Active Living Research

Background and Purpose
While there is growing faith in community organizing to influence policy as a way to improve the built environment and increase food or recreational equity, relatively little research is available comparing and contrasting the processes and outcomes of community organizing in Latino communities attempting to reduce obesity.  This paper presents preliminary findings from two community-based organizations organizing to increase access to physical activity and access to healthy foods in predominantly Latino areas.  The organizations are part of Communities Creating Healthy Environments (CCHE), a national initiative of the Robert Wood Johnson Foundation (RWJF) to prevent childhood obesity.  Both community-based organizations achieved redistribution of public resources to improve local safety, though they used different leadership models and organizing activities.  We discuss the study’s implications, such as the need for evaluation research that examines community organizing as 'intervention' for changes to public policy.

Objectives
For participants to: 1) Understand that there is very little formal evaluation documenting organizing efforts designed to reduce obesity. 2) Describe the similarities and differences between the policy change goals of each organization. 3) Describe the similarities and differences in leadership development and community organizing activities of the two organizations. 4) Describe the outcomes for each organization.

Methods
We present preliminary process and outcome evaluation findings from two organizations organizing to increase recreational justice (increased access to physical activity) and food equity (access to healthy foods) in predominantly Latino areas. The organizations are the Community Coalition (Coalition) in South Los Angeles, CA and La Union del Pueblo Entero (LUPE) in Texas. We report on one year of process and outcome data that is qualitative and quantitative from the first year of project implementation for both grantees, January 1, 2011-December 31, 2011. We conducted phone interviews with each organization every three months (n=4) using an in-depth structured interview protocol. Organizations self selected at least one staff for the interviews that were most intimately involved with the community organizing activities of the CCHE project.  Typically, we interviewed simultaneously two staff per grantee and most often they were lead organizers, project coordinators or directors.  Interviews lasted one-and-a-half hours, on average.  We also reviewed archival documents for each grantee, such as grants and newsletters.

Results
The organizations differ in their long-terms policy goals.  The Coalition focused on changing land use policies (nuisance abatement to increase public safety) and gaining funds for prevention programs to increase recreation activities that will ultimately impact residents’ ability to burn more calories while consuming fewer non-nutritional calories.  LUPE’s policy focus is to make it easier for residents to burn calories via availability of health promoting environments, such as street lights and walking trails.  Both organizations share similar organizing strategies and tactics which include personal visits, door knocking, neighborhood or apartment building or house meetings, phone banking, and to a lesser extent, social media.  These strategies along with popular education are used to build their community resident base and develop their resident leaders.  Collectively, the organizations had a base of almost 300 and just over 70 leaders.  LUPE’s parent/ resident base was 476 and 67 of these were leaders.  for the Coalition, the numbers are much smaller given the relatively small area of the target neighborhood, with a parent/resident base of 223, of which 30% are youth (n=45), and 8 are leaders, most of which are parents/residents.   The organizations also differ in the type and nature of support they receive from “like minded” groups or organizations.  The Coalition has eight allies.  The most typical way allies provided support is by sharing or agreeing to share resources (e.g., staff, monetary, expertise), followed by allowing the grantee to use the ally’s name as a supporter to the CCHE campaign, participating in strategic planning, or leveraging outside resources for the grantee.  in contrast to the Coalition, LUPE has not engaged allies on this particular campaign, though it has an active network of allies from previous campaigns it can count on if needed.  Each organization achieved public and social policy outcomes, specifically related to resource allocation.  for instance, the Coalition obtained funding for needs driven recreation programs from the City’s Parks and Recreation Department (e.g., Summer Night Lights) despite local and national trends of cutting recreation programs if not entire elimination of parks and their programs.  LUPE secured funding from three commissioners who had committed to installing solar powered streetlights in five colonias and obtained a commitment for a walking trail in one colonia.

Conclusions
Both organizations achieved their objectives. While both are trying to improve safety, they do it for different reasons. Moreover, LUPE wishes to see relatively immediate health results while it is unclear when the Coalition expects to see healthier food options in the area.

Support / Funding Source
The primary author recognizes support for this study by a grant from RWJF New Connections program.

Background and Purpose
Pedestrian safety and injury prevention is a critical issue to address when building active, healthy communities. in North Carolina, more than 1,800 pedestrians are hit by cars each year, with a large majority of these people sustaining injuries. in the “Triangle” area of the state, which includes the municipalities of Raleigh, Durham, Chapel Hill, and Carrboro, among others, an average of more than 400 pedestrians are reportedly struck by motor vehicles each year. This figure represents only police-reported crashes that make it through the Department of Motor Vehicle (DMV) system. From 2004-2008, Raleigh and Durham were two of the four cities in the state with the highest rates of pedestrian crashes (HSRC, 2010). While Complete Streets policies and infrastructure improvements were being implemented, it was acknowledged in a survey of 16,000 active residents and professionals statewide that education and enforcement of laws to protect pedestrian safety were a complementary and critical priority.

Description
in August 2012, after a two-year-long effort by partners to plan and coordinate efforts, a pedestrian safety campaign entitled “Watch for Me NC” launched in the Triangle. The goals of the campaign were to raise awareness of pedestrian safety concerns, bring attention to relevant laws and enforcement operations, encourage safer roadway behaviors by drivers and pedestrians, and ultimately reduce pedestrian crashes and injuries. The campaign was shaped based on three key principles: 1) community-led, 2) data-driven, and 3) evidence-based. Community partners included NCDOT, local planning and public works departments, enforcement agencies, university staff, and others. Crash data, stakeholder input, field reviews, and observations of driver yielding rates were used to identify target audiences and priority locations for traffic enforcement operations (targeting speeding, motorist yielding to pedestrians in crosswalks, and other behaviors). The data was also used to guide the content and distribution of safety messages in a comprehensive public outreach effort. Public outreach included radio public service announcements, ads on buses and at gas stations in high crash corridors, outreach through universities and community centers, TV and print coverage, and social media efforts. Additional training and capacity-building efforts were aimed at enforcement and traffic safety professionals.

Lessons Learned
The process of developing an effective education and enforcement campaign aimed at pedestrian safety takes considerable resources, including time and funding from many partners. High-quality data is critical for informing the campaign approach and in securing campaign buy-in from key stakeholders such as decision-makers, law enforcement officials, and the media. Partner collaboration is essential to ensure broad and comprehensive program delivery and long-term sustainability. Examples of other pedestrian education and enforcement campaigns abound but evidence is limited in regards to what measures are most effective. Literature on theory and best practice from the fields of education, communication, and health behavior can support more effective messaging and delivery.

Conclusions and Implications
A carefully-designed and implemented education and enforcement campaign has the potential to complement policy and infrastructure improvements aimed at improving pedestrian safety. Many communities include “education” and “enforcement” pieces as part of their pedestrian safety master plans but few understand the process and inputs needed to build evidence-based campaigns. Results and lessons learned from this effort can provide a model for others seeking to reduce pedestrian injuries and fatalities through comprehensive education and enforcement efforts.

Next Steps
The campaign is currently being evaluated using both process and outcome measures by UNC-HSRC staff. Media impact, changes in organizational capacity, observable behavioral measures, and other outcomes will be included in the evaluation, which will conclude in October 2013. The program is also slated to receive additional funding by NCDOT to continue the effort in 2012-2013 and expand safety messaging to bicyclists.

Support / Funding Source
Funding for program development and evaluation was provided by the National Highway Traffic Safety Administration. Supplemental funding for PSAs, media, and print materials was provided by the North Carolina Department of Transportation.

Background and Purpose
Prior literature has identified cross-sectoral collaboration as a key lever for creating safe, activity-friendly neighborhoods. Current scholarship in sustainability science suggests that cross-sectoral collaboration can span boundaries between knowledge and action by balancing legitimacy (e.g., ensuring a fair, participatory process); salience (enhancing relevance to decision-makers at different levels), and credibility (developing data-driven methods and evidence to support action). However, few studies have critically examined the perceived benefits, drawbacks, and tensions of collaboration among different stakeholders in dynamic community contexts.  This study examined the adoption and implementation of a cross-sectoral collaboration to promote safe, healthy neighborhoods in Manchester, New Hampshire. We focused on Manchester’s Weed & Seed (W&S) initiative from 2001-2011, using a Community Based Participatory Research (CBPR) approach. Originating from a Department of Justice grant, W&S became a catalyst for bringing citizens, law enforcement, public health, social services, and other partners together to create safer, healthier neighborhoods.

Objectives
1. To examine the adoption and implementation of a cross-sectoral, collaborative vision for violence prevention and active living.  2. To examine the perceived benefits, challenges, and lessons learned from the W&S cross-sectoral collaboration.

Methods
Mixed methods were utilized, including qualitative analysis of over 45 historical documents/reports, key informant interviews with 12 primary stakeholders (e.g. community leaders and department directors), a web-based survey of secondary stakeholders (e.g., agency staff and service providers representing 15 different sectors (n=96)), and Photovoice with low-income youth.

Results
Manchester’s W&S initiative successfully created a cross-sectoral, city-wide vision for preventing violence and promoting active living using a social determinants of health lens. Institutional structures, policies, and procedures changed over time to sustain cross-sectoral collaboration. These changes included increased staff time to attend meetings in other departments/organizations, enhanced efforts to reach out to different stakeholders, and increased cross-training of staff to work collaboratively with different departments or organizations. The shared vision and institutional policies/practices were perceived as beneficial by a substantial percentage of stakeholders. for example, over 50% of survey respondents reported that W&S made it “much easier” or “somewhat easier” to have quality relationships with other organizations, to “get invited to the table,” and to have a better understanding of their organization’s role to promote safety, active living and neighborhood health. Several factors were critical to the adoption of the collaborative vision, including: 1) the original W&S mandate from the Department of Justice; 2) key community leaders who served as champions of the vision and acted as effective “boundary spanners”; 3) the institutional placement of W&S personnel across sectors (e.g., the Health and Police Departments); and 4) the utilization of neighborhood-level structures and strategies to support communication and collaboration (e.g., neighborhood watch groups, community policing, and Crime Prevention Through Environmental Design).Stakeholders' perceptions of the impact of W&S on safety and active living suggested that improvements had been made in many areas. for example, over 60% of secondary stakeholders reported that Manchester was doing “somewhat better” or “much better” with respect to creating opportunities for healthy eating, fostering trust between residents and law enforcement, improving the physical appearance of neighborhoods, sharing the results of efforts with community organizations, establishing neighborhood watch groups, and adopting strategies to enhance safety in areas where people could be physically active. However, only one-third of stakeholders reported that Manchester was doing “somewhat better” or “much better” with respect to limiting tobacco advertising in areas where youth play, or including the perspectives of senior citizens and youth in planning efforts. Stakeholders also identified several key challenges to fully implementing and sustaining the collaborative vision, including: 1) Reconciling a broad, holistic vision with the need to prioritize specific strategies to effect change, particularly in the context of limited funding; 2) Clearly defining roles and responsibilities in a manner that supports monitoring and accountability; 3) Maintaining sufficient levels of participation and engagement across sectors;  4) Communicating impacts to policymakers and residents; and 5) Envisioning how structures and processes may be redefined as the collaboration evolves. Given these challenges, Manchester has made considerable progress in transforming “small p” policies (organizational and institutional practices/policies and norms), but less progress in influencing “big P” policies-such as legislation, regulations, or city-wide strategic planning initiatives-to support violence prevention and active living.

Conclusions
Overall, W&S established the legitimacy of a cross-sectoral vision to address the intersection of violence prevention and active living by developing a collaborative process that was viewed as transparent and inclusive by many key stakeholders. W&S contributed to the development of new institutional policies, practices, and norms to promote safety and active living. However, stakeholders recognize that certain challenges (e.g., accountability, delineation of roles and responsibilities, and participation) warrant ongoing attention.   Findings from this study are currently being disseminated to inform policy processes at various levels, and to support the city’s commitment to neighborhood safety, active living, and quality of life for all residents.

Support / Funding Source
This study was supported by the Robert Wood Johnson Foundation's Active Living Research Program, Grant ID#68495. We thank the City of Manchester for their commitment to this work.

Background and Purpose
Achieving increased physical activity and improved health at the population-level requires innovative solutions, including changes that make active transportation choices the easy and obvious choices for people of all ages. While many factors in the built environment help to shape physical activity behaviors, trails are certainly acknowledged as an important component of the green infrastructure of a healthy community. Access to and use of trails is strongly associated with increased physical activity and improved health. However, data are lacking about the process of trail construction, which by nature, requires collaboration between groups. The purpose of this study was to evaluate the development, construction, and promotion of trail projects funded by a local foundation in the state of Kansas, between 2005-2012. There were two primary objectives of this study: 1). To identify key factors associated with the success of developing, constructing, and promoting the trail projects; and 2). To understand the trails’ perceived impacts on the community, including physical activity behaviors of community members.

Description
Since 2005, the Sunflower Foundation’s Sunflower Trails program provided funding to community entities to construct short trails that served as venues for physical activity and/or active connections between destinations. By 2012, over $900,000 was awarded for 72 trails across Kansas. Trails varied in surface material (e.g., crushed rock, asphalt, concrete) and length (e.g., 1/5 to 8.8 miles). In 2011, the foundation contracted with university researchers to conduct a formal evaluation of the trails’ impacts. Qualitative data were collected through key informant interviews (n=20) selected using a stratified random sample of primary contacts for the trail projects. Stratification was based on the type of primary organization for each project (i.e., school, community organization, or municipality). The structured interviews consisted of 12 over-arching questions in the following areas: collaborative process of building the trail, integration of the trail within the community, and impact of the trail. Participants provided verbal informed consent. Interviews lasted 20-30 minutes and were conducted by phone. All interviews were audio-recorded and transcribed verbatim. Two separate research assistants independently reviewed interview transcriptions and developed a list of themes. Together the research assistants refined the themes until consensus was reached. Interview transcripts were then double-coded using the themes.

Lessons Learned
Ten themes and 55 sub-themes were identified for 568 comments. The most comments (n = 259) were for “collaboration,” which were broken down further into 18 sub-themes that included collaborations with businesses, city administration, non-profit/community organization, school district, public works, local health and wellness organization, parks and recreation, the county, community members, convention and tourism group, university, developers, home-owners association, grass-roots organization, hospital, health department, safe routes to school, and the state. Eighty-three comments were made regarding the “impact of the trails on physical activity levels.” Six sub-themes included physical activity for the general population, children, walkers/joggers, the elderly, families, and through increased safety. The third theme, “future trail-related projects,” had 42 comments divided into 6 sub-themes: extension of the trail, no further work, other trails, addition of amenities, health and wellness activities, and creation of a bike/pedestrian task force. Thirty-seven comments were made about “events” associated with the trails; five sub-themes included walking clubs/programs, bike events, educational programs, other programming, and no events. “Promotional efforts” was mentioned in 36 comments and four sub-themes: advertised by news/websites, ceremony, local events, and other (e.g., brochures). “Additional costs” were the topic of 28 comments and four sub-themes: paid by the sponsoring organization, absorbed by local business, no additional costs, and other (e.g., fundraisers). Twenty-three comments mentioned a “champion” for the trail, with 5 sub-themes that included a city staff member/department, a local community member/organization, a school district employee, an elected official, and other (e.g., a county extension office). Twenty comments each were made for “assessment,” “maintenance,” and “level of difficulty” for constructing the trail. Only three trail project reported any type of assessment (e.g., trail counters), six trail projects were considered to be more difficult to complete than expected, and responsibility for trail maintenance belonged to city departments, the sponsoring organization, and the county.

Conclusions and Implications
Trail projects utilized collaborative efforts across disciplines. Completed trails positively impacted physical activity behaviors for users, including children. Most trails were successfully promoted through events and promotional efforts, and having a champion increased this success. Despite incurring additional costs, many participants indicated that they were planning more trail projects for the current or additional trails.

Next Steps
Future trail projects should incorporate formal assessment in order to objectively determine actual use and impact on community members. However, this lack of assessment provided us with the opportunity to conduct this evaluation project as a university-foundation-community partnership.

Support / Funding Source
This project was funded by the Sunflower Foundation of Kansas.

Background and Purpose
Parks are venues designed for leisure physical activity and are especially conducive to moderate-to-vigorous physical activity, which has been causally related to better health outcomes. Meanwhile most people do not meet national guidelines for physical activity and most parks are underutilized. We were interested in determining whether changes in programming, outreach, and marketing could increase park use and park-based physical activity.

Objectives
1). To determine if information from assessments of park use with the System for Observing Play and Recreation in Communities (SOPARC) and training on outreach and marketing could improve park use and park-based physical activity. 2). To determine if the involvement of Park Advisory Board in making decisions on how to improve park use would be superior to decisions made by park directors alone.

Methods
We randomized 50 parks to 3 study arms: a park director-led change arm, a Park Advisory Board (PAB)-involved study arm, and a control arm. After randomization, we assessed all parks using SOPARC and interviewed a sample of 75 park users and 75 local residents randomly selected from households within 1 mile of each park. In the PAB condition, members of the Park Advisory Board and local residents were invited to participate as paid data collectors. All data collectors were trained in SOPARC and survey methods prior to data collection. We conducted a baseline assessment and discussed the results with the two intervention arms, but not the control arm. After this discussion, both the park director- and PAB-involved parks were given $4000 to spend in ways they thought appropriate to attracting more park users. All park directors and PABs were invited to attend about 5 separate training sessions where a marketing expert provided guidance on outreach, the importance of excellent customer service, the importance of visibility, and using events to promote routine activities and programs. Study parks opted to use funded primarily for 1) signage, like banners, bulletin boards, floor mats, staff shirts, table covers, bubba kegs, clipboards, staff aprons and walking path signage, 2) promotional incentives like water bottles, bags, or key chains with the park name printed on them, and 3) increasing outreach and supporting group activities with equipment purchases. This latter category included increased e-mail communications and staff deliberately walking through the park and talking to more park users, hiring additional  instructors, and buying class/activity materials and as well as equipment like shades, tents, movie screen/projector, cameras, PA system for events or concerts in park. Two-three years after the baseline assessment, and in the same season and time period, we conducted follow-up assessments using the same methods as at baseline.

Results
The two intervention arms did not differ significantly on what they chose to spend the $4000. Most parks implemented more than one specific change across the categories of signage, promotional incentives, and group activities. Comparing baseline to follow-up the control parks had 146 fewer users per week (p=.07) and 325 fewer METS were expended per week (p < .05). representing a decline of 6-10% in the their average use. In contrast, relative to control parks, intervention arms experienced 174 more users/week/park; 571 more METS expended/week/park: equivalent to 429 more people walking briskly for 20 minutes every week, representing a 7-12% gain in the average park use. Based on an additional expenditure of $4000 and if the effect lasted at least 20 weeks, the cost per MET gained is approximately 36 cents. Intervention effects were more notable for males than females, with roughly 75% of the intervention effects were due to more males using the parks.  More than 50% of the increase in park use was attributable to investments in signage. However, the relative non-significant changes associated with other expenditure categories may also result from an insufficient number of parks spending in those categories. Significant factors associated with increased use were size of a park (with METs only), local population density, number of amenities/facilities, accessibility (facilities being open), season (summer has the highest usage), and number of supervised/organized activities. Factors associated with decreased use, but statistically insignificant, were poverty levels and perception of park safety. The intervention was limited by (a) challenges in organizing PABs that PABs in low-income neighborhoods, (b) many parks not spending their money until right before the follow-up measurement, so the time for the interventions to take effect was not uniform across sites, and (c) considerable park staff turnover due to budget cuts.

Conclusions
Involving park advisory boards in resource allocation decisions did not appear to be superior to having the parks directors do this alone. Parks have a large, untapped potential to increase population physical activity. They can attract more users, but doing so requires attention and modest investments.

Support / Funding Source
NHLBI # R01HL083869

Background and Purpose
Ecological models of behavior change posit that individual, interpersonal, environment, & policy factors affect physical activity (PA). MIPARC (Multilevel Intervention for Physical Activity in Retirement Communities) is a group randomized controlled trial assessing the effectiveness of a 12 month multilevel intervention for improving PA in Continuing Care Retirement Community (CCRC) residents. CCRC settings provide an excellent microcosm in which to examine the effects of multi-level interventions. The intervention includes individual, interpersonal, environmental, and policy components. Previous interventions have not targeted all levels of the model. This paper describes the quantitative and qualitative methods employed to evaluate this multilevel PA intervention in older adults.

Description
Residents at 7 intervention CCRCs were given pedometers and logs to track their daily walking. They received progress charts every 2 weeks to track their progress and individual telephone counseling to help them meet their step goals, adapt goals to overcome barriers and on-going health issues, and help participants develop goal setting skills. On the interpersonal level, participants engaged in bi-weekly 90 minute group education sessions led by a qualified health educator for 6 months. In the group sessions, participants were encouraged to share their progress, challenges and successes which provides the opportunity for social support and enhances group cohesion. Participants also attended active events led by a group of “peer leaders” who are active resident who complete training in organizing events. The peer leaders also advocated for environmental projects to improve walkabililty of their site or the surrounding neighborhood. Barriers to walking were identified following an introductory session by the pedestrian community advocacy organization Walk San Diego and action plans were developed to work toward solutions. Example projects included cleaning up a bridge that allowed participants to access a local farmer’s market more easily, redesigning a car park to prevent cars blocking a sidewalk allowing safer walking to a beach, trimming trees that were blocking a sidewalk, increasing pedestrian crossing times at an intersection as well as adding count down timers and auditory prompts. Process measures were used to assess implementation and exposure to all levels of the intervention. Surveys were developed to evaluate the mechanisms of change using validated scales from theoretical constructs, such as group cohesion, as well as scales adapted specifically for our target population. Individual level assessments include: self-efficacy, use of activity locations, satisfaction with facilities, barriers, walking location (self-report and GPS), satisfaction with each intervention component, and satisfaction with peer leaders. Interpersonal measures included: community cohesion, engagement, study group cohesion, social support, peer leader group cohesion, and session/event evaluations. The built environment was assessed through a quantitative audit tool that assesses the PA, educational and social opportunities on site (APARS) and site activity calendars. The policy and environment changes were tracked through progress reports and photo diaries.

Lessons Learned
We will present the evaluation results showing how different data sources can be summarized and patterns across sites investigated. We will demonstrate how qualitative data can be gathered together and given quantitative metrics. Data already demonstrated that attendance at group sessions has been high, 82%, and evaluations extremely positive. The high level of satisfaction however may reflect response bias, making other types of data helpful. The presentation will demonstrate how evaluation using mixed methods is important and what the challenges and solutions are. Case studies of successes and barriers to implementing the community projects and peer led activities will be highlighted. We will use configurational frequency analyses to detect variables occurring more or less frequently than by chance alone. Thresholds for each variable (high vs low) are created based on the numbers that present and the high and low group are compared. This method detects types and anti-types which is a way of indentifying clusters of communities that may share the same underlying systems.

Conclusions and Implications
A combination of quantitative and qualitative methods is necessary to assess community based interventions that use a multi level approach. Multi level interventions require evaluation tools at each level of the intervention, which can be challenging. There are more established quantitative techniques for the individual and interpersonal levels. Evaluating the impact of environmental changes remains difficult due to their diversity. In contrast to individual and interpersonal components that can be prescriptive and thus predictably assessed, environmental projects are context dependent, so measures need to be flexible and case specific. Comparing different projects and summarizing projects across multiple locations involves case study techniques and visual inspection of changes.

Next Steps
Future interventions will be informed by the current research results and we will present a model of an ecological intervention and its evaluation for others to use. We continue to learn the factors, such as local champions, that can result in more effective environmental projects. We also learn from the projects what features are common and may be more predictably measured in future.

Support / Funding Source
This study was funded by the National Heart Lung and Blood Institute, NIH. R01 HL098425.

Background and Purpose
Background: Walkability is a combination of built environment characteristics that may encourage or inhibit commuting and leisure time physical activity (PA). Several studies have supported its use and found a positive association between walkability and adult’s PA in high-income countries. However, to this date such associations have not been analyzed in regions with low and middle- income countries, such as Latin America (LA).

Objectives
The aim of this study was to examine the association between walkability and walking for commuting and leisure in adults from Curitiba, Brazil.

Methods
The Spaces for PA in Adults Study (ESPACOS Project) was conducted in Curitiba, Brazil. Data were collected in 2010 in thirty-two census tracts selected according to GIS-based walkability and income. Participants were 697 adults (52.0% women) randomly sampled and age between 18 and 65 years. The International Physical Activity Questionnaire was used to capture self-reported walking (leisure and transportation). The main effects of walkability and income and their interaction were the focus of these analyses. The dependent variable was walking at least 150 min/week so logistic regressions with random intercept adjusting for census tract clustering were performed and interaction terms between quadrants of walkability and income were included to test the moderator effect of quadrants income on the walkability-PA association.

Results
Walking for commuting at least 150 min/week was 21.1% in low-walkable areas and ranged from 33.5 to 35.0% in those areas classified as being high walkable. Walking for leisure for at least 150 min/week was achieved by roughly 12% of participants and did not vary across quadrants of walkability and income. After adjusting for all individual confounders (e.g.), quadrants of walkability versus income showed an independent association with walking for transport (prevalence odds ratio [pOR] =2.10; 95% confidence interval [CI]=1.31-3.37; p=0.002). No association was found between walkability and walking for leisure (pOR=1.01; 95%CI=0.63-1.62; p=0.971). No interaction between walkability and income was found for transport (pOR=0.91; 95%CI=0.36 -2.32; p=0.840) or leisure walking (pOR=0.86; 95%CI=0.34-2.19; p=0.753).

Conclusions
This was the first study that examined the association between walkability and walking outcomes in a developing country with identical protocol, design and instruments employed high- income countries. The main findings emerging from this study showed that adults living in highly walkable areas are more likely to achieve recommended levels of PA through walking as mode of transport. Additionally, no significant interaction between neighborhood walkability and income was found, indicating that walkability is strongly associated with walking for commuting regardless of the participants’ neighborhood income. Finally, walkability was not associated with walking for leisure. These results extend the evidence by demonstrating that built environment is an important PA correlate in developing countries. This study confirms findings from high-income countries and showed that walkability is positively associated with PA of adults living in Latin America.