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Developed through a partnership with the National Physical Activity Plan Alliance and the National Coalition for Promoting Physical Activity (NCPPA), Implementing Physical Activity Strategies profiles 42 physical activity programs that are helping people adopt more active and healthy lifestyles based on the U.S. National Physical Activity Plan (NPAP). This resource combines the expertise of editors Russell Pate and David Buchner as well as a host of respected researchers and practitioners well known for their long-term advocacy for a more physically active society.
Implementing Physical Activity Strategies highlights innovative and proven physical activity programs under way in eight sectors: education; mass media; health care; parks, recreation, fitness, and sports; business and industry; public health; transportation, land use, and community design; and volunteer and nonprofit organizations. For each, readers will find an explanation of how the physical activity program was executed, how it aligns with the NPAP, the target population of the program, cross-sector collaborations and their benefits, and assessments of program effectiveness.
A consistent presentation of information on each program makes this comprehensive reference easy to use. The text maintains a focus on topics such as cross-sector collaboration, tactics and troubleshooting tips, and how each program aligns with the NPAP. This ensures readers will find tools and information to bring success to their own initiatives. Many of the program profiles include sample press releases, ads, screen shots, photos, surveys, follow-up forms, and other hands-on materials to help readers more readily translate the ideas and materials of these programs into new physical activity initiatives. By sharing examples and case studies of proven programs, Implementing Physical Activity Strategies supports those seeking ways to bring the benefits of increased physical activity to their constituents:
• Officials and managers in public health and health care
• Volunteer and nonprofit organizations
• Recreation, fitness, and sport leaders
• Physical education teachers
• Worksite health promotion advocates
• Transportation, urban policy, and design workers
Implementing Physical Activity Strategies offers a detailed look into exemplary programs that have brought about an increase in regular physical activity for individuals where they live, work, and play. Stimulate new ideas, inspire creativity and innovation, and set in motion new results-oriented physical activity initiatives with Implementing Physical Activity Strategies.
Sector I: Education
Chapter 1. State Physical Activity Policies
Chapter 2. Public School Physical Activity Legislative Policy Initiatives: What We Have Learned
Chapter 3. Role of Recess and Physical Activity Breaks during the School Day
Chapter 4. Physical Activity in Early Childhood Centers: New York City as a Case Study
Chapter 5. After-School Programs and Physical Activity
Sector II: Mass Media
Chapter 6. VERB It’s What You Do! and VERB Scorecard: Bringing a National Campaign to Communities
Chapter 7. Start.Living.Healthy: Using Mass Media to Increase Physical Activity in Hawai’i
Chapter 8. ParticipAction: The National Voice of Physical Activity and Sport Participation in Canada
Chapter 9. Wheeling Walks: A Targeted Mass Media–Led Physical Activity Campaign
Chapter 10. Mass Media Campaigns to Promote Physical Activity: Australia and New Zealand as Case Studies
Chapter 11. Communication Strategies to Promote the 2008 Physical Activity Guidelines for Americans
Sector III: Health Care
Chapter 12. Institute of Lifestyle Medicine
Chapter 13. Exercise Vital Sign at Kaiser Permanente
Chapter 14. Profession MD—Lifestyle Program
Chapter 15. Development and Implementation of the Physical Activity Vital Sign
Chapter 16. Strides to Strength Exercise Program for Cancer Survivors
Sector IV: Parks, Recreation, Fitness, and Sports
Chapter 17. ParK Through 12 and Beyond: Converting Schoolyards Into Community Play Space in Crowded Cities
Chapter 18. Learning to be Healthy and Active in After-School Time: The Säjai Foundation’s Wise Kids Program
Chapter 19. Moovin’ and Groovin’ in the Bayou: Summer Camps Increase Youth Physical Activity Through Intentional Design
Chapter 20. Finding Common Ground: Play Space Modifications Can Increase Physical Activity for All Children
Chapter 21. Pioneering Physically Active Communities: YMCA of the USA’s Healthier Communities Initiatives
Chapter 22. Professional Sport Venues as Opportunities for Physical Activity Breaks: The San Diego Padres' FriarFit Instant Recess
Sector V: Business and Industry
Chapter 23. Fit to Drive: Integrated Injury Prevention, Health, and Wellness for Truck Drivers
Chapter 24. Instant Recess: Integrating Physical Activity Into the Workday at Kaiser Permanente South Bay Health Center
Chapter 25. ChooseWell LiveWell: An Employee Health Promotion Partnership between Saint Paul Public Schools and HealthPartners
Chapter 26. What’s Next? Keeping NextEra Energy’s Health & Well-Being Program Active for 20 Years
Chapter 27. Johnson & Johnson: Bringing Physical Activity, Fitness, and Movement to the Workplace
Chapter 28. Building Vitality at IBM: Physical Activity and Fitness as One Component of a Comprehensive Strategy for Employee Well-Being
Sector VI: Public Health
Chapter 29. State-Based Efforts for Physical Activity Planning: Experience From Texas and West Virginia
Chapter 30. Health Impact Assessments (HIA): A Means to Initiate and Maintain Cross-Sector Partnerships to Promote Physical Activity
Chapter 31. Move More Scholars Institute
Chapter 32. The National Society of Physical Activity Practitioners in Public Health:
Elevating the Issue of Physical Activity; Equipping Professionals to Do So
Chapter 33. Successful Cross-Sector Partnerships to Implement Physical Activity: Live Well Omaha Coalition
Chapter 34. Tracking and Measuring Physical Activity Policy
Chapter 35. Institutionalizing Safe Routes to School in Columbia, Missouri
Sector VII: Transportation, Land Use, and Community Design
Chapter 36. Local Public Health Leadership for Active Community Design: An Approach for Year-Round Physical Activity in Houghton, Michigan
Chapter 37. A Road Diet for Increased Physical Activity: Redesigning for Safer Walking, Bicycling, and Transit Use
Chapter 38. Incorporating Physical Activity and Health Outcomes in Regional Transportation Planning
Chapter 39. Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly
Sector VIII: Volunteer and Nonprofit
Chapter 40. Using Legal and Policy Muscles to Support Physically Active Communities
Chapter 41. Reducing Barriers to Activity Among Special Populations: LiveStrong at the YMCA:
Chapter 42. New York State Healthy Eating and Physical Activity Alliance
The National Physical Activity Plan Alliance is a not-for-profit organization committed to ensuring the long-term success of the National Physical Activity Plan (NPAP). The alliance is governed by a board of directors composed of representatives of organizational partners and at-large experts on physical activity and public health. The key objectives of the alliance are to support implementation of the NPAP’s strategies and tactics, expand awareness of the NPAP among policy makers and key stakeholders, evaluate the NPAP on an ongoing basis, and periodically revise the NPAP to ensure its effective linkage to the current evidence base.
The National Coalition for Promoting Physical Activity (NCPPA) is a blend of associations, health organizations, and private corporations advocating for policies that encourage Americans of all ages to become more physically active. NCPPA spearheads federal policy and advocacy work in support of the National Physical Activity Plan’s recommendations, and the organization maintains a strong voice for physical activity in Washington, DC, where NCPPA members and staff work together to encourage federal legislators to make policy changes that promote regular physical activity in all facets of life.
Russell Pate, PhD, is a professor in the department of exercise science at the University of South Carolina at Columbia. Pate led the development of the 2010 U.S. National Physical Activity Plan and served on the 2008 U.S. Physical Activity Guidelines Advisory Committee. He is the chairman of the board of directors of the National Physical Activity Plan Alliance and chairman of the coordinating committee of the National Physical Activity Plan Alliance.
Pate is a past president of the American College of Sports Medicine (ACSM) and served as lead author of the 1995 CDC-ACSM Statement on Physical Activity and Public Health. He is also past president of the National Coalition for Promoting Physical Activity. In 2012, Pate received the Honor Award from the ACSM. He received the Honor Award from the Science Board of the President’s Council on Physical Fitness and Sports in 2007.
He resides with his wife in Columbia, where he enjoys running, attending theater performances, and watching collegiate athletics.
David Buchner, MD, MPH, is a Shahid and Ann Carlson Khan professor in applied health sciences in the department of kinesiology and community health at the University of Illinois at Urbana-Champaign. From 2008 to 2013, he directed the master of public health program in his department. He is a board member for the National Physical Activity Plan Alliance. From 1999 to 2008, he was chief of the Physical Activity and Health Branch at the Centers for Disease Control and Prevention. In this role, Buchner chaired the writing group for the 2008 Physical Activity Guidelines for Americans and participated in numerous public health initiatives to promote physical activity. Buchner’s research has focused on physical activity and aging. He has studied the role of physical activity in preventing functional limitations, disability, and falls. His favorite recreational activity is backpacking and hiking with his family.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
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Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
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Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
Learn more about Implementing Physical Activity Strategies.
Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
Learn more about Implementing Physical Activity Strategies.
The contribution of regular physical activity to health
Research has established the contribution of regular physical activity to key health outcomes, such as obesity prevention and musculoskeletal development, and to educational outcomes, such as attentiveness, cognitive processing, discipline, and academic performance (USDHHS 2008).
Physical activity during the school day has traditionally come in the form of recess, a supervised but unstructured time for free play, imagination, movement, stress relief, enjoyment, rest, and socialization, with demonstrated physical, social, emotional, cognitive, and organizational benefits (Beighle 2012; Ramstetter et al. 2010). However, because of an increased emphasis on standardized testing, time allotted to recess during the elementary school day is decreasing (Lee et al. 2007; Pressler 2006; UCLA and Samuels and Associates 2007). (Time devoted to physical education is decreasing too, for the same reason; Henley et al. 2007; McKenzie and Kahan 2008). Some schools have banned traditional vigorous recess activities such as playing tag, climbing monkey bars, and running, because of fear of liability for injury (e.g., Bazar 2006), despite case law that makes this unlikely (Spengler et al. 2010).
Schwinn© is used by permission from Pacific Cycle Inc.
Ridgers and colleagues (2011) observed significant decreases in recess and lunchtime moderate and vigorous physical activity, with commensurate increases in sedentary time, during the periods 2001-2006 and 2003-2008; these changes were magnified in older children. Similarly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recommendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addition, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009).
In fact, studies in the emerging field of inactivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regarding physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data showing that teachers whose students were predominantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009).
A number of strategies can be used to increase children's physical activity levels during recess. These strategies, which are particularly effective in combination, include providing inexpensive playground equipment (e.g., plastic hoops, jump ropes, and bean bags), training recess supervisors to organize or teach games and interact with students, painting playground surfaces with lines for games or murals, and designating playground "activity zones" (Beighle 2012; Stratton and Leonard 2002; Taylor et al. 2011; Verstraete et al. 2006).
The private sector is responding to the recess deficit. One notable example is PlayWorks, a nonprofit group that serves 129,000 students in 320 schools across the United States by structuring recess using trained adult coaches and student coach assistants (Robert Wood Johnson Foundation 2007). Another is the Dannon company's Danimals Rally for Recess campaign, an online contest to encourage schools to resurrect recess, offering prizes for meeting certain benchmarks and lottery drawings to win construction of a playground. Many corporations and foundations provide play equipment to schools.
Reprinted, by permission, from Playworks. Photo: Anukul Gurung.
Despite the role of recess as a venerable and cherished school institution and recent efforts to increase the amount of energy children expend during recess (e.g., Morabia and Costanza 2009), little rigorous research has evaluated efforts to stem the erosion of recess. Considerable debate exists about the benefits of free play versus structured play, duration and timing of breaks, optimal supervision and monitoring arrangements, and changing needs as children age (Ramstetter et al. 2010; Robert Wood Johnson Foundation 2007). For example, a recent study found that permanent school playground facilities were associated with children's physical activity levels, but school physical activity policies were not. Two clear messages emerging from the sparse literature, and from practice-based evidence, are that recess should be considered children's personal time and should not be withheld for academic or punitive reasons and that physical activity (e.g., running, calisthenics) should not be used as a punishment (Ramstetter et al. 2010)
NPAP Tactics and Strategies Used in This Program
Education Sector
- Strategy 1: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in Pre-kindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
- Strategy 2: Develop and implement state and school district policies requiring school accountability for the quality and quantity of physical education and physical activity programs.
- Strategy 3: Develop partnerships with other sectors for the purpose of linking youth with physical activity opportunities in schools and communities.
Program Description
Physical activity breaks, opportunities to incorporate physical activity into the school day, can supplement the levels of activity obtained through recess and physical education classes (Barr-Anderson et al. 2011; Katz et al. 2010; Trost 2007; Trost, Fees, and Dzewaltowski 2008; Weeks et al. 2008). Unlike recess, a topic on which research has been scarce, physical activity breaks have been the subject of a number of recent studies. These breaks, which incorporate short, structured, group physical activities into the school routine, are an environmental intervention that requires minimal upfront or ongoing costs and offers ready exportability and cultural adaptability. The White House Childhood Obesity Task Force Report identified activity breaks as a key secondary school strategy, because recess is seldom an option for older students (United States White House Task Force on Childhood Obesity 2010). Research has demonstrated improvements in individual behaviors and health outcomes (e.g., increased MVPA, attenuated excess weight gain, lowered blood pressure, increased bone density) as well as organizational benefits (improved academic performance, longer attention spans, fewer disciplinary problems) among students participating in classroom physical activity breaks (Barr-Anderson et al. 2011; Murray et al. 2008). Furthermore, classroom physical activity breaks have been shown to improve students' attention and behavior, whereas breaks without physical activity do not (CDC 2010). An additional benefit of classroom-based physical activity interventions is that teachers and other school personnel may be engaged as active role models for students (Alexander et al. 2012; Donnelly et al. 2009; Erwin et al. 2011; Institute of Medicine 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; Woods 2011).
Take 10! (T10) and Instant Recess(IR) are examples of school-based physical activity break interventions with demonstrated success in increasing students' physical activity levels and improving academic engagement. In contrast to recess or physical education class, in which students are required to exit the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children's physical activity during the school day. The two programs take different approaches: T10 incorporates brief bouts of physical activity into students' academic lessons, whereas IR is intended as a mental respite for students and teachers. The programs are similar in that both align with a number of the Education Sector strategies endorsed by the National Physical Activity Plan (NPAP). This chapter provides a review of T10 and IR, including an overview of how they relate to those NPAP strategies.
Take 10! (T10)
Introduced in 1999, T10 isa school-basedprogram that has demonstrated the feasibility and utility of using 10-minute physical activity breaks in the elementary school classroom setting.Studies have shown that these breaks engage students in exercise of sufficient intensity and duration to count toward CDC-recommended levels: for example, average MET levels of 5 to 7 for first, third, and fifth graders, with commensurate caloric expenditures of 27 to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd et al. 2005; Stewart et al. 2004). (One MET is the metabolic equivalent equal to 3.5 milliliters of oxygen consumed per kilogram and per minute.)The breaks also improve on-task time, particularly in students who are easily distracted (Mahar et al. 2006; Mahar 2011). With its grade-level targeted curriculum, T10 provides an example of Strategy 1 of the Education Sector of the NPAP: Provide access to and opportunities for high-quality, comprehensive physical activity programs, anchored by physical education, in prekindergarten through grade 12 educational settings. Ensure that the programs are physically active, inclusive, safe, and developmentally and culturally appropriate.
Whereas T10 emphasizes being active while learning (Kibbe et al. 2011), Physical Activity Across the Curriculum (PAAC), a federally funded study of a variation of T10 that is being conducted at the University of Kansas, focuses on making physical activity integral to the lesson (DuBose et al. 2008). Research findings demonstrate that PAAC engaged 60 to 80 percent of elementary school non - physical education teachers in conducting T10 breaks in 24 low- to moderate-resource public schools in three eastern Kansas cities (Donnelly et al. 2009; Honas et al. 2008). Study staff provided teacher training in a six-hour, off-site in-service session at the beginning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a progressive cultural norm change (an average of 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal of 90-100 minutes a week after two years).
PAAC increased children's physical activity levels, in school and outside of school and on both weekdays and weekend days, suggesting that children do not offset increases in school-based physical activity with decreases in out-of-school physical activity. PAAC also improved reading, math, spelling, and composition scores. In the intervention schools that averaged more than 75 minutes of active lessons weekly, students gained less weight than those in control schools.
Instant Recess (IR)
IR, previously known as Lift Off!,consists of 10-minute themed physical activity breaks, usually performed to music, with simple movements based on sports or ethnic dance traditions. IR is scientifically designed to engage major muscle groups, maximizing energy expenditure, enjoyment, and engagement of individuals of varying ability levels while minimizing perceived exertion and injury risk. IR began as a worksite wellness project of the Chronic Disease Prevention division of the Los Angeles County Department of Health Services in 1999 and expanded as a partnership between state and local health agencies, universities, foundations, corporations, and nonprofit groups (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). Involvement with professional sports teams in 2006 led to the adaptation of IR for the school setting. In contrast to T10, in which the onus generally is on teachers to determine how best to incorporate activity into their lesson plans and to lead the physical activities themselves, IR is an extracurricular turnkey or "plug and play" intervention that is usually technology mediated (Yancey et al. 2009). IR breaks may be distributed as DVDs or CDs, streamed from the Internet, or uploaded as electronic files to district servers accessed by teachers through intranet "smart boards" or closed-circuit TV.
Learn more about Implementing Physical Activity Strategies.
Discover the three major lessons of successful program implementation
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
Program leaders identified three major lessons that will assist with future implementation of similar programming: (1) use technology to automate administrative components of the program; (2) cultivate community partnerships and leverage existing partnerships to enhance program success; and (3) introduce gradually and progress mindfully.
The first year of ChooseWell LiveWell was entirely "paper-based." The wellness program manager and SPPS wellness champions administered program registration, materials, and communications manually. The administrative burden placed on these individuals detracted from their ability to focus on motivating and coaching employees and limited the scope of the program's reach. The development and launch of the district wellness website enabled program staff and volunteers to focus their roles on health promotion. The website helped broaden the reach of the program by facilitating 24/7 access to program information, registration, and materials.
Another key lesson was to form partnerships whenever possible. By design, ChooseWell LiveWell was created as a partnership between a local health services organization and a community school district. Annual meetings among leaders from both institutions have helped to facilitate communication and ensure that programming is informed by the latest evidence and industry knowledge and meets the needs of the population. The success of the program also can be attributed to partnerships within the school district. In the first three years of the program, ChooseWell LiveWell staff partnered with staff who worked on student-focused wellness efforts. The program leveraged the existing network of wellness champions from the Steps grant, as well as Minnesota's Statewide Health Improvement Program, to partner and promote program options available to employees throughout the district.
ChooseWell LiveWell was developed at a gradual pace, and monitoring and evaluation were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the employee population and the latest evidence-based interventions.
Program Evaluation
An advisory group consisting of program staff and leaders from both the school district and HealthPartners convenes annually to evaluate and assess the effectiveness of the program. The group's meetings include a program overview and discussions about the number of sites involved, available program options, and population-level health indicators from the health assessment. The discussions have informed annual program planning and staffing and provide an opportunity for leaders within the school district and HealthPartners to share ideas and discuss planning for the coming year and strategy going forward.
Central to evaluation of the ChooseWell LiveWell program is the employee health assessment offered each fall. Developed by HealthPartners, the health assessment contains a cross section of scientifically validated questions and medically approved algorithms that can accurately predict a person's likelihood of developing diabetes or heart disease in the next two to three years. It includes a series of questions in several areas: personal demographics and health history, self-care, women's health, nutrition, physical activity, alcohol and tobacco, safety, and readiness to change. The health assessment is predictive of health care costs and worker productivity indicators and has been a key instrument for the documentation of the program's impact on health and costs over time.
Annual reports are generated based on health assessment information, including summary health scores. The summary health scores allow for tracking of population health over time and are used to estimate the impact of the program on cost-related outcomes, such as estimated health care cost savings over time. In general, these indicators have shown a progressive improvement in overall population health, resulting in cost savings. In year 5 of the program, HealthPartners estimated cumulative four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on the improvements in summary health scores. Additionally, a group of 1,942 unique individuals who participated in the program for all 5 program years, from 2005 to 2010, experienced statistically significant improvements in physical activity.
Tables 25.3 and 25.4 display the descriptive characteristics, key physical activity indicators, and aggregate improvement over time among a unique cohort of 1,942 participants who participated in the first five years of the ChooseWell LiveWell program.
Populations Best Served by the Program
The ChooseWell LiveWell program could be replicated in a variety of employer settings. The wellness website enabled easy communication and access to employees across the many sites in the school district. This program feature would serve employer populations in all sectors well, including small and medium-sized employers, and especially those with offices in many different locations.
Tips for Working Across Sectors
The core ChooseWell LiveWell program components - annual employee health assessment with personalized feedback, a variety of program options, incentives for participation and effective communications - have been demonstrated to be effective in other industries. Key to the success of this program was the leadership support from both major program partners as well as the focus on building and optimizing a culture of health within the organization. Future programs should consider the specifics of organizational culture and potential impacts on program implementation. The role of the wellness website, for example, may be less impactful in sectors in which computer access is limited.
Additional Reading and Resources
Bandura, A. Health promotion from the perspective of social cognitive theory. Psychol. Health 13:623-49.
Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self-monitoring in weight loss: A systematic review of the literature. J. Am. Diet. Assoc. 111:92-102.
Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Comparison of techniques for self monitoring, eating and exercise behaviors on weight loss in a correspondence-based intervention. J. Am. Diet. Assoc. 107:1807-10.
Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Rev. 22(3):381.
Lindberg, R. 2000. Active living: On the road with the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9.
Prochaska, J.O., and W.G. Velicer. 1997. The transtheoretical model of health behavior change. Am. J. Health Promot. 12(1):38-48.
N.P. Pronk. 2008. Designing a multisector approach to health and wellness. In: America's Health Insurance Plans (AHIP). AHIP innovations in prevention, wellness and risk reduction (pp. 18-21). www.ahip.org/redirect/AHIP_Innovations_Prevention.pdf.
Pronk, N.P., Ed. 2009. ACSM's Worksite Health Handbook, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Kinetics.
Pronk, N.P. 2009. Physical activity promotion in business and industry: Evidence, context, and recommendations for a national plan. Journal of Physical Activity and Health 6(Suppl. 2):S220-35.
Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. 2011. The association between health assessment-derived summary health scores and health care costs. J. Occup. Environ. Med. 53(8):872-8.
Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. Pronk. 2009. Employee health at BAE Systems: An employer-health plan partnership approach. In: ACSM's Worksite Health Handbook: A Guide to Building Healthy and Productive Companies (pp. 318-326). N.P. Pronk, Ed. Champaign, IL: Human Kinetics.
Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, and E.M. McGhee. 2004. The effectiveness of web-based vs. non-web-based interventions: A meta-analysis of behavioral change outcomes. J. Med. Internet Res. 6(4).
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Program development for cancer patients
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Current cancer treatments, although increasingly efficacious for improving survival, are toxic in numerous ways and produce negative short- and long-term physiological and psychological effects, including pain, decreased cardiorespiratory capacity, cancer-related fatigue, reduced quality of life, and suppressed immune function (Courneya and Freidenreich 2001).
Since the first research study on cancer patients and exercise was conducted in 1986, a growing body of evidence has demonstrated that exercise during and after cancer treatment is safe and minimizes the adverse effects of treatment. However, clinicians have historically advised cancer survivors to rest and to avoid activity.
In 2009, the American College of Sports Medicine (ACSM) assembled a roundtable of experts to review the body of evidence supporting the benefits of exercise among cancer survivors and to develop guidelines that could be used by fitness instructors and trainers. The ACSM recommendations for cancer survivors are the same as those from the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans (age-appropriate) as well as those from the American Cancer Society:
- Undertake 150 minutes per week of moderate to intense exercise or 75 minutes per week of vigorous exercise.
- Engage in strength training 2 or 3 times a week, completing 8 to 10 exercises of 10 to 15 repetitions per set, with at least one set per session.
- Avoid inactivity.
- Return to normal daily activities as quickly as possible.
- Continue normal daily activities and exercise as much as possible during and after nonsurgical treatments.
When making modifications to exercise regimens, practitioners must assess an individual's cancer type, treatment, and side effects. The LIVESTRONG at the YMCA program was developed to respond to the need for exercise opportunities for cancer survivors and adheres to the ACSM cancer exercise guidelines.
Lessons Learned
Through its national dissemination of LIVESTRONG at the YMCA, the Y and the LIVESTRONG Foundation have learned many lessons that have helped strengthen the program model and aid in program expansion. An initial, important lesson was that successful programming requires staff who have a deep understanding and empathy for cancer survivors in their communities.
Although the process of developing and delivering LIVESTRONG at the YMCA has evolved from experimental to more prescriptive, implementation of the program in individual communities and environments requires Ys to be flexible and adaptable to meet the wants, needs, and interests of cancer survivors in their community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one interviews and focus groups, before launching programs and services. This period of discovery not only is foundational to staff awareness but also builds and deepens staff empathy, a key competency for those who will connect and engage with cancer survivors.
A second lesson learned was that Ys must earn credibility with cancer survivors in their communities. Although the YMCA is uniquely suited to provide this program because of its commitment to community outreach and focus on those who need support to gain or regain health, the YMCA has had to establish its credibility as an organization with expertise in cancer survivorship. In a national survey of cancer survivors, the majority believed that a physical activity program at the Y was a good idea, but they wanted to know that it had the backing of their physician or local oncology center and that the instructors were well qualified. Offering the program at no charge was an important factor for often cash-strapped survivors. The Y and the LIVESTRONG Foundation have worked hard to ensure that LIVESTRONG at the YMCA meets these criteria, building active partnerships with local agencies that serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors.
A final lesson learned was that before offering the physical activity program, Ys must ensure that their environments are safe and supportive for cancer survivors. Staff of each participating Y must be sure that its atmosphere supports cancer survivors' physical, social, and emotional needs. This insight has led to a variety of changes in facilities: shortening the distance cancer survivors must travel to get into or through the building; installing handrails in hallways and stairways; providing hand gel sanitizer dispensers throughout the facility; having a "resting" or "support" chair in workout areas and changing areas; providing an area where private conversations can be held; and enlisting members in ensuring facilities are clean and germ-free for cancer survivor participants.
Populations Best Served by the Program
The National Cancer Institute estimates that there are more than 13 million cancer survivors living in the United States today. With 1 in 2 men and 1 in 3 women predicted to be diagnosed with cancer in their lifetimes, the need for services that focus on quality of life during and after treatment is increasingly important. Because current evidence suggests that being physically active following diagnosis may reduce the risk of recurrence of some types of cancer, offering programs that encourage and support survivors in living a physically active lifestyle is increasingly important.
LIVESTRONG at the YMCA is designed for in-treatment or posttreatment cancer survivors. The program is available in more than 226 cities and more than 250 branches. More than 13,000 individuals have completed the LIVESTRONG at the YMCA program, and the LIVESTRONG Foundation and the YMCA of the USA are seeking to extend the program to more facilities. The hope is that cancer survivors will have access to a community-based program that is designed to meet their needs, help them establish a healthy lifestyle that will improve their quality of life, and ultimately reduce the risk of cancer recurrence and the development of a second primary cancer.
Program Evaluation
Cancer survivors who participate in LIVESTRONG at the YMCA engage in pre- to postprogram functional and quality of life assessments. Functional assessments measure participants' strength, aerobic capacity, balance, and flexibility. Results from a sample 12-week session of LIVESTRONG at the YMCA showed the following:
- 56 percent improvement in leg strength
- 45 percent improvement in upper body strength
- 60 percent improvement in aerobic capacity (treadmill or bicycle ergometer time to fatigue)
A 29-question life assessment asks participants to rate their physical functioning, anxiety, depression, fatigue, sleep disturbance, satisfaction with social role, pain interference, and pain intensity. Quality of life assessment scores have not yet been compiled for evaluation.
Participants also complete a post-program survey. A sample of more than 100 of these surveys showed the following:
- 92 percent agree that they have made progress related to their health and well-being goals as a result of their participation in LIVESTRONG at the YMCA.
- 86 percent agree that they are part of a supportive community at the YMCA (as defined by four measures).
- 92 percent agree that their program leader has the understanding and skills needed to lead a physical activity program for cancer survivors.
- 93 percent plan to continue their health and well-being journey at the YMCA after the end of the program.
- 94 percent are highly likely to recommend LIVESTRONG at the YMCA to a friend or family member.
The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The following quotation is an example of the profound impact that LIVESTRONG at the YMCA has had on many cancer survivors' overall well-being:
This class changed my life. When you get the diagnosis, everything is so bleak - and then they tell you that you can't lift more than five pounds, and it is even more depressing. I felt very alone and then I came to the Y. This class is a community for me. I love it and am happy and thankful that I get to do it. I am so privileged to have had it; I believe it saved my life. This class gave me back my life, my sense of self, hope, and camaraderie and made me a stronger me. It improved my life and my mental outlook.
The program had a positive effect not only on cancer survivors but on YMCA staff members as well. One chief operating officer shared this about his involvement with LIVESTRONG at the YMCA:
At times we can become so overwhelmed with balancing budgets, building facilities, developing marketing tools, and managing staff that we forget why we are part of this mission-driven organization. My involvement with LIVESTRONG at the YMCA has allowed me to catch my breath and reconnect with the YMCA mission in a whole new way through the life-changing work that is being done in our YMCAs with cancer survivors.
With YMCAs in more than 10,000 communities across the United States, the potential impact of this program is tremendous. The YMCAs that have engaged in this work describe the experience as game-changing for the YMCA and life-changing for the staff involved. YMCAs are queued up for the chance to invest their own money and six months of their staff time to participate in this program that often transforms the way a YMCA functions and operates.
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