School-level data on PE exemptions and substitutions were obtained from the Centers for Disease Control and Prevention’s 2014 School Health Policies and Practices Study (SHPPS), conducted between February and June 2014. The 2014 SHPPS provides the most recent national data on PE substitutions and exemptions at the school level. Detailed information on the SHPPS methods has been published elsewhere (20). The SHPPS was reviewed and determined to be exempt under federal regulation 45 CFR 46.101(b).

The SHPPS has been periodically conducted at the state, district, school, and classroom levels since 1994. In 2014, data were collected at the school and classroom levels from a nationally representative sample of public, private, and state-administered K-12 schools drawn using a two-stage sample design with probability proportional to size. Trained interviewers completed each questionnaire module with the most knowledgeable respondent, as determined by the principal or other school contact, using computer-assisted personal interviews.

The analyses presented herein used data from the general PE module of the PE and activity questionnaire (21), for which the participation rate (percentage of eligible schools that participated in the study and completed at least some questions in the module) was 70%. About 8 in 10 (81%) of respondents were PE teachers. Respondents were asked, “Must students attending your school take any PE as a requirement for graduation or promotion to the next grade level or school level?” If they answered yes, they were asked to indicate if students could be exempted for one grading period or longer from taking required PE for any of 10 reasons. These analyses examined seven of these reasons: 1) achievement of positive, passing, or high physical fitness test scores; 2) participation in school activities other than sports, such as band or chorus (or JROTC, for high school students); 3) participation in community sports activities; 4) participation in community service activities; 5) enrolment in other courses, such as math or science; 6) participation in school sports; and 7) participation in vocational training. Item 2 used slightly different wording at the elementary/middle and high school levels but was treated as a single item for purposes of these analyses. The last three items were only asked at the middle and high school levels. Exemptions for religious reasons, long-term physical or medical disability, and cognitive disability were not analyzed, as they are not governed by the activity-related state exemption or substitution laws. Finally, although the SHPPS questionnaire specifically asked whether students could be “exempted” from PE, a number of the reasons given as response options in the survey include what would typically be exemptions (e.g., enrollment in other courses, such as math or science) as well as those that would typically be considered a “substitute” (e.g., JROTC or school sports). Thus, for this analysis, we refer to the school practices as being either exemptions or substitutions.

School-level data on PE exemptions and substitutions were linked to state law data on PE waivers, exemptions, and substitutions. The state laws were compiled through a two-step process. First, state laws that allowed for PE waivers, exemptions, or substitutions (of any kind) were identified from the National Wellness Policy Study and from the National Cancer Institute’s Classification of Laws Associated with School Students (CLASS; https://class.cancer.gov/) (22,23). Second, these initial laws were reviewed using commercial legal databases, Lexis and Westlaw (24,25), by two study authors (who are licensed attorneys) to code them for the types of activities or school practices that the given PE waiver, exemption, and/or substitution applied to and, in addition, to code whether the activity was “allowed” or was “prohibited or discouraged” for each school level. State laws that “allowed” for waivers, exemptions, and/or substitutions explicitly permitted them at the district or school levels. State laws that “prohibited or discouraged” these practices either did not allow them outright (prohibited) or discouraged districts or schools from allowing them. Laws were deemed relevant if in effect as of December 31, 2013, to correspond to the timing of SHPPS 2014 data collection. A table providing examples of the type of language included in the state laws is provided in the Supplemental Content, http://links.lww.com/TJACSM/A131.

School characteristics were included as control variables. School level (elementary, middle, or high school) was taken from the SHPPS data, and region was derived from state location, based on Census classifications (26). Data on the racial/ethnic distribution of enrolled students, free/reduced-price lunch eligibility, number of students, and locale were obtained from Market Data Retrieval (27) and were linked to the SHPPS data sets. Student race/ethnicity was summarized by a categorical variable historically used to classify school-level proportions of student racial and ethnic groups (28): ≥66% non-Hispanic White, ≥50% non-Hispanic Black, ≥50% Hispanic, and other. The percentage of students eligible for free or reduced-price lunch was used as a proxy for socioeconomic status (SES) (29) and was categorized in three levels: ≤40%, >40–<75%, and ≥75%. The 40% cutoff aligned with the school-level Title I threshold (30), whereas the 75% cutoff has been used by the National Center for Education Statistics to identify high-poverty schools (31). Student enrollment was categorized as small, medium, and large, with different cutoffs for elementary and middle schools as opposed to high schools to maintain similar numbers of schools in each category across school levels. For elementary and middle schools, enrollment was categorized as ≤300, 301–500, and >500. For high schools, enrollment was categorized as ≤350, 351–800, and >800. Locale was coded as urban, suburban, town, and rural based on metrocentric locale codes, which were collapsed from eight to four levels.

Because the state laws applied to public schools and school districts specifically, analyses excluded private and state-administered schools such as those of the Bureau of Indian Education and schools located on military bases. This reduced the sample from 574 to 458 schools. Analyses were restricted to schools that required PE for graduation or promotion to the next grade/school level, which further reduced the sample to 359 schools. Missing data on school characteristics reduced the sample to 321 schools, whereas item-specific missing data on school PE waivers reduced the final analytical sample to between 309 and 315 schools, or between 222 and 225 schools for those analyses limited to middle and high schools. The analytic sample was statistically comparable to the full sample except for school size, with the full sample comprising more smaller schools (original, 58.5%; analytic, 30.5%) and the analytic sample comprising more medium (original, 17.9%; analytic, 28.2%) and larger schools (original, 23.7%; analytic, 41.4%).The analytical sample was located in 42 states, only excluding Alaska, Delaware, the District of Columbia, Hawaii, New Hampshire, New Mexico, Oregon, South Carolina, and Vermont (Oklahoma was also excluded in some analyses limited to middle and high schools, as no middle or high schools in Oklahoma were included in the sample after the aforementioned exclusions).

SHPPS and state law data were linked on state name and school level. Survey-weighted descriptive statistics were computed separately by school level. Separate multivariable logistic regression models linked five of the seven school PE exemptions or substitutions to the corresponding state law variable, controlling for school characteristics. We were unable to provide the results of regression analyses for two SHPPS outcomes: 1) state laws did not address community service as a PE substitution or exemption, and 2) the estimates for the analysis linking state law to enrollment in other courses were imprecise. All other models shown herein passed link tests of model specification. In addition, because only one state allowed for fitness tests as an exemption, it was not possible to assess the association between state law for this exemption and schools allowing it; instead, we assessed whether there was an association between state law allowing “any exemptions” and schools allowing an exemption for fitness test results. Adjusted prevalence estimates were computed from the models showing the average predicted probability of having each type of exemption or substitution if all schools were in states that did versus did not allow the given exemption or substitution in state law. For instance, if the adjusted prevalence of a substitution for participating in school sports is 26% when state law allows this substitution, this suggests that if all states allowed this substitution, then 26% of schools nationwide would allow such an exemption. Analyses were carried out in Stata using svy commands to account for the complex survey design (32).

Table 1 presents the survey-weighted characteristics of the analytic sample and the school-level prevalence of the various exemptions and substitutions. A higher percentage of middle and high schools reported providing PE exemptions or substitutions than elementary schools. Across all school levels (including elementary), PE exemptions or substitutions for students participating in school activities other than sports (11.2% at the elementary, 14.2% at the middle school, and 32.5% at the high school levels) were the most commonly reported practice. Notably, at the high school level, more than one-quarter of schools reported that students were granted PE exemptions or substitutions for participating in school sports, and at the middle school level, more than 1 in 9 schools (11.6%) reported granting PE exemptions or substitutions for enrollment in non–activity-related courses such as math or science. Overall, approximately one half of schools had ≥66% non-Hispanic White enrollment, and schools were dispersed across types of locales, SES, school size, and region of the country.

As of December 2013 (the year of the state laws included in this study), laws in 24 of the 42 states included in the analysis addressed PE exemptions, substitutions, or waivers. (Two additional states (Delaware and South Carolina) had relevant laws but were not included in the analysis because no SHPPS data were available for the state. The Supplemental Content, http://links.lww.com/TJACSM/A132 provides details on all states with relevant laws as of December 31, 2013.)

Table 2 summarizes the extent to which state laws allowed waivers for PE or addressed (i.e., allowed or prohibited/discouraged) each of the seven types of exemptions or substitutions addressed in the SHPPS survey. Overall, states included in the analysis were more likely to allow rather than prohibit/discourage each of the provisions. Substitutions were more commonly addressed than exemptions, and they were both more common for high school rather than middle or elementary school levels. The most commonly addressed provisions were substitutions for school sports, other school activities, and community sports.

Results of the multivariable analyses examining the association between the school-level exemptions and substitutions and state laws allowing for the given exemption or substitution are presented in Table 3. In each of the five school practices modeled, schools had significantly higher odds of granting PE exemptions or substitutions in states with laws allowing exemptions or substitutions as compared with schools located in states that did not allow such practices (Table 3). The wide confidence intervals for some of the analyses (in particular, participation in school activities other than sports and participation in vocational training) should be noted. We speculate that this is due to somewhat limited prevalence of the given school-level substitutions/exemptions and relevant state laws for certain grade levels.

We also assessed whether state laws that prohibited/discouraged the given exemptions or substitutions were associated with school practices and whether state PE waiver provisions were associated with school practices. None of these models was significant.