Following the presentations and discussion on policy strategies to promote physical activity, the focus of the workshop shifted to community strategies in a session moderated by Jim Whitehead.
“Do built environments matter?” James Sallis asked. The short answer is, yes. In Sallis’s view, the American landscape of residential subdivisions and highway interchanges has dramatically reduced active travel. Not only are highways built not to accommodate walking or biking, but traveling on an interstate highway by foot or bicycle is against the law. Sallis discussed evidence on the design of activity-friendly communities and their impact on physical activity. Data from one study, for example, show that people who live in “walkable” neighborhoods are active 5 to 7 more minutes every day than those who do not live in such neighborhoods. That may not sound like much on a daily basis, Sallis said, but it amounts to about 50 minutes or 2 miles of additional walking weekly, or about 100 additional miles and 10,000 extra calories spent per year. Theoretically, 10,000 calories could prevent a weight gain of about 3 pounds, which is more than the average annual American weight gain. While it may be difficult to change a landscape once roads and buildings have been laid out, Sallis continued, it is possible to improve “micro-scale” features of the landscape, such as sidewalk quality and the safety of street crossings, to make it more walkable.
Although technology has engineered regular movement out of Americans’ daily lives, Abby King asked whether technology could be harnessed to do the opposite. In her opinion, the way technology captures real-
time information and delivers personalized messages could have extraordinary population reach and impacts on physical activity. She advocated for community-engaged “citizen science” and encouraged partnering with industry to capture the tremendous amount of real-time self-movement data being collected by individuals. Additionally, she envisions great potential for information technology to provide personalized advice, citing as an example “Carmen,” a bilingual virtual advisor developed for use in community centers as a way to increase walking among older Latino adults.
“Do built environments matter?” James Sallis began. The “American Landscapes” series of “Forever” U.S. postage stamps, with one stamp showing an image of a residential subdivision and another of a highway interchange, provide a sense of the massive scale of the built environment and the effect of policies that drive it. Residential subdivision communities have not only effectively reduced active travel but also, with their lack of parks, created limitations for leisure time activity. Highway interchanges were designed to meet the transportation goals of the United States, that is, to move as many cars as rapidly as possible. Not only are they designed not to accommodate walking or biking, but walking or biking on interstate highways is against the law. The postage stamp images of residential subdivisions and highway interchanges represent to Sallis one of the reasons Americans are among the least active and most obese people in the world. Yet, he said, “We do know how to create places where people can walk to destinations—so beautiful that they want to walk around.”
For Sallis, the evidence is clear that built environments matter. He presented an example of the evidence linking community design and health. As part of the Neighborhood Quality of Life Study of Adults (NQLS), he and his research team recruited participants from low- and high-income communities in the Seattle, Washington, and Baltimore, Maryland, regions; measured their physical activity with accelerometers; and evaluated the walkability of the different communities (Sallis et al., 2009). They found that people living in walkable neighborhoods were active 5 to 7 minutes more every day than those living in other neighborhoods. This was true regardless of the neighborhoods’ income level.
One might question whether 5 to 7 minutes per day is enough to justify changes in zoning and transportation policies, Sallis said. But 7 more minutes of physical activity per day, he explained, translates into 50 min-
1 This section summarizes information and opinions presented by James F. Sallis, Ph.D., University of California, San Diego.
utes or about 2 miles of walking per week. That 50 minutes amounts to nearly 2 days of the 30-minute per day physical activity guideline. When viewed over the course of 1 year, it amounts to about 100 miles of walking, which, at 100 calories spent per mile, translates to about 10,000 extra calories expended per year. Those 10,000 expended calories could, in theory, prevent a weight gain of about 3 pounds. Consistent with this reasoning, Sallis and colleagues (2009) found substantially lower rates of obesity and overweight in the walkable communities.
Sallis cautioned that not all evidence for a link between walkability and health is as clear or consistent as what he and his research team found in the 2009 study. Nonetheless, he and his colleagues have observed similar trends in other work and across age ranges.
Related to these findings, a policy “bright spot,” in Sallis’s opinion, is that the new form-based zoning codes, which relate to the shape and design of buildings as opposed to their use in a particular area, encourage mixed-use communities and that adoption of form-based codes has been increasing nationwide in recent years. “Over time,” he said, “these should drive changes in the way we build our communities.”
In contrast with Bogotá, Colombia, where activity-friendly “complete streets” streetscapes are designed for all users, including bicyclists, walkers, drivers, and transit users and with aesthetics in mind, most U.S. streets are not designed for active travel (see Figure 6-1; see Chapter 5 for a discussion of complete streets). Sallis mentioned a physical activity meeting he had attended in Atlanta, Georgia, where he and a colleague decided to take a walk but were able to go only a couple of miles because the sidewalk ended abruptly. He then showed an image of a woman pushing a stroller and walking with a child along the edge of a busy street with no sidewalks. He asked, “Should you have to put your life in danger to go out and take a walk?” That is the situation for millions of Americans, he said.
While it is difficult to change the macro-scale design of a community once roads and buildings have been laid out, Sallis presented a “snapshot” of data demonstrating how changing micro-scale streetscape features can encourage walking. The data were collected using MAPS-Mini, an observational assessment tool that people carry with them while walking down a street to identify what is present. The original MAPS-Mini assessment included 120 items. Sallis and his team reduced the list to 15 items, which they determined was a useful length to help learn how streets are designed and how their designs impact people’s experiences as they walk around. The items were selected based on correlations with physical activity, guidelines and recommendations, and modifiability. The 15-item MAPS-Mini was
FIGURE 6-1 A streetscape designed for vehicles and dangerous for active travel (top), compared with an activity-friendly streetscape designed for all users (bottom).
SOURCE: Presented by Jim Sallis on April 15, 2015.
evaluated for validity in more than 3,500 children, teenagers, adults, and older adults from three regions.
Sallis presented results showing that streetlights, benches, and buffers (i.e., a grass strip, parked cars, or some other barrier between pedestrians and traffic) are significantly correlated with active transportation in children, adolescents, and adults; sidewalks are significantly correlated with active transportation in children, adults, and seniors; and curb cuts are
significantly correlated with active transportation in children, adults, and seniors. He interpreted these findings to mean that not all features are important for all age groups and that getting the details right may be most important for children and adults.
When Sallis and his team considered what they called the total “score” for active transport, a measure taking into account all active transport-related variables, they found a significant correlation between that score and active transport across all age groups. Active transport increased as the total score increased, with a more than 200 percent difference in active transport days per week between the least and most walkable streetscapes (Sallis et al., in press). To Sallis, the linear nature of the correlation means a small improvement in the streetscape can lead to a small improvement in active transport, while improving the streetscape as much as possible can lead to a big improvement.
In terms of policy bright spots related to active-living streetscapes, Sallis mentioned the adoption of complete streets policies across the country—an increasing trend in recent years, with more than 600 such policies being adopted by local and state governments by 2014. The challenge now, he said, is to study the quality of these policies and whether they are actually being implemented and funded.
Active Transportation by Youth
An unfortunate trend, Sallis observed, is the observed decline in active transportation in youth (McDonald, 2007). Between 1969 and 2001, car travel to and from school increased (from less than 20 percent to above 50 percent), while walking and biking to and from school decreased (from more than 40 percent to around 12 percent). A Danish study found that adolescents who walked or biked to school were about half as likely to be overweight or obese as those who rode to school in motor vehicles (Østergaard et al., 2012).
In the United States, the Safe Routes to School initiative is intended to improve this situation given that, after distance, traffic safety concerns are the greatest barrier to walking and biking to and from school. In a multistate evaluation of Safe Routes to School programs, Stewart and colleagues (2014) found that most such programs involved building sidewalks, improving crosswalks, and making other similar changes, and that these programs were associated with a 40 percent improvement in walking and biking to and from school. Sallis mentioned but did not describe another study showing that the longer such improvements are in place, the greater is the level of active transport to and from school (McDonald et al., 2014). The distance barrier to walking and biking to and from school, Sallis said, is related to the way zoning separates schools from neighborhoods. He sug-
gested locating schools where the youth are—not on the edge of town but in the middle of the community.
A policy bright spot related to active transportation in youth was the 2005 federal Safe, Affordable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU). That legislation included a funding line item for the Safe Routes to School initiative for the first time—an allocation of $1.2 billion, with 14,000 schools receiving funding. The bad news, Sallis said, is that many states did not use their allocated funds. More bad news came in 2012, when the Moving Ahead for Progress in the 21st Century (MAP-21) federal transportation law deleted the Safe Routes to School line item and cut nonhighway funds by 30 percent. It was unclear at the time of the workshop what would happen in 2015.
Parks in Communities
A national study of U.S. adolescents (n = 20,745) showed that the greater the number of recreational facilities in a neighborhood, the more active youth are and the less likely they are to be overweight (Gordon-Larsen et al., 2006). People are most active, according to evidence reported by Deborah Cohen of RAND Corporation, on the linear elements of parks, that is, on walking tracks and sidewalks. In terms of a policy bright spot related to the link between parks and physical activity and health, Sallis mentioned the Rails-to-Trails Conservancy, which has increased rail-trails from 250 to more than 21,000 miles.
In conclusion, Sallis noted income disparities in many of the variables he had mentioned or described, with lower-income neighborhoods having, for example, less street lighting, fewer sidewalks, less traffic calming, and fewer marked crosswalks (Gibbs et al., 2012). Additionally, he mentioned a recently published review by himself and colleagues on the impact, or co-benefits, of designing places for active living. Sallis and colleagues (2015) showed that designing a place for active living impacts not just physical health but also mental, social, environmental, and economic health.
While technology is a major driver of many of society’s comforts, conveniences, and advances, it has engineered regular movement and activity out of Americans’ daily lives, Abby King began. “Is there a solution in all of this technology?” she asked. Is there a way to harness technology for good in terms of physical activity? Information technology (IT) captures real-time information; delivers personalized, contextually relevant messages and information; and has extraordinary population reach and impact. King noted the explosion of mobile devices worldwide and the growing number of countries, regardless of economic development, with more cell phones than people (UN, 2013). However, King cautioned, while the potential of IT is vast, “It’s really a wild west out there.” Very little is known about the efficacy of IT programs and which programs may work best for which people. Traditional science is too slow and not agile enough, in King’s opinion, to capture current trends in IT innovation. King suggested that one way to harness the potential of IT/mobile devices to promote physical activity is through community-engaged “citizen science,” which brings together researchers, public and private organizations, and residents. She considered in detail two different IT domains in which a citizen science approach is being used: the “me” domain and the “we” domain.
The “Me” Domain of IT
The “quantified self” movement—the use of mobile and wireless devices to sense and track one’s own physical activity—is an “incredible opportunity,” King said. Hundreds of thousands of n = 1 individual experiments are happening across the population at large that involve the personalized “just-in-time” sensing of physical activity and collection of health-related data points throughout the day. These data could be a “game changer” in this field, in King’s opinion. Data hubs are emerging in both the public and the private sector that combine and make sense of all these data, creating significant opportunities for partnering with industry in physical activity and other arenas. King encouraged researchers in the public sector to seek out these partnering opportunities.
In addition to quantification and assessment, the “me” power of IT can be harnessed through personalized IT advising—for example, through telehealth, the use of virtual “IT advisors,” and smartphone app platforms.
2 This section summarizes information and opinions presented by Abby C. King, Ph.D., Stanford University School of Medicine, Palo Alto, California.
King pointed out several evidence-based behavioral strategies that can help people change their behavior and are known to work across communication channels: realistic outcome expectations, increased awareness (mindfulness), exploration of personal benefits and costs, personal goal setting, self-monitoring, regular feedback, and social support.
With respect to telehealth by computer, a major question has been whether automated systems can actually replace human advisors in promoting regular physical activity. King remarked that, while making their flight reservations, some workshop participants probably spoke to an agent over the phone, while others probably used an automated interactive voice response system. In an 18-month study, she and her research team found no difference between phone advice delivered by humans and that delivered by a human-sounding automated advisor (King et al., 2007). At the beginning of the study, when asked which they preferred, human or automated, 85 to 90 percent of participants said they needed a human advisor. But in fact, the data show that human and automated advisors were equally effective in improving moderate- to vigorous-intensity physical activity (MVPA). King cautioned that people tend to prefer what they know, even if that may not be the best solution in the long run. She and her research team, in collaboration with Dr. Marcia Stefanick at Stanford and other investigators around the country, are scaling up the automated advice program as part of a trial involving about 40,000 women who have been participating in the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute’s (NHLBI’s) Women’s Health Initiative (WHI).
An important role for personalized technology, King continued, is in preventing the widening of the health disparities gap by helping to address underlying language- and reading-level issues, problems with computer access and skills, and health illiteracy. There has been a movement to develop virtual advisors that can provide tailored interactions through simple verbal and nonverbal conversations. In collaboration with Tim Bickmore and colleagues at Northeastern University, King and her team are testing “Carmen,” a culturally adapted bilingual (English, Spanish) advisor with which individuals can interact simply by touching a monitor screen (see Figure 6-2). Carmen was installed in computers at a community center in San Jose, California, where ”she showed herself to be an excellent physical activity coach,” King said. The virtual advisor was successful in increasing walking minutes, as measured by both pedometry and self-report, in Latino older adults, most of whom had never touched a computer before they started using Carmen (King et al., 2013a). When the investigators asked participants at a 4-month posttest what it was like to work with Carmen, participants reported that Carmen “cared” about them, they “felt close” to Carmen, they “trusted” Carmen, and they were interested in “continuing to work with Carmen.” In fact, King said, they did continue
FIGURE 6-2 Participant in the King et al. (2013a) telehealth study receiving physical activity advice from “Carmen,” a virtual advisor.
SOURCE: Presented by Abby King on April 15, 2015.
to work with Carmen for another 5 months after the study ended and did not want the researchers to remove Carmen from their community centers.
The next step for virtual advisors, King suggested, is to scale them up and test them in more community settings and with different populations, and to evaluate their longer-term effectiveness. At the time of this workshop, she and her research team were testing Carmen versus human advisors in the Latino community in the San Francisco Bay area. Examples of other potential settings for such virtual advisors, in addition to community centers, include clinics and pharmacies, libraries, worksites, recreational centers, schools, and shopping malls—anywhere people tend to have to wait or congregate, said King.
With respect to smartphone apps, which King noted are increasingly popular and ubiquitous, many have the potential to assess physical activity passively and provide real-time feedback, but few employ other theoretically or empirically based strategies for enhancing motivation and behavior over time. She and her colleagues have been developing smartphone apps to help users walk more and sit less. King and colleagues (2013b) tested
three apps based on different motivational frames (see Figure 6-3). The analytic app, which is based on facts and figures, provides users with data so they can see how they have been doing throughout the day. The affect/play motivational app, in contrast, has no facts or figures, but a bird avatar that tells users how they are doing. If they are doing well, the avatar is chipper and cheery and flying fast. If the user is not doing well, the avatar appears moribund. Finally, the social app provides feedback, but within a group format, with users being part of virtual teams and the feedback being in the form of the user’s team versus other teams.
The researchers found that all three apps increased self-reported physical activity (brisk walking) across a smartphone-naïve sample of midlife and older adults, but the social app had the greatest overall impact, relative to a control group, among this age group when an objective measure of physical activity—the smartphone’s built-in accelerometer—was employed. Additionally, they found more variability in responses to the analytic and affect apps compared with the social app—some people loved the analytic and affect apps, while others disliked them. Thus for King, the real question is not whether the apps work, but which apps work for whom. With respect to sedentary time, the analytic app appeared to perform the best in decreasing self-reported television sitting time. The social app performed the best overall with respect to sedentary behavior accumulated through-
FIGURE 6-3 Three smartphone apps, each based on a different motivational frame, designed to help users walk more and sit less.
SOURCE: Presented by Abby King on April 15, 2015.
out the day, measured objectively using the phone’s built-in accelerometer. These results suggest that different kinds of behaviors may require different kinds of motivational frames.
Looking to the future, King imagined technology that informs and motivates but “gets out of the way” of active living. Right now, she said, people are looking at the world through a screen. She foresees screens disappearing and predicted that people will increasingly be wearing IT, whether it be in the form of iWatches, clothing that “senses” what and how people are doing throughout the day, or Google Glass-–like wearables. That shift, she said, could be “freeing” in terms of physical activity and active living.
The “We” Domain
King described some ways in which the “we” domain of IT empowers citizen scientists to assess and advocate for healthier neighborhoods and social environments. For example, she and her research team have been developing a simple technology, the “Stanford healthy neighborhood discovery tool,” to help low-income, underserved residents identify features in their own neighborhoods that facilitate or hinder active living and healthy eating. Residents can use the data to prioritize issues (i.e., based on feasibility and cost), build community partnerships, and advocate for change with community decision makers (Buman et al., 2012). The technology is a very simple electronic tablet that captures barriers to walking and food access. Residents can carry the tablet with them as they walk around their neighborhood and use it to take geocoded photos and narrate problems they see. The resulting information can be assembled into an aggregated view so that policy makers and others can see, on a map, where barriers in the community are located, and can hear about problems (by clicking icons) in residents’ own voices.
As part of a “we” domain healthy neighborhood project in east Palo Alto, California, which King described as one of the poorest communities in the San Francisco Bay area, Winter and colleagues (2014) found that residents did a great job using the Stanford healthy neighborhood discovery tool to identify issues with traffic crossings and public transit paths and devise solutions. The residents presented their results to the city council, which in turn used this and related information to allocate about $400,000 for a city-wide environmental analysis, in addition to initiating sidewalk repairs and other improvements to facilitate walking.
The citizen science approach is being used to assess neighborhoods and social environments and advocate for improvements to make them healthier in many ways and in many places worldwide: low-income residents in north San Mateo County, California, for example, learned how to increase their food access; Latino teens and older adults in North Fair Oaks, California,
worked together to improve their neighborhoods for walking; citizens in Mexico formed a coalition to increase neighborhood cohesion and safety; Israeli Arab and Jewish residents in Israel are coming together, some for the first time, to talk about neighborhood barriers and generate collaborative solutions; residents in Bogotá, Colombia, have been evaluating citywide “open streets” recreational programs (ciclovía) (see Chapter 5); and residents of rural upstate New York have been catalyzing positive change in their food and activity environments. The goal, or dream, King said, is to build a network of community-engaged citizen scientists for promoting healthful lifestyles and reducing health inequalities around the world.
In addition to the use of IT in citizen science projects as a way to promote physical activity, King made a call for more research on the spread of physical activity through social networks. Evidence suggests that social networks can be harnessed for change through processes such as homophily, whereby perceived similarities lead people to identify with and associate with each other (Centola, 2011; Hinyard and Kreuter, 2007).
In summary, King offered some thoughts on what can be done with technology to increase levels of physical activity: harness the power of inter-sectoral and intergenerational teams to “push the envelope” in the physical activity field and learn IT language, culture, and opportunities; seek opportunities to partner with the private sector, as well as with community organizations; reach all groups to address health disparities; determine which communication channels work for which groups; consider “stealth” interventions, where the focus is not just on health but also on other motives and values; address issues of privacy, anonymity, and informed consent; continue to promote physical activity proactively as complementary and synergistic partners; and tackle challenges not just from the top down, via policy, but also from the bottom up, through citizen science engagement.
Finally, King challenged researchers, organizations, and residents to expand beyond their usual comfort zones and collaborate in leveraging the potential of IT. By doing so, she said, quoting from the Disparity Reducing Advances (DRA) Project of the Institute of Alternative Futures, “we will be better able to meet the challenge of not only anticipating the future, but creating it.”
Following Abby King’s presentation, she and Sallis participated in a panel discussion with the audience. This section summarizes the discussion.
U.S. Cities Taking a Smart Approach to Active Design
An audience member asked whether any U.S. city is taking a “smart approach” to active design. Sallis cited New York City as an example of a city that has taken some transformative steps, as well as Portland, Oregon. In his home state of Mississippi, he mentioned the city of Hernando, whose mayor, Chip Johnson, has become a national leader as a result of his efforts to make the town healthier. Sallis remarked that he had recently visited Jackson, Mississippi, where the main street was being torn up so that the sidewalks could be widened and a pedestrian-friendly roundabout built.
Harnessing Social Change
An audience member remarked that health departments often talk about policy, but not so much about community engagement or harnessing change in large numbers of people. She mentioned Toni Yancey’s work with instant recess (her notion that 10-minute bursts of physical activity can make a difference, which spawned a social movement to get people moving), and wondered whether there are other examples of communities harnessing social change to promote physical activity. Sallis suggested that active applause, whereby audience members stand up when they applaud, might become another physically active social movement.
King added that there are hundreds, if not thousands, of natural experiments going on across the United States. Because researchers and policy makers do not have a good way to harness those natural experiments, she encouraged paying attention to what community-based organizations are doing.
IT for Children
An audience member remarked that much of the IT work discussed by King was focused on older users and asked about the unique challenges of working with children. Might children be more difficult to engage, given competing interests in terms of access to technology?
King agreed that IT is “natural” for children—so much so that the goal with children often is not to engage them but to unplug them so they can actually look at their environment. She speculated that using IT to promote physical activity in children will likely require stealth approaches, an example being the way Dance Dance Revolution (a videogame that gets users up and moving) harnesses play. She suggested that children and adolescents themselves are leading the way for next generations in terms of how to use technologies to promote physical activity and healthy living.
Engaging the IT and Venture Capital Communities
King was asked to comment on ways to engage the IT and venture capital communities. She replied, “Silicon Valley is more ripe than ever for health-related technologies.” After being discouraged for a while, they are back to the table, she said. There is a new understanding of the synergies between making sense of all these data and both their own profit margins and their ability to do good in the world.