Date of Award


Document Type

Open Access Dissertation


Exercise Science

First Advisor

Michael W. Beets


Current research has suggested that supportive healthy eating and physical activity (HEPA) policy and practice environments play a significant role in shaping the physical activity levels and eating habits of youth. Subsequently, a wide array of audit tools assessing policy and practice environment characteristics across settings that care for youth were developed. However, the extent that available audit tools accurately reflect the policy environment characteristics of the settings that care for the youth population remains unknown. Therefore, this dissertation encompasses four studies. The purpose of the first study was to examine the measurement properties of audit tools currently in use for assessing policy environment characteristics across a variety of settings that care for youth. Fifty-three individual tools that met the inclusion criteria were identified. Reliability and validity data were available for only 11 tools. Reliability coefficients (median) for individual items across tools were 0.62 (kappa), 0.88 (ICC), 74.0% (percent agreement), 0.62 (Pearson correlation) and 0.73 (Cronbach’s α). Validity coefficients (median) for individual items across tools were 0.35 (kappa), 0.98 (ICC), 0.22 (r) and 74.7% (percent agreement). The purpose of the second study was to determine the feasibility of training afterschool program (ASP) leaders to use the Healthy Afterschool Program Index - Physical Activity (HAPI-PA) and the Healthy Afterschool Program Index – Nutrition (HAPI-N) scales] accurately. Forty-four program leaders across South Carolina were recruited. Program leaders were randomized to either in-person or distance training group. Ninety percent of the items in the in-person group and 73% of the items in the distance group had a kappa ≥ 0.70 for the HAPI-PA scale. In comparison, 83% of the HAPI-N scale items in the in-person group and 67% of the items in the distance group had a kappa ≥ 0.70. Equivalency between the two training methods was established for 5 of the 11 items in the HAPI-PA scale and 3 of the 12 items in the HAPI-N scale. The purpose of the third study was to evaluate the responsiveness of the HAPI-PA and HAPI-N scales to policy and practice environment characteristics change. Twenty afterschool programs across South Carolina serving over 1700 children (5-12 years old) participated Baseline data were collected during spring 2013 and post-1 year follow-up data during spring 2014. The HAPI-PA and HAPI-N scales median and interquartile range (IQR) score improved from a baseline score of 9.5 (±5.8) to 13.5 (±2.0) for HAPI-PA and a score 6.5 (±6.5) to 21.0 (±4.0) for HAPI-N after year 1 in the intervention group. For the intervention group the HAPI-PA and HAPI-N scales effect sizes were 0.70 and 2.23, standardized response median were 0.94 and 1.45 and responsiveness index were 1.07 and 2.5, respectively. In comparison, the HAPA-PA and HAPI-N scores showed non- significant changes between baseline and year 1 follow up in the control group in both the median and IQR and using the effect size indices.

The purpose of the fourth study was to examine the influence of both the physical and policy and practice environment characteristics of ASP’s settings on the HEPA behaviors of youth. A total of 1,302 children attending 20 ASPs across South Carolina wore accelerometers (ActiGraph GT3X+) for up to 4 non-consecutive days. Policy-level characteristics were evaluated using the HAPI-PA scale. Physical activity space was measured using a measuring wheel (indoor, ft2) and GIS (outdoor, acres). The structure (free-play or organized) of activity opportunities was evaluated via direct observation. For every 5000ft2 of utilized indoor activity space an additional 2.4 and 3.3 minutes/day of sedentary behavior was observed among boys and girls, respectively. A higher ratio of free-play to organized play was associated with higher indoor sedentary behavior among boys and girls (3.9 minutes/day and 10.0 minutes/day, respectively). For every one acre of outdoor activity space used, an additional 2.7 minutes/day of MVPA was observed for boys. A higher free-play to organized play ratio was associated with higher outdoor MVPA for boys and girls (4.4 and 3.4 minutes/day increase, respectively). Policy characteristics were unrelated to MVPA levels and time spent sedentary. In summer, this dissertation found that audit tools are widely used to quantify the impact of supportive HEPA policy and practice environmental characteristics across settings that care for youth, however, little effort is taken to evaluate the measurement properties of such tools. This wok showed that ASP’s site leaders are able to provide accurate information regarding their program HEPA policy and practice environment using a newly developed audit tool (i.e., the HAAND). Furthermore, the HANND instrument appears to be capable of detecting changes in the ASP’s HEPA environment. More effort should be directed towards providing ASP’s with strategies to meet current HEPA policy and practice recommendation.


© 2015, Rahma Jamea Yousef Ajja