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Article |

Are Perceived Neighborhood Hazards a Barrier to Physical Activity in Children? FREE

Andrea J. Romero, PhD; Thomas N. Robinson, MD, MPH; Helena C. Kraemer, PhD; Sarah J. Erickson, PhD; K. Farish Haydel, BA; Fernando Mendoza, MD; Joel D. Killen, PhD
[+] Author Affiliations

From the Mexican American Studies and Research Center, University of Arizona (Dr Romero); Stanford Center for Research in Disease Prevention (Ms Haydel and Dr Killen), the Division of General Pediatrics, Department of Pediatrics (Drs Robinson and Mendoza), and the Department of Psychiatry and Behavioral Sciences (Dr Kraemer), Stanford University, Stanford, Calif; and the Department of Psychology, University of New Mexico (Dr Erickson), Albuquerque.


Arch Pediatr Adolesc Med. 2001;155(10):1143-1148. doi:10.1001/archpedi.155.10.1143.
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Published online

Background  We hypothesized that children's perceptions of more neighborhood hazards would be associated with less physical activity, less aerobic fitness, and a higher body mass index.

Objective  To examine the association between a hazardous neighborhood context and physical activity in children.

Methods  Fourth-grade students (n = 796) of diverse ethnic and economic backgrounds completed measures of neighborhood hazards, self-reported physical activity, physical fitness, height, and weight. Parents (n = 518) completed telephone interviews and provided data on their education level and occupation.

Results  As expected, children from families of lower socioeconomic status perceived significantly more neighborhood hazards. Contrary to our hypothesis, the perception of more hazards was significantly associated with more reported physical activity. This finding was not explained by school heterogeneity, alteration of the hazards measure, or differences in socioeconomic status.

Conclusion  To further examine the relationship between neighborhood hazards and physical activity, we suggest that future studies include assessments of sedentary behavior, parental fear of violence, parental regulation of children's leisure activities, and cost and quality of available play areas and organized sports.

LOWER socioeconomic status (SES) is associated with lower levels of physical activity, more television viewing, and an increased amount of body fat in children and adolescents.14 In part, this association may be due to the comparatively hazardous physical environment in which many lower-income families live.2,57 For example, hazards that might serve as barriers to physical activity and general health include lack of recreational facilities or athletic programs and the presence of crime, gangs, traffic, drugs, noise, or prejudice.811 In our study we explore the subjective perception of neighborhood hazards that might pose barriers to physical activity in a sample of children.

Higher levels of neighborhood hazards have been linked to reports of less physical activity in 2 studies of middle-class adults of primarily European American descent.10,11 However, few studies have explored the relationship between physical environmental factors and physical fitness in children. One study of chronically ill children reported that activity patterns were directly related to child and parent perceptions of neighborhood safety.9 The generalizability of this study is unclear. Parents of chronically ill children may be more attuned to environmental dangers and may be more likely to limit their children's opportunities for physical activity.

Despite the potential for increased hazards in communities of low SES, the association between neighborhood hazards and physical activity among healthy children has not been examined. We looked for evidence of this relationship in a sample of children with diverse ethnic and economic backgrounds. We hypothesized that children who perceived more neighborhood hazards would be less physically active, less physically fit, and have a higher body mass index (BMI).

All fourth-grade students (N = 845) enrolled in 8 northern California elementary schools were eligible to participate in the study. Of the total eligible children, 796 (94%) participated. A passive-consent procedure was used; 12 parents refused to allow their children to participate, and other eligible children not included were absent or unavailable on assessment days. Parent or guardian telephone interviews were attempted for all eligible children, and 518 parents or guardians completed interviews. The study was approved by the Stanford University Committee for the Protection of Human Subjects in Research, Stanford, Calif.

PROCEDURE

Assessments were carried out by trained project staff. To ensure confidentiality, students were assigned a special identification number that was used for tracking. Each survey contained 2 cover sheets, the first including a printed label with the student's name and identification number and the second including a label containing only the identification number. Data collectors removed and destroyed the first cover sheet when they collected the survey. Children completed questionnaires during a regular class period. The survey was read aloud to the entire class and took approximately 45 minutes to complete. Surveys were prepared with facing pages written in English and Spanish or English and Vietnamese. Children were given the option to have the survey read aloud to them in English, Spanish, or Vietnamese; 88% of the children completed the survey in English, 9% in Spanish, and 3% in Vietnamese. All physical measures of participating children were obtained at stations set up in the classroom or at a nearby outdoor area.

All parent interviews were conducted on the telephone by trained project staff. The primary target adult in the household was the mother. Most interviews required 10 to 15 minutes for completion. Parent interviews were conducted in English (33.6%), Spanish (43.9%), and Vietnamese (22.5%). Active consent was obtained by telephone and recorded. All parent and child assessments were completed within the same 2-month period.

MEASURES
Demographics

Children self-reported their sex and date of birth. School district data provided pan-ethnic labels for all children, such as Latino, that combined several specific ethnic groups within 1 larger grouping. Parents reported their own sex and specific ethnic label.

Socioeconomic Status

Parents self-reported education levels and occupations for themselves and another parent or guardian living in the house. In this sample, parent occupation was chosen as an indicator of SES instead of parent education level or a combination of the two. Parent education level was not used as an indicator of SES because of the high percentage of immigrants in the sample, who may have been educated in another country but whose income in the United States may not reflect their education level. The higher occupation level was chosen if more than 1 parent or guardian occupation was reported. Parent occupation was coded into the 7 Hollingshead12 categories and then dichotomized into lower (1-4) and higher (5-9) SES levels based on the midpoint of the scale.

Child Acculturation

Child acculturation was determined based on language preference for English or another language when at home, with friends, and when watching television. These items were adapted from the language use subscale of the Bidimensional Acculturation Scale for Hispanics.13 We acknowledge that the acculturation process is more complex than what language use can represent; however, measurement of acculturation based on language has become a common shorthand method that typically accounts for more than half the variance of acculturation measures. Language use has been found to be the primary determinant of acculturation. English usage and other language usage items were averaged separately, and midpoint cutoff scores were used to dichotomize these measures into high and low categories. Four acculturation categories, as described by Cuéllar et al,14 were determined based on the following combinations: traditional (high use of another language/low English use), marginalized (low use of another language/low English use), assimilated (high English use/low use of another language), and bicultural (high use of another language/high English use).

Neighborhood Hazards

Children's perceived neighborhood hazards were assessed with 8 self-reported items based on a 3-point Likert-type scale: 1 indicated "not a problem," 2 indicated "a little problem," and 3 indicated "a big problem." This scale was adapted from the Hazards Scale developed by Aneshensel and Sucoff.8 All of the items used the beginning phrase "How much of a problem is . . . ?" The 8 items included the following neighborhood hazards: traffic, trash and litter, crime, too much noise, gangs, lack of access to parks, prejudice, and drugs. All 8 items were summed for a total score with a possible range of 8 to 24, with a higher score indicating the perception of more neighborhood hazards. Questions were chosen to reflect dangers that would be most relevant to a younger population and to outdoor physical activity. The original scale has previously demonstrated significant associations with lower SES and a variety of measures of mental well-being.8 In our sample, the internal consistency of this scale was found to be α = .76.

Self-reported Physical Activity

Self-reported physical activity was assessed with a modified version of the Self-administered Physical Activity Checklist (SAPAC) developed by Sallis et al15 for the National Heart, Lung, and Blood Institute's Child and Adolescent Trial for Cardiovascular Health project. The SAPAC has been demonstrated to be a reliable and comprehensive measure of physical activity in children. In the original SAPAC, children reported the number of minutes they participated in 21 common physical activities before, during, and after school on the previous day. Because of pretesting, we modified the SAPAC to include only after-school activities, added 2 more common activities (for a total of 23), and simplified the response to be a forced choice of "none," "less than 10 minutes," or "more than 10 minutes." Children reported their previous day's physical activity on 2 different days, and these 2 reports were averaged. These simplified response options have previously resulted in a high percentage of agreement (86%) with direct observation ratings of children's physical activity.16

Physical Fitness

The maximal multistage 20-m shuttle run test of physical fitness was used to assess cardiorespiratory fitness.17,18 In varied samples of children and adolescents, this test has been found to be a valid measure of fitness compared with maximum oxygen consumption as measured by treadmill testing (r = 0.69-0.87), and is sensitive to change.1923

Height, Weight, and BMI

Standing height was measured to the nearest millimeter using a portable direct-reading stadiometer. Students were measured with their shoes removed and with the body positioned so that the head, heels, and buttocks were against the vertical support of the stadiometer. The head was aligned so that the auditory canal and the lower rim of the orbit were in a horizontal plane. Two measures of height were obtained, and the average was used in the data analyses.

Body weight was determined to the nearest 0.1 kg using digital scales, with the subjects wearing light indoor clothing without shoes or coats. Two measures of weight were obtained, and the average was used in the data analyses.

Body mass index was computed from the formula kg/m2, which is generally considered to be the preferred index of relative body weight as a reflection of adiposity.24,25

DESCRIPTIVES AND ANALYSIS OF VARIANCE

Sample characteristics are shown in Table 1 and Table 2 for children and parents, respectively. The mean ± SD age of participating fourth-grade children was 9.0 ± 0.37 years. Differences between the sexes were found for the measure of physical fitness (t234 = − 4.18; P<.001); boys ran more laps than girls (mean ± SD, 17.61 ± 11.20 laps and 14.66 ± 7.58 laps, respectively). There were no significant differences between boys and girls for the perception of neighborhood hazards, self-reported physical activity, height, weight, or BMI.

Table Graphic Jump LocationTable 1. Sample Characteristics of Children
Table Graphic Jump LocationTable 2. Sample Characteristics of Parents*

One-way analysis of variance was conducted to examine differences by child acculturation, SES level, and ethnicity. There were no significant differences in neighborhood hazards, reported physical activity, or physical fitness by child acculturation level. There were no significant differences in physical fitness or reported physical activity by SES level, but there were significant differences in neighborhood hazards by this measure (F1398 = 4.26; P = .04). Children of lower SES reported more neighborhood hazards (mean ± SD, 13.51 ± 3.83) than children of higher SES (mean ± SD, 12.73 ± 3.48).

There were no significant ethnic differences in perceptions of neighborhood hazards. There were significant ethnic differences for reported physical activity levels (F4697 = 5.04; P<.001) and physical fitness (F4719 = 3.26; P = .01). Latinos reported significantly higher rates of physical activity than Asians (mean ± SD, 8.67 ± 4.61 and 7.19 ± 4.39, respectively), and Latinos ran significantly more total laps than Asians (mean ± SD, 17.21 ± 10.65 laps and 14.45 ± 7.36 laps, respectively).

CORRELATIONS

Spearman correlations among study variables are presented in Table 3. As expected, children of lower SES reported more neighborhood hazards. Contrary to our hypothesis, the perception of more neighborhood hazards was positively correlated with reported physical activity. Although there was a slight positive association between self-reported physical activity and BMI, amount of body fat as measured by BMI was significantly negatively associated with physical fitness.

Table Graphic Jump LocationTable 3. Spearman Correlation Coefficients*
Did School Effects Mask the True Association?

Children in the same school are more likely to live in similar neighborhoods. Therefore, we conducted analyses to examine whether school effects masked an association between neighborhood hazards and physical activity. First, 1-way analysis of variance and χ2 tests were conducted to examine differences in means for variables of interest by school. There were no significant differences by school for perception of neighborhood hazards, self-reported physical activity, or physical fitness. School differences were found for ethnicity (χ214 = 85.84; P<.001), SES level (χ27 = 46.35; P<.001), and BMI (F7737 = 2.58; R2 = 0.02; P = .01). Additionally, we investigated intraclass correlations with physical activity using mixed models with compound symmetry as the covariance structure. All intraclass correlations were close to 0; thus, the original Spearman correlations are reported.

Second, a test was conducted to determine homogeneity between schools and the correlations between neighborhood hazards and physical activity, physical fitness, and BMI. Results indicated no significant heterogeneity between schools (P>.05 for all tests). This test was conducted for Spearman correlations between neighborhood hazards and physical activity (pooled r = 0.14), neighborhood hazards and physical fitness (pooled r = − 0.01), and neighborhood hazards and BMI (pooled r = − 0.01), which are nearly identical with those in Table 3.

Correlations by SES

Neighborhood hazards and SES were negatively correlated (r = − 0.13; P = .01) (Table 3). Therefore, all further correlations were conducted separately by lower and higher SES levels (Table 4). For both SES levels, physical fitness and BMI were inversely correlated, as expected. There was no significant association between neighborhood hazards and reported physical activity or neighborhood hazards and physical fitness for the lower SES group. A significant but low negative correlation was found for neighborhood hazards and BMI for children of lower SES; a higher BMI was associated with the perception of fewer neighborhood hazards. For children of higher SES, the perception of more neighborhood hazards was associated with more reported physical activity. Neighborhood hazards were not significantly associated with physical fitness or BMI for children of higher SES.

Table Graphic Jump LocationTable 4. Spearman Correlation Coefficients by Parent Occupation Level*

Although children from families of lower SES reported more neighborhood hazards than their peers of higher SES, the hypothesis that the perception of more hazards would be associated with lower levels of physical activity and fitness was not supported. Indeed, several of our findings contradicted study hypotheses. Among children of lower SES, those with the perception of more neighborhood hazards had significantly lower levels of body fat. Among children of higher SES, those with the perception of more neighborhood hazards reported higher levels of physical activity.

Several caveats must be considered when interpreting the results of this study. First, the measure of neighborhood hazards used in this study may have lacked sensitivity because it did not directly assess the degree to which children perceived that the hazard was a barrier to their engaging in physical activity. Additionally, the measure did not assess perceived fear of the hazard; rather, participants rated the degree to which each potential hazard was a problem. Thus, whereas children may perceive that drug dealers in their neighborhood are problematic, they may not feel that such a problem poses a direct barrier to playing outdoors. This perception may vary by SES.

Second, the neighborhood hazards scale consisted of 8 potential barriers to physical activity, ranging from crime to noise. Other potential barriers to physical activity may exist in neighborhoods of lower SES that are not included in the 8-item scale. For example, researchers have discussed the effects of larger sociocultural issues on the health habits of lower-income families.26 It may be fruitful to assess competing time demands faced by lower-income children, such as baby-sitting or other family responsibilities. Moreover, the instrument did not include questions about the cost and quality of available locations for physical activity or organized sports. Future studies exploring the relationship between environmental barriers and physical activity in neighborhoods of lower SES should include assessments of cost and quality of accessible facilities for physical activity or organized teams.

Third, parents' perceptions of neighborhood hazards may affect the regulation of their children's opportunities for physical activity. This may explain the finding that children with higher BMI scores were more likely to perceive fewer neighborhood hazards; these children may not be as aware of neighborhood problems as their more active counterparts because of parental regulation of activity. Parents' perceptions of neighborhood hazards should be assessed when the relationship between perceived neighborhood hazards and a healthful lifestyle is studied in young children.

Fourth, the assessment of physical activity in children is difficult at best. The fact that the self-reporting of physical activity was not significantly correlated with physical fitness, whereas physical fitness and BMI were highly correlated, suggests that the self-report measure may contain significant measurement error. Problems with self-reported physical activity measures have been amply documented. Previous research has found poor to moderate correlation between self-reports of physical activity and accelerometer data in children.27 In reviews of the literature, the validity of self-report measures for children varies widely.28,29 It is possible that a demand bias exists in these measures; children are aware that they should be exercising more, and heavier children may be even more aware of this fact. The 1-day recall format, used here in the modified SAPAC, has typically demonstrated the highest correlations with direct observations. However, our results suggest that the instrument may be problematic for many assessment situations.

Our findings are not consistent with other research reports in this area,10,11 but our sample demographics were also different from those of previous studies. Whereas we did not find any ethnic differences in perception of hazards, children of lower SES reported more hazards than those of higher SES. Moreover, the significant relationships between hazards and physical fitness variables were different by SES level of children. Although there is not enough information in our study to interpret the meaning behind these differences, it appears that the relationship between SES and hazards is more complex than initially proposed.

In summary, this study provides no evidence to support the common assertion that children from neighborhoods of lower SES do not engage in physical activity or are any less physically fit because of neighborhood dangers such as crime or gangs. Although our findings show that children in neighborhoods of lower SES are more likely to perceive environmental dangers, these hazards do not appear to present direct barriers to their engaging in physical activity. Children from lower-income homes have been found to have higher rates of sedentary behavior and television watching, which may provide more insight into the link between lower income and low physical activity. We suggest that future studies in this area examine other potential barriers to physical activity for lower-income children by including assessments of sedentary behavior, parental fear of violence, parental regulation of children's leisure activities, and the cost and quality of available locations for physical activity and organized sports.

Accepted for publication April 26, 2001.

Funding for this research was provided by grant RO1 CA68082 from the National Cancer Institute, Bethesda, Md.

What This Study Adds

Research has reported that less physical activity is associated with higher levels of neighborhood hazards in populations of middle-class adults of European descent. Despite the potential for increased hazards in communities of low SES, the association between neighborhood hazards and physical activity in children has not been examined.

Children of lower SES report higher levels of neighborhood hazards. However, contrary to previous research, more hazards were associated with more physical activity in our results. This finding was not further explained by school or SES heterogeneity. The implication is that the relationship between neighborhood context and physical activity is complex, and future studies should include assessments of sedentary behavior, parental fear of violence, parental regulation of children's leisure activities, cost and quality of play areas, and availability of organized sports.

Corresponding author and reprints: Andrea Romero, Mexican American Studies and Research Center, University of Arizona, Economics Bldg, Rm 208, Tucson, AZ 85721 (e-mail: romeroa@u.arizona.edu).

Andersen  RECrespo  CJBartlett  SJCheskin  LJPratt  M Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. JAMA. 1998;279938- 942
Link to Article
Lacar  ESSoto  XRiley  WJ Adolescent obesity in a low-income Mexican American district in South Texas. Arch Pediatr Adolesc Med. 2000;154837- 840
Link to Article
McKenzie  TLSallis  JFNader  PRBroyles  SLNelson  JA Anglo- and Mexican American preschoolers at home and at recess: activity patterns and environmental influences. J Dev Behav Pediatr. 1992;13173- 180
Link to Article
Winkleby  MARobinson  TNSundquist  JKraemer  HC Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. JAMA. 1999;2811006- 1013
Link to Article
Brooks-Gunn  JGreg  JDuncan  PKato  KSealand  N Do neighborhoods influence child and adolescent development? Am J Sociol. 1993;99353- 395
Link to Article
Krieger  NFee  E Social class: the missing link in US health data. Int J Health Serv. 1994;2425- 44
Link to Article
LeClere  FBRogers  RGPeters  K Neighborhood social context and racial differences in women's heart disease mortality. J Health Soc Behav. 1998;3991- 107
Link to Article
Aneshensel  CSucoff  CA The neighborhood context of adolescent mental health. J Health Soc Behav. 1996;37293- 310
Link to Article
Holaday  BSwan  JHTurner-Henson  A Images of the neighborhood and activity patterns of chronically ill school age children. Environment and Behavior. 1997;29348- 373
Link to Article
Sallis  JFHovell  MFHofstetter  CR Predictors of adoption and maintenance of vigorous physical activity in men and women. Prev Med. 1992;21237- 251
Link to Article
Sallis  JFJohnson  MFCalfas  KJCaparosa  SNichols  JF Assessing perceived physical environmental variables that may influence physical activity. Res Q Exerc Sport. 1997;68345- 351
Link to Article
Hollingshead  ABRedlich  FC Social Class and Mental Illness.  New York, NY John Wiley & Sons1958;
Marín  GGamba  RJ A new measurement of acculturation for Hispanics: the bidimensional acculturation scale for Hispanics (BAS). Hispanic J Behav Sci. 1996;18297- 316
Link to Article
Cuéllar  IArnold  BMaldonado  G Acculturation rating scale for Mexican Americans, II: a revision of the original ARSMA scale. Hispanic J Behav Sci. 1995;17275- 304
Link to Article
Sallis  JFStrikmiller  PKHarsha  D  et al.  Validation of interviewer- and self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc. 1996;28840- 851
Link to Article
Simons-Morton  BGO'Hara  NMParcel  GSHuang  IWBaranowski  TWilson  B Children's frequency of participation in moderate to vigorous physical activities. Res Q Exerc Sport. 1990;61307- 314
Link to Article
Leger  LALambert  J A maximal multistage 20-m physical fitness test to predict Vo2 max. Eur J Appl Physiol Occup Physiol. 1982;491- 12
Link to Article
Leger  LAMercier  DGadoury  CLambert  J The multistage 20 metre shuttle run test for aerobic fitness. J Sports Sci. 1988;693- 101
Link to Article
Ahmaidi  SBVarray  ALSavy-Pacaux  AMPrefaut  CG Cardiorespiratory fitness evaluation by shuttle test in asthmatic subjects during aerobic training. Chest. 1993;1031135- 1141
Link to Article
Boreham  CAGPaczka  VJNichols  AK A comparison of the PWC170 and 20-MST tests of aerobic fitness in adolescent schoolchildren. J Sports Med Phys Fitness. 1990;3019- 23
Liu  NY-SPlowman  SALooney  MA The reliability and validity of the 20 metre shuttle test in American students 12-15 years old. Res Q Exerc Sport. 1992;63360- 365
Link to Article
Mahoney  C 20-MST and PWC170 validity in non-Caucasian children in the UK. Br J Sports Med. 1992;2645- 47
Link to Article
van Mechelen  WHlobil  HKemper  HC Validation of two running tests as estimates of maximal aerobic power in children. Eur J Appl Physiol Occup Physiol. 1986;55503- 506
Link to Article
Dietz  WHRobinson  TN Use of the body mass index (BMI) as a measure of overweight in children and adolescents. J Pediatr. 1998;132191- 193
Link to Article
Kraemer  HCBerkowitz  RIHammer  LD Methodological difficulties in studies of obesity, I: measurement issues. Ann Behav Med. 1990;12112- 118
Link to Article
Taylor  SERepetti  RLSeeman  T Health psychology: what is an unhealthy environment and how does it get under the skin? Annu Rev Psychol. 1997;48411- 447
Link to Article
Janz  KFWitt  JMahoney  LT The stability of children's physical activity as measured by accelerometry and self-report. Med Sci Sports Exerc. 1995;271326- 1332
Pate  RR Physical activity assessment in children and adolescents. Crit Rev Food Sci Nutr. 1993;33321- 326
Link to Article
Sallis  JF Self-report measures of children's physical activity. J Sch Health. 1991;61215- 219
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Sample Characteristics of Children
Table Graphic Jump LocationTable 2. Sample Characteristics of Parents*
Table Graphic Jump LocationTable 3. Spearman Correlation Coefficients*
Table Graphic Jump LocationTable 4. Spearman Correlation Coefficients by Parent Occupation Level*

References

Andersen  RECrespo  CJBartlett  SJCheskin  LJPratt  M Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. JAMA. 1998;279938- 942
Link to Article
Lacar  ESSoto  XRiley  WJ Adolescent obesity in a low-income Mexican American district in South Texas. Arch Pediatr Adolesc Med. 2000;154837- 840
Link to Article
McKenzie  TLSallis  JFNader  PRBroyles  SLNelson  JA Anglo- and Mexican American preschoolers at home and at recess: activity patterns and environmental influences. J Dev Behav Pediatr. 1992;13173- 180
Link to Article
Winkleby  MARobinson  TNSundquist  JKraemer  HC Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. JAMA. 1999;2811006- 1013
Link to Article
Brooks-Gunn  JGreg  JDuncan  PKato  KSealand  N Do neighborhoods influence child and adolescent development? Am J Sociol. 1993;99353- 395
Link to Article
Krieger  NFee  E Social class: the missing link in US health data. Int J Health Serv. 1994;2425- 44
Link to Article
LeClere  FBRogers  RGPeters  K Neighborhood social context and racial differences in women's heart disease mortality. J Health Soc Behav. 1998;3991- 107
Link to Article
Aneshensel  CSucoff  CA The neighborhood context of adolescent mental health. J Health Soc Behav. 1996;37293- 310
Link to Article
Holaday  BSwan  JHTurner-Henson  A Images of the neighborhood and activity patterns of chronically ill school age children. Environment and Behavior. 1997;29348- 373
Link to Article
Sallis  JFHovell  MFHofstetter  CR Predictors of adoption and maintenance of vigorous physical activity in men and women. Prev Med. 1992;21237- 251
Link to Article
Sallis  JFJohnson  MFCalfas  KJCaparosa  SNichols  JF Assessing perceived physical environmental variables that may influence physical activity. Res Q Exerc Sport. 1997;68345- 351
Link to Article
Hollingshead  ABRedlich  FC Social Class and Mental Illness.  New York, NY John Wiley & Sons1958;
Marín  GGamba  RJ A new measurement of acculturation for Hispanics: the bidimensional acculturation scale for Hispanics (BAS). Hispanic J Behav Sci. 1996;18297- 316
Link to Article
Cuéllar  IArnold  BMaldonado  G Acculturation rating scale for Mexican Americans, II: a revision of the original ARSMA scale. Hispanic J Behav Sci. 1995;17275- 304
Link to Article
Sallis  JFStrikmiller  PKHarsha  D  et al.  Validation of interviewer- and self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc. 1996;28840- 851
Link to Article
Simons-Morton  BGO'Hara  NMParcel  GSHuang  IWBaranowski  TWilson  B Children's frequency of participation in moderate to vigorous physical activities. Res Q Exerc Sport. 1990;61307- 314
Link to Article
Leger  LALambert  J A maximal multistage 20-m physical fitness test to predict Vo2 max. Eur J Appl Physiol Occup Physiol. 1982;491- 12
Link to Article
Leger  LAMercier  DGadoury  CLambert  J The multistage 20 metre shuttle run test for aerobic fitness. J Sports Sci. 1988;693- 101
Link to Article
Ahmaidi  SBVarray  ALSavy-Pacaux  AMPrefaut  CG Cardiorespiratory fitness evaluation by shuttle test in asthmatic subjects during aerobic training. Chest. 1993;1031135- 1141
Link to Article
Boreham  CAGPaczka  VJNichols  AK A comparison of the PWC170 and 20-MST tests of aerobic fitness in adolescent schoolchildren. J Sports Med Phys Fitness. 1990;3019- 23
Liu  NY-SPlowman  SALooney  MA The reliability and validity of the 20 metre shuttle test in American students 12-15 years old. Res Q Exerc Sport. 1992;63360- 365
Link to Article
Mahoney  C 20-MST and PWC170 validity in non-Caucasian children in the UK. Br J Sports Med. 1992;2645- 47
Link to Article
van Mechelen  WHlobil  HKemper  HC Validation of two running tests as estimates of maximal aerobic power in children. Eur J Appl Physiol Occup Physiol. 1986;55503- 506
Link to Article
Dietz  WHRobinson  TN Use of the body mass index (BMI) as a measure of overweight in children and adolescents. J Pediatr. 1998;132191- 193
Link to Article
Kraemer  HCBerkowitz  RIHammer  LD Methodological difficulties in studies of obesity, I: measurement issues. Ann Behav Med. 1990;12112- 118
Link to Article
Taylor  SERepetti  RLSeeman  T Health psychology: what is an unhealthy environment and how does it get under the skin? Annu Rev Psychol. 1997;48411- 447
Link to Article
Janz  KFWitt  JMahoney  LT The stability of children's physical activity as measured by accelerometry and self-report. Med Sci Sports Exerc. 1995;271326- 1332
Pate  RR Physical activity assessment in children and adolescents. Crit Rev Food Sci Nutr. 1993;33321- 326
Link to Article
Sallis  JF Self-report measures of children's physical activity. J Sch Health. 1991;61215- 219
Link to Article

Correspondence

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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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