Surveys were gathered from a nationally representative sample of 640 public elementary schools in the United States in the 2013-2014 school year.

The sampling frame was developed from publicly available datasets maintained by the National Center for Education Statistics⁴² using a stratified simple random sampling technique, with schools selected within districts. Beginning in January 2014, surveys were mailed to the principals at 1045 elementary schools. Respondents were offered $100 for completing the 20-page survey, which addressed school practices related to student wellness, nutrition, and physical activity. Reminder letters, emails, and phone calls were used to encourage responses until the end of July 2014, when the survey period closed. Surveys were returned by 640 schools (response rate = 61.2%). Analytic weights allow for inference to schools nationwide and adjust for potential nonresponse bias.

A literature review about OST policies and practices informed the development of the 10 survey questions that were used in the analyses;however, that search did not identify existing validated measures about these topics. The project director drafted items and a multidisciplinary team of 8 content specialists with expertise in education, health, policy, behavioral sciences, and quantitative methods provided feedback. The research team completed 2 iterative rounds of revision and then pilot tested the draft survey for comprehension and face validity with 2 potential respondents (K-12 educators). No additional revisions were deemed necessary.

A total of 10 items from the physical activity section of the survey were used in these analyses (Figure 1),⁴³ including 5 questions about full-year OST programs, and the same 5 questions about shorter duration OST programs. The questions assessed when programs were offered, by whom, how many students they reached, and whether programs had any physical activity and/or nutrition policies. The latter was followed by an open-ended question that asked programs to describe existing policies (Figure 1).

An introduction provided context about the 10 OST items:

At some schools, students can participate in organized out-of-school time programming. These before- or after-school programs may include childcare, sports, arts, or academic activities and can be sponsored by a variety of groups such as the school district or outside organizations (eg, Parks and Recreation departments, YMCA). Some programs operate through the entire school year (eg, daily after-school childcare), whereas others have a limited duration (eg, a 10-week art course). The following questions ask separately about full school-year and shorter programs.

School demographic data were obtained from public use files from the National Center for Education Statistics. These variables were used as sample descriptors (Table 1) and as covariates in all multivariate regression analyses to examine demographic differences in school-based OST programs (Table 3). US census region was classified as Northeast, Midwest, South, and West. Locale was classified as city, suburban, town, or rural. The total number of students was used as an indicator of school size, coded as smaller (≤450 students), medium (451-621 students) or larger (≥622 students). Each school’s student racial/ethnic composition was coded into 1 of 4 exhaustive and exclusive categories: predominantly white non-Latino (≥66%);majority black non-Latino (≥50%); majority Latino (≥50%); and other (diverse, or majority Asian or Native American). The percentage of students eligible for free/reduced-priced lunch (FRPL) was used as proxy for school-level poverty and was categorized into 3 groups (<40%; ≥40% to <75%; ≥75%). The 40% cutoff for FRPL eligibility was chosen to align with the school-level threshold for the USDA’s Community Eligibility Provision,⁴⁴ and the National Center for Educational Statistics uses ≥75% to identify high poverty schools.⁴⁵

We calculated frequencies to describe characteristics of elementary schools in the sample (Table 1). Next, we calculated frequencies to describe OST program characteristics (Table 2), including the timing of programming, the reach of programming (percentage of students served), and the administering organization. We use the term “full-year program” to refer to programs that meet daily for the duration of the school year and “partial-year program” to refer to programs that run less frequently. These terms were not mutually exclusive as schools could offer both full-year and partial-year programming. Logistic regression was used to estimate the adjusted prevalence of full-year and partial-year OST programs (Table 3). The adjusted prevalence represents the percentage of schools that have an OST program, accounting for all other school characteristics.

To determine whether programs had physical activity and/or nutrition policies in place, authors coded the open-ended responses, which mentioned formal written policies at the national, state, or local level as well as established practices. Blank values and responses such as “none” or “no” were interpreted as having no physical activity or nutrition policy or practice in place. Authors coded and grouped the remaining responses into the following categories to allow for quantification of the type of policy or practice that was present in the OST program: mentions physical activity only; mentions nutrition only; mentions physical activity and nutrition; other policy, including local wellness policies; other curriculum/other program; and unable to specify. These categories comprised having a physical activity and/or nutrition policy in place. Reviewing the written descriptions revealed multiple interpretations of the question. For example, 5.1% of schools referenced a general policy and 3.8% described a specific program that offers a framework for health-promoting practices, such as CATCH or SPARK. Given this diversity of responses, the phrase “policies and practices” is hereafter used when referring to respondents’ answers to this question.

Chi-square models were used to identify which school characteristics were associated with OST programs having physical activity and/or nutrition policies (Table 4). Analyses were conducted in Stata/SE statistical software (version 13.1; StataCorp LP, College Station, TX, 2013) using the svy command to account for the complex survey design and sampling.

This study analyzed nationally representative data to describe the types of OST programs on elementary school grounds and to identify school characteristics associated with having a program on site and having physical activity and/or nutrition policies or practices in place. Several limitations merit discussion.

These data are self-reported. Although the questions were evidence-informed and reviewed by experts and practitioners, they were not validated. School-level respondents may have been more familiar with the types of OST programs available on school grounds than with OST program policies—especially in programs the school or school district does not administer. This potential for lower awareness may have biased results regarding prevalence of physical activity and/or nutrition policies in OST programs run by organizations other than the school or school district. The write-in responses to the question regarding physical activity and/or nutrition policies revealed potential confusion around written policies versus programmatic practices, like having a curriculum. Rather than interpreting respondents’ intentions, we included both policies and practices when coding responses. We are therefore unable to estimate the prevalence of written policies that address physical activity or nutrition in OST settings.

Last, the questions estimated the availability of before- and after-school programming on school grounds. The questions do not address summer programs, which are a key area for future research and programmatic interventions given documented upticks in rates of weight gain and food insufficiency, as well as declines in physical fitness, during summer break.^59-61

Across the country, the majority of elementary schools have an on-site OST program; however, most programs have yet to adopt physical activity and/or nutrition policies. Given high levels of staff turnover in OST programs,^55,62,63 policies may help to institutionalize health-promoting practices.⁵⁵ School districts or schools administered most school-based OST programs. This presents school administrators and staff with an opportunity to disseminate consistent messages about physical activity and nutrition before, during, and after-school. Additionally, many full-year programs were operated by organizations with national commitments and resources to adopt the National Afterschool Association’s HEPA standards. Given the diversity of OST programs available on school grounds, practitioners may need to tailor their approach to local context, capacity, and readiness. For OST programs to maximize their ability to promote healthy lifestyle behaviors and support academic achievement, issues of equitable access and unmet demand need to be addressed.

The following list provides suggested steps different stakeholders can take.

A majority of parents have expressed that their children should have physical activity opportunities, and healthy foods and beverages in OST programs,^41,67 yet fewer believe that programs regularly offer physical activity and healthful foods.⁷⁶ As OST programs work to increase their adoption of HEPA standards, communicating about this progress may appeal to parents.

Several organizations, including Harvard University, Tufts University and National Recreation and Parks Association, make no-cost materials publicly available to support implementation of physical activity and nutrition policies and practices,^68,69,70 whereas other organizations make materials available to staff via online portals, local chapter websites, and other outlets. Organizations that offer shorter-duration, primarily volunteer run programs, including Boy Scouts and Girl Scouts, also have access to some no-cost resources and trainings that support the adoption of healthy behaviors.⁷⁰ Additionally, the Alliance for a Healthier Generation offers resources, trainings, and technical assistance to schools and OST programs on adopting healthy eating and physical activity policies.⁷¹

For schools with a large proportion of low-income students, federal nutrition programs like the Child and Adult Care Food Program, National School Lunch Program At-Risk Snack and Meals, and the Summer Food Service Program offer financial support for providing children and youth with nutritious snacks and/or meals. Further, nonprofits, including the Food Research & Action Center and No Kid Hungry, offer a center for best practices, informational calls and webinars, and other resources to help sites put these federal programs in place.^72,73

Ultimately, policy implementation happens locally. Community relationships can make a difference. For example, partnerships with local grocery chains can support healthy snack procurement,⁷⁴ and engaging the school food service department can help afterschool staff serve drinking water during snacktime.⁷⁵

The Institutional Review Board at the University of Illinois approved this study (#2006-0848). A waiver of written documentation of informed consent was approved, as consent was implied by the return of the mail-back survey.