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Methods
Using the L.E.A.D. Framework to Develop Overall Approach
We used the Institute of Medicine's L.E.A.D. framework to develop an explanatory, sequential, mixed-methods process to locate information from a national survey of children's perceptions of access to healthy foods (original research); published literature, reports, policies, and guidelines on physical activity and nutrition in OST settings; and interviews with senior administrators of national OST organizations. This information was evaluated and assembled to prioritize practices that reflected children's perceived access to healthful foods, evidence-informed guidelines and recommendations, and OST administrators' assessments of feasibility. Principles promoting these actions were drafted. Focus groups with local program leaders suggested revisions and implementation needs (Figure 1).
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Figure 1.
Applying the L.E.A.D. Framework to design a mixed-methods process for developing guiding principles for out-of-school time programs.
Mixed Methods for Assembling Evidence and Information
Harris Interactive, Rochester, New York, was commissioned to conduct an online survey of the perceptions of children aged 8 to 18 years (N = 1,178) about access to fresh fruits and vegetables, chips, cookies, and candy at home, at school, and in OST settings. The survey was administered in September 2010 with a stratified, nationally representative, random sample of respondents in the United States following methods detailed elsewhere. Questions included "How easy or difficult is it for you to get fresh fruits and vegetables at each of the following places?" and "How easy or difficult is it for you to get chips, cookies, or candy at each of the following places?" Respondents assessed the relative ease (very difficult, somewhat difficult, neither easy nor difficult, somewhat easy, very easy, and does not apply) of accessing these foods at home, at school, and at after-school activities. We excluded "does not apply" (<2% fruits and vegetables responses, <1% cookies, chips, and candies responses) and collapsed responses into "very easy" and "not very easy" and compared them using χ tests with significance set at P ≤ .05). Statistical analyses were conducted using SAS 9.2 (SAS Institute Inc.).
Peer-reviewed articles and publicly available white papers were reviewed to identify national OST organizations whose programming collectively reaches large numbers of children of both sexes, including urban and rural youths, specific racial or ethnic groups, and low-income populations. Next, a policy scan provided evidence-informed recommendations and guidelines addressing physical activity, foods, and beverages served in OST settings (Appendix). This scan first collected policies and recommendations from federal programs (eg, the Child and Adult Care Food Program) and national nonprofit and professional entities that use an evidence-informed approach (eg, Institute of Medicine). Lastly, guidelines were gathered from national research institutions and OST organizations. Reference lists were consulted to identify additional sources. To determine whether national OST programs had developed policies, Google and Google Scholar searches were conducted from November 2010 through February 2011 by using the terms policy, guidelines, snack, nutrition, food, wellness, physical activity, and combinations of the terms (using and or or), with the names of OST organizations identified. A matrix was constructed to compare guidelines and policy language and identify the most frequently targeted practices.
Senior administrators (eg, CEOs) from national OST organizations whose documents we reviewed were engaged to identify practices that could be implemented in various OST settings and to advise on implementation and dissemination needs. Two roundtable meetings were convened in the spring and summer of 2011, with 1 to 2 leaders from 9 organizations: YMCA of the USA, Boys and Girls Clubs of America, Boy Scouts of America, Girl Scouts of the USA, National Council of La Raza, National Urban League, Pop Warner, US Youth Soccer, and National Council of Youth Sports.
Drafting Principles and Testing in Focus Groups
A marketing agency crafted guiding principles to promote the selected evidence-informed practices. Eight focus groups were conducted with local program leaders from 4 OST organizations, Pop Warner, Girl Scouts of the USA, the National Council of La Raza, and the National Urban League. A semistructured interview protocol assessed reactions to and comprehension of the principles (eg, "What does the phrase [keyword] mean to you?"), identified potential revisions, and implementation needs ("What resources would help make this happen?"). Organizations representing scouting, sports, and enrichment programs reaching minority youths were selected to increase researchers' understanding of diverse OST programs. A point-person in each organization recruited participants via e-mail, phone calls, and fliers. Two focus groups were held per organization, with 5 to 12 participants per group, lasting 45 to 60 minutes each. Focus groups held in Chicago, Illinois; Tampa, Florida; Kansas City, Kansas; and Atlanta, Georgia, engaged 53 participants (35 women, 18 men).
The same trained moderator and note-taker attended all 8 focus groups. Detailed notes and audio recordings were taken at every focus group. Only 4 audio recordings were of adequate quality and were transcribed. After each session, the moderator and note-taker compiled and compared notes and observations.
Refining and Final Wording of Principles
Focus group findings informed revisions to the principles, which were finalized in consultation with a marketing group (Figure 1).
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