“Evidence into Action”: How to create societies that provide ongoing

physical activity support and promotion  

Dr Karen MartinSchool of Population Health,

The University of Western Australia

The Oxford Health Alliance Summit 2011

Creating active communities requires a multidimensional approach

Policies

Programs

Sustainable???

Partnerships

Planning and place

Before focusing on PA supportive environment - infrastructure for basic needs is priority (WHO Kobe Meeting Healthy Urban Planning)

1. Local economic development2. Safe, affordable and appropriate shelter3. Appropriate sanitation and drainage systems

Basic environmental needs come first

opportunity for redevelopment to support health including physical

activity…

rather than just redevelopment…..

Planning and place

Govt agreed to substitute the walls combination of stretches of • nature paths, including handrails for people with mobility problems • bicycle and skating paths • playgrounds

Rio de Janeiro, Brazil

Developing country example

Prioritise infrastructure improvements Hoehner, 2011

– comprehensive sidewalks– medians– crosswalks– street lighting– bike lanes– plantings

How to plan environments to support PA?

Planning and place

City of 7 million, of these 3 million live in poverty

Bogota’s former mayor shifted budgets intended forhighways to parks bike lanes mass-rapid public transit

Bogotá, Columbia

“I was almost impeached for getting cars off sidewalks which car owning upper classes had illegally appropriated for parking.”

Enrique Peñalosa, Mayor

Developing country example: focus on planning

300 km of bicycle lanes, stretch from the slums & suburbs into the capital

Ongoing project under concurrent development

Since lanes constructed, bicycle use increased by 5 x in the city

Between 300,000 and 400,000 trips made daily in Bogotá by bike

Bogotá, Columbia

Active commuting plus increasingpedestrian access

Ciclovia... Street closures

“I realized that we in the Third World are not going to catch up to the developed countries for two or three hundred years. If we defined our success just in terms of income per capita, we would have to accept ourselves as second- or third-rate societies – as a bunch of losers – which is not exactly enticing for our young people. So we are forced to find another measure of success. I think the only real obvious measure of success is happiness.”

Enrique Peñalosa

Bogotá, Columbia

Also some programs…

1. Point of decision prompts (Kahn 2002)strong evidence for effect effect sizes net increase from 2.5% to 128.6%

(see U Tube; piano stairs, the fun theory and Fast lane, the slide

2. Mass media campaigns (Leavy 2011)

few studies show effective reduction in PA when combined with other strategies (such as community involvement) may

be effective

What works??

Programs

Recent review of mass media PA campaigns campaigns reported higher awareness

• women• tertiary education• physically active women• women with active children

(Leavy 2011)

Messages and materials culturally adapted to specific populations improves intervention effectiveness (Müller-Riemenschneider 2008)

Mass-media interventions create awareness but not good investment for changing behavior when used alone (Müller-Riemenschneider 2008)

Do mass media programs preach to the converted???

more on mass media programs….

3. Community-wide programs/campaignsMass media plus social support

strong evidence for effect

4. School based programs↑ PE class (number/length),↑ MVPA, mandating PE

strong evidence for effect barriers: school or system based

5. Social support in community settingsSupport groups outside family, e.g. walking groups

strong evidence for effect barriers: costly, target fewer people

6. Individually adapted health behaviour change programsTeach participants specific skills relevant to their situation

strong evidence for effect barriers: costly, target fewer people (Kahn 2002)

Programs

PA promotion in Perth, Western Australia Western Australia, 2.3 mill, Perth city 1.7 mill, temperate climate • Various government and not-for-profit programs to promote PA

Find 30 everyday (adult- encourage 30 minutes each day) Be active (Physical activity taskforce, beactive.wa.gov.au) Travelsmart (encourage active transport transport.wa.gov.au/14890.asp)

• 61% respondents in recent adult survey were aware that 30 minutes of moderate-intensity PA is required on most days for good health.

s

Isolated city example: focus on programs

Adults; proportion participating in sufficient activity

1999 2002 2006 200950%

60%

70%

Proportion of adults sufficiently active in Western Australia btw 1999 and 2009

significant difference p< 0.05

PA trends in Perth, Western Australia

PA trends in Perth, Western Australia

Children’s physical activity remained stable between 2003 and 2008

41%59%

Primary school boysmet guidelines didn’t meet guidelines

27%

73%

Primary school girlsmet guidelines didn’t meet guidelines

38%62%

Secondary school boys

met guidelines didn’t meet guidelines

10%

90%

Secondary school girls

met guidelines didn’t meet guidelines

Take advantage of climate and place: Eg programs,

Nature Play natureplaywa.org.au

Opportunities in Perth….

Planning and infrastructure

likeridingabike.org

Congested city example: focus on programs PA promotion in London

Promising strategies and partnerships

Parks and recreation agencies (Bruton 2011)

Partnerships with schools e.g. sharing facilities, access to oval out of hours (Bruton 2011)

co-locating: with parks? community hub? 1. Maryland (co-location program)

2. Rosa Parks School, Oregonedfacilities.org/rl/community_use.cfm

Community participation (Bruton 2011)

Partnerships

San Diego County Childhood Obesity Initiative (COI)

Public/private partnership advocacy policy development environmental change government, healthcare, school and after school,

early childhood, community, media and business.

Early policy change success (school, workplace policies, planning policies etc)

Developed country example: focus on partnerships

Find a common agenda and shared solutions effectively engages partners from different sectors. e.g. climate change

Leadership and political will on multiple levels is critical

(Linton 2011)

(San Diego County COI)

Childhood Obesity Initiative recommendations

West Virginia University Department of Community Medicine

 

Place• Upgrading and connecting local trails

• Adding rest rooms and telephones

• Improving overall safety & aesthetics

• planning for an urban state park

• University engineering team to develop walkable community plan

Programs•mass media•involved local physician –prescription for walking•walking clinic

Developed country example: multifaceted

(Reger-Nash 2005)

Partnerships:

• On-going Walkable Wheeling Task Force (initiated by mayor)

• Local schools to expand youth physical activity

• Local clubs to develop walking opportunities• Engaged city agencies—mayor, streets, highways, parks, law

enforcement, planning, local clubs, government,• Schools, press, businesses, medical society, other

stakeholders

• Community advisory committee helped plan campaign

Wheeling Walks, West Virginia

Evaluation measuresMedia exposureSelf reported walking

Outcome30% of Wheeling's sedentary residents increased their walking to the recommended level compared to a 16% increase in a control community (14% net increase in Wheeling)

The cost pp to change sedentary to regular walker =$26.32 pp/per month.

Wheeling Walks, West Virginia

Results of intervention

Blue Zones Vitality Project, Albert Lea

http://www.bluezones.com/programs/vitality-cities/

Habitat

Community

Social Networks

Inner-self

Developed country example: multifaceted

Changes to the community

Partnerships:• AARP and the United Health Foundation funding• Local government• 60% city’s local restaurants, 51% largest employers, every school• Social, commercial, communal and professional networks

City of 18 000 people 25% participated in program

component

Initial program cost = approx $750 000

Albert Lea

Place• Workplace modifications• Space for community gardens• Bike and walking paths connected

Programs• Walking school bus and adult walking

teams• Standing or walking meetings

Policies• Amended school and workplace wellness

policies

Changes to the community

Albert Lea

Results of intervention

Project longevity:3.2 yrs

PA and weight:•Engaged in more PA•lost average 1.5 kg (every member of the community)

Other health benefits:•20% reduction in absenteeism for key employers •49% decrease in health care costs of city employees

Successful interventions are run by people who know the community and recommendations are specific and appropriate

(bespoke!)

Sustainable???

Albert Lea

Agita São Paulo, Brazil

• 37 mill State of Sao Paulo, started in 1996• WHO praised program as model for developing countries• Scientific board and executive board

Outcomes Reach: 60% Recall and knowledge: well distributed different socioeconomic groups The prevalence of people reaching the PA recommendation was 54.8%

Risk of being sedentary was smaller amongst those who knew the Agita message (7.1%) compared with those who did not know (13.1%).

Example in developed country: multifaceted

Key elements for program success

Agita São Paulo, Brazil

Scientific based information (university research centre)

Inclusion principle

Stakeholders

Simple message: “At least 30 min of PA per day”

Appropriateness of PA interventions

Linking existing policies

Cultural links

Specific messages relevant to intrapersonal factors

Qualitative and quantitative evaluation

Political and technical support

Participants choose enjoyable activities

(Matsudo 2004)

• every year since 1997• Every public schools and hundreds of

private schools• students participate in sports events

and a neighborhood walk

Agita São Paulo, Brazil

Agita Galera Day (Active Community Day)

recreational facilities:• availability

• accessibility • convenience

physical activity equipment

having a companion

psychosocial (e.g. enjoyment, expected

benefit)

(Sallis 2002, Wendel-Vos 2007)

healthy diet

program access

social support

SES education level

age (-)

sex (male)

race (white)

overweight/obese (-)

Climate/season

physician influence

Adult physical activity correlates

sex (male)intention to be

active

physical activity preferences

parental overweight status (-)

program access

perceived barriers (-)

previous physical activity

healthy diet

time spentoutdoors

Child physical activity correlates

perceived activity

competence

(Sallis 2000, Davidson 2007)

recreational infrastructure (access

to recreationalfacilities and schools).

transport infrastructure (sidewalks/controlled

intersections/ destination access / public transportation

local conditions (crime, area deprivation) (-)

transport infrastructure (N roads to cross/traffic density&speed) (-)

sex (male)

depression (-)

intentions

ethnicity (white)

previous physical activity

community sports

sedentary after school and on weekends (-)

opportunities to exercise

Adolescent physical activity correlates

sensation seeking

support from others

sibling physical activity

direct helpfrom parent & parent support

recreational infrastructure (access

to recreationalfacilities and schools).

transport infrastructure (sidewalks/controlled

intersections/ destination access / public transportation

local conditions (crime, area

deprivation) (-)

transport infrastructure (N roads to cross/traffic density&speed) (-)

(Sallis 2000, Davidson 2007)

age (-)physical activity

preferences

LOCAL COMMUNITY SPECIFICITY….

Example (low SES suburb, WA)

1. overweight & obesity rates/physical activity/low SES adolescents

2. place and partnerships

3. improving perceptions of safety, increased maintenance of skate parks (local council), working with schools to promote sport

Be locally specific with…..

1. identifying health promotion prioritieshealth issue/behaviour/target group

2. identifying strategy (i.e. program, planning and place/partnerships/policy)

3. identifying priority target

EFFECTIVE LOCAL STRATEGIES

1. Lobbying/partnerships with policy

makers

2. Brief brochures summarising

research findings to

stakeholders/policy makers (plus

journal publications)

3. Partnerships to help identify priorities

Take home messages…..

1. Opportunities within developing countries to plan for PA2. Remove barriers to physical activity 3. Programs alone are not enough4. Identify and target correlates5. Community wide approaches with community ‘buy-in’ 6. Ask how can we create sustainable changes in the local

community?

How can

governments and

people in power be

motivated to act

and prioritise?

Need to build an evidence base about

what works, what doesn’t ?

What are

barriers to

implementing

and sustaining

effective

programs?

More in-situ research (program evaluation)

How can programs be developed in

times of economic downturn?

Challenges for researchers....

More emphasis on interventions

“Over the past 80 years we have been building cities for cars much more than

for people. If only children had as much public space

as cars, most cities in the world would become

marvelous.”Enrique Peñalosa

References

•Bruton 2011 Active Living Research Annual Conference 2011

•Hoehner 2011 Active Living Research Annual Conference 2011

•Kahn 2002 Am J Prev Med 2002 22 (4s) 73-107•Linton 2011 Active Living Research Annual Conference 2011

• Leavy 2011 Physical activity mass media campaigns and their evaluation: a systematic review of the literature 2003-2010 Health Education Research Accepted March 2011

•Matsudo 2004 J Phys Act Health 2004; 81-97•Matsudo 2010 Med Sci Sports Exerc 2010; 45 (12); 2231•Reger-Nash 2005 Fam Community Health 2005;28:64-78•Sallis 2000 Med Sc Sports Exerc 2000; 32(5):963-975•Sallis 2002 Med Sc Sports Exerc 2002 34(12) 1996–2001 •Wendel-Vos 2007 Obesity reviews 2007 8 (5) 425

Enrique Peñalosa http://www.pps.org/articles/epenalosa-2/

karen.martin@uwa.edu.au