Organized Physical Activity Programs Research Articles

The impact of an organized physical activity program on the health indicators of students from differ-ent cultural groups in second chance school setting

The primary objective of this research was to assess the impact of a structured physical activity program on the health indicators of adult students attending a multicultural Second Chance School (SCS). The study encompassed a total of 62 SCS students aged 19 to 57, who were divided into two groups: experimental and control. The intervention program consisted of two sessions per week spanning 20 weeks, with each session lasting 60 minutes. The exercise intensity ranged from 65% to 85% of HRmax and included various activities such as aerobics, weight exercises, dumbbell routines, and hiking. Measurements were taken at both the commencement and conclusion of the organized physical activity program. Specialized equipment, including a wall-mounted stadiometer, precision scales, a unique tape measure, an automated sphygmomanometer, and the DXA machine, was employed for data collection. Data analysis involved ANOVA variance analyses, descriptive statistics, and T-Tests utilizing the SPSS software. The results revealed a statistically significant primary influence attributed to the 'measurement' factor (p<.001) across all health indicators, except for total BMD and total BMC, when comparing the experimental and control groups. In terms of gender disparities, men exhibited higher measurements in body mass, fat-free mass, belly size, and blood pressure, while women displayed greater fat mass and total body fat. To conclude, the intervention program had a positive impact on improving the health indicators of adult SCS students. Future research endeavors should explore the implementation of Physical Activity programs in other SCSs throughout Greece. Keywords: Adult Students; Health Indicators; Organized Physical Activity; Second Chance Schools

Willingness-to-pay in physical activity: how much older adults value the community-wide initiatives programs?

Previous studies have shown insufficient physical activity (PA) as a significant global health concern and a major risk factor for non-communicable diseases (NCDs). Community-wide initiatives in physical activity (CWIPA) is considered as a best-buy for Community-wide initiatives in physical activity (CWIPA) is considered as a best-buy for NCDs prevention. However, assessment regarding resource allocation and cost-effectiveness of existing programs is lacking. This study investigated local residents' willingness-to-pay (WTP) for community PA programs in Southern Thailand. The contingent valuation method (CVM) using the payment card approach was employed to elicit the WTP of 472 residents aged 45 years and over in selected provinces in which community PA programs had been implemented. Respondents were asked to indicate their WTP for the continuous offering of free CWIPA by choosing how much they were willing to pay from eight bid-value options, payable through their monthly electricity bill. The mean WTP of Thai older adults was found to be 72 baht/month ($2/month) or 868 baht/year ($25/year). This indicated the maximum amount an older person was willing to pay for any community-based PA program. More than half the sample (54.2%) chose zero as their answer, while there was a fairly large variation in other levels of WTP. The WTP was lower among older respondents and those who resided in rural areas but was higher among those with a history of participation in an organized PA program. The level of WTP can be interpreted as an indicator of community satisfaction with CWIPA. That finding can be used as evidence for the government and policy makers in allocating resources and designing future CWIPA. A variety of organized PA programs should be offered to all community members to ensure inclusivity and also to provide equal access for senior citizens.

Improving Awareness, Identification, and Treatment of Motor Impairments in Autism.

Autism represents a heterogenous group of neurodevelopmental disabilities characterized by the presence of social communication impairments and focused and repetitive behaviors.1 Motor impairments are also a frequent co-occurring behavioral and neurologic condition in autistic individuals. These motor impairments include delayed motor milestones, atypical gait, poor visual motor coordination, and difficulties with balance and postural control.2,3 Recent large-scale national cohort and database studies have estimated that motor impairments can affect 35% to 87% of autistic individuals across a lifespan.4,5 Furthermore, motor impairments have been posited to be one of the earliest signs of atypical development in autism and can negatively impact the development of social communication, adaptive function, and participation in physical activity.6–9 Thus, identification of and interventions for motor impairments can improve multiple neurodevelopmental and physical health outcomes. Despite their prevalence and pervasive nature, motor impairments remain under recognized and under screened by clinicians and researchers. One reason for this gap is that motor impairments are listed as an associated condition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, with no standardized guidelines on how to evaluate or categorize these impairments. In addition, current standardized motor assessments are not tailored for autistic individuals and intellectual disability and do not capture the heterogenous nature of motor impairments that can be seen in autistic individuals.10,11 There is a need for more objective motor measures that can evaluate autistic individuals across a life span with a range of intellectual abilities. These objective measures can improve our ability to characterize motor impairments in autism which, in turn, can improve: (1) screening guidelines for clinicians, (2) evaluation of outcomes of motor-based interventions, and (3) referral to more targeted motor interventions.The Autism Intervention and Research Network (AIR-P) neurology node is uniquely positioned to address these gaps in the field. The neurology node aims to (1) use objective quantitative and qualitative motor measurement methods to improve motor phenotyping across the lifespan, (2) evaluate the benefits of motor-based physical activity interventions on motor skills, adaptive functioning, and physical health outcomes, and (3) disseminate evidence-based information to caregivers and clinicians to improve screening of motor impairments and referral to interventions.Given the AIR-P’s focus on physical health outcomes and well-being, it is also important to elaborate on the second aim of the neurology node, which includes evaluation of the benefits of motor-based physical activity interventions for autistic individuals. Motor impairments can pose a barrier to engagement in physical activity and organized physical activity programs (eg, soccer, dance, tennis, or yoga). It has been reported that only 14% of autistic youth meet the recommended 60 minutes of physical activity a day.12 Decreased levels of physical activity can compound co-occurring medical conditions already prevalent in autism such as obesity, lower bone mineral density, and hyperlipidemia.13 Engagement in organized physical activity also provides opportunities for developing peer relationships.14 Barriers to engagement in sports represent missed opportunities for autistic individuals to benefit from these meaningful social experiences. Additional barriers to inclusion of autistic youth in organized physical activity programs include caregiver reports of lack of awareness and accessibility of these programs and limited training of staff to support autistic individuals.9,12 The AIR-P neurology node will directly address these issues by conducting clinical intervention studies to evaluate the benefits of motor-based physical activity for autistic individuals. The first phase of this work is underway and is focused on evaluating the benefits of an expressive movement-based dance program on motor skills, physical activity level, social communication, quality of life, and adaptive function.15 The goal of this work is to provide evidence-based recommendations to caregivers, clinicians, and community providers on how to refer and support autistic individuals in organized physical activity programs.The AIR-P neurology node will use a multifaceted approach to address gaps in identification, awareness, and interventions for motor impairments in autism. Specifically, the node will use methods to improve motor phenotyping in autistic individuals, evaluate motor-based interventions, and disseminate this knowledge to the community at large. The data gathered from the neurology node can help inform other nodes and researchers engaged in the AIR-P network and ultimately build the evidence needed to improve the diagnostic and treatment approach for this prevalent co-occurring neurologic and behavioral condition in autism.

Effects of a 12-Weeks Yoga Intervention on Motor and Cognitive Abilities of Preschool Children.

Since early childhood is regarded as an important period of motor and cognitive development, understanding the effects of physical activity on motor abilites and cognitive development in preschool children has major public health implications. This study investigates the effects of a 12 weeks' yoga intervention program on motor and cognitive abilities in preschool children. Preschool children (n = 45; age 5–6 years) attending regular preschool programs were non-randomly assigned to yoga intervention (n = 23; 30 min sessions three times per week) or a control group (n = 22; no additional organized physical activity program). Exercise training for the intervention group included yoga program. Motor abilities (BOT-2 subtests: fine motor integration, manual dexterity, balance and bilateral coordination), and cognitive abilities (School Maturity Test subtests: visual memory, stacking cubes and codes) were assessed before and after the intervention period in both groups. Data were analyzed using repeated-measures ANOVA. Participants in the intervention group improved fine motor integration (p = 0.022), fine motor skills in general (0.029), bilateral coordination (0.000), balance (0.000), and body coordination (0.000). Preschool children's participation in the preschool yoga intervention significantly improved their motor abilities, but not their cognitive abilities.

Organized Physical Activity Program Participation, Physical Activity, and Related Psychosocial Factors Among Urban Adolescents.

The study purpose was to examine whether adolescents who participated in organized physical activity (PA) programs differed from nonparticipants in motivation, social support, and self-efficacy related to PA; PA (min/hr); and sedentary screen time behavior. Thirty-nine 5th-7th grade adolescents participated in organized PA programs; 41 did not. Approximately 56.3% were Black, and 52.5% had annual family incomes <$20,000. Compared to nonparticipants, those who participated reported significantly higher social support (M = 2.32 vs. 3.13, p < .001) and fewer hours watching television or movies on a usual weekend day (M = 2.49 vs. 1.59, p = .016); and had higher accelerometer-measured vigorous PA (M = 0.58 vs. 1.04, p = .009) and moderate-to-vigorous PA (M = 2.48 vs. 3.45, p = .035). Involving adolescents in organized PA programs may be important for improving their moderate-to-vigorous PA, vigorous PA, and related psychosocial factors, as well as reducing sedentary screen time behavior.

Influence of Organized vs Non Organized Physical Activity on School Adaptation Behavior.

It is now well-established that physical activity has positive effects on both physical and mental health. However, the influence of organized physical activity (i.e., programs controlled and supervised by a trainer) on school adaptive behavior of adolescents with disabilities and/or behavioral disorders remains unclear. School behavior adaptation involves the ability to learn, conform to school norms and manage school activities without major behavior conflicts. A cross-sectional study was conducted to test the differences between organized physical activity and non-organized physical activity in an after school program. Eighty Romanian adolescents were recruited and allocated to three groups: (a) with disabilities [Ds; N = 17, Mage = 14.55 years (SD = 1.16), 12 males and 5 females], (b) with conduct disorders [CDs, N = 21, Mage = 14.52 years (SD = 1.11) 16 males and 5 females], and (c) participants who had not shown signs of conduct disorders or disabilities [as a control group; N = 42, Mage = 14.2 years (SD = 0.46) 20 males and 22 females]. Personality traits, school behavior, and sensorimotor coordination were assessed by using the Eysenck personality questionnaire—junior scale, school in-adaptability questionnaire scale, and Vienna Test System Sport (SMK—sensorimotor coordination test) respectively. Multivariate analysis of variance MANOVA (3 × 3) and discriminant analysis were used to examine differences between the psychological and sensorimotor coordination outcomes across three groups and three types of physical activity context: (a) organized physical activity, (b) non-organized physical activity, and (c) no physical activity. The findings indicate that not participating in an organized physical activity program results in a reduced level of physical mobility and consequently is associated with maladaptive social and psychological outcomes. Thus, we argued that attending in an organized physical activity program is more beneficial for participants with disabilities and/or behavior disorders, due to an increase in the probability of school integration and development of their motor skills. Clearly more research is needed in order to investigate these effects in neurophysiological levels.

Enhancing Engagement With Socially Disadvantaged Older People in Organized Physical Activity Programs.

Participation in physical activity (PA) is low among older adults in developed nations and even lower among several socially disadvantaged groups. This study aimed to identify the actions that can be taken in the promotion, design, and implementation of organized PA programs to improve engagement with socially disadvantaged and underrepresented older people. Research design and methods: Semistructured interviews were conducted with 30 community service providers and 5 focus groups with 42 older participants in existing PA programs. Data were analyzed thematically, and the PRECEDE-PROCEED model for program planning was used to broadly categorize themes. Results: Helpful strategies for addressing predisposing factors such as social anxiety and lack of confidence included user-centered program design and sensitive, informative messaging and promotion. Key enabling strategies were transport assistance and minimizing fees. Facilitating gentle entry to groups and fostering inclusion and safety were identified as valuable reinforcing strategies. Providers regarded organizational networks as beneficial for facilitating referral and addressing resource constraints. Discussion and implications: A multifactorial approach addressing a range of predisposing, reinforcing, and enabling factors is likely to be necessary to enhance engagement in organized PA by socially disadvantaged and underrepresented older people. Key factors relate to creating a positive sociocultural environment, identifying activities of interest, and enhancing ease of access.

Effects of the FITKids physical activity randomized controlled trial on conflict monitoring in youth.

The present study investigated the effect of a 9-month physical activity (PA) intervention on children's cardiorespiratory fitness levels and neuroelectric indices of conflict monitoring (i.e., error-related negativity, ERN). Four hundred twenty-eight preadolescent children (8-9 years old) were randomized into a PA intervention or wait-list control group, and completed a fitness and cognitive control assessment (i.e., modified flanker task) at pre- and posttest. Following exclusion criterion, 308 children were included in the analyses (PA intervention: n = 139; wait-list control: n = 169). Children in the intervention displayed greater improvements in fitness and response accuracy, which were accompanied by stability of ERN amplitude from pre- to posttest. In contrast, the control group revealed increased ERN amplitude at posttest compared to pretest, despite no change in fitness or task performance. These findings demonstrate the efficacy of daily PA for promoting children's fitness and underlying neural processes associated with effective conflict monitoring. Such findings have significant implications for promoting organized PA programs intended to foster overall physical and brain health in school age children.

Physical activity and motivational predictors of changes in health behavior and health among DM2 and CAD patients.

This study tested a physical activity intervention and the self-determination theory (SDT) process model of health-behavior change and health among 108 adult patients with both diabetes mellitus type 2 (DM2) and coronary artery disease (CAD). Patients were randomly assigned to an organized physical activity intervention group (led by instructors) or a non-physical activity control group. At baseline and after 12months, we measured the following: needs satisfaction, autonomous and controlled motivation for physical activity, perceived competence for physical activity and blood sugar testing, physical activity and blood sugar testing, body weight, glucose control (HbA1c), and self-perceptions of general health and vitality. The intervention produced, as hypothesized, significant changes in all study variables in favor of the experimental group (Cohen's d effect sizes: 0.23-0.72), except the non-significant result for controlled motivation and body weight. The data supported the SDT process model, in which the effect of the intervention significantly predicted indirect changes in behavior and health through motivation variables. Considering the moderate to large effects on increases in motivation, behavior, and health, promoting organized physical activity programs that are perceived as need-supportive may have important health implications for patients with DM2 and CAD.

The Influence of Organized Physical Activity (Including Gymnastics) on Young Adult Skeletal Traits: Is Maturity Phase Important?

We prospectively evaluated adolescent organized physical activity (PA) as a factor in adult female bone traits. Annual DXA scans accompanied semiannual records of anthropometry, maturity, and PA for 42 participants in this preliminary analysis (criteria: appropriately timed DXA scans at ~1 year premenarche [predictor] and ~5 years postmenarche [dependent variable]). Regression analysis evaluated total adolescent interscan PA and PA over 3 maturity subphases as predictors of young adult bone outcomes: 1) bone mineral content (BMC), geometry, and strength indices at nondominant distal radius and femoral neck; 2) subhead BMC; 3) lumbar spine BMC. Analyses accounted for baseline gynecological age (years pre- or postmenarche), baseline bone status, adult body size and interscan body size change. Gymnastics training was evaluated as a potentially independent predictor, but did not improve models for any outcomes (p > .07). Premenarcheal bone traits were strong predictors of most adult outcomes (semipartial r2 = .21-0.59, p ≤ .001). Adult 1/3 radius and subhead BMC were predicted by both total PA and PA 1-3 years postmenarche (p < .03). PA 3-5 years postmenarche predicted femoral narrow neck width, endosteal diameter, and buckling ratio (p < .05). Thus, participation in organized physical activity programs throughout middle and high school may reduce lifetime fracture risk in females.

Physical activity programs for promoting bone mineralization and growth in preterm infants.

Lack of physical stimulation may contribute to metabolic bone disease of preterm infants, resulting in poor bone mineralization and growth. Physical activity programs combined with adequate nutrition might help to promote bone mineralization and growth. The primary objective was to assess whether physical activity programs in preterm infants improve bone mineralization and growth and reduce the risk of fracture.The secondary objectives included other potential benefits in terms of length of hospital stay, skeletal deformities and neurodevelopmental outcomes, and adverse events.Subgroup analysis:• Given that the smallest infants are most vulnerable for developing osteopenia (Bishop 1999), a subgroup analysis was planned for infants with birth weight < 1000 g.• Calcium and phosphorus intake may affect an infant's ability to increase bone mineral content (Kuschel 2004). Therefore, an additional subgroup analysis was planned for infants receiving different amounts of calcium and phosphorus, along with full enteral feeds as follows. ∘ Below 100 mg/60 mg calcium/phosphorus or equal to/above 100 mg/60 mg calcium/phosphorus per 100 mL milk. ∘ Supplementation of calcium without phosphorus. ∘ Supplementation of phosphorus without calcium. The standard search strategy of the Cochrane Neonatal Review Group (CNRG) was used. The search included the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 9), MEDLINE, EMBASE, CINAHL (1966 to March 2013), and cross-references, as well as handsearching of abstracts of the Society for Pediatric Research and the International Journal of Sports Medicine. Randomized and quasi-randomized controlled trials comparing physical activity programs (extension and flexion, range-of-motion exercises) versus no organized physical activity programs in preterm infants. Data collection, study selection, and data analysis were performed according to the methods of the CNRG. Eleven trials enrolling 324 preterm infants (gestational age 26 to 34 weeks) were included in this review. All were small (N = 16 to 50) single-center studies that evaluated daily physical activity for three and one-half to eight weeks during initial hospitalization. Methodological quality and reporting of included trials were variable.Four trials demonstrated moderate short-term benefits of physical activity for bone mineralization at completion of the physical activity program. The only trial assessing long-term effects on bone mineralization showed no effect of physical activity administered during initial hospitalization on bone mineralization at 12 months corrected age. Meta-analysis from four trials demonstrated a positive effect of physical activity on daily weight gain (weighted mean difference (WMD) 2.21 g/kg/d, 95% confidence interval (CI) 1.23 to 3.19). Data from four trials showed a positive effect on linear growth (WMD 0.12 cm/wk, 95% CI 0.01 to 0.24) but not on head growth (WMD -0.03 cm/wk, 95% CI -0.14 to 0.08) during the study period. Only one trial reported on fractures (this outcome did not occur in intervention and control groups) and complications of preterm birth (no significant differences between intervention and control groups). None of the trials assessed other outcomes relevant to this review. Some evidence suggests that physical activity programs might promote short-term weight gain and bone mineralization in preterm infants. Data are inadequate to allow assessment of harm or long-term effects. Current evidence does not support the routine use of physical activity programs in preterm infants. Further trials incorporating infants with a high baseline risk of osteopenia are required. These trials should address adverse events, long-term outcomes, and the effects of nutritional intake (calories, protein, calcium, phosphorus).

A Community Survey on Neighborhood Violence, Park Use, and Physical Activity Among Urban Youth

Neighborhoods can be an important feature of the built environment influencing physical activity; however, neighborhood poverty and violence may pose significant barriers for youth physical activity. We conducted a community survey of 107 households with youth 3-12 years of age in select neighborhoods of the city of Newark, New Jersey, a highly impoverished and racially/ethnically segregated city of the United States. The majority of sampled households did not have access to a park, and nearly 60% of youth were not engaged in a team or organized physical activity program. Hearing gunshots and seeing drug deals in the neighborhood were reported by 74% and 56%, respectively, of study participants. In adjusted regression models, a 1-unit increase in self-reported neighborhood safety was associated with perceptions that parks were safe for youth to use (OR = 1.7, CI = 1.3, 2.3) and increased odds of youth using parks (OR = 1.3, CI = 1.0, 1.6). Self-reported neighborhood violence was marginally associated with lower levels of Metabolic Equivalent (MET)-min/week of moderate PA (β = -54.25, P = .05). To ensure national goals of increased physical activity and use of outdoor spaces, addressing the neighborhood contexts under which the most vulnerable of our youth live will be required.

Formative research conducted in rural Appalachia to inform a community physical activity intervention.

Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians. Eight focus groups and seven group key informant interviews were conducted. This study was conducted in eastern Kentucky, in central Appalachia. One hundred and fourteen rural Appalachian residents (74% female, 91% white) participated. Open-ended, semistructured, and structured questions regarding perceptions of, barriers to/facilitators of, and examples of successful/failed PA programs were asked. Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94%. In addition to barriers that are consistent with those found in other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Department of Agriculture's Cooperative Extension Service; programs that include families, are well advertised, and focus on health rather than appearance; and, underlying all suggestions, culturally relevant yet nonstereotyping activities. When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA.

Motivation and Physical Activity Behaviors among Older Women: A Self-Determination Perspective

Drawing upon Self-Determination Theory, the purpose of our study was to examine the motivational determinants of older women's dropout and participation in physical activity (PA). Older women who dropped out ( n = 242) or remained ( n = 332) in an organized PA program completed the Sport Motivation Scale as well as health and PA measures. We found that women who dropped out presented lower levels of self-determined motivations and higher levels of amotivation than persistent women. Cluster analyses revealed three motivational profiles among persistent participants: “High Combined” (high levels of self-determined motivation and introjected regulation as well as moderate levels of external regulation), “High Introjected” (moderate scores of self-determined motivation and high introjected regulation as well as low scores of external regulation), and “Moderate Introjected” (low levels of self-determined motivation, moderate levels of introjected regulation, and low levels of external regulation). Our study adds to our understanding of motivational processes and of older women's participation in and withdrawal from PA. It revealed that different motivations could drive active older women's engagement in PA, and it provided support for a person-centered approach in which distinctive combinations of motivations emerged among different groups of active older women. The messages delivered in order to promote PA may account for the multidimensionality of motivation and may be oriented toward different purposes, tapping into different forms of motivation and informing the design of interventions aimed at promoting women's health.

Uptake and effectiveness of the Children's Fitness Tax Credit in Canada: the rich get richer

BackgroundThe Government of Canada implemented a Children's Fitness Tax Credit (CFTC) in 2007 which allows a non-refundable tax credit of up to $500 to register a child in an eligible physical activity (PA) program. The purposes of this study were to assess whether the awareness, uptake, and perceived effectiveness of this tax credit varied by household income among Canadian parents.MethodsAn internet-based panel survey was conducted in March 2009 with a representative sample of 2135 Canadians. Of those, parents with children aged 2 to 18 years of age (n = 1004) were asked if their child was involved in organized PA programs (including dance and sports), the associated costs to register their child in these programs, awareness of the CFTC, if they had claimed the CFTC for the tax year 2007, and whether they planned to claim it in the upcoming year. Parents were also asked if they believed the CFTC has lead to their child being more involved in PA programs.ResultsAmong parents, 54.4% stated their child was in organized PA and 55.5% were aware of the CFTC. Parents in the lowest income quartile were significantly less aware and less likely to claim the CFTC than other income groups. Among parents who had claimed the CFTC, few (15.6%) believed it had increased their child's participation in PA programs.ConclusionsMore than half of Canadian parents with children have claimed the CFTC. However, the tax credit appears to benefit the wealthier families in Canada.

Does the theory of planned behavior elements mediate the relationship between perceived constraints and intention to participate in physical activities? A study among older individuals

Abstract This study aimed to investigate the degree to which the elements of the theory of planned behavior mediate the relationship between constraints and intention to continuing participation in physical activities. The sample of the study consisted of 119 (N = 119) older individuals who participated in organized physical activity programs. The results indicated that attitudes and perceived behavioral control were negatively correlated with constraints, whereas the subjective norm variable had no relationship with them. In terms of the mediation role of the elements of the theory of planned behavior, the results indicated that both attitudes and perceived behavioral control partially mediated the relationship between constraints and intention, with the perceived behavioral control variable being the strongest mediator. These findings suggest that the theory of planned behavior elements mediate the constraints–intention relationship and determine, in a large degree, the older individuals’ intention to continuing taking part in physical activities.

Attitudes of College Women toward High School Physical Education Programs

Abstract A revision of the Plummer attitude inventory and a background information questionnaire were administered to 1,126 freshman college women enrolled in the private four-year colleges in Iowa in September 1964. Attitude scores were determined and comparisons were made on the basis of background information. Significant differences in attitude toward physical education were found between those earning interscholastic athletic letters and those not earning letters, those participating in organized physical activity programs outside of school and those not participating in such programs, those from farms and those from cities, those from small high school graduating classes and those from large high school graduating classes, those who chose teaching careers and those who chose other careers, those who ratedselves above average in physical skills and those who ratedselves below average in physical skills, and those who enjoyedr high school physical education programs and those who did not. Significant ...