Implementing Physical Activity Strategies
Put the National Physical Activity42 Plan into action with proven programs
Russell R. Pate, PhD University of South Carolina David M. Buchner, MD, MPH University of Illinois
Human Kinetics Library of Congress Cataloging-in-Publication Data Implementing physical activity strategies / Russell R. Pate, David M. Buchner, editors. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-4504-2499-8 ISBN-10: 1-4504-2499-6 I. Pate, Russell R. II. Buchner, David. [DNLM: 1. Motor Activity--United States. 2. Exercise--United States. 3. Health Policy--United States. 4. Healthy People Programs--organization & administration--United States. 5. Physical Fitness--United States. 6. Sedentary Lifestyle--United States. WE 103] RA781 613.7'1--dc23 2013005847 ISBN-10: 1-4504-2499-6 (print) ISBN-13: 978-1-4504-2499-8 (print) Copyright © 2014 by National Physical Activity Plan Coordinating Committee and National Coalition for Promoting Physical Activity All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. The web addresses cited in this text were current as of June 2013, unless otherwise noted. Acquisitions Editor: Myles Schrag; Developmental Editor: Melissa J. Zavala; Managing Editor: Amanda S. Ewing; Assistant Editors: Amy Akin and Anne E. Mrozek; Copyeditor: Julie Anderson; Proofreader: Jim Burns; Indexer: Andrea J. Hepner; Permissions Manager: Dalene Reeder; Graphic Designer: Fred Starbird; Graphic Artist: Dawn Sills; Cover Designer: Keith Blomberg; Photographer (cover): Neil Bernstein; Photo Production Manager: Jason Allen; Art Manager: Kelly Hendren; Associate Art Manager: Alan L. Wilborn; Printer: Sheridan Books Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 The paper in this book is certified under a sustainable forestry program. Human Kinetics Website: www.HumanKinetics.com United States: Human Kinetics Australia: Human Kinetics P.O. Box 5076 57A Price Avenue Champaign, IL 61825-5076 Lower Mitcham, South Australia 5062 800-747-4457 08 8372 0999 e-mail: [email protected] e-mail: [email protected] Canada: Human Kinetics New Zealand: Human Kinetics 475 Devonshire Road Unit 100 P.O. Box 80 Windsor, ON N8Y 2L5 Torrens Park, South Australia 5062 800-465-7301 (in Canada only) 0800 222 062 e-mail: [email protected] e-mail: [email protected] Europe: Human Kinetics 107 Bradford Road Stanningley Leeds LS28 6AT, United Kingdom +44 (0) 113 255 5665 e-mail: [email protected] E5691 In memory of Antronette (Toni) K. Yancey, MD, MPH (1957–2013) We dedicate this book to our colleague and friend, Toni Yancey. A pioneer in the field of physical activity and health, Toni brought energy and passion to a career that spanned research, teaching, and public health practice. Toni’s commitment to social justice and promoting physical activity provided inspiration and leadership to a generation of public health professionals. She was an early advocate for promot- ing active lifestyles through evidence-based policy and environmental changes. She also touched the lives of children and adults through programs such as Instant Recess. She contributed to chapters 3, 22, and 24 of this book. We hope that this book embodies and honors her commitment to helping communities become more active.
Contents
Contributors ix Preface xi Acknowledgments xiii
▶ Sector I Education...... 1 Chapter 1 State Physical Activity Policies ...... 3
Chapter 2 Public School Physical Activity Legislative Policy Initiatives What We Have Learned ...... 15
Chapter 3 Role of Recess and Physical Activity Breaks During the School Day ...... 23
Chapter 4 Physical Activity in Early Childhood Centers New York City as a Case Study...... 31
Chapter 5 After-School Programs and Physical Activity ...... 37 ▶ Sector II Mass Media ...... 43 Chapter 6 VERB: It’s What You Do! and VERB Scorecard Bringing a National Campaign to Communities ...... 45
Chapter 7 Start.Living.Healthy Using Mass Media to Increase Physical Activity in Hawai’i ...... 55
Chapter 8 ParticipACTION The National Voice of Physical Activity and Sport Participation in Canada ...... 61
Chapter 9 Wheeling Walks A Targeted Mass Media–Led Physical Activity Campaign...... 71
Chapter 10 Mass Media Campaigns to Promote Physical Activity Australia and New Zealand as Case Studies ...... 81
Chapter 11 Communication Strategies to Promote the 2008 Physical Activity Guidelines for Americans ...... 91
v vi Contents
▶ Sector III Health Care ...... 103 Chapter 12 Institute of Lifestyle Medicine...... 105
Chapter 13 Exercise Vital Sign at Kaiser Permanente ...... 115
Chapter 14 Profession MD—Lifestyle Program ...... 123
Chapter 15 Development and Implementation of the Physical Activity Vital Sign (PAVS) ...... 131
Chapter 16 Strides to Strength Exercise Program for Cancer Survivors ..... 137 ▶ Sector IV Parks, Recreation, Fitness, and Sports ...... 143 Chapter 17 ParK–12 and Beyond Converting Schoolyards Into Community Play Space in Crowded Cities ...145
Chapter 18 Learning to be Healthy and Active in After-School Time The Säjai Foundation’s Wise Kids Program ...... 151
Chapter 19 Moovin’ and Groovin’ in the Bayou Summer Camps Increase Youth Physical Activity Through Intentional Design. . 159
Chapter 20 Finding Common Ground Play Space Modifications Can Increase Physical Activity for All Children...165
Chapter 21 Pioneering Physically Active Communities YMCA of the USA’s Healthier Communities Initiatives ...... 173
Chapter 22 Professional Sport Venues as Opportunities for Physical Activity Breaks The San Diego Padres’ FriarFit Instant Recess...... 181
▶ Sector V Business and Industry ...... 191 Chapter 23 Fit to Drive Integrated Injury Prevention, Health, and Wellness for Truck Drivers .....193
Chapter 24 Instant Recess Integrating Physical Activity Into the Workday at Kaiser Permanente South Bay Health Center ...... 201 Contents vii
Chapter 25 ChooseWell LiveWell An Employee Health Promotion Partnership between Saint Paul Public Schools and HealthPartners ...... 211
Chapter 26 What’s Next? Keeping NextEra Energy’s Health & Well-Being Program Active for 20 Years...... 221
Chapter 27 Johnson & Johnson Bringing Physical Activity, Fitness, and Movement to the Workplace...... 229
Chapter 28 Building Vitality at IBM Physical Activity and Fitness as One Component of a Comprehensive Strategy for Employee Well-Being ...... 239
▶ Sector VI Public Health ...... 247 Chapter 29 State-Based Efforts for Physical Activity Planning Experience From Texas and West Virginia ...... 249
Chapter 30 Health Impact Assessments A Means to Initiate and Maintain Cross-Sector Partnerships to Promote Physical Activity ...... 259
Chapter 31 Move More Scholars Institute...... 269
Chapter 32 The National Society of Physical Activity Practitioners in Public Health Elevating the Issue of Physical Activity; Equipping Professionals to Do So ..275
Chapter 33 Successful Cross-Sector Partnerships to Implement Physical Activity Live Well Omaha Coalition ...... 285
Chapter 34 Tracking and Measuring Physical Activity Policy ...... 295 ▶ Sector VII Transportation, Land Use, and Community Design ...... 303 Chapter 35 Institutionalizing Safe Routes to School in Columbia, Missouri . . 305
Chapter 36 Local Public Health Leadership for Active Community Design An Approach for Year-Round Physical Activity in Houghton, Michigan ....317 viii Contents
Chapter 37 A Road Diet for Increased Physical Activity Redesigning for Safer Walking, Bicycling, and Transit Use ...... 329
Chapter 38 Incorporating Physical Activity and Health Outcomes in Regional Transportation Planning ...... 337
Chapter 39 Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly...... 349 ▶ Sector VIII Volunteer and Nonproft ...... 357 Chapter 40 Using Legal and Policy Muscles to Support Physically Active Communities ...... 359
Chapter 41 Reducing Barriers to Activity Among Special Populations LIVESTRONG at the YMCA...... 369
Chapter 42 New York State Healthy Eating and Physical Activity Alliance .... 377
Index 385 About the NPAP and NCPPA 393 About the Editors 394 Contributors
Eydie Abercrombie, MPH, CHES, PAPHS Marie-France Hivert, MD, MMSc Amber T. Porter, BS Christiaan G. Abildso, PhD, MPH Nancy Huehnergarth Nicolaas P. Pronk, PhD Marice Ashe, JD, MPH Marian Huhman, PhD James M. Raczynski, PhD Birgitta L. Baker, PhD Lola Irvin, MED Amy Rea, BA Trever Ball, MS Fik Isaac, MD, MPH, FACOEM Bill Reger-Nash, EdD Tara Ballard, CET, MES Portia Jackson, DrPH, MPH Lori Rhew, MA, PAPHS Mary Balluff, MS, RD, LMNT Emily Jones, PhD Delia Roberts, PhD, FACSM Adrian Bauman, PhD, FAFPHM Elizabeth A. Joy, MD, MPH, FACSM Candace Rutt, PhD Bill Bellew, MPH, DPH Haley Justice-Gardiner, MPH, CHES Robert Sallis, MD, FAAFP, FACSM Megan Benedict, BS Manel Kappagoda, JD, MPH Sarah Samuels, DrPH Judy Berkowitz, PhD Abigail S. Katz, PhD Andrew Scibelli, MBA, MA Sarah Bilodeau, BSc Suzanne P. Kelly, MS Jennifer J. Selby, PE Terri Bopp, MPA Mary A. Kennedy, MS Michael Seserman, MPH, RD Ross C. Brownson, PhD Harold W. Kohl, III, PhD Ray Sharp, BA Sally Lawrence Bullock, MPH Mariah Lafleur, MPH Janet M. Shaw, PhD, FACSM Richard O. Burmeister, III, BAS Amy E. Latimer-Cheung, PhD Trevor Shilton, MSc Rachelle Johnsson Chiang, MPH Kay Loughrey, MPH, MSM, RD, LDN Kindal A. Shores, PhD Lesley Cottrell, PhD Jay Maddock, PhD Alice Silbanuz, BA Brian Coyle, MPH, PAPHS Andrew McGregor, MS Stewart Sill, MS Tiffany Creighton, MPH Grant McLean, BA(hons) Michael Skipper, AICP Amber Dallman, MPH, PAPHS Whitney Meagher, MSW Cathy Thomas, MAEd Carolyn Dunn, PhD Leslie A. Meehan, AICP Ian Thomas, PhD Lillian Dunn, MPH Andrew Mowen, PhD Amber Vaughn MPH Eloise Elliott, PhD Tinker D. Murray, PhD Melinda Vertin, MSN, NP Kelly R. Evenson, PhD Kelly Murumets Monica Hobbs Vinluan, JD Amy A. Eyler, PhD, CHES Jimmy Newkirk, Jr. Sue Walker, PhD Guy Faulkner, PhD Donna C. Nichols, MSEd CHES Rhonda Walsh, MPH Mark Fenton, MS Cathy Nonas, MS, RD Kristen Wan, MS Melanie Goodell, MPH Robert Ogilvie, PhD Dianne Ward, EdD Matthew Gurka, PhD Kara Peach, MA Jane D. Wargo, MA Melissa Hanson, BS, MBA Kerri R. Peterson, MS Melicia C. Whitt-Glover, PhD Peter Harnick, BA Jill Pfankuch, MS, MCHES, PAPHS David Winfield, BA Julie T. Harris, BS, MPA Edward M. Phillips, MD Antronette (Toni) K. Yancey, MD, MPH Katherine Hebert, MCRP Martha M. Phillips, PhD, MPH, MBA Joyce Young, MD, MPH Alison Herrmann, PhD Amanda Philyaw-Perez, MPH Sara Zimmerman, JD Ann-Hilary Heston, MPA Katrina L. Piercy, PhD Keith Zullig, PhD
ix
Preface
ost Americans are not physically active education, business and industry, health care) Mat levels that will beneft their health, and includes more than 250 specific strategies and many are completely inactive. A recent and tactics. A key goal of the plan is to promote article in The Lancet described very low levels effective strategies to help Americans become of physical activity, in the United States and more active, with an emphasis on policy and worldwide, as a “pandemic, with far-reaching environmental approaches. health, economic, environmental, and social This book supports the implementation of consequences” (Kohl et al. 2012). In an effort the National Physical Activity Plan and show- to get Americans moving and reverse the tide cases programs in all eight sectors that have of negative consequences, the U.S. Department implemented strategies outlined in the plan. of Health and Human Services released in 2008 By sharing examples and case studies of suc- the frst federally approved guidelines: the 2008 cessful programs, the book serves as a resource Physical Activity Guidelines for Americans. The for community organizations, schools, health guidelines provide detailed recommendations care providers, nonprofits, political leaders, and on the types and amounts of physical activity other people and organizations that are working that people should perform in order to gain (or want to work) to promote physical activity. important health benefts; specifc guidance for We hope that readers will find the book to be youth, adults, older adults, and other demo- both a useful resource for promoting physical graphic groups is provided. Clearly, issuing activity and a tool for improving the quality of these guidelines was a major step forward in life in their communities. We also hope that establishing physical activity as a public health readers will document and evaluate their own priority in the United States. programs, so that they may be shared with Although the 2008 guidelines set the stage for others (possibly as case studies in future edi- increasing physical activity among Americans, tions of this book*). Working together, we can guidelines alone are not enough to change move forward to achieve the vision established people’s health behaviors: The United States by the National Physical Activity Plan, that “one needed a clear and specific plan for helping day, all Americans will all Americans become physically active. For be physically active, and that reason, representatives of leading health they will live, work and organizations and more than 300 physical play in environments that activity experts began working in 2008 on the facilitate regular physical U.S. National Physical Activity Plan, which activity.” was released in 2010. The National Physical Activity Plan outlines a comprehensive strat- egy for changing America’s communities in Reference ways that will help many more people meet Kohl HW, Craig CL, Lambert EV, et al. 2012. The pan- the Physical Activity Guidelines. The plan is demic of physical inactivity: global action for public organized around eight sectors of society (e.g., health. Lancet 380;294-305.
*Readers who wish to share with us information about their community programs to promote physical activity can visit www.physi- calactivityplan.org/.
xi
Acknowledgments
his book was produced to highlight the goals. Clearly, this book could not have been Tways in which strategies included in the produced without the contributions of the pri- National Physical Activity Plan can be imple- mary authors who committed their energies to mented. It was possible to produce this book explaining how the initiatives called for in the only through the efforts of numerous talented National Physical Activity Plan can be brought and dedicated professionals. This project was to life in our communities. The work of those undertaken as a partnership between the authors gives us all hope that there is a more National Physical Activity Plan Alliance and physically active population in America’s future. the National Coalition for Promoting Physical Finally, the contributions of three very special Activity (NCPPA). NCPPA’s support, provided people must be recognized. Myles Schrag of through the contributions of Allison Topper- Human Kinetics Publishers has been consistently Kleinfelter and Cedric Bryant, was essential to and deeply supportive of this project from its the successful launch and completion of this inception. Janna Borden provided expert mana- project. gerial support to the coeditors and section edi- Central roles were played by the section tors, and that support ensured that this project editors, who provided wonderful leadership in would come to a successful completion. Gaye identifying topics and authors who produced Christmus, who edited the entire manuscript, is the core content of the book. The section edi- a remarkable professional whose expert editorial tors, to a person, are exceptional professional skills are reflected throughout this volume. leaders who have made enormous contributions Sincerest thanks to all who made this book to the National Physical Activity Plan and its possible!
xiii
Sector I Education
Elizabeth Walker, MS Association of State and Territorial Health Officials
he education setting provides an ideal North Carolina, Arkansas, West Virginia, and Tenvironment in which to promote physical Tennessee. Agencies and organizations in these activity in preschoolers, children, and youth. states are improving levels of physical activity With more than 54.9 million children under by using evidence-based and best practices. the age of 18 attending K-12 school in the Programs described in these chapters encourage United States (http://nces.ed.gov/fastfacts/ physical activity throughout the day and, as the display.asp?id=65) and more than 60 percent chapter authors highlight, improve children’s of children attending early care and education focus and reduce sedentary behavior. settings (www.census.gov/prod/2010pubs/ There is an increasing evidence base for p70-121.pdf), implementing evidence-based and improving physical activity in early care and best practice programs and policies is critical to education settings, and the case study of New instilling physical activity habits early in life. York City described in chapter 4 highlights The Community Guide, a publication of the feasible programs as well as barriers to imple- Community Preventive Services Task Force, mentation in a challenging setting. Child care highlights a wide range of programs for which centers often have high staff turnover rates, there is strong evidence of effectiveness at the employ teachers and paraprofessionals with school level, such as CATCH, Planet Health, varying education levels and ages, and serve and Spark Early Childhood; however, much children with a variety of cognitive and mobility has been written already about their results. ranges. The findings from this chapter describe This section focuses on how states and locali- the infrastructure, training, and resources that ties are able to implement evidence-based and should be available to begin successful imple- best practice tools. mentation. Chapters in this section highlight how policies are being implemented in Mississippi,
1
CHAPTER 1 State Physical Activity Policies
Rachelle Johnsson Chiang, MPH Whitney Meagher, MSW National Association of Chronic National Association of State Disease Directors (NACDD) Boards of Education (NASBE)
Kristen Wan, MS Association of State and Territorial Health Officials (ASTHO)
NPAP Tactics and Strategies Used in This Program
Education Sector STRATEGY 2: Develop and implement state and school the quality and quantity of physical education and district policies requiring school accountability for physical activity programs.
egular physical activity is essential for next example highlights Mississippi’s experi- Rchildren’s health, including maintenance ence adopting and implementing its Healthy of a healthy weight. Beyond providing physi- Students Act, which included various require- cal benefts, regular physical activity has been ments related to physical activity and physical shown to improve academic achievement, education in the schools. The last example is cognitive functioning, and behavior in students from Texas, where a state mandate for physical (U.S. Department of Health and Human Services activity enabled a local district to implement a 2010). The school environment plays an impor- strong physical activity program districtwide. tant role in providing children and adolescents Although the states differed in their approach with daily, high-quality physical activity. to policy making and implementation, all This chapter provides three examples of U.S. three succeeded in increasing physical activ- states that have taken the lead in enacting poli- ity in the school environment. They leveraged cies that support increased physical activity at partnerships, involved stakeholders, engaged school, at both the elementary and the second- legislators, and allowed for flexibility, all ary level. These states also have succeeded at while maintaining their objective of increasing perhaps the most challenging aspect of facilitat- physical activity in schools. Their experiences ing change through policy—implementation. demonstrate that despite the challenges, it is The first example is Tennessee, which adopted possible to translate national recommendations a law requiring all local education agencies to into a strong physical activity policy that will integrate a minimum of 90 minutes of physical work across an entire state and then implement activity per week into the instructional school the policy in a way that ensures success for day for elementary and secondary students. The individual districts and schools.
3 4 Chiang, Meagher, and Wan
Evidence Base Used to ensure that children are getting the physical activity they need not only to lead healthier During Program Development lives but also to achieve their fullest academic potential. The 2008 Physical Activity Guidelines for Americans recommend that children engage in 60 minutes or more of physical activity daily, Tennessee: with most of the time focused on moderate to vigorous physical activity (U.S. Department of Physical Activity Law Health and Human Services 2008). However, a In 2006, the General Assembly of the State of national study in the United States found that Tennessee passed the Physical Activity Law only 42 percent of children ages 6 to 11 meet (T.C.A. § 49-6-1021) mandating that elementary the recommendation, and as students move and secondary schools provide a minimum into adolescence, their activity levels decrease of 90 minutes of physical activity each week dramatically, with just 12 percent of male and for every student. In addition, to assist with 3 percent of female adolescents achieving the the implementation of statewide Coordinated recommendations (Troiano et al. 2008). Schools, School Health (CSH), the CSH Expansion Law which serve a large number of students for a (T.C.A. § 49-6-1022) was passed, creating posi- substantial portion of each day, play a critical tions for a physical education specialist and a role in ensuring that children and adolescents coordinator of school health within the Depart- are physically active. Consequently, the Insti- ment of Education. tute of Medicine recommends that state and local education agencies and school districts Program Description ensure that all students in grades K-12 have adequate opportunities to engage in 60 minutes In 2000, the Tennessee General Assembly of physical activity per school day (Institute of passed the CSH Improvement Act (T.C.A. § Medicine 2012). 49-1-1002) to address the increasing rate of Research confirms that school-based physical childhood obesity in the state. This made Ten- activity interventions can increase the duration nessee the only state in the United States with a of physical activity, improve aerobic capacity, legislative mandate to implement the Centers for and reduce cholesterol in students (Dobbins et Disease Control and Prevention’s CSH model; al. 2009). In addition, numerous studies have in addition, the State Board of Education cre- shown that students who are more physically ated CSH standards and guidelines. The CSH active and fit achieve higher grades and test Improvement Act provided state funding to start scores and have improved cognitive function, 10 CSH pilot sites. The aim of the CSH initiative concentration during instruction time, class- was to improve the health of Tennessee public room behavior, and attendance (Robert Wood school children. Johnson Foundation 2007; U.S. Department of By 2005, key infrastructure for CSH was in Health and Human Services 2010). Unfortu- place across the state and key stakeholders were nately, because of budgetary constraints and actively engaged, including physical education increased pressure for educators to improve teachers; the American Heart Association; the standardized test scores, high-quality physical Tennessee Association for Health, Physical Edu- education and other physical activity programs cation, Recreation and Dance; and other state are being reduced or eliminated completely by and local school-related organizations. In 2006, schools and school districts. with widespread support, the legislature passed Recent research has demonstrated that state- the Physical Activity Law. This law required all level mandates such as the ones discussed in local education agencies to integrate a minimum this chapter do make a difference, effectively of 90 minutes of physical activity per week into increasing school-based physical activity oppor- the instructional school day for elementary and tunities for youth (Slater et al. 2012). Mandates secondary students in all public and charter for increased physical activity in school can help schools. Implementation of the Physical Activ- State Physical Activity Policies 5 ity Law began in 2007.This requirement aligns Take 10! program) into lesson plans. Schools with Strategy 2 of the Education Sector of the provide daily physical education and morning National Physical Activity Plan: Develop and activities and look for opportunities to add more implement state and school district policies recess time. requiring school accountability for the quantity • Middle school—Schools use their explor- and quality of physical education and physical atory class period for physical activity time by activity programs. offering a variety of activities (e.g., walking, At the same time, the legislature passed the yoga, basketball) throughout the week. They CSH Expansion Law, creating the position of also have implemented schoolwide activities school health coordinator within the Depart- and intramural programs. ment of Education. Under the new law, each • High school—Despite the challenges that district was required to create an action plan exist with older students, schools are finding to describe how it planned to incorporate the creative ways to integrate physical activity, 90 minutes of physical activity into the school such as having the entire school participate week and to outline the steps it would take. in a walking program, developing intramural In addition, the Office of Coordinated School programs, and creating team-building activities. Health in the Department of Education and CSH coordinators motivate students and staff district CSH coordinators provided training, pro- through consistent messaging and reminders fessional development, and ongoing refresher of the positive effects of physical activity on courses to ensure that all programs were being academic achievement. implemented with fidelity. Implementation of the 90 minutes of physical activity has varied by school and by grade level. Program Evaluation Because schools are allowed to choose what The Physical Activity Law addressed a tactic works best for their staff and students, Tennes- of Strategy 2 of the Education Sector: Develop see schools have seen success at all grade levels. and implement state and school district policies • Elementary school—Each school works requiring school accountability for the quantity closely with its CSH coordinator to integrate and quality of physical education and physical classroom-based physical activity (e.g., the activity programs. In Tennessee, teacher, school, and district reporting has been built into the physical activ- ity policy to increase compliance. Teachers are required to document the number of minutes of physical activity offered during each school day. A school is considered compliant with the law when every student receives a minimum of 90 minutes of physical activity per week. If students in one class or one grade do not receive the mandated minimum amount of physical activity, the school is considered noncompliant. Each school works closely with its district CSH coordinator to collect the necessary data, which is then reported to the State Department of Education Office of Coordinated School Health, to document compliance quarterly and at year- end. Coordinators also conduct occasional site visits to ensure compliance with the law. All 95 counties in the state have accepted the law, and participation rates are high, Reprinted, by permission, from the Tennessee Department of Education. with 78 percent of school systems reporting
E5691/NPAP/fig1.1/458512/alw/r1 6 Chiang, Meagher, and Wan implementation in 2010-2011 (98 percent at the • A requirement that the physical activity elementary level, 90 percent middle school, and coordinator monitor districts for imple- 69 percent high school). In 2011, the legislature mentation of the physical education cur- passed a new amendment requiring the Office riculum. of Coordinated School Health to report to the • A requirement that school wellness plans General Assembly on the implementation of promote increased physical activity. the 90-minute physical activity requirement for public schools. With the new amendment in Program Description place, it is expected that the number of schools reporting compliance will increase each year. The Healthy Students Act was adopted in School staff and students across the state have response to legislators’ concern about the reported a positive response to the requirement increasing problem of childhood obesity in Mis- and related activities. sissippi. In 2007, 44 percent of youth ages 10 to The Physical Activity Law initially was 17 were overweight or obese, the highest rate passed to help combat childhood obesity (and in the United States. During the policy-making there has been a 2 percent reduction since process, there was broad consensus in the 2006), but other benefits have occurred. Tru- state legislature that action needed to be taken. ancy and the number of visits to school nurses However, many stakeholders were concerned have decreased, and student alertness, positive about the burden that the policy would impose feelings, and positive behavior have increased. on schools. In addition to creating the physical Most notably, academic performance has activity and physical education requirement, improved in all grade levels across the state, the act required 45 minutes per week of health which has encouraged and motivated school education instruction for grades K-8, bringing districts to continue looking for opportunities the total minutes required to 195 per week. In to integrate physical activity throughout the response to concerns about scheduling and not school day. competing with other tested subject areas, the policy was written to provide schools flexibility in how the requirements could be met. Mississippi: Implementation of the Healthy Students Act The Healthy Students Act began in 2008. That year, the Mississippi State Board of Education adopted regulations (policy In 2007, the Mississippi Legislature passed the 4012) defining physical education, physical Healthy Students Act, with the goal of strength- activity, and activity-based instruction and pro- ening physical activity, nutrition, and health viding guidance to schools on implementation education in public schools. The act included of the act. This included sample schedules for several mandates related to physical activity and elementary, middle, and high school; recom- physical education that align with Strategy 2 of mendations for class size; guidance on waivers the Education Sector of the National Physical and exemptions; and a requirement for fitness Activity Plan: Develop and implement state and testing in fifth grade and in one year of high school district policies requiring school account- school. The regulations also specified that phys- ability for the quantity and quality of physical ical education could be provided by a certified education and physical activity programs. classroom teacher in grades K through 8 and a certified physical education teacher in grades 9 • A requirement of 150 minutes of activity- through 12. This last requirement aligns with based instruction per week for grades K-8. one of the tactics of Strategy 1 regarding binding A minimum of 50 of the minutes must be requirements for the employment of certified, fulfilled with physical education. highly qualified physical education teachers in • Creation of the position of physical activity accordance with U.S. national standards and coordinator at the Mississippi Department guidelines. of Education, along with an appropriation The act addressed a tactic of Strategy 2: Pro- of funds to support the position. vide local, state and national funding to ensure State Physical Activity Policies 7 that schools have the resources (e.g., facilities, and health, with a primary focus on integrating equipment, appropriately trained staff) to pro- movement into the classroom. The development vide high-quality physical education and activity of Health in Action was made possible by a local programming. . . . At the state level, the Office funder, the Bower Foundation. of Healthy Schools (OHS) in the Department From the beginning, partnerships with other of Education has worked diligently to provide state agencies and organizations have played a technical assistance to districts and schools key role in the implementation of the Healthy regarding implementation of the act. The state Students Act. The Bower Foundation, Centers physical activity coordinator plays a key role in for Disease Control and Prevention, Center for organizing training across the state. During the Mississippi Health Policy, Robert Wood John- first year of implementation, the OHS provided son Foundation, National Association of State more than 10 regional training programs to Boards of Education, National Association physical education teachers, classroom teach- of Sport and Physical Education, Mississippi ers, administrators, and other school staff. The Community Education Center, Blue Cross Blue initial trainings focused on the policy require- Shield Foundation of Mississippi, Mississippi ments, health education and physical education, School Boards Association, and others have lent and physical activity lessons and activities that their support through training, funding, and could be integrated in the classroom. The OHS evaluation. These partnerships have ensured provides extensive resources to schools, includ- continued support, providing a mechanism for ing access to Health in Action (http://activities. ongoing training, grants to districts, and valu- healthyschoolsms.org/), a one-stop website that able information regarding the impact of the act. includes more than 1,400 web-based lesson During the 2010-2011 school year alone, OHS plans for physical education, physical activity, and partner organizations provided more than
Reprinted, by permission, from The Bower Foundation.
E5691/NPAP/fig1.2/458513/alw/r1 8 Chiang, Meagher, and Wan
25 training programs on integrating physical policies to promote physical activity, and the activity into the classroom. percentage of schools conducting fitness test- Implementation of the physical education ing. The evaluation showed strong, continued and physical activity requirements has varied support among lawmakers and district health significantly between schools, primarily because and education officials for the Healthy Schools of the flexibility of the policy and state board Act and motivation to continue improving on regulations. At the elementary level, schools the groundwork that has been laid. have modified schedules and trained classroom teachers in physical education in order to pro- vide every student with 50 minutes of physical Texas: Physical Activity Law education per week. Schools have used recess, Concerned about the growing problem of child- morning walks, and schoolwide activity breaks hood obesity, the Texas Legislature amended the and have integrated physical activity into aca- Education Code in 2005 to require 30 minutes demic lessons to reach the additional 100 min- of moderate to vigorous daily physical activity utes of physical activity per week. At the middle for students in grades K through 5. In 2009, school level, the challenges to implementation the legislature strengthened the requirement have been greater. Many schools have focused by extending it into middle school, requiring 30 on boosting athletics and intramurals as a way minutes of moderate to vigorous daily physical to meet the requirements, because the state activity for students in grades 6 through 8 for board regulations allow extracurricular activi- at least four semesters. ties such as sports, marching band, show choir, Additional aspects of the laws include the and cheerleading to be substituted for physical following: education. Other schools have chosen to build 150 minutes per week of physical education • Elementary schools unable to schedule into the schedule or have adopted a schoolwide daily physical activity may meet the morning exercise routine. requirement with 135 minutes of physical activity per week. Program Evaluation • Middle schools unable to schedule daily One of the tactics for Strategy 2 is to develop physical activity for four semesters may and implement a measurement and reporting provide students with 225 minutes over system to determine the progress of states the course of two weeks. toward meeting the strategy. In Mississippi, • School districts may provide an exemption monitoring of the physical activity and physi- for middle school students who participate cal education requirements is incorporated into in a structured extracurricular activity with the OHS coordinated school health monitoring a moderate to vigorous physical activity tool. Each year, OHS selects schools in various component. districts to monitor for compliance. Each district • Local school health advisory councils is monitored once every five years. The primary are required to make recommendations focus of the OHS monitoring is not to chastise to districts regarding the importance of noncompliant schools but to assist them in daily recess. implementation, and the monitoring tool helps • The physical activity requirement was to identify areas for improvement. accompanied by a requirement that schools The Center for Mississippi Health Policy conduct an annual fitness assessment for conducted a comprehensive two-year evalua- students in physical activity-based classes tion of the Healthy Students Act. The evalu- and activities in grades 3 through 12 using ation demonstrated significant increases in a the Fitnessgram program. variety of measures after the adoption of the Healthy Schools Act, including the percentage The requirements of the policy are in align- of students receiving a physical education cur- ment with Strategy 2 of the Education Sector riculum, the percentage of schools adopting of the National Physical Activity Plan: Develop State Physical Activity Policies 9 and implement state and school district policies but also to strengthen it with physical educa- requiring school accountability for the quantity tion. In fact, the program has been so successful and quality of physical education and physical that school board members have been reluctant activity programs. In addition, the policy aligns to relax the school health policies, even in the with the tactic that requires school districts to face of economic concerns. Data collection has annually collect, monitor, and track student- reinforced the belief that Austin has created related fitness data, including body mass index. a model program that has consistently led to The legislative process required flexibility. improvements in students’ Fitnessgram scores The legislation began as a physical education (table 1.1). By requiring that the program be requirement, initially requiring 30 minutes of a part of each school’s strategic planning pro- physical education every day with a qualified cess, the school board has ensured that schools physical education instructor. This was eventu- consistently look for ways to improve student ally changed to a physical activity requirement health. to provide schools more flexibility in imple- menting the mandate. Under the final policy, • At the elementary level, students have schools are allowed to count the time that physical education classes every third day students are at recess and to integrate physi- on a rotation with music and art class. This cal activity into other classroom activities, as provides them physical education twice for long as the activity is structured and provides the first two weeks of the rotation (90 min- for moderate or vigorous intensity. In addition, utes) and only once in the third week (45 the fitness assessment requirement began as an minutes). Classroom teachers are required annual requirement for all students grades 3 to provide physical activity to make up the through 12. However, in 2011, the requirement additional 45 or 90 minutes each week. was changed to include only those students in • At the middle school level, most students physical education classes or their substitutes, take a year of physical education in sixth rather than all students. The change was in grade and one semester in seventh and response to economic concerns and a desire to eighth grades. The program is designed minimize fiscal impact of an unfunded mandate to teach lifelong enjoyment of exercise on school districts. The biggest impact of this by focusing on lifetime recreation such as change is at the middle and high school levels, yoga, weightlifting, and circuit training. since most elementary students have physical Students also learn about places in the education throughout the year. community where they can participate in Despite economic concerns and ever-increas- those activities. ing academic pressures, the Austin Independent • At the high school level, the physical School District has found innovative ways not education requirement for high school only to fulfill the physical activity requirement graduation was kept at 1.5 credits, even
Table 1.1 Austin Independent School District Fitnessgram Results and Goals: Percentage of Third to Twelfth Grade Students in the Healthy Fitness Zone Body mass Aerobic Year index capacity Curl-up Push-up Sit and reach Trunk lift 2007-2008 60% 60% 85% 75% 73% 85% 2008-2009 60% 62% 85% 74% 73% 80% 2009-2010 60% 65% 86% 74% 74% 80% 2010-2011 61% 71%* 86% 75% 73% 82% *New aerobic capacity criterion. Reprinted, by permission, from Austin Independent School District. Available: www.austinschools.org/curriculum/pe_health/fitnessgram/dis_results.html 10 Chiang, Meagher, and Wan
though it was reduced to 1 credit statewide pass physical activity policies. In Texas, officials in 2009. Students also are required to take initially proposed a physical education require- 0.5 credits of health, even though the state ment, which was changed to a physical activity dropped this requirement as well. This requirement during negotiations. It is important demonstrated the Austin School Board’s to be patient and strategic in the policy-making commitment to student health. process and to recognize that there might be several unanticipated steps before reaching An important tactic of Strategy 2 is to ensure the ultimate goal. At the same time, it is also that schools have the resources to provide high- important to not wait until decisions are being quality physical education and physical activity made to become engaged in the legislative pro- programming. One way that elementary schools cess. Advocates need to take the time to let the supplement the physical education curriculum decision makers know their opinions. Most of with physical activity to reach the 135-minute decision makers will value knowing how cur- requirement is by scheduling classroom physi- rent policies are being implemented and what cal activity time. All elementary schools are changes should be considered. Being proac- required to schedule 20-minute segments of tive and engaging with representatives during structured physical activity time, called Work- quieter times in the legislative cycle allows ing Out for Wellness (WOW). Structured means advocates to establish a relationship with deci- that the activity must be based on the physical sion makers and increases the likelihood that education standards set by the Texas Educa- they will reach out to advocates when making tion Agency. Each school determines how to key decisions. schedule its WOW time each week. Classroom It is essential to engage a diverse network teachers are provided with a menu of grade- to support and create a policy. Mississippi and appropriate games that either are similar to Tennessee used a wide network of stakehold- what students do in physical education classes ers at every stage of the policy-making process. or have a component that reinforces classroom Their experiences highlight how important it is, lessons (table 1.2). Health lessons are often in the early stages of policy creation, to involve integrated into WOW time. key advocates and the leaders of groups that Other initiatives include a pilot project for will be involved with implementation (such as third grade students focused on training for membership associations for teachers, princi- leading WOW activities. By rotating through pals, and other school staff and administrators). different roles, all students try positions such Support from stakeholders helps the process go as leader, encourager, or referee. A few schools more smoothly, and they can offer diverse per- also have started marking playgrounds and spectives and feedback that may help to create a sidewalks to encourage students to use their stronger policy. Similarly, in each case discussed imaginations to create their own games. At these here, advocates cast a wide net and built strong schools, students may play on giant times tables relationships with school staff and others who or jump rope down specially marked paths were doing the work. There are many levels during recess. Administrators have provided of authority between those who make policies teachers with training in using Brain Break and those who implement them. Teachers, activities as a way to provide students with principals, and others who work directly with short activity breaks throughout the day. students can be the most vocal critics or sup- porters of a new policy, and understanding this can make the difference between meeting Lessons Learned minimum expectations and exceeding them. Strong relationships all the way down to the The experiences of these three states demon- school level can help policy makers understand strate that when it comes to policy making, the impact of their decisions. Strong relation- you have to start somewhere. Tennessee and ships all the way up to the state level can help Texas started by creating statewide coordinated schools feel supported and more willing to find school health programs and later went on to ways to overcome challenges in order to comply. Table 1.2 Working Out for Wellness (WOW) Activities for Third Grade Math Science Social studies Counting and exploring num- Healthy heart relay Citizenship and social studies bers skills Mingle, mingle Independence Day tag Jump rope math Dice-R-Cise It’s in the cards Texas symbols memory game American symbols memory game Money and addition number Mingle, mingle Mingle, mingle sense Mingle, mingle Go for the dough Adding and rounding Properties of matter Celebrate Freedom Week; Con- Ocean exploration 1 Free radical attack! stitution Day Columbus tag Nineteenth amendment Historical figures memory game Adding larger numbers States of matter Community location and Ready, set, show Free radical attack! maps; chronology; analyzing sources Vocabulary dribble Subtraction Force and motion Diverse communities and influ- Ocean exploration 1 Do you know your facts? ential heroes of society historical figures memory game Subtracting larger numbers Vibration is a push and pull How people learn about them- Ready, set, show Do you know your facts? selves Countries memory game Multiplication fact strategies Magnets and magnetism Structure and responsibility of (patterns) Cone crazy government; map skills Multiplication fact strategies Magnetism Fancy feet rock-paper-scissors (using unknown facts) (local) Ready, set, show Fancy feet rock-paper-scissors Ocean exploration 1 (state) Mingle, mingle Fancy feet rock-paper-scissors Ice on the pond (national) Multiplication patterns and Static electricity National government and number sense Do you know your facts? citizens Know your facts! Fancy feet rock-paper-scissors (local) Fancy feet rock-paper-scissors (state) Fancy feet rock-paper-scissors (national) Division meanings and facts Current electricity Lewis and Clark Ocean exploration 1 Do you know your facts? Historical figures memory game Do you know your facts?
(continued)
11 12 Chiang, Meagher, and Wan
Table 1.2 (continued) Math Science Social studies Fraction concepts Conductors and insulators Women’s history; primary Crows and cranes Vocabulary dribble resources Ocean exploration 1 Historical figures memory game Mingle, mingle The fraction fold Whole numbers and fractions The planets Cinco de Mayo on the number line Solar system scramble Mexico’s victory Number scramble Vocabulary dribble Congruency and symmetry Sun’s effect on earth’s water Jump rope math and weather Do you know your facts? Estimating and measuring Sun’s effect on planet earth length Do you know your facts? Air math Jump rope math Volume, capacity, weight, and Structures of plants mass Vocabulary dribble Time and temperature Crows and cranes Time and temperature data, Germination of seeds graphs, and probability Vocabulary dribble Crows and cranes Smarty pants Life cycles Fish gobbler/shark attack Vocabulary dribble Habitats Fish gobbler/shark attack Oyster tag Food chains and webs Fish gobbler/shark attack Oyster tag Predator prey WOW games should last 15 to 20 minutes. Objectives are in bold type. Reprinted, by permission, from Austin Independent School District. Available: www.austinschools.org/curriculum/pe_health/fitnessgram/dis_results.html
Mississippi leveraged the power of data year can demonstrate the impact of policies to help drive policy-related decision making. and strengthen arguments for their existence Policy makers were motivated to take action in the face of difficult circumstances. Policy- when they were shown, through data, that makers also understood the need to think cre- there was a need to strengthen school health atively about framing the link between physical policies. In addition, they kept data central to activity and academic achievement. It can be the policy-making process and used it as the challenging to get school administrators and basis for making decisions. Requiring schools policy makers to understand that healthy, more to collect and publicly share data from year to physically active students are better learners. State Physical Activity Policies 13
This makes it all the more important to use The adoption and implementation of physi- the powerful research available to focus on cal activity policy in schools is a challenging the “wins” for the educators: Healthy students endeavor that can have a powerful, positive attend school more often, are better able to impact on students and the school environ- pay attention in class, and perform better on ment. That said, significant policy changes achievement tests. often take a long time, and it can be hard to In the area of policy implementation, Tennes- maintain motivation throughout the process. see and Mississippi helped to ensure success Recognizing the smaller victories along the way by creating positions in the state departments can help provide energy and encouragement of education that were responsible, in part, for to continue the process. It is also important to implementation and monitoring of the policy. remember why policy is important. Establishing The Austin Independent School District hired a baseline ensures that every school provides new staff members to help ensure compliance some opportunity for physical activity. Even if with the state’s coordinated school health sufficient resources are not provided to imple- laws. Implementation-focused employees are ment the policy, pointing to its existence can important to the long-term sustainability of a encourage some reluctant school administrators policy because they are able to collect and dis- to comply. In the end, a strong physical activity seminate data to support the program, provide policy serves to lay a foundation. Some schools training and technical assistance, and create will far exceed that foundation, and others and disseminate resources. In addition, in all will just meet the minimum expectations. But three cases discussed in this chapter, school without the policy, far fewer schools would ever and district-level staff received support through have endeavored on their own to make physical training and resources. An intensive training activity an important part of the school day. schedule may be needed at the initial stages of policy implementation. But after everyone is more comfortable with a policy and has created Summary a routine for its implementation, web-based resources and shorter refresher courses can be The experiences of Tennessee, Mississippi, and adequate to support those who are implement- Texas provide excellent examples of successful ing a policy. policy creation and implementation related to The experiences of these states demonstrate increasing physical activity in the schools. They the importance of seeking additional resources also provide valuable lessons about the pro- and partners to strengthen implementation, cess, challenges, and barriers. Recognizing the monitoring, and evaluation. Private funders key actions that were critical to accomplishing who view increasing physical activity among policy change in these states can help others youth as a priority can often provide addi- replicate their success in ways that are suitable tional resources to strengthen professional to their own states and communities. development and training efforts. Partnerships with universities can provide expertise and resources for monitoring and evaluation. The Additional cases discussed here highlight the importance Reading and Resources of approaching each district and school with an open mind, a flexible agenda, and a positive Active Living Research. 2009. Active education: approach. Every district or school will start the Physical education, physical activity and academic policy implementation process in a different performance. http://activelivingresearch.org/files/ place and with a different set of supports and ALR_Brief_ActiveEducation_Summer2009.pdf. obstacles. A universally successful approach is Center for Mississippi Health Policy. 2011. Year two to consider school officials as partners and find report: Assessing the impact of the Mississippi ways to assist them rather than tell them how Healthy Students Act. www.rwjf.org/content/dam/ things need to be done. farm/reports/evaluations/2011/rwjf402274. 14 Chiang, Meagher, and Wan
Institute of Medicine. 2012. Accelerating progress in programs for promoting physical activity and fitness obesity prevention: Solving the weight of the nation. in children and adolescents aged 6-18. Cochrane www.iom.edu/Reports/2012/Accelerating-Progress- Database Syst. Rev. (1):CD007651. in-Obesity-Prevention.aspx. Institute of Medicine. 2012. Accelerating progress in Kelder, S.H., A.S. Springer, C.S. Barroso, C.L. Smith, obesity prevention: Solving the weight of the nation. E. Sanchez, N. Ranjit, and D.M. Hoelscher. 2009. www.iom.edu/Reports/2012/Accelerating-Progress- Implementation of Senate Bill 19 to increase physi- in-Obesity-Prevention.aspx. cal activity in elementary schools. J. Public Health Robert Wood Johnson Foundation. 2007. Active educa- Policy 30(1 Suppl.):S221-47. tion: Physical education, physical activity and aca- Robert Wood Johnson Foundation. 2007. Active educa- demic performance. www.rwjf.org/content/dam/ tion: physical education, physical activity and aca- web-assets/2007/11/active-education. demic performance. www.rwjf.org/content/dam/ Slater, S.J., L. Nicholson, J. Chiriqui, L. Turner, and web-assets/2007/11/active-education. F. Chaloupka. 2012. The impact of state laws and Tennessee Department of Education. 2010. Tennes - district policies on physical education and recess see coordinated school health 2008-09: Executive practices in a nationally representative sample of US summary. http://campaignforhealthykids.org/ public elementary schools. Arch. Pediatr. Adolesc. resources/TennesseeCoordinatedSchoolHealthEx- Med. 166(4):311-6. ecutiveSummary20082009%20(2).pdf. Troiano, R., et al. 2008. Physical activity measured in U.S. Department of Health and Human Services. 2010. the United States by accelerometer. Med. Sci. Sports The association between school-based physical Exerc. 40(1):181-8. activity, including physical education, and aca- U.S. Department of Health and Human Services. 2008. demic performance. www.cdc.gov/healthyyouth/ Physical activity guidelines for Americans. www. health_and_academics/pdf/pa-pe_paper.pdf. health.gov/paguidelines/. U.S. Department of Health and Human Services. 2010. References The association between school-based physical activity, including physical education, and aca- Dobbins, M., K. DeCorby, P. Robeson, H. Husson, demic performance. www.cdc.gov/healthyyouth/ and D. Tirilis. 2009. School-based physical activity health_and_academics/pdf/pa-pe_paper.pdf. CHAPTER 2 Public School Physical Activity Legislative Policy Initiatives What We Have Learned
Martha M. Phillips, PhD, MPH, MBA Amanda Philyaw-Perez, MPH Fay W. Boozman College of Public Fay W. Boozman College of Public Health, University of Arkansas Health, University of Arkansas for Medical Sciences for Medical Sciences
Melanie Goodell, MPH James M. Raczynski, PhD Fay W. Boozman College of Public Fay W. Boozman College of Public Health, University of Arkansas Health, University of Arkansas for Medical Sciences for Medical Sciences
NPAP Tactics and Strategies Used in This Program
Education Sector active, inclusive, safe, and developmentally and culturally appropriate. STRATEGY 1: Provide access to and opportunities for high-quality, comprehensive physical activ- STRATEGY 2: Develop and implement state and school ity programs, anchored by physical education, in district policies requiring school accountability for Pre- kindergarten through grade 12 educational the quality and quantity of physical education and settings. Ensure that the programs are physically physical activity programs.
s noted elsewhere in this volume, the and federal policy makers, state and local boards Aimportance of physical activity (PA) to of education, state departments of education, healthy growth and development in childhood school district superintendents, and principals) is well established (Borms 1986; Chakravarthy can promote children’s PA in two primary ways: and Booth 2004; Mein and Oseid 1982; Tompo- frst, by providing programs, including physi- rowski et al. 2008). Most children spend a large cal education (PE), intramural and extramural portion of their waking hours in schools; thus, sports, and PA programs before and after school, schools are an important venue for promoting and second, by implementing policies that PA, by teaching children about the relationship modify school PA practices and environments. between PA and health and by providing oppor- A wide range of options exist for school-based tunities for them to be physically active during PA policy interventions, including requiring (1) the school day (Story et al. 2009). Those who adequate time spent in PE; (2) adequate time guide schools in our communities (i.e., state spent in physical activity during PE classes;
Acknowledgments: This work was supported by the Robert Wood Johnson Foundation (grant numbers 30930, 51737, 60284, 61551). The preparation of this chapter has also been supported by the Arkansas Prevention Research Center (U48 DP001943). The authors acknowledge the assistance of Sherri Morris, Heather Johnston, Blake Talbot, Jennifer Montgomery, and Jada Walker in the preparation of this chapter.
15 16 Phillips, Goodell, Philyaw-Perez, and Raczynski
(3) PE teacher certifcation; (4) staff develop- activity) (Chriqui et al. 2009). Further, by insti- ment for PE teachers; (5) appropriate student tuting policies that required a specific amount to teacher ratios in PE classes; (6) time for of time for PA but not PE, a number of school physical activity outside of formal PE classes; districts actually made it harder for schools to and (7) modifcations to school environments meet expert recommendations for time spent to promote physical activity. in PE (Chriqui et al. 2009). State-based reviews This chapter explores the implementation of district policies have yielded similar results. of school policies designed to enhance school- In general, state evaluators have found poli- based PA opportunities, focusing on the content cies to be framed as recommendations rather and effect of federal and state efforts to influ- than requirements (Metos and Nanney 2007; ence school policies and lessons learned from Molaison et al. 2011; Probart et al. 2008) and those efforts. Legislative initiatives in three to lack specification and rigor in implementa- states—Arkansas, West Virginia, and Missis- tion and evaluation of their impact (Metos and sippi—are presented as examples of the efforts, Nanney 2007; Probart et al. 2008). Further, it challenges, and outcomes associated with has been reported that although district plans efforts to change school policies to promote generally meet the minimum requirements to physical activity. include goals related to both nutrition and PA, most address nutrition more extensively and comprehensively than PA (Brener et al. 2011; Federal Policy Initiatives Harris and Bradlyn 2009).
Control of schools is largely a state function, and thus most school policy initiatives arise from State Legislative Initiatives state legislatures and departments of education rather than federal initiatives. However, the A second avenue for influencing schools Child Nutrition and WIC Reauthorization Act is through policy made by state legislative of 2004 included a requirement that all local bodies, a popular approach in the past decade. education agencies participating in the federal Boehmer and colleagues (2007) identified school meals programs establish local wellness more than 1,000 pieces of legislation, includ- policies by the 2006-2007 school year, with the ing bills and resolutions, introduced in the 50 goal of improving PA and nutrition in schools. states during three years, 2003 through 2005. These policies were to be developed and imple- Approximately 25 percent of those legislative mented by local school wellness committees, initiatives involved PA or PE policy changes in with documented involvement of parents, stu- schools, and 28 percent addressed safe routes dents, school representatives, and members of to schools (Boehmer et al. 2007). A similar the public. These requirements were continued review of legislative initiatives related specifi- in the most recent reauthorization, the Healthy, cally to PE identified approximately 780 bills Hunger-Free Kids Act of 2010. introduced between 2001 and 2007, of which Unfortunately, research has indicated that only 21 percent were enacted (Eyler et al. 2010). PA policies promulgated by these committees Eight-five percent of PE bills enacted contained have been neither strong nor comprehensive. A strong language requiring action; however, only review of a national sample of district policies 23 percent were funded mandates and only 30 for the 2006-2007 and 2007-2008 school years, percent included a requirement that the bill’s completed by Chriqui and associates (2009), impact be evaluated (Eyler et al. 2010). found that the policies frequently were weak and fragmented and failed to include adequate Program Description plans for implementation and evaluation. The majority of policies did not meet evidence-based Three state legislative approaches to reduce recommendations for PA (e.g., daily recess) or childhood obesity, in Arkansas, West Virginia, PE (e.g., time devoted to moderate to vigorous and Mississippi, are noteworthy in that they Public School Physical Activity Initiatives 17 mandated multicomponent policy approaches to time being PE in grades kindergarten through 6, affect both nutrition and PA. In all three cases, beginning in 2007-2008; (3) each school district the Robert Wood Johnson Foundation funded would employ at least one certified PE teacher university-based research teams to evaluate the for each 500 students, beginning in 2008-2009; process, impact, and outcomes associated with and (4) all personnel teaching PE in grades the legislation. kindergarten through 12 would be certified to teach PE by the 2012-2013 school year. Arkansas: Act 1220 of 2003 to Combat Childhood Obesity West Virginia: In 2003, the Arkansas General Assembly The Healthy Lifestyles Act enacted Arkansas Act 1220 to combat child- In 2005, West Virginia passed the Healthy hood obesity. Heralded as one of the earliest Lifestyles Act (HB 2816), which was more pre- comprehensive approaches to reducing child- scriptive than Arkansas Act 1220, in that the hood obesity, this legislation contained only Healthy Lifestyles Act (1) restricted the sale of two specific immediate mandates for schools: soft drinks during the school day in elementary (1) restricting student access to vending and middle schools; (2) restricted beverage sales machines during the school day in elementary to water, 100 percent fruit and vegetable juices, schools; and (2) measuring body mass index low-fat milk, and juice beverages with at least (BMI) for all public school students, with reports 20 percent juice; (3) allowed the sale of soft sent to parents. The act went further, however, drinks outside of meal periods if the local board to (1) establish a statewide panel of experts of education specifically permitted it and if 50 and advocates, the Child Health Advisory Com- percent of the beverage offerings were healthy mittee, to make recommendations regarding beverages; (4) required a minimum time for nutrition, PA, and PE policies and standards PE instruction for all elementary students (90 for schools in a variety of areas; (2) require that minutes per week) and middle school students the Department of Health hire health promotion (2,700 minutes per year); (5) required one specialists to assist schools; (3) require schools PE course credit for high school graduation; to report publicly the revenues and expenditures (6) required that high school students be offered from competitive food and beverage contracts; instruction in physical activities likely to be and (4) require that each school district convene maintained over one’s lifetime; (7) required a nutrition and PA advisory committee to assist fitness testing and reporting for students in in the development of local policies for imple- fourth through eighth grades and in the required menting nutrition and PA standards. high school course; (8) required the collection The rules and regulations promulgated by the of BMI data for a scientifically drawn sample State Board of Education, based on the recom- of students and reporting of findings to state mendations made by the Child Health Advisory agencies; (9) required that schools teach the Committee, modified substantially the existing importance of healthy eating and PA to maintain nutrition and PE and PA policies and practices a healthy weight; and (10) required that health required of schools. In terms of PE and PA, the education assessment be conducted to measure new rules required that public schools establish student knowledge and program effectiveness. strategies to achieve 30 minutes of PA daily for The State Department of Education responded all students, kindergarten through 12th grade, by promulgating rules and regulations to opera- and begin to implement those strategies before tionalize the mandates, for example, specifying the end of the 2005-2006 school year. Further, the use of Fitnessgram for fitness testing and the rules specified that (1) a maximum student the Health Education Assessment Project to to adult ratio of 30:1 would be maintained in measure knowledge gained in health education grades kindergarten through 6, beginning in classes. Implementation of the school-based 2006-2007; (2) all students would receive 150 components of the Healthy Lifestyles Act began minutes of PA per week, with 60 minutes of that in August 2006. 18 Phillips, Goodell, Philyaw-Perez, and Raczynski
Mississippi: of the three pieces of legislation and associated The Healthy Students Act rules and regulations. In 2007, the Mississippi legislature passed the Lessons Learned Mississippi Healthy Students Act (SB 2369) to improve nutrition, PA, and health education The three evaluations found that efforts to in public schools, with the goal of reducing increase PA and PE for students received wide- childhood obesity. Described in more detail spread endorsement by parents and school elsewhere in this volume, the act required the personnel. PE teachers (Harris and Bradlyn development of local school wellness plans, 2009), principals (Harris and Bradlyn 2009), beginning with the 2008-2009 school year, to and parents (Harris and Bradlyn 2009; Phil- promote increased PA, healthy eating habits, lips et al. 2010; Center for Mississippi Health and tobacco and drug abstinence. It further Policy 2010) in the three states reported that directed the State Board of Education to adopt they wanted students to have more, even daily, regulations addressing school nutrition and opportunities to be physically active in school. specified the appointment of a committee to However, in general, the state-based evaluations advise the board on the development of these indicated that schools have had difficulty imple- rules and regulations. The bill also appropriated menting the mandated increases in time devoted state funds for the hiring of a PA coordinator to PE and PA. The West Virginia researchers within the state’s Department of Education. The found, for example, that even though 85 percent required rules and regulations regarding PE and of the principals viewed the PE time mandates health education adopted by the State Board of favorably after two years of implementation, Education went into effect in fall 2008. 31 percent of elementary schools and 8 percent of middle schools did not meet the specified requirements (Health Research Center 2005). Program Evaluation In Arkansas, after rules and regulations speci- fied increased PE time in all grades, school The Arkansas evaluation was initially funded personnel appealed to the Arkansas legislature in 2004 to assess baseline policy levels prior to to intervene. Thus, in the 2007 legislative ses- policy implementation; annual data collection sion, the Arkansas Department of Education concluded in spring 2012. In West Virginia, the rules were modified by law to specify that evaluation spanned two consecutive years, with elementary students would receive 60 minutes data collected in the 2007-2008 and 2008-2009 of PE and 90 minutes of PA each week, middle school years. The five-year Mississippi evalua- school students would receive 60 minutes of tion began in 2007 and concluded in 2012. Meth- PE instruction with no additional requirement ods used in each of these comprehensive evalu- for PA, and high school students would have ations have been described in detail elsewhere no requirement for PA beyond the 1/2 unit of (Harris and Bradlyn 2009; Phillips et al. 2010; PE required for graduation (Phillips et al. 2008). Center for Mississippi Health Policy 2010). Each Many Arkansas schools have, however, vol- evaluation included surveys of school principals untarily changed other PE and PA policies and and school district superintendents, interviews practices over time. For example, in 2010, 70 with parents of students attending the state’s percent of school districts reported that they public schools, and surveys or interviews of required regularly scheduled recess in elemen- other key stakeholders (e.g., school nurses, PE tary schools, compared with only 58 percent in teachers, health care providers, policy makers, 2004. Other policies established by schools or and others). Although the research questions school districts included the following (Phillips were state-specific, addressing the key issues of et al. 2011): relevance to each state’s stakeholders and the nuances of each state’s law, there was substan- • Requiring regular assessment of student tial overlap across the three states in methods fitness (44 percent of schools in 2010, up and variables, reflecting the common features from 26 percent at baseline in 2004) Public School Physical Activity Initiatives 19
• Forbidding the use of PA as punishment staffing the facilities after school hours (Phillips in PE classes (83 percent of schools, com- et al. 2010). Similarly, walking and cycling to pared with 77 percent in 2004) school have been affected by school attendance • Forbidding the punishment of bad behav- zoning (e.g., school choice, school consolida- ior by excluding students from PE (93 per- tions, busing) and may be reduced by early cent, up from 84 percent in 2004) or recess school start times, lack of crossing guards, lack (54 percent, up from 42 percent in 2004) of storage for coats and helmets, policies requir- ing bikers and walkers to leave after car riders, • Requiring that lifetime physical activity be and routing of cars and buses in drop-off and included in PE instruction in elementary pick-up zones (Ahlport et al. 2008). schools (55 percent, compared with 39 percent in 2004) Impact on PA Among Students • Requiring that newly hired PE teachers in elementary schools be certified in PE (89 and Their Families percent, up from only 69 percent in 2004) The impact of the changes to school PA and PE policies and practices on PA among students Barriers to PA and PE Policy and their families appears to have been mini- Change mal. For example, in Arkansas, no significant changes in the frequency of child or adolescent Although national, state, and local legislative physical activity (e.g., walking, playing games panels have focused on the need for compre- with family or friends, playing sports) have been hensive obesity reduction efforts, it appears noted since 2004 (Phillips et al. 2011). A change that schools are more likely to make changes in parental appreciation for physical activity has to nutrition policies and practices than to PA been noted, however. Although the proportion and PE policies (Harris and Bradlyn 2009; of parents who indicated that they were trying Phillips et al. 2010; Center for Mississippi to limit their children’s sedentary activity (i.e., Health Policy 2010). This difference in policy screen time) did not change significantly over implementation is likely related to the real and time (73 percent in 2004; 71 percent in 2010), perceived barriers to PA and PE policy change. the reason for making that effort did change. For example, principals, superintendents, and The percentage of parents reporting that they PE teachers interviewed in Arkansas and West wanted to give more time for physical activity Virginia cited (1) lack of adequate facilities, rose steadily from 33 percent at baseline (in with PE often taught in multiuse rooms that also 2004) to a high of 49 percent in 2009 (Phillips served as cafeterias and music rooms; (2) lack et al. 2011). Similarly, the percentage of parents of resources, with finances insufficient to hire who required their children to stay inside after enough certified teachers to serve all schools school rather than play outside dropped from and reduce PE class sizes; and (3) lack of time, a high of 11 percent at baseline to a low of 7 given substantial pressures placed on schools percent in 2009, and the percentage of parents to focus on academic instruction and improve who reported enrolling their children in sports test scores. Belansky and colleagues (2009), or exercise activities rose from 42 percent in investigating barriers to PA and PE policy 2004 to a high of 53 percent in 2009 (Phillips change in Colorado schools, noted a failure to et al. 2011). ensure accountability as a potential barrier to the effectiveness of policy initiatives. Specific barriers arise when attempts are Linkage to the National made to implement certain policies. For exam- Physical Activity Plan ple, the likelihood that schools will implement joint use agreements that allow community These three statewide school policy initiatives groups to use school facilities outside of the support the National Physical Activity Plan’s school day may be reduced by concerns over Education Sector Strategies 1 and 2. Implemen- liability and costs associated with security and tation of Strategy 1, which pertains to providing 20 Phillips, Goodell, Philyaw-Perez, and Raczynski
access to high-quality PA and PE programs at elementary schools in Colorado. J. Public Health all grade levels from prekindergarten to grade Policy. 30(Suppl. 1):S141-60. 12, is particularly reflected in Mississippi’s Boehmer, T.K., R.C. Brownson, D. Haire-Joshu, and efforts to provide guidance and training for M.L. Dreisinger. 2007. Patterns of childhood obesity teachers in state-of-the art, age-appropriate prevention legislation in the United States. Prev. physical activities and in how to incorporate PA Chronic Dis. 4(3):A56. into the academic curriculum. All three states Borms, J. 1986. Children and exercise: An overview. J. addressed Strategy 2, which is concerned with Sports Sci. 4:3-20. developing and implementing state and district Brener, N.D., J.F. Chriqui, T.P. O’Toole, M.B. Schwartz, policies regarding the quality and quantity of PA and T. McManus. 2011. Establishing a baseline mea- and PE programs. The states achieved this by sure of school wellness-related policies implemented addressing class size, certification of teachers in a nationally representative sample of school dis- providing PE instruction, quantity of time to be tricts. J. Am. Diet. Assoc. 111(6):894-901. allotted to PA and PE at various grade levels, Center for Mississippi Health Policy. 2010. Year One— and fitness or BMI testing. Assessing the Impact of the Mississippi Healthy Students Act. Center for Mississippi Health Policy, Jackson, MS. Summary Chakravarthy, M., and F. Booth. 2004. Eating, exercise and “thrifty” genotypes: Connecting the dots toward Experts and policy makers recognize the an evolutionary understanding of modern chronic opportunity to address childhood obesity by diseases. J. Appl. Physiol. 96:3-10. modifying school policies and environments Chriqui, J., L. Schneider, F. Chaloupka, K. Ide, and O. related to PA and PE. Evaluations of recent Pugach. 2009. Local Wellness Policies: Assessing legislative initiatives, however, suggest that School District Strategies for Improving Children’s even popularly supported changes are difficult Health. School Years 2006-07 and 2007-08. Chicago: for school districts and schools to implement. Bridging the Gap, Health Policy Center, Institute for Barriers to change, particularly financial barri- Health Research and Policy, University of Illinois at Chicago. ers and scheduling issues, must be addressed if such policy changes are to be implemented Child Nutrition and WIC Authorization Act of effectively. Further, although changes to school 2004 [S. 2507]. www.govtrack.us/congress/bill. xpd?bill=s108-2507. policies and practices related to PA and PE may increase PA during the school day, data suggest Eyler, A.A., R.C. Brownson, S.A. Aytur, et al. 2010. that those changes alone may not translate Examination of trends and evidence-based elements in state physical education legislation: a content into behavior change for students and families analysis. J. Sch. Health. 80(7):326-32. at home. Efforts to change PA and PE policies Harris, C., and A. Bradlyn. 2009. West Virginia Healthy in schools must be combined with efforts to Lifestyles Act: Year One Evaluation Report. Morgan- engage families in behavior change for maxi- town, WV: West Virginia University. mum effect and benefit on child health. Health Research Center. 2010. Year Two Evaluation West Virginia Healthy Lifestyles Act of 2005 Execu- tive Summary. West Virginia University, Morgan- References town, West Virginia Ahlport, K.N., L. Linnan, A. Vaughn, K.R. Evenson, Healthy, Hunger-Free Kids Act of 2010 [S. 3307]. www. and D.S. Ward. 2008. Barriers to and facilitators of govtrack.us/congress/billtext.xpd?bill=s111-3307. walking and bicycling to school: Formative results Mein, J., and S. Oseid. 1982. Physical activity in chil- from the non-motorized travel study. Health Educ. dren and adolescents in relation to growth and devel- Behav. 35(2):221-44. opment. Scand. J. Soc. Med. 9(Suppl. 2):121-34. Belansky, E.S., N. Cutforth, E. Delong, et al. 2009. Metos, J., and M.S. Nanney. 2007. The strength of Early impact of the federally mandated Local Well- school wellness policies: One state’s experience. J. ness Policy on physical activity in rural, low-income School Health 77(7):367. Public School Physical Activity Initiatives 21
Molaison, E.F., S. Howie, J. Kolbo, K. Rushing, L. 1220 of 2003 of Arkansas to Combat Childhood Zhang, and M. Hanes. 2011. Comparison of the local Obesity. Little Rock, AR: Fay W. Boozman College wellness policy implementation between 2006 and of Public Health, University of Arkansas for Medi- 2008. J. Child Nutr. Manag. 35(1):9. cal Sciences. Phillips, M., J. Raczynski, J. Walker, Act 1220 Evalua- Probart, C., E. McDonnell, J.E. Weirich, L. Schilling, and tion Team. 2008. Year Four Evaluation: Arkansas V. Fekete. 2008. Statewide assessment of local well - Act 1220 of 2003 to Combat Childhood Obesity. ness policies in Pennsylvania public school districts. Little Rock, AR: Fay W. Boozman College of Public J. Am. Diet. Assoc. 108(9):1497-1502. Health, University of Arkansas for Medical Sciences. Story, M., M.S. Nanney, and M.B. Schwartz. 2009. Phillips M, Raczynski J, Walker J, Act 1220 Evalua- Schools and obesity prevention: creating school tion Team. 2010. Year Six: Evaluation: Act 1220 of environments and policies to promote healthy eating 2003 of Arkansas to Combat Childhood Obesity. and physical activity. Milbank Q. 87(1):71-100. Little Rock, AR: University of Arkansas for Medical Tomporowski, P., C. Davis, P. Miller, and J. Naglieri. Sciences. 2008. Exercise and children’s intelligence, cogni- Phillips, M., J. Raczynski, J. Walker J, Act 1220 tion, and academic achievement. Educ. Psychol. Evaluation Team. 2011. Year Seven: Evaluation: Act Rev. 20:111-31.
CHAPTER 3 Role of Recess and Physical Activity Breaks During the School Day
Antronette K. (Toni) Yancey, MD, MPH Amber T. Porter, BS UCLA Kaiser Permanente Gramercy Research Group Center for Health Equity
Melicia C. Whitt-Glover, PhD Alison Herrmann, PhD Gramercy Research Group UCLA Kaiser Permanente Center for Health Equity
NPAP Tactics and Strategies Used in This Program
Education Sector STRATEGY 2: Develop and implement state and school district policies requiring school accountability for STRATEGY 1: Provide access to and opportunities for high-quality, comprehensive physical activity pro- the quality and quantity of physical education and grams, anchored by physical education, in Pre- physical activity programs. kindergarten through grade 12 educational settings. STRATEGY 3: Develop partnerships with other sectors Ensure that the programs are physically active, in- for the purpose of linking youth with physical activ- clusive, safe, and developmentally and culturally ap- ity opportunities in schools and communities. propriate.
esearch has established the contribution ventions that increase children’s physical activ- Rof regular physical activity to key health ity levels (Gonzalez-Suarez et al. 2009; Naylor outcomes, such as obesity prevention and mus- and McKay 2009). A Cochrane review of school- culoskeletal development, and to educational based physical activity programs showed that outcomes, such as attentiveness, cognitive pro- such interventions have resulted in increased cessing, discipline, and academic performance physical activity, decreased television viewing (USDHHS 2008). However, American children’s time, and improved aerobic capacity and blood physical activity levels have been declining cholesterol levels (Dobbins et al. 2009). during the past several decades (Knuth and Physical activity during the school day has Hallal 2009; Sturm 2005; Sturm 2008) and many traditionally come in the form of recess, a super- children and youth are not active at recom- vised but unstructured time for free play, imagi- mended levels. Young people spend approxi- nation, movement, stress relief, enjoyment, rest, mately half of their waking hours in school and socialization, with demonstrated physical, settings, and recent studies have demonstrated social, emotional, cognitive, and organizational a positive contribution of school-based physical benefits (Beighle 2012; Ramstetter et al. 2010). activity to children’s overall physical activity However, because of an increased emphasis levels and to weight management (Fernandes on standardized testing, time allotted to recess and Sturm 2011; Jackson et al. 2010; Wu et al. during the elementary school day is decreas- 2011). Hence, schools are prime targets for inter- ing (Lee et al. 2007; Pressler 2006; UCLA and
23 24 Yancey, Whitt-Glover, Porter, and Herrmann
tion, 6- to 11-year-olds spend an average of 5.9 hours per day in sedentary behaviors, whereas 12- to 15-year-olds spend 7.8 hours per day in sedentary behaviors (Whitt-Glover et al. 2009). In fact, studies in the emerging field of inac- tivity physiology have demonstrated the adverse consequences of prolonged sitting, independent of failure to achieve recommended levels of moderate to vigorous intensity physical activ- ity (MVPA) (Dunstan et al. 2011; Owen et al. 2010). The sharp decline in physical activity and increase in sedentary behaviors during the ages of transition to adolescence suggest that the period between childhood and adolescence may be a critical time for intervening regard- ing physical activity. This may be an especially important period for children from racial and ethnic minority backgrounds, given data show- ing that teachers whose students were predomi- nantly black or from low-income households reported less time allocated for recess than did teachers of white and more affluent students (Barros et al. 2009). Schwinn© is used by permission from Pacifc Cycle Inc. E5691/NPAP/fig3.1/458514/alw/r1 A number of strategies can be used to increase children’s physical activity levels during recess. These strategies, which are Samuels and Associates 2007). (Time devoted particularly effective in combination, include to physical education is decreasing too, for the providing inexpensive playground equipment same reason; Henley et al. 2007; McKenzie (e.g., plastic hoops, jump ropes, and bean bags), and Kahan 2008). Some schools have banned training recess supervisors to organize or teach traditional vigorous recess activities such as games and interact with students, painting playing tag, climbing monkey bars, and run- playground surfaces with lines for games or ning, because of fear of liability for injury (e.g., murals, and designating playground “activity Bazar 2006), despite case law that makes this zones” (Beighle 2012; Stratton and Leonard unlikely (Spengler et al. 2010). 2002; Taylor et al. 2011; Verstraete et al. 2006). Ridgers and colleagues (2011) observed sig- The private sector is responding to the recess nificant decreases in recess and lunchtime mod- deficit. One notable example is PlayWorks, a erate and vigorous physical activity, with com- nonprofit group that serves 129,000 students in mensurate increases in sedentary time, during 320 schools across the United States by struc- the periods 2001-2006 and 2003-2008; these turing recess using trained adult coaches and changes were magnified in older children. Simi- student coach assistants (Robert Wood Johnson larly, data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES) demonstrated that although approximately half (40-50 percent) of 6- to 11-year-old youth were active at levels that met current Centers for Disease Control and Prevention (CDC) recom- mendations (i.e., more than 60 minutes of at least moderate-intensity physical activity on five or more days per week), only 6 to 11 percent of 12- to 15-year-old youth achieved this level of activity (Whitt-Glover et al. 2009). In addi- Reprinted, by permission, from Playworks.
E5691/NPAP/fig3.2/458515/alw/r1 Role of Recess and Physical Activity Breaks 25
Foundation 2007). Another is the Dannon com- strategy, because recess is seldom an option for pany’s Danimals Rally for Recess campaign, an older students (United States White House Task online contest to encourage schools to resur- Force on Childhood Obesity 2010). Research rect recess, offering prizes for meeting certain has demonstrated improvements in individual benchmarks and lottery drawings to win con- behaviors and health outcomes (e.g., increased struction of a playground. Many corporations MVPA, attenuated excess weight gain, lowered and foundations provide play equipment to blood pressure, increased bone density) as well schools. as organizational benefits (improved academic Despite the role of recess as a venerable performance, longer attention spans, fewer and cherished school institution and recent disciplinary problems) among students par- efforts to increase the amount of energy chil- ticipating in classroom physical activity breaks dren expend during recess (e.g., Morabia and (Barr-Anderson et al. 2011; Murray et al. 2008). Costanza 2009), little rigorous research has Furthermore, classroom physical activity breaks evaluated efforts to stem the erosion of recess. have been shown to improve students’ attention Considerable debate exists about the benefits and behavior, whereas breaks without physi- of free play versus structured play, duration cal activity do not (CDC 2010). An additional and timing of breaks, optimal supervision and benefit of classroom-based physical activity monitoring arrangements, and changing needs interventions is that teachers and other school as children age (Ramstetter et al. 2010; Robert personnel may be engaged as active role models Wood Johnson Foundation 2007). For example, for students (Alexander et al. 2012; Donnelly et a recent study found that permanent school al. 2009; Erwin et al. 2011; Institute of Medicine playground facilities were associated with 2006, 2009; Kibbe et al. 2011; Sibley et al. 2008; children’s physical activity levels, but school Woods 2011). physical activity policies were not. Two clear Take 10! (T10) and Instant Recess (IR) are messages emerging from the sparse literature, examples of school-based physical activity and from practice-based evidence, are that break interventions with demonstrated suc- recess should be considered children’s personal cess in increasing students’ physical activity time and should not be withheld for academic levels and improving academic engagement. or punitive reasons and that physical activity In contrast to recess or physical education (e.g., running, calisthenics) should not be used class, in which students are required to exit as a punishment (Ramstetter et al. 2010) the classroom to engage in physical activity, these interventions bring physical activity into the classroom in order to increase children’s Program Description physical activity during the school day. The Physical activity breaks, opportunities to incor- two programs take different approaches: T10 porate physical activity into the school day, incorporates brief bouts of physical activity can supplement the levels of activity obtained into students’ academic lessons, whereas IR is through recess and physical education classes intended as a mental respite for students and (Barr-Anderson et al. 2011; Katz et al. 2010; teachers. The programs are similar in that both Trost 2007; Trost, Fees, and Dzewaltowski 2008; align with a number of the Education Sector Weeks et al. 2008). Unlike recess, a topic on strategies endorsed by the National Physical which research has been scarce, physical activ- Activity Plan (NPAP). This chapter provides a ity breaks have been the subject of a number review of T10 and IR, including an overview of of recent studies. These breaks, which incorpo- how they relate to those NPAP strategies. rate short, structured, group physical activities into the school routine, are an environmental Take 10! (T10) intervention that requires minimal upfront or Introduced in 1999, T10 is a school-based pro- ongoing costs and offers ready exportability gram that has demonstrated the feasibility and cultural adaptability. The White House and utility of using 10-minute physical activ- Childhood Obesity Task Force Report identi- ity breaks in the elementary school classroom fied activity breaks as a key secondary school setting. Studies have shown that these breaks 26 Yancey, Whitt-Glover, Porter, and Herrmann engage students in exercise of sufficient reading, math, spelling, and composition scores. intensity and duration to count toward CDC- In the intervention schools that averaged more recommended levels: for example, average MET than 75 minutes of active lessons weekly, stu- levels of 5 to 7 for first, third, and fifth graders, dents gained less weight than those in control with commensurate caloric expenditures of 27 schools. to 36 calories and step counts of 600 to 1,400 per 10-minute session (Kibbe et al. 2011; Lloyd Instant Recess (IR) et al. 2005; Stewart et al. 2004). (One MET IR, previously known as Lift Off!, consists of is the metabolic equivalent equal to 3.5 mil- 10-minute themed physical activity breaks, liliters of oxygen consumed per kilogram and usually performed to music, with simple move- per minute.) The breaks also improve on-task ments based on sports or ethnic dance tradi- time, particularly in students who are easily tions. IR is scientifically designed to engage distracted (Mahar et al. 2006; Mahar 2011). With major muscle groups, maximizing energy its grade-level targeted curriculum, T10 provides expenditure, enjoyment, and engagement an example of Strategy 1 of the Education Sector of individuals of varying ability levels while of the NPAP: Provide access to and opportunities minimizing perceived exertion and injury risk. for high-quality, comprehensive physical activity IR began as a worksite wellness project of the programs, anchored by physical education, in Chronic Disease Prevention division of the Los prekindergarten through grade 12 educational Angeles County Department of Health Services settings. Ensure that the programs are physically in 1999 and expanded as a partnership between active, inclusive, safe, and developmentally and state and local health agencies, universities, culturally appropriate. foundations, corporations, and nonprofit groups Whereas T10 emphasizes being active while (Yancey 2010; Yancey et al. 2004a, 2004b, 2006). learning (Kibbe et al. 2011), Physical Activ- Involvement with professional sports teams in ity Across the Curriculum (PAAC), a federally 2006 led to the adaptation of IR for the school funded study of a variation of T10 that is being setting. In contrast to T10, in which the onus conducted at the University of Kansas, focuses generally is on teachers to determine how best on making physical activity integral to the lesson to incorporate activity into their lesson plans (DuBose et al. 2008). Research findings dem- and to lead the physical activities themselves, onstrate that PAAC engaged 60 to 80 percent IR is an extracurricular turnkey or “plug and of elementary school non–physical education play” intervention that is usually technology teachers in conducting T10 breaks in 24 low- to mediated (Yancey et al. 2009). IR breaks may moderate-resource public schools in three east- be distributed as DVDs or CDs, streamed from ern Kansas cities (Donnelly et al. 2009; Honas et the Internet, or uploaded as electronic files to al. 2008). Study staff provided teacher training in district servers accessed by teachers through a six-hour, off-site in-service session at the begin- intranet “smart boards” or closed-circuit TV. ning of each school year. The gradual increase in the number of teachers engaged each year and the number of minutes provided reflected a Linkage to the National progressive cultural norm change (an average of Physical Activity Plan 70 minutes a week of activity was offered, and nearly 50 percent of teachers achieved the goal Now in its 13th year, IR includes a library of of 90-100 minutes a week after two years). more than 50 CDs and DVDs, with different PAAC increased children’s physical activity target audiences from preschoolers to seniors; levels, in school and outside of school and on topics include American Indian powwow, Latin both weekdays and weekend days, suggesting salsa, cumbia, reggae, hip hop, and line and that children do not offset increases in school- African dance, along with basketball, baseball, based physical activity with decreases in out- football, boxing, and soccer moves. The physical of-school physical activity. PAAC also improved activity breaks are in keeping with the Educa- Role of Recess and Physical Activity Breaks 27 tion Sector strategies of the NPAP, in that breaks Lessons Learned are designed to be safe, inclusive, and develop- mentally and culturally appropriate (Strategy Through efforts to promote physical activity 1) and represent successful partnerships with breaks in schools, researchers and practitioners other sectors (e.g., professional basketball and who use activity break programs have identified baseball teams) (Strategy 3). Funded in part by important lessons that are informing dissemina- the California state health department’s USDA- tion and implementation efforts: funded Network for a Healthy California, the program has been disseminated to thousands • Support from key decision makers, includ- of schools. ing school administrators and faculty lead- Consistent with Education Sector Strategy 2, ers, is crucial to the acceptance of activity Develop and implement state and school district breaks during the school day. policies requiring school accountability for the • Effective teacher training is important. quality and quantity of physical education and Teachers who understood the instructions physical activity programs, a randomized con- for activity breaks and felt comfortable trolled trial of policy implementation, funded and prepared to lead breaks were more by the Robert Wood Johnson Foundation, likely to implement breaks than were was conducted in eight elementary schools in teachers who were not comfortable with Winston-Salem/Forsyth County, North Carolina. the content. Teacher enthusiasm influ- The study engaged high school athletes in peer ences student enthusiasm, and conversely, modeling for younger students and encour- reluctance feeds reluctance—the more aged students to develop their own breaks, for reluctant teachers are to implement exer- example, Got Moves? contests. This one-year cise breaks, the more reluctant students evaluation, which used environmental audits are to participate, which then exacerbates in a sample of classrooms, demonstrated that teacher reluctance. A T10 study found IR not only increased activity minutes during that when teachers were active with the the school day but also improved on-task time students, student physical activity levels (Whitt-Glover et al. 2011). Because of the ele- were significantly higher (Donnelly et al. mentary school findings, the school superinten- 2009). A study of IR found an association dent mandated daily IR breaks in all 16 district between teacher engagement and activity middle schools (N = 12,000 students) during levels and students’ MVPA levels during an eight-week pilot test of the impact of IR on breaks (Alexander et al. 2012). the NC Healthy Active Children Policy (HSP-S- 000) (Alexander et al. 2012). An online student • Permitting teachers to space or vary the survey (N = 1,553) found that 77 percent had timing of activity breaks throughout the participated, 56 percent participated daily, and school day may allay concerns or resent- 73 percent participated first thing in the morn- ment over having classroom time inter- ing. Environmental audits of 75 classrooms rupted or controlled by administrators. demonstrated that IR breaks delivered a mean of • Exercise breaks during the first and last 10 8.0 ± 3.4 minutes of physical activity each day, minutes of the school day could lead to including 3.9 ± 3.0 minutes of MVPA. How- lower participation in middle schools. In ever, on-task time was not affected in middle qualitative evaluations of IR, adolescents school students. A study in six Los Angeles were reluctant to exercise at the beginning Unified School District elementary schools (N of the school day because they did not = 647 students across 68 classrooms) showed want to ruin their hairstyles or clothing; a 1,910-step increase in students’ daily activity students were reluctant to participate at levels after four to six weeks (Woods 2011). In the end of the last period because they this case, steps were measured across the entire were ready for the school day to end school day, not just during the breaks. (Alexander et al. 2012). 28 Yancey, Whitt-Glover, Porter, and Herrmann
• Including students in the development of cine annual conference, San Francisco, CA, May activity break content may be important 29, 2012. for acceptability and engagement, particu- Barr-Anderson, D., M. AuYoung, M. Whitt-Glover, B. larly among older children and adoles- Glenn, and A. Yancey. 2011. Structural integration cents. In the case of IR, this has led to the of brief bouts of physical activity into organizational creation of faster-paced, less-instructional routine: A systematic review of the literature. Am. activity breaks, similar to dance videos. J. Prev. Med. 40:76-93. • Data on the organizational benefits of Barros, R., E. Silver, and R. Stein. 2009. School recess activity breaks to schools (e.g., better and group classroom behavior. Pediatrics. 123:431-6. discipline and academic performance) Bazar, E. 2006, June 27. Not it! More schools ban are more persuasive than exhortations to games at recess. USA Today. Available at: http:// enhance student health. usatoday30.usatoday.com/news/health/2006-06-26- recess-bans_x.htm. Retrieved August 1, 2013. Beighle, A. 2012, January. Increasing Physical Activ- Summary ity Through Recess. Research Brief. Active Living Research Program. Princeton, NJ: Robert Wood Classroom-based physical activity breaks are a Johnson Foundation. promising means of increasing children’s physi- Centers for Disease Control and Prevention. 2010. The cal activity levels both inside and outside of the association between school-based physical activity, classroom. Evidence suggests that these breaks including physical education, and academic perfor- may also convey added benefits in the form of mance. Atlanta, GA: U.S. Department of Health and enhanced educational outcomes. Human Services. This chapter provides examples of two types Dobbins, M., K. De Corby, P. Robeson, H. Husson, of physical activity breaks that have been and D. Tirilis. 2009. School-based physical activity used successfully in classroom settings. One programs for promoting physical activity and fitness approach (T10) directly incorporates physical in children and adolescents aged 6-18. Cochrane Database of Systematic Reviews , Issue 1. Art. No.: activity into academic lessons, which may be CD007651. DOI: 10.1002/14651858.CD007651. appealing in selling the strategy to administra- tors desperate to maintain instructional min- Donnelly, J.E., J.L. Greene, C.A. Gibson, et al. 2009. Physical Activity Across the Curriculum (PAAC): utes. The other approach (IR) promotes cultur- A randomized controlled trial to promote physical ally relevant physical activity breaks as a brief activity and diminish overweight and obesity in mental break and may not be directly related to elementary school children. Prev. Med. 49:336-41. classroom content, which enhances the feasibil- DuBose, K.D., M.S. Mayo, C.A. Gibson, et al. 2008. ity of implementation in low-resource schools Physical activity across the curriculum (PAAC): with overcrowded classrooms and fewer teacher Rationale and design. Contemp. Clin. Trials 29:83- specialists. Both approaches have merits and 93. are in keeping with a number of the Education Dunstan D.W., A.A. Thorp, and G.N. Healy. 2011. Pro- Sector strategies outlined in the NPAP. Given the longed sitting: Is it a distinct coronary heart disease demonstrated, independent successes of each risk factor? Curr. Opin. Cardiol. 26:412-9. approach, both should be included in the menu Erwin, H., A. Beighle, C. Morgain, and M. Noland. of intervention offerings that increase physical 2011. Effect of a low-cost, teacher-directed classroom activity among school children. intervention on elementary students’ physical activ- ity. J. Sch. Health 81:455-61. Fernandes, M.M., and R. Sturm. 2011. The role of school References physical activity programs in child body mass trajec- Alexander, R., M.C. Whitt-Glover, S. Ham, N.P. Sutton, tory. J. Phys. Act. Health 8(2):174-81. J.M. Belnap, and T. Yancey. 2012. Impact of physical Gonzalez-Suarez, C., A. Worley, K. Grimmer-Somers, activity breaks on Healthy Active Children Policy and V. Dones. 2009. School-based interventions on (HSP-S-000): Adherence in middle schools. Poster childhood obesity: A meta-analysis. Am. J. Prev. presented at the American College of Sports Medi- Med. 37:418-27. Role of Recess and Physical Activity Breaks 29
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Sturm, R. 2008. Stemming the global obesity epidemic: cal activity during the school day. Prog. Community What can we learn from data about social and eco- Health Partnersh. 5(3):289-97. nomic trends? Public Health 122(8):739-46. Whitt-Glover, M.C., W.C. Taylor, M.F. Floyd, M.M. Yore, Taylor, R.W., V.L. Farmer, S.L. Cameron, K. Meredith- A.K. Yancey, and C.E. Matthews. 2009. Disparities Jones, S.M. Williams, and J.I. Mann. 2011. School in physical activity and sedentary behaviors among playgrounds and physical activity policies as predic- US children and adolescents: Prevalence, correlates, tors of school and home time activity. Int. J. Behav. and intervention implications. J. Public Health Pol. Nutr. Phys. Act. 8:38. 3:S309-34. Trost, S. 2007. Active Education. Oakland, CA: Active Woods, D. 2011, May. Implementation an evaluation Living Research, The California Endowment. of Instant Recess® in elementary school children Trost, S.G., B. Fees, and D. Dzewaltowski. 2008. Fea- (Dissertation). University of California Los Angeles. sibility and efficacy of a “move and learn” physical Wu, S., D. Cohen, Y. Shi, M. Pearson, and R. Sturm. activity curriculum in preschool children. J. Phys. 2011. Economic analysis of physical activity interven- Act. Health 5(1):88-103. tions. Am. J. Prev. Med. 40(2):149-58. UCLA and Samuels and Associates. 2007. Failing Fit- Yancey, A.K., W.J. McCarthy, W. Taylor, A.M. Raines, ness. Oakland, CA: The California Endowment. C. Gewa, M. Weber, and J.E. Fielding. 2004b. The United States White House Task Force on Childhood Los Angeles Lift Off: A sociocultural environmental Obesity. 2010. Solving the problem of childhood change intervention to increase workplace physical obesity within a generation. White House Task activity. Prev. Med. 38;848-56. Force on Childhood Obesity Report to the President. Yancey, A.K., L.B. Lewis, D.C. Sloane, J.G. Guinyard, Washington, DC: Executive Office of the President A.L. Diamant, L.M. Nascimento, W.J. McCarthy, and of the United States. the REACH Coalition. 2004a. Leading by example: U. S. Department of Health and Human Services. 2008. Process evaluation of a local health department- 2008 physical activity guidelines for Americans: be community collaboration to change organizational active, healthy, and happy (ODPHP Publication No. practice to incorporate physical activity. J Public U0036). Retrieved August 1, 2013 from www.health. Health Manag. Prac. 10(2):116-23. gov/paguidelines/pdf/paguide.pdf. Yancey, A.K., L.B. Lewis, J.J. Guinyard, D.C. Sloan, Verstraete, S., G. Cardon, D. DeClercq, et al. 2006. L.M. Nascimento, L. Galloway-Gilliam, A. Diamant, Increasing children’s physical activity levels during and W.J. McCarthy. 2006. Putting promotion into recess periods in elementary schools: The effects of practice: The African Americans Building a Legacy providing game equipment. Eur. J. Public Health of Health organizational wellness program. Health 16:415-9. Promot. Prac. 7(3):233S-246S. Weeks, B.K., C.M. Young, and B.R. Beck. 2008. Eight Yancey, A., D. Winfield, J. Larsen, et al. 2009. “Live, months of regular in-school jumping improves indi- learn and play”: Building strategic alliances between ces of bone strength in adolescent boys and girls: The professional sports and public health. Prev. Med. POWER PE study. J. Bone Miner. Res. 23:1002-11. 49:322-5. Whitt-Glover, M., S.A. Ham, and A. Yancey. 2011. Yancey, T. 2010. Instant Recess: Building a Fit Nation Instant Recess®: A practical tool for increasing physi- 10 Minutes at a Time. Berkeley, CA, UC Press. CHAPTER 4 Physical Activity in Early Childhood Centers New York City as a Case Study
Cathy Nonas, MS, RD Lillian Dunn, MPH NYC Department of Health NYC Department of Health and Mental Hygiene and Mental Hygiene
Rhonda Walsh, MPH NYC Department of Health and Mental Hygiene
NPAP Tactics and Strategies Used in This Program Education Sector STRATEGY 2: Develop and implement state and school district policies requiring school accountability for STRATEGY 1: Provide access to and opportunities for high-quality, comprehensive physical activity pro- the quality and quantity of physical education and grams, anchored by physical education, in Pre-kin- physical activity programs. dergarten through grade 12 educational settings. STRATEGY 4: Ensure that early childhood education Ensure that the programs are physically active, settings for children ages 0 to 5 years promote and inclusive, safe, and developmentally and culturally facilitate physical activity. appropriate.
ver the last 30 to 40 years, childhood Program Description Oobesity has increased to epidemic propor- tions, causing global concern for the increased The goal of the DOHMH regulations on physi- health risks it confers on our children. Obesity cal activity was to establish minimum amounts in children is associated with type 2 diabetes, of time children were active in the group child nonalcoholic fatty liver disease, high blood pres- care setting. sure, and dyslipidemia, among other risks. In 2006, the New York City Department of Health Establishing Regulations for Early and Mental Hygiene (DOHMH) published a study (Young et al. 2006) examining obesity Child Care rates in early childhood group centers in New Group child care centers were a natural target for York City. Shockingly, more than 42 percent of obesity interventions. National U.S. data from the more than 16,000 young children enrolled 2005 show that approximately 69 percent of in the study were overweight or obese. This four-year-olds spend time in child care facilities. chapter describes how the DOHMH responded, In New York City, more than 130,000 children specifcally highlighting its work to increase ages three to five years spend at least some of physical activity in early childhood through their time in group child care centers licensed by regulation and technical support. the DOHMH. These centers are visited regularly
31 32 Nonas, Dunn, and Walsh by DOHMH sanitarians and early childhood was sent to all early child care centers that the education consultants, who could be engaged changes affected. to support efforts to improve the health of these Although implementation of each regulation children. The New York City Charter empowers change required some education on the part of the New York Board of Health to amend and child care center staff, the DOHMH believed create regulations in the city’s health code that that the regulation on physical activity was pertain to the health of all New Yorkers. In other the most challenging for centers to implement. words, when it comes to the city’s health, the This rule required all centers to provide their Board of Health has the rule of law within the full-day three- to five-year-old classrooms with areas over which its jurisdiction extends, includ- at least 60 minutes of physical activity per ing child care centers. The DOHMH proposes day, 30 minutes of which had to be structured regulations to the Board of Health, and after a and led by teachers. The city council provided public comment period, the board then votes on funding to the DOHMH to help support centers’ whether to approve or reject those regulations as efforts to increase structured physical activity law. The laws are enforced by the DOHMH. All of time, particularly in the neighborhoods with these factors combined to make policy changes the highest rates of poverty and obesity-related an attractive—and potentially very powerful— disease. DOHMH released a request for proposal intervention to address obesity. to identify a curriculum with which to train staff In 2006, the DOHMH proposed new regula- working in early childhood centers on ways tions to the Board of Health that established a to provide physical activity in the classroom. minimum amount of time during which group Shortly thereafter, the city council significantly child care centers were required to provide increased funding to enable the program to physical activity, restricted sugary drinks from expand citywide. being served by centers, limited the amount of 100 percent juice that centers could provide to Training and Technical Assistance children, and required water to be made avail- to Support Compliance able to children at all times. In June 2006 the Board of Health modified the health code to SPARK! (Sports, Play, and Active Recreation for include these obesity-focused regulations. The Kids!) won the contract and DOHMH provided new regulations took effect on January 1, 2007. child care center staff with a one-day workshop on a modified SPARK!, a structured physical Implementing Regulations activity curriculum. Attendees received profes- sional development credit for the workshop After the modifications to the health code were and were provided with a manual that detailed approved, the DOHMH took several actions to structured physical activity lessons and an ensure that child care center directors were equipment kit that contained spot markers, informed of and supported through the changes. bean bags, scarves, and two music CDs (all of First, the DOHMH provided training regard- which were used in lessons demonstrated at the ing the new regulations for all internal staff training). The day included a number of hours members who regularly visited the centers. of practicing lessons with the help of a trainer. In These staff members were encouraged to talk addition, in three targeted neighborhoods where to center directors about the goals of the new rates of obesity were highest, on-site follow-up rules, the exact language of each statute, and support was provided to teachers after training. the importance of physical activity and proper The SPARK! curriculum had many strengths: nutrition in early childhood. Second, the Bureau Its lessons encouraged all children in the class- of Child Care (housed within the DOHMH) held room to participate in movement, it emphasized six open meetings for center directors during noncompetitive play, and it taught teachers how which the new provisions were discussed in to manage a classroom through physical activ- detail. Third, a letter announcing the changes ity. It also stressed the importance of teachers’ Physical Activity in Early Childhood Centers 33 role modeling of healthy behaviors for their For example, one yoga lesson called Nature students. Walk encouraged children to do yoga by taking However, there were a few drawbacks for them on an imaginary walk through nature and New York City. Many of the lessons in the asking them to hold their bodies in yoga posi- manual required more space than most child tions that resemble mountains, butterflies, and care centers could access. Some lessons used grass in the wind. Because teachers seemed to equipment that the Physical Activity Pro- use the same lessons over and over, the Move- gram did not provide because those materials to-Improve manual was shorter and included required large amounts of classroom or storage just 30 lessons. When possible, the program space (e.g., parachutes, large balls). Finally, the included music to match the exercises. Pro- SPARK! manual was so large, including more gram staff created equipment kits to match the than 100 lessons, that it intimidated many child lessons in the manual and included two CDs, care center staff. one with songs that guided children through Additionally, trainings and on-site support physical activities and another that provided continued to shed light on how physical activ- background music for lessons in the manual. ity was actually implemented in the NYC group Demand for physical activity training among child care context. Program staff noticed that child care centers has always been high. Staff teachers were modifying lessons to make them generally enjoy the experience of the work- work better for their classrooms. For example, shop and often declare it to be the best profes- teachers created stories that included the physi- sional development workshop they have ever cal activity lessons so that children could relate attended. Since the program began in 2004, better to certain kinds of movement. Teachers more than 15,000 child care center staff mem- tended to repeat the same lessons over and over, bers from more than 1,200 centers across New generally leading children in no more than 20 York City have been trained in either SPARK! activities all year long. Finally, teachers relied or Move-to-Improve. heavily on the music that was provided. Although the trainings are currently only In 2009, contractual complications required funded for elementary school teachers, pro- the DOHMH to look for a new physical activ- gram challenges remained among early child- ity curriculum. The Physical Activity Program care staff, despite all of the efforts to hone the investigated other existing curricula but did experience for participants. Because center not find an adequate replacement that was directors did not always know who could attend focused on early childhood, provided small workshops until the day of training, equip- classroom-based activities, and was offered by ment kits were not sent to centers until after a nonprofit organization (a funding require- a workshop training was completed. Delivery ment). Therefore, in 2009, the program leaders of these kits could take a month or more. In decided to create a new curriculum, building addition, the staff at child care centers tends to on the knowledge gathered from five years of be very transient. Ongoing training, therefore, training early childhood staff. In this way, the is required to make sure that new staff mem- DOHMH was able to create a program that was bers learn how to provide structured activity less expensive to administer and more tailored for their children. Because of limited budgets, to its needs. DOHMH could only provide a one-day training Learning from its experience, the Physical to participants, despite requests from child care Activity Program created the Move-to-Improve center staff for onsite follow-up and a second Early Childhood Program. Activities in this full-day workshop. Finally, budget constraints curriculum were designed for the small spaces made it impossible to provide the workshop typical of classrooms in New York City. Each or manuals in other languages. Although most lesson was embedded within a story, so that center staff members are conversant in English, children were not simply moving but were many would benefit from materials in Spanish engaging in physical activity as an experience. or other languages. 34 Nonas, Dunn, and Walsh
Program Evaluation activity data. Results of the RWJ-funded evalu- ation will be published elsewhere. Traditionally, child care centers have not been Programmatically, observational data have cited for violations in physical activity regula- proven the most useful for New York City. tions. When DOHMH staff members conduct To date, the DOHMH has used observational site visits, they review each classroom’s daily data to assess the impact of Move-to-Improve schedule (when available), discuss the impor- training in other age groups. These evaluations tance of physical activity with center staff, and provided qualitative data on how structured determine whether adequate time is allotted to physical activity actually happens in the class- physical activity. However, the regulatory staff room setting and resulted in a significant differ- members do not have time to observe every ence between trained and untrained classrooms classroom in every center. All of these factors in number of minutes dedicated to physical make it difficult to determine whether each activity. Although an observational study in classroom is providing the required amount early childcare centers was begun, it was not of physical activity. Cited violations, then, are completed due to budget cuts. not a sufficient way of assessing impact of the regulations or training on the quantity of physi- Linkage to the National cal activity children receive in the group child care setting. Physical Activity Plan However, some data exist to suggest that train- The regulations and technical support address ing in SPARK! or Move-to-Improve improves a three strategies of the Education Sector of the center’s capacity to comply with health code National Physical Activity Plan: regulations on physical activity. Because of funding constraints, evaluations of the Physical • Strategies 1 and 2 call for states and school Activity Program in early childhood have been districts to develop policies that require limited to self-reported data. In the 2006-2007 comprehensive physical activity programs school year, the program conducted pre- and and include mechanisms for monitoring postprogram surveys with trained child care implementation. DOHMH, the agency center staff to examine the impact of training on that oversees child care centers in New structured physical activity. Teachers in full-day York City, requested, implemented, and is classrooms stated that the number of minutes monitoring regulations that require centers of structured physical activity they provided to provide young children with 60 minutes rose from 78 minutes per week before training of physical activity per day. to 100 minutes per week after training. Teachers • Strategy 4 entails ensuring that early child- used the SPARK! curriculum for a median of hood education settings for children ages 0 75 minutes per week. This evaluation suggests to 5 years promote and facilitate physical that teacher training significantly increases activity. The DOHMH health care regula- activity in early childhood classrooms but also tions require all city-regulated child care suggests that centers do not provide enough centers to provide regular physical activity structured physical activity time. These results for all children 12 months and older, but are limited, however, by the self-reported nature include structured physical activity for of the evaluation. three- to five-year-old children. In 2008, the Robert Wood Johnson Founda- tion (RWJ) and the Centers for Disease Control and Prevention began an evaluation of the Evidence Base Used New York City regulations governing group During Program Development child care centers, including those on physical activity. This evaluation collected self-reported, The National Association for Sport and Physical observed, and accelerometry-based physical Education (NASPE) guidelines for early child- Physical Activity in Early Childhood Centers 35 hood state that toddlers should engage in at onstrates ways to manage a classroom through least 60 minutes of unstructured activity daily these activities is pragmatic and necessary. and 30 minutes of structured activity (NASPE Fourth, technical assistance does not have 2013). Recommendations released by the Insti- to be expensive. Lessons should be short, and tute of Medicine (IOM) in June 2011 state that CDs and a manual are the most important parts child care regulatory bodies should require of the training. Currently, the Move to Improve centers to provide opportunities for physical curriculum can be downloaded for free at the activity throughout the day (IOM 2011). DOHMH’s website. Fifth, evaluation of physical activity can be very challenging. Observational data are cred- Populations Best Served ible but expensive to gather. If possible, govern- by the Program ment agencies should provide evaluation funds when they enact new policies to ensure that the The policy changes and associated technical evaluation will take place. support created by the DOHMH are appropriate Ultimately, the goals of DOHMH’s changes for children two to five years old. to the health code and the technical assistance directed to support implementation have been well received. Informal feedback from center Lessons Learned directors and staff indicates that regulations concerning physical activity tend to be the most The DOHMH has learned a great deal about challenging to implement. Ongoing support of implementing regulations on physical activ- these efforts may be necessary to ensure that ity. First, having a policy in place to establish rules governing physical activity time are trans- a minimum amount of physical activity is an lated into action in child care centers. important foundation from which to begin working with child care centers. Although everyone agrees that physical activity is impor- Tips for tant for children, having an established policy Working Across Sectors elevates the discussion: Compliance with this Although DOHMH played the lead role in law becomes a part of each center’s legal implementing these regulations and associated requirements and places physical activity on an technical support, the NYC Administration for equal level of importance as protections against Child Services was a key partner in promoting infectious diseases through immunizations. compliance among group child care centers and Second, enforcing policies can be very chal- encouraging participation in the physical activ- lenging without requirements for centers to post ity trainings. Partnering with that organization daily classroom schedules. Although posting helped ensure that centers were aware of the physical activity schedules does not promise regulations and DOHMH technical support. compliance, it is one way to begin planning for physical activity in each classroom. This would also make it easier for inspectors to visit centers Additional to see the activities underway. Third, technical assistance for physical activ- Reading and Resources ity is welcomed by most child care centers. Additional reading on the regulations affecting Nobody understands the need for children to group child care centers in New York City, as move better than do the people who work with well as DOHMH’s policy guide recommending young children all day long. However, many additional policies that promote physical activ- staff members are daunted by or uncomfort- ity and healthy eating, can be found at www. able with leading activities in a room full of nyc.gov/html/doh/html/living/phys-move. three-year-olds. Technical assistance that dem- shtml. 36 Nonas, Dunn, and Walsh
National Association for Sport and Physical Education. References 2013. Active Start: A statement of physical activity Dunn L.L., J.A. Venturanza, R.J. Walsh, and C.A. guidelines for children from birth to age 5. 2nd ed. Nonas. 2012. An Observational Evaluation of Move- www.aahperd.org/naspe/standards/nationalGuide- To-Improve, a Classroom-Based Physical Activity lines/ActiveStart.cfm. Program, New York City Schools, 2010. Prev Chronic Young C.R., P. Peretz, R. Jaslow, S. Chamany, D. Berger, Dis 9:120072. et al. 2006. Obesity in Early Childhood: More Than Institute of Medicine of the National Academies. 2011. 40% of Head Start Children in NYC Are Overweight Early Childhood Obesity Prevention Policies: Goals, or Obese. NYC Vital Signs 5(2): 1-2. Recommendations and Potential Actions. Washing- ton, DC: The National Academic Press. CHAPTER 5 After-School Programs and Physical Activity
Submitted by the Afterschool Alliance (www.afterschoolalliance.org)
NPAP Tactics and Strategies Used in This Program Education Sector STRATEGY 5: Provide access to and opportunities for physical activity before and after school.
ears ago, physical education—PE—was a After-school programs that focus on posi- Yroutine part of American schoolchildren’s tive physical outcomes, in addition to positive day. But in the nation’s efforts to focus class- academic outcomes, are an invaluable resource room instruction on topics that standardized for alleviating the health crisis facing American tests measure, physical education has received youth. These programs allow schools and com- less time and attention. Until recently, physical munity organizations to encourage involvement education classes in schools could be relied on in physical activity, as well as to encourage to engage children in a half hour or more of sound nutrition. With 8.4 million children physical exercise or health instruction each day. participating in after-school programs and a But the increasing focus on test scores in the staggering 18.5 million more who would likely nation’s public schools has rendered physical enroll given the opportunity, after-school pro- education a luxury in many school districts and grams have the potential to affect the fitness of a has trimmed or reduced recess time in some large portion of the nation’s youth (Afterschool elementary schools (Fletcher 2010). One study Alliance 2009). found that in 2006, only 7.9 percent of middle After-school programs can be a particularly schools provided students with daily physical valuable physical activity resource because education (Lee et al. 2007). they Although schools have deemphasized physi- • serve children most at risk for being over- cal activity and fitness, there is little evidence weight, including minorities and those that children are compensating in other settings. from lower socioeconomic strata; According to the Centers for Disease Control and Prevention, 61.5 percent of children do not • operate during a time of the day when participate in any organized physical activity many children would otherwise be sed- outside of school hours (Centers for Disease entary and not likely to participate in Control and Prevention 2002). Thus, after- physical activity; school hours have become a focus of efforts • provide staff members who understand to ensure the healthy development of children children’s needs and can promote active and youth. It is a challenge that the nation’s lifestyles and healthy eating (Afterschool after-school programs have embraced eagerly. Investments Project 2006); and
37 38 Afterschool Alliance
• provide an opportunity for young people sequential, safe, inclusive, developmen- to interact with role models who display tally appropriate, and success oriented. the habit of regular physical activity. The standards also offer a series of best prac- The Afterschool Alliance has established tices for staff training, social supports intended a goal of promoting physical activity before to encourage children to enjoy and participate school, after school, and during the summer in physical activity, program supports, and envi- (collectively known as after-school). ronmental supports related to physical fitness equipment and facilities. Program Description A number of national organizations are work- Linkage to the National ing to help after-school programs build physical Physical Activity Plan activity and fitness into their daily offerings. One such effort, a set of health-focused stan- After-school programs support a key strategy of dards for after-school programs, is a result of the the Education Sector of the National Physical Healthy Out-of-School Time (HOST) coalition, Activity Plan: led by the National Institute on Out-of-School Strategy 5: Provide access to and opportunities Time at the Wellesley Centers for Women, the for physical activity before and after school. For University of Massachusetts College of Nurs- many children, after-school programs provide ing and Health Sciences, and the YMCA. With the best (and often only) opportunity to partici- funding from the Robert Wood Johnson Foun- pate in fun, health-promoting physical activity dation, HOST developed practical standards for after school. Increasingly, after-school organiza- healthy eating and physical activity in programs tions and providers are working to ensure that held outside of school time. The standards children who attend after-school programs have subsequently were adopted by the National opportunities every day to enjoy physical activi- AfterSchool Association (2011). ties and develop skills that promote lifelong The standards focus on evidence-based, physical activity. practical steps aimed at fostering the best pos- sible nutrition and physical activity outcomes Evidence Base Used During for K-12 children in programs held outside of school hours. The best practices Program Development • dedicate at least 20 percent or at least 30 The research to date indicates that programs minutes of morning or after-school pro- that take advantage of out-of-school-time hours gram time to physical activity (60 minutes to create opportunities for children to enjoy for a full-day program); physical activity and learn about healthy life- • provide physical activities in which stu- styles can improve student health outcomes. dents are moderately to vigorously active • A study that measured the health and for at least 50 percent of the physical social benefits of after-school programs activity time; found that after investigators controlled for • ensure that daily physical activity time baseline obesity, poverty status, and race includes aerobic activities and age-appro- and ethnicity, the prevalence of obesity priate muscle- and bone-strengthening was significantly lower for after-school activities; program participants (21 percent) com- • offer noncompetitive activities; and pared with nonparticipants (33 percent) • conduct physical activities that are inte- (Mahoney and Heather 2005). grated with enrichment, academic, or • A report by the U.S. Department of Edu- recreation content and are goal-driven, cation found that 10- to 16-year-olds who After-School Programs and Physical Activity 39
have a relationship with a mentor are less negatively affect their health. As a result, they likely to engage in unhealthy behaviors. can benefit greatly from the increased oppor- Forty-six percent are less likely to start tunities for physical activity that after-school using drugs and 27 percent are less likely programs can provide. Accordingly, after-school to start drinking alcohol (Riley et al. 2000). programs across the United States offer youth a • Active adolescents are more likely than mix of academic and physical enrichment that their sedentary peers to use contraception promotes positive physical, emotional, and during sexual intercourse and to delay the social development. initiation of first sexual intercourse (Miller et al. 1998). Lessons Learned • A recent evaluation of after-school pro- grams in California found that youth After-school programs offer countless health reached federally recommended levels of benefits, but efforts to include a focus on fit- moderate to vigorous physical activity for ness and well-being often face challenges. an average of 24.4 minutes daily when However, programs across the United States are they participated in structured activities. implementing innovative strategies that allow By contrast, students participated in only them to include health and wellness activities 13 minutes through unstructured activities in after-school offerings. Following are some (CANFit 2009). examples of the challenges programs face and • A study reported in the Journal of Ado- the solutions they have developed: lescence found that youth whose summer arrangements involved regular participa- • Funding is a universal concern for after- tion in organized activities showed signifi- school programs, and inadequate funding cantly lower risk for obesity than did other for staffing, professional development, youth. This was most evident during early and equipment is a particular problem for adolescence—the middle school years. physical activity efforts. Youth whose regular summer arrangement The San Antonio Youth Centers (SAYC) was primarily parent care without orga- are nine after-school programs in Texas nized activity participation showed the that address the funding challenge by greatest risk for obesity (Mahoney 2011). using funds from the federal- and state- supported Carol M. White Physical Edu- cation Program to implement a physical Population Best Served education and youth development curricu- by the Program lum. The centers seek to promote healthy lifestyles, improve academic achievement, After-school programs often serve children and foster and develop positive youth self- most at risk for being overweight, including esteem. Middle school students at SAYC minorities and children of low socioeconomic participate in at least 45 minutes of struc- status. After-school programming is particularly tured daily physical activities that are both important to the development of elementary fun and vigorous, including karate, swim- and middle school children, who are at criti- ming, cheerleading, and rock-climbing. cal points in their physical, social, and emo- Additionally, the centers educate youth tional development. Elementary students need about the dangers of smoking, alcohol, opportunities to develop the habits of physical and drugs and promote healthy decision activity and to hear and absorb messages about making. The programs offer weekly family its importance. Middle school students are “boot camp” sessions to cultivate parental fueled by a desire to find a place to belong and involvement and help ensure that healthy therefore are at risk of making decisions that living extends into the home. 40 Afterschool Alliance
• Physical activity is not always perceived the program offers 90 minutes of weekly as an essential need, particularly when mentoring opportunities for students at concerns about test scores pit physical two middle schools and a host of other activity and academics in competition for beneficial health education activities. after-school time. • High staff turnover limits the ability of Children participating in the Ed Snider programs to train staff to provide high- Youth Hockey Foundation (ESYHF) in quality physical activity. Philadelphia enjoy a host of positive youth The Ohio Afterschool Network received development outcomes that stem from one funding from the Ohio Department of basic hook: playing hockey. Developed Health to address the challenge of find- by former Philadelphia Flyers and 76ers ing qualified after-school program staff owner Ed Snider, ESYHF programs target trained in physical activity instruction. youth from inner-city neighborhoods who A diverse group of providers, educators, otherwise would not have an opportunity funders, health professionals, and other to participate in an after-school program. experts created guidelines that addressed In an effort to tackle the barrier of pitting types of activities; time and intensity; cur- academic support against physical activity, riculum; qualified staff; ratio; staff policies the program goes beyond on-the-ice physi- and administration; evaluation; facilities; cal development and promotes increased equipment; and family, school, and com- school attendance, provides homework munity connections. The guidelines were help, and offers a life skills curriculum disseminated in fall 2011. The guidelines that encourages healthy habits and smart have been presented at state and regional choices. conferences and trainings, and the network • For many programs, the absence of shared- is working to have the guidelines included use or joint-use agreements between in the state’s quality rating system for schools and the community-based orga- child care. nizations that operate after-school pro- grams is a significant problem, leaving Paying the Bill: Sustainability programs unable to access facilities. In and After-School Physical Activity some locations, physical space is limited for after-school programs’ physical activity Funding for after-school programs is almost uni- programming, sometimes because sports versally tight, but a number of funding streams leagues have rented out available fields are available to support fitness activities: or facilities. • The U.S. Department of Education’s Carol The main goal of the School Health M. White grants. In fiscal year 2013, the depart- Interdisciplinary Program (SHIP) in ment planned to award 95 grants ranging from Gainesville, Florida, is to combat child- $100,000 to $750,000 to local education agen- hood obesity through a combination of cies and community-based organizations to age-appropriate physical fitness, nutrition, support programs designed to develop, expand, and science- and math-related educational or improve physical education programs for activities. In addition to teaching children K-12 students. The estimated average size of the about the water cycle and food pyramid, grants was $375,000. The program is not spe- SHIP dedicates time to an array of active cific to after-school programs (U.S. Department outdoor pursuits, such as endurance run- of Education n.d.). The future of the Carol M. ning, aerobics, and energetic games. Using White program is cloudy, as some in Congress local community-based organizations have targeted it for elimination. and undergraduate and graduate student • The Centers for Disease Control and volunteers from the University of Florida, Prevention (CDC) state-based Nutrition and After-School Programs and Physical Activity 41
Physical Activity Program to Prevent Obesity the developers. Lincoln’s use of the program is and Other Chronic Diseases funds 25 states to funded by a federal Carol M. White grant. address obesity and other chronic diseases with statewide efforts that draw in multiple partners (CDC 2012). Additional • The 21st Century Community Learning Reading and Resources Centers initiative of the Department of Educa- tion provides funding for school- and com- The Healthy Out-of-School Time (HOST) Coalition munity-based after-school programs through recently finalized evidence-based, practical quality a state-level competitive process. Funds can standards for providing children with healthy food, be used to promote physical activity through beverages, and physical activity in out-of-school time. The charge to this project, funded by the Robert recreation programs. Wood Johnson Foundation, was to recommend healthy eating and physical activity standards that Using Evidence-Based Curricula foster the best possible nutrition and physical activ- ity outcomes for children in grades K-12 attending Physical activity curricula should ensure that an programs outside of school hours. after-school program is able to meet its outcome Promoting Physical Activity and Healthy Nutrition in goals. Many after-school programs use physical Afterschool Settings, published by the Department activity curriculum packages marketed by out- of Health and Human Services, is a useful resource side organizations. Following are examples of that includes strategies for enacting health and after-school programs that use evidence-based nutrition guidelines and standards. It is available curricula: at www.centuray21me.org/staticme21/resources/ fitness_nutrition.pdf. • The City of Las Vegas’s Safekey After- school Program partners with the Southern The Quaker Chewy Get Active: Be Healthy Afterschool Toolkit, developed by the Afterschool Alliance and Nevada Health District to bring the Coordinated Quaker Oats, offers creative, easy-to-implement Approach to Child Health (CATCH) Kids Club to ideas for incorporating health and wellness into children between the ages of 5 and 11 at its 68 after-school programs, including lesson plans, activi- after-school sites. The curriculum is marketed ties, and games in addition to a comprehensive set by FlagHouse, Inc., to schools and after-school of health-related resources that programs can access. programs. The after-school-specific version of It is available at http://afterschoolalliance.org/docu- the curriculum was piloted in 16 after-school ments/QuakerGetActiveToolKit.pdf. sites and, based on the results, was subse- First Lady Michelle Obama’s Let’s Move campaign has quently adopted in hundreds of after-school recognized the value and importance of after-school sites around the nation. The program encour- programs, and many of the recommendations put ages healthy eating habits, physical activity, and forward in the White House Task Force on Childhood parental involvement (CATCH n.d.). Obesity Report to the President echo the current • The 21st Century Community Learning efforts and initiatives of the after-school field. The Let’s Move website includes a variety of action steps Centers, Lincoln, Nebraska, use the Spark that after-school programs and families can use. It after-school physical activity program, which is available at www.letsmove.gov/. includes an after-school-specific curriculum featuring “cultural and aerobic games, dances The Alliance for a Healthier Generation (AFHG) web- site offers before-school and after-school providers from around the world, and enjoyable skill and an excellent page of tips, ideas, and success stories sport activities written in scope and sequence,” that address both physical activity and nutrition and as well as activities such as jump rope, para- snacks. The tips are available at www.healthiergen- chute play, jogging games, fitness circuits, and eration.org/take_action\out-of-school_time. Addi- beanbag activities (Spark n.d.). This research- tionally, AFHG operates the no-cost Healthy Schools tested curriculum is supported by staff train- Program, which offers free resources, tips, and ing, equipment, and follow-up support from tools for promoting healthy lifestyles in after-school 42 Afterschool Alliance
programs. Online registration for the program is Centers for Disease Control and Prevention. 2012. available at https://host.healthiergeneration.org. Overweight and obesity. www.cdc.gov/obesity/ Action for Healthy Kids and the National Football stateprograms/index.html. League developed ReCharge! Energizing After- Fletcher, A. 2010. Changing lives, saving lives: A step- School, a fun-for-kids curriculum designed to teach by-step guide to developing exemplary practices in students about good nutrition and engage them in healthy eating, physical activity and food security in physical activity. ReCharge! is a complete, easy-to- afterschool programs. Healthy Behaviors Initiative. use kit with lesson plans, equipment ideas, and www.ccscenter.org/afterschool/Step-By-Step%20 information for families. It is available at www. Guide. actionforhealthykids.org/what-we-do/534. Lee, S.M., C.R. Burgeson, J.E. Fulton, and C.G. Spain. The Center for Collaborative Solutions’ Healthy 2007. Physical education and physical activity: Behavior Initiative has recently released a free and Results from the School Health Policies and Pro- comprehensive publication, Step-by-Step Guide to grams Study 2006. J. School Health 77(8):435-68. Developing Exemplary Practices in Healthy Eating, Mahoney, J.L. 2011. Adolescent summer care arrange- Physical Activity and Food Security in Afterschool ments and risk for obesity the following school year. Programs. It is available at www.ccscenter.org/ J. Adolesc. 34(4):737-49. afterschool/Step-By-Step%20Guide. Mahoney, J.L. and L. Heather. 2005. Afterschool pro- gram participation and the development of child obe- References sity and peer acceptance. Appl. Dev. Sci. 9(4):202-15. Afterschool Alliance. 2009. America after 3PM. www. Miller, K.E., D.F. Sabo, M.P. Farrell, G.M. Barnes, and afterschoolalliance.org/AA3PM.cfm. M.J. Melnick. 1998. The Women’s Sports Founda- tion Report: Sport and Teen Pregnancy. Women’s Afterschool Investments Project. 2006. Promoting Sports Foundation. New York, NY. physical activity and healthy nutrition in afterschool settings: Strategies for program leaders and policy National AfterSchool Association Standards for Healthy makers. Washington, DC: U.S. Department of Health Eating and Physical Activity in Out-of-School Time and Human Services. Programs. 2011. www.niost.org/pdf/host/Healthy_ CANFit, Partnership for Public Health/Public Health Eating_and_Physical_Activity_Standards.pdf. Institute, Samuels & Associates. 2009. Promoting Riley, R., T. Peterson, A. Kanter, G. Moreno, and W. Healthier Afterschool Environments: Opportuni- Goode. 2000. Afterschool Programs: Keeping Kids ties and Challenges. The California Endowment. Safe and Smart. Washington, DC: U.S. Department Oakland. CA. of Education. CATCH. n.d. www.catchinfo.org/catchmagalog.html. Spark. n.d. www.sparkpe.org/after-school/. Centers for Disease Control and Prevention. 2002. Physi- U.S. Department of Education. n.d. Carol M. White cal activity levels among children aged 9-13 years. physical education program. www2.ed.gov/pro- MMWR: Morbid. Mortal. Wkly. Rep. 52(33):785-8. grams/whitephysed/applicant.html. Sector II Mass Media
Bess H. Marcus, PhD Department of Family and Preventive Medicine, University of California San Diego
ass media campaigns increasingly are potential to create broad interest in physical Mbeing used as part of a public health activity, increase the potential for change, and approach to address physical inactivity. The influence social norms regarding active and best mass media campaigns have a clear focus, sedentary lifestyles. Several examples in this include paid and earned media placements, and section highlight the fact that government sup- reach a wide population. Connecting campaigns port can play an important role in successful with national, state, or local partnerships and mass media campaigns, because government establishing clear links to community programs can provide the sustained support needed to and policy and environmental change strategies fund a dose of mass media sufficient to increase appear to be promising approaches. All cam- and sustain community awareness. Successful paigns, regardless of their focus, need to include campaigns also need adequate planning, good a clear and identifable message or “brand” and formative message development, and sufficient suffcient media exposure. Effective campaigns media duration and intensity. Without these key typically include political support, sustained components, it is unlikely that campaigns will funding, and well-established partnerships that produce change in the target population. support the many settings in which physical Finally, campaign planners must invest in activity can occur. quality evaluation at all stages of mass media The chapters in this section describe commu- campaign programming. First, they should nication strategies used in several mass media ensure that rigorous formative research, which campaigns to promote physical activity: a com- requires time and effort and should entail both munity-wide social marketing campaign in West qualitative and quantitative methods, is used Virginia, a mass media campaign to promote to create optimal messages. Second, process physical activity in Hawai`i, a U.S. national evaluation of a campaign is important for campaign to promote activity in children, and understanding which audiences were reached national campaigns in Canada, Australia, and by campaign activities and which ones were New Zealand. Each chapter tells a different story not. Third, outcome evaluations need to use about the challenges and opportunities inherent the strongest research designs and measures in promoting physical activity via mass media. so that campaign planners can determine what Mass media campaigns must be included worked and can ensure that the next campaign in public health approaches to promoting is even more successful. physical activity. These campaigns have the
43
CHAPTER 6 VERB: It’s What You Do! and VERB Scorecard Bringing a National Campaign to Communities
Marian Huhman, PhD Judy Berkowitz, PhD University of Illinois at Urbana-Champaign Battelle Institute
NPAP Tactics and Strategies Used in This Program
Mass Media Sector STRATEGY 4: Ensure that messages and physical activity plans developed by state and local public STRATEGY 1: Encourage public health agencies to health agencies and key stakeholders from the form partnerships with other agencies across the eight sectors are consistent with national mes- eight sectors to combine resources around com- sages. mon themes in promoting physical activity. STRATEGY 5: Sequence, plan, and provide campaign STRATEGY 2: Enact federal legislation to support a activities in a prospective, coordinated manner. sustained physical activity mass media campaign. Support and link campaign messages to commu- STRATEGY 3: Develop consistent mass communica- nity-level programs, policies, and environmental tion messages that promote physical activity, have supports. a clear and standardized “brand,” and are consis- STRATEGY 6: Encourage mass media professionals to tent with the Physical Activity Guidelines for Ameri- become informed about the importance of physi- cans. cal activity and the potential role they can play in promoting physical activity.
The VERB: It’s What You Do! social marketing 4, the campaign emphasized providing oppor- campaign used mass media, school and com- tunities for tweens to experience the brand munity promotions, the Internet, and partner- and to sample the product (physical activity) ships with national organizations and local through experiential marketing—national pro- communities to encourage children aged 9 to 13 motional tours, community events, and school years (tweens) to be physically active every day. and community promotions. The specifcs of the branding strategy (Asbury, Wong, Price, & Nolin 2008), the experiential marketing Program Description tactics (Heitzler, Asbury, & Kusner 2008), the description of the marketing activities for the ponsored by the Centers for Disease Con- four phases (including efforts that targeted Strol and Prevention (CDC), VERB imple- the general market and specifc ethnic groups) mented mass media and promotions nationally (Huhman et al., 2008), and an overview of the from 2002 to 2006 in four phases that spanned evaluation methods (Berkowitz et al., 2008) roughly one year each. The frst phase focused are summarized in a June 2008 supplement to on building a strong brand and brand aware- the American Journal of Preventive Medicine. ness among tweens. During phases 2 through The remainder of this chapter focuses on the
45 46 Huhman and Berkowitz national and community partnership compo- (2) connect the VERB brand to the point-of- nent of VERB, which was slower to develop purchase, and (3) drive tweens to the opportu- than national VERB and, in many ways, was nities, places, and programs where they could more complex. “purchase” the product of physical activity. The VERB created a demand for physical activity, VERB brand created a desire to be physically and communities supplied the opportunities for active, and communities provided the places tweens to be physically active where they lived. for tweens to be active. As a public health effort, VERB was created to One of the most comprehensive and success- engage communities as campaign partners by ful community programs was VERB Summer helping them assess their needs, build capacity, Scorecard, later shortened to VERB Scorecard, and customize VERB-related activities to meet which Lexington, Kentucky, implemented in those needs. As willing and eager partners, the summer of 2004 and continued for several communities wanted to own at least parts of summers. A high-functioning coalition of more the planning and implementation processes, than 50 members from businesses, schools, which often was not practical or efficient in the health services, recreation centers, and the fast-paced world of the private sector advertis- transportation system, as well as parents and ing and media groups. The creative agencies coaches, decided to focus its efforts on youth and media organizations were not used to physical activity. The centerpiece of VERB community coalitions or task forces as part- Summer Scorecard was the actual scorecard, ners, and they often could not accommodate a wallet-sized card with 24 squares on it; each the community’s preferences for venues and square represented one hour of physical activity. times. Plus, the creative team from the Centers Participating businesses and recreational outlets for Disease Control and Prevention (CDC) and stamped the cards and gave tweens discounts the creative agencies were very concerned that on physical activities and events, such as free all communications to the target audience be swimming at community pools and reduced “on brand.” They worried that loss of the cool admission prices to skating rinks and sports factor of VERB by well-intentioned but adult- clinics (figure 6.1). centric or unexciting community events would The coalition used a planning and implemen- dilute the assets of the young VERB brand. tation approach called “community-based pre- Thus, for the first two years, VERB planners vention marketing,” developed by the Florida and communities grappled with the best ways Prevention Research Center (FPRC) (figure to partner with each other. Communities were 6.2). Community-based prevention marketing ready to partner, but VERB was cautious until uses the four Ps of marketing—product, price, the brand was firmly established and campaign place, and promotion—as an implementation products were developed that were appropriate framework. With assistance from the FPRC, for communities to use. the coalition quickly developed a marketing After the VERB brand was established and mindset and worked to develop the places for partners learned about the importance of brand tweens to be active at the right price and even protection, the strategy that evolved entailed negotiated with the transportation system that communities’ using the VERB brand guidelines a scorecard could be used as bus fare—thus to develop materials for their community that removing an important barrier for tweens get- featured the VERB logo, bringing VERB’s cachet ting to their preferred places to be active. to the community’s efforts. VERB also provided CDC’s VERB team helped keep program activity toolkits with appealing premiums for development costs low for the coalition by pro- schools and organizations to use with tweens. viding the extensive audience research about CDC’s VERB Partnership Team consulted with tweens and parents that had been conducted by community partners to ensure that their mes- CDC to develop the VERB brand and messages. sage was consistent with that of the national This was possible because the Lexington staff campaign by helping them (1) reframe their recognized that many of the research findings physical activity programs as fun and exciting for the same target audience were applicable and avoid a should do, good for you message, regardless of geographic location. CDC’s team VERB: It’s what you do! and VERB Scorecard 47
Figure 6.1 The VERB Summer Scorecards from Lexington’s (left to right) 2004, 2005, and 2006 community- based campaigns listed the discounts and special events available for tweens. Tweens also tracked their physical activity hours on the VERB Scorecard (farE5691/NPAP/fig6.1/458520/alw/r1 right) and then redeemed completed cards for great prizes. Reprinted, by permission, from Nutrition and Fitness Coalition.
Figure 6.2 Community-based marketingE5691/NPAP/fig6.2/458524/alw/r1 from the VERB website. Reprinted, by permission, from Iowa State University. Available: http://www.iowaverb.org
supported the Lexington coalition’s efforts for evaluation. By the end of 2006, 17 other through consultation on the brand guidelines communities in several states (e.g., Indiana, and local marketing strategies. CDC’s evaluation Iowa, and Florida) had adapted the Lexington team provided guidance on the coalition’s plans VERB Scorecard program for their community. 48 Huhman and Berkowitz
VERB Summer Scorecard in Sarasota, Florida, VERB effects were sustained as tweens aged closely modeled the Lexington program and into their later teen years. was evaluated through a partnership with the VERB Summer Scorecard in Lexington was FPRC. Some other U.S. communities have pro- assessed with process and outcome measures. grams planned for 2011, five years after VERB’s In 2004, tweens redeemed more than 350 com- national funding ended. pleted VERB Scorecards that reported more than 8,400 hours of physical activity during the 13-week community campaign. Participants Program Evaluation redeemed more than twice as many completed VERB Scorecards in 2005 and 2006. Scorecard National VERB was evaluated extensively. participants were more likely to be physically Process evaluation, which assesses how faith- active than were tweens who did not participate. fully the campaign was implemented, included In addition to affecting the individual-level vari- monitoring the reach and frequency of the ables, the efforts in Lexington led to changes in advertising, conducting a national tracking macro-level variables, affecting the local health survey to monitor the likeability of the VERB department’s relationship with local media, brand, and assessing the number of promo- public transportation, and businesses. tions and events, attendance at events, and The Sarasota County program evaluators receptiveness of tweens to the promotional used a post-only comparison group design to events. VERB conducted an annual outcome evaluate their 2005 Summer Scorecard program. evaluation through nationally representative They found that tweens who participated in the telephone surveys. The evaluation surveyed intervention were more likely to be physically tweens and parents regarding their attitudes active than tweens in the comparison group and behaviors related to physical activity. The and more physically active than youth in the survey tool, the Youth Media Campaign Longi- intervention community who did not participate tudinal Survey, was developed specifically for in the scorecard program. Sarasota evaluators VERB and was found to be reliable and valid also used their scorecard program experiences (Welk et al. 2007). The survey is available at to study community capacity to implement and www.cdc.gov/youthcampaign. sustain health interventions. The outcome evaluation showed that after year one of the campaign, 74% of U.S. tweens were aware of VERB and 90% of those who were Linkage to National aware understood at least one of the key mes- Physical Activity Plan sages. Subgroups of tweens (e.g., girls, younger tweens) who were aware of the campaign did The campaign used six of the eight strate- more physical activity than tweens who were gies included in the Mass Media Sector of the not. After the second year, total population-level National Physical Activity Plan (NPAP). effects (no significant differences across gender, Strategy 1: Encourage public health agencies age, race, socioeconomic status) were found to form partnerships with other agencies across for six of the seven attitude and behavioral the eight sectors to combine resources around primary outcomes. After evaluators controlled common themes in promoting physical activity. for baseline levels of physical activity, tweens VERB partnered with more than 50 county and who were aware of VERB reported more physi- local public health departments, coalitions, and cal activity sessions in their free time than did task forces in 20 cities; national organizations tweens who were not aware of the campaign. (e.g., Girl Scouts); and marketing and media After four years of the campaign, the final out- businesses that wanted to dedicate resources to come analysis showed continuing effects, and a physical activity mission. VERB worked across a dose response analysis found that increasing sectors at the national level and supported amounts of VERB exposure resulted in stronger community-level programs that partnered with attitude and behavioral effects. Some positive health departments, local businesses, trans- VERB: It’s what you do! and VERB Scorecard 49 portation systems, schools, and recreational communities during year one had mixed results. facilities. These activities exemplify two of the VERB administrators learned that communi- three tactics described in Strategy 1 of the Mass ties needed time to develop events, programs, Media Sector of the National Physical Activity and activities that matched their interests Plan (NPAP). www.physicalactivityplan.org/ and resources. VERB also needed to provide media_st1.php. tangibles (e.g., promotional items) to support Strategy 2: Enact federal legislation to support communities, but CDC was still developing a sustained physical activity mass media cam- and refining those resources. The most com- paign. A congressional appropriation funded prehensive, and some of the most successful, the CDC to develop and implement a campaign community VERB programs used the systematic that became VERB. The program was funded planning approach of community-based preven- for five years for a total of $340 million. The tion marketing. Coordinating mass media efforts VERB campaign exemplifies Strategy 2 for the with community planning is recommended as Mass Media component of the NPAP (www. a tactic of Strategy 5 of the Mass Media Sector physicalactivityplan.org/media_st2.php). of the NPAP (www.physicalactivityplan.org/ Strategy 3: Develop consistent mass communi- media_st5.php). cation messages that promote physical activity, Strategy 6: Encourage mass media profession- have a clear and standardized “brand,” and are als to become informed about the importance consistent with the Physical Activity Guidelines of physical activity and the potential role they for Americans. The foundation of the campaign can play in promoting physical activity. When was the VERB brand, which was associated in VERB purchased media placement, media the minds of tweens with the fun, cool, and companies (e.g., Disney, Nickelodeon) offered social benefits of physical activity. Although the campaign added-value opportunities such the tween messages never mentioned getting as producing VERB ads with their talent (i.e., the recommended 60 minutes of physical activ- TV stars, cartoon characters) and placing the ity a day, VERB parent materials encouraged ads on their channels and in their national parents to help their children be physically print media (e.g., Sports Illustrated Kids). VERB active at recommended levels. These activities found that youth physical activity and obesity exemplify one of the tactics of Strategy 3 for the prevention appealed to everyone, including Mass Media Sector of the NPAP (www.physica- high-profile media companies such as Black lactivityplan.org/media_st3.php). Entertainment Television (BET), AOL (origi- Strategy 4: Ensure that messages and physical nally known as America Online), and Warner activity plans developed by state and local public Bros (WB). Media companies wanted to go the health agencies and key stakeholders from the extra mile and help to ensure VERB’s success. eight sectors are consistent with national mes- These activities exemplify two of the four tactics sages. CDC directed media partners, national recommended for Strategy 6 of the Mass Media organizations, and community partners to Sector of the NPAP (www.physicalactivityplan. follow carefully the brand guidelines developed org/media_st6.php). by CDC for using the national campaign VERB logo, including color, typeface, and context guidelines for using the logo, as recommended Evidence Base Used in Strategy 4 of the Mass Media Sector of the During Program Development NPAP (www.physicalactivityplan.org/media_ st4.php). Between 2001 and 2005, the CDC’s Guide to Strategy 5: Sequence, plan, and provide cam- Community Preventive Services issued recom- paign activities in a prospective, coordinated mendations regarding evidence-based, com- manner. Support and link campaign messages munity-level interventions to promote physi- to community-level programs, policies, and envi- cal activity. The guide strongly recommended ronmental supports. VERB’s initial attempts to community-wide campaigns but could not coordinate national promotions in nine local recommend mass media interventions because 50 Huhman and Berkowitz insufficient evidence exists regarding their Lessons Learned effectiveness. These two approaches share some characteristics with VERB, but VERB is not a CDC’s VERB team recommends the following: typical example of either approach. Community- If the physical activity promotion strategy is wide campaigns generally are tailored to a com- built around a brand, and the brand is meant munity, balance marketing and nonmarketing to provide an identity that communities can approaches, and mobilize substantial local leverage, build the brand presence first. Develop partnerships (e.g., the adult-focused Wheeling marketing materials for communities that they Walks). VERB built a strong brand as a founda- can adapt while the national campaign is being tion for messages, emphasized social marketing, established. Examples include turnkey kits for and involved national-local partnerships. VERB physical activities in the classroom or an after- was also more than a mass media intervention school program, press releases, tip sheets for (e.g., it included school and community promo- engaging community partners, and guidelines tions). Research indicates that social marketing for parents. These types of materials provide is effective when done correctly, with examples communities with something on which they including the “truth” campaign for prevention can build. of tobacco use in adolescents, campaigns to Consider a system of categories to determine promote low-fat milk (1% Milk campaign), the right match for partner involvement. CDC’s campaigns to promote use of seat belts, and VERB team used a tiered model in which the non-health-related campaigns such as promo- tier 1 or ideal community or national partner tion of recycling. Although no large campaigns had four characteristics: have focused on physical activity in children, there is increasing evidence that social market- 1. An existing coalition or community ing approaches can be effective in promoting network that facilitated access to the physical activity (Gordon, McDermott, Stead, supply of physical activity opportunities & Angus. 2006). in the community The success of VERB substantially adds to 2. A champion within the network who the evidence that social marketing campaigns provided leadership and ensured follow- to promote physical activity can be effective through in general and can be effective specifically in 3. Its own funding (including donated children. media time and space) to support community-wide campaigns or promo- Populations Best Served tional events 4. A firm understanding of the social mar- by the Program keting model and “a marketing mindset” The VERB national campaign targeted all U.S. Partners at the tier 2 level had contact with tweens. This age group was chosen because the national campaign planners, some fund- group members are beginning to make their ing resources, and some understanding of a own lifestyle choices but still are strongly influ- marketing mindset and ability to protect the enced by their parents. brand. VERB helped these partners conduct VERB’s national and community partners on-brand events and promotions with their also targeted the tween age group but in some own resources. cases further segmented the audience. For Tier 3 partners included schools, recreational example, some of the communities using the centers, and similar organizations that had none scorecard program specified that they were tar- of the previously described characteristics and geting moderately active tweens or “passives,” no funding resources. VERB provided these which they defined as tweens who participated partners with a turnkey kit that they could in no physical activity. implement in a classroom or an after-school VERB marketing Partner characteristics resources and support Outputs expected
Partner had... VERB provided... The partner did... • Existing network with • Intensive social marketing • Execute on-brand tween intention and ability to consultation from the VERB community deliver physical activity in VERB Partnership Team, campaign, including a tween-centric manner the Florida Prevention special event and through an entire Research Center, and promotions, with own community or other top tier partners resources organization • First access to VERB • Participate in VERB turn- • Network champion to turn-key kits, premiums, key kit promotions by lead and follow through and other ready-to-use aggressively promoting it and who had significant materials within the whole organization or contact with the YES • VERB artwork and VERB team graphics that partners community • Funding for a community used to develop their • Use VERB event or event or campaign community-based promotion as a catalyst • Firm understanding of the campaign materials for stimulating community marketing mindset • VERB logo and style ownership and solutions (consumer-based guide to issues related to decision-making) and a • National guerrilla regular tween physical commitment to deliver marketing tours and in- activity the VERB brand of community promotions physical activity • Marketing and communication materials NO for pilot-testing before materials were made available to other partners
Missing some of the More than entry-level partners above characteristics received, but less than Partner had... top partners • Ability to deliver VERB provided... physical activity • Social marketing More than a one-time limited to a part of consultation from the implementation, yet less the community or VERB Partnership Team than full community- organization • Access to VERB turn-key based campaign • Network members kits, premiums, and other The partner did... that had contact with ready-to use materials • Execute on-brand tween the VERB team • Limited access to VERB VERB event or promotion • Limited funding artwork and graphics that with own resources resources could be tailored upon • Participate in VERB turn- • Some understanding approval key kit promotions of the marketing • VERB logo and style mindset or some guide for use upon ability to protect the approval with each VERB brand execution
Missing most of the Limited materials and basic above characteristics marketing information Partner had... VERB provided... One-time implementation with • Limited quantities of little follow up • Ability to deliver physical VERB turn-key kits and The partner did... activity limited to a few other ready-to-use classrooms, programs, • Use VERB turn-key kits materials for one-off or clubs VERB games and • Network members that • implementation activities to download (implemented only one- had minimal contact with from the VERB partners the VERB team time or in one classroom website or program) • No funding resources Materials to reach parents No understanding of the • • Distribute parent or adult • and other adult influencer materials marketing mindset or no influencers to download commitment to protect from the VERB partners’ the VERB brand website
Figure 6.3 VERB partnerships: aligning marketing resources with partner characteristics. Reprinted from American Journal of Preventative Medicine, Vol. 34 (6S), R. Bretthauer-Mueller et al., “Catalyzing community action within a national campaign: VERB™ community and national partnerships,” pgs. S210-S221, copyright 2008, with permission of Elsevier. E5691/NPAP/fig6.3/458519/alw/r3-kh
51 52 Huhman and Berkowitz
program. Using this tiered approach based on Materials related to the Lexington and Sarasota County the community partner’s level of readiness VERB Summer Scorecard programs: allowed CDC to target its limited partnership Alfonso, M.L., J.E. Nickelson, D.L. Hogeboom, J. and staffing resources to communities that were French, C.A. Bryant, R.J. McDermott, and J.A. able to create sustainable efforts (figure 6.3) Baldwin.(2008). Assessing local capacity for health intervention. Evaluation and Program Planning, 31,145-59. Tips for Bryant, C.A., A.H. Courtney, R.J. McDermott, M.L. Working Across Sectors Alfonso, J.A. Baldwin, J. Nickelson, K.R. McCor- mack Brown, R.D. Debate, L.M. Phillips, Z. Thomp- It is important to negotiate a process for timely son, and Y. Zhu. (2010). Promoting physical activity clearance and approval of marketing and media among youth through community-based prevention materials, a step that often is needed when marketing. Journal of School Health, 80(5), 214-24. working with public health agencies. VERB Bryant, C.A., K. McCormack Brown, R.J. McDer- negotiated an expedited clearance process that mott, R.D. Debate, M.A. Alfonso, J.L. Baldwin, P. was essential for the timelines needed across Monaghan, and L.M. Phillips. 2009. Community- several sectors, especially media organizations based prevention marketing: A new planning frame- and businesses. work for designing and tailoring health promotion Another important strategy is to build in interventions. In: Emerging Theories in Health expectations with the creative team members Promotion Practice and Research: Strategies for Improving Public Health. 2nd ed. R. DiClemente, that communities and national partners will R.A. Crosby, and M.C. Kegler, Eds. San Francisco: carry the mass media messages to their con- Jossey-Bass. stituents and communities, thereby sustaining DeBate, R.D., J. Baldwin, Z. Thompson, J.E. Nickelson, the behavior in the target audience. Establish M. Alfonso, C.A. Bryant, L.M. Phillips, and R.J. strong brand protection guidelines and provide McDermott. (2009). VERB Summer Scorecard: Find- careful oversight of partners’ implementation to ings from a multi-level community-based physical ensure that partners’ efforts are consistent with activity intervention for tweens. American Journal the brand specifications. of Community Psychology. 44, 363-73.
Additional References Reading and Resources Asbury, L.D, F.L Wong, S.M. Price, and M.J. Nolin. VERB legacy products and tools and data for the out- 2008. The VERBcampaign: Applying a branding come evaluation are available at www.cdc.gov/ strategy in public health. American Journal of Pre- youthcampaign. ventive Medicine, 34 (6S), S183-S187. Articles in the June 2008 Supplement to the American Berkowitz, J.M., M. Huhman, C.D. Heitzler, L.D. Potter Journal of Preventive Medicine are available at M.J. Nolin, and S.W. Banspach. 2008. Overview of www.cdc.gov/youthcampaign. The following are formative, process, and outcome evaluation methods especially relevant: used in the VERB™ campaign. American Journal of Bretthauer-Mueller, R., J.M. Berkowitz, M. Thomas, et Preventive Medicine, 34 (6S), S222-S229. al. (2008). Catalyzing community action within a Gordon, R., L., M. McDermott, M. Stead, and K. Angus. national campaign: VERB community and national 2006. The effectiveness of social marketing to partnerships. American Journal of Preventive Medi- improve health: What’s the evidence? Public Health, cine, 34(6S).S210-1. 120, (12):1133-9. Wong, F.L., M. Greenwell, S. Gates, and J.M. Berkowitz. Heitzler, C.D., L.D. Asbury, and S.L. Kusner. 2008. (2008). It’s what you do! Reflections on the VERB™ Bringing “play” to life: The use of experiential mar- campaign American Journal of Preventive Medicine, keting in the VERBcampaign. American Journal of 34(6S),S175-82. Preventive Medicine, 34 (6S), S188-S193. VERB: It’s what you do! and VERB Scorecard 53
Huhman, M., J.M. Berkowitz, F.L. Wong, E. Prosper, Welk, G.J., E. Wickel, M. Peterson, C.D. Heitzler, J.E. M. Gray, D. Prince, and J. Yuen. 2008. The VERB- Fulton, and L.D. Potter. 2007. Reliability and validity campaign’s strategy for reaching African-American, of physical activity questions on the Youth Media Hispanic, Asian, and American Indian children and Campaign Longitudinal Survey. Medicine & Science parents. American Journal of Preventive Medicine, in Sports & Exercise, 39 (4), 612-21. 34 (6S), S194-S209.
CHAPTER 7 Start.Living.Healthy Using Mass Media to Increase Physical Activity in Hawai`i
Jay Maddock, PhD Alice Silbanuz, BA University of Hawai`i at Ma¯noa Hawai`i Department of Health
Lola Irvin, MED Bill Reger-Nash, EdD Hawai`i Department of Health West Virginia University
NPAP Tactics and Strategies Used in This Program
Mass Media Sector a clear and standardized “brand,” and are consis- tent with the most current Physical Activity Guide- STRATEGY 1: Encourage public health agencies to form partnerships with other agencies across the lines for Americans. eight sectors to combine resources around com- STRATEGY 5: Sequence, plan, and provide campaign mon themes in promoting physical activity. messages in a prospective coordinated manner. Support and link campaign messages to commu- STRATEGY 3: Develop consistent mass communica- tion messages that promote physical activity, have nity-level programs, policies, and environmental supports.
tart.Living.Healthy uses paid and earned nutrition in Hawaii. Start.Living.Healthy is the Smedia to encourage adults ages 35 to 55 state’s umbrella brand for all physical activity to walk at least 30 minutes a day. Based on and nutrition messages. It has been used since the Theory of Planned Behavior, the campaign 2002 and is widely known in Hawai`i. The HHI titled Step It Up, Hawai`i presents common is housed in the Hawai`i State Department of decision points to allow people to decide to Health and includes a steering committee of become active. community stakeholders.
Program Description Campaign Foundations The walking campaign was the third phase Start.Living.Healthy is a social marketing of the overall social marketing campaign. In umbrella campaign designed as part of the phase I of the overall campaign, messages were Healthy Hawai`i Initiative (HHI) (Maddock et developed for individuals in the precontempla- al. 2006), an ongoing, multilevel, statewide, tion stage of change for physical activity and mass media-led intervention in Hawaii. HHI, nutrition. Results of the campaign showed high which is funded by the tobacco settlement, awareness and increased knowledge about addresses tobacco control, physical activity, and government recommendations for physical
55 56 Maddock, Irvin, Silbanuz, and Reger-Nash activity and nutrition (Maddock and Johnson Preproduction Research 2006). In phase II, a research-tested mass media campaign to encourage individuals to switch Preproduction research was carried out in two to low-fat milk was adapted and culturally phases. In the first phase, program staff con- tailored to the population. This campaign was ducted open-ended elicitation surveys to gen- very successful, with more than 10 percent of erate key beliefs about exercising 30 minutes a high-fat milk drinkers switching to low-fat milk day. They asked 32 clerical, skilled, and trade (Maddock et al. 2006). workers, ages 35 to 55 years, to generate key To plan for phase III, the management team of beliefs on social norms, attitudes, and perceived the HHI conducted extensive formative research behavioral control for physical activity. The (Maddock et al. 2008b), using the data from responses yielded unique Theory of Planned its psychosocial surveillance system (Maddock Behavior belief statements. Staff then created a et al. 2003). Data showed that (1) a large per- quantitative survey to measure these key beliefs centage of adults were in the contemplation and assess self-reported behaviors related to and preparation stages (Marcus et al. 1992) regular walking. Snowballing sampling meth- for physical activity, and (2) the percentage ods were used, and the survey was sent to all of adults meeting physical activity guidelines county health offices in the state of Hawaii. decreased significantly with increasing age: Health department staff used their contacts in 58.4 percent of 25- to 34-year-olds, 49.2 per- the local communities to recruit 35- to 55-year- cent of 35- to 44-year-olds, and 48.2 percent of old adults to complete the survey. Respondents 55- to 64-year-olds (Centers for Disease Control were classified into those who performed the and Prevention 2007). The management team behavior at the recommended level (i.e., at decided to promote regular walking among 35- least 30 minutes of physical activity, five days to 55-year-olds for this campaign as a means a week; N = 85), and those who did not (N of helping Hawai`i residents meet the national = 300). A discriminant functional analysis recommendations (Pate et al. 1995). was conducted to assess which beliefs differed between the groups. Program staff then used Identifying Target Behaviors the beliefs most different between the groups as the basis for developing the media messages. Next, program planners identified the target The significantly different variables were (1) “I behavior for the campaigns. The national guide- don’t have enough time,” (2) “I think I should lines for physical activity at the time were 30 exercise 30 minutes a day most days of the minutes or more of moderate physical activity week,” and (3) “It is hard staying motivated.” a day, on most days of the week, or 20 minutes or more of vigorous physical activity on three Production Testing or more days per week (Pate et al. 1995). These recommendations were seen as too complex The program hired a creative team to develop to convey in a cluttered world of mass media message concepts based on the key beliefs sound bites. In addition, recommending vigor- identified in the preproduction phase. The ous exercise to 35- to 55-year-olds who are not team presented three concepts to the steering sufficiently active seemed impractical. National committee, which rejected one message that surveillance data showed that walking was the did not clearly articulate the core concepts. activity most frequently reported by adults who The remaining two messages were titled All in met the guidelines (Simpson et al. 2003), and the Family and Decision Point. The All in the moderate-intensity walking is consistent with Family message was based on Wheeling Walks, the Physical Activity Guidelines for Americans a research-tested mass media program (Reger (Physical Activity Guidelines Advisory Com- et al. 2002). In the All in the Family approach, mittee 2008). Therefore, the program planners participants were introduced to someone who chose moderate-intensity walking as the target successfully improved his or her health through behavior. the motivation and support of a family member. Start.Living.Healthy 57
The Decision Point message focused on making also presented in this book. Staff made other choices and taking small steps to follow a more decisions about the campaign logistics based healthy lifestyle. The actors were presented with on HHI’s previous evaluation data. Decisions a decision point between a sedentary activity on media channels were based on evaluation (e.g., watching television) and a more active data from the successful 1% or Less campaign activity (e.g., walking with friends during their (Maddock et al. 2007). The intensive walking planned time together). Another spot posed a campaign lasted 10 weeks, similar to Wheeling choice between taking the elevator or the stairs. Walks (Reger et al. 2002). The overall campaign These two approaches were then tested with brand was Start.Living.Healthy, which has been two separate focus groups of males and females. used by HHI since 2002 and is well recognized Focus group participants were adults ages 35 in the community. The specific campaign slogan to 55 who were active less than 150 minutes was Step It Up, Hawai`i! per week. During the groups, facilitators pre- The campaign was launched on April 4, sented the two concepts (i.e., All in the Family 2007, with a press conference led by the lieu- and Decision Point). Participants discussed tenant governor. Program staff began writing what they liked and did not like about the two a weekly column on walking, which appeared approaches and whether the approaches influ- in the state’s largest newspaper. All 65,000 enced their core beliefs regarding these behav- government employees received a pay stub iors. The order in which the campaigns were message encouraging walking. Media relations introduced was switched for the two groups to events resulted in earned mass media campaign control for order effects. Participants marked message communication worth approximately their responses on paper during the focus group $51,000. Gross rating points were 2,205 for tele- so that statistics could be calculated after the vision and 3,443 for radio. Campaign posters group. were placed in 300 locations, including malls The All in the Family approach was not well and doctors’ offices, across the state. The cam- received. Only three participants (15.8 percent) paign website received more than 2,000 visits found it believable, and few (10.5 percent) during the campaign. thought that the advertisements would get them to start walking. The general feeling was that the family approach was overdone and that the Program Evaluation spots were not exciting or motivating enough to The data for this study were collected as part maintain behavior change. The Decision Point of an ongoing statewide surveillance survey for approach fared much better. Most participants physical activity and nutrition (Maddock et al. (89.5 percent) found it believable, and almost 2003). A stratified, random-digit dialing system all thought it would motivate them to become was used to reach a random sample of 3,600 active (94.7 percent). Participants liked the tone of Hawaii’s noninstitutionalized adult popula- of the advertisements, found them empowering, tion on all major inhabited islands: 1,800 from and were more accepting of the advice offered the island of Oahu, 600 from Hawaii, 600 from to improve their health. Based on this feedback, Kauai, 500 from Maui, 75 from Molokai, and program planners selected the Decision Point 25 from Lanai. The disproportionate design advertisements for development. was randomized across counties and included both listed and unlisted telephone numbers. Campaign Launch The sample size was selected to give statewide HHI used results from the formative research precision estimates of ±2 percent. to develop three 30-second television commer- This analysis used only the results from the cials, four 30-second radio commercials, mall 2007 cross-sectional survey, which was con- advertisements, and posters for the walking ducted immediately following the conclusion campaign. The campaign method was patterned of the campaign and included variables that after the Wheeling Walks campaign, which is provided data on the potential knowledge gap. 58 Maddock, Irvin, Silbanuz, and Reger-Nash
Overall, 54 percent of respondents said that governor served as the spokesperson for the they had heard (via prompted recall) of the campaign. The state Office of Human Resources Start.Living.Healthy campaign in the prior allowed campaign messages to be placed on the six months, and 70.3 percent of respondents paystubs of all state employees. In the private recalled seeing or hearing the message “people sector, the Honolulu Advertiser, the state’s larg- should walk 30 minutes a day for at least 5 est newspaper, provided a free weekly column days a week.” Sixty-four percent of all respon- for the entire campaign. dents recalled hearing that “walking gives you Strategy 3: Develop consistent mass commu- energy.” About 50 percent recalled the mes- nication messages that promote physical activ- sages that “there is benefit in walking only ity, have a clear and standardized “brand,” and 10 minutes” (52.7 percent) and that “walking are consistent with the most current Physical gives you time, because you have more energy Activity Guidelines for Americans. The cam- to do things” (49.0 percent). Overall, half (51.7 paign used the well-tested brand called Start. percent) of respondents recalled seeing Start. Living.Healthy. This is the state’s umbrella Living.Healthy advertisements on television, brand for all physical activity and nutrition including 12.2 percent who said that they had messages. It has been used since 2002 and is seen “a lot” of such commercials. Recall of radio widely known in Hawai`i. All of the messages commercials was much lower—only 20 percent encouraged 30 minutes of physical activity a of all respondents recalled having heard Start. day, consistent with national recommenda- Living.Healthy radio ads. Fewer than half of tions. all respondents (42.9 percent) recalled seeing Strategy 5: Sequence, plan, and provide cam- news stories about the campaign. A complete paign messages in a prospective coordinated analysis of campaign awareness by subgroups manner. Support and link campaign messages has been reported by Buchthal and colleagues to community-level programs, policies, and envi- (2011). Smaller pre- and postcampaign surveys ronmental supports. This campaign was phase of 400 people examined attitudes and behavior. III of an overall campaign. It built directly on an No significant differences were seen for the earlier campaign geared toward people in the Theory of Planned Behavior variables or behav- precontemplation stage of change; that program ior, indicating little or no effect of the campaign was titled You’ve Got to Start Somewhere. The on changing the underlying theoretical variables campaign is part of the broader HHI, which uses or walking behavior (Maddock et al. 2008a). a social ecological approach to create change in communities and schools and promote policy Linkage to the National for physical activity. Physical Activity Plan Evidence Base Used The Start.Living.Healthy walking campaign During Program Development was consistent with three strategies of the Mass Media Sector of the National Physical Activity This program was developed using the Theory Plan. of Planned Behavior (Montano and Kasprzyk Strategy 1: Encourage public health agen- 2002), which has been tested in numerous cies to form partnerships with other agencies research studies and found to be applicable across the eight sectors to combine resources to many behaviors, including physical activ- around common themes in promoting physical ity (Nigg et al. 2009). The campaign used the activity. Public and private partnerships were principles of other research-tested campaigns, essential to increasing the penetration of the including Wheeling Walks, Active Australia, campaign. The Hawai`i Department of Health and the earlier Start.Living.Healthy campaigns and the University of Hawai`i already had a (figure 7.1). The entire campaign was based long-standing partnership and formed the core on the six steps proposed by Noar (2006) for of the campaign. In addition, the lieutenant effective mass media campaigns. Start.Living.Healthy 59
that all of the steps are taken and that theory is truly integrated into the campaign. Recognize that what worked in another com- munity may not work in your community. We were surprised that the Wheeling Walks–style commercials called All in the Family did not test well in the target population. Taking campaigns that worked in one location and implementing them in a new location, instead of looking at the underlying deep structure around cultural norms and expectations, often does not work well. Use public figures cautiously. The lieutenant governor appeared in one of the campaign spots and also hosted the kickoff events. During this time, he was considering a run for governor. This caused statewide controversy. Several news stories questioned whether it was appropriate for him to appear in the spots. Now that a new governor of a different political party has been elected, the program cannot use any of the campaign materials that feature the lieutenant governor. Figure 7.1 E5691/NPAP/fig7.1/458527/alw/r1Flier used to promote Start.Living. Healthy’s walking program. ©Jay Maddock, Lola Irvin, Alice Silbanuz, and Bill Reger-Nash. Tips for Working Across Sectors Populations Best Served This program is part of the larger HHI. The HHI by the Program seeks to increase physical activity using the social ecological approach and partners with This program was designed for 35- to 55-year- several groups throughout the state, including olds in multiethnic Hawai`i. Women and all the state departments of transportation, parks ethnic groups, including Native Hawaiians and and recreation, and land and natural resources; Filipinos, had a high recall of the campaign and community coalitions; county governments; a positive response to the advertisements. How- and nongovernmental agencies. Partnership ever, recall of the campaign was lower among is an ongoing iterative process that is never those at 130 percent or less of the federal pov- complete. In areas in which the program has erty line and those with less than a high school been successful, key factors have included education, indicating that the campaign did articulating an enticing vision of the future, not reach some at-risk populations (Buchthal understanding the goals of partners, develop- et al. 2011). ing roles for all partners, sharing credit, and celebrating successes. Lessons Learned Start planning early. To develop an effective the- Additional ory-based campaign, allow at least six months Reading and Resources prior to the kickoff event. Political and funding realities often make it difficult to secure this Campaign Advertisements are available at preparation time, but it is necessary to ensure www.healthyhawaii.com/about/about_start_ 60 Maddock, Irvin, Silbanuz, and Reger-Nash
living_healthy/step_it_up_hawaii_media_cam- Maddock, J.E., A. Silbanuz, and B. Reger-Nash. 2008. paign.htm. Formative research to develop a mass media cam- paign to increase physical activity and nutrition in a multiethnic state. J. Health Commun. 13:208-15. References Marcus, B.H., V.C. Selby, R.S. Niaura, and J.S. Rossi. Buchthal, O.V., A.L. Doff, L.A. Hsu, A. Silbanuz, K.M. 1992. Self-efficacy and the stages of exercise behav- Heinrich, and J.E. Maddock. 2011. Avoiding a knowl- ior change. Res. Q. Exerc. Sport 63:60-6. edge gap in a multiethnic statewide social marketing Nigg, C.R., S. Lippke, and J.E. Maddock. 2009. Facto- campaign—Is cultural tailoring sufficient? J Health rial invariance of the Theory of Planned Behavior Commun. 16:314-27. applied to physical activity across gender, age and Centers for Disease Control and Prevention. 2007. ethnic groups. Psychol. Sport Exerc. 10:219-25. Behavioral Risk Factor Surveillance System Survey Montano, D.E. and D. Kasprzyk. 2002. The theory of Data. Atlanta, GA: U.S. Department of Health and reasoned action and the theory of planned behav- Human Services, Centers for Disease Control and ior. In: Health Education and Behavior. 3rd ed. K. Prevention. Glanz, B. Rimer, and F. Lewis, Eds. San Francisco: Maddock, J.E., and C. Johnson. 2006. Effects of a social Jossey-Bass. marketing campaign on chronic disease related Noar, S.M. 2006. A 10-year retrospective of research behaviors in a multi-ethnic community. Int. J. Behav. in health mass media campaigns: Where do we go Med. 13:S141. from here? J. Health Commun. 11:1-22. Maddock, J.E., C.A. Maglione, J.D. Barnett, C. Cabot, Pate, R.R., M. Pratt, S.N. Blair, W.L. Haskell, C.A. J. Jackson, and B. Reger-Nash. 2007. Statewide Macera, et al. 1995. Physical activity and public implementation of the 1 Percent or Less campaign. health—A recommendation from the Centers for Health Educ. Behav. 34:953-63. Disease Control and Prevention and the American Maddock, J.E., C. Marshall, C.R. Nigg, and J.D. Bar- College of Sports Medicine. JAMA. 273:402-7. nett. 2003. Development and first year results of a Physical Activity Guidelines Advisory Committee. 2008. psychosocial surveillance system for chronic disease Physical Activity Guidelines Advisory Committee related health behaviors. Calif. J. Health Promot. Report. Washington, DC: USDHHS. 1(5):54-64. Reger, B., L. Cooper, S. Booth, H. Smith, A. Bauman, M. Maddock, J.E., L. Takeuchi, B. Nett, C. Tanaka, L. Irvin, Wootan, S. Middlestat, B. Marcus, and F. Greer. 2002. C. Matsuoka, and B. Wood. 2006. Evaluation of a Wheeling Walks: A community campaign using paid statewide program to reduce chronic disease: The media to encourage walking among sedentary older Healthy Hawai`i Initiative, 2000-2004. Eval. Prog. adults. Prev. Med. 353:285-92. Plann. 29:293-300. Simpson, M.E., M. Serdula, D.A. Galuska, C. Gillespie, Maddock, J.E., A. Silbanuz, L. Irvin, and B. Reger-Nash. R. Donehoo, C. Mecera, and K. Mack. 2003. Walking 2008. Using social marketing to increase physical trends among US adults: The Behavioral Risk Factor activity and improve nutrition in Hawaii. Ann. Surveillance System, 1987-2000. Am. J. Prev. Med. Behav. Med. 35:s95. 25:95-100. CHAPTER 8 ParticipACTION The National Voice of Physical Activity and Sport Participation in Canada
Amy E. Latimer-Cheung, PhD Kelly Murumets Queen’s University ParticipACTION
Guy Faulkner, PhD University of Toronto
NPAP Tactics and Strategies Used in This Program
Mass Media Sector Support and link campaign messages to commu- nity-level programs, policies, and environmental STRATEGY 1: Encourage public health agencies to form partnerships with other agencies across the supports. eight sectors to combine resources around com- STRATEGY 6: Encourage mass media professionals to mon themes in promoting physical activity. become informed about the importance of physi- cal activity and the potential role they can play in STRATEGY 2: Enact federal legislation to support a sustained physical activity mass media campaign. promoting physical activity. STRATEGY 7: Encourage local, state, and federal pub- STRATEGY 3: Develop consistent mass communica- tion messages that promote physical activity, have lic health agencies and key stakeholders from the a clear and standardized “brand,” and are consis- eight sectors to integrate into their physical activity tent with the most current physical activity guide- plans and programs Web- and new media-based lines. physical activity interventions that are supported by evidence. STRATEGY 4: Ensure that messages and physical activity plans developed by state and local public STRATEGY 8: Expand the definition of media for me- health agencies and key stakeholders from the diated interventions to include new and emerging eight sectors are consistent with national mes- technologies such as global positioning systems, sages. video gaming, and other technologies. Identify funding for research to develop evidence that sup- STRATEGY 5: Sequence, plan, and provide campaign ports or opposes the use of existing and emerging activities in a prospective, coordinated manner. technologies for increasing physical activity.
articipACTION is a national not-for-proft active living for all Canadians. The organization Porganization solely dedicated to inspiring and its message became a Canadian source of and supporting active living and sport partici- infuence, recognition, and pride (fgure 8.1). pation for Canadians. Established in 1971, Par- In December 2000, ParticipACTION closed its ticipACTION operated for nearly 30 years and doors because of insuffcient resources. With was a leading catalyst to encourage healthy, the looming physical inactivity crisis, however,
61 62 Latimer-Cheung, Murumets, and Faulkner
ParticipACTION received a renewed commit- continually moves in a direction consistent with ment from the Canadian government and was its mission and vision. revitalized in February 2007; its 3-year vision, mission, and strategic goals for 2009-2012, the Strategic Plan period immediately after its revitalization, are The plan identified three strategic focus areas: discussed in this chapter. Since this chapter communications, capacity building, and knowl- was written, ParticipACTION has renewed its edge exchange. These areas were selected vision, mission, and strategic plan for 2012- because they leverage the strengths of the 2015. Details of recent strategic initiatives are organization and provide value to the physical available on the ParticipACTION website. activity sector in Canada (i.e., all organizations with an interest in promoting physical activity Program Description and sport participation). ParticipACTION also recognized that a single organization cannot Within a year of its revitalization, ParticipAC- address the inactivity crisis on its own. Reflect- TION undertook a comprehensive strategic ing the need for a unified approach to tackling planning process (figure 8.2). The ParticipAC- inactivity, these focus areas emphasize provid- TION board of directors and advisory com- ing resources and support to empower partner mittees and experts from across Canada who organizations within and across the physical work in relevant areas (i.e., research, health activity sector. The objectives associated with promotion, government) provided input into each area of focus are described next. the process. The resulting three-year strategic ParticipACTION’s communications objectives plan for 2009 to 2012 is presented in figure 8.2. include (1) delivering messages through mul- This plan has been critical in guiding decision timedia for the purpose of raising awareness, making. It has helped to streamline organiza- educating, inspiring, and supporting behavior tional activities, ensuring that ParticipACTION change and (2) coordinating communications
Vision ParticipACTION’s vision is to work with its partners to ensure a Canadian society where people are the most physically active on Earth.
Mission ParticipACTION’s mission is to provide leadership in collaboration and communication to foster the “movement” that inspires and supports Canadians to move more.
To animate the To have “physically To develop a legacy To set the stage for movement that active” be a part of of collaboration and long-term inspires and who we are as partnerships to sustainability of the supports Canadians Canadians and how realize the movement to become more we want to be seen movement active by the world
Figure 8.1 ParticipACTION’s vision and mission statement for 2009-2012. Reprinted, by permission, from ParticipACTION.
E5691/NPAP/fig8.1/458528/alw/r1 Vision
Leadership Communications Capacity building Knowledge exchange Marshal Deliver messages Facilitate capacity Initiate, gather, resources and through multimedia building through translate, and facilitate for the purpose of leveraging of disseminate collaborative raising awareness, assets within the information, partnerships in educating, inspiring, sector. Support data, and research order to achieve and supporting and manage (includes evaluation). the collective behavior change. development and vision. Coordinate implementation of Influence, communications to properties (but support, and promote ensure consistent, do not deliver for sustainable change. unified messaging programs). across and within the sector.
Revenue generation
Operations
Vision:E5691/NPAP/fig8.2a/458529/alw/r2-kh • A Canadian society where people are the most physically active on earth
Long-term outcomes: • “Physical activity and sport participation” is a Canadian social norm • Social and physical environments make physical activity a natural choice
Short-term outcomes: • Active collaboration with partners • Awareness of ParticipACTION and its messages
Communications Capacity building Knowledge exchange Goal: To inspire Goal: To develop a Goal: To be accessed as a Canadians to move legacy of collaboration central source or hub of more and inspire society and partnerships in the physical activity and sport to make it easier to do so. sector. participation.
Leadership Initiatives: Initiatives: Initiatives: •Public relations •Sogo active •Researcher relationships Goal: To have •National communications •AHKC Partnership •Representation, opinions, ParticipACTION campaign •Sports Day in Canada expertise embraced as •Digital/online •Amgen •Tools and tool kits synonymous •Corporate and stakeholder •Bienestock natural •Lifestyle Tips and Research Files with physical communications playgrounds •Evaluations: Programs and activity •Communications •CIRA ON Playground campaigns/ParticipACTION partnerships games organization •ParticipACTION tool kit •ParticipACTION Partner •Syndication of content •Improve the Grade campaign Network •International leadership •Speakers bureau •A-Team •Active Canada 2020 •CSEP
Revenue generation–Goal: To attract significant investment to the sector. Initiatives: • Government relations strategy • Sponsorship strategy • Licensing agreements • Charity of choice • Foundation grants Operations–Goal: To be effectively managed and operate with the highest standards of good governance. Initiatives: • HR initiatives–Pams–Policies and procedures • Finance processes–budgeting–reporting • IT plan • Systems and processes • Corporate governance • Strategic plan • Quebec/French Canada plan • Toronto office expansion
Figure 8.2 ParticipACTION’s strategic planning process. Reprinted, by permission, from ParticipACTION. 63
E5691/NPAP/fig8.2b/458530/alw/r3-kh 64 Latimer-Cheung, Murumets, and Faulkner to ensure consistent, unified messaging across advisory group, a policy advisory group, and a and within the physical activity sector. Since marketing and communications advisory group. its renewal in 2007, ParticipACTION has under- Group members have extensive expertise and taken three multifaceted mass media campaigns are able to keep ParticipACTION informed of as one of its approaches to meeting these com- the latest research evidence and practice issues. munications objectives. The target audience, ParticipACTION also is committed to creating time frame, and timing for each campaign were new knowledge by publishing findings from its determined by identifying the needs of the ongoing evaluation activities. physical activity sector and conducting exten- All of the activities ParticipACTION under- sive evaluation. The campaigns are archived on takes to meet its strategic objectives are listed ParticipACTION’s website (www.participaction. in figure 8.2. To further demonstrate how com). ParticipACTION is accomplishing its strategic ParticipACTION’s capacity building objec- objectives, several exemplary activities for each tives include (1) leveraging strengths within the focus area are presented in the following. physical activity sector by forging partnerships with and between organizations committed Communications Activities to promoting physical activity and sport par- ticipation in Canada and (2) supporting and The Think Again campaign, launched in Janu- managing the development and implementa- ary 2011, exemplifies how ParticipACTION meets tion of physical activity and sport participa- its communication objectives. The campaign tion initiatives (but not delivering programs). focused strategically on promoting awareness As a strategy for meeting the first objective, of the Canadian Physical Activity Guidelines for ParticipACTION created the ParticipACTION children and youth by targeting mothers, who Partnership Network (PPN). The PPN is a robust exert a key influence on children’s physical activ- network of organizations dedicated to physical ity (Gustafson and Rhodes 2006), and youth. activity and sport participation. Through the Using a comprehensive, integrated approach, PPN, members expand their awareness of and the campaign disseminated information via access to resources, initiatives, and expertise national media (television advertisements, print within the physical activity sector while mini- and magazine advertisements and advertorials, mizing the duplication of efforts. In addition, and digital displays), social media (blog posts, the PPN coordinates and builds on existing Facebook posts, and tweets), the ParticipAC- infrastructure and communication channels to TION website, and public relations outreach provide a mechanism for disseminating consis- activities (press releases, direct media contact). tent messaging about physical activity and sport A preliminary campaign evaluation indicated participation broadly across Canada. that, consistent with ParticipACTION’s goal ParticipACTION’s objective for knowledge of raising awareness, a greater proportion of exchange is to position itself as a hub of infor- mothers, compared with the general population, mation, data, and research related to physical recalled (without prompting) seeing an ad about activity and sport participation. ParticipACTION children’s physical activity (41 percent versus 35 aims to make the latest research findings acces- percent). Forty percent of mothers who saw the sible to policy makers and practitioners in an ad accurately recalled the key campaign mes- effort to encourage evidence-informed decision sage without prompting. Although the remaining making. In turn, ParticipACTION works to raise mothers could not recall the key message exactly, awareness among researchers regarding the the majority did recall a message consistent with gaps in the physical activity and sport partici- children’s physical activity. pation evidence base that policy makers and The Think Again campaign met the second practitioners have identified. To facilitate these objective, coordinating a consistent message knowledge exchange processes, ParticipACTION across the physical activity sector, in several established three advisory groups: a research ways. The campaign’s specific focus on mothers ParticipACTION 65 and youth allowed ParticipACTION to marshal Canadian Fitness and Lifestyle Research Insti- its resources to support national and govern- tute, a national not-for-profit research agency, ment initiatives that launched new physical to produce The Research File and the Lifestyle activity guidelines and aimed to get children Tips series. The Research File includes monthly and youth more active. ParticipACTION pro- reports summarizing research findings on vari- vided organizations in its PPN with co-branding ous topics related to physical activity. The Life- opportunities on its television and print media style Tips series, also published monthly, offers materials. As a result, PPN organizations could practical suggestions for daily physical activity. adopt ParticipACTION materials as their own, These reports are available on the ParticipAC- thus saving the organizations thousands of TION website. dollars on campaign production costs and ensuring a consistent national physical activity promotion message. Ten partner organizations Program Evaluation took advantage of this opportunity, including ParticipACTION conducts regular and ongoing national organizations (e.g., the YMCA), provin- evaluations of all its activities. This section dis- cial organizations (e.g., the Nova Scotia Provin- cusses why ParticipACTION places an emphasis cial Government), and municipal organizations on evaluation, what it evaluates, and how it (e.g., the Chatham-Kent Public Health Unit). conducts its evaluations. It also describe the baseline evaluation that was conducted imme- Capacity-Building Activities diately before ParticipACTION’s relaunch. The Sogo Active, now known as the ParticipAC- data collected at that time serve as a benchmark TION Teen Challenge, illustrates the types of for all subsequent evaluations, and they position activities it undertakes to meet its objective ParticipACTION as a natural experiment that related to building capacity in program devel- allows researchers to study the effectiveness opment. Sogo Active is a youth-focused physi- of national strategies for promoting physical cal activity movement that encourages youth activity and sport participation. to find fun reasons and new opportunities to incorporate physical activity into their daily Why? lives. Coordinated primarily through an online The data gathered from ongoing evaluations portal, the program encourages youth to sign provide evidence that ParticipACTION is accom- up for and participate in Sogo Challenges. plishing its strategic goals and moving toward Youth themselves and community organizations its vision. This evidence is used to demon- (e.g., community centers, sport leagues, yoga strate accountability to funders and to build a studios) put forth the challenges. ParticipAC- strong case when they are seeking new funding TION supports the challenges by maintaining opportunities. In line with its commitment to the online portal and providing small grants for evidence-based practice, ParticipACTION relies community groups to host challenge events. heavily on the outcomes of its evaluations to In this way, ParticipACTION does not replicate inform the development of new initiatives. services provided by organizations that offer For example, data from previous campaign physical activity programs for youth. Rather, evaluations were integral in shaping decisions ParticipACTION provides these organizations about modes of dissemination for the campaign with resources to support their programs and released in January 2011. The availability of data empowers youth to become active agents in from specific initiatives and campaigns also puts tackling the physical inactivity crisis. ParticipACTION in a position to generate new research knowledge about the effectiveness of Knowledge Exchange Activities physical activity and sport participation initia- As an example of its knowledge exchange tives—an objective within the organization’s activities, ParticipACTION collaborates with the knowledge exchange strategy. 66 Latimer-Cheung, Murumets, and Faulkner
What? established protocols for measuring media impressions and uptake. Using the strategic framework (figure 8.2) as a starting point, ParticipACTION has developed Baseline Evaluation: a logic model to guide its evaluation approach. The logic model outlines the organization’s A Natural Experiment long- and short-term goals as well as the activi- With support from a strategic funding oppor- ties it will undertake to achieve these goals. tunity from the Canadian Institutes of Health Metrics have been assigned to evaluate each Research, an independent research team col- goal and activity. These metrics are diverse and lected extensive baseline data before the official include outcomes related to awareness (e.g., relaunch of ParticipACTION in 2007. This was unaided recall of the ParticipACTION brand), an important research opportunity, because usage (e.g., the number of website visits), limitations in the evaluation of the original exposure (e.g., the number of media impres- ParticipACTION weakened the organization’s sions), behavior (e.g., the number of mothers ability to understand its real impact on physical who have looked for more information about activity. At the time of ParticipACTION’s initial physical activity for their children since view- launch in 1971 (Bauman et al. 2004), formal ing a campaign ad), uptake (e.g., the number evaluation techniques designed to assess the of community organizations that have hosted effectiveness of public health programs were a Sogo Challenge), and satisfaction (e.g., the limited. The relaunch of ParticipACTION pre- satisfaction of members within the PPN). From sented a unique opportunity to address this gap 2010 to 2011, ParticipACTION conducted 17 by collecting baseline data as a basis for future, individual evaluations, including evaluations ongoing evaluation in the form of a natural of its campaigns and activities such as Sogo experiment. Active. It surveyed the general public, members Two primary projects were embedded within of the PPN, the advisory groups, the staff, and the baseline data collection. First, the evaluation the board of directors in order to provide input team assessed baseline awareness and under- on ParticipACTION’s activities. standing of ParticipACTION at an individual level using a population-based survey of 4,650 How? Canadians conducted over six months, from August 2007 to February 2008 (see Spence et al. Because ParticipACTION is constantly involved 2009). Approximately 8 percent of Canadians in evaluation, it has been essential for the orga- were aware of ParticipACTION unprompted, nization to establish streamlined, cost-effective and 82 percent were aware when prompted. procedures for data collection. Thus, it uses a Both education and income were significant professional research agency to conduct surveys correlates of awareness. Notably, higher educa- of the general population. Survey participants tion and income were associated with greater are drawn from existing community panels, odds of ParticipACTION awareness. Second, the allowing ParticipACTION to survey specific team collected baseline data concerning orga- segments of the population quickly and easily. nizational capacity for physical activity promo- The surveys are developed by ParticipACTION, tion in Canada using an Internet-based survey with input from the research agency and the instrument and interviews with key informants advisory groups. Surveys of partners and staff across Canada. Key informants painted a gener- have been conducted online using a commer- ally positive picture of current organizational cially available online survey interface. Many capacity to promote physical activity messages, of the metrics related to usage are generated programs, and services in Canada (e.g., Faulkner from online tracking tools monitoring outcomes, et al. 2009). Overall, these studies provide the such as website visits and downloads. Partici- basis for assessing the short-, mid-, and long- pACTION monitors its media impact through a term impact of ParticipACTION at the individual partnership with a communications firm with level (in terms of awareness, attitudes, and ParticipACTION 67 behavior) and the organizational level (in terms Strategy 3: Develop consistent mass communi- of organizational capacity, readiness, and advo- cation messages that promote physical activity, cacy regarding physical activity). have a clear and standardized “brand,” and are In 2012, five years after baseline data collec- consistent with the most current physical activity tion, additional research funding from the Cana- guidelines. In accordance with standard mar- dian Institutes of Health Research was received keting practices, ParticipACTION has a brand to conduct a follow-up evaluation. The baseline strategy with a brand pyramid (available on data collection will be replicated and extended request). Up to 94 percent of Canadian adults to determine the impact of ParticipACTION’s are familiar with the ParticipACTION brand. activities since its revitalization in 2007. ParticipACTION’s messages are aligned entirely with the most current Canadian Physical Activ- ity Guidelines (refer to the 2011 Think Again Linkage to the National campaign). ParticipACTION was a principal Physical Activity Plan partner in the release of the new Canadian Physical Activity Guidelines. ParticipACTION’s activities are relevant to mul- Strategy 4: Ensure that messages and physi- tiple sectors identified in the National Physical cal activity plans developed by state and local Activity Plan (NPAP). For example, its activities public health agencies and key stakeholders from incorporate the NPAP sectors Volunteer and the eight sectors are consistent with national Nonprofit; Public Health; Parks, Recreation, Fit- messages. ParticipACTION participates in the ness, and Sports; and, most of all, Mass Media. Federal, Provincial, and Territorial Social Mar- This section relates ParticipACTION’s activities keting Working Group and has initiated the to each of the NPAP mass media strategies. PPN to encourage consistent messaging across Like the NPAP, ParticipACTION recognizes the the sector. importance of consistent and coordinated mes- Strategy 5: Sequence, plan, and provide cam- sages that promote participation in physical paign activities in a prospective, coordinated activity and sport. The implementation of the manner. Support and link campaign messages PPN and the development of detailed brand, to community-level programs, policies, and envi- government, media, and public relations strat- ronmental supports. When launching a cam- egies are central activities that contribute to paign, ParticipACTION undertakes an extensive ParticipACTION’s success in accomplishing planning process, setting short-, medium-, and this goal. long-term objectives. Campaigns are linked to Strategy 1: Encourage public health agencies the sector through the PPN. to form partnerships with other agencies across Strategy 6: Encourage mass media profession- the eight sectors to combine resources around als to become informed about the importance common themes in promoting physical activity. of physical activity and the potential role they The PPN includes members from all sectors and can play in promoting physical activity. Using encourages cross-sector dialogue and resource strategic objectives for knowledge exchange, sharing. ParticipACTION has established a media and Strategy 2: Enact federal legislation to sup- public relations strategy to educate and advo- port a sustained physical activity mass media cate for heightened awareness of physical activ- campaign. ParticipACTION has developed a ity and sport participation issues among media government relations strategy (available on personnel. This strategy also involves promoting request) to ensure that physical activity and the PPN so that messages can be deployed by sport participation have a prominent place on local organizations. the government’s funding and policy agenda. Strategy 7: Encourage local, state, and The Canadian government does not have its federal public health agencies and key stake- own physical activity mass media campaign holders from the eight sectors to integrate into but rather relies on ParticipACTION to be the their physical activity plans and programs national voice on this issue. Web- and new media-based physical activity 68 Latimer-Cheung, Murumets, and Faulkner interventions that are supported by evidence. components of its success in developing and To facilitate this process, ParticipACTION has implementing evidence-based practice. Partner- initiated the development of a national Cana- ships with researchers and research agencies dian physical activity plan, Active Canada facilitate access to and interpretation of the most 20/20. The plan aims to provide an integrated current research evidence. Regular interaction multisectoral platform to tackle the physical with practitioners ensures that ParticipACTION’s inactivity crisis. activities align with current trends in the field. Strategy 8: Expand the definition of media Having its own extensive database that docu- for mediated interventions to include new and ments the effectiveness of its practices ensures emerging technologies such as global positioning that ParticipACTION directs its resources to systems, video gaming, and other technologies. initiatives that will continue to move the orga- Identify funding for research to develop evidence nization forward. Moreover, having a strategic that supports or opposes the use of existing and goal of knowledge exchange ensures that the emerging technologies for increasing physical organization is abreast of emerging evidence activity. ParticipACTION’s Think Again cam- and that the use of evidence is at the forefront paign exemplifies the use of emerging technol- of all decision-making processes. ogy to communicate physical activity and sport participation messages. The campaign uses traditional media (print, television) as well as Populations Best Served social media and public relations to disseminate by the Program key messages. ParticipACTION’s long-term goal is to get all Canadians moving more. However, in align- Evidence Base Used ment with the priorities of the physical activity During Program Development sector, many of ParticipACTION’s recent initia- tives emphasize promoting physical activity and ParticipACTION strives to model evidence- sport participation among children and youth. based practice. When developing its strategic Each activity ParticipACTION undertakes has a plan, ParticipACTION conducted an extensive specific target group, including (but not limited market analysis, drawing on evidence from large to) mothers of young children, policy makers, epidemiological studies that documented Cana- researchers, practitioners, media personnel, and dians’ physical activity patterns (e.g., Bryan and government officials. Katzmarzyk 2009; Iannotti et al. 2009). Current evidence from research and practice serves as the foundation of each ParticipACTION mass Lessons Learned media campaign (e.g., Colley et al. 2011; Lat- Since its revitalization in 2007, ParticipACTION imer et al. 2010; Tremblay et al. 2011a, 2011b). has learned some key lessons. For example, the concept for the 2011 Think Again campaign emerged from a national report that documented parents’ lack of awareness Have a Plan . . . for Everything of their children’s levels of inactivity (Active ParticipACTION has an extensive strategic Healthy Kids Canada 2009). The content of the plan as well as plans for brand development, campaign was determined through extensive communication, evaluation, and government, focus group testing with the target audience. media, and public relations. By developing and Decisions related to modes of dissemination implementing these plans, ParticipACTION can were based on evaluations of ParticipACTION’s ensure that all of its activities are aligned with previous campaigns. the organization’s vision, that actions are evi- ParticipACTION’s partnerships with research- dence informed, and that metrics of evaluation ers and practitioners and its commitment to are matched appropriately to the outcomes of evaluation and knowledge exchange are key the plan. ParticipACTION 69
Use Advisory Groups to tackle the issue of inactivity. A coordinated effort across sectors capitalizes on, leverages One of ParticipACTION’s organizational resources for, and strengthens initiatives to pro- strengths is its willingness to listen to and learn mote physical activity and sport participation. from the physical activity sector in Canada. ParticipACTION has been especially successful Being receptive to feedback from its two advi- in facilitating cross-sectoral activities through sory groups has allowed ParticipACTION to its PPN. The PPN has created channels of com- shape and strengthen many of its initiatives to munication between sectors, and it provides reflect cutting-edge research and to respond to a mechanism for sharing resources. The PPN the needs of the sector. builds capacity at the grass roots community level. Keep the Organization’s Message Simple and Targeted Summary Nationwide initiatives promoting physical activity and sport participation often require ParticipACTION is a national not-for-profit a substantial investment of time and financial organization committed to getting Canadi- resources. As a consequence, organizations ans moving. The activities it undertakes to often try to ensure value for their investment by accomplish this goal are guided by detailed covering multiple issues at once and targeting strategic plans for communication, capacity broad segments of the population. However, building, and knowledge exchange. Central to ParticipACTION has learned that simple, tar- ParticipACTION’s success has been its efforts geted messages are quite valuable. The target to work in partnership with and across sectors. audience can more easily comprehend, inter- This collaborative approach capitalizes on the nalize, and implement a simple message than strengths of organizations within the physical a complex one. As a result, physical activity activity sector and optimizes resources. Con- organizations must adjust and align their own sistent with the fundamental principles under- initiatives with simple messages. lying the National Physical Activity Plan, the philosophy of ParticipACTION is that the only Work in Partnership With the way to tackle the inactivity crisis is through unified and comprehensive initiatives across Physical Activity Sector all sectors including, but not limited to, the ParticipACTION has carefully aligned its efforts industry, education, health care, and public with the physical activity sector’s needs and sectors. activities. This alignment ensures that the sector presents a coordinated and consistent message to the public and policy makers, while also Additional optimizing resources. Reading and Resources Visit the ParticipACTION website at www.participac- Tips for tion.com. The website includes detailed descriptions of current initiatives underway and an archive of all Working Across Sectors previous mass media campaigns. Although working across sectors (e.g., health, ParticipACTION and its activities have been featured in two special issues of academic journals: The education, physical activity) can be challeng- Canadian Journal of Public Health, available for ing at times, its value is immeasurable. The free download from http://journal.cpha.ca/index. inactivity crisis cannot be overcome by a single php/cjph/issue/view/248; and the International organization or a single sector for that matter. Journal of Behavioral Nutrition and Physical Activ- Rather, all sectors with an interest in enhancing ity, available for free download from www.ijbnpa. the health of the population must work together org/series/participaction. 70 Latimer-Cheung, Murumets, and Faulkner
Iannotti, R.J., M.D. Kogan, I. Janssen, and W.F. Boyce. References 2009. Patterns of adolescent physical activity, screen- Active Healthy Kids Canada. 2009. The 2009 report card based media use, and positive and negative health on physical activity for children and youth. www. indicators in the U.S. and Canada. J. Adolesc. Health activehealthykids.ca/ReportCard/ArchivedReport- 44(5):493-9. Cards.aspx. Latimer, A.E., L.R. Brawley, and R.L. Bassett. 2010. A Bauman, A., J. Madill, C.L .Craig, and A. Salmon. 2004. systematic review of three approaches for construct- ParticipAction: This mouse roared, but did it get the ing physical activity messages: What messages work cheese? Can. J. Public Health 95(Suppl. 2):S14-19. and what improvements are needed? Int. J. Behav. Nutr. Phys. Act. 7(1):36. Bryan, S.N., and P.T. Katzmarzyk. 2009. Are Canadians meeting the guidelines for moderate and vigorous Spence, J.C., L.R. Brawley, C.L. Craig, R.C. Plotnikoff, leisure-time physical activity? Appl. Physiol. Nutr. M.S. Tremblay, A. Bauman, G.E.J. Faulkner, K. Chad, Metab. 34(4):707-5. and M.I. Clark. 2009. ParticipAction: Awareness of the ParticipAction campaign among Canadian Colley, R.C., D. Garriguet, I. Janssen, C.L. Craig, J. Adults—Testing the knowledge gap hypothesis and Clarke, and M.S. Tremblay. 2011. Physical activity of a hierarchy-of-effects model. Int. J. Behav. Nutr. Canadian children and youth: accelerometer results Phys. Act. 6:85. from the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 22(1):15-23. Tremblay, M.S., A.G. Leblanc, I. Janssen, M.E. Kho, A. Hicks, K. Murumets, et al. 2011a. Canadian sedentary Faulkner, G., C. McCloy, R.C. Plotnikoff, A. Bauman, behavior guidelines for children and youth. Appl. L.R. Brawley, K. Chad, L. Gauvin, J.C. Spence, Physiol. Nutr. Metab. 36(1):59-71. and M.S. Tremblay. 2009. ParticipAction: Baseline assessment of the capacity available to the “new Tremblay, M.S., D.E. Warburton, I. Janssen, D.H. Pat- ParticipAction”: A qualitative study of Canadian erson, A.E. Latimer, R.E. Rhodes, et al. 2011b. New organizations. Int. J. Behav. Nutr. Phys. Act. 6:87. Canadian physical activity guidelines. Appl. Physiol. Nutr. Metab. 36(1):36-58. Gustafson, S.L., and R.E. Rhodes. 2006. Parental cor- relates of physical activity in children and early adolescents. Sports Med. 36(1):79-97. CHAPTER 9 Wheeling Walks A Targeted Mass Media–Led Physical Activity Campaign
Bill Reger-Nash, EdD Keith Zullig, PhD West Virginia University West Virginia University
Adrian Bauman, PhD, FAFPHM Lesley Cottrell, PhD Sydney University West Virginia University
Christiaan G. Abildso, PhD, MPH Matthew Gurka, PhD West Virginia University West Virginia University
NPAP Tactics and Strategies Used in This Program
Mass Media Sector health agencies and key stakeholders from the eight sectors are consistent with national mes- STRATEGY 1: Encourage public health agencies to form partnerships with other agencies across the sages. eight sectors to combine resources around com- STRATEGY 5: Sequence, plan, and provide campaign mon themes to promote physical activity. activities in a prospective, coordinated manner. Support and link campaign messages to commu- STRATEGY 3: Develop consistent mass communica- tion messages that promote physical activity, have nity-level programs, policies, and environmental a clear and standardized “brand,” and are consis- supports. tent with the most current Physical Activity Guide- STRATEGY 6: Encourage mass media professionals to lines for Americans. become informed about the importance of physi- cal activity and the potential role they can play in STRATEGY 4: Ensure that messages and physical activity plans developed by state and local public promoting physical activity.
hysical inactivity contributes signifcantly daily moderate-intensity walking among insuf- Pto morbidity and mortality in the United fciently active 50- to 65-year-old residents of States (U.S. Department of Health and Human Wheeling, West Virginia (Reger et al. 2002). The Services 2008; Lee et al. 2012). Therefore, estab- project garnered policy support from multiple lishing the effectiveness of whole-community agencies, with a focus on changing individual interventions to promote physical activity is an behavior, the community, and the environment important component of health promotion and in support of physical activity. Mass media–led disease prevention. The Wheeling Walks cam- social marketing is a cost-effective method for paign used a community-wide social marketing infuencing defned population groups within a campaign to promote 30 minutes or more of targeted geographic region.
71 72 Reger-Nash, Bauman, Abildso, Zullig, Cottrell, and Gurka
Program Description Characteristics of Wheeling • Located in northern West Virginia (Ohio The Wheeling Walks intervention was con- and Marshall Counties) ducted between June 1999 and June 2002 • Population 31,420 (in 2000) in Wheeling, West Virginia. To build on the strengths of the community, a participatory • 92.7 percent of population Caucasian planning process (Green and Kreuter 2005; • 21.6 percent of population 65 years or older Minkler and Wallerstein 2003) was initiated in • 18.0 percent of population below poverty August 1999. The process involved 37 commu- • West Virginia per capita income 75 percent nity members from local and state health agen- of the national average (in 2001). cies; business; industry; labor unions; hospitals; health clinics serving low-income residents; • Two daily newspapers the National Association for the Advancement • Two television stations of Colored People; regional voluntary associa- • 12 radio stations tions such as the American Heart Association, www.census.gov the American Cancer Society, and Diabetes Associations; civic groups such as Kiwanis and Mass Media Rotary; local parks and recreation agencies; public and private schools; colleges; faith-based Mass-reach media has the potential to com- groups; and government offices (García et al. municate to large segments of the population 2009). The participatory planning group met for and set the agenda for community-wide change one hour per week for 12 consecutive weeks to (Bauman and Chau 2009). The initial mass better understand the public health challenge media–led campaign began April 17, 2001, and of physical inactivity and to work collabora- ran for eight weeks, with paid print, television, tively toward a solution. From this group, task and radio messages (produced by Zimmerman forces were established to identify the potential and Markman of Santa Monica, California). target behavior (walking); an at-risk population Formative research determined that lack of time (residents 50-65 years of age); campaign compo- and perceived lack of energy were the two most nents (paid media, media relations to generate common barriers to regular physical activity earned media, public health activities, policy, that the target audience reported. Therefore, the environment, and evaluation); potential funding advertisements focused on helping the target sources; infrastructure challenges; and potential audience overcome these specific barriers to intersectoral partners. Twenty months of plan- regular walking. (See www.wheelingwalks.org/ ning preceded the 12-month social marketing WW_TrainingManual/TM_index.asp.) intervention, which included an initial intensive People live in a media-cluttered world and are eight-week paid mass media–led campaign, bombarded with myriad messages to support an earned media–led booster with extensive their unhealthy behaviors. The Wheeling Walks media relations and no paid ads during the fifth campaign communicated a single overarching month, and a final paid mass media–led booster tagline, “Walk at least 30 minutes daily,” to campaign during month 11. The participatory more than 85 percent of the target population planning process successfully brought together during the first eight-week campaign. The community representatives to own the public prime-time television and radio advertising health problem of physical inactivity. The purchase included 683 prime-time 30-second majority of the participatory planning members television ads and 1,988 prime-time 60-second volunteered to become the Wheeling Walks radio ads, which represented more than 5,100 Community Advisory Board and to work col- television and 3,400 radio gross rating points laboratively in campaign planning, fund-raising, (Reger et al. 2002). Each gross rating point implementation, and evaluation. represents a theoretical campaign exposure to Wheeling Walks 73
1 percent of the market. Thus, accumulation of local dignitaries, such as the mayor, the medi- 100 television and radio gross rating points sug- cal director of the local health department, and gests that up to 100 percent of the market would representatives of the participating organiza- be exposed to the television and radio ads. The tions. The campaign kickoff message was dis- campaign also ran 28 one-eighth-page ads (see seminated by television, radio, and newspaper figure 9.1) in the local daily newspaper and to more than 100,000 consumers in the media aired 1,164 thirty-second cable television ads. catchment area through coverage of this event. Media relations events communicated cam- A weekly column on walking was included in paign messages without purchasing advertise- the Sunday edition of the largest daily newspa- ments, a process known as “earned media.” per (figure 9.2). Public health campaign organizers cannot The eight-week campaign included public present information alone to news gatekeepers health education activities designed to facilitate (Abroms and Maibach 2008). Rather, campaign walking-related social networking and social messages must be linked to newsworthy events. support. These included a speakers’ bureau Therefore, the initial phase of the campaign and worksite wellness walking campaigns. included five media relations events, spaced Physicians volunteered to write prescriptions for approximately two weeks apart. walking, as appropriate to their patients’ health The campaign kickoff, for example, was held status and needs. A professional engineer from in the brightly decorated foyer of the Wheel- West Virginia University conducted a workshop ing Civic Center. Approximately 200 people titled Walkable Wheeling to help community attended this event, which included a dais of leaders appreciate the role that public policy and
Figure 9.1 Print newspaper advertisement, which featured the same actors as in the TV commercials. Reprinted, by permission, from Zimmerman and Markman, Inc. E5691/NPAP/fig9.1/458532/alw/r1 74 Reger-Nash, Bauman, Abildso, Zullig, Cottrell, and Gurka
Figure 9.2 Newspaper column from theE5691/NPAP/fig9.20/458533/alw/r1 Wheeling News-Register that highlighted the Wheeling Walks cam- paign kickoff. Reprinted, by permission, from J. Michael Myer, 2001, Wheeling News-Register. the physical environment can play in enabling more than 300 participants, was cosponsored and reinforcing or discouraging walking. The with Ogden Newspapers, which also sponsored mayor of Wheeling established the Walkable the United States National 20K running cham- Wheeling Task Force, which has met every two pionship in Wheeling. Because of the Wheeling months since May 2001 to promote programs, Walks campaign, a walking category was added policy, and environmental change. to the running event. A four-week media relations booster cam- paign was planned to generate earned media Funding during September 2001. The catastrophic terror- ist events of September 11, 2001, resulted in the In 1999, the West Virginia Bureau for Public cancellation of this phase of campaign actions. Health provided a $20,000 participatory plan- The campaign conducted booster activities ning grant to address the growing problem during month 11, March 2002, which included of obesity in Wheeling, and the Benedum 521 and 370 local network television and radio Foundation provided a $30,000 grant for the gross rating points, respectively. The campaign development of the campaign message and also purchased four 1/8th-page newspaper ads materials. In 2001, the Robert Wood Johnson and orchestrated four media relations events. Foundation provided a $354,000 grant for A multiweek walking clinic, which attracted the design, implementation, and evaluation Wheeling Walks 75 of the targeted physical activity intervention. cent of wave 4 Wheeling respondents. Eighty- Additional funding was provided by Wesbanco one and 83 percent of telephone respondents ($15,000), a Wheeling-based bank; the West reported an awareness of the campaign in the Virginia Tobacco settlement fund ($20,000 to news (earned media) for wave 2 and wave 4, examine the impact of walking on tobacco use); respectively. Overall, Wheeling, the interven- and two local hospitals ($17,500). tion community, showed a 14 percent increase in the likelihood of walking (attained at least 30 minutes, five days per week) compared Program Evaluation with the matched control community. This change among the most inactive at baseline was Process evaluation data comprised the number observed immediately after the most intense of community events, number of participants, social marketing campaign and was still in place ads purchased, earned media hits, and self- 12 months later. The mass media campaign reported campaign awareness. In addition, the was integrated with other strategies, includ- campaign monitored task force commitment ing health professional advice programs and and engagement with Wheeling Walks over environmental and policy change initiatives. time. Impact evaluation used a quasi-experi- The latter involved developing and maintaining mental design with a demographically matched partnerships across sectors, and these elements comparison community. Data were collected have been maintained for more than a decade. from cohort samples through four waves (base- As a result, rail-trail mileage in the Wheeling line, 3 months, 6 months, and 12 months after area has more than doubled since 2002, and a baseline) of random-digit-dial telephone surveys regional trail plan is now complete (see www. in Wheeling and Parkersburg, West Virginia, wheelingheritage.org/pdf_docs/WHTX.pdf). a comparison community on the Ohio River This community program shows the effects of (Reger-Nash et al. 2005a). Impact data included mass media as an initial catalyst to community assessment of awareness, behavioral intention, awareness, promotion of interagency engage- and walking behaviors from baseline to 3 and ment, and development of sustainable struc- 12 months after baseline. tures to carry forward the process of building The participatory planning process served as environments that support physical activity. a springboard for process and impact changes, which have resulted in the long-term sustain- ability of the intervention. The 37 participatory Linkage to the National planning members represented more than 10 sectors of the community. Some members of Physical Activity Plan the original Walkable Wheeling Task Force Wheeling Walks was an exemplary community- (now called the Ohio Valley Trail Partners) wide program that optimizes the principles continue to lead the efforts to effect policy and outlined in the Mass Media Sector of the environmental changes 10 years later. Changes National Physical Activity Plan. The campaign observed over time among the task force mem- had a clear message and a local “brand,” and it bers included increased commitment, shared consisted of a planned sequence of messages, purpose, and interagency trust across the plan- public relations, and community programming. ning process (Reger-Nash et al. 2006a). Impact The most important principle was that paid evaluation surveys showed high community mass media was required as an initial focus of campaign awareness in Wheeling, with 92 per- Wheeling Walks, but this was integrated into a cent and 89 percent awareness reported by wave comprehensive set of community activities that 2 and wave 4 respondents (3 and 12 months were broader than the mass communications after baseline), respectively (Reger-Nash et al. component alone. The maintenance of the local 2005a). The television ads specifically were task forces epitomized partnership formation, recalled by 77 percent of wave 2 and 93 per- which led to the sustained environmental and 76 Reger-Nash, Bauman, Abildso, Zullig, Cottrell, and Gurka policy work to build infrastructure to support messages. Some of the early community work physical activity in the community. This best- suggested that the campaign should be titled practice approach requires local leadership to One Mile or More, For Sure! However, forma- take over and sustain community programs after tive research indicated that “Walk at least 30 formal funding has ceased. minutes daily” was a more effective message The efforts of the Wheeling Walks interven- and consistent with the 1996 Surgeon General tion model support the strategies in the Mass guidelines. In addition, Wheeling Walks pro- Media Sector of the National Physical Activity cedures were consistent with the second tactic Plan: identified in Strategy 4: “Develop a . . . training Strategy 1: Encourage public health agencies manual on the use of the mass media messages to form partnerships with other agencies across . . . for use by state and local campaigns and the eight sectors to combine resources around key stakeholders. Involve users in creation of common themes to promote physical activity. these tools.” Campaign leaders and community From the inception of the intervention, the stakeholders developed an implementation transdisciplinary campaign team worked dili- guide that is generalizable to other settings and gently to partner with key community groups. communities. This manual is freely available For example, the participatory planning task at www.wheelingwalks.org/WW_Training- forces of Wheeling Walks formed partnerships Manual/TM_index.asp. with the local hospitals, which have a vested Strategy 5: Sequence, plan, and provide cam- interest in addressing health problems related paign activities in a prospective, coordinated to physical activity. Hospital representatives manner. Support and link campaign messages served on the task forces and advisory board, to community-level programs, policies, and and the hospitals contributed $17,500 to deliver environmental supports. The Wheeling Walks the campaign’s targeted message. Educational intervention approach called for broad-based programs, such as the 20 Weeks to the 20K community capacity building, which led to walking workshop, were held in the community policy-related changes. This was conducted at facilities of our intervention partners. The West the local city level. The Wheeling Walks model Virginia Bureau for Public Health contributed supports the National Physical Activity Plan and $20,000 to the campaign’s mass media pur- the West Virginia State Physical Activity Plan. chases to help address the comorbidities of Strategy 6: Encourage mass media profession- inactivity and tobacco use. als to become informed about the importance Strategy 3: Develop consistent mass communi- of physical activity and the potential role they cation messages that promote physical activity, can play in promoting physical activity. Over have a clear and standardized “brand,” and are time, the Wheeling model has been refined. consistent with the most current Physical Activ- During the initial campaign, the mass media ity Guidelines for Americans. The local Wheel- gatekeepers were clearly supportive of the ing Walks message was clearly “branded” and efforts. In Morgantown, West Virginia, the same showed high population reach, with recognition mass media community intervention model by 90 percent of the target population. The cam- was used from 2003 to 2005. In that city, the paign promoted a single unequivocal message, local newspaper became a major proponent “Walk at least 30 minutes daily,” which was of improvements in pedestrian infrastructure. developed in accordance with the 1996 Surgeon When the Morgantown Municipal Pedestrian General’s Report on Physical Activity and Health Safety Board developed a tax schedule to fund and remains consistent with the 2008 Physical changes to better support walking in the city, Activity Guidelines for Americans. the local newspaper, The Dominion Post, hosted Strategy 4: Ensure that messages and physi- a public forum to further promote the idea. cal activity plans developed by state and local The newspaper has been willing to cover news public health agencies and key stakeholders from events related to walking and bicycling, almost the eight sectors are consistent with national regardless of the content. Wheeling Walks 77
Evidence Base Used During 2001). Paid mass media offers the possibility of directing communications specifically to audi- Program Development ence segments or subpopulations. For example, Nielsen television ratings specify which sub- Promoting small changes across a large number populations are watching individual television of people in a community is more of a public programs. Similar targeting is possible when health approach than are intensive interven- purchasing newspaper and radio advertising. tions that focus on large changes among a few The most powerful single source of informa- individuals (Rodgers et al. 2004). The 1996 tion in the United States is television (Nielsen Surgeon General’s Report on Physical Activity Company 2009). Wheeling Walks identified a and Health recommended engaging in at least segment of the Wheeling-Steubenville television 30 minutes of daily moderate intensity physical broadcast mass media market, insufficiently activity and stated that walking is an excellent active 50- to 65-year-old residents of Wheeling, way of attaining the recommended amount of as its target population. There are 215 network physical activity. television and 210 cable television mass media Following the guidance provided by the markets within the United States. Most of Ottawa Charter for Health Promotion (1986), these markets are served by at least one daily Wheeling Walks used a participatory planning newspaper and several dominant radio stations. process (Reger et al. 2002) to mobilize the com- These avenues enable providers to bombard the munity to address physical inactivity among the population segment to communicate a message. target population (Green and Kreuter 2005). The Specific replication efforts explored the poten- goals were to better appreciate the epidemio- tial implications of generalizing the Wheeling logical, behavioral, environmental, and policy Walks program to other settings and age groups. aspects of the problem and to work with the In Welch Walks (Reger-Nash et al. 2005b), the community to develop sustainable solutions age group was expanded to include those ages to them. 35 to 65 years. BC Walks (Reger-Nash et al. Research has shown that mass media can 2006b) and WV Walks (Reger-Nash et al. 2008) be used effectively to communicate targeted focused on residents ages 40 to 65 years. The messages to select populations (Snyder and results of these campaigns (briefly described Hamilton 2002). By following the CDC Preven- later in the chapter) were not as robust as those tion Guide (www.thecommunityguide.org/ for Wheeling Walks. index.html) recommendations, programmers can effectively integrate mass media into a multicomponent campaign (Kahn et al. 2002). Lessons Learned In Wheeling, the campaign messages were A single unambiguous message (campaign designed using the Theory of Planned Behavior theme, brand, or tagline) is critical for effective (Ajzen 2002) and the Communications Hierar- public communication (Snyder and Hamilton chy of Effects Theory (McGuire 1984). 2002). Problems in public health are so numer- ous that practitioners and researchers often Populations Best Served attempt to do and communicate too much. by the Program To attempt to do everything is to do nothing. Adequate planning with formative research can Often the segments of the population most in help to avoid pitfalls in the implementation of need are those least likely to become involved a program into a community. in health promotion programs. The needs Available funding will determine the amount assessment for Wheeling Walks demonstrated of time needed for planning. Wheeling Walks that nearly 80 percent of those ages 55 to 64 (Reger et al. 2002) and the subsequent WV years were insufficiently active (West Virginia Walks program (Reger-Nash et al. 2008) had Department of Health and Human Resources little money when planning began, and each 78 Reger-Nash, Bauman, Abildso, Zullig, Cottrell, and Gurka community intervention required 18 months to plan. By contrast, BC Walks had significant funding through the New York State Health Department (Reger-Nash et al. 2006b) at the start of the program. In this case, the planning period was shorter, with a six-month time frame from initial planning to social marketing campaign implementation. Developing a “logic model” of the expected impacts and outcomes of the program at each stage can be a useful planning tool (Huhman et al. 2004; Reger- Nash et al. 2011). Paid mass media facilitates effective targeting of subpopulations within a community. By pur- chasing newspaper and prime-time television and radio advertisements, campaign planners "B.C. Walks" logo appears with permission of John L. Hart FLP. are able to focus specifically on certain popula- E5691/NPAP/fig9.3/458534/alw/r1 tions within defined geographic boundaries. Mass media markets are not always as they resulted in a significant 12 percent increase in appear. First, program planners need to verify the likelihood of walking in the intervention that the television, radio, and newspaper media community compared with the control commu- markets cover the targeted region. The experi- nity (Reger-Nash et al. 2008). These replication ence of the WV Walks campaign in Morgan- studies, which adapted the original Wheeling town, West Virginia, was illustrative. Although Walks campaign, produced smaller but consis- most Morgantown residents receive their local tently reliable results. network television from West Virginia affiliates, By making slight modifications to profes- program planners learned late that approxi- sionally prepared mass media materials, pro- mately one fourth of the region was covered grammers can adapt advertising packages and by the Pittsburgh television market, which was generic messages to fit different communities. too expensive to purchase for the small number Media relations provide an opportunity to tailor of targeted residents. Media coverage was also campaign materials to the local community, as an issue in the quasi-experimental design for live local personalities and talents are incorpo- evaluation, as planners tried to ensure that rated into staged media events. The Wheeling comparison communities were uncontaminated experience showed that the mass media can cat- by the media campaign messaging in the inter- alyze and synergize targeted intervention efforts vention region. at the community level to influence change. The community model described here can Social marketing activities done correctly, with be scaled up or down. Welch, West Virginia, initial extensive and paid mass media, can serve used another version of this community inter- as high-energy, high-profile initial intervention vention model in a much smaller community, elements, which a community can then embrace with a total budget of $10,000. That program as a significant value-added component. created change in knowledge, but not behavior, in the low-income community of 5,000 (Reger- Nash et al. 2005b). BC Walks represented a Tips for more rigorous, scaled-up implementation of Working Across Sectors the model in Broome County, New York, a com- munity in excess of 200,000. That campaign The effectiveness of a community-wide effort resulted in a statistically significant increase in is predicated on involving a broad spectrum of campaign awareness and walking (Reger-Nash community sectors in the intervention. Promot- et al. 2006b). WV Walks, which targeted the ing physical activity requires involving much 15-county area of north-central West Virginia, more than the health sector, as education, urban Wheeling Walks 79 planning, recreation, and other sectors all play 1986. Ottawa charter for health promotion. Paper key roles in developing sustainable policy and presented at the First International Conference on environmental infrastructure for physical activ- Health Promotion, Ottawa, Canada. ity. Many of these groups will be in competition with one another for local government resources and may be reluctant to support an initiative References that is perceived to be “owned” by only one agency. For Wheeling Walks, a steering commit- Abroms, L.C., and E.W. Maibach. 2008. The effec- tiveness of mass communication to change public tee linked the campaign to West Virginia Uni- behavior. Ann. Rev. Public Health 29:219-34. versity and the County Health Department, both perceived to be politically neutral. Invitations Ajzen, I. 2002. Perceived behavioral control, self- efficacy, locus of control, and the theory of planned were also extended to labor unions, low-income behavior. J. Appl. Soc. Psychol. 32(4):665-83. advocacy groups, public and private schools, all local colleges, voluntary associations, faith Bauman, A., and J. Chau. 2009. The role of media in promoting physical activity. Journal of Physical and minority-based groups, civic organizations, Activity and Health 6(Suppl 2):S196-210. and health-related professional organizations. Bauman, A. and D. Nutbeam. 2013. Evaluation in a By initially working together for the 12 weeks Nutshell: A Practical Guide to the Evaluation of of the participatory planning process, the plan- Health Promotion Programs 2nd Ed. Sydney, Aus- ning group developed better collaboration and tralia: McGraw-Hill. a shared agenda. Campaign news updates were García, R., A. Bracho, P. Cantero, and B.A. Glenn. 2009. sent to groups that were unwilling or unable “Pushing” physical activity, and justice. Prev. Med. to attend the participatory planning sessions, 49(4):330-3. in order to keep them involved. The Walkable Green, L.W., and M.W. Kreuter. 2005. Health Program Wheeling Task Force continues to serve the Planning: An Educational and Ecological Approach. policy and environmental needs of the commu- 4th ed. New York: McGraw-Hill. nity, as is illustrated at www.wheelingheritage. Huhman, M., C. Heitzler, and F. Wong. 2004. The org/pdf_docs/WHTX.pdf. VERB™ campaign logic model: A tool for planning A key feature of the Wheeling Walks model and evaluation. Prev. Chronic Dis. 1(3). www.cdc. was that it used mass media to initiate com- gov/pcd/issues/2004/jul/04_0033.htm. munity actions. The models used in communi- Kahn, E.B., L.T. Ramsey, R.C. Brownson, G.W. Heath, ties elsewhere in West Virginia and New York E.H. Howze, K.E. Powell, et al. 2002. The effective- State (Welch Walks, WV Walks, and BC Walks) ness of interventions to increase physical activity: were derived from the initial Wheeling program A systematic review. Am. J. Prev. Med. 22(Suppl and reported smaller but still clear community 4):73-107. effects on walking. A public health program Lee, I.M., E.J. Shiroma, F. Lobelo, P. Puska, S.N. Blair, should be tested, replicated, and, if deemed and P.T. Katzmarzyk. 2012. Effect of physical inactiv- effective, generalized (disseminated) across a ity on major non-communicable diseases worldwide: state or larger region (Bauman and Nutbeam an analysis of burden of disease and life expectancy. 2013). This up-scaling appears warranted based The Lancet, 380(9838), 9-19. on the results of this set of community-level McGuire, W.J. 1984. Public communication as a strategy mass media campaigns. These campaigns also for inducing health-promoting behavioral change. support the potential for mass media as an Prev. Med. 13(3):299-313. initial step in increasing physical activity at the Minkler, M.E., and N.E. Wallerstein. 2003. Community population level. Based Participatory Research for Health. San Fran- cisco: Jossey-Bass. The Nielsen Company. 2009. A2/M2 Three screen Additional report: 1st quarter 2009. http://blog.nielsen.com/ Reading and Resource nielsenwire/wp-content/uploads/2009/05/nielsen_ threescreenreport_q109.pdf. Canadian Public Health Association, Health and Reger, B., L. Cooper, S. Booth-Butterfield, H. Smith, A. Welfare Canada, and World Health Organization. Bauman, M. Wootan, et al. 2002. Wheeling walks: A 80 Reger-Nash, Bauman, Abildso, Zullig, Cottrell, and Gurka
community campaign using paid media to encourage Chronic Dis. 3:A90. www.cdc.gov/pcd/issues/2006/ walking among sedentary older adults. Prev. Med. jul/05_0138.htm. 35(3):285-92. Rodgers, A., M. Ezzati, S. Vander Hoorn, A.D. Lopez, Reger-Nash, B., A. Bauman, S. Booth-Butterfield, L. R.-B. Lin, C.J.L. Murray, et al. 2004. Distribution of Cooper, H. Smith, T. Chey, et al. 2005a. Wheeling major health risks: Findings from the global burden walks: Evaluation of a media-based community of disease study. PLoS Med. 1(1):e27. intervention. Family and Community Health Snyder, L.B., and M.A. Hamilton. 2002. A meta-analysis 28(1):64-78. of us health campaign effects on behavior: Empha- Reger-Nash, B., A. Bauman, L. Cooper, T. Chey, and K. size enforcement, exposure, and new information, Simon. 2006a. Evaluating communitywide walking and beware the secular trend. In: Public Health interventions. Eval. Program Plann. 29:251-9. Communication: Evidence for Behavior Change Reger-Nash, B., A. Bauman, L. Cooper, T. Chey, K.J. (pp. 357-83). R. Hornik, Ed. Mahwah, NJ: Lawrence Simon, M. Brann, et al. 2008. WV walks: Replication Erlbaum. with expanded reach. Journal of Physical Activity U.S. Department of Health and Human Services. and Health 5(1):19-27. 1996. Physical Activity and Health: a Report of the Reger-Nash, B., A. Bauman, B. Smith, C. Craig, C.G. Surgeon General. Atlanta, GA: National Center for Abildso, and K.M. Leyden. 2011. Organizing an effec- Chronic Disease Prevention and Health Promotion. tive communitywide physical activity campaign: A U.S. Department of Health and Human Services. 2008. step-by-step guide. ACSM’s Health Fit. J. 15(5):21-7. 2008 Physical Activity Guidelines for Americans (p. Reger-Nash, B., L. Cooper, J. Orren, and D. Cook. 2005b. 61). Atlanta, GA: Office of Disease Prevention and Marketing used to promote walking in McDowell Health Promotion. County. WV Med. J. 101(3):106. West Virginia Department of Health and Human Reger-Nash, B., P. Fell, D. Spicer, B.D. Fisher, L. Cooper, Resources, Bureau for Public Health, Office of Epide- T. Chey, et al. 2006b. BC walks: Replication of a miology and Health Promotion. 2001. West Virginia communitywide physical activity campaign, Prev. 1999 Behavioral Risk Factor Survey. Charleston, WV. CHAPTER 10 Mass Media Campaigns to Promote Physical Activity Australia and New Zealand as Case Studies
Adrian Bauman, PhD, FAFPHM Sue Walker, PhD Sydney University Sport and Recreation New Zealand (SPARC)
Grant McLean, BA (hons) Trevor Shilton, MSc Sport and Recreation New Zealand Heart Foundation and University (SPARC) of Western Australia
Bill Bellew, MPH, DPH Sydney University
ass media campaigns increasingly are had clear links to community programs and Mbeing used as part of a public health policy and environmental change strategies, in approach to addressing physical inactivity. They addition to the mass reach communications. are purposive and usually include paid media These features, plus a focus on defining a clear placements that have a wide population reach. brand for physical activity, use of marketing In this chapter, we provide three examples of strategies, and sufficient media exposure, made mass reach campaigns that used paid communi- the three campaigns more typical of social cations through the media to promote moderate- marketing than simple mass media campaigns intensity, regular physical activity (PA) to adult (Maibach et al. 2002). The three campaigns are populations in Australia and New Zealand. described separately and then compared with The first was a national campaign in New each other and with the mass media strategies Zealand, Push Play, led by the national sport recommended in the U.S. National Physical and recreation agency, between 1999 and 2009. Activity Plan. The next example is the Active Australia cam- paign, conducted initially in New South Wales and subsequently in other states. It emanated New Zealand: Push Play from Active Australia, a federal partnership of health departments and sport and recreation Mass media campaigns are often developed by departments, and lasted from 1998 to 2001. government to highlight health issues, promote The last example is from the state of Western awareness, and increase community engage- Australia, where the Find Thirty campaign has ment. In New Zealand, the comprehensive been conducted for almost a decade; here we program, Push Play, was facilitated by the report findings from the first phase of this initia- national sport agency initially named the Hillary tive, 2002 to 2006. Commission and later called SPARC, Sport and One feature of the campaigns is worth noting. Recreation New Zealand, which managed and All three were strongly grounded in intersectoral delivered the Push Play mass media and social national or state partnerships or task forces and marketing campaign.
81 82 Bauman, McLean, Walker, Shilton, and Bellew
Program Description were followed by a longer message showing a variety of New Zealanders making choices Push Play (phase 1: 1999-2002; phases 2 and to include physical activity in their lives. The 3: 2003-2009) was a national mass media campaign logo for Push Play looked like a green campaign to promote physical activity. The “play” button on a video recorder, suggesting campaign built gradually over several years, that people make a start to become more active. with the initial focus (phase 1) to raise aware- Push Play was built as a social marketing brand ness of the 30-minutes-a-day physical activity to reflect the positive values of being upbeat, message among New Zealand adults. Push Play fresh and clean, fun, Kiwi, family-based, and later focused on defining and targeting priority physically active. subpopulations through an audience segmen- In addition to paid major media, extensive tation analysis (phase 2). Phase 3 included a resources and merchandising supported the specific focus on young people. The campaign campaign. Other national initiatives were emanated from New Zealand’s response to the implemented under the umbrella of Push Play, U.S. Surgeon General’s Report on Physical Activ- including the well-evaluated Green Prescrip- ity and Health; a National Health Committee tion Scheme for General Practitioners (family report, Active for Life: A Call for Action (1998); physicians) (Elley et al. 2003) and He Oranga and the Hillary Commission’s (now SPARC) Poutama (since 1997), a program encouraging Physical Activity Taskforce Report: More People, healthy lifestyles for Maori (the indigenous More Active, More Often (1998). The latter New Zealand population). Regional sports recommended a comprehensive multisectoral trusts, which are independent nongovernment approach to promoting physical activity for sports agencies, worked with local public health health, starting with a national mass media agencies to develop and promote local events, campaign. The strategy initiated a joint policy including local celebrations of the national Push statement on physical activity signed by both Play Day. the Hillary Commission and the Ministry of Phase 2 of the Push Play campaign moved Health. from focusing on raising awareness among the Details of the Push Play campaign are shown general population to targeting less active popu- in table 10.1, left column. Phase 1 promoted 30 lation subgroups. A national survey of physical minutes of daily, moderate-intensity physical activity barriers and motivators called Obstacles activity as a fun and easy-to-achieve goal that to Action (SPARC 2003) provided audience seg- New Zealand adults could integrate into com- mentation research for this phase. From 2003 munity life. The objectives were to increase through the end of the campaign, Push Play awareness of the benefits of physical activity media focused on inactive population groups. and to encourage people to think about becom- New Push Play mass media, resource develop- ing more physically active. The campaign was ment, and on-the-ground initiatives (e.g., the supported by community-level and health care Activator, Push Play Nation, Push Play Family programs and events. The latter included a phy- Challenge) were aimed at providing specific sician’s written advice and referral for patients information and resources for these groups. to become more physically active, using a Green Phase 3 of Push Play (2006-2009) targeted Prescription (Elley 2003). The Green prescrip- children and young people and coincided with tion was an evidence-based tool for primary SPARC’s issuing PA guidelines for youth, which care doctors to prescribe physical activity, recommended that youth participate in 60 and these were disseminated, and physicians minutes of physical activity on most days and trained, through the Push Play initiative. The limit time spent watching television (SPARC Push Play campaign was launched in 1999 with 2007). SPARC and the Ministries of Health two 15-second silent commercials that showed a and Education developed this phase jointly. It person in a sedentary pose with signal distortion included mass media and used the school set- lines across the screen and a written message ting for resource and program marketing and “Do not adjust your set, adjust your life.” These distribution. Table 10.1 Elements of the Australian and New Zealand Mass Media Campaigns Active Australia Find Thirty, Western Characteristic Push Play NZ 1999-2009 1998-2000 Australia 2002-2006 Demography, setting NZ, population 4.3 State of NSW, Australia; Western Australia; million, mix urban and highly multicultural mix, growing population , rural; 1 in 7 indigenous population 7 million; currently 2.3 million; (Maori). >85% in coastal com- most in urban Perth; 3% munities; 2% indig- indigenous. enous. Phases of campaign Phase 1: 1999-2002; Phase 1: adults 25-60 Phase 1: 2002-2006 of and target population middle-aged adults. years old. annual Find Thirty cam- Phase 2: target seg- Phase 2: seniors 55-75 paigns; targeted middle- ments. years old. aged adults in state of Phase 3: youth cam- Both carried out in NSW Western Australia. paign. state only. Formative evaluation Use of population Extensive use of popula- Use of population data surveillance data; focus tion PA data and quali- and formative research groups and consulta- tative focus group to (TNS Social Research tions in 1999; identified develop messages for 2006). generic approach, mes- phases 1 and 2. sage, logo. Implementation: cost, Phase 1: $3 million Phase 1: $700,000 $700,000 funding; aver- reach, TARPs and GRPs (NZD)* TARPs: every (AUD)* funding; 800 age 800 TARPs in three adult had seen each TARPs reaching 65% of media waves per year. Push Play message 5-8 the target audience in Lower TARPs in mainte- times. prime time. nance periods. Research design Serial cross-sectional Phase 1: independent Up to 14 small sample surveys 1999-2002; population samples in serial cross-sectional smaller tracking surveys NSW; comparison in tracking surveys from thereafter. rest of Australia; and 2002 (year 1) to 2006. cohort pre-post only in NSW.** Initial or baseline aware- Specific PP message Pre-campaign ex- Spontaneous recall in ness 29.8% at year 1, recog- act message recall year 1 was 43%, sub- nized logo 13.5%. 2.1%, prompted recall sequent median 45%; 12.9%.*** prompted recall 84%, Phase 2: 3.9% subsequent median 77%; spontaneous slo- Peak awareness Specific PP message Phase 1: Post-campaign gan recall 22% at end 57.2% at year 3; recog- exact recall 20.9%, of year 1; subsequent nized logo 52.0%. prompted recall 50.7%. median 17%. Phase 2: 48.5% Other impact reported In phase 1, no sustained In phase 1, knowledge Understand how much changes in PA levels, items and efficacy about PA is needed for health although in other popu- PA increased in NSW; baseline 44%, subse- lation surveys, 3% in- no change elsewhere; quent median 57%. Suf- crease in PA was noted PA showed a small ficient PA 51% at year among adults between increase in NSW, de- 1, subsequent median 1997 and 2001. creased elsewhere. estimate 65.5%. GRP = gross rating points; NZ = New Zealand; NSW = New South Wales; PA = physical activity; PP = Push Play; TARPs = target audience rating points. TARPs are similar to GRPs in North America. *Dollar values are Australian dollars (AUD) and New Zealand dollars (NZD) and at the times of these campaigns were typically 70 to 80 cents US (AUD) and around 60 cents US (NZD). **For details of this research design see (Bauman et al. 2001). ***Note that these are “ghost” (spurious baseline) values, because they were measured before the campaign had ever been shown.
83 84 Bauman, McLean, Walker, Shilton, and Bellew
Program Evaluation tion and in targeted messages to particular subgroups. Collaborative local messaging and Phase 1 of Push Play was evaluated with annual associated activities contributed to the cam- cross-sectional population surveys (1999-2002) paign’s success. The long-term sustainability of that monitored the impact of the campaign on the Push Play campaign was noteworthy, and message awareness, recognition of the Push even since its formal suspension in 2009, local Play logo, intention to be active, and recent regions and areas continue to market events activity (table 10.1). Process evaluation data under the Push Play brand. suggested sufficient media purchased to reach The key features that made this campaign almost all adults at least once and for them to successful included the development and sus- have seen a Push Play message approximately tained use of a strong recognizable brand with five to eight times. Phase 1 of the Push Play repeated use of paid television mass media media campaign was successful in reaching the throughout the campaign. Further, the over- general adult population and increasing aware- arching tagline was a simple, consistent core ness in this broad population group (see table message for all marketing (with consistent 10.1; also Bauman et al. 2003). A key element messaging referring to 30 minutes or half an in its success was the supportive role played by hour of physical activity daily). The Push Play community programs, primary care programs, campaign had strong links to community-based and regional events. initiatives across settings—sport and recre- Cross-sectional tracking surveys of the Push ation, primary care, community events, and Play campaign were continued for phases 2 schools—and capitalized on cross-government and 3 between 2004 and 2009. This monitoring agency policy and program support, including indicated a continuation of strong recognition national and regional strategies and national of the Push Play message (averaging 50 percent physical activity guidelines (adults and young unprompted and 80 percent prompted among people). To increase the longevity of the initia- the target group). There was a trend toward tive, it was supported by an interdisciplinary stronger message recognition and intention advisory group (consisting of practitioners, to change behavior and even some increase marketing experts, social science profession- in reported physical activity among the broad als, and researchers) and was subject to ongo- target groups. Parents also were surveyed to ing monitoring, evaluation, and review of the assess their awareness of the Push Play guide- impact and relevance of the campaign. lines for young people and allied initiatives targeting young people. Levels of awareness tended to be lower than in phase 1, possibly Active Australia Campaign reflecting the addition of new messages and some confusion around the messages for Phases 1 and 2 30-minute (adult) and 60-minute (children) The Active Australia partnership between the recommendations. Independent national physi- health sector and the sport and recreation sector cal activity prevalence surveys conducted by was an important national initiative to promote SPARC (2007-2008) and the Ministry of Health physical activity in the late 1990s. A first step (2002-2003 and 2006-2007) found that physi- in Active Australia was to pilot a mass media cal activity levels (48-52 percent meeting the campaign in one state that focused on the new 30-minute guideline) among adults remained moderate intensity physical activity recom- stable during the period of the Push Play cam- mendation. paign’s implementation (both the mass media and allied community initiatives). Program Description Lessons Learned The Active Australia mass media program The Push Play mass media campaigns dem- phases 1 and 2 were conducted in the State of onstrated good reach into the general popula- New South Wales (NSW) Australia in March Mass Media Campaigns to Promote Physical Activity 85
1998 and March 1999. Focusing primarily on 6,500 family physicians across the state. Local people who were insufficiently active, phase 1 and regional initiatives included community- targeted people aged 25 to 60 years, and phase based walking and physical activity events, 2 targeted people aged 55 years and older. A promotions organized by health sector staff complementary program activity in phases 1 in some areas, and the use of regional and and 2 targeted general practitioners (family community-level media (Bauman et al. 2001); physicians), other health professionals, and these were part of a statewide physical activity sport, recreation, and fitness professionals. plan (Simply Active Every Day 2004). Both phases of the program featured the slogan Phase 2 targeted older adults and inten- “Exercise. You only have to take it regularly, tionally coincided with the United Nations not seriously.” International Year of Older Persons. The NSW The communication objectives of phases 1 State Health Department again coordinated the and 2 were to increase the target population’s program, this time targeting people aged 55 awareness of the benefits of regular, moderate years and older. The total budget was smaller physical activity (in particular of importance of than that of phase 1, less than $500,000 for 30 minutes of accumulated, moderate intensity communications in NSW. Paid media mes- exercise) and to maintain motivation among sages coincided with Seniors Week. The tele- people who were already sufficiently active. vision commercial depicted a “tin man” who Details of the campaigns are shown in the becomes aware that being physically active is middle column in table 10.1. healthy, fun, and involves only moderate levels The campaign was managed by the NSW of physical activity. Planning was integrated State Health Department, in collaboration across agencies, including the Department of with state and national health and sport and Sport and Recreation and Health. In addition, recreation departments, as part of an overall the Department of Veterans Affairs sent 30,000 Active Australia initiative. Media components resource kits to veteran health professionals consisted of paid television advertising (two across Australia (Commonwealth Department 15-second television commercials), paid of Health and Ageing 2000). advertisements in metropolitan and rural print media, a multilingual component for minor- Program Evaluation ity communities, community-level support from Health Service and Sport and Recreation Before launch, the program partners conducted regional staff (including a toll-free telephone extensive formative research, both quantitative line), and marketing of program merchandise to and qualitative, to inform message and program optimize media exposure. The total media costs development. Qualitative research was used to were $700,000. The television component of the determine the communication concepts most program had a weighting of 800 target audience likely to resonate with target audiences. For rating points from some 200 showings of the phase 1, a quasi-experimental research design message across New South Wales, reaching was used, with independent population samples 65 percent of the target audience during prime surveyed before and after the March 1998 pro- viewing time. In addition, six weeks of paid gram in NSW and independent samples sur- media inserts (portraying local and domestic veyed at the same times in the rest of Australia. environments for moderate activity) were run A NSW cohort sample of 1,185, representing a in the weekend editions (Saturday and Sunday) response rate of 87.2 percent (Bauman et al. of lifestyle magazines and daily newspapers. 2001), was also surveyed. The surveys showed A mail-out was used to inform primary care high rates of exact program theme and specific physicians about the new moderate-intensity tagline recall, which increased significantly in physical activity message. Information packs the NSW cohort and independent samples but were sent to all public health professionals two not in the comparison sample from the rest of months before the campaign launch, and physi- Australia (see table 10.1). For phase 2, a NSW cal activity counseling kits were mailed to all cohort of 1,102 older adults was assessed before 86 Bauman, McLean, Walker, Shilton, and Bellew and after the campaign. Prompted recall of the the Heart Foundation in Western Australia for tin man message increased from 3.9 percent to several years as a serial set of reinforcing social 48.5 percent following the campaign, and recog- marketing campaigns. nition of the overarching Active Australia slogan “Exercise. You only have to take it regularly, not Program Description seriously” increased from 33 percent before to Find Thirty was a community-wide social mar- 64.1 percent after the program. Intention to be keting program undertaken by the West Austra- more active improved marginally, and self-effi- lian Department of Health (2002-2006). Find cacy increased significantly between pre- and Thirty targeted Western Australian adults aged postprogram surveys, but there was no change 20 to 54 years (see table 10.1, right column). in reported actual physical activity (Australian Later, the state Department of Health contracted Sports Commission 2000). In summary, evalua- the National Heart Foundation in Western tion was reasonably comprehensive for a mass Australia to conduct another Find Thirty cam- media campaign and provided good evidence paign (2008-2011). This section describes the that observed effects on awareness and under- 2002-2006 program and its development and standing of the physical activity message could evaluation. be attributed specifically to the campaign. The initial Find Thirty campaign objectives were to increase awareness of the type and fre- Lessons Learned quency of physical activity necessary for good The main findings of the evaluation of the NSW health; demonstrate how moderate-intensity Active Australia campaign are discussed subse- physical activity could be incorporated into quently. The findings suggest that mass media everyday life (modeling active living); and campaigns have an important role in increas- cognitively reframe the daily recommended ing awareness of physical activity but that this 30 minutes of PA as relatively easy to achieve. communication takes place in a socio-cultural The Find Thirty campaign was based on social milieu that reinforces sedentary lifestyles. This cognitive theory, with the tag line “It’s not a big suggests that campaigns alone may not result in exercise” conveying the message that physical a measurable population-level effect on behav- activity could be incorporated easily into the ior; an integrated set of multi-sectoral popula- day and the fact that it’s easy to find the 30 tion health strategies and services are needed minutes needed for good health. to support, maintain, and extend the reach of Find Thirty featured three television adver- the mass media component. Active Australia tisements in its first campaign wave in April and was informed by quantitative and qualitative May 2002. A wide range of additional strate- formative research that established baseline gies supported the television campaign. These levels of the problem, identified target audience included information for the general public; segments, set specific communication objec- targeted communications to primary care physi- tives, and pretested communications concepts cians and other health professionals; public rela- and advertising materials. tions and regional activities; publications and merchandise carrying the campaign message; signage on taxi tops, billboards and bus shelters; Western Australia’s and the website www.findthirty.com. Added media included purchased weather segments Find Thirty— that featured celebrity endorsement in news It’s Not a Big Exercise bulletins. The campaign’s television budget across 2002-2006 was approximately $600,000 In Australia, some campaigns are developed by per annum. To put this in context, the State of government but are sustained by not-for-profit Western Australia has just three commercial (nongovernment) organizations; as an example, television stations, which serve a total popula- the Find Thirty initiative was maintained by tion of two million people, with three-quarters Mass Media Campaigns to Promote Physical Activity 87 living in the capital city of Perth. In 2004, new task force imprimatur. As with the other two materials were developed that showed how campaigns, a critical element of success was physical activity can be accumulated in bouts the link to other sectors (especially transport) of 10 minutes or more. The television messages and to community programs to extend the reach showed people being active while on hold on of the campaign and create important policy the phone, while waiting for an appointment, synergies. Finally, the West Australian campaign and while waiting for a download on a com- was a multiyear serial campaign under an over- puter. These added the dimension that physical arching theme and tagline. This allowed for a activity can be incidental, accumulated in short sequenced approach, building from messages bouts, and easily fit into everyday life. about physical activity to more action-focused messages providing examples of active living Program Evaluation and information about accumulating PA across the day. Continuous formative research was used to inform the development of sequential phases of the Find Thirty 2002-2011 campaign. Enablers Linkage to the National and barriers to being active were examined by Physical Activity Plan segments of interest, with a particular focus on people who are not sufficiently active, low The U.S. National Physical Activity Plan Mass socioeconomic status groups, rural residents, Media Sector includes eight recommended strat- and indigenous people. For the 2002 campaign, egies. Table 10.2 demonstrates that the three program planners conducted research to deter- Australasian campaigns were concordant with mine the suitability of creative concepts, adver- these strategies even though the campaigns tising executions, enjoyment, and perceived were initiated a decade before the National salience of the proposed communications. Physical Activity Plan. Impact evaluation of the Find Thirty 2002-2006 The U.S. NPAP describes the need for part- campaign used a campaign tracking survey, nerships, interagency policy congruence, and with weekly computer-assisted telephone sustained messaging (Strategies 1-3 of the Mass interviews of random samples of adults. The Media Sector). In particular, the Push Play and objectives of this evaluation were to assess the Find Thirty campaigns in New Zealand and impact of television messages in the campaign Australia had long durations, and all three on awareness, understanding of the 30-minute campaigns were initiated and overseen by state physical activity message, beliefs, attitudes, or federal task forces and agencies. All three intentions. and behavior (see table 10.1). campaigns were responsive to the need for mes- sage and brand consistency (Strategies 3 and 4), Lessons Learned even when themes or target groups changed. Campaign planning identified a sequence of The West Australian campaign identified the campaign elements over several years, using importance of ongoing formative research to a strategic framework to create and sustain reduce the chance of delivery failure; mass community awareness and interest in physical media production is an expensive undertak- activity (Strategy 5) (see table 10.2). All three ing, and program promoters may have only campaigns worked with the media industry one chance to convey their message and and engaged in media advocacy to add value to select appropriate communication (creative the PA messages (Strategy 6). Finally, although concepts, channel selection). For mass-reach these three campaigns incorporated some web strategies, it is essential to obtain appropriate and Internet engagement, they partly preceded government agency support and funding for the recent surge in web 2.0 approaches, which specific campaigns. The duration of the Find could be included in contemporary mass reach Thirty campaign was contingent on sustained campaigns, especially those targeting youth government support and state physical activity (Bauman and Chau 2009). Table 10.2 Mass Media Recommendations of the U.S. National Physical Activity Plan: How Well Did the Australian and New Zealand Campaigns Do? Characteristics and Active Australia 1998- Find Thirty, Western Strategy* Push Play NZ 1999-2009 2000 Australia 2002-2007 Form partnerships with Developed from national Developed and closely Started by state health other agencies; PA task sport agency (Hillary collaborated with state department and then forces (1) Commission, later Sport inter-sectoral NSW taken over by Heart and Recreation New Physical Activity Task Foundation to con- Zealand, SPARC). Links Force work program; tinue delivery. Linked to education and health multiple agencies and to 10-year strategy of sectors throughout. sectors contributed to cross-governmental PA Push Play was sup- campaign components. task force; embedded in ported by a national statewide policy for PA physical activity and and walking. Good links strategy (Healthy Eat- to walking and cycling ing—Healthy Action), led messages with transport by the Ministry of Health sector. in partnership with government agencies including SPARC (NZ Ministry of Health 2008). Obtain funding for Sustained 9-year cam- Funding for 3-year Ac- 4-year funding for phase sustained mass media paign from same lead tive Australia campaign 1. Find Thirty has been campaign (2) agency with Push Play provided; campaign adopted by two other brand, with different adopted by other states state jurisdictions in populations targeted. in years 2 and 3. Australia. Develop consistent mes- Push Play with logo of a Clear brand and mes- “Find Thirty—It’s not a sage local to national, fast-forward button on a sage. “Exercise. You only big exercise” as tagline brand, logo (3, 4) VCR, indicating activa- have to take it regularly, and theme through all tion or getting move- not seriously.” messages and commu- ment; logo sustained nication channels. across campaign years and target groups. Sequence campaign Phase 1: 1999-2002 Clear campaign plan, Phase 1 targeted PA elements, link to policy, targeted middle-aged starting phase 1 with dose, i.e., 30 minutes. programs (5) adults; phase 2: defined motivated but inactive Phase 2 indicated that and targeted inactive middle-aged adults, and 30 minutes can be accu- population segments; year 2, seniors aged 55- mulated in doses of 10 phase 3: 2006-2009 75 years. minutes or more. After targeted young people. 2006, the focus was on sessions, i.e., “Find thirty every day.” Educate the media, Worked with media lo- Worked with media to Strong focus on ongo- engage media channels cally and nationally in generate publicity. Sepa- ing public relations (6) NZ. rate PR agency: “unpaid media. Collaboration media”; value of unpaid with added value ideas coverage generated such as buying space in estimated at $300,000. weather bulletins.
88 Mass Media Campaigns to Promote Physical Activity 89
Characteristics and Active Australia 1998- Find Thirty, Western Strategy* Push Play NZ 1999-2009 2000 Australia 2002-2007 Use web, new media as Online components, PA Toll-free telephone line Campaign website supportive new tech- “activators,” interactive supported phase 1 and developed. Consumer nologies (7, 8) website. Especially in 2: provided a consumer input regarding ways to phase 3, added new link to regional sport and Find Thirty. Otherwise media. recreational services limited (preceded new media). Additional information: Resources and informa- Campaign support A manual and materials *written manual *docu- tion on Push Play avail- manual developed for developed to assist re- mentation able at www.sparc.org. local health and sport/ gional and rural uptake. * policy and environ- nz/en-nz/communities- recreation sectors; PA Innovation included mental support and-clubs/Push-Play/. counseling kits mailed to consistency of the Find *most innovative fea- Innovation included family physicians. Phase Thirty brand/slogan; tures community connection 1: Community activities link of this slogan to to local sport and recre- supported the campaign the PA guideline about ation delivery network (local walking events; 30 minutes; thorough and local messaging; flyers attached to pay and ongoing formative cultural adaptation and slips). Phase 2: com- research to “get the local flexibility; sustain- munity grants scheme. message right”; strong ability and duration. School and municipality engagement of walking funding to networks to and transport mes- support PA. Innovation: sages; linked to a cross- was the first large media governmental task force; campaign linked to a thorough and ongoing large interagency PA impact evaluation. task force. PA = physical activity. *Strategy numbers from the National Physical Activity Plan, Mass Media Sector are in parentheses.
Summary media campaigns, and without adequate plan- ning, good formative message development, Campaigns led by mass-reach media should and sufficient media duration and intensity, be included in public health approaches to little can be expected from these initiatives. promoting physical activity. The examples from Further, embedding campaigns in large-scale Australasia described in this chapter indicate national or state-level planning for physical that such campaigns have the potential to activity and having the policy support from a create interest in physical activity, catalyze the task force are essential features illustrated here. potential for change, and influence social norms Having met these conditions, the three Austral- regarding inactive lifestyles. Important elements asian campaigns achieved substantial reach of effective campaigns include political support, into their respective target communities. The sustained funding, and well-established inter- populations targeted were mostly middle-aged agency partnerships that support the myriad adults, with the exception of phase 3 of Push settings and sectors in which physical activity Play, which targeted young people. can be promoted. Finally, investing in quality evaluation at all Overarching government support was a con- stages of mass media campaign programming sistent feature of these three campaigns, provid- (Bauman et al 2006) is important. Formative ing the sustained support to fund a sufficient research to optimize message development dose of mass media to increase and sustain com- requires time and effort and needs to be rigor- munity awareness. This is the sine qua non of ous and comprehensive, usually using a mix of 90 Bauman, McLean, Walker, Shilton, and Bellew
qualitative and quantitative research. Process lian Adults 1999. Perth, Western Australia: Health evaluation of the reach of campaign activities Department of Western Australia and Sport and includes an assessment of audience reached Recreation. (target audience rating points or gross rating Commonwealth Department of Health and Ageing. 2000. points). These measures indicate that media Annual Report 1999/2000. Canberra, Australia: Author. placement occurred as intended and exposure www.health.gov.au/internet/main/publishing was likely to be sufficient to achieve mass reach. .nsf/.../outcome8.pdf In addition, tracking the population reach of Elley, R., N. Kerse, B. Arroll, and E. Robinson. 2003. other campaign resources, use of ancillary com- Effectiveness of counselling patients on physical munity programs, and participation in related activity in general practice: Cluster randomised mass events are crucial. Impact evaluation controlled trial. Br. Med. J. 326:793. needs to be rigorous, using the best research Hillary Commission (Department of Sport, now Sport designs and measures that the program can New Zealand), Wellington. 1998. Physical Activity afford; such evaluation indicates to program Task Force Report: More People, More Active, More developers what works, in turn leading to better Often. subsequent campaigns. All three of these cam- Maibach, E., M.L. Rothschild, and W.D. Novelli. 2002. paigns, especially Push Play and Find Thirty, Social marketing. In: Health Behavior and Health Education (pp. 437-461). 3rd ed. K. Glanz and B.K. emphasized evaluation and used the results to Rimer, Eds. San Francisco, CA: Jossey-Bass. improve subsequent programs. We have much to learn from these efforts at promoting physical Milligan, R., G.R. McCormack, and M. Rosenburg. 2007. Physical Activity Levels of Western Austra- activity in Australia and New Zealand and from lian Adults 2006. Results from the Adult Physical the comprehensive way in which campaigns Activity Survey. Perth, Western Australia: Western were nested in broader policy frameworks and Australian Government. linked to good evaluation. National Health Committee, New Zealand. 1998. Active for life: A call for action. http://nhc.health.govt. References nz/publications/nhc-publications-pre-2011/active- life-call-action. Bauman, A., Bellew, B., Vita, P., Brown, W., Owen, New Zealand Ministry of Health. 2008. Healthy N. March 2002. Getting Australia active: towards Eating—Healthy Action, Oranga Kai—Oranga better practice for the promotion of physical activ- Pumau. Progress on Implementing the HEHA strat- ity. National Public Health Partnership. Melbourne, egy 2008. www.moh.govt.nz/moh.nsf/indexmh/ Australia, (pp. 80-81). ISBN: 0-9580326-2-9. Acces- heha-progress-dec08. sible from archive at: fulltext.ausport.gov.au/full- Simply Active Every Day. 2004. NSW Physical Activity text/2002/nphp/gaa.asp. Task Force. A plan to promote physical activity in Bauman, A., B. Bellew, N. Owen, and P. Vita. 2001. NSW 1998-2002. Evaluation report, NSW health Impact of an Australian mass media campaign tar- department. www.health.nsw.gov.au/pubs/2004/ geting physical activity in 1998. Am. J. Prev. Med. pdf/simplyactive.pdf. 21(1):41-7. SPARC. 2003. Obstacles to Action: Overview Report. Bauman, A., B.J. Smith, E.W. Maibach, and B. Reger- A Study of New Zealanders Physical Activity and Nash. 2006. Evaluation of mass media campaigns Nutrition. A report produced by AC Nielsen for for physical activity. Eval. Prog. Plann. 29:3:312-22. SPARC. Wellington, South Australia: SPARC. Bauman, A., G. McLean, D. Hurdle, S. Walker, J. Boyd, SPARC. 2007. Physical activity guidelines for children I. van Aalst, and H. Carr. 2003. Evaluation of the and young people (5-18 years old). Obstacles to national “Push Play” campaign in New Zealand: Action: Overview Report. A Study of New Zea- Creating population awareness of physical activity. landers Physical Activity and Nutrition. A report NZ Med. J. 116(1179):U535. produced by AC Nielsen for SPARC. Wellington, Bauman, A., and J. Chau. 2009. The role of media in South Australia: SPARC. www.sparc.org.nz/en-nz/ promoting physical activity. Journal of Physical young-people/Activity-Guidelines-5-18-Years/. Activity and Health. 6(Suppl 2):S196-210. TNS Social Research. 2006. Physical activity campaign Bull, F., R. Milligan, M. Rosenberg, and H. McGowan. track, October 2002–December 2005. TNS Social 2000. Physical Activity Levels of Western Austra- Research and Department of Health WA. CHAPTER 11 Communication Strategies to Promote the 2008 Physical Activity Guidelines for Americans
Katrina L. Piercy, PhD, RD Kay Loughrey, MPH, MSM, RD, LDN U.S. Department of Health and Human Services, Whole Mind Wellness, LLC, Gaithersburg, Office of Disease Prevention and Health Promotion Maryland
Jane D. Wargo, MA Presidential Youth Fitness Program
NPAP Tactics and Strategies Used in This Program
Mass Media Sector Public Health Sector STRATEGY 3: Develop consistent mass communica- STRATEGY 4: Disseminate tools and resources im- tion messages that promote physical activity, have portant to promoting physical activity, including a clear and standardized “brand,” and are consis- resources that address the burden of disease due tent with the most current Physical Activity Guide- to inactivity, the implementation of evidence-based lines for Americans. interventions, and funding opportunities for physi- cal activity initiatives.
he Physical Activity Guidelines for Ameri- of moderate-intensity physical activity on most, Tcans, issued on October 7, 2008, provide preferably all, days per week. In 1996, Physical science-based guidance to help Americans Activity and Health: A Report of the Surgeon ages 6 years and older improve their health General supported this same recommendation. through regular physical activity. Before 2008, This chapter provides background on the devel- the U.S. federal government had never issued opment of the Physical Activity Guidelines for comprehensive physical activity guidelines Americans (PAG) and identifes communica- for the nation, although the guidelines were tions activities and ongoing efforts to promote preceded by government-sponsored recommen- the guidelines. dations. For example, in 1995 the Centers for Maintaining a healthy lifestyle includes a bal- Disease Control and Prevention (CDC) and the ance of both good nutrition and regular physi- American College of Sports Medicine (ACSM) cal activity. Therefore, the PAG and the Dietary published physical activity recommendations Guidelines for Americans (DGA, www.health. for public health; the report stated that adults gov/dietaryguidelines) provide complementary should accumulate at least 30 minutes per day and consistent advice for physical activity.
Acknowledgments: The authors thank Richard P. Troiano, PhD, federal coordinator for the development of the 2008 Physical Activity Guidelines for Americans and executive secretary of the Physical Activity Guidelines Advisory Committee; and Suzanne Hurley Zarus, Centers for Disease Control and Prevention, for their contributions to this chapter. The authors also acknowledge Rachel Polon, MPH, RD; Holly McPeak, MS; and Richard Olson, MD, MPH, from the HHS Offce of Disease Prevention and Health Promotion for their con- tributions and assistance in editing. 91 92 Piercy, Loughrey, and Wargo
The DGA were first released in 1980 and are recommendation and similar recommendations. federally mandated to be updated on a five-year However, the scientific evidence does not allow cycle. The most recent release of the DGA in researchers to say, for example, whether the 2010 incorporates the recommendations from health benefits of 30 minutes of activity on five the PAG to provide guidance on the importance days a week differ from the health benefits of 50 of being physically active and eating a healthy minutes on three days a week. As a result, the diet to promote good health and reduce the risk guidelines allow for adults to accumulate two of chronic disease. hours and 30 minutes a week in various ways. In October 2006, the U.S. Department of People can choose from many activities and can Health and Human Services (HHS) sponsored, accumulate activities in bouts of 10 minutes and the Institute of Medicine planned, a work- throughout the week. In addition, adults can do shop titled Adequacy of Evidence for Physical moderate-intensity activity, vigorous-intensity Activity Guidelines Development. On Octo- activity, or a combination of the two. Muscle- ber 27, 2006, HHS Secretary Michael Leavitt strengthening activity is advised on two or more announced plans for the development of federal days per week. Unlike previous recommenda- Physical Activity Guidelines for Americans to be tions, the PAG provide more direct guidance issued in 2008. HHS decided that the PAG would for older adults, women who are pregnant or serve as a benchmark and a single, authorita- in the postpartum period, persons with chronic tive voice for providing science-based guidance conditions, and persons with disabilities. Addi- on physical activity for health promotion. The tionally, recommendations for children and ado- department solicited expert advisory commit- lescents ages 6 to 17 are included—60 minutes tee members through the Federal Register and of activity each day plus muscle-strengthening simultaneously outlined a communications and bone-strengthening activities at least three campaign to promote the messages of the PAG. days a week. In February 2007, Secretary Leavitt appointed The PAG include several key messages: 13 members to the PAG advisory committee and charged the committee to review existing • Regular physical activity reduces the risk scientific literature to identify whether sufficient of many adverse health outcomes. evidence existed to develop a comprehensive • Some physical activity is better than none. set of physical activity recommendations and identify areas where further scientific research • For most health outcomes, additional was needed. benefits occur as the amount of physical Nine subcommittees of the advisory commit- activity increases through higher intensity, tee focused on specific topics: all-cause mortal- greater frequency, or longer duration. ity, cardiorespiratory health, metabolic health, • Most health benefits occur with at least energy balance, musculoskeletal health, func- two hours and 30 minutes (150 minutes) tional health, cancer, mental health, adverse per week of moderate-intensity physical events, and youth and understudied popula- activity, such as brisk walking. Additional tions. The PAG advisory committee submitted benefits occur with more physical activity. its findings and recommendations to Secretary • Both aerobic (endurance) and muscle- Leavitt in spring 2008. HHS staff used the PAG strengthening (resistance) physical activi- advisory committee report to develop the Physi- ties are beneficial. cal Activity Guidelines for Americans. • Health benefits occur for children and ado- lescents, young and middle-aged adults, Description of the older adults, and those in every racial and ethnic group, as well as for people with Physical Activity Guidelines disabilities. The PAG affirm that it is acceptable for adults • The benefits of physical activity far out- ages 18 and older to follow the CDC-ACSM weigh the possibility of adverse outcomes. Physical Activity Guidelines for Americans 93
Development ville, Maryland. The goal of this research was to learn how to encourage understanding, of Communication Materials awareness, and acceptance of the PAG among HHS relied on user-centered methods (www. this segment of the U.S. population. The focus usability.gov) and evidence-based health lit- groups also provided information that served eracy principles (Health literacy 2013) to ensure as the foundation for developing messages that that communication surrounding the PAG was were relevant, clear, and easy for the general relevant and included steps people could take public to understand. Focus group participants to incorporate more physical activity into their evaluated taglines and icons that might be used lives. User-centered methods were incorporated to promote the PAG; participants characterized to ensure that the content of the materials was the tagline “Be active. Be healthy. Be happy” as engaging, relevant, and appropriate to the audi- motivating, meaningful, and appealing. ence. Health literacy principles played a critical role in guiding the development of consumer Tagline and Concept Testing materials that were appropriate for people of dif- In May 2008, the HHS Office of Disease Preven- ferent ages, genders, and cultural backgrounds. tion and Health Promotion (ODPHP) contracted Materials, written at the fifth-grade level, were with the American Institutes for Research conversational and friendly and used the active (AIR) to conduct six focus groups to examine voice. The materials used limited scientific consumer reactions to concepts and taglines jargon, explained new terms in several ways, for the PAG and to design a consumer booklet. and used interactive techniques. The material AIR tested materials with consumers ages 25 to developers paid careful attention to the visual 64, in groups separated by gender and level of appearance of the materials, limiting line length physical activity, in Chicago, Illinois; Jackson, and depth, using subheadings to break up text, Mississippi; and Bethesda, Maryland. The loca- and using photographs to amplify text. tions selected included large and small urban The agency conducted two rounds of focus and suburban areas, different racial and ethnic groups to help shape the messages. Its research populations, and different climates. Participants was primarily on the U.S. adult population with reacted to four creative concepts developed low health literacy, most with less than a high by AIR and five additional taglines. They also school education, but the ability to read simple shared their perceptions of physical activity text. HHS wanted to ensure that the messages and their understanding of the word guidelines. used to promote the PAG were relevant to the daily lives of U.S. adults, including the 77 mil- Concepts Tested lion Americans with limited health literacy. • Join the Movement • Active Life Focus Group Tagline and Icon • Making it Easier Testing • Role Model Prior to the release of the PAG, the CDC con- Taglines Tested ducted communications research related to individuals’ understanding of physical activity • Physical activity. Every move counts. and the PAG as well as message development • Physical activity. Just what the doctor and testing. It conducted two sets of focus ordered. groups in 2008; the first set included adults • Be active. Be healthy. Be happy. with limited health literacy and was conducted • Physical activity is for everyone. One step in Houston, Texas; Memphis, Tennessee; and at a time. Baltimore, Maryland. The second set, which included inactive adults who were contem- • Physical activity is for everyone. Step it up! plating becoming more physically active, was • Physical activity. For your body, mind, conducted in Richmond, Virginia, and Catons- and spirit. 94 Piercy, Loughrey, and Wargo
Feedback from these focus groups showed a some activity and are planning to do more. preference for the Role Model concept, which Field testing demonstrated that the booklet had a headline of “If I can do it, you can do it.” was well matched to the experience, logic, and Many mentioned that the concept made them language of respondents and was well received feel motivated and, in some cases, reminded as attractive, informative, understandable, and them of personal experiences in which they had motivational. been inspired to start being active by someone else who was more active than they were. The Resources for the Key Message: tagline “Be active. Be healthy. Be happy” was Be Active Your Way well received, and many people noted the con- nection between physical activity and a per- As a result of the focus groups, Be Active Your son’s health and happiness. This research was Way was selected as a key communication mes- consistent with the focus groups conducted on sage. This message emphasized the importance behalf of the CDC. Focus group participants also of finding and doing the physical activities that a favored the use of success stories and quotes person enjoys. Several consumer guides, includ- from “real people,” as well as using images to ing a fact sheet and a booklet for adults, were depict “regular” people (e.g., family, friends, developed using this message and following rig- and neighbors) incorporating physical activ- orous health literacy standards. These resources ity into their everyday lives. Additionally, the were part of a larger toolkit that HHS developed focus groups reinforced previous findings that for the launch and shared with partner organiza- self-efficacy and social support are important tions. The PAG toolkit, accessible online (www. when promoting physical activity. health.gov/paguidelines/adultguide/default. aspx), contains the following print resources Field Testing of Consumer Booklet (along with a CD of all materials): Following focus group testing, ODPHP devel- Physical Activity Guidelines for Ameri- oped and field tested a booklet designed to cans Toolkit Components have broad appeal for American adults, with • 2008 Physical Activity Guidelines for an emphasis on persons with low literacy or Americans limited time. The goal of the booklet was to • Be Active Your Way: A Guide for Adults inform people about how much activity they (booklet) need, to convince them that being active at recommended levels is possible for them, • Be Active Your Way: A Fact Sheet for Adults and to suggest ways to add more activity into • Physical Activity Guidelines for Americans their busy lives. The format of the booklet Toolkit User’s Guide was different from a typical linear approach to • Posters (4) organizing content. Because most people are • Event flyers (4) inactive and the concepts are complex, the big- gest challenge was to help people think about • At-a-Glance: A Fact Sheet for Professionals how to start engaging in physical activity and • Frequently Asked Questions learn how to build up gradually. Therefore, • Federal Resources the booklet was designed to focus on various • PowerPoint presentation (available on audience segments, mirroring progress through CD–ROM only) the Transtheoretical Stages of Change Model (precontemplation, contemplation, preparation, In 2011, HHS released Spanish versions of two action, and maintenance). For example, the first resources from the PAG: Be Active Your Way: A chapter targeted people who are not currently Guide for Adults (booklet) and Be Active Your active but are thinking about becoming more Way: A Fact Sheet for Adults. These documents active (precontemplation or contemplation were first translated into Spanish and then stage). The second chapter targeted people in tested with a Hispanic audience to ensure that the preparation phase, those who are doing key messages were conveyed. Reprinted from Health and Human Services. E5691/NPAP/fig11.2L/458545/alw/r1
95 Reprinted from Health and Human Services.
E5691/NPAP/fig11.2R/471824/alw/r1 96 Physical Activity Guidelines for Americans 97
CDC Youth Physical Activity Communications Strategy Guidelines Toolkit for Schools, HHS used a three-fold communication strategy Families, and Communities to promote the PAG: the launch, media out- Although many of the toolkit components reach, and partnerships. The communications focused on promoting the PAG for adults, the strategy was designed to raise awareness of the CDC Division of Adolescent and School Health guidelines among professionals and consum- developed a toolkit to promote the guidelines ers, develop partners, increase people’s con- for youth. The Youth Physical Activity Guide- fidence in their ability to meet the guidelines, lines Toolkit highlighted strategies that schools, and ensure that Americans received consistent families, and communities can use to support and accurate messages about the PAG from all youth physical activity and targeted community sources. The following three sections detail the leaders; physical education and health educa- components of the strategy. tion teachers; physical activity coordinators at the school, district, and state levels; and physi- Launch cal activity practitioners working in health or The Physical Activity Guidelines for Americans community-based organizations. The toolkit were launched on October 7, 2008. President is available at www.cdc.gov/HealthyYouth/ Bush announced the guidelines at a White physicalactivity/guidelines.htm. House event followed by an official launch by Youth Physical Activity Guidelines Secretary Leavitt at HHS. ODPHP and the Presi- Toolkit Components dent’s Council on Fitness Sports and Nutrition • User guide (step-by-step guidance, custom- (PCFSN) hosted a partnership forum imme- izable resources, fundamental strategies, diately following the launch. Representatives and key examples of use pertaining to from lead partner groups, including ACSM, the toolkit contents) International Health, Racquet and Sportsclub Association (IHRSA), the National Association • Fact sheets for Sport and Physical Education (NASPE), • Youth Physical Activity: The Role of the National Coalition for Promoting Physical Schools Activity (NCPPA), the YMCA, and the American • Youth Physical Activity: The Role of Heart Association shared their plans to promote Communities and disseminate the PAG. • Youth Physical Activity: The Role of Families Media Outreach • PowerPoint presentations An extensive media outreach campaign fol- • The Role of Schools in Promoting Youth lowed the launch of the PAG. A majority of the Physical Activity media coverage was online, comprising 48% • The Role of Communities in Promoting of the visibility, followed by print with 27% Youth Physical Activity and television with 25%. Coverage of the PAG generated more than 15 million message con- • The Role of Families in Promoting tacts during October, November, and December Youth Physical Activity 2008. Stories on msn.com, MSNBC, and CNN • The Role of Schools, Families, and Com- provided an especially strong online presence. munities in Promoting Youth Physical Coverage also appeared on regional affiliates of Activity major broadcast networks, including ABC, NBC, • Poster: Be Active and Play, 60 Minutes FOX, and CW. Articles in USA Today, the New Every Day! York Times, the Chicago Tribune, the Washing- • Video: Active Children and Adolescents: ton Post, and other major newspapers helped The Physical Activity Guidelines in Action the PAG to reach a broad, national audience. News Release
For Immediate Release Tuesday, October 7, 2008 Contact: HHS Press Offce HHS Announces Physical Activity Guide- Key guidelines by group: lines for Americans Children and adolescents—One hour or more Adults gain substantial health benefits from two and of moderate or vigorous aerobic physical activ- a half hours a week of moderate aerobic physical ity a day, including vigorous intensity physical activity, and children benefit from an hour or more of activity at least three days a week. Examples physical activity a day, according to the new Physical of moderate intensity aerobic activities include Activity Guidelines for Americans. The comprehen- hiking, skateboarding, bicycle riding, and brisk sive set of recommendations for people of all ages walking. Vigorous intensity aerobic activities and physical conditions was released today by the include bicycle riding, jumping rope, running U.S. Department of Health and Human Services. and sports such as soccer, basketball, and The guidelines are designed so people can easily ice or field hockey. Children and adolescents fit physical activity into their daily plan and incorpo- should incorporate muscle-strengthening rate activities they enjoy. activities, such as rope climbing, sit-ups, Physical activity benefits children and adoles- and tug-of war, three days a week. Bone- cents, young and middle-aged adults, older adults, strengthening activities, such as jumping rope, and those in every studied racial and ethnic group, running, and skipping, are recommended three the report said. days a week. “It’s important for all Americans to be active, and Adults—Adults gain substantial health ben- the guidelines are a roadmap to include physical efits from two and one half hours a week of activity in their daily routine,” HHS Secretary Mike moderate-intensity aerobic physical activity, Leavitt said. “The evidence is clear—regular physi- or one hour and 15 minutes of vigorous physi- cal activity over months and years produces long- cal activity. Walking briskly, water aerobics, term health benefits and reduces the risk of many ballroom dancing, and general gardening diseases. The more physically active you are, the are examples of moderate intensity aerobic more health benefits you gain.” activities. Vigorous-intensity aerobic activi- Regular physical activity reduces the risk in adults ties include racewalking, jogging or running, of early death; coronary heart disease, stroke, high swimming laps, jumping rope, and hiking uphill blood pressure, type 2 diabetes, colon and breast or with a heavy backpack. Aerobic activity cancer, and depression. It can improve thinking should be performed in episodes of at least 10 ability in older adults and the ability to engage in minutes. For more extensive health benefits, activities needed for daily living. The recommended adults should increase their aerobic physical amount of physical activity in children and adoles- activity to five hours a week moderate-intensity cents improves cardiorespiratory and muscular or two and one half hours a week of vigorous- fitness as well as bone health and contributes to intensity aerobic physical activity. Adults should favorable body composition. incorporate muscle strengthening activities, The Physical Activity Guidelines for Americans such as weight training, push-ups, sit-ups, and are the most comprehensive of their kind. They carrying heavy loads or heavy gardening, at are based on the first thorough review of scientific least two days a week. research about physical activity and health in more Older adults—Older adults should follow the than a decade. A 13-member advisory commit- guidelines for other adults when it is within tee appointed in April 2007 by Secretary Leavitt their physical capacity. If a chronic condition reviewed research and produced an extensive prohibits their ability to follow those guidelines, report. they should be as physically active as their
98 Physical Activity Guidelines for Americans 99
abilities and conditions allow. If they are at risk and 15 minutes of vigorous aerobic activity of falling, they should also do exercises that a week. They should incorporate muscle- maintain or improve balance. strengthening activities involving all major Women during pregnancy—Healthy women muscle groups two or more days a week. should get at least two and one half hours When they are not able to meet the guidelines, of moderate-intensity aerobic activity a week they should engage in regular physical activity during pregnancy and the time after delivery, according to their abilities and should avoid preferably spread through the week. Pregnant inactivity. women who habitually engage in vigorous People with chronic medical conditions— aerobic activity or who are highly active can Adults with chronic conditions get important continue during pregnancy and the time after health benefits from regular physical activity. delivery, provided they remain healthy and They should do so with the guidance of a discuss with their health care provider how and health care provider. when activity should be adjusted over time. For more information about the Physical Activ- Adults with disabilities—Those who are able ity Guidelines for Americans, visit www.hhs.gov or should get at least two and one half hours of www.health.gov/paguidelines. moderate aerobic activity a week, or one hour Reprinted from Health and Human Services.
Radio Media Tour http://en.wikipedia.org/wiki/Physical_Activ- ity_Guidelines_for_Americans. Following the launch, the Surgeon General, The agency also used Healthfinder.gov to Steven Galson, MD, promoted the PAG through deliver messages about the PAG and provide a variety of outlets that were coordinated resources, tips and links for additional informa- through a contractor with CDC. A media cam- tion. It conducted extensive focus group testing paign reached more than 60 cities during the and research with more than 750 people to live on-air portion and many additional loca- inform the content of the Healthfinder mate- tions through replays. A podcast was created for rial. Healthfinder.gov distributed seasonal the HHS Health Beat, and the Surgeon General e-cards that could be personalized and sent was interviewed for a National Institutes of to family and friends to encourage them to be Health (NIH) Vodcast Radio episode that aired active. The Be Active Your Way quiz, found on in February 2009. A three-part series about the the PAG website, is linked to physical activity PAG also aired on NIH radio during February information found on Healthfinder.gov. The and March 2009. quiz widget can be copied and used on other E-Marketing and Web sites to promote the PAG. HHS used a variety of e-marketing and web CDC Exercise Videos techniques to reach the public in a cost-effec- CDC created a series of videos that help explain tive manner, including blogs and podcasts, the physical activity guidelines, provide tips e-newsletter articles, and announcements on how to meet them, and demonstrate proper sent to listservs, external partners, advocates, techniques for muscle strengthening exercises. professionals, educators, and policy makers. These videos were based on usability testing Consistent messages and resources related to conducted in fall 2008. The testing showed that the PAG were posted on a variety of websites, the general public prefers simple explanations, including those of ODPHP, PCFSN, and CDC. A simple visuals, icons, and personal testimonies Wikipedia article provided an overview of the of meeting the PAG. The videos can be accessed health benefits of physical activity and the key at www.cdc.gov/physicalactivity/everyone/ PAG recommendations for adults and youth: videos/index.html. 100 Piercy, Loughrey, and Wargo
Partnerships timeline and limited funding, a strong effort was made to communicate the messages of Partnerships have been a critical component of the PAG to the public in a variety of ways, as the PAG communications strategy, and partners described in this chapter. For future iterations continue to disseminate key physical activity of the PAG, it will be necessary to have a strong messages within their communities. PAG lead- communications plan in place, with sufficient ers created the Physical Activity Guidelines time to fully develop and test messages. for Americans Supporter Network prior to the release of the guidelines, and key partners were Timeline invited to attend the launch and share their ideas for dissemination. By October 2009, the One challenge in developing and releasing the supporter network included more than 3,400 PAG was the tight timeline to complete the organizations; by 2011, it included more than project prior to the end of the Bush adminis- 5,100. The PAG gained support from a variety of tration. Secretary Leavitt announced plans for sectors, including government, education, and the PAG in 2006 and, in just under 2 years, the nonprofit and community-based organizations. guidelines were released. The condensed time- Organizations interested in becoming a part of line made it challenging to fully develop a large the supporter network can sign up through the and comprehensive communications plan to PAG website, www.health.gov/paguidelines/. be released concurrently with the PAG. Unlike Members of the supporter network attended the DGA, the PAG are not federally mandated; webinars on the guidelines between January however, it may be helpful to have a timeline 2009 and January 2011. Hosted by ODPHP for subsequent iterations of the PAG so that in collaboration with PCFSN and CDC, the funding, time, and staff can be allocated for the webinars covered a range of topics, including advisory committee report, policy document, CDC’s Guide to Community Preventive Services, and supporting consumer materials. This would evidence-based strategies on physical activity, provide an opportunity for the department to and the National Physical Activity Plan. During highlight the importance of physical activity in the webinars, supporters updated participants a regular manner, similar to the nutrition mes- on implementation of the PAG in their com- sages delivered in the DGA. munities. Communications Be Active Your Way Blog Experts in communication assisted with writing The Be Active Your Way blog was created to the PAG to help address some of the key com- stimulate a virtual dialog among profession- munication challenges, including appropriately als interested in helping Americans be more targeting the intended audience, clarifying target active. Launched on November 4, 2009, the amounts of activity, defining levels of intensity, blog provides a forum where professionals can and supporting dissemination and maintaining learn from and connect with each other through public awareness (Troiano and Buchner 2011). content that is updated weekly and comments Although focus groups were conducted to test in response to the content. Additionally, the the tagline and concepts, it would also be help- blog highlights a number of community-based ful to have the language of key messages tested programs that participating organizations are to identify messages that resonate with the key using to increase physical activity in their com- target audience. The goal would be to develop munities. messages that promote action, not simply awareness of the recommendations. Lessons Learned Partners There were several challenges in communi- Partners played a key role in disseminating the cating the PAG to the public. Given the tight PAG, and several lessons can be learned from Physical Activity Guidelines for Americans 101 partner relationships. Solid commitments with and the importance of regular physical activity. actionable items and clear roles for each partner These agencies recommend that a scientific can help target messages to specific audiences. advisory committee review the science and This will ensure that messages reach a variety make recommendations to update the guide- of sectors, including youth, who are targeted lines every 10 years. Revised guidelines should through schools, coaches, and parents. The be accompanied by a robust communication message needs to be consistent across partners, campaign that highlights the new recommen- including health care providers, from whom dations and reiterates the core messages of the many consumers get their health information. Physical Activity Guidelines for Americans. Changing people’s behaviors to increase physi- cal activity will require a significant change in the culture of our country. This culture shift Additional would benefit from engaging partners across a Reading and Resources wide variety of sectors, such as CEOs of large corporations and educational leaders, who Physical Activity Guidelines for Americans policy could provide opportunities for physical activity document: www.health.gov/paguidelines/pdf/ throughout the work and school day. paguide.pdf Physical Activity Guidelines Advisory Committee Report: www.health.gov/paguidelines/Report/ Tips for Default.aspx Working Across Sectors Partnership Toolkit: /www.health.gov/paguidelines/ adultguide/default.aspx The PAG were a successful collaborative effort CDC Toolkit for Youth: www.cdc.gov/HealthyYouth/ across many sectors of HHS. The PAG steering physicalactivity/guidelines.htm committee consisted of representatives within List of federal websites that promote physical activity: the ODPHP, PCFSN, and the Physical Activity www.health.gov/paguidelines/federalresources. and Health Branch of CDC. The primary coor- aspx E-cards to promote physical activity: http:// dinating office was ODPHP, whereas CDC man- healthfinder.gov/ecards/cards.aspx?jscript=1 aged the literature review and scientific man- Recorded radio media tour, HHS HealthBeat: www.hhs. agement. The advisory committee consisted of gov/news/healthbeat/2009/04/20090414a.html. experts in academia across the United States. In The Surgeon General interview, National Institutes addition, the Food and Nutrition Board and the of Health (NIH) Vodcast Radio episode (Feb- Board on Population Health and Public Health ruary 23, 2009): www.nih.gov/news/radio/ Practice, both of the Institute of Medicine, were feb2009/20090220PAG.htm (transcript) integral in planning the workshop Adequacy www.youtube.com/watch?v=bn5gr4Jc3to (video) of Evidence for Physical Activity Guidelines Development. Additional names and titles of NIH radio three-part series; www.nih.gov/news/radio/ podcast/2009/e0077.htm; individuals who assisted with the PAG process are outlined in the report of the PAG advisory www.nih.gov/news/radio/podcast/2009/e0078.htm committee, representing the teamwork required www.nih.gov/news/radio/podcast/2009/e0079.htm to complete the PAG. References Summary Health literacy. 2013. http://health.gov/communica- As this chapter highlights, participating agen- tion/literacy/. cies communicated key messages of the PAG Troiano, R.P., and D.M. Buchner. 2011. National Guide- with minimal resources. ODPHP, PCFSN, and lines for Physical Activity. In: Physical Activity and CDC, along with partner agencies and the sup- Public Health Practice (pp. 196-209). B.E. Ainsworth porter network, continue to promote the PAG and C.A. Macera, Eds. CRC Press, Boca Raton, FL.
Sector III Health Care
Robert Sallis, MD, FAAFP, FASCM Kaiser Permanente Medical Center
he association between physical activity and high blood pressure, to engage in regular Tand good health has been well established. physical activity. In fact, research has shown there is a dose- Health care is America’s largest industry, and response relationship between a person’s activ- its costs threaten to become unsustainable if ity level and his or her health status. That is, we don’t change the way we practice medicine. those who are active and ft tend to live longer Most experts agree, and studies suggest, that a and healthier lives, whereas those who are sed- focus on preventing disease will achieve better entary and unft are more likely to suffer from results at lower cost than our current system’s chronic disease and to die at a younger age. emphasis on pills and procedures. Increasing Research also has shown that the connection physical activity among patients is a key health between physical activity and health exists in care strategy that has the potential to prevent every subgroup of the population. The research and treat disease at a low cost. across race and ethnic groups, age groups, and This section of the book presents five genders is clear—people who are physically programs that are working to make the con- active are healthier and live longer than those nection between exercise and health. The who are sedentary. Exercise really is a powerful starting point for making this connection is to medicine that can be used to prevent and treat assess and prescribe exercise at every patient myriad conditions. encounter by looking at physical activity as a Unfortunately, health care systems gener- “vital sign”; chapters 13 (Sallis) and 15 (Joy et ally have ignored this research and have not al.) describe initiatives that have successfully integrated it into standard disease prevention adopted this approach. Another important and treatment paradigms, thereby failing to strategy is to develop a health care systems harness the power of exercise to prevent and approach to promoting physical activity as a treat disease. This is troubling, given that our treatment for disease, and chapter 16 by Bal- society is experiencing an explosion of non- lard describes how this can be done. A final communicable diseases that result in large part key strategy is to improve education for physi- from sedentary lifestyles. Can you imagine if a cians about physical activity and health, not pill or medical procedure provided even a frac- just for patients but for themselves as well. The tion of the proven health benefits of exercise? chapters by Kennedy and Phillips and Bilodeau Surely it would be the most widely prescribed provide excellent examples of how to do this. therapy known to humankind, and patients These chapters provide both motivation and would demand access to it! Thus, it is time for a blueprint that other health care systems can health care providers to begin advising patients, use to harness the power of physical activity particularly those at risk for or diagnosed with to improve the health and longevity of the chronic diseases such as diabetes, heart disease, patients they serve.
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CHAPTER 12 Institute of Lifestyle Medicine
Mary A. Kennedy, MS Edward M. Phillips, MD Institute of Lifestyle Medicine, Institute of Lifestyle Medicine, Joslin Diabetes Center, Boston MA Joslin Diabetes Center, Boston MA Harvard Medical School Harvard Medical School
NPAP Tactics and Strategies Used in This Program
Health Care Sector STRATEGY 5: Include physical activity education in the training of all health care professionals.
he Institute of Lifestyle Medicine (ILM) is a and efficiently address weight management in Tnonproft professional education, research, their patients by incorporating health coaching and advocacy organization that is leading a techniques into clinical encounters. Although comprehensive effort to reduce lifestyle-related government agencies, private employers, and death and disease in society through clinician- insurance companies have developed programs directed interventions with patients. Edward to address obesity and promote wellness, the M. Phillips, MD, founded the ILM at Harvard medical profession is lagging in its efforts to Medical School (HMS) and Spaulding Reha- educate physicians about physical inactivity bilitation Hospital (SRH) in 2007. In 2013 the and other lifestyle behaviors and train them to institute transitioned from SRH to the Joslin address these issues. The ILM seeks to fill the Diabetes Center, a Harvard teaching affliate. void of wellness education for physicians and The ILM offers concrete tools and training to other health care professionals. health care professionals, conducts research to demonstrate the effcacy of lifestyle medicine Introducing the Concept education, and advocates for national adoption of lifestyle medicine and reform of medical of Lifestyle Medicine education to include lifestyle medicine. It also In 2004, Dr. Phillips collaborated with Margaret promotes health improvement by empowering Moore, MBA, founder and CEO of Wellcoaches, clinicians to adopt healthier habits, facilitate to write and publish an online continuing medi- behavior change, and stimulate a culture of cal education (CME) program offered through health and wellness for their patients. the HMS Department of Continuing Education. This course, Lifestyle Medicine for Weight Man- agement, was supported by a small grant from Program Description the HMS Department of Physical Medicine and The ILM as it exists today took several years Rehabilitation, where Dr. Phillips is an assistant to evolve. It began as an effort to educate professor. This unique online education module physicians about a new way to effectively used the term lifestyle medicine to describe the
105 106 Kennedy and Phillips skills physicians need to deal effectively with Building on Established Expertise the obesity crisis. Many of the competencies needed to address obesity—including health The ILM was structured with education at its coaching—are not taught in medical school. core, and, for that reason, its leaders focused on This course was one of the first to provide a that agenda first. Following completion of the template for clinical interventions using rudi- courses in India, momentum had been build- mentary coaching techniques to help patients ing to establish similar courses in the United with weight management. Since its release in States. As a first step toward achieving that 2005, more than 2,000 clinicians from over 100 goal, ILM created a one-day CME course titled countries have completed this course (www. Introduction to Lifestyle Medicine. This course, harvardlifestylemedicine.org). developed to provide a general introduction to lifestyle medicine, drew 125 attendees when Gaining an International Reach it was first held in Boston in fall 2008. The feedback from the course was very positive; Leaders of a wellness program at Apollo however, participants made it clear that they Hospitals in Hyderabad, India, learned about needed concrete tools to make changes to their the online weight management course and practices. ILM leaders used this feedback to requested in-depth, onsite training in lifestyle update the course. The name was changed to medicine for their clinicians. A second small Lifestyle Medicine: Tools for Promoting Healthy grant from HMS allowed Dr. Phillips to expand Change, and the format was updated to provide the material taught in the online course and more resources that the attendees could readily create a two-day interactive training curricu- use in their work. This updated one-day course lum that covered exercise prescription, stress has been held annually in Boston every June management, nutrition, smoking, physician since 2009 and was expanded to a two-day health, obesity, and behavior change theory. format in 2013. The course included a personal health assess- In addition to creating this introductory ment and coaching demonstration and provided course, ILM wanted to provide an opportunity CME credits from HMS. Harvard clinicians for clinicians to focus on physical activity. taught the course in four Indian cities in March To meet that need, institute leaders created a 2006, which proved timely, considering the two-and one-half day CME course titled Active recent epidemic of lifestyle illnesses that the Doctors, Active Patients: The Science and Expe- country was experiencing. At end of two weeks rience of Exercise. This course was launched in India, there was a clear need to establish a in November 2009 and drew more than 125 formalized institute to serve as a resource for participants. It was designed to teach the basic clinicians worldwide seeking to learn the skills science of exercise and physical activity, provide to effectively counsel patients about lifestyle information about physical activity recommen- interventions. dations, and introduce the principles of health coaching techniques through didactic training. Forming the Right Partnerships It provided course participants with an oppor- Drawing on their experiences in India, the tunity to attend four exercise sessions taught by course facilitators agreed that the time was right certified exercise professionals at a local health to establish an institute that would serve as a club. The sessions included aerobic, strength, resource for clinicians who wanted to counsel and flexibility options. The U.S. Surgeon Gen- their patients about lifestyle interventions. Dr. eral, Regina Benjamin, MD, MBA, recognized Phillips agreed to lead the effort to form the the efforts of the Active Doctors course by ILM. His home institution, SRH, and academic presenting the keynote address at the course in home, HMS, agreed to host the institute, and 2010. She also led an event titled White Coats, key national organizations such as the American White Sneakers, Walk for a Healthy and Fit College of Sports Medicine supported it. The Nation on the Boston Common in concert with ILM was launched on October 1, 2007. the Active Doctors course (figure 12.1). Institute of Lifestyle Medicine 107 © Massachusetts General Hospital © Massachusetts General
Figure 12.1 Surgeon General Dr. Regina Benjamin leading the White Coats, White Sneakers, Walk for a Fit and Healthy Nation at the 2010 Active Doctors course. She is joined by Drs. Damian Folch, Pamela Peeke, and Edward Phillips, plus more than 100 course attendees. ©MaryKennedy In response to participant feedback and in countries have completed one or more of these recognition of the need to expose the entire courses. health care team (not just physicians) to infor- Expansion of the ILM’s reach and impact mation about lifestyle medicine, ILM leadership required additional infrastructure to help with renamed the course Active Lives: Transform- research and advocacy for policies to support ing Ourselves and Our Patients. The updated lifestyle medicine. With limited funding, the course, in which participants practice the skills ILM has recruited a small army of profession- of promoting physical activity and prescribing als who volunteer their time and expertise to exercise, was introduced in November 2011. promote the vision of more healthful behav- The exercise sessions in the revamped course iors through clinician intervention. A team are conducted in an open area next to the of researchers also has begun to carve out a conference center rather than within a health specific research agenda for the institute, which club. This change provides an inexpensive and will focus on education, and to identify funding reproducible model for participants to recreate opportunities. The goal of the research agenda in clinical settings when they return to practice. is to strengthen the institute’s education and CME efforts. Expanding the Foundation Since the first online course was released in Program Evaluation 2005, ILM has developed six additional courses, and several more are in production. To date, ILM conducts participant surveys before and more than 6,800 clinicians in more than 115 after each CME course. The pre-course surveys 108 Kennedy and Phillips are sent out approximately one week prior prescribed exercise to their patients increased to the course, and the post-course surveys from 41 percent preconference to 63 percent at are conducted 90 days after the course ends. 90 days after the conference. This represents a These surveys are conducted primarily online. significant change (p = .05). Surveys follow- In November 2012, the results of these surveys ing subsequent Active Doctors courses and the were published in Medical Teacher. The article, Tools for Promoting Healthy Change courses “The Impact of Lifestyle Medicine Continuing yielded similar results. Education on Provider Knowledge, Attitudes, and Counseling Behaviors,” by Dacey and col- leagues is summarized here: Linkage to National Two hundred participants completed surveys Physical Activity Plan before and 90 days after each CME program. Results indicated that all of the barriers that The ILM directly addresses Strategy 5 of the were targeted during the programs (i.e., lack Health Care Sector of the National Physical of knowledge and skills, lack of materials, Activity Plan (NPAP): Include physical activ- and perceived poor patient compliance) ity education in the training of all health care showed highly significant improvement. professionals. The ILM fulfills this strategy by Participants also reported significant changes including physical activity in continuing educa- in knowledge, confidence, and counseling tion programs, using the recommendations from behaviors in the areas of exercise and stress the 2008 Physical Activity Guidelines for Ameri- management. Some improvements occurred cans. Through the institute’s two annual CME in areas that the CME programs did not courses and the online CME training programs, target as much, specifically nutrition, smok- health care professionals learn why physical ing, and weight management. The greatest activity needs to be an integral part of health predictor of change was the baseline level care. These programs provide the scientific sup- of score—those participants who could most port for the relationship of physical activity to benefit from change showed the largest health and the tools providers need to integrate improvements. This work suggests that live physical activity measures, prescriptions, and CME programs can be effective in educating general advice into health care practice. health care providers about topics within the expanding field of lifestyle medicine. The ILM has taken this tactic a step further by incorporating physical activity education Further findings not included in the paper into the curricula of medical school students reveal the conference was successful in edu- and residents in training. For medical students, cating participants about physical activity the ILM started the Lifestyle Medicine Interest as well as inspiring them to incorporate this Group at HMS in 2009, which HMS formally rec- knowledge into both their clinical practice and ognized as an official student group in 2011. The their personal lives. Attendees were asked to Lifestyle Medicine Interest Group is supported rate their current knowledge of exercise and by ILM funds and organized in cooperation physical activity as well as their confidence in with HMS students. In addition, the ILM coor- their ability to discuss those subjects with their dinates a series of lunchtime lifestyle medicine patients before and after the course. On a scale presentations by ILM faculty, staff, and invited of 1 to 10 (1 = not knowledgeable; 10 = very guests that is open to all HMS students. This knowledgeable), course attendees’ knowledge is an initial effort to create a parallel curricu- increased from 7.1 precourse to 8.3 at 90 days lum that focuses on health promotion as ILM after the course; their confidence increased from works to integrate lifestyle medicine into the 7.4 to 8.9. Both represent a significant change formal medical school curriculum. The ILM is (p < .001). Data suggest that knowledge and working closely with the University of South confidence translated into practice. The survey Carolina School of Medicine at Greenville and found that the percentage of attendees who ACSM’s Exercise Is Medicine campaign to create Institute of Lifestyle Medicine 109 a national curriculum on physical activity for Medical Association, American College of Sports medical schools. Medicine (ACSM), and American College of For residents, the ILM has developed an Lifestyle Medicine—addressed the knowledge innovative curriculum in lifestyle medicine for gap that exists for primary care physicians trainees in Yale Medical School’s combined in relation to counseling their patients about Internal Medicine and Preventive Medicine lifestyle medicine interventions. Today, the Residency program; the curriculum is based on education programs within the ILM address the the lifestyle medicine competencies published competencies described in JAMA. in the Journal of the American Medical Associa- The specific physical activity components of tion (JAMA) in 2010. A Health Resources and the ILM’s programs are based on the Physical Services Administration grant awarded to Yale Activity Guidelines for Americans. The exercise and the ILM supports this work. Residents par- prescription techniques taught by ILM were ticipate in all of ILM’s online training courses derived from material created by ACSM over and have the opportunity to attend both of the the years. These techniques are detailed in the CME courses. They also have the option to visit book ACSM’s Exercise Is Medicine: A Clinician’s Boston for a two-week rotation in lifestyle medi- Guide to Exercise Prescription (described in the cine during their senior year. Finally, speakers Additional Reading and Resources at the end of give presentations on lifestyle medicine topics, this chapter). Dr. Phillips, director of the ILM, including physical activity, at Yale on an ongo- is a coauthor of the book, which was published ing basis throughout the three-year program. in cooperation with the ILM. The residents rotating in Boston gain first- hand experience in physical activity through meeting with an exercise physiologist to assess Populations Best Served their personal exercise routine, monitoring their by the Program physical activity with an accelerometer, partici- pating in laboratory-based exercise assessments, The ILM was created to serve clinicians of all and providing a final formal presentation that types who have the ability to promote lifestyle reflects on some aspect of their personal health medicine interventions with their patients. The habits addressed during the rotation. institute’s education courses were designed originally with the physician in mind; how- ever, clinicians in every area of the health care Evidence Base Used system have the ability to influence patients’ During Program Development lifestyle habits. As a result, ILM recently made a focused effort to encourage clinicians of all Lifestyle medicine is a relatively new field. types to attend its courses by expanding the Although the competencies necessary to coun- types of continuing education credits offered. sel patients on specific health topics (e.g., physi- Additionally, ILM is working to connect health cal activity, diet) have been described in the care providers with exercise professionals to literature, only recently have the competencies establish a strong referral network. As such, that address many health topics been brought exercise professionals can also benefit from the together using the term lifestyle medicine. The ILM’s programs and from understanding the first official description of these competencies needs of clinicians. was published in JAMA in a 2010 commentary titled “Physician Competencies for Prescribing Lifestyle Medicine.” These competencies were Lessons Learned the result of a blue ribbon panel convened in 2009 by the American College of Preventive The ILM continues to grow and learn. ILM lead- Medicine, in which members of multiple pro- ers have learned several lessons that may help fessional societies—including the American other organizations working in related areas. 110 Kennedy and Phillips
Work Together the achievements of your organization. Figure 12.2 is an award the ILM applied for, received, Identify and reach out to people and orga- and leveraged through media exposure. Even nizations that are working on similar goals. small awards make people take notice of your Although working with other organizations work. Use the web as much as possible. Create can be time consuming and complex, it can a well-designed website that highlights your lead to stronger and more enduring results. organization’s mission and provides evidence- The most meaningful change will happen when based information. Avoid commercial material all of the stakeholders are at the same table, or links that could cloud your mission or efforts. working together, and learning how to lever- Create links between your site and related sites age each other’s resources most effectively. to draw in traffic. For example, in 2011, ILM conducted a survey of sports medicine doctors’ attitudes and prac- Be Patient and Stay Focused tices in recommending physical activity and exercise to their patients. This survey resulted Change is slow, and organizations do not from collaboration between ILM, ACSM, and the embrace it readily. Although the need for International Health, Racquet and Sportsclub change is urgent, changes may take years to Association (IHRSA). IHRSA funded the work implement and sustain. Be patient and creative and ACSM granted ILM access to its member in your efforts. If you work within an organiza- physicians’ contact information. The addition tion, continually assess new ways in which you of the ACSM contacts expanded the potential can collaborate while staying in sync with their number of survey participants and allowed overall mission. If no progress occurs after a ILM to achieve more robust results. In the end, sustained effort by two or more organizations, all three groups benefited from the collabora- reassess whether the organizations are a good tion. The results of the survey are available at fit for this type of work. www.instituteoflifestylemedicine.org/file/doc/ publications/featured_publications/GlobalSur- Tips for veySportsMed_FullReport.pdf. Working Across Sectors Think Outside the Box Working across sectors can be difficult, but it Find ways to move forward despite limited is critical to extending an organization’s reach. resources. First, cultivate champions. Many Reaching across sectors can expand the audi- people are willing to volunteer time to work ence for an organization and its mission. One toward achieving your goals. Take advantage of the best ways to work with groups in differ- of these early adopters to help spread the ent sectors is to find common ground. Look for message of your organization. Collect contact ways to attach your organization to an issue information from the people you encounter and that resonates with other groups. For example, build a robust mailing list. ILM collects contact when the media reported on the advent of the information from all course attendees in order to Medicare Annual Wellness Visits in January keep them informed about the institute’s work 2011, the ILM provided background material and to encourage them to continue spreading for the Time magazine article “Wellness: Does the lifestyle medicine message. Your Doc Know What to Look For?” Dr. Phillips Second, use the media. Public relations is shared his perspective on the Annual Wellness critical and will yield very positive results. Reach Visits, while also discussing their relationship out to newspapers, magazines, television, and to lifestyle medicine. It was a win-win and radio shows that might be interested in learning ultimately allowed ILM to get its message to about and sharing your organization’s mission. thousands of people who were not familiar with Apply for local and national awards to highlight the institute or its mission. Figure 12.2 Press release for Spaulding’s Institute of Lifestyle Medicine. (continued) E5691/NPAP/fig12.1/458549/alw/r1
111 112 Kennedy and Phillips
Figure 12.2 (continued) Press release for Spaulding’s Institute of Lifestyle Medicine. E5691/NPAP/fig12.1/458549-2/alw/r1
Time magazine article: Russo, F. 2011, January 29. Additional Wellness: Does your doc know what to look for? Reading and Resources TIME. http:// www.time.com/time/magazine/ article/0,9171,2040210,00.html ILM website: www.instituteoflifestylemedicine.org ACSM’s Exercise Is Medicine initiative: http://exerci- ILM online courses: httwww.harvardlifestylemedicine. seismedicine.org/ org/index.php American College of Preventive Medicine: http://acpm. Medical Teacher CME article: Dacey, M., F. Arnstein, site-ym.com M.A. Kennedy, J. Wolfe, and E.M. Phillips. 2012. JAMA article: Lianov, L., and M. Johnson. 2010. Physi- The impact of lifestyle medicine continuing educa- cian competencies for prescribing lifestyle medicine. tion on provider knowledge, attitudes, and coun- JAMA. 304(2):202-3. seling behaviors. Med Teach. 35:e1149-56. http:// informahealthcare.com/doi/pdf/10.3109/01421 ACSM’s Exercise Is Medicine—A Clinician’s Guide to 59X.2012.733459. Exercise (Baltimore: Lippincott Williams & Wilkins, 2009). Written by Drs. Steve Jonas and Edward Institute of Lifestyle Medicine 113
Phillips (ILM), this book is the essential field guide patients on the importance of exercise and how to for health professionals being called upon to pro- design practical exercise programs for patients of mote active lifestyles for their patients and clients all ages and fitness levels, as well as those with and serves as the primary text in support of the special conditions such as pregnancy, obesity, and ACSM’s Exercise Is Medicine program. This book cancer (http://www.instituteoflifestylemedicine. teaches practitioners how to motivate and instruct org/publications/).
CHAPTER 13 Exercise Vital Sign at Kaiser Permanente
Robert Sallis, MD, FAAFP, FACSM Kaiser Permanente Medical Center
NPAP Tactics and Strategies Used in This Program
Health Care Sector STRATEGY 1: Make physical activity a “vital sign” that all health care providers assess and discuss with their patients.
he Exercise Vital Sign (EVS) was launched at the beginning of each visit and listed in the Tin Kaiser Permanente’s Southern California patient’s chart. The EVS at Kaiser Permanente region in October 2009 as a way to make physi- was designed as a way to assess each patient’s cal activity assessment and exercise prescription physical activity habits at every visit; the EVS a standard of care for all patient visits. Founded provides a numerical value for the amount (in in 1945, Kaiser Permanente (KP) is one of the minutes per week) of exercise or physical activ- largest health plans in the United States, serving ity, of moderate or greater intensity, that each almost 9 million members. KP is a staff model patient reports (Sallis 2011). health maintenance organization (HMO) whose To accomplish this, patients are asked two members pay a monthly premium and receive questions regarding their typical exercise and all of their health care from KP physicians and physical activity habits, and their responses are staff at KP facilities. Therefore, KP has a tre- recorded in the KP electronic medical record mendous incentive to invest in prevention and (EMR) (see figure 13.1): keep patients healthy, thereby avoiding the costs associated with caring for more advanced dis- 1. On average, how many days each week ease. For this reason, helping patients become do you engage in moderate or greater more active is a key priority in the organiza- physical activity (like a brisk walk)? tion’s quest to help them achieve total health. Based on the patient’s response, the staff member clicks a box that corresponds to the number of days reported, from zero Program Description to seven days. It is customary for patients’ vital signs to be 2. On those days, on average, how many measured at almost every visit to a health minutes do you engage in this physical care provider. Traditional vital signs include activity? Again, based on the patient’s blood pressure, pulse, respirations, and tem- response, the staff member clicks a box perature. These are most often recorded by a that corresponds to the number of min- medical assistant or licensed vocational nurse utes reported (10, 20, 30, 40, 50, 60).
115 116 Sallis
Figure 13.1 Screen shot of the Kaiser Permanente Electronic Medical Record showing the Exercise Vital Sign. E5691/NPAP/fig13.1/458552/alw/r1 Reprinted, by permission, from Kaiser Permanente.
The computer then multiplies the two Program Evaluation responses to calculate the minutes per week of moderate or greater physical activity that the After the first year of use, KP conducted a study patient has reported that he or she undertakes to evaluate the implementation and validity during a typical week. This number is displayed of the EVS. The study found that 81 percent on the patient’s chart in the vital sign header, of adult KP members who had an office visit next to the traditional vital signs (see figure during the first year of implementation had an 13.1). The patient’s body mass index (BMI) and EVS recorded on their chart. This was remark- smoking history also are recorded. able, given that recording the EVS was not The EVS allows the physician or other health mandatory, and this finding seemed to reflect care provider to assess quickly how much the acceptance of the EVS among physicians physical activity the patient performs. In keep- and staff. In reviewing the 1,500,947 adult KP ing with the Physical Activity Guidelines for patients who had an EVS recorded between Americans, adult patients who are engaged January 1, 2010, and February 28, 2011, the in less than 150 minutes per week of physical investigators found that 36 percent of these activity and children who are engaged in less patients were completely inactive (reported than 420 minutes per week are flagged as not no regular exercise or physical activity), 33 meeting optimal levels of physical activity. Most percent were insufficiently active (reported providers will then use this information as a 10-149 minutes per week), and 31 percent segue into a brief discussion about how physi- were meeting public health guidelines (150 or cal activity can affect health. more minutes per week of moderate or greater Exercise Vital Sign at Kaiser Permanente 117 exercise or physical activity) (Sallis and Cole- live at a KP clinic in the Colorado region. This man 2011). survey revealed that 85 percent of respondents As in previous studies that used self-reported believed that the EVS was easy to use, and physical activity, the results varied based on 78 percent did not believe that it significantly the patient’s age, gender, ethnicity, and BMI. slowed down their clinic; 67 percent said they Reported physical activity tended to decrease as were more likely to discuss exercise with their the age of the patient increased. Men reported patients since using the EVS, and 65 percent doing more physical activity than women, and felt more confident about having this discussion ethnic minorities reported doing less physi- with patients. These results indicate that most cal activity than nonminorities, with whites staff believed the EVS was easy to use and an reporting the most, followed by blacks and then effective tool to aid in assessing and prescribing Hispanics. Patients with a higher BMI tended to exercise to patients. report less physical activity than patients with Although the EVS tool is relatively new, its a lower BMI. use has been accepted readily by KP leader- KP compared results from the EVS study with ship as an effective way to capture information data from the National Health and Nutrition about the exercise and physical activity habits Examination Survey (NHANES) (Tucker et al. of patients and to bring the topic of physical 2011), which is generally regarded as one of the activity and its importance to health into the best data sets for identifying current trends in exam room. After an initial rollout in the KP the health and nutrition status of Americans, Southern California region in October 2009, the including physical activity status. The NHANES KP Northern California region adopted EVS in survey reports data on physical activity using 2011. Plans are currently in place to roll out the both self-report and accelerometry. Typically, EVS to every KP region. the accelerometer reports of physical activity are much lower than the self-reports, reflect- ing a tendency for respondents to overestimate Linkage to the National the amount of physical activity they engage in Physical Activity Plan during a typical week. When compared with the NHANES physical activity measures, the Health care is the largest industry in the United EVS provided a more conservative estimate States and currently consumes $2.6 trillion than the NHANES self-report measure but a per year, the bulk of which is spent to care for higher estimate than the accelerometer report. patients who have chronic diseases that are This suggests that the EVS is, in fact, a valid directly related to inactivity (Emanuel 2012). indicator of patient physical activity levels in The KP EVS is directly linked to the Heath Care this setting. In addition, the NHANES data Sector of the National Physical Activity Plan on physical activity reported similar trends as (NPAP), specifically to Strategy 1. the KP EVS data, with lower levels of activ- Strategy 1: Make physical activity a “vital ity reported by older patients, women, ethnic sign” that all health care providers assess and minorities, and patients with higher BMI. The discuss with their patients. With the EVS, KP KP results may reflect the willingness of patients has shown clearly that this strategy can be to be more truthful about their physical activ- implemented successfully on a large scale. In ity habits when being questioned by a medical developing the EVS, KP followed the NPAP’s professional, compared with being questioned suggested tactics for this strategy by encour- by a research surveyor. This offers the potential aging KP physicians and staff to assess their for the KP EVS to provide information about patients’ physical activity habits and encour- the relationship between physical activity and age them to make progress toward meeting the health that has not been available previously at Physical Activity Guidelines for Americans. The the population level. EVS allows KP providers to accurately identify A survey of physicians and other personnel patients who, by self-report, are not meeting was conducted two months after the EVS went these guidelines. In addition, Kaiser is among 118 Sallis the first health care plans to include fields for how and why they should start walking. The tracking physical activity in its electronic medi- program also includes a helpful Every Body cal record and has shown that this can be done Walk! mobile app that can be downloaded onto with minimal disruption to patient flow. smartphones to help people track and personal- At the same time, KP has encouraged phy- ize their walks (see figure 13.2). sicians and staff to serve as role models for active lifestyles for their patients. This effort started with the organization’s long-running Evidence Base Used During marketing campaign called Thrive. The tag line Program Development for this campaign is “At Kaiser Permanente, we want you to live well, be well and thrive.” The evidence base documenting the health This campaign includes internal and external benefits of exercise is incontrovertible. It is clear components and encourages all KP employees that a dose-response relationship exists between to live the brand. In keeping with this message, a patient’s activity level and his or her health internal campaigns called Thrive Across Amer- and longevity (Wen et al. 2011). This relation- ica and KP Walk have encouraged staff to join ship exists regardless of the patient’s gender, together to become more active and to get out race, or age (Physical Activity Guidelines for and walk. At the same time, KP Chairman and Americans 2008). There is no disputing the CEO George Halvorson launched a campaign importance of physical activity to health or that called Every Body Walk! (see www.everybody- it is the single most important lifestyle interven- walk.org) in January 2011. This is a nonbranded tion a person can make to improve his or her campaign designed to get Americans walking. health, and clear consensus exists that 150 min- Featuring an interactive website as the hub of utes per week of moderate or greater physical the campaign, it contains videos and articles activity (like a brisk walk) is the amount that designed to inspire and inform patients about every adult should strive for (Physical Activity
Figure 13.2 The Every Body Walk! mobile app is a useful tool to help patients track and personalize their walking. E5691/NPAP/fig13.2/458553/alw/r1 Reprinted, by permission, from Kaiser Permanente. Exercise Vital Sign at Kaiser Permanente 119
Guidelines for Americans 2008; World Health physicians can implement exercise assessment Organization 2013). For this reason, KP believes and prescription into their routine office visits. that physicians have an obligation to assess the Although progress has been made toward exercise habits of their patients and inform them increasing the number of physicians and other of the risks of being inactive (Weiler et al. 2012). health care professionals who recommend exer- The American College of Sports Medicine cise or physical activity to their patients, much and American Medical Association have gone additional work needs to be done. Data from the so far as to suggest that exercise is similar to a National Health Interview Survey in 2000, 2005, medication that should be prescribed as a first- and 2010 showed that the percentage of adults line therapy for the prevention and treatment of receiving advice from their physician or other disease (Sallis 2009). In 2007, these organiza- health care professional to exercise increased tions launched a campaign called Exercise Is by almost 10 percent between 2000 and 2010 Medicine that calls on all physicians and health (Barnes and Schoenborn 2012). However, only care personnel to make exercise assessment and about a third of adults aged 18 and older who prescription a standard part of the disease pre- had seen a physician or other health profes- vention and treatment paradigm for all patients sional in the past year had been advised to begin (see www.exerciseismedicine.org). The Exercise or continue to do exercise or physical activity. Is Medicine initiative has developed widespread Adults who were overweight or who suffered support among a range of medical organizations from chronic diseases such as hypertension, car- around the world, with most calling on their diovascular disease, cancer, and diabetes were members to assess and prescribe exercise to all more likely to receive advice on exercise than their patients. In addition, Healthy People 2020 were adults without these conditions. Kaiser’s includes two objectives aimed at increasing the EVS is an excellent tool that can help increase proportion of physician office visits that include the percentage of physicians and other health counseling or education related to the effects care professionals who counsel their patients of physical activity on health (Office of Disease on exercise and physical activity. Prevention and Health Promotion n.d.). Unfortunately, the evidence suggesting that health care providers can change the exercise Populations Best Served habits of their patients is not as strong. In fact, by the Program the U.S. Preventive Services Task Force has said that insufficient evidence exists that physicians It is well established that the benefits of exercise prescribing exercise in their practice actually apply to everyone, regardless of age, gender, cause a sustained increase in the exercise habits or ethnicity (Physical Activity Guidelines for of their patients (Eden et al. 2002). However, Americans 2008). Further, there is almost no this area of research is woefully underfunded, disease or disability that is not improved by and it is still in its infancy. Similar concerns regular exercise. In fact, a wide range of estab- were expressed almost 50 years ago about the lished clinical guidelines recommend physical ability of physicians to convince their patients activity promotion as a first-line treatment to stop smoking, when the American Medical (Weiler et al. 2012). For conditions as diverse Association first spoke out about the dangers as diabetes, fibromyalgia, and low back pain, of smoking. Certainly, as long as physicians regular physical activity is touted as a treatment resist the call to actively prescribe exercise to that generally should be used before prescribing patients, it is unlikely that those who are most medications. For that reason, KP clinical man- at risk from inactivity, patients suffering from agement recommends that the EVS be used on chronic disease, will ever attempt to change all populations and by all medical specialties. their sedentary ways. For this reason, the KP At KP, the EVS is used in all clinical depart- EVS is a very important step in proving that ments and by every provider who interacts with 120 Sallis patients. In keeping with the Physical Activity administrators in turn trained their personnel Guidelines for Americans, children ages 6 to 17 on how to ask the EVS questions. Educational are encouraged to participate in 60 minutes of handouts, videos, and a Wiki page were devel- physical activity daily, and adults age 18 and oped to provide ongoing support and education older are encourage to engage in 150 minutes regarding use of the EVS (see figure 13.3). per week. The EVS went live in October 2009 for use by every KP provider at every patient visit in South- ern California. Since exercise has been proven Lessons Learned to be of value to virtually every patient, every The first lesson: Ensure that a new program or clinical department within KP was encouraged activity will fit easily into the organization’s to use the EVS, from primary care to specialty usual practice. Educate providers and staff care. However, there was no mandate that pro- about the rationale for the program and how viders record an EVS as part of their standard to integrate it into usual practice, and address routine. their questions and concerns. The EVS began as The third lesson: Address push-back and a pilot project in several KP Southern California respond to provider and staff concerns about medical centers in early 2009. The pilot was the program. As expected, physicians and clinic designed to determine the instrument’s ease staff initially “pushed back” a bit regarding the of use and effect on patient flow. Key concerns request to add another task to an already-busy were that the EVS might slow down office staff schedule. In today’s health care environment, or physicians or that it might not be viewed as and particularly since the advent of the EMR, valuable information in caring for patients. To there has been a significant increase in the ensure that the EVS could be recorded quickly, number of issues physicians are asked to discuss the two brief questions were selected and more with patients at each visit. Although KP physi- detailed questioning on intensity of exercise cians acknowledged the importance of exercise was eliminated. Prior to launch of the EVS, to health, they were leery about adding one the author visited every KP medical center in more item to their already-full plate. Manage- Southern California to discuss the rationale and ment responded by emphasizing how important importance of assessing and prescribing exer- exercise is to a patient’s health and showing cise to patients. This helped set the stage for them how to incorporate the EVS information implementation and was a chance to address into normal patient flow quickly and easily. physician concerns and encourage physicians and other providers to incorporate exercise prescription into their daily practice. Tips for The second lesson: Test new programs to Working Across Sectors ensure that they achieve the desired goals, and train providers and staff to implement them The EVS is a tool with which health care work- properly. Another concern was that responses to ers can bring the topic of exercise and physi- the two questions would not accurately reflect cal activity into the examination room for all patients’ true physical activity levels. KP wanted patients. If the EVS shows that a patient is not to ensure that physical activity other than tra- meeting guidelines for exercise and physical ditional exercise, such as vigorous activity or activity, providers can discuss how the patient brisk walking done at work or other times in can do so. Such a discussion can be made easier the day, was included in the EVS recorded on and more effective if physicians and other pro- each patient’s chart. To ensure that these forms viders are aware of opportunities in their com- of activity were included, KP management munity that are available to increase patients’ held a series of meetings with the department activity levels. Such opportunities could include administrators of all KP clinical departments in park and recreation sites that encourage hiking Southern California to provide training on how or other physical activity, community resources to administer and record the EVS properly. The such as bike and walking trails, or school-based Figure 13.3 Kaiser Permanente handout on documenting the Exercise Vital Sign in adult patients as part of the proactive office encounter. Reprinted, by permission, from Kaiser Permanente. E5691/NPAP/fig13.3/458554/alw/r1
121 122 Sallis
programs to help children become more active. A summary of the evidence for the U.S. Preventive For these reasons, it is essential that good Services Task Force. Ann. Intern. Med. 137:208-15. communication and idea sharing take place Emanuel, E.J. 2012. Where are the health care cost across all of the sectors of the National Physi- savings? JAMA. 307(1):39-40. cal Activity Plan. Other sectors should develop Office of Disease Prevention and Health Promo- and publicize resources with an eye toward tion. Healthy People 2020 summary of objectives. attracting patients who are most at risk from n.d. www.healthypeople.gov/2020/topicsobjec- chronic diseases that are directly attributable tives2020/pdfs/EducationalPrograms.pdf. to an inactive lifestyle. Physical Activity Guidelines for Americans. 2008. Washington, DC: U.S. Department of Health and Additional Human Services. Sallis, R.E. 2011. Developing health care systems to Reading and Resources support exercise: Exercise as the fifth vital sign. Br J Sports Med. 45:473-4. Learn more about Exercise Is Medicine, the interna- tional campaign designed to encourage all health Sallis, R.E. 2009. Exercise is medicine and physicians care providers to assess and review every patient’s need to prescribe it! Br. J. Sports Med. 43:3-4. physical activity program at every visit: www.exer- Sallis, R.E., and K.J. Coleman. 2011. Self reported exer- ciseismedicine.org cise in patients using an exercise vital sign. Med. Sci. Learn more about Every Body Walk!, a national cam- Sports Exerc. 43(5 Suppl):S376. paign to get Americans walking to achieve better Tucker, J.M., G.J. Welk, and N.K. Beyler. 2011. Physi - health: www.everybodywalk.org cal activity in US adults: Compliance with physical Learn more about the Kaiser Permanente Thrive activity guidelines for Americans. Am. J. Prev. Med. campaign, which encourages its members to adopt 40(4):454-61. healthy lifestyles, including regular physical activity, Weiler, R., P. Feldschreiber, and E. Stamatakis. 2012. to achieve total health: www.kp.org/thrive Medicolegal neglect? The case for physical activity promotion and exercise medicine. Br. J. Sports Med. References 46:228-32. Wen, C.P., J.P. Wai, M.K. Tsai, et al. 2011. Minimum Barnes, P.M., and C.A. Schoenborn. 2012. Trends in amount of physical activity for reduced mortality Adults Receiving a Recommendation for Exercise or and extended life expectancy: a prospective cohort Other Physical Activity From a Physician or Other study. Lancet 378:1244-53. Health Professional. NCHS Data Brief, No 86. Hyatts- World Health Organization. Global recommendations ville, MD: National Center for Health Statistics. on physical activity for health. 2013. www.who.int/ Eden, K.B., C.T. Orleans, C.D. Mulrow, et al. 2002. Does dietphysicalactivity/factsheet_recommendations/ counseling by clinicians improve physical activity? en/index.html. CHAPTER 14 Profession MD—Lifestyle Program
Sarah Bilodeau, BSc Marie-France Hivert, MD, MMSc Université de Sherbrooke Université de Sherbrooke and Massachusetts General Hospital
NPAP Tactics and Strategies Used in This Program
Health Care Sector STRATEGY 5: Include physical activity education in the training of all health care professionals.
he primary preventable causes of death in about the importance of their own lifestyles Tthe world are noncommunicable chronic and (2) to increase students’ knowledge about diseases such as obesity, diabetes, cardiovascu- the benefits of a healthy lifestyle and teach lar diseases, and cancer. Most of the morbidity them skills for supporting patients in behavior and mortality related to those conditions are changes toward a healthier lifestyle. attributable to lifestyle factors, primarily physi- Early adulthood is a critical period for making cal inactivity, poor dietary choices, and tobacco personal choices about lifestyle that are likely use. Physicians are key health professionals who to last throughout adulthood. It is a favorable are highly trusted by the public to provide infor- time to inform young adults about the benefits mation about healthy lifestyles and to support of a healthy lifestyle and to demonstrate how patients in modifying their health behaviors. daily choices can affect their personal health Unfortunately, in most medical doctorate (MD) significantly in the short term (e.g., physical curricula in North America, very limited edu- activity for stress management and improved cation time is devoted to knowledge and skills concentration for studying) and long term about physical activity and nutrition counsel- (e.g., physical activity for maintenance of a ing. Consequently, physicians feel inadequately healthy weight and prevention of cardiovascular prepared to fulfll this role. diseases). As part of the academic program, In 2008, the Université de Sherbrooke students monitor their own lifestyle in order to Medical School, in Sherbrooke, Quebec, imple- learn that aspects of their lifestyle might need to mented a new educational program that spans be improved and that behaviors such as dietary the entire preclinical medical curriculum. This intake and physical activity levels are not easy program, known as Profession MD, is divided to measure. Students choose one lifestyle habit into several content components, including they would like to improve or one behavior they one that focuses on teaching the benefits of a would like to modify. By doing so, students healthy lifestyle and training future physicians learn that changing is not easy, which should in lifestyle counseling techniques. The principal help them approach with empathy their patients aims of the Profession MD—Lifestyle program who are struggling to change behaviors. Physi- are (1) to raise medical students’ awareness cians serve as role models for their patients, and
123 124 Bilodeau and Hivert
physicians who practice healthier lifestyles are in their counseling skills. Prior to 2008, the more credible and inspiring for their patients MD curriculum at Université de Sherbrooke (Hash et al. 2003). In addition, studies have included almost no information or training shown that physicians with healthier personal about physical activity, nutrition, and behavior habits are more likely to discuss related preven- modification, and the situation is similar at most tive behaviors with their patients (Frank et al. other medical schools. 2004; Frank et al. 2010). This chapter presents the content and format Despite the fact that most physicians and of the Profession MD—Lifestyle program, the patients believe in the importance of a healthier lessons learned through the process of imple- lifestyle, the frequency of lifestyle counseling by mentation, and preliminary results of a formal physicians remains low; physician self-reported program evaluation. rates of lifestyle counseling are approximately 34 percent (Lobelo et al. 2009). A much smaller percentage of patients, 20.5 percent, report Program Description that they have been counseled about physical Figure 14.1 shows the current MD curriculum activity by their physician (Bleich et al. 2011). at the Université de Sherbrooke Medical School. Barriers that may explain the low levels of The Profession MD—Lifestyle curriculum, physician counseling include physicians’ lack which received an award from the Minister of of knowledge about physical activity, nutrition, Education of Quebec for its innovative approach and other lifestyle habits and lack of confidence and the quality of the academic material, is
MD Program
Ist year Phase I Christmas Phase II Preventive Health and Medical biology Clinical Nervous Musculoskeletal medicine and Introduction medicine Psychiatry Holidays I and II immersion system system public throughout life 10 weeks health
PROFESSION MD LIFESTYLE COMPONENT CLINICAL AND PROFESSIONAL INTEGRATION (CPI)
2nd year Christmas Phase II PBL in Reproductive Cardiovascular Respiratory Gastrointestinal Urinary Infectious Endocrine Hematology community system and system system system system diseases system Holidays setting sexuality 10 weeks LIFESTYLE COMPONENT CLINICAL AND PROFESSIONAL INTEGRATION (CPI)
3rd year Phase III Christmas Clerkship (Rotations)
Family Multidisciplinary unit Elective Elective Community medicine and Medicine Preclerkship Interdisciplinarity I II health emergency Holidays 1 week LIFESTYLE COMPONENT PROFESSION MD CLINICAL SKILLS
4th year Christmas Clerkship (Rotations) Integration and Obstetric Selective Selective Elective Pediatrics Psychiatry Surgery preparation gynecology I II III to MMCCQE-1 Holidays 3 weeks PROFESSION MD
= Terminal exam (Medical Council of Canada = Promotion = Diploma Qualifying Examination, part I)
Figure 14.1 Profession MD—Lifestyle throughout the preclinical medical curriculum. Reprinted, by permission, from Université de Sherbrooke MD Program.
E5691/NPAP/fig14.1/458557/alw/r2-kh Profession MD—Lifestyle Program 125 represented by the red ribbon. Components of basic physiologic concepts related to nutrition the curriculum are described next. and physical activity, and public health recom- mendations (from Health Canada) regarding Self-Monitoring Exercises physical activity and nutrition. This introduc- tory lecture is provided in a large-group setting First-year students complete several self-moni- (the entire first-year class), but the format is toring exercises, including keeping a three-day structured so that students actively participat- food diary and a three-day physical activity ing in many of the educational activities during diary and wearing a pedometer. Students are the class. not evaluated on their results but are informed that the self-monitoring is required and that they Small-Group Seminars will use some of their data in future educational exercises. Students repeat the self-monitoring Beginning in January of the first year and exercises in the fall of the second year in order continuing through the end of second year, to assess the evolution of their health habits the program is built on small-group seminars, over time. aligned with preclinical modules (see figure Students also learn to conduct anthropometric 14.1). The seminars last for 60 minutes and take measurements, including waist circumference. place about once a month, with five seminars in The goal of training future physicians in these the first year and eight in the second year. The skills is that it will lead to higher frequency of small groups are composed of 12 students and measuring weight and waist circumference in one professor to optimize interaction. Seminar the future, something that is often overlooked themes include benefits of physical activity, in clinical practice. concepts of nutrition for clinical practice, tools to help with smoking cessation, psychological Introductory Lecture aspects of behavior modification, and basic concepts of motivational interviewing. The In December of the first year, students attend complete list of seminar topics is shown in a three-hour introductory class. The topics table 14.1. covered in this class include epidemiology of The seminars are led by professors from the lifestyle and its consequences on the health medical school faculty who have received spe- of the population and the health care system, cific training (for standardization of educational
Table 14.1 Brief Description of Profession MD—Lifestyle Program First year: Auto-monitoring Introductory session (large Second year: Third year: group, three hours) Auto-monitoring Auto-monitoring Interactive sessions (small group, Interactive sessions (small group, Clinical integrations session on 45 minutes) 45 minutes) lifestyle counseling (simulated Lifestyle and society Smoking cessation patients, two hours) Basics of healthy eating Motivational interviewing Psychological aspects of lifestyle Environmental influences on change nutrition Physical activity (part I) Food labeling Nutraceuticals and functional Physical activity (part II) foods Demystifying diets Sleep: management and reper- cussions on health Impact of family on lifestyle 126 Bilodeau and Hivert content). Didactic documents were developed obesity, stroke, and musculoskeletal problems for professors and students to facilitate compre- (in line with the modules in the MD curricu- hension and to standardize key messages taught lum). In the second year, they learn about physi- to students. The student workbook contains ref- cal activity as it relates to myocardial infarc- erences and reflection exercises as well as space tion, chronic pulmonary obstructive disorders, to take notes on the educational activities during peripheral vascular disorders (claudication), the seminars. The professors’ guide includes the and cancer. Students learn about the American same items presented in the student workbook College of Sports Medicine’s statements related as well as key messages from selected references to various diseases, and they study relevant (often complementary to mandatory readings). readings. They examine case studies of patients Professors receive a detailed animation guide with these medical conditions and identify the for the educational activities so that they can specific benefits of physical activity for each easily lead the seminars. case. In addition, students learn to take into Students are required to complete educa- account special considerations related to each tional activities in preparation for the seminars, condition (such as potential limitations and which usually include reading one or more common medications). scientific articles related to the main theme Physical activity content is also covered in and completing a related activity. The seminars other seminars, including those that focus on often begin with a discussion based on the stages of change, motivational interviewing, readings or activities. Educational content is sleep, and pregnancy. presented through short case studies, quizzes, or other forms of interactive activities. Students Counseling Skills and Practical often work in smaller groups and then share Integration Session what they have learned with the larger group. To conclude the seminar, the professor and During the fall of the third year (before stu- students discuss the relevance of the seminar dents begin clinical rotations), the Profession topic to clinical practice. MD—Lifestyle program includes a session that integrates knowledge and skills about lifestyle Physical Activity Seminars counseling into clinical practice. This educa- tional activity uses simulated patients who Several of the seminars are devoted to topics are trained to role-play a case, receive lifestyle related to physical activity. The first seminar counseling, and then give personalized feed- addresses the impact of sedentary time on back about their perceptions while receiving health and introduces the concept of nonexer- the counseling. This type of activity requires cise activity thermogenesis (NEAT). The impor- integration of knowledge, skills, and attitudes tance of NEAT in the total energy expenditure (including interview techniques). By practicing calculation and as a key component of energy lifestyle counseling on simulated patients, stu- balance is presented, as is its potential impact dents experience how to use counseling tools on the population trend in obesity. During the and learn to understand the patient’s point of seminar, students learn ways to increase NEAT view. This activity is a very good preparation in daily living, for their personal application and for the objective structured clinical examination for future counseling. Students also learn about (OSCE), an evaluation of clinical skills. the importance of physical activity for promot- ing concentration and optimizing learning. Academic Evaluation Two seminars cover specific benefits of physical activity in prevention, treatment, and Academic evaluation is based on professor management of medical conditions. Assessment evaluation, written exams, and performance at tools are presented, and basic recommendations the OSCE. Professors give an assessment of each regarding physical activity planning and goal student based on level of preparation (includ- setting are reviewed. In the first year, students ing completion of the self-monitoring exercises) learn about the benefits of physical activity for and participation during the seminars. Written Profession MD—Lifestyle Program 127 exams at the end of each of the two first years 14.2). In brief, the students in the 2008 cohort cover the content of the introductory class had higher knowledge concerning lifestyle on and seminars. The third-year OSCE already the written exams and better specific skills for included one case that involved counseling behavior counseling during the OSCE. The study skills; it was modified to incorporate content also collected data about dietary habits, physical that Profession MD—Lifestyle brought to the activity levels, and anthropometric measures overall curriculum. in participating students. A modified version of the Canadian Community Health Survey, which assesses food habits, leisure physical Program Evaluation activity, study time, sedentary activities, sleep, and transportation, was completed every year In addition to collecting feedback from students (Statistique Canada 2002). Complete analysis of and professors, the medical school is conducting data from the two cohorts is underway. a research project to evaluate the curriculum. The study compares the students receiving the new program (intervention cohort, 2008-2012) Linkage to the National to a group of volunteers recruited from the pre- Physical Activity Plan ceding academic year who did not receive the program (control cohort, 2007-2011). The goal The Profession MD—Lifestyle curriculum of the study is to evaluate the impact of the addresses Strategy 5 of the Health Care Sector program on students’ knowledge and counsel- of the National Physical Activity Plan: Include ing skills. Data were collected longitudinally physical activity education in the training of all every year in the two groups, including results health care professionals. The program trains of the written and oral (OSCE) exams (see table all medical students to incorporate education
Table 14.2 Students Results of Written Exam 1 and 2, OSCE Exam
Intervention cohort Control cohort Evaluation (N = 200)* (N = 31)* p Written exam year 1 (median for 86.4 (81.5-90.1) 58.6 (53.1-68.6) <.0001** grade over 100 points) Written exam year 2 87.7 (87.7-91.1) 51.6 (43.9-57.0) <.0001** (median for grade over 100 points) OSCE exam year 2 Global note 57.3 ± 14.5 52.8 ±12.3 .22*** (mean [SD] for grade over 100 points) Assessment of physical activity level 24.2 12.9 .70**** Proportion (%) of students with grade A Use of motivational interviewing 32.0 12.9 .0005**** skills Proportion (%) of students with grade A Follow-up and monitoring 80.8 0.0 <.0001**** Proportion (%) of students with grade A *Values are percentages. **Mann-Whitney. ***Independent t test. ****Fisher exact test. 128 Bilodeau and Hivert and counseling about physical activity into tion or disease prevention) by adding new their medical practices and to adopt physical ingredients or more of existing ingredients. activity habits that allow them to model posi- For example, "vitamin-enriched" products are tive health behaviors. A shorter, adapted version functional foods. (Agriculture and Agri-food of the program is also included in the nurse Canada , 2012). The seminar material includes practitioner training program at the Université tables with the level of scientific evidence and de Sherbrooke. recommended intakes for vitamin D, omega-3, and dietary fiber in diverse conditions, so that professors can refer to the latest scientific data Evidence Base Used when students have further questions. During Program Development The Profession MD—Lifestyle program was Lessons Learned based on a pilot study conducted by Marie- Using the formal feedback collected from both France Hivert from 2002 until 2005. This students and professors, the faculty revised randomized controlled study, which used some of the seminars, adding or deleting refer- small-group interactive seminars on healthy ences, refining some of the themes, and modify- lifestyles, demonstrated prevention of weight ing some of the activities. Overall, both students gain over the first two years of university in 115 and professors reported that the material was volunteer medical students (Hivert et al. 2007). very complete and highly pertinent and that The intervention successfully prevented weight they enjoyed the sessions. gain in normal-weight medical students and One of the seminars that is still a challenge provided some of the rationale that convinced is the one that covers motivational interviewing the medical school administration to include a (MI). MI is not an easy concept to teach; few of lifestyle component in the new Profession MD the professors learned about this approach as curriculum in 2008. part of their clinical training. For second-year Other publications also provided evidence students, it is hard to grasp the importance of demonstrating the importance of increasing this kind of approach, as they have had very lim- education about lifestyle and counseling in ited clinical exposure. The program coordinator the medical curriculum. Numerous studies simplified the educational activities included in show that the percentage of patients receiving the MI seminar but kept MI as one of the main counseling about nutrition and physical activ- themes. The aim of the seminar is not to have ity is low (Bleich et al. 2011). Clear evidence students master the MI approach but rather to also exists to show that health professionals’ introduce the basic concepts that support it. own lifestyles influence their counseling prac- Given experience with the curriculum to date, tice. Attending a medical school that promotes the program coordinator advises adding another healthy personal practices and following these MI session later in the curriculum, possibly at practices significantly predict whether physi- the end of the clinical rotations (fourth year) cians will counsel patients about preventive or during residency (especially for primary care medicine (Frank et al. 2008). Furthermore, specialties). physicians’ personal health behaviors appear to affect patients’ attitudes and motivation to make lifestyle changes (Frank 2004). Scheduling Issues Because the fields of physical activity and Initially, the curriculum developers allocated nutrition change rapidly, the content of the only 45 minutes per seminar, and both students program is based on the latest guidelines and and professors believed that it was too little input from experts in each field. For example, time. Consequently, beginning in 2011, they one of the seminars focuses on functional allocated 60 minutes for each seminar. The foods, defined as a food given an additional seminars are scheduled during lunchtime on function (often one related to health promo- the same days that the students have to be on Profession MD—Lifestyle Program 129 campus for the clinical and professional integra- education and pedagogy reviewed the format of tion sessions; this arrangement was chosen to some of the educational activities and offered minimize students’ travel time. This schedule recommendations. received mixed reviews from professors and students, and the medical school administration is considering other possible schedules. Summary Profession MD—Lifestyle program has added Feedback From Professors great value to the MD curriculum at the Univer- Professors who choose to teach the Profession sité de Sherbrooke. Both students and professors MD—Lifestyle component come from very believe that the material is very pertinent and diverse specialties (anesthesiology, orthopedics, of high quality. The faculty see the difference cardiology, endocrinology, nephrology, family in the approach that the medical students take medicine) and some are non-MD health profes- with patients in the current clinical rotations sionals (dietitian, social worker). Because most compared with previous cohorts of medical stu- of the professors had little knowledge about the dents. Faculty are confident that the curriculum actual content of the program, the curriculum will lead clinicians to become more aware of developers had to ensure that the didactic mate- and more likely to address prevention in their rial was very clear and complete. The feedback practices, which in turn will lead to adoption of from the professors has confirmed that the healthier behavior in the population and, it is intensive effort that was devoted to developing hoped, to a reduction in chronic diseases over the didactic material was necessary and appre- the long term. ciated. The professors’ guide highlights all key messages and summarizes the main references References to ensure that all professors communicate the same take-home messages. Moreover, profes- Agriculture and Agri-food Canada, What are functional sors reported that they learned a lot and could foods and neutraceutics?, 2012 www.agr.gc.ca/ apply the knowledge to both their own lives eng/industry-markets-and-trade/statistics-and- market-information/by-product-sector/functional- and their clinical practices. foods-and-natural-health-products/functional- foods-and-nutraceuticals-canadian-industry/ Populations Best Served what-are-functional-foods-and-nutraceuticals- /?id=1171305207040, Consulted 2013-07-25. by the Program Bleich, S.N., O. Pickett-Blakely, and L.A. Cooper. 2011. The program is designed for medical students, Physician practice patterns of obesity diagnosis and and a shorter version is provided to nurse weight-related counseling. Patient Educ. Couns. 82(1):123-9. practitioner students. The program could be adapted for other health professional training Frank, E. et al., 2010. Predictors of Canadian physi- programs. This type of program is needed in cians’ prevention counseling practices. Can. J. Public Health 101(5):390-5. other medical schools in Canada and the United States and will become increasingly important Frank, E. 2004. Physician health and patient care. as the prevalence of chronic diseases increases. JAMA. 291(5):637. Frank, E., E. Tong, F. Lobelo, J. Carrera, and J. Dup- erly. 2008. Physical activity levels and counseling Tips for practices of U.S. medical students. Med. Sci. Sports Working Across Sectors Exerc. 40(3):413-21. Hash, R.B. et al., 2003. Does physician weight affect Many health professionals, including kinesiolo- perception of health advice? Prev. Med. 36(1):41-4. gists, dieticians, behavioral scientists, and phy- Hivert, M.F., et al. 2007. Prevention of weight gain in sicians, provided input into the development of young adults through a seminar-based intervention the curriculum. In addition, experts in medical program. Int. J. Obes. 31:1262. 130 Bilodeau and Hivert
Lobelo F., et al. 2009. Physical activity habits of doc- Statistique Canada. (2002). Enquête sur la santé tors and medical students influence their counseling dans les collectivités canadiennes: Premier coup practices. Br. J. Sports Med. 43(2):89. d’oeil. www.statcan.gc.ca/daily-quotidien/020508/ dq020508a-fra.htm. CHAPTER 15 Development and Implementation of the Physical Activity Vital Sign (PAVS)
Elizabeth A. Joy, MD, MPH, FACSM Janet M. Shaw, PhD, FACSM Intermountain Healthcare University of Utah College of Health
Trever Ball, MS University of Utah College of Health
NPAP Tactics and Strategies Used in This Program
Health Care Sector STRATEGY 1: Make physical activity a patient “vital” sign that all health care providers assess and dis- cuss with their patients.
rief physical activity (PA) counseling minutes or more? (in three 10-minute Bduring every routine medical visit has the bouts, or one 30-minute bout) potential to increase physical activity among a 2. How many days in a typical week do large segment of the American population. To you perform a similar activity? implement this type of counseling, health care providers need a simple tool that can be admin- Answers to these two questions generate a istered at every visit, similar to assessment of PAVS score ranging from a minimum of 0/0 to vital signs. To provide physicians and other a maximum of 7/7. The answers provided by providers with such a tool, primary care physi- patients and reviewed by physicians begin the cians and public health faculty at the University process of patient education with respect to of Utah created a measure called the Physical PA. The PAVS is designed to provide reliable Activity Vital Sign (PAVS), designed specifcally information about PA within the constraints of for use in primary care settings. The PAVS tool a busy office practice. helps providers assess physical activity levels in their adult patients. It consists of two ques- tions that a nurse or medical assistant asks each Program Description patient (adults and older adolescents) at the beginning of every offce visit: Intervention trials that have evaluated the effects of PA counseling have found a direct 1. How many days during the past week relationship between the frequency of counsel- have you performed physical activity ing and patient PA levels (Calfas et al. 1996). during which your heart beats faster and Implementing such counseling, however, is you breathe harder than normal for 30 difficult without a system for assessing current
131 132 Joy, Ball, and Shaw physical activity levels. The PAVS is designed activity in a typical week. In the same sample, for use in busy primary care practices. It builds the odds of obesity were significantly lower for on assessments that are already familiar to pro- each day that included PA, as reported on the viders and patients, such as checking weight PAVS (Greenwood et al. 2010). and blood pressure at every office visit. The One study assessed the criterion validity of developers of the PAVS intend for it to become the PAVS in a small sample (N = 45) of pre- as accepted as other measurements of vital signs dominantly female, primary care clinic staff. during office or clinic visits. Ball and colleagues (2011) gathered participants’ Despite the mounting evidence supporting responses to the PAVS and compared these with office-based PA counseling by physicians, an the same participants’ results from seven days inadequate number of physicians regularly of objectively measured PA by accelerometry. assess and counsel their patients about PA (Anis This homogenous sample was chosen primar- et al. 2004). To increase this number, medical ily to familiarize clinic staff with the PAVS and practices need to adopt a systematic approach facilitate implementation of PAVS into regular to help physicians acquire information about clinical use. their patients’ PA levels. This approach should In this sample of clinic staff, the PAVS cor- include participation of other members of the rectly identified 92% of the respondents who health care team in data collection. Techno- were not sufficiently active. This suggests a logical advances, such as devoted data fields strong ability for the PAVS to identify people in electronic health records, can ensure that most in need of counseling for PA. The PAVS staff and providers collect and record PA data responses were significantly correlated with for every patient. number of days measured by accelerometry The PAVS is designed to be administered and with 30 minutes or more of moderate to vigor- recorded by a nurse or medical assistant before ous PA performed in cumulative bouts of 10 the physician enters the examination room. minutes or more (r = .52, p < .001). The PAVS Taking only 30 seconds to complete, the PAVS was 91% accurate overall in assessing whether does not consume a significant amount of time respondents did or did not meet current PA in the outpatient encounter. The score is inter- recommendations (kappa = .46, p < .001). preted by the physician and discussed with the The PAVS has demonstrated preliminary patient during that visit. For patients who need evidence of effectiveness in identifying insuf- additional help to become physically active, ficiently active patients who would most benefit future visits can be scheduled for counseling from PA counseling. The ability of the PAVS to and development of an exercise prescription accurately assess changes in PA behavior over that meets the patients’ needs. time, or its repeatability, is still unknown.
Program Evaluation Linkage to National Physical Activity Plan The PAVS has been evaluated against con- structs related to PA, such as obesity deter- The PAVS addresses the first strategy of the mined by body mass index (BMI) (Greenwood Health Care Sector of the National Physical et al. 2010), and against PA measured objec- Activity Plan. tively by accelerometry (Ball 2011; Ball et al. Strategy 1: Make physical activity a patient 2012). Greenwood and colleagues (2010) found “vital” sign that all health care providers assess in a sample of 261 primary care patients that and discuss with their patients. The process of BMI was 0.91 units lower for each day in a developing and implementing the PAVS links typical week during which a patient engaged directly to this strategy. When the PAVS is in 30 minutes of activity, as reported on the integrated into patient care visits, it provides PAVS. BMI was 2.90 units lower in patients a patient’s health care provider with valuable who reported five or more days of physical information. Assessing PA during office or clinic Physical Activity Vital Sign 133 visits brings PA into the discussion between The PAVS aligns with recommendations that patient and physician and allows the physician adults should achieve 30 minutes of moderate to to more completely address chronic disease risk. vigorous intensity physical activity on at least 5 Under the premise that “you manage what you days of the week, en route to a minimum of 150 measure,” physicians and patients both benefit minutes per week (U.S. Department of Health from a systematic approach to PA assessment. In and Human Services 2012). addition, documenting patient physical activity The PAVS was designed with busy primary levels in the medical record contributes to clini- care clinicians in mind. Taking only seconds to cal epidemiology concerning the relationship administer, it fits into clinic workflow without between PA and health outcomes. Finally, the disruption. The scale of 0/0 to 7/7 resembles PAVS is a tool that can improve the quality of a blood pressure recording, taking advantage health care delivery. of pattern recognition by physicians. Pattern recognition is a cornerstone of clinical practice, often guiding further diagnostic testing and Evidence Base Used therapeutic decision making. A physician’s in Program Development approach to medical care is often predicated on his or her ability to rapidly assess patterns in a The more often a physician discusses the patient’s clinical presentation. In the primary importance of PA with a patient, the greater care setting, where face-to-face time with the the likelihood the patient will change his or patient is limited, both standardization of care her behavior (Lewis et al. 1991; Manson et al. and well-designed workflows are key factors in 2004). A survey of 1,818 U.S. adults found that the delivery of comprehensive and cost-effective the frequency of exercise advice increased with care. the number of physician visits over the course Implementation of the PAVS also helps of a year: 24.5% for zero or one visit per year health care systems meet established quality versus 40.9% for four or more visits per year improvement metrics. The National Committee (Glasgow et al. 2001). This finding raises impor- on Quality Assurance maintains the Healthcare tant issues that can be addressed by implement- Effectiveness Data Information Set (HEDIS), ing the PAVS in a medical practice. Individuals which includes measures that are used to deter- who visit a physician frequently are more likely mine the quality of health care provided. Two to have chronic conditions that require regular HEDIS measures are designed to assess how monitoring, compared with those who see a well health care systems assess physical activity physician zero or one time per year (Van Den assessment and counseling in older adults (≥65 Bussche et al. 2011). The former are also more years old) and children and adolescents (2-17 likely to need assistance with developing a years old) (Agency for Healthcare Research and regular PA program. Quality 2012; National Committee for Quality Assurance 2010). Although not designed for use in children, the PAVS has been used in older Populations Best Served adults and adolescents. by Program The Physical Activity Vital Sign is designed for Lessons Learned use with older adolescents and adults. Written at the eighth-grade reading level, the PAVS can The PAVS has been used for more than six be understood by the majority of patients for years in both academic and community-based whom it is intended. A medical assistant or primary care clinics. Anecdotal reports from nurse administers the PAVS before the patient providers indicate mixed support for regularly is seen by a physician. The PAVS is recorded in assessing patient PA. However, assessing and the medical record along with other vital signs counseling for physical activity require more such as weight and blood pressure. than a discrete field in an electronic medical 134 Joy, Ball, and Shaw record. This process requires a cultural shift a significant component of health. Likewise, it among clinic providers and staff, which gener- links to the overarching strategies of the NPAP: ally requires the presence of an enthusiastic raising awareness about the health benefits of leader who strongly supports this shift in regular PA, providing an opportunity for physi- practice. Further, providers cannot be the only cians to educate patients about these benefits, source of information for patients concerning and promoting development of a best-practice the importance of physical activity for health. approach to office-based PA promotion as The shift in practice must occur in all aspects providers learn what works and doesn’t work of the clinic. in real-world environments (National Physical In recent clinic-based research that used Activity Plan 2012). accelerometry to examine the criterion valid- Implementation of the PAVS has been depen- ity of PAVS, very few clinic staff (primarily dent on the assistance and support of the other medical assistants) achieved 150 minutes per NPAP sectors. In turn, a physical activity vital week of moderate to vigorous physical activ- sign also supports the efforts of other sectors. ity, as recommended by the Physical Activity Guidelines for Americans (Ball et al. 2011). In • Public Health: Dissemination of the PAVS the study, participants who were trying to lose into various health care settings (e.g., academic weight had similar PA levels (approximately health care clinics, community health centers) 17 accumulated daily minutes of moderate PA) has occurred with the support of public health as those who were not trying to lose weight professionals and funding. (Goh et al. 2012). Therefore, the majority of the • Education: The Education Sector encour- clinic staff in the sample were not engaging in ages postsecondary institutions to incorporate ideal PA behaviors for health or for weight loss. population-focused PA promotion in relevant Interestingly, some participants in the study disciplines such as nursing, medicine, and were medical assistants who were familiar with physical therapy. The integration of the PAVS and had administered the PAVS. Clearly, having into clinical care has led to efforts to educate knowledge of PA guidelines and working in a health care professionals about the importance medical setting, even one that addresses PA of PA on health, ways to assess PA, and methods with patients, are not always sufficient to help for counseling patients and families about PA. a person change his or her PA behavior. • Transportation, Land Use, and Community Although the literature shows that a physi- Design, and Parks, Recreation, Fitness, and cian’s personal PA level is a predictor of his Sports: PAVS prompts health care providers or her PA counseling behaviors (Lobelo et al. to discuss with their patients environmental 2009), much less is known about the role of strategies to promote increased physical activity, clinic staff in promoting PA behavior though linking to strategies in the Transportation, Land modeling. Preliminary data suggest that much Use, and Community Design Sector and the more research on clinic culture and patient PA Parks, Recreation, Fitness, and Sports Sector. For is needed. example, a PA assessment prompt like the PAVS may lead providers to discuss with patients both their activity preferences and local resources Tips for provided by parks and fitness facilities. Working Across Sectors • Business and Industry: Discussion of PA during clinical visits can prompt discussions Implementation of PAVS links with the strate- between physicians and patients about strate- gies and tactics developed by other sectors of gies to improve PA levels in the workplace, such the National Physical Activity Plan (NPAP). One as taking the stairs, using standing or walking of the main advantages of the PAVS is that it desks, and participating in active transportation highlights the importance of physical activity as to work. Physical Activity Vital Sign 135
bers 65 years of age and older who had a doctor’s Summary visit in the past 12 months and who received advice Given the shift in public health recommenda- to start, increase or maintain their level of exercise tions for PA in adults, which have changed or physical activity. http://qualitymeasures.ahrq. gov/content.aspx?id=32405. from 30 minutes of moderate physical activity on most days of the week to 150 minutes per Anis, N.A., R.E. Lee, E.F. Ellerbeck, N. Nazir, K.A. week of at least moderate intensity activity, Greiner, and J.S. Ahluwalia. 2004. Direct observa- tion of physician counseling on dietary habits and the PAVS has been reworded to be consistent exercise: Patient, physician, and office correlates. with this change. Now three questions long, Prev. Med. 38(2):198-202. the PAVS asks, Ball, T., E.A. Joy, T.L. Goh, J.M. Shaw, and J.C. Hannon. 1. On average, how many days a week 2011. Validity of two brief physical activity self-report do you perform physical activity or assessments used in primary care. Presented at the exercise? 2011 Annual American College of Sports Medicine Conference, Denver, CO. 2. On average, how many total minutes of physical activity or exercise do you Ball, T., E.A. Joy, J. Greenwood, and J.M. Shaw. 2012. Agreement of a repeated primary care physical perform on those days? activity measure with accelerometry. Presented at Days per Week × Minutes per Day 2012 Annual American College of Sports Medicine = Total Minutes per Week. Conference, San Francisco, CA. Calfas, K.J., B.J. Long, J.F. Sallis, W.J. Wooten, M. Pratt, 3. Describe the intensity of your physical and K. Patrick. 1996. A controlled trial of physician activity or exercise: counseling to promote the adoption of physical light = casual walk activity. Prev. Med. 25:225-33. Glasgow, R.E., E.G. Eakin, E.B. Fisher, S.J. Bacak, and moderate = brisk walk R.C. Brownson. 2001. Physician advice and support vigorous = jogging for physical activity: Results from a national survey. Am. J. Prev. Med. 21:189-96. In a recent pilot project within a primary care Goh, T.L., T. Ball, J.M. Shaw, and J.C. Hannon. 2012. clinic in Salt Lake City, researchers reviewed Physical activity and dietary behaviors of health medical records from nearly 600 clinic visits. clinic workers trying to lose weight. Health. Physical activity assessment and counseling Greenwood, J.L., E.A. Joy, and J.B. Stanford. 2010. The increased from a mean of 44% (range, 22%- Physical Activity Vital Sign: A primary care tool to 69%) of visits at baseline to a mean of 78% guide counseling for obesity. J. Phys. Act. Health (range, 57%-93%) of visits in just four weeks. 7(5):571-6. At six months, 79% of all visits included PA Joy, E.A., and M. Briesacher. 2012. Implementation of assessment (Joy and Briesacher 2012). the physical activity vital sign (PAVS). Presented at Integrating the PAVS into clinical workflow the FIMS Annual Meeting, Rome, Italy, September is essential to making the information avail- 28, 2012. able in a way that allows providers to act on it. Lewis, C.E., C. Clancy, B. Leake, and J.S. Schwartz. Likewise, providers and office staff need both 1991. The counseling practices of internists. Ann. knowledge and skills to use the PAVS to counsel Intern. Med. 114:54-8. patients regarding the benefits of PA in promot- Lobelo, F., J. Duperly, and E. Frank. 2009. Physical ing health and preventing disease. activity habits of doctors and medical students influence their counseling practices. Br. J. Sports References Med. 43(2):89-92. Manson, J.E., P.J. Skerrett, P. Greenland, and T.B. VanIt- Agency for Healthcare Research and Quality. Physical alie. 2004. The escalating pandemics of obesity and activity in older adults: percentage of Medicare mem- sedentary lifestyle. Arch. Intern. Med. 164:249-58. 136 Joy, Ball, and Shaw
National Physical Activity Plan: Overarching Strategies. elderly patients with special reference to chronic 2012. www.physicalactivityplan.org/theplan_over- diseases and multimorbidity—Results from a claims arching.php. data based observational study in Germany. BMC U.S. Department of Health and Human Services. 2012. Geriatr. 13;11:54. Physical Activity Guidelines for Americans. www. Weight Assessment and Counseling for Nutrition and health.gov/paguidelines/guidelines/summary.aspx. Physical Activity for Children/Adolescents. 2010. Van Den Bussche, H., G. Schön, T. Kolonko, H. Hansen, National Committee for Quality Assurance (NCQA). K. Wegscheider, G. Glaeske, and D. Koller. 2011. www.ncqa.org/portals/0/Weight%20Assess- Patterns of ambulatory medical care utilization in ment%20and%20Counseling.pdf CHAPTER 16 Strides to Strength Exercise Program for Cancer Survivors
Tara Ballard, CET, MES Novant Health: Presbyterian Medical Center Cancer Care
NPAP Tactics and Strategies Used in This Program
Health Care Sector STRATEGY 4: Reduce disparities in access to physical services in health care. STRATEGY 1: Make physical activity a patient “vital sign” that all health care providers assess and dis- STRATEGY 5: Include physical activity education in the cuss with their patients. training of all health care professionals. STRATEGY 3: Use a health care systems approach to STRATEGY 6: Advocate at the local, state, and institu- promote physical activity and to prevent and treat tional level for policies and programs that promote physical inactivity. physical activity.
he purpose of the Strides to Strength pro- 2000, in response to the clear evidence dem- Tgram is to maintain or improve the quality onstrating the positive impact of exercise on of life of cancer survivors through a medically cancer survivors, Novant Health: Presbyterian supervised exercise program. Medical Center Cancer Care began investigat- ing the structure, staffing, and other resources Program Description that would be required to provide a medically supervised exercise program to its survivors. Nearly 12 million cancer survivors are living in Strides to Strength is a personalized exer- the United States, and this number increases cise therapy, fatigue management, nutritional each year (Hewitt et al. 2006; Horner et al. counseling, education, and support program 2006.). The term cancer survivor, as defined by for cancer survivors. Novant Health: Presby- the National Coalition for Cancer Survivorship, terian Medical Center Cancer Care began the includes people from the time of diagnosis until program by adding one class to the hospital’s the end of life. The American Cancer Society cardiac rehabilitation program. The program recommends exercise for cancer prevention, for then increased to four classes a week, offered symptom management, and to increase qual- on a private floor in the community’s YMCA. ity of life. Research also suggests that exercise It now includes 14 one-hour classes per week, may decrease the chance of recurrence up to 50 offered by the hospital’s cancer rehabilitation percent. However, little research has examined department (which also includes services such approaches to implementing exercise rehabilita- as yoga, massage, nutrition, physical therapy, tion in cancer survivors (Mina et al. 2012). In and lymphedema therapy). The hospital began
137 138 Ballard developing the program by creating an advisory Education board, with clinical direction from physicians (surgical oncologist, medical oncologist, radia- Strides to Strength offers classes that present tion oncologist) and staff. It then created a mis- state-of-the-art information on stress manage- sion and vision, setting guidelines on staffing ment, lymphedema, nutrition, osteoporosis, requirements and training and establishing exercise and medication, home exercise pro- short- and long-term goals. All participants are grams, genetic counseling, and fear of recur- assessed before and upon completion of the pro- rence. The program focuses on the research that gram by an oncology registered nurse, clinical links exercise and nutrition with lowered risk exercise physiologist (certified cancer exercise factors for cancer, obesity, stroke, heart disease, trainer), oncology social worker, and oncology and many more health conditions. Strides to nutrition specialist. Assessments include fitness, Strength staff members believe strongly in pro- quality of life, function, fatigue, pain, distress, viding participants with the knowledge, tools, nutrition, and goals. and skills they need to manage their recovery and health. Exercise Support Strides to Strength is tailored to benefit all cancer survivors, from nonexercisers to ath- Strides to Strength offers regular contact and letes, through a medically driven, personalized monitoring by a licensed oncology social worker exercise program. Data on program participants through weekly support groups and individual show that supervised exercise not only improves counseling. Survivors are empowered by strength, endurance, and flexibility but also learning to understand and manage emotions reduces cancer-related fatigue and improves commonly experienced by cancer survivors. quality of life. Activities include a variety of Through education and discussion, participants cardiovascular exercises, strength training, and learn to take an active role in their emotional, flexibility exercises. Classes are limited to 10 psychological, and spiritual health, creating a survivors and include warm-up, individual exer- feeling of safety, support, and peace of mind. cise prescription (e.g., treadmill, arm ergometer, This service also allows for direct referrals for recumbent bike), group functional strength the survivor, caregiver, and other family mem- training, relaxation, and monitoring of heart bers to additional services offered through the rate, rate of perceived exertion, oxygen satura- hospital’s cancer psychosocial department, the tion, and blood pressure. Buddy Kemp Cancer Support Center. Nutrition Program Team Strides to Strength survivors learn about the Cancer survivors typically have one or more latest trends in cancer nutrition. Each survivor other health issues or chronic diseases prior to receives individual consultation, a personal- diagnosis, and these must be addressed along ized nutritional plan, periodic monitoring with with cancer treatment side effects. To help feedback, and formal nutrition classes. Classes survivors address these issues, the Strides to include topics such as nutrition during cancer Strength team includes a wide range of highly treatment, herbs and nutritional supplements, qualified and trained oncology staff: and interactive cooking classes. Each survivor • Oncology registered nurses completes a three-day food diary and MedGem analysis (a simple breathing test that measures • Exercise physiologists, certified cancer oxygen consumption and calculates resting exercise trainers metabolic rate [the number of calories burned • Registered dieticians, certified in oncology at rest]), allowing the oncology nutrition spe- nutrition cialist to create a nutrition plan that meets the • Licensed clinical social workers, certified survivor’s and the physician’s goals. in oncology Strides to Strength 139
Program Evaluation current chemotherapy, post chemotherapy, current radiation therapy, and post radiation Strides to Strength collects program and clinical therapy. These numbers show that all types outcomes data both subjectively and objec- of survivors have a desire to feel better and tively. Over the years the program diagnosis improve their quality of life. These same out- mix has included more breast cancer survivors, comes support the need for staffing qualified averaging 62 percent, followed by people with and trained professionals (figures 16.2 and urologic diagnoses at 16 percent and a mix of 16.3). other diagnoses. The diagnosis percentages Eighteen percent of program graduates for program participation reflect the hospital’s achieve the exercise guideline of 150 minutes patient population (figure 16.1). a week, months after completing the program, Participants include the full range of treat- ment statuses, including pre- and postsurgery, Other Stage 0 2% 4% Unknown 4% Other Thoracic 6% n = 62 Gynecological 5% Stage I 2% Stage IV 24% 15%
GU 16%
Stage III 11%
Hematologic 3% Breast 62% GI 6% Stage II 40%
Figure 16.1 Strides to Strength cancer diagnosis Figure 16.2 Staging for cancer survivors, 2010- 2011-2012. 2011. E5691/NPAP/fig16.1/458560/alw/r1 E5691/NPAP/fig16.2/458561/alw/r2-kh Pre Tx, 8.8% n = 216
Post Tx, 51.4%
Current Tx, (radiation or chemotherapy), 39.8%
Figure 16.3 Treatment status during Strides to Strength.
E5691/NPAP/fig16.3/458562/alw/r1 140 Ballard
similar to the 19 percent of the U.S. adult popu- criteria (based on diagnosis, treatment status, lation who meet the goal (CDC National Center and other factors) to generate an automatic for Health Statistics 2013). The most impressive referral to Strides to Strength. Strides to Strength assessments are the clinical outcomes, which also is listed on the Comprehensive Oncology surprise both the survivors and their physicians. Referral form that is used by all staff and MDs Results vary, but improvements are consistently for referrals to services within the cancer center. observed in all areas measured. In a group of Strategy 3: Use a health care systems approach participants who completed all 24 exercise to promote physical activity and to prevent and sessions and a postprogram evaluation (N = treat physical inactivity. Novant Health Presby- 56), the quality-of-life measurement, FACT-G, terian Medical Center, the health care system, improved from 81 to 86.7 (average improve- and its physicians support and promote physi- ment, 5.7; “important difference” noted, 3-7). cal activity for cancer survivors through the FACIT-Fatigue improved from 36.6 to 41.4 (aver- Strides to Strength program. This health care age improvement, 4.8; important difference, system promotes the program because of the 3-4). Fitness (as assessed with a six-minute value it brings to the survivors, the hospital walk) improved from 1,761 to 1,903 feet (aver- downstream revenue, and cost savings for the age improvement, 142 feet; figure 16.4) (Ballard hospital and survivors resulting from decreased et al. 2010). hospital admissions and emergency room visits attributable to healthier patients. The Strides to Strength program is based on the successful Linkage to National cardiac and pulmonary rehabilitation models Physical Activity Plan that have come to be standard programs within hospitals. Although hospital systems rely on Strides to Strength supports six of the Health insurance to cover services, this health care Care Sector strategies of the National Physical system sees the current and future benefits for Activity Plan (NPAP). survivors, hospitals, and community. Strategy 1: Make physical activity a patient Strategy 4: Reduce disparities in access to “vital sign” that all health care providers assess physical services in health care. The program and discuss with their patients. Strides to provides scholarships for survivors who have Strength encourages physician partners and financial barriers to participation, to ensure that staff to assess and discuss with all survivors the people at high risk for chronic disease and side benefits of physical activity, both during and effects related to their cancer diagnosis have after treatment. The cancer center’s navigators equal or better access to services. and the second opinion clinic give educational Strategy 5: Include physical activity education material to survivors and initiate referrals upon in the training of all health care professionals. diagnosis. Many physicians have established New employees at the cancer center tour the Strides to Strength program to learn about the benefits of physical activity for survivors. All 4.0 PLF is a 0-10 scale where 0 = No fatigue and 10 = Extreme fatigue cancer center nursing employees take an edu- 3.5 cational course that addresses the importance 3.0 of cancer rehabilitation services, including 2.5 physical activity, for symptom management. 2.0 American College of Sports Medicine (ACSM) 1.5 cancer exercise guidelines and updates are given 1.0 to the physicians on an annual basis during 0.5 tumor board conferences.
Perceived level of fatigue (PLF) level Perceived 0.0 Strategy 6: Advocate at the local, state, and All Breast Nonbreast institutional level for policies and programs that = Pre = Post promote physical activity. At the institutional Figure 16.4 Perceived level of fatigue (PLF) com- level, the program complies with the Commis- parison: patients with versus without breast cancer. sion on Cancer and the Association of Com- E5691/NPAP/fig16.4/458563/alw/r2-kh Strides to Strength 141 munity Cancer Centers standards and program hormones, oxidative stress, inflammation, guidelines. Strides to Strength staff advocate immune parameters) for cancer and physical activity programs at • Improved sleep patterns the state and national level. Such promotions • Decreased depression have included presentation at the North Caro- lina Cancer Control Plan’s Navigators annual • Decreased anxiety conferences and state survivorship summits. • Decreased symptoms and adverse effects Staff members also have presented both posters (including pain) and colloquiums on the survivors’ outcomes • Improved quality of life at national conferences, such as ACSM. The • Increased adherence and compliance to author advocates for physical activity programs treatment for cancer survivors at the state level by sitting • Decreased chance of recurrence on the Survivorship Subcommittee and at the national level as chair of the Cancer Exercise The ACSM released the 2010 guidelines for Interest Group with ACSM. exercise and cancer (http://journals.lww.com/ acsm-msse/Fulltext/2010/07000/American_Col- lege_of_Sports_Medicine_Roundtable_on.23. Evidence Base Used aspx#) after a number of experts in cancer and During Program Development exercise science reviewed the current status of safety and efficacy of exercise training during During the development of the Strides to and after adjuvant cancer therapy and research Strength program, very few similar programs on physical activity and cancer survivorship. existed nationally, little research was available, The general guidelines for cancer survivors were and cancer exercise guidelines had not been to avoid inactivity (some activity is better than developed. The information and programs that none) and be as physically active as possible, did exist focused on breast cancer and fatigue considering abilities and conditions. Recom- (NCCN Guidelines 2012.). The evidence base mendations were made for weekly amounts of used to develop Strides to Strength came from activity for cancer survivors: the model of cardiac rehabilitation, with input • Aerobic: 150 minutes of moderate-intensity from oncology nursing, reviews of the litera- or 75 minutes of vigorous-intensity exer- ture, physician direction, and research on the cise benefits of exercise as it relates to symptoms (nausea, osteoporosis, heart health, balance). • Strength training: two or three sessions Research on the benefits of exercise for cancer that involve the major muscle groups survivors undergirded the program. These ben- • Flexibility: stretching of major muscle efits include the following (Schmitz et al. 2010): groups on days that other exercises are performed (Schmitz et al. 2010) • Improved physical function and physical fitness Lessons Learned • Improved aerobic fitness • Increased muscular strength Strides to Strength staff recommend the fol- lowing: • Improved flexibility • Improved or maintained ideal body size • Create a strong foundation and infrastruc- (weight, body mass index, muscle mass, ture to gain the confidence of the hospital and body composition) administration, referring physicians, and survivors. Key components include hiring • Increased bone health highly trained professionals, modeling • Help with lymphedema-related outcomes the program after successful programs, (Schmitz et al. 2009) complying with hospital policies and stan- • Improved physiological outcomes (e.g., dards, and communicating and working hemoglobin, blood lipids, IGF pathway closely with clinical care teams. 142 Ballard
• Track program and clinical outcomes. Additional Examples of data that should be collected include age, diagnosis, stage, treatment Readings and Resources status, baseline physical assessments (six- Doyle, C., L. Kushi, T. Byers, et al. 2006. Nutrition and minute walk, body mass index, balance, physical activity during and after cancer treatment: weight), subjective assessment tools, satis- An American Cancer Society guide for informed faction with program, adherence, income, choices. CA Cancer J. Clin. 56:323-53. compliance to exercise, completion of Holmes, M., W. Chen, D. Feskanich, et al. 2005. Physical program, and barriers. activity and survival after breast cancer diagnosis. • Cancer survivors want and need this type JAMA. 293:2479-86. of program. If it is available, they will Ligibel, J., W. Demark-Wahnfried, P. Goodwin, et al. come. 2009. Diet, exercise, and supplements: Guidelines for cancer survivors. Am. Soc. Clin. Oncol. Educational Populations Best Served Book. Alexandria, VA: ASCO, 2009, pp.541-547. Meyerhardt, J., E. Giovannucci, M. Holmes, et al. 2006. by the Program Physical activity and survival after colorectal cancer diagnosis. J. Clin. Oncol. 24:3527-34. Research has shown that exercise for cancer survivors is safe and beneficial (Schmitz et al. 2010). For that reason, Strides to Strength is References available to any cancer survivor over the age of 18. Survivors may participate with any diag- Ballard, T., P. Downey, P. Nebus, et al. 2010. Reha- bilitation: Group exercise is beneficial for improving nosis, at any stage, at any phase of treatment quality of life, reducing fatigue and increasing fit- or recovery. The program truly best serves all ness. Poster abstract presented at ACSM. American cancer survivors. College of Sports Medicine, 57th Annual Meeting & 1st World Congress on Exercise is Medicine June Tips for 1-5, 2010, Baltimore, Maryland. CDC National Center for Health Statistics. 2013. Sum- Working Across Sectors mary health statistics for U.S. adults: National Health Interview Survey. www.cdc.gov/nchs/fastats/ The Strides to Strength program is open and exercise.htm. receptive to working across sectors and build- Hewitt, M., S. Greenfield, E. Stovall, Eds. 2006. From ing relationships. As a department within the Cancer Patients to Cancer Survivor: Lost in Transi- nonprofit health care sector, the marketing and tion. Washington, DC: National Academies Press. community relations department works with Horner, M.J., L.A. Ries, M. Krapcho, et al. 2006. SEER the media to inform and educate the public cancer statistics review, 1975-2006. Bethesda, MD: about the program. It also collaborates with National Cancer Institute. www.seer.cancer.gov/ educational institutions, working with local csr/1975_2006/. universities to provide internship opportunities Mina, D., S. Alibhai, A. Matthew, et al. 2012. Exercise within the program. in clinical cancer care: A call to action and program Exploring collaboration with other sectors development description. Curr Oncol. 19(3):e136- of the National Physical Activity Plan would 144. enhance opportunities for cancer survivors to NCCN Guidelines. 2012. Cancer-related fatigue. NCCN be more active. Examples could include working Version 1. Schmitz, K.H., R.L. Ahmed, A. Troxel, et with the Transportation, Land Use, and Com- al. 2009. Weight lifting in women with breast cancer- munity Design Sector to facilitate access to and related lymphedema. N. Engl. J. Med. 361:664-73. safety within environments that promote walk- Schmitz, K., K. Courneya, C. Matthew, et al. 2010. ing and cycling or with the Parks, Recreation, American College of Sports Medicine roundtable on Fitness, and Sports Sector to provide access to exercise guidelines for cancer survivors. Med. Sci. additional physical activity opportunities. Sports Exerc. 2010; 42 (7):1409-1426. Sector IV Parks, Recreation, Fitness, and Sports
Andrew Mowen, PhD Pennsylvania State University
he Parks, Recreation, Fitness, and Sports (chapter 18, Hanson and Rea) and summer T(PRFS) Sector is a critical partner in efforts day camp programs (chapter 19, Baker and to address the physical inactivity crisis in the McGregor) and in a professional sports setting United States. This sector is represented by a (chapter 22, Yancey et al.). Other chapters wide range of public, nonproft, and corporate focus on environmental (chapter 20, Shores) organizations whose mission is to provide and policy approaches (chapter 17, Harnik healthy recreational opportunities to their con- and Mowen) that improve access to physically stituents. PRFS services exist in practically every active spaces. Finally, chapter 21 (by Vinluan) American community and often are available at provides an overview of the YMCA of the low or no cost to participants. Although these USA’s campaign to engage in community-wide services have been available for more than a collaboration through multiple active living century, the increasingly sedentary lifestyles of strategies. Each chapter provides an overview most Americans are compelling PRFS provid- of core approaches used and acknowledges the ers to increase the physical activity impact of challenges faced in implementation. those services, particularly for those at great- Collectively, these programs illustrate the est risk for inactivity and its associated health importance and potential of the Parks, Recre- consequences (e.g., low-income families). This ation, Fitness, and Sports Sector to other sectors sector is quickly recognizing the need to partner in their quest to increase active living in the with other sectors (e.g., education, health care, United States. Despite the early promise and business and industry) and is actively engaged success illustrated by these and other model in initiatives to combat physical inactivity. This programs, challenges and concerns lie ahead. sector also recognizes that no single approach For example, there remains a need to document is likely to be as effective as multiple strategies the effectiveness of interventions in terms of working in unison. Indeed, model programs that their long-term physical activity effects. Today’s have achieved success typically involve a com- PRFS organizations also must move beyond bination of efforts, including policy changes, their sector “silos” to identify, pool, and lever- environmental changes, programming, and age resources with organizations in other sec- promotional strategies. tors. Indeed, the current budgetary situation Model programs selected for this section has forced many in the sector to ally with non- include a cross section of approaches, illus- traditional partners (e.g., insurance companies, trate the potential of emerging strategies, and businesses) that can provide complementary reinforce the notion that solving America’s skills and assets, alliances that not only ensure inactivity crisis requires collaborative and the continuation of existing initiatives but also adaptive efforts to make both short-term and provide expanded reach to a greater cross sec- long-term gains in increasing physical activity. tion of the nation. Despite these challenges, These programs were selected based on their readers are encouraged to consider and adopt ability to reach broad segments of the popula- the approaches discussed in this section for their tion, use of diverse strategies, and availability own initiatives. The future health and vitality of effectiveness data. For example, chapters of the next generation are at stake. focus on program interventions in after-school
143
CHAPTER 17 ParK–12 and Beyond Converting Schoolyards Into Community Play Space in Crowded Cities
Peter Harnik Andrew Mowen, PhD Center for City Park Excellence, Pennsylvania State University The Trust for Public Land
NPAP Tactics and Strategies Used in This Program
Parks, Recreation, Fitness, and Sports Sector workplace, public, private, and non-profit recre- ational sites) to provide easy access to safe and STRATEGY 1: Promote programs and facilities where people work, learn, live, play, and worship (i.e., affordable physical activity opportunities.
arks provide many opportunities for Ameri- K-12 school spaces into public parks that com- Pcans to lead active, healthy lives. In fact, munity members can access during nonschool a number of studies have found a positive con- hours is a promising approach that can lead nection between people’s access to parks and to higher physical activity levels for the whole their physical activity levels (Kaczynski and community. Henderson 2007). Communities that provide Commonly referred to as schoolyard parks, residents with easy access to parks, recreation, these facilities represent a cooperative venture sport, and ftness facilities also have more between a board of education and a parks active and healthier residents. However, many and recreation department. The movement to communities lack convenient access to these create schoolyard parks has undergone pre- types of environments. For example, a study of cipitous growth in recent years, as New York, California youth found that one in four reported Denver, Boston, Chicago, and Houston have having no access to a safe park in his or her made schoolyard conversions a central strategy neighborhood (Babey et al. 2008). The problem in their efforts to increase recreational space is particularly severe in crowded, built-up urban capacity. areas where lack of open land makes it diffcult and expensive to develop new park, recreation, sport, and ftness facilities. Linkage to the National One way to increase park capacity and acces- Physical Activity Plan sibility is to make better use of existing open space through policy changes—for example, Converting schoolyards to public parks during increasing the utility and benefits of existing nonschool hours supports Strategy 1 of the schoolyards. In many urban communities, Parks, Recreation, Fitness, and Sports Sector schoolyards are fenced, and they are locked of the National Physical Activity Plan: Promote when school is not in session. Converting these programs and facilities where people work,
145 146 Harnik and Mowen learn, live, play, and worship (i.e., workplace, address this deficiency, PlaNYC set a goal of public, private, and non-profit recreational sites) providing a public park or playground within a to provide easy access to safe and affordable 10-minute walk of every New Yorker. Planners physical activity opportunities. These conver- quickly calculated that schoolyard parks could sions represent the kind of joint use agreements provide about 1,170 acres of additional recre- to increase operating hours that are specifically ation space and that they would be an essential recommended by the national plan. In addition, component of reaching this goal (Brewer 2006). schoolyard parks meet one of the evidence- The Schoolyards to Playgrounds initiative, a based recommendations of the Guide to Com- partnership between the city’s Department of munity Preventive Services’ Systematic Review Education, Department of Parks and Recreation, for Promoting Physical Activity (CDC 2001). and the TPL (as well as private funders MetLife, Not surprisingly, creating a schoolyard park Credit Suisse, Deutsche Bank, and the Michael is not a simple task. However, a significant and Susan Dell Foundation) was formally number of cities have taken on the challenge, announced in July 2007. The goal was to spend and more are following suit. What follows is $110 million to transform 290 decrepit and unin- an overview of the substantial progress made viting schoolyards into showcase parks by 2010 in New York City and a discussion of common (Harnik 2010). Not all the conversions involved barriers and tips for overcoming them. the Department of Parks and Recreation, but all involved TPL and the Department of Education. Despite having a strong mayoral system of Program Description government, New York does not have a political Converting schoolyards into community play- culture in which top-down decrees are sent from grounds is not an entirely new concept. The first headquarters. Rather, the decision-making pro- such transformation occurred in 1938 at Fort cess is a bottom-up approach and, in the case of Hamilton High School in New York City (and schoolyard parks, includes the voices of school the agreement is still in effect today). However, principals, parent-teacher associations, and within the past decade, as cities have been community stakeholders. Indeed, schoolyard driven by the increasing demand for athletic park proposals can be derailed by teachers who fields and playgrounds in heavily populated don’t want to lose parking spaces, by custodians urban areas, the number of schoolyard parks who don’t want to handle park maintenance, or has mushroomed. New York City has taken the by communities that don’t want kids out late concept the furthest. Working with the Trust for playing basketball. Moreover, although New Public Land (TPL), a U.S. national nonprofit York school recreation grounds are owned by with a mission of parks for people, the New the Department of Education, the schoolyard York Board of Education piloted joint-use agree- conversions have been overseen by TPL and the ments that leveraged private sector funding for Department of Parks and Recreation. high school sport fields (Dolesh 2009). The “This program is community-run,” says success of this pilot program led TPL to begin a Mary Alice Lee, director of TPL’s New York City schoolyard-to-playground initiative in 25 of the Playground Program (as cited by Dolesh 2009). city’s most underserved neighborhoods. Although all properties are fenced and have After his election in 2001, Mayor Michael locks, in some places the school custodial staff Bloomberg announced PlaNYC, the massive have the only key, whereas in others the key is process of adopting a new comprehensive held by the neighborhood sponsoring organiza- plan for the city. A review of park capacity tion or a block association. A few of the parks data revealed that New York lagged behind are permanently unlocked. Each community other cities, with only 4.6 acres of parkland per sets its own hours, with a typical schedule of 1,000 residents (below the median of 6.8 acres 8 a.m. to dusk seven days a week except when per 1,000 for 13 densely populated cities). To school is in session. In some neighborhoods, ParK—12 and Beyond 147 Reprinted, by permission, from The Trust for Public Land. Photo by David Barker. David by Photo Land. Public for Trust The from permission, by Reprinted,
P.S. 129Q’s schoolyard in Queens, after it opened to the public in fall 2009. The New York Schoolyards to Playgrounds program has added more than 100 acres of open space since its launch in 2007 the community wants the park closed earlier; work hard, learning how to innovate, compro- the most restrictive schedule is 3 p.m. to 6 mise, and reach a consensus when their initial p.m. weekdays, 10 a.m. to 2 p.m. Saturdays, ideas turn out to be too expensive or require and closed on Sundays. Maintenance is the too much space. “Because of the kids,” says responsibility of the school custodial staff, so it Lee, “we’ve created murals and mosaics, a hair- is important that they are involved in all design braiding area, a jump-rope zone, planting gar- decisions from the beginning. Often they turn dens, performance stages, outdoor classrooms, down a particular piece of equipment; in some rain gardens, and bowling lanes—as well as the cases they have nixed the playground entirely. usual soccer fields, running tracks, basketball As for natural grass, it has proven impossible to and tennis courts, and play equipment” (Harnik maintain under intense use, and TPL now uses 2010, p. 114). only artificial turf for the playgrounds’ ballfields (Harnik 2010). Designing a schoolyard park can take up to Populations Best Served three months. Children are the lead designers, by the Program responding to a set of questions and opportuni- ties posed by TPL. Certain realities, however, Unlike schoolyards, schoolyard parks serve a including liability, equipment breakability, hor- wide range of ages and have the potential to ticultural survivability, cost, and lessons from provide significant physical activity benefits to previous schoolyard park conversions, affect the whole community. In addition to school-age decision making (Harnik 2010). The children children, teenagers and adults of all ages can 148 Harnik and Mowen enjoy recreation activities within these spaces. each jurisdiction that allow the general public However, communities can limit who can be to use school facilities during nonschool hours served (and when). Many communities are (Keener, et al. 2009). Proven methods and mea- opposed to nighttime use because of noise and surements exist for assessing park features and possible questionable activities. In some cases, conditions as well as on-site levels of physical the community may decide to limit recreation activity within these converted spaces. Many options (such as mandating basketball courts of these monitoring tools (and instructions for with one hoop rather than two) in order to dis- using them) are available from Active Living courage overuse. In some instances, schoolyard Research at www.activelivingresearch.org/ park conversions take away parking opportu- resourcesearch/toolsandmeasures. nities from school staff and neighbors. At one Boston site, a conflict broke out when parents proposed converting a school parking lot into Lessons Learned a soccer field; ultimately, the parents raised Since there are a large number of real and enough money in private funds to complete the perceived barriers to opening school facilities conversion (Harnik 2010). to the general public, success in schoolyard conversions requires a strong commitment from Program Evaluation elected officials and unit administrators. Ideally, both the school system and the park system Although schoolyard park conversions are an are under the direction of the mayor; without increasing phenomenon, and several evalua- this kind of singular authority, one partner can tions have looked at the condition of play and simply withdraw from the key shared agree- support features as well as the presence of on- ments when obstacles arise (Harnik 2010). The site supervision, few systematic evaluations success rate increases when the community is have examined their impact on visitation and warmly invited to participate and engage in activity. One evaluation, by the Office of the the process. Residents and schoolyard users New York City Public Advocate, found that 16 (particularly the affected children) should (23 percent) of the first 69 converted school- have a direct role in design and policy develop- yards continued to be locked or inaccessible ment—they are, after all, the primary users and to the public on weekdays and 28 (40 percent) beneficiaries. were inaccessible on weekends (Gotbaum Naturally, initial capital costs can be signifi- 2008). Of those that were accessible, 94 percent cant in cases where the old schoolyard had little did not have a Department of Education staff or no parklike infrastructure, such as benches, member present during nonschool operating backstops, play equipment, or grass. In New hours, and few schoolyard parks had adequate York, playground parks routinely cost $1 million activity and support features such as playground or more each, including the cost of artificial turf. climbing features, swings, shade provision, and Maintenance costs and responsibility are benches, even though most were judged to be other major challenges. Many school admin- in good overall condition (Gotbaum 2008). The istrators are reluctant to invest school funds review concluded that schoolyards without play in upkeep when those funds are needed for features and support amenities were unlikely core educational programs. At the same time, to provide an environment conducive to youth school officials may be reluctant to hand off physical activity, and it recommended that sites maintenance to the parks department, fearing without such amenities be slated for capital a loss of control. There is also the question improvements. of who should be responsible for locking and As additional schoolyard parks are created, a unlocking these schoolyards and monitoring more systematic evaluation of use and physical their use. This is a particular problem if no activity will be needed. A simple starting point custodian or attendant works on the premises is to determine the percentage of schools in during nonschool hours. ParK—12 and Beyond 149
Concerns over user liability can derail joint- to inadequate maintenance). Moreover, joint use schoolyard agreements. In a U.S. nation- use policies that allow schools to maintain site wide survey of school principals in low-income operational control and guarantee the ability to and minority communities, although 69 percent convert the space back to school use entirely of respondents reported that their school recre- may promote buy-in from school administrators. ational facilities were already open to the public after hours, the primary barriers to additional openings included issues of liability, safety, and Tips for insurance (table 17.1). Working Across Sectors In several cities, including Houston, this concern has been addressed in part through Although the challenges associated with con- state indemnity clauses that protect schools verting schoolyards to public use are significant, and cities from certain incidents that occur on key tips and strategies may enhance the success public grounds (aside from incidents related of these joint use endeavors.
Table 17.1 Perceived Barriers to Opening School Facilities
% Extremely important Perceived barriers barrier Liability and security Liability 61 Insurance 61 Safety 58 Vandalism 46 Burglary and theft 41 Graffiti 37 Resources Cost of running activities and programs 60 Staffing for security 56 Cost of maintenance 56 Staffing for maintenance 54 Scope of maintenance responsibilities 54 Staffing for activities and programs 53 Limited space and facilities (availability) 49 Hours of operation 36 Social support Priority of use 36 Opens facilities to controversial groups 33 Lack of school support 28 Lack of community support 28
Reprinted, by permission, from J.O. Spengler, J.Y. Ko, and D. Connaughton, 2011, “An analysis of perceived barriers to after hours use of schools in under-resourced communities.” Eighth Active Living Research Annual Conference (San Diego, CA). 150 Harnik and Mowen
• Ensure that the highest levels of local yards to Playgrounds initiative, including progress government support this type of facility reports, is available at www.nycgovparks.org/ sharing. (If the mayor controls both the sub_about/planyc/playgrounds.html. school system and the park system, so much the better.) • Ensure that the planning and design of References specific schoolyards are delegated at the Babey, S., T. Hastert, H. Yu, et al. 2008. Physical activity local level and use participatory decision among adolescents: When do parks matter? Am. J. making. The process should include teach- Prev. Med. 34(4):345-8. ers, students, parents, maintenance staff, Brewer, G.A. 2006. Accessible schoolyards: A report and local residents. by the Office of Council Member Gale A. Brewer • Establish clear schedules for community on the public accessibility of New York City school- use and school use, and ensure that these yards. Council of the City of New York. www. publicadvocategotbaum.com/policy/documents/ schedules match the staffing and security sy2pgreportfinal.pdf. resources available. Centers for Disease Control and Prevention. 2001. • Consider working with local businesses Increasing physical activity: A report on recommen- and private foundations to raise funds and dations of the Task Force on Community Preven- engage community members. tive Services. MMWR Morbid. Mortal. Wkly. Rep. • Develop a clear plan for who will be 50(RR-18):1-16. responsible for long-term maintenance. Dolesh, R. 2009. School of thought: Schoolyards as • Consider using nonprofit “friends groups,” playgrounds is not a radical concept. Putting it into both school-by-school and citywide, to practice, however, takes cooperation. Parks and Recreation 44(8): 14-18. advocate for schoolyard conversions and keep school and park officials focused on Gotbaum, B. 2008. Space to play, room for improve- the project. ment: An evaluation of the schoolyards to play- grounds program. Public Advocate for the City of • Avoid a one-size-fits-all approach to school New York. http://publicadvocategotbaum.com/ conversions. Locking policies, hours of policy/documents/sy2pgreportfinal.pdf. operation, and maintenance responsibility Harnik, P. 2010. Urban Green: Innovative Parks for will vary from site to site. Resurgent Cities. Washington, DC: Island Press. • Focus on developing schoolyard parks Kaczynski, A.T., & K.A. Henderson. 2007. Environ- in areas where real deficiencies in park mental correlates of physical activity: A review of access and opportunity exist, particularly evidence about parks and recreation. Leisure Sci- for children’s after-school play. ences 29(4):315-54. Keener, D., K. Goodman, A. Lowry, S. Zaro, & L. Kettel Khan. (2009). Recommended community strategies Additional and measurements to prevent obesity in the United States: Implementation and measurement guide. Reading and Resources Atlanta, GA: U.S. Department of Health and Human The National Policy & Legal Analysis Network to Pre- Services, Centers for Disease Control and Prevention. vent Childhood Obesity (NPLAN) has developed Spengler, J.O., J.Y. Ko, and D. Connaughton. 2011. An resources and a toolkit to assist cities through model analysis of perceived barriers to after hours use of joint-use policies; these resources are available at schools in under-resourced communities. Eighth www.changelabsolutions.org/childhood-obesity/ Active Living Research Annual Conference, San joint-use. More information on New York’s School- Diego, CA, February 2011. CHAPTER 18 Learning to be Healthy and Active in After-School Time The Säjai Foundation’s Wise Kids Program
Melissa Hanson, BS, MBA Amy Rea, BA Säjai Foundation Säjai Foundation
NPAP Tactics and Strategies Used in This Program
Parks, Recreation, Fitness, and Sports Sector STRATEGY 5: Improve physical activity monitoring and surveillance capacity to gauge program effec- STRATEGY 1: Promote programs and facilities where tiveness in parks, recreation, fitness, and sports people work, learn, live, play and worship (i.e., settings based on geographic population repre- workplace, public, private, and non-profit recre- sentation and physical activity levels, not merely ational sites) to provide easy access to safe and numbers served. affordable physical activity opportunities.
hildhood obesity is a national crisis in the important areas that combat obesity and health CUnited States. In more than 30 states, the problems: healthy eating, physical activity, and percentage of overweight and obese children is connection to the natural world. Interventions 30 percent or higher. One in three children born that increase time spent in outdoor physical after the year 2000 is projected to develop dia- activity and promote healthy eating boost emo- betes, physicians prescribe cholesterol medica- tional skills, improve children’s social skills, tions for children as young as 8 years, and more and increase their ability to focus in the class- than 23 percent of children ages 9 to 13 get no room. First Lady Michelle Obama’s Let’s Move physical activity. Long-term risks for these chil- campaign calls for community partnerships to dren include type 2 diabetes, cancer, and heart effectively curb childhood obesity trends. The disease, leading to predictions that this genera- Säjai Foundation and its Wise Kids program tion will be the frst in two centuries to have a have taken a big step forward in helping youth- shorter life span than its parents. A poll by the serving agencies and their community partners Nature Conservancy found that only about 10 do just that. percent of children spend time outdoors every day. More than ever, today’s children need to make smart nutrition and activity decisions Program Description and spend more time outdoors, improving their The Säjai Foundation, a nonprofit organization health and developing a greater appreciation for that focuses on providing preventive education the world around them. that promotes healthy living (nutrition, physi- Research suggests that purposeful after- cal activity, and outdoors), developed the Wise school programming promotes success in three Kids program to provide youth leaders and
151 152 Hanson and Rea caregivers with easy-to-use tools for teaching the program uses games and techniques that children about wellness. The Wise Kids program make physical activity less skill-based, more is designed to be fun, experiential, and educa- children feel comfortable participating, thereby tional while promoting nutritional awareness increasing time spent being active. Some of the and increasing physical activity and outdoor key topics covered include energy balance, food involvement in youth ages 6 to 11. By using labels, the heart, and activity. after-school hours to weave in preventive mes- The Säjai Foundation initially worked with sages and provide opportunities to be physically beta sites to implement and test the program in active, both indoors and outdoors, organizations multiple settings across the United States. The that work with children can help them develop foundation assessed process implementation positive attitudes and healthy habits. and impact of the Wise Kids program at four Wise Kids is a nine-lesson preventive wellness recreation centers in St. Paul, Minnesota. A total program that teaches children ages 6 to 11 about of 96 youth ages 7 to 12, from diverse socioeco- healthy living. The Wise Kids program follows nomic and cultural backgrounds, participated in a learn–do–play format to introduce children the program. Program implementation spanned to the concept of energy balance (calories in 8 weeks, with the formal testing spanning a = calories out), provide them with hands-on 10-week period in winter-spring 2007. Park and opportunities to apply the concepts, and help recreation locations in the cities of Minneapolis, them increase physical activity. Children spend Minnesota, Tampa, Florida, and East Hartford, 15 minutes learning about the energy balance Connecticut, also implemented the program concept through workbooks and discussion. and provided weekly feedback to help refine it They then transition into learning activities to for broader use. A total of 394 children in these help them understand the concept in a hands-on communities participated before the program way. Finally, participants spend 30 minutes in was rolled out on a national level. physical activities designed to get them moving. The Theory of Planned Behavior (TPB) was Activities encourage everyone to participate, not applied to the evaluation of the program. TPB just those who are athletically inclined. Because is based on the concept that individuals are © Melissa Hanson and Amy Rea. © Melissa Hanson and Amy Säjai Foundation’s Wise Kids Program 153 more likely to intend to participate in physical into the effectiveness of the program. Pre-to- activity and adopt healthy eating habits if they post testing in key areas used during the initial are positively disposed toward those behaviors, study helped to create the Wise Kids Evaluation if they perceive social pressure to do so, and if tool, which is an integral part of each program they believe they will be successful. Because kit. Communities are encouraged to conduct intention plays such a critical role in under- pre- and postprogram testing with participating standing behavior in the TPB model, it serves children. To date, 48 of the 130 participating as a mediator between attitudes, values, norms, agencies have conducted such tests. The testing and perceived behavioral control. results continue to indicate positive changes in Having formal and informal testing locations children’s attitudes and behaviors, including enabled the Säjai Foundation to receive input physical activity (see figures 18.3 and 18.4). from diverse communities and program formats. Program leaders in all locations provided input to help build a program that is easy to lead Linkage to the National and easy to replicate. Qualitative feedback was Physical Activity Plan used to modify workbook activities and leader training materials and to provide enhancements The Wise Kids program aligns with the National to some of the physical activities. For example, Physical Activity Plan under two primary strat- some activities were simplified to ensure that egy areas of the Parks, Recreation, Fitness, and more activity was involved, and the program Sports Sector: developers added messages to leaders, encour- Strategy 1: Promote programs and facilities aging them to customize and localize the pro- where people work, learn, live, play and worship gram to meet the needs of their children and (i.e., workplace, public, private, and non-profit location. recreational sites) to provide easy access to safe and affordable physical activity opportu- nities. Wise Kids is designed for after-school Program Evaluation and summer camp programs. Because it was developed to be easy to lead, youth leaders of An initial evaluation conducted by Recreation, all abilities and experience levels, from novice Parks, and Leisure Studies and the School of teenagers to experienced adults, have success- Kinesiology faculty at the University of Min- nesota in St. Paul demonstrated that Wise Kids had positive and significant impacts on attitudes and behaviors that influence healthy eating and 3.0 physical activity behaviors in youth. In addition, the results suggested that Wise Kids positively 2.0 affected children’s trends in body mass index (BMI) and has the potential to stem increases 1.0 in BMI (figure 18.2). Finally, the evaluation highlighted that it is feasible to implement this 0.0 type of program in after-school environments BMI change that serve youth, such as recreation centers, −2.0 and that such programs welcome structured and purposeful programs that focus on physical −2.0 activity and nutrition. Test group Control group Since the formal studies were conducted, BMI test vs. control Wise Kids has been used in agencies in 40 Figure 18.2 Wise Kids shows potential to posi- states to reach nearly 15,000 children. The Säjai tively affect participants’ BMI. E5691/NPAP/fig18.4/458569/alw/r1 Foundation is conducting ongoing research © The Säjai Foundation. 154 Hanson and Rea
120%
100% 95 % 97% 80% 87% 90% 77% 78% 60% 71% 72%
40% Percentage change Percentage 20%
0% Choose to be Eating fruits I like Drinking water is physically active and veggies eating important to me because it helps is important breakfast me feel good about to me myself Attitudes and values = Presurvey = Postsurvey
Figure 18.3 Change in attitudes and values from pre- to postprogram testing. © The Säjai Foundation.
E5691/NPAP/fig18.1/458566/alw/r1 100% 92% 90 % 90% 87% 79% 80% 71% 74% 74% 70% 60% 50% 40% 32% 30%
Percentage change Percentage 20% 10% 0% Frequency of Frequency of Frequency of Screen time eating breakfast eating fruits physical and veggies activity Behavior = Presurvey = Postsurvey Figure 18.4 Change in behavior from pre- to postprogram testing. © The Säjai Foundation.
E5691/NPAP/fig18.2/458567/alw/r1 fully implemented the program. More than effectiveness in parks, recreation, fitness, and 8.4 million children participate in after-school sports settings based on geographic population programs, providing an excellent opportunity to representation and physical activity levels, not teach them about the value of physical activity. merely numbers served. Wise Kids addresses After-school care encompasses a large portion Strategy 5 by offering agencies a way to ensure of a child’s day, so programs that enable them consistency in program delivery and to mea- to learn about activity and be physically active sure changes in values, beliefs, and behaviors meet the intent of Strategy 1. regarding physical activity and healthy living. Strategy 5: Improve physical activity monitor- Ensuring that evaluation is part of the program ing and surveillance capacity to gauge program helps agencies to track program effects over Säjai Foundation’s Wise Kids Program 155
time and quantify efforts to increase physical has had a profound impact on how my son activity. Pre-to-post testing is also a great way views food as well as exercise. He now actively to determine how children feel about being makes healthier choices on his own. . . . It has physically active and to determine how their provided a mindset about food and exercise behaviors are changing. Wise Kids encourages that he will carry with him throughout his life. collaborative efforts between the Säjai Founda- . . . The key was teaching him at a young age.” tion, youth-serving agencies, and third parties, Creating changes in the home can help improve such as grant makers, volunteer groups, and both the child’s and the family’s physical activ- local businesses, that agree to participate in ity levels. functions related to the program (e.g., grocery stores that provide food for Wise Kids family nights). Populations Best Served Parent evaluations show that wellness learn- by the Program ing goes home. Sixty-four percent of parents in one community noted that their children Wise Kids has been implemented and evalu- brought information on Wise Kids home on a ated in numerous environments, including weekly basis. As one parent noted, “Wise Kids after-school programs, parks and recreation settings, YMCA camps, school programs, and faith and community-based programs. Children Table 18.1 Wise Kids Results Attitudes, ages 6 to 11 respond best to the program; the Norms, and Behaviors Test vs. Control materials and activities are designed for their interests and developmental stage. Childhood % Change obesity affects children in all demographic groups, and the program can be successful in Attitudes 5.5 both urban and suburban settings and a variety Norms 2.6 of economic conditions. Research on Wise Kids indicates that the earlier the program reaches Behaviors 4.1 children, the greater their interest in learning © The Säjai Foundation. more (figure 18.6). 156 Hanson and Rea
Table 18.2 Highlights from Pre-to-Post Testing in Milwaukee Participating children—Milwaukee Public Schools Pre Post % Change Healthy eating (true or very true for me) Choose foods that are good for me 55.9% 69.4% 24.2% Healthy snacking (almost every day or every day) Last week’s behavior: choosing healthy snacks 68.6% 73.9% 7.7% Physical activity (almost every day or every day) Last week’s behavior: physical activeness 70.2% 84.7% 20.7% Knowledge of 5 health concepts Junk foods 47.6% 74.5% 56.5% Nutritious foods 43.5% 70.7% 62.5% Food labels 38.2% 69.4% 81.7% Physical activity 31.9% 66.2% 107.5% Energy balance 21.5% 62.4% 190.2% Highlights from Milwaukee Public Schools/Milwaukee Recreation Services—Wise Kids 2009. © The Säjai Foundation.
97% • A high level of support within the imple- menting organization increases the effec- tiveness of Wise Kids with children and 96% the broader community. For example, 96% 96% if the organization has a strategic plan that calls for increased levels of physical 95% activity for the children it serves, direc- tors or supervisors are likely to push for
Level of interest Level incorporating these elements into the 94% after-school or summer camp hours and to 94% 94% support staff in doing so in order to meet the overarching plan. 93% % satisfaction % want to learn more • The level of youth leader engagement Age of children directly affects overall success with par- = Glen Lake = Meadowbrook ticipating children. For example, if the leader participates in games and activities Figure 18.6 Kids in Hopkins, Minnesota, com- along with the children or openly shares pleted the Wise Kids program and wanted to learn more. E5691/NPAP/fig18.3/458568/alw/r2-kh his or her success with and enjoyment of Wise Kids Evaluation tool © Melissa Hanson and Amy Rea. physical activity, the children are more likely to participate and feel comfortable Lessons Learned talking about their experiences. • Agencies can engage community partners The program developers and participating agen- to support efforts. For instance, one agency cies learned a number of lessons while creating working with the Wise Kids program and implementing Wise Kids: invited a local university dance team to Säjai Foundation’s Wise Kids Program 157 © Melissa Hanson and Amy Rea. © Melissa Hanson and Amy
demonstrate and teach children some and support from multiple sectors (business, easy dance moves. Another invited a local nonprofit, health care, and schools) in order to grocer to bring in healthy foods for the kids provide quality programs. The Säjai Foundation to try. To increase effectiveness, agencies has helped connect financial resources with should invite dance and karate studios, deserving after-school agencies, creating suc- health clubs, fishing groups, gardening cessful partnerships involving all of these sec- clubs, health organizations, and similar tors to bring the Wise Kids program to agencies organizations to send representatives to across the country. To be successful in securing add additional education and interest to funding, agencies should seek out organizations the program. that have a vested interest in healthy living or • Tracking mechanisms can help moti- overall community health. As the community vate children to become involved and becomes involved in Wise Kids and similar to continue the program. For example, programs, efforts to help children be active pedometers provide children with an will become easier to sustain. Beyond financial easy-to-understand way of measuring resources, other sectors can bring their expertise their activity levels. Likewise, posters or or services to an after-school agency and the charts that track things like steps taken children it serves to demonstrate physical activ- or minutes running can be a fun way to ity opportunities. This help can be as simple motivate children. as inviting local businesses to demonstrate wellness-related concepts, such as providing opportunities for children to try new activities Tips for (yoga, karate, lacrosse, tennis, hiking, running), Working Across Sectors or it can be as complex as asking a business to provide adult volunteers who serve as physical Park, recreation, fitness, and sports agencies activity role models. Finally, agencies should and programs play a central role in promot- collaborate with other sectors in developing pro- ing physical activity, especially with children. grams that combine physical activity with infor- Often, these organizations rely on funding mation about health and wellness. For example, 158 Hanson and Rea an introductory running program combined Additional with learning about physical activity and health is more likely to promote long-term change than Reading and Resources is either activity in isolation. A YMCA might Physical Activity for Everyone: The CDC Guidelines: want to incorporate a nutrition or physical activ- www.cdc.gov/physicalactivity/everyone/guide- ity component into an outdoor camp but may lines/children.html need expertise from another organization or a Physical Activity and Children (from the American business to develop that component. Among the Heart Association): www.heart.org/HEARTORG/ barriers to these kinds of partnerships are lack GettingHealthy/Physical-Activity-and-Children_ of full commitment by one partner, divergent UCM_304053_Article.jsp goals of the participating organizations, fund- Moving and Learning: www.movingandlearning.com ing difficulties, and changing values. Frequent, Physical Activity Guidelines for Children: www.pbrc. clear communication can help overcome some edu/pdf/PNS-physicalactivity.pdf of these barriers. All sectors should find ways Children and Physical Activity (PBS Teachers): www. to collaborate in encouraging children and pbs.org/teachers/earlychildhood/articles/physical. families to become active and should saturate html the community with positive health messages. Indoor Physical Activity Ideas for Kids: www.food- No single physical activity program or venue linkny.org/pdfs/Physical_Activity_Ideas_for_Kids. provides a magic solution. Rather, agencies, pdf organizations, and businesses should look for Physical Activity (American Academy of Pediatrics): ways to promote learning and create physical www.healthychildren.org/english/healthy-living/ activity opportunities across sectors. fitness/Pages/default.aspx CHAPTER 19 Moovin’ and Groovin’ in the Bayou Summer Camps Increase Youth Physical Activity Through Intentional Design
Birgitta L. Baker, PhD Andrew McGregor, MS Louisiana State University at Baton Rouge Louisiana State University at Baton Rouge
NPAP Tactics and Strategies Used in This Program
Parks, Recreation, Fitness, and Sports Sector to disseminate policy and environmental interven- tions that promote physical activity. STRATEGY 1: Promote programs and facilities where people work, learn, live, play and worship (i.e., STRATEGY 6: Increase social marketing efforts to max- workplace, public, private, and non-profit recre- imize use of recreation programs and facilities and ational sites) to provide easy access to safe and promote co-benefits with environmental and other affordable physical activity opportunities. related approaches. STRATEGY 2: Enhance the existing parks, recreation, fitness, and sports infrastructure to build capacity
ess than 49 percent of boys and 35 percent for the Parish of East Baton Rouge; BREC) and Lof girls ages 6 to 11 in the United States a university kinesiology department (Louisiana meet the guidelines that recommend 60 min- State University Department of Kinesiology; utes of physical activity on all or most days of LSU). The pilot test of the program, described the week (Troiano et al. 2008). Evidence also in this chapter, involved three camps that suggests that children’s patterns of change in implemented Moovin’ and Groovin’ and three body mass index are less healthy during the comparison camps. Since the pilot test, many summer than during the school year (Downey of the other summer camps run by BREC have and Boughton 2007). Summer camp settings implemented the program. The program design may provide an opportunity for children to incorporates several strategies and tactics from attain recommended levels of physical activ- the U.S. National Physical Activity Plan. ity and promote healthy growth patterns. One such program, Moovin’ and Groovin’, integrates physical activity into summer camp programs Program Description through intentional design. The goal of Moovin’ and Groovin’ is to increase physical activity The Moovin’ and Groovin’ program is a compo- levels of children participating in a summer nent of BREC’s initiative to address low activity day camp. The design, implementation, and levels in children and is part of a wider partner- evaluation of this program involve a partner- ship between BREC and the LSU Department ship between a municipal park and recreation of Kinesiology. The partnership also includes agency (the Recreation and Park Commission Family Fitness Fun Days and an after-school
159 160 Baker and McGregor program. In initiating the Moovin’ and Gro- summer camp staff. The Moovin’ and Groovin’ ovin’ program, summer camp organizers asked training includes information about the pro- faculty and students from LSU to partner with gram goals, activities, and evaluation. To build them to design, implement, and evaluate the excitement and buy-in among program staff, program. The program included four key strat- training includes discussions of the potential egies: (1) add additional designated physical benefits of the program for the children and a activity times to the schedule of an existing description of the program design, which was program, (2) train staff and build excitement intended to minimize additional work for the about the program, (3) provide staff with a staff. The majority of the camp staff in the pilot variety of activity options, and (4) evaluate the project were K-12 teachers or college students, program. The first three strategies are described and many of them had previous experience next. The fourth strategy, program evaluation, facilitating children’s physical activity. is described in a later section. Provide Staff With a Variety Add Additional Designated of Activity Options Physical Activity Times to the Staff receive a list of activities with descrip- Schedule of an Existing Program tions and instructions. They are instructed to The BREC summer camps run for eight weeks, implement a variety of activities in their camps and participants ages 6 to 12 years can attend during the designated Moovin’ and Groovin’ all or part of the eight weeks. The camps are time slots. Some of the activities are suitable for located at BREC park facilities throughout the specific age groups and some are suitable for parish. Each of the six facilities that took part the full group. This allows camp staff to tailor in the pilot project have a recreation center, the program to times when all the campers are most of which include an indoor gym. Camp together and times when they are divided into activities include outdoor and indoor games, age groups. arts and crafts, and field trips. Field trips occur Activities are designed to enhance a range of one or two times per week and include trips to physical fitness outcomes, including cardiovas- the zoo, swimming pools, “exergaming” facili- cular fitness, muscular strength and endurance, ties, and museums. Camp prices range from and flexibility. The aerobic and muscular fit- $12.50 to $73 per week depending on the camp ness activities are games designed to maximize location and the participant’s family income. participation and enjoyment. Activities also Camps run from 8 a.m. to 5 p.m., and pre- and are designed to be easy to set up and explain. postcamp activities are offered from 7 to 8 This minimizes transition time and maximizes a.m. and from 5 to 6 p.m. for an additional fee time spent engaged in the activity. Examples of of $12 per week. All of the camps offer some activities included small side soccer (three to opportunities for physical activity. Moovin’ and five players per team with cones used as goals), Groovin’ was designed to supplement the exist- obstacle courses (set up either in the gym or ing summer camp program by incorporating an outside using the playground equipment), additional 30-minute activity break on non–field jump rope, and push-up tag (similar to freeze trip days. An LSU student hired by BREC was tag but instead of standing still while waiting responsible for coordinating the Moovin’ and to be “unfrozen” after being tagged, the player Groovin’ pilot program and providing support does push-ups until touched by someone other for the camp staff. than “it”). During the pilot project, program staff Train Staff and Build Excitement encouraged camp staff members to select activities they believed their campers would About the Program enjoy, to adapt the activities to the needs and Moovin’ and Groovin’ training occurs during abilities of their campers, and to incorporate precamp staff training attended by all of BREC’s alternative activities in consultation with the Moovin’ and Groovin’ in the Bayou 161 program coordinator. Staff who were physical place indoors rather than outdoors to ensure education teachers during the school year were the safety of the participants. particularly effective in identifying alternative Reports from the campers support the staff activities and in structuring activity sessions to perceptions. Campers reported that the activi- provide quick, active transitions. ties were fun and that they wanted to do more. A few of the younger campers indicated that when activities were not structured, they were Program Evaluation excluded by the older campers. This appeared to be particularly relevant when informal bas- Evaluation of the pilot program focused on ketball games occurred during free-play time. accelerometer-measured moderate to vigorous physical activity (MVPA). Data were collected by faculty and students from LSU. Six camps Linkage to National were grouped into pairs based on location and Physical Activity Plan participant demographics. One camp in each pair was then randomly assigned to the Moovin’ Moovin’ and Groovin’ addresses several strate- and Groovin’ group and the other camp served gies of the Parks, Recreation, Fitness, and Sports as a control. Participants at each camp wore Sector of the National Physical Activity Plan: accelerometers for four days during the eight- Strategy 1: Promote programs and facilities week program. Accelerometer data between the where people work, learn, live, play and worship hours of 8 a.m. and 4 p.m. were used in the (i.e., workplace, public, private, and non-profit analyses. This eliminated variability resulting recreational sites) to provide easy access to safe when campers arrived late or left early. As a and affordable physical activity opportunities. result, some campers, particularly those who Programs in summer day camps address a key participated in the extended pre- and postcamp tactic of this strategy—provide programs in activities, would have accumulated additional parks, recreation, fitness, and sports that have physical activity that was not included in the demonstrated positive physical activity out- evaluation results. comes that are appropriate for children of both The campers at the Moovin’ and Groovin genders, those from diverse cultures, and those camps participated in an average of 64 minutes with different abilities, developmental stages, of MVPA per day, whereas those in the regular and needs. The Moovin’ and Groovin’ program camps participated in about 54 minutes per serves children ages 6 to 12 years. The program day. These results were statistically significant design allows staff to adapt the program to a and indicate that (1) summer day camp pro- range of ages and ability levels. It includes gramming can create an environment in which games and activities appropriate for only the children can accumulate the recommended younger age group (ages 6-9), only the older 60 minutes of MVPA per day and (2) physical age group (ages 10-12), or all ages, allowing activity levels can be increased in camp settings camp staff to select developmentally appropri- through structured activity time. ate options. The day camp setting allows the Process evaluation indicated that most camp program to reach racially and socioeconomically staff found the program easy to implement and diverse groups of participants. Summer camps that staff believed that the children enjoyed are located throughout the parish (county), and benefitted from the activities. Challenges allowing children to attend camps close to included identifying activities that all campers, their homes or where their parents work. The regardless of age and ability, could enjoy and program evaluation provided evidence that pro- ensuring that campers did not overheat in the gram participants obtained at least 60 minutes Louisiana summer weather. Physical activity of physical activity on more than half the days. times were alternated with lower activity times, Strategy 2: Enhance the existing parks, recre- children had unrestricted access to water, and, ation, fitness, and sports infrastructure to build on very hot and humid days, activities took capacity to disseminate policy and environmental 162 Baker and McGregor interventions that promote physical activity. ity, primarily aerobic, on all or most days of Moovin’ and Groovin’ addresses one of the tac- the week, and that at least three days include tics recommended as part of this strategy—use muscle-strengthening activities. The Moovin’ volunteers and education entities to increase and Groovin’ program incorporates three the sector’s ability to execute the National 30-minute activity sessions into the daily camp Physical Activity Plan. The partnership between schedule to ensure that participants have suf- BREC and LSU’s Department of Kinesiology ficient opportunities to accumulate 60 minutes allowed program development and evaluation at of activity while allowing for activity transitions minimal cost, enabling BREC to direct program and down time. funds toward providing camp experiences. The Research indicates that enjoyment (Vierling partnership also provided LSU undergraduate et al. 2007; Wilson and Rodgers 2004) and a and graduate students with valuable hands-on sense of competence (Sollerhed et al. 2008; experiences in program design and evaluation. Trost et al. 1997; Welk and Schaben 2004) Strategy 6: Increase social marketing efforts to are important factors in maintaining physical maximize use of recreation programs and facili- activity behaviors. The Moovin’ and Groovin’ ties and promote co-benefits with environmental program was designed to be fun, with a focus and other related approaches. The program on games rather than on exercise. The program increased physical activity opportunities for less includes a variety of activities for all ages to help active groups (e.g., girls, children with mental participants develop feelings of competence. or physical disabilities, and low-income youth) through increased programming, social market- ing, and transportation assistance. Two of the Populations Best Served three parks in which Moovin’ and Groovin’ by Program was piloted were reduced-fee camps located in low-income areas. These camps served high Moovin’ and Groovin’ is designed for and imple- proportions of campers from low socioeconomic mented with children ages 6 to 12 years. The backgrounds who were at increased risk for low basic components of Moovin’ and Groovin’— levels of physical activity. The expansion of the incorporating additional physical activity oppor- program following the successful pilot project tunities into existing programs, training staff, also reaches camps in low income areas. and providing staff with a variety of activity options—could be applied to a range of addi- tional age groups, with the time and activities Evidence Base Used appropriately modified. This program is effec- tive in reaching children from groups at risk for During Program Development low levels of physical activity. Existing camps A 2004 Institute of Medicine report, Prevent- and after-school programs could incorporate ing Childhood Obesity: Health in the Balance, similar strategies to increase physical activity highlighted the importance of community-based levels among their participants. programs (including programs that provide physical activity opportunities) that target Lessons Learned groups at higher risk for obesity. The Moovin’ and Groovin’ program targets children from Partnerships between parks and recreation low income families through community-based agencies and local higher education providers programming in the neighborhoods in which can benefit both parties. In the case of Moovin’ they live. and Groovin’, the parks and recreation agency The 2008 Physical Activity Guidelines for benefits from physical activity programming Americans recommend that individuals ages 6 and evaluation expertise provided by the uni- to 17 accumulate 60 minutes of physical activ- versity, whereas faculty and students from the Moovin’ and Groovin’ in the Bayou 163 university gain opportunities to apply concepts dents involved in program evaluation learned in real-world settings and to hone their practi- that fitness testing is more challenging when cal skills. you are testing 6- to 12-year-olds than when you Quality programs require quality staff. Pro- are testing your college classmates and that the viding camp staff with autonomy to choose logistics of measuring physical activity in the activities worked well during the pilot project. field are complicated. Staff reported that they appreciated the option to Allow extra lead time to negotiate chal- select activities that matched the skill and abil- lenges. Policies and procedures of both the ity level of their campers. As camp staff imple- university and the parks and recreation agency mented the program, they identified activities often extended planning and approval time that were suitable for younger campers, older beyond what would have been required by campers, or all campers and tailored activity either entity working alone. University require- choices to the makeup of the group. Variability ments included institutional review board in the specific physical activities chosen by approval for collecting data and the constraints the camps was evident from observations and of semester schedules. BREC requirements from camp schedules. Different camps favored included approval processes for programming different activities, and staff selected different and advertising and timing of parent meetings activities in the same camp setting when they and staff training. Negotiating these challenges were programming activity time with younger required intensive communication, anticipation versus older participants. In addition, staff who of potential sticking points, and a willingness worked at the camps during the summer and as of both partners to adjust to the timelines and physical education teachers during the school requirements of the other. year were very effective. Actively recruiting local physical education teachers provided BREC with a source of highly skilled day camp staff who Summary were seeking summer-only rather than year- The success of the Moovin’ and Groovin’ pro- round employment. gram was facilitated by the partnership between BREC and LSU and by enhancement of an existing program rather than creation of a new Tips for program. For agencies looking to implement Working Across Sectors similar programs, partnering with a local college or university can provide access to expertise and Identify the benefits for each partner in advance person power to enhance programming, par- of program design and implementation. In the ticularly through service-learning partnerships. implementation of the pilot program, benefits Increasing physical activity opportunities in an to BREC included the expertise of LSU students existing program allowed Moovin’ and Groovin’ and faculty, particularly in the areas of design- to increase physical activity without the chal- ing evidence-based programs and measuring lenges of staffing, marketing, and development physical activity and physical fitness. The LSU that would have been required to start a new students benefitted from the practical experi- program. Relatively short activity breaks could ence. The opportunity to apply concepts from be integrated into a variety of existing pro- their course work to a setting in which things grams, including summer camps, after-school did not run as smoothly as they do in theory was programs, and cultural education programs. invaluable. While designing and implementing The summer camps that implemented Moovin’ the program, LSU students learned that it can be and Groovin’ already provided opportunities for challenging to ensure that a program is carried physical activity, and the program increased the out consistently across sites and that quality physical activity levels compared to the exist- staff are crucial to the success of a program. Stu- ing format. 164 Baker and McGregor
the United States measured by accelerometer. Med. Additional Sci. Sports Exerc. 40(1):181-8. Reading and Resources Trost, S., R. Pate, R. Saunders, D.S. Ward, M. Dowda, More information on the Moovin’ and Groovin’ program and G. Felton. 1997. A prospective study of the can be obtained by contacting the Recreation and determinants of physical activity in rural fifth-grade Park Commission for the Parish of East Baton Rouge. children. Prev. Med. 26:257-63. Vierling, K.K., M. Standage, and D.C. Treasure. 2007. Predicting attitudes and physical activity in an “at- References risk” minority youth sample: A test of self-determi- Downey, D.B., and H.R. Boughton. 2007. Childhood nation theory. Psychol. Sport Exerc. 8:795-817. body mass index gain during the summer versus Welk, G.J., and J.A. Schaben. 2004. Psychosocial during the school year. New Dir. Youth Dev. 114:33- correlates of physical activity in children: A study 43. of relationships when children have similar oppor- Sollerhed, A.C., E. Apitzsch, L. Rastam, and G. Ejlerts- tunities to be active. Meas. Phys. Educ. Exerc. Sci. son. 2008. Factors associated with young children's 8(2):63-81. self-perceived physical competence and self-reported Wilson, P.M., and W.M. Rodgers. 2004. The relation- physical activity. Health Educ. Res. 23:125-36. ship between perceived autonomy support, exercise Troiano, R.P., D. Berrigan, K.W. Dodd, L.C. Masse, T. regulations and behavioral intentions in women. Tilert, and M. McDowell. 2008. Physical activity in Psychol. Sport Exerc. 5(3):229-42. CHAPTER 20 Finding Common Ground Play Space Modifications Can Increase Physical Activity for All Children
Kindal A. Shores, PhD East Carolina University
NPAP Tactics and Strategies Used in This Program
Parks, Recreation, Fitness, and Sports Sector STRATEGY 5: Improve physical activity monitoring and surveillance capacity to gauge program effec- STRATEGY 2: Enhance the existing parks, recreation, fitness, and sports infrastructure to build capacity tiveness in parks, recreation, fitness, and sports to disseminate policy and environmental interven- settings based on geographic population repre- tions that promote physical activity. sentation and physical activity levels, not merely numbers served.
lay is essential to development, because disabilities. According to national surveillance Pit contributes to the cognitive, physical, data from 2005, approximately 19 percent of social, and emotional well-being of children and children ages 5 to 17 have some type of disabil- youth (Burdette and Whitaker 2005). Play pro- ity (Brault 2008), including social, emotional, motes healthy development and reduces child- and cognitive developmental delays, as well as hood obesity (Brown and Vaughn 2009; Sothern physical disabilities. Although no clearinghouse 2007). The American Academy of Pediatrics, of U.S. playgrounds exists, it is clear that far Centers for Disease Control and Prevention, fewer than 19 percent of playgrounds meet the and American Public Health Association have needs of children with disabilities. A national all linked a lack of gross motor playtime to the registry that tracks accessible play spaces in current childhood obesity epidemic (Centers for the United States has identified 403 accessible Disease Control and Prevention 2009). Indeed, park playgrounds in the 50 states (not includ- play is so essential that the United Nations ing the more than 100 inclusive playgrounds in Convention on the Rights of the Child states New York City) (www.accessibleplayground. that the right to play is a fundamental human net). This discrepancy is problematic. Children right that must be guaranteed for all children. with disabilities tend to have higher body mass Children’s play can occur in many places. indices and lower levels of physical activity than Local parks and school playgrounds are prime their peers who are developing typically (Hardy locations for play. However, the vast majority of et al. 2004). Formative research also suggests playgrounds in the United States and around the that children with disabilities can make greater world are geared to the needs of children without developmental gains when playing outdoors or
165 166 Shores at playgrounds, compared with their typically of youth activity, it demonstrated the ability developing peers (Hobbs et al. 2011). of existing surveillance tools to monitor the To address concerns about the lack of play effectiveness of this environmental change. spaces for children with disabilities and to The playground renovation also serves as an provide universally accessible play spaces, example of small-scale actions that contribute communities are now working to build or alter to Strategy 5: Improve physical activity monitor- the physical play environment to accommodate ing and surveillance capacity to gauge program all children through play opportunities. These effectiveness in parks, recreation, fitness, and inclusive playgrounds are designed to help sports settings based on geographic population children with and without disabilities interact representation and physical activity levels, not informally and play together. This provides merely numbers served. Specifically, this is an social benefits for both groups. Further, inclu- example of one of the tactics of Strategy 5 that sive playgrounds often are a favorite among all calls for assessing physical activity levels asso- children because these spaces provide more ciated with use of these facilities and services diverse play activities than do typical modular and evaluating cases of major improvement. playgrounds. A typical playground will focus almost exclusively on physical challenges (climbing, sliding), whereas inclusive play- Program Description grounds provide new physical challenges (hand In 2007, Elm Street Park was a well-loved and trikes, sand backhoe manipulation) as well as busy city park. The 12-acre green space housed sensory challenges (multiple textures, use of one large parking lot, a lighted youth baseball water and sounds) and intellectual challenges field, grass softball field, two playgrounds (riddles, word games). (one for children 2-5 years of age, the other for The community of Greenville, North Caro- children 6 years and older), six lighted tennis lina, hosts an inclusive playground. Green- courts, community center, gymnasium, open ville is a community of approximately 72,000 space, and picnic shelters with grills. Much of residents (2010 Census) that wanted to improve Elm Street Park remains the same today. How- the quantity and quality of play opportunities ever, the city made two substantial changes for youth. In 2008, the Greenville Recreation to enhance youth play and physical activity. and Parks Department removed a traditional First, it converted the grassy softball diamond toddler park and installed an inclusive play- to an accessible baseball and softball diamond. ground, designed for children with and without Second, it removed the playground for children disabilities to play actively and cooperatively. At ages 2 to 5 and replaced it with a new play- the same time, the city converted a grass softball ground structure designed for all children ages field to a fully accessible baseball field. These 2 to 12. initiatives are in line with the National Physi- The softball field is named in honor of Sarah cal Activity Plan (NPAP)’s, Recreation, Fitness, Vaughn. Sarah is a young woman with mobil- and Sports Sector, Strategies 2 and 5. Strategy 2 ity impairments who, together with her family, seeks to Enhance the existing parks, recreation, catalyzed the community into action. In 2008, fitness, and sports infrastructure to build capac- the Sarah Vaughn Field of Dreams, a fully acces- ity to disseminate policy and environmental sible baseball field, was built at the Elm Street interventions that promote physical activity. By Park (figure 20.1). The accessible ball field removing the existing toddler playground for features a flat cushioned synthetic turf, embed- children without disabilities and installing an ded bases, spacious field-level dugouts, and an accessible playground, the community gained audiovisual score sign. This field is used for infrastructure that allowed more children to unplanned play, family events, and game days engage in active play. Since the city elected to as well as for spring, summer, and fall baseball evaluate this renovation, using observations leagues for children and adults with disabilities. Play Space Modifications 167
Upon installation of the Vaughn field, the city its inaugural year, and 80 participated in 2009. started a Challenger baseball league for children In 2010, the Exceptional Community Baseball ages 5 to 18 (see figure 20.2). More than 50 League (ECBL) was formed with the coopera- youth participated in the Challenger league in tion of the Greenville Recreations and Parks © Kindal A. Shores.
Figure 20.1 Sarah Vaughn Field of Dreams. © Kindal A. Shores.
Figure 20.2 Game day at the inclusive baseball field. 168 Shores
Department and a grant from the Cal Ripken Sr. more than $300,000 in total renovations. The Foundation. The ECBL formed three divisions: accessible field and play space were both open youth (ages 5-14), senior youth (ages 15-24), by summer 2008. and adult (ages 25 and up). In the first spring season in 2010, the ECBL increased from 80 youth players to more than 150 participants of Populations Best Served all ages. by the Program The same community group that advocated for the inclusive baseball field also championed Communities of almost every size can install an inclusive playground. The group’s momen- accessible playgrounds. Costs of these facilities tum and success in fund-raising allowed the (surfacing, fencing, equipment) vary widely but ball field and the inclusive playground, the begin at around $15,000 for a small installed Common Ground Playground for All, to open play set. Extensive structures with towers in the same year. The inclusive playground and custom components can cost upward of consists of approximately 2,500 square feet (762 $100,000. Individual play components such as square meters) of play space (see figure 20.3). toddler bouncers or a raised, wheelchair-acces- The fenced space is anchored on each end by sible sand and water table can be purchased at a set of four swings and is divided roughly in prices beginning at $500 per component. Ide- half by an entrance arch and ramp. One half ally, rural communities and cities with limited features an approximately 1,100-square-foot formal resources for children with disabilities (102-square-meter) play structure that includes will benefit the most. Data from Greenville, three types of slides, three climbers, one step however, suggest that children with and without entrance that is in compliance with the Ameri- disabilities stand to benefit from this environ- cans with Disabilities Act (ADA), two separate mental change. ramp entry and exits, and four play panels in the Communities must determine the philoso- structure. An open area on the other side of the phy that will guide development of their play- play space offers additional play panels, spring ground before they can design an appropriate riders, a large raised sandbox, hand trikes, and facility. This chapter uses the term accessible an in-ground sandbox with an ADA-compliant playground, which is a global term that encom- backhoe. passes several types of playgrounds. Accessibil- The evolution of the Vaughn Field of Dreams ity is a general term that refers to the degree and the Common Ground Playground for All to which a service or environment can be used in Greenville resulted from a grassroots initia- (accessed) by as many people as possible. In the tive that local officials and corporate partners context of an accessible playground, the play embraced. A conversation between Sarah space should allow any child to play without Vaughn’s parents and other parents of children barriers. The words accessible, inclusive, uni- with disabilities sparked a movement to benefit versal, boundless, and ADA compliant are often the more than 6,500 residents of Greenville used interchangeably in conversation; however, who have disabilities. A working group for each term refers to a specific type of playground inclusive recreation was established in Green- and reflects the targeted population and goals ville in early 2006, and the group coordinated for that space. For example, accessible play- its efforts with the Greenville Recreation and grounds can be designed for children with dis- Parks Department. Local contractors, private abilities, for interactive play between children donors, a county priority fund, and a grant with and without disabilities, for simultaneous from the North Carolina Parks and Recreation but separate play, and, at a minimum, to allow Trust Fund provided funding. Ongoing programs children with disabilities physical access to and services at these facilities are sponsored a space. In contrast, an ADA-compliant play- primarily by local businesses, regional sport ground must meet minimal federal guidelines teams, and individual gifts. No single source related to access and mobility within a space contributed more than $100,000 toward the but is not specifically designed to meet the Play Space Modifications 169 needs of people with emotional and social dis- (2007, 2008, 2009), the city evaluated park abilities. Universal playgrounds, in contrast, visitation outcomes at Greenville’s Elm Street are playgrounds that have been designed using Park. To document use and physical activity at the seven design principals of Universal Design the playground site before and after renovation, for Learning. In these spaces, the playground is the city adopted the protocol outlined in the not designed for children with disabilities but System for Observing Play and Recreation in is designed so that all of the equipment works Communities (SOPARC). Developed and tested for people with and without disabilities. An by McKenzie, Cohen, Sehgal, and colleagues inclusive playground takes the design one step (2006), SOPARC relies on momentary time sam- further and encourages children of multiple pling techniques in which trained researchers abilities to play together—not just in close prox- undertake systematic and periodic scans of park imity to each other. environments. The evaluation focused on the It may be helpful for communities to iden- playground and the softball field. tify a target population for the play space. Data were collected during June and July Playground equipment manufacturers are now each year using systematic scans of target creating highly specialized play components areas at four time intervals throughout the day that encourage play for children with limited (7:30-8:30 a.m., 12-1 p.m., 3:30-4:30 p.m., and upper-body mobility, challenge children to prob- 6:30-7:30 p.m.). During each scan, the number lem solve, or engage children with autism spec- of participants and their observable personal trum disorders in sensory play. For example, characteristics and physical activity intensity the Common Ground Playground at Elm Street were recorded. Two observations were taken Park incorporates a hand trike for upper-body for each time point, at each target area, on each exercises for children with upper-body mobility of the seven days of the week. Thus, a total of and inclusive swing seats that provide stability 56 scans of the two target areas were obtained for children with limited upper-body control or each year. strength (figure 20.4). With regard to problem- Prior to renovation, when Elm Street Park solving challenges, a play panel asks children a still had an enclosed toddler playground and a riddle and then provides the answer in braille. grass field with a softball backstop, the evalu- However, the braille station to “decode” the ation found that 206 people visited these two answer requires the child to run or push up a areas over seven summer days (table 20.1). ramp to match the braille letters with alpha- The playground had 96 visits, most of which betical letters. Finally, a play panel with texture included moderate or vigorous physical activ- is incorporated into the play structure. These ity. The open field had 110 visitors; only 16 of sensory experiences are fun for all children but these visits were vigorous physical activity. critical for the development of children with In late spring 2008, the playground and new autism spectrum disorders. Each play panel ballfield opened to the public. During summer provides space for the child to roll up and place 2008, 290 visits were observed at these sites. his or her legs under the station. This allows Total visits increased and physical activity at for play by children without disabilities and the ball field increased modestly. Three-quarters by children who use a wheelchair. However, if of playground visitors were physically active park space is limited, a community may place before the renovation; 78 percent were active a premium on the needs of one group of special after the renovation. Prior to the renovation, needs in the design plan. 53 percent of visits to the softball field were active; 72 percent were active immediately following the renovation. More than one year Program Evaluation after the renovations were completed, use had risen again. In 2009, the evaluation recorded 215 To gauge the impact of the environmental visits at the playground and 148 visits at the ball changes, it is important to collect empirical field. Although the percentage of active users data. For three consecutive summer seasons in 2009 was similar to that in 2008, the overall 170 Shores increase in visitation resulted in significantly some traditional playground structures and more people engaged in physical activity after require adequate space to access and maneuver the accessibility renovations. Prior to the reno- around each element. Ideally, the play space vations, 129 visitors were engaged in moderate should provide access to nature or natural and vigorous physical activity in this part of the elements, since many children with sensory park. One year after the renovations, 281 visitors processing disorders are comforted by green were engaged in physical activity in these park and natural elements. Best practices in inclusive spaces. This represents a considerable percent playgrounds also call for quiet spaces within the increase in physical activity. more chaotic play area. For all visitors, shade is an important consideration, and the site must be well graded and level. Wide ramps that integrate Tips for and match the entire play structure should be Working Across Sectors provided for children to access the play area, and a child should be able to enter and exit the The first challenge to overcome in developing playground using more than one approach. In an accessible play space is the need to recruit other words, the structure should draw the child a passionate and dedicated group of residents into and through the play area by engaging him to advocate for resources. Success stories from or her physically and mentally. Finally, sites around the United States have a common theme: must be large enough to allow for the addition local champions. Of the documented accessible of accessible parking for convenient park use. playgrounds in the United States, one in five is Site selection and playground design are, of named for a child or family who inspired and course, influenced by financial considerations as advocated for the play space. Many play areas well. As described previously, a range of options have been successful in achieving funding when exists for accessible playgrounds, from simply a local child or family can provide a human face ADA-compliant to interactive, inclusive play to raise the consciousness of donors, granting spaces. For the most successful play areas, the agencies, and local government officials. more inclusive components should be selected. Once a team of dedicated residents is assem- However, this decision has to be ratified consis- bled, the most common challenges to creating tently by those championing the effort at each an accessible playground are typically site point in the design process. One of the first selection and funding. Accessible playgrounds decisions that must be made is the surface for tend to include larger physical components than the playground. According to ADA legislation,
Table 20.1 Physical Activity Levels at Elm Street Park Before and After Renovation 2007: BEFORE RENOVATION 2008: NEWLY RENOVATED 2009: 1 YEAR AFTER (N = 216) (N = 290) RENOVATION (N = 363) Playground Field Playground Field Playground Field Sedentary visits 24 (25%) 52 (47%) 36 (12%) 34 (28%) 42 (20%) 40 (27%) Moderate/walking 31 (32%) 42 (38%) 55 (33%) 74 (60%) 72 (33%) 80 (54%) visits Vigorous visits 41 (43%) 16 (15%) 76 (45%) 15 (12%) 101 (47%) 28 (19%) Totals 96 110 167 123 215 148 Play Space Modifications 171 loose fill (engineered wood, shredded rubber), matched the donations. The Vaughn family pea gravel, and sand are appropriate options for story has been echoed across the United States surfacing the play area. “Pour in place” recycled in the development of almost every inclusive rubber and polymer surfacing, rubber mats or facility. Although difficult to finance, a reno- tiles, and artificial grass with rubber underneath vated play area for children with and without are more durable, are easier to maintain, and disabilities is a relatively small investment provide a more functional surface for a greater on the scale of community spending. For this number of park visitors; however, these surfaces reason, grassroots advocacy and an individual are more expensive. Maintaining a consistent champion can make a considerable impact design philosophy in the face of budget chal- on a city or county government’s decision to lenges is difficult. fund this type of project. If local funding is Changing existing playground spaces or cre- not achieved or remains inadequate, the busi- ating new ones can be an expensive proposi- ness sector can be approached: Most major tion. In most communities in the United States, playground manufacturing companies offer public playgrounds are built and maintained competitive grants for inclusive playgrounds. by a local parks and recreation department. Without exception, matching funds and sweat As leaders of a city or county entity, parks and equity are required of the awarded grantees. recreation administrators must make the case Finally, a less common but equally impor- for the health, environmental, and social value tant psychological barrier exists to building an of parks and playgrounds in order to receive a inclusive playground or ball field. Residents portion of the city’s general fund, pass a bond (often parents) who have never seen or used an resolution, or receive grants and donations accessible playground are sometimes hesitant toward the environmental change. To advocate to support these efforts. Residents worry that effectively for the value of parks to communi- extensive community resources will be spent ties, local officials have partnered with research- on inclusive playgrounds that will serve only ers to collect monitoring and change data on a few select children. Despite assurances that the outcomes that park spaces may achieve. The inclusive playgrounds are for everyone, a field observation and documentation of visitors to trip, active video, and images of other suc- Elm Street Park before and after renovations is cessful sites are often required so that parents an example of this process. Objective scientific can see that the play space is available and data are a valuable tool that can be used to attractive to children with and without special make the case for government funding for an needs. Evaluation data that track use can also inclusive playground. help make the case that inclusive play spaces Unfortunately, this type of monitoring data can increase the use of a park area by children cannot be achieved until funds have been com- with and without disabilities. mitted to a site. To achieve an initial investment for playgrounds, park and recreation profes- sionals typically rely on a piecemeal approach. Additional This was the case for the renovations at Elm Street Park. David Vaughn, the father of Sarah Reading and Resources Vaughn, initiated the redevelopment process If you are interested in working toward an acces- for the inclusive baseball field as a grassroots sible play space in your community, the follow- movement. An avid baseball fan and Little ing resources, organizations, and websites serve League coach to Sarah’s brothers, David Vaughn as valuable starting points: thought that his daughter and other children deserved a place to play. He established a work- Boundless Playgrounds is a nonprofit organization that ing group of recreation, business, and political works with communities to develop playgrounds leaders who acquired significant donations of accessible by all children, with or without disabili- in-kind materials and labor. The city council ties: www.boundlessplaygrounds.org 172 Shores
KaBOOM! is a nonprofit agency that seeks to provide Burdette, H.L., and R.C. Whitaker. 2005. Resurrecting a play space within walking distance of every child free play in young children: Looking beyond fitness in America: www.kaboom.org and fatness to attention, affiliation, and affect. Arch. National Institute for Play is a nonprofit agency that Pediatr. Adolesc. Med. 159:46-50. promotes play to improve human health, imagina- Centers for Disease Control and Prevention. 2009. tion, and intellect: http://nifplay.org Prevalence of no leisure-time physical activity--35 National Program for Playground Safety is a clear- States and the District of Columbia, 1988-2008. Mor- inghouse of information on safety regulations and bidity and Mortality Weekly Report, 53(4), 82-86. recommendations for outdoor playgrounds in the Hardy, K.R., J.S. Harrell, and L.A. Bell. 2004. Over- United States. weight in children: Definitions, measurements, National Recreation and Park Association is the leading confounding factors, and health consequences. J. advocacy and professional organization dedicated Pediatr. Nurs. 19(6):376-84. to the advancement of public park and recreation Hobbs, T., L. Bruch, J. Sanko, and C. Astolfi. 2001. opportunities: www.nrpa.org Friendship on the inclusive playground. Teaching Exceptional Children 33(6):46-51. McKenzie, T.L., D.A. Cohen, A. Sehgal, S. Williamson, References and D. Golinelli. 2006. System for Observing Play and Recreation in Communities (SOPARC): Reli- Brault, M. 2008. Americans with disabilities: 2005. Cur- ability and Feasibility Measures. Journal of Physical rent populations reports. U.S Bureau of the Census. Activity and Health 3(S1), S208-S222. www.census.gov/prod/2008pubs/p70-117.pdf. Sothern, M.S. 2007. Obesity prevention in children: Brown, S., and C. Vaughan. 2009. Play: How It Shapes physical activity and nutrition. Pediatrics 119(1):182- the Brain, Opens the Imagination, and Invigorates 91. the Soul. New York: Penguin Books. CHAPTER 21 Pioneering Physically Active Communities YMCA of the USA’s Healthier Communities Initiatives
Monica Hobbs Vinluan, JD YMCA of the USA
NPAP Tactics and Strategies Used in This Program
Public Health Business and Industry STRATEGY 3: Engage in advocacy and policy develop- STRATEGY 1: Identify, summarize, and disseminate ment to elevate the priority of physical activity in best practices, models, and evidence-based physi- public health practice, policy, and research. cal activity interventions in the workplace. STRATEGY 5: Expand monitoring of policy and envi- STRATEGY 2: Encourage business and industry to in- ronmental determinants of physical activity and the teract with all other sectors to identify opportunities levels of physical activity in communities (surveil- to promote physical activity within the workplace lance), and monitor the implementation of public and throughout society. health approaches to promoting active lifestyles (evaluation). Parks, Recreation, Fitness, and Sports STRATEGY 1: Promote programs and facilities where Education people work, learn, live, play and worship (i.e., STRATEGY 1: Provide access to and opportunities for workplace, public, private, and non-profit recre- high-quality, comprehensive physical activity pro- ational sites) to provide easy access to safe and grams, anchored by physical education, in pre-kin- affordable physical activity opportunities. dergarten through grade 12 educational settings. Ensure that the programs are physically active, Mass Media inclusive, safe, and developmentally and culturally STRATEGY 3: Develop consistent mass communica- appropriate. tion messages that promote physical activity, have STRATEGY 5: Provide access to and opportunities for a clear and standardized “brand,” and are consis- physical activity before and after school. tent with the most current Physical Activity Guide- lines for Americans. Health Care STRATEGY 5: Sequence, plan, and provide campaign STRATEGY 1: Make physical activity a patient “vital activities in a prospective, coordinated manner. sign” that all health care providers assess and dis- Support and link campaign messages to commu- cuss with their patients. nity-level programs, policies, and environmental STRATEGY 3: Use a health care systems approach to supports. promote physical activity and to prevent and treat Transportation, Land Use, physical inactivity. and Community Design STRATEGY 4: Reduce disparities in access to physical activity services in health care. STRATEGY 3: Integrate land-use, transportation, com- munity design and economic development plan- STRATEGY 5: Include physical activity education in the ning with public health planning to increase active training of all health care professionals. transportation and other physical activity.
173 174 Hobbs Vinluan
STRATEGY 4: Increase connectivity and accessibility identified in the National Physical Activity Plan that to essential community destinations to increase promote physical activity. active transportation and other physical activity. STRATEGY 2: Convene multi-sector stakeholders at lo- Volunteer and Nonproft Sector cal, state, and national levels in strategic collabora- tions to advance the goals of the National Physical STRATEGY 1: Advocate to local, state and national Activity Plan. decision makers for policies and system changes
ommunity-based organizations play a nity organizations to ensure that healthy living Ccrucial role in providing opportunities is within reach of the people who live in those for individuals to engage in physical activity. communities. Ys that are engaged in Y-USA’s Thousands of organizations provide not only Healthier Communities Initiatives (Pioneering venues for physical activity but also programs Healthier Communities; statewide Pioneering that support physical activity. The YMCA is one Healthier Communities; and ACHIEVE) are of these organizations; it is the largest nonproft creating active communities by using Complete provider of youth sports and after-school activi- Streets initiatives to make streets safer for all ties in the United States. users; developing safe routes to schools to give The Y is helping to improve the nation’s parents peace of mind when their kids walk health and well-being through efforts to pro- to school; working with schools to increase mote community-based healthy living and pre- physical education and physical activity during vent chronic disease. The Y is influencing and the school day; and conducting many related motivating positive lifestyle behavior changes activities. among children, adults, and families who need Y-USA’s Healthier Communities Initiatives ongoing support to make healthy living a reality (HCIs) engage community leaders, convened by in their lives. Local YMCAs accomplish this by local YMCAs, in policy, systems, and environ- creating opportunities for individuals, families, mental change efforts that support and promote and communities nationwide to make and sus- healthy lifestyles. These initiatives empower tain healthier choices. local communities by providing them with The Y is strengthening communities through proven strategies and models to create and sus- youth development, healthy living, and social tain positive, lasting change for healthy living. responsibility. For nearly 160 years, YMCAs have The chief strategic objectives of these initia- helped improve physical, social, emotional, and tives include the following: spiritual health and well-being for millions of people in diverse communities across the • Communicating the importance of a United States. Today, YMCAs continue to pro- healthy lifestyle mote healthy living by providing people with • Building relationships within communities the support they need to take control of their by focusing on the leading health issues health. YMCAs not only are changing the way facing the United States they work inside their facilities to influence • Strengthening the capacity for coalition and motivate individuals and families to make building in communities positive changes but also are working in their • Attracting a new set of volunteers to the communities to support approaches that help effort to build a healthy community people overcome barriers to healthier living. • Increasing the community’s ability to pro- mote policy and environmental changes Program Description that encourage and support healthy living In nearly 200 communities across the United Y-USA’s Healthier Communities Initiatives States, Ys are collaborating with other commu- include three distinct initiatives: Pioneering YMCA of the USA’s Healthier Communities Initiatives 175
Healthier Communities, Statewide Pioneering the National Recreation and Park Association, Healthier Communities, and ACHIEVE. and Y-USA. Several key efforts undergird all three initia- Pioneering Healthier Communities tives: Pioneering Healthier Communities (PHC, • High-level community leaders are involved launched in 2004) focuses on local YMCAs’ at every step, using their positions, influ- engagement with community leaders, working ence, and ability to make changes within together to create an environment that promotes their organization and the greater com- health and developing policies that promote and munity. sustain healthy changes. With support from • Multiple sectors and diverse organizations the Centers for Disease Control and Prevention are involved to maximize experience, (CDC) and corporate and foundation donors, assets, resources, and skills. more than 100 communities are participating in PHC. • Participating organizations work to influ- ence policy and environmental changes to Statewide Pioneering Healthier improve community environments. Communities • Local initiatives are organically grown, with strategies specific to the needs of Y-USA received funding from the Robert Wood each community. Johnson Foundation (RWJF) to launch a state- • YMCA serves as convener in the com- wide PHC policy change initiative at the local munity and co-leads the initiative with and state levels in six states and 32 communities partner organizations. over five years, starting in 2009. This initia- tive addresses the childhood obesity epidemic By September 2011, 190 YMCAs and their through policy and environmental changes that communities were participating in these ini- will have implications for communities, states, tiatives. Participating communities include a and the nation. The work is taking place in variety of sizes (urban, suburban, rural), hard- Connecticut, Illinois, Kentucky, Michigan, Ohio, to-reach populations (low-income, underserved, and Tennessee. and racial and ethnic minority populations), and geographic areas. Action Communities for Health, HCI sites are selected through a competitive Innovation, and Environmental application process. Preference is given to com- munities with demonstrated capacity to engage Change in policy change work and a proven history The Action Communities for Health, Innova- of collaboration with multiple sectors of their tion, and Environmental Change (ACHIEVE) community. For example, applicants that have initiative was launched in 2008 to support local engaged in policy change work in one school health departments and YMCAs in advancing and now want to address policy change with community leadership in the nation’s efforts the entire school district would be considered to prevent chronic diseases. ACHIEVE was competitive applicants. Communities that are inspired, in part, by YMCA of the USA’s PHC selected to participate in an HCI initiative are initiative. The goals of ACHIEVE are to build on supported by Y-USA through a variety of learn- the success of PHC and to formalize the rela- ing experiences. The leadership team of each tionship between YMCAs, local and state health community receives technical assistance to departments, parks and recreation departments, learn about innovative strategies to influence and other community-based organizations. policy, systems, and environmental (PSE) ACHIEVE is supported by the CDC and is a changes. Each community team learns how to partnership between the National Association engage community members, develop a shared of Chronic Disease Directors, the National vision, and design and implement a community Association of County and City Health Officials, action plan. 176 Hobbs Vinluan
The HCI model consists of the following key department data as well as GIS (Geographic actions by a Y and a partner coach: Information Systems) and U.S. census data. By gathering and analyzing these data, Ys and • Build a multisectoral community leader- their partner agencies can prioritize the needs ship team. of the community, inform the decision-making • Understand the importance of a policy process, and build awareness of opportunities approach to community change. within the community. • Conduct a community assessment to A community action plan is designed to help understand community needs. capture the strategic directions for a leadership • Develop a community action plan to create team and provide a way for coaches to track policy and environmental changes that and monitor progress in the team’s PSE efforts. promote a healthier community. The community action plan is designed to be a living document and is meant to reflect shift- • Implement the community action plan. ing priorities for the team and capture shifts in • Evaluate progress and update plans based implementation timelines. on results. Each community team creates a community • Sustain the collaboration within the com- action plan that establishes the vision and mis- munity to generate more PSE changes. sion of the team, identifies specific efforts to increase opportunities for physical activity, lays Y-USA provides funding and technical assis- out action plans for accomplishing these objec- tance to each community leadership team to tives, and identifies strategies for measuring ensure that the community accomplishes its the objectives. Community action plans focus goals. YMCAs participating in HCI initiatives on a variety of sectors and a number of policy receive funding for planning, traveling to meet- interventions, equally divided between physical ings, and implementing the activities identified activity and healthy eating focus areas. in their community action plans. The exact makeup of each community leader- ship team is different from community to com- Program Evaluation munity. Typically, members of the leadership team come from schools, after-school programs, HCI communities and states move through five public agencies, and private industry. Com- steps that improve health outcomes. munity leadership teams are very deliberate in • Step 1: HCI communities and states build considering who is included on the team. their capacity to effect change by building a An essential component of the technical high-functioning and multisectoral leadership assistance that Y-USA provides to local com- team. munity teams is the Community Healthy Living • Step 2: Each team creates and implements Index. This tool was developed to measure a plan and makes PSE changes that promote opportunities for physical activity and healthy healthy eating and active living. eating for an entire community, including after- school child care sites, early childhood pro- • Step 3: PSE changes lead to environmental grams, neighborhoods, schools, work sites, and improvements that support healthy eating and the community at large. Communities that use physical activity. this index indicate that it helps them focus their • Step 4: Individuals increase healthy eating efforts, strengthen or create partnerships, build and active living behaviors. consensus, and gain early wins. In addition to • Step 5: Individuals attain improved health. the Community Healthy Living Index, many other data collection processes are available to Through Healthier Communities Initiatives, help communities in their assessment activities. community leaders from public health, govern- Typically, these include city or county health ment, education, business, and philanthropy YMCA of the USA’s Healthier Communities Initiatives 177 can work together to plan and implement poli- In schools and after-school programs, HCI cies that support healthy living, such as these: communities advanced 3,223 changes designed to promote physical activity • Increasing access to and use of attractive before, during, and after the school day: and safe locations for physical activity • 1,261 after-school sites added physical • Developing supportive environments to activity or increased the amount of complement and support individual and physical activity they provide. family efforts to make healthy decisions • 172 schools added or enhanced a Safe • Providing all students with adequate Routes to School program. opportunities for physical activity before, • 618 schools added or improved physi- during, and after school through recess, cal education criteria. intramural activities, and other offerings • 594 schools instituted classroom physi- • Influencing work site policies and imple- cal activity breaks during the day. menting work site wellness programs • 242 schools added or expanded recess • Influencing policies such as requiring during the day. sidewalks and countdown cross signals in • 336 sports-related programs were neighborhoods and ensuring that school added to the after-school setting. food contracts include more fruits and In commercial work sites, HCI communi- vegetables and whole grain foods ties advanced 2,091 changes that helped • Reducing the disparities in health and employers incorporate healthier food and access to opportunities for physical activ- beverage options or expand opportunities ity and healthy eating in low-income for physical activity into their work sites: communities • 386 work sites improved vending options. In a recent survey of 91 of Y-USA’s HCI sites, local leaders reported that they influenced • 368 work sites improved food choices 14,459 changes to support healthy living within available in meetings. their communities, affecting 34.3 million lives. • 866 work sites incentivized their Following are some of the highlights related employees to engage in physical activ- to physical activity interventions from this ity or nutrition education. survey: • 211 work sites promoted commuting options that include physical activity. Leaders advanced 318 strategies and encour- • 260 work sites promoted physical activ- aged changes in the physical environments ity breaks during the workday. of their neighborhoods to provide greater access to physical activity, including creat- In community-based organizations and public ing the following: agencies, HCI communities advanced 1,277 changes that helped incorporate healthier • 112 sidewalks designed or improved to food and beverage options or expanded increase physical activity options opportunities for physical activity into their • 71 traffic safety improvements or settings: enhancements to increase physical • 218 organizations and agencies activity options improved vending options in their • 52 “complete streets” that are open work sites. and accessible to all users, including • 343 organizations and agencies bicyclists, pedestrians, and people with improved food choices available in disabilities meetings. 178 Hobbs Vinluan
• 239 organizations and agencies incen- Specifically, sites are engaging in policy, tivized their employees to engage in systems, and environmental changes in each physical activity or nutrition education. of the National Physical Activity Plan sectors. • 238 organizations and agencies pro- Following are examples of some of the strategies moted commuting options that include that HCI sites are pursuing: physical activity. Public Health • 239 organizations and agencies pro- • Strategy 3: Engage in advocacy and policy moted physical activity breaks during development to elevate the priority of physi- the workday. cal activity in public health practice, policy, The goal of the Healthier Communities Ini- and research. tiatives is to create long-term cultural shifts • Strategy 5: Expand monitoring of policy that promote health. Although it is too early to and environmental determinants of evaluate changes in health status, community physical activity and the levels of physical leaders should look for signs that HCI teams are activity in communities (surveillance), on course. Signs of early-stage success include and monitor the implementation of public these: health approaches to promoting active life- styles (evaluation). • New policies, systems, and environmental changes: These types of changes are being Education put into place across virtually all HCIs. • Strategy 1: Provide access to and oppor- Many of these changes have a strong tunities for high-quality, comprehensive research basis to suggest that they will physical activity programs, anchored by produce lasting behavioral changes that physical education, in pre-kindergarten lead to health improvements. through grade 12 educational settings. • Behavioral change and health outcomes: A Ensure that the programs are physically large number of HCI teams are measuring active, inclusive, safe, and developmentally and observing behavior changes in favor and culturally appropriate. of healthy living. To support behavior • Strategy 5: Provide access to and opportu- changes, HCI sites are working to make nities for physical activity before and after the healthy choice the easy choice. school. • Growth of collaborative culture: Although this is difficult to measure, signs indicate Health Care that a truly collaborative culture is starting • Strategy 1: Make physical activity a patient to form across the traditional community “vital sign” that all health care providers sectors that typically focus only on their assess and discuss with their patients. own agendas. Evidence includes height- • Strategy 3: Use a health care systems ened community engagement, increased approach to promote physical activity and cooperation among partners, and renewed to prevent and treat physical inactivity. interest by involved organizations to • Strategy 4: Reduce disparities in access to strengthen community. physical activity services in health care. • Strategy 5: Include physical activity edu- Linkage to National cation in the training of all health care Physical Activity Plan professionals. HCI communities are engaging in hundreds of Business and Industry policy interventions, many of which align with • Strategy 1: Identify, summarize, and the National Physical Activity Plan. disseminate best practices, models, and YMCA of the USA’s Healthier Communities Initiatives 179
evidence-based physical activity interven- strategic collaborations to advance the tions in the workplace. goals of the National Physical Activity Plan. • Strategy 2: Encourage business and indus- try to interact with all other sectors to Tips for identify opportunities to promote physical activity within the workplace and through- Working Across Sectors out society. During eight years of working to engage com- Parks, Recreation, Fitness, and Sports munities in the Healthier Communities Initia- • Strategy 1: Promote programs and facilities tives, Y-USA leaders have identified practices where people work, learn, live, play and that are the key to implementing this model worship (i.e., workplace, public, private, successfully: and non-profit recreational sites) to provide 1. Start with a shared, compelling vision and easy access to safe and affordable physical spirit of inquiry: Like others involved in col- activity opportunities. laborative efforts, HCI teams have found that Mass Media identifying shared values and creating a com- • Strategy 3: Develop consistent mass com- pelling vision provide a strong foundation upon munication messages that promote physi- which they can address subsequent opportuni- cal activity, have a clear and standardized ties and challenges. By developing an end goal “brand,” and are consistent with the most that is bigger than the goal any organization or current Physical Activity Guidelines for group can achieve on its own, HCI teams open Americans. a door to new, often unexpected, opportunities for learning and collaboration. • Strategy 5: Sequence, plan, and provide campaign activities in a prospective, coordi- 2. Adapt to emerging opportunities: Given nated manner. Support and link campaign the speed at which the world changes around messages to community-level programs, us, most detailed plans won’t remain relevant policies, and environmental supports. for very long. By developing a shared vision and an opportunistic mind-set, HCI leaders are Transportation, Land Use, and better able to adapt their efforts to emerging Community Design opportunities, while still staying on track. • Strategy 3: Integrate land-use, transporta- 3. Borrow from others and build your own: tion, community design and economic Believability is a big part of change. When development planning with public health people believe that the desired change is pos- planning to increase active transportation sible, they are more likely to help create the and other physical activity. change in their own communities. Many HCI • Strategy 4: Increase connectivity and acces- participants are inspired to move into action sibility to essential community destinations because they see what members of another to increase active transportation and other community have done and the results they physical activity. have achieved. 4. Engage cross-boundary leaders who care: Volunteer and Nonproft A key to the success of HCI teams has been their • Strategy 1: Advocate to local, state and ability to build cross-sectoral teams of action- national decision makers for policies and oriented community decision makers for whom system changes identified in the National community well-being is a core motivation. Physical Activity Plan that promote physi- HCI teams typically include leadership from cal activity. Ys, schools and academic institutions, govern- • Strategy 2: Convene multi-sector stakehold- ment agencies and elected offcials, hospitals, ers at local, state, and national levels in health insurance companies, public health 180 Hobbs Vinluan organizations, businesses, community- and Although there is no single model for orga- health-focused foundations, faith-based groups, nizing an effective HCI structure, these seven media, and other community sectors. common elements characterize the most effec- 5. Serve in multiple roles: HCI leadership tive ones. teams have discovered that the role the com- munity needs them to play varies over time, depending on the needs of a particular action Summary area. At different times, HCI teams may fnd Across America, innovative collaborations, such themselves serving as conveners, promoters, as Y-USA’s Healthier Communities Initiatives, policy advocates, educators, or implement- are adapting to the changing needs of their ers. Most have found this role versatility to be members and communities. Through changes essential, and they have found it important to in programming, staffing, and the physical envi- be clear about these roles with partners. ronment, Ys are seeking to foster and support 6. Use data to guide, not drive, the effort: HCI sustained relationships with individuals and sites use various types of data throughout their families who want to experience greater total process. However, they also recognize that HCI is health and well-being. As a result, members are about creating change, not collecting data. Having becoming more engaged and are having better limited time and resources means that data col- success reaching their goals. lection and analysis need to be focused primar- No single organization can effectively solve ily on identifying, understanding, and acting on the chronic disease crisis in the United States; strategic opportunities. Perhaps less important is YMCAs are leading a national movement to a traditional comprehensive needs assessment at mobilize communities to respond to this public the beginning of the process. How the data are health crisis. Collectively, all sectors of our collected and used depends on the availability of communities and nation must come together to the data, current understanding of issues among advance a common strategy to remove the bar- stakeholders, and the scope of the initiative. riers and increase the opportunities for physical 7. Develop leadership structures that distrib- activity for all. ute ownership and action: Leading an initiative Community organizations and local agen- with ambitious aims, limited staffng, and busy cies can connect with their local Ys to find out volunteers requires a well-designed structure whether they are engaged in Healthier Commu- and effective processes. The structure and nities Initiatives. If they are already involved, processes have a great infuence on how team organization leaders can ask to be included on members use their talents and time and whether the leadership team to complement its efforts they stay engaged. In some cases, HCI teams to make policy changes to create a healthier are designed to complement the structure of community. In communities that are not yet existing initiatives, and in other cases they work participating in HCI, community organizations more independently. can encourage their local Ys to get involved. CHAPTER 22 Professional Sport Venues as Opportunities for Physical Activity Breaks The San Diego Padres’ FriarFit Instant Recess
Antronette (Toni) K. Yancey, MD, MPH Sally Lawrence Bullock, MPH UCLA School of Public Health University of North Carolina Gillings School of Global Public Health
Portia Jackson, DrPH, MPH Mariah Lafleur, MPH UCLA School of Public Health The Sarah Samuels Center for Public Health Research & Evaluation David Winfield, BA Sarah Samuels, DrPH San Diego Padres The Sarah Samuels Center for Public Health Research & Evaluation
Andrew Mowen, PhD Pennsylvania State University
NPAP Tactics and Strategies Used in This Program
Parks, Recreation, Fitness, and Sports Sector STRATEGY 3: Use existing professional, amateur (Amateur Athletics Union, Olympics), and college STRATEGY 1: Promote programs and facilities where (National Collegiate Athletics Association) athlet- people work, learn, live, play and worship (i.e., ics and sports infrastructures and programs to en- workplace, public, private, and nonprofit recre- hance physical activity opportunities in communi- ational sites) to provide easy access to safe and ties. affordable physical activity opportunities.
ew Americans participate in physical sedentary to signifcantly active. Changes in Factivity at recommended levels, and most policies and practices within a broad range Americans do not enjoy the many benefts of of institutions and organizations may help to a physically active lifestyle. Children are not expand opportunities for physical activity (Mit- exempt from this trend, and many experts telmark 1999). believe that societal norms must shift if we Regular and sustained participation in are to arrest the epidemic of childhood obesity physical activity may be enhanced by making (Institute of Medicine 2004, 2006, 2009). New physical activity the default option, or path of and innovative ways to reengineer physical least resistance, requiring people to consciously activity back into daily life will be needed to avoid physical activity, or “opt out.” Integrating shift the American paradigm from primarily short activity bouts into organizational routine
181 182 Yancey, Jackson, Winfield, Bullock, Lafleur, Samuels, and Mowen is such an “active by default” policy, one that media messages that promote physical activity, incorporates experiential learning and facili- (4) spectator physical activity experiences drive tates fitness conditioning in an organization’s attendance and fosters experiential learning, normal routines and practices. This type of and (5) teams can continue their tradition of policy has been implemented across a number youth-targeted philanthropic involvement by of settings, including work sites, schools, and promoting physical activity for young fans. religious institutions. The activity bouts (typi- cally 10 minutes or less) have taken the form of brief aerobic routines held during meetings Program Description or events or at certain times during the day, The FriarVision Fitness Fanatics Initiative (Fri- walking meetings, and restrictions on nearby arFit) is a multiyear healthy food and physical parking and elevator use. Engaging captive audi- activity initiative developed by the San Diego ences (i.e., those convened for other purposes) Padres and the California Endowment, in part- in structured group physical activity provides nership with the San Diego Childhood Obesity built-in social support and activates peer (social Initiative, UCLA, and SportService (Petco Park conformity) pressure, a strategy that relies less concessionaire) (The Sarah Samuels Center on individual initiative and motivation than do for Public Research & Evaluation 2009). In traditional “pull” strategies (e.g., gym member- response to the alarming increase in childhood ship subsidies, exercise classes, on-site fitness obesity, FriarFit’s long-term goal is to improve and shower facilities). the health of all San Diegans through collab- One example of an intervention that focuses orative community efforts to improve physical on short bouts of physical activity is Instant activity and healthy eating in schools and by Recess (IR), an evidence-based, technology- providing appealing opportunities for physical driven approach designed to integrate enjoyable activity and healthier food and beverage options 10-minute group physical activity breaks into the at the ballpark. Working with schools and the routine daily conduct of business. Instant Recess community, FriarFit aims to create momentum aims to create a fitness-promoting cultural and for widespread changes in sociocultural norms, social norm change and render prolonged sitting policies, and practices that will contain and as socially unacceptable as drinking and driving ultimately reverse the obesity epidemic for all or smoking (Yancey 2009; Yancey et al. 2009). San Diego residents. Instant Recess break movements are simple and In collaboration with public health expert low impact, usually choreographed from sports Dr. Toni Yancey and the Professional Athletes or ethnic dance traditions and performed to Council, the Padres adopted IR as the primary music, and are captured on CDs and DVDs that physical activity component of FriarFit. The can be used in a variety of settings. The breaks team developed an IR break that was choreo- are scientifically designed to maximize energy graphed and set to original music (commis- expenditure while minimizing injury risk and sioned by an outside artist), with nine baseball perceived exertion, permitting individuals of dif- moves representing each of the nine innings in fering levels of fitness and agility to participate a baseball game (or nine players on the field). together (Yancey et al. 2004, 2006; Yancey 2010). The break is implemented during the pregame One of the more innovative applications of show at family-focused Sunday games and IR has been its use in sports arenas as pregame, other youth events, for example, as a warm-up time-out, and half-time entertainment. Profes- or cool-down during baseball clinics (Yancey sional sports organizations are natural allies et al. 2009). The featured moves include these: in the quest to increase physical activity, and 1. Batter on Deck (warm-up) sports arenas are natural settings for short-dura- tion physical activity breaks for several reasons: 2. Batter Up (1) athletes serve as high-profile models for fit- 3. Fast Ball ness, (2) communities identify with teams, (3) 4. The Wave teams and arenas provide opportunities to share 5. Foul Ball San Diego Padres’ FriarFit Instant Recess 183
6. Celebration start of the game, which gets spectators to the 7. Seventh Inning Stretch park early, an added benefit for the team. The Park in the Park area, a joint use venue with San 8. Grounder Diego County Parks and Recreation, is popular 9. The Ump (followed by a one-minute with families, as it features reduced admission cool-down) and serves as a place to meet Padres athletes Each move is simple, low impact, and easily and obtain their autographs in advance of the modified for individuals with limited mobility. game. As soon as the athletes depart, the Pad The routine is presented in a DVD produced Squad staff and the Friar mascot perform the by the Padres in cooperation with UCLA. The IR with children and their families. DVD features Dr. Yancey and Dave Winfield (a Major League Baseball Hall of Famer and School and Youth Program former Padres player, currently executive vice Outreach president and senior advisor for the team and an ESPN color commentator) leading youth in The Padres Foundation for Children hosted the break, with clips of Padres athletes demon- a launch press event to publicize FriarFit in strating moves or snippets of in-game footage April 2008, at the start of the baseball season. highlights. The duration is 10 minutes, with Schools and youth groups were invited, and free each move lasting for about a minute. transportation was provided. Free tickets are The Padres held training sessions at the ball- regularly offered to youth-serving organizations park to instruct teachers and other community throughout the season, providing additional partners to lead IR in various settings. The opportunities to expose children and program location served as an incentive for participa- staff to IR. Media coverage (traditional and tion, especially for PE teachers, who were often social) helped to increase both the popularity former athletes themselves. At the training ses- and draw of the pregame breaks as well as to sions, the rationale for the activity breaks and drive enthusiasm and interest in participating in implementation methods was presented, along IR in other venues. The breaks became a regular with data demonstrating the impact that activity feature during player visits to schools and other breaks can have on student health and class- public service appearances. room performance. The DVDs were originally In schools and after-school programs, FriarFit labeled with player images and stats in order leaders encourage teachers to play the IR CD or to serve as “trading discs,” similar to baseball DVD in the classroom between subjects, during trading cards, among students. However, rapid transitions such as settling children down after and unanticipated player turnover, even of fran- lunch, and during homeroom or recess periods. chise players, led to a more generic branding For example, the San Francisco Boys and Girls with the FriarFit logo. Clubs incorporated IR as a lead-in to its Power Hour study period. Implementation at the Ballpark Public and Private Sector Before the Sunday, family-focused home base- ball games and at special events, the FriarFit Partners of FriarFit IR DVD is shown on a large video scoreboard The San Diego Padres organization was one of in the “Park at the Park,” a general-use area of the first professional sports teams to embrace Petco Park, adjacent to the stadium. The Pad obesity prevention as a philanthropic goal. Inte- Squad (fan ambassadors and promotion team) gral to the Padres’ interest in partnering with helps to gather children and lead them in the the California Endowment (TCE) was a manage- break activities. ment decision that a focus on obesity prevention IR is advertised on all television monitors would better align the team’s community ben- throughout the park, along with a countdown, efit efforts with its identity as an organization and occurs approximately one hour before the grounded in healthy living (The Sarah Samuels 184 Yancey, Jackson, Winfield, Bullock, Lafleur, Samuels, and Mowen
Center for Public Research & Evaluation 2009). active. The Padres Foundation for Children hosts Team leadership also recognized the opportu- special events featuring IR: for example, the nity to enhance the fan experience and to profit launch of the national Let’s Move campaign in by “doing good” (Elder and Yancey 2009). TCE May 2011. The DVD is updated periodically to recognized the natural alignment of pro sports replace retired or traded players with talent on and kids’ fitness, and it funded and staffed an the active roster as video subjects. exploration of the feasibility of increasing physi- cal activity and access to healthy foods within the stadium. This study contributed to the pool Program Evaluation of evidence linking environmental and policy The California Endowment provided funding approaches to active living and healthy eating for an outside organization to evaluate FriarFit’s outcomes (The Sarah Samuels Center for Public accomplishments, challenges, lessons learned, Research & Evaluation 2010). The foundation and best practices. The evaluation provided an took an active role in convening and leveraging opportunity to demonstrate the unique impact support from public health experts to ensure of FriarFit as well as to assess the influence that FriarFit used the most effective educational, of its environmental and policy approach on policy, and environmental strategies to promote activity and eating behaviors. The evaluation fitness among ballpark patrons and the San used a multimethod design to measure Fri- Diego community (The Sarah Samuels Center arFit’s influence on outcomes such as changes for Public Research & Evaluation 2009). TCE to the Petco Park menu, integration of physical identified and hired an expert consultant (Toni activity into ballpark routine, and the effect of Yancey) to assist the Padres in developing the these changes on park patrons’ food purchases initiative. TCE provided funding that proved and activity levels. The evaluation also covered vital to expanding the reach of the initiative. the Padres’ organizational engagement and The UCLA School of Public Health created and business approach for promoting fitness and choreographed the FriarFit IR break, incorporat- the impact on school and community settings. ing evidence-based practices into the program- Qualitative and quantitative methods were used matic approach. The state health department’s to capture FriarFit’s challenges and value-added Network for a Healthy California and California results. The evaluation focused on three specific Project LEAN worked with schools and com- components of the initiative that were imple- munity programs to disseminate IR and encour- mented during the first phase of the FriarFit age participation in the FriarFit initiative. The rollout in the 2008 season: network also incorporated distribution of the CD and DVD as part of the Children’s Power • Engaging patrons (adults and children) in Play! campaign. 10-minute physical activity sessions (IR) in The FriarFit consultant, TCE staff, and Padres the open area at the ballpark (Park in the executives worked with SportsService, Petco Park), using the FriarFit theme, with play- Park’s concessionaire, to identify and introduce ers and fan ambassadors as role models 10 nutrient-rich food options, including sweet • Working with SportService (Petco Park pepper hummus with baked pita chips, grilled concessionaire) to offer a line of healthy veggie dogs and burgers on whole wheat buns, foods and beverages at the ballpark salads, yogurt parfaits, and fresh fruit cups. • Training local school staff and teachers to At the time of this writing, in September offer IR breaks to children using FriarFit 2011, the FriarFit initiative was completing its IR DVDs, to reach school children outside fourth season. The Pad Squad staff continues of the ballpark to conduct IR prior to each Sunday home game. Throughout the school year, the Pad Squad, and occasionally Padres players or executives, visit Process: Qualitative Assessment local schools to lead the breaks and distribute According to a survey conducted with Padres incentives that encourage youth to be more professionals and other key stakeholders, fan San Diego Padres’ FriarFit Instant Recess 185 participation in physical activity breaks was not the initiative’s community engagement activi- consistent, as fans were sometimes distracted ties, were not fully developed when the evalu- by other ballpark offerings while IR was taking ation was conducted. Stakeholders believed place. However, IR was well received overall that promotion of FriarFit and IR needed to be and helped to call attention to the Park in the coordinated across multiple departments within Park activity space while providing the Padres the Padres organization to maximize visibility organization with the unique opportunity to and recognition. Stakeholders recommended engage fans in fun and exciting activities during that IR be implemented and more aggressively games. One of the survey respondents stated, marketed throughout the stadium. It is really unique that [ball park patrons] can Outcome: Quantitative Assessment be a part of IR before the game and interact with people around them. This is what the A modified System for Observing Fitness ball park experience is all about. Instruction Time (SOFIT) tool was used to assess activity levels of individuals before, Another stakeholder was especially proud during, and after IR breaks that occurred before of the increase in children’s awareness and Sunday games in 2008 and 2009. The levels of interest in IR: physical activity during IR did not differ sig- nificantly from the baseline to endpoint obser- Kids now realize what’s going on and are vation, but there were differences in activity able to have fun with it. The day we had the YMCA groups out there was great too. levels at baseline and endpoint before, during, It was good to see the whole workout done and after IR and for those who were actively on a large scale. engaged in IR. For example, at endpoint the study found that activity equivalent to brisk Although instituting IR at the ballpark was walking occurred more during IR than before considered a significant accomplishment, full or after. The study also observed less sitting implementation of FriarFit’s environmental and lying down during IR than after (figure changes, particularly those related to marketing 22.1). Additionally, individuals engaged in IR and advertising in promoting the breaks and (actively paying attention and participating in
80%
60%
40%
Percentage of children Percentage 20%
0%
Brisk walk Very active Standing slow Unobservable Sitting lying down Activity level
= Before instant recess = During instant recess = After instant recess
Figure 22.1 Physical activity levels before, during, and after Instant Recess during endpoint observation. Reprinted, by permission, from Sarah Samuels Center for Public Health Research and Evaluation.
E5691/NPAP/fig22.1/458589/alw/r1 186 Yancey, Jackson, Winfield, Bullock, Lafleur, Samuels, and Mowen the activities ) were significantly more active Evidence Base Used than those not engaged in IR. On scale of 1 to 4 (1 = sitting, 4 = running), activity levels were During Program Development 2.22 for those who were engaged in IR versus IR breaks are scientifically designed to maxi- 1.82 for those who were not engaged. At end- mize energy expenditure while minimizing point, 80 percent of those who were engaged in injury risk and perceived exertion, permitting IR reached levels 3 or 4 (moderate to vigorous individuals of differing levels of fitness and physical activity), whereas only 17 percent of agility to participate together (Yancey et al. those who were not engaged reached the same 2004). Bouts of physical activity as short as 10 level of activity. These findings indicate that the minutes have been found to be more predictive activities during IR encouraged more individu- of overweight or obesity status independent of als in the Park in the Park area to be physically the accumulated volume of minutes engaged in active while the IR was occurring. exercise, which can have a substantial impact on largely sedentary populations (Troiano et Linkage to National al. 2008). Elementary school students in class- Physical Activity Plan rooms that engaged in Instant Recess for 10 minutes a day were found to have higher levels This approach addresses the following strate- of light to moderate physical activity than their gies and tactics of the Parks, Recreation, Fit- peers who did not participate (Whitt-Glover ness, and Sport Sector of the National Physical et al. 2011). Given that 38 percent of students Activity Plan. report that they do not take physical education Strategy 1: Promote programs and facilities classes at school, it is important to find alter- where people work, learn, live, play and worship native ways for youth to be active (Diamant et (i.e., workplace, public, private, and nonprofit al. 2011). recreational sites) to provide easy access to safe By having team athletes demonstrate base- and affordable physical activity opportunities. ball moves on the DVD, FriarFit leverages the Tactic: Provide programs in parks, recreation, influential capacity of role models to motivate fitness, and sports that are appropriate for youth to engage in healthy behaviors. A study individuals of both genders, diverse cultures, found that adolescents who listed an athlete abilities, developmental stages and needs and as a role model were twice as likely to report that have demonstrated positive physical activ- engaging in moderate to vigorous physical ity outcomes. activity as were their peers who did not report Strategy 3: Use existing professional, amateur having a role model (Yancey et al. 2011). Finally, (Amateur Athletics Union, Olympics), and col- FriarFit worked with a nutritionist from the lege (National Collegiate Athletics Association) Network for a Healthy California as well as with athletics and sports infrastructures and pro- SportsService to provide fans with the option grams to enhance physical activity opportunities of purchasing foods that meet recommended in communities. standards for fat, saturated fat, and daily caloric Tactic: Train athletes and sports manage- intake, in addition to traditional ballpark fare ment staff to deliver environmental and policy (Patringenaru 2010). interventions in addition to individual change interventions. Populations Best Served • Use sporting event venues as opportuni- ties for delivering messages and creating by the Program opportunities for active participation. IR initiatives could occur in a variety of com- • Use social marketing approaches to change munities beyond the Major League Baseball spectator sports culture and use it as a markets. Minor League Baseball, for example, lever to increase physical activity. includes 227 teams across the United States. San Diego Padres’ FriarFit Instant Recess 187
These Minor League games attract not only • Gain top management and executive lead- the core baseball enthusiasts but also families. ership buy-in. Parents bring their children to these venues to enjoy the atmosphere of excitement and antici- pation and to participate in promotional activi- Tips for ties offered during the games. Although FriarFit IR was implemented at a Major League venue Working Across Sectors (and in a large urban area), similar programs Initiatives involving public health entities could serve the 49 million people who attend and professional sports organizations are, in Minor League baseball games each year. essence, a form of community-based partici- patory research with a much more powerful Lessons Learned community partner (The California Endow- ment 2008; Yancey et al. 2009). True partner- Leadership from senior management helps to ing between these disparate sectors requires ensure the success of a program. Franchise strategic realignment of assets and strengths to leaders established the initiative as a priority realize the potential of this collaboration. Public and promoted it with the foundation, conces- health offers the content expertise or “game sionaire, and other partners. Dave Winfield’s plan,” while the business of sports provides hands-on involvement was pivotal to the sub- the dissemination skills to get the message out stance and success of FriarFit, and the decision and to engage the audience. This capitalizes to house the initiative under the umbrella of on corporate nimbleness and ability to speak the Padres Foundation for Children protected to people’s desires and aspirations versus their FriarFit when the team changed ownership. needs, as defined by health experts and often Academic and public health partners worked rejected by the intended audience. with the Padres to guide the development and Public health aims must be addressed in a implementation of the initiative in the ballpark way that is financially viable and fiscally sus- and other settings. As FriarFit unfolded, part- tainable (presumably an amalgam of product ners worked to increase the player-featured sales and other revenue, public and commu- advertising and the variety of FriarFit foods in nity relations value, and brand marketing). For the ballpark and to market and position IR in example, the profitability of FriarFit product a way that increased fan participation. When sales versus distribution of materials via the production of the DVD was delayed, this slowed Padres Foundation for Children as giveaways program uptake in settings outside of the ball- had to be assessed strategically, given the park, demonstrating that the DVD was a crucial associated overhead (the portion of revenues element of intervention exportability. required by players’ agents, contractors that pro- From the FriarFit experience, the Padres vided services within the stadium, and others). learned that a family-friendly physical activ- Consequently, FriarFit IR DVDs and CDs must ity break program is a good business practice be mass produced through mostly corporate that enriches fans’ overall ballpark experience. donations to the Padres Foundation for Chil- Teams and sports venues considering a similar dren, disseminated locally through the regular Instant Recess initiative should follow these activities of the foundation, and distributed to tactics: partners for dissemination beyond the team’s catchment area. • Clarify goals and objectives first. Ideally, the success of the public health effort • Embrace a long-term comprehensive would increase the corporate bottom line. Near- approach that builds on early success. term seed money (e.g., grant funding through • Encourage collaboration between public foundations or health care organization com- and private organizations to leverage munity benefit funds) ultimately should be resources. supplanted by public relations value-added and 188 Yancey, Jackson, Winfield, Bullock, Lafleur, Samuels, and Mowen
long-term private sector support—corporate Matthews, C.E., K.Y. Chen, P.S. Freedson, M.S. sponsorship, sales, and other revenues. Buchowski, B.M. Beech, R.R. Pate, et al. 2008. Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am. J. Epidemiol. Summary 167(7):875-81. Minor League Baseball Teams by Affiliation: http:// FriarFit provides a local model for collaboration web.minorleaguebaseball.com/milb/info/affilia- between professional sports and public health tions.jsp agencies to advance population physical activ- Minor League Attendance Analysis (2012): www.num- ity. However, to achieve broad-based success in bertamer.com/files/2012_Minor_League_Analysis. arresting the epidemic of childhood obesity, this pdf model must be scaled up on a national level, Padres FriarFit initiative: http://sandiego.padres.mlb. with the support and active participation of com/sd/community/friarfit.jsp athletes, sports leagues, foundations, corpora- tions, and elected and appointed government Sibley, B., R. Ward, T. Yazvac, K. Zullig, and J. Pottei- ger. 2008. Making the grade with diet and exercise. officials. Youth, families, and communities are Journal of Scholarship and Practice 5(2):38-45. ready. Bring it on! The African American Collaborative Obesity Research Network (AACORN): www.aacorn.org Additional The FriarFit Instant Recess® video: www.youtube.com/ Reading and Resources watch?v=aEvF3brYvb4 White House Childhood Obesity Task Force Report. Barr-Anderson, D.J., M. AuYoung, M.C. Whitt-Glover, 2010. Washington, DC: USDHHS. B.A. Glenn, and A.K. Yancey. 2011. Integration of World Stadiums. 2011. Stadiums in the United States. short bouts of physical activity into organizational www.worldstadiums.com/north_america/coun- routine: A systematic review of the literature. Am. tries/united_states.shtml J. Prev. Med. 40(1):76-93. Ya n c ey, A., N. Pronk, and B. Cole. 2007. Workplace Brownson, R.C., T.K. Boehmer, and D.A. Luke. 2005. approaches to obesity prevention. In: Handbook of Declining rates of physical activity in the United Obesity Prevention (pp. 317-47). S. Kumanyika and States: What are the contributors? Ann. Rev. Public R.C. Brownson, Eds. New York: Springer. Health 26(1):421-43. Yancey, A., J. Siegel, and K. McDaniel. 2002. Role Donnelly, J.E., J.L. Greene, C.A. Gibson, B.K. Smith, models, ethnic identity, and health-risk behaviors R.A. Washburn, D.K. Sullivan, et al. 2009. Physical in urban adolescents. Arch. Pediatr. Adolesc. Med. Activity Across the Curriculum (PAAC): A random- 156(1):55-61. ized controlled trial to promote physical activity and diminish overweight and obesity in elementary school children. Prev. Med. 49(4):336-41. References Honas, J., R. Washburn, B. Smith, J. Greene, and J. Diamant, A., S. Babey, and J. Wolstein. 2011. Adoles- Donnelly. 2008. Energy expenditure of the Physical cent Physical Education and Physical Activity in Activity across the Curriculum intervention. Med. California. Los Angeles: UCLA Center for Health Sci. Sports Exerc. 40(8):1501-5. Policy Research. Instant Recess: www.toniyancey.com/IR_Book.html Elder, S., and A. Yancey. 2009. San Diego Padres’ Fri- Keen’s Recess Is Back campaign to launch a Recess arFit: Lessons learned. Partnering with business to Revolution: http://recess.keenfootwear.com prevent obesity break-out session. Presented at the Knuth, A., and P. Hallal. 2009. Temporal trends in Grantmakers in Health Annual Conference, Long physical activity: A systematic review. J. Phys. Act. Beach, CA, April 1, 2009. Health 6(5):548-59. Institute of Medicine. 2004. Weight management: Mahar, M., S. Murphy, D. Rowe, J. Golden, A. Shields, State of the science and opportunities for military and T. Raedek. 2006. Effects of a classroom-based programs. Subcommittee on Military Weight Man- program on physical activity and on-task behavior. agement, Committee on Military Nutrition Research. Med. Sci. Sports Exerc. 38(12):2086-94. www.nap.edu/catalog/10783.html. San Diego Padres’ FriarFit Instant Recess 189
Institute of Medicine. 2006. Food Marketing to Children Whitt-Glover, M., S. Ham, and A. Yancey. 2011. Instant and Youth: Threat or Opportunity? Washington, DC: Recess®: A practical tool for increasing physical National Academies Press. activity during the school Day. Prog. Community Institute of Medicine. 2009. Local Government Actions Health Partnersh. 5(3):298-7. to Prevent Childhood Obesity. Washington, DC: Yancey, A., D. Grant, S. Kurosky, N. Kravitz-Wirtz, National Academies of Sciences. and R. Mistry. 2011. Role modeling, risk, and resil- Mittelmark, M.B. 1999. The psychology of social influence ience in California adolescents. J. Adolesc. Health and healthy public policy. Prev Med. 29(6 Pt. 2):S24-9. 48(1):36-43. Patringenaru, I. 2010. Healthy meals a home run for San Yancey, A., D. Winfield, J. Larsen, M. Anderson, Diego Padres: Baseball club and UC San Diego team P. Jackson, J. Overton, et al. 2009. “Live, Learn up to offer FriarFit menu at PETCO Park. This Week and Play”: building strategic alliances between @ UCSD: Your Campus Connection. http://ucsd- professional sports and public health. Prev. Med. news.ucsd.edu/thisweek/2010/06/07_Padres.asp 49(4):322-5. The Sarah Samuels Center for Public Research & Evalu- Yancey, A.K. 2006. Changing the sociocultural environ - ation. 2009. Findings from the FriarVision Fitness ment to promote physical activity: capitalizing on Fanatics Initiative (FriarFit) stakeholder interviews. cultural assets. Paper presented at the Society of 1222 Preservation Park Way, Oakland, CA 94612. Behavioral Medicine Annual Meeting, San Francisco, The Sarah Samuels Center for Public Research & CA, March 24, 2006. Evaluation. 2010. Findings from the evaluation of Yancey, A.K. 2009. The meta-volition model: Organi- the FriarVision Fitness Fanatics Initiative (FriarFit). zational leadership is the key ingredient in getting 1222 Preservation Park Way, Oakland, CA 94612. society moving, literally! Prev. Med. 49(4):342-51. The California Endowment. 2008. The San Diego Yancey, A. 2010. Instant Recess: Building a Fit Nation Padres’ FriarFit Initiative: Lessons learned and -- 10 Minutes at a Time. Berkeley, CA: University unlearned in developing strategic alliances between of California Press. professional sports and public health. 1000 N Alam- Yancey Antronette K, McCarthy William J, Taylor eda St, Los Angeles, CA 90012. Wendell C, Merlo Angela, Gewa Constance, Weber Troiano, R., D. Berrigan, K. Dodd, L. Masse, T. Tilert, Mark D, Fielding Jonathan E. 2004. The Los Ange- and M. McDowell. 2008. Physical activity in the les Lift Off: a sociocultural environmental change United States measured by accelerometer. Med. Sci. intervention to integrate physical activity into the Sports Exerc. 40(1):181-8. workplace. Preventive medicine, 38(6): 848-56.
Sector V Business and Industry
Nicolaas P. Pronk, PhD HealthPartners and Harvard School of Public Health
verall occupational physical activity in tinuous improvement. Despite their uniqueness, Othe United States has declined over the they all share a set of common principles. As past 50 years. In today’s workplace, many job you read the case studies, you will undoubt- tasks are characterized by prolonged periods edly notice that each organization paid close of sitting and other sedentary activities. Such attention to its program design. Common prolonged periods of low-intensity physical design principles include the importance of activity, often accompanied by static tension organizational culture, leadership support, a of large muscle groups, predispose workers set of comprehensive program options, multi- to musculoskeletal problems, upper-back and level interventions (from individual behavior neck pain, absenteeism, short-term disability, change efforts to environmental and policy reduced quality and quantity of work, overall solutions), program communications, program- work impairment, and excess health care costs. matic aspects relevant to the employees as well For these reasons, it behooves employers to as the company, and evaluation that allows for implement programs that improve the level of reporting of program impact and continuous physical activity among workers. improvement. However, for physical activity programs to be Resources that provide high-quality informa- adopted and sustained, they need to be designed tion on work-site-based studies and research to fit into the overall context of the workplace. are highly accessible. Examples include the They need to be sensitive to the culture of the Community Preventive Services Task Force, organization, be accessible and relevant to which regularly generates recommendations the participants, fit effortlessly into the daily on what works to promote physical activity workflow, address the psychological and physi- and health at the work site and presents these ological concerns of the workforce, and generate findings as part of the Community Guide (see positive impact in both the short and long term. www.communityguide.org). Other organiza- As such, physical activity programs need to be tions, such as the Cochrane Collaboration and an integral part of a company’s business strat- the National Institute for Health and Clinical egy and the overall efforts to promote health Excellence, provide similar reviews and reports. and well-being at the work site. Additional support for practitioners in promot- This section of the book presents six case ing physical activity and health at the work site studies that provide important insight into exists in such organizations as the International successful implementation efforts for health Association for Worksite Health Promotion (see improvement at the work site. The programs www.iawhp.org), an organizational affiliate of represent a wide variety of industries—from the National Physical Activity Plan. Although truck drivers to school systems to energy com- a lot of information is available on what may panies and health care organizations. Some effectively promote physical activity in the programs are newly designed; others celebrate work site, most of such information is based decades of successful implementation and con- on generalized knowledge, not necessarily
191 192 Business and Industry company-specific experiences. The goal of this It is my sincere hope that you will enjoy read- section is to provide field-based examples, prac- ing these stellar efforts conducted by organiza- tical advice, and deeper insight into successful tions that so graciously shared their experiences programs. The collection of stories presented in order to promote physical activity in our here more than delivers on that goal. companies and communities across the country. CHAPTER 23 Fit to Drive Integrated Injury Prevention, Health, and Wellness for Truck Drivers
Delia Roberts, PhD, FACSM Selkirk College
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector to promote physical activity and healthy lifestyles within the workplace and throughout society, giv- STRATEGY 1: Identify, summarize, and disseminate best practices, models, and evidence-based physi- ing particular consideration to efforts targeting low- cal activity interventions in the workplace. resource populations. STRATEGY 3: Educate business and industry leaders regarding their role as positive agents of change
he purpose of the Fit to Drive program is left the road, resulting in fatalities. Following Tto improve the health of drivers who haul those tragedies, Weyerhaeuser approached a logs from harvesting sites to the log yard; the science researcher who had helped the company intent is to decrease injury claims and increase develop other health and wellness programs. the safety of their driving. The company asked the researcher to develop an integrated health and safety program specifi- cally for log haulers, based on a sport science Program Description approach. The researcher conducted a study, Weyerhaeuser, a multinational corporation funded by the company, to evaluate the work- headquartered in Federal Way, Washington, place demands, physiology, and lifestyle of the was founded in 1900 and currently operates target population. After the study was initiated, in 10 countries. In recent years the company the British Columbia Forest Safety Council has begun to implement employee health and joined Weyerhaeuser in funding the program. wellness programs, and it has been interested First, company executives and the researcher for some time in developing an additional pro- presented the program proposal to company gram for drivers and heavy equipment opera- health and safety committees in two geo- tors in Canada and the United States. In 2009, graphical regions. In both regions, employees, the year preceding development of the Fit to the union, and management supported the Drive program, two drivers suffered coronary program. However, the union required that events while driving. In both cases the trucks multiple test sites be included to ensure that
193 194 Roberts all subregions of the company were engaged composition measures (Omron Model HBF- in the process. Although expanding the proj- 306CAN, Scarborough, Ontario). The project ect throughout the company allowed a much team interviewed drivers regarding injury and greater level of engagement, it also increased activity history, lifestyle preferences, and dietary the logistical complexity of the project. habits and helped each participant complete a The company then recruited 40 participants familiarization session of three to five trials of using a multistep process. Union and occupa- a reaction time and cognitive testing tool (Brain tional health and safety committee representa- Checkers software, version 3.01, Behavioral tives reported to their constituent drivers and Neuroscience Systems LLC, Springfield, Mis- encouraged them to consider enrolling in the souri), run on Palm Tungsten E2, Palm Inc., project. Approximately half of the volunteers Milpitas, California). The reaction time and came forward with this first call. The researcher cognition testing consisted of a battery of tests, then conducted short information sessions in including a simple stimulus response time as an effort to recruit additional participants. The well as more complex tasks that involved execu- remaining spaces were filled at those sessions. tive function, including interpretation of visual Hauling volumes for sites in Canada peak input, memory, and decision making. The test during months when the road surfaces are output consisted of reaction time, anticipatory frozen and are more resistant to damage by events, null events, number of correct scores, the very heavy loads on road beds. As a result, and a calculated compilation score that includes data collection at the Canadian test sites was both accuracy and speed, called throughput carried out in January 2011. Data were collected (TPut). in Washington and Oregon in April 2011. Reaction time and cognition (RTC) data, The participant orientation and demographic symptom inventory, and blood glucose levels data collection session began with a step- were measured on two successive workdays by-step review of the informed consent form with similar driving conditions. When drivers with each participant. This was of particular reported to the testing site following an eight- importance because most participants had not hour fast, project staff weighed them, attached a gained a good understanding of the details of heart rate and activity monitor (Actiheart, Mini- the project from the recruitment process. Several mitter, Bend, Oregon), and conducted the first participants were very concerned about confi- glucose and RTC testing session (fasting). On dentiality, and many were initially suspicious the first day, drivers were instructed to follow of the project. Although improving health is their normal eating pattern, including breakfast. ultimately of great benefit to the individual, On the second day, drivers received a series of developing trust with the drivers was critical; small snacks that were prepared according to without this trust, the project team could not their food preferences but were designed to pro- implement changes designed to promote health vide approximately 200 calories every two hours and wellness. However, enforcement of regula- (60-65 percent carbohydrate, 15-20 percent tory requirements by the employer may create protein, 15-25 percent fat). On both trial days, a relationship that lacks trust. Addressing risk drivers reported for RTC evaluation, symptom issues (e.g., financial, medical), ethical con- inventory, and blood glucose testing every time cerns, and other culture-specific considerations they returned to the log yard, approximately was considered an absolute necessity in order every three hours for the duration of the work- to engage the group, especially considering the day (three times per day). Each time the drivers relatively poor level of health in the population. visited the testing site they spent approximately For this reason, the program developers did not half an hour with the researcher discussing their measure and record blood pressure as part of lifestyles, goals, concerns, and potential strate- the program evaluation. gies for making positive changes by increasing Each participant completed height, body physical activity and improving diet. At the final mass, body mass index, and estimated body testing session the heart rate and activity moni- Fit to Drive 195 tors were removed and subjects were weighed. minute, 5 ± 6 minutes between a heart rate The difference between morning and afternoon of 130 and 139 beats per minute, and only 4 weights was considered to be a measure of ± 5 minutes at a heart rate over 140 beats per hydration status. Drivers also underwent an minute, confirming the very low physical work exit interview to determine their perceptions of output during a day of driving. what they had learned by participating in the Two to four weeks following completion of data collection phase. the data collection for each group, a report of the As a group, the drivers were in very poor findings was sent to participating drivers, along health. Although the mean ± standard devia- with information about how the next phase of tion (SD) age was 45 ± 8 years, 95 percent of the program would be delivered. This commu- the drivers were overweight, including the 85 nication was intended primarily to maintain the percent who were obese (based on estimated drivers’ focus on the lifestyle changes initiated percentage body fat levels). The mean ± SD during the data collection phase. No formal estimated body fat was 30 ± 6 percent and counseling was provided to drivers to make any the mean calculated body mass index was 34 changes at that point; however, drivers were ± 5. Twenty-five percent of participants were encouraged to try some of the changes and to smokers. The mean ± SD fasting blood glucose stay in communication with the research team. was 128 ± 49 milligrams per deciliter, with 45 One month later, the research team conducted percent of the values exceeding the upper limit an additional follow-up by e-mail and phone. of normal. Ten percent of the drivers had fasting Although weight loss was not a targeted out- levels on both test days that were indicative of come of the project, 7 of the 40 drivers had lost undiagnosed diabetes (participants with known weight (an average of 20 ± 4 pounds) within diabetes were excluded from participation). two months by implementing what they had Blood glucose levels on the diet intervention learned about improving diet and increasing day were significantly lower (mean ± SD for activity during this early informational phase. the day = 104 ± 29 milligrams per deciliter) The next phase of the program produced a than on the day when drivers ate their normal set of training materials for the drivers that fit diets (mean ± SD for the day = 116 ± 45 mil- with their work culture and the unique situation ligrams per deciliter) (p < .0004). of their job. These materials included a pocket- The RTC data are unitless calculated values sized booklet titled Top Ten Tips to present key that normalize speed for accuracy; a higher physical activity and nutrition concepts simply score indicates a better performance. In all and clearly; a manual titled Power Driving, cases, performance was better (p < .02) on which included more in-depth information on the intervention diet day than on the day when how to increase physical activity levels and drivers consumed their normal food choices. make positive diet and lifestyle changes; and The average level of dehydration from a a series of double-sided laminated cards that day of driving was 1.8 ± 0.6 percent. Only focused on specific topics (Increasing Physical 12 percent of drivers reported engaging in any Activity, Choosing a Healthy Diet, and Saving physical activity on a regular basis. Ninety-five Your Back). percent of drivers experienced chronic pain; These materials were introduced to the 65 percent had back pain, 50 percent had knee participating drivers during safety meetings at pain, 45 percent had shoulder pain, 20 percent each site; attendance by spouses was optional. had ankle pain, 20 percent had upper extremity Each driver received a package with the train- pain, and 10 percent had neck pain. The mean ing materials and a customized report of his heart rate for 9.5 hours of driving was 89 ± 13 individual results. Program staff then conducted beats per minute. Drivers spent an average of one-on-one coaching sessions with the drivers only 16 ± 14 minutes between a heart rate of to set long- and short-term goals and create a 110 and 119 beats per minute, 8 ± 8 minutes specific action plan to achieve the first set of between a heart rate of 120 and 129 beats per short-term goals by the follow-up visit. During 196 Roberts the goal-setting process, drivers were directed included a Top Ten Tips and parent manuals toward specific focus areas such as losing for the nutrition and training programs, which weight, lowering blood pressure, decreasing were placed in the public domain (www.selkirk. blood glucose, and decreasing specific joint pain ca/treeplanting). Weyerhaeuser offered a fee- and were provided with information to help waived program delivery to all of its tree plant- them achieve their goals. Drivers learned how to ing contractors, and after four years the injury use the booklets to access more information on rates were reduced by an order of magnitude in each topic, including step-by-step instructions the operations that participated in the program. for making the changes and motivational tips The recordable incidents were so much lower in to support behavior change. these operations that the program was instituted As with the preliminary follow-up, the find- across Canada. In August 2011, the company ings at the time of the program launch were announced that it had achieved zero recordable surprisingly positive. Drivers who had begun incidents for the first time in Canadian history. to make lifestyle changes following the testing had been able to maintain their focus over the intervening six months, and other drivers were Linkage to National able to begin the process. Physical Activity Plan The final results of this program will not be available until after the publication date of this Fit to Drive supports these strategies of the book; however, these preliminary findings show Business and Industry Sector of the National that investigative, intervention-based work-site Physical Activity Plan: health and wellness programs can be extremely Strategy 1: Identify, summarize, and dissemi- effective at overcoming barriers to workers’ nate best practices, models, and evidence-based making positive dietary and physical activity physical activity interventions in the workplace. changes. Over the next year, the researcher and Data were collected on a representative group company management will monitor compli- of drivers and analyzed with sound scientific ance, injury, and illness rates and compare them principles, and the findings were used to to rates in similar operations within the forestry describe the health and lifestyle deficits of this sector that did not implement the program. population. The research findings then were used to develop a lifestyle program, designed to promote changes in diet and physical activ- Program Evaluation ity. The program is based on sport science and medical research findings and is focused on The Fit to Drive program is being implemented the interests and needs of the target popula- currently, but early results appear very promis- tion. The program will be placed in the public ing. Driver engagement is excellent, with a 94 domain, where it can be accessed by business percent fully committed participation rate. Early and industry. results for weight loss, behavior changes, and Strategy 3: Educate business and industry risk reduction indicators are all very strong. The leaders regarding their role as positive agents of program will be assessed by comparing injury change to promote physical activity and healthy and illness rates in the sites that receive the Fit lifestyles within the workplace and throughout to Drive program compared with similar-sized society, giving particular consideration to efforts operations that have not received the program. targeting low-resource populations. Industry and The concept behind the Fit to Drive program government groups have put into place a route is similar to that of the Fit to Plant program. for delivery of the program. The program will Eleven years ago, Weyerhaeuser and the same be announced through various industry publi- researcher developed the Fit to Plant program, cations and presented at a series of important which was based on a similar field study industry and government conferences, seminars with manual tree planters. That program also and workshops. Fit to Drive 197
Evidence Base Used (Lemaire et al. 2010) have shown that improv- ing eating patterns can stabilize blood glucose During Program Development levels and enhance reaction time and decision making. The incidence of occupational injuries and Another approach to injury prevention is illness in the transportation sector has been to reestablish joint and muscle reflexes that reported to be 8.2 claims per 100 person-years, protect against changes in loading of these tis- well in excess of the all-industry average of sues. Sport science techniques have been used 3.5 claims per 100 person-years for 1999-2008 with excellent results to reduce back pain and (WorkSafe BC 2009). In the United States, inju- protect against back, knee, and shoulder inju- ries in truck drivers account for nearly $900 ries (Roberts 2006, 2007, 2008, 2009). Sensory million and 15 percent of workplace fatalities motor programs have been shown to increase every year. Furthermore, when drivers are joint stability in sport injury rehabilitation piloting heavy loads on public highways, the (Caraffa et al. 1996; Hoffman and Payne 1995) human and financial cost of an accident can and to decrease work-related injuries in tree be greatly exacerbated. These statistics clearly planters (Roberts 2003, 2008, 2009) and heli-ski show that truck drivers in the logging industry guides (Roberts 2007). Proprioceptive recep- are in great need of techniques that can help to tors in muscle, tendon, and joint capsules are reduce costly accidents and injuries as well as responsible for coordinating muscular contrac- promote increased vigilance and good health. tion such that a joint is stabilized as the forces The link between vigilance and injury occur- applied to it increase. In a healthy system, rence has been established for other popula- muscle will contract within 10 milliseconds tions. The nervous system requires blood glu- of the beginning of an applied force, whereas cose for optimal performance, and when blood it requires approximately 50 milliseconds for glucose levels are variable or drop too low, the forces to reach peak levels. Unfortunately, attentiveness and decision-making capability these small proprioceptive nerve endings are can decline (Lemaire et al. 2010). Reaction time easily damaged, which slows the stabilization in response to an unexpected stimulus also is response or even leads to inappropriate muscle impaired (Lieberman et al. 2005; Stevens et recruitment patterns. Fatigue, vibrations, minor al. 1989; Strachan et al. 2001). Hypoglycemia injury, edema, inflammation, dehydration, has been shown previously to be a factor in and low blood glucose will reduce the speed motor vehicle accidents (Cox et al. 2000) and of response such that the pattern of muscle may contribute to the human error that has recruitment is slowed and is less likely to result been implicated in 80 percent of all aviation in stabilization of a joint prior to the develop- accidents (Li et al. 2002). Optimized nutri- ment of peak force in the joint. This leaves the tion can be used to sustain work output and joint very susceptible to injury. Fortunately, it concentration over extended periods of high is also relatively easy to reset the proprioceptive physical and mental stress with great success, reflexes; simple exercises can be used to relearn and these techniques can be used to improve the correct movement pattern and speed up the occupational health and wellness (Roberts reflex contractions that will stabilize the joint, 2005). For example, a nutrition and fitness irrespective of the other contributing factors program in the forestry (silviculture) industry (Roberts 2007, 2008, 2009). resulted in a reduction of injuries from 20 The current study with log haulers has percent to less than 2 percent and an increase documented eating patterns, blood glucose and in productivity of 12.5 percent. (Roberts 2003, vigilance levels, and physiological responses in 2008, 2009). Similar projects with mountain drivers during typical workdays. It repeated the guides (Roberts, 2007), tree fallers and buckers measures on days when blood glucose levels (Roberts and Donnelly 2007), helicopter pilots were stabilized through an eating regimen. (Roberts and Dinsmore 2008), and physicians Preliminary findings of the study have shown 198 Roberts that performance on a complex visual task business, and because the program combines improves when blood glucose levels are stable. financial gain (less cost associated with work- In addition, the study improved movements ers’ compensation) with social gain (improved and reflexes related to driving tasks. These health and wellness), it may attract national or findings should encourage both companies even international attention. and drivers to implement diet and physical The scientific aspect of the data can be pre- activity programs designed to improve driving sented in the educational sector by describing performance. programs in books and peer-reviewed publica- tions and linking the program to an educational site. For example, a previous study with forestry Populations Best Served (silviculture) workers called Fit to Plant estab- by Program lished a resource webpage that is hosted on the website of a postsecondary institution (Selkirk This program is suitable for all types of com- College), where it receives well over 15,000 hits mercial drivers, including long- and short-haul annually. The program is used as a case study truck drivers, bus and taxi drivers and couriers, by instructors in the forestry program, the health and heavy equipment operators. Many of these and human services programs, and the business occupations require long periods of time in the programs of the college. sitting posture with little opportunity to move and stretch. They also all require a high degree of concentration in the face of repetition and Lessons Learned monotony. Many of these occupations are not highly paid. For a program to be successful, it must become part of the culture of the organization. Workers will not give the program credence unless all Tips for levels within the organization, including unions Working Across Sectors and management, endorse it. Management must actively demonstrate that it is behind the In business and industry, the outcomes of a program in a meaningful way, proving support program for increased physical activity are in the form of time, money, and other aspects. placed into a very clear framework of profit Furthermore, the organization must repeat its versus loss. Profit and loss are easily reported endorsement consistently for at least four years and are of great interest to the media and edu- before a program becomes incorporated into the cational sectors. Thus, when the outcomes of culture of the organization. an industry-sponsored project are communi- Workers must feel respected throughout cated with the media and educational sectors, program implementation. Their concerns must the project gains a much larger audience than be validated or they will not be willing to con- would otherwise be possible. sider lifestyle changes. Part of this comes from For example, presenting at industry con- recognition by management regarding the effort ferences provides an opportunity to describe each worker makes to do his or her job well, and the program to the target audience. Typically part of it comes from the value that managers these conferences are attended by the editors and peers place on the program. The program of industry-specific publications who can then implementation team must be very aware of be approached to include articles about the this culture of respect and must foster it at all program in their newsletters and magazines. levels. The program must be contextually and Because the program is taking a very different culturally specific, and each worker should approach to a costly and difficult problem for believe that the program has been customized industry, it becomes newsworthy. Likewise, to meet his needs. Once workers are engaged local media are interested in the health of local in the program, the program staff must work Fit to Drive 199 to maintain focus and momentum throughout Lieberman, H., G. Bathalon, C. Falco, M. Kramer, C. the course of the program. Moran, and P. Niro. 2005. Severe decrements in Each participant, supervisor, and manager cognition function and mood induced by sleep loss, must receive an intrinsic reward from the pro- heat, dehydration, and undernutrition during simu- gram. The reward will be different for different lated combat. Biol. Psychiatry 57:422-9. levels and individuals within the organization, Roberts, D. 2003. Effects of physiological status of but it should be clearly identified, recognized, tree-planters on occupational injury and planting and encouraged at every opportunity. productivity and quality (pp. 1-29). Federal Way, WA : Weyerhaeuser Company, North American For- estlands Division. Additional Roberts, D. 2005. The occupational athlete: Fitness nutrition and hydration. Med. Sci. Sports Exerc. Reading and Resources Mini-symposium, Nashville TN. The program materials can be viewed at www.selkirk. Roberts, D. 2007. Fitness levels, dietary intake and ca/research/faculty/trucking/. injury rates in heli-ski guides [abstract]. Med. Sci. The tree planting program is available at www.selkirk. Sports Exerc. 39:S217. ca/treeplanting/ Roberts, D. 2008a. Case studies: a) biochemical evalua- Dinsmore, K., B. MacIntosh, and D. Roberts. Quan- tion of physical and mental stress in the workplace, tifying physiological workload of employees in a b) characterization of workload in the workplace, plywood processing mill. Appl. Physiol. Nutr. Met. and c) assessment of workload during manual timber Submitted. harvesting. In: Hard Work: Physically Demanding Occupations, Tests and Performance. B. Sharkey Lemaire, J., J. Wallace, K. Dinsmore, and D. Roberts. and P. Davis, Eds. Champaign, IL: Human Kinetics. 2011. Food for thought: An exploratory study of how physicians experience poor workplace nutrition. Roberts, D. 2008b. Efficacy of carbohydrate feeding on Nutr. J. 10:18. occupational injury rate and productivity in refores- tation workers in energy deficit [abstract]. Med. Sci. Roberts, D., and S. Donnelly. 2006. The fluid balance Sports Exerc. 40(5 Suppl. 1):S160. and sweat rates during manual timber harvesting [abstract]. Med. Sci. Sports Exerc. 38:S173. Roberts, D. 2009a. Efficacy effects of chronic consump- tion of electrolyte beverages by mill workers on markers of metabolic syndrome [abstract]. Med. Sci. References Sports Exerc. Suppl. Roberts, D. 2009b. The occupational athlete: Injury Caraffa, A., G. Cerulli, M. Proietti M, et al. 1996. Preven- reduction and productivity enhancement in refor- tion of anterior cruciate ligament injuries in soccer. estation workers. In: ACSM’s Worksite Health Knee Surg. Sports Traumatol. Arthrosc. 4:19-21. Handbook: A Guide to Building Healthy Companies Cox, D.J., L.A. Gonder-Frederick, B.P. Kovatchev, D.M. (pp. 309-16). 2nd ed. N.P. Pronk, Ed. Champaign, Julian, and W.L. Clarke. 2000. Progressive hypogly- IL: Human Kinetics. cemia’s impact on driving simulation performance: Roberts, D., and K. Dinsmore. 2008. Physiological Occurrence, awareness and correction. Diabetes profile and work load assessment of helicopter Care 23:163-70. pilots and ground crews working at Heli-ski lodges Hoffman, M., and G.V. Payne. 1995. The effects of pro- [abstract]. Appl. Physiol. Nutr. Metab. 33(Suppl. 1). prioceptive ankle disk training on healthy subjects. Stevens, A.B., W.R. McKane, P.M. Bell, P. Bell, D.J. King, J. Orthop. Sports Phys. Ther. 21:90-3. and J.R. Hayes. 1989. Psychomotor performance and Lemaire, J., J. Wallace, K. Dinsmore, A. Lewin, W. counterregulatory responses during mild hypoglyce- Ghali, and D. Roberts. 2010. Physician nutrition and mia in healthy volunteers. Diabetes Care. 12(1):12-7. cognition during work hours: Effect of a nutrition Strachan, M.W., I.F. Deary, F.M. Ewing, S.S. Ferguson, based intervention. BMC Health Serv. Res. 10:241. M.J. Young, and B.M. Frier. 2001. Acute hypogly- Li, G., L.P. Baker, M.W. Lamb, J.G. Grabowski, and G.W. cemia impairs the functioning of the central but Rebok. 2002. Human factors in aviation crashes involv- not peripheral nervous system. Physiol. Behav. ing older pilots. Aviat. Space Environ. Med. 73:134-8. 72(1-2):83-92.
CHAPTER 24 Instant Recess Integrating Physical Activity Into the Workday at Kaiser Permanente South Bay Health Center
Antronette (Toni) K. Yancey, MD, MPH Alison K. Herrmann, PhD UCLA School of Public Health UCLA School of Public Health
Tiffany Creighton, MPH Kaiser Permanente South Bay Health Center
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector Health Care Sector STRATEGY 1: Identify, summarize, and disseminate STRATEGY 3: Use a health care systems approach to best practices, models, and evidence-based physi- promote physical activity and to prevent and treat cal activity interventions in the workplace. physical inactivity.
aiser Permanente (KP) invests in promot- Program Description King physical activity at both the population level, through its community beneft initiatives, KP South Bay Health Center is a large urban and the individual level, through its clinical medical center located in Southern Los Ange- prevention services for patients and its work-site les County. One of 12 medical centers in the wellness program. One KP facility, South Bay KP Southern California Medical Group, the Health Center, seeking to augment and comple- KP South Bay facility employs 3,150 staff and ment its existing work-site wellness program, 428 physicians throughout its 65 departments. adopted Instant Recess (IR), an evidence-based During the first eight months of 2011, South strategy that integrates brief group activity Bay launched IR in 12 departments. In a stag- breaks into the everyday routine of the workday gered rollout, the center’s wellness coordinator during nondiscretionary time. IR breaks are sci- introduces IR and implements it in collaboration entifcally designed to maximize engagement, with unit-based teams (UBTs) that consist of enjoyment, and energy expenditure while mini- departmental employees and managers charged mizing injury risk and perceived exertion among with working to achieve department goals and the typical sedentary overweight employee. objectives. All departments that have adopted
201 202 Yancey, Herrmann, and Creighton
IR to date have adapted the activity to suit the center in 2010. Team leaders gained increased nature of their work environment and schedule confidence and comfort in leading IR by prac- as well as the preferences of their employees. ticing with new agents, who were training in Examples of the different types of departments a separate location, prior to leading IR breaks in which IR has been integrated successfully among existing call center staff. include the call center, the laboratory and The UBT decided to launch IR in a fashion pathology department, and an inpatient unit. similar to that of a movie premiere. Announce- Implementation in these departments is detailed ments, “Recess is coming January 20, 2011,” next. were posted throughout the call center. On the The call center was the first department to launch date, staff members were permitted launch IR at KP. The 85 agents employed in to wear workout clothes and were provided this department work four- to eight-hour shifts, with “goodie bags” containing healthy living during which nearly all time is spent seated, resources (e.g., pedometers, water bottles, and with little opportunity for physical activity. In fitness logs). The wellness coordinator and late 2010, prior to the launch of IR, the depart- several members of upper management were ment established as priorities lowering the high present for the IR launch, visibly and verbally rates of reported injuries and sick leave, issues signaling their enthusiastic and unqualified commonly experienced in call centers. support. IR was formally introduced to the call center The call center UBT has developed creative UBT at its November 2010 meeting. At that solutions to issues that arose following the time, team members were uncertain about the implementation of IR, including an increase feasibility of implementing IR in their depart- in hold times. The duration of IR was further ment, where the nature of the work dictates shortened from four to two minutes, and team that staff do not take breaks together as a group groupings were made more flexible so that (i.e., agents need to be available to accept employees on a call when their team began IR incoming calls). Additionally, middle managers could complete that call and join another team expressed concern regarding potential adverse for IR after the call had ended. consequences of IR for performance numbers Following the successful launch of IR in the and hold times. Staff members were concerned call center, upper management requested that about who would lead IR and whether other the wellness coordinator launch IR in the labo- employees would voluntarily participate. Ulti- ratory, a department that had recently experi- mately, the UBT agreed to consider ways to enced multiple significant changes, including implement IR prior to its next monthly meeting. a need for employees to reapply for their job Two months following the wellness coordina- positions, a move to a temporary space, shift tor’s introduction of the IR concept, in large part changes, new processes, new equipment, and attributable to strong support from upper man- a new computer system. Employee morale had agement, IR was launched in the call center. To suffered, and workplace injury reports had minimize the impact on performance and hold soared. times, the UBT decided to implement a rolling Lab managers were initially skeptical of IR IR, staggered such that each of the department’s and did not think that it would work for their eight teams conducted the breaks one at a time, large and busy department. Upper-management beginning at 10:30 a.m. and 3:30 p.m. each day. executives intervened, however, relaying posi- Team leaders worked with the wellness coor- tive changes experienced following adoption of dinator to create a shortened IR (4-5 minutes IR in the call center—a department with more vs. 10 minutes), allowing call agents to stand employees and less flexible work schedules than up, move, and stretch, with the goal of reduc- the lab. The wellness coordinator again chose to ing ergonomic strain, since ergonomic injuries implement IR with the help of the UBT, whose were the leading source of injury in the call members were enthusiastic about IR after she Instant Recess 203 Photo courtesy of Kaiser Foundation Health Plan, Inc. Foundation of Kaiser Photo courtesy Photo courtesy of Kaiser Foundation Health Plan, Inc. Foundation of Kaiser Photo courtesy
led them through a break. Staff reported that department than in the call center. Several their department was already set up for IR since lab staff requested to take turns leading IR the breaks could be incorporated at the end of and adapted the breaks to correspond to their two daily department huddles, during which personal and cultural preferences. Employees all areas of the lab stop work and provide an did the chicken dance, incorporated meringue update on their work status. Additionally, UBT dance moves, and choreographed moves to members were optimistic about the potential Michael Jackson’s “Beat It” (by far the most for IR to improve group cohesiveness in the lab. popular break). In addition to taking part in Since the entire lab was able to do IR together, the two regularly scheduled daily IR breaks energy and excitement levels surrounding held at the conclusion of staff huddles, lab staff implementation of IR were even greater in this reported using IR at other times to lower their 204 Yancey, Herrmann, and Creighton stress levels. For example, a clinical lab scientist used to capture changes in staff morale and commented that running a certain series of tests the working environment associated with IR as is time-sensitive and very stressful for her. Since reported by departmental managers and staff. IR implementation, she often announces to her Objective measures were used to assess changes team that an IR is needed after finishing the test in absenteeism and injury rates in relation to series to provide a fresh start before moving on IR implementation. to the next task. After launching IR in several additional and smaller outpatient departments, the wellness Subjective Measures coordinator decided to explore the feasibil- Since launching IR in the call center, managers ity of IR in an inpatient setting. Managers of have observed improvements in the depart- Unit 3000, an inpatient medical-surgical floor ment’s morale. On days that the leads forget that had employee attendance issues, were to start IR, the staff request it, and many staff approached to gauge their interest in IR. They members have reported that it helps them to were very supportive and passed the idea along manage their stress. During a recent Employee to the UBT. Although initially skeptical, after Assistance Program event at the call center, participating in an IR break the UBT enthusi- several staff members reported lower levels of astically agreed to adopt IR and nominated two stress since the launch of IR. charge nurses to lead the department activity. Management also has observed a change in Once again, the wellness coordinator worked morale and collaboration within the lab. Line with the UBT to fit IR into the departmental staff report that doing IR with their managers work schedule, ultimately settling on the end of has made them feel more connected and that the peak times (e.g., medication passing, change of managers seem more approachable. As noted shift) to avoid compromising patient care. Unit earlier, the laboratory was under construction 3000 decided to implement IR three times per and was to move to a new location in fall 2011; day, so that staff on each of the three shifts (day, a major concern of the staff when they met with evening, and night) would have an opportunity construction planners was that they wanted to participate. During the day and evening IR, their new space to allow them enough room available staff members gather around the to continue IR. As is typical for many scientific nurses’ station, inform the patients and visitors personnel, the lab staff tends to be quiet and that IR is about to begin, and invite them to introverted, which did not foster a collaborative join in—which often occurs. The department work environment. IR has brought the entire has made IR its own by starting breaks with team together, from management to lab assis- standard stretches and movements led by the tants, and promoted bonding. This department charge nurse and then asking each employee was recently asked to attend the Torrance Lead- to lead the group through free-style movements ership Conference, a training workshop for the of his or her choice. Recently, a patient being city’s business leaders. Four employees from the discharged joined IR and commented that she lab attended the conference and led the group had heard the music all week and was happy in a five-minute IR break to “Staying Alive.” It that she could finally participate, even while was considered the highlight of the day. Many seated in her wheelchair! business leaders said that IR was an easy and low-cost way to give their staff a boost in energy Program Evaluation and reduce their sick time and injury rates. There is ample evidence that Unit 3000 The impact of IR at the KP South Bay Health has perceived IR very positively. “I feel that Center was evaluated with both subjective and Instant Recess takes you out of the stress of the objective measures. Subjective measures were moment,” said one of the RNs, quoted in the Instant Recess 205 monthly KP newsletter. “You come back with recorded a 35 percent decrease in injury reports a new attitude and have a smile on your face.” among its 86 employees. Accepted claims have Seven large departments at the South Bay decreased from 18 to 12, again with no ergo- Health Center have implemented IR, and four nomic injuries reported since IR began. other departments are in the process of training Unit 3000 has experienced a significant and developing their work plan for IR. Leaders reduction in sick leave of 1.9 days per FTE (from of several regularly scheduled meetings now 6.2 to 4.3) compared with the same time period incorporate IR into those meetings, and the in 2010, and the unit has not had a workplace program has earned a slot on the agenda of the injury in the two months since implementing IR. monthly meeting of department administrators. At a recent meeting with approximately 100 volunteers for the medical center, staff incor- Linkage to the National porated IR into the meeting, following a period Physical Activity Plan of extended sitting. The mood in the room changed, and the activity sparked requests from KP’s approach bridges two of the NPAP’s sec- many of the volunteers that IR be incorporated tors: the Business and Industry Sector and the into their day on a regular basis. One older Health Care Sector. volunteer said that he volunteered in order “to Strategy 1: Identify, summarize, and dissemi- get out of my house and get up on my feet!” nate best practices, models, and evidence-based physical activity interventions in the workplace. Objective Measures Implementation of Instant Recess falls within Strategy 1 of the Business and Industry Sector. Each of the three large departments implement- Specifically, IR aligns with the tactics recom- ing IR for at least two months has documented mending that specific approaches be developed improvements in injury rates, absenteeism, or that appeal to work sites with large numbers both. Data retrieval and analyses were con- of lower-income and ethnic minority workers ducted jointly by each department director and and that key business and industry leaders play the wellness coordinator. central roles in influencing their peers (Pronk & Decreases in sick time and injuries have Kottke 2009). IR provides unique opportunities been observed in the eight months since the to model physical activity promotion by “walk- call center implemented IR. An evaluation of ing the talk” for patients, partners, grantees, and sick leave in 2010 compared with 2011, for the competitors (Boyle, et al. 2009). same pay periods, revealed that the call center Strategy 3: Use a health care systems approach experienced a decrease of 1.8 days per full-time to promote physical activity and to prevent employee (FTE) (from 7.5 to 5.7). Injuries, as and treat physical inactivity. IR implementa- reflected in accepted claims (those deemed tion resides in Strategy 3 of the Health Care legitimate by KP’s workers’ compensation Sector. The tactic most consistent with this KP department), have decreased from 3 in 2010 to 0 approach is the identification and evaluation during the same time period in 2011 among the of best practices for physical activity in health department’s 85 employees, with no ergonomic care, particularly those effective in population injuries reported since IR’s launch. segments at high risk of physical inactivity. The laboratory-pathology department has However, KP also builds on successful pro- seen substantive changes. This department did grams already in place to create a central role not previously have high absenteeism rates, for physical activity, in this case adopting an having met its goals in this area, and no change evidence-based model that influences socio- was apparent. However, a comparison of 2010 cultural norms and grants high visibility and and 2011 data showed that the department priority to physical activity. 206 Yancey, Herrmann, and Creighton
Evidence Base Used During (Troiano et al. 2008); (2) the modest amount of physical activity delivered by most workplace Program Development interventions—slightly more than 600 steps per day (Conn, et al. 2009); (3) the association of A growing body of evidence suggests that inter- monitored activity and compulsory participa- rupting prolonged periods of sitting and other tion with higher levels of adherence and greater sedentary behaviors, and increasing engage- effectiveness, particularly among the sedentary ment in moderate to vigorous physical activity, (Seymour, et al. 2004; PAGAC 2008); (4) emerging are necessary to promote well-being and prevent evidence of a link between moderate to vigorous chronic disease (Danaei et al., 2009; Owen et al., physical activity that is accumulated in bouts of 2009; Bankoski et al., 2011; Thorp et al., 2011). 10 minutes or more and body mass index and Workdays are associated with nearly one hour waist circumference (Strath, et al. 2008); and more of sitting than are nonwork days (McCrady (5) the potential of these models to deliver both & Levine 2009). In fact, the 50-year decline in individual and organizational benefits. occupational energy expenditure was recently equated to the caloric imbalance associated with the obesity epidemic (Church, et al. 2011). Populations Best Served Physical activity programs have typically by the Program been regarded as the “easiest sell” in worksite wellness (Batt 2009). However, even mature Workers lower in the organizational hierarchy and comprehensive work-site health promotion usually derive greater benefits from “active by programs have typically been less successful default” practices and policies than do manag- in influencing physical activity than other risk ers and executives (Yancey, Bastani, & Glenn indicators, such as tobacco use, dietary fat, 2007). Lower-level workers are at higher risk for and blood pressure (Soler et al., 2010; Henke inactivity and associated chronic illnesses and et al., 2011). In part, this may be attributable injuries, and thus small incremental changes to dismally low participation rates, particularly are more likely to produce health and economic among workers at higher risk of chronic disease, benefits. These workers also have less private and to approaches that use organizations as space and greater exposure to others, increasing staging venues for individually targeted edu- the influence of the social interaction sparked by cation and counseling rather than address the IR. Typical workplace culture dictates that good organizational infrastructure (Dishman et al., employees are those who are work-focused, that 1998; Mattson-Koffman et al., 2005; Beresford et is, “chained to their desks”; they arrive early, al., 2007; Yancey, Pronk, & Cole 2007; Robroek leave late, and remain tethered to their smart- et al, 2009). According to the National Business phones or tablet computers and laptops when Group on Health, the typical corporate “pull” traveling. Consequently, structured group activ- strategies that rely on individual motivation ity breaks tend to be more appealing to blue and (e.g., onsite fitness centers and classes, gym pink collar or lower-level administrative staff membership subsidies) are being abandoned by whose hours are closely supervised and con- many corporations, which consider these strate- trolled (e.g., workers who punch a time clock) gies to be costly and ineffective (Yancey 2010). than to “knowledge economy” workers who Emerging models of policy and environmental are paid to accomplish certain outcomes and intervention enhance regularity and sustain- have flexible schedules and decisional latitude. ability of participation by making short bouts of In addition, IR builds on such cultural assets activity the default option. The viability of these as dance, music and sports traditions, and col- models is predicated on (1) the very low aver- lectivist versus individualist community values. age adult physical activity levels (eight minutes Workplace physical activity promotion is per day) documented by objective monitoring particularly critical among less affluent work- Instant Recess 207 ers, given the obstacles of lack of discretionary job responsibilities and accountability. Individu- time (e.g., longer workdays and commutes), als across the organizational hierarchy were less decisional latitude, less flexible time sched- involved and actively demonstrated their sup- ules, more pressing basic priorities, and fewer port for IR as it was being launched at depart- resources for active leisure (Wolin, et al. 2008; ments throughout the health center. When Yancey 2010; Day 2006; Marcus, et al. 2006). In managers or leaders who were hesitant to begin 2008, 23 percent of whites in the United States IR in their departments presented roadblocks, reported no leisure activity, compared with 32 these roadblocks were easily managed when percent of blacks and 35 percent of Hispan- upper management communicated support for ics, respectively (CDC 2008). Thus, lowering IR to middle management. the “cost” of physical activity participation for As in many large organizations, each depart- workers by intervening on paid time is critical. ment within the Health Center has a unique Diffusion of active living practices in socioeco- climate, workflow, and schedule. With this in nomically and ethnically diverse populations mind, the wellness coordinator engaged each is more likely to occur at work than in other department UBT and provided technical assis- settings (Sorenson, et al. 2005). Spillover of tance and troubleshooting to encourage the activity breaks from work and school to outside team to take ownership of IR and select the best life has been documented (Yancey, et al. 2006; method by which to implement it. This collabo- Donnelly, et al. 2009). ration has allowed for ongoing modifications in IR that keep pace with changing departmental needs and staff preferences, such as shorten- Lessons Learned ing the breaks in the call center and sharing responsibility for choosing and leading activity KP South Bay Health Center provides an excel- among participants in the breaks on Unit 3000. lent example of important issues associated The importance of an energetic leader, or with successfully implementing and maintain- sparkplug, within each department was also ing IR. As the intervention spread throughout apparent. Having someone available, energetic, the medical center, the importance of factors and motivated to gather the staff, encourage such as involvement of individuals at multiple participation, and lead other staff members levels of the organization (i.e., upper manage- through movements proved to be a critical ment, middle management, supervisors and line component of IR’s success in a department. staff), clear and unwavering leadership support However, having only one sparkplug could jeop- and engagement, tailoring of the program to ardize the sustainability of IR within that depart- suit the needs of the organization and prefer- ment. Momentum may be difficult to maintain ences of employees, and the presence of readily if that person is out of the office (on sick leave identifiable and committed program champions or vacation), transfers out of the department, or (“sparkplugs,” in IR parlance) became increas- leaves the organization. Having a higher ratio ingly evident. Each of these factors has been of sparkplugs to staff members improves IR’s demonstrated in prior research to be critical to sustainability (Maxwell, et al. 2011). the success of IR and similar innovations (Barr- Finally, throughout the implementation pro- Anderson, et al. 2011; Hopkins, et al. 2012). cess, leaders at the health center have noted KP South Bay Health Center represents a a synergistic energy created by IR. As more “perfect storm” of the key elements needed to departments successfully launched IR and make IR work. The wellness coordinator, a well- demonstrated positive results, more managers connected and public health–trained employee, and staff have requested that IR be brought to selected IR as a possible solution to her orga- their departments. Initial levels of resistance nization’s challenges, and implementation and to IR expressed by departmental managers and evaluation of the program became a part of her staff have lessened significantly. In fact, a recent 208 Yancey, Herrmann, and Creighton
feature on IR in the KP Southern California routine: A systematic review of the literature. Am. employee newsletter and website resulted in J. Prev. Med. 40:76-93. five new requests from other departments for Batt, M.E. 2009. Physical activity interventions in the the wellness coordinator’s assistance in bringing workplace: The rationale and future direction for IR to their employees. workplace wellness. Br. J. Sports Med. 43:47-8. Beresford, S.A, E. Locke, S. Bishop, et al. Worksite study promoting activity and changes in eating (PACE): Tips for Design and baseline results. Obesity (Silver Spring). Working Across Sectors 2007;15 Suppl 1:4S-15S. Boyle, M., S. Lawrence, L. Schwarte, L. Samuels, and “Minimal intensity” intervention strategies may W. McCarthy. 2009. Health care providers’ perceived be particularly appealing to the vast majority role in changing environments to promote healthy of employers who, unlike KP, do not have the eating and physical activity: Baseline findings from will, resources, or capacity to implement com- health care providers participating in the healthy prehensive work-site wellness programs. Docu- eating, active communities program. Pediatrics mented return on investment in economic and 123(Suppl. 5):S293-300. health benefits is frequently cited by employers Centers for Disease Control and Prevention. 2008. US as a critical factor in their willingness to adopt Physical Activity Statistics: State Comparisons. brief group activity breaks, and this chapter Division of Nutrition, Physical Activity, and Obesity, illustrates the organizational benefits of IR to National Center for Chronic Disease Prevention and KP. This approach to increasing physical activity Health Promotion. Centers for Disease Control and is especially relevant to the health care sector, Prevention. Atlanta, GA. as KP is both an employer and a health care Church, T.S., D.M. Thomas, C. Tudor-Locke, P.T. delivery system. Katzmarzyk, C.P Earnest, et al. 2011. Trends over 5 decades in U.S. occupation-related physical activ- ity and their associations with obesity. PLoS One Additional 6:e19657. Reading and Resources Conn, V., A. Hafdahl, P. Cooper, L. Brown, and S. Lusk. 2009. Meta-analysis of workplace physical activity Instant Recess Products and Resources are available at interventions. Am. J. Prev. Med. 37:330-9. www.toniyancey.com. Danaei, G., E.L. Ding, D. Mozaffarian, B. Taylor, J. Toolkits for implementation of Instant Recess are avail - Rehm, C.J. Murray, et al. 2009. The preventable able at www.keenfootwear.com/recess. causes of death in the U.S.: Comparative risk assess- Details about the development and rationale of Instant ment of dietary, lifestyle, and metabolic risk factors. Recess are available in Yancey, T. 2010. Instant PLoS Med. 6:e1000058. Recess: Building a Fit Nation 10 Minutes at a Day, K. 2006. Active living and social justice: Planning Time. Berkeley, CA: University of California Press. for physical activity in low-income, black, and Latino This book is available from the publisher, in many communities. J. Am. Plann. Assoc. 72:88-99. Barnes & Noble and BooksAMillion stores, or online Dishman, R.K., B. Oldenburg, H. O’Neal, and R.J. at www.amazon.com or www.bn.com. Shephard. 1998. Worksite physical activity interven- tions. Am. J. Prev. Med. 15(4):344-61. References Donnelly, J.E., J.L. Greene, C.A. Gibson, et al. 2009. Physical Activity Across the Curriculum (PAAC): A Bankoski, A., T. Harris, J. McClain, R. Brychta, P. Case- randomized, controlled trial to promote physical rotti, K. Chen, D. Berrigan, R. Troiano, and A. Koster. activity and diminish overweight and obesity in 2011. Sedentary activity associated with metabolic elementary school children. Prev. Med. 49:336-41. syndrome independent of physical activity. Diabetes Henke R.M., R.Z. Goetzel, J. McHugh, and F. Isaac. Care 34:497-503. Recent experience in health promotion at Johnson Barr-Anderson, D., M. AuYoung, M. Whitt-Glover, B. & Johnson: Lower health spending, strong return on Glenn, and A. Yancey. 2011. Structural integration investment. Health Aff (Millwood). 2011;30(3):490- of brief bouts of physical activity into organizational 499. Instant Recess 209
Hopkins, J.M,, B.A. Glenn, B.L. Cole, W. McCarthy, Soler, R., K. Leeks, S. Razi, et al. 2010. A systematic and A. Yancey. 2012. Implementing organizational review of selected interventions for worksite health physical activity and healthy eating strategies on promotion. Am. J. Prev. Med. 38(2S):S237-62. paid time: Process evaluation of the UCLA WORK- Sorensen, G., E. Barbeau, A.M. Stoddard, M.K. ING pilot study. Health Educ Res. 27(3):385-398. Hunt, K. Kaphingst, and L. Wallace. 2005. Pro- Marcus, B., D. Williams, P.M. Dubbert, J.F. Sallis, A.C. moting behavior change among working-class, King, A.K. Yancey, et al. 2006. Physical activity inter- multiethnic workers: Results of the healthy direc- ventions: What we know and what we need to know. tions—small business study. Am. J. Public Health A statement from the American Heart Association. 95(8):1389-95. Circulation 114:2739-52. Strath, S.J., R.G. Holleman, D.L. Ronis, A.M. Swartz, Matson-Koffman, D.M., J.N. Brownstein, J.A. Neiner, and C.R. Richardson. 2008. Objective physical and M.L. Greaney. 2005. A site-specific literature activity accumulation in bouts and nonbouts and review of policy and environmental interventions relation to markers of obesity in US adults. Prev. that promote physical activity and nutrition for Chronic Dis. 5:A131. cardiovascular health: What works? Am. J. Health Thorp, A., N. Owen, M. Neuhaus, and D. Dunstan. Promot. 19:167-93. 2011. Sedentary behaviors and subsequent health Maxwell, A.E., A.K. Yancey, M. AuYoung, J.J. Guinyard, outcomes in adults. Am. J. Prev. Med. 41:207-15. W.J. McCarthy, and R. Bastani. 2011. Dissemina - Troiano, R., D. Berrigan, K. Dodd, L. Masse, T. Til- tion of organizational wellness practice and policy ertand, and M. McDowell. 2008. Physical activity in change: A mid-point evaluation of the L.A. basin the United States measured by accelerometer. Med. REACH US Center of Excellence in Eliminating Sci. Sports Exerc. 40:181-8. Disparities. Prev. Chronic Dis. 8(5) [serial online]. Wolin, K.Y., G.G. Bennett, L.H. McNeill, G. Sorensen, McCrady, S.K., and J.A. Levine. 2009. Sedentariness and K.M. Emmons. 2008. Low discretionary time as at work: How much do we really sit? Obesity a barrier to physical activity and intervention uptake. 17(11):2103-5. Am. J. Health Behav. 32:563-9. Owen, N., A. Bauman, and W. Brown. 2009. Too much Yancey, A. K. (2010). Instant recess: Building a fit sitting: A novel and important predictor of chronic nation 10 minutes at a time. Berkeley: University disease risk? Br. J. Sports Med. 43(2):81-3. of California Press. Physical Activity Guidelines Advisory Committee Yancey, A.K., R. Bastani, and B. Glenn. 2007. Racial/ (PAGAC). Physical Activity Guidelines Advisory ethnic disparities in health status. In: Changing the Committee Report. 2008. Washington, DC: U.S. U.S. Health Care System: Key Issues in Health Ser- Department of Health and Human Services. www. vices, Policy, and Management. 3rd ed. R. Andersen, health.gov/paguidelines/committeereport.aspx. T.H. Rice, and G.F. Kominski, Eds. San Francisco: Pronk, N.P., and T.E. Kottke. 2009. Physical activ- Jossey-Bass. ity promotion as a strategic corporate priority to Yancey, A.K., L.B. Lewis, J.J. Guinyard, D.C. Sloan, improve worker health and business performance. L.M. Nascimento, L. Galloway-Gilliam, A. Diamant, Prev. Med. 49:316-21. and W.J. McCarthy. 2006. Putting promotion into Robroek, S., F.J. van Lenthe, P. van Empelen, and A. practice: The African Americans Building a Legacy Burdorf. 2009. Determinants of participation in of Health organizational wellness program. Health worksite health promotion programs: A systematic Promot. Pract. 7:233S-46S. review. Int. J. Behav. Nutr. Phys. Act. 6:26. Yancey, A., N. Pronk, and B. Cole. 2007. Environmental Seymour, J.D., A.L. Yaroch, M. Serdula, H.M. Blanck, and policy approaches to obesity prevention in the and L.K. Khan. 2004. Impact of nutrition environ- workplace. In: Handbook of obesity prevention : mental interventions on point-of-purchase behavior a resource for health professionals. S. Kumanyika in adults: A review. Prev. Med. 39(Suppl. 2):S108-36. and R. Brownson, Eds. New York: Springer; 2007.
CHAPTER 25 ChooseWell LiveWell An Employee Health Promotion Partnership Between Saint Paul Public Schools and HealthPartners
Abigail S. Katz, PhD Terri Bopp, MPA HealthPartners and HealthPartners Institute Saint Paul Public Schools for Education and Research Richard O. Burmeister, III, BAS Suzanne P. Kelly, MS HealthPartners and Saint Paul Public Schools Saint Paul Public Schools Nicolaas P. Pronk, PhD HealthPartners, HealthPartners Institute for Education and Research, and Harvard University
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector to promote physical activity and healthy lifestyles within the workplace and throughout society, giv- STRATEGY 1: Identify, summarize, and disseminate best practices, models, and evidence-based physi- ing particular consideration to efforts targeting low- cal activity interventions in the workplace. resource populations. STRATEGY 4: Develop legislation and policy agendas STRATEGY 2: Encourage business and industry to in- teract with all other sectors to identify opportunities that promote employer-sponsored physical activity to promote physical activity within the workplace programs while protecting individual employees’ and throughout society. and dependents’ rights. STRATEGY 5: Develop a plan for monitoring and evalu- STRATEGY 3: Educate business and industry leaders regarding their role as positive agents of change ating worksite health promotion programs.
his chapter describes a multiyear com- by 2011, includes a variety of physical activity Tmunity partnership aimed at improving interventions. The program, titled ChooseWell the health and well-being of employees of the LiveWell, has resulted in sustained health Saint Paul Public Schools (SPPS) system in improvements among the more than 5,800 Minnesota. In partnership with HealthPartners, employees in the school district. a not-for-proft, member-governed integrated health system, SPPS implemented a worksite health promotion program that focused on cre- Program Description ating a culture of wellness among employees. The partnership, which began in 2005 with a The ChooseWell LiveWell program was devel- pilot program at 9 sites and expanded to 80 sites oped in partnership with HealthPartners in an
211 212 Katz, Burmeister, Bopp, Kelly, and Pronk effort to improve employee health and address given the choice of a $10 medical plan co-pay the affordability of health care for the SPPS reduction or a $100 lower deductible. Over district. The goal of the program is to cultivate time, the incentive evolved to a $20 medical a wellness culture within the school system for plan co-pay reduction or $200 deductible and a the purpose of improving employee health and $1,000 difference of the out-of-pocket minimum to model positive lifestyle behaviors for students between participants and nonparticipants. in the district. In the initial two years of the program, employees, retirees, and their covered spouses Saint Paul Public School System could participate in ChooseWell LiveWell. Beginning in the third year, and in subsequent As Minnesota’s second-largest school district, years of the program, COBRA members also SPPS consists of 64 schools with a total of 80 could participate. sites, more than 5,800 employees, and a diverse student body. The district is committed to the health and well-being of both employees and Implementation students. The ChooseWell LiveWell program was first implemented in 2005 across different seg- Employee Wellness Programs ments of the school system. District schools and offices were invited to participate through Effective health promotion programs include an application process. Requirements for a site multiple components, most notably an indi- to participate included a staff member desig- vidual health risk assessment and programs nated as a wellness champion, a functioning to support employee health. In each year of wellness committee, and a dedicated wellness ChooseWell LiveWell, the program has offered bulletin board. In the first year, nine sites were employees an online self-reported health assess- selected: three elementary schools, two middle ment as well as a variety of wellness program schools, two high schools, and two administra- options of varying lengths, ranging from eight tive buildings. weeks to a full calendar year (table 25.1). Many The program made an effort to connect and of the programs have been well received and are partner with other wellness programs within repeated annually; additional program offerings the school district, including one related to the vary each school year. More than one third of all Steps to a HealthierUS grant (Steps), which program offerings have focused specifically on focused on physical activity at the student physical activity. Other activities, such as those level. By leveraging the existing Steps network, related to stress management, often include a ChooseWell LiveWell was able to reach beyond physical activity component. the initial sites selected for the program. Beginning as a pilot program and developing The initial nine sites continued into Septem- into a comprehensive wellness program, Choos- ber 2006. Later that fall, the district launched eWell LiveWell worked to create a strong culture the employee wellness website. Since that time, of health at SPPS. Program volunteers and staff the wellness website has served as the hub of promoted available programs, distributed com- the ChooseWell LiveWell program, enabling munications, and worked in conjunction with staff to access wellness information, including student wellness programs and administration program registration, program materials, and on policy and program development. The pro- related resources. SPPS also enacted a school gram offered incentives to encourage employee district-wide wellness policy in year 2. participation in ChooseWell LiveWell. The value The wellness policy requires physical activ- of the incentives increased over each program ity and nutrition to be addressed for students year, and all involved some form of preferred within the district. Section IX of the wellness health plan benefit—that is, a lower co-pay or policy specifically addresses the valued role deductible for participants. In the first years of of district staff in affecting student wellness: the program, employees who participated were ChooseWell LiveWell 213
Table 25.1 SPPS ChooseWell LiveWell Physical Activity Programs by Year School Program year year Program title Program description 1 2005-2006 10,000 Steps Online walking program Walk to Key West Group walking challenge Hydrate and Head-out Individual activity program 2 2006-2007 10,000 Steps Online walking program Get Moving, Get Fit 1:1 telephonic coaching Walkabout Wellness Individual activity program Walking Tour of Italy Group walking challenge GetFit Twin Cities Group walking challenge Tour de SPPS cycling club Individual cycling program 3 2007-2008 10,000 Steps Online walking program Get Moving, Get Fit 1:1 telephonic coaching Walkabout Wellness Individual activity program Tour de SPPS cycling club Individual cycling program Walking Tour of Australia Group walking challenge 4 2008-2009 10,000 Steps Online walking program Get Moving, Get Fit 1:1 telephonic coaching Tour de SPPS cycling club Individual cycling program Walking Tour of America Group walking challenge 5 2009-2010 10,000 Steps Online walking program Get Moving, Get Fit 1:1 telephonic coaching Tour de SPPS cycling club Individual cycling program Start to Finish 5K training Individual training program Exercise Your Right 5K event Group run-walk event 6 2010-2011 10,000 Steps Online walking program Get Moving, Get Fit 1:1 telephonic coaching Tour de SPPS cycling club Individual cycling program Start to Finish 5K training Individual training program Exercise Your Right 5K event Group run-walk event Tri It Triathlon training online program
“School staff serves as role models for students strengthened its commitment to wellness in and are the key to successful implementation year 3 with the introduction of the employee of student wellness programs. Therefore, the wellness DVD. This DVD was shown at each district and schools should offer staff wellness new employee orientation, distributed to lead- programs. This may include workshops, and ers throughout the district, and posted on the presentations on health promotion, educa- district’s wellness website. The video sought to tion, and resources that will enhance morale, demonstrate to new staff that the district under- encourage healthy lifestyles, prevent injury, stands and recognizes the key role staff play in reduce chronic diseases and foster exceptional facilitating and modeling wellness throughout role modeling.” the district. The program expanded in year 3 with the By year 4 of the program, 43 of 80 sites were addition of 15 sites, for a total of 24 pilot sites participating. Although the program had imple- out of 80 total sites districtwide. The district mented several successful short-term walking 214 Katz, Burmeister, Bopp, Kelly, and Pronk challenges in previous years, year 4 included manager position. The paid full-time profes- the first year-long physical activity challenge, sional who fills this position is dedicated to the Walking Tour of America. Participants in the coordinating employee wellness within the dis- walking tour received pedometers to track daily trict, including collaborating with the network steps in a virtual tour of the globe. of volunteer wellness champions. The respon- By September 2009, the beginning of year 5, sibilities of the wellness program manager all 80 sites were participating, which provided include drafting and disseminating wellness the potential to reach all 5,800 employees. The communications, creating and delivering health program increased access in year 5 by removing promotion campaigns, distributing monthly cost barriers and providing programs to employ- wellness newsletters, facilitating group-based ees at no cost. These included health coaching health coaching, and serving as the main point and online health improvement programs. of contact for wellness within the district. The 2010-2011 school year marked the sixth The existing network of wellness champions year of the ChooseWell LiveWell program. Pro- has continued to develop. In a survey of the grams were up and running at all district sites wellness champions conducted in fall 2009, this and provided at no cost to employees. Many group of leaders reported noticeable changes in popular programs from previous years con- both employee and student health attributable tinued, such as the fifth annual Tour de SPPS to the program. Among these changes, champi- cycling club. ChooseWell LiveWell added new ons reported an increased sense of community, activities, including the Tri It triathlon training a shared goal among employees to make healthy program, a six-week online program that con- choices, a visible difference in physical activ- sists of two levels of training to accommodate ity during work time, and modeling of positive both beginner and experienced triathletes (table behaviors for the student body (e.g., walking 25.2). breaks, healthy food choices). Staffing Evidence Base Used At the start of the ChooseWell LiveWell pro- gram in 2005, employee wellness in the district During Program Development was organized through a network of wellness The ChooseWell LiveWell program was designed champions. The champions network consisted to build progressively toward a full-scale, com- of SPPS staff serving in a volunteer capacity. prehensive, multicomponent, and multilevel The district then created a wellness program work-site health promotion program that
Table 25.2 SPPS ChooseWell LiveWell Program Expansion Number of ChooseWell Program year School year LiveWell program sites 1 2005-2006 9 2 2006-2007 9 3 2007-2008 24 4 2008-2009 43 5 2009-2010 Districtwide (80+) 6 2010-2011 Districtwide (80+) ChooseWell LiveWell 215 resulted in measurable outcomes in employee and Industry Sector of the National Physical health and health care costs. Physical activity Activity Plan (NPAP). is often at the heart of health and wellness pro- Strategy 1: Identify, summarize, and dissemi- gramming because of its wide-ranging health nate best practices, models, and evidence-based benefits, and such has been the case with physical activity interventions in the workplace. ChooseWell LiveWell. Inactivity is a modifiable Working in partnership with HealthPartners, the risk factor for many chronic conditions, includ- ChooseWell LiveWell program has offered par- ing diabetes, heart disease, back pain, and cer- ticipants new evidence-based physical activity tain cancers. Low levels of physical activity have interventions each year of the program. These been associated with negative consequences in have included the use of pedometers or logs the workplace, including absenteeism, reduced for tracking physical activity, the use of social quality and quantity of work, excess health care support for health behavior change, and inter- costs, short-term disability, and overall work active online health interventions. America’s impairment. For SPPS, a goal of the wellness Health Insurance Plan has summarized and program included improving the ability of staff shared the program as an employer–health plan to tackle the challenges of working in a busy partnership model of best practices in the area urban school system by building a comprehen- of intersectoral collaborations around health sive program with a focus on physical activity. and wellness. The ChooseWell LiveWell program is Strategy 2: Encourage business and indus- grounded in the Transtheoretical Model of try to interact with all other sectors to identify Behavior Change. Because all individuals vary opportunities to promote physical activity within in their readiness to make changes regarding the workplace and throughout society. The their health, the program offers a variety of pro- ChooseWell LiveWell program is a partnership gram options, program lengths, and modalities. between HealthPartners and SPPS, an urban Tracking one’s own behavior, or self-monitor- school district. HealthPartners’ mission is to ing, is a key feature of many of the ChooseWell improve the health of its members, its patients, LiveWell program options (tables 25.3 and and the community. Through disseminating 25.4). Self-monitoring is most commonly associ- lessons learned from this six-year partnership, ated with weight loss interventions and also has HealthPartners and SPPS set an example for the been applied to physical activity interventions. broader community, representing an effective All of the physical activity programs offered as intersectoral health promotion partnership. part of ChooseWell LiveWell include a log for Strategy 3: Educate business and industry tracking physical activity or a pedometer for leaders regarding their role as positive agents of participants to track their daily steps. When change to promote physical activity and healthy applied to physical activity interventions, the lifestyles within the workplace and throughout process of documenting behavior (e.g., pedom- society, giving particular consideration to efforts eter steps) involves purposeful attention to the targeting low-resource populations. Although behavior. To change behaviors, individuals need the ChooseWell LiveWell program has been to pay close attention to their own actions, the aimed at employees of SPPS, it was designed conditions under which those actions occur, and to complement and reinforce existing student- the short- and long-term effects of those actions. focused health promotion efforts in the district. The district serves a diverse urban population, where nearly half of the student body (45 per- Linkage to National cent) come from a home where English is not Physical Activity Plan the primary language and more than 70 percent are eligible for free and reduce priced lunches. The ChooseWell LiveWell program addresses all Strategy 4: Develop legislation and policy five of the strategies included in the Business agendas that promote employer-sponsored 216 Katz, Burmeister, Bopp, Kelly, and Pronk
Table 25.3 Baseline Characteristics of the Sample (N = 1,942) Average age (years) 47 Gender (% female) 72 Average body mass index (kg/m2) 27.4 Race American Indian or Alaska Native 1% Asian or Pacific Islander 3% African American or Black 5% Caucasian 80% Other race 2% Unknown 9% Ethnicity (% Hispanic or Latino) 3%
Table 25.4 Physical Activity Indicators Over Time School year 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 % Below 2008 DHHS Physical Activity 21.1% 14.7% 13.7% 13.9% 13.1% Guideline* % Low muscle strengthening 64.5% 58.4% 53.9% 53.6% 52.6% % Low muscle stretching (flexibility) 41.3% 31.7% 30.7% 31.2% 29.5% % Sedentary 2.1% 1.0% 1.4% 1.2% 1.4% Vigorous activity (days/week) 3.01 3.50 3.54 3.54 3.59 Vigorous activity (minutes) 38.39 40.28 39.61 38.40 39.38 Moderate activity (days/week) 4.27 4.59 4.61 4.62 4.58 Moderate activity (minutes) 41.10 41.28 41.73 41.80 42.23 Muscle strengthening (days/week) 1.27 1.45 1.60 1.65 1.69 Flexibility (days/week) 2.48 2.89 3.00 2.93 3.07 Data pertain to the cohort of the Saint Paul Public Schools employees (N = 1,942) who participated in all 5 program years. Data from year 6 were not available at the time of publication. *2008 U.S. Department of Health and Human Services. Guidelines available at www.health.gov/paguidelines/ physical activity programs while protecting indi- Strategy 5: Develop a plan for monitoring vidual employees’ and dependents’ rights. The and evaluating worksite health promotion ChooseWell LiveWell program has evolved to a programs. ChooseWell LiveWell includes an stage where policy solutions have been imple- ongoing evaluation component, enabling the mented to effectively scale the program to reach program to demonstrate marked changes in all employees. A districtwide wellness policy employee health. Annually, representatives was designed and implemented and now may from the school district and HealthPartners be used as an example to other school districts meet to review population-level results obtained to show what is possible. through the annual health assessment, as well ChooseWell LiveWell 217 as outcomes specific to each of the programs grant, as well as Minnesota’s Statewide Health offered. Estimated cost savings and return on Improvement Program, to partner and pro- investment based on changes in the summary mote program options available to employees health scores are reviewed periodically, and throughout the district. changes in the program are based on a com- ChooseWell LiveWell was developed at a bination of these data and input and feedback gradual pace, and monitoring and evaluation from participants. were used to inform program changes from year to year. Program expansion was mindful and deliberate, taking into account the needs of the Lessons Learned employee population and the latest evidence- Program leaders identified three major lessons based interventions. that will assist with future implementation of similar programming: (1) use technology to Program Evaluation automate administrative components of the program; (2) cultivate community partnerships An advisory group consisting of program staff and leverage existing partnerships to enhance and leaders from both the school district and program success; and (3) introduce gradually HealthPartners convenes annually to evaluate and progress mindfully. and assess the effectiveness of the program. The first year of ChooseWell LiveWell was The group’s meetings include a program entirely “paper-based.” The wellness program overview and discussions about the number manager and SPPS wellness champions admin- of sites involved, available program options, istered program registration, materials, and and population-level health indicators from communications manually. The administrative the health assessment. The discussions have burden placed on these individuals detracted informed annual program planning and staffing from their ability to focus on motivating and and provide an opportunity for leaders within coaching employees and limited the scope of the school district and HealthPartners to share the program’s reach. The development and ideas and discuss planning for the coming year launch of the district wellness website enabled and strategy going forward. program staff and volunteers to focus their Central to evaluation of the ChooseWell roles on health promotion. The website helped LiveWell program is the employee health broaden the reach of the program by facilitating assessment offered each fall. Developed by 24/7 access to program information, registra- HealthPartners, the health assessment contains tion, and materials. a cross section of scientifically validated ques- Another key lesson was to form partnerships tions and medically approved algorithms that whenever possible. By design, ChooseWell can accurately predict a person’s likelihood of LiveWell was created as a partnership between developing diabetes or heart disease in the next a local health services organization and a com- two to three years. It includes a series of ques- munity school district. Annual meetings among tions in several areas: personal demographics leaders from both institutions have helped to and health history, self-care, women’s health, facilitate communication and ensure that pro- nutrition, physical activity, alcohol and tobacco, gramming is informed by the latest evidence safety, and readiness to change. The health and industry knowledge and meets the needs assessment is predictive of health care costs and of the population. The success of the program worker productivity indicators and has been a also can be attributed to partnerships within key instrument for the documentation of the the school district. In the first three years of the program’s impact on health and costs over time. program, ChooseWell LiveWell staff partnered Annual reports are generated based on health with staff who worked on student-focused well- assessment information, including summary ness efforts. The program leveraged the existing health scores. The summary health scores network of wellness champions from the Steps allow for tracking of population health over 218 Katz, Burmeister, Bopp, Kelly, and Pronk time and are used to estimate the impact of well as the focus on building and optimizing the program on cost-related outcomes, such as a culture of health within the organization. estimated health care cost savings over time. Future programs should consider the specifics of In general, these indicators have shown a pro- organizational culture and potential impacts on gressive improvement in overall population program implementation. The role of the well- health, resulting in cost savings. In year 5 of ness website, for example, may be less impactful the program, HealthPartners estimated cumula- in sectors in which computer access is limited. tive four-year (2005-2006 through 2008-2009) health care cost savings of $632 per participant (or $158 per participant per year), based on Additional the improvements in summary health scores. Reading and Resources Additionally, a group of 1,942 unique individu- als who participated in the program for all 5 Bandura, A. Health promotion from the perspective of program years, from 2005 to 2010, experienced social cognitive theory. Psychol. Health 13:623-49. statistically significant improvements in physi- Burke, L.E., J. Wang, and M.S. Sevick. 2010. Self- cal activity. monitoring in weight loss: A systematic review of Tables 25.3 and 25.4 display the descriptive the literature. J. Am. Diet. Assoc. 111:92-102. characteristics, key physical activity indicators, Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Com- and aggregate improvement over time among a parison of techniques for self monitoring, eating unique cohort of 1,942 participants who partici- and exercise behaviors on weight loss in a corre- spondence-based intervention. J. Am. Diet. Assoc. pated in the first five years of the ChooseWell 107:1807-10. LiveWell program. Hogan, B.E., W. Linden, and B. Najarian. 2002. Social support interventions: Do they work? Clin. Psychol. Populations Best Served Rev. 22(3):381. Lindberg, R. 2000. Active living: On the road with by the Program the 10,000 steps program. J. Am. Diet. Assoc. 100(8):878-9. The ChooseWell LiveWell program could be Prochaska, J.O., and W.G. Velicer. 1997. The trans- replicated in a variety of employer settings. The theoretical model of health behavior change. Am. wellness website enabled easy communication J. Health Promot. 12(1):38-48. and access to employees across the many sites N.P. Pronk. 2008. Designing a multisector approach to in the school district. This program feature health and wellness. In: America’s Health Insurance would serve employer populations in all sec- Plans (AHIP). AHIP innovations in prevention, well- tors well, including small and medium-sized ness and risk reduction (pp. 18-21). www.ahip.org/ employers, and especially those with offices in redirect/AHIP_Innovations_Prevention.pdf. many different locations. Pronk, N.P., Ed. 2009. ACSM’s Worksite Health Hand- book, Second Edition. A Guide to Building Healthy and Productive Companies. Champaign, IL: Human Tips for Kinetics. Working Across Sectors Pronk, N.P. 2009. Physical activity promotion in busi- ness and industry: Evidence, context, and recom- The core ChooseWell LiveWell program com- mendations for a national plan. Journal of Physical ponents—annual employee health assessment Activity and Health 6(Suppl. 2):S220-35. with personalized feedback, a variety of pro- Pronk, N.P., M. Lowry, M. Maciosek, and J. Gallagher. gram options, incentives for participation and 2011. The association between health assessment- effective communications—have been demon- derived summary health scores and health care strated to be effective in other industries. Key to costs. J. Occup. Environ. Med. 53(8):872-8. the success of this program was the leadership Thygeson, M.N., J.M. Gallagher, K.K. Cross, and N.P. support from both major program partners as Pronk. 2009. Employee health at BAE Systems: An ChooseWell LiveWell 219 employer-health plan partnership approach. In: Wantland, D.J., C.J. Portillo, W. Holzemer, R. Slaughter, ACSM’s Worksite Health Handbook: A Guide to and E.M. McGhee. 2004. The effectiveness of web- Building Healthy and Productive Companies (pp. based vs. non-web-based interventions: A meta- 318-326). N.P. Pronk, Ed. Champaign, IL: Human analysis of behavioral change outcomes. J. Med. Kinetics. Internet Res. 6(4).
CHAPTER 26 What’s Next? Keeping NextEra Energy’s Health & Well-Being Program Active for 20 Years
Andrew Scibelli, MBA, MA NextEra Energy
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector STRATEGY 3: Educate business and industry leaders regarding their role as positive agents of change STRATEGY 1: Identify, summarize, and disseminate best practices for physical interventions in the to promote physical activity and healthy lifestyles workplace. within the workplace and throughout society, giv- ing particular consideration to efforts targeting low- STRATEGY 2: Encourage business and industry to in- resource populations. teract with all other sectors to identify opportunities to promote physical activity within the workplace STRATEGY 5: Develop a plan for monitoring and evalu- and throughout society. ating worksite health promotion programs.
he NextEra Energy Health & Well-Being gram for FPL employees and their families. The Tprogram began in 1991 as FPL-WELL, a program was created primarily as a benefit for wellness program designed for Florida Power employees to help improve their overall health & Light Company (FPL) employees. For the and well-being. A secondary motivation for next 20 years, the program fourished as it grew investing in employee health was the belief and changed in tandem with the company. In that encouraging employees to take charge of January 2009, when FPL changed its name into their health could help the company control NextEra Energy, Inc., the FPL-WELL program health care costs. The initial program included transitioned into the NextEra Health & Well- on-site fitness centers and exercise program- Being program. NextEra Energy, which oper- ming, health promotion programming, and an ates in 26 U.S. states and Canada, is one of the employee assistance program (EAP). leading clean energy companies in the United During the program’s early years, a network States and employs nearly 15,000 employees of volunteer wellness coordinators supported globally. Although the program’s offerings the small staff at the corporate headquarters. have evolved to better target its audience of Together, they worked to engage FPL employ- 33,000 employees, dependents, and retirees, ees by delivering wellness programs and ser- the program has continued to focus primarily vices to the company’s many sites throughout on employee health and well-being. Florida. Leadership has been fundamental to the program’s success. Since its inception in 1991, Program Description the program has enjoyed strong support from The NextEra Health & Well-Being program was senior leaders. In fact, leadership constitutes implemented 20 years ago at the direction of three of the five pillars that support NextEra the CEO of FPL as an employee wellness pro- Energy’s corporate culture of health: 221 222 Scibelli
1. Senior leadership demonstrates its sup- disease management, body composition port by incorporating employee health analysis, allergy shots, physical therapy, into the company culture and including dietary counseling, and immunizations. health as a potential core competency 4. Nutrition and weight management for senior management, operational offers personal nutrition counseling, leaders, and employees. group nutrition presentations, dietary 2. Operational leaders add further support consultation for company cafeterias, by encouraging employee participation catering services, and healthy options in wellness programs and being flexible for on-site vending machines. with employees who want to participate 5. EAP and mental health programming in programs during work hours. includes personal consultation, triage, 3. Management encourages employees to and referral and group presentations practice self-leadership in health matters and workshops on behavioral health by assuming responsibility for their own issues. health and the health of their families. The NextEra Health & Well-Being program 4. The company reinforces employees’ consists of many programs and activities: self-leadership and positive health behaviors through well-placed program • Steps to Success is a personalized, long- incentives. term weight management program that 5. Measurement across all aspects of the pairs individuals who are obese or over- program—risk status changes, costs, weight and have multiple risk factors with engagement, participation, vendor a health team, including a dietitian, fitness performance, health claims data, and center staff member, and EAP counselor, performance indicators—drives future who help them lose weight and sustain program growth and direction. weight loss. • Healthy Back/Healthy Neck is an exercise With senior leadership support, NextEra and lecture series designed to prevent Energy has ingrained wellness into all aspects musculoskeletal injury and discomfort by of the work environment. The company has strengthening the back, core, and neck and tobacco-free policies in all facilities, and caf- teaching proper body mechanics. eterias offer subsidized wellness meals. On-site exercise opportunities thrive even in moderate- • Active Parenting Now is a video-based sized work sites, and signage and coworker parent education program led by an EAP watchfulness reinforce safety policies. specialist who uses video vignettes to Basic health and wellness programming is demonstrate parenting skills and lead a structured along five focus areas: discussion on positive discipline and com- munication techniques. 1. Fitness centers offer exercise prescrip- • NextEra Health & Well-Being staff and tions, group classes, specialty classes, safety group teamed up to create the personal training, fitness assessments, Back Reinjury Prevention Program, team challenges, and independent exer- which includes specialized materials on cise opportunities. stretching, lifting, and body mechanics 2. Health promotion includes office and for employees who have experienced a field ergonomic assessments, health loss-time back injury. screenings, flu shots, tobacco cessation • The Cigna Personal Health Team deliv- options, massage therapy, and wellness ers an integrated approach to health and challenges. well-being in the form of confidential, 3. Health centers include annual physicals, one-on-one support for employees and preventive screenings, primary care, family members with multiple risk factors NextEra Energy’s Health & Well-Being Program 223
or maternity or chronic health needs. A health assessment, and 49 percent had team of 12 health professionals, staffed by participated in a health screening. the company’s contracted health insurer • Participation in the on-site health centers (Cigna), coach participants to achieve increased by 10 percent from 2009 to 2010, optimal health through education, inter- with a total of more than 20,000 visits in vention programs, and assistance working 2010. The average return on investment with the health care delivery system. (ROI) for the company’s three health Short-term or seasonal programs complement centers was $2.29 for every dollar spent the ongoing programs and keep the offerings in 2010. fresh and employees engaged. The 20-20-20 • Flu shots were administered to 41 percent Challenge, which motivates employees to exer- of employees in 2010, an increase of 11 cise at least 20 minutes each day for a month, is percent over the previous year. an example of a seasonal program. Employees • In the company cafeterias, 27 percent of earn tokens for each workout and increase their employees chose the healthy food option chances to win a raffle with each additional in 2010, an increase of 4 percent since token they earn. In another seasonal program, 2008. These healthy options represented Spring Into Fitness!, fitness center members are 39 percent of the total cafeteria sales in encouraged to engage in physical activity and 2010. exercise routines with weekly challenges and • With 62 fitness centers across the com- prizes, including a prize for referring a new pany, ample opportunity exists to use member to one of the fitness centers. an on-site facility; 60 percent of eligible Company and program managers con- employees are enrolled in their on-site tinuously measure the success of the NextEra fitness center. In 2010, the total number of Health & Well-Being program in terms of par- fitness center visits increased by 5 percent ticipant health maintenance and improvement. compared with 2009. Although health for any large population is distributed along points of a continuum, the • The internal EAP staff counseled 1,952 program’s founder holds a core belief that suc- employees and family members in 2010. cess depends on some key items: Strong employee participation is an impor- • Keeping risk low for healthy people tant component of the company’s multiyear • Encouraging behavior change to reduce health benefits strategy. In 2009, the program risk for marginally healthy people encouraged employees to participate in health assessments and screenings to “know their • Providing effective programs for people numbers” and to reduce their risks by participat- with chronic conditions or catastrophic ing in behavior change programs. The company health events reinforced these behavior changes by offering The program’s success starts with strong health incentives to employees who participated participation from employees and their family in the assessments and took action to reduce members: identified risks. • Ninety percent of employees participated in at least one on-site program in 2010, a Linkage to National 7 percent increase over 2009. Physical Activity Plan • Forty-five percent of employees reported they had participated in the program This approach addresses the following strategies continuously for three years in 2010, a 10 and tactics of the National Physical Activity Plan percent increase since 2008. Business and Industry Sector. • In 2010, 80 percent of employees eligible Strategy 1: Identify, summarize, and dissemi- to receive incentives had taken the annual nate best practices for physical interventions in 224 Scibelli the workplace. NextEra Energy was one of only resources. Community resources are used to 22 employers to be awarded platinum-level rec- offer on-site health fairs and screenings, and ognition as the Best Employer for Healthy Life- sometimes local management pays to bring styles for Employees by the National Business wellness staff members on site to offer ergo- Group on Health. NextEra Energy participates nomic assessment of job tasks. For example, at in several regional and national health care one wind energy site, workers were experienc- forums to share ideas with other companies and ing some muscular stress from carrying tools agencies. Andrew Scibelli, manager of Employee up the stairs to the top of the wind turbines. Health & Well-Being at NextEra Energy, is a The wellness staff created a series of stretching founding board member of the Institute on the and strengthening exercises to help alleviate Cost and Health Effects of Obesity and, as a potential strains. national subject matter expert, has addressed Members of the Cigna Personal Health Team the Florida Health Coalition and published identify and confidentially contact high-risk numerous articles in health journals. individuals, who receive one-on-one coaching Strategy 2: Encourage business and industry and are directed to tailored health improvement to interact with all other sectors to identify oppor- programs. tunities to promote physical activity within the Strategy 5: Develop a plan for monitoring and workplace and throughout society. Although pri- evaluating worksite health promotion programs. marily geared toward employees and their fami- Twenty years ago, as the NextEra Health & lies, NextEra Health & Well-Being recognizes its Well-Being program was under development, responsibility to reach out within its communi- a nationwide assessment in the United States ties. NextEra Energy has been the local sponsor was conducted to help define what the program of Race for the Cure in West Palm Beach, Flor- would include. Program leaders interviewed ida, an event held by Susan G. Komen for the senior managers, studied medical claims, and Cure, and consistently recruits more than 900 evaluated the corporate culture to determine employees to participate in the race. Employee which health promotion services employees teams also participate in the American Heart needed and which offerings would be suc- Association’s annual Heart Walk. Each year on cessful. The company has conducted similar Take Your Child to Work Day, physical activities evaluations on a biannual basis to ensure that are conducted throughout the company for chil- the services remain relevant and useful to dren of employees. Most recently, staff members employees. consulted with the Palm Beach County School District regarding additional ways to promote fitness in county schools. Lessons Learned Strategy 3: Educate business and industry leaders regarding their role as positive agents of The most important lesson that company and change to promote physical activity and healthy program managers learned was to understand lifestyles within the workplace and throughout how the organization operates before design- society, giving particular consideration to efforts ing programs. A successful health promotion targeting low-resource populations. The program program must have a champion who is willing takes special care to target underserved popula- to visibly and vocally influence the rest of the tions and those with the highest-risk behaviors. organization in favor of the program. A mistake The underserved employee population includes many new health promotion programs make is those working outside of the corporate offices to roll out initiatives without identifying and who have limited access to health centers and engaging such a champion or without under- larger fitness centers located at central facilities. standing the organization and culture. Even if When space is available at a remote location, employees support healthy lifestyles and would on-site exercise rooms or outdoor recreational choose health promotion benefits over other areas, such as sand volleyball courts, are cre- forms of indirect compensation, if the corpo- ated using staff expertise and local financial rate culture is not one that supports wellness, NextEra Energy’s Health & Well-Being Program 225 employees will be reluctant to participate. Once members also work with the on-site wellness managers begin to serve as role models for well- champion and local community resources to ness, programming will naturally follow. arrange for on-site services such as flu shots, Once established, a successful program must health fairs, and biometric testing. Whenever continue to re-create itself before its life cycle possible and within security limitations, these ends. In the case of the NextEra Health & Well- programs also are available to covered spouses Being program, integrating services—such as and dependents. traditional wellness services with safety and Because unionized employees generally work employee benefits—keeps offerings meaning- in the field during the day, special arrange- ful to employees and simplifies their personal ments must be made to include them in any health improvement efforts. Integrating well- on-site programming. With local management ness with safety means that health promotion approval, work hours can be adjusted and pro- has both a personal improvement component gram times altered so that wellness services and tangible work significance. Similarly, are available to all employees. When feasible, integrating wellness with health care benefits wellness programming can be incorporated expands awareness of health promotion to into monthly safety meetings for unionized family members who previously would have employees. shown interest only in benefits. Finally, program managers need to stay on top of current trends. With the proliferation of Tips for social media and near-universal online access, Working Across Sectors the program is placing greater emphasis on reaching people online. The internal health and Strong leadership support has helped the Nex- well-being website was redesigned to make it tEra Health & Well-Being program operate suc- easier to use and accessible from almost any- cessfully for 20 years. Because of this support, where. The web-based programs offered and the program has been able to circumvent the housed on this website make achieving health challenges that a geographically diverse com- and wellness more convenient for employees pany often faces. and their families. Support from senior leaders opens the door to working with management at remote company sites. When NextEra Energy senior leaders made Populations Best Served “fostering a culture of health” a performance indicator, they motivated general managers of by the Program remote sites to seek out health and wellness programs to bring to their locations. Local sup- Employees at highly populated sites are the port is further demonstrated when managers easiest to reach for programming given econo- and supervisors identify a wellness coordinator mies of scale. NextEra Energy staffs fitness or champion who distributes monthly wellness centers and health centers at the company’s materials sent by corporate staff, schedules most highly populated sites, making services health fairs, and promotes fitness challenges more readily accessible and allowing staff to and other events among site employees. Local increase employee awareness of additional management support is needed to give the well- program services. ness coordinator time each month to devote to Because NextEra Energy operates in so many these activities and allow employees to partici- locations, it is important to offer programming pate in the scheduled events during work hours. that can be implemented at remote sites. Loca- Because some employees at remote sites are tions willing to pay for staff travel costs can part of a bargaining group, support of union bring wellness staff members on site to offer leadership is necessary. Meeting with union rep- a series of lectures, fitness testing, nutrition resentatives regularly and giving them advance counseling, and other programming. These staff notice of upcoming events and promotions are 226 Scibelli critical to garnering full employee participation health center. Last, the average ROI for all three among the unionized workforce. Since benefits health centers was $2.13 per dollar invested differ between union and nonunion employees, in 2009 and $2.29 per dollar invested in 2010. and because wellness is closely integrated with Higher compliance with medical guidelines and health benefits, clear communications about a larger ROI provide a strong business case for which programs are available to union employ- offering on-site health centers. ees encourages greater involvement. Recognizing that outcomes drive strategy, NextEra Energy tracks and assesses metrics relative to health improvement, engagement, Program Evaluation participation, employee satisfaction, vendor performance, program integration, health claims Since winning the prestigious Deming Award for data, and leadership engagement. quality improvement in 1989, NextEra Energy In 2011, NextEra Energy began matching has made it standard practice to base actions incentives with healthy outcomes. Employees on research findings. The health and well-being who meet certain biometric indicators are eligi- program is no exception. ble to receive a credit to their health reimburse- The company has conducted several studies ment account. This approach was incorporated of the program throughout its 20-year history, into the employee benefit plan for 2012. and in 2010, OptumInsight, a health care ana- NextEra Energy regularly publishes metrics lytics vendor, evaluated the effectiveness of that reflect program objectives and track effec- the on-site health centers. The study set out to tiveness. These metrics include a 16-risk health test the hypothesis that employees who use the assessment, which surveys active employees health centers have lower health care costs and regarding self-reported conditions and willing- better compliance with nationally recognized ness to change. The health assessment also medical guidelines. Episode risk groups and includes a productivity review that monitors evidence-based medicine were used to evaluate changes in both presenteeism (productivity loss current and future health risks and compliance. while at work) and absenteeism (productivity The episode risk groups used medical claims loss due to absence from work) and compares and demographic data to predict an individual’s them with a national norm. need for health services and costs. Evidence- The program consistently seeks and ben- based medicine is a quality-of-care assessment efits from employee feedback, collecting tool that evaluates compliance with the pre- pre-to-post measurements on all programs. A dicted need for services. The treatment cost of vendor conducts a survey every two years to an off-site health care provider versus an on-site assess employee perceptions of the health and health center was collected and incorporated well-being program and offer suggestions for into the ROI analysis. The population size of improvement. The last survey was conducted 2,630 was based on unique employee visits to in 2010 and demonstrated an 89 percent sat- one of NextEra Energy’s three on-site health isfaction rate with the health and well-being centers during two years; the average number program, compared with an 84 percent satis- of visits per patient ranged between 3.9 and 5.7 faction rate in 2008. These results show that at the different locations. even a progressive, evolving program like the Findings from the study demonstrated that NextEra Health & Well-Being program has room on a risk-adjusted basis, employees who use the to improve. on-site health centers have annual costs that are $706 lower than employees who do not use the health centers. Employees who use the on-site Additional health centers also showed a compliance rate with nationally recognized medical guidelines Reading and Resources of 81 percent, compared with a compliance rate NextEra Health & Well-Being (formerly known as of 74 percent for employees who did not use the FPL-WELL) was featured on ABC World News NextEra Energy’s Health & Well-Being Program 227
Tonight on March 22, 2007. This two-minute video “Value-based” health plan designs focus on health, not shows the fitness center, health center, and cafete- merely dollars: Successes found in upfront spending ria in the corporate headquarters in Juno Beach, that avoids long-term, higher costs. 2007, October Florida. http://video.google.com/videoplay?do 29. Business Insurance. cid=-348372692272836281# Working at change: executive lifestyles, workplace FPL group wins award for health program. 2007, wellness. 2008, January 1. Florida Trend. November 27. South Florida Business Journal. How FPL’s approach to weight management helped FPL successful with on-site clinics, fitness centers. 2008, improve its company wellness. 2004, October 1. September 22. Disease Management News. Managing Benefit Plans.
CHAPTER 27 Johnson & Johnson Bringing Physical Activity, Fitness, and Movement to the Workplace
Fik Isaac, MD, MPH, FACOEM Melinda Vertin, MSN, NP Johnson & Johnson Johnson & Johnson
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector to promote physical activity and healthy lifestyles within the workplace and throughout society, giv- STRATEGY 1: Identify, summarize, and disseminate best practices, models, and evidence-based physi- ing particular consideration to efforts targeting low- cal activity interventions in the workplace. resource populations. STRATEGY 4: Develop legislation and policy agendas STRATEGY 2: Encourage business and industry to in- teract with all other sectors to identify opportunities that promote employer-sponsored physical activity to promote physical activity within the workplace programs while protecting individual employees’ and throughout society. and dependents’ rights. STRATEGY 5: Develop a plan for monitoring and evalu- STRATEGY 3: Educate business and industry leaders regarding their role as positive agents of change ating worksite health promotion programs.
his chapter tells the story of how John- this dedication was understood and valued. As Tson and Johnson (J&J) created and then far back as 100 years ago, J&J provided medi- sustained a culture of health for its employees. cal centers, health education and lectures, and Although physical activity and movement play physical activity resources for all company important roles in the story, good nutrition, employees. mental well-being, and other health-related components contribute to the global culture of health. Programs that encompass all of these Program Description health components have made signifcant con- tributions to the overall health and well-being Given this commitment and history, in 1979, of J&J employees for the past 125 years. the company created a successful health and J&J has longstanding dedication to the health wellness initiative: Live for Life. At that time, of its employees. This commitment is based in J&J’s company group chairman, Jim Burke, its credo, which drives decisions and actions at believed that unhealthy behaviors, such as all levels of the corporation. The credo includes smoking, overeating, alcohol abuse, emotional a pledge to the health and welfare of all J&J stress, hypertension, and unsafe driving, were employees and retirees. Even before General responsible for a large share of the company’s Robert Wood Johnson created the credo in 1943, health care costs in the United States.
229 230 Isaac and Vertin © Johnson & Johnson Historic Archive Collection. © Johnson & Historic Archive
Program success required understanding the health offerings. Prior to expanding these goals, workplace culture and setting goals and targets the company had only offered these programs that drove the program and led to sustained in a few sites outside of the United States. improvements in health outcomes. Such goals In 2010, the company set corporate sus- garnered the support of management at all tainability goals called Healthy Future 2015. levels, which was essential if the program was to These goals are centered on the philosophy of achieve goals and sustain results year after year. sustainability and managing for the long term. Employee health promotion goals have Goals in the area of employee health challenge evolved over time at J&J, expanding the pro- all employees to “know their health numbers” gram’s reach and targets. For example, program and reduce their health risk factors. The aim is goals have been aligned with external goals to encourage sites to actively choose and use (such as Healthy People 2010 or the National available health programs to assist employees Physical Activity Plan), which allow the com- in lowering their health risks. pany to standardize and validate its efforts. Established health and wellness policies and Additionally, initial program efforts focused on standards support Healthy Future 2015 goals as four key risk factors; current efforts focus on well as define minimum program expectations. 11, including physical inactivity. The company conducts assessments to monitor Programs that were initially based in the these standards (as well as other environmental United States have now moved to company health and safety standards) at least annually. locations across the globe. For example, in 2012, For example, operating companies are required 95 percent of all sites worldwide (379) offered to provide access to and improve physical activ- some form of physical activity opportunities to ity initiatives. Management action plans address their employees. More than 84 percent of sites these expectations to ensure that senior man- (335) offered comprehensive programs. These agers are aware of and support the initiatives. outcomes resulted from goals and targets that The Office of the Chairman and members of the sought to expand physical activity and other Executive committee support these programs, Johnson & Johnson 231 © Johnson & Johnson Historic Archive Collection. © Johnson & Historic Archive © Johnson & Johnson Historic Archive Collection. © Johnson & Historic Archive policies, and practices related to the health and baseball team. In the early 1900s, it built out- safety of employees. This high level of corporate door and indoor tennis and badminton courts commitment ensures that employee health pro- and a swimming pool for employees. Female grams remain a priority of the company. employees were offered dancing and callis- J&J has a long history of understanding the thenic classes, and the male employees formed value of physical activity and providing physi- the J&J Athletic Association. Many employees cal activity opportunities for employees. As joined sports clubs for basketball, tennis, or early as 1895, the company fielded a men’s bowling. Today, of the 11 population health 232 Isaac and Vertin risks that J&J has targeted to track and reduce provides reimbursement of $200 per year so that over time, physical inactivity remains one of employees can purchase gym memberships, the most important. The company recognizes enroll in exercise classes close to home, or buy the well-documented positive effects of physi- exercise-related equipment. cal activity on other health risk factors (e.g., • Walking trails: Most locations strive to offer obesity, high glucose, hypertension, stress) and safe pathways around the facility for walkers as the role physical activity can play as a positive a means to promote activity throughout the day. alternative to negative health habits (smoking, A checklist is used to ensure the trails are walk- alcohol use). able, allowing for adequate distance and safety. Despite the well-known positive effects of • Million Step Challenge: This program physical activity, inactivity is increasing in the encourages movement by providing free pedom- workplace. A recent study found that up to 80 eters and sponsoring competitions that motivate percent of jobs in today’s workforce are pre- employees to increase their daily steps (with dominantly sedentary. This has been an issue the goal of 10,000 steps a day). In 2012, 7,307 for J&J as well, and physical inactivity continues unique employees participated in the Million to be one of the top three health risks for our Step Challenge (22.3 percent of the U.S. J&J employees (along with obesity and unhealthy population) compared with 7,268 in 2011. Of eating). these participants, 1,562 employees walked at Table 27.1 illustrates that compared with least one million steps by year-end, whereas national norms (with trends moving in the 1,725 employees walked two million or more wrong direction), J&J has made steady progress steps. A 2012 survey of participants found that in addressing the issue. The success J&J has 60 percent reported more energy, 40 percent achieved in reducing physical inactivity and lost weight, 15 percent lowered blood pressure, improving employee health behaviors is built 14 percent lowered cholesterol, and 27 percent on the success of the following programs: were less troubled by stress. • On-site fitness centers: On-site employee • Job Fit: This program is designed to fitness centers are located at 210 company sites improve health and productivity by preventing worldwide. These centers are fully equipped and reducing musculoskeletal injuries. The and staffed with fitness professionals who pro- program focuses on ergonomic demands of the vide personal coaching and advice. Exercise job as well as the employee’s overall fitness. classes are offered based on the site’s needs • Community health activities: Each site and requests. Fitness professionals tailor fitness works to align with community and recreational offerings specifically to the employee population events and may coordinate with fundraising at each site. Access to the fitness centers is free events like Race for the Cure, American Heart of charge for all employees and retirees. Association Heart Walk, and Relay for Life. For • Exercise reimbursement: For employees example, LifeScan (a J&J company) has been who cannot access on-site fitness centers, J&J involved in the rider recruitment, fund-raising,
Table 27.1 Percentages of Physically Inactive Employees Over Time 1995-1999 average 2007-2008* 2009 2010 2011 Johnson & Johnson 39% 31.5% 20.4% 20.8% 20.9% CDC Comparison 52.7% *Questions addressing physical inactivity were altered in 2008 to better align with the new physical activity guidelines and accurately capture employees’ moderate- and vigorous-intensity activity. This update may have affected the risk percentage for physical inactiv- ity when compared with previous years since those numbers were calculated differently. Johnson & Johnson 233 and marketing of the Silicon Valley Tour de tailored online assistance and digital coaching Cure. This is an annual benefit ride supporting to J&J employees. The program devises a cus- the American Diabetes Association. In 2010, tomized activity plan specific for each employee the LifeScan team played an integral role in and works with the employee to track progress recruiting more than 100 riders and helping and goals. to raise $103,000. Over the last two years, the team has raised nearly $200,000 for the Ameri- can Diabetes Association. The on-site staff has Program Evaluation partnered with other wellness professionals to promote the Tour de Cure at other J&J operat- Evaluations of the Live for Life program have ing companies. These efforts have drawn more proven Jim Burke to be right and have demon- than 1,000 riders, and more than $540,000 is strated that good health is good business. An raised nationally. independent study evaluated the program’s • Family activity challenge: This 12-month results from 1979 through 1983 and found program is built on the concept that becoming that hospitalization costs at J&J locations that active as a family and focusing on good health implemented the program were a third of those habits are rewarding ways to improve the at other company locations. Absenteeism rates health of loved ones while teaching children were 18 percent lower, and improvements in healthy habits that will last a lifetime. Included weight, blood pressure, cholesterol, and smok- are monthly activity calendars encompassing ing cessation contributed to an estimated 3 to healthy eating, physical activity, hydration, the 5 percent reduction in overall health care costs. importance of sleep, and reducing screen time. (Bly et al. 1986) Principles from Energy for Performance in Life More recent evaluations revealed similar find- and healthy eating are incorporated in the cal- ings. Figure 27.1 shows the overall decrease in endar activities. A pedometer challenge incor- employees considered to be “high risk” (five porates e-mails, raffle prizes, and incentives. or more lifestyle risk factors) over the past five • Move (from HealthMedia): Move is a vir- years, and figure 27.2 shows the decline of tual training program that provides unique and specific risks since 1995.
100% 87.1% 87% 87.5% 90% 85% 78.1% 77.8% 80% 70% 60% 50% 40% Percentage 30% 20.5% 20.6% 20% 13.9% 12% 12.1% 11.8% 10% 1.4% 1.6% 1.1% 0.9% 0.9% 0.7% 0%
2006 2007 2008 2009 2010
2011-2012 Year = Low = Medium = High = Linear (low)
Figure 27.1 Population health risk reduction (2006-2012).
E5691/NPAP/fig27.1/458606/alw/r1 234 Isaac and Vertin
60%
50%
40%
30% Percentage 20%
10%
0% U.S. population J&J 1995-99 J&J 2007-08 J&J 2009 J&J 2010 J&J 2011-12 2007-08 (CDC) Year
= Inactivity = Smoking = High blood = High cholesterol pressure
Figure 27.2 Johnson & Johnson decline in four major health risks (1995-2012). E5691/NPAP/fig27.2/458607/alw/r3-kh
Following are key findings from recent studies organization), J&J is able to leverage resources of the Live for Life program: and gather data in a consistent, quality-driven fashion. Data are reported to the highest levels • Johnson & Johnson had significantly fewer of the company to bring attention to population employees at risk for high blood pressure, health risk status and progress; the data are also unhealthy eating, obesity, and tobacco use used at the site level to develop customized compared with benchmarked companies. interventions that address population health • Johnson & Johnson’s program produced a risk needs. Strong incentives drive participa- $565 savings per employee per year. tion in the Health Profile (J&J’s health risk • With an average annual program cost assessment), which highlights an individual’s ranging from $144 to $300 per person, unique risks and follows through with specific the return on investment for Johnson & interventions (such as physical activity) to Johnson’s program ranged from $1.88 to address them. $3.92 saved for every dollar spent. Strategy 2: Encourage business and indus- try to interact with all other sectors to identify opportunities to promote physical activity within Linkage to the National the workplace and throughout society. J&J rec- Activity Plan ognizes the importance of affecting change in the external community as a strategy for main- The J&J programs have a natural synergy with taining change within the organization. In a the efforts described for the Business and recent article, Jack Groppel, cofounder of the Industry Sector of the U.S. National Physical Human Performance Institute, a J&J company, Activity Plan: explored the possibility of achieving effective Strategy 1: Identify, summarize, and dissemi- community behavior change through the appli- nate best practices, models, and evidence-based cation of sport science. According to Groppel, physical activity interventions in the workplace. helping people understand their missions and By providing a consistent approach to deliver- the reason for movement and wellness is where ing known best practices (to a decentralized community leaders must step in. He implores Johnson & Johnson 235 leaders in the fields of health, physical educa- programs are respected because they continue tion, recreation, and dance to lead the charge by to be completely voluntary, observe all privacy improving awareness, making movement matter regulations and recommendations, and remain on an individual level, and helping individual accessible to present and past employees and communities rewrite their stories. Starting the their families. conversation across sectors is the first step. Strategy 5: Develop a plan for monitoring and (Groppel 2011) evaluating worksite health promotion programs. Strategy 3: Educate business and industry The real success of these programs is often leaders regarding their role as positive agents of seen in the personal stories of employees: No change to promote physical activity and healthy longer required to take cholesterol medication; lifestyles within the workplace and throughout lost 30+ pounds; lowered blood pressure; lost society, giving particular consideration to efforts 5 inches off waistline; quit smoking! These are targeting low-resource populations. The J&J real results attained by real Johnson & Johnson Global Health leadership team sets an annual employees. However, although such anecdotes goal to participate with and give back to exter- help tell the story, it is also critical to rigor- nal organizations (other employers, government ously measure and analyze results. Two studies and nongovernment organizations, academics, have done this. The first, published in Health and professional organizations) through speak- Affairs (Henke et al. 2011), measured the long- ing engagements, benchmarking and sharing term effectiveness of the workplace health and of best practices, and participation on relevant wellness programs to contain costs and reduce boards. Beyond J&J Global Health, the execu- health risks among employees compared with tive business leadership within J&J has helped 16 other large employers (detailed results are develop and implement initiatives such as the mentioned in the Commitment to Health sec- CEO Cancer Gold Standard, a series of cancer- tion of the article). A second study, published in related recommendations developed by the the Journal of Occupational and Environmental CEO Roundtable on Cancer, to fight cancer in Medicine (Carls et al. 2011), found that Johnson workplaces in the United States. & Johnson employees who maintain a healthy In 2008, J&J acquired the Human Perfor- weight have average annual medical costs of mance Institute (HPI) and is continuing the $285 per year, whereas those who gain weight legacy that the institute has brought to the field and are at risk for obesity have average annual of human energy management. The institute’s medical costs of $1,267. Combined, these 30-plus year history is deeply rooted in the arena studies are a testament to the effectiveness of of high performance in the face of enormous the Johnson and Johnson workplace wellness stress, and it continues to reach business lead- programs. ers. In 2009, 24 of the Fortune 100 companies participated in the Corporate Athlete, HPI’s premier training program. Evidence Base Used Strategy 4: Develop legislation and policy During Development agendas that promote employer-sponsored physical activity programs while protecting indi- Although the company has achieved some suc- vidual employees’ and dependents’ rights. J&J cess in this area, physical activity remains a is a leader in the field of employee health and key focus area for J&J given ongoing employee well-being. As a result, other companies and risk assessments, the increasing number of organizations often ask J&J to share opinions predominantly sedentary jobs within the com- or advice on best practices. During the most pany (and the associated risks), and current recent health care reform activities, J&J was literature indicating ever-increasing inactivity asked by the White House to share its best within employee and general populations. Most practices and observations in regard to what recently, the principles of “energy management” works in health and wellness programs. These have been incorporated into the program. 236 Isaac and Vertin
Energy management uses a holistic approach ees make changes and sustain them over the to incorporate personal wellness goals as part long haul. Annual marathons, bikathons, and of a deeper personal mission to improve health. other team events to raise money for charity are This mission provides a long-term goal and popular—employees train for and participate in purpose that drives short-term aspirations and these events year after year. Leveraging social lifestyle changes. (For example, “I am purpose- media has allowed for a virtual community fully making healthier choices so that I can be among remote and global employees in order to fully present and active with my children as encourage and reinforce healthy practices. J&J they grow up.”) Part of this energy management also develops or supports health programs that approach shifts the emphasis from program encourage community residents to take charge goals and corporate objectives to individualized of their health. The Five Steps for Your Health stories and motivation that drive behavior. initiative, for example, trained health care work- Employees are now taught that movement ers to help diabetes patients stay active, eat well, and physical activity are linked to their energy monitor body weight, and increase other posi- levels. There are three key principles of energy tive health behaviors. As an established global management: leader in the field of employee wellness, J&J supports many of its leaders to serve on national • Manage your energy through strategic and international committees and forums in movement, deep breathing, and sleep. order to promote growth and development of • Expand your energy capacity through the field. Therefore, the populations served by strategic exercise. the program are widespread and varied. • Incorporate strategic movement into your daily routine. Lessons Learned The company uses communication and marketing campaigns to remind and motivate The essence of J&J is that it is the “caring” employees to remain active. Some of the cam- health care company. As such, it continues paigns provide video links and training. Some to commit to the health and well-being of its are tailored to the employee (such as those employees. Its employee health programs build from the Move program), whereas others are on the legacy and foundation of the past 125 site-specific and related to activity campaigns years while evolving to meet the challenges and competitions for that location. of the 21st century. An important piece of this J&J recently implemented the concept of journey has been to recognize and understand the health champion as a strategy designed to key lessons along the way: sustain positive changes and ensure that senior • A focus on health risk factors can yield managers, who serve as health champions, are strong results. visible and engaged in health promotion pro- grams in their regions. This approach combines • To sustain health and well-being within an top-down encouragement and regional solu- organization, leadership is critical, includ- tions and encourages employees at all levels to ing that of middle management. get involved. The company’s vice president of • Engaging employees in the program is a human resources, who is an Executive commit- critical success factor. tee board member, leads this effort. • Increased productivity and engagement can generate significant cost savings and Populations Best Served improved performance. • Start small, and build on simple gains to by the Program increase program engagement. Many of the J&J physical activity programs • A seamless and holistic approach at the encourage involvement of family and the com- organizational and individual level will munity. Building this connection helps employ- drive participation and behavior change. Johnson & Johnson 237
• Increasing rates of chronic disease, rising • Identify site-specific population risk factors health care costs, economic downturns, and develop culturally appropriate programs to a stretched work force, and health care address these risk factors. Because J&J oper- reform present the opportunity to improve ates within a diverse range of countries and employees’ health and wellness. operating environments, it introduced “culture • Partnering with policy makers can be an of health” toolkits that assist companies in effective strategy to improve labor pro- developing a local culture of health strategy. ductivity and economic competitiveness. Each operating company may be at a different Successful U.S. strategies and tactics can stage of its health promotion strategy, so the be leveraged in other regions across the toolkits help each site either enhance an exist- world. ing strategy or start from step 1 and develop a fully comprehensive strategy. These lessons highlight the notion that from • Partner with external resources, commu- a business and industry perspective, employee nity leaders, and policy makers to create an health can be positioned as a strategic and environment that focuses on health educa- competitive advantage. Physical activity, fitness, tion and health promotion; this highlights the and human movement are important factors importance of effecting change in the external in the adoption and long-term maintenance of community as a strategy for maintaining change employee health. within the organization. • Strive for continuous improvement by Tips for evaluating and re-evaluating programs and by creating, revising, and resetting goals based on Working Across Sectors emerging trends within employee and general A successful global program depends on the populations. following minimal criteria: • Ensure that upper and middle management Summary personnel provide committed leadership and lead by example. Executive and senior leaders Johnson & Johnson has not written “the end” who have taken the lead in creating a sustain- to the story of bringing physical activity, fitness, able global culture of health have been essential and movement to the workplace but rather has drivers in the alignment of health and business written “to be continued”. J&J will continue priorities. This leadership commitment, coupled to build on its successes and progress toward with challenging goals, has been pivotal in having the healthiest, most engaged workforce making health and wellness programs sustain- possible, allowing for full and productive lives, able at Johnson & Johnson. and providing sustainable and effective ser- vices to improve the health of its employees • Recognize the importance of setting goals, worldwide. establishing a baseline, and assessing progress. In 2009, J&J began to look back at its progress toward the healthiest employee population Additional while considering the next five-year goals. What emerged is Healthy Future 2015, which presents Reading and Resources the five-year goals for corporate citizenship and Arnst, C. 2009, November 23. 10 ways to cut health- sustainability commitments across key strategic care costs now. Business Week. www.businessweek. priorities. Each business sector worldwide has com/magazine/content/09_47/b4156034717852. embedded these goals into its business impera- htm. tives and performance, and the progress of those Carls, G.S., R.Z. Goetzel, R.M. Henke, et al. 2011. The goals (related to employee health) is tracked impact of weight gain or loss on health care costs annually through a global health assessment for employees at the Johnson & Johnson family of tool. companies. J. Occcup. Environ. Med. 53(1):8-16. 238 Isaac and Vertin
Isaac, F., & P. Flynn. 2001. Johnson & Johnson Live for Life® program: Now and then. Am. J. Health References Promot. 15(5):365-67. Bly, J., R.C. Jones, and J.E. Richardson. Impact of Isaac, F. 2010, August. A legacy of health and wellness. worksite health promotion on health care costs and Benefits & Compensation Digest. 47(8):1-15. utilization: evaluation of Johnson & Johnson’s LIVE Ozminkowski, R., D. Ling, R. Goetzel, et. al. 2002. FOR LIFE programs. JAMA. 1986; 256: 235-240. Long-term impact of Johnson & Johnson’s health Goetzel, R., R. Ozminkowski, J. Bruno, et.al. 2002. The & wellness program on health care utilization long-term impact of Johnson & Johnson’s health and expenditures. J. Occcup. Environ. Med. and wellness program on employee health risks. J. 44(1):21-9. Occcup. Environ. Med. 44(5):417-24. Robertson, I., and C. Cooper, Eds. 2011. Well-Being— Groppel, J. 2011. Thinking beyond the playing field. Productivity and Happiness at Work. Great Britain, Journal of Physical Education, Recreation and London: Palgrave McMillan. Dance. 82(6):35-40. Weldon, B. 2011, January/February. Fix the health care Henke, R., R. Goetzel, J. McHugh, and F. Isaac. 2011. crisis, one employee at a time. Harvard Business Recent experience in health promotion at Johnson Review. http://hbr.org/2011/01/web-exclusive-fix- & Johnson: Lower health spending, strong return on the-health-care-crisis-one-employee-at-a-time/ar/1 investment. Health Aff. 30(3):490-9. CHAPTER 28 Building Vitality at IBM Physical Activity and Fitness as One Component of a Comprehensive Strategy for Employee Well-Being
Nicolaas P. Pronk, PhD Megan Benedict, BS HealthPartners and HealthPartners Institute IBM Corporation for Education and Research, and Harvard University
Joyce Young, MD, MPH Stewart Sill, MS IBM Corporation IBM Corporation
NPAP Tactics and Strategies Used in This Program
Business and Industry Sector to promote physical activity and healthy lifestyles within the workplace and throughout society, giv- STRATEGY 1: Identify, summarize, and disseminate best practices, models, and evidence-based physi- ing particular consideration to efforts targeting low- cal activity interventions in the workplace. resource populations. STRATEGY 4: Develop legislation and policy agendas STRATEGY 2: Encourage business and industry to in- teract with all other sectors to identify opportunities that promote employer-sponsored physical activity to promote physical activity within the workplace programs while protecting individual employees’ and throughout society. and dependents’ rights. STRATEGY 5: Develop a plan for monitoring and evalu- STRATEGY 3: Educate business and industry leaders regarding their role as positive agents of change ating worksite health promotion programs.
he IBM Corporation is redefning well- energy and vitality. This approach positions IBM Tness, moving from focusing on health risk employees to be healthy, optimistic, energetic, reduction to building the capacity to fourish. and resilient. The goal is to better meet the emerging needs Physical activity promotion remains an of employees and the company by using mul- important component of the overall Vitality tiple approaches to build employees’ capacity Strategy for IBM. Physical activity and fitness to fourish in business settings that feature fast are integral parts of all dimensions of vitality, pace, constant change, and demand for creative including the physical, mental, emotional, solutions. Building capacity to fourish and and values dimensions. As such, the company thrive offers new and exciting opportunities implements a variety of physical activity pro- for employees to experience higher levels of grams. The program highlighted in this chapter,
Acknowledgments: The support in this project from the following Medift Corporate Services employees is greatly appreciated: Paul Couzelis, PhD, Linda Raymond, Aymii Couzelis, and Debi Kelly.
239 240 Pronk, Young, Benedict, and Sill the Virtual Fitness Center (VFC), has reached to encompass strategies beyond health risk tens of thousands of IBM employees and fami- reduction. Additional programmatic approaches lies over the past decade, improved employees’ need to be included in the overall program health status, and reduced health care costs. options and choices that move into the area of The VFC program is only one component of well-being, a strategy that IBM refers to as its the overall Vitality Strategy of IBM but deploys Vitality Strategy. The Vitality Strategy consid- all five strategies included in the Business and ers four dimensions that collectively refer to an Industry Sector of the National Physical Activ- employee’s overall vitality level: ity Plan. The VFC was introduced by IBM as an online 1. Physical dimension—the ability to respond resource for promoting physical activity after physically to everyday situations. Physical activ- many years of using approaches such as onsite ity remains an integral part of this dimension, fitness centers, campaigns, and other programs which also includes functional movement, (figure 28.1). Although the VFC continues to be nutrition, hydration, and sleep. an important tool in the IBM toolbox for physi- 2. Mental dimension—the capacity to sus- cal activity behavior change, it represents only tain focus and attention. It prepares the mind one part of the overall Vitality Strategy that is for challenging situations, reframes negative designed to improve and optimize the health thoughts, and identifes achievements. Research and well-being of IBM employees across the shows that physical activity is directly relevant corporation. to mental health. Other components include To build the capacity for employees to daily recovery, energized thinking, and meeting flourish and thrive, the IBM program needs preparation.
Figure 28.1 Redefining wellness at IBM. Reprinted, by permission, from IBM Integrated Health Services.
E5691/NPAP/fig28.1/458612/alw/r1 Building Vitality at IBM 241
3. Emotional dimension—the capacity to physical activity options) appears to be larger manage positive and negative emotions. Higher than the sum of all individual physical activity levels of physical activity are associated with programs combined. fewer emotional concerns, even when physical activity is only one of a cluster of modifable Program Description health behaviors. Positive thinking and opti- mism are key components of the emotional This chapter focuses on the VFC, a program dimension. that targets adoption and maintenance of physi- 4. Values dimension—the capacity of a cal activity and fitness within the larger set of person to connect with his or her purpose and employee health initiatives that IBM offers to understand the value of good health. By iden- its employees. The VFC is an Internet-based tifying and prioritizing personal values (i.e., resource that employees can use to participate fguring out what matters most), employees in an online physical activity program. IBM enhance overall vitality. worked with Medifit Corporate Services to develop the program and launched it in 1999. The Vitality Strategy ensures that physical Originally, it adapted the Centers for Disease activity is part of a larger set of programmatic Control and Prevention’s March Into May physi- options from which employees can choose in cal activity campaign into an online applica- order to personalize their own and their fami- tion. However, the VFC evolved over time into lies’ health goals. The strategy recognizes that a state-of-the-art, online interactive behavior physical activity programs are most successful change tool that provides access to information when they are implemented as part of a larger and resources to support year-round physical health and wellness strategy. This observation activity programming. was also noted in the National Physical Activ- IBM has provided access to on-site fitness ity Plan white paper for business and industry. centers and other physical activity programs Although individual physical activity programs for many years. However, not all of the approxi- may result in successful outcomes, the net ben- mately 300 sites across the United States are efit of comprehensive, multicomponent, mul- large enough to house a fitness center, and tilevel worksite health programs (that include a large number of employees work remotely.
Figure 28.2 Some of the features shown on the VFC website. Reprinted, by permission, from IBM Integrated HealthE5691/NPAP/fig28.2a-c/458613/alw/r1 Services. 242 Pronk, Young, Benedict, and Sill
Hence, creating an online resource for promot- physical activity trend over time and progress ing physical activity improved access signifi- by specific exercise categories (figure 28.3). cantly. • Ask Our Pros online Q&A—Participants The VFC program includes several key can submit questions via an online portal and features that are fundamental to supporting receive answers from professionally trained behavior change (see figure 28.2): and certified staff. Fitness staff members use • Goal setting—Employees can establish the most common questions to develop e-mail and monitor customized physical activity goals messages for all program participants. across a variety of aerobic (e.g., walking, run- • Incentives—In 2004, IBM enhanced its ning, cycling) and nonaerobic (e.g., strength commitment to physical activity promotion by training, flexibility) activities. adding the Healthy Living Rebate, a $150 cash • Activity logging—The VFC provides physi- incentive for employees who participate in the cal activity logs to keep track of activities per- VFC program. Employees are eligible to receive formed. Employees can use month-by-month the incentive if they elect to participate during calendar views to monitor their progress. the annual fall benefits enrollment, join the VFC program, log their minutes of physical activity • Team-based 12-week seasonal program online, and engage in at least 20 minutes of campaigns throughout the year—Workout cam- physical activity, three days per week, for 10 of paigns offered during the winter, summer, and 12 consecutive weeks. fall provide opportunities for teams to engage in friendly competition while moving toward achieving physical activity goals. The program Linkage to National provides weekly motivational messages via e-mail, and the campaigns often offer small Physical Activity Plan incentives such as pedometers, books, or other IBM’s efforts meet all five strategies of the token items. Business and Industry Sector of the National • Progress reports—Participants can monitor Physical Activity Plan. their progress in the program by viewing activ- Strategy 1: Identify, summarize, and dissemi- ity graphs in the VFC, including graphs of the nate best practices, models, and evidence-based
Figure 28.3 Progress report, Q&A, andE5691/NPAP/fig28.3a-c/458616/alw/r1 incentives features of the VFC website. Reprinted, by permission, from IBM Integrated Health Services. Building Vitality at IBM 243 physical activity interventions in the workplace. of employees includes investing in prevention Through the VFC program and the broader and primary care, developing programs for Vitality Strategy, IBM has become a best practice healthy lifestyles among employees and their organization for promoting physical activity and families, and scaling programs and services fitness. The web-based delivery of the VFC is through web-based health care tools in ways supported by comprehensive health plan cover- that enable employees to be informed, acti- age for preventive care and wellness and healthy vated, and engaged in their health care. This workplace environment policies and initiatives. strategy entails developing supportive policies The VFC program is highly scalable and can be at the workplace and playing an active role in applied to all types of worksites and workforces. collaborations with other employers through Strategy 2: Encourage business and indus- coalitions such as the National Business Group try to interact with all other sectors to identify on Health. opportunities to promote physical activity within Strategy 5: Develop a plan for monitoring the workplace and throughout society. IBM is and evaluating worksite health promotion pro- a well-recognized leader with a strong track grams. Monitoring and evaluation of worksite record of working across sectors to encourage health promotion programs are integral parts of physical activity within the workplace and IBM’s process for managing employee health throughout society. The company plays key programs. Independent researchers have con- leadership roles in organizations and initiatives ducted formal evaluations of the VFC program, such as the National Business Group on Health, and the results are published and shared in the the Institute of Medicine, efforts to address public domain so that the field can learn from childhood obesity, and efforts to establish the the IBM experiences. patient-centered medical home, among others. Within each of these examples, physical activity plays a central role related to preventing disease Program Evaluation or optimizing health. IBM implemented the VFC in 1999, and ini- Strategy 3: Educate business and industry tially it generated approximately 16,000 users leaders regarding their role as positive agents of per year. However, when the company added change to promote physical activity and healthy the Healthy Living Rebate incentive program lifestyles within the workplace and throughout in 2004, participation increased significantly, society, giving particular consideration to efforts to an average of more than 80,000 participants targeting low-resource populations. Strong per year. Although participation statistics are leadership within IBM continues to promote important, the company wanted more informa- an agenda that focuses on promoting health tion and a more extensive evaluation. Formal and well-being, reducing risk, and creating the research conducted by independent researchers capacity to flourish. This agenda applies to all was designed to answer two questions: employees regardless of income, race, gender, or health risk status. The company’s integrated 1. Is a financial incentive for participation approach brings together components of occu- in an online physical activity program pational medicine, industrial hygiene, safety, associated with increased employee health benefits, and wellness and implements participation and improved health status programs that are proactive, relevant, and effec- among participants compared with non- tive in managing the highly complex, diverse, participants? and ever-changing health and safety needs of 2. Is participation in an incentive-based the employees. online physical activity program for Strategy 4: Develop legislation and policy employees associated with moderation agendas that promote employer-sponsored of health care costs? physical activity programs while protecting indi- vidual employees’ and dependents’ rights. The Research on question 1 was conducted IBM global strategy for improving the health among VFC participants and nonparticipants 244 Pronk, Young, Benedict, and Sill during 2004 and was based on responses to a well-being. Epidemiological data clearly show health risk appraisal. Among the 126,372 eli- the importance of physical activity in disease gible employees, 78,952 (62.5 percent) enrolled prevention, health maintenance, and functional in the VFC and 67,324 (53.3 percent) were status, including work performance. Senior considered active participants. This 53 percent health managers have been guided by national active participation rate represents an increase guidelines for physical activity, the results of over the prior year of almost 400 percent (16,777 major intervention studies, and the Guide to participants of 129,628 eligible employees). Community Preventive Services. The scientific On average, health risks related to low physi- literature on self-monitoring techniques, stages of cal activity were reduced by −8.2 percentage change, social support, incentives, and exercise points (a 52 percent relative reduction) among science has played an important role in IBM’s VFC participants. In addition, participants program design approach. The company has experienced significant improvements in life continuously translated research findings into satisfaction, perception of health, risk status, practical tools and approaches, tested these tools smoking, and body weight. Although improve- in real-life workplace settings, and revised and ments were greatest among VFC participants improved programs based on the results of this who completed enough physical activity to testing. This cycle of continuous improvement is earn the rebate incentive, all VFC participants an integral part of the IBM wellness management demonstrated significant improvements. system and allows for innovations to improve The study that addressed question 2 consid- after they are introduced into practice. ered the trends in health care claims from 2003 to 2005 among a matched sample of participants and nonparticipants. Medical, pharmacy, hos- Lessons Learned pital inpatient, and emergency room costs were Several observations are recognized by the pro- examined. Results of this analysis indicated gram staff as important lessons learned. These that average annual health care expenditures lessons relate to the program’s reach, the degree among VFC participants increased by $291 per of engagement over time, the type and diversity year, compared with an increase of $360 per of workers involved, the role of champions and year among nonparticipants (p = .09). The local leaders, and the importance of capturing study found significant differences between the program’s value. participants and nonparticipants for inpatient hospital costs, heart disease costs, and costs Maximize Employee Engagement to treat diabetes. In addition, higher levels of participation were associated with smaller Worksite health promotion efforts have tra- increases in health care costs. ditionally been plagued by low participation In general, the results of formal research rates and, therefore, limited impact. Employee studies on the VFC program indicated that a engagement relies on creative approaches that cash incentive can boost participation in an maximize visibility and interest. IBM’s Healthy online physical activity program, reduce popu- Living Rebate programs have provided signifi- lation health risks, and, as a result, reduce the cant exposure to wellness initiatives and stimu- increase in health care costs among participat- lated positive employee response. Increasing ing employees. intervention penetration in this way is the first step in influencing the population. Evidence Base Used During Reach a Diverse, Dispersed Program Development Employee Population A strong evidence base undergirds the design Facilitating employee access to health and well- of the VFC and IBM’s approach to health and ness programs is challenging when employees Building Vitality at IBM 245 live in many locations and participate in a wide its implementation among employees of a range of work arrangements. IBM’s 300-plus single company. It is reasonable, however, to U.S. worksites and its increasing population of consider this a highly scalable program across mobile and remote employees require unique participant age (with a range of at least 18-65 approaches to employee engagement. Variety years), gender, income level, race, and ethnicity and flexibility are key program attributes for groups. It is also reasonable to consider that this such a diverse population, which has a wide program may be effective among various types range of needs, interests, and motivations. IBM of industry (service, manufacturing), business has determined that using multiple delivery environments (union, nonunion), and company mechanisms, including online, telephone, on- sizes (small, medium, large). Obviously, a limi- site, and hard copy materials, leads to maximum tation is the fact that it is implemented online. population impact. Health champions provide peer support and encouragement. The volunteer team captains in Tips for the VFC programs serve as influential models Working Across Sectors of healthy behavior and mentors to those need- ing assistance. Company management support The following recommendations can facilitate for wellness initiatives has also contributed to efforts to implement similar programs across consistent delivery and engagement. various sectors in the community setting: Demonstrate the Value of Well- • Ensure equitable access to online resources. • Address any disparities in health literacy, Being as a Personal Benefit web-based training and knowledge, and IBM’s wellness communications strategy incor- language. porates a key concept of behavior change science, • Translate implementation processes from that the benefits of engaging in healthy behaviors the worksite setting into the specifics of must outweigh the barriers in order for people the other sectors, for example, a commu- to take action. As many program messages as nity setting, an education or school setting, possible highlight the value of maintaining and or a health care setting. improving health status. Leading employees to measure and record their individual results is a key component of this strategy. This focus helps Additional them recognize the personal outcomes they Reading and Resources achieve from their healthy living efforts. A Per- sonal Outcomes Assessment feature is included Books on the VFC to measure fitness, central body Committee to Assess Worksite Preventive Health Pro- fat, and energy balance so that participants can gram Needs for NASA Employees, Food and Nutri- determine the specific impact of their physical tion Board. 2005. Integrating Employee Health: A activity behaviors. Use of the Personal Outcomes Model Program for NASA. Institute of Medicine, Assessment reinforces the value of well-being to National Academy of Sciences. Washington, D.C. the individual and helps him or her refine actions Prochaska, J.O., C.A. Redding, and K.E. Evers. 1997. to better achieve personal targets. The transtheoretical model and stages of change. In: Health Behavior and Health Education: Theory, Research, and Practice (pp. 60-84). 2nd ed. K. Glanz, Populations Best Served F.M. Lewis, and B.K. Rimer, Eds. San Francisco: by the Program Jossey-Bass. Seligman, M.P. 2011. Flourish: A Visionary New Under- The VFC program was designed for active standing of Happiness and Well-Being. New York: adult employees, and this chapter reports on Free Press. 246 Pronk, Young, Benedict, and Sill
Articles optimal lifestyle adherence and short-term incidence Helsel, D.L., J.M. Jakicic, and A.D. Otto. 2007. Com- of chronic conditions among employees. Popul. parison of techniques for self monitoring, eating Health Manag. 13(6):289-95. and exercise behaviors on weight loss in a corre- Pronk, N.P., A.S. Katz, J. Gallagher, E. Austin, D. spondence-based intervention. J. Am. Diet. Assoc. Mullen, M. Lowry, and T.W. Kottke. 2011. Adherence 107:1807-10. to optimal lifestyle behaviors is related to emotional Herman, C.W., S. Musich, C. Lu, S. Sill, J.M. Young, health indicators among employees. Popul. Health and D.E. Edington. 2006. Effectiveness of an incen- Manag. 14(2):59-67. tive-based online physical activity intervention on Sepúlveda, M-J., C. Lu, S. Sill, J.M. Young, and D.W. employee health status. J. Occup. Environ. Med. Edington. 2010. An observational study of an 48(9):889-95. employer intervention for children’s healthy weight Keyes, C., and J.G. Grzywacz. 2005. Health as a com- behaviors. Pediatrics 128(5):1153-60. plete state: The added value in work performance and health care costs. J. Occup. Environ. Med. Other Materials and Web-Based 47(5):523-32. Resources Lu, C., A.B. Schultz, S. Sill, R. Petersen, J.M. Young, and D.W. Edington. 2008. Effects of an incentive-based The National Physical Activity Plan website: www. online physical activity intervention on health care physicalactivityplan.org/index.php costs. J. Occup. Environ. Med. 50(11):1209-15. The National Physical Activity Plan Business and Indus- Pronk, N.P. 2009. Physical activity promotion in busi- try Sector web pages including the strategies and ness and industry: Evidence, context, and recom- tactics: www.physicalactivityplan.org/theplan.php mendations for a national plan. J. Physical Activity and www.physicalactivityplan.org/business.php Health. 6 (Suppl. 2), S220-S235. Guide to Community Preventive Services and the Task Pronk, N.P., M. Lowry, T.E. Kottke, E. Austin, J. Gal- Force on Community Preventive Services: www. lagher, and E. Katz. 2010. The association between thecommunityguide.org/index.html Sector VI Public Health
Jackie Epping, MEd U.S. Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and Obesity
he public health sector plays a critical role at all levels, conducting PAPH surveillance, and Tin promoting physical activity at the popu- evaluating programs and policies to promote lation level. Physical activity is fundamental to physical activity. These roles are specifcally maintaining health and preventing disease, and identifed within the fve strategies outlined in public health organizations and professionals the Public Health Sector of the National Physi- are responsible for monitoring, protecting, and cal Activity Plan. promoting the public’s health. As the feld of The chapters in this section illustrate the physical activity and public health has grown ways that public health organizations and pro- and evolved, particularly over the past decade, fessionals promote physical activity in a variety several key roles for the public health sector of settings and contexts. The section includes have emerged. One of those roles is developing case studies of cross-sectoral collaborations to and maintaining a diverse and competent physi- promote physical activity, including collabora- cal activity and public health (PAPH) work- tions that use health impact assessments to force, which requires developing professional inform policy decisions about land use. The standards, creating and providing professional section also describes programs that are devel- development opportunities, connecting PAPH oping the PAPH workforce at both the state and professionals, and developing and providing national levels. One chapter discusses the use of physical activity resources. Another role is surveillance and evaluation to inform physical creating, maintaining, and leveraging partner- activity policy, and two chapters describe the ships and coalitions that can promote physical process of developing state physical activity activity across all sectors of society. Because plans. the public health sector exists at the national, The authors and editors hope that these chap- state, and local levels, it is well positioned to ters will provide useful examples of the roles convene and connect partners and stakeholders the public health sector can play in advancing at multiple levels and across many sectors. The the field of physical activity and public health public health sector also can engage in PAPH and promoting physical activity at the popula- policy development by educating policy makers tion level.
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CHAPTER 29 State-Based Efforts for Physical Activity Planning Experience From Texas and West Virginia
Eloise Elliott, PhD Donna C. Nichols, MSEd, CHES West Virginia University University of Texas Health Science Center - Houston Emily Jones, PhD Tinker D. Murray, PhD West Virginia University Texas State University Harold W. Kohl, III, PhD University of Texas Health Science Center – Houston and University of Texas at Austin
NPAP Tactics and Strategies Used in This Program
Public Health Sector faith communities; mass media; and organizations serving historically underserved and understudied STRATEGY 2: Create, maintain, and leverage cross- sector partnerships and coalitions that implement populations. effective strategies to promote physical activity. OVERARCHING STRATEGY 3: Disseminate best practice Partnerships should include representatives from physical activity models, programs, and policies to public health; health care; education; parks, rec- the widest extent practicable to ensure Americans reation, fitness, and sports; transportation, urban can access strategies that will enable them to meet design, and community planning; business and federal physical activity guidelines. industry; volunteer and non-profit organizations;
lanning is an essential function for public Historically, state health departments have Phealth. Strategic public health planning developed public health plans to reflect state allows agencies and organizations to set pri- health priorities, which are usually tied to fund- orities for action, ensures access to services ing sources. U.S. federal and private funding and activities across a broad population, and sources often require states that request fund- helps develop essential partnerships across and ing to have a formal plan for using the funding within sectors to identify and achieve common and other resources. State plans often address goals. Nations, states, and local governments cardiovascular disease, diabetes, tobacco con- have established public health plans to address trol, cancer, obesity, and other major areas a wide range of health problems (Kohl et al. of public health concern. Some state plans 2012). Planning is key to addressing public include physical activity in sections or plans health problems and maximizing the health that address noncommunicable diseases, but of populations, because although plans don’t until very recently no state plans have focused ensure success, success is much less likely specifically on physical activity. without a plan. 249 250 Elliott, Jones, Nichols, Murray, and Kohl
The development of the U.S. National Physi- instead of a specific state agency allowed for cal Activity Plan (NPAP) emphasized physical flexibility to leverage partnerships across a wide activity as an independent public health prior- variety of agencies and organizations. ity and focused attention on the importance of physical activity planning (Pate 2009). NPAP Capacity Building provides a key framework for translating and mobilizing efforts at the state and local levels. In January 2009, state planners organized a In this chapter, we describe two state efforts two-day conference in Austin to gather input that resulted from the development of NPAP on developing a state plan for making physical and were designed to make physical activity activity a health priority. Known as the Fit City a state public health priority through public Summit, the conference attracted community health planning efforts. leaders, elected officials, representatives of state and municipal agencies, and other interested stakeholders. The summit was hosted by the Texas Program Description— mayor of Austin, and several state-level offi- Active Texas 2020 cials participated. Approximately 400 people attended this meeting. While the National Physical Activity Plan was During the summit, breakout sessions being conceptualized and formulated, Texas addressed several key questions. These ses- convened a steering committee in mid-2008 to sions, organized by sector (schools, work sites, determine how to make the U.S. national plan transportation, health, parks and recreation) relevant to Texas. The committee, consisting of were designed to get maximal input from local School of Public Health faculty, other academic leaders about how municipalities in the state leaders, and members of the Texas Governor’s could make physical activity a health priority. Advisory Council on Physical Fitness (GCPF), Each session began with a review of evidence- discussed strategies and approaches to making based strategies for promoting physical activity, physical activity a health priority in the state. and moderators were prepared with discussion The steering committee decided to back an points to lead the discussion. Extensive notes effort to develop a statewide planning docu- were obtained from each 90-minute session. ment for physical activity. Active Texas 2020, These notes and the session summary were the Texas physical activity plan, resulted from used to inform the development of the state this effort (Active Texas 2020, 2012). plan. The partnership between the School of Public After gathering input from the summit, a Health and the GCPF was advantageous for sev- writing group began to draft the state plan. This eral reasons. First, the GCPF is a group of state effort was supported by a small development leaders already committed to physical activity. grant from the Directors of Health Promotion These leaders strongly supported the idea of a and Education, a national nonprofit public state physical activity plan. Second, the School health organization. The writing group circu- of Public Health was able to provide expertise lated drafts to various leaders and requested in public health planning. Third, developing a feedback and input. The group then posted plan under the auspices of the GCPF provided a penultimate draft on the internet for public structure for the plan and created avenues for comment. The Texas state plan for promoting developing partnerships and involving mul- physical activity—Active Texas 2020—was final- tiple sectors. This allowed the Texas planners ized in September 2010. to avoid the limited buy-in that often occurs The vision of Active Texas 2020 is that “Texas when one agency develops a state plan (e.g., will succeed in efforts to improve health by if the state health department develops a plan, making physical activity a health priority across then implementing the plan becomes the sole the state.” An overarching theme of Active Texas responsibility of the health department) and 2020 is to enable and empower local leaders to positioned physical activity as a multisectoral advance physical activity as a health priority. problem that must be addressed on many fronts. Active Texas 2020 assumes that state and local Fourth, housing the plan in the governor’s office leaders across Texas share a sense of priority Physical Activity Planning in Texas and West Virginia 251 for improving health and that a key strategy to can develop strategies for effectively promoting improve health is to increase physical activity. physical activity. Guided by that assumption, Active Texas 2020 focuses on informing and supporting commu- Plan Development nity leaders across the state to take action and make changes that will increase physical activ- Eight guiding principles form the foundation ity in their communities. The six main sections for Active Texas 2020 (table 29.1). These prin- of the plan highlight ways that local leaders ciples were established to ensure that efforts to
Table 29.1 Guiding Principles for Active Texas 2020 Principle Rationale Physical activity improves health. Active Texas 2020 relies on recent public health guide- lines (U.S. Department of Health and Human Services 2008) and the vast scientific literature on physical activity and health. Public health approaches to increasing Individually based promotion programs are effective for physical activity are needed to improve the individuals; public health approaches are needed for health of populations. populations. Make the healthier choice the easier choice. Public health approaches can focus on removing barriers and promoting enablers for physical activity where people eat, work, play, and pray. All health is local. The emphasis on improving health through increased physical activity must take place at the community level. National and state health officials can and should provide a scientific and policy context and information, tools, and resources for making changes that will improve health. However, local leaders hold the power to make neces- sary changes. Health is everyone’s business. In addition to the health benefits of physical activity, sub- stantial economic benefits can be realized with a popula- tion that is more physically active. Prioritize leadership collaboration and part- Success in changing communities to promote physical nerships. activity will require community leaders to create collabor- ative partnerships with a diverse set of partners, including elected officials, business leaders, faith-based organiza- tions, medical professionals, nonprofits, school districts, neighborhoods, and more. Work from the evidence base. Strategies for successful physical activity promotion must be rooted in the scientific evidence. Nothing is gained (and much can be lost) if non-effective or non-recom- mended strategies are implemented. Evaluate effectiveness. Fundamentally, evaluating the effectiveness of any implemented strategy is a core element of public health practice. Evaluation of the strategies used is critical to understanding how the population’s health has changed with certain interventions. The evaluation should pro- vide further evidence of which practices are effective for increasing activity and which are not. 252 Elliott, Jones, Nichols, Murray, and Kohl increase physical activity to improve health will West Virginia Program focus on effective leadership, evidence-based recommendations, and actionable strategies. Description—Active WV 2015 Although West Virginia has a number of Measuring Plan Success health problems and disparities, it also has a Implementation and evaluation efforts for population of enthusiastic citizens and lead- Active Texas 2020 are ongoing. The emphasis ers who are dedicated to improving the state on local actions for physical activity promotion and, specifically, improving the health of the extends to the measurement and evaluation of state’s citizens. These citizens and leaders have success. A guiding principle used in developing worked across sectors to address a number of the plan (table 29.1) addresses effectiveness health issues. For example, state government evaluation. Process and outcome evaluation has passed legislation related to health promo- strategies are ideal for evaluation of Active Texas tion, including improved physical education and 2020. Because local actions to promote physi- nutrition offerings in schools; state agencies cal activity will differ, a cookbook approach have adopted policies and developed plans to to evaluation was not supportable; rather, the include physical activity promotion and prac- importance of doing the work and collecting tice; nonprofit organizations are spearheading appropriate data relevant to a local community’s programs that educate children and adults about goals is emphasized. the need for physical activity and are provid- Currently, the state has not identified ing suggestions for community initiatives; and resources to evaluate overall dissemination, community groups are stepping up to showcase diffusion, and implementation strategies for local projects that are working in their commu- Active Texas 2020, although efforts to secure nities. These efforts reflect a state ready to make evaluation resources are underway. positive changes in the health and well-being of its citizens. However, the missing element among all of these efforts is a strategic vision The National Physical Activity to unify activities to address increasing health Plan as the Foundation care costs, the need for environmental changes, and the prevalence of chronic diseases. The NPAP provided the framework for translat- Based on recommendations from the NPAP, a ing and mobilizing efforts at the state level. The statewide initiative to develop a physical activity activity at the national level helped to justify plan for West Virginia was born. Active WV is attention and commitments at the state level. designed to provide a strategic vision and direc- The evidence-informed strategies within the tion to create a culture that facilitates physically NPAP were used to develop the strategies and active lifestyles in every societal sector and tactics that provide the foundation for Active region of the state, regardless of barriers. Active Texas 2020. WV provides the strategic vision and represents the collective voice of West Virginians pro- Concluding Comments claiming the values and physical activity needs Active Texas 2020 is one of the first state-level of our state. The following sections provide physical activity plans in the United States. an overview of the capacity-building efforts, It was designed to make physical activity a development process, launch, and measures of health priority in the state by providing specific success of Active WV. strategies for local design and implementation of physical activity promotion. The plan can Capacity Building be used to enhance existing planning efforts For Active WV to effectively guide state and regarding noncommunicable disease because local policies and practices, key individuals of the role that physical activity plays in pro- needed to be involved in every step of the devel- moting health. opment, implementation, and dissemination. Physical Activity Planning in Texas and West Virginia 253
The target audience of Active WV consists of leaders included the governor’s chief of staff, three main constituency groups: (1) state and members of a joint Senate and House health local policy leaders, (2) key stakeholders who committee, funding officers of foundations, represent state and local organizations and directors of state agencies, and health coalition groups in each sector, and (3) West Virginia leaders. Many key partnerships transpired from citizens. Individuals in each group serve as lead- the recommendations that emerged from these ers, contributors, and advocates in the process meetings, and the leaders provided advice on of creating a physically active West Virginia. Key coordinating strategies to involve government, capacity building efforts involved in creating funding agencies, and local decision makers Active WV are described next. (e.g., county commissioners). The opportunity to inform these key stakeholders at the begin- Establishing Organizational ning of the planning process proved to be sig- Governance nificant in moving forward. Following the May 2010 release of the NPAP, Establishing Sector Teams a multidisciplinary group of researchers and organizational leaders from across West Virginia and Organizational Partners convened to discuss the potential of a statewide Another Active WV capacity-building strategy physical activity plan. Participants concluded used the NPAP’s eight-sector framework to that West Virginia needed strategic direction for identify targeted population groups. Unique to physical activity promotion, and the Active WV Active WV, a policy group was added to the list coordinating committee, which would serve as of sectors in an attempt to intentionally involve the primary governing body of the statewide those who may directly influence state, regional, initiative, was established. The coordinating and local policies related to physical activity and committee, whose members represent a variety health. As a result, the representative sectors of social and professional sectors, determined included education; public health; business and that the goal of Active WV would be “to serve industry; volunteer and nonprofit; parks, recre- as a blueprint for connecting, supporting, and ation, fitness, and sports; transportation, land building upon existing efforts within the state,” use, and community design; health care; mass while focusing on strategies that would require media; and policy. Participation and leadership policy, environmental, and systems changes at of key stakeholders within each sector was both the state and local levels. To that end, the formalized through the development of sector committee identified key factors for ensuring teams. The sector teams consist of 70 leaders the effectiveness of the plan, including (1) input from organizations such as state government, and participation from all sectors, as identified local health departments, county and city lead- in the NPAP; (2) a unified leadership team of ers, medical schools, community and worksite dedicated state and local stakeholders working wellness programs, and state media outlets. toward a solution; and (3) policy leaders who These teams, each of which is led by a team see physical activity as a health priority in the leader, finalized the development of the plan state and will advocate for policy and envi- strategies and tactics for their respective sectors. ronmental changes to provide more localized This 70-member group continues to lead efforts physical activity opportunities. to implement the plan statewide and at the community level. The roles of the sector team Garnering Support From Policy members and the team leaders were adapted Leaders and Key Stakeholders from the NPAP and are outlined in table 29.2. During the early stages of conceptualizing and Hosting a Statewide Event developing the plan, the chair of the Active WV coordinating committee met with many state The first West Virginia Physical Activity Sym- government officials and health policy lead- posium was held in Charleston in June 2010 ers to increase the visibility of Active WV and as the initial step in developing a working to seek advice and recommendations. These plan that could potentially change the state’s 254 Elliott, Jones, Nichols, Murray, and Kohl
Table 29.2 Roles of Sector Leaders and Sector Team Representatives Sector leaders Sector team representatives • Review national strategies from the NPAP and make • Review national strategies from the NPAP and make recommendation for refinement for West Virginia, recommendation for refinement for West Virginia, based on the outcomes of West Virginia systematic based on the outcomes of West Virginia systematic analyses analyses • Designate leaders for specific strategies within a sec- • Contribute to the final development of Active WV tor strategies and tactics • Lead the final development of Active WV strategies • Advocate for changes in policies and practices that and tactics will influence physical activity behaviors • Set forth changes in policies and practices that will • Influence plan implementation on the state and local influence PA behaviors levels • Advise and influence plan implementation • Represent the plan within their respective organiza- • Support state and local advocacy related to the plan tions and throughout the sector • Represent the plan within their respective organiza- • Encourage community action tions and throughout the sector physical activity culture. The intent of the two- ers and gaps. Data from these working groups day symposium was to bring together as many informed the development of the final strategies people as possible from all nine sectors and all and tactics for Active WV. regions of the state to learn about the NPAP, showcase what is currently happening in West Securing Financial Support Virginia related to physical activity programs Three organizational partners, including two and research, and build awareness and support university-based programs and a statewide for a statewide strategic plan for physical activ- nonprofit physical activity advocacy group, ity. More than 250 participants representing all provided the primary resources for the devel- sectors and regions of the state attended the opment of Active WV. Many businesses, orga- event. Seven nationally recognized speakers, nizations, agencies, and a regional foundation including the chair of the NPAP coordinating provided support for the statewide symposium. committee, shared national and global perspec- Efforts are underway to secure financial support tives on physical activity related to all of the and resources for implementing, disseminating, sectors. More than 50 West Virginia programs and evaluating Active WV. and research projects presented information in either poster or oral formats. The West Virginia Plan Development governor and first lady provided support for the The coordinating committee used a systematic event, including an all-conference reception at process to develop the plan and to ensure input the governor’s mansion. Celebrities who carry from a wide range of audiences, sectors, and the message for increased physical activity regions. Input used in formulating the final participated and truly enhanced the symposium written plan came from four sources—the program. Twenty-three organizations and agen- NPAP’s strategies and tactics, results of the West cies sponsored or contributed to the success Virginia Physical Activity Symposium sector of the symposium. During day 2, sector and working groups, results of an online concept regional working group sessions began the mapping exercise, and sector team expertise. process of gathering input pertinent to develop- ing the plan. Small group discussions, focused National Physical Activity Plan on some of the NPAP strategies in each sector, as the Foundation resulted in sector-specific recommendations for The NPAP provided the framework for translat- action steps and identification of regional barri- ing and mobilizing efforts at the state level. The Physical Activity Planning in Texas and West Virginia 255 evidence-informed strategies and tactics within area, each sector team generated one specific the NPAP underpinned the Active WV strategies strategy that best represented its sector. Tactics, and tactics, although planners considered the or action steps, for each strategy were then contextual variables specific to West Virginia. considered from all data sources. Each sector team selected five top tactics that team members Concept Mapping Exercise believed could be achieved in the next five years In an attempt to gather input from citizens for inclusion in the final written plan. The Activ throughout the state regarding the need for eWV plan development subcommittee finalized physical activity policy and environmental the written document and, after public review, changes, Active WV planners used an inte- prepared it for widespread dissemination. grated, web-based approach called concept map- ping. Concept mapping is a strategy used to help Release of Active WV 2015 show connections between ideas and concepts, and it proved to be a valuable tool for gathering Active WV 2015: The West Virginia Physical and synthesizing strategies for the statewide Activity Plan was officially released on Janu- plan. For the purposes of Active WV, planners ary 19, 2012, at the State Capitol in Charleston implemented a multiphase concept mapping (Active WV n.d.). The all-day event at the process. The four phases included brainstorm- Capitol included displays, physical activity ing; statement analysis and synthesis; sorting demonstration groups, state dignitaries and key and rating of statements; and data analysis and stakeholders, and two national celebrities who interpretation. The actions and results of each are role models for physical activity. A launch phase of the concept mapping exercise and plan ceremony included the signing of a declaration development are shown in table 29.3. by the governor to make the day West Virginia Physical Activity Day, a proclamation by the Face-to-Face Sector Team Meeting West Virginia Legislative Senate to make physi- At a face-to-face meeting, sector team partici- cal activity a health priority, and support mes- pants (N = 72) wrote sector-specific strategies sages from West Virginia congressional leaders. for each of the five priority areas identified by Across the state, schools and communities sup- the concept mapping process. For each priority ported the launch of Active WV by hosting local
Table 29.3 Phases of the Concept Mapping Process Phase Action Result Phase 1: brainstorming Informational Active WV webinar 154 participants from all sectors Invitation to respond to a prompt that responded to the prompt. encouraged submission of ideas 240 ideas generated Phase 2: statement analy- Review of the 240 ideas 61 single-idea, physical activity- sis and synthesis Elimination of non–physical activity related statements were generated. ideas Synthesis of similar ideas into single-statements Phase 3: sorting and rating Statements sorted into like groups Five discrete priority areas for Ac- of statements Statements rated on importance and tive WV were determined. feasibility scales Phase 4: data analysis and Informational Active WV webinar Sector-specific Active WV strate- interpretation Sector team review of priority areas gies and tactics were identified and and statements finalized. 256 Elliott, Jones, Nichols, Murray, and Kohl events. A powerful example was the participa- Concluding Comments tion of the schools throughout West Virginia. In conjunction with the West Virginia Department With a comprehensive physical activity blue- of Education’s Office of Healthy Schools Let’s print now in place, West Virginia is poised to Move WV initiative, 100,652 students (from 313 influence the culture of physical activity state- schools) did a popular line dance simultane- wide. Through the organizational partnerships ously at 1:00 p.m. to highlight physical activity developed as a result of the sector teams, and in the schools. Also, 44 county commission- through positive leadership of policy leaders, ers (out of 55) signed resolutions to support West Virginia may now make physical activ- increased physical activity in the communities ity a primary health priority. Communication where West Virginia citizens live, learn, work, and implementation, however, will drive its and play. Key television, radio, and newspaper success. Lead organizations and groups must media outlets participated in both the capitol step up and assume primary roles in advocacy, event as well as many local happenings. implementation, and evaluation. Funding Shortly after the release of the plan, the sector must be secured to support these endeavors as teams were reconvened for another face-to-face well as to create a state coordinator position meeting to begin formulating the implementa- to ensure accountability, continuity, and sus- tion plan and to make recommendations for the tainability. Communities must be targeted as next steps in implementation, dissemination, the real venues for change. An ongoing social and evaluation of Active WV. marketing campaign is needed to raise aware- ness of the importance of physical activity, and Measuring Plan Success community leaders will need action strategies to guide implementation of the plan at the local Although the ultimate goal of the plan is to level. Community groups interested in physical increase physical activity among all West Vir- activity promotion will need support, including ginians, other more immediate measures of strategies for assessing local needs, overcoming effectiveness are whether barriers, planning interventions, and evaluating • state and local organizations adopt the outcomes. Evaluation of the plan’s success must plan’s strategies, focus on the community. As with the initial plan development process, there must remain a • local communities implement the action- focus on “one vision, one voice.” West Virginia able tactics that are outlined in the plan, still has much work ahead to make a difference and in the health and quality of life of its citizens. • West Virginia policy makers and other key The West Virginia Physical Activity Plan is a stakeholders support and enact change for step toward success—toward Active WV 2015. improved physical activity opportunities. Process, impact, and outcome evaluation Linkage to National methods were developed at the state and Physical Activity Plan local levels. Process evaluation will review and document the plan development process. Although the physical activity plans in Texas Impact evaluation will examine the short-term and West Virginia were developed by processes impact of program interventions and dissemi- different than that of the NPAP, both plans have nate efforts on the physical activity behaviors; elements that include the eight sectors and strat- public awareness; and policy, system, and egies of the NPAP. The local articulation of the environmental changes within the state. Finally, overarching vision of the NPAP is a common outcome evaluation methods will monitor the thread between the two state plans. Other long-term influence on statewide public health states can use these models to develop local- goals related to physical activity. ized plans using the NPAP as a framework that Physical Activity Planning in Texas and West Virginia 257 create, maintain, and leverage cross-sectional is a relevant issue (e.g., public health, edu- partnerships and coalitions that can be used cation, economic development, health care, for physical activity promotion. transportation). As a result, physical activity promotion becomes everyone’s responsibility and physical activity becomes a public health Lessons Learned priority for the entire population. After all, the State-level planning for physical activity is rare, goal of the NPAP is to “improve health, prevent but the need for such action has never been disease and disability, and enhance quality of clearer. When the NPAP was released in 2010, life” (National Physical Activity Plan 2010); this it called for grassroots efforts to mobilize and can become a reality when states invest in and support strategies and tactics nationally but also take steps to change the environments, systems, provided an evidence-based blueprint to enable and policies that can affect the physical activity states to develop their own physical activity behaviors of all citizens where they live, work, plans. Texas and West Virginia are two of the learn, and play. first states to follow a systematic process to develop such plans. Although these two states followed different development processes, they References learned many of the same lessons: Active Texas 2020: Taking action to promote physical activity. 2012. https://sph.uth.tmc.edu/research/ • Involve key stakeholders and partners from centers/dell/active-texas-2020/. many sectors. ActiveWV 2015: The West Virginia Physical Activity • Take steps in the beginning and throughout Plan. n.d. http://wvphysicalactivity.org/. the process to establish a systematic and Kohl, H.W., III, C.L. Craig, E.V. Lambert, S. Inoue, ongoing forum for discussion, input, buy- J.R. Alkandari, G. Leetongin, S. Kahlmeier; Lancet in, and participation. Physical Activity Series Working Group. 2012. The • Empower local and state leaders to make pandemic of physical inactivity: global action for physical activity a health priority. public health. Lancet 380:294-305. • Encourage and enable communities to take The National Physical Activity Plan. 2010. www.physi- responsibility for implementing the plan calactivityplan.org. at the local level. Pate, R.R. 2009. A national physical activity plan for the United States. J. Phys. Activ. Health 6(Suppl. Once states have developed, disseminated, 3):S157-8. and implemented statewide physical activity U.S. Department of Health and Human Services. 2008 plans, these plans should be integrated into Physical Activity Guidelines for Americans. www. other state plans for which physical activity health.gov/paguidelines.
CHAPTER 30 Health Impact Assessments A Means to Initiate and Maintain Cross-Sector Partnerships to Promote Physical Activity
Katherine Hebert, MCRP Candace Rutt, PhD Davidson Design for Life Centers for Disease Control and Prevention
NPAP Tactics and Strategies Used in This Program
Public Health Sector STRATEGY 4: Disseminate tools and resources im- portant to promoting physical activity, including STRATEGY 2: Create, maintain, and leverage cross- resources that address the burden of disease due sector partnerships and coalitions that implement to inactivity, the implementation of evidence-based effective strategies to promote physical activity. interventions, and funding opportunities for physi- Partnerships should include representatives from cal activity initiatives. public health; health care; education; parks, rec- reation, fitness, and sports; transportation, urban Transportation, Land Use, design, and community planning; business and and Community Design Sector industry; volunteer and nonprofit organizations; faith communities; mass media; and organizations STRATEGY 3: Integrate land-use, transportation, com- serving historically underserved and understudied munity design, and economic development plan- populations. ning with public health planning to increase active transportation and other physical activity. STRATEGY 3: Engage in advocacy and policy develop- ment to elevate the priority of physical activity in public health practice, policy, and research.
ecisions made outside of the traditional amenities; County Health Rankings & Roadmaps Dpublic health and health care sectors can 2013) may determine an individual’s ability have immense effects on individual and popula- to be physically active every day. By increas- tion health. For example, policy and planning ing access to means of active transportation decisions that shape the built environment (such as bicycle lanes and sidewalks), places (defned as human-made resources and infra- of inexpensive recreation (such as parks and structure designed to support human activity, greenways), and safe environments for walking, including buildings, roads, parks, and other playing, and learning within neighborhoods and
Acknowledgments: The authors thank Dr. Holly Avey (Fort McPherson HIA), Amanda Thompson (Decatur Transportation Plan HIA), Karen Leone de Nie (Decatur Transportation Plan HIA), and Michelle Marcus (Atlanta BeltLine HIA) for their insight on the collabora- tions that were necessary to conduct the HIA. The authors also thank Amy Lang with the CDC’s Geospatial Research, Analysis, and Services Program (GRASP) for her assistance with the map titled HIA Case Studies in the Greater Atlanta Region.
259 260 Hebert and Rutt urban areas, city planners and decision makers impact assessment is one means of addressing can positively infuence many aspects of health health inequities and changing policies and (fgure 30.1). environments by promoting cross-sectoral col- The social determinants of health (defined as laboration and bringing potential public health the conditions in which people are born, grow, concerns to the attention of decision makers live, work, and age; World Health Organiza- from various sectors. tion 2013) include the options and resources available to people in their neighborhoods; the cleanliness of the air, water, and food they Program Description consume; the safety of their neighborhoods and Health impact assessment (HIA) is “a system- workplaces; their education; and their social atic process that uses an array of data sources ties to friends, family, and neighbors (Healthy and analytic methods and considers input from People 2020, 2012). These conditions play a stakeholders to determine the potential effects vital role in determining health. Health inequi- of a proposed policy, plan, program, or project ties can be attributed largely to differences in on the health of a population and the distribu- social determinants of health. Cross-sectoral tion of those effects within the population. HIA collaborations that focus on the potential health provides recommendations on monitoring and impacts of decisions on vulnerable populations, managing those effects” (National Research who often lack access to the resources needed Council 2011, p. 46). to live a healthy and physically active lifestyle, HIA consists of six steps: screening, scop- can help to address these disparities. A health ing, assessment, recommendations, report-
Factors Partners
Work environment and unemployment Business owners, employers
Education and learning opportunities Socioeconomic, Universities, libraries, schools cultural, and Agriculture and food production environmental Farmers, markets, gardeners conditions Water and sanitation Public works engineers
Health care services Living and working Doctors, nurses, pharmacists conditions Housing options Planners, realtors, developers
Transportation network Planners, transit agent, engineers Social and community Recreational opportunities Parks and recreation, Y, Schools networks
Individual lifestyle choices
Age, sex, and hereditary factors
Figure 30.1 Social determinants of healthE5691/NPAP/fig30.1/458622/alw/r4 and potential partners. Health Impact Assessments 261 ing, and monitoring and evaluation (figure before a decision is made, preferably early 30.2). These steps are fluid and tend to influ- enough in the process that the HIA findings ence each other. HIA uses a combination of can be incorporated into the decision-making sources and methods of analysis, depending process. on the topic and sector in which the HIA is The overarching purpose of an HIA is to being conducted. Each sector is unique, and provide decision makers with accurate and the flexibility of the HIA process to evaluate scientifically based information and recom- potential health outcomes of diverse decisions mendations concerning the potential health is one of its greatest strengths. Because it is a impacts of their decisions. As well as leading participatory process, HIA involves gathering to better-informed decisions, HIAs typically stakeholder input and involving the public result in increased awareness of community at every stage. It emphasizes considering the health concerns; collaborations across multiple needs of people who may be most adversely disciplines and a better understanding of each affected by a policy decision (such as the discipline’s influence on the social determi- placement of a new road or the opening or nants of health; broader spillover effects and closing of a park). Perhaps most important, support for encompassing policies, such as a HIA is proactive and offers recommenda- Complete Streets policy; and more equitable tions to promote positive health impacts and and community-driven planning and policy prevent or mitigate negative health impacts. making through increased community engage- This means that the HIA must be completed ment (NACCHO 2008).
1. Screening: determines whether a proposal is likely to have health impacts and whether the HIA will 6. Monitoring and evaluation: provide information useful to the records the adoption and stakeholders and decision-makers. 2. Scoping: establishes the implementation of HIA scope of health effects that recommendations, monitors the will be included in the HIA, the changes in health and health populations affected, the HIA determinants, and evaluates the team, sources of data, methods to process, impact, and outcomes of be used, and alternatives to be an HIA. considered.
The HIA Process
3. Assessment: involves a two-step 5. Reporting: documents and process that first describes the presents the findings and baseline health status of the recommendations to stakeholders affected population and then 4. Recommendations: suggest and decision-makers. assesses potential impacts. alternatives that could be implemented to improve health or
actions that could be taken to manage the health effects, if any, that are identified.
Figure 30.2 HIA process. E5691/NPAP/fig30.2/458623/alw/r2-kh 262 Hebert and Rutt
The principles guiding the practice of HIA than a rapid HIA. If a very thorough assessment support the use of collaborations in health pro- of the potential health impacts is warranted motion and disease prevention. These principles (usually in the case of major projects or poli- include democracy and public participation, cies that affect a large number of people or are equity and equality, ethical and transparent use considered politically controversial), then a of evidence, sustainability, a comprehensive comprehensive HIA should be done. Compre- approach to health and health promotion, inter- hensive HIAs commonly involve collecting new disciplinary or collaborative orientation, and quantitative and qualitative data and engaging an efficient use of time and resources (Hebert the community at a high level, and these can et al. 2012). take years to complete. The type of HIA conducted—rapid, intermedi- The remainder of this chapter describes part- ate, or comprehensive—depends on the amount nerships formed to conduct three HIAs that con- of time available before a decision is made and sidered the potential impacts of three proposals the resources that can be dedicated to the HIA. on physical activity in the greater Atlanta area: Rapid HIAs take days to weeks to finish, use the interim zoning policies for the redevelop- limited resources, and typically provide a broad ment of Fort McPherson, Decatur’s Community overview of potential health impacts without Transportation Plan, and the proposed Atlanta collecting new, site-specific data. Intermediate BeltLine (figure 30.3). Each HIA was conducted HIAs can take weeks to months to complete, at a different geography (development site, city, involve a greater degree of community engage- and regional scale) and focused on a different ment, and provide more detailed information type of decision, and all three resulted in the
Legend Beltline corridor Fort McPherson City of Decatur Expressways Major roads
Figure 30.3 HIA case studies in greater Atlanta. E5691/NPAP/fig30.3/458625/alw/r1 Health Impact Assessments 263 development of partnerships to perform and Health Policy Center’s leaders were introduced implement the HIA recommendations. to other participants and important organiza- tions, including a Department of Defense rep- Fort McPherson resentative; contractors from the planning and architectural design firm hired to revise the Fort McPherson, an Army installation consisting redevelopment plan; Georgia Stand Up, which of 488 acres located between downtown Atlanta is a community organizing group affiliated with and Hartsfield Jackson International Airport, the McPherson Action Community Coalition; was scheduled to be shut down in 2011 as part and a professor at the Georgia Institute of Tech- of the Department of Defense’s Base Realign- nology who conducted a design studio on the ment and Closure program. A city unto itself, redevelopment project for planning students. Fort McPherson supports a wide variety of At the conclusion of the HIA, the HIA community facilities, including a bank, library, report recommended zoning actions to the convenience store, gas station, health facilities, City of Atlanta Department of Planning and office space, and more than 200 acres of outdoor Community Development that could improve recreational facilities, including historic parade opportunities for physical activity during the grounds and a golf course. interim period while the property is redevel- The closure and redevelopment of Fort oped. Recommendations were based on several McPherson could potentially span decades. premises: (1) people are more physically active Interim use of the property during the first 5 to when they have access to trails and parks; 10 years of redevelopment could have significant (2) people are more likely to use trails when economic and health impacts on the surround- they can access them from multiple places; and ing communities. As a result of a larger Health (3) walking trails may increase physical activ- in All Policies (HiAP) project funded by the ity in particular for two population subgroups Centers for Disease Control and Prevention, that are less likely to exercise—women and the Georgia Health Policy Center conducted an people of limited income. The recommenda- HIA of the proposed redevelopment plan. The tions included permitting the use of existing scope of the HIA was limited to the 5- to 10-year outdoor recreational facilities and green space interim period and focused on the zoning pro- by neighboring communities and maximizing visions that address permitted uses, available accessibility to existing recreational facilities green space, and transportation. The center and green space with ADA-compliant roads or estimated impacts on physical activity levels paths at multiple entry points. (among other impacts) for those living within a half mile of the property. At the beginning of City of Decatur’s Community the HIA, the Centers for Disease Control and Prevention brought together all of the stakehold- Transportation Plan ers in the redevelopment process to learn more The City of Decatur’s Community Transpor- about HIA and to share their perspectives. tation Plan, completed in 2007, is organized To conduct the Fort McPherson HIA, the around the goal of creating an “active living Georgia Health Policy Center worked closely community,” defined in the plan as “a place with multiple partners, including the City of where residents and visitors can readily par- Atlanta Department of Planning and Commu- ticipate in everyday physical activity, regardless nity Development, which regulates the zoning of physical limitations” (Decatur Community and permitting process for the redevelopment; Transportation Plan 2007, appendix F, p. 2). the McPherson Local Redevelopment Authority, Decatur is a historic town 6 miles (9.6 kilo- which is responsible for planning the redevel- meters) east of downtown Atlanta, spanning opment of the property; and the McPherson 4.2 square miles (10.8 square kilometers) and Action Community Coalition, which represents consisting of approximately 20,000 residents. interested residents from the surrounding Founded in 1826 and experiencing a lack of neighborhoods. Through these partnerships, the developable land since the 1960s, Decatur has 264 Hebert and Rutt increased development in the core of the city tive health impacts; (2) concerns over bicyclist and has redeveloped surface parking lots over and pedestrian safety could be mitigated by the last 10 years to restructure the built environ- the plan; and (3) implementation of the plan ment to include mixed-use midrise buildings should be prioritized to meet the needs of vul- featuring residential units on the upper floors nerable populations. Since the adoption of the and commercial development on the ground plan and the completion of the HIA, the city floor. has formed an Active Living Advisory Board, With the task of incorporating an “active composed of Decatur residents and business living framework” into the transportation plan, owners, and an Active Living Division within the City of Decatur partnered with the Georgia the city government to continue to coordinate Institute of Technology’s Center for Quality efforts to promote physical activity and healthy Growth and Regional Development, Kimley eating within the city. Horn and Associates, and Sycamore Consulting to conduct an HIA to evaluate the plan’s goals Atlanta BeltLine from a health perspective. These goals included (1) setting a course for a transportation and land The Atlanta BeltLine, considered one of the use connection to make Decatur a healthy place largest redevelopment projects in United to live and work; (2) maintaining a high quality States history, is expected to convert 22 miles of life in Decatur; and (3) increasing opportuni- (35.4 kilometers) of abandoned railway into a ties to use alternative modes of transportation combination of trails, parks, light rail transit, (Decatur Community Transportation Plan 2007). residential buildings, and commercial develop- To help identify potential community health ment. The oval loop, measuring 2 to 4 miles concerns about the plan, the city hosted a one- (3.2-6.4 kilometers) from Atlanta’s city center, day workshop and invited local residents and travels through 45 distinct neighborhoods and business owners; nonprofit organizations and each of Atlanta’s council districts. The project area churches; and local, regional, and state is expected to improve 700 acres of existing government officials. During the workshop, parks and add 1,300 acres (5.3 square kilome- experts on the built environment, HIA, and ters) of new green space, including 33 miles public health from the Centers for Disease (53 kilometers) of trails. Construction along Control and Prevention, the Center for Quality the BeltLine is expected to produce 12 million Growth and Regional Development, and the square feet (slightly more than 1 million square DeKalb County Board of Health provided par- meters) of office, retail, light industrial, and ticipants with local health information, back- public or private institutional space and create ground information on the relationship between 29,000 housing units. The tax allocation district the built environment and health, and group established to fund the BeltLine is expected to facilitation assistance. At the conclusion of the raise $1.7 billion over the next 25 years, while workshop, participants identified four broad increasing the overall tax base by $20 billion areas within the plan that would have a direct within the same period. effect on health: (1) intersection improvements, In 2005, the Georgia Institute of Technology’s (2) biking facilities, (3) sidewalk improvements, Center for Quality Growth and Regional Devel- and (4) traffic safety. They also identified opment, with funding from the Robert Wood particularly vulnerable populations, including Johnson Foundation and technical assistance youth and the elderly, persons with disabilities, from the Centers for Disease Control and Pre- and low-income and minority populations. vention, embarked on a comprehensive HIA After the workshop, each element of the that would take more than a year to complete. plan was evaluated for its potential impacts on The HIA’s study area consisted of 30,500 acres health. There were three major findings of the (123.4 square kilometers) (35 percent of the HIA: (1) the plan could help the city increase city’s land area), forming a half-mile (.8-kilo- physical activity levels and promote other posi- meter) buffer around the BeltLine’s Tax Alloca- Health Impact Assessments 265 tion District. The HIA considered the following expertise” (Atlanta BeltLine HIA 2007, p. 38). health impacts: (1) access and social equity as The larger HIA team was responsible for the they related to parks and trails, transit, housing, scoping and appraisal steps of the HIA and and healthy food; (2) physical activity levels, included representatives from Atlanta BeltLine, particularly in the southeast, southwest, and the Atlanta Development Authority, BeltLine west-side areas where mortality rates are higher Partnership, the Metropolitan Atlanta Rapid because of the prevalence of chronic disease; Transit Authority (MARTA), Park Pride, the (3) safety from injury and crime; (4) social Path Foundation, the Trust for Public Land, capital; and (5) environmental factors such as and City of Atlanta departments (planning and air and water pollution, noise and vibration, and community development, public works, water- the cleanup of formerly polluted sites. shed management, and parks, recreation and Because of the vast differences in the social cultural affairs). and economic characteristics of the regions through which the BeltLine passes (the south- east, southwest, and west-side populations Linkage to National are primarily nonwhite and, compared with Physical Activity Plan the north-side and northeast populations, are younger and have almost twice the level of The practice and application of HIA can con- poverty and significantly lower levels of car tribute to accomplishing four of the strategies ownership), health equity and the distribution included within the National Physical Activity of the associated health impacts were critical Plan: Public Health Sector Strategies 2, 3, and components of the HIA. Vulnerable populations 4 and the Transportation, Land Use, and Com- identified within the HIA included low-income munity Design Sector Strategy 3. populations, children, older adults, those who Strategy 2: Create, maintain, and lever- have disabilities, renters, and those who do not age cross-sector partnerships and coalitions have access to a car. that implement effective strategies to promote After a series of public workshops and physical activity. Partnerships should include surveys, detailed health data collection, and representatives from public health; health care; an intensive literature review, the HIA team education; parks, recreation, fitness, and sports; reported on more than 50 recommendations transportation, urban design, and community for improving health along the BeltLine. Some planning; business and industry; volunteer and of the recommendations were specifically nonprofit organizations; faith communities; tailored to increasing physical activity levels: mass media; and organizations serving histori- (1) form a Safe Routes to School program; cally underserved and understudied populations. (2) include bicycle and pedestrian advocates on HIAs often are led by public health profession- the BeltLine’s advisory committees; (3) create als, who make a concerted effort to involve park access equal to 10 acres (40,500 square professionals from many sectors, community meters) per 1,000 people and trail access every residents, and other stakeholders. quarter of a mile (400 meters); (4) develop trail Strategy 3: Engage in advocacy and policy spurs, especially to underserved neighborhoods; development to elevate the priority of physical (5) set design standards for multiuse trails and activity in public health practice, policy, and offer a variety of park types; and (6) launch an research. The findings of an HIA can be used educational campaign for increasing physical in advocacy efforts and for promoting physical activity on the BeltLine. activity in all policy decisions. Because of the complexity of the BeltLine Strategy 4: Disseminate tools and resources project, the HIA team consisted of numerous important to promoting physical activity, includ- partners, including an HIA advisory committee ing resources that address the burden of disease that assisted with “overall project direction, due to inactivity, the implementation of evidence- component-specific guidance, and analytical based interventions, and funding opportunities 266 Hebert and Rutt for physical activity initiatives. HIA is a tool their leadership style or overall personality. that can be disseminated to promote physical Having this knowledge helped the HIA coordi- activity through evidence-based decisions. The nators determine whether to involve individuals reporting stage of an HIA involves disseminating in the collaboration and how to approach them information on the burden of disease as well as in a way that would convince them to support presenting recommendations to decrease and the collaboration. fairly distribute this burden. Another component of successful HIA collab- Strategy 3: Integrate land-use, transportation, oration is awareness of the political climate and community design, and economic development context in which the HIA is being conducted. planning with public health planning to increase Finding a topic that all stakeholders can rally active transportation and other physical activity. behind and identifying a political champion HIA can be applied to plans and development for the HIA or for public health in general can projects that result in collaborations between increase the success of the collaboration and the public health and planning fields and inform the acceptance of the HIA’s recommendations. planning and design efforts to increase physical In the Decatur Community Transportation Plan activity opportunities such as active transporta- HIA, government officials and department lead- tion and park development. ers had already identified the need for incorpo- rating an active living framework into their work Lessons Learned and therefore were willing to support efforts to assess the potential health impacts of the plan. The collaborations that occurred within these The discussion framework of public health also three HIAs represent the partnerships com- created an opportunity to shift the conversation monly found in HIAs, which include repre- from a competitive, resource-limited viewpoint sentatives of local government departments, of alternative transportation versus vehicle community organizations, university centers, drivers to an opportunity-rich environment of public health experts, and local stakeholders transportation choice. Elected officials were (table 30.1). Through these partnerships, the given a chance to offer transportation choices HIA coordinators were better able to connect to instead of favoring one mode of travel at the decision makers, vulnerable populations, other expense of another. previously unidentified stakeholders, and those Developing a common understanding of what in positions to bring about desired changes. In an HIA is and how it can be used to improve the establishing and maintaining these relation- health impacts of a proposed policy or program ships, HIA coordinators learned a number of also contributes to establishing a successful col- lessons that could be useful for fostering cross- laboration. For the Fort McPherson redevelop- sectoral collaboration. ment HIA, providing an opportunity for all of The key to developing all three of these col- the partners to meet and learn from each other laborative efforts was identifying those who proved to be a turning point. Follow-up meet- should participate in the collaboration and ings for smaller groups that focused on specific getting to know them. By asking who would components of the HIA contributed to support be affected by the proposal, who had author- for the process and the outcome. ity to make changes to the proposal, who was To ensure continuation of the collaboration responsible for implementing the proposal, beyond the HIA’s completion and acceptance and who could provide the expertise needed to of the recommendations by decision makers, it strengthen the proposal, the HIA coordinators is crucial to prioritize the impacts considered identified potential members of the HIA team. within the HIA’s scope and make sure that the Once these individuals were identified, the coor- team’s objectives and recommendations are dinators researched them further to determine realistic. In particular, the comprehensive nature what networks they commonly worked in, what of the Atlanta BeltLine HIA required the team their responsibilities and motivations were, and to limit its scope of work to the communities Table 30.1 Partners, Stakeholders, and Decision Makers in Atlanta Case Studies Fort McPherson Decatur Community Rapid HIA–Zoning Atlanta BeltLine Transportation Plan in Interim Period Lead organizations Center for Quality Growth Center for Quality Growth Georgia Health Policy and Regional Develop- and Regional Develop- Center at Georgia State ment at Georgia Institute ment at Georgia Institute University of Technology of Technology; Sycamore Consulting Main partners Atlanta BeltLine, Atlanta City of Decatur (facilities City of Atlanta Depart- Development Author- maintenance, community ment of Planning and ity, BeltLine Partnership, and economic develop- Community Develop- MARTA, Park Pride, ment, recreation and com- ment, McPherson Path Foundation, Trust munity service, police and Local Redevelopment for Public Land, City of fire, housing authority), Authority, and McPher- Atlanta (planning and DeKalb County Commis- son Action Community community development, sioners, Atlanta Regional Coalition public works, watershed Commission, Georgia management, parks, rec- Department of Transpor- reation and cultural affairs) tation, Georgia Regional Transportation Author- ity, Georgia Division of Public Health, Agnes Scott College, City of Decatur Schools, neighborhood associations, nonprofit organizations (Georgia Conservancy, Decatur Preservation Alliance, PEDS), local businesses, churches HIA technical CDC (National Center for CDC, Georgia Tech Center CDC assistance Environmental Health, for Quality Growth and Division of Unintentional Regional Development, Injury Prevention, Divi- DeKalb County Board of sion of Nutrition, Physical Health Activity, and Obesity), Fulton County Department of Health and Wellness, Emory University Decision makers City of Atlanta City Coun- Decatur City Commission City of Atlanta Depart- cil, Fulton County Board ment of Planning and of Commissioners, Atlanta Community Develop- Public School Board ment
267 268 Hebert and Rutt
within a half-mile (.8 kilometers) of the corridor Transportation Plan. www.decaturga.com/Modules/ and to highlight the most feasible and meaning- ShowDocument.aspx?documentid=1211. ful recommendations for decision makers. Center for Quality Growth and Regional Development. 2007. Atlanta BeltLine Health Impact Assessment. www.hiaguide.org/sites/default/files/beltline_hia_ Summary final_report.pdf. County Health Rankings & Roadmaps. 2013. Health Because overcoming barriers to increasing Factors: Built Environment. www.countyhealthrank- physical activity levels nationwide is such a ings.org/our-approach/health-factors/built-envi- complex and encompassing challenge, col- ronment laboration among multiple fields is necessary Healthy People 2020. 2012. Social Determinants of to create physically active, healthy, and vibrant Health. http://healthypeople.gov/2020/topicsobjec- communities for today’s population as well as tives2020/overview.aspx?topicid=39. future generations. Health impact assessments Hebert, K.A., A.M. Wendel, S.K. Kennedy, and A.L. are effective and should be considered when Dannenberg. 2012. Health impact assessment: a organizers are creating these types of col- comparison of 45 local, national, and international laborations, promoting physical activity, and guidelines. Environmental Impact Assessment achieving long-term public health goals such Review. 34:74-82. as those found within the National Physical National Association of County and City Health Offi- Activity Plan. cials. 2008. Health Impact Assessment: Quick Guide. http://activelivingresearch.org/files/NACCHO_HIA- QuickGuide_0.pdf Additional National Research Council. 2011. Improving Health in the United States: The Role of Health Impact Assess- Reading and Resources ment. Washington, D.C.: The National Academies Press. Georgia Health Policy Center, Fort McPherson rapid health impact assessment: Zoning for health benefit Ross, C. L. 2007. Atlanta BeltLine Health Impact to surrounding communities during interim use. Assessment. Atlanta: Center for Quality Growth 2010. www.healthimpactproject.org/resources/ and Regional Development, Georgia Institute of document/FortMcPherson_at_ays_129.pdf. Technology. Sycamore Consulting Inc., Kimley-Horn & Associates, Georgia Institute of Technology Center for Quality References Growth and Regional Development. 2007. Decatur Community Transportation Plan. www.decaturga. Center for Quality Growth and Regional Development. com/index.aspx?page=422 2007. Pathways to a healthy Decatur: A rapid health World Health Organization. 2013. Social Determinants impact assessment of the City of Decatur Community of Health. www.who.int/social_determinants/en/. CHAPTER 31 Move More Scholars Institute
Lori Rhew, MA, PAPHS Carolyn Dunn, PhD North Carolina Division of Public Health North Carolina Cooperative Extension, North Carolina State University Cathy Thomas, MAEd Jimmy Newkirk, Jr. North Carolina Division of Public Health National Society of Physical Activity Practitioners in Public Health Kara Peach, MA Dianne Ward, EdD North Carolina Division of Public Health University of North Carolina at Chapel Hill Amber Vaughn, MPH University of North Carolina at Chapel Hill
NPAP Tactics and Strategies Used in This Program
Public Health Sector STRATEGY 2: Create, maintain, and leverage cross- sector partnerships and coalitions that implement STRATEGY 1: Develop and maintain an ethnically and culturally diverse public health workforce of both effective strategies to promote physical activity. genders with competence and expertise in physi- cal activity and health.
he Move More Scholars Institute (MMSI) national Physical Activity and Public Health Tis a four-day training course for commu- Practitioners (PAPH) course, offered annually by nity-based physical activity professionals. It is the Centers for Disease Control and Prevention the frst state-level course modeled after the (CDC) and the University of South Carolina. The MMSI was developed to create a statewide workforce skilled in addressing physical activity as a public health issue. Program Description Today’s public health workforce requires the knowledge and skills needed to shape poli- cies and environments that create access to Reprinted, by permission, from the Physical Activity and Nutrition Branch, North Carolina Division of Public Health. and opportunities for physical activity. Public
Acknowledgments: We would like to acknowledge the Move More Scholars Institute Advisory Committee for their ongoing contributions to the course: Rich Bell, project offcer, Active Living By Design; Phil Bors, project offcer, Active Living By Design; Carolyn Crump, PhD, research associate professor, Department of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill; Carolyn Dunn, PhD, professor and nutrition specialist, North Carolina Cooperative Extension Service, North Carolina State University; Lisa Macon Harrison, director, Offce of Healthy Carolinians and Health Education. 269 270 Rhew, Thomas, Peach, Dunn, Newkirk, Ward, and Vaughn health professionals need to understand how capacity to promote physical activity to the administrative, organizational, and legislative public (Martin and Vehige 2013). These bench- policies affect physical activity; how the built marks are (1) develop and sustain effective environment influences physical activity; and partnerships; (2) use public health data as a how to build partnerships across sectors, includ- tool to develop and prioritize community-based ing transportation, education, and community interventions; (3) understand and implement planning, to create policies and environments a sound approach to planning and evaluation; that support active living. (4) implement evidence-based strategies at Physical Activity and Health: A Report of the informational, behavioral, and social and the Surgeon General, released in 1996, was a environmental policy levels; (5) and develop ground-breaking report that highlighted the an organizational structure that contributes to association between physical activity and health program growth and sustainability by encourag- (Franks et al. 2005). Since the release of this ing and supporting professional development report, the evidence base for physical activity and fostering successful collaborations within as a public health priority and the research and outside the health department (Martin base on how to increase physical activity have and Vehige 2013). In 2005, the National Soci- increased significantly. For example, in 2008 the ety of Physical Activity Practitioners in Public first Physical Activity Guidelines for Americans Health, in partnership with CDC, created core were published, and in 2010 the first National competencies, specific to physical activity and Physical Activity Plan for the United States public health practice, that were based on these was released. In 2011, the National Prevention benchmarks (Dallman et al. 2009). Translating Strategy outlined the importance of prevention, state-level benchmarks and competencies into recognized physical activity as a key health community-based practice is an essential step behavior, and noted the importance of inter- for creating change that supports population disciplinary partnerships to address physical levels of physical activity that will enhance activity as a public health priority (National Pre- health. This chapter describes how a state-level vention Council 2011). This increased emphasis course, modeled after the national PAPH practi- on the importance of physical activity, coupled tioners course, was created to train practitioners with increased evidence regarding strategies in the skills and competencies needed to address to increase physical activity and the need for physical activity as a public health priority. an interdisciplinary approach, has created a In 2006, the Physical Activity and Nutrition unique set of competencies that public health Branch of the North Carolina Division of Public practitioners need if they are to address physical Health, in partnership with the School of Public activity as public health priority. In particular, Health, University of North Carolina at Chapel practitioners need information about effective Hill, developed a state version of the PAPH prac- interventions and require skills for working with titioner course, called the Move More Scholars professionals from a variety of backgrounds to Institute (MMSI). The MMSI is an intensive put successful strategies into practice. four-day training course for community-based Since 1996, the PAPH courses have been physical activity professionals in North Caro- offered annually by the CDC and the Univer- lina. It is the first state-specific course modeled sity of South Carolina. The research course on the PAPH course, integrating the core com- is designed to develop research competencies petencies established by the National Society of related to physical activity and public health, Physical Activity Practitioners in Public Health. and the practitioner course is designed to The development of the inaugural MMSI was increase the ability of practitioners to trans- guided by an expert advisory committee made late research to practice. In 2003, the Physical up of representatives from the PAPH course, Activity and Health Branch at CDC established the North Carolina Division of Public Health, five benchmarks, outlining the areas of train- Active Living by Design, the University of North ing and technical assistance that state health Carolina at Chapel Hill, and the University of departments need to address to improve their Tennessee at Chattanooga. Committee members Move More Scholars Institute 271 were chosen based on their expertise in policy and Recreation; the Institute for Transportation, and environmental change for physical activ- Research, and Education; and other agencies. A ity and their knowledge of principles of adult key goal of the MMSI is to help scholars connect learning. The committee’s goal was to develop with professionals across the state who work in a course modeled after the PAPH course, with a variety of settings. The combination of state a curriculum specific to North Carolina that and local participants provides an opportunity focused on policy and environmental initiatives. for increased learning about state and local MMSI was first conducted in the spring of perspectives. 2006 and then again in 2008 and 2011. The Several factors contribute to the effectiveness course continues to be guided by an advisory of the MMSI. First, the course is based on adult committee that has grown to include represen- learning principles. It includes both didactic and tatives from North Carolina State University, interactive sessions and provides time for inter- the North Carolina Cooperative Extension, the action between faculty and scholars. Second, University of North Carolina at Asheville, the the course instructors are considered state- Center for Health and Wellness, and the Office level, and frequently national-level, experts in of Healthy Carolinians and Health Education. physical activity and health. These instructors The advisory committee is instrumental in provide a state-of-the-art perspective on pro- guiding the course to address national recom- moting physical activity through policy and mendations within the context of the needs of environmental change. Third, faculty members North Carolina. focus the course material on the needs of North The course is limited to 30 scholars to maxi- Carolina practitioners and provide examples mize opportunities for networking and inter- specific to the state. The result is a statewide action with faculty. A competitive application network of public health, transportation, parks process, similar to that for the PAPH course, is and recreation, education, and other profession- used to select scholars. Applicants must submit als who develop and engage in local and state three items: (1) a resume; (2) a letter explaining efforts to increase physical activity. their role in their organization, experience part- nering with other organizations to implement physical activity interventions, and what they Program Evaluation plan to do as a result of attending the MMSI; and (3) a letter from their supervisor explaining why The MMSI is assessed through daily evalua- the applicant is a good candidate for the MMSI tions, overall course evaluations, and a one- and how the agency will support the candidate year follow-up evaluation. The results of these in applying what he or she learns at the course. evaluations show that the MMSI is successful Applicants are selected to attend based on their in increasing engagement, leadership, and experience, their ability to apply what they learn partnerships that support physical activity. The from the MMSI in their daily work, and their daily and overall course evaluations indicate organization’s support for their participation that the scholars appreciate the opportunity and application of the things they learn. to interact with professionals with a variety of Scholars come from a variety of sectors, backgrounds. Scholars report that the connec- including health promotion coordinators from tions established with other professionals are local health departments, family and consumer some of the most highly beneficial aspects of science agents from the North Carolina Coop- the course and that sharing and partnership erative Extension, local transportation planners, development are key aspects of the course. city and county planners, staff of parks and The one-year follow-up evaluations have recreation departments, school staff, and staff of been conducted for the 2006 and 2008 courses. faith-based and nonprofit organizations. State- Scholars reported that their level of work level professionals attend the course each time involvement in physical activity interven- it is offered, including professionals from the tions has increased as a result of attending the North Carolina Division of Public Health, Parks MMSI, that their leadership role in physical 272 Rhew, Thomas, Peach, Dunn, Newkirk, Ward, and Vaughn activity promotion has expanded, and that they both genders with competence and expertise in regularly apply what they learned at the MMSI physical activity and health. to their work. In addition, they reported initi- Tactic: Support and expand training opportu- ating professional contact with other scholars nities (e.g., Physical Activity and Public Health after the course, increasing their interactions Course) based on core competencies for practi- with other professionals in their community as tioners and paraprofessionals. Ensure interdisci- a result of attending the MMSI, and becoming plinary training such that physical activity and more involved with statewide physical activity public health concepts are connected to other initiatives. Table 31.1 outlines these evaluation disciplines and also include leadership devel- results. opment and team-building. Augment the entry of physical activity professionals by engaging ethnic minority and disability organizations in Linkage to the National public health, medicine, and related disciplines. Physical Activity Plan The MMSI has trained more than 75 profes- sionals from 11 disciplines to use a policy and The MMSI addresses Strategy 1 of the Public environmental approach to increase population Health Sector of the National Physical Activity levels of physical activity in North Carolina. A Plan: Develop and maintain an ethnically and key to the success of the course is to involve culturally diverse public health workforce of professionals from a variety of backgrounds
Table 31.1 Key Results from the Move More Scholars Institute Evaluation OVERALL COURSE EVALUATION 2006 (n = 19) 2008 (n = 26) 2011 (n = 19) Did the MMSI meet your expectations? 100% yes 100% yes 100% yes Did the MMSI sessions fit well together? 100% yes 100% yes 100% yes One-year follow-up evaluation 2011 not 2006 (n = 21) 2008 (n = 17) available How has your level of work involvement in 57.1% increased 47.1% increased physical activity interventions changed as a result of attending the MMSI? Have you become more involved with state- 85.7% yes 64.7% yes wide initiatives as a result of attending the MMSI? Do you apply information from the MMSI to 33.3% often 29.4% often your work in physical activity promotion? 52.4% regularly 58.8% regularly Have you initiated any professional contact 85.7% yes 47.1% yes with any of the scholars since the MMSI? Has your leadership role in physical activ- 76.2% yes 47.1% yes ity promotion increased since attending the MMSI? Have you increased your interaction with other 76.2% yes 64.7% yes professionals in your community as a result of attending the MMSI? Move More Scholars Institute 273 and disciplines, which promotes informal and course is marketed to attract professionals with formal learning and networking among the a variety of professional backgrounds. scholars. The MMSI also addresses Strategy 2 of the Public Health Sector: Create, maintain, and Lessons Learned leverage cross-sector partnerships and coalitions Key lessons learned through the process of cre- that implement effective strategies to promote ating and conducting the MMSI include these: physical activity. Tactic: Encourage public health profession- • Recruit a diverse advisory committee to als to both educate and learn from partners guide curriculum development and par- in order to strengthen the effectiveness of the ticipant recruitment. partnership and the efforts of each member. A • Limit the number of participants to maxi- diverse advisory committee ensures that the mize networking opportunities. course meets the needs of professionals from • Include peer-to-peer learning as a key a variety of backgrounds. Advisory committee aspect of the course. members have extensive technical expertise in adult learning and policy and environmental • Include participants from different disci- change and a strong understanding of the public plines to enhance learning. health context in North Carolina. • Select quality speakers and those with expertise in state issues to ensure that information is immediately applicable. Evidence Base Used During • Provide time for interaction between schol- Program Development ars and faculty throughout the course. • Adapt course content based on the needs The MMSI is built on the CDC benchmarks of the participants. that outline the areas of training and technical assistance that state health departments need • Select a high-quality venue that enhances to address to improve their capacity to promote the learning experience. physical activity (Martin and Vehige 2013). It also incorporates the core competencies for physical activity and public health practice Tips for developed by the National Society of Physical Working Across Sectors Activity Practitioners in Public Health (Dallman et al. 2009). The result is a course based on A key to working across sectors for the MMSI national competencies that were established by was to ensure that the course content met the experts in public health workforce and promo- needs of public health professionals and then tion of physical activity. Each time the course to gradually widen the range of professionals is offered, the curriculum is designed to align who attended the course. The inaugural MMSI with current efforts in North Carolina. The goal focused on three specific groups of profession- is to increase engagement in statewide physical als who work in the area of community-based activity efforts. physical activity programming in North Caro- lina: (1) health promotion coordinators from local health departments, (2) coordinators of Populations Best Served local physical activity and nutrition coalitions, by the Program and (3) family and consumer science agents from cooperative extensions. The course plan- The MMSI is targeted to community-based phys- ners targeted these professionals because they ical activity professionals in North Carolina. A play leadership roles in local communities’ community-based professional is anyone who efforts to integrate physical activity interven- partners with other organizations in his or her tions with policy-level and environmental-level community to promote physical activity. The change. These professionals were encouraged 274 Rhew, Thomas, Peach, Dunn, Newkirk, Ward, and Vaughn
to share information about the course with any Scholars Institute: A state model of the physical of their community partners who may have an activity and public health practitioners course. Prev. interest in applying to attend. A majority of the Chronic Dis. [serial online] www.cdc.gov/pcd/ inaugural scholars represented public health issues/2007/jul/06_0157.htm. agencies or cooperative extensions. The range of professionals who attend the MMSI has increased gradually each year. When References the MMSI was offered in 2011, it had equal rep- Dallman, A., E. Abercrombie, R. Drewette-Card, M. resentation from public health, nonprofit, parks Mohan, M. Ray, and B. Ritacco. 2009. Elevating phys- and recreation, and city and county planning ical activity as a public health priority: Establishing agencies. core competencies for physical activity practitioners A key aspect to ensuring the relevance of the in public health. J. Phys. Act. Health 6:682-9. course across sectors was to avoid jargon and Franks, A.L., R.C. Brownson, C. Bryant, K. McCormack acronyms. In addition, the participant list and Brown, S. Hooker, D.M. Pluto, et al. 2005. Preven- an example of a project on which each scholar tion research centers: Contributions to updating is working are shared with the faculty prior the public health workforce through training. Prev. to the course. This allows the faculty to better Chronic Dis. [serial online] /www.cdc.gov/pcd/ understand the background of the scholars and issues/2005/apr/04_0139.htm. the work that they are doing. Martin, S.L., and T. Vehige T. 2013. Establishing public health benchmarks for physical activity programs. Prev. Chronic Dis. [serial online] www.cdc.gov/pcd/ Additional issues/2006/jul/06_0006.htm. Reading and Resources National Prevention Council. 2011. National Preven- tion Strategy. Washington, DC: U.S. Department of Schneider, L., D. Ward, C. Dunn, A. Vaughn, J. Health and Human Services, Office of the Surgeon Newkirk, and C. Thomas. 2007. The Move More General. CHAPTER 32 The National Society of Physical Activity Practitioners in Public Health Elevating the Issue of Physical Activity; Equipping Professionals to Do So
Jimmy Newkirk, Jr. Amber Dallman, MPH, PAPHS National Society of Physical Activity Practitioners Minnesota Department of Health in Public Health Eydie Abercrombie, MPH, CHES, PAPHS Jill Pfankuch, MS, MCHES, PAPHS Public Health Institute NSPAPPH Volunteer
NPAP Tactics and Strategies Used in This Program
Public Health Sector appropriately consider physical activity and health as they develop policy. STRATEGY 1: Develop the capacity of the public health workforce—addressed through conference of- STRATEGY 4: Disseminate tools and resources—ad- ferings, webinars, networking, development and dressed by organizing more than 700 national, promotion of core competencies, and the PAPHS state, and local tools and resources in a web- certification. based matrix that is searchable by setting, target audience, or state. STRATEGY 2: Create, maintain, and leverage cross- sector partnerships—addressed by the practitio- STRATEGY 5: Expand the monitoring (surveillance and ners themselves as well as the organization. evaluation) of PA and PA interventions—addressed by practitioners’ evaluation and surveillance efforts STRATEGY 3: Engage in advocacy and policy devel- opment—addressed by practitioners who work to with their state and local programs. educate decision makers, enabling them to more
he National Society of Physical Activity gies. To achieve this goal, NSPAPPH builds the TPractitioners in Public Health (NSPAPPH) capacity of the public health workforce, lever- is working to elevate the issue of physical activ- ages partnerships to promote physical activity, ity (PA) and help practitioners develop the skills advocates, disseminates resources, and supports and abilities to promote physical activity strate- monitoring.
Acknowledgments: Since the writing of this chapter, the National Society of Physical Activity Practitioners in Public Health (NSPAPPH) has undergone a signifcant organizational shift. NSPAPPH has transitioned its entire operation, strategic plan, and capacity building efforts to a new organization, the National Physical Activity Society, to allow for improved service and impact. The content of this chapter remains accurate but is now assumed under the National Physical Activity Society. More information is available at: www. PhysicalActivitySociety.org.
275 276 Newkirk, Abercrombie, Dallman, and Pfankuch
Program Description The creation and promotion of these core competencies and KSAs add value to the prac- NSPAPPH began as an informal network of titioner, the employer, and the profession as a practitioners who recognized the need to share whole. Practitioners now have a reference point ideas, resources, and lessons learned across the for their training, professional growth, and profession to support and promote physical development. Employers now have a standard activity on a population level. It was created to for hiring criteria, job descriptions, and work meet the needs of practitioners (Kimber 2009). plans. And the profession as a whole, described NSPAPPH, now a developing nonprofit as an “emerging subdiscipline” (Kohl et al. organization, focuses on elevating the issue of 2006), has a baseline for training and develop- physical activity (PA) and equipping the prac- ment of a workforce. titioners who do so. These efforts lend them- The field of physical activity is a critical com- selves directly and indirectly to implementation ponent in public health. The original NSPAPPH of the National Physical Activity Plan (NPAP). core competencies defined the recommended Connections to the NPAP include building the essential competencies for public health staff capacity of the workforce, developing partner- assigned to physical activity efforts. The set ships to promote PA, advocating, disseminating has been revised and expanded with the resources, and monitoring. American College of Sports Medicine (ACSM)– NSPAPPH Physical Activity in Public Health Core Competencies Specialist (PAPHS) certification, which calls them knowledge, skills, and abilities (KSAs); NSPAPPH recognized that PA practitioners need however, only the core competencies are here to have both a specialized skill set to work with given space limitations. A competent physical many diverse partners and a skill set common activity practitioner should be in a position to to public health. It also recognized that PA review and advise the health department on all practitioners were coming to the field with physical activity initiatives, to ensure that they diverse backgrounds and training. NSPAPPH are consistent, based on best available evidence, worked with the Centers for Disease Control coordinated with each other, and likely to be and Prevention (CDC) Division of Nutrition, effective. For a complete set of the core compe- Physical Activity and Obesity to develop a set tencies with their associated KSAs, please visit of five core competency areas that are based http://physicalactivitysociety.org/wp-content/ on CDC’s five benchmarks for physical activity uploads/2010/08/approved_bod_cc_011410.pdf. and public health practice (Martin 2013). The core competency areas were later revised and a sixth area was added (Dallman 2009): NSPAPPH Core Competencies: Essentials for Public Health Physical Activity Prac- • Partnerships titioners • Data and scientific information Competency Area 1: Partnerships • Planning and evaluation • Interventions Core Competency 1.1: Educate, collaborate, • Organizational structure and engage with external partners from a variety of disciplines to promote physical • Exercise science in the public health set- activity at multiple settings and in a variety ting of populations. These competency areas are subcategorized Core Competency 1.2: Work with organi- into 34 core competencies. Each of the core zations and individuals to capitalize on competencies is further subdivided, for a total complementary strengths, capabilities, of 129 knowledge, skills, and abilities (KSAs) resources, and opportunities for the pro- (Dallman 2009). motion of PA. National Society of Physical Activity Practitioners in Public Health 277
Core Competency 1.3: Communicate appro- Core Competency 3.3: Address cultural, priate public health physical activity mes- social, behavioral, and environmental fac- sages to intended audiences through a tors that contribute to disease progression variety of media channels. and health promoting behaviors as part of Core Competency 1.4: Educate partners on the a physical activity program or intervention. distinction between advocacy and lobbying Core Competency 3.4: Identify internal and and how they can take appropriate action external issues, such as changes and trends to influence policy change. in financing, regulation, legislation, and policies that may affect delivery of public Competency Area 2: health physical activity services. Data and Scientific Information Core Competency 3.5: Use social marketing principles to target and learn specifically Core Competency 2.1: Identify and use public about the population for physical activity health data as a tool to develop and pri- intervention. oritize community-based interventions, including policies, to promote physical Core Competency 3.6: Oversee the develop- activity. ment and implementation of a state physi- cal activity plan, which includes goals, Core Competency 2.2: Maintain professional SMART objectives, and strategies. knowledge of current trends, develop- ments, guidelines, recommendations, and Core Competency 3.7: Work with key staff to research in the field. develop an evaluation plan for all physical activity related interventions. Core Competency 2.3: Review and recom- mend best and evidence-based practices Core Competency 3.8: Use both quantita- and procedures for the development and tive and qualitative analysis to determine implementation of PA promotion efforts. process, impact, and outcome measures of physical activity programs. Core Competency 2.4: Summarize data to illuminate public health issues in terms of Competency Area 4: Interventions disparity or access as well as other ethical, political, scientific, or economic determina- Core Competency 4.1: Recommend and tions associated with physical activity. translate effective intervention strategies to partners and other constituents. Core Competency 2.5: Understand sources of data from professions outside of public Core Competency 4.2: Coordinate the efforts health to address program needs (e.g., of local and community organizations (e.g. transportation data). worksites, coalitions, agencies, schools, etc.) to create local policy and environmen- Core Competency 2.6: Use measurement tal changes that increase opportunities for and surveillance mechanisms to assess PA physical activity. levels across populations. Core Competency 4.3: Educate key stakehold- ers (participants, partners, implementers, Competency Area 3: and decision makers) to influence and Planning and Evaluating effect policy and environmental change. Core Competency 3.1: Use theoretical frame- Core Competency 4.4: Understand and com- works and models to plan and evaluate municate the importance of using ecologi- physical activity interventions. cal approaches, and advise on evidence- Core Competency 3.2: Serve as a technical based strategies to affect each of these advisor in the design, implementation, and levels. evaluation of physical activity interventions Core Competency 4.5: Understand and com- to address chronic disease. municate theories and mechanisms of 278 Newkirk, Abercrombie, Dallman, and Pfankuch
policy development and appropriations, Core Competency 6.4: Understand physical including how political and organizational activity recommendations and program- agendas are set and pursued, to affect ming. public health. Core Competency 6.5 Understand caloric bal- Core Competency 4.6: Collaborate with the ance and weight management related to media to communicate appropriate public physical activity. health and physical activity messages to intended audiences. Practitioners and Partnerships Competency Area 5: In the relatively brief history of the PA practitio- Organizational Structure ner in public health, most have been employed Core Competency 5.1: Identify appropriate in health departments at the state or local resources and continuing education for the level. These practitioners generally work with implementation of a personal professional partners and organizations to increase physical development plan, which includes train- activity opportunities in various settings. For ing and ongoing technical assistance for example, practitioners may do the following: promoting physical activity. • Work with land use and transportation Core Competency 5.2: Establish partnerships planners to ensure that they see the impact with relevant partners at the federal, state, of their efforts on the public’s health. They and local levels and other public and pri- often work to help create and promote vate sectors to promote physical activity as Complete Streets policies, Safe Routes to a critical health behavior. School, land use or community design Core Competency 5.3: Understand the budget policies, and specific pedestrian and management process related to policy and bicycle policies. department budgetary processes (e.g., • Work with school administrators and how funding allocations are made), budget educators to teach and reinforce lifelong appropriations, required budgetary report- physical activity skills of the whole child. ing, and documentation. Their collective efforts may increase the Core Competency 5.4: Demonstrate and main- quantity or quality of physical education tain knowledge in the roles of federal, state, as well as PA opportunities before, during, and local government and specific legisla- and after the school day. tive processes to address policy changes • Work with employers and economic lead- that affect physical activity. ers to ensure that a healthy community Core Competency 5.5: Write and submit grant environment leads to increased market- applications, reports, and manuscripts for ability for business growth. They work to professional and other publications and improve the health of employees, increas- deliver presentations for programmatic and ing productivity and reducing health care scientific meetings. costs. Competency Area 6: • Work with faith communities and other Exercise Science in Public Health Setting community-based organizations to serve as a resource and advocate within the Core Competency 6.1: Understand exercise community. physiology and related exercise science. • Work with the media to convey that health Core Competency 6.2: Understand health is an individual choice that is heavily influ- promotion and disease prevention. enced by the policies and environments Core Competency 6.3: Understand physical in which we live, and work to make the activity assessments. healthy choice the easy choice. National Society of Physical Activity Practitioners in Public Health 279
These examples provide a glimpse into the Each of these priorities builds on and sup- multifaceted work of practitioners. Similar ports the others, as described next. activities are taking place across the United States with partners in parks and recreation, Increase Membership health care, and preschools. and Engagement The face of the practitioner continues to Increased membership and engagement serve change, however. In increasing numbers, pro- two primary purposes. A larger body of prac- fessionals and volunteers from these partner- titioners creates an amplified, collective voice ing industries are realizing that they too are for PA strategies. It also creates a larger pool of PA practitioners and their work affects the practitioners with whom to network and share physical activity behaviors and health of their resources, challenges, and successes. target audience. As such, they are beginning to join the broad public health efforts to promote Build Capacity and Certification physical activity, not only for the sake of health Increased capacity building has taken several but also because of its positive impact on their forms, including trainings, identification and own work. promotion of resources, and the creation of It is critical that practitioners document and a first-ever Physical Activity in Public Health evaluate their efforts. The nature of their work Specialist certification. is unique, it has a long-term effect, it affects The NSPAPPH annual conference has virtually 100 percent of the population, and yet included a blend of national, state, and local it remains poorly funded. Practitioners usually speakers covering physical activity promotion conduct project-specific evaluation and sup- strategies for persons of all ages and abilities, in port statewide surveillance efforts such as the all settings. For example, a speaker on national Behavioral Risk Factor Surveillance System. In transportation issues may be followed by a local addition, NSPAPPH and its members have sup- practitioner discussing local implementation ported national evaluation efforts. For example, and impact of national policies. Conference ses- NSPAPPH assisted the Physical Activity Policy sions, as well as webinar sessions, are selected Research Network in the evaluation of the to meet the specific requests and needs of the National Physical Activity Plan implementation. organization’s members. NSPAPPH has taken advantage of routine Efforts to Support Practitioners webinars, which allow great flexibility of topic and speaker. Current issues are presented in Practitioners have told NSPAPPH through a timely manner, while ongoing issues can needs assessments that networking and sharing be examined from different perspectives and among fellow practitioners are highly valued. approaches. Single keynote speakers or panel Practitioners want to learn about and be con- combinations are constructed to ensure appro- nected with national efforts, to have readily priate topic coverage. Webinar platforms are identifiable resources, and to be supported as also carefully chosen to optimize interactive professionals. NSPAPPH has sought to provide visual and voice presentations with audience for each of these practitioner needs. participation. In response, NSPAPPH adopted the following Networking and learning from other mem- organizational priorities: bers are essential to NSPAPPH as a society of practitioners. The organization has initiated an 1. Increase membership and engagement. ongoing web-based PA resource matrix, which 2. Increase capacity building and certifi- allows efficient sharing of resources among cation. practitioners. More than 700 resources have 3. Increase advocacy (education of deci- been collected and made available to members sion makers). on the organization’s website: www.physical 280 Newkirk, Abercrombie, Dallman, and Pfankuch activitysociety.org). These tools and resources fessional growth and development. The PAPHS have been created and used by practitioners certification is comparable to the licensing and nationwide as well as by national organiza- credentialing of other recognized professions, tions. They are categorized into a matrix that is validating the significance of this young and searchable by state, setting, or type of resource. emerging profession (Kohl 2006). Capacity-building efforts, including the vari- NSPAPPH’s capacity-building efforts, ety of training opportunities and resources, pro- although highly valuable, are not intended as vide the foundation of an organizational news- an end unto themselves: They are designed to letter called NSPAPPH Matters. This newsletter empower practitioners to effectively and effi- has assumed the functions of the previous CDC ciently influence physical activity behaviors. PA listserv and includes grant opportunities, job If NSPAPPH is to influence these behaviors, announcements, conference announcements, it must address policies, environments, and and newsworthy items. systems. NSPAPPH has taken capacity building to the next level with the creation of the Physical Increase Advocacy: Activity in Public Health Specialist (PAPHS) Educating Decision Makers certification. In collaboration with the ACSM, and building on the core competencies estab- Advocacy, which NSPAPH defines as educating lished with CDC (Dallman 2009), the PAPHS decision makers (and is distinctly different than certification was launched as a new national lobbying), is carried out by many practitioners standard for physical activity practitioners and their organizations. NSPAPPH supports working for the health of the public (Newkirk these efforts by building the capacity of practi- 2010). The certification exam, available at more tioners to inform and educate on physical activ- than 4,300 Pearson Vue testing centers, consists ity issues. Additionally, through membership of 100 questions that evaluate domains of tasks and networking efforts, NSPAPPH is creating and related knowledge, skills, and abilities to a collective, unified voice of PA practitioners, promote physical activity on a population level. allowing them to join together on larger issues. The domains and the test percentages given for As the body of practitioners grows, and as each area include partnerships (12 percent), individual and corporate capacity increases, data and scientific information (18 percent), the collective voice of PA practitioners will cer- planning and evaluating (23 percent), interven- tainly have a great influence on physical activity tions (20 percent), organizational structure (10 behavior. NSPAPPH, as an organization, will percent), and exercise science in public health continue to speak on behalf of practitioners and settings (17 percent). Partnerships, planning PA issues, but the unified voice of the members and evaluating, and organizational structure of the organization will be even more effective make up almost half of the exam. Additional (Newkirk 2010). information is available at www.paphscert.org. The PAPHS certification adds value to indi- vidual professionals, to employers, and to the Linkage to National profession as a whole. Individuals benefit Physical Activity Plan through achieving the certification, which dem- onstrates their knowledge, skills, and abilities NSPAPPH’s efforts directly support the imple- and validates their qualifications. Employers mentation of the National Physical Activity benefit by using the PAPHS certification as Plan. In particular, each of the Public Health a hiring or employment criterion, ensuring Sector strategies is addressed: that candidates have a solid understanding of Strategy 1: Develop the capacity of the public core competencies. Employers can also use health workforce—addressed through conference the core competencies in job descriptions and offerings, webinars, networking, development work plans. The continuing education credits and promotion of core competencies, and the required for the PAPHS certification ensure pro- PAPHS certification. National Society of Physical Activity Practitioners in Public Health 281
Strategy 2: Create, maintain, and leverage Lessons Learned cross-sector partnerships—addressed by the practitioners themselves as well as the organiza- The development of core competencies was tion. NSPAPPH members work and collaborate beneficial to establishing a baseline of knowl- with partners in all settings to promote and edge, skills, and abilities for PA practitioners. create opportunities for PA. As an organization, These will likely continue to evolve given the NSPAPPH is creating partnerships with cross- changing definition and profile of practitioners. sector organizations. As such, our capacity-building efforts, advo- Strategy 3: Engage in advocacy and policy cacy, and support for practitioners will continue development—addressed by practitioners who to develop. work to educate decision makers, enabling them Monthly webinars and annual conferences to more appropriately consider physical activity sponsored by NSPAPPH are linked to our and health as they develop policy. NSPAPPH will knowledge, skills, and abilities to ensure that also continue to support education efforts from individuals seeking PAPHS continuing educa- a national organizational level. tion credits meet ACSM requirements and are Strategy 4: Disseminate tools and resources— awarded credits for attending training sessions addressed by organizing more than 700 national, at no additional cost. NSPAPPH’s professional state, and local tools and resources in a web- development committee continually evaluates based matrix that is searchable by setting, target training sessions to confirm that we are address- audience, or state. ing the core competency areas and meeting the Strategy 5: Expand the monitoring (surveil- continuing education needs of our members. lance and evaluation) of PA and PA interven- Needs assessments have identified additional tions—addressed by practitioners’ evaluation training topics requested by our members, and and surveillance efforts with their state and continuing education credits are offered when local programs. Organizationally, the strategy is training is scheduled. NSPAPPH partners with supported by partnering with Physical Activity other organizations to offer continuing educa- Policy Research Network and other researchers tion credits for PAPHS-certified individuals for to expand PA monitoring. other approved trainings. In addition to making direct contributions One notable challenge for practitioners in to the public health strategies, NSPAPPH indi- general, and an area of continued learning, is rectly supports many other NPAP strategies by determining how to assess the impact of and tell building the capacity of members to promote the story of the PA practitioner. Much of the PA PA in other sectors, such as transportation and practitioners’ policy, environment, and systems schools. change work is completed through partnerships, making it difficult to directly attribute their spe- cific impact. Additionally, assessing the impact Evidence Base Used During of policy, environment, or systems changes Program Development on physical activity behavior is problematic because of the inherently lengthy process and In developing the core competencies, practi- the potential impact of numerous other factors. tioners conducted a literature review and ref- The difficulty in directly demonstrating impact erenced related competencies and certification and long-term outcomes creates challenges not (Dallman 2009). The benchmark areas were only in evaluation but also in terms of justify- organized under CDC’s five benchmarks for ing the value of the effort to funders. Through physical activity and public health practice networking, and the sharing of ideas, successes, (Martin et al. 2013). For training opportunities, and struggles, we will work through this chal- such as webinars or conference presentations, lenge that is inherent to the profession. the evidence base is specific to the topic and, To build the profession, NSPAPPH’s initial therefore, varies greatly from presentation to efforts concentrated on PA practitioners within presentation. public health. Now these efforts are expanding 282 Newkirk, Abercrombie, Dallman, and Pfankuch to include other disciplines, even those that do that partners have in common, even though not consider PA to be their primary focus. For there may be different purposes for the inter- example, transportation planners may not have vention. Practitioners recognize how promoting health as their primary goal; however, they may physical activity fits into a variety of settings. see PA as a strategy to achieve transportation With NSPAPPH’s support, PA practitioners efficiency goals. By working together, both par- work with partners to advance policy, systems, ties may achieve their desired outcomes. or environmental changes that support and NSPAPPH has worked to meet the profes- encourage regular physical activity in a variety sional development and capacity-building of settings. needs of its members by soliciting feedback and As an example, in Minnesota a PA practi- input through a needs assessment process. As tioner worked with transportation, education, the field of PA interventions continues to grow and nonprofit partners to support legislators and as new evidence-based and promising in establishing the Safe Routes to School pro- practices emerge, it is crucial that professional gram in the 2012 legislative session. The PA development opportunities meet the needs of practitioner, as a technical expert and resource, the practitioners. As NSPAPPH membership provided partners with information about further evolves and becomes increasingly pro- what was happening across the state related fessionally diverse, ongoing input and feedback to health improvement efforts in schools. This from practitioners are critical. To maintain and vital contributory role led to the passage of the increase the perceived value of the organization, legislation. NSPAPPH will continue to use a member needs While working with partners outside of assessment to create a professional develop- public health it is important to recognize that ment and training framework. language matters. For example, the words intervention and surveillance can be perceived differently outside of public health. When prac- Populations Best Served titioners discuss the most common forms of by the Program physical activity—walking and bicycling—they may be interpreted differently by partners. For The networking, advocacy, and capacity- example, to transportation partners, walking building activities of NSPAPPH are suited and bicycling could mean nonmotorized trans- to anyone who promotes physical activity. portation; to parks and recreation partners, Although oriented toward those addressing walking and bicycling could mean leisure-time policy, systems, or environmental changes, exercise opportunities. Either way, PA practi- the organizational offerings also include indi- tioners must be skilled in adapting to promote vidual and interpersonal approaches. In the physical activity among diverse partner and 2011 Physical Activity Policy Research Network stakeholder groups. survey, more than 34 percent of respondents indicated that they were not employed primarily as a physical activity practitioner (www.unc. Program Evaluation edu/~kevenson/_NSPAPPH_SurveySummary. pdf). NSPAPPH welcomes anyone who wishes NSPAPPH is continually assessing how busi- to promote physical activity, whether employed ness is done and is adapting to the evolving or volunteer, and whether at the local, state, field of physical activity promotion among national, or international level. diverse populations and settings. Members are surveyed biannually to determine their techni- cal assistance and training needs to promote Tips for physical activity. This survey assists planners Working Across Sectors in selecting training webinars and topics for the annual conference. Practitioners routinely work across sectors to PA practitioners who have completed the find the win-win solution, identifying strategies certification provide another snapshot of exist- National Society of Physical Activity Practitioners in Public Health 283 ing capacity. The certification exam allows the implementation of the National Physical NSPAPPH to get a better picture of what com- Activity Plan in their communities and states petency areas are strongest among practitioners and across the nation. and where more training is needed. The number of candidates who have sat for the certification is another indicator of how NSPAPPH is grow- Additional ing the field of physical activity promotion. Reading and Resources In the first three years since the certification was established, and with virtually no market- The complete set of core competencies, titled Core ing, more than 237 practitioners have become Competencies and Knowledge Skills and Abili- PAPHS certified. ties: Essentials for Public Health Physical Activity Practitioners, can be found at http://physicalac- To assist our members in capacity building, tivitysociety.org/wp-content/uploads/2010/08/ NSPAPPH and its partners provide resources approved_bod_cc_011410.pdf. to self-assess PA in public health competency levels. These resources include the NSPAPPH monthly webinars; continuing education online References courses (www.acsm.org); the core competen- cies–KSA document; a 15-question free practice Kimber, C., E. Abercrombie, J.N. Epping, L. Mordecai, exam (www.acsmlearning.org); the PAPHS J. Newkirk, Jr., and M. Ray. 2009. Elevating physical certification exam; the PAPHS certification activity as a public health priority: Creation of the National Society of Physical Activity Practitioners informational (www.PhysicalActivitySociety. in Public Health. Journal of Physical Activity and org); and the more than 700 resources provided Health 6:677-81. to members on the NSPAPPH website. Dallman, A., E. Abercrombie, R. Drewette-Card, M. The ACSM–NSPAPPH PAPHS Certification Mohan, M. Ray, and B. Ritacco. 2009. Elevating Exam Preparation Course was recently released. physical activity as a public health priority: Estab- This course, which was developed in conjunc- lishing core competencies for physical activity tion with the ACSM and NSPAPPH, is a perfect practitioners in public health. Journal of Physical resource for PA practitioners and other health Activity and Health 6:682-9. professionals looking to better understand the Kohl, H.W., III, I-M. Lee, I.M. Vuori, F.C. Wheeler, A. role of physical activity in public health as well Bauman, and J.F. Sallis. 2006. Physical activity and as those seeking continuing education credits. public health: The emergence of a sub discipline. The online course includes the Foundations of Journal of Physical Activity and Health 3:344-64. Physical Activity and Public Health (Kohl and Kohl, H.W., III, and T. Murray. 2012. Foundations of Murray 2012) textbook. To learn more, visit Physical Activity and Public Health, Champaign, www.physicalactivitysociety.org. IL: Human Kinetics. NSPAPPH is elevating the issue of physical Martin, S.L., and T. Vehige. 2013. Establishing public activity by uniting a new profession, educating health benchmarks for physical activity programs. decision makers, and building the capacity of Prev. Chronic Dis. [serial online] www.cdc.gov/pcd/ practitioners to influence all levels of decisions issues/2006/jul/06_0006.htm. that affect physical activity. NSPAPPH will Newkirk, J. 2010. The NSPAPPH: Answering the continue its efforts to support its members—PA call. Journal of Physical Activity and Health practitioners—who are themselves leaders for 7(Suppl. 1):S7-8.
CHAPTER 33 Successful Cross-Sector Partnerships to Implement Physical Activity Live Well Omaha Coalition
Kerri R. Peterson, MS Mary Balluff, MS, RD, LMNT Live Well Omaha Douglas County Health Department
Brian Coyle, MPH, PAPHS Nebraska Department of Health and Human Services
NPAP Tactics and Strategies Used in This Program
Public Health Sector industry; volunteer and non-profit organizations; faith communities; mass media; and organizations STRATEGY 2: Create, maintain, and leverage cross- sector partnerships and coalitions that implement serving historically underserved and understudied effective strategies to promote physical activity. populations. Partnerships should include representatives from STRATEGY 3: Engage in advocacy and policy develop- public health; health care; education; parks, rec- ment to elevate the priority of physical activity in reation, fitness and sports; transportation, urban public health practice, policy, and research. design, and community planning; business and
ive Well Omaha (LWO) is a long-term col- Llaborative effort of individuals and organi- zations, both public and private, representing all levels of government, schools, health care, public health, faith-based organizations, com- munity organizations, and businesses. These strategic partners share a vision to improve the overall health of area residents and position Omaha as a thriving community for the future. LWO serves as a catalyst for discussions about community health issues and guides partners to collaborate, facilitate infrastructure changes, and address policy opportunities to create and sustain a healthier community. The mission of LWO is to improve the community’s health, Reprinted, by permission, from Live Well Omaha.
285 286 Coyle, Peterson, and Balluff through a forum of organizations, positively more of vigorous physical activity three or affecting health outcomes for all individuals more times a week (Live Well Omaha Com- and families. munity Report Card 2002). Seeing evidence that indicated an imminent obesity epidemic in Omaha, LWO focused its efforts on increasing Program Description the community’s capacity to mobilize resources to address obesity prevention, with an emphasis Beginning in 1995, the Douglas County on physical activity, by facilitating communica- (Nebraska) Health Department collaborated tion among key stakeholders such as health care with Alegent Health, a large hospital and health agencies, nonprofit organizations, and major system, to create a local healthy community employers. movement. That same year, 18 organiza- Omaha’s built environment provided both tions came together to form LWO. This group challenges to and opportunities for active living. included both public and private partners that Omaha had experienced rapid westward growth were interested in addressing community health in recent decades. Unfortunately, the city was needs. Priorities for LWO were based on a com- unable to build and expand certain infrastruc- munity health assessment that identified health ture (e.g., public transportation, sidewalks, needs. The assessment was a coordinated effort trails, bike lanes) at the same pace. Many neigh- between local public health agencies and the borhoods, both new and old, lacked the nec- LWO board of directors and staff. These initial essary infrastructure for sidewalks. Bike trails organizations included the local health depart- had only recently been constructed. Although ment, hospital and health systems, insurance there were more than 60 miles (96.5 kilome- companies, and other public and private cor- ters) of recreational trails in Omaha, they were porations such as Blue Cross and Blue Shield not well connected. Other factors that limited of Nebraska, Union Pacific, and Valmont Indus- active living behaviors included traffic condi- tries. This innovative partnership fostered new tions, aggressive drivers, poor street design, lack collaborations and leveraged funding to support of bike lanes, hilly terrain, and harsh winters. health initiatives specific to increasing physical Because of these factors, few residents engaged activity and healthy eating to prevent obesity. in active living, specifically bicycling. Most In the early 2000s, as initiatives and part- bicycle trips in Omaha were recreational only. nerships grew, LWO became a separate entity Transportation-related trips were rare because from the Douglas County Health Department. of the lack of east-west trail connectivity. However, a strong, collaborative relationship Early funding was secured through the remained between the two organizations. Omaha Community Foundation, Blue Cross In 2002, LWO used vital statistics, a com- and Blue Shield of Nebraska, and Nebraska munity health assessment, and Behavior Risk Department of Health and Human Services and Factor Surveillance System data to describe featured joint efforts between local public health the current health status of the community. and LWO. The first of many major milestones This was the first LWO biannual Community for the LWO was a funding opportunity called Report Card, which served as a wakeup call Active Living by Design, which was created for the community. The report card indicated by the Robert Wood Johnson Foundation. This an increase in the number of community mem- grant funding focused on increasing physical bers who were either overweight or obese (59 activity options through community design. percent were overweight or obese compared By providing support for changes in commu- with the Healthy People 2010 goal of less than nity design, specifically related to land use, 15 percent). Twenty-seven percent had high transportation, parks, trails, and greenways, the blood pressure, compared with the Healthy Active Living by Design initiative was intended People 2010 target of 16 percent or less. Only to make it easier for people to be active as 43.7 percent of adults reported 20 minutes or part of their daily routines. Active Living by Live Well Omaha Coalition 287
Design’s community action model provided five active living strategies, known as the 5Ps, targeting community change through prepara- tion, promotions, programs, policy influences, and physical projects. The 5P model provided a comprehensive approach to increasing physical activity through short-, intermediate-, and long- Funding for these items was made possible (in part) by the cooperative term community changes. In November 2003, agreement award 1U58DP002394-01 from the Centers for Disease Control and LWO was 1 of 44 communities in the United Prevention. The materials do not necessarily refect the offcial policies of the Department ofE5691/NPAP/fig33.2/458631/alw/r1 Health and Human Services. States to receive $300,000 for a five-year fund- ing period. The new initiative, under the LWO work and log their miles. The project featured umbrella, was branded LWO: Activate Omaha maps noting routes across the city and provided and focused primarily on promotional efforts. awards to company teams with the most miles. The inclusive 5P model facilitated the integra- LWO: Activate Omaha provided the technical tion of policy approaches, physical projects, and support, route identification, incentives, and a vast number of programmatic efforts specific program maintenance. to active living. The program, promotion, and As the number of activities and grant oppor- partnership-building efforts that were part of tunities increased, LWO: Activate Omaha cre- LWO: Activate Omaha helped to build credibility ated a number of subcommittees, including for the active living movement and generated media, Safe Routes to School, policy, and support for infrastructure and policy change. fund-raising (see figure 33.1). This allowed The mission of LWO: Activate Omaha was volunteer members to use their expertise, to create awareness, advocacy, and excitement skills, and resources to create a more effective about activity and to highlight the importance and efficient partnership. In the third year of of designing the community for active lifestyles. the Active Living by Design grant, local orga- LWO: Activate Omaha is a community-wide nizations expressed an interest in forming a initiative designed to encourage community bicycle-friendly community design coalition members to incorporate activity into daily under the umbrella of LWO: Activate Omaha. living and to support changes in urban design, LWO: Activate Omaha used programs and land use, and transportation policies to culti- promotions to build community demand and vate and support active living. A 2004 health establish rapport with community members in report card released by LWO found no change order to influence policy change. The partner- in obesity or physical activity levels (Live Well ship worked with partners to promote active Omaha Community Report Card 2004). Initial living policies by providing resources and infor- programmatic efforts were aimed at increasing mation to community members about how to citizen awareness of the benefits of physical become well-informed citizens and advocates activity and the range of activities that could for change, often through existing programs. increase physical activity. Several campaign LWO: Activate Omaha continues to implement messages were used: Physical activity can be small- and large-scale environmental changes fun, physical activity can be done any time and through the following policies and programs, in many places, and physical activity works best among others: as a part of everyday living. As the campaign messages continued to show success, efforts Bicycle-Pedestrian Advisory Committee changed and LWO: Activate Omaha became This technical advisory group (composed of the resource for physical activity opportunities city planners, local health department person- and initiatives in the community. Perhaps LWO: nel, cycling advocates, and others) advises the Activate Omaha’s most successful effort was the mayor on issues such as improving conditions commuter challenge, which encouraged busi- for bicycling, walking, and other forms of alter- nesses to support teams of bicyclists to ride to native transportation. 288 Coyle, Peterson, and Balluff
Board of directors
Collaborating council membership body Committees of the board LWO Kids CTG • Finance (advise and coordinate) • Communications • Development • Evaluation • Policy • Convening
Executive director .25 Admin assist.
Administration Communications Program Project management • Accounting .5 FTE- 1 FTE-Activate Omaha -Summit • HR/Lease/Contracts Communications and RWJ Healthy Kids -Initiative interface specialist Healthy Communities including Pioneering Healthy Communities, Omaha by Design -Convening support
Figure 33.1 Live Well Omaha organizational chart. Funding for these items was made possible (in part) by the cooperative agreement award 1U58DP002394-01 from the Centers of Disease Control and Prevention. The materials do not necessarily refect the offcial policies of the Department of Health and Human Services. E5691/NPAP/fig33.3/458630/alw/r3-kh Land Use and Street Design Policy master plan. Subsequently, in 2012, the city • The city council unanimously passed a planning board approved a transportation plan. package of revisions and additions to the Bike Amenities city’s zoning and subdivision code struc- ture for streetscapes, signage, landscaping, • LWO: Activate Omaha increased commu- building design, pedestrian networks, nity demand for bicycle lanes and other public spaces, and connections between bicycle infrastructure such as bike racks city neighborhoods, commercial centers, and parking amenities. and civic districts. • The partnership identified streets that • The partnership supported this effort by needed to be redesigned and requested providing information and encouraging that bike lane signage and striping be residents to write letters and attend meet- incorporated. The partnership targeted ings. streets that could easily accommodate bike lanes. Bicycle and Pedestrian Loop • More than 20 miles (32 kilometers) of The partnership received funding to develop a on-street enhancements were in design 20-mile (32-kilometer) bicycle and pedestrian phases as a result of funding provided by loop in Omaha as a pilot project to increase a number of private foundations. Federal physical activity. The partnership hoped that transportation enhancement funds were the success of the pilot project would encour- also secured through the city planning age the funder to invest additional resources office for “road diets” (i.e., a reduction in expanding the loop and would serve as in traffic lanes), bicycle lanes, and other the groundwork for a citywide transportation amenities. Live Well Omaha Coalition 289
• The city planning and public works depart- 2008, the Robert Wood Johnson Foundation ments agreed to allocate an additional 10 awarded a Healthy Kids Healthy Communities feet (3 meters) of right-of-way on all road- grant to the Douglas County Health Department widening projects. and LWO Kids. In 2009, the Douglas County • In collaboration with local bicycle shops, Health Department with the LWO collaboration LWO: Activate Omaha offered inexpensive was awarded funding from the Communities bicycle racks to businesses throughout Putting Prevention to Work (CPPW), a grant the city. opportunity from the Centers for Disease Con- trol and Prevention that is part of the American • Bike racks were added to all buses and Recovery and Reinvestment Act. This $5.7 mil- trains that were part of the metro area lion grant was possible because of the leveraged transit system. community partnerships and capacity created by the LWO collaboration. LWO Kids The CPPW funding addressed multiple As the momentum began to build around health issues, including healthy eating and combating obesity, another key partnership active living. This allowed LWO and the Doug- occurred. Alegent Health made a significant las County Health Department to move exist- investment in the community in 2006 when ing efforts forward as well as to create new it committed more than one million dollars in activities. The funding broadened the scope of funding and staff resources to create a commu- after-school programs and provided training nity coalition dedicated to fighting childhood for Safe Routes to School and bike pedestrian obesity in Omaha and surrounding communi- safety initiatives. As a new venture it added a ties. The initiative was moved under the LWO revision to the transportation element of the umbrella. This ensured strategic alignment city’s master plan. These funding opportunities across LWO: Activate Omaha and LWO: Kids and the alignment of community efforts have and prevented duplication. built and facilitated a strong foundation for Following are examples of successful projects the recently released Community Transforma- that have been led by LWO Kids: tion Implementation Grants provided by the Centers for Disease Control and Prevention. As • Physician training to measure patients’ of September 27, 2011, Douglas County Health body mass index at every office visit. Department was 1 of 61 funded organizations to • Implementation of a social marketing receive this grant funding. The funding focuses campaign called 54321Go! This program, on tobacco-free living, active living, healthy which was modeled after a Chicago pro- eating, and provision of high-quality clinical gram, focuses on the number of healthy and preventive services. behaviors kids should engage in each day. LWO uniquely exemplifies an aligned effort • A school-based physical activity during across community coalitions working to elimi- recess initiative funded by the Robert nate childhood obesity, encourage active living, Wood Johnson Foundation. and promote healthy eating. The infusion of CPPW funding into the Omaha community, As LWO grew in partnership and experience, along with the leveraging of community-based so did the opportunities to affect community funding, has allowed for the collaboration to health efforts through new collaborative efforts make a significant step in solving some of the and funding opportunities over the years. health issues affecting the city. To be strate- Omaha became 1 of 45 communities that par- gic and efficient, the LWO coalition serves as ticipated in the Pioneering Healthier Communi- the umbrella organization to guide and unite ties efforts in 2007. This was a national initiative four existing collaborative initiatives to create from the YMCA Activate America program. In community-wide, sustainable change. 290 Coyle, Peterson, and Balluff
Linkages to the National promoting tools to improve individual- and community-based physical activity habits. Many Physical Activity Plan of the tools and resources help to promote bike and pedestrian efforts, such as the commuter LWO’s successes in addressing Strategy 2 for challenge, Safe Routes to School programming, the Public Health Sector can be directly linked and policy and advocacy efforts. to the cross-sectoral partnerships that have been created, maintained, and leveraged. In collaboration with the Douglas County Health Evidence Base Used During Department, LWO has built an exceptional com- munity model that began with the engagement Program Development of nonprofit organizations and a large health The combined effects of society, family, and care–based organization. Buying into the vision individual factors intensify the causes of obesity of LWO and providing funding allowed the (Davison and Birch 2001; DeMattia and Denney coalition to come together in a unified effort 2008). Research suggests that environmental to address poor nutrition, physical inactivity, change is critical at all levels of the ecologi- obesity, and other identified health issues. cal model to support individual change (Budd Through continuous leveraging of resources and and Hayman 2008; Ferreira et al. 2001; Sallis partners, LWO has developed a large network and Glanz 2006). Throughout this collabora- that can address physical activity strategies tive process, the primary goal was to create a within the areas of public health, health care, community that supported physical activity. education, parks, recreation, transportation, The collaborative used three models to produce urban design, community planning, worksites, such an environment: an ecological model, nonprofit organizations, faith communities, a health policy model, and the Robert Wood and underserved populations. These strategic Johnson’s Active Living by Design 5P model. partners also help to carry out other strategies The ecological model served as the cornerstone found in the National Physical Activity Plan, and clearly defined the scope of work needed specifically the Business and Industry; Educa- to create meaningful results. The ecological tion; Mass Media; Transportation, Land Use, model requires planners to identify elements and Community Design; and Volunteer and in the community that affect a behavior, from Nonprofit Sectors. personal elements such as homes and work to Building on these cross-sectoral partnerships public elements such as faith-based organiza- has allowed LWO to address two additional tions and legislative bodies. strategies in the National Physical Activity Plan, The second model used in the planning pro- Public Health Sector. Drawing on Strategy 3 of cess was the health policy model. According this sector, the partnership has helped LWO to Richmond and Kotelchuck (1991, 1993), in create a policy and advocacy agenda to improve order to effectively implement system change the health of the citizens of Douglas County. An across a community, planners must develop a example of this work was the recently approved knowledge base, gain political will to support citywide transportation master plan, which change, and create a social strategy to accom- includes a Complete Streets policy approach plish change. An adequate knowledge base is that highlights the need for an integrated trans- needed to facilitate decision making. Political portation system that is available for all citizens. will provides a mechanism by which communi- This policy work was accomplished through col- ties’ needs are heard and resources allocated. laboration of various key partners from public The way in which knowledge is applied and the health, community planning, public works, political will is built is the social strategy. These local coalitions, local government agencies, and social strategies may help to reset behaviors and the public. Regarding Strategy 3 of the Public contribute to sustained change. Health Sector, Activate Omaha has extensive The third model that helped to integrate the experience in developing, disseminating, and LWO: Activate Omaha was the 5P model, The Live Well Omaha Coalition 291
5P model, created by Active Living by Design, addition, 77 percent of students reported that a national program of the Robert Wood Johnson they never biked or walked to school, attribut- Foundation, featured preparation, partnership, able in great part to a lack of infrastructure promotion, policy, and physical environment connecting schools to trails, bike paths, green focuses. The model establishes innovative spaces, and parks. approaches to increase physical activity through community design, public policies, and com- munications strategies (Bussel, et al. 2009). The Lessons Learned model suggests that a community that engages LWO used several strategies that contributed in a range of activities, from partnerships to to its early successes. The strongest keys to programming and policy change, creates lasting success thus far have been (1) building on a sustainable change. history of partnerships, (2) creating awareness by setting an agenda for change, (3) following Populations Best Served a planning model in developing programs, and (4) implementing some activities on a rolling by the Program basis. LWO serves the entire Omaha metropolitan area and focuses on Douglas County. The U.S. Building on a History Census Bureau’s 2010 population estimate for of Partnerships the City of Omaha is 408,958; the estimate for Douglas County is 510,199. The population of Central to LWO’s success has been the history Douglas County is diverse (72 percent white, of the Douglas County Health Department and 12 percent Black, 11 percent Hispanic, and 5 LWO partnerships with other organizations percent other racial and ethnic groups) and in the community and the ability to leverage faces a number of challenges, including poverty, existing activities in the community. Before the health disparities, and health risks related to introduction of CPPW funding, the network poor nutrition, physical inactivity, and other of 19 partners and members of Omaha’s busi- chronic disease risk factors. ness community had engaged in several early Omaha’s health ranking is extremely low— collaborations to address obesity and physical 142 out of 182 metropolitan cities, according activity in the community. Many of these early to 2009 data from the Behavioral Risk Factor activities laid the groundwork for LWO’s CPPW Surveillance System. Five indicators contribute current objectives and activities, allowing it to to this classification: current smokers, binge build on the existing efforts and interests of drinkers, physical activity levels, consumption the community and to hit the ground running of fruits and vegetables, and overweight and at the time of the award. A key to success has obesity (Centers for Disease Control and Preven- been the joint effort by the two organizations tion 2009). Douglas County exceeds the 2009 to leverage funding opportunities by aligning national rates for diabetes-related deaths and the leadership processes and plans with the overweight youth. The county’s rankings (Uni- strengths of each organization. versity of Wisconsin Population Health Institute 2011) indicate that only 77 percent of Douglas Creating Awareness Through County residents have access to healthy foods Media and Setting an Agenda such as fruits and vegetables, compared with 92 percent nationally. In a 2008 random survey of for Change 894 Douglas County youth ages 12 to 19 years, Another key to success noted by LWO CPPW more than 50 percent reported that they rarely staff is the use of media to engage members of ate fresh fruits and vegetables and less than 10 the community. The media campaign’s early percent reported eating five servings of fruits messages to the community regarding Omaha’s and vegetables each day (Wang et al. 2009). In poor health ranking caught people’s attention E5691/NPAP/fig33.4a/458632/alw/r1 E5691/NPAP/fig33.4c/458634/alw/r1
E5691/NPAP/fig33.4d/458635/alw/r1
Funding for these items was made possible (in part) by the cooperative agreement award 1U58DP002394-01 from the Centers for Disease Control and Prevention. The materials do not necessarily refect the offcial policies of the Department of Health and Human Services.
E5691/NPAP/fig33.4b/458633/alw/r1 292 Live Well Omaha Coalition 293 and spurred greater interest and involvement. Tips for As explained by one LWO CPPW staff member, the overall goal of the media activities is not just Working Across Sectors to inform people about health issues but also to In working across sectors, program leaders must create a movement for improving health in the define key concepts, strategies, and outcomes. community. Central to this strategy has been These definitions require a common vision, branding LWO CPPW across the set of project resulting in a common language. Finding a activities so that people in the community common language is key as new partners join associate the individual or smaller environ- an initiative: The language a public health ment, policy, or systems change activities with officer uses may be different than that used by a much larger effort to improve the community a planner. and its health. • Align project duties with an organization’s agendas and strengths. In order to make projects Following a Planning Model simple, they should contain clearly delineated in Developing Programs duties for every partner, depending on each partner’s expertise. This allows partners to LWO CPPW staff found that their experience work in tandem with others doing the same using the Robert Wood Johnson Foundation 5P functions, and their combined work contrib- model for change was helpful. LWO was intro- utes to the common good. When partners use duced to this model through its participation similar strategies aimed at a common goal, their in the Robert Wood Johnson Foundation Active combined efforts create a more robust product. Living by Design community grant program and An example is the installation of bicycle lanes. has used its basic approach with subsequent These lanes could be viewed by public health projects. Using the model prompted staff to officers as a means to increase physical activity, think about policy as a part of change and to whereas public works planners may consider draw on a holistic framework for evaluating and bicycle lanes as a means of promoting public addressing health issues in the community. By safety and reducing car traffic. Further, planners using this model in designing programs, LWO and developers may view bicycle lanes as an CPPW staff are better able to strike a balance engaging design element. between working directly on policy change and creating public education, interest, and involve- • Create meaningful dialogue that acknowl- ment, which they believe is required for changes edges the importance of the project in each in policy to be enacted. partner’s overall scope of work. This requires mutual respect and an open dialogue that honors all partners’ points of view and contri- Implementing Activities butions. Respectful dialogues allow partners to on a Rolling Basis discuss the value of their achievements with each other and with the greater community. Several LWO CPPW strategies have been imple- Remember that what might seem trivial to one mented on a rolling basis; some organizations group can be important to another. and communities participated in or completed program efforts in the first year and others • Persevere in your efforts to communicate. became engaged in the second year. Although Success requires continuous and positive the intent of this design was mostly to make engagement. these activities more manageable, this phased-in approach has allowed LWO staff to gain experi- ence and refine their efforts and has provided References opportunities for staff to present success stories Budd, G.M., and L.L. Hayman. 2008. Addressing the to potential future partners and the city as a childhood obesity crisis. MCN. Am. J. Matern. Child whole. Nurs.33(2):111-8. 294 Coyle, Peterson, and Balluff
Bussel, Leviton, and Orleans. 2009. Active living by Live Well Omaha Community Report Card. 2004. Omaha, design: Perspectives from the Robert Wood John- NE: Douglas County Health Department. son Foundation. American Journal of Preventive Richmond, J.B., and M. Kotelchuck. 1991. Co-ordination Medicine. (37):6S2. and development of strategies and policy for public Centers for Disease Control and Prevention. 2009. health promotion in the United States. In: Oxford Text- Behavioral Risk Factor Surveillance System Survey book of Public Health. W.W. Holland, R. Detels, and G. Data. Atlanta, GA: U.S. Department of Health and Knox, Eds. Oxford, UK: Oxford Medical Publications. Human Services, Centers for Disease Control and Richmond, J.B., and M. Kotelchuck. 1993. Political influ- Prevention. ences: Rethinking national health policy. In: Handbook Davison, K.K., and L.L. Birch. 2001. Childhood over- of Health Professions Education. C. Mcquire, R. Foley, weight: A contextual model and recommendations A. Gorr, and R. Richards, Eds. San Francisco: Jossey- for future research. Obes. Rev. 2(3):159-71. Bass. DeMattia, L. and S.L. Denney. 2008. Childhood obesity Sallis, J.F., and K. Glanz. 2006. The role of built envi- prevention: Successful community-based efforts. ronments in physical activity, eating, and obesity in Ann. Am. Acad. Pol. Soc. Sci. 615:83-99. childhood. Future Child. 16(1):89-108. Ferreira, I., K. van der Horst, W. Wendel-Vos, S. Kre- University of Wisconsin Population Health Institute. 2011. mers, F.J. van Lenthe, and J. Brug. 2001. Environ- County Health Rankings & Roadmaps. Madison, WI: mental correlates of physical activity in youth: a Robert Wood Johnson Foundation. review and update. Obes. Rev. 8(2):129-54. Wang, H.M. et al. 2009. Youth physical activity and dietary Live Well Omaha Community Report Card. 2002. behavior in Douglas County survey findings. www. Omaha, NE: Douglas County Health Department. livewellomahakids.org. CHAPTER 34 Tracking and Measuring Physical Activity Policy
Amy A. Eyler, PhD, CHES Kelly R. Evenson, PhD Washington University in St. Louis University of North Carolina
Ross C. Brownson, PhD Washington University in St. Louis
NPAP Tactics and Strategies Used in This Program
Overarching Strategies STRATEGY 4: Establish a center for physical activity policy development and research across all sectors STRATEGY 3: Disseminate best practice physical ac- of the National Physical Activity Plan. tivity models, programs, and policies to the widest extent practicable to ensure Americans can access strategies that will enable them to meet federal physical activity guidelines.
or decades, health professionals have environment, which has the potential to affect Frecommended regular physical activity as physical activity at the population (rather than a way to improve health and prevent disease. individual) level (Centers for Disease Control Despite the proven health benefts of regular and Prevention 2011). The objectives of this physical activity, about half of adults in the chapter are (1) to defne physical activity policy, United States do not participate in physical (2) to describe and provide examples of aspects activity at recommended levels, and about 25 of physical activity policy surveillance within percent do not participate in any leisure-time the National Physical Activity Plan, and (3) to physical activity (Centers for Disease Control provide examples of mechanisms for physical and Prevention 2008). Because participa- activity policy surveillance. tion rates have changed very little over time, public health, medical, and other concerned organizations are promoting new and broader Program Description strategies to help people become more active. Physical activity policies are legislative actions, These new strategies focus less on individual organized guidance, or rules that may affect the or small group changes, since these approaches environment or behaviors related to physical are not very effcient and the changes often activity (Schmid et al. 2006). These policies don’t last (Brownson et al. 2006). Current can be in the form of formal written codes (e.g., strategies include changing policies and the state legislation requiring physical education)
295 296 Eyler, Evenson, and Brownson or standards that guide choices (e.g., a bicycle strategies, participants must learn more about or pedestrian master plan for a community). existing (or missing) policies. Physical activity (PA) policies involve many disciplines. Public health, education, recreation, urban planning, transportation, and advocacy PA Policy Surveillance groups are some of the key stakeholders. Exam- Public health surveillance is a cornerstone of ples of PA policies include those within schools, public health (Lee and Thacker 2011). The such as required physical education, recess United States has surveillance or tracking sys- policies, and active transport policies, and those tems that provide excellent data for estimating within worksites, such as policies that reward the person, place, and time dimensions of PA or flexible schedules that allow employees physical activity. Although these are helpful, it to exercise. Municipalities may develop and is also important to identify and track policies maintain quality public spaces, such as parks that have the potential to influence population and trails, and implement policies that encour- PA. Information provided by policy surveillance age their use. Transportation policies, when they systems can be an enormous asset when plan- consider all users of transportation resources, ners are developing new policies or when trying including bicyclists and pedestrians, can pro- to solicit support for policies. For example, a mote physical activity in a community. school district representative can examine data Research on and surveillance of these policies on rates of physical activity for a community can help determine best practices for improv- and its schools to justify the development of ing population levels of PA. This is consistent a joint-use policy. Databases for existing and with the aim of the National Physical Activity successful joint-use agreements can provide Plan (NPAP) to “create a national culture that important guidance and language in policy supports physically active lifestyles” (National development. Physical Activity Plan Coordinating Committee Physical activity policy surveillance involves 2010). three steps: identifying policies, identifying policy content, and exploring implementation. Linkage to National Physical Activity Plan Identifying Policies The first step in determining the most effective PA policy and surveillance are integral to the PA policies is to identify what policies exist. NPAP. Two of the overarching strategies of the Identification is challenging because of the NPAP encompass the need for best practices in broad and complex scope of policies that can PA policies and policy information dissemina- influence PA. Obtaining information on the tion. policies can be difficult, because each level Strategy 3: Disseminate best practice physical of government (state, county, municipal) and activity models, programs, and policies to the each sector may have its own tracking and widest extent practicable to ensure Americans data system. For example, a state may have a can access strategies that will enable them to database that provides information on physical meet federal physical activity guidelines. education, including a list of physical education Strategy 4: Establish a center for physical policies enacted or in place within a certain time activity policy development and research across frame at the state level. At the local level, how- all sectors of the National Physical Activity Plan. ever, few comprehensive databases or tracking Additionally, each of the eight sectors within tools exist for compiling or examining policies. the NPAP includes at least one priority strategy Surveillance of local policies often requires the that relates to policy research, development, use of secondary data sources, such as school advocacy, or action. To best accomplish these district policy documents or municipal web- Tracking and Measuring Physical Activity Policy 297 sites. Following is a brief case study of policy and regional policies as a measure of advocacy identification. progress. Case Study: Complete Streets Policy Identifying Policy Content Surveillance The second step in PA policy surveillance is For many PA policy topics, no single, easy identifying policy content. Content included in method exists for gathering information. How- a policy can determine effectiveness. Assess- ever, by using several methods and data sources ing the content for the inclusion or lack of an and some creative thinking, interested individu- evidence base is important for evaluation and als or organizations can collect information on PA improvement. A policy that mandates proven policies. A good example is collecting Complete strategies will more likely have expected out- Streets policy information. A Complete Streets comes than will a policy not based on evidence. policy supports the premise that transportation Additionally, content analysis on policies planners and engineers should design and oper- can show trends and patterns over time. For ate the entire roadway with all users in mind— example, content analysis can show trends in including bicyclists, pedestrians of all ages and how evidence is disseminated into both policy abilities, and public transportation vehicles and practice. Last, examining content of PA and riders (National Complete Streets Coalition policies can help in the development of model 2010). By way of these policies, people will have legislation. An assessment of many policies on a more options for active travel and therefore may certain topic usually will reveal a range of qual- increase their physical activity. An inventory of ity in terms of policy content. The best policies such policies can show geographical trends, iden- may be used to develop model policy language. tify gaps and opportunities for dissemination, and provide important information for active Case Study: Evidence-Based Content transportation advocates. Surveillance of Complete Streets policies in State Physical Education Policies can be complex, because such policies can be Public health and education professionals enacted at state, regional, and local levels. In increasingly agree that policy-based approaches 2010, the National Complete Streets Coalition targeting the school environment, such as found that more than 100 jurisdictions—state, physical education (PE), may have the greatest local, and regional—had adopted Complete impact on child and adolescent physical inactiv- Streets policies (National Complete Streets ity and childhood obesity (Masse et al. 2007). Coalition 2010). This organization defines model PE is a policy area for which specific evidence- policies and attempts to identify emerging and based components exist, and aspects of PE are existing policies for surveillance purposes. known to increase the quality and quantity Despite national efforts, achieving a comprehen- of PA in children and adolescents. National sive list of these policies can be difficult. State recommendations include (1) a minimum legislative databases can provide information requirement for PE minutes, (2) an increase in on existing statutes (state laws), legislation that moderate to vigorous activity in PE class, (3) a has been introduced, or resolutions. For a local recommendation for PE teacher qualifications, perspective, assessments of metropolitan plan- and (4) access to a sufficient environment and ning organizations within states may provide equipment for PE (Centers for Disease Control information on the presence of Complete Streets and Prevention 2011; National Association for policies. Another potential way to inventory Sport and Physical Education 2004). To assess Complete Streets policies is to glean informa- to what extent these four evidence-based com- tion from advocacy groups within states that ponents are included in state PE legislation, focus on the built environment or transportation Eyler and colleagues (2010) used online state improvements. These agencies often track local legislation databases to collect a list of all state 298 Eyler, Evenson, and Brownson bills (introduced and enacted). More than 800 activity opportunities for people of all ages. bills were identified during the time period They also connect people with social destina- 2000-2007. Each bill was read and coded for tions or points of interest and ensure sustained the four evidence-based components, and the opportunity for physical activity (Rails to Trails levels of content across the bills were analyzed. Conservancy 2013). Developing a community Researchers concluded that many state-level trail often involves policies across scales and PE policies were not evidence based. Only 272 sectors. Some policies within communities can contained at least one of the four evidence- facilitate trail development (e.g., an established based components. Enactment rates of bills bicycle and pedestrian plan), whereas others with and without evidence-based components can hinder it (e.g., restrictive zoning policies). varied. Forty-three of the 272 bills with at least The Physical Activity Policy Research Net- one evidence-based element were enacted (16 work conducted a case study on the policy percent), compared with 23 percent for the rest process of trail development by examining six of the bills in the sample (Eyler et al. 2010). trails in several states (Eyler et al. 2008). The goals of this case study were to identify the Exploring Implementation policy influences on trail development, explore the roles of key players in trail development, The third step in PA policy surveillance is and compare and contrast findings from the exploring implementation. Once a policy is different trails. Drawing from 46 key informant enacted, it is important to assess how and to interviews, researchers found that policies at what extent it is being put into action. This step all governmental levels were apparent in trail involves gaining information on the implemen- development. Both federal and state funding tation process. Implementation analysis could policies and design standards were reported include the following: by representatives in all trail projects studied. • Information on barriers and enablers of Local policies that addressed funding and land implementation acquisition were also important. Leadership, advocacy, community group involvement, and • Necessary stakeholders residential input were all factors in the success • Successful methods of media advocacy of the trail projects (Eyler et al. 2008). • Best practices for implementation Case Study: Evaluation of the National Analysis of this type of process information Physical Activity Plan involves collecting data in a variety of ways. Key informant or stakeholder interviews, focus National plans that address health problems groups, or event observations can be used to are meant to demonstrate the extent of the assess what it takes for a PA policy to be imple- problem and recommend multilevel strategies to mented. improve the specific health condition within the population. These strategies are often divided Case Study: Analysis of Policy by sector and include many aspects of policy Implementation for Development and environmental change. Additionally, such plans can increase visibility of the issue at the of Community Trails political level and allow stakeholders to follow Strategy 2 in the Transportation, Land Use, and common objectives and strategies for improve- Community Design Sector of the NPAP calls for ment (Daugbjerg et al. 2009). The U.S. National the development of trails. A trail is defined as Physical Activity Plan is one such example. This a travel way established either by construction plan followed the release of the 2008 Physical or use that is passable by a variety of modes, Activity Guidelines for Americans (U.S. Depart- such as walking, bicycling, in-line skating, and ment of Health and Human Services 2008). wheelchairs (Federal Highway Administration Although the guidelines provided evidence- 2005). Community trails provide healthy and based recommendations on the types and safe recreation, transportation, and physical amounts of PA that are needed to yield health Tracking and Measuring Physical Activity Policy 299 benefits, the national plan detailed changes that active transportation may include better accep- were needed to put those recommendations into tance of walking or cycling for short errands. place (Pate 2009). As in the case of both behavioral and economic With the development of physical activ- outcomes, environmental and cultural changes ity plans in the United States and around the are difficult to measure and to quantify in terms world, several groups have called for the need of their relationship to the policy. to evaluate these national plans (Bornstein et al. 2009). To accomplish this goal for the U.S. national plan, several initial activities have Evidence Base Used During occurred. The evaluation team created an Program Development evaluation strategy guided by the theoretical underpinnings of the Diffusion of Innovations As exemplified in the case study examples, Theory (Rogers 2004) and the RE-AIM model many resources and sources of information exist (reach, effectiveness, adoption, implementa- for identifying PA policies. These resources vary tion, maintenance) (Glasgow et al. 2006). The in scope of information, comprehensiveness, evaluation team identified three major, measur- and relative ease of use. able activities for the initial, short-term evalu- • Databases: For information on policies at ation of the National Physical Activity Plan: the state or federal level, subscription-based (1) sector reports, (2) survey of the members of databases can provide an easy way to search the National Society of Physical Activity Practi- federal and state legislation by topic and state. tioners in Public Health, and (3) case studies. Additionally, each state has its own legisla- tive search website available for free access, Lessons Learned although these vary in the amount of informa- tion available and search capabilities. The most important, yet the least explored, • National organizations: National organi- aspect of PA policy surveillance is determining zations that promote or support PA can be a the outcomes of the policy. Outcomes can be source for policy surveillance. For example, defined in many ways. Behavioral outcomes the National Conference of State Legislatures (e.g., increased PA in school children) as a result provides comprehensive information on many of specific policies (e.g., PE policies) are of inter- physical activity policy topics. Advocacy asso- est to researchers, advocates, and policy makers. ciations such as the American Alliance for These behavioral outcomes can reach beyond Health, Physical Education, Recreation and PA and potentially influence health conditions, Dance provide information on school-specific such as diabetes or obesity. However, without policies (e.g., PE, recess). Disease-specific the use of complicated study methods, it is organizations, such as the American Heart extremely difficult to say with certainty that the Association, are involved in PA policy advocacy policy brought about the outcome. Economic and have included policy information on their outcomes are another potential measure of PA websites and in reports. policy effectiveness, but they too are difficult to measure precisely, given the complex nature • National surveillance: Survey systems such of these policies. as CDC’s School Health Policy and Programs Other outcomes could include environmental Study and its Behavioral Risk Factor Surveil- or culture change as a result of PA policy. These lance System include some information about types of outcomes may be indirectly related PA behavior and policy. Other surveillance to physical activity. For instance, if policies systems, such as the National Household Travel promote the increase of active transportation, Survey and the American Time Use Survey, can this could reduce the number of automobiles provide comparative PA data. on the road and thus increase physical activity • Research networks: The Physical Activ- but could also lower air particulates. A cultural ity Policy Research Network is a CDC-funded change as a result of more opportunities for network of academic professionals and their 300 Eyler, Evenson, and Brownson community affiliates who study effective elements • Some high-quality sources of national and outcomes of policies that have the potential and state PA policy information exist, but to improve population physical activity rates. local policies are often difficult to assess Although this network is not a comprehensive because of a lack of a unified data source. database for PA policy, the products from the net- • Assessing the evidence base in policy con- work’s research studies can provide information tent is important to this developing field. on evidence-based policies and other background • There is a need for better assessment of information that can inform policy advocacy or policy implementation in order to inform practice. evaluation of outcomes. Active Living Research is an organization funded by the Robert Wood Johnson Foundation to provide a platform for quality active living References research and dissemination, particularly focus- Bornstein, D.B., R.R. Pate, and M. Pratt. 2009. A ing on policy and environmental change. The review of the national physical activity plans of six organization has an extensive resource list on its countries. J. Phys. Act. Health 6(Suppl. 2):S245-64. website that includes academic articles, policy Brownson, R.C., D. Haire-Joshu, and D.A. Luke. briefs, and other PA policy-related information. 2006. Shaping the context of health: A review • Miscellaneous resources: Many topic- of environmental and policy approaches in the specific resources for PA policy surveillance prevention of chronic diseases. Annu. Rev. Public exist. Advocacy agencies that promote increases Health 27:341-70. in the use of Complete Streets policies, Safe Centers for Disease Control and Prevention. 2008. Routes to School, and joint use, for example, all Behavioral Risk Factor Surveillance System: have policy resources on their websites. These National Center for Chronic Disease Prevention websites vary in scope but can provide a good and Health Promotion. Atlanta: Centers for Disease baseline of policy information devoted to the Control and Prevention. topic of interest. Centers for Disease Control and Prevention. 2011. Guide to community preventive services. Promot- ing physical activity: Environmental and policy Summary approaches. www.thecommunityguide.org/pa/ environmental-policy/index.html. Policies are an important part of a comprehen- Daugbjerg, S.B., S. Kahlmeier, F. Racioppi, et al. 2009. sive strategy to improve population PA. These Promotion of physical activity in the European policies are complex and span many sectors region: Content analysis of 27 national policy docu- and levels of government. Assessing the poli- ments. J. Phys. Act. Health 6(6):805-17. cies, their content, and implementation through Eyler, A., R. Brownson, S. Aytur, et al. 2010. Examina- surveillance is essential for gathering evidence tion of trends and evidence-based elements in state for effective policies, informing policy develop- physical education legislation: A content analysis. ment, and advocating for policy support. J. Sch. Health 80(7):326-32. Surveillance and assessment of PA policies Eyler, A., R. Brownson, K. Evenson, et al. 2008. Policy can help inform future efforts to implement the influences on community trail development. J. NPAP and contribute to the growing body of Health Polit. Policy Law. 33(3):407-27. literature on best practices and evidence-based Federal Highway Administration. 2005. Safe, Account- policy strategies to increase populations PA. able, Flexible, Efficient Transportation Equite Act: Despite its importance, there are several gaps A Legacy for Users. Washington, DC: U.S. Depart- in current surveillance efforts: ment of Transportation. Glasgow, R., L. Klesges, D. Dzewaltowski, P. Esta- • Policy measurement and surveillance are brooks, T.M. Vogt. 2006. Evaluating the impact not at the capacity needed to address the of health promotion programs: Using the RE-AIM increasing recommendations for policy inter- framework to form summary measures for decision ventions by authoritative bodies, including making involving complex issues. Health Educ. NPAP. Res. 21:688-94. Tracking and Measuring Physical Activity Policy 301
Lee, L.M., and S.B. Thacker. 2011. The cornerstone of Pate, R. 2009. A national physical activity plan for public health practice: Public health surveillance, the United States. J. Phys. Act. Health 6(Suppl. 1961-2011. MMWR. Morbid. Mortal. Wkly. Rep. 2):S157-8. 7(60):15-21. Rails to Trails Conservancy. 2013. Plan, design, build: Masse, L., J. Chriqui, J. Igoe, et al. 2007. Development Accessibility. www.railstotrails.org/ourwork/trail- of a Physical Education-Related State Policy Classi- building/toolbox/informationsummaries/acces- fication System (PERSPCS). Am. J. Prev. Med. 33(4 sibility.html. Suppl.):S264-76. Rogers, E.M. 2004. A prospective and retrospective National Association for Sport and Physical Educa- look at the diffusion model. J. Health Commun. tion. 2004. Moving Into the Future: National 9(Suppl. 1):13-19. Standards for Physical Education. Reston, VA: Schmid, T., M. Pratt, and L. Witmer. 2006. A framework McGraw-Hill. for physical activity policy research. J. Phys. Act. National Complete Streets Coalition. 2010. Complete the Health 3(Suppl. 1):S20-9. streets. http://www.completestreets.org. U.S. Department of Health and Human Services. 2008. National Physical Activity Plan Coordinating Commit- Physical Activity Guidelines for Americans. Wash- tee. 2010. National Physical Activity Plan. www. ington, DC: U.S. Department of Health and Human physicalactivityplan org. Services.
Sector VII Transportation, Land Use, and Community Design
Mark Fenton, MS Tufts University, Friedman School of Nutrition Science and Policy
his section takes a somewhat surprising use, and Portland, Boulder, and Davis have Tapproach to sharing two critical lessons the advantage of a 10- to 20-year focus on with readers. The chapters are written primar- bicycle-oriented policies and infrastructure. ily by professionals in felds other than the Instead, this section visits wintry Houghton, in traditional physical activity promotion felds. Michigan’s Upper Peninsula, where post-mining These authors demonstrate the broad range of economic decline and long, snowy winters disciplines and backgrounds that must come would seem to fly in the face of investment together to implement true policy and envi- in infrastructure to support physical activity. ronmental approaches to increasing popula- The section also visits Omaha and Nashville, tion levels of physical activity. One author, Ray models of so many middle-American cities that Sharp, is a public health community planner in once enjoyed a hearty core but in the latter Houghton, Michigan. Kerri R. Peters and Julie T. 20th century were economically eviscerated by Harris are part of Live Well Omaha, a nonproft automobile-oriented sprawl spilling out into the public-private partnership focused on sustain- surrounding farmlands and forests. The most able community health. Ian Thomas works with walkable, bike-friendly parts of these cities PedNet, a pedestrian and bicycle advocacy non- were undermined as the middle class migrated proft in Columbia, Missouri. Leslie A. Meehan out into an indistinguishable and unwalkable and Michael Skipper are planners with Nash- landscape of housing tracts, strip malls, and ville’s Metropolitan Planning Organization. Jen- big box stores. Columbia and Urbana are col- nifer J. Selby is a transportation engineer who lege towns that illustrate how transportation shares work she did with the Urbana, Illinois, challenges, from school-induced traffic jams Department of Transportation. Only Sharp is to inefficient roadways, can be resolved in in a traditional public health role, and even his ways that systematically increase opportunities chapter emphasizes the need to partner with for regular walking, bicycling, and transit use the city manager, public works department, among all residents, from elementary school planning offcials, economic developers, and students to adults. school offcials. Two lessons described in the chapters in this You might expect a chapter on transportation, section are especially notable. The first is that land use, and community design to espouse the establishing partnerships outside traditional virtues of well-known pedestrian-friendly cities health roles is critical to building a community such as Boston, New York, and Chicago or high- that supports increases in routine physical activ- profile models of bicycle-oriented design such ity across the population. The second lesson is as Portland, Oregon; Boulder, Colorado; and that communities must pursue environmental Davis, California. Although worthy of accolades and policy approaches to increasing physical and study, Boston, New York, and Chicago have activity. These lessons frame the approaches the advantage of having developed decades or that all communities must use to build healthier even centuries before widespread automobile lifestyles for all residents.
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CHAPTER 35 Institutionalizing Safe Routes to School in Columbia, Missouri
Ian Thomas, PhD Mark Fenton, MS PedNet Coalition Tufts University
NPAP Tactics and Strategies Used in This Program
Transportation, Land Use, STRATEGY 3: Integrate land-use, transportation, com- and Community Design Sector munity design, and economic development plan- ning with public health planning to increase active STRATEGY 1: Increase accountability of project plan- transportation and other physical activity. Tactic: ning and selection to ensure infrastructure support- Support the development of standards and identifi- ing active transportation and other forms of physi- cation of “best practices” for the dissemination and cal activity. Tactic: Support annual reporting by all adoption of “safe routes” initiatives such as Safe schools of their transportation mode split. Routes to School, Bike-to-Work, and other active STRATEGY 2: Prioritize resources and provide incen- transportation programs. tives to increase active transportation and other STRATEGY 4: Increase connectivity and accessibility physical activity through community design, infra- to essential community destinations to increase structure projects, systems, policies, and initiatives. active transportation and other physical activity. Tactic: Support and increase incentives for the Tactic: Expand Safe Routes initiatives at national, adoption and expansion of “safe routes” initiatives state, county. and local levels to enable safe walk- such as Safe Routes to School, Bike to Work, and ing and biking routes to a variety of destinations, other active transportation programs. especially to schools.
n 2006, West Boulevard Elementary School in The goal of the Safe Routes to School (SRTS) IColumbia, Missouri, conducted a moderately program was to use a comprehensive approach successful “walking school bus” program with to increase the number of children walking and support from PedNet Coalition, a pedestrian and cycling to school. The program attempted to bicycle advocacy organization and its partners. increase physical activity for as many students However, only a fraction of the students eligible as possible, even those who typically took the to walk and bike to school did so. This was in school bus or were driven by car. The effort part because of traffc congestion around the began with a community workshop and walk- school, which many parents believed created about that identified the possibility of having unsafe conditions for pedestrians and cyclists. bus drivers and parents drop students off at a Ironically, many of those parents then opted to park adjacent to the school. Students could then drive their children to school, thus worsening walk to school on a one third of a mile (half the very traffc they found concerning. a kilometer) pathway connected to the school
305 306 Thomas and Fenton grounds. Several major steps were taken to about 15 percent traveled by car. By 2001 those develop the program: numbers had practically reversed, with fewer than 15 percent walking and cycling and nearly • Several “test days” were held to allow 50 percent arriving by car. But now a handful parents and bus drivers to try dropping of studies and an increasing body of practical students off at the park. experience suggest that a structured Safe Routes • All key stakeholders were involved, includ- to School approach can turn the tide on this ing school administrators and faculty; trend, by increasing the percentage of students planning, public works, and parks and walking, cycling, and taking the bus. recreation staff; public safety and health In 1997, the Partnership for a Walkable professionals; parents and students; and America, a coalition of government, private, members of the school board. and nonprofit transportation, safety, and health • A two-day design and planning charrette organizations, launched an annual Walk to was conducted during which walking and School Day. The National Center for Safe Routes bicycling advocates shared current Safe to School at the University of North Carolina Routes to School best practices, students (www.saferoutesinfo.org) promotes an annual provided feedback, and adult stakehold- Walk to School Day (usually the first Wednesday ers developed recommendations based on in October) and Bike to School Day (in early the 5E model: evaluation and planning, May), provides technical assistance and exten- engineering, education, encouragement, sive information on safe routes best practices, and enforcement. and maintains a national registry of participat- • A more sustained test of the remote drop- ing schools. Along with the National Safe Routes off area at the park was conducted for Partnership (a coalition of organizations sup- bus riders. porting Safe Routes to School efforts across the United States; www.saferoutespartnership.org), Key results of this process included a renewed these groups recommend not only launching effort around all components of the 5E model, one-day events but also creating comprehensive including the development of an additional programs that address all five components of crosswalk near the park and a more direct path- the 5E model in an ongoing effort to get more way through the park to the school entrance. children walking and cycling regularly: The school then adopted the remote drop-off as formal school policy for designated days and • Evaluation and planning: Best when done seasons, giving all bus riders a short daily walk as the first of the 5Es, this includes measuring to school, while strongly encouraging parents to travel modes; conducting parent, student, and drop off at this area as well. Together with other school staff surveys; and examining traffic, traffic and pedestrian safety measures over two speed, and crash data, development patterns years, these steps helped promote walking and and plans, and similar information collected bicycling to school for nearby students (attribut- by local officials. able in part to an easing of the traffic in front • Education: This entails teaching students of the school) and increased physical activity and adults safe behavior, proper procedures for students riding the bus. (e.g., for arrival and dismissal), and the per- sonal and community benefits of routine walk- ing and cycling. Program Description • Encouragement: People are encouraged In the past 30 to 40 years, a dramatic change to participate through programs and events to has occurred in how children travel to school. reward walking and cycling (such as punch A study by Ham and colleagues (2008) showed cards, prize drawings, and healthy breakfasts), that more than 40 percent of children walked as well as adult-led walking and bicycling and biked to school in 1969, whereas only groups and safety measures, which can help Safe Routes to School 307 allay parental concerns, especially for students ing better student health, improved academic considered too young to walk or bike alone. performance and behavior, positive environ- • Enforcement: Components of a program can mental impacts, and reduced traffic congestion be enforced by reducing speed with improved and associated safety risks at school arrival and markings and information (e.g., speed feedback dismissal times. The event also allowed PedNet signs), enhanced fines, and increased presence to evaluate current conditions and learn what of officers, crossing guards, and volunteers. was needed to increase walking and bicycling, using the following steps: • Engineering: The physical infrastructure can be improved in ways such as using signs • Conducting show-of-hands tallies on pupil and crosswalk paint, constructing sidewalks and travel modes preceding and on Walk to multiuse pathways, installing bicycle lanes and School Day (“Raise your hand if you covered bike parking, and using traffic calming walked to school today. Rode your bike. measures (e.g., roundabouts and median islands). Took the school bus. Came by car.”) The PedNet Coalition of Columbia, Missouri, • Asking parents and students to complete is a nonprofit pedestrian and bicycle advocacy walkability or “bikeability” checklists, group that began its Safe Routes to School reviewing the conditions on their walk or efforts by organizing one-day walk-to-school bike trip to school, and identifying chal- events in 2003. The coalition participated lenges and opportunities. in International Walk to School Day, which • Conducting surveys of parents and stu- allowed local organizers to promote the benefits dents regarding their attitudes about walk- of routine walking and cycling to school, includ- ing and cycling to school and what would © Ian Thomas and Mark Fenton.
Parents and children should assess available walking and cycling routes, including the presence of quality crosswalks. 308 Thomas and Fenton
be needed for them to walk or bike more The model Safe Routes to School program routinely. at West Boulevard Elementary School moved through several phases, including one-day Concerns regarding their children’s safety is walk-to-school events, the launch of walking often cited as the reason many parents don’t school buses, community workshops to build allow their children to walk or bike to school. consensus on ways to increase routine walking In response, PedNet launched its daily “walk- and cycling to school, and implementation of ing school bus” program in spring 2005. The those tactics in a phased approach. premise of a walking school bus is to designate The first phase was the initial launch of Walk a route to the school that is walked by an adult to School Day events at elementary schools leader on a schedule, picking up student walkers around the city, which began in 2003 at just four along the way. Communities have taken vari- schools. PedNet, the city’s nonprofit pedestrian ous approaches to finding walking school bus and bicycle advocacy organization, took the leaders, such as parent volunteers on a rotat- leading role in launching these events. This ing schedule, retirees, hired leaders (similar to phase grew over time to include two Walk to crossing guards), and college students fulfilling School Days a year (October and May) with community service obligations. 2,000 to 3,000 students participating. Most of the participating children lived within The positive reaction to the one-day events one mile (1.6 kilometers) of the school, but that led to a walking school bus program, launched was only a fraction of those eligible to walk. in 2005. PedNet’s walking buses began with just An ongoing challenge has been to increase 30 children walking to school along four super- participation of those within a mile of school vised routes over a six-week period. Since then, and to include children living farther away. At the program has grown to include more than many schools the pick-up and drop-off traffic 400 registered children at 14 different schools, is substantial and chaotic enough to intimidate walking on 60 routes under the supervision of potential pedestrians. Also, the ideal program 120 trained volunteers, many of them college would provide physical activity opportunities students earning credits or community service for all students, not just those within walking hours. Businesses have sponsored T-shirts to and bicycling distance. help create program identity. Frequent walker With the federal government’s authorization cards, on which a punch or mark is made for of the U.S. SRTS program and a growing part- every day a child walks or bikes, allows kids nership between PedNet, the Columbia Public to earn incremental incentives to stay with the School district, West Boulevard Elementary program and to enter drawings for bigger prizes School, and the City of Columbia, an oppor- such as a bike or skateboard. “Walk stop” (as tunity arose in 2006 to apply for a “noninfra- opposed to bus stop) signs mark locations in structure” SRTS grant. The grant would be used neighborhoods where students can meet their to explore the idea of developing a remote bus walking school bus; these signs also increase and car drop-off program that could potentially program visibility in the community. The pro- allow 100 percent of children to engage in at gram has even used banner ads on public buses, least some physical activity during the daily an inexpensive way to advertise the program, trip to school. A park immediately next to the to recruit both volunteers (used on university school offered an ideal location for the drop-off bus routes) and student participants (used on area, as the students could then walk through neighborhood bus routes). the park directly to the school, never crossing a One of the target schools for this effort, West roadway. PedNet and its school and community Boulevard Elementary, implemented a walking partners saw this as an opportunity to execute school bus program, but only a fraction of the a case study at one elementary school, using a eligible students participated. One concern of comprehensive planning process that could then parents was traffic congestion at the school be replicated at schools throughout the city. during arrival and dismissal, making it unsafe Safe Routes to School 309 © Ian Thomas and Mark Fenton.
A walking school bus on the way to West Boulevard Elementary School. for pedestrians. In 2004 PedNet hosted a Healthy as many stakeholders as possible participating, Community Design workshop in a location near along with the media. Participants included the West Boulevard Elementary. During a walk audit school principal and superintendent, school of the area, walking advocates and community board members, teachers, parents, students, members recognized that Again Street Park health care and public health professionals, abuts the school grounds and that a very nice the mayor, city council members, law enforce- trail through the park could allow students to ment officials, traffic engineers, city planners, walk to school after being dropped off at the and PedNet advocates. The following elements far side of the park. This led the community to were included to ensure success of the charrette; submit a grant application to the state’s depart- these are strongly recommended for similar ment of transportation SRTS program for funds planning efforts: to execute a more comprehensive SRTS planning effort around the school in 2007-2008. This plan- • Engage an energetic, upbeat, and tech- ning process included a brief trial of the remote nically knowledgeable facilitator. The drop-off idea and a highly collaborative design facilitator’s job is first to teach the funda- workshop (called a charrette). mentals of Safe Routes to School and then For the practice “remote drop-off,” school to stimulate constructive dialogue among buses dropped children off at the far side of the participants, making it inspiring and park and allowed them to walk to the school engaging for everyone. (Providing food can with adult guides. This allowed everyone to promote a collegial environment.) gauge student reaction and to assess what • Open with an educational component needed to be done if the remote drop-off was for all participants. In this case, an open- to be used regularly. ing PowerPoint presentation highlighted The community charrette was then held to proven SRTS tools and principles but plan the program in detail. The goal was to use a used local photos to illustrate how the highly open, transparent, inclusive process with proven methods could be applied to local 310 Thomas and Fenton
challenges and opportunities. This was on the far side of the park and increasing done before the facilitator asked for feed- promotion of the walking school bus were back, so all participants started with a combined with more funding for sidewalks similar base of knowledge. around schools, new traffic-calming cross- • Engage the full group in developing and walk devices, and model design guidelines sharing ideas in the form of smaller round- for Complete Streets around schools. table working groups. As the working Following the workshop, a number of stake- groups report to the full group, the facilita- holders, including school administrators, the tor should respond positively to every idea PedNet team, and city staff in planning, public and constructively to every challenge; the works, and parks and recreation, followed up on existing body of SRTS experience (see the implementing many of the recommendations. Additional Readings and Resources at the The premise of the plan was to use a phased end of the chapter) provides many excel- approach to shift vehicle traffic away from lent solutions to common challenges and the front of the school to ease dangerous and concerns. uninviting traffic conditions, improve walking • Conclude with full-group sharing to find and bicycling infrastructure, and renew efforts areas of consensus and pull together spe- to promote those travel modes over time. The cific action ideas for moving forward. plan recommended priority actions for each • Engage students. In this case the students component of the 5E model. who had tried the drop-off at the far side of the park took part in a focus group in Evaluation and Planning which they drew pictures and told stories about their experiences. Their enthusiasm Begin measuring and reporting travel mode for the walk through the park was critical split at the school twice per year, through a in convincing adults to move forward and show-of-hands survey. Continue to reach out make it a more regular opportunity. to parents and learn why some choose not to • Have the professional team (in this case let their children walk and bike, and identify the facilitator, planning and engineering what would make them more comfortable. Most staff, and PedNet advocates) spend an important, share the findings of this evaluation intensive session analyzing and organizing with parents, administrators, and the school the community input and create a compre- board so that they can more effectively imple- hensive presentation of recommendations. ment policies supporting walking and cycling. This presentation need not be elaborate (e.g., fancy graphics aren’t necessary) but Enforcement it should display direct quotations and Begin by inviting adults who drive students to evidence of community input, such as voluntarily drop off at the far side of the park, sketches participants created of alternative and have two school buses (of the four that vehicle routings or maps of walking routes. serve the school) drop off alternately at the • Invite everyone to review and respond to park each day (two buses one day, the other the summary and recommendations. Pro- two the next). Over time, evolve from volun- duce a final report with specific, detailed tary use of the remote drop-off to restriction action items and next steps, and send it of automobile drop-off in front of the school to all of the key stakeholders within a few (e.g., limit it to children with physical needs or weeks. those carrying heavy or cumbersome items). • Tie policy and environmental changes to One policy approach to shifting pick-up to the programmatic and outreach activities in remote location is to institute a five-minute the plan. In this plan, for example, having safety delay on cars picking up at the school, buses drop students off at a staging post holding cars until all pedestrians, bicyclists, and Safe Routes to School 311 buses have cleared the school zone. This dra- health and environmental benefits of walking matically reduces potential vehicle-pedestrian and cycling. Provide students with increased conflicts, and it creates an incentive for kids bicycle and pedestrian safety instruction (e.g., to urge their parents to use the remote pick-up in physical education classes and during assem- location, because most students would prefer to blies). Reach out to parents directly, and teach be dismissed with the pedestrians rather than students the arrival and dismissal procedures. wait for the automobile pick-up line. Encouragement Engineering As traffic adjacent to the school eases, promote Pursue funding to construct a trail through the walking school buses with renewed vigor. Use park from the drop-off area to the school, to frequent walker cards, which are punched or improve pathway connections to the surround- marked every day a child walks to school. Once ing neighborhood, to paint bicycle lanes, to filled, a card can be turned in for a small prize repaint crosswalks and increase their visibil- (a pencil or zipper pull) and entered into a ity, and to study other possible traffic calming drawing for a large prize (e.g., a donated bike, measures. iPod) at the end of the year. A comprehensive approach to encouraging Education walking and cycling is ongoing. Successes include construction of the direct walking path Offer SRTS education initiatives designed to through the park and creation of an enhanced reach teachers, students, and parents. Provide crosswalk approaching the park. These envi- teachers with information on the link between ronmental changes provide a lasting benefit student physical activity and academic perfor- to the community, beyond the Safe Routes to mance and with curricular materials on the School program. © Ian Thomas and Mark Fenton. A large walking school bus in Columbia avoids the traffc congestion surrounding the school. 312 Thomas and Fenton
Linkage to the National tives such as Safe Routes to School, Bike-to-Work, and other active transportation programs. The Physical Activity Plan design charrette and interventions at West Bou- levard Elementary have been used as a model The Safe Routes to School approach is men- at other elementary schools in Columbia; cus- tioned explicitly in four of the strategies iden- tomized SRTS plans and initiatives have been tified in the National Physical Activity Plan’s developed for each of these schools. Transportation, Land Use, and Community Strategy 4: Increase connectivity and acces- Design Sector. The work in Columbia aligns sibility to essential community destinations to with all of those recommendations: increase active transportation and other physical Strategy 1: Increase accountability of project activity. Tactic: Expand Safe Routes initiatives at planning and selection to ensure infrastructure national, state, county. and local levels to enable supporting active transportation and other forms safe walking and biking routes to a variety of of physical activity. Tactic: Support annual destinations, especially to schools. This project reporting by all schools of their transportation helped connect residents not only with the mode split. The SRTS design charrette recom- neighborhood elementary school but also with mended creating physical infrastructure to the adjoining park. The increased activity in the support walking and cycling, including a new park and the development of the walking trail trail through the park adjacent to the school made the park more inviting and accessible to and creation of a bus pull-out area on the quiet many nearby residents. street along the park, farthest from the school, for minimum traffic impact. Other recommenda- tions included routinely measuring and report- Evidence Base Used During ing travel mode split at the school as well as Program Development painting bicycle lanes and constructing missing sidewalks, crosswalk markings, and neighbor- An increasing number of publications and hood links to the trail in the park. position statements recommend the use of Safe Strategy 2: Prioritize resources and provide Routes to School to increase physical activity incentives to increase active transportation among youth. Comprehensive programs provide and other physical activity through community other benefits as well, such as reducing traffic design, infrastructure projects, systems, policies, congestion and improving air quality at schools, and initiatives. Tactic: Support and increase improving behavior and academic performance incentives for the adoption and expansion of among students, and potentially lowering trans- “safe routes” initiatives such as Safe Routes to portation costs when fewer students require School, Bike to Work, and other active transpor- bus service. The reference list at the end of this tation programs. This campaign moved well chapter includes review papers (Active Living beyond a one-day event by creating procedural Research 2007; Centers for Disease Control and changes that provide much greater incentive for Prevention 2010; Davison and Lawson 2006; routine walking to school for all students. For Fenton 2012), position statements (Environmen- example, on days the remote drop-off area is tal Protection Agency 2003, 2012; Institute of used, students arriving by bus have no choice Medicine 2009), and original research (Centers but to get a 10- to 15-minute walk through the for Disease Control and Prevention 2005; Heelan park to school. et al. 2009; Staunton et al. 2003) that detail the Strategy 3: Integrate land-use, transportation, case for SRTS initiatives. community design, and economic development Although the review papers make clear planning with public health planning to increase that the built and policy environments have active transportation and other physical activity. a substantial impact on children’s levels of Tactic: Support the development of standards physical activity, the Institute of Medicine and and identification of “best practices” for the dis- Environmental Protection Agency make the semination and adoption of “safe routes” initia- case that conscious policy decisions must be Safe Routes to School 313 made in support of routine walking and bicy- and bicycle accommodation: grades 9 cling to school, including choices about where through 12 schools are located and the construction of the surrounding infrastructure for walking and bicycling. Summaries by the Centers for Dis- Lessons Learned ease Control and Prevention and Active Living A number of key lessons were learned from the Research confirm that more active and physi- work on this Safe Routes to School Program. cally fit children perform better academically The first two lessons are the most important. and see fewer disciplinary problems. Creating a truly interdisciplinary team and Some studies suggest that SRTS efforts can focusing on policy and infrastructure changes have a significant impact on a school’s travel are absolutely necessary conditions for long- mode split. Heelan and colleagues (2009) term success in shifting more students to routine showed that over a two-year period, schools walking and cycling. with a walking school bus program had 27 percent more frequent walking to school by stu- • Create a fully diverse partnership for a dents compared with a control school, and that healthy community and welcome everyone. frequent walkers engaged in 25 percent more Not just the obvious partners—school officials, physical activity on average while gaining 58 parent organizations, public health officials, percent less body fat. Staunton and colleagues and planning and public works staff—but also (2003) conducted research on the decade-long other stakeholders such as law enforcement Marin County comprehensive SRTS program agencies, parks and recreation staff, neighbor- that showed a 64 percent increase in walking, hood groups, local business owners, historical a 114 percent increase in bicycling, a 91 percent society members, and others. increase in carpooling, and a striking 39 percent • Focus on policy and infrastructure change. reduction in the number of vehicles driving one Encouragement programs can get the ball roll- child to school. ing, but the ultimate goals must be to create physical infrastructure (e.g., sidewalks, trails, bike parking), set policies (e.g., defining dis- Populations Best Served tricts and walking zones), and establish prac- by the Program tices that promote walking and cycling as the default travel choice for as many students as A unique aspect of this SRTS effort was that possible. it benefited children beyond those who lived within walking and bicycling distance of the • Commit significant effort to media and school. The addition of the remote drop-off area community outreach and focus on positive means that even children who ride the bus or outcomes. Show everyone how SRTS benefits are driven to school have an opportunity for them: healthier, better-performing students; physical activity via their walk to the school less traffic congestion in neighborhoods near through the park. In general, the reach of the schools; less money spent on student busing. SRTS efforts in Columbia varied by grade level: • Identify heroes. Let everyone know about the great leadership or commitment of the prin- • Walk to School Day events and walking cipal, superintendent of schools, director of the school bus program: grades K through 5 public works department, mayor, or wealthy • Bicycle skills courses and the bike brigade philanthropist. This helps spread the credit for (a dedicated group that rides bikes to success, lets key players know they are appreci- school every day for an entire year, right ated for their efforts, and rewards their courage. through winter!): grades 6 through 8 • Make children into advocates. Equipping • Education on public policy advocacy, students to conduct community surveys, take encouraging students to become active photos, provide feedback in focus groups, and advocates for more and safer pedestrian even provide testimony before key decision 314 Thomas and Fenton makers (board of education, city council, plan- are equipped with adequate clothing for ning commission) can be a powerful tool in walking or bicycling through the winter. helping adults to truly understand the stakes (Lack of proper clothing can keep parents and take meaningful action. in lower-income households from allow- • Identify confident kids who are comfortable ing their children to walk in the colder being a bit “different,” and help them become weather.) role models. Kids who are willing to begin • Local businesses can sponsor frequent bicycling, walking, or skateboarding to school walker prizes, as simple as notebooks before it’s the norm can be the critical “early and pencils, colored shoelaces, and zipper adopters” who demonstrate to others that it’s pulls for backpacks. more fun, they are more independent, and it’s cooler than riding in the car. Additional Tips for Readings and Resources The following describes two invaluable, practi- Working Across Sectors cal resources. Both provide an archive of webi- A successful SRTS program will not be com- nars on relevant topics, ranging from launching pleted by one sector or group in a community. your program to dealing with liability and safety It is important to maintain a politically balanced concerns. team throughout the effort. In Columbia, some National Center for Safe Routes to of the early adopters were more politically lib- School: www.saferoutesinfo.org eral, but with careful framing, attractions for This center has a lot of useful information on conservative partners were identified, including organizing a Safe Routes to School program and the local community focus, provision of greater specific materials such as sample press releases transportation choices, and the fiscal benefits and program announcements, parent and stu- of the program. dent survey materials and tally sheets (for doing It requires a conscious effort to bring a variety show-of-hands surveys in the classroom and of organizations and agencies together to work observation counts outside the school), and toward a common goal, including continual curricular materials. It also maintains a national education on the benefits of SRTS and identifica- registry of participating schools, so you can find tion of the common goals they share. Engaging a school doing this work in your region or state. other entities in the community provides easy, almost turnkey ways for them to support SRTS. National Safe Routes to School Partner- ship: www.saferoutespartnership.org • The school district can include walking school bus leaders and other volunteers This national coalition supports SRTS programs in its routine background check process. at the state and local level, providing regional coordinators and technical assistance to com- • A college or university nutrition, health munity efforts across the United States as well promotion, sports, recreation, or exercise as national advocacy for continued federal science program can give students aca- funding and program support. Your state or demic credit for serving as volunteer walk region likely has an SRTS partnership that can group leaders. provide technical assistance as you launch your • A local bike shop can send a mechanic to program. bike classes to fix problems, teach skills, and generate relationships with next- generation cyclists. References • A local Rotary Club or other service Active Living Research. 2007. Physical education, organization can lead a coat, hat, mitten, physical activity, and academic performance. www. and boot drive to ensure that all children activelivingresearch.org/files/Active_Ed.pdf. Safe Routes to School 315
Centers for Disease Control and Prevention. 2005. Bar- Fenton, M. 2012. Community design and policies for riers to children walking to or from school—United free-range children: Creating environments that States, 2004. MMWR. Morbid. Mortal. Wkly. Rep. support routine physical activity. Child. Obes. 54:949-52. 8(1):44-55. Centers for Disease Control and Prevention. 2010. Ham, S.A., S. Martin, and H.W. Kohl, III. 2008. Changes The association between school-based physical in the percentage of students who walk or bike to activity, including physical education, and aca- school—United States, 1969 and 2001. J. Phys. Act. demic performance. www.cdc.gov/healthyyouth/ Health 5:205-15. health_and_academics/. Heelan, K.A., B.M. Abbey, et al. 2009. Evaluation of a Davison, K.K., and C.T. Lawson. 2006. Do attributes walking school bus for promoting physical activity in the physical environment influence children's in youth. J. Phys. Act. Health 6(5):560-7. physical activity? A review of the literature. Int. J. Institute of Medicine. 2009. Local government actions Behav. Nutr. Phys. Act. 3:19. to prevent childhood obesity. www.iom.edu/ Environmental Protection Agency. 2012. School siting Reports/2009/Local-Government-Actions-to-Pre- guidelines. www.epa.gov/schools/siting. vent-Childhood-Obesity.aspx. Environmental Protection Agency. 2003. Travel and Staunton, C.E., D. Hubsmith, and W. Kallins. 2003. environmental implications of school siting. EPA Promoting safe walking and biking to school: the report 231-R-03-004. www.epa.gov/smartgrowth/ Marin County success story. Am. J. Public Health school_travel.htm. 93(9):1431-4.
CHAPTER 36 Local Public Health Leadership for Active Community Design An Approach for Year-Round Physical Activity in Houghton, Michigan
Ray Sharp, BA Western Upper Peninsula Health Department
NPAP Tactics and Strategies Used in This Program
Transportation, Land Use, STRATEGY 3: Integrate land-use, transportation, com- and Community Design Sector munity design and economic development plan- ning with public health planning to increase active STRATEGY 1: Increase accountability of project plan- transportation and other physical activity. ning and selection to ensure infrastructure support- ing active transportation and other forms of physi- STRATEGY 4: Increase connectivity and accessibility cal activity. to essential community destinations to increase active transportation and other physical activity.
lmost everyone who influences public for local policy and environmental changes that Apolicy decisions represents a particular support an active lifestyle. interest group—taxpayers, property owners, Although many important public health poli- developers, preservationists, environmentalists, cies are decided by state and federal lawmakers walkers, cyclists, ATV riders, parents, retirees, and agencies, the creation of a community that business owners, and public sector workers. encourages physical activity depends heavily on Public health professionals, in contrast, work for local professionals and policy makers who are and on behalf of all residents. The only agenda not in the health department. In many cases the of health department staff is to help people live best approach is to work with a city, township, longer, healthier lives by advocating for decisions neighborhood, or school district, where many and policies that improve everyone’s health and policies that directly affect people’s daily lives quality of life. When public health professionals are crafted. Often a local public health profes- make recommendations to city councils, plan- sional can be a “big fish in a small pond,” ning commissions, and city staff based on best someone others in the pond know and respect. practice and scientifc evidence, it helps policy To illustrate how such an approach can work, makers make tough decisions and do the right this chapter discusses how health department thing for their communities. And when it comes staff, key city staff in nonhealth disciplines, and to preventing heart disease, stroke, diabetes, and elected and appointed officials can lead the way other chronic diseases, the right thing is to work for positive change at the local level.
317 318 Sharp © Ray Sharp. © Ray
Houghton’s historic downtown district is pedestrian friendly, with a mix of small shops, restaurants, offces, and upstairs apartments that attract residents and visi- tors of all ages.
Programmatic Approach— munity, including WUPHD staff, is committed to providing leadership in policy, systems, and Focus on Local Policy environmental strategies to increase physical activity. Houghton’s efforts of the last few years Admittedly it seems like an unlikely proposi- exemplify these efforts and are closely linked tion—to create a pedestrian- and bike-friendly to strategies from the National Physical Activity community in the rugged and remote Western Plan. But this effort did not begin in a vacuum, Upper Peninsula region of Michigan. Houghton, and at its heart it was focused on making every a small city of 8,000 residents located near Lake city professional and even elected officials Superior, 200 miles (322 kilometers) north of understand and consider the health impacts of Green Bay, Wisconsin, faces many challenges their routine decisions. to active community design, including long winters that deliver an average of 250 inches Healthy Community Planning: (6 meters) of snow, extremely hilly terrain, and a stagnant economy. Help Build a Vision The Western Upper Peninsula Health Depart- Houghton’s commitment to active community ment (WUPHD) is the local public health design has evolved over 40 years, since the agency, serving the 70,000 residents of five closing of the copper mines in 1968 left the rural counties bounded by Wisconsin on the region searching for new focus and vitality. The south and Lake Superior on the north. The consequences of land use decisions made in the health department provides public health ser- 1970s and 1980s to maintain public access to vices aimed at preventing disease in the general Houghton’s waterfront, a long-time emphasis population. With obesity on track to become the on nonmotorized trail development to attract leading preventable cause of chronic disease and retain a young and active work force, and and premature death, the public health com- coordinated policy and environment initiatives Local Public Health Leadership for Active Community Design 319 © Ray Sharp. © Ray
Houghton receives 200 to 300 inches (5-7 meters) of snow per year. Snow removal on principal pedestrian routes, like this wide sidewalk connecting Michigan Tech Univer- sity to the downtown area, is done by the city workers with small trucks and mini- plows. established since 2002 have helped Houghton made possible by cheap and plentiful gasoline, burnish its reputation as one of the most livable Houghton’s waterfront became a neglected small towns in the Upper Midwest. Houghton shambles. The adjacent downtown business has avoided the fate of many declining Rust district declined as well, with shopping malls Belt towns by envisioning a healthy and vibrant and big box stores springing up at the city’s future that includes year-round access to physi- periphery, where real estate was more afford- cal activity and working to make it a reality. able. As locally owned businesses lost custom- Houghton City Manager Scott MacInnes has ers to national chains and residents gradually worked for the City of Houghton since gradu- stopped walking their main street, many cities, ating from Michigan Tech University with a especially in the northern Midwest, lost their degree in engineering in the mid-1970s, so he identity and reason to exist. has seen first-hand the process of gradually The Houghton city council and its planning reinventing the city. When MacInnes was a commission, however, envisioned a different student at Michigan Tech, students were warned future. They sent delegations to visit other lake- to stay away from the city’s waterfront along shore cities, such as Traverse City, Michigan, to Portage Lake (a navigable waterway connected learn from their successes (and regrets). After to Lake Superior) because the submerged piers several of these fact-finding missions, the coun- and dilapidated warehouses, remnants of the cil and planners reached a decision—to preserve copper mining boom, were hazardous. As the shoreline for public access instead of selling happened in many American cities that began out to private development—so that all citizens along the water but turned their backs on the would benefit. In the ensuing decades, the city shoreline as they grew outward, with rings of gradually acquired most of the shoreline prop- suburbs designed around the automobile and erty in the two-mile (3.2-kilometer) stretch from 320 Sharp west of the business district, past the downtown in this regard. Studies show that when a new area, all the way to the Michigan Tech campus sidewalk or bike path is constructed—even on the east. The industrial ruins were removed in the absence of any health promotion cam- and replaced with parks, marinas, a new public paign—significantly more residents will report library, and a paved bicycle and pedestrian trail getting 30 minutes of exercise per day, a true that is used by hundreds of walkers, bikers, case of “build it and they will come.” skaters, and stroller-pushers daily. In a survey of residents conducted by the city as part of its Public Health Can Support master planning process, the waterfront trail Economic Health ranked as the most-used city facility, with an average of 36 days of use per respondent. Some In the 1990s, MacInnes and local architect residents use it almost daily for commuting, Pat Coleman, founder of the international recreation, or exercise. Winter Cities Institute, engaged city planners When asked whether city leaders knew the in designing streetscapes that better served trail would become some so popular, MacInnes residents year-round, even in long, harsh, and said the original intent was to cover just a short very snowy winters. In 1997, Houghton hosted section of decommissioned railroad tracks with the Winter Cities Institute annual conference, asphalt for safety and aesthetic reasons. How- attended by urban planners from as far away as ever, so many residents started using the path Russia, Scandinavia, and Japan, who came to that there was an outcry for the city to finish the talk about how cities and residents can endure, job, and it eventually paved the railroad grade, and thrive, in far-northern climates. Practical little by little, all the way to the town line on measures implemented by Houghton include both ends, a distance of five miles (8 kilome- smaller, more cost-effective vehicles for clearing ters). Houghton’s experience was not unusual snow from pedestrian routes; textured paving © Ray Sharp. © Ray
Houghton’s nonmotorized waterfront trail, located on a former industrial land and rail corridor, extends nearly fve miles (8 kilometers), connecting the city center to parks and residential districts. Local Public Health Leadership for Active Community Design 321 to provide pedestrian safety in slippery condi- last 10 years, which has hosted regional and tions; and covered stairs and walkways in public national championship events but is also used areas, such as connecting routes from parking by hundreds of residents who will never ski structures to shopping areas. Awnings over a competitive race in their lives. The system doorways of stores and restaurants are another features more than 20 miles (32 kilometers) of simple feature that makes a destination more groomed Nordic ski trails; approximately 5 miles inviting to pedestrians and helps keep sidewalks (8 kilometers) of trails are lit for night skiing. clear of snow. Details like these often go unno- The same terrain is used for mountain biking in ticed when they work well, but they go a long summer. Houghton now has more miles of off- way toward making walking more convenient road trails than paved streets, providing ample and comfortable in winter. recreational opportunity and attracting people Another factor that makes winter cities more seeking a fun and healthy place to live. livable is the presence of facilities such as public As residents become more physically active, ice rinks and ski and snowshoe trails where they naturally turn to their local government residents can remain physically active in winter. officials with ideas for further improving active Houghton has many indoor and outdoor skating transportation infrastructure. At the urging of venues, from small neighborhood parks to large the West Houghton Neighborhood Association arenas, owing to its legacy as “the birthplace in 2002, Houghton’s planning commission of professional hockey.” Cross-country skiing is developed a walkability plan. The city inven- increasingly popular and offers the advantage toried sidewalks and assessed traffic accidents that it can be enjoyed at any age, alone or with involving pedestrians and then took public friends. The university developed a world- comments at neighborhood forums. Planning class ski and snowshoe trail system over the staff developed a plan for pedestrian facilities, © Ray Sharp. © Ray
The city plows the sidewalks when it snows. Snow removal is a constant battle from Halloween to Easter. 322 Sharp © Ray Sharp. © Ray
Houghton has more miles of bicycle, walking, ski, and snowshoe trails than city streets. including a pedestrian tunnel under a principal School assessment and planning, was named roadway so residents could reach waterfront a Bicycle Friendly Community by the League parks and trails. That project was funded by the of American Bicyclists, passed an innovative state highway department and has alleviated a bike-parking ordinance, and enacted a Complete dangerous crossing of a five-lane highway. Streets ordinance that requires accommodating In 2007, bike commuters contacted the city to the needs of pedestrians, cyclists, and transit express interest in creating a bicycle plan. That users of all ages and abilities in roadway design. fall, the Houghton Bike Task Force was formed Today in Houghton, residents and visitors will as an ad hoc group to study the issue and report find new bike lanes, connector trails, bike racks, to the city council. The task force created a and midblock pedestrian crossings; more miles short online survey to ask residents about their of off-road recreation trails than paved city summer and winter bike commuting routes. An streets; and a local public health department astounding 384 people completed the survey, that is a partner in all these initiatives, contrib- more than 5 percent of the city’s population. uting staff time, training, grant funding, and a The group created maps showing summer and rationale for building a healthier community. winter use patterns and compiled and evalu- The effort that led to these changes did not ated comments about safety concerns. A city focus solely on a specific infrastructure improve- bike plan, with routes and projects identified, ment. Rather, the goal has been to incorporate was submitted to the city council and approved. consideration of health outcomes in all city infrastructure and policy actions. The power of the change in processes out- Program Evaluation lined here is well illustrated by this case study Despite the economic, topographic, and weather of Safe Routes to School planning and imple- challenges, Houghton has developed bike and mentation. Staff from the Western Upper Pen- pedestrian plans, expanded its network of bike insula Health Department in Michigan attended lanes and side paths, conducted Safe Routes to a small meeting with the Houghton-Portage Local Public Health Leadership for Active Community Design 323
Township School Wellness Team, in the city of community members with an interest in stu- Houghton. The meeting was a group planning dent health and safety. The students and their session, called a charrette in the parlance of parents were the most important stakeholders urban design. The school wellness team brought in the process. The students described where together members of the school’s Safe Routes they normally walk and bike to and from to School team and the City of Houghton’s bike school, and the parents shared their concerns and pedestrian committee to hash out routes about dangerous roads and intersections. The and identify priorities for construction projects city manager showed a map of the city streets to make school travel safer for walkers and and presented optional routes leading from the bikers. Both the Safe Routes to School plan- school to three nearby neighborhoods. By the ning initiative and Houghton’s commitment to end of the meeting, the participants had agreed Complete Streets (Houghton passed a Complete on four streets that should be designated as Streets ordinance in 2010, described later in principal routes to school, and which needed the chapter) came about with a push from the sidewalks, and three intersections that needed Western Upper Peninsula Health Department. better crosswalks plus center islands to act Health department staff had convened planning as traffic-calming devices and give students a groups at the city and school district, provided midstreet refuge while crossing. training and technical assistance, and helped These recommendations were reported to the city win small grants from state and federal the rest of the city’s bicycle and pedestrian sources to improve infrastructure with new bike committee, discussed at neighborhood forums, racks and signage and striping for bike lanes. and incorporated into the nonmotorized trans- Also attending the charrette were the Hough- portation plan that was to be adopted as part ton city manager, the police chief, the director of the city’s new master plan. The city man- of public works, the school superintendent ager pledged to start the search for sidewalk and middle school principal, a school board funding and believed he could complete the member, and teachers, parents, students, and three enhanced intersections in the near future. © Ray Sharp. © Ray
The Houghton-Portage Township School District is a partner with city and public health offcials in Safe Routes to School planning. 324 Sharp
Although that one meeting resulted in a number the health department, Houghton is taking steps of positive changes, the meeting was in large toward a faraway but attainable goal—reversing part the culmination of months of work by the the epidemic of childhood and adult obesity and health department. This work helped commu- inadequate physical activity. nity committees form, grow, build trust, and Strategy 4: Increase connectivity and acces- work together toward the common goal of a sibility to essential community destinations to healthier community where all residents have increase active transportation and other physical access to safer routes for active transportation. activity. The health department and its part- ners have established short-term objectives, including increasing the number of children Linkage to National and adults walking or biking to school, work, Physical Activity Plan and errands; reducing traffic congestion and automobile emissions; and improving pedes- The Western Upper Peninsula Health Depart- trian and cyclist safety. Anticipated long-term ment is working to embrace all of the principles community benefits include healthier residents, of the Transportation, Land Use, and Com- a healthier environment, sustainable economic munity Design Sector of the National Physical development, and improved quality of life. Activity Plan. However, it has found particular Houghton’s Complete Streets law and other traction in working on the following three strat- policies will guide transportation and land egies from that sector, given the engagement use planning, resource allocation, engineering of allies in planning, economic development, design, and the creation of a network of active public safety, and engineering. transportation routes connecting neighbor- Strategy 1: Increase accountability of project hoods, schools, parks, work sites, shopping, planning and selection to ensure infrastructure and other destinations. supporting active transportation and other forms of physical activity. The health department is taking a leading role in encouraging the inte- Tips for gration of physical activity infrastructure into Working Across Sectors community design, land use planning, and transportation network development, especially Houghton’s story has been driven by many through work on Complete Streets and efforts players, not just public health professionals; to extend the community’s trail network. visionary leaders who have targeted economic Strategy 3: Integrate land-use, transportation, redevelopment have been central to the city’s community design and economic development success. In fact, public health professionals tra- planning with public health planning to increase ditionally had not played a role in city planning. active transportation and other physical activity. But faced with compelling and incontrovertible As part of its mission to reduce the prevalence of evidence that our vehicle-centric cities and chronic diseases such as heart disease, cancer, suburbs are slowly killing Americans through and diabetes and to improve well-being and inactivity-related chronic disease, many public quality of life, WUPHD works with local gov- health professionals are beginning to see the ernment officials, transportation agencies, plan- connections between clean sidewalks and clean ning commissions, police departments, schools, arteries, healthy networks of bicycle pathways, bike and pedestrian advocates, neighborhood and healthy children. associations, environmental groups, state and In 2010, WUPHD pursued and was awarded federal health and transportation agencies, pri- grants from several public and private sources vate foundations, and faculty and students from to work with community partners to reduce Michigan Tech University to make it safer and chronic disease through local policy initiatives. more convenient for people to walk and bike as The health department was given a seat on the part of their daily lives. With leadership from community’s Bicycle Task Force, which was Local Public Health Leadership for Active Community Design 325 exploring trends in active living design and ered data about miles of bike lanes and trails, studying what the nation’s leading bike-friendly classes, community events, and police programs communities, such as Portland, Oregon; Boul- and then asked city leaders to pass a Bicycle der, Colorado; and Madison, Wisconsin, have Friendly City Resolution, allowing submission done to make their communities safer and of an application in July 2010. In September more convenient for cycling. One of the first 2010, Houghton was designated a bronze-level policy successes was a bike-parking ordinance, Bicycle Friendly Community. adapted from an innovative policy from Madi- Part of the local health department’s grant son and presented to the planning commission. funding came from the state health depart- The ordinance, passed by the city council after ment’s cardiovascular disease section and was a public hearing in April 2010 and amended to designated to promote collaboration with the the parking section of the city zoning code, calls city to pass a Complete Streets policy. A Com- for the provision of adequate parking facilities plete Streets training session was organized in for bikes, with specifications based on the size September 2010 for 30 local government officials of business or apartment building. and citizen advocates, with help from state The next order of business was to assess the health and transportation experts. In October city’s status with regard to cycling infrastruc- and November, the health department worked ture and programs. A bike-friendly community with the planning commission and Bicycle Task survey developed by the League of American Force on Complete Streets ordinance language. Bicyclists was used to perform a gap analysis. The city manager determined where to insert The instrument is a detailed 84-section survey Complete Streets language into the city’s exist- that is completed online after gathering infor- ing codes for street and subdivision design. mation about the community’s status in five By December, the city council took up the domains, called the 5 Es—evaluation and plan- proposal, and after two meetings and public ning, engineering, education, encouragement, hearings to review the costs and benefits of and enforcement. The Bicycle Task Force gath- the law, Houghton adopted it on December 22, © Ray Sharp. © Ray
Downtown Houghton sidewalk furnishings include benches, bike racks and planters. 326 Sharp
2010, becoming the sixth Michigan city, and the planning, they may be pleasantly surprised to first in the Upper Peninsula region, to enact a find that policy makers are ready to listen to Complete Streets ordinance. information on the health benefits of sidewalks and bike lanes. Lessons Learned Speak the Language That Key Stakeholders Hold Dear Health educators often hesitate to wade into the unfamiliar waters of public policy. Two elements Don’t restrict the discussion to arguments about of the Houghton effort, along with seven tips health and safety. It is rare to meet an elected for success, suggest a way forward, even for official who doesn’t favor the concept of a health departments that have never participated healthier community for all residents, especially in healthy community design. when health includes social, environmental, and economic health. But the inevitable first Jump Into Current Efforts, question will be “How much is this going to cost us?” Health professionals should be prepared to and Build on Existing Momentum pivot from health and safety to discussions of Admittedly, in Houghton the public health tourism, economic development, job creation department was lucky to join the Complete and employee retention, and increased property Streets effort well into what was truly a 30-year values, all benefits of bicycle- and pedestrian- process. Houghton’s vision of public access friendly community designs. When speaking along the waterfront, creation of a waterfront before a city council or town hall meeting, trail, attention to the details of winter cities health professionals should provide one-page design, and citizen involvement in bike and color handouts on the health and economic pedestrian planning all contributed to readi- benefits of Complete Streets, bike lanes, and ness to pass a Complete Streets ordinance. non-motorized trails, with enough copies for But Houghton certainly was not unique in this policy makers, members of the media, and regard. Many school districts around the nation the public. Health advocates should provide participate in Safe Routes to Schools planning, arguments, in clear and succinct language, in using the same 5 Es approach as the Bicycle a form that others can share with friends and Friendly Communities program. Most cities coworkers. (Many of the resources at the end update their master plans every five years and of this chapter provide such facts and talking hold forums to get citizen input on streets, points.) When city council members, police sidewalks, and parks. Existing groups such as officers, school principals, business owners, cycling clubs, parent-teacher organizations, and and friends and neighbors are all talking about neighborhood committees are natural allies in the benefits of active community design, it will active communities planning. Cities, townships, be clear that the public health department has and counties have planning commissions that played a leadership role in shaping the conver- routinely consider changes to building codes, sation about a healthier future. zoning, and land use plans. And increasingly, in Michigan and many other states, highway Use Seven Tips for Success funding allocations favor projects that include Some of these final lessons may seem obvious, enhancements for pedestrians, cyclists, and but can ease the transition of public health into transit users. State and local highway depart- a leading role in creating a healthy community. ments are in the midst of a generational change, defined not by age but by interest in new Com- 1. Public health is not a narrow interest plete Streets approaches to transportation plan- group. It represents everyone who is ning. When public health professionals attend concerned with health, safety, and qual- a meeting to talk about active communities ity of life. Local Public Health Leadership for Active Community Design 327
2. All policy is local. Work with schools, This describes the League of American Bicyclists’ neighborhood groups, park districts, Bicycle Friendly Communities program, with criteria, cities, and townships in your jurisdic- applications, and lists of honorees: www.bikeleague. tion; wherever you can be a big fish in org/programs/bicyclefriendlyamerica a small pond. The Rails-to-Trails Conservancy is a national body in the 3. Begin with a vision based on the pub- United States; many states have chapters or similar organizations: www.railstotrails.org lic’s sense of what its community should become, a vision that is large enough to The Michigan Trails & Greenways Alliance is a state- inspire yet is practical and achievable. level nonprofit agency dedicated to rails-to-trails projects: www.michigantrails.org 4. Build it and they will come. New parks, The Michigan Complete Streets Coalition is one of an trails, sidewalks, and bike routes will be increasing number of statewide coalitions; this web- used if they are well designed and lead site includes local and state news, such as reports to places people want to go. on the Michigan Complete Streets Advisory Council, 5. Discuss community health in the and a compendium of local ordinances, resolutions, broadest terms—physical, social and and policies: www.micompletestreets.org emotional, economic, and environmen- This Michigan-based website is one of the best sources tal—to broaden support for healthy for plans, policies, fact sheets, and links to other communities policies and projects. helpful resources: www.mihealthtools.org/mihc/ CompleteStreetsResources.asp 6. Measure the effectiveness of your work (through evaluation) and celebrate suc- The Houghton city website has bike and pedestrian plans and ordinances, as well as information on cesses to strengthen the coalition and trails, parks, community gardens, and other healthy public support. communities facilities and plans: www.cityofhough- 7. Policy and built-environment changes ton.com are stickier than health promotion pro- Beyond the Blue Building: Partnerships for a Healthier grams. Exercise classes come and go Western Upper Peninsula Region is the Western with the seasons, but a multi-use trail Upper Peninsula Health Department’s blog about lasts a lifetime. initiatives and partnerships promoting healthy living: http://healthywup.wordpress.com. This site provides information on how the Western Additional Upper Peninsula Health Department and its com- Reading and Resources munity partners are working to prevent childhood obesity through multiple strategies with support Maintained at the University of California at San Diego, from the Robert Wood Johnson Foundation’s Healthy this is an outstanding resource library and bibliogra- Kids, Healthy Communities grant program: www. phy of the latest research and practical information healthykidshealthycommunities.org/communities/ on factors leading to active community environ- houghton-county-mi ments; it is an ideal first stop if you’re looking for The National Center for Safe Routes to School is the best evidence supporting policy efforts: www. loaded with information on creating 5E plans for activelivingresearch.org schools and answers to common questions: www. The National Complete Streets Coalition has a wealth saferoutesinfo.org of information on Complete Streets, including fact The Winter Cities Institute links northern cities world- sheets, model ordinances, news, and advocacy: wide in the pursuit of sustainable designs for active www.completestreets.org living: www.wintercities.com
CHAPTER 37 A Road Diet for Increased Physical Activity Redesigning for Safer Walking, Bicycling, and Transit Use
Jennifer J. Selby, PE Foth Infrastructure and Environment
NPAP Tactics and Strategies Used in This Program
Transportation, Land Use, STRATEGY 2: Prioritize resources and provide incen- and Community Design Sector tives to increase active transportation and other physical activity through community design, infra- STRATEGY 1: Increase accountability of project plan- structure projects, systems, policies, and initiatives. ning and selection to ensure infrastructure support- ing active transportation and other forms of physi- STRATEGY 4: Increase connectivity and accessibility cal activity. to essential community destinations to increase active transportation and other physical activity.
n 2005, the new mayor and city council of city. One of the many benefits would be an IUrbana, Illinois, set a goal to “get Urbana increase in the number of people able to use bicycling.” As the frst step in reaching that goal, bicycling for routine trips and thus get more they created a Bicycle and Pedestrian Advisory physical activity as a part of their daily tasks. Commission. The commission’s frst major task One of the first priorities was the conversion was to oversee the development of a citywide of Philo Road, along a stretch from Colorado bicycle master plan. Avenue to Florida Avenue, from a four-lane The Urbana Bicycle Master Plan, approved cross section to a three-lane cross section with in April 2008, set forth three goals for the city: bike lanes. Often referred to as a “road diet,” this was the first master plan project that the 1. Increase the percentage of persons using city implemented. Although the Philo Road bicycles for transportation in Urbana by project would help the city reach the goals 50 percent in the next five years. set forth in the bicycle master plan, city lead- 2. Achieve a Bicycle Friendly Community ers also hoped that the road diet would allow award through the League of American the city to improve mobility and access for all Bicyclists. roadway users. 3. Substantially expand the bicycle net- work. Program Description The end product of the bicycle master plan was a defined network of recommended bike- From the 1960s through the 1980s, Philo Road ways—such as bike lanes, bike routes, and between Colorado Avenue and Florida Avenue shared-use paths—that, when implemented, served as a regional retail center. The corridor would connect all of the neighborhoods in the contained a shopping center with a grocery
329 330 Selby store and a drug store as anchors as well as a undertook several initiatives during 2003 and large discount retail store and a second grocery 2004 to combat the demise of this area. All of store in the vicinity. these efforts were commendable, but the area Until the late 1970s, Philo Road was a two- remained blighted. Although residents were lane road. Because of the many businesses and patronizing businesses in the area because of resulting increased traffic, the city widened part loyalty and convenience, the public consensus of the road from two lanes to four in the late was that the existing buildings needed to be 1970s. Following additional retail construction updated, with better signage and lighting, and in the 1980s, the entire road from Colorado that the overall appearance, landscaping, and Avenue to Florida Avenue was widened to four security of the area needed to be improved. lanes. In 1991, Philo Road lost its designation as Illinois Route 130 to High Cross Road, a north- Linkage to National south corridor to the east. High Cross Road Physical Activity Plan became a major artery serving regional traffic, and Philo Road became a minor artery serving Developers believed that the area had the image neighborhood traffic. Additional changes to the of an aging, inactive, and open area and that the retail market in Urbana and Champaign in the marketability was fair to poor. They thought that 1990s led retail traffic to move away from Philo road improvements—such as wider, multilane Road. By 2003, two of the three grocery stores roads with boulevards—would improve the and the large discount retail store were gone. appearance of and access to the area and could Soon, Philo Road became a blighted com- help with revitalization. Fortunately, the city mercial area with several large vacant buildings, took a more enlightened view and developed vast underused parking lots, and many unused a strategic approach that aligns with several parcels. Litter and loitering became problems, strategies in the Transportation, Land Use, and and the community, city council, and mayor Community Design Sector of the National Physi- became concerned about the area. The city cal Activity Plan. © Jennifer J. Selby.
Photo of Philo Road bus stop. Safer Walking, Bicycling, and Transit Use 331
Strategy 1: Increase accountability of project tion of Philo Road south of Colorado Avenue planning and selection to ensure infrastructure was improved to provide better access between supporting active transportation and other forms southeast Urbana—which had the fastest grow- of physical activity. City leaders did not believe ing neighborhoods in the city—and the com- that widening the road to improve access for mercial district between Colorado Avenue and vehicles was the solution. In January 2005, city Florida Avenue. Following completion of these council adopted the Philo Road Business District improvements, the city developed a beautifica- Revitalization Action Plan. The plan proposed tion plan for Philo Road, which included con- redevelopment policies and programs to be verting the four lanes on Philo Road between implemented through specific action elements. Florida Avenue and Colorado Avenue to three One of the action elements recommended plan- lanes, with possible inclusion of bike lanes. ning and constructing infrastructure improve- These improvements would promote a more ments, including rebuilding Philo Road south of pedestrian- and bike-friendly and safer envi- Colorado Avenue and reducing the number of ronment. lanes to three, improving pedestrian crossings, In presenting the beautification plan, city and extending bike trails. This approach spe- staff noted that the current budget included no cifically considered not just the motor vehicle funding for such improvements. Two months functionality but also the bicycle and pedestrian later, the city council and mayor revised the functionality of the roadway. The city council annual budget ordinance, reducing the capital noted that the road’s average daily traffic was improvement fund by $125,000 in order to only about 11,000 vehicles per day. Transporta- set aside the funds to construct infrastructure tion planners acknowledged that three lanes, improvements on Philo Road. properly designed, are quite sufficient for this Strategy 4: Increase connectivity and acces- traffic volume. sibility to essential community destinations to Strategy 2: Prioritize resources and provide increase active transportation and other physi- incentives to increase active transportation cal activity. In early 2008, the Urbana Bicycle and other physical activity through community Master Plan identified Philo Road between design, infrastructure projects, systems, policies, Colorado Avenue and Florida Avenue as a pri- and initiatives. In the summer of 2006, the sec- ority project for implementation. Members of © Jennifer J. Selby.
Photo of Philo Road median. 332 Selby the public were requesting installation of bike and restriped from four lanes of vehicle traffic lanes in this segment, primarily because of the (two lanes in each direction) to one lane of destinations it served, both commercial and vehicle traffic in each direction, a continuous residential. The commercial corridor contained two-way left turn lane in the center, and one a large grocery store, a drug store chain, restau- bike lane in each direction. The bike lanes rants, banks, and office space surrounded by connected to an existing shared-use path on single-family and multifamily homes, including the east side of Philo Road south of Colorado several senior assisted living facilities. Further, Avenue and, in the future, would connect to this segment of the road would provide a key bike lanes planned for north of Florida Avenue link (or connectivity) in the bicycle network by (constructed in 2010). connecting with a shared-use path to the south Other types of transportation, particularly and planned future bike lanes to the north. bus transportation, also benefitted from the In summer 2008, Philo Road between Colo- improvements. The city constructed bus stop rado Avenue and Florida Avenue was resurfaced pads that complied with the Americans with © Jennifer J. Selby. © Jennifer J. Selby.
Philo Road before and after the addition of bicycle lanes. Safer Walking, Bicycling, and Transit Use 333
Disabilities Act (ADA) to better accommodate road is much safer for pedestrians, because waiting, boarding, and accessibility. The new the reduced number of travel lanes and the bus stops included shelters, benches, trash cans, raised median shorten the crossing distance recycling cans, and real-time signs to indicate and reduce exposure time. Reducing the travel when the bus would arrive. The new bus stop lanes from four to two often reduces speeds, locations were shifted slightly and offset so because the first car sets the pace. Speed is an that the midblock crosswalks were behind the important factor for pedestrian safety, because bus stop. This placement prevented buses from as vehicle speeds decrease, the chance of obstructing pedestrians’ view of oncoming traf- a pedestrian surviving a crash significantly fic when they were crossing the street, and it increases. allowed bus drivers to pull away from the stop The addition of bike lanes improved mobility without danger that pedestrians were attempt- for bicyclists. The bike lanes dedicate a space ing to cross in front of them. for bicycles, making it easier for bicyclists and The city constructed a raised landscaped motorists to share the road. The bike lanes also median in the two-way left turn lane at the benefit pedestrians by creating a buffer between midblock bus stop crossing. The median broke pedestrians on the sidewalk and motorists on what used to be a complex four-lane cross- the street. ing into two simpler one-lane crossings. This The addition of a raised median and marked shorter crossing distance reduced pedestrian midblock crosswalk at the bus stops improved exposure time, making the crossing safer, espe- mobility and access for transit riders. The cially important given that many of the transit continental-style crosswalk markings and cross- riders in this corridor are seniors. An added walk warning signage brought attention to the safety element of the raised median involved fact that pedestrians cross at this location and constructing an angled crossing in the median. motorists should be aware. Because the crossing is angled, pedestrians who The changes to Philo Road resulted in sig- are crossing through the median are facing the nificant revitalization of the area, one of the traffic that is approaching them. primary goals of the project. During the road Separate from the street improvement project, work, a new shopping center was completed a major landscaping project was undertaken and a national drug store chain moved onto that included planting perennials, ornamental the street. Subsequently, a new bank, three cell grasses, and trees; regrading and sodding turf phone stores, a fast food restaurant, and other areas; installing ornamental boulders; installing businesses were constructed or remodeled. ornamental benches and trash cans; and install- The existing shopping center underwent façade ing pedestrian lighting on the east side of the improvements, the vacant drug store space was street. Finally, the city added an art component remodeled into a specialty shop, and a new to the project. Concrete pads were constructed restaurant opened. at two locations along the corridor and two As for the goals set forth in the Urbana Bicy- sculptures that enhanced the prairie theme of cle Master Plan, the city was named a Bronze- Philo Road were installed. level Bicycle Friendly Community in May 2010. In October 2008, the city held a press confer- Approximately four more miles (6.4 kilometers) ence and ribbon cutting announcing completion of bike lanes and two miles (3.2 kilometers) of of the first bike lanes implemented from the shared lane markings were installed to expand Urbana Bicycle Master Plan. The ceremony was the bicycle network. The shared lane markings attended by business owners and residents of were installed on Philo Road south of Colorado the Philo Road area and city staff. Avenue in 2009 to help bicyclists and motorists share the road, even though an off-street side path is also present in that stretch. The bike Program Evaluation lanes north of Florida Avenue to Washington The city achieved several of its goals with the Street were constructed in 2010, completing project. The changes improved mobility and the Philo Road corridor recommended in the access for all roadway users. The renovated bicycle master plan. 334 Selby
Evidence Base Used During • Popular or essential bike or pedestrian routes Program Development • Commercial reinvestment areas An increasing number of design guidelines • Main or historic streets, often in or near and manuals identify road diets as one of the central business districts many tools that can improve the built environ- Implement bike lanes whenever the oppor- ment for walking, bicycling, and transit while tunity presents itself. Much of the negative improving motor vehicle safety and efficiency. feedback from the public about the bike lanes Public health and physical activity advocates was that they “didn’t go anywhere.” The section can use the following materials as references of Philo Road between Colorado Avenue and while making the case for considering a road Florida Avenue was only .4 miles (643 meters) diet, whereas engineers and planners can refer in an almost 2-mile (3.2-kilometer) corridor. The to them for more detailed design guidance. bike lanes north of Florida Avenue were not con- structed until 2010. However, waiting until 2010 Populations Best Served to stripe the bike lanes on Philo, when it was being resurfaced in 2008, would not have been by the Program the right decision. A bicycle network cannot be Philo Road is now a complete street, which ben- constructed overnight— it must be constructed efits all roadway users. Pedestrians cross shorter in pieces, as it was here. distances and are protected by slower speeds, Get residents invested in the project. The fewer lanes, and median and bike lane buffers. road diet and bike lane ideas were presented at Bicyclists and transit riders particularly have several public meetings called charrettes, design benefited from the improvements. Bicyclists gatherings in which many approaches may be benefit from dedicated on-street space with the considered, that were held at a neighborhood addition of bike lanes, and transit riders benefit church. Local business owners, neighborhood from shorter crossing distances, angled cross- association representatives, and residents ings, better crosswalks, and ADA-compliant bus attended the charrettes. Everything from the stop shelters. Perhaps the biggest benefactors road diet to the landscaping to the lighting was of the improvements are the senior adults who discussed, and these gatherings were crucial live in adjacent neighborhoods and who can in both revealing the community’s priorities now walk, cycle, and use the buses more safely. and building public support for the project. Physical activity advocates can play a critical role in convening such meetings and ensur- Lessons Learned ing a constructive environment. Perhaps most important, health advocates can ensure that the Start with roads that are well suited to a diet. long term community-wide physical activity City governments, road planners, and pedes- benefits of such a project can be kept in clear trian, bicycle, and health advocates should focus throughout the process. look for roads that meet some of the following criteria: • Currently a four- or five-lane profile, with Tips for two travel lanes in each direction Working Across Sectors • A concern regarding rear-end and side- Although physical activity advocates may easily swipe collisions embrace the notion of a road diet, the concept • Average daily traffic fewer than 20,000 may be counterintuitive to those unfamiliar vehicles a day with the idea. Many people assume that a • Transit corridors with bus service three-lane road cannot carry as much traffic Safer Walking, Bicycling, and Transit Use 335 as a four-lane road and that adding pedestrian FHWA summary report: Evaluation of lane reduction and bicycle facilities will make problems even “road diet” measures and their effects on crashes and worse. Therefore, physical activity supporters injuries. www.fhwa.dot.gov/publications/research/ must be ready with an evidence-based case for safety/humanfac/04082/04082.pdf this type of improvement, and the argument National Complete Streets Coalition: completestreets. must be based on factors that are important org/complete-streets-fundamentals/factsheets/ to key collaborators, such as elected officials, health/ and www.completestreets.org/webdocs/ transportation planners, engineers, local busi- factsheets/cs-health.pdf ness owners, and residents. Road diet handbook: Setting trends for livable streets, Jennifer Rosales. www.ite.org/emodules/scriptcon- tent/Orders/ProductDetail.cfm?pc=LP-670 Additional Road diets: Fixing the big roads, Dan Burden and Peter Reading and Resources Lagerway. www.walkable.org/assets/downloads/ roaddiets.pdf FHWA proven safety countermeasures. “Road diet” Road diets: Designing streets for pedestrians and bicy- (roadway reconfiguration) http://safety.fhwa.dot. clists, Michael Ronkin. www.smartgrowthonlineau- gov/provencountermeasures/fhwa_sa_12_013.pdf dio.org/np2007/310c.pdf
CHAPTER 38 Incorporating Physical Activity and Health Outcomes in Regional Transportation Planning
Leslie A. Meehan, AICP Michael Skipper, AICP Nashville Area MPO Nashville Area MPO
NPAP Tactics and Strategies Used in This Program
Transportation, Land Use, physical activity through community design, infra- and Community Design Sector structure projects, systems, policies, and initiatives. STRATEGY 1: Increase accountability of project plan- STRATEGY 3: Integrate land-use, transportation, com- ning and selection to ensure infrastructure support- munity design, and economic development plan- ing active transportation and other forms of physi- ning with public health planning to increase active cal activity. transportation and other physical activity. STRATEGY 2: Prioritize resources and provide incen- STRATEGY 4: Increase connectivity and accessibility tives to increase active transportation and other to essential community destinations to increase active transportation and other physical activity.
hysical activity plays an important role communities caused many Americans to rely on Pin combating preventable diseases and the car as the dominant mode of transportation improving overall health. In general, states in the and created an environment in which transpor- southeastern United States have the lowest rates tation funding is almost exclusively focused on of physical activity and experience the highest improving the flow of vehicular traffic (U.S. rates of preventable diseases. In 2010, Tennessee Department of Transportation 2009). ranked frst among the states in adult inactivity, However, public policy makers are increas- second in the rate of overweight adults (more ingly acknowledging the strong connection than 68 percent), third in the rate of obese adults between the built environment and the health (over 30 percent), fourth in extreme obesity, and of citizens. Specifically, researchers and urban ffth in the percentage of children ages 10 to 17 planners are recognizing the relationship who are overweight or obese (Centers for Disease between transportation and land use and Control and Prevention 2010). observed levels of physical activity. The types The opportunity to include physical activity of transportation infrastructure built in a com- as part of travel requires that the places people munity, and the modes of travel supported, may want to go are connected by safe, convenient, enhance or inhibit physical activity as part of and reliable transportation facilities such as the local travel experience. Opportunities exist sidewalks, bike lanes, greenways, and public to change transportation policy at the federal, transit. The rise of automobile travel and the state, and local levels to be more inclusive of movement toward building automobile-oriented health-related objectives and to provide greater
337 338 Meehan and Skipper opportunities for citizens to be physically active On average, states spend only 1.2 percent as part of local travel. of federal transportation dollars on walking and bicycling facilities (Alliance for Biking and Walking 2010). To encourage more spending Providing Opportunities on infrastructure for these modes, an increas- for Physical Activity ing number of transportation plans and reports as Part of Transportation are recommending the construction of facilities, such as sidewalks, bike lanes, and greenways, Providing increased opportunities for physical that provide opportunities for transportation, activity as part of transportation trips begins recreation, and physical activity. However, with building infrastructure that supports active transportation policies and funding mechanisms transportation. Active transportation is a term generally do not align with these recommenda- used to describe modes of transportation that tions. require physical activity as part of the mode (Walkable and Livable Communities Institute 2011). Active transportation typically refers to Linkage to National walking, bicycling, and taking transit, since Physical Activity Plan transit trips routinely involve a walk or bicycle trip to a transit stop or station. The National Physical Activity Plan calls for People who take active transportation trips communities, agencies, and organizations to may obtain significant amounts of physical prioritize physical activity in planning, pro- activity. Studies show that nearly one third gramming, and initiatives. The Transporta- of transit riders get their daily recommended tion, Land Use, and Community Design Sector physical activity by walking to and from a addresses the fact that transportation systems, transit bus stop or station. Other factors, such land use patterns, and the ways communities as a reduction in traffic crashes, are significant are designed affect physical activity as part of public health benefits of transit (Lachapelle daily routines, such as getting to work or school and Frank 2009; Litman 2010). Several studies or doing errands within a community. The plan have found that users of public transit reduce includes four strategies designed to help trans- their body mass indices and are less likely to portation and land use increase physical activity become obese (MacDonald et al. 2010; Morabia levels. These strategies relate to incorporating et al. 2010). Similar studies show that physical physical activity outcomes into transportation activity obtained from bicycling can increase policy, planning, and funding and creating con- overall health and add to life expectancy (Besser nectivity between travel modes and destinations and Dannenberg 2005; de Hartog et al. 2010; in transportation systems. Pucher et al. 2010). The Nashville Area Metropolitan Planning According to the 2009 National Household Organization (MPO) has emerged as a national Travel Survey, 41 percent of all trips taken in the leader in supporting the strategies prioritized in United States are three miles (4.8 kilometers) the National Physical Activity Plan by emphasiz- or less and nearly 19 percent are one mile (1.6 ing increased physical activity as the center of kilometers) or less (Litman, 2011). The average the MPO’s policies and funding mechanisms. person can walk one mile in approximately 20 Strategy 1: Increase accountability of project minutes and can bicycle the same distance in planning and selection to ensure infrastructure less than 10 minutes. However, nearly 60 per- supporting active transportation and other forms cent of trips of one mile or less are taken by car of physical activity. The Nashville Area MPO (Federal Highway Administration 2009). One addresses this strategy by adopting project of the primary reasons for taking short trips by scoring criteria for roadway projects in which car is the absence of safe and convenient trans- more than half of the points are awarded for portation facilities for bicycle and pedestrian improving opportunities for physical activity, modes of travel. increasing safety for all modes, and providing Physical Activity and Health Outcomes in Regional Transportation Planning 339 a variety of transportation options. The restruc- sisting of more than 1,000 miles (1,600 kilome- turing of the project scoring criteria has placed ters) each of bikeways and sidewalks; planners an emphasis on health and safety as priority placed priority on segments of bikeways and outcomes of a transportation network. sidewalks that provided connections to existing Strategy 2: Prioritize resources and provide facilities and connected important community incentives to increase active transportation destinations such as schools, community cen- and other physical activity through community ters, parks, stores, jobs, and transit. design, infrastructure projects, systems, poli- cies, and initiatives. In addition to adopting the scoring criteria mentioned previously, which Nashville Area MPO are used to allocate several billion dollars in The Nashville Area MPO is one of 385 federally federal transportation funds, the MPO created designated regional transportation planning a reserved portion of funding to be spent on organizations, called metropolitan planning active transportation. This funding comes from organizations, in the United States. MPOs were the MPO’s surface transportation program established by Congress in the 1960s to coor- allocation and reserves 15 percent off the top dinate transportation planning on a regional for projects that provide active transportation level. Regions are defined by urbanized areas infrastructure or education. These projects are with populations greater than 50,000 residents. conducted in addition to active transportation The primary purpose of MPOs is to help infrastructure provided as part of roadway local governments prioritize improvements to projects. the transportation system to efficiently move Strategy 3: Integrate land-use, transportation, people and goods throughout a region. MPOs community design, and economic development also help governments allocate funding from planning with public health planning to increase federal, state, and local sources to transporta- active transportation and other physical activity. tion projects. The process of prioritizing and The MPO is addressing this strategy by includ- programming transportation projects is outlined ing a land-use allocation model as part of its in the federation transportation bill and is con- transportation analysis tools and by coding ducted in the development of a long-range plan areas that have high rates of minority, elderly, for each region that estimates funding revenues and impoverished households as populations and assigns funding to transportation projects that are more likely to have high rates of health for spans of 20 or more years. The plan, often disparities and chronic diseases as well as lower referred to as a long-range or regional trans- physical activity levels. Additionally, the MPO portation plan, must be updated every four to analyzed food environments by mapping exist- five years. The process is guided by a technical ing grocery and convenience stores in the region coordinating committee, typically consisting of in proximity to high concentrations of at-risk municipal planners and engineers in the MPO populations while analyzing the surrounding region, as well as an executive board made up active transportation infrastructure. The Nash- of elected officials of the jurisdictions located ville Area MPO is placing a strong emphasis on within the MPO boundary and with populations the health outcomes of transportation planning, of at least 5,000 people (U.S. Department of highlighting the ways that transportation sys- Transportation 1992). tems provide access to important destinations, The Nashville Area MPO consists of 22 city such as food stores, and provide opportunities and county governments in addition to local and for physical activity. regional transit authorities and the Tennessee Strategy 4: Increase connectivity and acces- Department of Transportation. The region is sibility to essential community destinations to home to approximately 1.3 million people and increase active transportation and other physi- this population is expected to increase by 1.3 cal activity. The MPO addresses this strategy million people in the next 25 years (Nashville through its Regional Bicycle and Pedestrian Area MPO 2010). The policies and programs Study, which created a proposed network con- of the MPO affect all those who live and work 340 Meehan and Skipper in the MPO region. The MPO is involved in ings, surveys, and a bicycle and pedestrian funding hundreds of transportation projects, advisory committee consisting of community including interstates, roadways, transit systems, members and representatives from local gov- sidewalks, bikeways, and greenways, as well as ernments (figure 38.1). Working with local intelligent transportation infrastructure such as governments, businesses, nonprofit organiza- traffic signals and electronic message boards. tions, and the general public, the Nashville Area MPO designed the study to gain a better understanding of bicycle and pedestrian needs Documenting the Need to within the region. The study looked at the many Increase Opportunities for advantages of bicycle and pedestrian facili- Active Transportation ties, such as the ability to make transportation trips by nonmotorized modes, the benefits for To increase opportunities for active transporta- congestion and air quality, and the benefits tion, the case first has to be made that residents for physical activity levels. The study served in the area are interested in having access to several functions: such facilities. To provide this evidence, the Nashville Area MPO conducted the region’s first • Provided a comprehensive inventory of bicycle and pedestrian study from 2008 to 2009, existing and proposed on- and off-road which created a strategic vision for a network bicycle and pedestrian facilities in greater of walking and bicycling facilities throughout Nashville the greater Nashville area. This strategic vision • Increased the region’s understanding of feeds into the MPO’s 2035 Regional Transpor- how nonmotorized transportation adds tation Plan and provides the foundation on to the capacity of the transportation which future funding priorities of the MPO are system by improving connectivity between established for bicycle and pedestrian accom- residential areas, employment centers, modations. schools, retail centers, recreational centers, The study was guided by public input in and other attractions (with an emphasis the form of public meetings, stakeholder meet- on short-distance trips)
If it were safe and convenient, how likely would you be willing to walk or bike for the following reasons? Exercise or go to park
Run errands
Go shopping or to eat
Go to work
Purpose Go to school
Access transit
Other reason
0% 20% 40% 60% 80% 100% Percentage = Very likely = Somewhat likely = Not likely
Figure 38.1 Bicycle and pedestrian study: public input. Reprinted, by permission, from NashvilleE5691/NPAP/fig38.1/458659/alw/r2-kh Area Metropolitan Planning Organization. Physical Activity and Health Outcomes in Regional Transportation Planning 341
• Served as a framework for identifying and with populations that engaged in low levels of selecting bicycle and pedestrian projects physical activity and experienced high rates of for the 2035 Regional Transportation Plan health disparities and chronic diseases. Staff • Provided guidance for engineering, educa- members focused on sections of the MPO region tion, enforcement, encouragement, and with high concentrations of minority, senior evaluation activities to help improve the adult, and impoverished populations, because safety of nonmotorized travel modes these populations tend to experience high rates of preventable chronic diseases. For this reason, The Regional Bicycle and Pedestrian Study MPO staff used census data to help prioritize provided the MPO an opportunity to make trans- regional improvements for active transportation portation policy recommendations to improve facilities to improve population health (Surface physical activity levels and overall population Transportation Policy Project 2011; U.S. Depart- health. ment of Health and Human Services 2001). Areas with above-average prevalence of these populations were identified and mapped, so Addressing Health that areas with high concentrations of all three and Health Disparities groups could be identified. These were labeled as high health impact areas and received priority MPO staff were particularly interested in priori- consideration for active transportation facilities tizing bicycle and pedestrian facilities in areas to improve population health (figure 38.2).
Figure 38.2 High health impact areas. Reprinted, by permission, from Nashville Area Metropolitan Planning Organization. E5691/NPAP/fig38.2/458660/alw/r1 342 Meehan and Skipper
Prioritizing Bicycle and the region that, combined with local sidewalks and streets, link neighborhoods, businesses, Pedestrian Facility Needs and other community facilities to one another. The high health impact areas were one of six factors upon which the regional prioritization of bicycle and pedestrian facilities was based. Staff Adopting Policy to Support used five additional factors to analyze more Active Transportation than 3,300 miles (5,310 kilometers) of road- way throughout the MPO region to determine During the development of the 2035 Regional which areas should receive priority for bicycle Transportation Plan in 2009 to 2010, planning and pedestrian facilities. Staff determined staff provided the public and interested stake- (1) whether a roadway was congested and holders with a variety of opportunities to share could benefit from nonmotorized travel options; ideas for improving walking and bicycling in (2) whether a new bicycle or pedestrian facility their communities. During the course of that would connect to a network of existing facilities; community outreach, several themes regarding (3) whether a proposed sidewalk or bikeway obstacles, challenges, and solutions surfaced had been identified in a local government plan consistently. Residents mentioned the need for as a priority for a community; (4) whether a more sidewalks and bicycle lanes and the need high number of bicyclists and pedestrians were to make sure that these facilities connect with expected to make trips in an area (based on the other facilities and destinations and do not outputs of a latent demand Bicycle and Pedes- end abruptly. There was also a strong desire trian Travel Demand Model); and (5) how well to create a culture among roadway users and a current roadway was safely serving bicycle law enforcement that is supportive of walking, and pedestrian trips (figure 38.3). bicycling, and transit in Nashville. Residents The project evaluation method and process want walking and bicycling to be accepted were developed based on citizen input and modes of travel by the community and want the objectives and strategies of the Regional to feel encouraged and supported to take Bicycle and Pedestrian Study. The prioritiza- these modes. This could include feeling more tion method continues to provide a consistent respected on the roadway and feeling as though yet flexible means for selecting bicycle and law enforcement officers will enforce laws that pedestrian facility improvement projects for protect the rights of bicyclists and pedestrians. funding. The process provides the MPO with Combining the public input with peer reviews, an objective and quantifiable way of assess- best practice research, and the results of the ing walking and biking project needs that are Regional Bicycle and Pedestrian Study, the MPO consistent with the MPO’s regional goals and established regional objectives for advancing objectives. Feedback from the public about the active transportation choices and providing a need for bicycle and pedestrian facilities in the platform for the development of walkable and region, and the quantitative tools developed bikeable communities that support increased by the study to help prioritize where facilities physical activity. should be located, were then incorporated into In December 2010, the Nashville Area MPO the MPO’s 2035 Regional Transportation Plan. adopted the 2035 Regional Transportation Plan, The MPO’s strategic vision for walking and formally responding to the need for increasing bicycling emphasizes roadways that serve as opportunities for bicycle and walking trips by major commuting corridors and commercial making infrastructure recommendations and corridors and connect communities, activity prioritizing policy and funding for these modes. centers, transit, and major destinations through- Supporting active transportation and walkable out the region. These roadways serve as the communities was one of three policy initia- backbone for other roadways and streets in tives in the plan, along with creating a bold E5691/NPAP/fig38.3a/458661/alw/r1
Figure 38.3 Creating a scoring system to evaluate bicycle and pedestrian projects. Reprinted, by permission, from Nashville Area MetropolitanE5691/NPAP/fig38.3b/458662/alw/r1 Planning Organization.
343 344 Meehan and Skipper new vision for mass transit and preserving and portation infrastructure, up significantly from enhancing existing roadways first versus build- the estimated 2 percent of projects in the 2030 ing new infrastructure. The policies, project plan (figure 38.4) scoring criteria, and funding levels included in the plan marked a significant shift to increase the support for active transportation projects. Dedicated Funding for Active Transportation Scoring In addition to adopting a new set of scoring cri- Transportation Projects: teria for the plan, the MPO reserved 15 percent of the STP funds for additional active transpor- Including Physical Activity tation projects. Projects eligible for the reserved To ensure that transportation projects include funds include active transportation infrastruc- infrastructure for bicyclists and pedestrians, the ture projects, such as sidewalks and bikeways, MPO adopted a systematic process by which that were not included as part of a submitted candidate roadway projects are evaluated, roadway project, and noninfrastructure projects scored, and ranked by how well they serve the such as bicycle and pedestrian safety classes. needs of bicyclists and pedestrians. This priori- The reserved STP funds for active transportation tization process is based on the six evaluation are intended to support the objectives of the factors developed as part of the Regional Bicycle Regional Bicycle and Pedestrian Study—provide and Pedestrian Study and is used to assist the facilities, build support, create policies and MPO as it considers funding bicycle and pedes- programs, and increase awareness for bicycle trian investments throughout the region. and pedestrian travel. Example expenditures As part of the 2035 Regional Transportation could include adding sidewalks or bikeways to Plan, the MPO developed new scoring criteria an infrastructure project that does not have a on which to rank roadway improvement proj- budget for these facilities; funding stand-alone, ect proposals seeking funding from the MPO’s multiuse facilities such as greenways; support- largest highway funding source—the Federal ing education programs such as Safe Routes to Highway Administration Surface Transportation School; providing classes on bicycle and pedes- Program (STP) funds. Sixty of the 100 points trian safety; and purchasing gear to be provided on which roadway transportation projects were in bicycle and pedestrian safety classes, such as scored were based on positive outcomes for helmets and reflective safety items. air quality, provision of active transportation The MPO reserved 10 percent of STP funds to facilities, improvement of personal and environ- be combined with grants from the Federal Tran- mental health, injury reduction for all modes, sit Administration to be used for transit-related and equity of transportation facilities in under- improvements. Including this funding with served areas. More than 400 roadway projects, that of the criteria-ranked projects and the 15 such as new roads and roadway widenings, percent active transportation funding, the MPO were submitted for the plan and were scored is programming a significant portion of federal according to the new criteria. MPO staff saw funding for active transportation infrastructure a significant shift in the type of transportation and education. projects submitted for the estimated $6 billion dollars in available funding, with 75 percent Lessons Learned of the submitted roadway projects including an active transportation element such as a One of the most important lessons learned by bikeway, sidewalk, or greenway. In the final staff in the development of the 2035 Regional regional transportation plan, 70 percent of the Transportation Plan was how to frame the adopted roadway projects have active trans- issues. Staff began the conversation by invit- Physical Activity and Health Outcomes in Regional Transportation Planning 345
Figure 38.4 Adopted roadway projects that include bicycle and pedestrian facilities. Reprinted, by permission, from Nashville Area Metropolitan Planning Organization.
E5691/NPAP/fig38.4/458663/alw/r1 ing stakeholders and community members to that residents and stakeholders envisioned for create a vision for a vibrant and thriving com- their communities. The MPO also developed munity. These stakeholders included represen- priorities first and determined which funding tatives from various sectors such as land use source best fit the priorities, rather than start- planning, engineering, parks, schools, health, ing with the estimated amount from a funding law enforcement, economic development, source and determining which projects should housing, tourism, and others. From the vision, receive the funding. This approach allowed the a series of goals and objectives were created MPO to ensure that top priorities were funded by staff for how transportation could support first and allowed staff to think creatively about the vision. The goals and objectives were in how to make funding sources fit the needs of turn translated into the scoring criteria, which the region. were presented to the public for feedback and One of challenges faced by the MPO was endorsed by the MPO executive board. By start- a lack of data on populations with health ing with a vision and not specific projects, and disparities and high rates of chronic diseases by engaging community members and stake- such as asthma, diabetes, and heart disease at holders throughout the process, the MPO was a subregional level. To address this, the MPO able to develop policies based on the commu- has collected health data as part of a regional nity character and transportation components household travel survey. 346 Meehan and Skipper
Next Steps: Gathering Data of the MPO’s policies on health. Should funding become available, the MPO could be a potential and Benchmarking Progress candidate for a full evaluation conducted by the CDC. The MPO is conducting the Middle Tennessee Transportation and Health Study to survey 6,000 households on travel behavior, health habits, Summary and overall health of household members. The study includes a subset of 600 participants who The Nashville Area MPO has made a commit- wore GPS units and accelerometers to collect ment to providing increased opportunities for data on their transportation trips and rates of physical activity through its regional transporta- physical activity. These participants also com- tion policies and dedicated funding for bicycle pleted a survey that asks questions about food and pedestrian facilities. That commitment is security, physical activity rates, and prevalence expected to affect positively the health of a of chronic diseases among household members. large number of people over the next several The study collected data that are integral to decades by increasing the availability of active illustrating the relationships among transpor- transportation infrastructure and community tation, physical activity, and overall health. awareness about the importance of a transpor- These data will be used in the next update of tation system that includes adequate transit, the MPO Regional Transportation Plan to shape bikeways, sidewalks, and greenways. Over additional tools and policies on health outcomes time, the impacts of the policies may include in the regional transportation planning process. improved air quality, increased opportunities for physical activity, decreased traffic crashes for all modes, and increased active transporta- Program Evaluation tion facilities for all populations. The MPO staff believes that the 2035 Regional Transportation The MPO policies recently underwent review Plan policies represent a paradigm shift in trans- by the Centers for Disease Control and Preven- portation policy and take important steps to link tion, Division of Nutrition, Physical Activity transportation with health outcomes to increase and Obesity (DNPAO). The review includes opportunities for physical activity as part of an assessment of the MPO’s policies related to the regional transportation system. This shift physical activity and obesity, and as a result broadens the conversation around public policy the MPO will be promoted throughout the to emphasize that issues such as public health United States as a model that can be replicated and physical activity are the responsibility of all by other MPOs for supporting active trans- government agencies, including transportation portation. The MPO also underwent a review agencies. By engaging with multiple sectors, by the CDC-funded Center for Translational the MPO is working to create policy that has Research and Training (TRT) in the Center a positive impact for transportation, land use, for Health Promotion and Disease Prevention environmental and personal health, economic (Prevention Research Center) at the University prosperity, and quality of life. of North Carolina, Chapel Hill. The MPO was selected by the Center TRT to be reviewed as an emerging intervention that shows promise for Additional potential public health impact on one or more Reading and Resources obesity-related outcomes based on theory and approach. In a separate process, the Center TRT 2035 Regional Transportation Plan: www.nashvillempo. org/plans_programs/rtp/ conducted a site visit with the MPO and created an evaluation logic model and process for the MPO’s Health and Well-Being Initiatives: MPO to conduct a self-evaluation of the impact www.nashvillempo.org/regional_plan/health/ Physical Activity and Health Outcomes in Regional Transportation Planning 347
Middle Tennessee Transportation and Health Study: Litman, T. 2011. Short and sweet: Analysis of shorter www.middletnstudy.com/welcome.aspx trips using national personal travel survey data. CDC Pre-Evaluation Site Visit Summary Report: www. Victoria Transport Policy Institute. www.vtpi.org/ nashvillempo.org/docs/Health/Nashville%20 short_sweet.pdf. MPO%20Summary%20Report_FINAL.pdf MacDonald, J., R. Stokes, D. Cohen, A. Kofner, and K. Ridgeway. 2010. The effect of light rail transit on body mass index and physical activity. Am. J. Prev. References Med. 29(2):105-12. www.ajpmonline.org/article/ Alliance for Biking and Walking. 2010. Bicycling and S0749-3797(10)00297-7/abstract. walking in the U.S.: 2010 benchmarking report. Morabia, A., F.E. Mirer, T.M. Amstislavski, H.M. Eisl, www.peoplepoweredmovement.org/site/index. J. WerbeFuentes, J. Gorczynki, et al. 2010. Potential php/site/memberservices/C529. health impact of switching from car to public trans- Besser, M., and A. Dannenberg. 2005. Walking to public portation when commuting to work. Am. J. Public transit: Steps to help meet physical activity recom- Health 100(12):2388-91. mendations. Am. J. Prev. Med. 29(4):273-80. Nashville Area MPO. 2010. 2035 regional transportation Centers for Disease Control and Prevention. 2010. plan. www.nashvillempo.org/plans_programs/rtp/. Behavioral Risk Factor Surveillance System (BRFSS). Pucher, J., R. Buehler, D.R. Bassett,, and A.L. Dan- http://apps.nccd.cdc.gov/brfss/. nenberg. 2010. Walking and cycling to health: A de Hartog, J., H. Boogaard, H. Nijland, and G. Hoek. comparative analysis of city, state and international 2010. Do the health benefits of cycling outweigh data. Am. J. Public Health 100(10):1986-92. the risks? Environ. Health Perspect. 118(8):1109-16. Surface Transportation Policy Project. 2011. Fact sheet. Federal Highway Administration. 2009. National Transportation and poverty alleviation. www.trans- household travel survey—2009. http://nhts.ornl. act.org/library/factsheets/poverty.asp. gov/download.shtml. U.S. Department of Health and Human Services. 2001. Lachapelle, U., and L. Frank. 2009. Transit and health: The Surgeon General’s call to action to prevent and Mode of transport, employer sponsored public transit decrease overweight and obesity. www.surgeonge- pass programs, and physical activity. J. Public Health neral.gov/topics/obesity/calltoaction/toc.htm. Policy 30:S73-94. U.S. Department of Transportation. 1992 Urban trans- Litman, T. 2010. Evaluating public health transpor- portation planning in the U.S. A historical overview. tation benefits. Victoria Policy Institute and the http://ntl.bts.gov/DOCS/UTP.html. American Public Transit Association. www.apta. U.S. Department of Transportation. 2009. National com/resources/reportsandpublications/Documents/ household travel survey: Summary of travel trends. APTA_Health_Benefits_Litman.pdf. http://nhts.ornl.gov/2009/pub/stt.pdf.
CHAPTER 39 Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly
Kerri R. Peterson, BS, MS Julie T. Harris, BS, MPA Live Well Omaha Executive Director Live Well Omaha Program Coordinator
NPAP Tactics and Strategies Used in This Program
Transportation, Land Use, physical activity through community design, infra- and Community Design Sector structure projects, systems, policies, and initiatives. STRATEGY 1: Increase accountability of project plan- STRATEGY 3: Integrate land-use, transportation, com- ning and selection to ensure infrastructure support- munity design, and economic development plan- ing active transportation and other forms of physi- ning with public health planning to increase active cal activity. transportation and other physical activity. STRATEGY 2: Prioritize resources and provide incen- STRATEGY 4: Increase connectivity and accessibility tives to increase active transportation and other to essential community destinations to increase active transportation and other physical activity.
n a city where the longest commute is 25 Program Description Iminutes east to west and where the design is intentional for automobiles, the last few years Omaha is a classic Midwestern city with a have seen an unprecedented movement toward huge sense of community pride. If you ask the creating a bikeable community in Omaha. average citizen, he or she will say that Omaha Recognizing the limitations on city and county is a great city. However, it currently ranks government in terms of vision and resources, 142 out of 182 in health factors among cities Omaha has reached outside government to across the United States (indicators measured leverage private funding streams and “people included physical activity, nutrition, obesity, power” to change the environment. As a result, tobacco use, and binge drinking). Although Omaha has intertwined public and private changing the behaviors that lead to this poor funding to redefne the vision for Omaha’s ranking are important, Omaha will not make transportation system, a vision that the city significant changes until the healthy choice is now embraces. In this vision, streets should be the easy choice. For that to happen, Omaha designed to move people, not just cars—so that must become a place where biking, walking, biking, walking, and using mass transit are all and using mass transit are safe, convenient, safe and convenient; such a design increases and enjoyable activities that support the needs connectivity by ensuring access to and use of of all citizens, including children, seniors, and bicycle facilities, ride parks, green spaces, and those who either can’t afford a car or choose trails. not to own or drive one. Since 1995, Omaha has
349 350 Peterson and Harris embraced a collaborative approach to improving television), developed targeted messages for the health of the community through a healthy different population segments, and maintained community initiative, Live Well Omaha (LWO). a single brand to represent the initiative. One In 2003, the Robert Wood Johnson Founda- of the first successes the partnership achieved tion released a grant opportunity called Active was launching the Bicycle Commuter Challenge. Living by Design, offering funding to communi- In 2006, the mayor kicked off the challenge by ties to increase physical activity options for their announcing his support for a bicycle-friendly citizens through community design. By advocat- Omaha. Magazine and newspaper articles ing for changes in community design, specifi- and interviews on local television channels cally land use, transportation, parks, trails, and promoted the program. In later years, the pro- greenways, the Active Living by Design initiative gram incorporated incentives to attract new was intended to make it easier for people to be participants. active in their daily routines. The Active Living The Bicycle Commuter Challenge was very by Design community action model provided successful. In the first year, more than 300 five steps to influence community change: participants from 27 businesses logged 77,000 preparation, promotions, programs, policy influ- miles (124,000 kilometers). Subsequent years ences, and physical projects. The 5P model is a saw increases: 109,000 miles (175,000 kilo- comprehensive approach to increasing physical meters) in year 4 and 135,000 miles (217,000 activity through short-, intermediate-, and long- kilometers) in year 5. The LWO: Activate Omaha term community changes. This inclusive model partnership viewed the program as a way to facilitated the integration of policy, physical generate evidence and support for the need project, and programmatic efforts. In November for infrastructure change. The partnership did, 2003, Omaha was 1 of 44 communities nation- however, encounter resistance from partici- wide (out of more than 800 applicants) that pants. The city’s streets were not conducive to received a five-year, $200,000 grant as part of commuting by bicycle: There was only one the Active Living by Design national program official mile of bicycle lanes, and drivers were (www.activelivingbydesign.org). Through the impatient with cyclists. leadership of Live Well Omaha and its ties in As a result of that feedback, LWO: Activate the community, and with the funding from Omaha developed a bicycle commuter map for Active Living by Design, the city launched Live the Omaha–Council Bluffs metro area, using Well Omaha: Activate Omaha (LWO: Activate a Robert Wood Johnson Foundation Special Omaha) to increase levels of active living in the Opportunities Grant (figure 39.1). The purpose community. (“Active living” is a way of life that of the map was to assist commuters in identi- integrates physical activity into daily routines fying routes to reach their destination safely in order to accumulate at least 30 minutes of and conveniently. Participants in the Bicycle activity each day.) Commuter Challenge served on the technical Local businesses, health-focused organiza- advisory committee that developed and field- tions, and community planning and urban tested the map. Five thousand copies were designers formed an executive leadership com- distributed in one month through local bike mittee for LWO: Activate Omaha. The commit- shops, bike clubs, and libraries. Seeing the high tee and the organization capitalized on existing level of interest in the map, the LWO: Activate relationships to reach out to the business com- Omaha partnership pursued a $7,000 grant from munity and cultivate buy-in from business lead- the Eastern Nebraska Trails Network to fund ers. The LWO: Activate Omaha partnership was printing additional copies. able to leverage funding from private donors However, despite the success of the Bicycle through the philanthropy of these organizations. Commuter Challenge and interest in the map, a To promote awareness of the effort, LWO: significant problem loomed. Omaha is a city that Activate Omaha created messaging for various was designed around a car; it is a point of pride communication channels (e.g., print, radio, in Omaha that it is so easy to get around the city Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly 351
Figure 39.1 Map of Omaha bicycle network.E5691/NPAP/fig39.1/458666/alw/r1 Reprinted, by permission, from Douglas County Health Department.
by driving. Therefore, promoting and increasing cars, not bikes,” said Tammie Dodge, former active transportation remained a problem. In project coordinator of LWO: Activate Omaha. addition, Omaha’s built environment provided To educate and influence policy makers challenges to active living. Omaha has experi- and decision makers, LWO: Activate Omaha enced rapid westward growth in recent decades invited key players in the city to participate in but has been unable to build and expand cer- partnership-sponsored events. For example, the tain types of infrastructure at the same rate. In partnership invited several community leaders 2004, many neighborhoods, both old and new, to participate in a trip to Boulder, Colorado, to lacked pavements, and although 60 miles (100 learn more about successful alternative public kilometers) of recreational trails existed, they transit systems. This trip led to improved rela- were not well connected. Other factors that tionships and increased participation by policy limited active living included traffic conditions, makers and decision makers in active living aggressive drivers, poor street design, lack of efforts. bike lanes, hilly terrain, and harsh winters. As enthusiasm for active living grew, the Because of these factors, few residents engaged leaders of Live Well Omaha realized that fund- in active living of any kind, including bicycling. ing for additional changes was not likely to Most bicycle trips in Omaha were recreational come from city government, which was not only, and transportation-related trips were rare. driving the change and was constrained by a “Our city planner told us his job was to move tight budget. The partnership pursued funding 352 Peterson and Harris through the Peter Kiewit Foundation and give the city and county grassroots support for another private funder to develop a 20-mile the resulting planning decisions. (32-kilometer) bicycle loop in Omaha as a pilot project to increase physical activity. At an informational meeting with both funders, Program Evaluation the leaders of Live Well Omaha went out on Although no comprehensive evaluation is in a limb and told funders that if the city built it place given the lack of funding, LWO is tracking (the bicycle loop), they (bicyclists) would come. some quantitative measures: The private funders agreed to pay $600,000 to construct the bicycle loop. • Use of bike racks: Since the installation of The finished system (to be completed in the bike racks on all metro buses, the usage of 2014) will be a compilation of sharrows (shared- the bike racks has increased every year—a 150 lane markings), new bicycle lanes, existing trail percent increase from 2008 to 2009, an 8 percent connectors, and changes to existing road lanes. increase from 2009 to 2010, and a 59 percent The partnership hoped that the success of the increase from 2010 to 2011. pilot project would encourage the funders to • Participation in the Bicycle Commuter Chal- invest additional resources in expanding the lenge: Every aspect of the commuter challenge loop. By bringing the funding to the city, the has increased in the past two years. The number partnership created a win-win dynamic: The of teams increased 108 percent, the number of city could get credit for enhancing the transpor- riders increased 62 percent, the number of trips tation system at little to no cost to city taxpayers. increased 34 percent, and total miles logged As a result of this pilot work and the emerging increased 22 percent. From 2009 to 2011, in cycling infrastructure, the city has since applied the months of May to August, 444,558 miles for and received an additional $300,000 to put (715,446 kilometers) were tracked. in 10 more miles of bicycle lanes. • Use of the pedestrian bridge by bicycles: In Another key to success is to invest in policy May 2011, the Bob Kerry Pedestrian Bridge was work. A local health care system, Alegent observed for three days. Over those days the Health, funded in part the salary of Omaha’s bridge was visited 5,050 times, and 9.3 percent first bicycle and pedestrian transportation coor- of the visits were on bikes. dinator. The city leveraged this funding and funded the remaining salary cost through the • Bike-friendly businesses: The number of local area metro transit budget. This is a huge bike-friendly businesses has increased from one step for the city’s planning department, as it is in 2009, to seven in 2010, and to nine in 2011. the first time a staff member has been dedicated • Bicycle-Friendly City: In 2011, Omaha to addressing bicycle and pedestrian issues. applied for and received a Bicycle-Friendly City Live Well Omaha and the Douglas County designation at the bronze level. Health Department received a grant in 2010 • Bike to the Ballpark: In 2011, its first year, that will be used to address policy that affects Bike to the Ballpark attracted 700 bikes and the physical environment. From this grant, 50 volunteers. This event was held during the $300,000 was given to the City of Omaha to College World Series. update its transportation master plan to include accommodations for bicycles, pedestrians, and transit users. Again, this is an example of how Linkage to the National outside funding was leveraged to create sus- Physical Activity Plan tainable policy change in Omaha. The plan, complete with public input, was completed The efforts by Live Well Omaha to create a com- in 2012 and it will forever affect the design of munity that supports active living and active the city. Advocacy groups such as Mode Shift transportation are linked to four strategies of Omaha and Omaha Bikes are now working to the Transportation, Land Use, and Community Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly 353
Design Sector of the National Physical Activity makes it more convenient to merge transit and Plan. bicycle users. A shared bicycle system, B-Cycle, Strategy 1: Increase accountability of project is being installed to create connectivity from planning and selection to ensure infrastructure west to east, focusing on reducing the number supporting active transportation and other forms of automobile trips that are shorter than two of physical activity. Live Well Omaha and its miles (3.2 kilometers). partners have consistently provided educational opportunities to planners and engineers to begin to change the decision-making culture in the Evidence Base Used During city’s planning department. In addition, the Program Development city is updating its transportation master plan so that it focuses on designing for all forms of In 2012, the Institute of Medicine released a transportation, not just cars. report titled Accelerating Progress in Obesity Strategy 2: Prioritize resources and provide Prevention: Solving the Weight of the Nation. incentives to increase active transportation The report issued recommendations for accel- and other physical activity through community erating the progress in preventing obesity. One design, infrastructure projects, systems, policies, entire goal focuses on making physical activity and initiatives. Through the updated transporta- routine. tion master plan and community input, the city has developed a priorities list, based on specific Goal 1: Make physical activity an inte- criteria. The partnership provides political cover gral and routine part of life. and public support to the city when decisions Recommendation 1: Communities, transporta- are made to support multimodal forms of trans- tion officials, community planners, health portation. A dedicated effort is made to leverage professionals, and governments should funding when public resources are not available. make promotion of physical activity a pri- Strategy 3: Integrate land-use, transportation, ority by substantially increasing access to community design, and economic development places and opportunities for such activity. planning with public health planning to increase Strategy 1-1: Enhance the physical and built active transportation and other physical activ- environment. Communities, organizations, ity. The Douglas County Health Department community planners, and public health received a Robert Wood Johnson Foundation professionals should encourage physical grant to conduct three health impact assess- activity by enhancing the physical and ments, which Live Well Omaha hopes will be built environment, rethinking community just the beginning of the integration of health design, and ensuring access to places for impact into planning and designing decisions such activity. Following are two of the within the city and county. The head of the potential actions that have been suggested: city’s planning department has joined leader- Communities, urban planners, architects, ship teams that guide the city’s work on obesity developers, and public health professionals prevention. should develop and implement sustain- Strategy 4: Increase connectivity and acces- able strategies for improving the physical sibility to essential community destinations to environment of communities that are as increase active transportation and other physi- large as several square miles, or as small cal activity. Live Well Omaha and its partners as a few blocks, in ways that encourage are working hard on increasing connectivity. and support physical activity. Communi- From increasing the miles of existing bicycle ties and organizations should develop and lanes to ensuring that essential connectors of maintain sustainable strategies to create the trail system are completed, connectivity or enhance access to places and programs requires coordination of many sectors. All metro where people can be physically active in a buses have had bicycle racks installed, which safe and enjoyable way. 354 Peterson and Harris
Live Well Omaha’s comprehensive approach convenient way for the last 30 years, building to increasing routine levels of physical activity, relationships and educating staff were key ele- using the Robert Wood Johnson’s 5P model ments in taking small steps forward and expe- approach, covers many of the Institute of Medi- riencing success. Patience and compromise led cine’s recommendations. to important changes. • Come to the table with resources. LWO and Populations Best Served its partners brought more than one million dol- lars to the city for infrastructure and program- by the Program matic support. Collectively, LWO has worked in tandem to plan and re-envision what could be The steps taken by Live Well Omaha and LWO: for Omaha. LWO also arranged two community Activate Omaha are designed to benefit people site visits (in Boulder and Minneapolis) for key of all age, socioeconomic, and ethnic and racial leaders in the city to see first hand how change groups. Omaha is the largest city in Nebraska, has occurred. with approximately 430,000 residents, rep- resenting more than a quarter of the entire • Provide political cover when needed. state’s population. Like many growing cities, Omaha drivers have been somewhat resistant Omaha has a dense, urban section of the city to the issue of bicyclists on the roads. The city and a sprawling suburban geographic area. planners are the first to hear the complaints. Business dominates Omaha’s decision-making When possible and appropriate, LWO and its infrastructure, as it is home to five Fortune 500 partners publically acknowledge and celebrate companies, including Mutual of Omaha and Con the steps the city takes to ensure multimodal Agra. The city is primarily white (81 percent) forms of transportation. with small racial and ethnic populations (11 percent African American, 7 percent Hispanic and Latino). Omaha neighborhoods tend to be Tips for defined by race and ethnicity and by income. Working Across Sectors Omaha has a relatively young population, with 27 percent of residents younger than 18 years Live Well Omaha used several strategies that and 31 percent between 25 and 44 years old. have contributed to its early successes. The Omaha also has one of the highest percent- strongest keys to success thus far have been ages of working mothers in the nation, result- building on a history of partnerships, using ing in a large number of children in full-time media to create awareness and set an agenda daycare. Eighty-five percent of residents have for change, and following a planning model in an education level of a high school diploma or developing programs. greater, and 14 percent live below the poverty level ($22,050 per year for a family of four, Building on a History U.S. Census). The estimated median household of Partnerships income in 2009 was $46,595. Low-income and minority populations are disparately affected Central to the success of Live Well Omaha to by overweight and obesity. date has been its history of partnering with other organizations in the community and using those partnerships to leverage resources in the Lessons Learned community. LWO’s network of more than 100 partners and members of Omaha’s public and It has taken almost nine years to make the head- private community engaged in several early way that Omaha is beginning to see and experi- collaborations to address obesity and physical ence. The top lessons learned include these: activity in the community. Many of these early • Change takes time. In a city that that has activities laid the groundwork for LWO’s cur- focused on moving automobiles in the most rent work. Leveraging Public and Private Relationships to Make Omaha Bicycle Friendly 355
Using Media to Create Awareness experience in thinking about policy as a part of change as well as a more holistic framework for and Set an Agenda for Change thinking about and addressing health issues in Another key to success is the use of media to the community. By using this model in design- engage members of the community with the ing its programs, LWO was better able to strike culture shift that was underway. Residents a balance between working directly on policy were not used to seeing bicycles on the road. change and creating public interest and involve- As a result, LWO launched Omaha’s first Share ment, which is required for changes in policy the Road campaign, IRide. LWO built a new to be enacted. website and shared stories in the media about successes (e.g., number of people participating Additional in the Bicycle Commuter Challenge). Reading and Resources Following a Planning Model Burk, M., with Kurmaskie, J. 2010. Joyride: Pedaling in Developing Programs Toward a Healthier Planet . Portland, OR: Cadence Press. Much of the work was grounded in the Robert Mapes, J. 2009. Pedaling Revolution: How Cyclists Are Wood Johnson Foundation’s 5P model for Changing American Cities. Corvallis, OR: Oregon change (preparation, promotions, programs, State University Press. policy, and physical). LWO was introduced Parker, L., A.C. Burns, E. Sanchez, and the Committee to this model through its participation in the on Childhood Obesity Prevention Actions for Local Robert Wood Johnson Foundation’s Active Governments. 2009. Strategies to Prevent Childhood Living by Design community grant program and Obesity. Washington, DC: Institute of Medicine has used this basic approach with subsequent and National Research Council of the National projects. Using this model provided staff with Academies.
Sector VIII Volunteer and Nonprofit
Colleen Doyle, MS, RD
he data are clear: Americans are not suf- youth, the elderly, racial and ethnic minority Tfciently physically active, putting their populations, and health professionals, and can health and their quality of life at risk. Also clear therefore leverage those existing relationships is that facilitating lifelong physical activity will and efforts. Finally, the mission and infrastruc- require improvements in the environments in ture of some nonprofits may be valuable in which people live, work, learn, and play and helping to advance more applied, community- reduction of the barriers to active lifestyles based physical activity research. All of these that many people face. To achieve these goals, characteristics can and should be leveraged to national, state, and local organizations must advance physical activity policy and systems work together on activities that result in policy change priorities nationwide. and environmental changes in workplaces, The initiatives that follow exemplify a variety schools, neighborhoods, health care facilities, of these unique characteristics and competen- and faith-based communities, among others. cies of nonprofit organizations and demonstrate Nonproft organizations, because of their mis- how organizations are leveraging them to help sion, infrastructure, and unique capabilities, facilitate physical activity among all Ameri- can serve as effective partners in creating and cans. You will see how nonprofit organizations sustaining more physically active lifestyles have increased capacity at national, state, and among all Americans. local levels to advocate for policy and systems Whether a nonprofit organization focuses changes through training and technical assis- on disease prevention or health promotion, tance, development of effective coalitions, and targets particular audiences of health profes- community mobilization; how nonprofits have sionals or consumers, or focuses on particu- partnered to create and disseminate an effective lar age groups, these organizations possess physical activity program for a special popula- many characteristics and competencies that tion group and have reduced organizational can be leveraged to build capacity to support barriers that could affect adoption of such a more physically active lifestyles. They tend program by individuals; and how a national to have a broad base of support—volunteers, nonprofit organization identified evidence- members, and other constituents—whose pas- based strategies to promote physical activity sion for advancing the organization’s mission in a workplace setting, tested and evaluated can be used to advance policies and systems those strategies in a real-world setting, and changes. Many function at multiple levels and used its nationwide infrastructure to dissemi- can therefore help to coordinate the multilevel nate strategies that have resulted in physical strategies needed for maximum impact. Many activity policy and environmental changes in nonprofit organizations are leaders in promot- workplaces throughout the country. These ing legislation and in building the capacity of examples should stimulate new ideas, inspire communities to advocate for legislative priori- creativity and innovation, and demonstrate the ties. Some nonprofits focus their work within critically important role that nonprofit organiza- specific sectors, but many work across sectors tions play in achieving the vision set forth by and can act as key conveners of cross-sectoral the National Physical Activity Plan: One day, all coalitions and collaborations. Many nonprofits Americans will be physically active, and they already work through key systems and target will live, work, and play in environments that their work to particular audiences, including facilitate regular physical activity.
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CHAPTER 40 Using Legal and Policy Muscles to Support Physically Active Communities
Manel Kappagoda, JD, MPH Robert Ogilvie, PhD ChangeLab Solutions ChangeLab Solutions
Sara Zimmerman, JD Marice Ashe, JD, MPH ChangeLab Solutions ChangeLab Solutions
NPAP Tactics and Strategies Used in This Program
Overarching Strategies tions to advance the goals of the National Physical Activity Plan. STRATEGY 1: Advocate to local, state, and national decision makers for policies and system changes STRATEGY 3: Conduct outreach to nonprofit groups’ identified in the National Physical Activity Plan that members, volunteers, and constituents to change promote physical activity. their own behaviors and advocate for policy and system changes outlined in the National Physical STRATEGY 2: Convene multisector stakeholders at lo- cal, state and national levels in strategic collabora- Activity Plan.
hen local government offcials in Kansas and city council members of the policy’s value WCity, Kansas, passed a Complete Streets and feasibility. Since that policy passed, one resolution pushing for the development of safer other county and four other cities in the metro and more walkable streets in 2011, the victory Kansas City area have passed Complete Streets offered a powerful example of how nonproft policies. The advocacy of KCHK was instru- advocacy and partnerships can create policy mental in the policy’s passage. In the words of successes for physical activity. In celebrating Samara Klein, KCHK’s advocacy director, model the resolution’s passage, Mayor Joe Reardon policies gave advocates and policy makers “a noted that the process of developing the policy starting-off point,” making it easier for busy had already forged new partnerships between people to move issues forward effectively. (For city engineers and the city’s public health more information on Kansas City Healthy Kids, department as the staff explored new ways go to www.kchealthykids.org/.) of looking at the health implications of local The purpose of this chapter is to highlight streets. Using model policies developed by how legal and policy technical assistance can ChangeLab Solutions, advocates from Kansas support the efforts of leading organizations that City Healthy Kids (KCHK) who were living and are trying to change the built environment to working in Wyandotte County, Kansas, were support physical activity. For the purposes of able to convince community groups, mayors, illustration, this chapter focuses on the work of
359 360 Kappagoda, Zimmerman, Ogilvie, and Ashe
ChangeLab Solutions, a nonprofit organization advocates. This approach to policy develop- based in Oakland, California. For nearly 15 years, ment strives to achieve system-level changes ChangeLab Solutions has helped communities in a range of settings, including households, create laws and policies that make the healthy schools, entertainment venues, corporations, choice the easy choice. Our team of attorneys, and government agencies. The changes are city planners, and policy analysts consult with institutionalized informally through cultural advocates and policy makers on tough legal and expectations and peer pressure and formally policy challenges, develop practical model poli- through legislation and law enforcement. Of the cies, and train local leaders on specific policy many movements that have shaped the society strategies and additional resources. ChangeLab we live in today—everything from seatbelt Solutions is one of several organizations that use and recycling to civil rights and disability provide specialized legal and policy support on rights—almost all have taken a social norm issues that affect the public’s health. (See, for change approach. example, the Network for Public Health Law: Regular physical activity plays a critical role www.networkforphl.org/.) Our approach to in mitigating obesity and other chronic diseases. policy change was developed through our work However, modern life and current social norms on the tobacco control movement, and over the make it difficult for the average person to incor- years we have applied the same method to new porate sufficient physical activity into daily life. issues. We take an interdisciplinary approach By supporting efforts that focus on policy and to physical activity policy, incorporating legal social norm change, national nonprofits can and urban planning expertise to develop poli- assist advocates and policy makers on a wide cies that make communities more walkable, range of issues, from broad land use plans to bikeable, and supportive of physical activity. focused place-based strategies like regulating physical activity in child care settings. Program Description Neighborhoods Designed One of the most effective ways to change the for Active Living behavior of large numbers of people is by chang- ing the underlying social expectations about Increasing evidence demonstrates a strong rela- the types of behavior that are acceptable or tionship between our health and the environ- approved—an approach known as “social norm ment in which we live. The way neighborhoods, change.” A social norm involves the expecta- streets, and homes are designed affects whether tions of appropriate and desirable behavior children can play outside and walk to school, widely shared throughout a community or soci- whether families can easily access healthy food ety (Marshall 1998; Zhang et al. 2010). The goal and basic services, whether taking transit to of a social norm change movement is to change work is a realistic option, and even whether people’s behavior, but not by nagging them or neighbors can socialize and look out for one educating them about the need for change and another (Design Community & Environment not by requiring each individual to act a certain 2006; Jackson and Kotchtitzky n.d.). way. Instead, a social norm change movement In an effort to curb growing rates of chronic changes people’s behavior indirectly by creating disease such as diabetes, asthma, and heart a social environment and legal climate in which disease, planners and public health profession- harmful conduct becomes less desirable, less als are combining their resources and expertise, acceptable, and less convenient, while healthier working to design and redevelop neighborhoods behavior becomes the norm (California Depart- so that healthy choices are available. One of the ment of Health Services 1998). main tools that planners and public health offi- National nonprofits can serve as a catalyst cials have at their disposal for creating healthier for social norm change, working in partnership communities is the comprehensive plan. Com- with local, state, and federal policy makers and prehensive plans are the primary documents Using Legal and Policy Muscles to Support Physically Active Communities 361 guiding land use development patterns, and tive orders from elected officials. Communities they can be used to ensure that future devel- across the nation are working to make their opment and redevelopment facilitate physical streets complete, from Kentucky to Washington activity. The American Planning Association to New York. Model policies and implementa- recently surveyed the interaction between plan- tion assistance can be crucial in making these ners and public health departments around the campaigns successful. United States, finding that only 27 percent had adopted comprehensive plans that explicitly Safe Routes to School address health; thus, there is much work to be Like Complete Streets, Safe Routes to School done (American Planning Association 2011). (SRTS) is a policy approach that focuses on A wide range of communities, such as reinstating walking and bicycling as common King County, Washington; Chino, California; ways for children and adults to get around. and Port Towns, Maryland, are beginning to Research shows that children who walk or revise their comprehensive plans to address bicycle to school have higher daily levels of residents’ health. Legal and policy assistance physical activity and better cardiovascular from nonprofits such as ChangeLab Solutions fitness than do children who do not actively is key to enabling jurisdictions to effectively commute to school (Davison et al. 2008). SRTS identify areas of improvement such as increas- advocates may work with their school district to ing access to recreational facilities, calling for pass a district policy that promotes and supports future developments to be designed to encour- SRTS or work with their municipal or county age daily physical activity, and building acces- government to incorporate SRTS concepts in the sibly so that seniors can age comfortably in comprehensive plan (National Policy & Legal place. National nonprofits can also work with Analysis Network 2010). communities on revising zoning and subdivi- Communities often need to clarify questions sion codes to promote health and on adopting about legal issues that arise in connection ordinances and regulations that support bicycles with SRTS programs. For example, when Nita and pedestrians. Mizushima, president of the Nevada City School Board, encountered liability concerns as she Complete Streets was setting up the district’s first walk-to-school week, she consulted with a staff attorney at Over the last four decades, transportation ChangeLab Solutions to explore various issues planning has increasingly focused on the that had emerged. Could school employees rapid movement of large numbers of motor participate? Were waivers necessary? Did the vehicles—the result being that today’s streets district have built-in protections from liability? are often dangerous and inconvenient for With the ability to easily access expertise in this pedestrians and bicyclists. In contrast, Com- area, she quickly found answers that allowed plete Streets are streets designed and operated her to move forward with clarity and assurance. to be safe, comfortable, and convenient for all users—pedestrians, bicyclists, motorists, and transit riders of all ages and abilities (National School Siting Complete Streets Coalition 2010). Putting a local Forty years ago, almost half of all students Complete Streets policy into place ensures that walked or biked to school (U.S. Department of transportation agencies routinely design and Transportation 2008); now only 13 percent do operate the entire right of way to enable safe so (McDonald et al. 2011). The biggest reason access for everyone (National Complete Streets for this change is because today’s schools are Coalition 2010). Complete Streets policies can located too far from children’s homes for walking take a variety of forms, including ordinances or biking to be practical (Martin et al. 2007). In and resolutions, revisions of design manuals, recent decades, in response to a variety of pres- inclusion in comprehensive plans, and execu- sures, schools have increasingly been built on 362 Kappagoda, Zimmerman, Ogilvie, and Ashe the outskirts of communities (Martin et al. 2007). to open space, parks, and recreation facilities The consequence is that two thirds of today’s where residents can play and exercise safely. schools are located far from where children live But almost all communities have schools with (U.S. Department of Health and Human Services a variety of recreational facilities, like gymna- 2008). Since 1980, obesity rates in children siums, playgrounds, fields, courts, and tracks. and adolescents have more than tripled, and These facilities could potentially provide com- currently almost one-third of children are over- munity members with opportunities for exercise weight or obese.(Ogden et al. 2008). after school hours and on weekends, if only But school locations can be an important they were open to the public. Most states have factor in students’ health. When schools are laws that encourage or even require schools located close to where students live, not only to open their facilities to the community for can children get regular physical activity on the recreation or other civic uses, but too often way to school through SRTS programs, but also these are ignored by school officials who are they may be able to take advantage of school worried about exposure to liability and about playgrounds and facilities outside of school the extra maintenance and operations expenses hours (see section titled Joint Use Agreements). that could be incurred. To ensure that schools are located near where Despite these valid concerns, many school students live, districts must do two things: districts around the United States routinely (1) retain existing schools that are centrally partner with local government agencies and located, and (2) look within communities nonprofit and civic organizations through what instead of on their outskirts when building new are known as “joint use” (or “shared use”) schools. By prioritizing proximity of schools to agreements—formal agreements, often between students’ homes, school districts can ensure the a school district and a city or county agency educational success, physical health, and over- or a local nonprofit organization, that set forth all well-being of students and their community. the terms and conditions for the shared use School districts and community advocates of their properties. (Note that joint use agree- benefit from access to national resources on ments can be used for more than just opening school siting issues. In Billings, Montana, for up recreational facilities. Such agreements can instance, a school board member searched be used to share all kinds of governmental and in vain for examples of strong school siting community assets including libraries, theaters, policies from state or national school board and kitchens.) Commonly, these agreements associations, ultimately contacting ChangeLab address access to the recreational facilities of Solutions. As our staff attorneys began draft- the partners, but often they go beyond that to ing model policies for the district to use, they provide access to kitchens for meal programs, participated in meetings involving the Montana land for community gardens, and rights of way School Board Association and a diverse group for recreational trails. In Spokane, Washington, of personnel from planning departments, transit where the parks and recreation department agencies, school districts, and smart growth owns no indoor facilities and the school district organizations, as well as developers, architects, has few outdoor facilities, a joint use agreement advocates of safe routes to schools, and others. has been in place since the early 1930s giving This wide range of perspectives informed the each partner access to the other’s property as work, and the Billings School Board hopes to needed, sharing maintenance expenses, and be the first school board in the nation to adopt indemnifying each partner from legal action. the model policies. Assistance by national nonprofits is invaluable for communities across the United States look- Joint Use Agreements ing to implement new agreements or improve existing ones; this assistance can take the form Many communities, particularly urban low- of toolkits that provide guidance on negotiat- income and rural communities, lack access ing joint use agreements, a selection of sample Using Legal and Policy Muscles to Support Physically Active Communities 363 and model contracts, or one-on-one legal and nonprofit organizations. In table 40.1, we set policy support. out a number of examples of community-based policy change, identifying linkages to additional Physical Activity in Child Care aspects of the NPAP. Strategy 1: Advocate to local, state, and Settings national decision makers for policies and system Children under the age of five are a particularly changes identified in the National Physical Activ- important target population for physical activ- ity Plan that promote physical activity. State and ity policy strategies. At this early stage of life, local government agencies—including public regular physical activity is critical not only to health departments, planning departments, prevent excess weight gain and avoid chronic parks and recreation agencies, and transporta- health problems but also to promote optimal tion agencies—have important roles to play in physical, social, and psychological development implementing and improving laws and policies (Institute of Medicine 2011). The child care set- related to physical activity, active transporta- ting presents an ideal opportunity to promote tion, and access to recreational facilities. These physical activity and the early development of agencies craft and implement regulations that healthy behaviors. The Institute of Medicine flesh out the laws on the books. For nonprofit (2011) recommends that children in child care actors to influence agency actions, they need settings be given the opportunity to engage in to understand legal and policy issues that may at least 15 minutes of light, moderate, or vig- arise during policy implementation and the orous physical activity every hour while they relationships that must be in place for the policy are in care. initiative to flourish. Few states set physical activity requirements Community advocates can use legal tech- for child care. Only three states require that nical assistance to address barriers to policy child care settings provide a specified number change. One example comes from New York of minutes of physical activity per day (Benja- State, involving an incident that occurred when min et al. 2008). In Florida, the Miami-Dade Janette Kaddo Marino and her son biked to his County Health Department decided to work on middle school one day. When they arrived at improving standards related to physical activity, the school, they were turned back by school nutrition, and screen time in child care settings. administrators and a state trooper, who told Local experts on the Miami-Dade County Child them that they were in violation of a school Care Task Force developed model standards for policy prohibiting bicycling to school. Janette child care providers. The standards are now was ordered to return to campus immediately used as a voluntary training tool for county in a car to pick up her son’s bike (Yusko 2009). providers, offering the potential to make a huge Janette was outraged by this policy, which she difference for thousands of Florida’s children. believed violated common sense. Working with the Safe Routes to School National Partner- ship (SRTSNP), she pushed to get the policy Linkage to National changed. Through SRTSNP, she was connected Physical Activity Plan to an attorney who explained that by regulating how students get to and from school, the school The overarching strategies of the NPAP call district likely exceeded the authority granted for a cross-sector approach that works at all to it by the state and may have even violated levels of government and includes, at its core, parents’ constitutional rights. The school board a grassroots advocacy effort to create policy subsequently reversed this rule, instituting a change. Legal and policy technical assistance new policy that allows children to walk and can facilitate efforts to promote physical activ- bike to school. ity policy via the three strategies laid out in Strategy 2: Convene multisector stakeholders the NPAP recommendations for volunteer and at local, state and national levels in strategic Table 40.1 Examples of Community-Based Physical Activity Policy Community action NPAP sector and strategy Policy area Community advocates in a small rural commu- Education Strategy 3 Joint use agreements nity with no parks pushed the school district to Develop partnerships with allow community access to a vacant lot owned other sectors for the purpose by the district. The district and the town entered of linking youth with physi- into a joint use agreement in 2011 that shares cal activity opportunities in the costs and responsibilities of opening the schools and communities plot of land to the community. Location: Earlimart, CA A community-based child care task force devel- Education Strategy 4 Physical activity oped physical activity and nutrition policies for Ensure that early child- standards in child care child care settings and provided a policy analy- hood education settings for settings sis of nutrition, physical activity, and screen children ages 0 to 5 years time regulations to state legislators to encour- promote and facilitate physi- age the adoption of state-level policy. cal activity Location: Miami-Dade County, FL A mother wanted her son to be able to bike to Education Strategy 5 Safe Routes to School school so she petitioned her local school board Provide access to and oppor- policy to change district policy prohibiting students tunities for physical activity from biking to school. After months of concert- before and after school ed effort, she convinced the school board to change its policy. Location: Saratoga Springs, NY A school board wanted to work more closely Transportation Strategy 2 School siting policy with the municipal planning department to en- Prioritize resources and courage better land use decisions. The board provide incentives to increase worked with ChangeLab Solutions to develop active transportation and school siting policies for the district and a list of other physical activity through 10 fundamental aspects of smart school siting community design, infra- for school districts and local government. structure projects, systems, Location: Billings, MT policies, and initiatives The City of Longmont has a program called Transportation Strategy 3 Land use planning and Live Well Longmont, which facilitates healthy Integrate land use, transpor- design for active living choices related to food and physical activity. tation, community design, The local collaborative focused on developing and economic development a health element for the city’s comprehensive planning with public health plan that promoted active transportation and planning to increase active opportunities for physical opportunity. transportation Location: Longmont, CO The Cascade Land Conservancy spearheaded Transportation Strategy 4 Complete Streets a coalition that wanted to get Complete Streets Increase connectivity and policy policies in place in the city of Edmonds, Wash- accessibility to essential ington. After over a year of determined advo- community destinations to cacy, the council approved a Complete Streets increase active transportation ordinance in June 2011. and other physical activity Location: Edmonds, WA Technical assistance resources related to each policy area are available on the ChangeLab Solutions website: www.changelabsolu- tions.org.
364 Using Legal and Policy Muscles to Support Physically Active Communities 365
collaborations to advance the goals of the Evidence Base Used During National Physical Activity Plan. For some types of policy change, layer upon layer of interlock- Program Development ing, mutually supportive efforts by stakehold- The tobacco-control movement in the United ers are necessary. One such area involves the States provides evidence that the law is an promotion of joint use, where many partners are important driver of social norm change in the involved in determining state and local policies public health arena. The results have been and practices. The Strategic Alliance Promoting staggeringly impressive. The state achieved a Healthy Food and Activity Environments is a 35 percent reduction in adult smoking rates network of stakeholders at the city, county, and between 1988 and 2005: from 22.7 percent to state levels who develop and advance cutting- 14 percent (California Department of Health edge policies to improve healthy eating and Services 2006). This evidence of success has physical activity opportunities for Californians. pointed to the potential for a similar social norm The Strategic Alliance was formed in 2001 by change approach to chronic disease prevention, the Prevention Institute, a national nonprofit including physical activity policy. that promotes policies and collaborative efforts One of the most prominent initiatives build- to improve health and quality of life. Because ing the evidence base for physical activity policy of the importance of joint use agreements as is Active Living Research (ALR), a program a strategy for promoting physical activity, the funded by the Robert Wood Johnson Founda- Strategic Alliance developed a Joint Use Stake- tion (RWJF). This program supports research holders Task Force. The leadership and coordi- examining how environments and policies nation of the Strategic Alliance have helped put affect physical activity, especially among chil- joint use agreements into action in communities dren of color and those living in low-income across the state. For more information, visit the communities. ALR encourages a wide array of website of the Strategic Alliance: http://preven- experts—in fields as diverse as public health, tioninstitute.org/strategic-alliance. public administration, law, economics, trans- Strategy 3: Conduct outreach to nonprofit portation, medicine, and architecture—to work groups’ members, volunteers, and constituents together to identify promising approaches for to change their own behaviors and advocate increasing physical activity and preventing for policy and system changes outlined in the obesity among children and families. For more National Physical Activity Plan. A strong and information about Active Living Research, go vibrant network of groups and funders across to http://activelivingresearch.org. the United States are working on physical Given that research developing the evidence activity policy. The diverse but complementary base for active living policy is ongoing, many initiatives include the California Endowment’s policy strategies are being tested before science California Convergence (Lee et al. 2008), the has confirmed their effectiveness. Significantly, Robert Wood Johnson Foundation’s Childhood our legal system accommodates the reality that Obesity Prevention initiative (Strom 2007), and public health interventions evolve in concert the U.S. Centers for Disease Control’s Com- with our understanding of public health prob- munity Transformation Grants (U.S. Centers lems. Generally, there need only be a “rational for Disease Control and Prevention 2012). basis” for laws promoting public health, rather Other national groups play leadership roles in than scientific certainty. This means that policy specific spheres, like the American Planning makers can take action to prevent obesity before Association, the Safe Routes to Schools National the scientific community coalesces around the Partnership, and the National School Boards most effective interventions. In fact, states and Association. The diverse range of organizations localities contribute to the obesity-prevention working on this issue reflects the myriad ways evidence base by passing novel policies and that physical activity needs to be incorporated working with researchers to evaluate the into policy development. health effects of these policies. For a detailed 366 Kappagoda, Zimmerman, Ogilvie, and Ashe explanation of the concept of rational basis, see ing bridges between the policy makers who Gostin (2008). can jointly have a profound impact. City plan- ners, public health departments, parks and recreation staff, and redevelopment agencies Populations Best Served may not understand how and why to work by Program together. Translating the jargon and specialized knowledge across disciplines and engaging with Changing social norms regarding physical activ- nontraditional partners is critical if healthier ity works best with strong support at the local places are to be built. level. As a result, legal and policy technical • Ensure that partners at all levels under- assistance efforts target local policy makers stand the distinction between a physical activ- and agency staff as well as community-based ity program and a physical activity policy. A organizations. It is important to pay particu- public health program is a plan that an agency lar attention to underserved communities by implements to provide a service. A public health writing health equity language directly into a policy, in contrast, refers to a law enacted by a policy whenever possible. Nonprofits should government at the local, state, or federal level. incorporate tenets of the civil rights movement As interventions, policies have important advan- into their work. For example, while working on tages over programs because they have broader school siting policies that promote walking and reach and longer-lasting impact. Through policy biking to neighborhood schools, we identified we can influence systems and the environment a potential tension between these policies and in which programs and individuals operate, desegregation efforts; in response, we asked affecting many more individuals and reaching national civil rights groups to serve as expert them earlier. Additionally, policies are generally advisors as we worked to design policies that longer-lasting because they codify change and support schools that are walkable and diverse. survive individual leadership transitions.
Lessons Learned Summary From our work over the past 15 years, we have identified the following key lessons for changing The time is ripe for using policy and legal social norms to encourage increased physical strategies to change social norms and increase activity: physical activity—particularly with growing momentum toward “Health in All Policies,” an • Take a multijurisdictional approach, paying approach that requires government agencies to special attention to capacity-building at the collaborate with each other to ensure that health local level. When RWJF made its $500 million is considered when policies are developed. (See, commitment to reverse the childhood obesity for example, California Executive Order S-04-10 epidemic, it placed a major focus on local policy [2010], which establishes a Health in All Policies change. RWJF recognized that localities, in col- Task Force.) With continued research connect- laboration with states, wield significant power ing physical activity to policy strategies, as well over how land is used, how restaurants operate, as advocates’ increasingly tenacious strategic how transit is laid out, how schools function, efforts, the need for specialized legal and policy and many other details of the built and social support and innovation will only become more environment. Public health movements can critical in campaigns to promote physical activ- build momentum at the local level through local ity in communities nationwide. policy change, and this local momentum can be very influential at the state and federal level. • Invest in training and support for inter- References agency collaboration. It is crucial to identify American Planning Association, Planning and Commu- the links among a multitude of issues, build- nity Health Research Center. 2011. Comprehensive Using Legal and Policy Muscles to Support Physically Active Communities 367
planning for public health: Results of the planning Convergence Partnership. www.calendow.org/ and community health research center survey. uploadedFiles/Publications/Publications_Stories/ www.planning.org/research/publichealth/pdf/ builtenvironment.pdf. surveyreport.pdf. Marshall, G., Ed. 1998. A dictionary of sociology. Benjamin, S., A. Cradock, E.M. Walker, M. Slining, Oxford, UK: Oxford University Press. www.ency- and M.W. Gillman. 2008. Obesity prevention in clopedia.com/doc/1O88-norm.html. child care: A review of US state regulations. BMC Martin, S., S. Lee, and R. Lowry. 2007. National preva- Public Health 8(188):4-5. www.biomedcentral.com/ lence and correlates of walking and bicycling to content/pdf/1471-2458-8-188.pdf. school. Am. J. Prev. Med. 33(2):98-105. California Department of Health Services, Tobacco McDonald, N., A. Brown, L. Marchetti, and M. Pedroso. Control Section. 1998. A model for change: The Cali- 2011. U.S. school travel 2009: An assessment of fornia experience in tobacco control. Sacramento, trends. Am. J. Prev. Med. 41(2):146. CA: Department of Health Services. www.cdph. National Complete Streets Coalition. Complete Streets ca.gov/programs/tobacco/Documents/CTCPmod- FAQ. 2010. www.completestreets.org/complete- elforchange1998.pdf. streets-fundamentals/complete-streets-faq. California Department of Health Services, Tobacco National Policy & Legal Analysis Network to Prevent Control Section. 2006. Adult smoking prevalence. Childhood Obesity. 2010. Resources on safe routes Sacramento, CA: Department of Health Services. to school programs. Oakland, CA: ChangeLab Solu- www.cdph.ca.gov/programs/tobacco/Documents/ tions. http://changelabsolutions.org/childhood- CTCPAdultSmoking06.pdf. obesity/safe-routes-schools. California Executive Order S-04-10. 2010. http://sgc. Ogden, C.L., M.D. Carroll, and K.M. Flegal. 2008. High ca.gov/hiap/docs/about/Executive_Order_S-04-10. body mass index for age among US children and pdf. adolescents, 2003-2006. JAMA. 299(20):2401-5. Davison, K., J. Werder, and C. Lawson. 2008. Children’s Strom, S. 2007, April 4. $500 million pledged to fight active commuting to school: Current knowledge and childhood obesity. New York Times. www.nytimes. future directions. Prev. Chronic Dis. 5(3):1-3. com/2007/04/04/health/04obesity.html. Design Community & Environment. 2006. Understand- U.S. Centers for Disease Control and Prevention. 2012. ing the relationship between public health and the Community transformation grants. www.cdc.gov/ built environment: A report prepared for the LEED- communitytransformation/index.htm. ND Core Committee. www.usgbc.org/ShowFile. U.S. Department of Health and Human Services, Centers aspx?DocumentID=1736. for Disease Control and Prevention. 2008. KidsWalk: Gostin, L. 2008. Public Health Law: Power, Duty, Then and now—barriers and solutions. www.cdc. Restraint. Berkeley, CA: University of California gov/nccdphp/dnpa/kidswalk/then_and_now.htm. Press. U.S. Department of Transportation. 2008. National Institute of Medicine. 2001. Early childhood obesity Household Travel Survey. Travel to school: The prevention policies. www.iom.edu/Reports/2011/ distance factor. www.saferoutesinfo.org/program- Early-Childhood-Obesity-Prevention-Policies.aspx. tools/travel-school-distance-factor. Jackson, R., and C. Kotchtitzky. n.d. Creating a healthy Yusko, D. 2009, September 29. School district could environment: The impact of the built environ- backpedal on policy. The Times Union. www. ment on public health. Washington, DC: Centers timesunion.com/local/article/School-district-could- for Disease Control and Prevention. Sprawl Watch backpedal-on-policy-557196.php#ixzz1aJzX5pMb. Clearinghouse. www.bvsde.paho.org/bvsacd/cd53/ Zhang, X., D. Cowling, and H. Tang. 2010. The impact creating.pdf. of social norm change strategies on smokers’ quitting Lee, V., L. Mikkelsen, J. Srikantharajah, and L. Cohen. behaviours. Tobacco Control 19(Suppl. 1):i51. http:// 2008. Strategies for enhancing the built environ- tobaccocontrol.bmj.com/content/19/Suppl_1/i51. ment to support healthy eating and active living. full.pdf.
CHAPTER 41 Reducing Barriers to Activity Among Special Populations LIVESTRONG at the YMCA
Haley Justice-Gardiner, MPH, CHES Ann-Hilary Heston, MPA The LIVESTRONG Foundation YMCA of the USA
NPAP Tactics and Strategies Used in This Program
Health Care Sector Public Health Sector STRATEGY 1: Expand research that identifies and eval- STRATEGY 2: Create, maintain, and leverage cross- uates best practices for physical activity in health sector partnerships and coalitions that implement care, particularly those effective in population seg- effective strategies to promote physical activity. ments at high risk of physical inactivity. Dissemi- nate current best-practice guidelines for promoting Parks, Recreation, Fitness, and Sports Sector physical activity in high-risk subpopulations. In- STRATEGY 1: Promote programs and facilities where clude approaches relevant to primary, secondary, people work, learn, live, play, and worship (i.e., and tertiary prevention. workplace, public, private, and nonprofit recre- ational sites) to provide easy access to safe and affordable physical activity opportunities.
his chapter describes a collaboration outside of medical facilities to emphasize that Tbetween two national nonproft organi- LIVESTRONG at the YMCA is about health, zations that developed an initiative designed not disease. The goal of the program is to help to improve physical activity among cancer participants build muscle mass and strength, survivors by building the capacity of ftness increase flexibility and endurance, and improve professionals and creating safe and supportive functional ability. Additional goals include environments in which survivors can exercise. reducing the severity of therapy side effects, LIVESTRONG at the YMCA is a 12-week, preventing unwanted weight changes, and small-group program designed for adult cancer improving energy levels and self-esteem. A final survivors. The program supports the increasing goal of the program is to assist participants in number of cancer survivors who are seeking developing their own physical fitness program physical activity programs to help them cope so they can continue to practice a healthy life- with the emotional and physical effects of style, not only as part of their recovery but as cancer treatment. The program is conducted a way of life. In addition to providing physical
369 370 Justice-Gardiner and Heston benefits, the program gives participants a sup- in cancer survivorship—researchers, academi- portive environment and a feeling of community cians, and public and private practitioners and with their fellow survivors and YMCA staff and administrators. These experts helped identify members. YMCA fitness instructors work with and define a series of gaps in service for cancer each participant to tailor the program to his or survivors that YMCAs could fill: her individual needs. The instructors are trained to provide postrehabilitation exercise and sup- • Target population: YMCAs should make an portive cancer care. effort to understand and reach out to health- seeking cancer survivors in their communities. • Relationships: YMCAs should look to Program Description develop genuine, caring relationships with and among cancer survivors in their communities. LIVESTRONG at the YMCA is part of a mul- tiyear collaboration between YMCA of the • Program: YMCAs should offer a variety of USA, the national resource office for the Y, programs, activities, clubs, and events devel- and the LIVESTRONG Foundation, an orga- oped with and for cancer survivors. nization dedicated to improving the lives of • Staff competency: YMCA staff should have people affected with cancer. The Foundation a special understanding of and skills to support is known for its powerful brand LIVESTRONG cancer survivors in their pursuit of health and and is a leader in the global movement to fight well-being. cancer on behalf of 28 million people around • Environment: YMCA environments should the world living with the disease. The Y is one be conducive to cancer survivors’ pursuit of of the leading nonprofits in the United States health and well-being. working to improve health through community- • Partnerships: YMCAs should build partner- based initiatives that support healthy living. ships with targeted organizations in the cancer LIVESTRONG at the YMCA, launched in 2008, community to better support the cancer survi- is designed to improve health and day-to-day vor population. quality of life for the increasing population of cancer survivors and their families in the United In 2008 and 2009, two cohorts of 10 YMCAs States by providing supportive environments sought ways to close these gaps, including and experiences in a safe setting. piloting physical activity programs for cancer The program evolved from the desire of the survivors using the Institute for Healthcare LIVESTRONG Foundation and the YMCA of Improvement’s Breakthrough Series. This series the USA to provide support to this growing is an evidence-based model designed to help population and to address the need for safe organizations achieve breakthrough innova- and effective physical activity options for indi- tions to better meet the needs and interests of viduals diagnosed with cancer. According to their constituents. Through this formal learning the National Coalition for Cancer Survivorship, process, the YMCAs worked at both their local cancer survivorship begins at the point of diag- facility and collectively with the other cohort nosis and continues throughout the balance of members to develop leading practices and a a person’s life. Friends, family members, and signature program, LIVESTRONG at the YMCA. caregivers are also considered cancer survivors. These leading practices are now a part of a six- Participation in the LIVESTRONG at the YMCA month learning and implementation process program is limited to individuals who have that YMCAs must commit to in order to offer been diagnosed with cancer; however, many LIVESTRONG at the YMCA. Ys extend a free family membership to pro- YMCAs chosen to participate in this learn- gram participants, providing an opportunity for ing and implementation process must meet family members or caregivers access to health- minimum criteria, demonstrating their capac- related/physical activity programming. In 2007, ity and willingness to develop and sustain the organizations convened a group of experts LIVESTRONG at the YMCA. After selection, LIVESTRONG at the YMCA 371
YMCAs engage in activities to close the pre- service organizations like the American Cancer viously listed gaps, including creating and Society, the YMCA is becoming known in local enhancing partnerships in the oncology commu- communities as a valued and respected partner nity, training program leaders, and modifying in the long-term care of cancer survivors. the environments in their YMCAs. Participating • Increased volunteerism: Many who partici- YMCAs must agree to follow program standards, pate in LIVESTRONG at the YMCA seek to give including ensuring required staff competencies back to the program that has meant so much and offering LIVESTRONG at the YMCA at no to them. charge to participants. • Membership conversion: The majority of LIVESTRONG at the YMCA engages cancer LIVESTRONG at the YMCA participants are survivors through an approach that focuses on nonmembers, many never having been regular the whole person. Survivors work with trained exercisers. Following their participation in the Y staff to build muscle mass and strength, program, many elect to continue their health increase flexibility and endurance, and improve and well-being journey with the YMCA and functional ability. In addition to providing become members. physical benefits, the program focuses on the emotional well-being of survivors and their • Laying the basis for work with other spe- families by providing a supportive community cial populations: Having proved their ability environment where people affected by cancer to address the needs, wants, and interests of can connect during treatment and beyond. As cancer survivors, YMCAs are now being invited a result of their commitment to and focus on to translate their expertise to other special cancer survivors, YMCAs have achieved some populations, including those with diabetes, notable organizational changes: multiple sclerosis, heart disease, and stroke, all of whom can benefit from physically active • Program expansion to additional YMCA lifestyles. branches within the association: Many YMCAs are associations, made up of several branches. The number of YMCAs around the United Most YMCAs initially engage one to three States offering the LIVESTRONG at the YMCA branches in the learning and implementation program continues to increase. By the end of process. Upon seeing the success of their col- 2012, LIVESTRONG at the YMCA was offered leagues, leaders at nonparticipating branches at more than 250 Ys around the country. To often seek to become involved, expanding the date, approximately 13,000 cancer survivors program throughout the YMCA’s service area. have participated in the program nationwide. YMCA of the USA and the LIVESTRONG Foun- • Development of programs: Recognizing dation will continue to engage YMCAs in the that they could meet additional needs, wants, six-month learning process in order to deliver and interests of cancer survivors and their loved LIVESTRONG at the YMCA to additional com- ones, many YMCAs increased their program munities. With YMCAs in more than 2,600 offerings. Several, like YMCA of the Treasure locations, serving more than 10,000 communi- Valley in Boise, Idaho, now offer a menu of ties, the YMCA and the Foundation are poised cancer survivorship programs, including yoga, to make a real difference in the lives of cancer aquatics, a family cancer program, a cancer survivors throughout the country. lecture series, a support group for caregivers, and cancer screening events. • Partnership growth: Although the YMCA Linkage to the National has long been a key community member, it had Physical Activity Plan never before been seen as a credible player in the field of cancer survivorship resources and LIVESTRONG at the YMCA advances a variety support. Having developed partnerships with of strategies and tactics of the National Physi- local hospitals, oncology centers, and cancer cal Activity Plan, including those within the 372 Justice-Gardiner and Heston
sectors of health care; public health; and parks, Evidence Base Used During recreation, fitness, and sports. These include the following: Program Development Health Care Strategy 1: Expand research Current cancer treatments, although increas- that identifies and evaluates best practices for ingly efficacious for improving survival, are physical activity in health care, particularly toxic in numerous ways and produce negative those effective in population segments at high short- and long-term physiological and psycho- risk of physical inactivity. Disseminate current logical effects, including pain, decreased car- best-practice guidelines for promoting physical diorespiratory capacity, cancer-related fatigue, activity in high-risk subpopulations. Include reduced quality of life, and suppressed immune approaches relevant to primary, secondary, function (Courneya and Freidenreich 2001). and tertiary prevention. Evidence suggests the Since the first research study on cancer importance of a physically active lifestyle for patients and exercise was conducted in 1986, a individuals undergoing cancer treatment as growing body of evidence has demonstrated that well as for those who have finished treatment. exercise during and after cancer treatment is safe LIVESTRONG at the YMCA sought to expand and minimizes the adverse effects of treatment. existing research showing that physical activ- However, clinicians have historically advised ity was not only safe but feasible, during and cancer survivors to rest and to avoid activity. after treatment, and to disseminate an effective In 2009, the American College of Sports program through the nationwide Y network. Medicine (ACSM) assembled a roundtable of Individuals who have been diagnosed with experts to review the body of evidence sup- cancer are important audiences for such a porting the benefits of exercise among cancer program, as many are at high risk of physical survivors and to develop guidelines that could inactivity, and inactivity may increase the risk be used by fitness instructors and trainers. The of recurrence as well as the risk of developing ACSM recommendations for cancer survivors other types of cancer. are the same as those from the U.S. Department Public Health Sector Strategy 2: Create, of Health and Human Services Physical Activity maintain, and leverage cross-sector partner- Guidelines for Americans (age-appropriate) as ships and coalitions that implement effective well as those from the American Cancer Society: strategies to promote physical activity. Working with multiple partners, representing research- Undertake 150 minutes per week of moderate ers, academicians, and public and private to intense exercise or 75 minutes per week practitioners and administrators, the Y and of vigorous exercise. the LIVESTRONG Foundation collaborated Engage in strength training 2 or 3 times a to create, evaluate, and disseminate an effec- week, completing 8 to 10 exercises of 10 tive physical activity program. The program to 15 repetitions per set, with at least one has resulted in additional local partnerships set per session. that further support healthy, active lifestyles Avoid inactivity. among individuals who have been diagnosed Return to normal daily activities as quickly with cancer. as possible. Parks, Recreation, Fitness, and Sports Strat- Continue normal daily activities and exercise egy 1: Promote programs and facilities where as much as possible during and after non- people work, learn, live, play, and worship surgical treatments. (i.e., workplace, public, private, and nonprofit recreational sites) to provide easy access to safe When making modifications to exercise and affordable physical activity opportunities. regimens, practitioners must assess an indi- The Y has worked extensively with national and vidual’s cancer type, treatment, and side effects. local partners to promote LIVESTRONG at the The LIVESTRONG at the YMCA program was YMCA (figure 41.1). developed to respond to the need for exercise Figure 41.1 LIVESTRONG at the YMCA flier. Reprinted with permission from LIVESTRONG at the YMCA. ©2013 by YMCA of the USA, Chicago, All rights reserved. E5691/NPAP/fig41.1/458669/alw/r3
373 374 Justice-Gardiner and Heston opportunities for cancer survivors and adheres active partnerships with local agencies that to the ACSM cancer exercise guidelines. serve cancer survivors, creating a rigorous staff training process, and providing programs at low or no cost to cancer survivors. Lessons Learned A final lesson learned was that before offer- Through its national dissemination of ing the physical activity program, Ys must LIVESTRONG at the YMCA, the Y and the ensure that their environments are safe and LIVESTRONG Foundation have learned many supportive for cancer survivors. Staff of each lessons that have helped strengthen the pro- participating Y must be sure that its atmosphere gram model and aid in program expansion. An supports cancer survivors’ physical, social, initial, important lesson was that successful and emotional needs. This insight has led to a programming requires staff who have a deep variety of changes in facilities: shortening the understanding and empathy for cancer survi- distance cancer survivors must travel to get into vors in their communities. or through the building; installing handrails in Although the process of developing and hallways and stairways; providing hand gel san- delivering LIVESTRONG at the YMCA has itizer dispensers throughout the facility; having evolved from experimental to more prescriptive, a “resting” or “support” chair in workout areas implementation of the program in individual and changing areas; providing an area where communities and environments requires Ys to private conversations can be held; and enlisting be flexible and adaptable to meet the wants, members in ensuring facilities are clean and needs, and interests of cancer survivors in their germ-free for cancer survivor participants. community. To that end, Ys must listen to and learn from cancer survivors, via one-on-one Populations Best Served interviews and focus groups, before launching programs and services. This period of discovery by the Program not only is foundational to staff awareness but The National Cancer Institute estimates that also builds and deepens staff empathy, a key there are more than 13 million cancer survivors competency for those who will connect and living in the United States today. With 1 in 2 engage with cancer survivors. men and 1 in 3 women predicted to be diag- A second lesson learned was that Ys must nosed with cancer in their lifetimes, the need earn credibility with cancer survivors in their for services that focus on quality of life during communities. Although the YMCA is uniquely and after treatment is increasingly important. suited to provide this program because of Because current evidence suggests that being its commitment to community outreach and physically active following diagnosis may focus on those who need support to gain or reduce the risk of recurrence of some types of regain health, the YMCA has had to establish cancer, offering programs that encourage and its credibility as an organization with expertise support survivors in living a physically active in cancer survivorship. In a national survey of lifestyle is increasingly important. cancer survivors, the majority believed that a LIVESTRONG at the YMCA is designed for physical activity program at the Y was a good in-treatment or posttreatment cancer survivors. idea, but they wanted to know that it had the The program is available in more than 226 cities backing of their physician or local oncology and more than 250 branches. More than 13,000 center and that the instructors were well quali- individuals have completed the LIVESTRONG fied. Offering the program at no charge was an at the YMCA program, and the LIVESTRONG important factor for often cash-strapped survi- Foundation and the YMCA of the USA are seek- vors. The Y and the LIVESTRONG Foundation ing to extend the program to more facilities. The have worked hard to ensure that LIVESTRONG hope is that cancer survivors will have access at the YMCA meets these criteria, building to a community-based program that is designed LIVESTRONG at the YMCA 375 to meet their needs, help them establish a 94 percent are highly likely to recommend healthy lifestyle that will improve their quality LIVESTRONG at the YMCA to a friend or of life, and ultimately reduce the risk of cancer family member. recurrence and the development of a second primary cancer. The physical benefits are great, but the social and emotional aspects of the program seem to be the most meaningful to cancer survivors. The Program Evaluation following quotation is an example of the pro- found impact that LIVESTRONG at the YMCA Cancer survivors who participate in has had on many cancer survivors’ overall LIVESTRONG at the YMCA engage in pre- to well-being: postprogram functional and quality of life assessments. Functional assessments measure This class changed my life. When you get the participants’ strength, aerobic capacity, balance, diagnosis, everything is so bleak—and then and flexibility. Results from a sample 12-week they tell you that you can’t lift more than session of LIVESTRONG at the YMCA showed five pounds, and it is even more depressing. the following: I felt very alone and then I came to the Y. This class is a community for me. I love it 56 percent improvement in leg strength and am happy and thankful that I get to do 45 percent improvement in upper body it. I am so privileged to have had it; I believe strength it saved my life. This class gave me back my 60 percent improvement in aerobic capacity life, my sense of self, hope, and camaraderie (treadmill or bicycle ergometer time to and made me a stronger me. It improved my fatigue) life and my mental outlook. A 29-question life assessment asks partici- The program had a positive effect not only on pants to rate their physical functioning, anxiety, cancer survivors but on YMCA staff members depression, fatigue, sleep disturbance, satisfac- as well. One chief operating officer shared this tion with social role, pain interference, and pain about his involvement with LIVESTRONG at intensity. Quality of life assessment scores have the YMCA: not yet been compiled for evaluation. Participants also complete a post-program At times we can become so overwhelmed survey. A sample of more than 100 of these with balancing budgets, building facilities, surveys showed the following: developing marketing tools, and managing staff that we forget why we are part of this 92 percent agree that they have made prog- mission-driven organization. My involve- ress related to their health and well-being ment with LIVESTRONG at the YMCA has goals as a result of their participation in allowed me to catch my breath and reconnect LIVESTRONG at the YMCA. with the YMCA mission in a whole new way 86 percent agree that they are part of a through the life-changing work that is being supportive community at the YMCA (as done in our YMCAs with cancer survivors. defined by four measures). With YMCAs in more than 10,000 commu- 92 percent agree that their program leader nities across the United States, the potential has the understanding and skills needed to impact of this program is tremendous. The lead a physical activity program for cancer YMCAs that have engaged in this work describe survivors. the experience as game-changing for the YMCA 93 percent plan to continue their health and and life-changing for the staff involved. YMCAs well-being journey at the YMCA after the are queued up for the chance to invest their end of the program. own money and six months of their staff time 376 Justice-Gardiner and Heston
to participate in this program that often trans- content/full/14/7/1588?maxtoshow=&HITS=10 forms the way a YMCA functions and operates. &hits=10&RESULTFORMAT=&author1=Schmitz %2C+K&searchid=1&FIRSTINDEX=0&resourcet ype=HWCIT. Additional Lawlor, D., K. Fox, and C. Stevinson. 2004. Exercise Reading and Resources interventions for cancer patients: Systemic review of controlled trials. Cancer Causes Control 15:1035-56. Free Resources www.jstor.org/pss/3553586. American College of Sports Medicine Cancer Exercise Guidelines: http://journals.lww.com/acsm-msse/ Textbooks Fulltext/2010/07000/American_College_of_Sports_ ACSM’s Exercise Management for Persons with Chronic Medicine_Roundtable_on.23.aspxAmerican Cancer Diseases and Disabilities J. Larry Durstine and Geof- Society: www.cancer.org frey Moore. Human Kinetics, Champaign, IL. www. CA: A Cancer Journal of Clinicians: http://onlinelibrary. humankinetics.com wiley.com/doi/10.3322/caac.21142/pdf Breast Cancer Recovery Exercise Program, 2nd ed. Anna The LIVESTRONG Foundation: www.LIVESTRONG. Schwartz & Naomi Aaronson. Desert Southwest Fit- org/wecanhelp or www.LIVESTRONG.org/ymca ness. www.dswfitness.com National Lymphedema Network: www.lymphnet.org Cancer Fitness: Exercise Programs for Patients and Survivors. Anna Schwartz. Simon & Schuster. www. National Cancer Institute: www.cancer.gov/cancertop- simonsays.com ics/factsheet/Risk/obesity Exercise and Cancer Recovery. Carol Schneider, Carolyn www.cancer.gov/cancertopics/pdq/supportivecare/ Dennehy, Susan Carter. Human Kinetics, Cham- nutrition paign, IL. www.humankinetics.com www.cancer.gov/cancertopics/chemotherapy-and-you Handbook of Cancer Survivorship. Michael Feuerstein www.cancer.gov/cancertopics/factsheet/Detection/ (Ed). Springer, New York, NY. www.springer.com/ staging public+health/book/978-0-387-34561-1 www.cancer.gov/cancertopics/factsheet/Sites-Types/ Cancer Symptom Management, 3rd ed. Connie Henke metastatic Yarbro, Margaret Hansen Frogge, Michelle Goodman. http://riskfactor.cancer.gov/areas/weight/ Jones and Barlett Publishers, Sudbury, MA. www. jbpub.com/catalog/9780763721428/ Journal Articles Cancer Prevention and Management Through Exercise Rock, C.L., C. Doyle, W. Demark-Wahnefried, J. Meyer- and Weight Control. Anne McTiernan (Ed). Taylor & hardt, K.S. Courneya, A.L. Schwartz, E.V. Bandera, Francis Group. www.taylorandfrancis.com K.K. Hamilton, B. Grant, M. McCullough, T. Byers, and T. Gansler. 2012. Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Jour- References nal for Clinicians. http://caonline.amcancersoc.org. Schmitz, K. 2005. Controlled physical activity trials in Courneya, K.S., and C.M. Freidenreich. 2001. Frame- cancer survivors: A systematic review and meta- work PEACE: An organizational model for examining analysis. Cancer Epidemiol. Biomarkers Prev. physical exercise across the cancer experience. Ann. 14(7):1588-95. http://cebp.aacrjournals.org/cgi/ Behav. Med. 23:263-72. CHAPTER 42 New York State Healthy Eating and Physical Activity Alliance
Michael Seserman, MPH, RD Nancy Huehnergarth American Cancer Society New York State Healthy Eating and Physical Activity Alliance
NPAP Tactics and Strategies Used in This Program
Volunteer and Nonproft Sector tions to advance the goals of the National Physical Activity Plan. STRATEGY 1: Advocate to local, state, and national decision makers for policies and system changes STRATEGY 3: Conduct outreach to nonprofit groups’ identified in the National Physical Activity Plan that members, volunteers, and constituents to change promote physical activity. their own behaviors and advocate for policy and system changes outlined in the National Physical STRATEGY 2: Convene multisector stakeholders at lo- cal, state, and national levels in strategic collabora- Activity Plan.
his chapter describes a nonproft, state- • Increase funding for obesity prevention Tbased coalition designed to advance state- efforts in NYS. wide physical activity (and nutrition) policy • Improve NYS policies that promote health- priorities. The New York State Healthy Eating ier eating, including those that encourage and Physical Activity Alliance (NYSHEPA) was breastfeeding. founded in November 2006 as a statewide • Improve physical education and physical partnership dedicated to improving policies activity policies and practices in NYS. and practices that promote healthy eating and physical activity. NYSHEPA is designed to unite like-minded organizations and individuals who Program Description are involved in obesity prevention, nutrition, and ftness into one state-level voice in sup- In 2005, American Cancer Society (ACS) Eastern port of the organization’s mission. The primary Division staff met with representatives from focus of the alliance is policy and environmental the New York State Department of Health’s changes to support dietary improvement and (NYSDOH) obesity prevention program to dis- active living. NYSHEPA’s goals are these: cuss implementation of the state’s obesity pre- vention plan. Many of the objectives of the plan • Enhance communication and coordination involved policy changes, and NYSDOH clearly among New York State (NYS) organiza- needed the support of the voluntary and non- tions and individuals working to improve profit sector to support plan implementation. nutrition and physical activity. ACS had already been a part of the planning
377 378 Seserman and Huehnergarth group for the obesity prevention plan and had Summit to be held in November 2006 in Albany hosted many of the community forums across to plan a meeting to propose NYSHEPA to other the state that helped to identify and prioritize nonprofit, stakeholder organizations. The meet- the plan’s strategies. By the end of the meeting, ing included a briefing by the director of the it became clear to ACS that a state coalition Coalition for a Healthy NY on the process and should be developed to support improvements success of that state partnership. Some of the in nutrition and physical activity policies. ACS same nonprofit representatives at the meeting had experience working with such a coalition; also served on the Coalition for a Healthy NY, a decade earlier, ACS initiated and continues to vouched for the strategy, and helped promote spearhead a state tobacco control partnership the idea. to advance tobacco policy changes in New York All of the groups that attended the meet- (Coalition for a Healthy NY—originally funded ing agreed on the need for the new group and by the Robert Wood Johnson Foundation’s became the founding steering committee for SmokeLess States grant). NYSHEPA. Although the committee made a few The following year, ACS staff met with a minor changes, it accepted the draft mission local volunteer from Westchester who had and planning document. There was no desire cofounded a local school health coalition and to develop bylaws or other complicated rules implemented a successful regional conference of governance. The focus was, and continues to on the subject. The volunteer had ambitions of be, simply coming together to move statewide forming a statewide coalition to more aggres- policy change forward, to keep constituents sively take on the issue of school nutrition informed, and to mobilize those in support of and, more broadly, childhood obesity. There this agenda. was strong agreement that most nutrition and physical activity organizations across New York Founding steering committee had little or no influence in Albany, the state for NYSHEPA capital, where important obesity-related policy • American Cancer Society decisions needed to be made. Therefore, ACS • American Heart Association and the volunteer decided to work together to establish a state policy-focused nutrition and • American Academy of Pediatrics NYS physical activity coalition. The new organi- • NYS PTA zation would be based on both the Coalition • Be Active New York State for a Healthy NY and the Strategic Alliance • NYS Nurses Association of California, a successful coalition led by the • YMCA of New York State Prevention Institute. After many discussions and drafts, a group • NYS Dietetic Association that consisted of ACS staff and the volunteer • Schuyler Center for Analysis and Advocacy drafted a planning document and presentation • NYS Public Health Association that could be shared with potential partners. The planning document included a suggested The volunteer who developed the original vision, mission, goals, and guiding principles. vision for a statewide coalition became the The group also proposed a simple structure, director of NYSHEPA and took responsibility initial objectives, and a name for the new group: for facilitating and coordinating all meetings. the New York State Healthy Eating and Physical ACS became the chair of the steering commit- Activity Alliance, or NYSHEPA (nye-shep-a). tee. These leaders established a schedule of One of the group’s key recommendations was monthly meetings or calls to collaborate on the to preserve the coalition’s credibility and inde- alliance’s priorities. pendence by not accepting funds from the food Initial tasks completed to support NYSHEPA or beverage industry. included developing an informational website ACS used its position on the planning (www.nyshepa.org), creating a comprehensive committee for a NYSDOH Childhood Obesity database of stakeholders and supporters, and New York State Healthy Eating and Physical Activity Alliance 379 prioritizing a list of state and local policies to community designs with a greater emphasis on support. public transportation, all of which are associ- Since that time, NYSHEPA has been at the ated with increases in physical activity. forefront of nutrition and physical activity To date, NYSHEPA has built a statewide policy change by reaching out to constituents, coalition and network of more than 800 public legislators, and the media to help frame the health, consumer, and education organizations debate. NYSHEPA representatives have spoken and individuals dedicated to improving policies regularly on television and radio and in print and practices that promote healthier eating and about nutrition and physical activity issues and physical activity. To that end, NYSHEPA has policies. NYSHEPA has generated frequent press mobilized and led advocacy efforts across the releases and held numerous press conferences state. For instance, NYSHEPA organized memos to increase media coverage of policy options of support for numerous policies, including regarding obesity prevention and nutrition menu labeling, school nutrition standards, the and physical activity. Likewise, the NYSHEPA Green Carts program, Complete Streets, Safe director and steering committee members have Routes to School funding, the sugar sweetened generated dozens of letters to the editor and beverage tax, the Breastfeeding Bill of Rights, editorials in publications like the New York and increased funding for obesity prevention. Times, Albany Times Union, Buffalo News, To further advance a policy agenda that sup- Journal News, LI Newsday, Rochester Democrat ports active living, NYSHEPA convened a Built and Chronicle, and Syracuse Post Standard. Environment Task Force to develop a strategic NYSHEPA has created and disseminated fact plan for statewide built environment policy sheets on numerous nutrition and physical change. A wide range of expert stakeholders activity policies to assist advocates across the participated in the process and produced two state. The policy documents and other infor- documents laying out NYSHEPA’s statewide mation are distributed via www.nyshepa.org. physical activity priorities; one publication was Regular updates and action alerts on nutrition used to educate policy makers and the other and physical activity issues and policies also to guide and mobilize advocates. The built are provided to NYSHEPA members. In 2009, environment policies identified as priorities NYSHEPA and the New York State Department included promoting Complete Streets, amend- of Health received 1 of only 10 grants of its ing a law that undermines children’s walking or kind from the National Governors Association bicycling to school, encouraging smart growth, to work on obesity prevention. As part of that increasing green space, and using health impact project, NYSHEPA developed an after-school assessments. toolkit to improve nutrition and physical activity In 2010, NYSHEPA helped to pass the Smart policies and practices in after-school programs. Growth and Public Infrastructure bill described Although nutrition policy took the forefront earlier. During the 2011 legislative session, the in the early years, more recently NYSHEPA Complete Streets bill also was signed into law. became involved in the campaign to pass Another statewide policy that passed in 2011 Complete Streets legislation. Complete Streets has the potential to support physical activity. policies require that most new or reconstructed The Land Bank Act provides localities with new roads be accessible to all users, not just motor tools to bundle abandoned properties for sale or vehicles. Another important physical activity– other uses. As a result, new parks, green space, related policy that NYSHEPA supported was the and other recreation areas could be created by Smart Growth and Public Infrastructure bill. local governments. Access to and promotion of This bill mandates that all state agencies and recreational areas have been shown to increase authorities with funding for infrastructure, such physical activity in a community (Community as the Department of Transportation, prioritize Preventive Services Task Force 2010). their funding and implement decisions using NYSHEPA also initiated a close working smart growth criteria. Smart growth principles relationship with the NYS Office of the State promote more densely populated, multiuse Comptroller and successfully encouraged the 380 Seserman and Huehnergarth comptroller to audit school compliance with action in support of policies such as Complete NYS physical education requirements, which Streets legislation. This type of grassroots edu- are among the toughest in the nation. The cation or mobilization takes place via letters to results were startling; the comptroller found the editors in newspapers located in key political only 1 of 20 schools audited to be in compliance districts or by action alerts to NYSHEPA mem- with state law. NYSHEPA also encouraged the bers and member organizations. comptroller to audit competitive foods sold in schools. Consequently, in 2009 and 2012, the NYS Office of the State Comptroller released Linkage to National childhood obesity reports that included a rec- Physical Activity Plan ommendation to “take steps necessary to bring physical education programs into compliance As a nonprofit organization, NYSHEPA has with state regulations.” worked with other organizations to advance Because of its extensive advocacy work, in all of the strategies recommended within the 2010 NYSHEPA was awarded the New York Volunteer and Nonprofit Sector of the National Public Health Community Advocacy Award by Physical Activity Plan: the Public Health Association of New York City. Strategy 1: Advocate to local, state, and Despite its successes, however, NYSHEPA has national decision makers for policies and system not received consistent funding. A lack of fund- changes identified in the National Physical Activ- ing for advocacy by state coalitions on nutri- ity Plan that promote physical activity. NYSHEPA tion and physical activity is a major barrier to advocated for a Complete Streets bill in the state promotion of physical activity policies. A state legislature for three years. coalition model focused on physical activity and Strategy 2: Convene multisector stakeholders other public health policies has proven to be an at local, state, and national levels in strategic col- extremely cost-effective strategy and should be laborations to advance the goals of the National replicated in every state. Physical Activity Plan. NYSHEPA convened the Built Environment Task Force to collaborate on a strategic plan to advance physical activity in Program Evaluation NYS by creating environments that facilitate and No formal evaluation of NYSHEPA has been support active living. NYSHEPA recruited addi- conducted. However, since late 2006, when tional stakeholder nonprofits, such as AARP, NYSHEPA was created, tremendous progress Green Options, and Transportation Alternatives, has taken place in NYS on food- and physical from across the state to join the Task Force. activity–related policy change that exceeds Strategy 3: Conduct outreach to nonprofit changes in most other states. New York City, groups’ members, volunteers, and constituents where NYSHEPA also has focused, and New to change their own behaviors and advocate York State in general, are now widely recognized for policy and system changes outlined in the nationally as leaders in nutrition and physical National Physical Activity Plan. NYSHEPA activity policy and supportive environments. organizational members regularly communi- cate with their own members and constituents to educate them on priority policy issues and Populations Best Served encourage them to become involved in policy by the Program issues that affect them in their communities. The primary target audience for this type of program is policy makers at the state and local Evidence Base Used During level who make decisions regarding physical Program Development activity–related policy. NYSHEPA also targets the general public and constituents of health As mentioned previously, the development of groups across the state to urge them to take NYSHEPA was informed by the SmokeLess New York State Healthy Eating and Physical Activity Alliance 381
States National Policy Initiative of the Robert Lessons Learned Wood Johnson Foundation, which funded state coalitions between 1993 and 2004. A program The NYSHEPA experience in New York illus- evaluation released in 2005 reported the fol- trates the effectiveness of deliberate and stra- lowing results: tegic statewide collaboration and coordination among nonprofit health organizations to pro- • Coalition policy campaigns, underwritten mote physical activity– and nutrition-related by matching funds, led to increased excise policy interventions. It also demonstrates the taxes in 35 SmokeLess States, clean indoor advantage of having a lead organization that air legislation in 10 states, and ordinances can facilitate the drafting of legislative support to restrict youth access to tobacco products memos and the compilation of signatures across in 13 states. multiple sectors to support a particular bill. • Eight coalitions defeated or blocked pre- One of the key lessons learned for develop- emption bills and four states repealed or ing and maintaining a policy-minded coalition partially repealed preemption. is that a strong and committed leader must be • The SmokeLess States grantees secured identified. As occurs with any collaboration, funds (at least $10 million) for compre- natural ebbs and flow occur in the levels of hensive tobacco prevention and control involvement, camaraderie, success, and fund- programs from the $206 billion Master ing. NYSHEPA’s experience shows that commit- Settlement Agreement with the tobacco ment, determination, and long-term perspective industry, signed in 1998 (Gillespie 2009). among its leadership and, especially, its director are very important. For example, when funding The parallel, peer-reviewed literature from dries up, someone must take the lead to seek out tobacco control also supports a policy-based and apply for new funding sources. Someone approach using state and local collaboration. must continue to maintain the coalition at a The Centers for Disease Control and Preven- minimal level. In NYSHEPA’s case, the director tion’s Best Practices for Comprehensive Tobacco and the American Cancer Society took that role, Control Programs, originally released in 1999 with some help from other partners. and updated in 2007, provides ample justifica- The coalition leader must possess good tion and citations supporting state- and com- communication and negotiation skills in order munity-level coalitions to facilitate collaboration to gain enough agreement among steering for social norm and policy change. committee members for the coalition to take In the area of nutrition and physical activ- a position on a bill. Every organization has a ity, NYSHEPA was modeled after a successful representative with an opinion. Some, often the state coalition in California called the Strate- same few, will express that opinion forcefully, gic Alliance, run by the Prevention Institute. but other groups on the steering committee will Since 2001, when the statewide partnership at times need to be pushed to take a supportive was created, the Strategic Alliance has led or opposing position on a state issue. Perhaps a or made major contributions to many state local representative of a national organization policy achievements. These successes include can’t take a position because policy decisions making California the first state in the country are made by national leadership. Sometimes to require menu labeling at chain restaurants; the issue is simply not a priority or there is not establishing, in 2005, the most rigorous nutrient agreement within an organization. For some standards in the nation for foods sold outside of participants, legislative advocacy beyond sup- school meals; banning the sale of sodas, K-12, porting their own membership-specific financial in California’s schools; and passing a parks and interests is not a familiar or comfortable activ- water quality bond that provided funds for the ity. A coalition that is working well will help development of open space and parks in com- push organizations outside their comfort zone munities that currently lack space for active and move beyond their bureaucratic inertia or play (Strategic Alliance n.d.). traditional focus to take action on an issue. 382 Seserman and Huehnergarth
In New York, coalitions have been most effec- significantly change our environment and sup- tive and are arguably best suited for educating port active living. and advocating for policy change or funding If state coalitions are to be successful, regard- rather than program implementation. Coalition less of how the coalition is supported, one of the work to change state and local policies is inher- most important elements is to have a full-time, ently a conflict-driven activity because there paid director who is adept at using the media are those who support and those who oppose to advance the public debate and visibility of a given proposal. Some health groups shy away an issue. The coalition director should be a from politics and want to focus on health educa- very good group facilitator and collaborator, as tion, but that is not where the greatest public well as someone who is politically astute and health gains have been realized. It is often easier has strong media advocacy skills. Staff turnover for organizations to take a controversial position is a major threat to a strong coalition. It takes by signing a support letter under the umbrella time to rebuild relationships and understand of a group such as NYSHEPA rather than doing the group dynamics to create a high-performing so on their own. coalition. The way NYSHEPA decided to support a par- ticular bill evolved over time. The method used for the past few years has been to take a vote; Tips for if a majority of the steering committee mem- Working Across Sectors bers who can take a position are in support, A critical factor in the success of state coalitions NYSHEPA will work to pass that bill. If only is to include representatives from a variety of certain members support a policy proposal, an sectors within the coalition membership. In the ad hoc group is formed to promote the proposal, case of NYSHEPA, a mix of organizations that and only the names of supporting organizations represent health care, education, workplace are included on public documents such as press health promotion, health-related nonprofit releases and memos of support. organizations, and parents helps to ensure that NYSHEPA’s problem of lapsed funding speaks a variety of policy issues are identified, priori- to the need to research and formulate a funding tized, and addressed. and sustainability strategy from the beginning. Another important factor is to recognize On the positive side, NYSHEPA did ensure that not all member organizations may share that there was one organization committed the same policy agenda or policy priorities. for the long haul to sponsor and support the NYSHEPA has successfully navigated this poten- coalition. However, nonprofit funding is quite tial challenge by creating the process described limited, so external grants are required; unfor- previously for determining how, or whether, tunately, securing funding for policy advocacy a bill will be supported by NYSHEPA or by is extremely difficult because of restrictions on a subset of NYSHEPA members. Anticipating using foundation and public sector funds for these challenges and creating a plan ahead of lobbying. Therefore, partnerships like NYSHEPA time ensures that important issues continue to are frequently forced to divert attention and move forward, despite the fact that the entire labor to focus on fundable projects (e.g., pro- coalition does not support each issue. grams) that are much less impactful. This fund- ing conundrum is unfortunate and underlies the disadvantage that nonprofits confront when Additional taking on the private sector, which can simply Reading and Resources hire lobbyists and mount an ad campaign against a proposal to improve health. Hence, Extensive information on this state coalition funding mechanisms that do not have lobbying model is available on the NYSHEPA website restrictions must be identified to support policy (www.nyshepa.org). The website includes addi- education and action in each state in order to tional information about the coalition’s goals, New York State Healthy Eating and Physical Activity Alliance 383 guiding principles, and members as well as its providers implement the program easily. membership process. The site also includes a It includes compilation of both NYSHEPA-specific resources • a self-assessment instrument, which and resources created by other organizations will help the provider evaluate its cur- that have been helpful in advancing coalition rent nutrition, physical activity, and priorities. screen time environment; The website provides a few different types • implementation resources and strate- of examples of NYSHEPA resources that can be gies; and used as models for other state coalitions, such as the following: • materials to help parents support their Healthy Kids, Healthy New York after-school after-school program in implementing model guidelines, toolkit, and recognition pro- the guidelines and to develop healthier gram (www.nyshepa.org/documents/healthy_ home environments. kids_healthy_ny_afterschool_toolkit.pdf) The Healthy Kids, Healthy New York initiative was launched in July 2007, thanks to a grant References from the National Governors Association. The Centers for Disease Control and Prevention. 2007. goal of the initiative is to fight childhood obesity Best Practices for Comprehensive Tobacco Control and create healthy after-school environments. Programs—2007. Atlanta, GA: U.S. Department of The program focuses on three areas—nutri- Health and Human Services, Centers for Disease tion, physical activity, and screen time. Model Control and Prevention, National Center for Chronic guidelines are provided for each area, which, if Disease Prevention and Health Promotion, Office on followed, will ensure the following: Smoking and Health. • Children are served only nutritious snacks Community Preventive Services Task Force. 2010. The community guide. www.thecommunityguide.org/ and beverages at after-school programs. pa/environmental-policy/index.html. Children engage in an adequate amount of physical activity in after-school programs. Gillespie, K. 2009. SmokeLess States national tobacco policy initiative. Robert Wood Johnson Foundation. • Television and recreational screen time are www.rwjf.org/pr/product.jsp?id=16549. reduced in after-school programs. Strategic Alliance. n.d. Our accomplishments. www. • The toolkit, which includes the guide- preventioninstitute.org/about-us-sa/our-accom- lines, was designed to help after-school plishments.html.
Index
Note: The italicized f and t following page numbers refer to figures and tables, respectively. A ongoing needs 256 Atlanta Beltline 264-265, 267t accountability 3, 19, 65 plan development 254-255 Austin Independent School District 9 Action Communities for Health, Innova- release of 255-256 Fitnessgram results 9t tion, and Environmental Change sector roles 254t hiring new staff 13 (ACHIEVE) 175 sector teams 253 Australia. See Active Australia; Find Thirty Active Australia 58 statewide event hosting 253-254 (Australia) comparison to NPAP 87, 88-89t target audience 253 awareness. See also mass media campaigns elements 83t activities measuring 58, 66 lessons learned 86 moderate intensity 96 media campaigns for 291, 350, 355 partnerships 85 structured versus free-play 10, 25, 39, of physical activity benefits 85, 134, 287 program description 84-85 161 B program evaluation 85 summertime 39, 159 ballpark nutrition 182, 184, 186 target population 85 vigorous intensity 96 baseball fields 166-168, 167f Active Canada 20/20 68 during winter 321 baseball leagues 167-168, 186-187 Active Living by Design 286, 290, 291, activity logging 242 BC Walks 77, 78 293, 350 adolescents behavior change active living communities. See also Hough- physical activity guidelines for 4 in youth 154f, 155t ton, MI sexual behavior 39 behavioral change bicycle-friendly 322, 325, 326, 329 summer activities 39 barriers to 20 comprehensive plans 360-361 tween years 24, 45, 50 benefits versus barriers 245 defined 263 adults in families 20, 57 funding 325, 326 ages 20 to 54 years 86 and healthy choices 174, 178 identifying areas of improvement 361 ages 25 to 60 years 85 online tools for 242 land use decisions 318 ages 35 to 55 years 55, 59 in patients 133, 134 local health departments role 317, 318, ages 50 to 65 years 71, 77 with policies 299 324 ages 55 and older 85 through social norm change 360 planning models for 290-291, 355 percentages meeting guidelines 56 Behavioral Risk Factor Surveillance System planning participants 326 seniors 334 279, 291, 299 policy support 317, 327, 360 Afterschool Alliance 38 beverages 17, 32 public support 327 after-school programs. See also Wise Kids Bicycle Commuter Challenge 350, 352 zoning 325, 361 program bicycle-friendly communities 322, 325, Active Living Research 300, 365 curricula for 41 326, 329 Active Texas 2020 evidence base for 38-39 bicycling capacity building 250-251 funding 39, 40-41 bike parking 325, 352 guiding principles 251t Instant Recess in 183 documenting needs for 340 lessons learned 257 lack of joint-use agreements 40 and health 338 measuring plan success 252 lessons learned 39-40 lanes for 332, 333, 334 NPAP as foundation 252, 256-257 NPAP linkage 38 network connectivity 332, 334, 339 partnerships 250 participation 37 prioritizing needs for 342 plan development 251-252 population served 39 routes 286, 287, 288, 351f program description 250 program descriptions 38 sharing the road 333, 352 active transportation 338, 340. See also staff turnover 40 Bike to School Day 306 bicycling; Urbana road diet standards for 38 body mass index 116 documenting needs for 340-341 student health outcomes 38-39 correlation to PAVS 132 expenditures 344 value of 37-38 recording at doctor visits 116, 289 funding 289, 339, 344, 350, 352 Y-USA’s Healthier Communities Initia- and short bouts of activity 206 pedestrian amenities 320, 321, 322 tives 177 tracking of students 9, 17 pedestrian safety 264, 306, 321, 333, American Cancer Society 137, 377 of truck drivers 195 344 American College of Sports Medicine Wise Kids program impact 153f policy to support 342 (ACSM) Brain Break activities 10 prioritizing projects 341, 342, 345 Exercise is Medicine campaign 108, 119 Business and Industry Sector 191-192. See program evaluation 322-324, 333, 346 on lifestyle medicine 109 also worksite settings public input on 310, 326, 340, 342 PAPHS Certification Exam 283 best practices (Strategy 1) 196, 205, 215, visioning for 319, 345 physical activity recommendations 91 223-224, 234, 242-243 Active WV recommendations for cancer survivors communicating outcomes 196, 198 capacity building 252-253 141, 372 cross sector interaction (Strategy 2) 215, concept mapping 255 American Heart Association 4 224, 234-235, 243 description 252 American Medical Association 119 health care costs 215, 218, 226, 233, 244 face-to-face meetings 255 Americans with Disabilities Act (ADA) 168, leaders as change agents (Strategy 3) financial support 254 332-333 196, 205-206, 215, 224, 235, 243 garnering support 253 Arkansas Act 1220 legislation and policies (Strategy 4) 215- governance 253 Child Health Advisory Committee 17 216, 235, 243 lessons learned 257 evaluation 18 management support 202, 207, 221-222, measuring plan success 256 lessons learned 18 225, 237 NPAP as foundation 254-255, 256-257 program description 17 media relations 198
385 386 Index
Business and Industry Sector 191-192. See Children’s Power Play! campaign 184 D also worksite settings (continued) ChooseWell LiveWell Danimals Rally for Recess 25 monitoring and evaluation (Strategy 5) employee costs 214 data collection 216-217, 224, 235, 243 employee wellness programs 212 accelerometry 117, 132, 134, 161, 346 organizational culture 191, 198, 218, evidence base used 214 baseline evaluations 66-67 224, 237 implementation 212-214 clinical outcomes 139-140, 142 return on investment 208, 217, 223, 226, keys to success 218 for communities 176 234 lessons learned 217 as guide not driver of efforts 180 union employees 225-226 linkage to NPAP 215-217 impact data 75 working across sectors 198, 218, 225- PA indicators over time 216t for mass media campaigns 66 226, 237, 245 partnerships 211, 212, 215, 217 metropolitan area health rankings 291 observational data 34, 169 C populations served by 218 online surveys 108 California programs 184, 365, 381 program description 211-214 population health data 346 Canadian Fitness and Lifestyle Research program evaluation 216f, 217-218 in schools 5 Institute 65 program expansion 214t, 217 surveys 18, 48, 57-58, 85 Canadian Physical Activity Guidelines programs by year 213t on transportation 340-341, 346 64, 67 self-monitoring 215 databases 296, 297, 299 Canadian programs 61-69 staffing 214 Decatur, GA transportation plan 263-264, cancer survivors. See also LIVESTRONG at chronic disease 119, 123, 215 267t the YMCA; Strides to Strength clinicians. See physicians Dietary Guidelines for Americans (DGA) benefits of exercise for 141, 372 collaboration. See partnerships Communications 91-92 cancer diagnosis 139f Diffusion of Innovations Theory 299 activities 64-65 education for 138 disease prevention 103, 244 idea sharing 122 guidelines for 372 Douglas County (NE) 286, 291 lessons learned 100 PA and risk of recurrence 374 DVDs materials development 93 perceived level of fatigue 140f on employee wellness 213 objectives 62, 64 programs 137, 142, 369 for Instant Recess 26, 182, 183, 187 service gaps for 370 partners in 100-101 staging 139f simplicity 69 E statistics 370, 374 strategy 97-99 early childhood supportive environments 138, 371, 374 targeted messages 69 activity guidelines 34-35, 363 term definition 137 Communications Hierarchy of Effects obesity 31 treatment status 139f Theory 77 early childhood centers 1, 363. See also capacity building 64, 250-251, 252-253, 283 communities. See also active living com- NYC Department of Health and Mental Hygiene (DOHMH) Carol M. White program 39, 40, 41 munities; Y-USA’s Healthier Com- beverages served in 32 celebrity endorsements 86 munities Initiatives compliance 35 Center for Mississippi Health Policy 8 action plans of 176 establishing regulations for 31-32 Centers for Disease Control (CDC) adapting campaigns to 59, 78 health code 32, 34 Best Practices for Comprehensive Tobacco local policies 364t implementing regulations for 32 Control 381 mass media campaigns for 49-50, 71 model standards 363 CHS model 4 prevention marketing in 46 obesity in 31 funding from 40-41, 289 Communities Putting Prevention to Work (CPPW) 289 physical activity time 31, 32, 34, 363 Guide to Community Preventive Services space for activity 33 The Community Guide 1 49, 146 staff training 32-33 Community Healthy Living Index 176 model 4 technical assistance 32-33, 35 Community Preventive Services Task Prevention Guide 77 Ed Snider Youth Hockey Foundation Force 1 professional training benchmarks 270 (ESYHF) 40 Complete Streets 290, 379 recommendations 24, 91 education. See also curricula advocacy for 359 youth PAG toolkit 97 for cancer survivors 138 ChangeLab Solutions 359, 360 funding 325 for health care professionals 105, 106, charrettes 306, 309, 323, 334 ordinance language 325 109, 134 child care centers. See early childhood policy forms 361 lifestyle medicine 106, 108, 123 centers policy surveillance 297 online courses 106, 283 Child Nutrition and WIC Reauthorization compliance for parents 222 Act 16 at early childhood centers 35 as part of 5E model 306, 311 childhood obesity hiring staff to ensure 13 for patients 131 in early childhood 31 monitoring for 8 for physical activity professionals 269 health risks with 31, 151 reporting requirements 5, 6 postsecondary institutions 134 legislative approaches to 16, 40 site visits 5 professional development 281, 283 in Mississippi 6 concept mapping 255 on SRTS 306, 311 in Tennessee 4, 6 Coordinated Approach to Child Health Education Sector 1. See also early child- children. See also students; youth (CATCH) Kids Club 41 hood; school settings activities for 160 Coordinated School Health (CSH) 4 access and opportunities (Strategy 1) as advocates 313 counseling 124, 126, 131, 222 19-20, 26, 34, 178 at-risk for overweight 39, 162 CSH Expansion Law 4, 5 before and after school (Strategy 5) 38, with disabilities 165 CSH Improvement Act 4 178 motivating 157 cultural shifts 178, 181, 182 early childhood care (Strategy 4) 34 participation rates 4, 19, 24 curricula. See also education; physical edu- federal policy initiatives 16 physical activity guidelines for 4, 24 cation; Profession MD school accountability (Strategy 2) 8-10, play 165 for after-school programs 41 20, 27, 34 preventive wellness for 152, 155 early childhood 32, 33, 35 working across sectors 35 role models for 25, 33, 38 integration of PA into academics 20, 26 elementary schools time spent in sedentary behaviors 24 medical schools 108-109, 128 after-school programs at 39 time spent outdoors 151 online courses 106 classroom activity time 10, 18 Index 387
CSH program at 5 populations served by 186-187 lessons learned 266, 268 lifetime physical activity promotion 19 product sales 187 linkage to NPAP 265-266 in Mississippi 8 program description 182 partners 260f, 266, 267t physical education time 9, 17, 18 program evaluation 184-186 and political climate 266 in Texas 8, 9, 10 in schools 183 process 261f e-marketing 99 training 183 program description 260-263 employee programs. See worksite settings use of role models 186 social determinants of health 260f energy management 235-236 youth outreach 183 types of 262 environmental changes 178 funding Health in Action 7 built environment policy 259, 379 of after-school programs 39, 40-41 “Health in All Policies” 366 in neighborhoods 177 from Centers for Disease Control (CDC) Health in All Policies (CDC) 263 epidemiological data 68, 133, 244 40-41, 289 health literacy 93 Every Body Walk! app 118f constraints in early childhood centers health promotion specialists 17 evidence-based medicine 226 34 health risks excitement building 160, 202, 287 of coordinator positions 6, 18 assessments 212, 226 exercise. See physical activity federal sources 40, 41, 289 factor reduction 230, 233f, 234f, 244 Exercise is Medicine 119, 121f foundations 74, 289 higher risk populations 291 exercise rehabilitation 137, 141 grants 40, 74, 289, 350 of obesity 31 exercise videos/DVDs 99, 187 near-term versus long-term 187-188 role of physical activity on 232 Exercise Vital Sign (EVS) 115 parks & recreation sector 157, 171 Healthcare Effectiveness Data Information evidence based used 118 and planning time 77-78 Set (HEDIS) 133 handout for physicians 121f for policy advocacy 382 Healthfinder.gov 99 lessons learned 120 public health initiatives 187-188 Healthier Communities Initiatives. See linkage to NPAP 117-118 from tobacco settlements 55, 75 Y-USA’s Healthier Communities marketing campaign 117 G Initiatives partnerships 120, 122 goal setting HealthPartners 211, 217 physical activity scores 115-116 corporate 230, 237 Healthy, Hunger-Free Kids Act 16 populations served by 119-120 of employees 195-196, 242 healthy eating 17, 151. See also nutrition program description 115-116 revisions 237 Healthy Hawai`i Initiative (HHI) 55-56, 59 program evaluation 116-117 short- and long-term 66, 195, 236 healthy lifestyles 123-124, 152 F strategic 62f, 66, 345 Healthy Lifestyles Act (West Virginia) facilities grassroots efforts 168, 171, 257, 380 program description 17 access 145-149 Green Prescription 82 program evaluation 18 for after-school programs 40 Guide to Community Preventive Services Healthy Out-of-School Time coalition 38 at early childhood centers 33 (CDC) 49, 146 Healthy People 2010 286 joint-use agreements 19, 40, 146, 149, H Healthy People 2020 119 362-363 Hawai`i initiative 55 Healthy Students Act (Mississippi) 3 at workplaces 221, 222, 232 health care costs 103, 117, 218, 221, 243-244 activity per week requirements 6 Family Fitness Fun Days 159 for businesses 215, 218, 226, 233, 244 implementation 6, 7 family interventions 56, 57, 97, 155, 233 with obesity 235 physical activity coordinator 6 Find Thirty (Australia) 83t health care sector 103. See also physicians program description 6-8, 18 comparison to NPAP 87, 88-89t access to services 140 program evaluation 8, 18 elements 83t addressing push-back 120 support for 7 lessons learned 87 advocating for programs 139-140 high schools program description 86-87 disparities in access (Strategy 4) 178 CSH program at 5 program evaluation 87 health care systems approach (Strategy graduation requirements 9, 17 Fit to Drive 193 3) 140, 178 joint-use of sports fields 146 communicating outcomes 198 medical schools 109, 129 peer modeling 27 data collection 194 PA as vital sign (Strategy 1) 117-118, physical education requirements 9-10, evidence base used 197-198 132-133, 178, 372 18 lessons learned 198-199 PA education (Strategy 5) 108-109, 127- Hispanic populations 94, 117 linkage to NPAP 196 128, 178 Houghton, MI 318 populations served by 198 patient behavior change 133, 134 active community planning 318-320 program description 193-196 physical activity education 108, 127- bike plan 322, 325 program evaluation 196 128, 140 Complete Streets efforts 325, 326 training materials 195 physical activity scores 115-116, 131 funding 325 Fit to Plant 196, 198 primary care settings 115, 131, 133 lessons learned 326 fitness testing 6, 8, 9, 18 program integration 120 link to NPAP 324 Fitnessgram 8, 9t, 17 quality improvement 133 local policy focus 318 5E model 306-307, 325, 326 quality-of-care 226 off-road trails 321 5P model 287, 290, 291, 355 working across sectors 110, 120, 122, pedestrian amenities 321, 322 FlagHouse, Inc. 41 129, 134, 142 program evaluation 322-324 Florida Prevention Research Center 46 health coaching 105-106, 214 pubic health and economy 320-322 Fort McPherson 263, 267t health departments snow removal 319, 320, 321 FPL-WELL (Florida Power & Light) 221 benchmarks for 270 walkability planning 321-322 Friar Fit (FriarVision Fitness Fanatics Initia- as partners 48, 81, 175, 253 waterfront areas 319-320 tive) 182 role in city planning 318, 324, 361 winter activities 321 evidence base used 186 health disparities 291, 339, 341, 345 I featured moves 182-183 health equity 265, 366 IBM Corporation 239 funding 184 health impact assessment 259-260 employee vitality 239, 240-241 implementation at ballpark 183 Atlanta Beltline 264-265 evidence base used 244 lessons learned 187 case study locations 262f lessons learned 244 linkage to NPAP 186 Decatur’s transportation plan 263-264 linkage to NPAP 242-243 nutrition improvement efforts 182, 186 Fort McPherson 263 populations served by 244 partnerships 183-184, 187-188 guiding principles 262 program description 241-242 388 Index
IBM Corporation 239 (continued) and school siting 362 mass media campaigns 291, 293, 355. See program evaluation 243-244 schoolyard park conversions 146, 149 also marketing redefining wellness at 239, 240f K applying in different communities 59, Virtual Fitness Center 240, 241-242 Kaiser Permanente 115, 201. See also Exer- 78 inactivity physiology 24 cise Vital Sign (EVS); Instant Recess awareness 48, 58, 64, 75, 85 Instant Recess. See also FriarFit Kansas City Healthy Kids 359 communication activities 64-65 in after-school programs 183 communication strategy 62, 64, 97-99 applications 182 L evaluation metrics 58, 66, 75, 84, 87 description 26, 182 Land Bank Act 379 government support 87 energetic leaders 207 land use 318, 337, 339 information dissemination 64, 72-73, environmental audits 27 Las Vegas’s Safekey Afterschool Program 41 74f, 85 evidence base 186, 206 legal assistance 359, 361 long-term sustainability 75, 84 feasibility in workplace 202, 203 legislation. See physical activity policies; media relations events 57, 73 implementing at sport venues 182, 183 public school policies messages 52, 67, 69, 72, 77, 82 at Kaiser Permanente 201-204 Let’s Move campaign 151 planning time 50 lessons learned from 27-28, 207-208 life expectancy 338 public relations 64, 67, 68, 110 link to NPAP 26-27, 205-206 lifestyle counseling (UNDER health care sequenced approach 87 modifications to 207 sector) 124, 126 use of public figures 59, 86 objective measures 185-186, 204-205 lifestyle medicine 105, 109. See also Insti- websites 57 organizational benefits 208 tute of Lifestyle Medicine (ILM) mass media sector 43 PA levels before, during, after 185f, 205f Lift Off! 26 branding (Strategy 3) 49, 58, 67, 76, 179 populations served by 186-187, 206-207 Live Well Omaha 285-286 cross-sector partnerships (Strategy 1) program champions 207 Activate Omaha initiative 287, 350 48-49, 58, 67, 76, 87 program evaluation 27, 184-186, 204- bicycle route projects 287, 288-289, emerging technologies (Strategy 8) 68 205 350-352, 351f federal legislation (Strategy 2) 49, 67, in schools 26, 27, 183, 186 common language across sectors 293 87 subjective measures 27, 184-185, 204 evidence base used 290-291, 353 informing mass media (Strategy 6) 49, sustainability 207 funding 289, 350, 352 67, 76, 87 teacher engagement 27 implementation on rolling basis 293 message consistency (Strategy 4) 49, teacher training 27 kids program 289 67, 76, 87 Institute for Healthcare Improvement 370 land use and street design 288 sequence and planning (Strategy 5) 49, Institute of Lifestyle Medicine (ILM) 105 lessons learned 291, 293, 354 58, 67, 76, 87, 179 building on established expertise 106- linkages to NPAP 290, 352-353 Web- and media-based interventions 107 media campaign 291, 292, 293, 350 (Strategy 7) 67-68 collaboration 110 organizational chart 288f working across sectors 52, 59, 69, 78-79, evidence base used 109 partnerships 286, 290, 291, 354 101 expansion 107 planning models 290, 293 media events 57, 78 formation 105, 106 populations served by 291, 354 mentoring 39, 40 international reach 106 program description 286-289, 349-352 metropolitan planning organizations, 339 lessons learned 109-110 program evaluation 352 middle schools linkage to NPAP 108-109 LIVESTRONG at the YMCA 369-376 after-school programs at 39 partnerships 106 credibility 374 CSH program at 5 populations served by 109 evidence base used 370, 372, 374 daily activity 8, 9 press release 111-112f flier 373f physical education time 9, 17, 37 program description 105-107 goals of 369 weekly PA 18 program evaluation 107-108 lessons learned 374 milk campaigns 56 Institute of Medicine (IOM) 35, 92, 162 linkage to NPAP 371-372 minority groups 24, 37, 39, 117, 291 Internet. See also websites partnerships 371 mission statements 62f blogs 100 populations served 374-375 Mississippi schools 3, 6, 7, 18. See also lesson plans on 7 program description 370-371 Healthy Students Act (Mississippi) mass media campaigns 87, 97, 99 program evaluation 375 mobile applications 118f online behavior change tools 241-242 program expansion 371 moderate activities 96 online education courses 105, 106, 107, staff considerations 374 moderate to vigorous intensity 24, 161 108-109 local public health policy 317 Moovin’ and Groovin’ 159 online portals 65 Los Angeles County DHS 26 activity options 160-161 online presence 97 M adding to existing programs 160 J market analysis 68 evidence base used 162 Johnson & Johnson program 229 market testing excitement building 160 evidence base used 235-236 field testing 94 lessons learned 162-163 goal setting 230, 237 focus groups 57, 68, 93-94 linkage to NPAP 161-162 health risk reduction 233f, 234f marketing partnerships 159, 162, 163 Healthy Future 2015 230 advertisements 57, 72, 73f, 85 populations served by 162 lessons learned 236-237 branding 50, 52, 67, 76, 84 program description 159-160 linkage to NPAP 234-235 clearances 52 program evaluation 161 Live for Life 229 community-based 46, 47f quality staff 163 percent physically inactive 232t consumer booklets 94 staff training 160 population served by 236 materials 50, 65, 93 motivational interviewing 128 program description 229-233 merchandise 82, 85, 86 Move More Scholars Institute (MMSI) 269 program evaluation 233-234 online 87, 97, 99 advisory committee 270-271 success factors 237 press releases 98-99, 111-112f application process 271 joint-use agreements 362-363 print media 74f, 76, 77, 85, 86 cross-sector work 273-274 assistance by nonprofits on 362, 365 resource matching 51f evidence base used 273 barriers to 19 taglines 72, 93, 94, 118 key results 272t link to NPAP 364t target audiences 68, 69, 77, 78 lessons learned 273 need for after-school programs 40 toolkits 94, 97 linkage to NPAP 272-273 Index 389
populations served by 273 program evaluation 226 urban areas 145, 379 program description 269-271 at remote company sites 225-226 use of existing infrastructure (Strategy program evaluation 271-272 nonexercise activity thermogenesis 126 2) 161-162, 166 Move-to-Improve curriculum 33, 34 nonprofit organizations 357. See also Vol- working across sectors 149-150, 157- music unteer and Nonprofit Sector 158, 163, 170-171, 179-180, 187-188 in early childhood centers 33 North Carolina public health 270 ParticipACTION 61-62 for physical activity breaks 182, 204 North Carolina schools 27 baseline data collection 66-67 in school settings 26 NPAP evaluation 297-298 capacity-building 64, 65 N nutrition. See also school nutrition communications 62, 64, 65 evidence base used 68 Nashville Area MPO 339-340 cancer survivor education 138 knowledge exchange 64, 65 Nashville transportation plan 339-340 counseling 222 lessons learned 68-69 adopted roadway projects 345f functional foods 128 linkage to NPAP 67-68 bicycle and pedestrian study 340f policies 379, 381 mission statement 62f data gathering 346 recommended intakes 128 populations served by 68 documenting needs 340-341 at sport venues 182, 186 program description 62 funding 344 in workplaces 197 program evaluation 65-66 health disparities 341 NYC Administration for Child Services 35 strategic plan 62, 63f lessons learned 344-345 NYC Department of Health and Mental vision 62f policy adoption 342, 344 Hygiene (DOHMH) 31 ParticipACTION Partnership Network (PPN) prioritizing needs 342 compliance 32-33, 35 enforcement 35 64, 69 program evaluation 346 ParticipACTION Teen Challenge 65 scoring projects 343f, 344 establishing regulations 31-32 evidence base for 34-35 participatory planning 72, 77, 79 stakeholders 345 implementing regulations 32 partnerships 260 National Afterschool Association 38 lessons learned 35 barriers to 158 National Association for Sport and Physical collaboration for change 110 Education (NASPE) 34-35 linkage to NPAP 34 population served by 35 collaborative culture 178 National Health and Nutrition Examination program evaluation 34 common language 282, 293 Survey (NHANES) 24, 117 with community coalitions 46 O National Health Interview Survey 119 in education 7 obesity. See also childhood obesity; weight National Prevention Strategy (US) 270 Exercise Vital Sign (EVS) 120, 122 management National Society of Physical Activity finding common ground 110 and body mass index 132 Practitioners in Public Health 270, guiding principles for 262 health care costs with 235 273, 275 with health departments 48, 81, 175, health risks 31 advocacy 280 253, 324 and occupational energy expenditure capacity-building efforts 279-280, 283 with hospitals 76 206 certifications 280, 282-283 leveraging 3, 64 and playtime 165 core competencies 276-278 with nonprofit organizations 357 prevention program 377 efforts to support practitioners 279-280 for Physical Activity Guidelines 100, 101 Observing Fitness Instruction Time (SOFIT) evidence base used 281 in PRFS sector 143, 156-157 185 lessons learned 281-282 with researchers 68 Obstacle to Action 82 linkage to NPAP 280-281 schoolyard parks 148, 150 Ohio Afterschool Network 40 populations served by 282 shared agendas 79, 293, 382 Omaha metro area 285, 291, 349, 354. See practitioner settings 278-279 shared vision 179, 293 also Live Well Omaha professional development 281-282 tiered-approach 50, 52 online programs. See Internet; websites program description 276 universities 13, 40, 142, 159, 162 organizational change 110 program evaluation 282-283 for VERB 46, 50, 51f resources provided by 281, 283 P patient counseling 124, 126, 131, 132 working across sectors 282 Padres Foundation for Children 183, 184, patient education 131 national surveillance 299 187 pedestrian safety 264, 306, 321, 333, 344 Network for a Healthy California 27, 186 parents pedestrians. See active transportation New York State Healthy Eating and Physical education 222 PedNet Coalition 305, 307 Activity Alliance (NYSHEPA) 377 evaluations by 155 pedometers 157, 232, 233 evidence base used 380-381 involvement 39, 49 peer modeling 27 founding steering committee 379 lack of awareness 68 peer support 245 funding 380, 382 surveys of 18, 19 physical activity. See also physical activity goals 377 targeting mothers 64 guidelines information dissemination 379 parK-12 145 barriers to 72, 82, 207 lessons learned 381-382 Parks, Recreation, Fitness, and Sports benefits in children 15 linkage to NPAP 380 (PRFS) sector 143. See also play- as default option 181, 182, 206 population served by 380 ground renovations; schoolyard for disease treatment 103, 119 program description 377-380 parks at early childhood centers 32 program evaluation 380 access to opportunities (Strategy 1) 145- factors in maintaining 162 New York state policies 379, 382 146, 153, 161, 179, 186, 372 and health 103 New York state programs 79, 377 approvals 163 logging 242 New Zealand campaign. See Push Play funding 157, 170, 171 making PA routine 353 (New Zealand) lead time for programs 163 minimal intensity 208 NextEra Energy Health & Well-Being 221 leader engagement 156 prescribing by doctors 82, 103, 119 employee participation 223 partnerships 143, 156-157 as punishment 19 leadership 221-222 professional athletics infrastructure use recording levels in patient records 115, lessons learned 224-225 (Strategy 3) 186 133 linkage to NPAP 223-224 program monitoring (Strategy 5) 154, self-reports of 116-117 measurement of success 223 166 short bouts of 182, 186, 206 populations served by 225 social marketing (Strategy 6) 162 Physical Activity Across the Curriculum program description 221-223 support 156, 157 (PAAC) 26 390 Index
Physical Activity and Public Health Prac- Physical Activity Vital Sign (PAVS) 131 physicians 85 titioners (PAPH) course 269, 270 administration 132 seniors 334 physical activity breaks. See also Instant evidence base used 133 Profession MD 123-124, 124f Recess lessons learned 133-134 academic evaluation 126-127 benefits of 26, 28 linkage to NPAP 132-133 counseling skills 126 lessons learned 27-28 physical activity scores 131 evidence base used 128 music incorporation 182, 204 populations served by 133 introductory lecture 125 NPAP linkage 26-27 program description 131-132 lessons learned 128-129 programs 25-26 program evaluation 131-132 linkage to NPAP 127-128 support for 28 working with other sectors 134 populations served by 129 teacher enthusiasm 27 physical education professor feedback 129 timing of 28 class sizes 6, 19 program description 124-125, 125t physical activity coordinators 6 in elementary schools 9, 17, 18 program evaluation 127 physical activity guidelines 4, 56 exclusion for bad behavior 19 scheduling issues 128-129 for ages 6 to 17 years 162 extracurricular activities credit 8 self-monitoring exercises 125 American College of Sports Medicine facilities 19 seminars 125, 126 (ACSM) 91, 141 in high schools 9-10, 17, 18 professional sport venues. See Friar Fit (Fri- for cancer survivors 141, 372 in K-6 in Arkansas 17, 18 arVision Fitness Fanatics Initiative) by CDC 91 in K-8 in Mississippi 6, 8 program champions 110, 170, 207, 214, for early childhood 34-35 lack of time 19 224, 236 weekly versus daily 92 in middle schools 9, 17 program evaluations. See also data col- Physical Activity Guidelines (2008) 4, 91-92 minimum requirements for 6, 9 lection blog 100 national recommendations for 297 behavioral change 178 communication materials 93 reduction in 4 cost-related outcomes 218, 226 communication strategy 97-99 resources 19 curriculum evaluations 127 concept testing 93-94 school compliance in NY 380 dose response analysis 48 description of 92 state policy content 297-298 at early childhood centers 34 development 92 web-based lesson plans 7 health outcomes 178, 217, 226 fact sheet for adults 95, 96 physical education teachers 4 mass media metrics 58, 66, 75, 84, 87 field testing of consumer booklet 94 certification requirements 6, 17, 19 for national plans 298-299 icon testing 93 participant surveys 375 classroom teachers as 6, 8, 9 key messages 92, 94 pre-and post testing 153, 155, 375 qualifications 4, 6 launch 97 school policy implementation 18 training 7, 8, 10, 20 lessons learned 100-101 telephone interviews 87 physicians media outreach 97, 99 using a logic models 66, 78 anthropometric measurement taking partnerships 100, 101 wellness program metrics 196, 217-218, 125 press release 98-99 226, 233-234, 243-244 competencies for lifestyle medicine tagline testing 93, 94 prolonged sitting 24, 182 prescription 109 timeline 100 Public Health Sector 134, 247 continuing education for 105, 109 toolkit components 94 advocacy and policy (Strategy 3) 178, counseling patients 124, 126, 132 Physical Activity in Public Health Specialist 265, 281, 290 (PAPHS) 280 prescribing exercise 82, 103, 109, 119 community health assessments 286 Physical Activity Law (TN) referrals to exercise professionals 109 cross-sector partnerships (Strategy 2) implementation 5 as role models 118, 134 265, 273, 281, 290, 372 participation rates 5 Pioneering Healthier Communities 175, 289 diversity (Strategy 1) 272, 280 program description 4-5 PlaNYC 146 financially viable programs 187 program evaluation 5-6 play 25, 165 local health departments 317, 318, 324 reporting 5 playground renovations. See also school- monitoring, surveillance and evaluation Physical Activity Law (TX) 3, 8 yard parks (Strategy 5) 178, 281 physical activity policies 295-296. See also accessibility 168 NPAP framework 250, 252 public school policies ADA-compliant 168, 170-171 professional competencies 270, 273 advocacy for change 359, 361, 363 advocating for 170, 171 resource dissemination (Strategy 4) 265- community-based examples 364t Common Ground Playground 168, 169 266, 281 content analysis 297-298 evaluation before and after 169-170, state health departments 249, 270, 273 disciplines involved 296 170t state-level planning 249, 257 evidence base for 365-366 funding 170, 171 support of economic health 320-321 examples 296 inclusive 165, 166, 169 sustainable programs 187 health equity in 366 installations 168 working across sectors 273-274, 282, identification of 296-297 linkage to NPAP 166 324, 326 implementation analysis 298-299 site selection 170 public meetings 306, 309, 323, 334 interagency collaboration 366 surfaces 170-171 public school policies. See also compliance interest groups 317 target populations 168-169 advocate role 10 legal assistance for 359, 361, 363 universal 169 barriers to policy change 19 lessons learned 299, 366 PlayWorks 24 burden on schools 6, 9 link to NPAP 296, 363, 364t, 365 policies. See physical activity policies; data-driven decision making 12 local momentum 366 public school policies enforcement 35 outcomes 299 populations. See also adults; children federal initiatives 16 policies versus programs 366 at-risk 37, 339, 341 flexibility of 6, 8, 9 policy initiatives 365 cancer survivors 142, 369, 370 as foundation 13 rational basis for 365-366 Hawaiians 59 impact on students 19 resources 299-300 Hispanic populations 94, 117 implementation 3, 13 surveillance 296-299 individuals with disabilities 165 lessons learned 10, 12-13 physical activity practitioners. See National low socioeconomic status 24, 37, 39, linkage to NPAP 19-20 Society of Physical Activity Practitio- 162 recommendations versus requirements ners in Public Health minorities 24, 37, 39, 117, 291 16 Index 391
school-based interventions 15-16 strategies to increase activity levels 24 Start.Living.Healthy 55 state legislative process 10 supervisor involvement 24-25 campaign launch 57 state policies 1, 3, 4, 16 time for 5, 8, 9, 18, 23 evidence base used 58 support networks 10 school settings 1. See also physical edu- foundations 55-56 Push Play (New Zealand) 81 cation; school nutrition; school lessons learned 59 comparison to NPAP 87, 88-89t recesses; students linkage to NPAP 58 lessons learned 84 activity-based instruction 6 messages 56-57 partners in 82 activity offerings 5, 8 partnerships 59 program description 82, 83t classroom-based physical activity 5, 7, populations served by 59 program evaluation 84 9, 10 preproduction research 56 recommendations followed 82 class sizes 17 production testing 56-57 R commuting to school 16, 19 program evaluation 57-58 RE-AIM model 299 district policies 3 promotional flier 59f resources. See funding fitness testing 6, 8, 9 target behaviors 56 road diets 329, 334. See also Urbana road health education 6, 10 state coalitions 378-380, 381-382 diet intramural programs 5, 8 state policies. See physical activity policies; role models 38, 94 physical activity breaks 25-27 public school policies children as 314 physical activity requirements 3, 4, 8, step counting programs 212, 222, 232 clinical staff as 134 17 Strategic Alliance (CA) 365, 381 managers as 225 program evidence base 4 strategic plans 62, 63f, 68 physicians as 118, 123 resources 13 strategic visions 62f, 179, 345 professional athletes 186 staff training 7, 8, 10, 13, 20, 27 Strides to Strength 137 teachers as 25, 33 wellness plans 6 education 138 S Y-USA’s Healthier Communities Initia- evidence base used 141 Safe Routes to School (SRTS) 16, 305-306 tives 177 exercise 138 cross-sector work 314, 323 school siting policy 362 lessons learned 141-142 education 306, 311 Schools to Playgrounds initiative 146 linkage to NPAP 140-141 encouragement 306-307, 311 schoolyard parks 145 nutrition 138 enforcement 307, 310-311 amenities 147, 148 other sector support 142 engineering 307, 311 costs 148 populations served by 142 evaluation 306, 307, 310 decision making on 146, 147 program description 137-138 evidence base used 312-313 designing 147 program evaluation 139-140, 139f Houghton case study 322-324 hours of operation 146-147, 148 program team 138 lessons learned 313-314 lessons learned 148-149 support 138 liability concerns 361 liability issues 149 structured activities 25, 39 linkage to NPAP 312 linkage to NPAP 145-146, 146 students. See also after-school programs partnerships 306, 313 maintenance 147, 148 academic achievement 3, 4, 6, 12 policy support 313, 361, 363 partnerships 148, 150 aerobic capacity 4, 23 populations served by 313 perceived barriers to 149t attendance 4, 6 positive outcomes 313 populations served by 147-148 behavior 3, 4, 6 program description 306-310 program description 146-147 cholesterol 4, 23 program development 306 program evaluation 148 cognitive functioning 3 public meetings about 309-310 strategies 150 concentration 4, 23 remote drop-offs 306, 308, 309 sedentary behavior involvement with SRTS 310, 313, 314 and school siting 361-362 and health 103 lifelong activity 9, 17 stakeholder involvement 306, 309, 310, negative workplace consequences 215 lifetime physical activity promotion 19 313 time children spend in 24 measuring BMI 9, 17 student involvement 310, 313, 314 self-monitoring 125, 215 in minority groups 24, 37 Saint Paul Public School System 211, 212 Share the Road campaigns 355 on-task time 26 Säjai Foundation 151, 152. See also Wise Smart Growth and Public Infrastructure 379 out-of-school activity 19, 26, 37 Kids program SmokeLess States 381 policy impact on 19 San Antonio Youth Centers (SAYC) 39 social cognitive theory 86 weight 26 San Diego Padres 182, 183. See also Friar social determinants of health 260 summer activities. See also Moovin’ and Fit (FriarVision Fitness Fanatics social marketing campaigns 45, 50, 55, Groovin’ Initiative) 71, 289 adolescent participation 39 school accountability 3, 5, 6, 9, 15, 19, social media 64, 68, 225, 236 camps 159 23, 27, 31 social norm change 360, 366 summer scorecards 47f school health coordinators 4, 5 social norms 181, 182 Surgeon General’s Report 77, 82, 91, 270 School Health Interdisciplinary Program socioeconomic status 24, 37, 39, 162 surveillance systems 279, 291, 299 (SHIP) 40 Sogo Active 65 T school meals programs 16 SPARC (New Zealand) 81, 82 Take 10! 5, 25-26 school nutrition 6, 18 SPARK! (Sports, Play, and Active Recreation teachers. See physical education teachers beverages 17 for Kids!) 32, 34 technical assistance 32-33, 35, 175, 176 policies 16, 19 Spaulding’s Institute of Lifestyle Medicine technology public reporting on contracts 17 (ILM) 111-112f to automate administrative tasks 217 vending machines 17 stakeholders emerging 68 school recesses. See also Instant Recess in active transportation 345 interventions through 26 activities during 10 in health impact assessments 266, 267t television watching 23, 82 banned activities 24 participation 253, 268, 309, 310 Tennessee 3, 4-6, 337. See also Nashville benefits of 23 in physical activity policies 296, 306 transportation plan changing needs with age 25 in school policy 4, 6, 10, 18 Texas 3, 8, 10, 39. See also Active Texas 2020 exclusion for bad behavior 19 speaking their language 326 Theory of Planned Behavior 55, 56, 58, free play versus structured 25 support 7, 10, 253 77, 152-153 for minority groups 24 surveying 18 Think Again campaign 64, 68 playground equipment 24, 25 working together 3, 4, 110 tobacco-control movement 365 392 Index
tobacco use 50, 76, 234 linkage to NPAP 48-49 White House Childhood Obesity Task Force toolkits message 46, 48, 49, 52 Report 25 on culture of health 237 partnerships 46, 51f, 52 Wise Kids program PAG for Americans 94 populations served 50 attitude change with 154f, 155t PAG for Youth 97 program description 45-48 behavior change with 154f, 155t training. See also education program evaluation 48 collaboration 155, 157-158 course for professionals 269 summer scorecards 47f, 48 effect on BMI 153f at early childhood centers 33 vigorous activities 96 implementation 152 employee 195 vision 62f, 179, 345 interest level 156f materials 195 Volunteer and Nonprofit Sector 357 lessons learned 156-157 online 109 advocacy (Strategy 1) 179, 363, 380 linkage to NAPAP 153-155 school staff 7, 8, 10, 13, 20, 27 funding issues 382 parent evaluations 155 summer camp staff 160 outreach (Strategy 3) 365, 380 populations served by 155 transportation 303. See also active transpor- stakeholder collaborations (Strategy 2) pre-to-post testing 153, 155, 156t tation; Nashville transportation plan 179, 363, 365, 380 program description 151-153 federal spending on 338, 344 working across sectors 382 program evaluation 153 funding allocations 339 W values change with 154f, 155t and physical activity levels 337, 338 Walk to School Day 306, 307, 308 Working Out for Wellness (WOW) 10, 11-12t planning 361 walking programs 77, 214. See also Safe workplace fatalities 197 prioritizing projects 341 Routes to School (SRTS) worksite settings. See also Fit to Drive; scoring projects 338, 344 for adults age 33 to 55 years 55, 56 Instant Recess; wellness programs short trips 338 for adults age 50 to 65 years 71 absenteeism 205, 215, 226, 233 transit riders 332-333, 338 at schools 5 consequences of inactivity 215 Transportation, Land Use and Community walking school bus programs 305, 308 continuous improvement 191, 226, 237, Design Sector 303. See also active walking trails 75, 232, 263 244 living communities webinars ergonomic injuries 202, 205 accountability (Strategy 1) 312, 324, by NSPAPPH 279, 281, 283 forestry workers 197, 198 331, 338-339, 353 on physical activity guidelines 100 injury prevention 197, 222, 232 building on existing efforts 326 websites 110, 225, 241. See also Internet lower-level worker audience 206-207 connectivity and accessibility (Strategy weight management 23 minimal intensity interventions 208 4) 179, 324, 331-333, 339, 353.312 employee programs 222 nutrition in 197 integration with public health planning health coaching on 105-106 obstacles to physical activity 207 (Strategy 3) 179, 266, 312, 324, 339, occupational injuries 191, 197 maintenance 3 353 on-site facilities 221, 222, 232 weight gain prevention 128 resources and incentives (Strategy 2) on-site health centers 223, 226 Welch Walks 77, 78 298, 312, 331, 339, 353 organizational culture 191, 198, 218, wellness programs using media for awareness 355 224, 237 community activity participation 232, working across sectors 314, 324-326, remote employees 225, 236, 245 236 334-335, 354-355 Y-USA’s HCI changes 177 employee access 225, 236, 244-245, 245 Transtheoretical Stages of Change Model WV Walks 77, 78 employee engagement 198, 244 94, 215 Y truck drivers. See also Fit to Drive employee health assessments 212, 217, YMCA 174. See also LIVESTRONG at the blood glucose levels 195, 197-198 222 YMCA; Y-USA’s Healthier Communi- data collection on 194-195 exercise reimbursements 232 ties Initiatives dehydration 195 implementation 198 yoga 33 reaction time 194, 195, 197, 198 incentives 199, 212, 226, 242, 243, 244 youth vigilance and injury 197 obstacles to participation 207 attitude change 154f, 155t tweens 45, 48, 49, 50 online resources for 225, 241-242 behavior change 154f, 155t 21st Century Community Learning Cen- personal benefits emphasis 236, 245 outreach 183 ters 41 program evaluation metrics 196, 217- physical activity guidelines 97 U 218, 226, 233-234, 243-244 sports 40 university partnerships 13, 40, 142, 159, program integration 225, 243 time in sedentary behaviors 24 162 programming activities 26, 134, 212, Youth Media Campaign Longitudinal Urbana road diet 329 222, 232-233 Survey 48 area revitalization with 333 in school settings 6, 16, 18 youth-focused campaigns 65, 82 beautification plan 331 short-term or seasonal 223, 242 Y-USA’s Healthier Communities Initia- cross-sector work 334-335 team based 242 tives 174 evidence base used 334 wellness visits 110 changes in schools 177 funding 331 Western Upper Peninsula Health Depart- collaboration 178, 179-180 lessons learned 334 ment (WUPHD) 318, 322, 323, 324 community-based organizations linkage to NPAP 330-333 West Virginia 17. See also Active WV; 177-178 populations served by 334 Healthy Lifestyles Act (West Vir- community leadership 175, 176 program description 329-330 ginia) key actions 176 program evaluation 333 Weyerhaeuser 193 key efforts 175 U.S. Department of Education 40, 41 Wheeling Walks 58, 59, 71 linkage to NPAP 178-179 U.S. Department of Health and Human community partners 72, 76, 78-79 neighborhood interventions 177 Services 92 evidence base used 77 participating communities 175 user-centered methods 93 funding 74-75 program description 174-176 V lessons learned 77-78 program evaluation 176-178 The VERB: It’s What You Do! 45 linkage to NPAP 75-76 site selection 175 brand 46, 49, 50 mass media 72-74 steps to improved outcomes 176 community-based marketing 47f population served by 77 strategic objectives 174 evidence base used 49-50 program description 72 technical assistance provided 175, 176 lessons learned 50, 52 program evaluation 75 worksite changes 177 About the NPAP and NCPPA
The National Physical Activity Plan Alliance The National Coalition for Promoting Physi- is a not-for-profit organization committed to cal Activity (NCPPA) is a blend of associations, ensuring the long-term success of the National health organizations, and private corporations Physical Activity Plan (NPAP). The alliance is advocating for policies that encourage Ameri- governed by a board of directors composed of cans of all ages to become more physically representatives of organizational partners and active. NCPPA spearheads federal policy and at-large experts on physical activity and public advocacy work in support of the National Physi- health. The key objectives of the alliance are to cal Activity Plan’s recommendations, and the support implementation of the NPAP’s strate- organization maintains a strong voice for physi- gies and tactics, expand awareness of the NPAP cal activity in Washington, DC, where NCPPA among policy makers and key stakeholders, members and staff work together to encourage evaluate the NPAP on an ongoing basis, and federal legislators to make policy changes that periodically revise the NPAP to ensure its effec- promote regular physical activity in all facets tive linkage to the current evidence base. of life.
393 About the Editors
Russell Pate, PhD, is a professor in the depart- David Buchner, MD, MPH, is a Shahid and ment of exercise science at the University of Ann Carlson Khan professor in applied health South Carolina at Columbia. Pate led the devel- sciences in the department of kinesiology and opment of the 2010 U.S. National Physical Activ- community health at the University of Illinois ity Plan and served on the 2008 U.S. Physical at Urbana-Champaign. From 2008 to 2013, he Activity Guidelines Advisory Committee. He is directed the master of public health program in the chairman of the board of directors of the his department. He is a board member for the National Physical Activity Plan Alliance and National Physical Activity Plan Alliance. From chairman of the coordinating committee of the 1999 to 2008, he was chief of the Physical Activ- National Physical Activity Plan Alliance. ity and Health Branch at the Centers for Disease Pate is a past president of the American Col- Control and Prevention. In this role, Buchner lege of Sports Medicine (ACSM) and served as chaired the writing group for the 2008 Physical lead author of the 1995 CDC-ACSM Statement Activity Guidelines for Americans and partici- on Physical Activity and Public Health. He is pated in numerous public health initiatives to also past president of the National Coalition promote physical activity. Buchner’s research for Promoting Physical Activity. In 2012, Pate has focused on physical activity and aging. received the Honor Award from the ACSM. He He has studied the role of physical activity in received the Honor Award from the Science preventing functional limitations, disability, Board of the President’s Council on Physical and falls. His favorite recreational activity is Fitness and Sports in 2007. backpacking and hiking with his family. He resides with his wife in Columbia, where he enjoys running, attending theater perfor- mances, and watching collegiate athletics.
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