Increasing Physical Activity in Rural Communities

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Increasing Physical Activity in Rural Communities
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2005-2009 PRC Project

• Purpose
• To promote both indoor and outdoor walking
  programs coinciding with the cold and warm months
  of the year
• Partnership
• UA-PRC
• Parks Trails New York
• Local community steering committees

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BACKGROUND
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Why is Physical Activity (PA) Important?

• Decreases risk of premature death
• Coronary heart disease, diabetes, colon cancer
• Controls/reduces blood pressure
• Reduces stress and promotes psychological well
  being
• Builds/maintains healthy bones, muscles and
  joints
• Helps older adults avoid falls and maintain
  functional independence

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Why Focus on Walking?

• PA-related health benefits occur for brisk
  walking
• Almost everyone does it at least once in awhile
• Almost everyone can do it
• Requires less physical effort
• Less likely to cause serious injury
• Inexpensive
• Comfortable shoes and clothes
• Involves no specialized equipment
• Can be conducted in a variety of settings

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PA in Rural Communities

• People in rural communities have lower levels
  than other communities
• Less likely to meet PA recommended levels
• More similar to urban than to suburban
• LTPA and sedentary behavior patterns demonstrate
  the largest differences
• Unique environmental barriers
• Fewer facilities and safe places to walk
• No sidewalks
• Unattended dogs
• Wild animals

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PA in Rural Upstate New York
Core Project 2002-2004

• Community assessment in Columbia and Greene
  Counties
• Surveyed 104 rural adults with diabetes about
  physical activity and nutrition
• 70 did not meet recommended levels of PA
• Walking most common form of exercise
• 40 identified environmental barriers to PA
• Inadequate sidewalks
• Lack of programs, facilities, transportation

• Too many hills
• Heavy traffic
• Inclement weather

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Pilot Walking Program
Core Project 2004-2005

• Walk With Us
• Greenville
• February 2005
• Program
• School building access
• Maps
• Pedometers
• Incentives

• Evaluation
• Utilization rates
• Participant characteristics
• Participant views of program

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Results from Pilot

• 54 registrants 76 walkers
• Walking profiles varied
• Frequent walkers were older and lived closer to
  the school
• Participant identified benefits
• Safety
• Non-stop walking
• Convenience
• Participant identified barriers
• Distance to building
• Conflicts with schoolactivities

• Weather independence
• Social aspect

• Lack of personnel
• Inadequate facilities

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Conclusions from Pilot

• Rural school-based walking programs
• Inexpensive
• Support PA efforts
• Motivate the sedentary
• Social factors are critical to program success
• STILL OPERATIONAL!
• Open 6-9pm, 3 eves/week from November-mid-May
• Operates under Adult Continuing Education

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Bridge to New Core Project

• Partners in planning
• Community steering committees
• PRC CAB
• Parks Trails New York
• Statewide advocacy organization
• Protect New York's parks
• Help communities create new parks
• Based on pilot experience
• Expand to year-round indoor/outdoor walking
  program
• Local public school buildings
• Community trails

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2005-2009
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CONCEPTUALIZING THE PROGRAM
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Intervention Mapping

• To translate theory into intervention element
• Performance Objectives (6)
• Identify place to walk
• Set initial walking goals
• Develop a walking plan
• Personal Determinants (5)
• Knowledge/Awareness
• Outcome Expectations
• Self-Efficacy
• External Determinants (6)
• Interpersonal Relationships
• School Walking Environment
• Trail Characteristics

• Begin walking
• Evaluate goal and revise
• Maintain walking over time

• Psychological Stress
• Social Status

• Reinforcements
• Income Inequality
• Neighborhood and Community Social Characteristics

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Conceptual Map Walk 5 times per week for 30
minutes at a time
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Theoretical Framework
Environment
Personal
Behavior
Psychological Stress
Neighborhood Community Physical Characteristics
Outcome Expectancy
School Treatments
Interpersonal Relationships
Regular PA
Self Efficacy
Trail Treatments
Social Inequality
Self-Regulation
Neighborhood Community Social Characteristics
Walking Program Initiation maintenance
treatments
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Walking Program Treatments

• Use and enhance community resources
• Create access to schools
• Promote the use of trails
• Provide support for personal determinants
• Self-Confidence
• Knowledge of the benefits of regular walking
• Support the maintenance of regular walking

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University at Albany PRC Core Project 2005-2009
Preparation
Late summer/early fall
Spring/summer

• Literature reviews
• intervention strategies
• data collection/ evaluation strategies
• School districts identified
• Interest in participation discussed
• school officials
• community groups
• Get approval from schools
• Form community steering
• committee (CSC)
• Plan the Walking Program
• with the CSC

2.5 Cycles
Walking program advertisements and promotions
begin
Indoor walking program
Recreational trail promotion
2 communities added each year
2006 Mamakating Millerton/Amenia
2007Fort Edward Fort Plain
2008 SalemStillwater
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Program Locations
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PROGRAM IMPLEMENTATION
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Initiation

• ID candidate communities
• No active school-based walking program
• Community trails in the vicinity of the school
• Acquire formal commitment to the program
• Local government representatives
• School administrators
• Form community steering committees
• Develop/implement strategies for
• Marketing
• Retention
• Sustainability
• Train walking club leaders

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Local Steering Committee

• Membership
• Convene representatives from
• Schools
• Local governments
• Health care organizations
• Trail organizations
• Civic leaders
• School and local officials usually take the lead

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Local Steering Committee

• Roles
• Tailors the program for the community
• Identifies
• Which local schools
• Which outdoors walking routes
• Local health concerns
• Potential program barriers (and remediation)
• Specifies operational parameters for their
  community
• Operating schedule
• Age range
• Evaluation components
• Program supervision levels

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Marketing Strategies

• Identified by steering committees based on local
  information access
• Mass media Newspaper, radio, TV
• Church bulletins
• Flyers posted throughout community
• School based backpack mailings
• Community web sites
• Variable Message Signs on school, town and
  village halls
• Contact with local civic leaders, known
  walkers/runners
• Mailings to local health care providers and
  business community
• Proactive outreach to local senior centers

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Promotional Events

• Initial kick-off
• Orientation to project by PRC staff
• Open registration opportunities
• Guidebook
• Walking logs
• Ongoing program events
• To support ongoing recruitment, and retention
• Always includes kick-off for indoor/outdoor
  transitions
• Educational speakers
• Scavenger/historical treasure hunts
• Seasonal Contests introduced

• Motivational incentives
• Initial registration
• Meeting PA milestones
• Top walker prizes

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Educational Events

• Planned and implemented based on
• Community steering committee recommendations
• Suggestions from the walkers (program
  participants)
• Local community experts spoke on
• Nutrition
• Chronic disease management
• Cancer prevention
• Stretching
• Proper walking attire

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Walking Club Leaders Training

• Pilot Project
• An independently funded component
• Office of Womens Health Region II
• Mini-Grant, USDHHS
• Goals
• Develop and test a toolkit for walking clubs for
  women concerned about diabetes.
• Incorporate materials into Prevention Research
  Center activities aimed at increasing access and
  support for physical activity.

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Walking Club Leaders

• Roles
• Monitor PA levels
• Provide support/education to walkers
• Ease transition from indoor to outdoor program
• Teach relapse prevention techniques

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Walking Club Leader Training

• Outcomes
• Program conducted in Harlem Valley and Mamakating
• Clubs walked 3 times a week for 16 weeks
• A total of 70 individuals participated
• Group size ranged from 9 to 24
• Assessment
• Walking logs
• Focus groups (2) with walking club members
• Informal surveys of walking club leaders

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Walking Club Leader Training Focus Group Findings

• Motivating factors of walking clubs as reported
  by focus group members
• Social support
• Seeing results
• Being accountable
• Consistency

• Preliminary conclusions
• Walking club leaders found the toolkit and
  training useful
• Leaders report positive experiences with
  training and clubs
• Walking club members reported health and other
  benefits
• 50 doubted their ability to maintain regular
  exercise without the group

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Trail Assessments and Enhancements

• Minigrants
• Universal Trail Assessment Process (UTAP)
• Trail User Surveys
• Study Participant Survey Responses

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Trail Enhancement Mini Grants

• Mamakating
• Trail amenities
• Benches
• Bike rack
• Trash receptacles

• Harlem Valley
• Trail brochures
• Promote use by walkers
• Trail maps
• mailed to all area residences

Inauguration of new Park Recreation building at
trail head
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UTAP Report

• Universal Trail Assessment Process (UTAP)
• Developed by Beneficial Designs
• Measures the trail and surrounding areas for
  accessibility
• Benefits
• Provides Trail Access Information
• Documents and monitors trial conditions
• Improves trail access for all types users

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Trail User Survey

• Suggestions to improve trails include the
  following
• Maintain/clean regularly
• Extend trail
• Add amenities
• Pave trail
• Promote leash laws
• Increase patrols

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Sustainability

• Planning
• Began on Day One
• Ongoing review of program barriers
• Enumeration of community resources
• Fiscal support -- staff salaries, incentives,
  school liability insurance, PR
• Infrastructure development
• Who will assume responsibility for program?
• Who will lead the steering committee?
• Program Participants Polled
• Prioritize their needs
• Identify potential sponsors

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Sustainability

• Community Tool Kit
• Tool Kits individualized to programs, provided on
  CD-ROM
• Walking Program Guidebook
• Walking Club Leader Manual
• Walking logs
• Brochures
• Poster drafts for events
• Educational Speakers Bureau
• PR contact list
• Donations contact list
• Registration materials
• Liability waiver forms
• PA/Health education information
• Community pictures from walking program
• List of registered walkers on Excel database
  for schools only

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Sustainability Keep Walking Summit

• To establish inter-community networks
• Attended by funded and unfunded programs
• Poster session
• Recognition awards
• Focus group on CBPR experience from community
  perspective

• Guest speakers from
• Hudson Headwater Youth Conservation Corps
• NYS/DOH Healthy Heart Program
• Parks and Trails New York
• Local media coverage

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PRELIMINARY FINDINGS
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Data Collection
Data processing not completed
2006 Mamakating Millerton/Amenia
2007Fort Edward Fort Plain
2008 SalemStillwater

• 18 month panel in process for Fort Edward and
  Fort Plain
• 6 month panel in process for Salem and Stillwater

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Community Participants

• Mean walkers/visit 18
• Mean total visits
• Study participants 18.3
• Non-study participants 8.9

• Registered walkers 1,217
• Logged visits 14,203
• Total hours walked 10,402
• Percent female 74.6
• Percent minors 13.2
• Average per walker
• Visits 13.4
• Minutes/visit 44.6

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Study ParticipantsDemographics

• Total 318
• Average age 55
• Percent Female 79
• Education
• 57 at least some college
• Median household income
• 51,679
• Employment
• Full/part time 63
• Retired 25
• Homemaker 7

• Arthritis 26
• Back problems 16
• Diabetes 11
• Heart problems 8
• Unhealthy weight 75
• 34 Overweight
• 41 Obese

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Walking for Exercise

• Our Goal Regular walking for exercise
• 5 days per week AND 30 minutes each time

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Walking Confidence Scale

• I think I can
• Confident in becoming a regular walker 530
• 11 question scale

I can stick to my walking schedule when I am
tired

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Walking Outcomes

• Expecting results from regular walking
• Knowledge of what will happen from being a
  regular walker
• 9 statements, 5 point agreement scale

If I slowly and steadily increase my daily
walking I will feel less stress

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Walking Outcomes Matter

• Expected outcomes matter to you
• Same 9 statements as expected outcomes
• Ranked on 5 point outcome matters scale

If I slowly and steadily increase my daily
walking I will sleep better

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Walking Intentions

• How well a person can control their walking
  behavior
• 7 statements regarding regulating behavior
• Ranked on 5 point frequency scale
• Scores are reversed and summed

Take short walking or physical activity breaks
during the day

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Ancillary Projects

• Assessing self-reported measurement of Walking
  Behavior
• CBPR The Community Perspective
• Built Environment and PA in Rural Settings
• Reliability testing a street audit tool
• Association between PA and Built Environment

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Assessing Self-reported Measurement Of Walking
Behavior

• Self-reported walking compared to pedometer
• Limited to intentional exercise
• Procedures
• Pedometer worn during walking session for 7 days
• Coordinator records 7 day tally or steps
• Respondent keep walking journal exercise
  experience days/time/steps
• Self-administered survey at the end of 7 day
  period

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Assessing Self-reported Measurement Of Walking
Behavior

• Preliminary Results
• Participants
• 26
• Average age 58
• 80 Female
• All white
• Self-reported minutes and pedometer counted steps
• Correlation .88

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CBPR The Community Perspective

• Summit Focus Group
• To assess our partnership
• Key themes of successful programs identified
• Year 6 Components
• Partnership Assessment of Steering Committees
• Community Success at Sustaining Walking Programs

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Street Audit Tool

• Reliability test of an established pedestrian
  environment audit in rural settings
• In press at AJHP

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Summary

• Purpose To test inter-rater reliability and
  internal consistency
• Setting Five rural school districts in western
  New York.
• Subjects A random sample of 391 street segments
• 50 segments observed by a second team
• Instrument PEDS

• Analysis
• Reliability
• Kappa
• PABAK
• Percent agreement
• Spearmans rho
• Internal Consistency
• Cronbachs Alpha
• Results
• 19 measures useful for rural setting
• Average Kappa .43
• Average PABAK .72

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PEDS
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Relationships between BMI, PA, and Walkability
in Rural Communities

• Masters Thesis Sandra Richardson (March, 2009)
• Combined data from the street audit survey with
  PA behavior telephone surveys
• Parsed 5 rural communities into 2 types of areas
• Inside Rural higher poverty, higher population
  density
• Outside Rural lower poverty, less dense
• Regressed walking minutes on individual factors
  and walkability
• Walkability and income were the only significant
  factors predicting walking minutes for
  self-reported walkers

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Publication Plan

• Description of 2004-2005 core project
• Journal of Primary Prevention, Under review
• The 2005-2009 core project
• Description of the communities and the
  treatments, cross-sectional analysis of baseline
  characteristics of participants
• January 2010
• Analysis of longitudinal program outcomes
• April 2010
• CBPR as experienced by the community
• Focus group study conducted at the Keep Walking
  Summit
• Year 6 steering committee partnership assessments
• October 2010
• Ancillary Projects
• Built Environment and Physical Activity in Rural
  Settings
• Reliability test of an established pedestrian
  environment audit in rural settings
• American Journal of Health Promotion, In Press
• Assessment of relationship of the Built
  Environment and PA behavior
• October 2010

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Lessons Learned

• Focus on inter-community networking earlier
• Maximize days and times program is available
• Coordinate approach to indoor/outdoor components
• Staggered Intervention
• Helps implementation
• Hinders analysis

• Promotion should target high risk populations
• health care sites
• Weight Watchers
• Tobacco Cessation
• Focus on retention
• External motivation needed
• Physician, wellness centers,
• Ongoing outreach from program
• Steering committees structured for fluid
  membership