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Table 5.

AORs for Risk of High Levels of Physical Activity and Inactivity Among Given Sociodemographic Contexts*

Family Income

Family income was associated with both physical activity and inactivity ( Table 5 ). Adolescents from households with highest family income had an increased likelihood of falling in the highest category of moderate to vigorous physical activity (AOR: 1.43; CI: 1.22–1.67; ≤ .00001) and decreased likelihood of falling in the highest category of inactivity (AOR: .70; CI: .59–.82; ≤ .00001). In addition, adolescents of medium family income were at increased likelihood of falling in the highest category of moderate to vigorous physical activity (AOR: 1.19; CI: 1.04–1.36; ≤ .013).

Interactions Between Ethnicity and Sex and Determinants

Logistic regression models were used to test sex and ethnicity interactions with each set of environmental determinants (PE participation, recreation center use, and neighborhood crime). Differential effects were seen only for inactivity for neighborhood crime and sex and recreation center and race. Females living in high crime areas were at increased likelihood of falling in the highest category of inactivity (AOR: 1.29; CI: 1.03–1.62; ≤ .027). Non-Hispanic black ethnicity and recreation center use were associated with an increase in likelihood of inactivity (AOR: 1.61; CI: 1.22–2.11; ≤ .001).

Effect of Determinants on Physical Activity and Inactivity Among Subpopulations

The above analysis, repeated using the subpopulation groups of Hispanics (Cuban, Puerto Rican, Central/South American, Mexican/Chicano, and other Hispanics) and Asians (Chinese, Filipino, and other Asians) showed small and nonsignificant differences for physical activity. Adjusted odds ratios for inactivity were significant for Filipino (AOR: 1.71; CI: 1.05–2.80; ≤ .032), non-Hispanic black (AOR: 1.86; CI: 1.54–2.24; ≤ .0001), and Puerto Rican (AOR: 1.46; CI: 1.10–1.95; ≤ .009) adolescents.

Add Health, a unique survey with its rich sample of ethnic subpopulations and detailed activity and inactivity, sociodemographic, and environmental data, investigates modifiable physical activity determinants vitally important to current efforts to increase physical activity among our nation's adolescents. The high levels of obesity and inactivity and low levels of physical activity illustrate the public health importance of this analysis. 3

The results fit well with US teen obesity patterns. 2 Inactivity was highest and physical activity lowest for non-Hispanic black and Hispanic adolescents. These trends were exaggerated for females and older adolescents.

PE Matters but Few Participate

The national push away from comprehensive PE in US schools is remarkable. Although our results show important associations between participation in PE and activity patterns, particularly on a daily basis, few teens receive PE. Our results indicate that PE classes may represent the only opportunity for many adolescents to engage in weekly physical activity. Conversely, the number of PE classes per week was not associated with level of inactivity of these adolescents. As shown, age, sex, and ethnicity were important factors in PE use. Clearly, these are modifiable relationships. Indeed, the Child and Adolescent Trial for Cardiovascular Health has shown that a program aimed at improving school PE has been successful in increasing moderate to vigorous physical activity in PE classes.

Logistic regression results show a strong impact of PE programs on physical activity patterns. To place these results in context of potential program outcome, simulations run from the logistic regression models ( Tables 4 and 5 ) show increases in adjusted proportion of adolescents participating in the highest category of moderate to vigorous physical activity by number of days of PE per week. For example, the adjusted proportion of adolescents to fall in the highest category of moderate to vigorous physical activity increases from 30.3% for those adolescents with no weekly PE to 37.6% for those having PE 1 to 4 times per week and to 46.8% for those having PE 5 times per week. This represents a marked increase in the percentage of adolescents who would be participating in substantial levels of weekly moderate to vigorous physical activity.

Community Recreation Facilities Might Offer a Key Intervention

Adolescents who used a community recreation center (as with those in PE) reported markedly higher levels of moderate to vigorous physical activity than those who did not. As indicated, sex, non-Hispanic black ethnicity (with a strong ethnicity-sex interaction) and Hispanic female ethnicity were important factors in community recreation center use.

Crime Reduces Physical Activity

Total number of incidents of serious crime in the adolescents' neighborhood was significantly associated with a decrease in physical activity. Crime was also associated with an increase in inactivity, although this relationship was not significant. Crime was very clearly associated with ethnicity, but there were no significant age, sex, and sex–ethnicity interactions. However, logistic regression results showed a differential association between high neighborhood crime and increased inactivity (AOR: 1.29; CI: 1.03–1.62; ≤ .027) for females relative to males.

Key Environmental Factors Do Not Reduce Inactivity

The key modifiable factors that had an impact on activity did not affect inactivity. Thus, it is clear that physical activity and inactivity were influenced by very different determinants. Although physical activity was most influenced by environmental factors, inactivity was much more influenced by sociodemographic factors. Higher socioeconomic status measured by maternal education and family income had a substantial impact on likelihood of engaging in inactivity. Advanced education and high income were associated with lower levels of inactivity.

Related Research

Other scholars have found that participation in community sports is an important predictor of physical activity and have suggested the need for improving access to community-based physical activity opportunities, health-oriented improvements in PE programs, daily PE programs that are fun and stress lifelong physical activity habits, and a possible role for clinicians in educating parents about appropriate community play places.

This study has 1 limitation. The data on community recreation centers were based on actual use, not availability. Data on availability are unavailable in any national database. This actual use response may produce misleading results because physically active people may be more likely to use recreation centers. Additional research is needed to determine the types of facilities that might offset the impact of crime on physical activity and inactivity.

The data presented here confirm what researchers and pediatricians have known intuitively; however, these relationships have not been tested empirically, nor have they been studied in any national dataset. These findings show that patterns in inactivity cannot be explained using the environmental factors studied here and, thus, it is clearly important that researchers search for other environmental determinants likely to impact inactivity. This further demonstrates the difficulty that researchers and pediatricians face in developing public health efforts to decrease inactivity.

The results of this study show the importance of PE classes and recreation centers in increasing physical activity and give powerful evidence supporting the importance of increasing opportunities for physical activity and the potential impact of PE programs and community recreation programs on physical activity of US adolescents. In addition, it is imperative that we provide safe and accessible places for exercise for our nation's youth. In many communities, the only such place may be the school.

Clearly our national public health initiatives should consider these options. More research is needed on the role of these factors in affecting activity and inactivity and on ways to most effectively change them. PE and community recreation programs should receive attention at a national level, particularly for segments of the population without resources to locate and pay for extracurricular and extracommunity physical activity opportunities. Availability of such resources will increase success for pediatricians in recommendations to patients to increase physical activity and decrease inactivity. This research also suggests that with increased opportunities for physical activity, adolescents may opt to selectively engage in these activities instead of more inactive behaviors.

ACKNOWLEDGMENTS

This work was supported in part by National Institute of Child Health and Human Development Grant P01-HD31921 and the Dannon Institute Postdoctoral Fellowship in Interdisciplinary Nutrition Science.

We thank Frances Dancy for her helpful administrative assistance and Tom Swasey for assistance with the graphics.

Footnotes

Reprint requests to (P.G.-L.) University of North Carolina at Chapel Hill, Carolina Population Center, CB 8120 University Square, 123 W Franklin St, Chapel Hill, NC 27516-3997. E-mail: [email protected]

The surge in hospital employment of physicians predated Obamacare by at least six years, and had two key drivers. The first was independent baby-boomer physicians— particularly those in primary care— found themselves unable to recruit new partners. Newer physicians, heavily burdened by student debt, were not inclined either to take on entrepreneurial risk or the 60-hour work weeks independent practice entailed.

The second was cuts in Medicare payments for office-based imaging. Thanks to the Deficit Reduction Act of 2005, specialties such as cardiology, orthopedics, and medical oncology that relied on the revenue that imaging generated were hit hard. As a result, many found it advantageous to be employed by hospitals. Under Medicare rules, in addition to professional fees, hospitals can charge a Part B technical fee for their services and therefore can pay practitioners more than they could earn in private practice.

Then, beginning in 2009, the Obama administration’s policies increased the exodus of physicians from private practices to health systems. The “meaningful use” provisions of the HITECH Act of 2009 provided both incentives and penalties for physicians to adopt electronic records, but hospitals and very corporate enterprises had more resources to comply with meaningful-use requirements.

The value-based-payment schemes created by the Affordable Care Act also markedly increased documentation requirements and, as a result, the overhead of practices, driving more physicians into hospital employment models .

There have been a number of reasons hospitals have been hiring physicians. Some, particularly those in rural areas, had no choice but to turn physicians into employees. Retiring independent physicians were leaving large gaps in care in their economically challenged communities. Consequently, hospitals that did not step in to fill the gaps were in danger of closing.

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who hospitalized their patients at competing facilities. These physicians’ inpatient and, particularly, outpatient imaging and laboratory volume generated additional revenues for the acquiring hospital or system.

A third apparent motivation was to corner the local physician market in order to obtain more favorable rates from health insurers. This seemed to have been a major rationale for St. Luke’s Health Systems acquisition of Seltzer Medical Group, Idaho’s largest independent, multi-specialty physician practice group, which led to an anti-trust action .

Yet another reason for making physicians employees was to position the organization for capitated, or value-based, payment. Hospitals believed that “salarying” physicians would help control clinical volumes and thus make it easier to perform in capitated contracts.

Finally, some hospital and system CEOs were tired of negotiating with local independent physician groups or national physician-staffing firms like MedNax and TeamHealth over incomes and coverage of the hospitals’ 24/7 services such as the emergency department, the intensive care unit (ICU), and diagnostic services like radiology and pathology. Building an in-house staff of physicians seemed like an attractive alternative.

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About the Textual Concepts project

The Textual Concepts project is the product of a collaboration between the Learning and Teaching Directorate, NSW Department of Education and the English Teachers Association NSW.

PROJECT AIMS

  • Create greater clarity about the discipline of English for planning and conceptualprogramming

  • Make visible the understandings about subject English which are embedded in the syllabus

  • Facilitate curriculum transition between stages K-12

  • Create a common understanding of the knowledge and skills of subject English.

The resources were developed over a three year period.

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Contact info

Any questions or suggestions?Please send us an email to:

[email protected]

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