Enhanced Access to Places for PA Combined with Informational Outreach

Part 1: Needs Assessment

• Describe in detail the population and setting with which you will work. Identify the public health problem. Use surveillance data to support the needs of the community. As appropriate, discuss the health disparities of your target community. (20 points)
  • Obesity is a serious problem in the United States, and while rates in a few states have declined over the years, there are certain states that have a higher rate compared to other states across the nation. Alabama is one of those states. According to The State of Obesity: Better Policies for a Healthier America released in September 2016, Alabama has the second highest adult obesity rate in the nation (State of Obesity, 2016). This average rate is up to 35.6%. Adults aged 45-64 have the highest rate at 40.4% (State of Obesity, 2016). Childhood obesity is also a problem in this state, with children aged 10-17 having the highest rate of obesity at 18.6% (State of Obesity, 2016). There are also several health gaps and disparities that can be leading to these high obesity rates in Alabama. Physical inactivity is one of them. American adults should be aiming for the recommended 150 minutes of moderate-vigorous physical activity a week and 75 minutes of vigorous activity to receive the health benefits associated with physical activity (World Health Organization, 2016). They should also be getting 300 minutes of physical activity to lose weight or maintain weight loss (World Health Organization, 2016). However, Alabama residents are not getting this amount; some are actually getting no physical activity at all. 29% of Alabama residents have reported doing no leisure-time physical activity, compared to the 20% United States average (County Health Rankings, 2015). In addition, children should be getting 60 minutes of physical activity for daily, however, only 19.4% of Alabama adolescents were meeting that recommendation (Centers of Disease Control, 2012). Physical inactivity is one of the top ten leading risk factors for death (World Health Organization, 2016). It is also a key risk factor for cardiovascular disease, cancer and diabetes (World Health Organization, 2016).
  • While this is a statewide problem, it can also be focused to a county problem. Mobile County, Alabama is the second most populous county in Alabama (US Census Bureau, 2015). Its obesity rate is 42.1%. Its demographics are about approximately 59.8% white, 35.5% African American, and the rest of the population is Hispanic, Asian or other races (US Census Bureau, 2015). It is very important to note that this county has an estimated 19.6% of its population living in poverty (US Census Bureau, 2015). In 2014, there were approximately 243.8 counts of heart disease per 100,000 population (Alabama Public Health Department, 2015).
  • One of the prominent public health problems in this county is that only 69% of population have access to exercise opportunities, including parks and recreational facilities, which is under both the United States and Alabama average (County Health Rankings, 2015). While this number seems pretty decent, there are some barriers and limitations to this number. For example, while a person may live close to a park there might a fee to enter, or the park entrance may be far. Another limitation to this data is that this does not account for multi-modal transportation. This can skew the numbers and make it appear that more people have access to parks and exercise facilities than actually do. This may be reflected in the physical inactivity rate of 29.3% for Mobile County, which is worse than the United States median of 25% (Centers of Disease Control, 2012). In 2011, only 39% of female Mobile County residents were meeting the recommended physical activity guidelines, compared the national average of 52.6% (Institute for Health Metrics and Evaluation, 2013). Men were slightly better, with 52.5% of males getting the recommended amount, compared to the national average of 56.3% (Institute for Health Metrics and Evaluation, 2013). It is evident that there is a physical inactivity problem in this county and access may be a prominent factor in it.
• What stakeholders may be needed along the way? Describe the role of each stakeholder, and the questions they may want answered about the intervention. Also briefly describe how a successful intervention would impact that stakeholder, and how an unsuccessful program might impact that stakeholder. Stakeholders may be individuals, groups, or organizations. (20 points)

Part 2: Intervention Identification

• State and define the intervention strategy – what does it mean? What populations has this strategy been used with? What settings has it been used in? How are your community characteristics similar or different to those of the communities in which the strategy has been effective? (20 points)
  • Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities: This intervention includes the efforts of communities to create or provide access to facilities where people can be physically active. Some examples of interventions include: providing access to weight-training and aerobic fitness equipment in fitness centers and facilities, creating walking trails, or providing access to fitness centers that are already nearby, via altering operating hours or reducing fees (Kahn et al, 2002). These interventions also included an educational component in addition to the increased access. Some examples of the educational component include “training on the equipment, health behavior education and techniques, seminars, counseling, risk screening, health forums and workshops, referrals to physician or additional services, health and fitness programs, and support or buddy systems.” (Kahn et al, 2002) Therefore, this intervention has multiple components that are extremely effective together in increasing physical activity and improving physical fitness of the community.
  • This intervention strategy has been implemented and effective in the United States with many different settings and diverse communities, including, but not limited to worksites, universities, federal buildings, low-income communities, men, women, and minorities (Kahn et al, 2002).
  • Mobile County is a diverse community with minorities making up 40% of the population. Also, it had an estimated 19.6% of its population living in poverty (US Census Bureau, 2015). Since the intervention has been so successful in a variety of populations, this intervention should be applicable and effective in Mobile County, provided it is adapted for the target population.
• Is the strategy recommended by the Task Force? Why or why not? (10 points)
  • Yes, this strategy is strongly recommended by the Task Force. The Task Force recommends these interventions because they have been proven to be effective at increasing physical activity many different populations. It has also been effective in decreasing adiposity, and produced no negative effects (Kahn et al, 2002).
• Provide at least 3 examples from existing articles (peer-reviewed preferably, but could come from other places). These should be different than the research-tested intervention programs(RTIP) listed already. You can include or link to this information, but you should provide different examples. (45 points total)
• #1:  (Wilson et al.)
  • Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
    • The PATH (Positive Action for Today’s Health) trial was a 24-month environmental intervention that improved safety and increased access to walking trails in underserved African-American communities. There were three communities which all received a different intervention: a police-patrolled walking program with social marketing, a police-patrolled walking program, or no-walking related intervention (general health education only). The trail was about 2 miles, and all of the walking leaders and coordinators were trained and CPR and safety prevention. Off-duty police officers were hired to patrol the trail during the regular scheduled walks (once a day on 6 days/week). Those in the community with the social marketing received five specific messages: 1) safety related to walking on the identified path, 2) improving physical health, 3) improving mental health and well-being, 4) building self confidence in engaging in regular walking and 5) improving community connectedness. They received these messages through a 12-month calendar which included spaces for goal setting, self-rewards and tracking progress. They also received print materials to reinforce monthly messages.
  • What were the outcomes measured?
    • The PATH research staff conducted health screening and measurement assessments at baseline, 6, 12, 18, and 24 months. They measured 7-day accelerometry estimates of PA, casual blood pressure, height and weight, blood sugar levels, waist circumference, medication use, psycho-social surveys and a 4-week PA recall.
  • What amount of change did they find?
    • The community with the social marketing and police-patrolled walking trails increased the number of walkers from 40 to 400 walkers per month by 9 months, and had an average of 200 walkers per month. However, there was no between group difference in the amount of MVPA.
• #2: (Koepp et al.)
  • Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
    • The researchers believed increased access to treadmill desks might help people lose weight, decrease sedentariness, and increase daily physical activity. This was a 1-year study that was conducted at Educational Credit Management Corporation (ECMC) in Oakdale, MN. Any employee with a sedentary job could volunteer to be a part of the trial. A 2-week baseline period preceded the treadmill desk intervention during which the subjects worked seated normally and underwent a measurement of daily physical activity. Then, a treadmill desk would replace their pre-existing desks. The treadmills had a maximum speed of 2 mph, and could be lowered for chair use at the press of a button.
  • What were the outcomes measured?
    • The researchers measured height and weight. Body composition was measured by an air-displacement plethysmography. Daily physical activity was monitored by a belt-worn accelerometer. Blood draws included measurements of glucose, HDLs, LDLs, total cholesterol, triglycerides, thyroid stimulating hormone, and hemoglobin A1C. Blood pressure was also measured. Resting, sitting, and walking energy expenditure was measured using indirect calorimetry. Surveys were conducted every 3 months to assess overall workplace performance, quality of work, quantity of work and quality of interactions with coworkers. Weekly surveys focused on workplace performance as self-assessed or assessed by their supervisors.
  • What amount of change did they find?
    • Daily sedentary time was reduced from 1,020 + 75 mins/day to 978 + 95 mins/day in 12 months. There was increase in daily physical activity from 70 + 25 mins/day to 109 + 62 mins/day in 12 months. The desk accounted for 90% of the increased activity. There were no significant changes in employee workplace performance or fat mass. Weight change ranged from -9 kg to +4 kg. HDLs significantly increased from 55 + 20 mg/dl to 60 + 23 mg/dl.
• #3: (Verstraete et al.)
  • Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
    • The purpose of this pretest-posttest study was to evaluate whether providing game equipment during recess and lunch breaks would have an effect on children’s activity levels. The study took place in three schools in Belgium with fifth and sixth grade children. All schools had a morning recess, lunch break, and afternoon recess. Those in the intervention group received game equipment and activity cards with examples of games and activities that could be performed with the equipment. Teachers agreed to help stimulate the children to play with game equipment. The game equipment included: two jump ropes, two double dutch ropes, two scoop sets, two flying discs, two catchballs, one poco bal, one plastic bal, two plastic hoops, two super grips, three juggling scarves, six juggling rings, six juggling beanballs, one diabolo, one angel-stick, four spinning plates, two sets of badminton racquets and two sets of oversized beach paddles.
  • What were the outcomes measured?
    • Accelerometers were used to measure children’s physical activity levels, and this data was then categorized into light, moderate or vigorous intensity activity. Data was expressed in percentages of recess time to account for school differences in recess length.
  • What amount of change did they find?
    • The average time spent on moderate and moderate to vigorous intensity physical activities increased significantly in the intervention group (48 to 61%), while it decreased in the control group (55 to 45%). The time spent on low intensity PA decrease in the intervention group and increased in the control group.

Part 3: Intervention Fit

• Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)

• Smart Objectives

  • By the end of the educational sessions, 95% of all of the people attending will be have reduced their sedentary time 33%.
  • Three months after gaining a gym membership, 75% of gym members will be reaching the physical activity guideline of 150 minutes of physical activity a week.

• Explain the logic of why this intervention may work. For example, why would teaching children about healthy eating change their actual eating behaviors? Or why would adding sidewalks increase physical activity for transportation or recreation? (15 points)
  • Improving access to and creating new areas where people can be more physical activity will definitely be effective in increasing the amount of physical activity a person is doing on a daily basis. There are many barriers to exercise, and they differ according to certain demographics. Based on a study that looked at motivation and barriers to exercise in college students, one of the main barriers to exercise was facility location.¹ In a study conducted with low-income individuals with type 2 diabetes, they found that the main barriers to exercise were lack of time, equipment, and exercise partners.² Lastly, among older adults with mobility limitations, their common barriers included lack of social support and unsuitable environment.³ This multi-component intervention includes (1) increasing access to gyms by reducing membership fees and increasing operating hours, (2) building more gym facilities, and (3) education on how to utilize the equipment. So, with this intervention we can reduce some of these main barriers that are affecting a wide variety of individuals. By reducing these barriers, people would be more likely to engage in more leisure-time physical activity and maybe even improve their weight status.
    • 1. Ebben, William, and Laura Brudzynski. “Motivations and barriers to exercise among college students.” Journal of Exercise Physiology Online 11.5 (2008): 1-11.
    • 2. Dutton, Gareth R., et al. “Barriers to physical activity among predominantly low-income African-American patients with type 2 diabetes.” Diabetes Care28.5 (2005): 1209-1210.
    • 3. Rasinaho, Minna, et al. “Motives for and barriers to physical activity among older adults with mobility limitations.” Journal of aging and physical activity15.1 (2007): 90.
• Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)
  •  Some limitations and things to mindful include:
    • Building new facilities is time and resource intensive. It could be very expensive and it is not guaranteed that the community will actually use them.
    • Building and zoning problems may prevent the process of actually building the facilities. This would prevent any behavior change since the facilities would not be available.
    • Incorrectly or inadequately trained staff members can affect success. This may prevent community members from continuing to use the facilities, or can result in an injury.
    • Poor advertisement can affect people from coming to the new facilities. Perhaps the community members did not know that the membership price was reduced or operating times are extended, so they do not come to the gyms, thus preventing behavior change.
    • Increased membership to gyms may cause them to be crowded which might turn people who regularly use the gyms away.
    • Transportation problems may be issue. Community members might want to go to the new facilities however, they may not have sidewalks or bus routes nearby that allow them to access them.

• What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)
  • I would collect the following information:
    • Number of new gym memberships
    • Demographic information
    • Leisure-time physical activity per individual
    • Knowledge of gym equipment (via pre- and post-test)
    • Aerobic capacity
    • Anthropometric measurements (weight, BF%, blood pressure, lipid panel)
    • Perceived self-efficacy and barriers
    • Gym equipment being used
    • Utilization of the support system
    • Number of education sessions attended
  • This information would give me clues on what is working and what is not working in the intervention. Since this is a community intervention, I want the community to feel like their needs are being met, so adjustments might need to be made. I also want the intervention to be effective and successful, so I would like to look at data involving the anthropometrics and physical activity measurements to see if the intervention is having the desired effect.
  • Process Evaluation: In regards to dose, five education sessions will be required for all new gym members so they can properly learn all of the gym equipment functions. By collecting data on the number of educational sessions attended I will be able to see if the correct dose is being met. Since 31% of Mobile county, Alabama residents report not having to access to areas for physical activity, we would like to reach those individuals. Data should be collected on demographic information to evaluate whether we are reaching the intended population. This data would also let us know if we are unintendedly reaching those who already have access. I would also like survey the target population to see if they aware of the program, since this could affect reach. For fidelity and implementation, I would collect data on the quality and accuracy of the educational sessions, facilities, and staffing and training to ensure that the intervention is consistent across all sites, and enough handouts are available. Also, I would collect information on participant satisfaction to see if there was something that they wanted included in the program that was not.

Part 4: Reflection

• Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)
  • While I believe that “Enhanced Access to Places for Physical Activity Combined with Informational Outreach” is the best suited strategy for this population, sometimes that is not what is feasible.  So, in order to choose the perfect second-choice strategy, it is important to know more about the population. According to the CDC, 13.5% of adults in Alabama have diabetes, and 40.4% have hypertension, while 18.6% of children in Alabama are obese. Physical inactivity is a key risk factor for chronic diseases, therefore, a strategy that would address this would be ideal for this population. Also, Mobile County AL has a diverse population, so it is important to have a strategy that reaches all races, ethnicities, age groups, and income levels. Thus, I believe the best strategy for this community and identified behavior would be a community-wide campaign. Not only are community-wide campaigns proven to be effective in increasing physical activity and improving physical fitness in adults and children, but they also increase knowledge of exercise and physical activity which is important for Mobile County AL community members.  In addition, community-wide campaigns are similar to the enhanced access strategy, in that they are both multicomponent, which allows the strategy to reach multiple people in a way that best suits them. Lastly, community-wide campaigns are very large-scale across multiple media platforms, which would be ideal for the second most populous county in Alabama. So, if I had to choose a second-choice strategy, community-wide campaigns would definitely be the next best choice.
• Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)
  • I really liked the Community Guide. I felt that it was a good resource that had several different evidence-based recommendations that can be utilized in a variety of situations. I liked how the recommendations provided answers to some of the common questions that are asked about interventions, such as “what has worked for others, and how well?” what might this intervention approach cost, and what am I likely to achieve through my investment? and what are the evidence gaps?”. I feel that answers to these questions really allow a health professional to choose the best suited intervention for their target population. I also liked how you could compare intervention strategies with each other. This makes it easy to really choose the ideal intervention. Lastly, I love that there are research-tested invention programs and their materials available for any health professional to use. This makes interventions able to be implemented at a quicker rate. However, I would really like to see a better formulated website. There should be a section where you can enter your target population characteristics and the website gives you interventions that might work for that community. This prevents accidently overlooking a strategy in a different category that might be perfect for your population. Something I did not like about the Community Guide is that the nutrition interventions were very limited. I definitely believe that there needs to be more collaboration with organizations like Academy of Nutrition and Dietetics in order to enhance this section. Overall, I believe that the Community Guide website (since it has been updated) is very user-friendly and with a little bit of improvement, will make the experience better for practitioners to use.