On the second day of the workshop, the focus shifted from the science of physical activity to the promotion of behavior that promotes physical activity. Russell Pate provided some introductory remarks. Then, in the first session of the day, which was moderated by Ginny Ehrlich, Amy Eyler and Jamie Chriqui discussed policies aimed at promoting physical activity. Pate’s introductory remarks, Eyler’s and Chriqui’s presentations, and the discussion at the end of their session are summarized in this chapter.
First, Eyler asked, why policy? In her opinion, two key advantages of policies are, first, that they reach a large percentage of the population and, second, that they remain sustainable over time. She described public policies across several sectors that impact physical activity and identified barriers to promoting and implementing innovative policies of this sort. In community planning and zoning, a major challenge is not only to build sidewalks and places where people can walk but also to maintain those areas. In the public transportation sector, while ballot issues that would encourage physical activity (e.g., installing a bus stop that would encourage walking) often receive widespread support, funding remains a challenge (e.g., people are not willing to approve tax increases). In Eyler’s opinion, promoting physical activity will require a culture change, similar to that required to promote smoking cessation—one that will likely emerge from a convergence of top-down (public) and bottom-up (organizational) policies.
Chriqui discussed research results on a wide range of public policies and explained how research has helped identify challenges to promoting
and implementing policies on physical activity. Most of this work, she said, has been in the education sector. For example, studies have shown that many state laws are silent on the actual amount of time in physical education classes devoted to moderate- to vigorous-intensity physical activity (MVPA). That reality, combined with the confusing wording of many state laws regarding what physical activity actually means, results in many students failing to engage in the nationally recommended amount of physical activity. Among other gaps in the evidence base, Chriqui highlighted the lack of data on how “complete streets” policies impact not just health outcomes but economic development outcomes as well.1 In her opinion, moreover, studies too often focus on single policies, mainly in education, and only on policies that have been implemented. She called for longitudinal studies examining the collective impact of policies across multiple sectors.
Physical activity is a complex behavior, Russell Pate began, yet people often use the term “physical activity” as though it were a simple construct. Over recent decades, as physical activity has begun to achieve a place in U.S. public health, the fact that it is a complex behavior that takes many forms and is packaged in many ways, with multiple combinations of frequency, intensity, duration, and dose, has become increasingly clear. Additionally, physical activity is performed for many reasons—not just positive health outcomes, which Pate characterized as far from the only reason and probably one that historically played very little role. Historically, Pate suggested, people likely were physically active because they had to be in order to survive or live the way they wanted. Adding to its complexity, physical activity is influenced by many factors, so that, Pate opined, it is highly unlikely that there is a single magic bullet for promoting it.
Research on promoting physical activity typically has been theory based, Pate continued, with many different and, over the years, evolving theories being applied to the design and testing of interventions aimed at increasing physical activity. One widely applied theory is that of planned behavior, which, Pate explained, posits that intention to be physically active is a central construct. Social cognitive theory is another frequently applied theory, according to which important interactions among an individual, behavior, physical activity, and the environment in which the activity is performed profoundly influence future participation in that activity. One’s
1 Complete streets policies are designed to ensure that new streets are built not just for cars but for all users, including pedestrians, bicyclists, and public transportation vehicles and users.
2 This section summarizes the day two introductory remarks provided by Russell Pate, Ph.D., Arnold School of Public Health, University of South Carolina, Columbia.
confidence and sense of competence with regard to being physically active are important concepts of social cognitive theory. Finally, the stages of change theory posits that when thinking about the promotion of physical activity, it is important to recognize that not all people are equally ready to adopt physical activity. According to this theory, Pate explained, some people have never even thought about exercising; others have been thinking about it but have not spent much time trying it; still others are “nibbling” at it, trying it with limited success; and some have mastered the behavior such that it is part of their lifestyle. The stages of change theory suggest to Pate that trying to apply a single intervention to a range of people with varying readiness to be active makes little sense.
Every multivariate analysis of the prediction of behavior with which Pate is familiar has revealed a great deal of unexplained variance, which to him suggests that researchers cannot measure very well what accounts for whether people are engaged in a behavior on a regular basis. Nonetheless, researchers do know that participation in physical activity is influenced by interpersonal variables (i.e., social factors), institutional characteristics (e.g., features of schools, worksites, and other places where people spend their time), and community characteristics (e.g., where people live), as well as more distal factors related to public policy and mass media. As work on the promotion of physical activity has evolved, what researchers refer to as the social ecological model, which takes all of these different factors into account, has become a framework for thinking about what will be required to make real progress on physical activity at the population level.
Intervention studies designed to determine what works to increase physical activity have tested a range of targets, Pate continued, including individuals, peer groups and families, institutions (e.g., schools, worksites), community resources, and policies and media. With respect to the effectiveness of tested interventions, Pate referred workshop participants to the physical activity component of the Guide to Community Preventive Services, which, although dated, is based on a rigorous review of the then-current literature on physical activity interventions (i.e., papers published between 1980 and 2000) (Kahn et al., 2002). That review generated a number of conclusions. First, Pate noted, the literature offered strong evidence in support of community-wide campaigns as an informational approach to increasing physical activity, but less support for other informational approaches. Additionally, strong evidence was found for three types of behavioral and social strategies for increasing physical activity: school-based physical education, social support interventions in community settings, and individually adapted health behavior change programs. Among environmental and policy approaches studied, the review yielded strong evidence for the creation of or enhanced access to places for physical
activity. Pate said he looks forward to an updating of the community guide given how much research has been conducted since its publication.
Also as a source of information on the effectiveness of tested interventions, Pate mentioned the Physical Activity Guidelines for Americans Midcourse Report, which summarizes evidence on interventions for increasing physical activity in children and adolescents according to setting (i.e., school, preschool and childcare centers, community, family and home, primary care) (HHS, 2012). Only two intervention strategies received what Pate said was the highest level of support (i.e., “sufficient,” as opposed to “suggestive,” “emerging,” or “insufficient”): multicomponent school interventions and school-based interventions focused entirely on enhancement of physical education. In Pate’s opinion, the less than sufficient rating received by other interventions does not necessarily mean they are ineffective in “the real world.” Rather, it means the evidence available at the time the review was conducted was not compelling enough to warrant higher ratings. Some of the strategies, such as classroom-based activity breaks, have been studied only fairly recently, with literature still emerging.
Finally, Pate mentioned the National Physical Activity Plan as another source of evidence-based information on the effectiveness of various interventions (National Physical Activity Plan Alliance, 2010). Based on a compilation of evidence-based approaches to promoting physical activity, the plan provides a comprehensive set of policies, practices, and initiatives aimed at increasing physical activity in the U.S. population. According to Pate, the plan was developed differently from similar plans in other countries. In most other countries, development of a national physical activity plan is a government undertaking. In the United States, while government supported, this effort was based largely outside of government and under the leadership of a coalition of organizations, most in the health sector but some in other sectors as well. The plan was developed by panels of experts who recommended strategies organized around eight societal sectors (public health; education; volunteer and nonprofit organizations; transportation, urban design, and community planning; mass media; health care; business and industry; and parks, recreation, and sports). The plan recommends more than 250 strategies and tactics.
“Why policy?” Amy Eyler began. Policies, she said, more so than individual-level interventions, have the potential to impact a broad commu-
3 This section summarizes information and opinions presented by Amy A. Eyler, Ph.D., C.H.E.S., Washington University in St. Louis, Missouri.
nity or population. Once in place, they also have the potential to be more sustainable over time compared with trends. In Eyler’s opinion, much of the major impact of public health over the past decades is attributable to policies. She cited as examples changes in sanitation, fluoridation, drunk driving, and tobacco use.
Policies can affect physical activity in many ways. They can improve access to opportunities for physical activity—for example, by changing the way communities are designed and increasing bike lanes or parks. They can regulate, as is the case with state laws related to the quantity and quality of physical education. They can promote programs and national campaigns, such as First Lady Michelle Obama’s Let’s Move!. They can provide funding to promote physical activity from the state down to the local level. Finally, they can coordinate efforts, particularly at the state level—for example, through state laws that create councils or boards to share information and resources across activities.
Like the definition of policy itself, the definition of physical activity policy is broad, Eyler continued. It can be legislative action, organized guidance, or just a general rule. It can be formal (e.g., a formal written code) or informal (e.g., written standards).
Policies have a broad range of actual and potential impacts. Since about 2005, Eyler has been inventorying state laws related to childhood obesity and examining the quality and quantity of 27 categories of legislation. As an example of what she considers a weak policy, she described how, every year since 2009, a Missouri state law was introduced to designate the jumping jack as the state’s official exercise; finally, in 2014, the law was enacted. Apparently, Eyler explained, jumping jacks were “created” by Missouri-born General John J. Pershing in the late 1800s as a drill exercise for cadets. In Eyler’s opinion, the jumping jacks law is a weak physical activity policy because it does not, for example, require everyone to do jumping jacks for 20 minutes three times per week. In contrast, a law enacted in Oklahoma in 2014, Enrolled Senate Bill No. 1876, specified detailed improvements in the physical education curriculum.
In the mid-2000s, Tom Schmid and colleagues at the Centers for Disease Control and Prevention (CDC) created a physical activity policy framework outlining the different sectors and scales of policy that can impact physical activity. They identified five relevant sectors (health care, transportation/planning, parks/public spaces, worksite, and school) and four scales (local, regional, state, and national). For the remainder of her presentation, Eyler discussed each of the five sectors in turn.
Physical Activity Policy in the Health Care Sector
Physicians need to change their paradigm and start considering physical activity evaluation and exercise prescription as essential parts of patient care. Exercise prescription needs to be as equally important as medication prescription. —Chen et al., 2013
Policies related to physical activity counseling could play an important role in facilitating physical activity, Eyler suggested. In her opinion, however, and touching on some of what Gabriel Shaibi had discussed on the first day of the workshop (see Chapter 4 for a summary of Shaibi’s presentation), there are several barriers to developing, implementing, and enforcing such policies. First, physicians have no diagnostic code to use on their charts so they can be reimbursed for counseling on physical activity aside from any comorbidity. Additionally, exercise prescriptions would require systems of referral, that is, systems that would provide the means for physicians to communicate with community partners so that patients could be given not just exercise prescriptions but also detailed information about where to go. Providers also would have to be trained to counsel and give advice about physical activity, raising questions about what type of curricular changes would be needed in medical schools to facilitate such policies.
Barriers to physical activity policy in the health care sector, Eyler continued, stem not necessarily from a lack of support for “Exercise is Medicine” and other initiatives, but from a lack of priority. She observed that physicians and medical care systems are overwhelmed, and physical activity counseling is not a priority. Another barrier is a lack of personal interest or knowledge. If one were to ask physicians what the U.S. national physical activity guidelines are, Eyler said, their answers would vary. Other barriers include time, cost, and the need for integration of services (e.g., coordinating and maintaining counseling provided by ancillary health care workers).
Physical Activity Policies in the Transportation/Planning Sector
Eyler pointed to two examples of federal transportation policies with implications for physical activity: (1) the Safe, Affordable, Flexible, Efficient Transportation Equity Act: A Legacy for Users, or SAFETEA-LU; and (2) Moving Ahead for Progress in the 21st Century, or MAP-21. Both programs provided funding not only for transportation in general but also for ways to promote active transportation—more so, according to Eyler, in SAFETEA-LU than in MAP-21. Programs such as the Safe Routes to School initiative, which promotes safe ways for youth to walk or bike to and from school through the funding of infrastructure (e.g., sidewalks) and educational programs, grew out of these federal funding programs, Eyler
explained. She noted that the Safe Routes to School initiative was being evaluated for its impact on physical activity as well as on body mass index (BMI) and social factors (e.g., neighborhood awareness).
In addition to the promotion of active transportation, how communities are planned and zoned has a large impact on opportunities for physical activity, Eyler continued. She cited sidewalks as an important example. If walking is the main exercise in the United States but people lack safe places to walk, that clearly is a barrier to physical activity. Sidewalks need to be not only built, Eyler emphasized, but also maintained. She referred to the Guide to Community Preventive Services (Kahn et al., 2002), which Pate had mentioned in his introductory remarks, and identified three types of policies recommended for increasing physical activity that are relevant to planning and zoning: (1) community-scale urban design and land use policies, (2) street-scale urban design and land use policies, and (3) creation of or enhanced access to places for physical activity combined with informational outreach activities.
Regarding access to places for physical activity, Eyler noted that, based on a 2010 survey, Smart Growth America reported that almost three-quarters of Americans feel they have no choice but to drive as much as they do. This finding suggests to Eyler that changing not only the infrastructure but also the mindset of the U.S. car-driving community will require a great deal of work. She noted that more than half of those surveyed indicated they would like to spend less time in their cars.
Complete streets policies have taken hold and are being implemented in communities across the country, said Eyler, with almost 500 such policies in place in 2014. The policies range in scope and strength. Eyler mentioned Boulder, Colorado, and Portland, Oregon, as good examples of communities where complete streets policies have been not only implemented but also evaluated, and with good results.
Public transportation policy is another area of the transportation and planning sector with implications for physical activity. Americans who use transit, according to Eyler, have the opportunity to walk to and from transit stops as part of their recommended 30 minutes of daily physical activity. Like sidewalks, however, transit stops need to be maintained, Eyler said, not just built, and funding remains an issue. She and her colleagues conducted a survey through the Physical Activity Policy Research Network to gain insight into Americans’ support for physical activity policy. When asked whether their city should allocate funds for building or maintaining public transit, 65 percent of those surveyed responded “yes”; when asked whether they would support a tax increase to pay for the public transit, however, barely half said “yes.” According to Eyler, many public transportation policies are ballot issues that require a majority to pass. So while there is support for building and maintaining public transit, the funding of
such efforts is problematic largely because of how people prioritize their communities’ needs.
Physical Activity Policy in the Parks/Public Spaces Sector
Again, one of the evidence-based recommendations in the Guide to Community Preventive Services is to create or enhance access to places for physical activity, combined with information outreach activities (i.e., the promotion of those places). In a focus group study, Eyler and colleagues asked women across the country why they did or did not engage in physical activity and whether there were places in their communities where they could do so. The majority of respondents reported that there were parks in their communities, but when asked why they were not using those parks, they replied that the parks were not well maintained. For example, one woman told Eyler that she had to walk over homeless people to get to the park, while another told her that there were dirty needles at the end of the slide in her park. In addition to building parks and instituting policies that create or enhance access to them, Eyler said that, as with sidewalks and transit stops, “Maintaining the quality of those parks is equally important.”
In addition to parks, trails are an important component of public space with implications for physical activity. People who live near trails have easy access to physical activity, Eyler said, whether they ride their bikes, walk, or rollerblade. Policies to build, maintain, connect, and update trails can facilitate this behavior.
Promoting physical activity in the public sector is a matter of not just building and maintaining sidewalks or trails, Eyler continued, but also connecting them. She mentioned that her own neighborhood has about a three-quarter-mile stretch without sidewalks. She showed a photo of some out-of-town visitors to her neighborhood who, on their way to an ice cream store, were struggling with a stroller on the side of a dangerous road. She said, “Having policies in place that connect these [sidewalks or trails] to make sure that the destinations can be reached safely is another important aspect of policy.”
Open streets policy, which originated in Bogotá, Colombia, in the 1980s, closes streets to motor vehicles and opens them to physical activity for a period of time. Even though the open streets period may occur only once per week or once per month, it nonetheless, in Eyler’s opinion, gives individuals in the community an opportunity not only to interact with each other but also to become aware of places where they can be physically active. About 100 cities across the United States have some form of open streets policy. These policies are currently being evaluated, Eyler noted.
Finally, another component of parks/public spaces policy that can affect physical activity is joint-use policy. Joint-use policies are agreements
between schools and communities to make school facilities available when school is not in session. The benefits of such policies are that they are low cost, and the facilities are already built. Barriers include maintenance and liability issues and the facilities themselves.
Physical Activity Policy in the Worksite Sector
Given that the majority of Americans spend a great deal of time at work, Eyler observed that worksite policies offer a good opportunity to facilitate physical activity. Flextime policies, facilities (e.g., gyms, bike racks, lockers, or places to change clothes), and active transportation incentives (and also disincentives, such as high parking prices) all can facilitate physical activity. As an example, Eyler described the walking paths across the Washington University medical school campus (the “MedPaths” trails). Other informal worksite physical activity policies include standing desks, gym subsidies, the encouragement of breaks, and walking meetings.
Physical Activity Policy in the School Sector
No school house shall be considered in the city of New York without an open-air playground attached. —New York State Law, 18954
Physical activity policy in schools is probably the most obvious and most well-studied category of physical activity policy, Eyler said. She referred workshop participants to the 2013 Institute of Medicine (IOM) report Educating the Student Body (IOM, 2013) for information on opportunities before, during, and after school to promote physical activity among children and adolescents. During school, for example, physical activity can be promoted through physical education, through recess and breaks, and in the classroom. Eyler emphasized the importance of policies that not only promote recess but also discourage or forbid taking recess away as a punishment. Additionally, she noted that policies on before- and afterschool programs can require that a certain percentage of program time be dedicated to physical activity.
Eyler concluded by stating that policies can increase physical activity at the population level, but a culture change also is necessary. It used to be common, she noted, to walk into an office and see an employee smoking
4 N.Y. EDN. LAW § 2556: NY Code—Section 2556: Buildings, sites, et cetera.
a cigarette. “We don’t see that now,” she said, not just because of policies but also because of a culture change that occurred over time.
In her overview of research on physical activity policy, Jamie Chriqui focused on only some of the eight policy sectors highlighted in the National Physical Activity Plan, specifically those sectors for which more research has been conducted on public policies (or, as she referred to them, “big P policies”) enacted at the state, district, and local levels: the education, transportation, and parks and recreation sectors. She noted that her presentation was based on a very rapid review, not a systematic review, of key literature across these three sectors. Her intention, she said, was to provide a “broad brush” overview of what is known across these sectors about what works and where challenges exist.
The “punch line” of her presentation, she said, is that there is good news when it comes to physical activity policy, but there is also some challenging news. In her opinion, the most important thing to keep in mind when discussing public policy is that policy change is incremental. Large-scale, comprehensive policy changes rarely are made, particularly with respect to physical activity, given today’s funding and budgetary climate. Many of the strategies she would be discussing, Chriqui remarked, have been built up over time. Additionally, much of the work has been siloed, she said. She mentioned the call for a systems-level perspective in the 2102 IOM report Accelerating Progress in Obesity Prevention (IOM, 2012). Another “challenging” piece of news to keep in mind, she added, is that physical activity policies often are self-enforcing, with little compliance monitoring or enforcement.
Public Policy on Physical Activity in the Health Care Sector
Chriqui was unable to identify any studies on “big P” physical education policy in health care settings. However, she came across a systematic review of physical activity interventions in adults related to some of what Amy Eyler had discussed (Eyler’s presentation is summarized in the previous section). The authors (Müller-Riemenschneider et al., 2008) report that prescriptions for exercise can be incorporated into physician licensing standards and medical education and training as a way to promote physical activity.
5 This section summarizes information and opinions presented by Jamie F. Chriqui, Ph.D., M.H.S., University of Illinois at Chicago.
Public Policy on Physical Activity in the Education Sector
Most research on public policy on physical activity has been in the education sector, according to Chriqui, with a focus on physical education (PE). In a systematic review, Bassett and colleagues (2013) found that mandatory PE was associated with a one metabolic equivalent of task (MET)-hour increase in physical activity. Chriqui emphasized the mandatory nature of the association. “You really need the law,” she said. “You can’t just encourage something in the physical education arena.” Several other, more recent studies have found similar associations between state PE mandates, or requirements, and increased amounts of time spent in PE (Chriqui et al., 2013; Perna et al., 2012; Slater et al., 2012; Taber et al., 2013). Taber and colleagues (2013) found that the association between state PE time mandates and time spent in PE at the elementary and middle school levels holds particularly for girls, with strong state laws being associated with a 22 percent increase in PE participation among girls compared with schools with no state PE time mandates.
While state PE time mandates are necessary, implementing them remains a challenge, said Chriqui. The amount of PE time required in such laws varies greatly from state to state. While SHAPE America recommends 150 minutes of PE per week at the elementary level and 225 minutes per week at the middle and high school levels, Chriqui observed that most state laws do not come remotely close to those standards. More important, in her opinion, in a study based on interviews with state officials, Chriqui and colleagues found that most state laws fail to address the amount of time spent engaged in actual physical activity—particularly MVPA—in PE (Carlson et al., 2013). Additionally, they found that monitoring, implementation, and enforcement of such provisions, where they exist, are lacking.
With respect to recess policies, Chriqui and her research team found that elementary schools are more likely to offer at least 20 minutes or more of recess daily if state law encourages it (Slater et al., 2012). That is one area, she said, where encouragement as opposed to a mandate can actually help. The big “but,” she said, is that state laws often treat recess and PE as substitutes. That is, states that meet the minimum recommendations for PE often do not meet the recommendations for recess, and vice versa (Slater et al., 2012). Additionally, the wording in state laws often is such that physical activity is defined very broadly. Thus the physical activity requirement can be met in what Chriqui described as a “laundry list” of ways, including not just PE and recess, but also activity breaks and others. Chriqui observed that schools often take the “path of least resistance,” that is, the one easiest to implement and requiring the fewest resources.
With respect to after-school physical activity, Michael Beets and his research group at the University of South Carolina have done a great deal of
work in this area, according to Chriqui. Beets and colleagues (2010) found that policy requirements for physical activity time in after-school programs rarely are followed. But the biggest challenge, Chriqui opined, is that most after-school physical activity policies lack clearly defined benchmarks, making it difficult to measure and understand compliance and impact (Beets, 2012). While there are many state standards governing PE time during the school day, few standards govern before-school or after-school physical activity time.
In recent years, shared-use policies have emerged as a key target in the obesity prevention arena, with a focus on providing community access not just to school grounds but other institutional grounds as well. For example, Chriqui noted that she lives in a community where a baseball field was built on church land, and that many local baseball and softball teams are using the field through a shared-use agreement. She and her research team found that shared-use policies are associated with modest increases in physical activity in children (Slater et al., 2014; Spengler et al., 2011). Such policies may play a greater role in raising awareness than in changing physical activity behaviors, Chriqui suggested, because most of these policies, at least those that are school based, focus on school-affiliated groups and do not give priority to community residents. For example, they often do not allow evening, weekend, or holiday access. Additionally, Spengler and colleagues (2011) found that shared-use policies are lacking in low-income communities, primarily because of liability concerns.
Public Policy on Physical Activity in the Transportation Sector
In the transportation sector, Chriqui cited two “big P” policy studies related to Safe Routes to School laws and other active-travel school policies (Chriqui et al., 2012; Turner et al., 2013). First, Chriqui and colleagues (2012) found that state laws requiring infrastructure improvements around schools to facilitate active travel to school are associated with an increase in such travel. However, Barnidge and colleagues (2013) identified significant barriers to implementing Safe Routes to School policies, particularly in rural communities, including a lack of resources and a lack of support for implementation.
Regarding active transport to work, Chriqui noted that the National Institutes of Health (NIH) was funding five ongoing studies on the implementation and impact of light rail natural experiments in five different U.S. jurisdictions. The results were emerging, she said, with only the first couple of years of baseline data having been collected thus far.
With respect to community or urban design and land use, there has been very little to no work on how zoning policies impact opportunities for physical activity. Yet, as Chriqui explained, it is through their effect
on zoning codes that design and land use policies change such opportunities. Because of the lack of literature linking zoning policies to opportunities for physical activity, she and her research team, with funding from NIH’s National Cancer Institute, have been studying zoning policies whose requirements include active living elements (e.g., requirements for street connectivity, bike lanes, trails, paths, mixed-use development, parks, playgrounds, open space, green space). The researchers found that communities with such zoning requirements tend to have more physically active adults (Chriqui et al., in review). Additionally, communities with active living–oriented zoning tend to have more adults taking public transit to work.
With respect to complete streets policies, Chriqui observed that while such policies are diffusing nationally, as Eyler had described, with a couple of evaluations producing good results, the evidence base needs to be built. As part of her zoning study, she and her colleagues found that walking to work and use of public transit are higher in jurisdictions that require complete streets policies (Chriqui, 2015). However, she mentioned having recently attended a meeting where Smart Growth America representatives expressed the need for a body of evidence on the impact of complete streets not just on physical activity, but also on community economic development. She said, “Having a health community is important to policy makers, but if you can focus on the economic aspects of it, that’s really what’s going to make a difference.”
Public Policy on Physical Activity in the Parks and Recreation Sector
According to Chriqui, there is quite a bit of literature on the relationship between park access, availability, safety, renovations, and maintenance and park utilization and physical activity. Most reviews recommend policies that, first, invest in maintenance and improvements to amenities and recreational programming in existing parks and, second, focus on safety (Babey et al., 2005). “We don’t need to build a lot of new parks,” Chriqui said, “but we need to build up what we have and really improve what we have.” She mentioned a number of local-level natural experiments, including, for example, a series of park renovations under way in low-income areas of Chicago, that are facing implementation challenges and need to be studied.
Public Policy on Physical Activity in the Business and Industry Sector
Several studies have demonstrated that worksite promotion policies are associated with higher levels of physical activity and less sedentary behavior (Crespo et al., 2011; Dodson et al., 2008; Matson-Koffman et al., 2005). Additionally, as Eyler had mentioned, worksite transit benefit programs have been shown to increase walking and active travel to work (Lachapelle
and Frank, 2009). According to Chriqui, these can include pretax public policy programs, which require tax code changes, serving as an example of how a “big P” policy change can effect change at the organizational level.
In summary, Chriqui emphasized that a wide range of policies on physical activity have been studied in terms of implementation and impact. One of the biggest challenges for researchers studying such policies, in her opinion, is that most of these studies are conducted after policies have been enacted, and therefore are limited to cross-sectional analyses. While some statistical modifications can make the analyses more rigorous and allow for comparisons between communities with and without such policies, researchers cannot conduct randomized controlled trials of physical activity policies as they can with much standard bench science work. Chriqui called for more longitudinal studies as a way to truly understand the impact of these policies over time.
In addition to more longitudinal work, Chriqui emphasized the need for studies on the collective impact of the range of physical activity policies. Most studies have focused on the education sector. Chriqui concluded by stating that more research is needed in other sectors and on the combined magnitude of the impact from these policies in all sectors.
Following Jamie Chriqui’s presentation, she and Eyler participated in a panel discussion with the audience.
A Call for Community-Wide Strategies
Moderator Ginny Ehrlich opened the discussion by asking the panelists, “If we really want to move the needle around physical activity in the population, what have we learned thus far? What do we know has really worked in the policy realm, and what holds the greatest promise?”
In Chriqui’s opinion, although policy researchers have done the most work in the education sector, policies in that sector do not have the greatest impact on physical activity. Aside from the collective impact of policies in all sectors, she believes the greatest impact will come from community-wide strategies, such as infrastructure changes (e.g., trails and parks), that enable communities to facilitative active living. She encouraged more focus on community-wide activities and less on the education sector, especially given the competing demands faced by schools. The childcare sector is another area where more efforts need to be directed, in her opinion.
Eyler added that the promotion of community policies affects both schools, which is where the majority of children spend a good deal of their time, and worksites, which is where adults spend much of their time. Because both schools and worksites are within communities, she agreed with Chriqui on the importance of promoting community-wide policies.
Selection Bias, Longitudinal Data, and Natural Experiments
An audience member remarked that selection bias potentially confounds understanding associations between zoning and land use policies and physical activity. In other words, it is difficult to determine whether communities with policies that promote physical activity (e.g., through mixed-use agreements and trail networks) actually change behavior among people who already live in the community, as opposed to attracting people from elsewhere who want to have an active lifestyle. The audience member asked the panelists to comment on researchers’ understanding of that selection bias.
Chriqui responded that her research is among the first to examine the association of zoning and land use laws with physical activity. While the research shows that people are more physically active in communities that facilitate active living, it is not yet possible to determine which comes first. In terms of advocacy, in her opinion, it really does not matter. If people want to move to communities that support active living and are purposefully selecting into those communities, advocates still can use that phenomenon as a case for community improvements.
To truly understand the impact of zoning and land use policies on physical activity behavior will require more longitudinal research, Chriqui continued. She mentioned the growing number of “urbanist” code reforms being registered nationwide. For example, some communities along the Gulf Coast are essentially being rebuilt in the aftermath of Hurricane Katrina, providing a unique opportunity to study the impact of zoning changes longitudinally.
Approaching Policy Makers: How to Frame Funding
An audience member asked about the best way to frame conversations around funding. In Chriqui’s opinion, funding is the root problem with respect to both policy implementation and policy research. In her opinion, the more advocates can speak to policy makers about return on investment, in terms of not only physical activity outcome but also economic outcome, the more their case will resonate. Many communities across the country, she said, have been engaging in health impact assessments. But health impact assessments often are not what resonates with policy makers. What reso-
nates with policy makers, in Chriqui’s opinion, is economic development, particularly in parts of the country afflicted with budgetary problems. She said, “That’s really where I think the focus needs to be in discussions about funding.”
The same audience member also asked about the potential for modeling to help inform policy makers. Eyler responded that multiple sectors need to come together to develop a model of best practices within communities that can be used to draw support from policy makers and stakeholders.
Challenges to Policy Implementation
The panelists were asked what separates communities that implement policies from those that do not. For Eyler, implementation is a function of funding and policy wording. For example, Missouri passed a state law in 2008 requiring 30 minutes of physical activity daily in each elementary school grade. However, the law did not specify “physical education” but “physical activity.” Based on conversations Eyler had with people from various school districts, walking from class to class was considered part of the 30 minutes of daily physical activity. Nor was there any funding for enforcement of the law.
Chriqui added that universal compliance is another challenge. Among the studies she presented, not a single policy case had 100 percent compliance. “We need to figure out that missing gap,” she said. Also, particularly in the education sector, researchers need to determine why the gap exists. Sometimes there are competing demands; sometimes it is how a policy is worded; and sometimes the meaning of a policy has not been communicated very well. Also, policy implementation takes time. Administrative changes lead to changes in policy priorities, with activities being started and then stopped very quickly. “It’s a constant battle,” Chriqui said, one that requires a concerted effort across multiple sectors.
The Language of Physical Activity Policy
Continuing the discussion around wording, another audience member mentioned working with youth in a gym class in the District of Columbia where much of the class time was spent discussing the rules of playing games rather than actually physically moving. She asked the panelists whether and how language in policies is being regulated.
At the state level, Eyler replied, it varies. Some state laws are very specific with respect to the amount and time of physical education, what physical education should include, or the amount of physical activity required on a daily basis. Even so, whether those specific requirements are implemented
varies among schools, classrooms, and teachers because of a lack of mechanisms for implementation and enforcement.
In Chriqui’s opinion, this is a good area for advocacy efforts. She encouraged advocates to work with policy makers to make slight changes in state laws such that the laws include not only mandatory time for physical education but also specific standards regarding what physical education should include.
Physical Activity Policy in a Car-Based Society
An audience member suggested that the “elephant in the room” was the fact that the United States is a car-based society. For her, cars are a “lethal weapon” not only for people around them, but also for people in them. She referred to Howard Franklin’s writing and a study by the American Heart Association on the hidden health costs of transportation and suggested a policy intervention aimed at increasing the price of gas to reflect its true cost. Eyler noted that recent studies (i.e., natural experiments conducted after Hurricane Katrina and the recession) showed that higher gas prices can increase active commuting to work and walking and biking in communities. From a social justice perspective, however, she suggested that tax incentives might be a better recommendation than tax increases.