15 November 2014

Development of a Community Based Physical Activity Program

Development of a Community Based Physical Activity Program

Evaluation of the Walk Everyday Live Longer (WELL) Arizona Program

Abstract

Physical inactivity is a big problem in American society and results in several chronic diseases. Physical activity reduces the risk for cardiovascular disease, diabetes and premature death. It is important to increase the physical activity of the sedentary population because they can receive great benefits.

The program consists of an individual walking program and a local government based intervention aimed at changing current policy and legislation related to physical activity. Social support is an effective tool to help people with their health behavior change and will be implemented within the individual portion of the program. Existing health conscious organizations, once they will be working together, will take the initiative and lobby more fiercely for physical activity legislation.

Once barriers to physical activity are removed it is expected for the general population to increase their current level of physical activity by approximately ten percent.

Problem Definition
Physical inactivity is a pervasive problem within American society. Most of the population does not engage in enough physical activity to maintain or improve their health. Physical inactivity is a risk factor for cardiovascular disease, diabetes, and premature death (Plowman, 2005). In 1999 Blair et al reported that regular physical activity reduces the risk for morbidity and mortality. Figure 1 shows that Pratt and Macera found a significant increase in medical costs associated with physically inactivity (2000). According to their research this is because regularly active people were hospitalized less than inactive people (Pratt & Macera, 2000).

It is important to target the currently sedentary population because they can receive the greatest benefit by becoming moderately active. The goal for this population should be to move from a sedentary level of fitness to achieve the recommended level of thirty minutes of moderate physical activity daily (Pate, 1995).

Critical Inputs
Implement a health behavior modification program based on Social Cognitive Theory, capitalizing on self-monitoring, goal setting, and feedback using a pedometer (Tudor-Locke & Chan, 2006). Pedometers are an inexpensive tool to track progress. Pedometers could be used to help individuals monitor their walking. The program should be split into two phases: adoption phase and adherence phase. Adoption phase will consist of a four week period where people will congregate together at a community center once a week and review their steps for that week in a log book. The meetings will encourage participants to reflect on their current steps per day, build on their successes, and set personally realistic steps-per-day goals. The goals are to be recorded in individually kept log books. During the following eight week adherence phase participants shall continue to record their steps per day and shall meet bi-weekly to further discuss progress and review various successes (Tudor-Locke & Chan, 2006).

There is a small but significant difference in walking behavior attributable to the built environment. Residents of sprawling counties are more likely to walk less during leisure time than residents of compact counties (Ewing, Schmid, Killingsworth, Zlot, & Raubenbush, 2003). It is necessary to convince policy makers to support legislation that is supportive of physical activity. It is important to convince urban planners and developers to build communities that support active transportation. Urban planners have a responsibility to plan for active transportation. Urban planners have a responsibility to plan for active transportation to influence the frequency of biking and walking (Hoehner, Brennan, Brownson, Handy, & Killinsworth, 2003). It is important to mandate employers to encourage and facilitate activity among employees during the workday. It is necessary to break down barriers for children to be active at school and in the neighborhoods (Schmid, Pratt, & Witmer, 2006). Finance and budget reform can allow us to fund the necessary changes (Cheadle et al., 2005). Public policy should positively influence and promote physical activity.

Mediating Processes
Social support can be an effective tool to link the policy changes to our desired health outcomes. Social cognitive theory can be used to help build self-efficacy that facilitates physical activity and reduce barriers that hinder it (R. R. Pate et al., 2003). Those with fewer perceived barriers are more likely to engage in physical activity (Ewing et al., 2003). Communities can be utilized to create their own incentives for physical activities. After school programs that promote unstructured activity are a good way to involve children and possibly their parents (R. R. Pate et al., 2003).

Building community capacity for health promotion has three main aspects. First, the mobilization and channeling of existing community assets into productive investments that brings about an increase in physical activity. Second, the enlargement and diversification of a communities existing pool of assets over time. Third, the empowerment of community members to sustain health improvement efforts throughout extended periods through their continuing investments of time, energy, and other resources in pursuit of collectively defined health priorities (Stokols, Grzywacz, McMahan, & Phillips, 2003).

The first process works to bring together the existing community health efforts into a focused productive form. All health conscious community programs or organizations need to collaborate towards changing public administration in a way that is health supportive. The second process facilitates an increase in outside resources and/or a reinvestment of returns on initial investments back into the community’s pool of material or human resources. The third process encompasses active efforts among community members to gain a sense of mastery and actual control over the physical inactivity health problem. Together these processes may allow for a close community empowered to mobilize and enlarge its assets for achieving a greater prevalence of physical activity (Stokols et al., 2003).

The cost of the program is also an important process. Research shows that similar programs result in a cost-benefit ratio of 2.94 meaning that every $1 invested into the program leads to $2.94 in direct medical benefit (Wang et al., 2005).

Expected Outcomes
The intended outcome of a physical activity intervention is to increase the number of people in the moderate activity category and decrease the number of people in the sedentary category. A long term goal is to reduce the incidence of cardiovascular and respiratory diseases, diabetes, and improve the quality of life for people.

The immediate expected effect of the program intervention is to increase the steps walked per day. Figure 2 shows results from the Tudor-Lock & Chan study indicate that an increase of 3000 steps by the fourth week of the program (2006). Results from the Tudor-Lock & Chan study also show that at a period of nine months 25% of the participating population will still report an increase in their walking behavior when compared to baseline (2006).

A possible effect of this community intervention will be an increase in the number of physically active people by 21.0% to 83.8% (Kahn et al., 2002/5). This is the inter-quartile range for an increase in physical activity. A more modest goal of 10% should be attained.

Extraneous Factors
Environment, transportation, social capital, and time are all reported barriers to physical activity (Zlot, Librett, Buchner, & Schmid, 2006). Environmental factors include the presence of parks and sidewalks, crime, traffic, safety, and weather. Social capital includes level of community participation and perceived community involvement and satisfaction with government responsiveness to community issues. Time refers to a perceived amount of free time or not. Transportation factors include the presence and ease of use for public transportation. These perceived barriers can also be enablers to physical activity. Table 1 illustrates how perceived barriers to physical activity increase the odds that a person will not meet recommended physical activity levels (Zlot et al., 2006). Reducing the perceived barriers to physical activity will increase the chances that a person will be able to meet physical activity recommendations.

Implementation Issues
All resources and systems required for program delivery include: funding; trained health promotion personnel; fitness or exercise facilities; outdoor recreational areas; pedestrian friendly streets and neighborhoods; crime control; and an active transportation infrastructure (Schmid et al., 2006). Implementation at the individual level should be carried out primarily through the schools, community centers, and workplaces. Physical activity and health education are necessary to help influence people’s behavior.

Implementing active transportation and other related environmental projects are the responsibility of government officials and city developers. They should be guided by the recommendations of the collaborative efforts of the existing health conscious entities.

Funding can be obtained through state and federal grants and by taxing local and larger businesses and for profit corporations. Personnel can be obtained by offering the needed positions to the health promotion community and selecting the best candidate.

Summary
In conclusion there is a need for greater implementation of physical activity promotion programs because of the problem that physical inactivity poses. There is a need for a community wide increase in physical activity but in order for any program to be successful it must have the support of the local leadership. This leadership includes everyone from administrators to city legislators to business owners and church leaders.

At the individual level the use of pedometers and social support groups are great ways for people to come together and be more active. Uses of Social Cognitive Theory by health promotion personnel to help individuals with their physical activity goals will pave the way for active people and communities.

Public policy and environmental development offer the greatest capacity to influence behavior through legislation and urban planning for active transportation. Changing the environment poses a tremendous challenge but once transformed the environment is very capable of providing a means for activity on a community wide level. It will enable people to be active who may not have thought that they could live an active lifestyle. Future development requires that city officials and developers be conscious about constructing or renovating an active environment. It is their responsibility as an elected leadership to provide this for their citizens.

Full implementation of this program may increase current physical activity levels by as much as 80% but it is more likely to see an increase of 10-20%.

References
Cheadle, A., Senter, S., Procello, A., Pearson, D., Nelson, G. D., & Greenwald, H. P., et al. (2005). The california wellness foundation's health improvement initiative: Evaluation findings and lessons learned. American Journal of Health Promotion, 19(4), 286-286.

Ewing, R., Schmid, T., Killingsworth, R., Zlot, A., & Raubenbush, S. (2003). Relationship between urban sprawl and physical activity, obesity, and morbidity. American Journal of Health Promotion, 18(1), 47-57.

Hoehner, C. M., Brennan, L. K., Brownson, R. C., Handy, S. L., & Killinsworth, R. (2003). Opportunities for integrating public health and urban planning approaches to promote active community environments. American Journal of Health Promotion, 18(1), 14-20.

Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath, G. W., Howze, E. H., & Powell, K. E., et al. (2002/5). The effectiveness of interventions to increase physical activity: A systematic review and. American Journal of Preventive Medicine, 22(4, Supplement 1), 73-107.

Pate. (1995). Physical activity and public health. A recommendation from the centers for disease control and prevention and the american college of sports medicine. JAMA The Journal of the American Medical Association, 273(5), 402.

Pate, R. R., Saunders, R. P., Ward, D. S., Felton, G., Trost, S. G., & Dowda, M. (2003). Evaluation of a community-based intervention to promote physical activity in youth: Lessons from active winners. American Journal of Health Promotion, 17(3), 171-182.

Plowman, S. A. (2005). Physical activity and physical fitness: Weighing the relative importance of each. Journal of Physical Activity & Health, 2(2), 143.

Pratt, M., & Macera, C. A. (2000). Higher direct medical costs associated with physical inactivity. Physician & Sportsmedicine, 28(10), 63.

Schmid, T. L., Pratt, M., & Witmer, L. (2006). A framework for physical activity policy research. Journal of Physical Activity & Health, 3, S20-S29.

Stokols, D., Grzywacz, J. G., McMahan, S., & Phillips, K. (2003). Increasing the health promotive capacity of human environments. American Journal of Health Promotion, 18(1), 4-13.

Tudor-Locke, C., & Chan, C. B. (2006). An exploratory analysis of adherence patterns and program completion of a pedometer-based physical activity intervention. Journal of Physical Activity & Health, 3(2), 210-220.

Wang, G. (., Macera, C. A. (., Scudder-soucie, B. (., Schmid, T. (., Pratt, M. (., Mph), & Buchner, D. (., Mph). (2005). A cost-benefit analysis of physical activity using Bike/Pedestrian trails. Health Promotion Practice, 6(2), 174-179.

Zlot, A. I., Librett, J., Buchner, D., & Schmid, T. (2006). Environmental, transportation, social, and time barriers to physical activity. Journal of Physical Activity & Health, 3(1), 15-21.

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Evaluation of the Walk Everyday Live Longer (WELL) Arizona Program

Abstract
This paper provides a basic evaluation of the WELL AZ program in Flagstaff, Arizona. The WELL AZ program is a community based physical activity intervention implementing pedometers, log books, and group meetings to increase physical activity behavior. The program currently has a 43% completion success rate. The program makes use of a Par-Q, Baseline Activity Log, and WELL Pre and Post Questionnaires as evaluation tools.

The use of pedometers allows participants to accurately chart their progress in the log books and set realistic goals that enable them to be more physically active. This site lacks digital recordkeeping and the ability to easily implement a statistical analysis to determine the program’s effectiveness at increasing physical activity behavior and reducing the prevalence of chronic disease. An upgrade to digital recordkeeping, physiological data, and statistical analysis would show how effective this program can be.

Executive Summary
The Walk Everyday and Live Longer Arizona (WELL AZ) Program is a community based intervention aimed at increasing physical activity behavior through the use of pedometers, log books, and group meetings. This program is targeted at sedentary individuals. It lasts four weeks and its purpose is to reduce the prevalence of chronic disease. Currently the program is experiencing a completion success rate of 43%. The program is funded by a grant from the Center for Disease Control (CDC) through the Arizona Department of Health Services (ADHS). The program makes use of local resources such as meeting places and other health promotion programs and agencies to present information to its participants and facilitate behavior change through their planned walks.

The program currently lacks the capacity to easily analyze its data because it is not in digital form. There was not any readily available statistical data to confirm the efficacy of the program at increasing physical activity behavior or at decreasing the prevalence of chronic disease. A needs assessment could provide the Program Coordinator with relevant information about the direction the program should take. Physiological data taken at baseline and at the conclusion of the program would provide information into the program’s efficacy at reducing the prevalence of chronic disease. Statistical analysis of the physical activity behavior taken at baseline and at the program’s end would allow insight into whether or not the increased physical activity behavior is truly a result of the intervention. A long term follow up could also show whether the program is effective at reducing the risk for chronic disease.

Program Description
The WELL AZ Program is a four week community based intervention aimed at increasing the physical activity levels of sedentary Arizona residents. Pedometers and log books are tools used in the program for monitoring and motivating people to increase physical activity. There are weekly group meetings to discuss strategies and goal setting for each week. There is also a group walk each week of the program. Coconino County sometimes adds educational sessions to the group meetings. This program is sponsored and funded by the ADHS Division of Public Health Services (DPHS). The CDC provides grant money to ADHS. The Coconino County Health Department Heartbeat Physical Activity Program is responsible for promoting, implementing and evaluating the program. To receive the grant money the WELL AZ program must be implemented. This program is in an ongoing stage of implementation beginning every other month.

The mission of the WELL AZ program is to reduce the prevalence of chronic disease such as cardiovascular disease, diabetes, osteoporosis, and some types of cancer by increasing the number of Arizonans who get 30 to 60 minutes of moderate to vigorous intensity physical activity on most days of the week by walking. The target population is all sedentary people from high school to older adults. The program serves the general public that is looking to start or increase their current activity level.

WELL AZ was first implemented in 2003 by the Coconino County Health Department. The program is on a four week timeline. The first phase of the implementation of the program is to recruit participants. The second phase includes the four weekly meetings and involves establishing baseline data. The final phase includes an evaluation by the participants.

ADHS has tested this program through several counties and they have concluded that program goals and objectives have been reached. ADHS negotiates with each county about the number of participants that should be reached. The past two years Coconino County has been charged to reach 60 to 80 participants for the grant year. For the past two years Coconino County has reached 100 to 130 participants. There is no data readily available for the first two years of the program’s implementation.

During the last two years of the program, 225 have signed up and 97 have successfully completed the program and received completion certificates. This is a success rate of approximately 43%. Of the 225 that have signed up, 53 participants have dropped out. This is an attrition rate of approximately 24%. There have been three people that have dropped out and returned to complete the program. This is a rate of 6%. There have not been any adverse effects associated with program participation and the program meets the needs of the community by providing an easy an affordable way to be more physically active.

Program Objectives
The goal of the WELL AZ program is to help increase an individual’s daily steps. Objectives of the program are to enable participants to keep track of their steps using a pedometer, to be able to set step goals by using the WELL log book, and to become aware of their physical activity level by the use of materials, log book, and pedometer.

Program Resources
The program currently records all of its participants data in log books provided ADHS. Currently Coconino County has only hard copies of records, not in digital form. WELL AZ makes use of the several evaluation tools. The Par-Q (Appendix A), Baseline Activity Log (Appendix B), WELL Pre and Post Questionnaires (Appendix C & D, respectively), a Procedural Handbook (Appendix E), and the ADHS log book. WELL AZ. The grant funding allows the program to temporarily supply pedometers to participants, and calculators and timers to group facilitators. The log books are supplied by ADHS. The program purchases replacement pedometers at $225 each, calculators at $10, and timers at $5. Other budgeting information was not available at this time.

Other resources utilized by the program include the Northern Arizona University Skydome concourse. This provides a safe and comfortable are to walk since weather in Flagstaff can be unpredictable in the fall, winter, and spring. The program also makes use of other health promotion programs to do educational presentations during group meetings. Presentations include nutritional information, injury prevention, and a tobacco cessation program.

Participants are given evaluations about program operations and knowledge gained through participation. The Program Coordinator collects evaluations and enters data to help with program improvement within their community.

Evaluability Assessment Findings
The WELL AZ program is a good program that, according to ADHS, is successful at increasing physical activity in a sedentary population. The use of pedometers allows participants to accurately chart their progress in the log books. The use of log books allows the Program Coordinator to suggest or make changes to the implementation of the program. The mission of the program is to reduce the prevalence of chronic disease but there is currently no data to keep track of this progress. There is no readily available data based on participation of the program to indicate that the prevalence of chronic disease is being reduced. There is data, by looking at the log books, and the population that has completed the program to indicate that participants in the program are indeed increasing their physical activity behavior.

A lack of electronic data entry hinders the programs ability to be fully evaluated. It would be far easier to keep track of information and population progress if a digital system were in place. This would allow for quick statistical analysis to determine if changes in physical activity behavior are actually a result of participation in the program instead of random chance. For the four years that the program has been implemented there is only two years of data readily available. That hinders a longer term analysis of the program’s effectiveness. In addition, a needs assessment has not been conducted recently.

Participant evaluations provide an opportunity for the Program Coordinator to examine the effectiveness of the program in increasing physical activity behavior. This is an important aspect of program evaluation that allows participants to voice concerns and make suggestions.

Literature Review
Available literature shows that pedometers are a useful tool to increase physical activity in populations that have little to no interest in formal exercise programs (Tudor-Locke, Bell, Myers, Harris, Ecclestone, Lauzon, et al., 2004). The use of pedometers in a physical activity intervention program may be so effective that it increases physical activity by an average of 3000 steps per day (Chan, Ryan, & Tudor-Locke, 2004). Current public health agencies recommend at least 30 minutes of physical activities most days of the week. Research shows this to be approximately 3000 to 4000 steps (Tudor-Locke & Bassett Jr, 2004). Pedometer determined physical activity may be classified in the following categories: <5000 steps per day is sedentary; 5000-7499 steps per day may be classified as low active; 7500-9999 steps per day may be classified as somewhat active; >9999 may be classified as active; and >12500 may be classified as highly active (Tudor-Locke & Bassett Jr, 2004). One article suggests that health promotion programs should focus on accumulating 30 minutes of moderate intensity physical activity instead of simply having a universal step goal (Le Masurier, 2004). This is because there is not a step per day number that the available research has proven beneficial and any step per day recommendation is far to general to be easily applied to any population.

A review of the literature indicates that an active support system promotes physical activity behavior and increases adherence to physical activity programs (Tudor-Locke et al., 2004). Participation in some physical activity programs is associated with small reductions in waist and hip girths but is not associated with improved cardiovascular fitness (Tudor-Locke et al., 2004). A lifestyle intervention is as effective at producing beneficial changes in physical activity, cardiorespiratory fitness, blood pressure, and percentage of body fat at 24 months. This especially applies to sedentary persons who have many barriers to physical activity, such as a lack of time or a negative attitude towards structured exercise (Dunn, Marcus, Kampert, Garcia, Kohl, & Blair, 1999).

Program attrition is a documented problem. In one physical activity program, full program adherence dropped from 100% in the adoption phase of the program to 58% during the adherence phase of the program (Tudor-Locke et al., 2004). Self monitoring is useful in promoting short term adherence. The process of record keeping can be implemented to improve fitness walking adherence rates (Konradi & Lyon, 2000). One study recommends the use of a fitness walking log consisting of multiple weekly grids and one distance measure (Konradi & Lyon, 2000).

Behavior change models may be used as an effective tool to change behavior. One intervention used Social Cognitive Theory (SCT) and the Stages of Change (SC) model. Ten cognitive and behavioral strategies to help people progress through their behavior change journey are aimed at ways of things and at increasing specific behaviors (Dunn et al., 1999). The use of group leaders helps participants learn to set realistic goals, monitor their physical activity progress, and provides reinforcement. In a specific intervention, participants that failed to attend at least one session per week were contacted and encouraged to return to a regular schedule of exercise. Groups met for one hour once a week for the first 16 weeks. Groups met biweekly for weeks 17 through 24. Meetings consisted of activities and discussions aimed at addressing and increasing physical activity (Dunn et al., 1999).

Proposed Evaluation Plan
This evaluation shall make a few suggestions. The first is to create digital entries of all records. This makes it easier for statistical analysis and has the potential to reduce the amount of physical paperwork that the program needs to maintain. Conducting a needs assessment would provide greater insight into the current needs of the community and could strengthen the need for the program. Most importantly, recording some sort of physiological data of the program participants would allow for a more thorough evaluation into the effectiveness of the program’s ability to reduce the prevalence of chronic disease in the population. Simple measures of blood pressure, heart rate, height, and weight taken at baseline and at the conclusion of the program could strengthen the need for the program in the community. One possible problem with recording physiological data in this program is that the program lasts only four weeks and that may not be enough time for physiological changes to occur. Another drawback to recording a person’s weight is that it may create the expectation for an individual to attempt to lose weight. This goes against a new paradigm of health at every size and may create an environment of unrealistic expectations.

This evaluation proposes that the program implement the ability to record physiological data. Tools needed for this would be sphygmomanometers, scales, and height rods. Analysis of the data should be done regularly. Once the data is digital any statistical software would be easily implemented to determine whether differences in behavior or physiological improvements are really due to involvement in the program.

A longer term follow up should be conducted to determine if there is an impact on chronic disease and physical activity behavior. This will provide more information about the effect that the program has on chronic disease.

All of these suggestions could be readily implemented as long as there is money. This evaluation foresees that this would increase the financial needs of the program. More tools and devices would need to be purchased. Personnel may need to be hired to do the data entry. Statistical software can be quite expensive.

While these suggestions would improve the evaluability of the program they are not completely necessary. One of the goals of the program is to increase physical activity and as long as the community actively participates in the program, physical activity behavior should increase. Reference List

Chan, C. B., Ryan, D. A. J., & Tudor-Locke, C. (2004). Health benefits of a pedometer-based physical activity intervention in sedentary workers. Preventive Medicine, 39(6), 1215-1222.

Dunn, A. L., Marcus, B. H., Kampert, J. B., Garcia, M. E., Kohl III, H. W., & Blair, S. N. (1999). Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: A randomized trial. The Journal of the American Medical Association, 281(4), 327-334.

Konradi, D. B., & Lyon, B. L. (2000) Measuring adherence to a self-care fitness walking routine. Journal of Community Health Nursing, 17, 159-169.

Le Masurier, G. C., M, & S. (2004). Walk which way? ACSM'S Health & Fitness Journal, 8(1), 7-10.

Tudor-Locke, C., Bell, R. C., Myers, A. M., Harris, S. B., Ecclestone, N. A., Lauzon, N., et al. (2004). Controlled outcome evaluation of the first step program: A daily physical activity intervention for individuals with type II diabetes. International Journal of Obesity & Related Metabolic Disorders, 28, 113-119.

Tudor-Locke, C., & Bassett Jr, D. R. (2004). How many Steps/Day are enough?: Preliminary pedometer indices for public health. Sports Medicine, 34, 1-8.

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