2

Building Physical and Social Environments for Physical Activity in High-Risk Communities

Important Points Made by Speakers

•     Reducing disparities in access to places for physical activity will require multifaceted actions from a variety of stakeholders. (Sallis)

•     Disparities in access to physical activity, parks, green space, and physical education are civil rights issues that can be remedied in the courts and through voluntary compliance with equal justice laws, if necessary. (García)

•     Realizing the potential of parks to reduce health disparities will require increased proximity to parks, better park quality and safety, and promotion of their use. (Floyd)

•     Voters, including minority voters and low-income voters, have demonstrated that they are willing to tax themselves to support parks. (García)

The first goal articulated in Accelerating Progress in Obesity Prevention (IOM, 2012a) is making physical activity an integral and routine part of life (see Box 2-1). Physical activity encompasses a wide range of activities that are influenced by a comparably broad range of policies. The routine activities of daily life, activities performed for work or recreation, and exercise performed for health reasons all expend energy. Policies that shape when and how children, adolescents, and adults live, work, play, worship, and attend school all affect physical activity. Because of this diversity of activities and influences, a large number of factors can generate disparities in physical activity among groups.



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2 Building Physical and Social Environments for Physical Activity in High-Risk Communities Important Points Made by Speakers  Reducing disparities in access to places for physical activity will require multifaceted actions from a variety of stake- holders. (Sallis)  Disparities in access to physical activity, parks, green space, and physical education are civil rights issues that can be remedied in the courts and through voluntary compliance with equal justice laws, if necessary. (García)  Realizing the potential of parks to reduce health disparities will require increased proximity to parks, better park quality and safety, and promotion of their use. (Floyd)  Voters, including minority voters and low-income voters, have demonstrated that they are willing to tax themselves to support parks. (García) The first goal articulated in Accelerating Progress in Obesity Prevention (IOM, 2012a) is making physical activity an integral and routine part of life (see Box 2-1). Physical activity encompasses a wide range of activities that are influenced by a comparably broad range of policies. The routine activities of daily life, activities performed for work or recreation, and exercise performed for health reasons all expend energy. Policies that shape when and how children, adolescents, and adults live, work, play, worship, and attend school all affect physical activity. Because of this diversity of activities and influences, a large number of factors can generate disparities in physical activity among groups. 15

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16 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT BOX 2-1 Goal 1 from Accelerating Progress in Obesity Prevention Goal: Make physical activity an integral and routine part of life. Recommendation: Communities, transportation officials, community plan- ners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity. Three speakers at the workshop discussed ways to increase access to physical activity. James Sallis, professor of family and preventive medicine at the University of California, San Diego, listed actions that could be taken to pursue the strategies articulated in Accelerating Progress in Obesity Prevention. Robert García, founding director and counsel of The City Project in Los Angeles, described how civil rights laws can be used to achieve public health objectives. Myron Floyd, professor in the Department of Parks, Recreation, and Tourism Management at North Carolina State University, summarized the benefits associated with parks and recreational facilities and how those benefits can be extended to more people. The speakers in this session devoted more of their attention to parks and recreation than to transportation, community design, or other means of increasing physical activity, but many of the tactics they described could be used in other areas as well. STRATEGIES FOR INTEGRATING PHYSICAL ACTIVITY INTO EVERYDAY LIFE Summary of Remarks by James Sallis Many studies have demonstrated the existence of disparities in access to places for physical activity (Taylor and Lou, 2011). In a study of neighborhoods in and around Baltimore, Maryland; Washington, DC; and Seattle, Washington, for example, Sallis and his colleagues found that low-income neighborhoods are significantly disadvantaged in terms of opportunities for physical activity (Sallis et al., 2011). They have  significantly fewer and lower-quality walking and bicycling facilities,

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BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY 17  less pedestrian and traffic safety,  reduced aesthetic appeal (aesthetic appeal is a consistent predictor of physical activity),  less safety from crime,  reduced access to parks, and  fewer nearby gyms and other fitness facilities. Strategy 1-1 in Accelerating Progress in Obesity Prevention calls for communities, organizations, community planners, and public health professionals to enhance the physical and built environment, rethink community design, and ensure access to places for physical activity. Sallis listed several options, derived partly from his research, that could contribute to implementing this strategy:  Target funding for sidewalks and bike paths in neighborhoods with primarily low-income and minority populations.  Improve the safety of street crossings in neighborhoods with primarily low-income and minority populations.  Target traffic calming around schools and parks in neighbor- hoods with primarily low-income and minority populations.  Target support for joint-use agreements covering the use of school facilities in neighborhoods without parks.  Build parks and playgrounds in vacant lots.  Improve facilities for physical activity in parks in neighborhoods with primarily low-income and minority populations. The second strategy for increasing physical activity in Accelerating Progress in Obesity Prevention is to provide and support community programs. Among the options Sallis listed in this area are  Provide free after-school activity programs in parks and school grounds in neighborhoods with primarily low-income and minority populations.  Target training in physical activity leadership to after-school staff serving low-income and predominantly minority youth.  Encourage youth sports organizations to offer programs to youth of all ability levels on a sliding-fee scale.  Encourage youth sports, dance, and martial arts programs to provide sufficient activity for participants.

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18 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT The third strategy Sallis discussed is to adopt physical activity requirements for licensed child care providers. Potential components of this strategy include  Add physical activity requirements for Head Start programs, and provide resources and training to implement them.  Target training in physical activity leadership to child care providers serving low-income and predominantly minority children. The fourth strategy is to provide support for the science and practice of physical activity. To carry out this strategy, Sallis listed the following possibilities:  Recruit and support students from underserved racial and ethnic groups to major and become investigators in physical activity- related disciplines.  Expand the minority supplement programs of the National Institutes of Health.  Add “potential to reduce health disparities” as a criterion for evaluating grant proposals.  Target additional training to physical activity practitioners serving low-income and predominantly minority youth. Sallis also called attention to work he and his colleagues have been doing to translate research results in this area for nonscientists, including policy makers, program practitioners, and members of the public. For example, research has demonstrated that renovation of parks can increase their use (Cohen et al., 2009; Veitch et al., 2012). People on the front lines of community activism and planning need access to such results, which requires that research conclusions be presented simply, visually, and in a language people know. At the same time, more research is needed in areas of particular interest to members of the public, such as the effects of parks and recreational facilities on crime and perceptions of crime. Sallis also pointed out during the discussion period that parents are a critical audience. They need to be comfortable with allowing their children go to a park or participate in an activity, which may require the organization of supervised programs, especially in neighborhoods where crime is a concern.

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BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY 19 “Almost every neighborhood has a school, so joint-use agree- ments would allow for community use of those public facilities.” —James Sallis CASE STUDY: THE CITY PROJECT, LOS ANGELES Summary of Remarks by Robert García The mission of The City Project1 is to achieve equal justice, democracy, and livability for all. The pursuit of this mission entails influencing the investment of public resources to achieve results that are equitable, enhance human health and the environment, and promote economic vitality for all communities, with a particular focus on parks and recreation, schools, health justice, and transportation justice. The City Project uses five strategies to accomplish this mission: 1. community organizing and coalition building; 2. translation of research into policy, law, and systematic change; 3. strategic media campaigns, including the use of new social media; 4. policy and legal advocacy outside the courts; and 5. access to justice through the courts when necessary. The City Project has worked to achieve its mission in and around Los Angeles.2 García pointed out some of The City Project’s accomplishments, including  successful efforts to pass $10 billion in statewide park bond measures, with overwhelming support from minority voters and low-income voters;  working with diverse alliances, helping to create or preserve more than 1,000 acres of green space in park-poor, low-income Los Angeles communities;  being involved in greening the Los Angeles and San Gabriel rivers; 1 The City Project is a nonprofit policy and legal advocacy team. 2 More information about The City Project is available at http://www.city projectca.org.

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20 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT  helping to expand national recreation areas in the Santa Monica mountains;  keeping public beaches open for all despite efforts by wealthy homeowners to close them off;  supporting a transit-to-trails program to take children from inner- city communities to nearby mountains, beaches, rivers, and parks they have never visited;  helping to ensure that physical education requirements are enforced in public schools;  helping to raise $27 billion for Los Angeles Public Schools to build 130 new schools and modernize hundreds of existing schools; and  fostering agreements for the joint use of schools, pools, and parks. The City Project resorts to pursuing justice through the courts when all else fails, said García. Access to justice through the courts is a First Amendment right, and minority groups and low-income people face disparities in access to this right as well. García urged foundations to fund efforts by civil rights lawyers to overcome these disparities by going to court to create change. Actions to Address Underlying Disparities Minority children living in poverty in Los Angeles with no access to a car have the worst access to parks; the worst access to schools with more than 5 acres of playing fields; the highest levels of childhood obesity; and the greatest risk for exposure to gangs, crime, drugs, and violence. These disparities are not an accident of unplanned growth, said García. They are the result of a historical pattern of discrimination in land use, housing, and federally subsidized mortgages. The City Project’s flagship initiative was the preservation of a 40- acre site in downtown Los Angeles. The city and a wealthy developer were proposing to build warehouses on this site without conducting an environmental review or considering the park alternative and the impact on low-income minorities in the neighborhood. That site is now Los Angeles State Historic Park, which the Los Angeles Times Magazine called “a heroic monument” and “a symbol of hope” (García et al., 2004; Ricci, 2001). The City Project has extended this success by publishing an analysis of access to green spaces and equity in nine Southern California

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BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY 21 counties (García and Strongin, 2011). It also has influenced the National Park Service’s Strategic Action Plan: Healthy Parks Healthy People US, which argues that the Park Service has an obligation to address health disparities based on race, ethnicity, and income through equitable access to open spaces and natural places (National Park Service, 2011a). Just a few months before the workshop, for example, the Park Service published a study recommending that a national recreation area be established in the San Gabriel mountains (National Park Service, 2013). The draft study explicitly cited The City Project’s work and civil rights laws that address disparities (National Park Service, 2011b). Finally, the recently published Institute of Medicine report Educating the Student Body: Taking Physical Activity and Physical Education to School (IOM, 2013a) recommends actions that The City Project has been urging throughout its history. These actions include enforcing physical education laws in schools; building and modernizing schools; and arranging for the joint use of schools, pools, and parks. Disparities as Civil Rights Issues The disparities affecting low-income and minority communities are not just about parks, schools, and education, García stated. They are about human health and development, economic vitality, conservation values, culture, heritage, and spirituality. Disparities in access to parks, green space, physical activity, and physical education are civil rights issues that can be addressed in the courts, García emphasized. The focus may be race, color, or national origin, as in Title VI of the Civil Rights Act of 1964, or it may be gender, as in Title IX of the Education Amendments of 1972, but defined areas of inequity enable the application of legal frameworks that can yield progress. Furthermore, civil rights issues can be pursued not just in the courts but also through coalition building, policy advocacy, and other measures aimed at obtaining voluntary compliance with legal requirements. These approaches can extend beyond parks and physical education to encompass other areas, such as access to health care, that involve federal financial assistance and are marked by disparities based on protected characteristics. In such efforts, public health researchers, government officials, and concerned citizens can learn valuable lessons from working with civil right attorneys. García quoted from a commencement address given a few days before the workshop at Harvard University School of Public Health in which Larry Brilliant, president of the Skoll Global Threats Fund,

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22 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT referenced Martin Luther King, Jr.’s statement that “the arc of history is long, but it bends towards justice”: The arc of the universe needs your help to bend towards justice. It will not happen on its own.... Public health needs you to ensure health for all.... Bend that arc. I want you to leap up, to jump up, and grab that arc of history with both hands, and yank it down, twist it, and bend it. Bend it towards fairness, bend it towards better health for all, bend it towards justice! García suggested that the public health community needs to work with the civil rights community to bend the arc of justice toward public health for all. Civil rights laws have important implications for addressing, alleviating, and eliminating health disparities. Title VI of the Civil Rights Act of 1964 and its regulations, President Clinton’s Executive Order 12898 on Environmental and Health Justice, parallel state laws, and other laws establish an equal protection framework for addressing health disparities. Discussion During the discussion period, García talked in greater detail about ways of getting parks into underserved areas. Creating more parks takes more money, which can require raising taxes. According to García, discussion of higher taxes may be anathema for politicians, but voters, including minority voters and voters with a high school degree or less, have demonstrated that they are willing to tax themselves to support parks and schools. Low-income and high-minority communities suffer from environmental degradation much more than do other communities, and they have demonstrated their willingness to work hard to make improvements. It is then important to ensure that these communities get their fair share of the benefits they made possible. Furthermore, García pointed out that even within existing budgets, steps can be taken to increase access to parks and physical education, such as by lighting more parks at night or creating cooperative joint-use agreements to make better use of existing facilities. Outreach on these issues to the members of these communities and to nontraditional audiences is important, García said. Videos and social media can disseminate information much more widely than can legal briefs. Translating materials into Spanish is also important, despite the

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BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY 23 expense, because so many of the communities served by The City Project are predominately Spanish speaking. New technologies also can contribute to initiatives to expand access to parks. The City Project has used geographic information systems (GISs) mapping along with demographic analysis and census data to document disparities in environmental justice. In partnership with the GreenInfo Network, it has mapped the entire state of California at the census tract level to show which communities are park poor—defined as less than 3 acres of parks per 1,000 residents—and which communities are income poor—defined as a median household income of less than $47,000 per year (García and Strongin, 2011). García stated that such metrics are essential to measure equity, to invest resources, to determine progress, and to hold public officials accountable. García also called attention to the record of the Civilian Conservation Corps during the New Deal, which contributed to a massive expansion of parks and their use. Expansion of park space should be a central component of contemporary public works projects to get the nation back to work, he said. “If you don’t recall anything else from today’s meeting, remember this lesson: The civil rights laws are a tool for you in the public health community to look at, to use, and to consider to achieve health justice for all.” —Robert García ADVANCING HEALTH EQUITY THROUGH PUBLIC PARKS AND RECREATION SERVICES Summary of Remarks by Myron Floyd Public parks and recreation services can help eliminate disparities in physical activity and childhood obesity. In a study of more than 20,000 adolescents, those living in areas with more parks and recreational facilities engaged in more moderate and vigorous physical activities and had lower rates of being overweight (Gordon-Larsen et al., 2006). According to another study, girls living within 1 mile of parks get 35 more minutes of nonschool moderate or vigorous physical activity per week than girls living farther away from parks (Cohen et al., 2006). Even

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24 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT more fundamental measures of health disparities can be affected by access to parks. In a study in England, areas with the least amount of green space had the greatest disparities in mortality (Mitchell and Popham, 2008). How parks are designed and managed also affects physical activity, Floyd pointed out. For example, energy expenditure measured in 8 types of activity areas in 10 Tampa, Florida, neighborhood parks ranged from relatively high for basketball and tennis facilities to relatively low for fishing areas, picnic areas, and dog play areas (see Figure 2-1). Although the data on park availability are mixed, Floyd stated that some studies clearly indicate the existence of disparities. For example, areas of Los Angeles with predominantly Latino or black populations have far less park acreage per 1,000 residents than areas with predominantly white populations (Wolch et al., 2005). Similarly, blacks in Baltimore have less access than whites to park acreage (Boone et al., 2009), and census tracts in Maryland, New York, and North Carolina with more than 60 percent minority populations are more likely than those with smaller minority populations not to have a recreational facility (Moore et al., 2008). Disparities also exist in areas with higher or lower proportions of college-educated residents (Gordon-Larsen et al., 2006). Floyd noted that equal access to parks does not mean that the parks are of equal quality. In many low-income and high-minority areas, parks Mean Energy Expenditure per Person F = 144.13, p<.05 N = 6,922 (kcal/kg/min) Basketball Tennis Playgrounds Open Space Baseball Fishing area Picnic area Dog play area Activity Zone FIGURE 2-1 Energy expenditure is higher in some activity areas of parks than in others. SOURCE: Floyd et al., 2008.

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BUILDING PHYSICAL AND SOCIAL ENVIRONMENTS FOR PHYSICAL ACTIVITY 25 are smaller than in other areas (Boone et al., 2009; Sister et al., 2009). In a study in Los Angeles, white children had more access than minority children to play equipment, basketball courts, and walking and jogging tracks (Sister et al., 2010), which are the types of facilities that promote physical activity. And for some parks, less use has been associated with crime in the neighborhoods where they are located (Baran et al., 2013). The existing evidence indicates that realizing the potential of parks to reduce health disparities will require increased proximity, better quality and safety, and promotion of their use, Floyd said. He cited a strategy from the National Physical Activity Plan calling for increased funding for parks, recreation, fitness, and sports programs and facilities in areas of high need.3 Floyd noted that a major source of funding for state and local park development in the United States since the 1970s has been the Land and Water Conservation Fund, a major source of state and local park development funding, but in recent years its funding has been declining (see Figure 2-2). He suggested that returning appropriations to the levels of the first half of the past decade could make significantly more money available for developing and improving parks and recreational facilities. In addition, to receive grants through this fund, each state must prepare a comprehensive outdoor recreation plan and provide a 50/50 funding match. If these comprehensive plans were required to document how they will impact health and target areas of high need, health disparities could be reduced, Floyd said. Floyd also suggested intentionally designing and managing parks to balance active and passive recreation. In addition, school facilities, which are often closed after hours and on weekends, could be used to promote physical activity through joint-use agreements or intentional program- ming, particularly in areas without high-quality parks and recreational facilities. During the discussion period, Floyd talked about how to reclaim areas within neighborhoods for parks and recreational facilities. Doing so will require consideration of the connections between such areas and the surrounding neighborhoods. Are there convenient ways for people to get to the parks and facilities? Have they been designed to meet the needs of nearby residents? What is also needed, Floyd suggested, is cross-sector collaboration entailing regular dialogue among transportation planners, landscape architects, and parks and recreation planners and extension of 3 The plan is available at http://www.physicalactivityplan.org/NationalPhysical ActivityPlan.pdf.

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26 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT that conversation to public lands, social service, and public health agencies. Floyd commented that research is needed to better understand how funding is allocated to communities, including the capacity and expertise of local communities to write grant proposals to receive philanthropic support. Floyd also suggested that research is needed on standards for parks and recreational facilities, including how many and what types of facilities a community needs. In particular, to support efforts to reduce disparities, this research needs to identify which facilities and activities in parks contribute to better health. These features then can be designed into new parks, and funding can be pursued to incorporate them into existing parks. 160 140 120 Millions of Dollars 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Fiscal Year FIGURE 2-2 The Land and Water Conservation Fund has been a major source of funding for state and local park development, but its funding has declined in recent years. SOURCE: Vincent, 2010. “There is an important role for parks to play in reducing and eliminating health disparities.” —Myron Floyd