Active living by design: perspectives from the Robert Wood Johnson Foundation

Increasing Access to Physical Activity Within Low Income and Diverse Communities: A Systematic Review

Objective:

The purpose of this review is to uncover some best practices for increasing access to physical activity opportunities by examining efforts used within low income and diverse communities. The theoretical lens used is from the Active Living by Design (ALbD) Community Action Model, with a focus on the 6 essential practices (health equity focus, community engagement, facilitative leadership, sustainable thinking, culture of learning, and strategic communication) describing how partnerships can guide and sustain meaningful change in a community.

Methods:

A 2-step process guided the literature search. In step 1, 4 databases (PubMed, Psych INFO, Social Science Citation Index, and Cochrane Library) were searched using Boolean connections and variations in the key terms. Step 2 assessed articles by title, abstract, and full text to determine whether the studies met the inclusion and exclusion criteria guided by Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Additionally, included articles were compared against the 6 essential practices outlined by the ecological framework, ALbD.

Results:

Of 1775 total articles, 14 studies met inclusion criteria. Most of the studies were case studies located in the United States using several different approaches including, changes in the built environment, implementation of a community-based physical activity program, creating partnerships to leverage resources, and policy change. This review compared the 14 studies against the 6 essential practices of the ALbD model and found 2 studies that met all 6 criteria, and only a few studies meeting more than 2 criteria.

Conclusions:

Overall, the conclusions are 2-fold, (1) only 14 cases demonstrate success in increasing access to physical activity opportunities, suggesting that more can be done to address inequalities. (2) Of the existing efforts, few utilize crucial components to create a sustainable change in the community. Future research should take into consideration the ALbD ecological framework, the best existing theory for this type of work, to guide the creation and implementation of a sustainable community access effort.

Community Organizing for Healthier Communities: Environmental and Policy Outcomes of a National Initiative

INTRODUCTION

Childhood obesity is disproportionately prevalent in communities of color, partially because of structural inequities in the social and built environment (e.g., poverty, food insecurity, pollution) that restrict healthy eating and active living. Community organizing is an underexamined, grassroots health promotion approach that empowers and mobilizes community residents to advocate for, and achieve, environmental and policy changes to rectify these structural inequities. This paper presents outcomes of the Robert Wood Johnson Foundation's Communities Creating Healthy Environments initiative: the first national program to apply community organizing to combat childhood obesity-causing structural inequities in communities of color.

METHODS

Twenty-one community-based organizations and tribal nations (grantees) conducted 3-year community organizing-based interventions primarily designed to increase children's healthy food and safe recreational access. Grantees' policy wins (environmental and policy changes resulting from grantee interventions) were measured from 2009 to 2014 using semi-structured interviews conducted quarterly and 6 months post-grant, and independently coded and reviewed in 2015 by researchers and expert community organizers.

RESULTS

The 21 grantees achieved 72 policy wins (mean=3.43, SD=1.78) across six domains: two directly addressed childhood obesity by enhancing children's healthy food (37.50%) and recreational access (33.33%), whereas four indirectly addressed obesity by promoting access to quality health care (8.33%); clean environments (9.73%); affordable housing (8.33%); and discrimination- and crime-free neighborhoods (2.78%).

CONCLUSIONS

These findings provide compelling evidence that community organizing-based interventions designed and led by community stakeholders can achieve diverse environmental and policy solutions to the structural inequities that foment childhood obesity in communities of color.

"Boring" family routines reduce non-communicable diseases: a commentary and call for action

As global donors shift their efforts from infectious diseases to non-communicable diseases (NCD), it is critical to capitalize on our prior mistakes and successes. Policy makers and public health administrators are often looking for magic bullets: drugs or treatments to eradicate disease. Yet, each potential magic bullet requires consistent, daily implementation and adherence to a new set of habits to actually work. Families’ and communities’ daily, interlocking routines will be the battlefield on which scientific and technological breakthroughs will be implemented and succeed or not.

Currently, there are many evidence-based interventions (EBI) which have been demonstrated to shift specific habits which account for most NCD (eating, drinking, moving, and smoking). Yet, securing sustained uptake of these programs is rare – suggesting different intervention strategies are needed. Structural changes, policy nudges, and partnerships with private enterprise may be able to shift the health behaviors of more citizens faster and at a lower cost than existing EBI. Addressing concurrent risk and protective factors at the community level and intervening to shape new cultural routines may be useful to reduce NCD.

Active living by design sustainability strategies

BACKGROUND

Despite substantial increases in improving the translation of health promotion research into practice, community initiatives still struggle with maintaining changes once grant funding has ended. Researchers, funders, and community practitioners are interested in practices that maintain and sustain their efforts.

PURPOSE

This qualitative study conducted a content analysis of evaluation findings from Active Living by Design (ALbD) to identify activities that community coalitions implemented to maintain their initiative and secure ongoing influence in communities.

METHODS

Investigators analyzed data from interviews, focus groups, and the Progress Reporting System to identify sustainability approaches clustering into five areas: partnership expansion, sustainable funding, permanent advisory committees, policy change, and institution/organization change.

RESULTS

Partnership expansion occurred across sectors and disciplines and into broader geographic areas. Additional funding extended beyond grants to earned income streams and dedicated tax revenues. Permanent advisory committees were established to inform decision makers about a range of active living impacts. Policy changes in zoning and comprehensive plans ensured maintenance of health-promoting built environments. Sustainability through institution/organization changes led to allocation of dedicated staff and incorporation of active living values into agency missions.

CONCLUSIONS

Active Living by Design partnerships defined and messaged their projects to align with policymakers' interests and broad partnership audiences. They found innovative supporters and adapted their original vision to include quality of life, nonmotorized transport, and other complementary efforts that expanded their reach and influence. These sustainability strategies altered awareness within communities, changed community decision-making processes, and created policy changes that have the potential to maintain environments that promote physical activity for years to come.

Assessment for active living: harnessing the power of data-driven planning and action

BACKGROUND

Robert Wood Johnson Foundation's Active Living by Design (ALbD) grant program funded 25 communities across the U.S. The ALbD National Program Office (NPO) supported grantee community partnerships with technical assistance for assessment, planning, and implementation activities intended to increase population levels of physical activity.

PURPOSE

This paper analyzes and summarizes the range of assessments conducted to identify local barriers and opportunities for active living as important elements of a thorough intervention planning process.

METHODS

Evaluation of the partnerships focused on documenting community changes and strategies used to produce those changes. With support from NPO staff and external evaluators, partnerships tracked and summarized their community assessment approaches as well as strengths and challenges in conducting assessments.

RESULTS

The partnerships documented a range of assessment strategies and methods. Partnerships used several qualitative methods, including focus groups, individual and group interviews, and public meetings. Quantitative methods included surveys, audits, observations, and analysis of existing data, among others. The environmental audit was the most common assessment method used by the partnerships. Assessment processes and findings were used for not only intervention planning but also community engagement and direct advocacy. Assessment data collectors varied from professional staff to community volunteers.

CONCLUSIONS

Assessments were essential to the identification of local barriers and assets related to active living, which in turn helped ALbD partnerships prioritize and refine their action strategies. Assessment processes were also valuable in building relationships with new partners, community members, and local officials.

Identifying the role of community partnerships in creating change to support active living

BACKGROUND

Active Living by Design (ALbD) partnerships were established to change environments and policies as well as support complementary programs and promotions to increase physical activity in 25 communities across the U.S.

PURPOSE

This paper summarizes the structural and functional aspects of partnerships identified as having a substantial influence on these initiatives.

METHODS

A mixed-methods evaluation included qualitative (e.g., key informant interviews, focus groups) and quantitative (e.g., survey, web-based tracking) methods. Data were collected from 2003 to 2008, systematically analyzed to identify influential factors, and triangulated for model development.

RESULTS

The partnerships identified a number of structural and functional factors that were important to their success, including multisectoral partners, flexible governance structures, leadership, group management, action planning, and assessment/evaluation. Three types of partnership models-utilitarian, lead agency, and collaboration-emerged across the community partnerships. Most partnerships reported challenges with engaging community members and ensuring equitable distribution of resources at the local level.

CONCLUSIONS

The ALbD community partnerships utilized several structural and functional factors to enhance the success of their multisector collaborations. Yet, the varied types of lead agencies, partners, and partnership structures suggest that there is no one best way to bring partners together.

Programs and promotions: approaches by 25 Active Living by Design partnerships

BACKGROUND

From 2003 to 2008, a total of 25 community partnerships funded through Active Living by Design (ALbD) implemented physical activity programs and promotions as part of integrated approaches complementing policy and environment changes.

PURPOSE

This paper reviews the partnerships' efforts with respect to promotions and programs, the breadth and depth of these types of approaches, challenges, successes, and lessons learned.

METHODS

Through a mixed-methods approach, including interviews, focus groups, and web-based tracking, multiple sources of data were collected and analyzed from 2006 to 2010. Evaluators summarized quantitative data by counts or means and qualitative results using systematic coding procedures to identify themes, ideas, and concepts.

RESULTS

All 25 community partnerships were engaged in programs and promotions of varying degrees throughout the initiative. Programs were categorized as community walking and biking programs, school programs, afterschool programs, and worksite programs, among others. Promotional strategies were categorized as social marketing campaigns, media, events, and communications. The most common programs included Safe Routes to School, walking clubs, and Bike/Walk to School Day. Media efforts were undertaken by all 25 partnerships, totaling 2659 TV, newspaper, and radio hits.

CONCLUSIONS

Programs and promotions can be resource-intensive and have limited population impact when offered in isolation; however, these strategies help connect people to their environments (e.g., increase awareness of facilities, provide social support for use of facilities) in order to improve physical activity behaviors.

Evaluation of physical projects and policies from the Active Living by Design partnerships

BACKGROUND

Between 2003 and 2008, a total of 25 partnerships funded through the Active Living by Design (ALbD) program worked to change built environments and policies in communities to help citizens be active in their daily routines.

PURPOSE

This paper systematically summarized the scope of ALbD physical projects and policy changes, described resources generated by the partnerships, and highlighted supports and barriers to the process.

METHODS

Using a mixed-methods approach, multiple data sources, including key informant interviews, focus groups, and a web-based tracking system, were used to collect data during project implementation. Qualitative results were analyzed using systematic coding procedures to identify themes, ideas, and concepts derived from the data. Data analysis occurred in 2008-2010.

RESULTS

Most of the 25 partnerships documented physical projects and policy changes in each of the following sectors: urban planning (n=16); active transportation (n=23); trails/parks/recreation/open space (n=22); communities (n=22); and schools (n=18). ALbD community partnerships were successful at generating ≈ $256 million in resources beyond their initial grant, mostly through policy changes. Challenges included creating and sustaining political will and community support as well as securing technical expertise and resources. Planning and relationship building were critical to success in changing policy and implementing projects.

CONCLUSIONS

Although there is more to understand about how these change processes affect physical activity and health across populations and settings, as well as how social, cultural, and psychosocial factors influence community responses to the policy changes and physical projects, findings from this initiative provide a foundation for subsequent research and practice.

Evaluation of Active Living by Design: implementation patterns across communities

BACKGROUND

Twenty-five cross-sector, multidisciplinary community partnerships received funding through the Active Living by Design (ALbD) national program to design, plan, and implement innovative initiatives to support active living.

PURPOSE

This paper examines implementation patterns across ALbD community partnerships related to community characteristics; preparation efforts; and policy, environmental, programmatic, and promotional strategies.

METHODS

Investigators used a mixed-methods, participatory evaluation design, triangulating multiple qualitative and quantitative data sources collected from 2007 to 2009. Configural frequency analysis facilitated detection of variables as well as configurations of variables occurring more (types) or less (anti-types) frequently than patterns expected by chance alone.

RESULTS

Overall, community partnerships with more preparation activities (assessment, sustainability) implemented a larger number of active living promotions, programs, policy influences, and physical projects, cumulatively (type). Yet, community partnerships working in communities with >40% of the population from a non-Caucasian racial and ethnic background and >40% of the population in poverty implemented fewer active living promotions, programs, policy influences, and physical projects, cumulatively (type).

CONCLUSIONS

The resulting types and anti-types provide insight into patterns across communities that may be ascribed to varying configurations of community contexts, resources, and strategies implemented. Rigorous, systematic examination of the underlying causal structures related to the configurations of community characteristics, preparation efforts, and implementation strategies is needed.

Capturing community change: Active Living by Design's progress reporting system

The Active Living by Design (ALbD) National Program Office (NPO) developed an evaluation system to track progress of 25 community partnerships, funded by the Robert Wood Johnson Foundation (RWJF). Between June 2004 and October 2008, partnerships documented their actions and accomplishments through ALbD's online Progress Reporting System (PRS) database. All entries were verified and analyzed by the NPO. Results from the PRS suggest that the ALbD partnerships were successful fundraisers, leveraging $256 million from grants, policy decisions, in-kind and direct sources. The partnerships also documented newspaper coverage, TV, and radio air time and they developed physical activity programs such as exercise clubs and "walking school buses." Partnerships were adept at influencing decision makers to create or rewrite policies and improve built environments. Selected policy examples included, but were not limited to, approvals for capital improvements, street design standards, and development ordinances. Partnerships also contributed to the completion and approval of influential planning products, such as comprehensive land use, neighborhood, and roadway corridor plans. The most common built-environment changes were street improvements for safer pedestrian and bicycle travel, including new crosswalks, bicycle facilities, and sidewalks. The ALbD community partnerships' accomplishments and challenges contribute to knowledge and best practices in the active living field. Five years after their grant began, RWJF's initial investment showed substantial and measurable results.

Contextual factors influencing readiness for dissemination of obesity prevention programs and policies

Within the realm of obesity prevention research, there have been many promising interventions to improve physical activity and nutrition among diverse target populations. However, very little information is known about the dissemination and replication of these interventions. In 2007 and 2008 as part of a larger obesity prevention initiative, Missouri Foundation for Health funded 19 community-based programs throughout the state that showed promise of being model practices and committed to promoting their dissemination. Semi-structured key informant interviews were conducted with 64 individuals across the grant sites to help stage their readiness for dissemination. Through these interviews, the project team was able to identify the variables that impact a program's readiness for widespread distribution. Some factors contributing to readiness include: strong intervention planning and an existing sustainability plan; physical space available for the intervention; staff and monetary resources; administrative buy-in; community buy-in and engagement; a strong partner base and an agency with a healthy and active mission. These findings add to the literature by systematically identifying a set of key contextual variables. The qualitative data collected support a proposed framework and helps to establish a process for maintaining successful interventions based on several important factors that impact dissemination.

Walking: the first steps in cardiovascular disease prevention

PURPOSE OF REVIEW

Health professionals are presented with the challenge of prescribing physical activity that is likely to be sustained by the sedentary majority. Walking is eminently suited to physical activity prescription for inactive individuals as it is accessible to men and women of all ages and social groups and poses little risk of injury. This paper reviews recent evidence of the health benefits of walking and promotion of walking behavior.

RECENT FINDINGS

Large observational studies consistently show associations between walking and cardiovascular disease endpoints over long periods of follow-up. Intervention studies further support the health benefits of walking, showing improvements in clinical biomarkers and measures after shorter periods of follow-up. Walking appears to have cardiovascular disease-related health benefits in younger, middle-aged, and older men and women, in both healthy and patient populations. Pedometer-based, mobile phone-based, and computer-based programs are effective in increasing walking levels. Neighborhood and workplace amenities and programs may be important supports for walking behaviors.

SUMMARY

Walking has the potential to play a key role in the primary and secondary prevention of cardiovascular disease. Clinicians can prescribe walking to assist patients meet physical activity recommendations and help identify supports available to the patient.