Prolonged sitting time is a risk factor for adverse health outcomes and also has been associated with negative impacts on worker productivity (1,3,4,6–8,10–12,15). As an increasingly common instance of sedentary behavior, prolonged sitting time is related to premature mortality (1,7,12), chronic disease (3,4,6,11), metabolic syndrome (3,4), and obesity (3,6). Programs and products have emerged that are designed to assist individuals in breaking up extended periods of sitting time. Most of these interventions have occurred in workplace settings (10), where workers often spend more than half of their days sitting (8). This emerging body of research has shown positive effects, including physical as well as emotional health, such as mood states (14). Furthermore, the introduction of sit-stand and movement breaks also appears to impact worker performance and productivity positively (13).
Given that the introduction of sit-stand devices at the workplace made employees feel better and be more productive (13,14), it would make sense to translate such findings to other settings. Might we want to consider alternative contexts where improved mood and attention to task could really make an important difference in health and other nonhealth outcomes? For example, what if such lessons learned were applied to the classroom settings where students with special needs are taught technical skills to help them contribute meaningfully to society?
GENERATING PRACTICE-BASED EVIDENCE
Based on preliminary evidence (2,5,14,15) that intermittent standing improves performance among office workers, it is entirely reasonable to consider that a similar approach in an educational setting will generate a positive impact as well. Intermediate School District (ISD) 287 is a consortium of 12 school districts in Western Hennepin County, in the greater Minneapolis area. The Assistive Technology Training and Information Network (ATTAIN) Lab at ISD 287 serves youth aged 14 to 21 years with a variety of special needs. The ATTAIN Lab strives to assist and train students in building vocational skills through an applied technologically based curriculum. The goal of the program is to teach youth marketable technical skills that will increase their chances of leading meaningful work lives after graduation. During the course of 40 days in the fall of 2013, the ATTAIN Lab students participated in a Sit-Stand Action Research Project.
ACTION RESEARCH IN AN EDUCATIONAL SETTING
Action Research takes place within the existing operations of various settings, in this case, the ATTAIN Lab. It is often guided by practitioners in an effort to improve everyday practice (9). After reading about the effects of sit-stand devices on worker outcomes, the director of the ATTAIN Lab reached out to local researchers to learn if similar devices might help his students. The resulting partnership focused on a Sit-Stand Action Research Project designed to measure the impact of sit-stand devices on a variety of student outcomes. Using the Action Research framework, we systematically observed and measured sitting, standing, and related behaviors within the standard operating procedures of the ATTAIN Lab at ISD 287. The Project commenced in October 2013 and ran for 40 consecutive school days.
STUDY DESIGN AND DATA COLLECTION
Random assignment was used to group the 13 ATTAIN Lab students into the intervention and comparison groups. The intervention group received sit-stand devices that enabled them to alternate easily between sitting and standing. Devices were provided by Ergotron, an Eagan, Minnesota-based manufacturer of mobility products. Students were prompted by the ATTAIN Lab staff to stand for at least 5 minutes every 30 minutes and could opt to stand longer.
The daily work of students in the ATTAIN Lab is monitored by a job coach. It generally is the role of the job coach to supervise the student and provide project oversight and troubleshooting as appropriate. Building on this role, the job coach was responsible for daily data collection during the course of the 40-day project. The job coach was provided access to an iPad for the purpose of completing an online project questionnaire daily. For the majority of measures collected, the job coach observed the student’s behavior and completed the questionnaire. For select measures, the job coach engaged the student and entered the student’s responses on the questionnaire. The questionnaire was designed to measure behavioral and emotional outcomes (Supplemental Digital Content 1: Questionnaire, http://links.lww.com/FIT/A21).
In October 2013, a total of 13 students from the ATTAIN Lab were invited to participate in the project. Students ranged in age from 16 to 21 (average, 18 years). Special needs among the group included autism spectrum disorder, cerebral palsy, developmental cognitive disability, emotional and behavioral disorders, and speech and language disorder. Parental consent to participate in the action research project was obtained before the start. Random assignment was used in the selection of intervention and comparison group participants.
Students were excluded from the final analysis because of:
- Lack of data
- ○ Students with fewer than 30 valid questionnaires were excluded from the final analysis.
- ○ Several students from the comparison group were excluded from the final analysis because of persistent absenteeism and class reassignment.
After excluding seven students for these reasons, a total of six students were included in the final analysis. These included four students in the intervention group and two students in the comparison group (Supplemental Digital Content 2: Device photo, http://links.lww.com/FIT/A22).
Students were encouraged to stand for at least 5 minutes every 30 minutes and could choose to stand longer if desired. Initially, it took some time for students to get used to the devices. For the first week of the project, none of the students stood for the minimum recommended time. However, after 1 week with the desks installed, the majority of students in the intervention group started standing — and did so for more than the minimum suggested time.
Notable improvements were observed using the Quality of Work Scale. We used an existing ISD 287 measurement tool named Community-Curriculum-Based Assessment/Training Comprehensive Performance Profile. The scale rates students’ ability to perform a variety of tasks using a 1-to-5 rating (1 = unable; 5 = with minimal supervision). The job coaches rated each student during each day of the project. Students in the intervention group experienced, on average, greater improvements in Quality of Work during the course of the project compared with those in the comparison group. Students who were able to stand realized a 25-point increase on the scale between days 1 and 40, whereas students who did not have that option saw a 5-point increase (Supplemental Digital Content 3: Quality of Work Scale, http://links.lww.com/FIT/A23).
Improvements also were observed regarding student behavior. Behavior was measured using a set of 10 questions designed to assess students’ interpersonal problems, inappropriate behavior, unhappiness, and inability to learn. We created the behavior measurement scale based on constructs known to impact student behavior outlined in the 1997 Individuals with Disabilities Act. In this case, a higher score is equated with better overall behavior. The job coaches rated each student at baseline and again at the end of the project. Among the four students in the intervention group, behavior improved during the course of the 40-day project. For the two students in the comparison group, behavior either remained the same or worsened (Supplemental Digital Content 4: Behavior, http://links.lww.com/FIT/A24).
This pilot project represents a promising example of practice-based evidence, translating research from one setting (workplace) to another (classroom). Within 40 consecutive school days, we successfully collected data while maintaining the ongoing processes of the ATTAIN Lab and standard workload of the students.
Importantly, the project demonstrated initial evidence that alternating between sitting and standing can improve student outcomes. This was observed both in the quality of student work and an improvement in disruptive student behavior.
Workplace wellness successes may translate to other settings, thereby generating important improvements in health for other groups or populations. This approach may be useful in guiding efforts that reduce health disparities and address health inequalities that may exist in the community. In this case, a special needs population benefits from learnings derived among office workers both in terms of exposure to a healthier behavior as well as the nonhealth benefits of improved performance while at school. The potential of cross-sector collaborations that, at the local level, promote and improve community health is substantial. This project, with workplace wellness taking the lead, represents but one small example of how such progress may be made while positioning business and industry as important and meaningful partners in community health improvement.
1. Dunstan DW, Barr EL, Healy GN, et al Television viewing time and mortality: the Australian diabetes, obesity and lifestyle study (AusDiab). Circulation. 2010; 121 (3): 384–91.
2. Gilson ND, Suppini A, Ryde GC, Brown HE, Brown WJ. Does the use of standing “hot” desks change sedentary work time in an open plan office? Prev Med. 2012; 54 (1): 65–7.
3. Hamilton MT, Hamilton DG, Zderic TW. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease. Diabetes. 2007; 56 (11): 2655–67.
4. Healy GN, Dunstan DW, Salmon J, et al Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care. 2008; 31 (4): 661–6.
5. Husemann B, Von Mach CY, Borsotto D, Zepf KI, Scharnbacher J. Comparisons of musculoskeletal complaints and data entry between a sitting and a sit-stand workstation paradigm. Hum Factors. 2009; 51 (3): 310–20.
6. Inoue M, Yamamoto S, Kurahashi N, Iwasaki M, Sasazuki S, Tsugane S. Daily total physical activity level and total cancer risk in men and women: results from a large-scale population-based cohort study in Japan. Am J Epidemiol. 2008; 168 (4): 391–403.
7. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009; 41 (5): 998–1005.
8. Marshall S, Gyi D. Evidence of health risks from occupational sitting. Where do we stand? Am J Prev Med. 2010; 39 (4): 389–91.
9. McNiff J, Whitehead J. All You Need to Know About Action Research. 2nd ed. Thousand Oaks (CA): Sage Publications; 2011.
10. Neuhaus M, Eakin EG, Straker L, et al Reducing occupational sedentary time: a systematic review and meta-analysis of evidence on activity-permissive workstations. Am J Prev Med. 2012; 46 (1): 30–40.
11. Owen N, Bauman A, Brown W. Too much sitting: a novel and important predictor of chronic disease risk? Br J Sports Med. 2009; 43 (2): 81–3.
12. Patel AV, Bernstein L, Deka A, et al Leisure time spent sitting in relation to total mortality in a prospective cohort of U.S. adults. Am J Epidemiol. 2010; 172 (4): 419–29.
13. Pronk NP. Integrated worker health protection and promotion programs: overview and perspectives on health and economic outcomes. J Occup Environ Med. 2013; 55 (12 Suppl): S30–7.
14. Pronk NP, Katz AS, Lowry M, Payfer JR. Reducing occupational sitting time and improving worker health: the Take-a-Stand Project, 2011. Prev Chronic Dis. 2012; 9: 110323.
15. Thompson WG, Foster RC, Eide DS, Levine JA. Feasibility of a walking workstation to increase daily walking. Br J Sports Med. 2008; 42 (3): 225–8.