Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning.

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

The Impact of Financial and Psychological Wellbeing on Children's Physical Activity and Screen-Based Activities during the COVID-19 Pandemic.

The COVID-19 pandemic, and the public health measures to combat it, have strained the finances of many families. While parents transitioned to working from home, children transitioned to learning virtually, limiting their organized social and physical activities. Families also reduced the frequency and size of gatherings, impacting psychological wellbeing. This study sought to understand the influence of financial wellbeing on children's physical activity and leisure screen-based activities via mothers' and children's psychological wellbeing. In May and June of 2020, 254 Grade 7 Canadian children and their mothers completed separate online surveys assessing family financial wellbeing, mothers' and children's psychological wellbeing, and children's physical activity and leisure screen-based activities. Structural equation modelling was used to examine the indirect effects of mothers' and children's psychological wellbeing on the relationship between financial wellbeing and children's physical activity and leisure screen-based activities. Final models were adjusted for potential confounders. Study results indicate a significant indirect association between financial wellbeing and children's physical activity and leisure screen-based activities via mothers' and children's psychological wellbeing. These findings demonstrate that higher levels of financial wellbeing are associated with better mental and physical health benefits in children during the COVID-19 pandemic.

Individual and Environmental Factors Associated with Participation in Physical Activity as Adolescents Transition to Secondary School: A Qualitative Inquiry.

The transition from elementary to secondary school is an emotionally and socially complex time when adverse behaviors appear, such as decreased levels of physical activity (PA). Behavioral and environmental factors that influence PA during this time are poorly understood. Therefore, we aimed to identify factors that influence PA as adolescents transition to secondary school. Qualitative interviews were conducted with a sample of 27 ethnically diverse child-parent dyads within the public-school system in British Columbia, Canada (50% boys, 68% mothers, 25% White). The interviews probed for environmental and behavioral factors in school, family, and social contexts that potentially initiated changes in PA, specifically related to the adolescents' transitions. Interviews were recorded and transcribed verbatim. Thematic analyses identified factors at the individual, social, familial, and school levels that may trigger adolescents to change their participation in PA as they transition from elementary to secondary school. Twenty-two factors emerged from the qualitative analysis including school factors (8), household factors (3), social factors (4), and intrapersonal factors (7). These findings contribute to a better understanding of adolescents' PA behaviors and highlight the influence of changing environments as they transition from elementary school to secondary school.

Prevalence and Relationships among Physical Activity Policy, Environment, and Practices in Licensed Childcare Centers from a Manager and Staff Perspective.

Physical activity (PA) is critical to early childhood health and development, and childcare is a key setting for establishing physically active play. In British Columbia (BC), a provincial standard for active play in childcare was enacted, identified here as the Active Play (AP) standard. Pragmatic constraints limit real-world data collection for evaluating policy impact. We explored whether information about policies, practices, and the environment varied when it was collected from managers or staff. Surveys were distributed to BC childcare centers before AP standard enactment to ascertain current PA and fundamental movement skill policies and practices. The full sample (n = 1037 from 625 facilities) and a subsample of paired managers and staff (n = 261 centers) were used to explore agreement across managers and staff in reported prevalence and relationships among indicators. The policy prevalence and relationships for active play and outdoor play variables were relatively similar for manager and staff data, although the matched data had modest agreement and less than optimal intraclass correlations. The prevalence of manager-reported PA policies ranged from 47% for screen-time limits to 77% for fundamental movement skill activities. The manager and staff data highlighted indoor and outdoor space as a primary factor in AP standard adherence. With reliance on sampling staff unfeasible, it appears that the manager data may adequately describe the policies and practices of childcare providers with some notable issues.

Family-based, healthy living intervention for children with overweight and obesity and their families: a 'real world' trial protocol using a randomised wait list control design.

INTRODUCTION: Family-based behavioural weight management interventions are efficacious and widely used to address childhood obesity. Curriculum and strategies vary extensively and scale-up often depends on ensuring that the intervention fits the adoption context. AIMS AND OBJECTIVES: To evaluate the impact and implementation of a 'made in British Columbia' (BC) family-based early intervention programme (EIP) for 8-12 years old with overweight and obesity and their families. METHODS AND ANALYSIS: A randomised waitlist-control trial will assess a 10-week interactive, family-based lifestyle intervention followed by four maintenance sessions, in BC, Canada. We aim to enrol 186 families. The blended intervention includes at least 26 contact hours between participants and programme providers, including interactive activities and educational materials through weekly 90-min group sessions, an online family portal, and self-directed family activities. Curricular content includes information and activities related to healthy eating, physical activity (PA), positive mental health, parenting practices and sleep hygiene. The waitlist control group will receive a modified programme with the same 10-week sessions in the family portal, and four group sessions. Families participate in data collection at baseline, postintervention (week 10) and follow-up (week 18). The primary outcome is to assess changes in child body mass index z-score at 10 weeks between the groups. Secondary outcomes include changes at 10 weeks between the groups in child and parent PA behaviour and skills, healthy eating behaviour, and mental health. Process evaluation will address reach, implementation and maintenance (baseline, 10-week and 18-week) using recruitment tracking forms, parent questionnaire, programme attendance tracking forms, leader feedback surveys, parents and children satisfaction surveys and postprogramme interviews with facilitators, stakeholders and parents. Intention-to-treat analyses will be conducted. Process evaluation will be analysed thematically. ETHICS AND DISSEMINATION: Study procedures were designed to address research and community needs and will follow ethical standards. TRIAL REGISTRATION NUMBER: NCT03643341.

A psychometric study of the Family Resilience Assessment Scale among families of children with autism spectrum disorder.

BACKGROUND: The family system represents a critical context within which children develop. Although raising a child with a disability may represent a challenge to this dynamic system, research demonstrates that families have the capacity to demonstrate both maladaptation and resilience in the face of related stressors. In the current study, we examined the psychometric properties of the Family Resilience Assessment Scale (FRAS) among families of children with autism spectrum disorder (ASD). This tool is the only measure of family resilience that seeks to identify within-family protective factors, including the extent to which they rely on adaptive belief systems, organizational patterns, and communication processes. Identifying protective processes utilized by those who show resilience is critical within both clinical practice and research, as it aligns with a strength-based perspective that builds on what families are doing well. METHODS: Participants included 174 caregivers of individuals with ASD (84% mothers). Caregivers completed the FRAS, as well as the Beach Center Family Quality of Life Scale. The 54-item FRAS was submitted to an exploratory factor analysis, using the iterated principal factor method with a promax rotation. RESULTS: Fifty-one items across 3 factors (Family Communication and Problem Solving, Utilizing Social and Economic Resources, Family Spirituality) were retained, explaining 52% of the total variance. The final scale demonstrated convergent validity with the Family Quality of Life assessment tool. CONCLUSIONS: It is our hope that identifying the optimal scale structure will encourage other researchers to utilize this measure with families of children with ASD, thus continuing to advance the study of family resilience within this unique context.

Constraints to implementing guidelines for the identification, assessment, and management of childhood obesity in the clinical care setting: Prevention and treatment framework.

The "Pathway for the Identification, Assessment and Management of Overweight and Obese Children & Youth" was developed to support healthcare providers in identifying and treating childhood obesity in British Columbia (Canada). PURPOSE: The study aimed to determine the feasibility and effectiveness of using the Pathway in clinical settings. METHODS: 13 healthcare providers (7 family physicians, 2 pediatricians, 2 registered dietitians, and 2 nurse practitioners) assessed the Pathway and participated in semi-structured interviews in 2015. A direct constant comparative analysis guided the coding of the interviews in the NVivo 9 software. RESULTS: The interviews uncovered the complexity of factors that influenced practices of healthcare providers. Three broad issues were identified as required if the "Pathway" were to be used and fully implemented in practices. First, the "Pathway" needs to be modified in terms of how it is presented and explained and be supplemented with appropriate documentation and resources for its implementation, Second, the constraints that limit implementation need to be addressed and should include a focus on both individual (i.e., the healthcare providers themselves) and environmental (i.e., factors within and outside of providers' organizations) factors. Lastly, there is a need to establish processes and/or infrastructure for adapting the "Pathway" to the local context as resources and supports vary by organizations and regions. CONCLUSION: Healthcare providers should be involved in screening and managing childhood obesity. Addressing the challenges found in this study will enable healthcare providers to take a more active role in addressing childhood obesity in their day to day practices.

A population-based analysis of life satisfaction and social support among children of diverse backgrounds in British Columbia, Canada.

PURPOSE: The Satisfaction With Life Scale adapted for Children (SWLS-C) is a self-report measure of children's quality of life and has exhibited sound psychometric properties. In light of increasing ethno-cultural diversity, it is important to understand child life satisfaction across diverse subgroups. Employing children's language background as a proxy for cultural background among children in British Columbia, Canada, we examined (a) the cross-cultural measurement equivalence of the SWLS-C; and (b) cross-cultural relations of peer support and adult support with SWLS-C. METHODS: Participants were 20,119 children (Mage 9.2; 50.2% boys) who provided data as part of a self-report child health survey (the Middle-years Development Instrument). Measurement equivalence across eight language/cultural background groups was tested via multi-group confirmatory factor analysis. Multi-level analyses were used to compare: a) SWLS-C means; and b) associations of peer support and adult support with SWLS-C scores, by language/cultural background. RESULTS: Findings supported strict measurement equivalence between the English language/cultural background group and all other language/cultural background groups for the SWLS-C. Relative to the English language background group, SWLS-C means differed for several language/cultural background groups. Within every language/cultural background group, however, peer and adult support scale scores were significant positive correlates of SWLS-C scores. CONCLUSIONS: This study provided evidence for measurement equivalence of a life satisfaction measure across children from diverse language/cultural backgrounds and identified between-group differences in the level of child life satisfaction that were generally consistent with prior theory and findings. Moreover, results provided evidence of promotive associations of adult support and peer support with life satisfaction among diverse groups of children.

Food marketing in recreational sport settings in Canada: a cross-sectional audit in different policy environments using the Food and beverage Marketing Assessment Tool for Settings (FoodMATS).

BACKGROUND: Children's recreational sport settings typically sell energy dense, low nutrient products; however, it is unknown whether the same types of food and beverages are also marketed in these settings. Understanding food marketing in sports settings is important because the food industry often uses the promotion of physical activity to justify their products. This study aimed to document the 'exposure' and 'power' of food marketing present in public recreation facilities in Canada and assess differences between provinces with and without voluntary provincial nutrition guidelines for recreation facilities. METHODS: Food marketing was measured in 51 sites using the Food and beverage Marketing Assessment Tool for Settings (FoodMATS). The frequency and repetition ('exposure') of food marketing and the presence of select marketing techniques, including child-targeted, sports-related, size, and healthfulness ('power'), were assessed. Differences in 'exposure' and 'power' characteristics between sites in three guideline provinces (n = 34) and a non-guideline province (n = 17) were assessed using Pearson's Chi squared tests of homogeneity and Mann-Whitney U tests. RESULTS: Ninety-eight percent of sites had food marketing present. The frequency of food marketing per site did not differ between guideline and non-guideline provinces (median = 29; p = 0.576). Sites from guideline provinces had a significantly lower proportion of food marketing occasions that were "Least Healthy" (47.9%) than sites from the non-guideline province (73.5%; p < 0.001). Use of child-targeted and sports-related food marketing techniques was significantly higher in sites from guideline provinces (9.5% and 10.9%, respectively), than in the non-guideline province (1.9% and 4.5% respectively; p values < 0.001). It was more common in the non-guideline province to use child-targeted and sports-related techniques to promote "Least Healthy" items (100.0% and 68.4%, respectively), compared to the guideline provinces (59.3% and 52.0%, respectively). CONCLUSIONS: Recreation facilities are a source of children's exposure to unhealthy food marketing. Having voluntary provincial nutrition guidelines that recommend provision of healthier foods was not related to the frequency of food marketing in recreation facilities but was associated with less frequent marketing of unhealthy foods. Policy makers should provide explicit food marketing regulations that complement provincial nutrition guidelines to fulfill their ethical responsibility to protect children and the settings where children spend time.

Are the Physical Activity Parenting Practices Reported by US and Canadian Parents Captured in Currently Published Instruments?

BACKGROUND: The purpose of this study was to compare the physical activity parenting practices (PAPPs) parents report using with the PAPPs incorporated in the published literature. METHODS: PAPPs in the literature were identified by reviewing the content of 74 published PAPP measures obtained from current systematic reviews supplemented with a literature search. The types of PAPPs used by parents were identified by surveying a stratified sample of 134 Canadian and US parents of 5- to 12 year-old children. Items from the literature and parent responses were coded using the same coding scheme. Differences between the PAPPs emphasized by the parents and the literature were examined. RESULTS: Parents significantly emphasized different issues than what is measured in the literature (P < .001). Parents emphasized more control (13.6% vs. 6.9%), modeling and teaching (13.2% vs. 9.2%), and structural strategies (32.2% vs. 28.6%) and less autonomy support (11.8% vs. 14.0%), logistical support (9.9% vs. 12.8%), and responsiveness strategies (19.3% vs. 28.5%). CONCLUSIONS: Physical activity practices most often employed by parents are not the ones emphasized in current measures. The extent to which putting more emphasis on the areas identified by parents will increase the predictive validity of the measures warrants further examination.

Strategic Priorities for Physical Activity Surveillance in the United States.

PURPOSE: Develop strategic priorities to guide future physical activity surveillance in the United States. METHODS: The Centers for Disease Control and Prevention and the American College of Sports Medicine convened a scientific roundtable of physical activity and measurement experts. Participants summarized the current state of aerobic physical activity surveillance for adults, focusing on practice and research needs in three areas: 1) behavior, 2) human movement, and 3) community supports. Needs and challenges for each area were identified. At the conclusion of the meeting, experts identified one overarching strategy and five strategic priorities to guide future surveillance. RESULTS: The identified overarching strategy was to develop a national plan for physical activity surveillance similar to the U.S. National Physical Activity Plan for promotion. The purpose of the plan would be to enhance coordination and collaboration within and between sectors, such as transportation and public health, and to address specific strategic priorities identified at the roundtable. These strategic priorities were used 1) to identify and prioritize physical activity constructs; 2) to assess the psychometric properties of instruments for physical activity surveillance; 3) to provide training and technical assistance for those collecting, analyzing, or interpreting surveillance data; 4) to explore accessing data from alternative sources; and 5) to improve communication, translation, and dissemination about estimates of physical activity from surveillance systems. CONCLUSION: This roundtable provided strategic priorities for physical activity surveillance in the United States. A first step is to develop a national plan for physical activity surveillance that would provide an operating framework from which to execute these priorities.

A mixed-methods exploration of implementation of a comprehensive school healthy eating model one year after scale-up.

OBJECTIVE: To study the implementation of a school-based healthy eating (HE) model one year after scale-up in British Columbia (BC). Specifically, to examine implementation of Action Schools! BC (AS! BC) and its influence on implementation of classroom HE activities, and to explore factors associated with implementation. DESIGN: Diffusion of Innovations, Social Cognitive and Organizational Change theories guided our approach. We used a mixed-methods research design including focus group interviews (seven schools, sixty-two implementers) and a cross-sectional multistage survey to principals (n 36, 92 % response rate) and teachers of grades 4 to 7 (n 168, 70 % response rate). Self-reported implementation of classroom HE activities and reported use of specific AS! BC HE activities were primary implementation measures. Thematic analysis of focus group data and multilevel mixed-effect logistic regression analyses of survey data were conducted. SETTING: Elementary schools across BC, Canada. SUBJECTS: Thirty-nine school districts, thirty-six principals, 168 grade 4 to 7 teachers. RESULTS: Forty-two per cent of teachers in registered schools were implementing AS! BC HE in their classrooms. Users were 6·25 times more likely to have delivered a HE lesson in the past week. Implementation facilitators were school champions, technical support and access to resources; barriers were lack of time, loss of leadership or momentum. Implementation predictors were teacher training, self-efficacy, experience with the physical activity component of AS! BC, supportive school climate and parental post-secondary education. CONCLUSIONS: Our findings reinforce that continued teacher training and support are important public health investments that contribute to successful implementation of school-based HE models after scale-up.

Assessment of Capacity to Consent by Nurses Who Deliver Health Care to Patients Who Misuse Substances.

This qualitative study explored the current practice that nurses use to assess capacity to consent to health care (CTC-HC) in street outreach settings. Key informant interviews were conducted with a purposive sample of nurses from each of British Columbia's five regional health authorities, allowing nurses to describe their lived experiences with assessing CTC-HC. Content analysis was used to summarize information captured in the data. A total of 19 nurses participated in the study. Five themes emerged from the data: (a) internal guiding forces that contribute to the nurses' assessment, (b) external influences that contribute to the nurses' assessment, (c) measures that are important for assessing CTC-HC, (d) threshold setting, and (e) context (physical and interpersonal) within which assessment of capacity takes place. These elements will be incorporated into a capacity assessment tool that can be used in nursing best practices.

Changes to the school food and physical activity environment after guideline implementation in British Columbia, Canada.

BACKGROUND: High rates of childhood obesity have generated interest among policy makers to improve the school food environment and increase students' levels of physical activity. The purpose of this study was to examine school-level changes associated with implementation of the Food and Beverage Sales in Schools (FBSS) and Daily Physical Activity (DPA) guidelines in British Columbia, Canada. METHODS: Elementary and middle/high school principals completed a survey on the school food and physical activity environment in 2007-08 (N=513) and 2011-12 (N=490). Hierarchical mixed effects regression was used to examine changes in: 1) availability of food and beverages; 2) minutes per day of Physical Education (PE); 3) delivery method of PE; and 4) school community support. Models controlled for school enrollment and community type, education and income. RESULTS: After policy implementation was expected, more elementary schools provided access to fruits and vegetables and less to 100% fruit juice. Fewer middle/high schools provided access to sugar-sweetened beverages, French fries, baked goods, salty snacks and chocolate/candy. Schools were more likely to meet 150 min/week of PE for grade 6 students, and offer more minutes of PE per week for grade 8 and 10 students including changes to PE delivery method. School community support for nutrition and physical activity policies increased over time. CONCLUSION: Positive changes to the school food environment occurred after schools were expected to implement the FBSS and DPA guidelines. Reported changes to the school environment are encouraging and provide support for guidelines and policies that focus on increasing healthy eating and physical activity in schools.

School nutritional capacity, resources and practices are associated with availability of food/beverage items in schools.

BACKGROUND: The school food environment is important to target as less healthful food and beverages are widely available at schools. This study examined whether the availability of specific food/beverage items was associated with a number of school environmental factors. METHODS: Principals from elementary (n=369) and middle/high schools (n=118) in British Columbia (BC), Canada completed a survey measuring characteristics of the school environment. Our measurement framework integrated constructs from the Theories of Organizational Change and elements from Stillman's Tobacco Policy Framework adapted for obesity prevention. Our measurement framework included assessment of policy institutionalization of nutritional guidelines at the district and school levels, climate, nutritional capacity and resources (nutritional resources and participation in nutritional programs), nutritional practices, and school community support for enacting stricter nutritional guidelines. We used hierarchical mixed-effects logistic regression analyses to examine associations with the availability of fruit, vegetables, pizza/hamburgers/hot dogs, chocolate candy, sugar-sweetened beverages, and french fried potatoes. RESULTS: In elementary schools, fruit and vegetable availability was more likely among schools that have more nutritional resources (OR=6.74 and 5.23, respectively). In addition, fruit availability in elementary schools was highest in schools that participated in the BC School Fruit and Vegetable Nutritional Program and the BC Milk program (OR=4.54 and OR=3.05, respectively). In middle/high schools, having more nutritional resources was associated with vegetable availability only (OR=5.78). Finally, middle/high schools that have healthier nutritional practices (i.e., which align with upcoming provincial/state guidelines) were less likely to have the following food/beverage items available at school: chocolate candy (OR= .80) and sugar-sweetened beverages (OR= .76). CONCLUSIONS: School nutritional capacity, resources, and practices were associated with the availability of specific food/beverage items in BC public schools. Policies targeting the school environment are increasingly being considered as one of the strategies used to address childhood obesity, as a result it is important to further understand the factors associated with the availability of specific food/beverage items at school.

The relationship between income and weight control strategies among Canadian adults.

OBJECTIVE: The goal of this study was to examine use of weight control strategies in Canadian adults and the role of income as a barrier to using these strategies. METHODS: Data from the Canadian Community Health Survey cycle 4.1 on health behaviour change was used for this study. Analysis was restricted to adults (18+ years) residing in the 10 provinces of Canada. Respondents were categorized as having used weight control strategies in their lifestyle if they responded that they increased exercise, improved/modified their eating habits, or lost weight in the previous 12 months, as the primary means of health improvement. An adjusted household income ratio divided into deciles was used as a measure of income. Multivariable logistic regression was used to examine the relationship between income and weight control strategies adjusting for known confounders. RESULTS: Of the 103,990 respondents analyzed, 60% were overweight or obese and 45% reported using weight control strategies in the previous 12 months. Age, sex, ethnicity, having a regular doctor, education, and income were all significantly associated with using weight control strategies in the multivariable model. Results that included all two- and three-way interactions between sex, weight category, and income found that lower income was significantly associated with using fewer weight control strategies--more so for obese men and normal weight women. CONCLUSION: Efforts must be made to create equal access to services and food products that promote weight reduction or control strategies given the rising prevalence of adult obesity in Canada.

Awareness of national physical activity recommendations for health promotion among US adults.

PURPOSE: To examine whether knowledge of the 1995 Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) national physical activity recommendations varies by sociodemographic, behavioral, and communication-related factors. METHODS: Cross-sectional analyses of 2381 participants in the 2005 Health Information National Trends Survey, a national probability sample of the US population contacted via random-digit dial. RESULTS: Only a third of respondents were accurately knowledgeable of the CDC/ACSM physical activity recommendations. Recommendation knowledge was higher among women (OR = 1.70; 95% confidence interval (CI) = 1.35-2.14) than men, the employed compared with those not currently working (OR = 0.73; 95% CI = 0.55-0.95), foreign-born individuals (OR = 1.62; 95% CI = 1.15-2.30) compared with the US-born, and those meeting CDC/ACSM recommendations vs those who do not (OR = 0.74; 95% CI = 0.58-0.96). CONCLUSIONS: There is not widespread knowledge of the consensus national physical activity recommendations. These findings highlight the need for more effective campaigns to promote physical activity among the American public.

Factors influencing lunchtime food choices among working Americans.

There is growing interest in the usefulness of the workplace as a site for promotion of healthful food choices. The authors therefore analyzed data of U.S. adults (N = 1,918) who reported working outside the home and eating lunch. The majority (84.0%) of workers had a break room. About one half (54.0%) purchased lunch > or = 2 times/week, with higher percentages for males, Blacks, younger (age 18-34 years) versus older adults (age 55 years or older), and obese versus normal-weight persons. The most important lunch food choice value was convenience (34.3%), followed by taste (27.8%), cost (20.8%), and health (17.1%). The typical source for purchasing lunch was a fast-food restaurant (43.4%), followed by on-site cafeteria/snack shop (25.3%), full-service restaurant (16.9%), supermarket (5.2%), vending machine (4.4%), and convenience store (4.0%); younger adults and those less educated relied more on fast-food places. This study identifies individual factors and values that may influence future dietary health initiatives in the work site.

Waiting for child developmental and rehabilitation services: an overview of issues and needs.

Concern about the length of time that children, young people, and families may have to wait to access assessment, diagnostic, interventional, therapeutic, and supportive child developmental and rehabilitation (CDR) services is widespread, but adequate data collection and research on this issue remain limited. We review key concepts and issues relevant to waiting for CDR services from the published literature, a national workshop devoted to this topic, and international experience. We conclude that gaps in data, evidence, and consensus challenge our ability to address the issue of waiting for CDR services in a systematic way. A program of research coupled with actions based on consensus-building is required. Research priorities include acquiring evidence of the appropriateness and effectiveness of different models of intervention and rehabilitation services, and documenting the experience and expectations of waiting families. Consensus-building processes are critical to identify, categorize, and prioritize 'sentinel' components of CDR service pathways: (1) to reduce the inherent complexity of the field; (2) to create benchmarks for waiting for these respective services; and (3) to develop definitions for wait-time subcomponents in CDR services. Collection of accurate and replicable data on wait times for CDR services can be used to document baseline realities, to monitor and improve system performance, and to conduct comparative and analytic research in the field of CDR services.

Development of a Physical Education-Related State Policy Classification System (PERSPCS).

BACKGROUND: As policy-based approaches are increasingly proposed to address childhood obesity, this paper seeks to: (1) present the development of a system to systematically and reliably assess the nature and extent of state physical education (PE) and recess-related policies; (2) determine the inter-rater agreement in using the system; and (3) report on the variability in state policies using a December 31, 2003 baseline. METHODS: The PE and Recess State Policy Classification System (PERSPCS) was developed from a conceptual framework and was informed by reviewing the scientific and gray literatures and through consultations with an expert panel and key experts. Statutes and regulations enacted as of December 31, 2003 were retrieved from Westlaw (data retrieved and analyzed in 2004-2005). RESULTS: PERSPCS addresses five areas: PE time requirements, staffing requirements for PE, curriculum standards for PE, assessment of health-related fitness, and recess time (elementary schools only). The inter-rater agreement ranged from 0.876 (PE staffing requirements) to perfect agreement (recess time). Staffing requirements had more restrictive policies, followed in decreasing order by time requirements, curriculum standards, assessment, and recess time. Overall, state policies met minimal requirements across areas and grade levels as of December 2003. CONCLUSIONS: Extending PERSPCS to address other aspects of childhood obesity is a critical first step in understanding the range of state policy approaches in this area and their impact. PERSPCS should be examined in conjunction with school district-level policies to determine the overall effects of policies on school environmental and behavioral outcomes. PERSPCS is not designed to set policy guidelines.