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Statement of the Problem: Understanding physical activity (PA) behaviors in children with cerebral palsy (CP) who are non-ambulatory is important to design optimal fitness interventions that reduce sedentary behaviors and promote health. There is a growing body of evidence for children with CP who are ambulatory that indicates they have decreased PA as compared to neurotypical peers. These children are at risk for poor health status and in need of adapted strategies to promote activity and reduce sedentary behaviors. However, information on PA behaviors is limited for children with CP who are non-ambulatory. Evaluating the amount and intensity of PA in children with CP who are non-ambulatory is challenging because of the heterogeneous nature of the disease and the limited repertoire of movements available to these children. Developing assessments that accurately describe PA in this population is essential to understand the nature of these limitations and to develop targeted interventions. Materials & Methods: In Study 1, PA amount and intensity in children with CP who were non-ambulatory were examined using PA (accelerometers) and HR monitors along with video observation and parent journaling over 7 days. Children were observed during a range of daily tasks to provide a detailed observation in their home and school. Parents were asked to rate their opinion of their child’s level of PA intensity during these tasks (easy, medium or hard), and these ratings were compared to the PA intensity derived from the PA and HR monitors. Levels of agreement were reported between parent report and HR and PA monitors during video recording. In Study 2, Interviews with parents of children with CP who were non-ambulatory and physical therapists (PTs) working with this population were conducted to understand how they operationalized PA and to evaluate the face validity of the Patient Reported Outcome Measurement Information System (PROMIS) ® PA parent proxy short form 8a survey as a measure of PA in this population. Each child was classified by Gross Motor Functional Classification Scale (GMFCS), the eating, drinking, classification scale (EDACS), the communication and feeding classification scale (CFCS), and the manual abilities classification scale (MACS).Results: For Study 1, 10 children and families participated in the exploratory observation with a video recording of PA in the home. A minimum of 4 consecutive days of monitor wear data was obtained for 7 of the 10 children; 3 children experienced equipment or use malfunction. There was a positive correlation between the parent level of PA intensity and intensity measured by the HR monitors, but no correlation with the PA monitors. The level of agreement of parent-reported PA intensity and HR monitors were correlated with PediCAT daily activity and mobility scores and the EDACS, CFCS, and MACS, There was no correlation between the parent responses and PA monitor-derived PA intensity levels with any functional measure. The PA monitor-derived level of intensity was correlated with the parent-reported PROMIS T-scores. No correlation was seen with the HR monitors. For Study 2, 22 PTs and 15 parents of children with CP who were non-ambulatory participated in the interviews. The PT’s and parents’ interview responses generated shared opinions about PA and how it should be operationally defined in this population. Four major themes emerged: a) PA is defined by functional activities and active movement; b) PA is challenging to measure objectively in this population; c) the environment plays a crucial role in supporting PA; and d) personal factors influence PA uptake. Both parents and PTs believed PA in this population should be increased to improve health related benefits. PA definition focused on active mobility and independent motor control by PTs, whereas the parent's definition of PA highlighted the functional and mobility achievements of their children with examples of communication and use of assistive technology and adaptive equipment. Level of assistance was used by both PTs and parents to indicate PA measurement. Parents and PTs agreed on the appropriateness of various questions on PROMIS scale, with the most appropriate questions being those that inquired about PA frequency during the week (Questions 6 and 7) Conclusions: Accelerometers, HR monitoring, and video monitoring can provide insight into daily PA in children with CP who are non-ambulatory. PA derived from HR monitors was correlated with parent-reported PA intensity during specific daily tasks, suggesting that HR monitors may better reflect PA intensity than accelerometry-based monitors in this population. In capturing PA over a longer period (e.g., 1 week), the PROMIS parent-proxy measure correlated with PA monitor-derived levels of intensity. PA monitors may best reflect general activity levels throughout the week rather than specific intensity levels during daily activities. Defining PA in children with CP who are non-ambulatory is challenging, however, parents and PTs provided insights into methods that can be used to conceptualize this challenging construct. The PROMIS short form 8a PA had some qualities that were deemed appropriate by PTs and parents alike with a preference for specific questions (Questions 6 and 7) for children with CP who are non-ambulatory. Methods to address the implementation of cardiovascular and fitness goals in this population need to be further explored.

The first study (Chapter 3) examined the reliability and validity of the modified Children's Leisure Activities Study Survey (CLASS) questionnaire in assessing physical activity and sedentary behavior of the Hong Kong Chinese children. The modified Chinese questionnaire (CLASS-C) consisted of a checklist of 31 physical activities and 13 sedentary pursuits. The test-retest reliability of the questionnaire was examined in 84 boys and 136 girls aged 9 to 14 years by the comparison of data from the two survey administrations carried out one week apart. Intraclass correlation coefficients (ICCs) were analyzed to determine consistency in results. A sub-sample of 139 children completed the 7-day accelerometer protocol. The validity of the questionnaire was determined by comparing data from the second administration with the accelerometer estimates of moderate- and/or vigorous-intensity physical activity. Bland-Altman plots were performed to further examine the agreement of the two methods. Acceptable reliability was found in self-reported time in moderate-to-vigorous physical activity (MVPA) (ICC = 0.71, 95%CI: 0.61-0.77) and in the sedentary behaviors (ICC = 0.69, 95%CI: 0.59-0.77). Self-reported estimate in daily MVPA was moderately correlated with minutes assessed by the accelerometer (girls: r = 0.48, P<0.05; boys: r = 0.27, P>0.05). Bland-Altman plots showed that self-reports of vigorous physical activity were higher than those assessed by the accelerometer. / The second study (Chapter 4) developed an instrument based on the social ecological model to evaluate the socio-environmental correlates of the children's physical activity and sedentary behavior. The instrument consisted of segments that incorporated reports from both the children and their parents. Children were asked about intrapersonal factors and perceived environments at home and in the neighborhood. Corresponding parents reported demographic information (age, education, occupation, income, and weight status), their physical activity and sedentary behavior habits, the control on their child's sedentary behavior, and perception of physical environment in the neighborhood. The questionnaires were administrated in a group of 160 primary schoolchildren aged 10 to 14 years and their parents on two occasions with 8 to 10 days apart. The test-retest reliability of each individual item was determined using percent agreement and kappa statistics for the categorical variables and intraclass correlation coefficients (ICCs) for the continuous variables. The overall missing rates were 2.5% to 5.6% for children- and parent-reported items. The ICC values for continuous variables in children-reported individual and familial factors ranged from 0.66 to 0.79. For self-reported categorical variables, kappa values ranged from 0.27 to 0.76, and an percent agreement statistics were greater than 80%. Meanwhile, reliability statistics for parent-reported home and environment variables showed acceptable consistency with most of the ICC values greater than 0.70. / The third study (Chapter 5) aimed to investigate the physical activity and sedentary behavior patterns among a sample of 1013 primary 4-6 schoolchildren using the CLASS-C questionnaire. The individual, social and physical environmental correlates of the activity behaviors were investigated through a sub-sample of 303 children, whose habitual activity was objectively assessed by ActiGraph accelerometer, in addition to subjective measures by the CLASS-C questionnaire. The multiple correlates of activity behavior for the children in the sub-sample group were assessed using the environmental correlates questionnaire which was developed in Study II. Cluster analyses were used to group children with similar activity patterns. Hierarchical regression analyses were performed to assess the associations of the multiple variables with activity behaviors. Approximately half of the children did not reach the recommended physical activity level and one fifth of them engaged in excessive TV viewing of 2 hr every day. Cluster analysis identifies 5 clusters of children who shared similar patterns of physical activity and sedentary behaviors. Hierarchical regression analyses showed that participation in school sports team and having higher self-efficacy was positively associated with self-reports in MVPA in boys after controlling age, body mass index (BMI), and parental education. Girls who reported participation in school sports team and perceived the availability of more sports facilities at home self-reported more time spent in MVPA after controlling socio-demographic variables. Perception of parental support on physical activity was positively correlated with accelerometer-assessed MVPA among girls, while it was inversely associated with sedentary behaviors in boys. Residence density was positively associated with boys' sedentary behaviors, while girls whose parents reported more safety concerns on neighborhood environment were more likely to be sedentary. (Abstract shortened by UMI.) / Huang, Ya Jun. / Adviser: Stephen H. S. Wong. / Source: Dissertation Abstracts International, Volume: 70-06, Section: A, page: 1972. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 149-175). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

Family Child Care Homes (FCCHs) are the second largest provider of non-relative care in the U.S. However, despite providing care for nearly 1.9 million children under the age of 5, little is known about the physical activity levels of children attending FCCHs. This dissertation sought to provide new information with regards to physical activity in children attending FCCHs. The purpose of the first study was to objectively measure physical activity in children attending FCCHs. 114 children (60 boys and 54 girls) 3.7 �� 1.1 years of age from 47 FCCHs wore an ActiGraph GT1M accelerometer for the duration of child care attendance during a randomly selected week. Counts were classified as sedentary (SED), light (LPA), or moderate-to-vigorous (MVPA) using the cut-points developed by Pate et al. (2006). Total physical activity was calculated by summing time spent in LPA and MVPA. Non-wear time was estimated by summing the number of consecutive zero counts accumulated in strings of 10 minutes or longer. Children were included in the analyses if they had 2 or more monitoring days in which wear time was ���75% of the attendance time. On average, children accumulated 25.9 �� 5.7 min of SED, 10.1 �� 4.2 min of MVPA, and 34.1 �� 5.7 min of total physical activity per hour of attendance. Further analysis revealed that among healthy weight children, 4 year-olds exhibited significantly lower levels of SED and significantly higher levels of MVPA and total physical activity than 2- and 3- year-olds. Among 4-year-olds, overweight and obese children exhibited significantly higher levels of SED and significantly lower levels of MVPA and total PHYSICAL ACTIVITY than healthy weight counterparts. The results from this study indicated that preschool-aged children attending FCCHs are mostly sedentary and accumulate low levels of MVPA during the child care day. The purpose of the second study was to assess the validity of two proxy report instruments designed to measure physical activity in children attending FCCHs. Valid self-report measures are needed for large scale intervention studies and/or population-based surveillance studies in which more burdensome objective measures are not feasible. In Year 1 of the study, FCCH Providers (N=37) completed the Burdette parent proxy report, modified for the family child care setting, for 107 children aged 3.4 �� 1.2 years. In Year 2, 42 Providers completed the Harro parent and teacher proxy report, modified for the family child care setting, for 131 children aged 3.8 �� 1.3 years. Both proxy-reports were assessed for validity using objectively measured physical activity as a criterion measure (accelerometry). Significant positive correlations were observed between scores from the modified Burdette proxy report and objectively measured total physical activity (r = 0.31, p < 0.01) and MVPA (r = 0.33, p < 0.01). Across levels of Provider-reported activity, both total physical activity and MVPA increased significantly in a linear dose-response fashion. Provider-reported MVPA scores from modified Harro proxy report were not associated with objectively measured physical activity. These findings suggested that the modified Burdette proxy report may be a useful measurement tool in larger-scale physical activity studies involving FCCHs in which objective measures, such as direct observation or accelerometry, are not practical. The purpose of the third study was to evaluate the effects of two strategies to increase the use of portable play equipment in FCCHs ��� a community-based train-the-trainer physical activity intervention (INT), and the same trainer-the-trainer intervention supplemented with monthly emails promoting the use of portable play equipment (INT+). We hypothesized that Providers completing the standard train-the-trainer intervention would report significantly greater portable play equipment use than Providers completing the food allergy control training (CON). We further hypothesized that Providers completing the supplementary email intervention would report significantly greater portable play equipment use than Providers completing standard train-the-trainer intervention or the food allergy control training. A total of 50 FCCH Providers from Marion, Linn, Benton, Washington, and Lane County, Oregon were randomized to the INT or CON conditions. Twelve Providers from Lincoln County were assigned to the (INT+). The type, variety, and frequency of portable play equipment use was measured by means of self-report via a checklist and two items from the previously validated NAP-SACC Self-Assessment instrument. FCCH Providers who completed the INT reported significantly greater use of portable play equipment than Providers completing the CON training. However, portable play equipment use among Providers completing the INT+ was not significantly different from that reported by Providers in the INT or CON. Notably, neither intervention had a significant impact on the amount or variety of portable play equipment. The results showed that a comprehensive trainer-the-trainer intervention to increase physical activity in FCCHs could successfully increase the use of portable play equipment in the home. However, supplementing the intervention with monthly emails encouraging the use of PPE was not effective. / Graduation date: 2013