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June 2015 Volume 50 – Number 1
Arkansas Association for Health, Physical Education, Recreation, & Dance
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May 2015 – Arkansas Journal – Volume 50 – Number 1
CONTENTS
News and Information
Award Qualifications . . . . . . . 3
Message from the President. . . . . . . 4
ArkAHPERD Board of Directors. . . . . . 5
Special Topic
Arkansas Decreases Physical Education Requirement
by Andy Mooneyhan ASU, Mitchum Parker UCA . . . . 6
Faculty Peer Reviewed Articles
Adherence of Wellness Principles in Physical & Health Educators: Can
the Physical Dimension Predict Overall Wellness:
by Keri Essinger, WKU . . . . . 8
Reducing Breast Cancer Through the Utilization of the Health Belief Model:
A Literature Review
by Kendra Guilford, U of B, Lorit Turner, U of Alabama,and
Sharon Hunt U of Arkansas . . . . . . . 16
Preventing Sleep Deprivation through Behavior Modification: A Review
by Kathryn Jones UAB, Lori Turner, U of Alabama, Sharon Hunt U of Arkansas 27
Accessibility of Public Schools’ Extracurricular Activities for Homeschooled Students
by David Lavetter ASU . . . . . . . . 43
The Effects of Using Physical Activity in the Classroom to Enhance
Children’s Cognition by Blair McAlister ASU & Blair Dean ASU . . . 51
Student Submission Peer Reviewed Article
Arkansas High School Athletics: The Most Important Test That is Sometimes
Never Given by James Hines ASU . . . . . . . . . 66
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Lifetime Achievement Award
Candidate must meet the following qualifications:
A. Be at least 30 years of age and have earned a Master’s degree or its equivalent.
B. Have served the profession for at least five years prior to the nomination.
C. Be a current member of ArkAHPERD. Former members who have retired from professional work may be exempt.
D. Be of high moral character and personal integrity who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of our profession in the state of Arkansas. To indicate leadership or meritorious contributions,
the nominator shall present evidence of the nominee’s successful experiences in any two of the following categories of service:
1. Service to the association. 2. Advancement of the profession through
leadership of outstanding programs. 3. Advancement of the profession through
presentation, writings, or research.
Any ArkAHPERD member may submit nominations by sending six (6) copies of the candidate’s qualifications to Janet Forbess, [email protected].
TEACHER OF THE YEAR
Teacher awards are presented in the areas of elementary physical education, middle school physical education, secondary physical education, dance, and health.
Candidate must meet the following qualifications:
A. Have served the profession for at least three years prior to the nomination.
B. Be a member of AAHPERD & ArkAHPERD. C. Be of high moral character and personal integrity
who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of teaching in the state of Arkansas.
D. Be employed by a public school system in the state of Arkansas.
E. Have a full time teaching contract, and have a minimum of 60% of their total teaching responsibility in the nominated area.
F. Have a minimum of five years teaching experience in the nominated area.
G. Conduct a quality program. They must submit three letters of recommendation and agree to make complete NASPE application if selected.
Any ArkAHPERD member may submit nominations by contacting Bennie Prince, [email protected].
HIGHER EDUCATOR OF THE YEAR
Candidate must meet the following qualifications:
Scholarships
STUDENT
A. Have served the profession for at least three years prior to the nomination.
B. Be a member of ArkAHPERD C. Be of high moral character and personal
integrity who by their leadership and industry have made outstanding and noteworthy contributions to the advancement of teaching , research, or service in the state of Arkansas.
D. Be employed by an institution of higher education in the state of Arkansas.
Any ArkAHPERD member may submit nominations by sending a copy of the candidate’s qualifications to
Agneta Sibrava, [email protected].
ArkAHPERD awards four scholarships annually for students majoring in HPERD. They include the Newman McGee, Past President’s, Jeff Farris Jr., and John Hosinski scholarships. Students must possess a minimum 2.5 GPA. [See your academic advisor for details.]
Research Award
Research awards of $100, $50, and $25 are awarded to undergraduate and graduate students who are members of ArkAHPERD. Students must submit an abstract and a complete paper to Rockie Pederson, [email protected] by October 1. Papers selected for the research awards must be presented by the student in an oral or poster format at the November convention.
ArkAHPERD Web Site: http://www.arkahperd.com
AWARD QUALIFICATIONS
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Hello ArkAHPERD Members,
Thank you for believing in this public health and physical education teacher
and giving me the opportunity to serve as your association president through
the fall of 2015. Working together, we have no limits!
There are many highlights within our organization for which we can be proud:
• Our membership is strong and continues to grow as we work toward our goals.
• We have added additional summer workshops to reach out to those that may not
be able to attend our state convention.
• We are continuing our collaboration with the American Heart Association through
the Jump and Hoops for Heart programs and Let’s Move to raise funds to help our
Association continue the fight against heart disease.
• Future professionals are active within the organization as new leaders.
• Social media outlets are enabling the organization to connect our members with
other professionals at a state, regional, and national level.
• Our state convention is not only educational but also entertaining as we have our
workshops and time to network and play with other state professionals.
The Time is Now is this year’s theme. With all of the uncertainty that is going on in the state
legislature, now is the time for us to show that there is more than just rolling out the ball; but
that we believe in our programs and that our students’ health is of the greatest importance.
Advocating for quality health and physical education programs is crucial. Staying current
with needs, trends, and current research is critical to this advocacy. The Time is Now for all
of us to step up, encourage each other, and do our part. Help to send letters to our legislators,
lead professional development, or become an active board member.
I encourage you to mark your calendars for convention 2015 in Eureka Springs. It will be
one you don’t want to miss! Make a difference in someone else’s life by modeling a
healthy and active lifestyle.
Thank you, Leah Queen,
PRESIDENT ArkAHPERD
Message from the President
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ArkAHPERD Board of Directors
Executive Committee Leah Queen President [email protected] Allen Mooneyhan President-elect [email protected] Brett Stone Past-president [email protected] Andy Mooneyhan Executive Director [email protected]
Division Vice Presidents/VP-elects Leah Queen Health [email protected]
John Kutko Physical Education [email protected]
Allen Mooneyhan Recreation [email protected]
Cathryn Gaines Dance [email protected]
Jan Caldwell Athletics & Sports [email protected]
Shellie Hanna Exercise Science [email protected]
Dennis Perkey Athletic Training [email protected]
Claudia Benevidas Sports Management [email protected]
Agneta Sibrava Higher Education & Research [email protected]
University of Central Arkansas Future Professional
University of Central Arkansas Future Professional
District Senators Jeremy Mabry District I [email protected]
Shelia Jackson District II [email protected]
Kelly Spencer District III [email protected]
Amanda Turner District IV [email protected]
January Schultz District V [email protected]
Cyndra Robinson District VI [email protected]
Standing Committees Leah Queen Executive Committee [email protected]
Bennie Prince Teacher Awards [email protected]
Rockie Pederson Student Awards [email protected]
Bennie Prince Publications [email protected]
Janet Forbess Lifetime Achievement Award [email protected]
Andy Mooneyhan Constitution/Membership [email protected]
Additional Committee Members Mitch Parker Web [email protected]
Carhryn Gaines JRFH/HOOPS [email protected]
Janet Forbess Convention Planning [email protected]
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Special Topic- Peered Review Article Arkansas Decreases Physical Education Requirement
by Andy Mooneyhan ASU, Mitchum Parker UCA
Arkansas is decreasing its required physical education time. House Bill 1527, “an Act to
provide flexibility to school districts in scheduling Art, Music, and Physical education and for
other purposes” has made its way through the Arkansas legislature and is now Act 1079. The bill,
in part, decreases the required physical education time in Arkansas schools from 60 minutes per
week to 40 minutes per week. After a call from ArkAHPERD members to contact state house and
senate leaders the bill moved on to the Governor’s office. Governor Asa Hutchinson signed the bill
into law laying the way for a decrease in physical education in Arkansas.
At a time of high obesity rates and declining health of today’s children it seems the national
scene is looking to promote physical education and activity time. The national Society for Health
and Physical Educators (SHAPE) recommends 150 minutes of instructional physical education for
elementary school children. The Department of Health and Human Services (HHS) issues the
Physical Activity Guidelines for Americans that went even further in recommending 60 minutes of
activity every day for children 6-17. According to a SHAPE (2015) America press release, the
Senate Health, Education. Labor & Pensions Committee introduced bipartisan legislation, the
Every Child Achieves Act of 2015 that would elevate the role of physical education as an academic
subject (SHAPE 2015). Clearly national organizations and agencies are realizing a need for
increased physical education and activity time and even the federal government seems to be
moving forward in establishing the importance of physical education. During a time of obese
children and adults and the plethora of associated diseases and conditions it is time to increase
standards and actively combat this health concern – NOT decrease standards.
Currently Arkansas is one of the leading obese states, with only Mississippi and West
Virginia reporting higher obesity rates (CDC, 2013). Arkansas has however in the past placed a
focus on the health of its citizens in relation to fighting obesity and taking steps to decrease
associated health disparities. In fact, Arkansas began to make progress with health initiatives and
governmental support such as Act 1220 and ADE nutrition & physical activity rules. These
initiatives focused on healthier Arkansas children and provided a model for the nation. The
initiatives increase of quality physical education and time allocated for physical activity as well as
redefined the push for appropriate nutrition in our schools.
Beginning in 2012 we began to reverse the progress we had made. Couched in what
appears to be a very stringent set of regulations from Arkansas Department of Education was the
removal of the ACT 1220 requirements for trained physical educators and proper PE facilities in
elementary schools. The 2012 ADE Rules further eroded the process by allowing for non-certifies
physical education teachers in the classroom. Arkansas seems to be making decisions that no
longer focus on increased physical education and activity time needed to improve the health of our
children
The most recent decrease in physical education further jeopardizes the health of Arkansas
children. Act 1079 effectively decreases time in physical education for our children and appears to
continue the unfathomable push toward further regress. Arkansas is doing the opposite of what is
being done on the national scene in regards to physical education and activity as it decreases the
required time in physical education for Arkansas children. This is likely to bear directly on health
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care costs and lost revenue in the state. Aetna (2015) stated the following related to escalating
healthcare cost and corresponding chronic diseases.
“The growing burden of chronic diseases adds significantly to escalating health care
costs. Researchers predict a 42 percent increase in chronic disease cases by 2023,
adding $4.2 trillion in treatment costs and lost economic output.18 Much of this cost
is preventable, since many chronic conditions are linked to unhealthy lifestyles. For
example, obesity accounts for an estimated 12 percent of the health spending
growth in recent years” – AETNA,2015
Physical education is often among the first causalities of standardized testing, budget cuts,
and misinformation. This is erroneously believed to increase student tests scores and overall
performance. However these subjects have been shown to promote only positive effects on
academic performance. With PE, not only does the research demonstrate that increased time in
physical education does not negatively impact student performance (CDC, 2013), but has gone so
far as to demonstrate a direct link between PE and academic improvement (Crawley, Frisvold &
Meyerhoefer, 2012).
ArkAHPERD has identified specific senators to work with and will be formulating a plan
of action related to bringing about positive change to physical education in Arkansas. Interested
senators want to examine what physical education in Arkansas really consists of and look at ways
to make sure it leads to improved health of Arkansas children. The Governor’s office has been
contacted and ArkAHPERD representatives are awaiting a response on a request to meet. With
change coming ArkAHPERD will continue to address and push for appropriate health and physical
education. As we address these important issues we will remember that the health of our children is
at stake.
References 1. Aetna, 2015. The Facts About Rising Health Care Cost. http://www.aetna.com/health-
reform-connection/aetnas-vision/facts-about-costs.html
2. Center for Disease Control (CDC), 2013. Obesity Prevalence Maps: Obesity prevalence in
2013 varies across states and territories. http://www.cdc.gov/obesity/data/prevalence-
maps.html
3. Center for Disease Control (CDC), 2013. Supporting Quality Physical Education and
Physical Activity in Schools.
http://www.cdc.gov/healthyyouth/npao/pdf/LWP_PEPA_Brief_2012_13.pdf
4. Crawley, J.; Frisvold, D. &Meyerhoefer, C. 2012. The Impact if Physical Education on
Obesity among Elementary School Children. IZA Discussion Paper No. 6807.
http://ftp.iza.org/dp6807.pdf
5. Department of Health &Human Services (HHS), 2015. Physical Activity Guidelines.
http://www.health.gov/paguidelines/default.aspx
SHAPE, 2015. SHAPE America Salutes Inclusion of Physical Education as a Core Subject.
http://www.shapeamerica.org/pressroom/2015/pe-as-a-core-subject.cfm.
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Faculty Peered Review Article
Adherence of Wellness Principles in Physical and Health Educators: Can the Physical Dimension Predict
Overall Wellness?
Keri Essinger Ph.D Western Kentucky University
Introduction
Historically, physical educators have believed they need to model positive behaviors in regards to
physical activity (Spencer, 1998). In fact, physiologists, sociologists, and educational theorists consider
modeling to be one of the earliest ways in which children are socialized into their community (Gould &
Roberts, 1981). Research regarding modeling in the physical education and health field has primarily
focused on physical activity. However, recent evidence reveals that health and well-being are holistic and
much more than just physical.
Wellness is comprised of six dimensions, which were first proposed by Hettler. Components of the
six-dimension model include physical, emotional, intellectual, social, occupational, and spiritual wellness.
Hettler’s model is designed to emphasize the person creating a balance in life. The model highlights the
importance of creating co-existing areas that comprise one’s life and overall wellness status (National
Wellness Institute [NWI], 2006). Areas that affect wellness such as one’s social well-being, stress,
environment, spirituality, and occupation can also play a major part in overall health. All the dimensions of
health are interrelated and impact one another. The ability to deal with stress is an example of how one
dimension can affect another.
Despite the advances in knowledge regarding self-destructive behaviors, the progress the United
States has made toward healthy behaviors has been minimal, and the main focus has been on the physical
dimension (U.S. Department of Health and Human Services [USDHHS], 2000). When one looks at the
magnitude of what the United States is facing in the fight for the health of individuals health, it becomes
clear that researchers cannot focus only on issues pertaining to the physical dimension such as the obesity
crisis. There are other issues as well. In 2007, the teen suicide rate increased by 8% for 10-to-24-year-olds
following a previous suicide decline of more than 28%, the highest it has been in 15 years (CDC, 2004).
Healthy People 2010 indicated that while fitness is a key component in maintaining a healthy
lifestyle, it is no more important than the other components of wellness (USDHHS, 2000). However, when
discussing whether or not our physical and health educators are healthy, we often test them using a variety
of body composition tests and physical activity level, leaving out other components of wellness (Brandon &
Evans, 1988; Cardinal, 2001; La Vine & Ray, 2006; Whitley, Sage, & Butcher, 1988). Limited research
was found regarding wellness adherence of physical and health educators. Research regarding physical and
health educators as role models for students in the physical dimension was more substantial. Research in
this area commonly assesses the fitness dimension of wellness, basing role modeling on whether or not the
participants are adhering to recommendations within the physical dimension (Cardinal, 2001; Clark, Blair,
& Culan, 1988; La Vine & Ray, 2006; Spencer, 1998 Whitley et al., 1988). Researchers feel the physical
dimension determines if a physical educator is a positive representation of good health. Researchers have
stated that educators must exhibit positive health behaviors, and that fitness must be a way of life in order
for health and physical educators to portray themselves as role models (Bucher & Thaxton, 1981; Johnson,
1985).
Studies in the area of role modeling and adherence to a wellness lifestyle have mainly stayed within
the physical dimension. In an attempt to examine the area outside the physical dimension of wellness, Clark
et al. (1988) conducted a study addressing the lifestyle characteristics of health and physical educators.
They asked questions related to health and fitness knowledge, physical education instruction, physical
activity levels, intramural and interscholastic programs, and demographic information. However, the only
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area focused on in the discussion was the results of the physical activity levels of participants.
Despite the shift in focus in physical and health education from purely physical to a more balanced
wellness approach as evidenced by new mandates and laws (Chen & Ennis, 2004), little research was found
to assess actual wellness lifestyle behaviors of physical and health educators. Of the research reviewed,
little evidence was found to demonstrate whether or not physical and health educators are modeling positive
wellness behaviors outside the physical dimension. If we know improved wellness in all dimensions leads
to optimum health, then all dimensions need to be evaluated when assessing a person’s wellness. Physical
and health educators need to model positive health behaviors in all dimensions of wellness, not just the
physical dimension.
The purpose of this study was to determine to what extent physical and health educators adhere to
wellness principles. A secondary purpose was to determine if using exclusively the physical/nutritional
dimension of wellness could serve as a strong predictor of physical and health educators’ overall wellness.
The following research questions were used to guide the research:
1. To what extent do physical education and health educators demonstrate wellness?
2. Can the physical/nutritional dimension of wellness predict overall wellness?
Methods
This study involved kindergarten through 12th-grade physical and health educators from throughout
the state of Arkansas. They were contacted using a variety of electronic mail lists and/or calling the schools
for access to email addresses. The participants in the survey ranged in age from 24 to 71 with a mean age of
43.5. They had varying levels of teaching experience and varying levels of education ranging from
bachelors to doctoral degrees (31 Baccalaureate, 33 Masters, 3 Doctorate, 1 Other). Prior to contact with
the participants, the researcher was granted permission through the University of Arkansas Institutional
Review Board to carry out the research. All participants volunteered for the study and the researcher
obtained informed consent from each. Participants were given information regarding their wellness status
upon completion and provided the researcher’s contact information if they had any questions or concerns
following their participation in the research.
Instrumentation
The TestWell
HLQ was used to evaluate the overall wellness of the subjects and to determine
whether the physical dimension was correlated with the overall composite score of wellness. TestWell® is
based on the six-dimensional model of wellness conceived by Hettler over 25 years ago. This six-
dimensional model emphasizes the importance of creating a balance in the many different areas that
comprise a person’s life. Each of these affects the others and determines overall wellness status. TestWell®
is designed to help the individual assessment taker become aware of these different areas and to help him or
her identify areas that need improvement. The National Wellness Institute (NWI) developed the 100-item
instrument, which has 10 questions in each of 10 different categories. The categories include the following
dimensions: Physical/Nutrition, Self-Care, Safety, Environmental, Social, Emotional Awareness (sexuality),
Emotional Management, Intellectual, Occupational, and Spiritual.
The questionnaire uses a five-point Likert scale. Scores in the dimensions of wellness are computed
by adding the scores of specific categories together (Richards, 1996).
The NWI recommendations for interpretation of TestWell® scores are stated in Table 1. The
TestWell® HLQ has been found to be internally valid and reliable. The internal consistency coefficients for
the instrument as well as physical and non-physical factors suggest internal consistency. The test-retest
correlation coefficient was 0.96 (McClanahan, 1990). Plyometric properties of the TestWell® have also
been measured against two other instruments, the Wellness Inventory (WI) and Lifestyle Coping Inventory (LCI). The three instruments were highly correlated with one another with coefficient alpha scores at 0.79,
0.70, and 0.82 respectively (Palombi, 1994). Permission to use the survey and website was done by
purchasing a number of questionnaires, as well as paying a set-up fee.
Procedures
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An electronic mail was sent to approximately 400 educators via the listserv of the Arkansas
Department of Education (ADE). The participants of this survey were volunteers, and the researcher
obtained informed consent from each participant through the TestWell® website. Participants who did not
give consent were not given access to the survey. In the email, participants were given information and
instructions as to where they would be able to access the survey, accept the informed consent, take the 100-
item survey, and complete the demographic questions. Upon completion of the 100-item survey,
participants had the option of viewing their results through the TestWell® center, and receiving resources
that could potentially help them make positive behavioral changes concerning wellness. This was an
incentive that was stated in the electronic mail.
Statistical Analyses
Descriptive variables were analyzed using frequencies, means, and standard deviations. Pearson
correlation coefficient analyses were calculated to investigate the effects that the physical/nutritional
dimension have on predicting overall wellness of physical and health educators. Correlation Matrices were
used to ensure that all significant differences were a result of the TestWell® dimensions independently
showing significance. Pearson product–momentum correlations were calculated between overall wellness
and the physical/nutritional dimension. Correlations between .10 and .29 were classified as small,
correlations between .30 and .49 were classified as moderate, and correlations ≥ .50 were considered large
(Glass & Hopkins, 1984; Kirk, 1982). Statistical calculations were considered significant at the alpha level
of p < .05. The SPSS 17.0 statistical package was used to analyze all data. Data was imported from the
TestWell® website into the SPSS program.
Results
Preliminary data analysis included those on participant demographics. The following tables
illustrate descriptive variables. Table 2 lists frequency, percent, and mean ages of female and male
participants. Table 3 shows the frequency of individuals in the 40-and-over and under-40 age groups.
Tables 2–4 give the mean ages of each group. Table 4 presents frequencies of participants who taught both
health and physical education, or just physical education.
To what extent do physical and health educators demonstrate wellness was evaluated in research
question one. The data revealed physical educators and health educators demonstrated an overall composite
score of 773 and 795 respectively. Mean and standard deviations of each dimension of the TestWell® are
listed in Table 5.
Pearson product–momentum correlations were calculated between overall wellness and the physical
dimension of wellness subset to answer research Question #2; Can the Physical/Nutritional Dimension of
Wellness Predict Overall Wellness? Table 6 shows the results of the correlation analyses of the
physical/nutritional dimension of wellness as compared to the overall score. Results show there was a
moderate correlation (r2 = 0.44) for participants on overall wellness as compared to the physical/nutritional
dimension.
Discussion
The purpose of this study was to determine the extent to which physical and health educators adhere
to wellness principles, and to determine if using exclusively the physical/nutritional dimension of wellness
could serve as a strong predictor of physical and health educators’ overall wellness.
Research Question # 1: The Extent to Which Physical Educators and Health Educators Demonstrate
Wellness The researcher used descriptive statistics such as means and standard deviation to show the extent
to which physical educators and those who teach both health and physical education demonstrate wellness.
The data concerning the physical/nutritional dimension coincides with research on inactivity and
tobacco use (CDC, 2004). The lowest score was in the physical/nutritional dimension, ( = 63.79). While
these scores are not quite in the “room for improvement” area, the NWI suggests that anyone with a score
below the 80s in a single dimension should look to make positive improvements in that dimension. Since a
score of 60 is the cut off for the “good” category, the participants’ scores were not ideal for their profession.
The dimensions with the second and third lowest scores displayed were the environmental ( =
X
X
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67.47) and self-care ( = 69.85) dimensions. Though not in the low 60s, all of these scores were still at
least 10 points below the “excellent” rating that the NWI encourages individuals to use as their goal. The
last dimension in which participants did not reach a rating of 80 was the emotional management dimension (
= 75.76), with scores in the mid 70s.
The highest scores were demonstrated in the safety dimension ( = 92.00). In all other
dimensions—spiritual, occupational, social, and emotional awareness (sexuality)—scores were above 80
and considered “excellent.” This data supports past research, which states that many Americans have yet to
achieve overall wellness (Omizmo et al., 1992). Physical and health educators are doing a “good” job,
according to NWI standards, in the extent to which they demonstrate overall wellness. However, all things
considered, particularly their level of education and expectations of others, physical and health educators
should be looking to demonstrate wellness at the “excellent” level. Further research in this area may want
to look at whether specific dimensions and overall wellness show significant differences between the
physical and health educators, and non-health and physical education teachers.
Research Question #2: Physical/Nutritional Dimensions Predictability of Overall Wellness The researcher used a Pearson product–momentum correlation between overall wellness and the
subset physical dimension of wellness to calculate the physical/nutritional dimension’s predictability of
overall wellness. The results of the correlations showed there was a moderate correlation combined (r2 =
0.44) on overall wellness as compared to the physical/nutritional dimension. These results are very
important for future research in the areas of wellness and role modeling. Past research into role modeling in
physical education used primarily the physical dimension as the determining factor of whether physical and
health educators were positive role models (Brandon & Evans, 1988; Bucher & Thaxton, 1981; Cardinal,
2001; Clark et al., 1988; Johnson, 1985, La Vine & Ray 2006; Spencer, 1998, Whitley et al., 1988). Some
might say that is the way it should be. NASPE’s definition of a physically educated person describes,
among other things, one who “is physically fit.” If this were the case, then should not all professional
wrestlers with low body fat be considered positive role models? Does that mean that NFL wide receivers
and secondary players are better choices for role models than offensive linemen (who are not known for
their physique) like Will Shields, who is second only to Brett Favre in consecutive games played, has gone
to the Pro Bowl twelve times and all-pro nine times and was once named NFL Man of the Year, but may
have a higher BMI and not look physically fit? Shields works out and gives back to the community just like
many who live a balanced life of wellness. However, he will never have a physique like that of some of the
players in other positions. Does that mean that he is not “well” and cannot be a role model? Translating that
back to the classroom, is it fair to say that only the very physically fit educators can be role models? That is
not to say that one should not be working towards better physical/nutritional health at all times. But are we
really serving our students’ needs by saying a person is only a role model if their BMI is under a certain
number and they exercise a certain amount per week? That should be an equal part of total wellness, but
not the sole focus.
Limitations
The study had several limitations. First, while the TestWell® instrument was valid and reliable, the
nature of the data collection resulted in an initial low N. The instrument was too long for many physical and
health educators to want to complete. The sample was large enough for descriptive statistics and
correlations, but the sample ideally could have included more males. Another unforeseen issue brought to
the attention of the researcher was the nature of the questions in the survey. Some of the questions
regarding wellness dealt with sexual health and the researcher received feedback that there were physical
and health educators who stopped taking the survey upon reaching those questions. Lastly, those who
ultimately chose to participate may have been a limitation. The mean score of the entire group for
intellectual wellness was 79.03, which is almost within “excellent” range. This shows that the group who
chose to participate cares about intellectual health, learning, professional development, and potentially
helping a colleague by taking a survey.
X
X
X
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Conclusions Physical and health educators are demonstrating wellness at a level that coincides with what one
would expect of the general population, not what would be expected of individuals who teach physical
education and health. Much previous research states that physical and health educators are exhibiting
positive role modeling behaviors. However, the physical/nutritional dimension only showed a moderate
correlation with overall wellness, and much of what was found in this study indicated that physical and
health educators are showing no greater modeling behaviors in wellness than anyone else in the population.
Should physical and health educators even be expected to be wellness models? Upon completion of this
study, there are many more questions that need to be answered.
References
Brandon, L. J., & Evans, R. L. (1988). Are physical educators fit? Perceived and measured physical fitness
of physical educators. Journal of Physical Education, Recreation and Dance, 59(7), 73–75.
Bucher, C. A., & Thaxton, N. A. (1981). Physical education and sport: Change and challenge. St. Louis,
MO: Mosby.
Cardinal, B. J. (2001). Role modeling attitudes and physical activity and fitness promoting behaviors of
HPERD professionals and preprofessionals. Research Quarterly for Exercise and Sport, 72(1), 84–
90.
Centers for Disease Control. (2004, March 4). Physical Inactivity and Poor Nutrition Catching up to
Tobacco as Actual Cause of Death. Retrieved April 12, 2009, from
http://www.cdc.gov/od/oc/media/pressrel/fs040309.html
Chen, A., & Ennis, C. (2004). Goals, interests, and learning in physical education. Journal of Educational
Research, 97(6), 329–338.
Clark, D. G., Blair, S. N., & Culan, M. R. (1988). Are HPE teachers good role models? Journal of Physical
Education, Recreation & Dance, 59(7), 76.
Gould, D., & Roberts, G. C. (1981). Modeling and motor skill acquisition. Quest, 33(2), 214–230.
Johnson, M. W. (1985). Physical education—fitness or fraud? A call for curriculum reform. Journal of
Physical Education, Recreation and Dance, 57, 33–55.
La Vine, M. & Ray, C. (2006). Physical activity patterns of PETE majors: Do they walk the talk? Physical
Educator, 63(4), 184–195.
National Wellness Institute. (2006). Retrieved January 28, 2009, from http://www.nationalwellness.org/
Omizmo, M., Omizmo, S. A., & D’Andrea, M. J. (1992). Promoting wellness among elementary school
children. Journal of Counseling and Development, 71, 194–202.
Palombi, B. (1992). Psychometric properties of wellness instruments. Journal of Counseling &
Development, 71(2), 221–225.
Spencer, A. (1998). Physical educator: Role model or roll the ball out? Journal of Physical Education,
Recreation & Dance, 69(6), 58–63.
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U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and
improving health. Washington, DC: Author.
Whitley, J. D., Sage, J. N., & Butcher, M. (1988). Cardiorespiratory fitness: Role modeling by P.E.
instructors. Journal of Physical Education, Recreation & Dance, 59(7), 81. Table 1 Interpretation of TestWell
® Scores
Interpretation of Scores
In Each Section Overall Wellness
80–100 Excellent 800–1000 Excellent
60–79 Good 600–799 Good
Less than 60 Room for Improvement Less than 600 Room for Improvement
Table 2
Gender Frequencies
Gender Frequency Percent
X age of group
Female 50 73.5 43.92
Male 18 26.5 42.00
Table 3
Age Frequencies
Age Frequency Percent
X age of group
< 40 years old 28 41.3 32.78
≥ 40 years old 40 58.8 50.80
Table 4
Teaching Concentration Frequencies
Teaching Concentration Frequency Percent
X age of group
Health and Physical Education 35 41.3 44.83
Physical Education 33 58.8 41.91
Table 5 Descriptive Statistics for Total Sample (n = 68)
Wellness Section Mean SD
Physical/Nutrition 63.79 14.21
Self-Care 69.85 14.89
Safety 92.00 8.13
Environment 67.47 15.24
Social 87.09 11.67
Emotional Awareness 86.29 12.82
Emotional Management 75.76 11.67
Intellectual 79.03 12.64
Occupational 82.56 11.75
14
Spiritual 80.74 13.32
Overall Wellness 784.59 84.77
Table 6
Correlation (Physical/Nutrition Dimension and Overall Wellness)
Group Pearson r2 p-value
Whole Group 0.660 0.44 *0.001
*p < .05
Call for Presentations
For anyone wanting to present at the 2015 State Convention, the
proposal form is on the ArkAHPERD web page.
Congratulations!
Ronnie Bates, Meghan Head, Natalie
McNeely
2014 HFH Coordinators of the Year
15
Faculty Peered Review Article
REDUCING BREAST CANCER THROUGH THE UTILIZATION OF THE HEALTH BELIEF
MODEL: A LITERATURE REVIEW
Kendra Guilford, U of B, Lorit Turner, U of Alabama, Sharon Hunt U of Arkansas
INTRODUCTION
Many of the risk factors linked to the leading causes of morbidity and mortality in present
day America are clearly associated with health behavior and lifestyle choices (U.S. Department of
Health and Human Services [USDHHS], 2009). Chronic health diseases remain a leading public
health concern in the U.S. and have been for decades (Centers for Disease Control [CDC], 2008).
Because of its significance in terms of both incidence and mortality, a specific chronic disease that
warrants scrupulous reflection is cancer. An estimated 1,437,180 Americans received a new
diagnosis of invasive cancer in 2008; 565,650 Americans died in the same year due to this chronic
disease (CDC, 2009). For 2008, the overall annual cost of cancer for our country was $228.1
billion (CDC, 2009). Moreover, because of an increasing American population, cancer costs are
very likely to increase, as well (CDC, 2009).
A major goal outlined in Healthy People 2010 is to reduce the number of new cases of
cancer, cancer-related illnesses, and cancer-related deaths in our country (Loerzel & Busby, 2005).
Healthy People 2020 also contains a newly proposed objective specifically related to cancer: “to
increase education to the U.S. public about cancer risks and prevention” (USDHHS, 2009).
Furthermore, a myriad of organizations throughout the country – both governmental and private –
are dedicated solely to reducing health disparities in cancer in our nation at the local, state, and
national levels (American Cancer Society [ACS], 2009; Loerzel & Busby, 2005).
Because of its associated issues of depression, disfigurement, body image, and sexuality –
coupled with overwhelming financial constraints – breast cancer is unique from other forms of
cancer. Moreover, because it has significantly infiltrated virtually all classifications of women in
our country, in terms of ethnicity, socio-economic status, and religion, breast cancer has mandated
national (and global) attention. A major proposed objective of Healthy People 2020 that was
retained from Healthy People 2010 is to “reduce the female breast cancer death rate.” (USDHHS,
2009). An additional objective has also been proposed for Healthy People 2020 that directly
relates to the breast cancer incidence in our nation: “to decrease incidence of late-stage disease
breast cancer.” Accordingly, our federal government has increased funding for early detection,
diagnosis, and prognosis of breast cancer from $36.4 million to $73.2 million. Even more, the total
number of projects dedicated solely to early detection, diagnosis, and prognosis of breast cancer in
our country has risen from 197 to over 288 (NCI, 2009).
The overriding impact of community, social, environmental, and intrapersonal factors on
breast cancer incidence cannot be ignored. Factors such as diet, exercise, gender roles, income,
education, culture, and individual attitudes and beliefs are all interconnected in the schema of
underlying issues contributing to the prevalence of breast cancer.
According to the American Cancer Society (ACS) (2009), an estimated 192,370 women
were diagnosed with breast cancer in 2009, with 40,170 women dying from the disease. Although
the overall mortality rate due to breast cancer is on a decline (CDC, 2009); Welch, Miller, &
James, 2008), the incidence of breast cancer has risen gradually over the past century (Wood,
16
2009). This disease is currently considered the most common cancer (other than skin cancer), and
the second leading cause of cancer death among women in the U.S., surpassed only by lung cancer
(NCI, 2009). One out of every eight American women will develop breast cancer at some point in
her life. Each year in the United States, more than 192,000 women are diagnosed with breast
cancer (NIH,2009), and 250,000 U.S. women living with the disease are under the age of 40 (CDC,
2009). Moreover, younger women with breast cancer tend to experience worse outcomes and more
advanced disease than older women (CDC, 2009).
Impact of Breast Cancer
The overall impact of breast cancer ranges from the financial to the physiological to the
psychological and social (ACS, 2007). In the late 1990s, for instance, the total cost of illness for
breast cancer was an estimated $3.8 billion, $1.8 billion of which represented medical care costs.
The associated annual costs for breast cancer-specific medical treatment are now estimated at $8.1
billion (NCI, 2009); Welch et al., 2008). Even more, our country currently spends approximately
$548.7 million dollars in breast cancer research alone (NCI, 2009).
Even among women with comprehensive insurance, the financial burden of a breast cancer
diagnosis can still be quite considerable. Direct medical and nonmedical expenses such as
treatment, childcare, transportation, and income lost due to cancer-related morbidity and treatment
add to the financial constraints for many women, (Arozalla et al., 2004). Moreover, studies have
shown that women with cancer are more likely than men to have to pay for transportation, nursing
care, and housecleaning, to have inadequate family support, and to be without a spouse or
significant other.
In their study examining the financial burden of breast cancer, Arozullah et al. (2004)
interviewed a total of 156 women about cancer-related-out-of-pocket costs, as well as their
knowledge and use of cancer insurance policies. To be included in the study, participants had to be
over the age of 18, had to have received a confirmed breast cancer diagnosis within the past 24
months, and had to have a life expectancy greater than 6 months. Specifically, the researchers
assessed the women’s age, insurance status, education, marital status, ethnicity, time since
diagnosis, caregiver status, wages, annual household income, time missed from work, and out-of-
pocket costs related to cancer treatment during the previous 3 months. Patients’ age ranged from
29 to 78 years, with a mean of 52 years. Eighty percent of the patients described themselves as
white, 10% as black, 5% as Latino, and 4% as Asian. After conducting the study, researchers
found that the monthly financial burden of breast cancer averaged $1,455 per month. Individual
estimates ranged from $0 to $15,700 per month (Arozullah et al., 2004). In addition, researchers
found half (50%) of the overall financial burden associated with breast cancer was directly related
to lost income. In essence, this study showed that the financial impact of breast cancer can be quite
substantial, even among women fortunate enough to have comprehensive health insurance policies;
the impact can be even greater among women without health insurance. This study highlighted the
need for more affordable programs that provide reimbursements for medical and nonmedical costs
incurred after a breast cancer diagnosis, particularly for low-income women (Arozullah et.al.,
2004).
The burden of breast cancer exceeds financial factors to include physiological and
emotional concerns for women (NCI, 2009). Generally, early breast cancer does not cause
symptoms. However, as the tumor grows, the look and feel of the breast can be altered. These
physiological changes women experience include a change in the actual size or shape of the breast;
a lump or thickening in or near the breast or underarm area; scaly, red, or swollen skin on the
17
breast, nipple, or areola (dark area of skin at the center of the breast); a nipple that is turned inward
into the breast; and discharge from the nipple, particularly bloody discharge (NCI, 2009).
Other physiological consequences are also associated with breast cancer. Surgery is the
most common treatment for breast cancer (ACS, 2007). If a woman has to undergo a mastectomy
(surgical removal of the breast), in addition to potential permanent disfigurement, she is likely to
experience subsequent numbness and tingling in the chest area, underarm, shoulder, and arm.
These feelings usually go away within a few weeks or months, but for some women, numbness
does not ever subside (NCI, 2009). Removal of the breast due to breast cancer can also cause a
shift in weight, constant fatigue, and chronic pain (ACS, 2007). Removal of the breast may also
cause the women to feel off balance; this imbalance can, in turn, lead to discomfort in the neck and
back.
A mastectomy is regularly coupled with removal of the lymph nodes under the arm. This
procedure slows the flow of lymph fluid. Consequently, the fluid may build up in the arm and
hand, causing severe swelling. This swelling is known as lymphedemia. It can develop
immediately after surgery, or it can develop gradually over a duration of several months or even
years after surgery (NCI, 2009).
Aside from the physiological concerns, women may also experience psychological and
social consequences of breast cancer (Helms, O’Hea, & Corso, 2008). Just as various forms of
treatment for breast cancer can have potentially disfiguring effects in the physical sense, research
has indicated that the actual loss or mutilation of a woman’s breast can also have negative
psychosocial consequences (Helms et al., 2008).
For example, women often worry about the cancer one day coming back, or recurring.
They may also experience feelings of depression and isolation (ACS, 2007). Breast cancer also
affects a woman’s body image and feelings towards sexuality (Sheppard & Ely, 2008). Because
the breast is considered to be an integral component of a woman’s femininity and sexuality, breast
cancer may elicit coping strategies that are distinctly different from other kinds of cancer
(Choumanova, Wanat, Barrett, & Koopman, 2006). Many women are forced to deal with issues
related to body image because they oftentimes find that breast cancer treatment changed the way
they looked; such changes include hair loss, skin-related issues, and weight gain or loss (NIH,
2009).
Roid & Fitts (1998) suggest that body image refers to a mental image or picture of the
“physical self” that encompasses perceptions and beliefs associated with an individual’s skills, state
of health, sexuality, and physical appearance. Body image is accepted as being an essential
component of sexual health. According to Vaeth (1986), when a disease or disfiguring treatment
regimen jeopardizes the physical beauty of a woman’s body, it has the potential to negatively affect
the value of her body to herself and others (such as spouses or intimate partners). Moreover, the
breast has a social connotation of motherhood, femininity, and sexuality (Kahn et al., 2000). In this
view, for several women, the experience with and subsequent effects of breast cancer are
oftentimes interpreted as a “grievous assault on her femininity and her fundamental sense of herself
as a woman” (Vaeth, 1986).
Sheppard & Ely (2008) conducted a search of Medline databases in their investigation of
breast cancer and how it relates to sexuality. The authors relied on key words including “breast
cancer,” “body image,” “sexuality,” ”cancer,” “marriage,” and “relationship” to identify articles
related to their chosen theme. Their search of breast cancer-related literature revealed a few key
findings. First, as previously assumed, their research confirmed that breast cancer is intensely
18
distressing not only for the patient, but for her family, as well (Henson, 2002). Moreover, 50% of
women were shown to experience sexual difficulties following breast cancer treatment (Burbie &
Polinski, 1992). Common side effects cited include vaginal dryness and irritation, painful
intercourse, lowered libido, and hair loss (Sheppard & Ely, 2008). Another interesting finding
revealed from the author’s systematic review of the literature was that after a breast cancer
experience, many women reported feeling more self-conscious, less attractive, and as having an
overall poorer body image than their healthier counterparts (Sheppard & Ely, 2008).
Al-Ghazal, Fallowfield, & Blamey (1999) conducted a research study on 577 women to
assess the effects of breast cancer on psychological functioning and cosmetic satisfaction of the
breast. At their post-operative follow-up visit, participants completed a written questionnaire. The
researchers categorized the women according to the type of breast cancer surgery received –
lumpectomy, breast reconstruction, or simple mastectomy. Researchers found an overwhelming
91% of women in the lumpectomy group to be at least moderately satisfied with their breast’s
cosmetic appearance, compared to 80% in the breast reconstruction group, and 73% in the simple
mastectomy group (Al-Ghazal et al., 1999). The researchers also found that 10% of the women in
the simple mastectomy group were clinically depressed. This study suggested that the more
invasive the surgery for breast cancer, the greater the effect on the woman’s sense of cosmetic
satisfaction and psychological well-being (Al-Ghazal et al., 1999).
Hair loss is another issue with which many women with breast cancer are forced to deal
(ACS, 2007). The concept of hair possesses many connotations according to any given cultural
group. Hair is really associated with life, life processes, and personal growth (Batchelor, 2001).
Further, hair has also been linked to gender, beauty, maturity, age, and even religious affiliation
(Freedman, 1994; Helms et al., 2008). Thus, when an individual loses his or her hair, the crisis can
be associated with a loss of sexuality, individuality, and attractiveness (Helms, et al., 2008). It is
widely known that many of the chemical agents used in a common form of breast cancer treatment
– chemotherapy – cause hair loss, also known as alopecia.
It is important to note that in addition to body image concerns, some treatments for breast
cancer, such as chemotherapy, can actually alter a woman’s hormone levels and may reduce her
sexual interest or response (ACS, 2007). Some studies even suggest that younger women tend to
have more problems with these issues than older women (ACS, 2007).
Knowledge certainly is a basic requirement for any individual to maintain proper health.
Therefore, knowledge objectives are a vital element of virtually all health promotion activities
(Simon, 2006; Royse & Dignan, 2009). In the greater attempt to disseminate knowledge and
increase awareness about a given health-related issue such as breast cancer, researchers develop
and deliver health interventions tailored to a specific target population. Interventions that yield
desirable changes are ideally based on at least one theoretical framework (Glanz, Rimer, & Lewis,
2002). Theories help guide researchers’ investigation into why people do or do not engage in
specific health behaviors (NCI, 2009). They are useful during the various stages of planning,
implementing, and evaluating an intervention. Moreover, theories help explain behavior and
suggest ways to achieve behavior change (Glanz, Rimer, & Lewis, 2002).
The Health Belief Model (HBM) is a prime example of value-expectancy theory, which has
gained recognition for use in examining and describing health screening behaviors and associated
factors (Glanz, Rimer, & Lewis, 2002). It is considered the most widely used model for predicting
BSE behavior (Champion, 1984). The HBM has been used in several studies as a theoretical
framework to study BSE and other breast cancer detection behaviors (Champion, 1984; 1999).
Because of its long record of use in several studies exploring health behaviors in general, and
19
cancer screening behaviors, specifically, the purpose of this literature review is to examine the use
of the Health Belief Model to enhance breast cancer prevention and screening behaviors.
Health Belief Model
Researchers create and implement interventions as a major means by which to disseminate
knowledge and increase awareness about a given health problem, such as breast cancer.
Interventions that yield desirable changes are ideally based on at least one theoretical framework
(Glanz, Rimer, & Lewis, 2002). Health-behavior theories assist researchers by organizing their
inquiry into why people do or do not engage in specific health behaviors (NCI, 2009). They are
valuable during different stages of planning, implementing, and evaluating an intervention.
Theories also help explain behavior and suggest ways to achieve behavior change (Glanz, Rimer,
& Lewis, 2002).
The Health Belief Model (HBM) is an example of a health behavior theory that considers
one’s overall perceived risk of an illness as a precursor to positive, preventive behavior (Wendt,
2005; Janz & Becker, 1984). It was originally postulated in the 1950’s by social psychologists in
the U.S. Public Health Service (Janz & Becker, 1984); Rosenstock, 1974; Glanz, Rimer, & Lewis,
2002). Perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues
to action comprised the initial core components of the model; in 1977, Bandura added the self-
efficacy component to the HBM (Janz, Champion, & Strecher, 2002). This theory is known as a
value-expectancy theory and known to now be the most widely used model for predicting Breast
Self-Examination (BSE) behavior (Champion, 1990). The fundamental premise of the HBM is that
an individual’s desire to evade illness, coupled with a belief that a particular health action would
avert onset of the illness, can be interpreted and explained in relation to a number of diseases.
More detailed analysis can estimate an individual’s perceived susceptibility, severity, and cues to
action to attempt to reduce overall risk for a particular illness or disease (Glanz, Rimer & Lewis,
2002).
Earlier studies using the HBM centered typically on primary and tertiary preventive
behaviors. Janz and Becker (1984) conducted an extensive literature review of the usage of the
HBM in research beginning in the early 1970’s through 1984. Their review encompassed 46
studies including both prospective (n=18) and retrospective (n=28) studies investigating a
conglomeration of preventive-health behaviors and sick-role behaviors. The results of their review
suggested that the HBM concepts are valuable tools in research studies in that they can serve as
predictors in examining health behavior (Janz & Becker, 1984).
The year 1984 proved to be a major turning point for the HBM and research focusing on
cancer screening behaviors. In that year, Champion initiated an innovative research instrument that
directly linked the HBM constructs to breast cancer screening behaviors. (Prior to 1984, the HBM
was not frequently used to explain such behaviors). Champion used a convenience sample of 301
females who were at least 16 years of age and literate (Champion, 1984). The sample was
stratified for variation in socioeconomic status. Champion distributed written questionnaires via
postal service, as well as by hand; these collection methods yielded a 47% return rate. A retest
questionnaire mailed randomly later produced a 95% return rate. Champion (1984) concluded
from this study that her scales for susceptibility, seriousness, and barriers were internally consistent
and reliable. Additionally, she revised the benefits and health motivation scales due to their being
rejected for inconsistency (Champion, 1984).
Expanding her previous work studying HBM and BSE, Champion (1999) modified scales
20
used in measuring perceived susceptibility, benefits, and barriers to breast cancer screening
behaviors – and applied them to mammography, as well. Criteria for participant eligibility in this
study included not having had a mammogram in the last 15 months, not having had breast cancer,
and being able to read and write English (Champion, 1999). Additional scale items were presented
to participants via two focus group sessions. Results of the newly modified scales indicated
internal consistency ranging from .75 to .88, and test reliabilities between .59 and .72. Thus, these
scales represented an improvement from those Champion had developed earlier (Champion, 1999).
Since Champion’s work, the HBM has been used in a variety of populations and settings to explore
a wide range of health beliefs and behaviors.
Although the participants in Champion’s study included women age 50 and older, her
revised scale is applicable to virtually any age of adult women. This notion rests on the idea that
despite mammography screening being a current breast cancer screening recommendation for older
women; younger women should still be well informed and made aware of it, as they will certainly
encounter mammography screening later in life. Therefore, Champion’s (1999) revised scale
served a major component in assessing the level of breast cancer knowledge, beliefs, and screening
behaviors in this current study examining emerging adult women.
Relying on the main components of HBM, a cross-sectional, community-based study
examining why some women have either an optimistic or pessimistic bias about their breast cancer
risk was completed by Katapodi, Dodd, Facione, Humphreys, & Lee earlier (2010).
They utilized HBM to measure family history of breast cancer, worry about getting breast cancer,
overall knowledge about breast cancer risk factors, as well as women’s perceived susceptibility of
getting breast cancer. Consistent with findings in other studies, family history and breast cancer
worry were found to be significant predictors of personal risk judgments for the women surveyed.
Another finding was that women who overestimate their breast cancer risk may suffer unnecessary
stress, and anxiety, and may overuse health services (Katapodi et al., 2009).
In their study of the effects of peer and group education on knowledge , beliefs, and breast
self-examination practices of Turkish female university students, Karayurt et al. (2009) also used
the Health Belief Model as a theoretical basis. The study was conducted during the 2006-2007
academic year and included a total of 193 participants. Researchers used a written questionnaire to
collect data at baseline and after six months on socio-demographic characteristics, knowledge of
breast cancer and breast self-examination, frequency of breast self-examination practice, and
Champion’s Health Belief Model Scale (CHBMS). Specifically, the CHBMS was comprised of a
total of 42 items with six subscales, and used a 5-point Likert scale from 1 “strongly disagree” to 5
“strongly agree.” In compliance with the major constructs of HBM, CHBMS included subscales
related to susceptibility, seriousness, benefits, barriers, confidence/self-efficacy, and health
motivation. Results of the study showed that mean knowledge scores increased from 42.08 to
65.26 after peer education and from 41.44 to 63.74 after group education. The rate of regular
breast self-examination also increased significantly for both groups. Perceived benefits and
confidence related to breast self-examination increased and perceived barriers decreased
significantly after both interventions, as well. Thus, from this study the authors concluded that
both interventions (peer and group) are beneficial in increasing breast awareness among young
women (Karayurt et al., 2009).
Norman & Brain (2005) applied an extended Health Belief Model (HBM) to the prediction
of breast self-examination among women with a family history of breast cancer. This study also
examined the impact of breast cancer worries and past behavior on breast cancer screening
practices. Researchers compiled a written questionnaire measuring HBM variables (as used in
21
previous research studies), worry, and demographic variables. Specifically, researchers utilized the
Breast Cancer Worry Scale by Lerman et al. (1991) to assess the frequency of concerns about
developing breast cancer and the impact of breast cancer worries on mood and daily functioning.
Items were rated on a 4-point response scale, with high scores indicating breast cancer worries.
Respondents were asked to indicate the frequency with which they performed breast self-
examination. Finally, they were asked to indicate the number of first and second-degree relatives
affected with breast cancer as a measure of family history of breast cancer. Study results
emphasized the importance of focusing on over-performance and under-performance of breast self-
examination for breast cancer prevention. The study also highlighted a need for health
interventions designed to enhance women’s overall confidence in their ability to perform breast
self-examination. And, attempts to reduce worry related to breast cancer may encourage more
appropriate and effective breast self-examination, according to the study (Norman & Brain, 2005).
Wendt (2005) also applied the Health Belief Model to her examination of how female
undergraduates perceive their future risk of breast cancer and coronary heart disease. Participants
included 137 female undergraduate students attending a small liberal arts college in the
northeastern region of the U.S. Participants were asked to complete a written survey, which
assessed items such as perceived illness frequency, level of worry, awareness of risk factors,
cognitive variables, mental image, health behaviors, seriousness, etc. Demographic variables
included year in college, age, and ethnic/racial composition. Results of the study indicated
unrealistic pessimism regarding the women’s personal risk of breast cancer among peers. When
compared to coronary heart disease, participants were significantly more worried about getting
breast cancer; yet, they were less aware of breast cancer risk factors. Further, perceived risk of
breast cancer was not associated with breast self-examinations.
In summary, the HBM has been especially valuable in examining various concepts in
primary care, preventive medicine, and public health. It has been repeatedly utilized as a
theoretical framework to examine a range of health behaviors, including those associated with
chronic illness and disease, such as breast cancer. Additionally, the HBM model has been
frequently applied to the investigation of individual health-related beliefs, and more importantly, it
can suggest ways for women to achieve behavior changes that could potentially reduce their risk of
developing breast cancer in the first place.
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24
Faculty Peered Review Article
Preventing Sleep Deprivation through Behavior Modification: A Review
by Kathryn Jones UAB, Lori Turner, U of Alabama, Sharon Hunt U of Arkansas
Introduction
Sleep deprivation occurs when sleep is insufficient in quantity or quality
(American Academy of Sleep Medicine, 2008; HHS, n.d.-a). Short sleep is often defined
as averaging less than seven hours and long sleep defined as more than nine hours of
sleep in a night (Gallicchio & Kalesan, 2009). This can include being out of sync with
your circadian rhythm and sleeping at the wrong time of the day, excessive daytime
sleepiness, poor quality of sleep or diagnosis of a sleep disorder (American Academy of
Sleep Medicine, 2008; HHS, n.d.-a).
Estimates suggest 50 to 70 million Americans suffer from some form of sleep
disorder (Institute of Medicine, 2006) and almost 40% of adults have reported falling
asleep without meaning to during daytime activity in a given month (HHS, n.d.-a). The
National Sleep Foundation Sleep in America Poll (2008) found that 11% of respondents
were at risk for a diagnosis of insomnia, 14% for a diagnosis of obstructive sleep apnea
and 11% for restless leg syndrome, three of the most commonly diagnosed sleep
disorders. Sixty-five percent of these respondents reported experiencing sleep problems a
few nights a week, including difficulty falling asleep, waking during the night and not
feeling refreshed the next morning; 44% of all respondents reported getting less than
seven hours of sleep on workdays (National Sleep Foundation, 2008). Sleep disturbances
affect a substantial amount of the population.
Immediate effects of sleep deprivation include difficulty concentrating,
completing tasks (National Sleep Foundation, n.d.-d), and coping with change (HHS,
n.d.-a). Prolonged sleep deprivation can expand to a host of harmful effects on a person’s
physical and mental health, creating and exacerbating a multitude of health conditions
(HHS, n.d.-a; National Sleep Foundation, n.d.-d). Studies have found significant
relationships between insomnia and depression and anxiety after controlling for other
confounding variables (Taylor, Lichstein, Durrence, Reidel, & Bush, 2005). Insomnia is
predictive of the development of depression, anxiety, psychiatric distress, alcohol and
drug abuse and suicide (Taylor, Lichstein & Durrence, 2003). Individually diagnosed
mood disorders and anxiety are associated with severe insomnia symptoms, as well as
comorbid diagnoses with both anxiety and a mood disorder. Sixty percent of respondents
with comorbid anxiety and mood disorders indicated at least one insomnia symptom and
45% of individual diagnoses of anxiety or mood disorder only groups indicated at least
one insomnia symptom (Soehner, Allison, & Harvey, 2012).
Depression is often associated with sleep onset and anxiety with sleep
maintenance. Cross-sectional analyses revealed the risk of participants reporting
insomnia was four times greater with high anxiety. Prospective analyses showed that
both depression and anxiety were associated with developing insomnia at one year follow
up, demonstrating the interrelatedness of insomnia with depression and anxiety (Jansson
& Linton, 2006).
Stress is the primary cause of short-term sleep difficulties. Relationships with
family and friends, work or school related stressors, serious illness and death of a family
26
member are often sources of increased stress that influence sleep. If sleep is not managed
well at this juncture, sleep difficulties can persist after the initial stressor has passed
(National Sleep Foundation, n.d.-d).
Too little sleep can also affect your overall quality of life and social functioning
(HHS, n.d.-a). In a nationally representative sample, researchers observed significant
impairments in social functioning, cognitions, quantity and quality of work completed
and time out of role for normal daily activities in participants reporting severe insomnia
symptoms (Soehner et al., 2012). A qualitative study exploring quality of life in
individuals with insomnia found persistent themes of struggling through, isolation and
impediments to the desired self because of insomnia. Social functioning was impacted
through lack of enthusiasm or energy resulting in self-imposed social inclusion, inability
to plan social functions due to unstable sleep patterns, and diminished responsiveness in
social situations. The authors noted that participants frequently reported increased
irritability and changes in mood (Kyle, Espie & Morgan, 2010).
People who do not get enough sleep are at higher risk for developing heart
disease, cardiovascular disease, high blood pressure, infections, diabetes, obesity and
strokes (American Academy of Sleep Medicine, 2008; Cappuccio et al., 2008; National
Sleep Foundation, n.d.-c; Sabanayagam & Shankar, 2010; U.S. Department of Health and
Human Services, [HHS] 2011). Insomnia may serve as a stressor that initiates the
development of a predisposed disease state. Conversely, it may be symptomatic of a
disease or disorder and manifest before the onset of the full disorder (Taylor et al., 2003).
The National Highway Traffic Safety Administration reports between 2005 to
2009, an average of 2.5% of fatal automobile crashes and 2.2% of injuries from crashes
were caused by drowsy driving (2011). Williamson and Feyer (2000) found that sleep
deprivation results in impairments to cognitive and motor functioning that were similar to
levels of alcohol consumption that were at or above a blood alcohol level of 0.05%,
suggesting that drowsy driving is as potentially dangerous as intoxicated driving. The
National Sleep Foundation 2008 Sleep in America Poll found that 32% of respondents
admitted to having driven while drowsy and 36% of respondents reported having nodded
off or fallen asleep while driving in the past month.
Numerous studies have looked at the effects of short and long sleep on mortality.
Short sleep is often defined as averaging less than seven hours and long sleep defined as
more than nine hours of sleep in an a night (Gallicchio & Kalesan, 2009). In a meta-
analysis of 23 studies assessing sleep duration and all-cause and/or cause-specific
mortality, Gallicchio and Kalesan (2009) found that both short and long sleepers have an
increased risk of all-cause mortality than those who averaged seven to eight hours of
sleep each night. Another population-based meta-analysis of all-cause mortality and
sleep found that short sleepers had a 12% increased risk of death and long sleepers had a
30% increased risk of death (Cappuccio, D’Elia, Strazzullo, & Miller, 2010).
Sabanayagam & Shankar (2010) found that there was a positive association for both short
and long sleepers with cardiovascular disease in a large nationally representative study.
Sleep is clearly affecting health and mortality in a significant way.
The incidence of shift work in the United States has increased in recent history as
our world has globalized into a 24-hour society. The rise in shift workers in a variety of
sectors, including health care, customer service, safety and law enforcement and
transportation could be associated with greater health and safety risks due to sleep
27
deprivation. The National Sleep Foundation (n.d.-b) reports that shift workers are often
working in some of the most dangerous jobs, including police, firefighters, medical
personnel and other security personnel. The risks of poor attention, errors, and accidents
associated with sleep deprivation could lead to a higher incidence of injury and death
(National Sleep Foundation, n.d.-b).
Approximately $100 billion dollars are spent each year on direct and indirect
costs associated with sleep deprivation (National Sleep Foundation, n.d.-d). Sleep
deprivation results in nearly $50 billion dollars in lost productivity each year (HHS,
2011). As such, sleep deprivation is a neglected determinate of health status with the
potential for serious consequences (Luyster, Strollo, Zee, & Walsh, 2012).
Purpose
The purpose of this review is to conduct a narrative review of the literature
regarding sleep deprivation, sleep hygiene and theories that can address improving sleep,
specifically behavior modification. This paper explores studies using behavior
modification theory concepts to reduce sleep deprivation and improve people’s ability to
get sufficient quality sleep through methods commonly referred to as sleep hygiene.
Methods
Articles reviewed were obtained from PubMed and CINAHL Plus, as well as
reference lists from articles chosen for the review. Search terms included “sleep
deprivation” and “sleep hygiene” to provide a broad scope from which to select articles.
Inclusion criteria were articles that utilized adult human subjects ages 18 and older and
were in academic journals or listed as journal articles. Exclusion criteria included studies
that had a very narrow and specific target population, such as sleep deprivation in people
with schizophrenia or Alzheimer’s or a very specific medical condition such as traumatic
brain injury or in post-partum women. The articles chosen were intended to represent the
population at large and to focus on behavior modification.
Results
Ten articles were chosen for this review to highlight the myriad of approaches
that behavior modification could take under the broad scope of sleep hygiene techniques
used to improve sufficient sleep. The U.S. Department of Health and Human Services
(n.d.-a) and National Sleep Foundation (n.d.-a, n.d.-d) promote the adoption of broad
sleep hygiene techniques to improve sufficient and quality sleep.
The basic components of sleep hygiene as recommended by the National Sleep
Foundation (n.d.-a) include:
(a) Adhere to the same bed and waking time. This may help you to
regulate your body’s internal clock and to better fall asleep and stay asleep
during the night.
(b) Practicing a relaxing bedtime ritual, particularly away from bright
lights, helps you to unwind. This may help differentiate sleep from things
that create excitement, anxiety or stress, which sometimes make it more
difficult to fall asleep or stay asleep through the night.
(c) Avoiding naps, particularly in the afternoon, can help you feel tired
enough to sleep at night.
(d) Daily exercise is a great way to improve both physical and mental
health. Any activity, from vigorous to light, may help you settle into a
regular sleep routine.
28
(e) Sleep in a cool, dark room with minimal noise. Rooms between 60 and
67 degrees are optimal, with little to no disturbing noise. Disturbing
noises could include your partner’s snoring. To reduce light and noise,
consider using blackout curtains, sleep masks, white noise machines,
earplugs, or fans.
(f) Sleep on comfortable pillows and mattresses. The life span of a
mattress is between eight to ten years, and older mattresses may be
contributing to your difficulty sleeping. Pillows that are the correct
support for your favored sleeping position may also help. A comfortable
and attractive sleeping space makes the bedroom more inviting and
encourages a more restful night.
(g) Manage your circadian rhythm, your body’s natural internal clock, by
exposing yourself to bright light during the day and minimal light in the
evening.
(h) Avoid alcohol, cigarettes, caffeine and heavy meals in the evening as
each of these can disrupt sleep. Eating at least two to three hours before
bed is recommended.
(i) Avoid electronics before bed as the type of light from screens like
televisions, phones, and tablets is activating to the brain. This may make
it harder for you to fall and stay asleep.
(j) Use your bed only for sleep and sex. This helps to strengthen the
association of the bed with sleep instead of waking activities. If you
cannot sleep, get out of bed, go to another room, and do a relaxing activity
until you feel sleepy. Return to bed only when you feel sleepy (National
Sleep Foundation, n.d.-a).
Multicomponent or cognitive behavioral therapy is an effective behavior
modification technique for improving sleep hygiene (Edinger & Sampson, 2003; Edinger
et al., 2009; Epstein, Sidani, Bootzin, & Belyea, 2012; Espie, Inglis, Tessier, & Harvey,
2001; Mimeault & Morin, 1999; Ritterband et al., 2009; Rybarczyk, Lopez, Benson,
Alsten, & Stepanski, 2002). Sleep hygiene as psycho-education, sleep restriction therapy,
stimulus control (Stepanski & Wyatt, 2003; Morin, Bootzin, Buysse, Edinger, Espie,
Lichstein, 2006) relaxation techniques and cognitive behavioral therapy (Morin et al.,
2006) are terms used to describe subsets of sleep hygiene instructions. Many studies
utilize a multicomponent treatment design including two or more of these subsets in their
interventions (Morin et al., 2006) and different studies combined different subsets of
sleep hygiene techniques to create multicomponent or cognitive behavioral therapy.
Studies in this review utilized combinations of sleep education, often called sleep
hygiene within the study, stimulus control, sleep restriction (Edinger & Sampson, 2003;
Edinger et al., 2009; Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001), cognitive
therapy (Mimeault & Morin, 1999; Ritterband et al., 2009) and relaxation therapy (Espie
et al., 2001; Rybarczyk et al., 2002). Researchers used subjective measures of improved
sleep including sleep diaries and questionnaires (Edinger & Sampson, 2003; Mimeault &
Morin, 1999; Ritterband et al., 2009) and a combination of subjective and objective
measures including actigraphy and polysomnagraphy (Edinger et al., 2009, 2001; Epstein
et al., 2012; Espie et al., 2001; Rybarczyk et al., 2002).
Stimulus control therapy is concerned with associating the bedroom with sleep
29
instead of wakeful activities that may interfere with sleep (Bootzin, 1977). The
behavioral components of stimulus control therapy are (a) go to sleep only when sleepy;
(b) do not use your bed for anything but sleep and sex (i.e. don’t watch television, eat,
read, etc.); (c) if unable to fall asleep, get up and go to another room and don’t return to
bed until sleepy; (d) get up at the same time each day and (e) do not nap during the day
(Bootzin, 1977).
Sleep restriction therapy assumes that people spend too much time in bed
attempting to sleep, which leads to more wakefulness in bed and fragmented sleep. By
curtailing time spent in bed, the person will create a more consistent sleep-wake schedule
where the time spent in bed is spent sleeping (Spielman, Saskin, & Thorpy, 1987). In
comparing control groups to stimulus control and sleep restriction as stand-alone
treatments as well as the two in combination, Epstein et al. (2012) found no difference in
treatment outcomes with all treatment groups showing improvement in sleep measures
compared to the control group.
Sleep hygiene as an educational component of treatment is often concerned with
modifying factors associated with the bedroom, such as light and noise, as well as diet
and exercise (Espie et al., 2001; Pallesen, Nordhus, Kvale, Nielson, Havik, Johnsen, &
Skotskift 2003; Ritterband et al., 2009). Sleep education also gives information
regarding the function of sleep and sleep needs, including information about circadian
rhythms (Edinger & Sampson, 2003; Edinger et al., 2009, 2001; Rybarczyk et al., 2002).
This is typically paired with another subset of sleep hygiene techniques as an intervention
or used as the control group in studies.
Relaxation therapy can include progressive muscle relaxation (Means, Lichstein,
Epperson, & Johnson, 2000; Edinger et al., 2001) deep breathing, autogenic training and
imagery (Rybarczyk et al., 2002). College students with insomnia treated with relaxation
therapy including progressive muscle relaxation revealed improvements in sleep
outcomes compared to students with insomnia who were in the control group (Means et
al., 2000).
In comparing sleep education paired with either stimulus control or relaxation
tapes, researchers found no significant differences in treatment effectiveness between the
two interventions. Both treatment groups showed improvements in sleep parameters
compared to the wait list control group. These gains were maintained at six month follow
up (Pallesen et al., 2003).
Behavioral treatments to improve sleep are efficacious and benefits are sustained
over time (Edinger & Sampson, 2003; Edinger et al., 2009, 2001; Epstein et al., 2012;
Espie et al., 2001; Means et al., 2000; Mimeault & Morin, 1999; Pallesen et al., 2003;
Ritterband et al., 2009; Rybarczyk et al., 2002). Specifically, stimulus control therapy,
sleep restriction therapy, multicomponent cognitive behavioral therapy, and relaxation
training have been shown to be well-established treatment modalities (Morin et al., 2006;
Morgenthaler et al., 2006). Stimulus control therapy has often been considered the
standard to which other behavioral therapies have been compared (Bootzin & Epstein,
2011) and meta-analysis suggests that it may be the most effective single-component
intervention for insomnia (Morin et al., 2006).
Literature utilizing health education and promotion theories and interventions is
sparse. In an attempt to address this gap in the literature, Knowlden and Sharma (2014)
developed a behavior prediction model for sleep with college students using the health
30
belief model. The results of the study indicate that their model explained 34% of
variance in sleep behaviors. The health belief model constructs of perceived severity,
perceived barriers, cues to action and self-efficacy were significant predictors in the
model. Vincent, Lewycky, and Finnegan (2008) also created a measure using health
belief model constructs to ascertain barriers to engagement in stimulus control and sleep
restriction for improving sleep. The authors found that perceived barriers were
significantly associated with adherence to the sleep hygiene behaviors studied, affecting
improvements in sleep outcomes.
Robbins and Niederdeppe (2015) conducted a study utilizing integrative model of
behavioral prediction to examine predictors of healthy sleep behaviors in college
students. Their results indicate attitudes and perceived behavioral control as the strongest
predictors of engaging in sleep behaviors. This provides avenues for future studies to
create and implement interventions based on these constructs to improve sleep in this
population.
Implications
Psychological practices have used sleep hygiene instructions to demonstrate
effective ways to improve sufficient sleep through behavior modification (Edinger &
Sampson, 2003; Edinger et al., 2009, 2001; Epstein et al., 2012; Espie et al., 2001; Means
et al., 2000; Mimeault & Morin, 1999; Pallesen et al., 2003; Ritterband et al., 2009;
Rybarczyk et al., 2002). However, the lack of literature in health education and health
promotion (Knowlden & Sharma, 2014), specifically the lack of health education theory
based interventions, displays a gap in the research. Health education theories could
provide multiple avenues of exploration for models and interventions to improve
sufficient quality sleep. Knowlden and Sharma (2014) and Robbins and Niederdeppe’s
(2015) research employing the health belief model and integrative model of behavioral
prediction demonstrates that health education theories can be useful ways to create
models and work towards interventions to improve sleep. These studies are limited,
however, by their use of a convenience sample of college students. There is a need for
the creation of more measures and models using health education and promotion theories
to design interventions to address sleep deprivation with a wider population.
A clinical psychologist typically administers cognitive behavioral therapy for
improving sleep. It usually takes between six to eight sessions that last one to one and
half hours. This may be too long of a treatment modality to implement in settings outside
traditional therapy (Edinger et al., 2001). In this review, there was a wide variance of
session lengths, from two sessions to nine weeks of access to the intervention. This
variance poses a challenge to understanding what length of treatment can produce
clinically significant results.
Trained psychologists or therapists usually administer cognitive behavioral
therapy. This may create missed opportunities for other health care practitioners or
educators to assist in improving sufficient quality sleep. Research studying the impact of
cognitive behavioral therapy on general practice in medicine has been limited and sleep is
not always addressed in health care visits. Doctors may be unaware of the psychological
literature that promotes sleep hygiene behaviors. The traditional expectations about drug
therapy may outweigh a form of therapy that is often lengthy (Edinger & Sampson, 2003;
Espie et al., 2001).
This review highlights three studies that used methods other than the more
31
traditional clinical psychologist providing multicomponent cognitive behavioral therapy
for improving sleep. One study utilized a six session model with primary care nurses
providing the therapy (Espie et al., 2001). Other studies utilized a self-help approach to
administer the intervention via the internet (Ritterband et al., 2009) and mailed
bibliotherapy participants could complete at home (Mimeault & Morin, 1999). These
studies provide evidence that a wide variety of treatment modalities could be effective in
promoting improved sleep hygiene techniques. Future research should explore additional
ways that people could receive interventions to improve sleep that may be easier for a
wider population to access.
There is a need to increase understanding about the importance of sleep and its
relation to chronic health conditions and to train a wider variety of health care
professionals to better assess and educate patients through a general medical practice and
preventive care visits. Future research should continue to explore ways to implement
sleep hygiene practices in a wider variety of settings as clinical psychologists are in short
supply, particularly those who may have a strong interest in sleep, and pursuing sleep
hygiene in that setting may be time consuming and expensive (Espie et al., 2001). One
question of note is if the social stigma of attending counseling with a psychologist or
therapist could influence how people engage in that form of treatment to improve
sufficient sleep. This could be a future research question to help understand potential
barriers to treatment.
Few studies research how improving sufficient sleep results in improvements in
daytime functioning such as life satisfaction and daytime alertness (Pallesen et al., 2003;
Zammit, Weiner, Damato, Sillup, & McMillan, 1999). Pallesen et al. (2003) found that
improvements in daytime variables were smaller compared to the nocturnal variables
studied. The daytime variable gains evident at post treatment had disappeared by follow
up. Future studies should include more variables assessing daytime functioning and life
satisfaction, further enhancing the knowledge of how improving sleep interacts with
multiple aspects of people’s lives and wellbeing.
Differences in operational definitions of sleep hygiene techniques make it hard to
compare results across studies (Stepanski & Wyatt, 2003). The term “sleep hygiene”
often has different meanings in different studies, sometimes referring to the broad set of
recommendations, but most often referring to a small subset of instructions. Subsets of
traditional sleep hygiene techniques, such as multicomponent cognitive behavioral
therapy, may also contain different elements between studies. As such, replicating the
study findings may be a challenge. This also presents uncertainty as to which
components are truly necessary to see the improvements in sufficient sleep.
The only consistent sleep outcome measures from the studies included in this
review were sleep diaries. Some researchers only utilized subjective sleep data (Edinger
& Sampson, 2003; Mimeault & Morin, 1999; Ritterband et al., 2009). Within these
studies, the subjective measures varied greatly beyond the standard sleep diary. A few
studies used a combination of subjective and objective sleep outcome measures (Edinger
et al., 2009, 2001; Epstein et al., 2012; Espie et al., 2001; Rybarczyk et al., 2002),
however again there was variance as to which measures were utilized. These variances
create additional challenges in comparing results across studies and understanding the
mechanisms that promote sufficient sleep. Future studies should have larger populations
utilizing both subjective and objective measures of sleep outcomes (Edinger & Sampson,
32
2003).
The strategy summary table included in this review highlights the two main
behavior modification constructs that sleep hygiene techniques fall under, stimulus
control and reinforcement. Stimulus control is a process that strengthens a behavior or
increases the likelihood that a behavior will occur again in the future when a specific
antecedent stimulus is present prior to the desired behavior (Kazdin, 2001; Miltenberger,
2001). The sleep hygiene techniques recommended by the National Sleep Foundation
(n.d.-a) and described previously in this review fit best under the construct of stimulus
control.
Applying a reinforcing behavior is also recommended in the strategy summary
table. Reinforcement is a process that strengthens a behavior or increases the probability
that a behavior will occur again in the future by using a positive or negative reinforcer
following the desired behavior. Positive reinforcers are the stimuli or events proffered
after a behavior. Negative reinforcers are the removal of stimuli or events after a
behavior (Kazdin, 2001; Miltenberger, 2001). A token or reward system for following
through on the behavior modifications made using sleep hygiene techniques may increase
the persistence of these new behaviors. This is an example of creating a positive
reinforcement for sleep hygiene behaviors.
33
Behavior modification techniques for reducing sleep deprivation.
Construct Definition Application for increasing
sufficient sleep
Reinforcement Process that strengthens a
behavior or increases the
probability a behavior will
occur again in the future,
can have positive or
negative reinforcers
Create token/reward
system for following
sleep hygiene
techniques
Stimulus Control Process that strengthens a
behavior or increases the
probability a behavior will
occur again in the future
when a specific antecedent
stimulus is present prior to
the behavior
Go to sleep only
when sleepy
Use your bed for
sleep and sex only
If you aren’t asleep
in 20 minutes get out
of bed until sleepy
again
Get up at the same
time every morning
Do not nap
Exercise daily
Evaluate your room
for temperature,
noise, and light
Sleep on comfortable
mattress and pillows
Avoid bright light in
the evenings
Avoid alcohol,
cigarettes and heavy
meals before bed
Keep the same
bedtime and wake up
time
Practice a relaxing
bedtime ritual, like
progressive muscle
relaxation
Avoid electronic
devices before bed
Constructs adapted From Miltenberger, 2001*
*Constructs of behavior modification include punishment, extinction and respondent
conditioning, however sleep hygiene techniques did not fit in the criteria for these
constructs.
Reducing Sleep Deprivation through Behavior Modification Literature Review Matrix
Author, Date
Results Study Objective Participant
Demographics
Behavior
Modification
Construct
Study Design
Edinger, Olsen,
Stechuchak,
Means,
Lindeberger,
Kirby, &
Carney, 2009
To evaluate the
efficacy of CBT
compared to basic
sleep hygiene control
patients with primary
or comorbid insomnia
N = 81, 11
women
Mean age =
54.2 years, SD
= 13.7 years
Stimulus
Control
Randomized
parallel group
clinical trial,
Sleep diary,
actigraphy, 4
sessions, 6 month
follow up
Treatment group showed
significant improvements
over control group, 75%
of patients with primary
insomnia reported normal
sleep by post treatment
Edinger &
Samson, 2003
To assess
effectiveness of
abbreviated CBT with
primary care patients
N = 20, 2
women
Mean age =
51.0 years, SD
= 13.7 years
Stimulus
Control
Randomized
controlled trial,
Sleep diary, Self-
Efficacy Scale, 2
sessions, 3 month
follow up
ACBT group showed
significantly improved
SOL, WASO, SE
Results maintained at
follow up
Edinger,
Wohlgemuth,
Radtke, Marsh
& Quillian, 2001
To evaluate the
efficacy of CBT,
relaxation training
and placebo for
treating primary sleep
maintenance
insomnia
N = 75, 35
women Mean
age = 55.3
years
Stimulus
Control
Randomized,
double blind
placebo
controlled trial,
Sleep diary, 6
month follow up
CBT produced larger
improvements across the
majority of outcomes
measures compared to
relaxation training and
placebo
Epstein, Sidani,
Bootzin, &
Belyea, 2012
Compare placebo,
single component
(stimulus control or
sleep restriction) and
multicomponent
(stimulus control and
N = 179, 115
women, Mean
age = 68.9
years, SD = 8.0
years
Stimulus
Control
Randomized
controlled trial,
Sleep diary,
Actigraphy, 6
sessions, 3 month
and 1 year follow
Treatment groups
showed significant
improvements compared
to control group,
Treatment improvements
maintained at one year
sleep restriction)
behavioral treatments
for insomnia
up follow up
Espie, Inglis,
Tessier &
Harvey, 2001
Investigate
effectiveness of CBT
delivered by primary
care nurses
N = 139, 95
women, Mean
age = 51.4
years, SD =
17.1 years
Stimulus
Control
Randomized
controlled trial,
Sleep diary, Penn
State Worry
Questionnaire,
Epworth
Sleepiness Scale,
6 sessions, 1 year
follow up
CBT group showed
significant improvements
Treatment gains were
maintained at follow up,
84% of patients initially
using hypnotics were
drug free at follow up
Means,
Lichstein,
Epperson, &
Johnson, 2000
Compared students
on self-reported sleep
variables and
explored changes in
daytime functioning
after using
progressive relaxation
treatment for
insomnia
N = 118, 85
women, Mean
age = 21.2
years, SD = 5.2
years
Stimulus
Control
Randomized
controlled trial.
Sleep diary, IIS,
DBAS, ESS,
FSS, PSWQ, 3
sessions, 2
months follow up
Progressive relaxation
training compared to
control group resulted in
improvements. Students
with insomnia reported
more perceived impaired
day time functioning than
students without
insomnia
Mimeault &
Morin, 1999
Assess effectiveness
of self-help CBT with
and without guidance
for insomnia
N = 54, 32
women, Mean
age = 50.80
years, SD =
12.64 years
Stimulus
Control
Randomized
controlled trial,
Sleep diary, 6
sessions, 3 month
follow up
Both treatment
conditions were
comparable at follow up,
suggesting both
demonstrated effective
treatment gains over time
Pallesen,
Nordhus, Kvale,
Nielson, Havik,
Johnsen, &
Skjotskift, 2003
Compare two
behavioral
interventions for
insomnia treatment in
an older population
N = 55, 46
women, Mean
age = 69.8
years, SD =
6.53 years
Stimulus
control
Participants
randomized to
immediate
treatment or
waitlist, Sleep
diary, 4 sessions,
6 month follow
up
Treatment groups
exhibited improvements,
treatment gains
maintained at follow up,
Participants reported
improvements in daytime
functioning and life
satisfaction after
treatment
Ritterband,
Thorndike,
Gonder-
Frederick,
Magee, Bailey,
Saylor & Morin,
2009
Evaluate efficacy of
CBT via the internet
for adults with
insomnia
N = 44
34 women
Mean age =
44.86 years
SD = 11.03
years
Stimulus
Control
Randomized
controlled trial
Sleep diary, ISI
9 weeks access to
internet
intervention, 6
month follow up
Internet group exhibited
significant changes in
WASO and SE
Internet group showed
significant reductions in
ISI and maintained
reductions at 6 month
follow up
Rybarczyk,
Lopez, Benson,
Alsten &
Stepanski, 2002
Assess efficacy of
behavioral
interventions on
insomnia with
comorbid medical
illness in an elderly
population
N = 38, 22
women, Mean
age = 67.8
years
Stimulus
Control
Randomized
controlled trial,
Sleep diary,
Health Survey,
Pain
Questionnaire,
Life satisfaction
measure, 6-8
sessions, 4 month
follow up
CBT is an effective
treatment for insomnia in
older adults with
comorbid medical illness
37
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Thank you to our 2014 Platinum Sponsors
ArkAHPERD 2015 State Convention
November 5-6
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207 W. Van Buren
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Phone: 1-479-253-9768
2014 Teacher of the Year Awards
Elementary TOY – Brad Cowger
Middle School TOY – Leah Queen
High School TOY – Mike Morrison
Health Education TOY – Laura Abbott
40
Faculty Peered Review Article
Accessibility of Public Schools’ Extracurricular Activities for Homeschooled Students
by David Lavetter
Introduction
A growing number of parents in the United States are home-schooling their children as an
alternative to sending them to public or private schools. U.S. Department of Education (NCES,
2014) showed 2.3 million U.S. children were homeschooled in 2010, an increase of 52.2% since
2003 (1.1M). For various reasons, parents or guardians believe that they can provide an equivalent
or superior educational experience. Familiar reasons given for homeschooling are: Customize or
individualize the curriculum and learning environment for each child, academically challenge each
student more than schools can, use pedagogical approaches other than those practiced in public
schools, enrich family relationships between children and parents, and sometimes among siblings,
provide guided social interactions with youthful peers and adults in similar homeschool groups,
provide a safer environment for children and youth (e.g. bullying), and impart a particular set of
values, religious beliefs, and principles to students (Ray, 2015).
Yet, increasingly, homeschool parents have become interested in taking advantage of
extracurricular activities offered at public schools. Though a variety of reasons exist for parents
choosing to homeschool their children, many states’ extracurricular participation policies also vary.
In 1991, Washington was the first state to allow homeschooled students on public school teams
(Colb, 2005). Many states have since followed. The purpose of this paper discusses the legalities of
extracurricular participation in public schools of homeschooled students.
According to Homeschool Legal Defense Association (HLDA, 2013), homeschooling is
legal in every state; though requirements vary (districts within some states can also vary).
Currently, 36 states (Appendix, Table 1) allow home-school participation in public school extra-
curricular activities. States use a unique vocabulary describing their activities. Pay attention to the
meanings of various terminologies used by particular states and school districts. For example,
“extra-curricular,” “co-curricular,” “curricular,” “interscholastic,” “program,” “activity,” etc.
should be given due proper attention to distinguish one from another. How a state defines these
terms is essential. Additionally, many states’ policies can vary with the specific requirements to be
eligible to participate as a homeschooled extracurricular participant (HLDA, 2013).
Statutory Law Case Law
AZ, AR, CO, FL, ID, IL, IA, LA, MA, ME,
MN, MO, NE, NV, NH, NM, ND, OH, OR,
PA, RI, SC, SD, TN, TX, UT, VA, VT, WA,
WI, WY
MA, MI, MT, NJ, WV
Table 1. States allowing extra-curricular participation for homeschooled students (HLDA, 2013).
In states, where homeschooling has been an alternative to private and public school education,
plaintiffs’ arguments are usually focused on statutory and constitutional rights to participate in
extracurricular activities. Opponents cite a double standard under which public school students
must follow academic and attendance rules to play sports while homeschoolers do not.
Consider a few legal questions related to homeschoolers’ participation in school activities:
Do homeschoolers have a general right to send their children to a limited component (e.g.
interscholastic athletics) of the public school?
41
For those states that disallow extra-curricular participation for homeschoolers, does the “all-
or-nothing” consumption of the public school’s benefits place schools at greater risk for
potential lawsuits?
Does the greater right, to attend school, include the lesser right, to participate in extra-
curricular activities?
Are extra-curricular activities an inseparable part of public school education?
In states, where homeschooling has been an alternative to private and public school
education, plaintiffs’ arguments are usually focused on statutory and constitutional rights to
participate in extracurricular activities. Opponents cite a double standard under which public school
students must follow academic and attendance rules to play sports while homeschoolers do not. In
Davis v. Massachusetts Interscholastic Athletic Association (1995), the plaintiff filed suit because
defendant wouldn’t allow her to try out for the high school softball team. Plaintiff alleged actions
were arbitrary, capricious, and in violation of the Constitution of the Commonwealth of
Massachusetts and of the 14th
amendment. At issue is whether the plaintiff’s Equal Protection
rights are violated. As noted, religion is commonly a factor cited for some choosing to homeschool.
Thus, the Free Exercise Clause may also be applied by courts to determine if the school’s
participation policy is neutral and generally applicable for all students.
Trefelner et al. v. The Burrell School District (2009) concluded there is no reason to
distinguish between religiously motivated home education programs and other forms of religiously
motivated education programs, such as attending a parochial school. If the decision to enroll a
student in an education program is motivated by religion, then that action is protected by the Free
Exercise Clause if the policy is not neutral. The court found the district’s participation policy was
neutral and generally applicable.
Are homeschoolers’ constitutional rights violated when they are not allowed to participate
in interscholastic athletics? In Snyder v. Charlotte Public School Dist. (1985), the State Supreme
court held that public school’s extracurricular programs are open to all students unconditional upon
compulsory attendance law. Yet, Reid et al. v. Kenowa Hills Public Schools (2004), found that
state statutes do not require public schools to admit homeschooled students to their athletic
programs and that students do not have a statutory right to participate in interscholastic athletics.
As seen, state laws vary whether Equal Protection may be granted to homeschoolers.
Arkansas Law (Act 1469)
With the enactment of House Bill 1789 on April 22, 2013, homeschool students may now
participate in interscholastic activities at their resident school district in the state of Arkansas. The
term “interscholastic activity” means an activity between schools subject to the regulations of the
Arkansas Activities Association and is (1) outside the regular curriculum of the school district and
includes such things as an athletic activity, a fine arts program, or a special interest club or group
and (2) taught by an individual with a minimum of a high school diploma (Arkansas Code §6-15-
509).
Further, homeschooled student is defined as a student legally enrolled in an Arkansas home
school. The must enroll in school (at least one class per school day) and report to the district with
11 school days of fall or spring semesters. To engage in extracurricular activities, the homeschooler
(or parent) must provide notice to the principal of the student’s intention to pursue participation in
the activity prior to the signup, tryout, or participation deadlines established for public school
students. Participation is not guaranteed, but the homeschool student has an opportunity to try out
for the respective extracurricular teams or student organizations (Arkansas Code §6-15-509).
Additionally, “…the student’s parent must inform the principal in the notice that the student
42
has demonstrated academic eligibility by obtaining either a test score at or above the 30th
percentile on the Stanford Achievement Test, 10th edition, or another nationally recognized norm-
referenced test within the previous 12 months. In the alternative, the student may achieve a
minimum score on a test approved by the state board of education. Additionally, the homeschool
student must meet the same eligibility criteria established for participation by public school
students. A student who withdraws from an Arkansas Activities Association member school to be
homeschooled is prohibited from participating in an interscholastic activity for a minimum of 365
days from the student’s withdrawal” (Arkansas Code §6-15-509, ACT 1789, p. 1).
Expectedly, the student is required to meet the school’s criteria for joining the team, club,
or other extracurricular activity such as standards of behavior, or codes of conduct, academic
qualifications, class attendance policies, drug testing, practice times, exculpatory agreements (e.g.
waivers), medical exams, and possible activity fees (Arkansas Code § 6-15-509). A full description
of the code is as follows:
Arkansas Code Annotated § 6-15-509 (State of Arkansas 89th
General Assembly, 2013, pp. 1-3).
(a) The General Assembly recognizes that all students should have equal access to interscholastic
activities as a complement to the academic curriculum.
(b) As used in this section:
(1) “Athletic activity” means a varsity sport or another competitive sports-related contest,
game, event, or exhibition that involves an individual student or teams of students either
among schools within the resident school district or between schools outside of the resident
school district;
(2) “Home-schooled student” means a student legally enrolled in an Arkansas home school;
(3) “Interscholastic activity” means an activity between schools subject to regulations of the
Arkansas Activities Association that is:
(a) Outside the regular curriculum of a school district, including without limitation
an athletic activity, a fine arts program, or a special interest club or group; and
(b) Taught by an individual with a minimum of a high school diploma;
(4) “Parent” is a legal guardian or legal custodian;
(5) “Resident school” is the school to which the student would be assigned by the resident
school district; and
(6) “Resident school district” means the school district in which the home-schooled
student’s parent resides as determined under § 6-18-202.
(c) A home-schooled student shall not participate in interscholastic activities at a
public school other than the student’s resident school.
(d) A resident school district may permit a home-schooled student to participate in
an interscholastic activity if:
(1) For the purpose of subsection (g) of this section, the home-schooled
student reports to the resident school district within the first eleven (11) days of the
fall or spring semester of the resident school district; and
(2) The home-schooled student or his or her parent advises the principal of
the resident school in writing of the student’s request to participate in the
interscholastic activity before the signup, tryout, or participation deadlines
established for students enrolled in the resident school.
(e) The principal of the resident school shall permit a home-schooled student to
pursue participation in an interscholastic activity of the resident school if the student or the
student’s parent:
43
(1) Before the signup, tryout, or participation deadlines established for
students enrolled in the resident school, provides to the principal a notice of the
student’s desire to pursue participation; and
(2) Informs the principal in the notice that the student has demonstrated
academic eligibility by obtaining:
(A) A minimum test score of the thirtieth percentile on the Stanford
Achievement Test Series, Tenth Edition, or another nationally recognized
norm-referenced test in the previous twelve (12) months; or
(B) A minimum score on a test approved by the State Board of
Education.
(f) If a home-schooled student’s written request to participate in the interscholastic
activity is approved under this section, the student:
(1) Although not guaranteed participation in an interscholastic activity, shall
have an equal opportunity to try out and participate in interscholastic activities
without discrimination; and
(2) Shall not participate unless he or she meets the criteria for participation
in the interscholastic activity that apply to students enrolled in the resident school
district, including:
(A) Tryout criteria;
(B) Standards of behavior and codes of conduct; and
(C) The academic criteria under subdivision (e)(2) of this section;
(D) Practice times;
(E) Required drug testing;
(F) Permission slips, waivers, and physical exams; and
(G) Participation or activity fees.
(g) A home-schooled student who participates in an interscholastic activity may be:
(1) Required to be at school not more than one (1) period per school day; and
(2) Transported by the resident school district to and from interscholastic
activities as the resident school district transports other students who are enrolled in
the resident school.
(h) A student who withdraws from an Arkansas Activities Association member
school to be home-schooled shall not participate in an interscholastic activity in the resident
school district for a minimum of three hundred sixty-five (365) days after the student
withdraws from the member school.
Equal Protection and Free Exercise Clause
The concept of equal protection stands for the principle that all persons similarly situated
should be treated alike. “No state shall make or enforce any law which shall abridge the privileges
or immunities of citizens of the United States; nor shall any State deprive any person of life,
liberty, or property, without due process of law; nor deny to any person within its jurisdiction the
equal protection of the laws.” (U.S. Const. Amend XIV, § 1). The Free Exercise Clause may also
be applied by courts to determine if the school’s participation policy is neutral and generally
applicable for all students. “Congress shall make no law respecting an establishment of religion, or
prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the
right of the people peaceably to assemble, and to petition the Government for a redress of
grievances.” (U.S. Const. Amend. I § 1) (Italics added).
In Swanson v. Guthrie Independent School District (1998) an Oklahoma student was not
44
allowed to attend school on part-time basis to be enrolled only in foreign language, and vocal
music. The school district had no policy related to homeschool participation at the time. Following
the hearing, the district instituted a new policy but had limited applications. The plaintiffs claimed
under the Free Exercise Clause, students should be able to attend public school on part-time basis.
Yet, the courts found the district’s policy is neutral and of general application; it applies to all
persons who might wish to attend public school on a part-time basis (including home schooled
students). School district was granted summary judgment due to the neutrality of the policy (no
need to show a compelling governmental interest). The case law in this area establishes that parents
simply do not have a constitutional right to control each and every aspect of their children's
education and oust the state's authority over that subject. Federal District court affirmed.
In Trefelner (2009), a homeschooled plaintiff in Pennsylvania filed for a complaint for 1st and
14th
Amendments violation. The plaintiffs requested temporary restraining order in order to
participate in extra-curricular activities. Burrell instituted Policy No. 122, Co-Curricular Activities
whereby a student must attend the full curricula of classes each day the student is to participate in
an extracurricular activity offered by Burrell. After the adoption of Burrell's Policy No. 122, PA's
Public School Code, 24 PA, STAT. § 1-1-1 et seq. was amended to permit students who are home
schooled or students who attend charter schools to participate in extracurricular activities offered
by the school district in which they reside. Although plaintiffs raised an equal protection claim,
there is significant overlap between their equal protection claim and free exercise claim. Courts did
not distinguish between religiously motivated home education programs and other forms of
religiously motivated education programs, such as attending a parochial school. Courts view them
similarly. If the decision to enroll a student in an education program is motivated by religion, then
that action is protected by the Free Exercise Clause if the policy is not neutral. If a policy is
"neutral" and "generally applicable" with respect to religion, then it need not be justified by a
compelling governmental interest even if the law has the incidental effect of burdening a particular
religious belief or practice.
Exceptions to the policy, however, were made as the state Public School Code mandated
exceptions for purposes (i.e. home schooled children and students attending charter schools). These
exemptions undermined Burrell's policy to the same extent that permitting plaintiff to participate in
the marching band would undermine the policy. If the state-mandated exceptions were not made,
then the policy would violate state law. The Court of Appeals did not question whether the decision
to home-school a child was religiously motivated; it analyzed whether the courts found defendant
did not articulate any compelling reasons for their policy (Trefelner, 2009).
For collegiate athletics participation, the following outlines both National Association of
Intercollegiate Athletics (NAIA), and National Collegiate Athletic Association (NCAA) policies
for home-schooled students:
NAIA Initial Eligibility
Provide proof student received certificate (or equivalent) granted by the appropriate state
agency verifying successful home schooling requirements completion.
Achieve a minimum score of 18 on ACT or 860 on SAT.
If student resides in a state that has no home school requirements or a state agency that can
verify completion of requirements, student will need to seek an exception to the standard
rule under the process in Article V, Section L of the NAIA Bylaws.
In prior requests, a student who has scored well on the ACT or SAT has had an outstanding
chance of receiving an exception (NAIA, 2014).
NCAA Eligibility
45
Register with NCAA Eligibility Center (send required materials to Center)
Standardized test score
Transcript (core course requirements)
Proof of high school graduation
Proof homeschool was conducted in accordance with state law
List of textbooks used (NCAA, 2014).
Private School States
At least nine states do not have homeschool statutes. In these states homeschools are legally
considered private schools. Consequently, homeschoolers usually have more freedom from
burdensome state requirements. It is difficult to write a law allowing equal access for
homeschoolers when a “homeschool” is not defined by statute. In these situations, homeschoolers
do not want to lose the freedoms they have as private schools, and state officials are not usually
willing to throw access open to all private school students. Access legislation can be worded so that
it does not change the private school status of home educators, but such a bill has yet to pass in a
private school state (HSLDA, 2013).
While athletic association rules are not “law,” public schools are generally constrained to
operate within them, or their teams could be disqualified. Therefore, in states where case law has
established precedence in this area, state associations have followed suit. A trend of allowing
access for homeschooled students continues to increase under statutory state law during the last
decade. Generally, we shall probably see homeschool students to have greater access to limited
school activities, such as interscholastic athletics, as we look to the future.
References
Arkansas Code §6-15-509. ACT 1789 (2013). State of Arkansas 89th
General Assembly, Regular
Session 2103. Retrieved from ftp://www.arkleg.state.ar.us/Bills/2013/Public/HB1789.pdf.
Colb, S.F. (2005). Should parents who home-school their children have access to public school
extracurricular programs? Retrieved from http://writ.news.findlaw.com/colb/20050630.html
Davis v. Massachusetts Interscholastic Athletic Assoc. (1995), Inc. 3 Mass. L. Rep. 375, 1995
Mass. Super., LEXIS 791
Homeschool Legal Defense Association (HSLDA) (2013, September). State laws concerning
participation of homeschool students in public school activities. Retrieved from
http://www.hslda.org/docs/nche/Issues/E/Equal_Access.pdf
National Center for Education Statistics (NCES) (2014). Retrieved from
http://nces.ed.gov/pubs20014/2014030.pdf
NAIA (2014). NAIA Homeschool Eligibility Policy. Retrieved from
http://naia.cstv.com/memberservices/legislative/currentissues/FreshmenEligibilityRequirem
ents.htm
NCAA (2014). NCAA Homeschool Eligibility Policy. Retrieved from
http://www.ncaa.org/wps/ncaa?ContentID=417
Ray, B.D. (2015). Research facts on homeschooling. National Home Education Research Institute.
Retrieved from http://www.nheri.org/research/research-facts-on-homeschooling.html.
Reid et al. v. Kenowa Hills Public Schools (2004). 2004 Mich. App. LEXIS 645.
Snyder v. Charlotte Public School Dist. (1984). 417 Mich. 104; 365 N.W. 2d 151.
Swanson v. Guthrie Independent School District No. I-L (1998). 135 F.3d 694; 1998 U.S. App.
LEXIS 1259.
Trefelner v. The Burrell School District (2009). U.S. Dist. (PA) LEXIS 78785
46
Important Dates
National Coaching Conference
2015 PETE & HETE Conference
June 9-12, 2015
October 27-31, 2015
Morgantown, WV
Atlanta, GA
ArkAHPERD Convention November 5-6, 2015 Eureka Springs, AR
Southern District Convention February 10-13, 2016 Williamsburg, VA
2016 SHAPE America Convention April 5-9, 2016 Minneapolis, MN
ArkHEART Course-PD Opportunity
Course:
This six week course provides an introduction and review of the
heart and associated diseases. Take the course to refresh you
knowledge in the anatomy, function and diseases of the heart.
Cost:
Free to AHA event holders (JUMP or HFH)
Registration:
Sign up by contacting the ArkAHPERD office (a JUMP or HFH
event must be held)
Course Dates:
Spring and Fall courses offered
47
Faculty Peered Review Article
The Effects of Using Physical Activity in the Classroom to Enhance Children’s Cognition by Blair
McAlister ASU & Blair Dean ASU
Introduction
The No Child Left Behind Act of 2001 (NCLB) is a United States Act of Congress about
the education of children. The NCLB supports standards-based education reorganization, which is
based on the notion that setting high standards and measurable goals can improve individual
outcomes in education. Although the Act has recognized strengths: high learning expectations, the
attention on subgroups that have been known to trail behind, improved alignment, and better use of
data; some school administrators have voiced negative concern (Wada, 2009). The popularity of
NCLB's measures has been fiercely argued (Wada, 2009). A primary criticism suggests that
NCLB could reduce effective instruction and children’s learning because it may cause states to
lower achievement goals and encourage teachers to "teach to the test," (Wada, 2009).
NCLB’s primary focus has been on improving skills in reading, writing, and mathematics,
in order to become more competitive in the global market. With an overemphasis placed on core
subjects (reading, writing and math), an adverse effect has occurred in subjects labeled as “not
tested core curriculum” such as history, music, art and physical education (Wada, 2009). While
long term effects have yet to be measured, the short term effects may be detrimental for the non-
tested subject areas (Wada, 2009). Reports indicate that the majority of federal funding for schools
is earmarked for core tested subjects (Burgeson, 2004). This unbalance in funding has caused
instruction in other subjects to decrease by 71% (Burgeson, 2004). NCLB standards have caused
educators to teach to the measurable skills tested on State Benchmark exams. Teachers are
encouraged to spend the majority of their time teaching these measured skills for testing so that
improvement is seen among the student body. For instance, if a school body is going to be tested on
how students recite the Pledge of Allegiance, teachers are going to spend the majority of their time
teaching the Pledge of Allegiance, not the National Anthem (Wada, 2009). Reading, writing, and
mathematics are the focus of testing, therefore, schools will spend their funding, time, and energy
to prepare children for these content area skills. For this reason, the NCLB has been frequently
cited as one of the main causes for the strain on physical education (Wada, 2009).
The adverse effect on physical education is one of the many noted reasons childhood
obesity is growing in occurrence. It is no secret that childhood obesity is a serious problem in the
United States; according to a report from the White House Task Force on Obesity, one in three
children are now obese and $117 billion is spent annually to treat obesity-related diseases (Wada,
2009). Alarming research predicts parents of this generation could outlive their children due to
increased sedentary lifestyles (Sanders, 2003). Children who have poor nutritional habits are at a
greater health risk than children who participate in alcohol, drugs, and tobacco combined.
Likewise, being overweight can impair school performance in many ways, including health-related
absenteeism (Story, 2006). Among the health conditions linked with being overweight in school-
aged children are asthma, joint problems, type 2 diabetes, depression and anxiety, and sleep apnea
(Story, 2005). Social problems—such as being teased or bullied—loneliness, or low self-esteem,
can also affect how well children perform in school (Story, 2005)
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Just as the previously discussed negative effects of childhood obesity are undisputable, so
are the positive benefits of a quality physical education program. The quality of physical education
classes is also crucial in their effect on childhood obesity. In physical education, programs,
children learn the importance and value of being physically active. Children learn that daily
physical activity helps: build and maintain healthy bones, muscles, and joints; control weight, build
lean muscle; and lower high blood pressure. Likewise, recent studies concluded that regular
physical activity reduces the feelings of depression and anxiety; and through its effects on mental
health, enhances cognitive function (Rice, 2009). It is believed that physically active children have
a greater chance of being healthy for a lifetime (Sanders, 2003).
Moreover, “research suggests a strong correlation between children’s fitness and their
academic performance as measured by grades in core subjects and standardized test scores”
(Hellmich, 2010). It is a widely accepted concept that being physically active increases physical
health. It is also reported that good physical health is linked to brain health. There are several
reasons why physical activity is beneficial for the brain: increasing the blood and oxygen flow to
the brain, increasing growth factors that help create new nerve cells, and increasing chemicals in
the brain that help cognition, such as dopamine, norepinephrine, and serotonin (Dean, 2009).
Any time a child engages in physical activity, oxygen reaches the brain with more ease,
resulting in improved focus and cognition. Youth receiving additional physical activity tend to
show improved attributes such as increased brain function and nourishment, higher energy/
concentration levels, improved somatotypes, increased self-esteem and better behavior which all
support cognitive learning (Elliott, 2002). However, as of late, children are spending an alarming
amount of time sitting and remaining inactive during the school day.
Research suggests that children and teens need 60 minutes of physical activity daily for
adequate health (President’s Council, 2010). However, in many schools, opportunities for children
to be physically active are few and far between and becoming increasingly so. This is true because
time away from math, reading, and writing is viewed as academic time wasted. If instruction does
not directly lead to improved test scores it is discouraged or not allowed. Cardon’s (2003) research
results indicate that children in traditional schools spend 97% of the lesson time sitting (Cardon,
2003). Consequently, schools have become information rich and movement poor. “Physical
education cannot be viewed as merely a desirable option in a school system. It is an absolute
necessity, and it must be built into the curriculum to ensure that all children participate fully in a
program that will challenge them close to their limits,” (Instructor Web, 2010). Although there is a
significant fear of losing valuable instruction time to extra physical education, research shows
teachers who implement physical activity into classroom instruction will observe multiple
improvements in a child’s learning.
Enhancing academic learning through physical activities, resulting in an active hands-on
classroom, will find children with an increase in brain functioning, creating more connections for
learning (Scheuer, 2003). Also, implementation of an active classroom will see improvements in
memory formation, concentration, and social behaviors. Research has shown that when additional
time is devoted to physical activity, it does not interfere with learning and in some instances even
has accelerated learning (Noffsinger, 2005). This multi-sensory approach to teaching helps children
by allowing them to learn through more than one of the senses (Dean, 2009). Incorporating
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physical activities across the curriculum is the breath of fresh air for children who learn by doing,
not by sitting. American teachers cannot advocate to battle childhood obesity when children are
imprisoned to their desks.
Statement of the Problem
Schools must fit many subjects and activities into the school day and must balance state and
local resources, priorities, and needs for education. In recent years, however, the comprehensive
curriculum has been eroding, especially in the wake of the federal No Child Left Behind Act of
2001, which focuses on student achievement in defined core academic subjects (Burgeson, 2004).
As states develop or select standardized tests to hold schools and children accountable, content that
is not tested, such as physical education, has become a lower priority (Story, 2006). But, as noted,
time devoted to physical education does not lessen performance in other areas and can, in fact,
enhance both children’s readiness to learn and academic achievement (Sallis, 1999). The fact that
mandatory physical education classes have been watered down and recess time has decreased in
many school districts across the nation (Landers & Kretchmar, 2008) suggests a lack of
understanding among school administrators and the American public of the connection between
children’s physical and mental well-being.
Purpose of Study
Schools are unique in their ability to promote physical activity and increase energy
expenditure— and thereby help reduce childhood obesity. Knowledge of the effects of physical
activity on brain function is highly pertinent to teachers. This information should become part of
the knowledge base of teachers and should be included in the professional training of teacher
candidates. Education of the American public, including those who make critical decisions
regarding curriculum and budget allocation, is also necessary. The purpose of this paper is to
review the basic scientific findings of the role of movement as a significant vehicle to enhance
academic learning in the classroom.
Significance of Study
Due to NCLB standards, teachers have begun to base instruction on standardized testing or
“teaching to the test,” which has caused physical education to plummet. As a result, childhood
obesity is at an all-time high in America. This study is significant to the American teacher because
children will not adequately learn to the best of their ability if their physical needs are not met.
Because of recent legislation, teachers are evaluated based on their children’s test scores. If
implementing physical activity into the classroom can assist in achieving educational goals and
enhance children’s learning, the teacher will find this research to be very valuable.
Also, further educating the American public is needed regarding the benefits of physical
activity on the overall health, emotions, and intellectual capacity. It seems rational for teachers and
exercise professionals first to become familiar with the important research findings about the
effects of physical activity on the brain and cognitive function. This information may give
professionals a better understanding of the mechanisms by which physical activity might enhance
learning. With more knowledge, professionals may exert greater influence on children, parents, and
those who make curriculum and budgetary decisions that affect school curriculum (e.g., principals,
school board members).
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Review of Literature on Benefits of Physical Activity Introduction
With one in three children being classified as obese, (Wada, 2009), teachers must become
knowledgeable of the precedence physical activity plays in a child’s overall physical health.
Because children spend more waking moments in the classroom than at home, teachers should view
time spent in the classroom as opportune times to increase a child’s physical health, thus,
increasing their quality of life. The benefits of physical activity on children’s health are
undisputable, and should drive a teacher’s lesson planning.
Physical Activity and Improved Mental Clarity
“Physical activity will positively affect blood flow and oxygen to the brain, thereby
improving mental clarity” (National Association for Sport and Physical Education, 2011). When
individuals are physically active, blood circulation is increased resulting in an increase of oxygen
and glucose that reaches the brain. Research has shown that movement activities stimulate every
area of the brain, thus forming new connections between brain cells (Dean, 2009). When neurons,
specialized cells that send and receive signals within the body, receive these new connections, brain
activity is increased (MedicineNet, 2003). These special connections between neurons, also called
synapses, are associated with memory formation and storage in the cerebellum of the brain (Kleim,
2002). Children’s brains contain trillions of neurons waiting for synapses; therefore, educators
should provide rich movement experiences to accommodate this connection, which will stimulate
the brain and engage students in the formation of memory.
Physical Activity and Improved Attention Span
“Physical activity will also positively affect connections between nerves in the brain,
thereby improving attention and information-processing skills” (National Association for Sport and
Physical Education, 2011). Brain activity can be increased with the slightest of movements. For
example, “a 5-15% increase in blood and oxygen flow to the brain is created when one stands.”
This causes participants to become more alert, (Cummins). Also, blood pools in the seat and feet
after about twenty minutes of being seated. This moves essential blood circulation away from the
brain. Research results indicate that children in traditional schools spend approximately 97 % of the
lesson time sitting at their desks (Cardon, 2003). Without conditioning, research suggests that an
average child’s formal attention span, in minutes, is about as long as the age of the child (Bickta).
Implementing movement activities into the regular classroom will stimulate the brain by increasing
oxygen and blood flow, resulting in more effective memory formation and longer attention spans.
Physical Activity and Improved Physical Health
“Physical activity will help to build strong bones and muscles” (National Association for
Sport and Physical Education, 2011). Children require more than a balanced diet with proper
amounts of calcium and protein to build strong bones and muscles. Participation in movement
activities at an early stage of life helps lower the risk of chronic back and neck pain (Vorvick,
2011). “Osteoporosis, the disease that causes bones to become less dense and more prone to
fractures, has been called “a pediatric disease with geriatric consequences,” because the bone mass
attained in childhood and adolescence is an important determinant of lifelong skeletal health”
(National Institute of Health, 2011). Action taken to increase a child’s physical health will be
51
reflected in his/her life as an adult. Muscles get stronger when they are used and conditioned.
Similarly, bones will strengthen as they are conditioned through physical activity (National
Institute of Health, 2011). When teachers invest in each child’s physical health and well-being, they
will find that children miss less school because of health-related absenteeism.
Physical Activity and Decreased Obesity-Related Health Risks
“Physical activity decreases the likelihood of developing obesity and risk factors for
diseases such as type 2 diabetes and heart disease” (National Association for Sport and Physical
Education, 2011). The single greatest risk factor for contracting diseases such as Type 2 Diabetes
and heart disease is excess weight (WebMD, 2010). One of the greatest ways to reduce excess
weight is by remaining physically active. Research concludes that one in three children is now
obese and $117 billion is spent annually to treat obesity-related diseases like Type 2 Diabetes and
heart disease (Wada, 2009). Children spend more waking hours at school than at home. Because of
this, teachers should propose ways in which they can facilitate activities that will increase
children’s health and fitness.
Physical Activity and Positive Mental Health
“Physical activity promotes positive mental health and can reduce anxiety and depression”
(National Association for Sport and Physical Education, 2011). The Surgeon General’s Report on
Physical Activity and Health (Landers: Research Digest, 1996) concludes that physical activity
appears to relieve symptoms of depression and anxiety and improve mood” and that “regular
physical activity may reduce the risk of developing depression (Landers). “Studies have shown
that the process of exercise brings about both short- and long-term psychological enhancement
and mental well-being. Physical activity has been found to have a positive causal effect on self-
esteem changes in adults (Wilderdom, 2006). Aerobic activity can increase vigor and promote
clear thinking” (Wilderdom, 2006). Being physically fit, in most cases, brings about a sense of
improved self-esteem among individuals. Children who have improved self-esteem and mental
health will participate more eagerly in the classroom. There will also be an increased positive social
atmosphere in a classroom where children have increased mental health.
Review of Literature Benefits of Physical Activity to Enhance Cognitions Introduction
Providing children with an effective education will better prepare them for success in school
and life. To provide children with quality education, teachers must stay current with teaching
strategies that will ensure the best academic results. New research supports the idea of
implementing physical activity in the regular classroom to support children’s learning (Hellmich,
2010). Although there are several noted benefits of a physically active classroom, some educators
maintain reservations about lending core subject instructional time to alternative or not-traditional
forms of learning through physical activity.
Because of high-stakes testing involved in education for teachers and children alike,
teachers may view time away from direct instruction as academic time wasted. Teachers may feel
that implementing an active classroom will involve too much extra preparation, limited classroom
space for movement, as well as, the need for extra materials and equipment (Bonwell, 1991).
Although these reservations exist, they should not prevent the teacher from incorporating physical
activity into the curriculum. Active learning can occur within the confines of a small classroom
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area, on a carpet square or in the limited space around each child’s desk. Children of all ages can
develop spatial awareness and motor control while moving within limited space, reaping the
benefits of learning while being physically active.
Physical Activity and Cognition
Physical activity has capabilities of improving brain function which helps nerve cells to
multiply, thus, creating more connections necessary for learning (Rice, 2009). A healthy body will
nourish its brain, producing a healthier brain, which is necessary for increased improved learning.
Research suggests that “students who exhibit fitness achievement have increased odds of passing
state English and math tests” (Rice, 2009). One researcher believes, “the human qualities we
associate with the mind can never exist separate from the body, because movement is an
indispensable part of learning and thinking, as well as all integral parts of mental processing”
(Blakemore, 2003). Therefore, in the classroom, it is possible to uncover a very natural connection
between physical activity and the way one’s brain functions. As teachers plan and implement a
curriculum, they should pay close mind to the nourishment they are providing for children and their
brains.
Classroom Connection
When teaching mathematics, movement activities may be integrated throughout the lesson
in order to better engage students and in order to increase “sensory input and movement, which
assist the brain in learning more productively” (Pennington, 2010). With an experimental group of
children, a movement method of teaching the concept of fractions was carried out to give a more
dynamic means of experiencing this subject (Pennington, 2010). For example, the children could
“jump fractional distances on a measuring line,” and “beat the fractional rhythm of a song”
(Pennington, 2010). The teachers involved in this experiment, “claimed that the activities had a
positive effect because children stayed on task, needed little redirection, clearly enjoyed the
activities, and met the learning standards” (Pennington, 2010).
Using Physical Activity to Enhance Memory
The human brain’s memory formation may see significant improvements in short and long
term memory when more than one mode of information is used to present the new material (Rice,
2009). Traditionally, auditory or visual components are used by teachers in the classroom. When
movement components are combined with visual or auditory components, connections are
strengthened, making retrieval possible with more ease (Rice, 2009). In the classroom, teachers
may modify the traditional lesson format by integrating movement activities with typical visual or
auditory activities.
Classroom Connection
When planning lessons, teachers should integrate movement activity with visual or auditory
components, in order to, increase memory formation and retrieval among children. For example,
children may observe visual pictures or diagrams of particles in the various states of matter (solids,
liquids, and gases). To enhance memory formation, the teacher may also introduce a movement
activity, demonstrating what the particles of each state of matter may look like. Children will move
inside an area set up by cones, in a cluster-like movement (Dean, 2009). For a very open space,
53
students will be able to move around freely, much like gas particles (Dean, 2009). Then, as the
cones are placed closer together, making it more difficult for children to move around in a cluster,
the children are demonstrating particles found in a solid (Dean, 2009). This is a great visual for
children as they work to understand the differences between a solid, liquid, and a gas (Dean, 2009).
Physical Activity and Attention Span
Many teachers frequently struggle to maintain each child’s attention throughout the school
day. They may attempt to engage children by frequently asking questions about material being
discussed, moving about the room, and changing the tone of their voice. However, teachers may
find that attention may be increased by incorporating bouts of movement activities throughout the
school day (Rice, 2009). Research suggests that teachers who integrated movement activities
throughout the school day, observed children with improved on-task behaviors by 20 percent (Rice,
2009).
Classroom Connection
Almost all experienced early childhood teachers can attest to the difficulties of maintaining
a classroom of learning, with squirming children who have short attention spans. When children
begin exhibiting off-task behaviors, the learning process is handicapped, sometimes for the entire
classroom of learners. In order to combat struggling attention spans, teachers may implement
movement activities into the regular academic schedule to increase concentration among children.
For example, in kindergarten and first grade, teachers may implement movement activities into
handwriting and learning the alphabet by “painting the alphabet” (Dean, 2009). Instead of
remaining seated, monotonously reciting the alphabet or practicing handwriting on manuscript
paper, teachers may have children use different body parts to paint the alphabet on an imaginary
canvas (Dean, 2009). This activity provides children with hands-on alphabet practice and may
rescue faltering attention spans among the class.
Physical Activity and Mood
When children are actively involved in movement activities throughout the school day, their
mental health may see noticeable improvements, thus, getting children “in the mood to learn,”
(Rice, 2009). When children engage themselves in as little as fifteen minutes of movement activity,
their mood may significantly be elevated (Rice, 2009). Research has also found that creativity may
be significantly increased following bouts of movement activity (Rice, 2009). When children
exhibit increased self-esteem and an overall positive mood in the classroom, teachers may find that
those children are more willing to and more conditioned to learn the academic material being
presented.
Classroom Connection
“Vygotsky, (1978), founder of the social cognition theory, which encouraged play,
considered play as the most important learning activity for children” (Pennington). When teachers
integrate movement activities with the academic material being taught, children have a deeper
connection with this idea of socially learning among their peers through play. A science lesson with
the objective of having children classify animals according to their structures, can easily be
transformed into an exciting movement game called, “The Great Zoo Escape.” Children will work
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with classmates to rescue the escaped animals (pictures of animals) and return them to their homes
in the zoo, using their knowledge of the characteristics of mammals, birds, reptiles, fish, and
amphibians. Not only are children receiving a hands-on learning experience regarding the
classification of animals, but they are receiving opportunities to improve their mood and mental
health.
Programs and Research Supporting Physical Activity in the Classroom
The researched benefits ensure that children will benefit from the integration of physical
activity throughout the regular classroom curriculum, which results in programs being implemented
to carry out this idea of an active classroom. The Let’s Move in School initiative promotes this idea
of physical education implementation for schools across the United States (American Alliance for
Health, Physical Education, Recreation and Dance, 2011). This initiative highlights staff
involvement, physical activity during school, physical activity after school, and family/community
involvement (American Alliance for Health, Physical Education, Recreation and Dance, 2011).
Schools wishing to take part in the Let’s Move in School initiative follow a physical activity plan in
which they participate in drop-in physical activity opportunities throughout the day, have physical
activity integrated into classroom lessons, have physical activity breaks in the classroom, and when
appropriate, have regularly scheduled recess (American Alliance for Health, Physical Education,
Recreation and Dance, 2011). This initiative thrives on the consistency of the availability of
physical activity offered throughout the school day (American Alliance for Health, Physical
Education, Recreation and Dance, 2011).
Another successful use of physical activity implementation throughout the school day is
found in a school’s research experiment using an experimental and control group of children in the
fourth grade (American College of Sports Medicine, 2006). Researchers used pedometers to assess
children’s physical activity during school hours (American College of Sports Medicine, 2006). The
experimental group of children had their amount of physical activity measured with a pedometer,
along with, having participation in ten minute “energizers” (American College of Sports Medicine,
2006). These activities require little planning and no equipment, but provide spurts of increased
physical activity opportunities for this group of children (American College of Sports Medicine,
2006). The control group of children received no “energizer” activities (American College of
Sports Medicine, 2006). Researchers found that the experimental group had increased on-task
behaviors, verbal and motor behavior that follows the class rules and is appropriate to the learning
situation, by eight percent (American College of Sports Medicine, 2006).
Conclusion
Classrooms that promote physical activity provide teachers with opportunities to educate the whole
child. Teachers will find themselves teaching physical health, social health, mental health, and
emotional health, along with content area curriculum assessed on Standardized exams. Teachers are
held to the standard of providing children with a free and appropriate education. Assessing the
benefits of an active classroom, while heeding the warnings of an increased obesity rate, will find
educators searching for reforms in education that can be found in the components of an active
classroom. Many movement activities can be carried out with children standing behind or beside
their desks. Large spaces are not a necessity. Also, teachers will be enlightened to know that many
movement activities can be implemented in a very short amount of time, with few lesson plan
55
adjustments. Extravagant equipment and preparation is not a necessity. However, movement in the
classroom is a necessity for all children.
Implications for Teachers
The main role of a teacher is to teach children in a manner which yields positive outcomes,
especially on State standardized exams. Because stakes are high for both teachers and children,
classroom instruction time is held in high regards. A teacher must be able to account for the use of
all instruction time, and how this time spent has met State standards, giving children all of the tools
they need to succeed in performing Proficient or Above Proficient on standardized exams. Teachers
simply cannot afford to give valued instructional time to subjects or matters not tested on these
high-stakes exams.
At the same time, because of the emphasis placed on these exams, many schools whose
mission statements are to teach the whole child are proving unsuccessful at meeting the special
needs of children regarding the physical domain. Childhood obesity levels are at an all-time high,
but children spend the majority of their day being inactive (Cardon, 2003). The school day permits
little time for teachers to educate the physical child. A physically unfit child will not perform at
his/her highest potential (Hellmich, 2010). These children may exhibit a higher absentee rate, lower
attention span, and lower energy levels (Story, 2006). Teachers are caught at a crossroad between
focusing on a child’s physical health or their academic achievement.
Research, however, has linked a child’s physical health with his/her academic achievement
(Hellmich, 2010). With this research, teachers may develop and implement an active classroom
with the peace of mind knowing that the children will deliver the desired results of academic
learning and testing. Teachers must balance direct instruction with a more hands-on approach to
learning. This could easily be achieved through minor modifications in child grouping for lessons
and teaching methods used for lessons. A more active type of learning will not only increase blood
and oxygen flow to the brain for children; moreover, it will also increase social and academic
performance (NASPE, 2011). Children who remain active may have increased health and body
image (NASPE, 2011). Also, most of the active learning methods consist of social interactions
among cooperative groups of children. Children need this time of social learning to ensure that they
have grasped social milestones, along with the academic material being taught. When teachers
implement movement activities into the curriculum, children will build more brain connections,
which help store and retrieve information (Kleim, 2002). Children who learn using both sides of
their brain, will find that the information is more organized and retrievable in their memories
(Kleim, 2002). Teachers that implement movement activities throughout the curriculum may find
that their students have a longer attention span. Teachers must realize that implementation of
movement activities across the curriculum will increase physical health, while increasing children’s
learning. This realization will serve as motivation to educators as they make modifications to their
lesson plans in order to plan to teach the whole child.
Teachers must become knowledgeable about health matters regarding children. Resources
that provide easy-to-follow strategies for increasing physical activity and for improving food
choices among children are available to the public, especially through the internet. Also, teachers
may take advantage of professional development options that explore childhood obesity prevention
and overall nutrition. A child’s overall physical health, along with his/her mental health, must take
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precedence in the school system today. A teacher’s knowledge of a child’s basic nutritional and
exercise needs will assist in the development of an active classroom. In the largest respect,
knowledge of health matters regarding children will leave educators with the knowledge that
children need to be active. They should not remain seated for the majority of the day. This
knowledge will serve as a motivation for teachers in their implementation of an active classroom,
for the sake of the children’s health and well-being.
Teachers should also advocate for teaching the whole child: Mental, Intellectual, Social,
Emotional, and Physical. In a school system, teachers serve as the main advocate for children. The
regular classroom teacher spends the majority of the day with the children. Therefore, the regular
classroom teacher will have a greater voice in making sure that all of the children’s needs are being
met. Many schools’ mission statements contain a clause about meeting students’ diverse needs in
order to assist children in reaching their full academic potential. A classroom that uses physical
activity as a vehicle to learning will aide in fulfilling a mission statement about meeting children’s
diverse needs.
Teachers must make appropriate accommodations in lesson planning to ensure that children
are receiving adequate physical activity throughout the school day. Just as teachers accommodate
various learning styles and needs, they must also take into account whether or not children’s
diverse physical needs are being met. All children require physical activity to remain healthy. A
short recess or physical education class is not adequate physical activity for children each day.
Teachers have the opportunity to implement an active classroom, ensuring that children are
receiving physical activity, as well as, proper academic instruction.
Teachers may inform parents of the importance of physical health, in regards to their child.
Teachers send home progress reports of educational achievement and conduct for each child
several times throughout the school year. Teachers should also inform parents of the importance of
continuing healthy habits for each child at home. The teacher can communicate strategies used in
the classroom to provide opportunities for movement, as well as, healthy food options the child and
parent can explore. Enforcing a healthy lifestyle at school is not enough to ensure that children
pursue a life of health. Children need to be given this information and reinforcement at school and
in their home. Teachers can play a huge role in this process at home by providing parents with easy,
healthy alternative habits for their child in regards to food choices and the amount of time spent
being physically active. With encouragement and support from the classroom teacher, parents may
be more apt to try new strategies with their child.
Perhaps one of the greatest contributors to the success of the implementation of an active
classroom is the knowledge and attitude of the classroom teacher. Teachers should be aware of the
high health risks that affect overweight children. They should also be aware of the increased
occurrence of childhood obesity. Knowledge of the high risks, along with the ways to combat the
issue, will serve as a motivation for teachers to make modifications to their lesson plans that
accommodate children’s physical health needs. The regular classroom teacher will actively combat
this growing issue by implementing an active classroom.
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How to Implement Physical Activity throughout the School Day
Aside from reservations teachers may have regarding active classrooms, the implementation
of active classrooms can easily take place. The implementation of active classrooms does not
require huge amounts of time, preparation, space, or supplies. Teachers must first seek the many
benefits linked to the active learning in order to be grounded in motivation for the implementation.
When beginning the implementation of an active classroom, teachers must first create
boundaries for movement activities, which include basic rules, procedures, and space restrictions.
Classroom set-up will depend on the desired type of movement in the classroom. For some
activities, children may only need a small space behind their chair. For other activities, the teacher
may wish to provide a specific “activity space” that can be designated by carpet or tape.
In order to condition children to the routine of movement in the regular classroom, teachers
should routinely provide movement activities each day. Movement activities need to be a normal
occurrence, not a “special treat” for children. “A good rule of thumb is to allow children to change
activities after 20 minutes; therefore, a short movement activity break would be suitable following
a long session in which the children have been sitting and working at their desks,” (Erwin). A great
way to implement daily routine movement activities is to create “activity cards” which provide
random movement exercises, such as, hopping, crunching, or doing jumping jacks, which can be
used throughout each lesson. For example, a teacher may draw out two activity cards, hopping and
crunching. During a true/false questioning session, children will hop for ‘true’ and crunch for
‘false,’ (Erwin). This provides an easy movement implementation that keeps students on their toes
throughout the learning process.
Physical activity can also be implemented with the aid of music and the arts. Music
provides a vehicle for this implementation because of its natural tendency to cause involuntary
movement. “Music evokes movement and children require movement for their development and
growth,” (Musikgarten, 2011). “Music engages the brain while stimulating neural pathways
associated with such higher forms of intelligence as abstract thinking, empathy, and mathematics.
Music’s melodic and rhythmic patterns provide exercise for the brain and help memory. Who
among us learned the ABC’s without the ABC song?” Also, “Developmentally appropriate music
activities involve the whole child-the child’s desire for language, the body’s urge to move, the
brain’s attention to patterns, the ear’s lead in initiating communication, the voice’s response to
sounds, as well as, the eye-hand coordination associated with playing musical instruments,”
(Musikgarten, 2011). Teachers and publishers have provided multitudes of educational music and
dance that may teach content material in math, language arts, science, and social studies. Music
could be implemented during transition times. Transitions may be used as an opportunity to
energize children’s bodies.
For teachers who feel that they lack the creativity or time to implement movement activities
across the curriculum, short body “energizers” may be used to increase blood and oxygen flow
throughout the body. These activities could be as simple as reaching up toward the sky, then down
to the floor. Also, children could hop while counting or reciting information. Teachers should ask
themselves, “Could this learning activity be carried out while moving?” Teachers can invest in the
resource known as “Brain Gym” which “consists of 26 simple and pleasant movements aiming at
improving learning skills through the use of both brain hemispheres,” (BrainGym, 2010). Brain
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Gym activities may be carried out in a very short amount of time, with no supplies, and little
necessary space.
When appropriate, movement activities may be integrated through dramatic arts. Dramatic
arts can most easily be integrated throughout the curriculum in the form of role-playing. Not only
does this implementation provide movement activities, but it also boosts children’s creativity, self-
expression, and social skills. “Role playing encourages the use of critical thinking because it
involves analyzing and problem solving, therefore, role play is a cognitive learning method,”
(Hartman).
Similar to all areas of running an effective classroom, teachers must plan for this
integration. When plans are made and motivation is established, teachers will be more apt to carry
out an active classroom. The benefits of an active classroom are undeniable. Teachers looking to
teach the whole child: mind, physical body, and emotions, will make the modifications needed to
give students a vehicle for physical health, as well as, for academic success.
Experiences of an Intern
As an early childhood education intern, one is constantly reminded of the importance of
adequately teaching and meeting all academic standards set out by the state. In other respects,
interns are presented with materials that inspire teachers to look at a child’s education beyond the
scope of his/her academic achievement. Many schools have constructed mission statements which
claim to seek ways of educating the whole child. The concept of teaching the whole child revolves
around the idea of meeting a child’s mental, emotional, physical, and academic needs.
Through the process of researching how movement can be implemented into the regular
classroom, the researcher was inspired by the importance and significance of teaching the whole
child. Much like one would care for a plant by providing soil with nutrients, water, and sunlight, a
teacher must seek to provide children with all of the elements they need in order to be a nourished
individuals, that includes having their physical needs met. If an individual provides a plant with soil
only, it will not reach its full potential. In the same respects, if a teacher provides only academic
information to a child, they will not reach their full potential. A brain full of rich academic
information is near useless to a physically unhealthy and unable body. As a future teacher, one
must nourish all of the parts of a child.
One aspect of educating the whole child that seems to be overlooked much of the time is
ensuring that all students are having their physical needs met. Through this research experience and
classroom teaching experience, the researcher encountered numerous benefits of integrating
physical activity across the curriculum. The most noticeable outcome among children is their
motivation to learn and a decrease in off-task behaviors during instructional time. These results, in
and of themselves, have served as motivation to the researcher in making learning an active and
rewarding experience for children, socially, emotionally, physically, and academically, through the
implementation of an active classroom.
59
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Student Submission Peer Reviewed Article
Arkansas High School Athletics: The Most Important Test That is Sometimes Never Given by
James Hines ASU
Introduction
Professional athletes (Bennett, 2012) and in some cases billionaire owners of professional teams are
prime examples that no matter how much money you possess, someone suffering from substance
abuse cannot buy a fast and easy cure. Proper treatment typically involves helping the individual
stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at
work, and in society (National Institute on Drug Abuse (NIH), 2009). A combination of medication
and behavioral therapy, are important to the overall therapeutic process that often begins with
detoxification, followed by individualized treatment and relapse prevention (NIH, 2009). Statistics
collected from the 2011 Youth Risk Behavior Surveillance System (YRBSS) survey of 13-18 aged
high school students, shows the importance of addressing the behavior and implementing
preventive measurements (Sharma & Branscum, 2013). Based on research by the National Council
on Alcoholism and Drug Dependence (NCADD, 2015), parents and coaches should be aware that
each year more teens enter addiction treatment for marijuana dependence than all other illegal
drugs combined. Research provided through the Youth Risk Behavior Survey (YRBS, 2013), is
now showing that high school age students are graduating to more intense and hardcore drugs such
as ecstasy, heroin, and methamphetamines . The purpose of this paper is to:: (1) look into the
effects of drug and alcohol use; (2) present high school drug abuse statistics; (3) promote drug
awareness for high school sport; and (4) present information on substance prevention programs.
Effects of Drug and Alcohol Use
Numerous studies and literature address the negative health effects of substance use. Alcohol abuse
may impair an athlete’s performance through the loss of motor skills, dehydration, and the creation
of mood swings (NCAA Drug Policy, 2015). The National Council on Alcoholism and Drug
Dependence (NCADD, 2015), found that psychiatric problems such as depression, anxiety, and
suicide may develop with excessive alcohol use. The Mayo Clinic, (2015), defines alcoholism as “a
chronic and often progressive disease that includes problems controlling drinking, being
preoccupied with alcohol, continuing to use alcohol even when it causes problems, having to drink
more to get the same effect, or having withdrawal symptoms when you rapidly decrease or stop
drinking”. Deterioration of neurological aspects of performance, delayed injury recovery, and the
potential for an athlete to collapse or die from cardiac arrest are serious consequences that can
result from athletes abusing substances (Thomas, Dunn, Swift, & Burns, 2010). As of now,
although treatment is available, there is no cure for alcoholism. Alcoholism awareness and
prevention is the only way to ensure that high school students do not become victims of alcohol
dependence. Once the disease has been created within the body, the victim’s only hope for sobriety
is some form of treatment (National Institute on Alcohol Abuse and Alcoholism, 2014).
63
During the impressionable years of high school, some people experiment with drugs, while others
succumb to addiction (Sharma& Branscum, 2013). Perceptual misjudgments, time disorientation,
and confusion are other ramifications associated with subjecting the human body to drug abuse
(Thomas, et al, 2010). Drugs are chemicals and while each drug produces different physical effects,
all abused substances disrupt the normal function of the brain and responses to issues of self-
control, judgment, emotion, motivation, memory and learning (NCADD, 2015). For instance, the
drug cocaine and the crystal form crack can constrict blood vessels, increase body temperature,
cause headaches and abdominal pain (National Institute on Drug Abuse, 2013). Although a hotly
debated topic of conversation, the drug marijuana is not legal in the state of Arkansas and research
regarding high school age use suggests negative consequences. People who started smoking
marijuana heavily in their teens and had an ongoing cannabis use disorder lost an average of eight
IQ points between ages 13 and 38 (National Institute on Drug Abuse, 2013). Substance use
disorders have been shown to have a lifetime prevalence of 11.4% in the age group 13 to 18 years
(Sharma & Branscum, 2013; Merikangas, et al., 2010).
High School Drug and Alcohol Use Statistics
Results from the Youth Risk Behavior Surveillance System (YRBSS) conducted in 2011 found that
in the United States 44.7% of the students had ever smoked a cigarette, 70.8% had taken at least
one drink of alcohol, 39.9% had used marijuana, and 3% had used cocaine (Sharma, M, &
Branscum, P,2013; Eaton et al., 2012). The 2013 Youth Risk Behavior Survey (YRBS) found that
among high school students, during the past 30 days, 35% drank some amount of alcohol and 21%
binge drank. The National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2015), defines
binge drinking as a pattern of drinking that brings a person’s blood alcohol concentration to 0.08
grams percent or above. Community-based efforts are required to monitor the activities of youth
and decrease youth access to alcohol (CDC, 2015).
A study conducted by Dunn, (2014) found that throughout the literature there was not a consensus
on adolescent substance use based on sport participation. A key issue in fighting substance abuse
and dependence is the complex nature of the problem that involves multiple behavioral and social
factors (Sharma & Branscum, 2013). Most users begin using drugs habitually while they are in
school, due to the large number of young people, schools possess the opportunity to adopt and
enforce important educational policies (Sharma & Branscum, 2013; Faggiano, 2005).
High School Sports Awareness
When researching the Arkansas Activities Association (AAA) handbook, there is no mention of a
universal drug testing policy or recommendations for its implementation. There is evidence that
drug-testing policies are being implemented individually by high schools throughout the state of
Arkansas. In Texas, the University Interscholastic League includes an athletic coach code that
seeks to emphasize a chemical awareness program that informs and educates students of the
damaging effects of anabolic steroids and other illegal drugs (Texas UIL Constitution). This simple
64
statement acknowledges the requirement of responsibility for coaches and the importance of
establishing a substance free message at an early period of a child’s life.
Without direct influence from the AAA, schools may refrain from adequately sending a substance
free statement due to a variety of factors. Research shows students who are subject to testing report
significantly less marijuana and other illegal drug use and also have more positive attitudes toward
testing (R. Dupont, M. D. Campbell,T. G. Campbell, C. L. Shea, & H. S. Dupont, 2013). Two
factors that could potentially hinder drug and substance testing are the financial cost of performing
the tests and the possible lack of education on the schools legal ability to conduct the tests. As the
nationwide trend of requesting parents to financially contribute to interscholastic athletic programs
grows (H. Boyle, 2013), adding a small fee to each participant could fund a drug testing policy.
Research conducted by the NCADD (2015), shows that the younger the person begins using
substances, the greater the chance they will abuse illegal substances in the future.
Substance Use Prevention Programs
If financial issues are so dire that a small fee could result in the loss of athlete participation, at the
very least coaches and administrators should frequently speak to their athletes regarding drug and
alcohol use. Providing knowledge, refusal, and decision making skills are key components of
effective evidence based prevention programs (Kumar, R., O’Malley, P.M., Johnston, L.D., &
Laetz, V.B., 2013). Providing knowledge, or awareness of the harm that substances can commit to
the student’s body can deter the student from using substances. Teaching students how to properly
navigate situation where they must refuse substances and overcome peer pressure is a crucial aspect
of effective prevention programs. The highest rated effective component of the prevention program
came from teaching students to develop positive decision making skills that require maturity and
responsibility (Kumar, et. al, 2013). Many schools that institute prevention programs choose to
select from different established programs and health education texts to meet their needs (Kumar, et
al. 2013). This may direct the athlete’s behavior by giving them the information regarding the
substances and trusting them to make responsible long-term life choices about their health. Locally
developed An example is The Lion’s Quest prevention program, which teaches life skills at all
grade levels and actively solicits participation from family, community members, and the school
(Kumar, et al.,2013). The Lion’s Quest prevention program goes beyond the classroom to cultivate
social and emotional learning as a critical element of education that creates safe and supportive
classrooms and nurture healthy, well-balanced young men and women (“About Lions Quest”,
2015).
Conclusion
Fighting teenage drug and alcohol use is a difficult task for parents, teachers and coaches. While
there is research prevention programs, the intensity and efficiency of the programs vary depending
on the school and the instructor. AAA should consider a way to work with its member schools to
develop an effective substance prevention program for high school athletes in the state of Arkansas.
65
High school athletic departments taking the necessary steps to treat potential substance abuse like
the disease it can become is imperative to students understanding the negative ramifications that
can come from their actions at a young age. Although AAA like many other state athletic
associations do not mandate or control drug testing, providing resources to help ensure healthy high
school students and Arkansans can prove to be a sound investment. When reviewing these statistics
and researching the 1995 landmark Vernonia School District V. Acton drug testing case, the need
for substance abuse policies in high school activities, especially ones as life threatening as playing
sports. With the both national and state government cutting funding for educational programs,
Office of Safe and Healthy Students (OSHS, 2011), organizations like AAA are needed more than
ever the live up to its purpose and mission statement and invest in drug testing and prevention
programs for the betterment of Arkansas high school athletes. Currently, athletic departments
throughout the state of Arkansas are conducting their own drug tests to keep their athletes safe on
and off the playing field. Debunking stereotypes and in some cases ignorant traditions that high
school students should be experimenting with substances is the first step. There is no guaranteed
method to achieving a team of substance free athletes. Each coach must develop a program that
works in their community. Information is available online via multiple substance abuse prevention
and treatment programs. Future research is needed in the state of Arkansas to determine the success
rate of schools in the state that conduct their own drug testing. Research studies to find the reasons
why some schools refrain from drug testing is also needed.
References
About AAA. (2015). In Mission Statement. Retrieved from http://www.ahsaa.org/page/1/aaa
About Lions Quest. (2015). In About Lions Quest. Retrieved from http://www.lionsquest-
.org/mission.php
Alcoholism Definition. (2014) In Diseases and Conditions Alcoholism. Retrieved from
http://www.mayoclinic.org/diseases-conditions/alcoholism/basics/definition/CON-
20020866
Alcohol's Effects on the Body. (2015). In Overview of Alcohol Consumption. Retrieved from
http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body
Bennett, D. (2013). Harm reduction and NFL drug policy. Journal Of Sport & Social Issues, 37(2),
160-175.
Boyle, H. (2013). As sports fees rise, A young athlete learns that if you can't pay, you can't play.
Health Affairs, 32(7), 1326-1329. doi:10.1377/HLTHAFF.2012.1222
Dunn, M. S. (2014). Association between physical activity and substance use behaviors among
high school students participating in the 2009 Youth Risk Behavior Survey. Psychological
Reports, 114(3), 675-685. doi:10.2466/18.06.PR0.114k28w7
66
Dupont, R. L., Campbell, M. D., Campbell, T. G., Shea, C. L., & Dupont, H. S. (2013). Self-
reported drug and alcohol use and attitudes toward drug testing in high schools with
random student drug testing. Journal Of Child & Adolescent Substance Abuse, 22(2), 104-
119. doi:10.1080/1067828X.2012.730354
Frequently Asked Questions/Facts. (2015). In Learn About Alcohol. Retrieved from
https://ncad d.org /learn -about-alcohol/faqsfacts
Kumar, R., O'Malley, P., Johnston, L., & Laetz, V. (2013). Alcohol, tobacco, and other drug use
prevention programs in U.S. schools: A descriptive summary. Prevention Science, 14(6),
581-592. doi:10.1007/s11121-012-0340-z
NCAA Drug Policies Brochure. (2014). In Understanding the NCAA’s Drug Testing Policies.
Retrieved from http://www.ncaa.org/health-and-safety/policy/drug-testing
Sharma, M., & Branscum, P. (2013). School-based drug abuse prevention programs in high school
students. Journal of Alcohol and Drug Education, 57(3), 51-65.
Substance Abuse Treatment. (2014). In General. Retrieved from http://www.cdc.gov/pw-
ud/substance-treatment.html
Understanding Drugs and Drug Dependence. (2015). In Frequently Asked Questions/Facts.
Retrieved from https://ncadd.org/learn-about-drugs
What is Marijuana. (2015). In The Science of Drug and Alcohol Abuse. Retrieved from
http://www.drugabuse.gov/publications/drugfacts/marijuana
Lifetime Achievement Award - Congratulations!!!
Annette Holeyfield
Higher Educator of the Year - Congratulations!!!
Valarie Hilson
67
Arkansas Association for Health, Physical Education,
Recreation and Dance
Editorial Board
Janea Snyder Bennie Prince Brian Church
NEW GUIDELINES FOR AUTHORS
Material for publication and editorial correspondence should be address to Andy
Mooneyhan, PO Box 240, State University, AR 72467 [[email protected]]. Deadline for the
submission is March 1. Guidelines for materials submitted are those of the Publication Manual
of the American Psychological Association. For manuscripts, submit 3 copies. The title should
be included on a separate page with the author(s) name, position, address, phone number and
email address. The title of the manuscript, without the author(s) name, should appear on the
first page of the manuscript. Download the template online to use. If accepted, original copy of
the manuscript must be submitted on disk, or zip drive saved in Microsoft Word or Text format.
The Arkansas Journal is indexed in the Physical Education Index.
The Arkansas Journal is published annually in April with a subscription cost of $10.00. To obtain a hard copy contact ArkAHPERD Executive Director Andy Mooneyhan
The opinions of the contributors are their own and do not necessarily reflect those of ArkAHPERD or the journal editors. ArkAHPERD does not discriminate in this or any of its programs on the basis of race, religion, sex, national origin, or disabling condition.
Co-Editors
Bennie Prince Shelli Henehan
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