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Walking and bicycling for daily transportation are important ways to get regular physical activity, but such active travel has decreased dramatically over the past few decades. Investing transportation funds in sidewalks, traffic-calming devices, greenways, trails and public transit make it easier for people to walk and bike within their own neighborhoods and to other places they need to go. Designing communities that support active travel also creates recreational opportunities, promotes health and can even lower health care costs. Research that shows how infrastructure improvements promote active travel can help policy-makers, planners and other professionals create healthier communities for residents of all ages.

Download our Transportation-related Resources Sheet for the best evidence available about a variety of transportation-based strategies for promoting physical activity.

You can also view and download our The Role of Transportation in Promoting Physical Activity infographic.

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San Ysidro Border Health Equity Transportation Study

Date: 
02/23/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
Relationships between health and built environment are gaining increasing attention in local and regional policy arenas.  It is becoming more evident that the presence and concentration of various land uses and transportation systems shape communities and the people living there.  City planners and policy-makers however, typically do not directly consider individual and community health impacts of these features.  The Border Health Equity Transportation Study (BHETS) serves to evaluate the significance of various mobility/built environmental factors in the health of San Ysidro community members, with a particular focus on developing a model for integrating this understanding into typical long-range planning processes carried out by city planners and policy-makers at the local and regional level.  Ultimately, the study seeks to elucidate a process for directly including health considerations in long range land use and transportation planning practice.     San Ysidro is the southernmost community within the City of San Diego, adjacent to the world’s busiest land crossing border.  The San Ysidro community experiences a variety of distinct environmental, economic, and social impacts related to its proximity to the border.  As a majority of border crossers are traveling by car, approximately 35,000 northbound vehicles per day idling an average of 100 minutes, air quality impacts are of particular concern.  In addition to this unique dynamic, San Ysidro also shows high concentrations of low-income, minority populations, leading to broad concerns related to social and environmental quality.

Description
The initial existing conditions analysis utilized data from two publicly available sources: the 2012 Healthy Communities Atlas and the 2013 San Diego Community Profiles provided by the San Diego County Health and Human Services Agency.  The Healthy Communities Atlas includes seven groupings of mobility/built environment variables at the census block group level: 1) demographics; 2) transportation systems; 3) physical activity support; 4) traffic-related safety; 5) access to social support; 6) crime-related safety; and 7) food environment.  The community profiles provide health data aggregated by Subregional Areas (SRA), allowing for health outcome comparisons of 41 SRAs across San Diego County.   Partial correlations were performed to understand the significance, direction and strength of the relationships between mobility/built environment factors and health outcomes across San Diego County, while controlling for age and income.  Results of the partial correlations analysis were used to prioritize mobility/built environment factors having the most consistently significant effect on a range of health outcomes across the San Diego region.     Previous planning documents and studies were reviewed to identify a preliminary set of recommendations (for their potential to influence positively community health) related to the highest priority mobility/built environment factors resulting from the partial correlations analysis. These preliminary recommendations were then vetted with community members at a workshop and at a stakeholder group meeting.  The public review led to the identification of gaps in the preliminary recommendations, and further research was conducted to develop supplemental recommendations, leading to a final set of 16 focused mobility/built environment recommendations.

Lessons Learned
The analyses found that community members in the South Bay SRA (including the community of San Ysidro) appear to experience several health outcomes, such as diabetes, asthma, COPD, and rates of pedestrian injury, at relatively higher rates than the region as a whole.  In addition, mobility/built environment factors with the strongest and most consistent associations with health outcomes across the San Diego region include: Percent of Households within 500’ of Transportation-Related Air Pollution Sources; Sidewalks Coverage; Access to Trails and Parks; Pedestrian Safety (composite of pedestrian collisions, traffic density, high volume arterials, and sidewalks); Youth Safety (composite of access to parks, schools, daycare, cyclist collision, pedestrian collision, traffic density); and Youth Physical Activity Support (composite of trail access, sidewalks, and elementary school access).   A final set of 16 focused mobility/built environment recommendations have been identified, including a landscaped active transportation corridor that traverses the San Ysidro community, a recreational wayfinding program, an air quality monitoring program, installation of a traffic signals, and creation of a ten-acre park site.

Conclusions
The analysis process developed for this study is unique in that it establishes a framework for identifying significant health-related issues within a community, the mobility/built environment factors related to those health issues, and a set of land use/transportation recommendations intended to address the identified health issues.   It provides a model for integrating health directly into long range planning, thereby equipping local planners with ability to direct decision-making toward recommendations that will improve community health.

Next Steps
The next stage of the BHETS will focus on developing an evaluation and monitoring plan to provide a clear framework for local and regional governments to track trends in key mobility/built environment factors and health outcome known to be associated with them.

Support / Funding Source
The BHETS was made possible by funding from the Caltrans Environmental Justice Transportation Planning Grant program.

Authors: 
Sherry Ryan, PhD, Chen Ryan Associates / San Diego State University
Location by State: 

Investing in Health: An Analysis of Economic Development Initiatives that Promote Physical Activity and Healthy Lifestyles

Date: 
02/23/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
The health of New York’s economy, communities, and residents is inextricably linked. People living in low-income and distressed neighborhoods often experience poor health outcomes, and poor health and illness create an economic burden that affects individuals, companies, regions, and, ultimately, the entire state. New York ranks second highest in the United States for medical expenditures attributable to obesity, spending $11.1 billion (in 2009 dollars)[i] each year. Being physically active and eating healthy foods are two key variables that contribute to preventing obesity and other related chronic illnesses. Therefore, community and economic development that supports increased access to physical activity and healthy foods within all our communities is vital to addressing both the economic and physical health of New York State.   In 2011, New York State Governor Andrew M. Cuomo and Lieutenant Governor Robert Duffy created 10 Regional Economic Development Councils (REDCs) to develop long-term plans for economic growth across the state. The REDC plans have largely focused on job creation. An analysis was done by The New York Academy of Medicine (NYAM) as part of its Designing a Strong and Healthy New York (DASH-NY) Obesity Prevention Policy Center to show that economic development initiatives are also opportunities to simultaneously enhance public health. Staff reviewed the 725 projects funded through the REDC process in 2012 and 824 projects in 2013 and compared them against evidence-based and recommended interventions for increasing access to healthy foods and physical activity in communities. The analysis found close to two hundred projects that simultaneously meet health and economic development goals. This approach can be utilized by other states and communities to align economic development initiatives with community health improvement efforts.

Description
Research demonstrates that the way communities are designed can make it easier for people to live healthier lives.[ii]  For instance, physical activity has been shown to prolong life, and there are ways to design communities to make daily activities like walking, biking and shopping easier and safer.  Making physical activity an easier choice can reduce risks associated with leading chronic diseases, such as stroke, cardiovascular disease, and some types of cancer.[iii].  The methodology developed for this analysis can help others interested in building multi-sector partnerships develop and implement projects that promote health in a way that will have synergy with economic development goals.  This presentation will use NYAM's analysis of the New York State REDC funding process to show how specific evidence-based interventions that promote health can be incorporated into economic development initiatives.

Lessons Learned
1.  There are specific strategies to help shape communities’ physical and social environments in ways that promote healthy behaviors, prevent illness and premature death, and promote community and economic development. These strategies include promoting active design, encouraging transit oriented development, and making healthy and local foods available through investment in grocery stores, farmers markets, and improved regional agricultural infrastructure  2. Funding for projects that promote health in the REDC process is increasing, which shows there are great examples for how economic development and health can be mutually supportive. *Out of the 725 projects awarded in 2012, there were 45 potentially health promoting projects, with 21 projects supporting healthy eating and 24 projects supporting physical activity. The 45 projects represent 2.2% of total funding ($16 million of the total $738 million). *Out of the 824 projects that were awarded in 2013, there were 22 projects that support healthy eating and 109 that support physical activity. The 131 projects cover 7.4% of total funding ($53 million of the total $716 million).   3. The distribution of projects with potential to promote healthy eating and physical activity varies greatly. Opportunities exist through the REDC process to promote greater health equity across demographic and county lines.

Conclusions
Statewide economic development initiatives represent an exciting opportunity for strategic planning and alignment of multiple resources toward improving health. The 2012 and 2013 awards in New York State demonstrated increased opportunities for health promotion through the REDC process, the core goal of which may be economic development. As NYS refines its economic development initiatives, and other states consider similar initiatives, there will be additional opportunities to consider health as a core objective in economic development activities.  For example, the creation of metrics by which economic development projects can account for health in plans and setting targets for dollars invested in projects that have a positive impact on health.

Next Steps
NYAM plans to work with partners across the REDCs in NYS to inform its members about how health and economic development are mutually supportive and to identify future opportunities for synergistic projects.  NYAM also plans to repeat its analysis of the NYS REDCs with an expanded set of metrics for the next round of awards to see how funding for projects that support healthy behaviors are maybe changing over time.

References

  1. “Focus Area 1: Reduce Obesity in Children and Adults,” New York State Department of Health, accessed August 26, 2013, http://www.health.ny.gov/prevention/ prevention_agenda/2013-2017/plan/chronic_diseases/focus_area_1.htm.
  2. “Healthy Community Design,” Centers for Disease Control and Prevention, accessed August 14, 2014, http://www.cdc.gov/healthyplaces/factsheets/healthy_community_design_factsheet_final.pdf.
  3. McCann BA, Ewing R. Measuring the effects of sprawl: A national analysis of physical activity, obesity and chronic disease. Smart Growth America Surface Transportation Policy Project: September 2003, accessed August 14, 2014, http://www.smartgrowthamerica.org/documents/HealthSprawl8.03-1.pdf and Centers for Disease Control and Prevention. Physical activity for everyone [online], accessed August 14, 2014, www.cdc.gov/physicalactivity/everyone/guidelines/.

 

Support / Funding Source
The New York Academy of Medicine’s work on funding from the New York State Department of Health, DASH-NY serves as New York State’s Obesity Prevention Coalition and Policy Center.

Authors: 
Monica Chierici, MPA, The New York Academy of Medicine
Location by State: 
Study Type: 

Boosting Boston's State of Place: A Research and Practice Love Story

Date: 
02/23/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
Walkability is tied to many health, social, environmental, and most recently, economic benefits. Concurrently, walkability is influencing an increasing number of individuals and firms locational decisions: 80% of Americans aged 18-34 want to live in walkable places; over 40% of those over 50 want to live within a mile of daily needs and services; and in 2011, 58% of venture capital in the top five US markets went to firms located in walkable areas.   Yet walkability seems out of reach. The average walkability of US cities with populations over 200,000 is 47 out of a possible 100 based on Walk Score. While many real estate, community development, and government stakeholders recognize that walkability is key to livability and economic competitiveness, paving that path has proven challenging.   A number of barriers to implementing or facilitating walkable development exist. Public sector stakeholders lack mechanisms by which to identify the most effective interventions or investments. They often lack the metrics, capacity, expertise, or political will to implement evidence-based approaches that could maximize walkability and leverage community change. Moreover, many public stakeholders still find it difficult to communicate (and justify) the benefits – especially economic benefits – of walkable developments, both to the community and to developers (progressive or otherwise). On the private sector side, a growing number of responsible property investors are looking to fund projects with a social impact – like walkability – but lack proper metrics to gauge that impact, both in terms of predicting it pre-project and then measuring it post-project. This presentation will 1) describe State of Place, an empirically based data analytics and community engagement platform that helps cities and social impact stakeholders make smarter planning, economic development, and investment decisions to boost walkability and health and 2) present a case study of how State of Place served as a mechanism to guide the investment and development decisions of the Healthy Neighborhood Equity Fund (HNEF), a $30 million private equity real estate fund, created via a public-private partnership, that invests in high-impact, transformative real estate projects that deliver social, environmental, and community health benefits in addition to financial returns.

Description
State of Place was born out of the Irvine Minnesota Inventory (IMI), a widely-used, objective audit tool that measures built environment features tied to walkability funded by the Robert Wood Johnson foundation in the first round of Active Living Research grants. For years, practitioners sought ways to adapt this tool, but it lacked a non-researcher user friendly analytical framework. State of Place addresses that need and seeks to ameliorate existing barriers to implementing walkable development.  State of Place trains community stakeholders themselves to use an updated, app-based version of the IMI to collect data, block by block, on over 280 built environment features, fostering community engagement. The State of Place Index, a score from 0-100 that measures place quality, along ten urban design dimensions empirically tied to walkability and economic value, is then calculated. The State of Place Index classifies both existing places and projected projects’ assets and needs, helping to identify the most effective community interventions and investments, based on communities’ performance, budget, goals, capacity, feasibility, and community feedback. State of Place has been used in a number of projects, ranging from creating regional economic development strategies to guiding walkable development projects.   The HNEF was created by the Conservation Law Foundation Ventures (CLFV) group in partnership with the Massachusetts Housing Investment Corporation (MHIC) and the State’s Executive Office of Housing and Economic Development. The HNEF uses a “Quadruple Bottom Line” (QBL) approach, evaluating projects based on community, environmental, and health impacts in addition to financial returns, focusing on historically distressed Boston neighborhoods.   This presentation will explain the development of State of Place and how CLFV is using it as a key metric to screen and choose the projects they will fund and as a way to provide objective feedback to developers of ways to facilitate more walkability.

Lessons Learned
Translating research tools into evidence-based planning and real estate approaches is challenging, both in terms of establishing a viable business model and communicating the values of such tools in an effective, relatable way. Implementation requires flexibility on the researchers part and willing early adopters.

Conclusions
Building effective evidence based tools requires a transdisciplinary approach that not only incorporates various areas of research and methodologies, but also bridges academia and practice, including applying Lean Startup business development principles, using multi-channeled communication, and engaging across sectors – both in person and in print .

Next Steps
The State of Place tool will be translated into a Software as a Service (SaaS) platform that can be integrated into cities’, developers’, and investors’ decision-making processes. Also, additional studies will be conducted to assess the relationship between State of Place and potential health costs savings and to examine the actual impact of State of Place’s recommended investments and interventions.

Authors: 
Mariela Alfonzo, PhD, State of Place / New York University
Location by State: 
Study Type: 

The Role of Health-Related Community Investing as an Active Living Research Implementation Strategy

Date: 
02/23/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
The National Prevention Strategy [1] recognizes active living as a priority area for reducing the burden of chronic disease, and emphasizes safe and healthy community environments as a key strategic direction to guide actions that will demonstrably improve health. New financial incentives created by the Affordable Care Act to facilitate population health, complemented by recent private sector interest in health-related community investing [2-4] provide an unprecedented opportunity to implement active living policies and create healthy community environments, particularly for populations who need them most. For example, population subgroups that are at increased risk of obesity and related chronic diseases include lower socioeconomic (SES) persons [5], racial/ethnic minorities [6, 7], those living in rural areas of the U.S. [8], and persons with disabilities such as mobility limitations [9] [10, 11]. The purpose of this paper is to explore a key aspect of policy implementation pertaining to Active Living Research: Innovative financing mechanisms to support safe places for physical activity, such as high quality parks, trails, community recreation areas, access to healthy foods, and multi-modal transportation systems.   We will explore health-related community investing and new mechanisms created under the Affordable Care Act (ACA) that can be leveraged to support activity-friendly community environments.

Description
We will share lessons learned from the Financial Innovations Roundtable (FIR), which has created cross-sector partnerships among conventional and non-traditional lenders, community development organizations, and other types of financial institutions over the past 14 years to provide low-income communities with increased access to capital and financial services. Recently, the FIR entered into a partnership with the Federal Reserve Board of Governors in Washington, D.C., and selected health-related community investing as its focus for 2014. Although health is a new explicit focus for the FIR, many successful ideas developed at the FIR have been implemented, resulting in transformative investments in affordable housing, small and minority businesses, community facilities, and other community development efforts, in addition to new tools, policies and practices. Over the past year, the FIR engaged financial institutions, funders, and health partners to holistically examine the social determinants of health - including pertinent ALR domains such as community recreational environments and transportation systems.  Through document review, analysis of transcripts from the FIR’s 2014 dialogue, and interviews with FIR members, and case examples, we explore potential partnerships, synergies, and focus areas relevant to ALR goals.

Lessons Learned
We will have a complete summary of lessons learned as FIR continues its dialogues focused on healthy communities through 2014-15. Preliminary lessons learned include:  1)  FIR stakeholders established a matrix to delineate how various community stakeholders can define community, list accountability mechanisms, and identify opportunities for alignment; 2)   FIR stakeholders are deeply committed to addressing the social determinants of health and improving places where we live, learn, work, and play; 3)   FIR stakeholders expressed interest in learning more about shared metrics that allow us to measure positive change in communities. This is an important point of intersection with RWJF/ALR, as many existing metrics developed by RWJF/ALR may be useful to the FIR; 4)   Innovative examples from diverse communities were shared, such as Boston Community Capital’s focus on “transformation zones,” (which support grocery stores, health clinics, housing areas, commercial space, and housing).   Similarly, the Federal Reserve Bank of Boston’s Working Cities Challenge is helping to improve the health of low-income people while advancing collaborative leadership in Massachusetts’ smaller cities. As an awardee, the City of Fitchburg, MA works through its broad health promotion partnership, Fun ‘n FITchburg, to develop shared metrics for neighborhood health and well-being with the goal of making its North of Main neighborhood a place where residents choose to live, work, and invest. In Omaha, NE, traditional providers and funders of clinical care now invest in infrastructure projects to create better access to active transportation in the public space. The city’s new B-cycle membership bike rental system and rental stations have been supported by funders such as Blue Cross Blue Shield of Nebraska, Alegent Creighton Health, the Peter Kiewit Foundation and the Sherwood Foundation.  5)   FIR stakeholders identified Treasurers of hospitals as frequently overlooked partners,as they can facilitate collaborations between hospitals, Community Development Finance Institutions, and banks.

Conclusions
Raising awareness about innovative health-related community investing strategies and exploring ways to partner with community development and other types of financial institutions are key aspects of ALR policy implementation. By addressing these areas, the National Prevention Strategy’s key strategic directions pertaining to active living - safe and healthy community environments, empowered people, and elimination of health disparities - are more likely to be achieved.

Next Steps
The FIR stakeholders are currently exploring new opportunities for alignment, and discussing ways to diversify investment strategies to improve health outcomes. An important opportunity exists to explore synergies with ALR, particularly with respect to harnessing innovative financing mechanisms to  implement active living policies.

References

  1. National Prevention Council. National Prevention Strategy. 2011  [cited 2014 July 27]; Available from: http://www.surgeongeneral.gov/initiatives/prevention/strategy/index.html#The%20Strategic%20Directions.
  2. Mair, J., Milligan,K.,, Q&A Roundtable on Impact Investing. Stanford Social Innovation Review, 2012.
  3. Fleming, D., Achieving Individual Health through Community Investment: A Perspective from King County, Washington, R.C.t.B.a.H. America, Editor. 2013.
  4. Swack, M. Financial Innovations Roundtable. 2014  [cited 2014 August 14]; Available from: https://carsey.unh.edu/csif/financial-innovations-roundtable#.
  5. Go, A.S., et al., Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation, 2014. 129(3): p. e28-e292.
  6. Kurian, A.K. and K.M. Cardarelli, Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis, 2007. 17(1): p. 143-52.
  7. Mensah, G.A., et al., State of disparities in cardiovascular health in the United States. Circulation, 2005. 111(10): p. 1233-41.
  8. Cooper, R., et al., Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States findings of the national    conference on cardiovascular disease prevention. Circulation, 2000. 102(25): p. 3137-3147.
  9. Kirchner, C.E., E.G. Gerber, and B.C. Smith, Designed to deter. Community barriers to physical activity for people with visual or motor impairments. Am J Prev Med, 2008. 34(4): p. 349-52.
  10. US Census Bureau, American Community Survey and Peurto Rico Community Survey 2012 Subject Definitions. 2012.
  11. US Census Bureau, American FactFinder. Disability Characteristics 2010-2012 American Community Survey 3-Year Estimates. 2010.
Authors: 
Semra Aytur, PhD, MPH, University of New Hampshire
Location by State: 
Study Type: 

A National Survey of Correlates of Local Health Department Engagement in Community Policy to Encourage Physical Activity

Date: 
02/23/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
Evidence has accumulated that particular environmental conditions and characteristics correlate with walking and bicycling, including participation in these behaviors for active transportation.  Public health authorities have recommended strategies in the realms of land use and urban design, transportation and recreation access for communities to become more walk- and bicycle-friendly. Model policies in these domains exist. Policy development is one of the core functions of public health, and evidence suggests that policy activity or development by local health departments (LHDs) correlates with policy adoption. However, there are critical practice gaps. Participation by local health officials in the built environment policy process, including policies related to land use and urban design, transportation and recreational access that promote physical activity, is limited.  Greater LHD involvement could increase the adoption and implementation of policies needed for national physical activity objectives and benchmarks to be met. LHD characteristics and activities have been shown to affect delivery of essential public health services, engagement in quality improvement efforts, partnership involvement, ties to other LHDs that could facilitate implementation of evidence-based programming, and public health performance. Better understanding of LHD characteristics associated with participation in built environment policy processes is an important first step to developing tailored interventions to increase policy implementation.

Objectives
We assessed correlates of local health department (LHD) participation in community-focused policy and advocacy activities to encourage physical activity in the past two years in a nationally representative sample of LHD directors.

Methods
Cross-sectional data from the National Association of County and City Health Officials’ 2013 National Profile of Local Health Departments were analyzed. 490 LHD directors completed both Core and Module 1 of the web-based survey (79% response rate). Policy participation was measured by a series of questions that first asked if the LHD had participated in obesity/chronic disease prevention policy and advocacy activities in the past two years. Those who responded yes were specifically asked about involvement in community level urban design and land use policies to encourage physical activity, active transportation options, and expanding access to recreational facilities. Correlates included structural characteristics (population size served, region, jurisdiction type, staffing), quality improvement efforts (completion of Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP), Public Health Accreditation Board (PHAB) status, use of core competencies for public health workers, and use of Guide to Community Preventive Services), and collaboration (community land use partnership, cross-jurisdictional sharing of resources). Multivariable logistic regression models were used.

Results
Less than one-quarter of LHD directors reported that their department had been involved in policy and advocacy activities related to urban design and land use (25%), active transportation (16%) and recreational facility access (23%). In multivariable logistic regression models, LHDs with populations of 500,000 or more and consistent use of the Community Guide were associated with participation in each of the three policy types. Higher Full Time Equivalent (FTE) levels were associated with greater participation in policy to increase active transportation, with trends of an association with participation in policy for land use and urban design and expanding recreational access. LHDs with a community health improvement plan were more likely to participate in urban design and land use policy, whereas LHDs that were undecided about pursuing accreditation status were less likely to participate in recreational policy.  Participation in a community partnership related to land use was associated with urban design and land use and active transportation policy activity.

Conclusions
Population size served and staffing resources correlated with LHD participation in policy activities to increase community physical activity. Quality improvement efforts such as CHIP development, PHAB status and use of the Community Guide were associated with or show a trend toward policy participation. Collaboration in terms of partnering with the community on land use, but not resource sharing across LHDs, correlated with policy activity to increase physical activity at the community level.

Implications
Opportunities for interventions at the local level to boost policy implementation include assisting LHDs that serve smaller population sizes, integrating community physical activity strategies into LHD quality improvement efforts, and coaching LHDs on partnership-building with officials and the community in the areas of land use, transportation and recreation by increasing their capacity in these unfamiliar technical areas.

Support / Funding Source
This analysis is a product of a Prevention Research Center and was supported by Cooperative Agreement Number U48/DP001933 from the Centers for Disease Control and Prevention.

Authors: 
Karin Valentine Goins, MPH, University of Massachusetts Medical School
Location by State: 
Population: 
Study Type: 

Evaluation of Healthy Kids, Healthy Communities

Date: 
02/25/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
The evaluation of the Robert Wood Johnson Foundation’s (RWJF) Healthy Kids, Healthy Communities (HKHC) national program is an example of an effort to apply systems science and mixed-methods evaluation approaches to comprehensive policy, systems, and environmental interventions. The HKHC national program (www.healthykidshealthycommunities.org) supported community-based efforts to implement policy, system, and environmental changes aimed to make communities healthier, particularly for higher-risk children and families (ethnic/racial minorities, lower-income populations, or those living in southern states), by increasing both active living and healthy eating. RWJF funded one year of evaluation planning (mid-March 2009 to mid-March 2010) and four subsequent years to support a mixed-methods evaluation of HKHC (April 2010 to March 2014), including all 49 communities across the United States and Puerto Rico. Communities selected to participate in this multi-year demonstration varied in population and geographic sizes (municipal to eight counties), sociodemographic composition (median annual household income, race/ethnicity, urban/suburban/rural), scale (county-wide to specific organizations or settings), scope of their proposed strategies (e.g., new or modified parks versus nutrition assistance in farmers’ markets), lead organizations (nonprofit, education, philanthropy, government), and age of the community partnerships. The evaluation did not focus on changes in individual behaviors and health outcomes.

Description
Eight complementary evaluation methods addressed four primary aims seeking to: 1) coordinate data collection for the evaluation through the web-based project management system and provide training and technical assistance for use of this system; 2) guide data collection and analysis through use of the Assessment & Evaluation Toolkit; 3) conduct a quantitative cross-site impact evaluation among a subset of community partnership sites; and 4) conduct a qualitative cross-site process and impact evaluation among all 49 community partnership sites. The evaluation consisted of the following key components: HKHC Community Dashboard: This web-based project management system (www.hkhcdashboard.org) coordinated data collection for the evaluation. It was designed to encourage the formation of a collective learning network among community partnerships, Project Officers, and Evaluation Officers. This website included functions such as social networking, progress reporting, and access to the assessment and evaluation toolkit to maintain a steady flow of users over time and increase peer engagement across communities. Individual and Group Interviews: Evaluators collaborated with community partnerships to conduct individual and group interviews with staff, partners, and community representatives before, during, and after site visits. Interview protocols focused on organizational and community factors influencing processes and means used to develop, implement, and enforce policies. In addition, evaluators tracked costs and funding associated with the design, development, implementation, and enforcement of cross-site strategies. Group Model Building: The evaluation team and partners from the Social System Design Lab at Washington University in St. Louis co-designed a group model building process to develop behavior-over-time-graphs and graphical system dynamics models (causal loop diagrams) with community partnerships. These exercises provide deeper and shared insights among representatives from the community partnerships into the drivers of obesity dynamics, better understanding of local systems at play, more rigorous critique of assumptions underlying the systems, and greater “buy in” to high-leverage prevention policy recommendations. Enhanced Evaluation: The evaluation team created tools, protocols, and trainings for environmental audits and direct observations associated with cross-site strategies to be conducted by community partnerships. Participation in these methods was voluntary, yet 31 of 49 community partnerships engaged in these activities. Supplemental Methods: Evaluators also collected and analyzed data from an online partnership and community capacity survey, photos, community partnerships’ annual narrative and financial reports, and surveillance systems (e.g., U.S. census). A synopsis of cross-site findings with community examples will be presented.

Lessons Learned
Several themes emerged, including: the value of systems approaches, the need for capacity building for evaluation, the value of focusing on upstream and downstream outcomes, and the importance of practical approaches for dissemination. Constraints included: a lack of standards in the field for indicators and measures of many of these factors, difficulty in attributing effects or impacts to specific strategies, and challenges with analyzing, interpreting, and applying what is learned, particularly with respect to complex systems science methods.

Conclusions
Community-based initiatives such as HKHC provide promising approaches for addressing childhood obesity. This presentation illustrates how mixed-methods evaluation approaches can provide practice-relevant evidence that has the potential to improve population health. The mixed-methods evaluation of HKHC advances evaluation science related to community-based efforts for addressing childhood obesity in complex community settings.

Next Steps
This evaluation will inform research and practice related to the design, implementation, and evaluation of policy, system, and environmental interventions; key partners to engage in the process to change community environments; and possible causal relationships among social determinants as well as factors associated with partnership and community capacity that influence healthy eating and active living policies and environments, and health and health behaviors.

References
Evaluation of Healthy Kids, Healthy Communities Supplement  to be published in March/April 2015.

Support / Funding Source
Support for this evaluation was provided by a grant from the Robert Wood Johnson Foundation (#67099).

Authors: 
Laura Brennan, PhD, MPH, Transtria LLC
Location by State: 

A Longitudinal Study: The Impact of a Signalized Crosswalk on Crossing Behaviors in a Low-Income Minority Neighborhood

Date: 
02/24/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
There is a paucity of research exploring the behaviors of low-income community residents in context of their neighborhoods (Gordon-Larsen et al., 2006; Zhu & Lee, 2008). These underserved communities often are comprised of an outdated built environment with high-speed, high-volume streets resulting in limited access to parks and active transportation. Studies show that key neighborhood features, including high-speed traffic and general walkability, directly influence physical activity (Kaczynski et al., 2014; Handy et al., 2008). We have previously shown that the completion of a signalized crosswalk and median linking low-income housing with a public park showed positive effects on active living behaviors (Schultz et al., 2014). Additional data collection in 2014 provided an opportunity to examine the longevity of these behavioral changes associated with the crosswalk installation.

Objectives
This study aims to explore if previously observed built environmental influences on street crossing behaviors and traffic speed reductions have been sustained in a low-income minority neighborhood with significant barriers to physical activity opportunities.

Methods
Data collection occurred at one Intervention site (Providence Road) and one Control site (College Avenue) in Columbia, MO. The Control site was selected by examining relevant characteristics of the neighborhood (e.g., size, income level), and the corresponding street (e.g., number of lanes, typical traffic volumes/speeds, pedestrian crossing facilities). Street crossing behaviors were collected using direct observation and assessed the mode of transportation, designation of the crossing (e.g., Designation Zone: Designated Crossing [at intersections/crosswalks] or Non-Designated Crossing [e.g., other crossing point]), as well as race/ethnicity, gender, and age within 5-6 predetermined zones at both sites. Magnetic traffic detectors were also embedded in both the Intervention and Control streets during the data collection to capture traffic volume and speed. Data collection ran concurrently, at both sites, for a total of 21 observational shifts over the same two-week period in June 2012 (pre-intervention), June 2013 (post-intervention) and June 2014 (follow up). Crossing behaviors were recorded during three hour-long shifts (7:30am, 12:30pm, and 3:30pm), while traffic data were collected continuously for 150 hours during the first week. Traffic sensors were unavailable at the Control Site in 2014. Descriptive statistics were calculated for all variables. Analysis of Covariance (ANCOVA) models assessed changes in crossing behaviors at each site from 2012 to 2014, controlling for temperature. Changes in traffic speed (above the speed limit/below the speed limit) and volume at each site from 2012 to 2014 were analyzed using Pearson’s Chi Square.

Results
Total pedestrian crossings at the Intervention site did not significantly change from 2012(n=1,408) to 2013(n=1,352) or 2014(n=1,380; p=0.561), but there was a significant year*designation zone interaction(p=0.018). Pairwise comparisons of the Designated Crossings indicated an overall increase between Years 2012(M=1.050) and 2014(M=1.248; p=0.012) and Years 2012(M=1.050) and 2013(M=1.233; p=0.033), but not between Years 2013(M=1.233) and 2014(M=1.248; p=0.995). Pairwise comparisons of the Non-Designated Crossings indicated no change overall between Years 2012 and 2014(p=0.533), Years 2012 and 2013(p=0.917), or Years 2013 and 2014(p=0.894). There was also a significant year*designation zone*race interaction (p<0.001).

Conclusions
This study suggests that street crossing infrastructure improvements can help support lasting changes in pedestrian behavior. These data may help inform decisions regarding future street-crossing interventions and could be used to guide policies promoting physical activity in similar communities where high-speed arterials are barriers to parks and active living.

Implications
By demonstrating increased pedestrian safety and traffic calming longitudinally, this study adds support to the feasibility of advocacy efforts to promote transportation practices that favor safe pedestrian accessibility over vehicular traffic. These successful outcomes could be used to support advocacy efforts seeking to modify the built environment to increase physical activity in underserved neighborhoods.

References

  1. Gordon-Larsen, P., Nelson, M. C., Page, P., & Popkin, B. M. (2006). Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics, 117(2), 417-424. doi: 10.1542/peds.2005-0058.
  2. Handy, S. L., Cao, X., & Mokhtarian, P. L. (2008). The causal influence of neighborhood design on physical activity within the neighborhood: evidence from Northern California. American journal of health promotion, 22(5), 350-358.
  3. Kaczynski, A., Mohammad, J. K., Wilhelm Stanis, S. A., Bergstrom, R., & Sugiyama, T. (2014). Association of street connectivity and road traffic speed with park usage and park-based physical activity American journal of health promotion, 28(3), 197-203. doi: 10.4278/ajhp.120711-QUAN-339.
  4. Schultz, C., Wilhelm Stanis, S.A., Sayers, S., & Thomas, I. (March, 2014). Oral presentation for the 2014 Active Living Research Annual Conference. San Diego, CA.
  5. Zhu, X., & Lee, C. (2008). Walkability and safety around elementary schools economic and ethnic disparities. Am J Prev Med, 34(4), 282-290. doi: 10.1016/j.amepre.2008.01.024.

 

Support / Funding Source
University of Missouri Research Board Grant

Authors: 
Courtney Schultz, MS, North Carolina State University
Location by State: 

Learning from Outdoor Webcams: Capturing Active Commuting Behavior Across Environments

Date: 
02/24/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
Physical activity plays a role in numerous health outcomes including obesity, diabetes, heart disease, and cancer. Over 30% of adults and 17% of children and adolescents in the US are obese, with lack of physical activity due to constraints in the built environment being an important influence. Lack of safe places to walk and bicycle and lack of access to parks and open space can impact the frequency, duration, and quality of physical activity of residents in urban settings. Physical activity may be purposive such as a jog in a park, or incidental such as a ten minute walk from home to a public transit stop. In both purposive and incidental cases the designs of urban built environments influence the decisions and experience of physical activity behaviors.

Objectives
Our team is investigating a line of research using publically available outdoor webcams, such as street intersection webcams, to capture active transportation in urban settings. A necessary initial step in this work is understanding the prevalence of active transportation across a variety of captured webcams.

Methods
Two webcams in the Archive of Many Outdoor Scenes (AMOS) captured the addition of a painted crosswalk (November 2007) for a commercial and residential street intersection in Washington, DC. For this analysis, we used photographs from AMOS captured every 30 minutes over a 14-month period between 7am and 7pm in both locations, before and after crosswalk additions (May-November, 2007 and 2008). The use of this webcam data allowed for a pre–post crosswalk travel-mode analysis across intersections located in different land use areas. Amazon Mechanical Turk (MTurk) was used to crowdsource image annotation, counting the number of pedestrians, cyclists, and vehicles per image. The odds of observing each transportation mode in Year 2 compared to Year 1 were examined. We are currently analyzing seasonal differences in peak active transportation in both locations.

Results
A total of 12076 pedestrians and 833 cyclists were observed in the commercial intersection, compared to 506 pedestrians and 166 cyclists in the residential location. The presence of a painted crosswalk predicted a significant increase in the number of pedestrians in both commercial (OR=1.62, 95% CI=1.36-1.93) and residential (OR=1.47, 95% CI=1.07-2.01) locations on weekdays. Pedestrian activity peaked at three times downtown (9am, 1pm, 6pm) and twice in the residential location (8am and 6pm) Afternoon biking activity peaked an hour earlier (6pm) in the downtown location than the residential location (7pm). Pedestrian activity was highest on Wednesdays for both groups. Both locations experienced the highest rates of bicycling and pedestrian activity during the summer season and on weekdays. Findings are consistent with previous observation and personnel-intensive studies of peak commuting activity.

Conclusions
Findings suggest webcams and crowdsourcing have great potential for capturing active transportation patterns. The use of public webcams and MTurks offer an inexpensive (US$0.02/photo) means to evaluate patterns of commuting behavior and potentially the effectiveness of built environment policies and interventions.

Implications
Using an eight-year archive of captured webcam images and crowdsources, we have demonstrated that improvements in urban built environments are associated with subsequent and significant increases in physical activity behaviors. Webcams are able to capture a variety of built environment attributes and our previous studies have shown that webcams are a reliable and valid source of built environment information. As such, the emerging technology of publicly available webcams facilitates both consistent uptake and potentially timely dissemination of physical activity and built environment behaviors across a variety of outdoor environments. The AMOS webcams have the potential to serve as an important and cost-effective part of urban environment and public health surveillance to evaluate patterns and trends of population-level physical activity behavior in diverse built environments.

References

  1. Brownson, R. C., Hoehner, C. M., Day, K., Forsyth, A., & Sallis, J.F. . (2009). Measuring the Built Environment for Physical Activity: State of the Science. American Journal of Preventive Medicine, 36(4 Supplement), S99-123.e112. doi: 10.1016/j.amepre.2009.01.005
  2. Jackson, R. J. (2003). The Impact of the Built Environment on Health: An Emerging Field. Am J Public Health, 93(9), 1382-1384. doi: 10.2105/AJPH.93.9.1382
  3. Jackson, R. J., Dannenberg, Andrew L., & Frumkin, Howard. (2013). Health and the Built Environment: 10 Years After. American Journal of Public Health, 103(9), 1542-1544. doi: 10.2105/ajph.2013.301482
  4. CDC. (2009). Division of Nutrition, Physical Activity and Obesity. Available from: http://www.cdc.gov/nccdphp/dnpa/index.htm.
  5. CDC. (2011). Guide To Community Preventive Services. Atlanta, GA: Epidemiology Program Office, CDC.

 

Support / Funding Source
This work is supported by a National Cancer Institute (NCI) grant #1R21CA186481-01s. The opinions or assertions contained herein are the private ones of the authors and are not considered as official or reflecting the views of the NCI.

Authors: 
Alicia Manteiga, MPH, Washington University in St. Louis
Location by State: 
Population: 

Factors Influencing Choice of Commuting Mode

Date: 
02/24/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
Walking and cycling are recommended forms of moderate-to-vigorous physical activity (MVPA) that can serve as means of travel to substitute for short car trips. Walking and cycling to work (active commuting) have the potential to be incorporated into commuters’ daily routine and might therefore be more easily adopted and maintained than other forms of physical activity. In addition, active commuting is specifically associated with reduced cardiovascular risk, physical fitness, and weight control in adults. The proportion of walking and cycling to work in the US (5%) is extremely low compared to many European countries, such as Denmark (31%), Germany (32%), the Netherlands (47%), and Switzerland (50%). The use of public transit usually involves walking or cycling to and from bus or train stations and has shown the potential to contribute to the commuter’s overall physical activity level. Despite that, public transit and multi-modal transit have been studied less as a mode choice compared to active commuting. In order to develop effective interventions to promote alternative commuting modes (other than car driving), an understanding of the factors associated with this particular behavior is required.

Objectives
Using data from a large sample of working adults in four Missouri metropolitan areas, this analysis examines the combined impact of self-reported home and worksite neighborhood environmental factors and worksite supports and policies on employees’ commuting modes.

Methods
The participants were from the Supports at Home and Work for Maintaining Energy Balance (SHOW-ME) study, a cross-sectional study designed to understand environmental and worksite policy influences on employees’ obesity status. Between 2012 and 2013, participants residing in four Missouri metropolitan areas were interviewed via phone and provided informations on socio-demographic characteristics. A subset of questions from the Physical Activity Neighborhood Environment Survey (PANES) was used to measure built environment features in the home neighborhood environment. Ten PANES questions were adapted to ask similar questions about the worksite neighborhood environment. Worksite supports and policies were determined using eighteen questions asking whether specific policies or features supporting physical activity were available at the worksite and if the participants ever used them. Commuting mode were self-reported and categorized into car driving, public transit, and active commuting (or multi-modal). Commuting distance was calculated using geographic information system. Multivariate logistic regressions were used to examine the correlates of using public transit and active commuting (or multi-modal) respectively, adjusting for selected significant covariates such as age, sex, BMI, education, marital status, number of children in the household, household income and household car ownership,. All analyses were performed using Stata version 12.0 (STATA Corp., College Station, Texas, USA).

Results
The majority of 1,338 included participants (69.3% women) reported commuting by driving (88.9%); while only 4.9% used public transit and 6.2% used active modes. In final adjusted models, living within 10-15 minutes walking distance from a transit stop is associated with higher likelihood of using public transit (3.78, CI 95%: 1.00-14.9) compared to those home neighborhoods without transit stops within walking distance. Employees who reported ever having used worksite incentives to use public transit had a higher likelihood of using public transit modes (23.9, CI 95%: 10.4 – 54.8) compared to those whose worksites provide no such incentive. For multi-modal or active commuting mode, living 10 miles or further from work is associated with less likelihood (0.12, CI 95%: 0.05 – 0.29) of using any active mode to commute compared to commuters who drive. While having free or low cost recreation facilities around the worksite is associated with higher likelihood (1.85, CI 95%: 1.03 – 3.32) of using active commuting mode. In addition, reporting having ever used the bike facility to lock bikes at the worksite is associated with higher likelihood (9.17, CI 95%: 3.84 – 21.8) of using active commuting mode.

Conclusions
Both environmental factors and worksite supports and policies are associated with the use of public transit, active commuting or multi-modal transportation. These findings add to the body of research evidence on the promotion of alternative commuting mode other than car driving, in order to promote physical activity in the employed population at large. Using longitudinal design, future studies should explore the potential of alternative commuting mode interventions, including policies and supports that involve worksites effort.

Implications
While an improvement to the built environment may require long-term effort, worksite supports and policies such as incentives and safe bike storage could be implemented in the short-term with minimum effort. The prevalence of active commuting in the US as well as our study sample is noticeably lower than many European countries. Thus there is a potential to implement and evaluate the cost-effectiveness of worksite supports and policies in promoting alternative commuting mode other than car driving, as well as the longitudinal impact on wider health outcomes and productivity associated with active commuting.

Support / Funding Source
The SHOW-ME study is supported by the Transdisciplinary Research on Energetics and Cancer (TREC) Center at Washington University in St. Louis. The TREC Center is funded by the National Cancer Institute at NIH (U54 CA155496), Washington University and the Alvin J. Siteman Cancer Center. We acknowledge all the participants in this study. We thank to Dr. Jung Ae Lee for providing statistical consultant for this work.

Authors: 
Lin Yang, PhD, Washington University in St. Louis
Location by State: 
Study Type: 

Worksite Policies and Supports for Physical Activity

Date: 
02/24/2015
Description: 

Presentation at the 2015 Active Living Research Annual Conference.

Abstract: 

Background
The etiology of obesity is believed to be multi-factorial, including genetic, metabolic, behavioral, psycho-social, and environmental influences. Individual behaviors that directly affect energy balance include diet and physical activity (PA), which are influenced by larger psycho-social, environmental, organizational, and policy factors. If the factors responsible for physical inactivity and obesity at multiple levels can be better understood, we can identify more appropriate targets for dissemination and implementation. Because many employed adults spend at least half of their waking hours at work, worksites are excellent venues for health promotion. Due to rising costs of healthcare associated with obesity-related illness and disability, there is interest among employers in offering programs or benefits to assist employees in making healthful decisions. A particularly promising type of worksite health promotion strategy involves environmental and policy changes that may assist employees in making healthful choices at work (e.g., easy access to stairways, on-site exercise facilities, time or breaks for PA during the work day).

Objectives
The overall goal of this project is to understand how environments and policies where employed adults work are associated with energy balance. Here we examine whether specific types of worksite supports for PA are predictive of total and domain-specific PA.

Methods
Participants were from the Supports at Home and Work for Maintaining Energy Balance (SHOW-ME) study, a cross-sectional study to understand environmental and worksite policy influences on employees’ obesity status. Census tracts in four Missouri metropolitan areas (St. Louis, Kansas City, Springfield, and Columbia) were used for sampling. Between 2012 and 2013, 2,015 participants were recruited who met each of the following criteria: between the age of 21 and 65 years; employed outside of the home at one primary location; employed for 20 or more hours per week at one site with at least five employees; not pregnant; and no physical limitation to prevent walking or bicycling in the past week. Recruited participants completed a telephone-based survey. The survey instrument was developed using existing self-reported and environmental assessment instruments and input from a Questionnaire Advisory Panel. Worksite supports for PA included 18 unique items (e.g., ‘Does your workplace offer…’ ‘Incentives to use public transit, such as free or reduced transit pass,’ ‘Flexible time for PA during the work day’) as well as specific usage questions for 14 of the 18 items (e.g., ‘Have you used X in the past two months?’). PA and PA sub-domains (travel, work, and leisure) were measured using the International Physical Activity Questionnaire long form.  Analyses include unadjusted and adjusted odds of meeting domain-specific and total PA CDC recommendations (150 minutes per week), provided access and use of the 32 worksite support questions. Analyses adjusted for race, gender, age, income, employer size, self-reported health, obesity, and hours worked per week. Limited stratified results have been completed. Cumulative results (e.g., access and use to incentives to bike/walk to work AND access to a shower) are forthcoming.

Results
Access to five of 18 worksite supports for PA were significantly associated with increased odds of meeting the CDC’s recommended 150 minutes of moderate and vigorous PA. These were access to bike storage, flextime for PA, PA breaks during meetings, incentives to bike/walk to work, and maps or signs of worksite walking routes. Nine of 14 use of PA supports were associated with significant odds of meeting PA recommendations, including use of bike storage, shower at work, and outdoor exercise facilities. Of specific interest was the worksite supports associated with travel-domain PA. In unadjusted analyses, access to bike storage was associated with a 1.31 (95% CI: 1.03, 1.65) increase in odds of obtaining 150 minutes of PA during travel alone. Using bike storage was associated with a 4.40 (2.75, 7.02) increase in odds of meeting 150 minutes of PA. After adjustment the odds of obtaining 150 minutes of travel PA were only reduced to 4.32 (2.48, 7.52). For age groups there was a stepped progression in odds of meeting 150 minutes of travel PA. Odds ratios for meeting 150 minutes of travel PA were 4.06, 4.68, and 8.14, respectively for employees under the age of 45, 45-54, and older than 55 years. Each result was significant at p<0.05.

Conclusions
Access to and use of specific worksite policies and supports for PA increase the likelihood of employees meeting the CDC’s recommendation of 150 minutes of PA per week. The use of supports had greater associations with PA than mere access to supports, suggesting future research and intervention efforts should be primed to move from awareness of supports for PA to regular use of the supports.

Implications
Worksite wellness plans are on the rise across the US with worksites eager for evidence-based supports for increasing PA and reducing sedentary time. Our team is working to package results such that worksites can be informed of likely benefits associated with 18 unique supports as well as costs of specific supports.

Support / Funding Source
U54 CA155496-01 (Colditz, Center PI; Hipp, Project PI) NCI/NIH.  ‘A multilevel approach to energy balance and cancer across the life course: worksite policies and neighborhood influences on obesity and cancer risk.’

Authors: 
J. Aaron Hipp, PhD, Washington University in St. Louis
Location by State: 
Population: 
Study Type: 

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