eating Standards., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Text4baby (T4b), a free nation-wide mobile health information service, delivers health-related text messages (SMS) to pregnant women. The objective of this study was to determine the effectiveness of physical activity (PA) specific SMS to improve PA in pregnant women (vs standard T4b) and the most effective dose/timing of PA-specific SMS to improve PA. Pregnant women (N = 80) were randomized to one of four groups that differed in frequency and time of SMS. The Fitbit™ Flex measured PA. Data were analyzed using mixed model analyses. There were no increases in PA regardless of frequency or time. Those that received six PA SMS/week had greater decreases in activity and greater increases in sedentary time. SMS may not be a "potent" enough strategy to improve PA. Future studies should explore a modified focus on behavior change (e.g., decrease sedentary activity, increase light activity) and incorporate SMS as part of a multi-level approach with other evidence-based strategies.

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., (© 2017, American School Health Association.)

Background: Summer day camps (SDCs) serve 14 million children yearly in the U.S. and aim to provide participating children with 60 minutes of moderate-to-vigorous physical activity (MVPA). This study evaluated an intervention designed to increase the percent of children meeting this MVPA guideline., Design: Two-group, pre-post quasi-experimental., Setting/participants: Twenty SDCs serving 1,830 children aged 5-12 years were assigned to MVPA intervention (n = 10) or healthy eating attention control (n = 10)., Intervention: The STEPs (Strategies to Enhance Practice) intervention is a capacity-building approach grounded in the Theory of Expanded, Extended and Enhanced Opportunities. Camp leaders and staff receive training to expand (e.g., introduction of activity breaks/active field trips), extend (e.g., schedule minimum of 3 hours/day for PA opportunities), and enhance (e.g., maximize MVPA children accumulate during schedule activity) activity opportunities. Camps in the comparison condition received support for improving the types of foods/beverages served., Main Outcome Measures: Percent of children accumulating the 60min/d MVPA guideline at baseline (summer 2015) and post-test (summer 2016) measured via wrist-accelerometry., Results: Multilevel logistic regression conducted fall 2016 indicated boys and girls attending intervention SDCs were 2.04 (95CI = 1.10,3.78) and 3.84 (95CI = 2.02,7.33) times more likely to meet the 60min/d guideline compared to boys and girls attending control SDCs, respectively. This corresponded to increases of +10.6% (78-89%) and +12.6% (69-82%) in the percentage of boys and girls meeting the guideline in intervention SDCs, respectively. Boys in comparison SDCs increased by +1.6% (81-83%) and girls decreased by -5.5% (76-71%). Process data indicated intervention SDCs successfully extended and enhanced PA opportunities, but were unable to expand PA opportunities, compared to control SDCs., Conclusions: Although substantial proportions of children met the MVPA guideline at baseline, no SDCs ensured all children met the guideline. This intervention demonstrated that, with support, SDCs can help all children in attendance to accumulate their daily recommended 60min MVPA., Trial Registration: ClinicalTrials.gov NCT02161809.

Objective: Initial efficacy of a magazine-based discussion group for improving physical activity (PA), self-worth, and eating behaviors in female college freshmen., Design: Randomized control trial., Setting: A large university in southwestern United States., Participants: Thirty-seven female college freshmen were randomized to the intervention (n = 17) and control groups (n = 20) in September 2013., Intervention: Participants completed an 8-week magazine-based discussion group program, Fit Minded College Edition, adapted from Fit Minded, a previously tested theory-based intervention. Education on PA, self-worth, and nutrition was provided using excerpts from women's health magazines. Participants also had access to a Web site with supplementary health and wellness material. The control group did not attend meetings or have access to the Web site but received the magazines. Interventions focusing on concepts of self-worth with less focus on weight and appearance may promote long term PA participation and healthy eating behaviors in college women., Main Outcome Measures: Self-reported PA, global self-worth, knowledge self-worth, self-efficacy, social support, eating behaviors (ie, fruit/veggie/junk food/sugar-sweetened beverage consumption), satisfaction, and Web site usage., Results: Mean age of participants was 18.11 (SD = 0.32) years. Time × Intervention effects were observed for PA minutes per week (Partial η = 0.34), knowledge self-worth (Partial η = 0.02), and daily sugar-sweetened beverage consumption (Partial η = 0.17) (P < .05), with the intervention group reporting greater increases in PA and knowledge self-worth and greater decreases in sugar-sweetened beverage consumption., Conclusions: A magazine-based discussion group may provide a promising platform to improve health behaviors in female college freshmen.

This study examines the link between implementation of Strategies to Enhance Practice (STEPs) and outcomes. Twenty after-school programs (ASPs) participated in an intervention to increase children's accumulation of 30 minutes/day of moderate to vigorous physical activity (MVPA) and quality of snacks served during program time. Outcomes were measured via accelerometer (MVPA) and direct observation (snacks). STEPs implementation data were collected via document review and direct observation. Based on implementation data, ASPs were divided into high/low implementers. Differences between high/low implementers' change in percentage of boys accumulating 30 minutes/day of MVPA were observed. There was no difference between high/low implementers for girls. Days fruits and/or vegetables and water were served increased in the high/low implementation groups, while desserts and sugar-sweetened beverages decreased. Effect sizes (ES) for the difference in changes between the high and low group ranged from low (ES = 0.16) to high (ES = 0.97). Higher levels of implementation led to increased MVPA for boys, whereas girls MVPA benefited from the intervention regardless of high/low implementation. ESs of the difference between high/low implementers indicate that increased implementation of STEPs increases days healthier snacks are served. Programs in the high-implementation group implemented a variety of STEPs strategies, suggesting local adoption/adaptation is key to implementation., (© 2016 Society for Public Health Education.)

Purpose: The aim of this study was to evaluate an intervention designed to assist after-school programs (ASPs) in meeting snack nutrition policies that specify that a fruit or vegetable be served daily and sugar-sweetened beverages/foods and artificially flavored foods eliminated., Design: The study used a 1-year group-randomized controlled trial., Setting: The study took place in ASPs operating in South Carolina, United States., Subjects: Twenty ASPs serving over 1700 children were recruited, match-paired postbaseline on enrollment size and days fruits/vegetables were served per week, and randomized to either intervention (n = 10) or control (n = 10) groups., Intervention: The study used Strategies To Enhance Practice for Healthy Eating (STEPs-HE), a multistep adaptive intervention framework that assists ASP leaders and staff to serve snacks that meet nutrition policies while maintaining cost., Measures: Direct observation of snacks served and consumed and monthly snack expenditures as determined by receipts were used., Analysis: The study used nonparametric and mixed-model repeated measures., Results: By postassessment, intervention ASPs increased serving of fruits/vegetables to 3.9 ± 2.1 vs. 0.7 ± 1.7 d/wk and decreased serving sugar-sweetened beverages to 0.1 ± 0.7 vs. 1.8 ± 2.4 d/wk and sugar-sweetened foods to 0.3 ± 1.1 vs. 2.7 ± 2.5 d/wk compared to controls, respectively. Cost of snacks increased by $0.02/snack in the intervention ASPs ($0.36 to $0.38) compared to a $0.01 per snack decrease in the control group ($0.39 to $0.38). Across both assessments and groups, 80% to 100% of children consumed FVs., Conclusions: The STEPs-HE intervention can assist ASPs in meeting nationally endorsed nutrition policies with marginal increases in cost., (© 2016 by American Journal of Health Promotion, Inc.)

Introduction: Afterschool programs (ASPs) across the US are working towards achieving the standard of all children accumulating 30min of moderate-to-vigorous physical activity (MVPA) during program time. This study describes the two-year impact of an intervention designed to assist ASPs meeting the 30min/day MVPA standard., Methods: Using a two-year delayed treatment, group randomized controlled trial, 20 ASPs serving ~1700 children/year (6-12yrs) were randomized to either an immediate (n=10, baseline-2013 and 2yrs intervention fall-2013-to-spring-2015) or delayed group (n=10, baseline 2013-2014 and 1yr intervention fall-2014-to-spring-2015). The intervention, Strategies-To-Enhance-Practice (STEPs), focused on programming MVPA in the daily schedule, training of staff and leaders, and ongoing technical support/assistance. Accelerometry-derived proportion of children meeting the 30min/day MVPA standard was measured in the spring of each year. Mixed model logistic regressions were used to examine the change in the odds of achieving the MVPA standard. Analyses were conducted in 2015. Data were collected in one southeastern US state., Results: Immediate boys (n=677) and delayed girls (n=658) increased the percent achieving 30min MVPA/day from 35.9% to 47.0% (odds ratio [OR]=1.88, 95% CI 1.18-3.00) and 13.1% to 19.1% (OR=1.42, 95% CI 1.03-1.96). Immediate girls (n=613) and delayed boys (n=687) exhibited a nonsignificant increase from 19.1% to 21.6% (OR=1.20, 95% CI 0.84-1.72) and 29.0% to 31.3% (OR=1.13, 95%CI 0.80-1.58)., Conclusions: STEPs can have an impact on children's MVPA and time spent sedentary, yet was unable to fully achieve the goal of all children accumulating 30minMVPA/day. Additional efforts are need to identify strategies ASPs can use to meet this important public health standard., Competing Interests: Potential conflicts of interest: The authors declare that there are no conflicts of interest, (Copyright © 2016 Elsevier Inc. All rights reserved.)

Text4baby is a free, mobile health information service for pregnant and post-partum women. This study aims to understand preferences of physical activity text messages (SMS), sequentially develop prototype SMS, and determine preferred dose of SMS to inform a future study utilizing Text4baby. This study had a user-centered design with three phases: (1) literature review and interviews with pregnant women for development of prototype SMS, (2) interviews with health care professionals and pregnant women for prototype SMS feedback, and (3) survey to determine preferred dose of SMS. Data from interviews identified knowledge and support as major themes. Prototypes were developed (N = 14) and informed 168 SMS. Pregnant women (N = 326) thought three SMS/week were about right (50.2 %) and preferred three SMS/week throughout pregnancy (71.9 %). There is a need for opportunities for behavioral scientists to incorporate evidence-based practices within scalable interventions. As such, this research will inform utilization of Text4baby to potentially improve physical activity participation.

Standards targeting children's healthy eating and physical activity (HEPA) in after-school programs call for staff to display or refrain from HEPA-promoting or -discouraging behaviors that are linked to children's HEPA. This study evaluated strategies to align staff behaviors with HEPA Standards. Staff at four after-school programs serving approximately 500 children participated in professional development training from January 2012 to May 2013. Site leaders also attended workshops and received technical support during the same time frame. Changes in staff behaviors were evaluated using the System for Observing Staff Promotion of Activity and Nutrition in a pre- (fall 2011) multiple-post (spring 2012, fall 2012, and spring 2013), no-control group study design. A total of 8,949 scans were completed across the four measurement periods. Of the 19 behaviors measured, 14 changed in the appropriate direction. For example, staff engaging in physical activity with children increased from 27% to 40% of scans and staff eating unhealthy foods decreased from 56% to 14% of days. Ongoing training and technical assistance can have a measureable impact on staff behaviors linked to child-level HEPA outcomes. Future research should explore the feasibility of disseminating ongoing trainings to after-school program staff on a large scale., (© 2015 Society for Public Health Education.)

This study describes the link between level of implementation and outcomes from an intervention to increase afterschool programs' (ASPs) achievement of healthy eating and physical activity (HE-PA) Standards. Ten intervention ASPs implemented the Strategies-To-Enhance-Practice (STEPs), a multi-component, adaptive intervention framework identifying factors essential to meeting HE-PA Standards, while 10 control ASPs continued routine practice. All programs, intervention and control, were assigned a STEPs for HE-PA index score based on implementation. Mixed-effects linear regressions showed high implementation ASPs had the greatest percentage of boys and girls achieving 30 min of moderate-to-vigorous physical activity (47.3 and 29.3%), followed by low implementation ASPs (41.3 and 25.0%), and control ASPs (34.8 and 18.5%). For healthy eating, high/low implementation programs served fruits and vegetables an equivalent number of days, but more days than control programs (74.0 and 79.1% of days versus 14.2%). A similar pattern emerged for the percent of days sugar-sweetened foods and beverages were served, with high and low implementation programs serving sugar-sweetened foods (8.0 and 8.4% of days versus 52.2%), and beverages (8.7 and 2.9% of days versus 34.7%) equivalently, but less often than control programs. Differences in characteristics and implementation of STEPs for HE-PA between high/low implementers were also identified., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: After-school programs (ASPs) are a promising opportunity for increasing girls' physical activity (PA). Few curricula are targeted specifically for the needs of girls, and the effectiveness of most of these curricula is unknown. One curriculum that is specifically designed to facilitate PA in girls in the ASP setting but has not been formally evaluated is GoGirlGo! (GGG). The purpose of the qualitative assessment was to explore staff's overall satisfaction with GGG and to identify best practices for implementation., Method: A qualitative case study consisting of semistructured interviews with staff (n = 21) was conducted. Data were analyzed using the process of immersion/crystallization., Results: A majority of participants reported being satisfied with GGG. Best practices for implementation included having site directors schedule time and space for GGG and adapting GGG to fit the needs of the girls. Suggested improvements included increasing the intensity of the PA offered, adding visuals (e.g., videos), and providing interactive staff training., Discussion: This qualitative exploration of GGG provided several suggested modifications for GGG. These modifications may strengthen GGG and other girl-focused ASP programs to improve girls' ability to obtain recommended levels of PA in ASPs., (© 2014 Society for Public Health Education.)

Background: Fewer than 50% of middle-aged women participate in regular physical activity (PA). Innovative approaches that engage women who may not otherwise participate in PA programs are warranted. The purpose of this study was to explore the acceptability and feasibility of a 12-week tablet-based book club for improving middle-aged women's PA., Materials and Methods: Thirty women (35-64 years of age) were randomized to the Fit Minded Tablet (n=15) and the Standard Fit Minded (i.e., face-to-face intervention) (n=15) groups. The Fit Minded Tablet was adapted from the Standard Fit Minded, a previously tested, theory-based book club intervention using books as a platform for discussion and group support to help women adopt regular PA. Both interventions met weekly for 3 months, for a total of 12 sessions. Tablet group participants accessed materials (e.g., e-books, workbook, live/recorded videoconferencing) via a tablet computer; Standard group participants received materials (e.g., printed books, workbook, live face-to-face meetings) in person. Feasibility (i.e., implementation and expansion) was assessed using process evaluation, qualitative interviews, satisfaction surveys, and quantitative outcome assessments., Results: Women in the Tablet group attended fewer meetings (mean, 8.25) than women in the Standard group (mean, 9.9). Videoconferencing, digital literacy, and participant engagement limitations were observed in the Tablet group. Tablet participants enjoyed the e-books but thought technology barriers hindered their engagement during meetings. Women in both groups valued the support they received from other group members. Standard participants cited this support as a key contributor to their PA changes, whereas Tablet participants reported needing in-person contact to feel more connected., Conclusions: Given the popularity of tablet computers and the value that middle-aged women place on group interaction to support their PA behaviors, additional research is warranted to determine best strategies for optimizing social support, mitigating technology barriers, and improving engagement in online and mobile health promotion programs targeting middle-aged women.

There is a need to improve girls' physical activity (PA) in afterschool programs as girls' PA levels are consistently lower than boys'. An evidence-based professional development framework, the 5 Ms, has been effective in helping staff to improve PA in both girls and boys but further improvements in girls' PA are needed. Little is known about staff's perceptions of using PA promotion strategies to promote girls' PA. Therefore, the purpose of this study was to explore staff perceptions of the use of evidence-based PA promotion strategies for promoting PA in girls. Semi-structured interviews were conducted with staff from three community-based afterschool programs located within a school setting (n=18). Data were analyzed using the process of immersion/crystallization. A majority of staff had some knowledge of PA promotion strategies but few staff consistently utilized these strategies and a majority felt several strategies were unnecessary (i.e., having a PA policy). Newer staff reported depending on senior staff to promote PA in girls. Overall, findings suggest that staff's perceptions may impact their use of PA promotions strategies. The results of this study will contribute to the enhancement of an existing staff training framework (the 5 Ms) to improve girls' PA in afterschool programs., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

National and state organizations have developed policies calling upon afterschool programs (ASPs, 3-6 pm) to serve a fruit or vegetable (FV) each day for snack, while eliminating foods and beverages high in added-sugars, and to ensure children accumulate a minimum of 30 min/d of moderate-to-vigorous physical activity (MVPA). Few efficacious and cost-effective strategies exist to assist ASP providers in achieving these important public health goals. This paper reports on the design and conceptual framework of Making Healthy Eating and Physical Activity (HEPA) Policy Practice in ASPs, a 3-year group randomized controlled trial testing the effectiveness of strategies designed to improve snacks served and increase MVPA in children attending community-based ASPs. Twenty ASPs, serving over 1800 children (6-12 years) will be enrolled and match-paired based on enrollment size, average daily min/d MVPA, and days/week FV served, with ASPs randomized after baseline data collection to immediate intervention or a 1-year delayed group. The framework employed, STEPs (Strategies To Enhance Practice), focuses on intentional programming of HEPA in each ASPs' daily schedule, and includes a grocery store partnership to reduce price barriers to purchasing FV, professional development training to promote physical activity to develop core physical activity competencies, as well as ongoing technical support/assistance. Primary outcome measures include children's accelerometry-derived MVPA and time spend sedentary while attending an ASP, direct observation of staff HEPA promoting and inhibiting behaviors, types of snacks served, and child consumption of snacks, as well as, cost of snacks via receipts and detailed accounting of intervention delivery costs to estimate cost-effectiveness., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: GoGirlGo! (GGG) is designed to increase girls' physical activity (PA) using a health behavior and PA-based curriculum and is widely available for free to afterschool programs across the nation. However, GGG has not been formally evaluated. The purpose of this pilot study was to evaluate the effectiveness of the GGG curricula to improve PA, and self-efficacy for and enjoyment of PA in elementary aged girls (i.e., 5-13 years)., Methods: Nine afterschool programs were recruited to participate in the pilot (within subjects repeated measures design). GGG is a 12-week program, with a once a week, one-hour lesson with 30 minutes of education and 30 minutes of PA). Data collection occurred at baseline, mid (twice), post, and at follow-up (3-months after the intervention ended). PA was assessed via accelerometry at each time point. Self-efficacy for and enjoyment of PA was measured using the Self-Efficacy Scale and the Short-PA enjoyment scale and was assessed at baseline, post, and follow-up. Fidelity was assessed at midpoint., Results: Across all age groups there was a statistically significant increase in PA. Overall, on days GGG was offered girls accumulated an average of 11 minutes of moderate-to-vigorous PA compared to 8 minutes during non-GGG days. There was a statistically significant difference in girls' self-efficacy for PA reported between baseline and post, which was maintained at follow-up. An improvement in enjoyment of PA for girls was found between baseline and follow-up. According to fidelity assessment, 89% of the activities within the curriculum were completed each lesson. Girls appeared to respond well to the curriculum but girls 5-7 years had difficulties paying attention and understanding discussion questions., Conclusions: Even though there were statistically significant differences in self-efficacy for PA and enjoyment of PA, minimal increases in girls' PA were observed. GGG curricula improvements are warranted. Future GGG programming should explore offering GGG every day, modifying activities so that they are moderate-to-vigorous in intensity, and providing additional trainings that allow staff to better implement PA and improve behavior management techniques. With modifications, GGG could provide a promising no-cost curriculum that afterschool programs may implement to help girls achieve recommendations for PA.

Background: The purpose of this study was to determine the effectiveness of Ready for Recess, an elementary school recess intervention targeting staff training (ST) or providing recreational equipment (EQ) separately, and the combination (EQ+ST) on physical activity (PA)., Methods: Participants were children attending 1 of 12 elementary schools (grades 3rd-6th) included in the study. Separate analytical models were used to evaluate the effects of the intervention conditions on children's accelerometry and direct observation derived PA measures., Results: Boys and girls were measured using accelerometry (n = 667). Boys in EQ+ST increased their MVPA by 14.1% while ST decreased their MVPA by -13.5%. Girls in ST decreased their MVPA by -11.4%. Neither boys nor girls in EQ increased their time spent in MVPA. A total of 523 (boys) and 559 (girls) observations were collected. For boys' and girls' sedentary and vigorous activity there were no significant main effects for treatment condition, time, or treatment condition-by-time effects., Conclusions: Environmental modifications are only as strong as the staff that implements them. Supervision, if not interactive, may be detrimental to PA participation, especially in girls. Research related to staff training for encouragement and promotion of PA coupled with appropriate use of equipment during recess is warranted.

Background: Frontline-staff are critical to achieving policies related to child physical activity and nutrition (PAaN) in out-of-school-time programs (OSTP). Recent policies call upon staff to demonstrate behaviors related to PAaN. Currently, no instrument exists to measure these behaviors. This study fills the gap between policy mandates and staff behaviors by describing the development of the System for Observing Staff Promotion of Activity and Nutrition (SOSPAN) in OSTP., Methods: SOSPAN items were aligned with existing OSTP policies. Reliability and validity data of SOSPAN were collected across 8 OSTP: 4 summer day camps and 4 afterschool programs. Validity of SOSPAN staff behaviors/management of PA was established using the percent of children active measured concurrently via direct observation., Results: A total of 6437 scans were performed. Interrater percent agreement ranged from 74%-99% across PAaN behaviors. Children's activity was associated with staff facilitative behaviors/management, such as playing with the children and providing 2 or more activities for children to choose, while prohibitive behaviors/management, such as waiting in line were related to increased sedentary behavior. Staff nutrition behaviors were observed in less than 0.6% of scans., Conclusion: SOSPAN is a reliable and valid tool to assess staff behaviors/management of PAaN in OSTPs.

School community readiness (CR) for health promotion efforts may be critical to the effectiveness of school-based interventions aimed at promoting youth physical activity and reducing childhood obesity. The purpose of this study was to: (i) identify key informants who scored highest on school CR at baseline and (ii) determine the effects of Ready for Recess on changes in CR among school key informants from baseline to post-intervention. Key informants (N = 98) across 17 schools participated in CR interviews. Interview questions focused on school CR for physical activity and childhood obesity efforts across six dimensions. At baseline, principals scored higher than teachers in overall readiness and knowledge of the issue and higher than recess staff and nurses in leadership. Leadership readiness decreased across key informants at post-intervention and principals demonstrated greater decreases when compared with recess staff. Baseline disparities between principals and other key informants suggest principals may have overestimated the readiness of staff implementing the intervention. Declines among principals indicate that they may not have been prepared to deliver adequate support to successfully implement the intervention. These results illuminate the importance of assessing/improving school readiness prior to interventions. The CR model may provide an opportunity to improve school-based physical activity interventions.

Background: Children's achievement of recommendations for moderate-to-vigorous physical activity (MVPA) in afterschool programs (ASP) is complex. It is unclear what elements of the ASP environment influence children's physical activity (PA). The purpose of this study was to determine the relationship of staff behaviors and ASP features (eg, organized activity, recreational equipment) to MVPA participation in youth attending ASPs., Methods: Data were collected in 12 ASPs in the Midwest. Staff behavior and child PA was measured using the System for Observing Play and Leisure Activity in Youth. The percentage of children's MVPA was examined in relation to staff behaviors and ASP features., Results: Increases in MVPA were observed when staff were directly engaged in PA, verbally promoted MVPA, and when PA was organized and equipment was present. When 3 or more of these characteristics were present, the proportion of children engaged in MVPA increased by 25%-30%. Conversely, MVPA levels decreased when these characteristics were absent and when staff were attending to other ASP duties or were supervising., Conclusion: This study provides evidence about the specific staff behaviors that may influence higher proportions of youth being active during ASP and implies specific skills that need to be incorporated into ASP staff training.

Background: Ideal approaches to increasing long-term physical activity (PA) adherence in women remain unclear. This study used a longitudinal mixed-methods approach to 1) determine the effectiveness of an 8-month book club intervention for increasing PA participation and self-worth, and reducing barriers at 1-year followup; and 2) identify reasons why completers and noncompleters did or did not maintain PA., Methods: One year after the cessation of Women Bound to be Active (WBA), completers (participated in posttesting; n = 30) and noncompleters (did not participate in posttesting; n = 22) responded to questionnaires and interviews assessing their body mass index (BMI), current PA participation, barriers, and global self-worth., Results: Compared with noncompleters, completers reported decreases in BMI, higher motivation for PA, higher ratio of benefits to barriers, and more consistent PA. Both groups still reported barriers to PA, especially time; however, completers more often reported strategies for overcoming these barriers. Completers more directly discussed the impact of their improved self-worth on their PA participation., Conclusions: In the future, a greater focus on time management and self-regulation strategies should be emphasized in PA interventions, specifically those that focus on women. This may help to prevent program and long-term PA attrition.

Afterschool programs (3-6 p.m.) are positioned to play a critical role in combating childhood obesity. To this end, state and national organizations have developed policies related to promoting physical activity and guiding the nutritional quality of snacks served in afterschool programs. No conceptual frameworks, however, are available that describe the process of how afterschool programs will translate such policies into daily practice to reach eventual outcomes. Drawing from complex systems theory, this article describes the development of a framework that identifies critical modifiable levers within afterschool programs that can be altered and/or strengthened to reach policy goals. These include the policy environment at the national, state, and local levels; individual site, afterschool program leader, staff, and child characteristics; and existing outside organizational partnerships. Use of this framework and recognition of its constituent elements have the potential to lead to the successful and sustainable adoption and implementation of physical activity and nutrition policies in afterschool programs nationwide.

Background: Activate Omaha (AO), a community-wide health initiative, was awarded a grant by Active Living by Design in 2003., Purpose: To establish credibility of the partners in AO and increase awareness of active living in the community by emphasizing promotions (branding, logo recognition)., Methods: Media, including billboards, TV and radio ads, high-profile spokespersons, grassroots efforts, and worksite "toolkits" featuring tips and creative messaging on physical activity were combined to incentivize people to be physically active. Campaign surveys were conducted by the Market Survey Research Group each year from 2005 to 2008., Results: Survey data based on the first campaign indicated that 86% of Omahans wanted to be part of an active community and to be active with younger generations. The second campaign focused on getting families physically active together, and this survey data showed that citizens wanted to be a part of an active community. A third campaign added practical examples of citizens being active within the community and efforts expanded to worksites with consistent messaging for employees. The final survey indicated that 78% of respondents found Omaha to be an active community compared to 63% who had that response 3 years earlier., Conclusions: Activate Omaha was successful in gaining credibility and leveraging additional funding to implement complementary programming and physical projects, and as a result, changing community perceptions and influencing policy decisions., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: The recess environment in schools has been identified as an integral part of school-based programs to enhance physical activity (PA). The purpose of this study was to report pilot findings on the extent to which the Ready for Recess intervention was associated with a different amount of increase in moderate to vigorous PA (MPVA) during recess and the rest of the school day between girls and boys, and between nonwhites and whites., Methods: The Ready for Recess intervention modified the recess environment of schools by providing staff training and recreational equipment. The MPVA levels of 3rd, 4th, and 5th grade students (n = 93) at 2 schools were measured pre- and post-intervention using ActiGraph accelerometers. Multiple regression models with robust variance were utilized to test for the interaction of intervention with gender and race/ethnicity., Results: The intervention was associated with an adjusted increase of 4.7 minutes (P <.001) in moderate/vigorous PA during recess. There was no evidence that this effect varied by gender (P = .944) or race (P = .731). The intervention was also associated with an adjusted increase of 29.6 minutes (P < .001) in moderate/vigorous PA during rest of the school day. While this effect did not vary by gender, there was some evidence (P = .034) that nonwhites benefited more from the intervention than whites., Conclusion: Simple strategies such as staff training and recreational equipment may be an effective way to increase PA in children (despite gender or ethnicity) during recess time as well as during the rest of the school day.

Background: After-school programs (ASPs, 3 pm to 6 pm) have been called upon to increase the amount of daily physical activity children accumulate and improve the nutritional quality of the snacks served. To this end, state and national physical activity and nutrition (PAaN) policies have been proposed. Frontline staff who directly interact with children on a daily basis are charged with the responsibility to meet policy goals. Without appropriate skills, staffers' ability to achieve such goals is limited. The gap between policies and improvements in PAaN must be bridged through professional development training. This article describes the development of an ASP staff professional development training program., Methods: A systematic review was performed to identify relevant theoretical perspectives, empirical evidence, and recommended best practices relating to promoting PAaN of children., Results: A comprehensive professional development framework was developed that incorporated the key elements identified from the review. These elements were distilled into 5 primary categories and conceptually referred to as the 5 Ms: mission-clearly defined policy/standards for PAaN; motivate-providing choices, developmentally appropriate activities, feedback, and encouragement; manage-structuring and managing the environment for safety, routines, and discipline; monitor-ongoing evaluation of PAaN; and maximize-incorporating all former Ms., Conclusions: The application of this training framework should lead to improved implementation and eventual achievement of policy goals for PAaN in ASPs. These competencies need to be developed in all ASPs if widespread improvements in PAaN within the ASP setting are to be realized., (© 2012, American School Health Association.)

Background: The purpose of this study was to determine the effectiveness of Ready for Recess: an elementary school recess intervention targeting staff training (ST) and providing recreational equipment (EQ)., Methods: Ready for Recess had 4 intervention schools: 1) EQ+ST, 2) EQ, 3) ST, and 4) control. Moderate-to-vigorous physical activity (MVPA) was assessed with accelerometers at the four schools in 257 3rd- to 6th-grade children. Random intercept models for overweight/obese (OWOB) and healthy weight (HW) for boys and girls separately, examined change in percentage of time spent in MVPA during recess across EQ+ST, EQ, and ST compared with the control from baseline to postintervention., Results: HW boys receiving EQ+ST increased MVPA by 19.4%, OWOB boys receiving ST increased MVPA by 4.5%, OWOB girls receiving EQ-ST increased MVPA by 6.0%, while HW girls receiving EQ decreased MVPA by 13.6% in comparison with the control., Conclusions: Ready for Recess represents a possible means to increase MVPA in OWOB girls/boys, populations least likely to meet MVPA recommendations. However, the effect of the intervention was not uniform across all subgroups.

Background: Creating an optimal environment at recess may be necessary to maximize physical activity (PA) participation in youth. The purpose of this study was to determine the initial effectiveness of an elementary school recess intervention on the amount of moderate PA (MPA) and vigorous PA (VPA) during recess and the school day., Methods: This school-based intervention included staff training, activity zones, and playground equipment. The PA levels of third, fourth, and fifth grade students (n = 93) at two schools were measured at baseline and post-intervention using ActiGraph accelerometers. Paired t tests were used to compare percentage of time spent during recess in MPA and VPA. Multiple regressions were utilized to model the effect of intervention, age, sex, race, body mass index, and school on minutes spent in MPA and VPA., Results: The multiple regression results demonstrated increases of 2.5 minutes of MPA (p < .001) and 2.2 minutes of VPA (p < .001) at recess and an increase of 18.7 minutes of MPA (p < .001) and 4.7 minutes of VPA (p < .001) during the school day. These represent respective increases of 51.2% and 112.2% in the adjusted means of MPA and VPA during recess and respective increases of 92.2% and 71.6% in the adjusted mean of MPA and VPA during school day., Conclusion: Staff training, recreational equipment, and playground markings are inexpensive, simple ways to increase PA during recess so that children can accumulate minutes of PA to meet the recommended guidelines of 60 minutes per day., (© 2011, American School Health Association.)

Objective: Activate Omaha Kids, a community collaborative, was designed, implemented, and evaluated with the aim of preventing childhood obesity in the Omaha community. Activate Omaha Kids brought together key stakeholders and community leaders to create a community coalition. The coalition's aim was to oversee a long-term sustainable approach to preventing obesity. Following a planning phase, a business plan was developed that prioritized best practices to be implemented in Omaha., Methods: The business plan was developed using the Ecological Model, Health Policy Model, and Robert Wood Johnson Foundation Active Living by Design 5P model. The three models helped the community identify target populations and activities that then created a single model for sustainable change., Results: Twenty-four initiatives were identified, over one million dollars in funding was secured, and evaluation strategies were identified., Conclusion: By using the models from the initial steps through evaluation, a clear facilitation of the process was possible, and the result was a comprehensive, feasible plan. The use of the models to design a strategic plan was pivotal in building a sustainable coalition to achieve measurable improvements in the health of children and prove replicable over time.

Little progress has been made toward increasing physical activity in women. This study aimed to determine if an 8-month theory-based book club intervention (Women Bound to Be Active) was effective in increasing: (a) self-worth, (b) benefits relative to barriers to physical activity, and (c) physical activity in women (n = 51). Findings suggested a book club was effective for improving: self-worth, the benefits relative to barriers to physical activity, and possibly participation in physical activity. This is an innovative model to help women become more active and learn skills that may enable them to be active on their own long after a physical activity program has ended.

Background: Omaha, an urban Nebraska community, represents 26% of the state's population. Activate Omaha, formed in 2003, addressed the obesity epidemic caused by physical inactivity and poor infrastructure to support active living in the community., Intervention: Activate Omaha's efforts focused on a strategic social-marketing campaign, using baseline and annual data for guidance. Complementary programming was implemented parallel to the marketing campaigns. Safe Routes to School infrastructure projects were federally funded, and 20 miles of on-street bicycle facilities were funded privately. The mayor's Bicycle Pedestrian Advisory Committee was formed, including directors from city planning and public works., Results: The initiative became recognized by the community as the lead resource promoting physical activity. This enabled the initiative to be instrumental in infrastructure changes and programming targeting the underserved. The initiative leveraged an additional $1,475,000 over 5 years. These funds created opportunities to invest in shared community resources such as providing bicycles for underserved youth, building infrastructure through Safe Routes to School initiatives, and successful worksite programming., Lessons Learned: Partners should be utilized in a strategic manner, where they are engaged purposefully and serve a role in assuring successful outcomes. Community readiness should determine the focus on policy, physical projects, and promotional and programmatic strategies, as well as the integration of these strategies., Conclusions: Activate Omaha grew into a credible organization moving public policy and leveraging new public-private relationships through multilevel strategies. This approach ultimately led to sustainable changes in the community infrastructure and the behavior of its citizens.

The purpose of this investigation was to assess the effectiveness of a lifestyle intervention (a women's book club; Women Bound to be Active) in promoting long-term physical activity. Thirty-five women (26-70 years; mean age 50.6 years) completed the 8-month intervention and participated in the one-year follow-up. At follow-up, physical activity returned to baseline levels; however, self-worth and body mass index significantly improved. Women were more knowledgeable about physical activity at follow-up; however, they failed to maintain physical activity after the intervention. Components of the intervention were effective in improving self-worth and lowering BMI at one-year follow-up. To enhance long-term physical activity adherence, continued research and intervention modifications are needed.

Context: The majority of children do not participate in sufficient amounts of daily, health-enhancing physical activity. One strategy to increase activity is to promote it within the after-school setting. Although promising, the effectiveness of this strategy is unclear. A systematic review was performed summarizing the research conducted to date regarding the effectiveness of after-school programs in increasing physical activity., Evidence Acquisition: Databases, journals, and review articles were searched for articles published between 1980 and February 2008. Meta-analysis was conducted during July of 2008. Included articles had the following characteristics: findings specific to an after-school intervention in the school setting; subjects aged

Increasing physical activity (PA) has become a national health objective due to its associated health benefits, but low participation rates. Therefore, the purpose of this study was to determine the feasibility of an 8-month (September 2006-April 2007) PA book club (Women Bound to Be Active-WBA) in increasing PA and self-worth (SW) among women. Fifty-six adult women participated in an 8-month intervention consisting of weekly meetings designed to improve PA knowledge, awareness, confidence, and SW. Results indicated a significant increase in PA and SW. The WBA program represents a creative theory-based approach to empowering women to be more active.

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.)

Background: The purpose of this study was to describe which theory-based behavioral and technological features middle-aged women prefer to be included in a mobile application designed to help them adopt and maintain regular physical activity (PA). Methods: Women aged 30 to 64 years (N = 120) completed an online survey measuring their demographics and mobile PA application preferences. The survey was developed upon behavioral principles of Social Cognitive Theory, recent mobile app research, and technology adoption principles of the Unified Theory of Acceptance and Use of Technology. Frequencies were calculated and content analyses conducted to identify which features women most preferred. Results: Behavioral features that help women self-regulate their PA (PA tracking, goal-setting, progress monitoring) were most preferred. Technological features that enhance perceived effort expectancy and playfulness were most preferred. Many women reported the desire to interact and compete with others through the application. Conclusions: Theory-based PA self-regulation features and theory-based design features that improve perceived effort expectancy and playfulness may be most beneficial in a mobile PA application for middle-aged women. Opportunities to interact with other people and the employment of social, game-like activities may also be attractive. Interdisciplinary engagement of experts in PA behavior change, technology adoption, and software development is needed. [ABSTRACT FROM AUTHOR]

Background: National and state organizations have called upon afterschool programs (3-6 PM, ASP) to promote physical activity (PA). Few strategies exist that ASPs can use to increase the PA of children enrolled. This study evaluated a policy-level intervention (Movin' Afterschool, MAS) designed to increase PA through staff implemented policy-level changes and ongoing technical support. Methods: Twelve preexisting communitybased ASPs serving 580 children (5-12 yrs, 57% girls) were invited to take part in MAS. Evaluation of children's PA, staff behaviors (engaged or promote PA, other ASP tasks, general supervising), and environmental features (equipment, organized PA) at baseline (Fall 2010) and postassessment (Spring 2011) were collected using SOPLAY (System for Observing Play and Leisure Activity in Youth) for boys and girls, separately. Random effects models evaluated changes in PA categories (sedentary, walking, vigorous). Results: The percentage of boys and girls sedentary decreased by 11.8% and 11.4%, respectively. Girls walking increased by 6.9% while boys vigorous PA increased by 6.5%. Greater increases in vigorous activity were observed as postassessment in organized activities for boys and during indoor activities for girls. Conclusions: Findings indicate a policy-level approach targeting staff training and ongoing technical support can produce notable increases in PA within the ASP setting. [ABSTRACT FROM AUTHOR]

Purpose: Essential thrombocythemia, polycythemia vera, and myelofibrosis are rare chronic hematological malignancies known as myeloproliferative neoplasms (MPNs) and are characterized by deregulated myeloid lineage cell production, splenomegaly, and heterogeneous symptom profiles. MPN patients suffer from a significant symptom burden (eg, fatigue, depressive symptoms, early satiety) and an impaired overall quality of life (QoL). Current treatments typically include pharmacological approaches, which may come with additional side effects and may be limited by treatment-associated toxicities (ie, cytopenias). Nonpharmacological approaches such as physical activity may be beneficial for reducing symptom burden and improving QoL. To date, no studies have examined physical activity as a nonpharmacological approach in MPN patients despite preliminary evidence supporting its benefit in other hematological cancers. The purpose of this article is to (1) review the literature related to physical activity and specific hematological cancer subtypes and to (2) make suggestions for future research involving physical activity in MPN patients as a symptom management strategy. Methods: A brief review of studies examining physical activity in leukemias, lymphomas, and myelomas (excluding stem-cell transplant patients) was conducted. Results: There is preliminary evidence to suggest that physical activity may be an effective approach to improve patient-reported outcomes (fatigue, depression, anxiety, sleep), physical fitness (cardiovascular fitness, balance, body composition), and overall QoL in other hematological cancers. Conclusions: Based on encouraging findings in other hematological cancers, future research should examine the feasibility and effectiveness of physical activity in MPN patients. [ABSTRACT FROM AUTHOR]

Afterschool programs (ASPs) have potential to provide children moderate to vigorous physical activity (MVPA). The availability and types (e.g., free play or organized activities) of physical activity opportunities, their structure (e.g., presence of lines, elimination games), and staff behaviors (e.g., encouragement, engaged) can influence children’s MVPA. This study explored these factors in 20 ASPs serving over 1,700 elementary-age children. The occurrence, types, and structure of physical activity opportunities, and staff behaviors were collected via the SOSPAN (System for Observing Staff Promotion of Physical Activity and Nutrition). A total of 4,660 SOSPAN scans were completed across 63 complete program days (1,733 during physical activity opportunities). Physical activity opportunities were observed on 60 program days across all 20 sites, with 73% of those opportunities classified as free play. ASPs scheduled an average of 66.3 minutes (range 15-150 minutes) of physical activity opportunities daily. Games played included basketball, tag, soccer, and football. Staff rarely engaged in physical activity promotion behaviors, and the structure of organized games discouraged MVPA. For example, staff verbally promoted physical activity in just 6.1% of scans, while organized games were more likely to involve lines and elimination. Professional development training may enhance staffs’ physical activity promotion and the structure of activity opportunities. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND Snacks served in afterschool programs ( ASPs, 3-6 pm) represent an important opportunity to promote healthy eating. ASP policies suggest a fruit/vegetable is served daily, while sugar-sweetened foods/beverages and artificially flavored snacks are eliminated. Limited information exists on the types of snacks served in ASPs, if snacks meet existing nutrition policies, whether children eat the snacks, and their cost. METHODS Direct observation of snacks served and consumed was collected in 20 ASPs serving over 1700 elementary age children. The number of days that snacks were served/week was evaluated for compliance with nutrition policies. Costs of snacks were collected via receipts. RESULTS Programs served desserts and artificially flavored salty snacks on 2.7 and 2.1 days/week. Fruits and vegetables were served 0.6 and 0.1 days/week, respectively. Sugar-sweetened beverages were served 1.8 days/week. Of the children (N = 383) observed, 75% to 100% consumed the snack served, with 95% and 100% of served fruits/vegetables consumed. No ASP served fruit/vegetables daily, 18 served sugar-sweetened foods, 16 served artificially flavored snacks, and 14 served sugar-sweetened beverages. Desserts and salty snacks cost $0.27-$0.32/snack vs $0.38-$0.40/snack for vegetables/fruits. CONCLUSIONS The quality of snacks failed to meet nutrition policies and consists of predominately high-sugar and artificially flavored options. Strategies to improve snack offerings in ASPs while addressing price barriers are required. [ABSTRACT FROM AUTHOR]