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Implementation of Strategies That Promote Physical Activity
Although many interventions to promote physical activity are known to be effective in specific populations and contexts, the challenge, in Bill Kohl’s opinion, is to determine whether those same interventions are translatable in other scenarios and, more important, whether they are scalable and sustainable. Often when interventions are rolled out, he said, they lose their resources or champions and disappear. The challenge, he suggested, is to move from intervention to true systems change. In the final session of the workshop, three panelists discussed programs that Kohl views as being not only effective at promoting physical activity but also translatable, scalable, and sustainable.
First, Linda Fondren described the origins and activities of Shape Up Sisters, a gym she founded in Vicksburg, Mississippi, and the efforts of the nonprofit Shape Up Mississippi. Then, Sean Hinkle described DC SCORES, an after-school program for youth in Washington, DC. Finally, Marisa Molina described Everybody Active/Todos Activos, a Centers for Disease Control and Prevention (CDC)-funded exercise and healthy lifestyle intervention designed to promote physical activity among Latinos in San Diego, California.
The panelists’ descriptions of their programs triggered a lively discussion with the audience. Several major themes emerged, with all three panelists agreeing on the important role of social support (i.e., in keeping participants coming back), leadership (i.e., having a champion, or champi-
ons, to help expand the program), and partnerships (e.g., with the public health sector and with schools).
This chapter summarizes the introductory remarks of the session, the three panelists’ descriptions of their programs, and the discussion that followed. It ends with a summary of workshop closing remarks by Russell Pate.
Many strategies for promoting physical activity have proven effective, while others appear promising or are just emerging, and all of these strategies have helped to identify what works and where resources should be directed, Bill Kohl began. But, he said, “Nothing is moving.” Occupation-related physical activity is declining (Church et al., 2011); leisure time physical inactivity is probably increasing, according to some data; transport-related physical activity has remained the same; and, while difficult to measure according to Kohl, household and other related physical activity has remained the same as well. In sum, he described the situation as “static” and “stagnant,” suggesting that “more of the same is not enough.” He believes that to move forward, “We have to think a little differently, look a little bit to the side.”
Rather than individual, one-on-one changes, Kohl called for changes at the population level. Not only should interventions be effective (with data showing that they work in specific populations and scenarios) and translatable (into other scenarios), but more important, in his opinion, they should also be scalable. Instead of affecting just three third-grade classrooms, for example, can a classroom-based physical activity program affect all third-grade classrooms in an entire school district or state or even across the country? Finally, in addition to being scalable, interventions should be sustainable, suggested Kohl. Often, he observed, when interventions found to be effective are rolled out, resources and champions disappear.
Physical activity is a complex behavior, Kohl continued. Managing that complexity requires, in his opinion, systems-level thinking, not just cause- and-effect thinking. Borrowing from business thinking (Sterman, 2000), Kohl suggested that researchers studying physical activity consider not just the goals, actions, and results that can be seen “above” the surface, but also the competing interests, actions of others, unintended consequences, and other public health phenomena “underneath” the surface.
When studying ways to promote physical activity, Kohl explained, researchers typically apply a behavior change theory to the problem,
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1 This section summarizes introductory remarks made by Harold W. (Bill) Kohl III, Ph.D., University of Texas Health Science Center at Houston and University of Texas at Austin.
conduct the intervention, see a behavior change, publish those findings, and move on to the next project. Similarly with policy or environmental approaches to promoting physical activity, an intervention is proposed and tested, results are published, researchers are promoted, and everyone moves on to the next grant proposal. “This is not a systems approach,” Kohl said. He encouraged researchers to think more broadly about strategies for implementation and to consider systematic changes across multiple sectors, including the education, health, planning and built environment, transportation, workplace, and sports and recreation sectors (Kohl et al., 2012). He noted that “systems variables,” such as how people adapt to interventions and whether effects are delayed, often are missing from studies. For example, most National Institutes of Health (NIH) grants extend over 5 years, which means that delayed changes that may not show up for 6 or 7 years are missed.
Kohl suggested that the three panelists in this session would be describing strategies that are not only effective but also scalable and sustainable, and that can contribute to a systems-level approach to promoting physical activity.
“Those who live fit live better and longer,” Linda Fondren began. Her sister was at a very unhealthy weight as a consequence of a lack of physical activity. Months after her sister’s death at age 54, Fondren opened a gym in Vicksburg, Mississippi, called Shape Up Sisters, and founded a nonprofit called Shape Up Mississippi. She did not want other women to “have that same fate.”
By opening Shape Up Sisters, Fondren was creating a social environment where women could receive continual support and encouragement to “come back in.” Many women in the gym have met their best friends there, she said, while others lacked social lives before attending. The social support offered by the gym is what makes it sustainable, in Fondren’s opinion. “They have a place they can come back to for that encouragement and that support,” she said.
Obesity affects not just the women who attend Shape Up Sisters, Fondren learned, but their families as well. Many women attending the gym would tell her that they wished their husbands or children would “get off the couch.” So she reached out to the wider community; mobilized the support of elected officials, churches, restaurants, other gyms, hospitals, and other individuals and institutions; and founded Shape Up Mississippi.
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2 This section summarizes information and opinions presented by Linda Fondren, community leader and founder of Shape Up Sisters and Shape Up Vicksburg, Vicksburg, Mississippi.
Among other activities, Shape Up Mississippi formed a walking club, and through partnerships with the university and the city of Vicksburg, has been teaching community members how to grow healthy foods (at city-wide community gardens) and be physically active (through trainings conducted by Shape Up Sisters). Through the collective efforts of Shape Up Mississippi and its community partners, Fondren said, the town has collectively lost 15,000 pounds.
In addition to its community work, Shape Up Mississippi conducts trainings in workplaces. Based on her experience, Fondren observed that many companies do not know how to start wellness programs. In addition to teaching about body composition and weight, the number one piece of advice she communicates to them is, “What you do has to be social. . . . People love to interact with each other.”
DC SCORES is a free after-school program serving more than 1,500 low-income youth at 44 elementary and middle schools in Washington, DC. Its goal is to instill self-expression, physical fitness, and a sense of community through what Sean Hinkle described as a unique model combining soccer, poetry, and service learning.
With respect to the “ins and outs” of how DC SCORES operates, Hinkle said, teachers are hired to run the program at schools. At each site, 2 writing coaches and 2 soccer coaches lead teams of 32 students—16 boys and 16 girls. Each week, the teams participate in two 90-minute writing sessions, two 90-minute soccer practices, and an official soccer game on either Thursday or Friday. For the soccer games, a team from one school is bussed to another school so the students can meet youth from other neighborhoods and make new friends. With the sidelines usually filled with parents, administrators, other students, and people from the community, Hinkle said, “It is a wonderful environment.”
Hinkle shared findings from a recent evaluation of the program: 78 percent of students participating in DC SCORES improved their body mass index (BMI) percentile, 65 percent increased their aerobic capacity, 100 percent reported feeling confident that they will graduate from high school, 95 percent reported feeling a lot of pride in themselves, and another 95 percent reported feeling as though they are a positive part of their community.
The program started “organically,” Hinkle said, in 1994, at Marie Reed Elementary School in the Adams Morgan neighborhood of Washington, DC. A teacher started playing soccer with students after school. Then
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3 This section summarizes information and opinions presented by Sean Hinkle, program director, DC SCORES, Washington, DC.
one day it rained, and the teacher moved the students inside and started writing with them. That dual focus picked up, Hinkle said, gained momentum, and spread to other schools. In 1999, DC SCORES grew into America SCORES, which now serves 8,000 youth in 14 cities.
EVERYBODY ACTIVE/TODOS ACTIVOS4
Everybody Active/Todos Activos was an exercise and healthy lifestyle intervention study in south San Diego, California, funded by the CDC Prevention Research Centers Program. The primary aim of the study, according to Marisa Molina, was to create a sustainable community program that would promote physical activity among Latinos living in south San Diego along the United States–Mexico border.
The study was funded for two 5-year funding cycles. In the first funding cycle, 35 volunteer community health workers were trained to provide free exercise classes in schools, recreation centers, community centers, apartment complexes, and parks. Most of the group exercise programs involved Zumba or dance aerobic classes. Results from the first funding cycle showed significant decreases in blood pressure, waist circumference, and symptoms of depression.
In the second funding cycle, a healthy lifestyle program was added to the group exercise class. Thirty-two community health instructors were trained to teach the exercise class and healthy lifestyle program. Additionally, three community coordinators were hired from local agencies to support the community health workers. Preliminary results from the second funding cycle suggest that participants experienced improvements in blood pressure, waist circumference, BMI, fitness, and flexibility. Additionally, participants reported consuming less fat and drinking fewer sugary drinks (over a period of 6 months to 1 year). Most notably, in Molina’s opinion, during the peak of the program, 47 free exercise classes were being offered weekly throughout south San Diego. On average, there were 22 participants per class, with some classes averaging 60-100, and more than 2,500 people registered to participate in the program (i.e., not including the 450 participants already enrolled in the study).
Now that the funded study activities have ended, 27 classes, both free and paid, continue to be offered to the community by the program’s community partners. Because of the training they received through Everybody Active/Todos Activos, many of the community health workers went on to find jobs with the program’s community partners. One of the program’s community health workers opened a dance studio, Molina said, offering
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4 This section summarizes information and opinions presented by Marisa Molina, M.P.H., Institute for Behavioral and Community Health, San Diego, California.
17 classes per week, including some free classes for the community. Molina noted that the woman who opened the dance studio was not a dance or exercise instructor before being trained by the program. Clearly, Molina said, the program had a tremendous impact not only on class participants but also on the community health workers providing the classes. That the classes are still being offered to the community reflects the program’s sustainability, in her opinion.
The Institute for Behavioral and Community Health is expanding and will be testing the program in other types of organizations, according to Molina. In 2013, it piloted a small study in collaboration with the County of San Diego Health and Human Services Agency to test the model within the context of the Welfare-to-Work program. Although the number of participants was small, with only 19 women taking part in the study, results indicate improvements in health, in participation in Welfare-to-Work activities, and in employment outcomes. The Institute is seeking funding to disseminate the intervention model to other health departments and Welfare-to-Work programs.
A lesson learned from all the work accomplished thus far, Molina observed, is the added social benefit of group exercise classes. The original intent of Everybody Active/Todos Activos was to promote active transportation and the use of community parks. But researchers found that participants preferred exercising in groups and indoors. Everybody Active/Todos Activos expanded over the years, Molina said, not through marketing, but through word of mouth.
The three presentations prompted a lively discussion with the audience, with Fondren, Hinkle, and Molina fielding a broad range of questions about the success and sustainability of their respective programs.
The Important Role of Social Support
When asked why she thought social support was such an important part of Shape Up Sisters, Fondren said, “It is fun. . . . It is a feel good thing.” Most people, in her experience, lack a clear understanding of health. They think about health in terms of sickness, but “it means so much more than that,” she said. Getting people to participate requires talking to them about what health really means—the ability to have choices and “just to be a part of life.” Then they get motivated, Fondren said. “I think physical activity should be like wearing a seatbelt,” she added. “If you don’t wear one, you don’t feel safe.”
Embedding Physical Activity into the Culture
An audience member asked the speakers what evidence exists to indicate that physical activity among the programs’ constituents has increased outside of the context of the programs.
DC SCORES starts at a young age—third grade—Hinkle replied. The program has strategically clustered its schools so that when children leave elementary school, they will likely be continuing in a middle school that also offers the program. While DC SCORES has no formal evidence indicating that youth continue seeking additional physical activity opportunities after they leave middle school, Hinkle knows that participants, especially girls, go on to populate, and sometimes even create, high school soccer teams.
Molina replied that, while the community health workers encouraged participants in Everybody Active/Todos Activos to exercise outside of the classroom, it is difficult to know what physical activity actually took place outside of the program and whether total physical activity was increasing over time as a result of program participation.
Fondren pointed to the success of the walking club that grew out of Shape Up Mississippi and the collective loss of 15,000 pounds among participants as indicators of the spread of physical activity in the community. Additionally, Shape Up Mississippi partnered with the city of Vicksburg to install a quarter-mile walking track in one of the city’s parks so that parents can walk while watching their children play. Another quarter-mile track is being planned in another park. Fondren also mentioned the walking trails through downtown Vicksburg, with interpreters offering directions and information about the city. Finally, Shape Up Mississippi partnered with the Vicksburg National Military Park, a civil war park, to allow free walks through the park four times per year. All of these various programs get people moving and, in Fondren’s opinion, make the Shape Up efforts sustainable.
The panelists were asked whether, when people in their programs lose weight or improve their metabolic profiles, it is because the programs are helping people who were inactive become active, or because the programs are attracting already active people?
More than 80 percent of participants in Everybody Active/Todos Activos, Molina replied, were overweight or obese when they entered the program. Many were stay-at-home moms who failed to meet the national physical activity guidelines at baseline. Most of Molina’s community work, including that with Shape Up Sisters/Shape Up Mississippi, is with underserved African American communities. Often when she recruits people for the Shape Up Sisters 6-week nutrition and exercise program, they ask, “Why?” She told the audience about approaching a woman who was sitting
in her front yard on a lawn chair, which was about to collapse beneath her. When Molina told the woman about the program, the woman wanted to know why she needed it and how much it cost. Molina had to keep going back to the woman until, eventually, she decided to show up with her child in tow. “She was still apprehensive,” Molina said, “but she showed up. She showed up because we did not give up.” “We have to keep going with the ‘I won’t,’” Molina said, “until we get ‘I might.’ Then we can move them on to ‘I will.’”
DC SCORES has free enrollment, Hinkle said. Some students who decide to participate are interested in soccer, some in poetry, and others in service learning. Others enter the program because their parents have enrolled them. The program also has a fair number of children referred by counselors or other school administrators who think the children would benefit from participating. Hinkle told the audience about a student who joined the program in the third grade upon referral by his counselor. The child was struggling with his weight. On the first soccer game day, he was embarrassed to run around the field, so he did not play, nor did he want to play the next week either. But in the third week, he saw a child on the other team who looked just like him and who was playing and enjoying himself, so he jumped onto the field, and he has played soccer every day since then. So children come to DC SCORES in many different ways, said Hinkle.
External Funding and Sustainability
An audience member asked how Everybody Active/Todos Activos and DC SCORES sustain themselves, given that they are dependent on external funding. Molina replied that it will be interesting to see how the Everybody Active/Todos Activos program continues now that its funding period has ended. Many schools and recreation centers have adopted the community health workers trained and certified (e.g., Zumba certified) through the program. Some of the schools have offered to pay for liability insurance for the instructors. Some of the recreation centers are charging a small fee, such as $2 per class, with half the money going to the instructor and the other half to the center for maintenance.
For Hinkle, sustainability is a challenge. Because the DC SCORES program has been in some schools since 1995, it is ingrained in the culture of those schools, and the schools bring the program to the table for discussions about government and other funding opportunities. Over the last few years, however, the organization has been trying to gain more long-term individual donors and multiyear grants to allow for longer-term projection.
Working with Schools
When Allison Nihiser asked how receptive schools are to offering the DC SCORES program, Hinkle replied that the organization has a wait list of about 12 schools. Resources are the greatest barrier. For example, neither the city nor the school system provides buses for student transportation, so DC SCORES must cover those costs itself because game days are an integral part of the program. DC SCORES needs be sure it can offer a complete program and provide students with its full experience before entering a school.
Nihiser also asked whether there were any barriers to expanding Everybody Active/Todos Activos into schools. Molina replied that administration buy-in is an important factor. She described the relationship with schools as a partnership, with community health workers working alongside school custodial staff, and said it is leadership that makes that possible. Schools with principals who have real interest and motivation with respect to providing community programs to their students and parents are easy to work with, she said. Schools without a supportive administrator, in which priorities are elsewhere, are more difficult. Molina emphasized that schools do not incur a cost in offering the program. In some of the lower-income schools, where resources were limited, Everybody Active/Todos Activos provided such things as soap and toilet paper.
Partnering with the Health Care Sector
An audience member asked whether any of the programs had worked with health care providers or with the health care sector, and if so, how that partnership started and what role it plays in the program. Shape Up Sisters works with physicians’ offices in Vicksburg, Fondren said, with many female patients being referred to the program by one physician in particular. Most of these women cannot afford to pay, so Fondren opens the gym to them on Saturdays for free. The referred women are shown what to do and can work out with “fitness motivators” so they do not have to work out alone.
Everybody Active/Todos Activos worked with the San Ysidro Health Center in San Diego, Molina said. In fact, the health center was one of three local agencies selected to help with supervision during the second funding cycle. In addition to supervising some of the program’s community health workers, the center helped distribute exercise calendars so that visitors to the center could see when Everybody Active/Todos Activos classes were being offered. There was some cross-promotion as well, with Everybody Active/Todos Activos promoting San Ysidro Health Center’s health education and cooking classes. Additionally, Everybody Active/Todos Activos and the San Diego Prevention Research Center conducted a training with
medical residents at the health center on physical activity, in which the residents learned about identifying risk factors indicating that a person is ready and able to participate in exercise. Molina was not sure how effective that training was in terms of bringing people into the Everybody Active/Todos Activos program. Although the program received a few referrals, it may not have been a primary priority for many of the doctors.
Another audience member asked the panelists how their programs could benefit from support, whether technical, funding, or infrastructure support, from their state health departments. Hinkle replied that DC SCORES needs help certifying its coaches in cardiopulmonary resuscitation (CPR) and first aid. Not only is the certification expensive, but most of the coaches are teachers, which makes scheduling difficult. Molina agreed that, for Everybody Active/Todos Activos to expand, support to help with training will be very important. The community health workers need a hub where they can find that support, she said.
Shape Up Mississippi is already working with the state health department in a couple of different ways, according to Fondren. The program is part of the Mayor’s Health Council, which Shape Up Mississippi helped to found, and the council conducts health screenings at community events hosted by Shape Up. Hinkle added that just the presence of the state health department at an event being hosted by DC SCORES is important.
Economic Benefits of Promoting Physical Activity
An audience member asked the panelists whether their or similar programs have demonstrated economic benefits—for example, in the form of people moving to a new community because it has these types of programs. Fondren described Vicksburg as a tourist town. People want to do more than go to the casinos when they visit the city, she said; they want to visit the community. Creating walking trails draws tourists. The bridge crossing the Mississippi River, in Fondren’s opinion, could be a major driver of economic development. She is working with elected officials to turn the bridge, which is no longer used, into a pedestrian park.
Another audience member observed that the 100 percent self-efficacy for graduating from high school mentioned by Hinkle during his presentation (i.e., that 100 percent of DC SCORES participants are confident they will graduate from high school) in and of itself reveals substantial economic benefits for the individual student, the student’s family, and the community. Hinkle agreed, especially given that the high school graduation rate in Washington, DC, is around 50 to 60 percent. “For the kids to have that much confidence is tremendous,” he said. He reiterated that DC SCORES is about giving youth opportunities to succeed in as many ways as possible.
Scalability
Kohl asked Hinkle how DC SCORES was able to scale up so successfully from Washington, DC, to the now 14 cities across the country, and he asked all of the panelists to reflect on what they would do if they could scale up their programs and reach a larger population.
Hinkle explained that DC SCORES identified core components and then built a training platform that allowed its coaches to acquire the knowledge necessary to deliver the program in the best way possible. The training platform has been growing, especially as new technologies have become available. With respect to moving the program outside of Washington, DC, and into new communities, Hinkle said that in addition to know-how related to the program, there needs to be someone in the community who wants to bring the program there, as well as funding in place.
Fondren stressed the importance of community role models, that is, people in leadership positions whom underserved people want to follow. “I would like to see many more role models saying, ‘Look at me. I did it.’ That is what will make someone else do it too,” she said.
Everybody Active/Todos Activos is planning to create a program package with manuals and training videos that can be given to any organization interested in implementing the program. The cost of actually providing training to help organizations implement the program will probably be the greatest challenge, in Molina’s opinion. Outside of that challenge, creating partnerships in the community and leveraging locations will be important.
Is the Emphasis on Losing Weight or on Moving?
An audience member asked the panelists whether the emphasis of their programs was on losing weight, moving, or both.
Hinkle described DC SCORES as a youth development program. It is about youth engagement—youth enjoying themselves and having fun. Physical activity is built into the curriculum, with an attempt to ensure that all sessions include the maximum amount of movement possible. But much of the training of coaches is focused on youth development principles so the coaches can create supportive environments where the youth can thrive. “The soccer takes its own route,” Hinkle said.
Everybody Active/Todos Activos, Molina said, takes a whole well-being approach, with a focus on many different aspects of health, including healthy eating and emotional health, not just physical activity. That said, exercise is the main component of the intervention, and the greatest amount of time is dedicated to exercise. If a particular community health worker has an interest in weight loss, he or she may verbally share that interest with class participants, but otherwise there is no focus on weight loss.
Shape Up Sisters promotes physical activity. “When you do it, you feel good,” Fondren said. In her opinion, there is something about physical activity that makes people want to eat better, do better, and try new things.
In his concluding remarks, Russell Pate relayed three anecdotes that he believes collectively capture, as he said, “where we are with this challenging issue.” The first was a media story about a so-called free range family in Silver Spring, Maryland, that was encouraging its elementary school-aged children to walk to a nearby park by themselves, unsupervised by adults. This behavior eventually resulted in the police picking the children up and citing the parents for child abandonment. The same thing happened again just days before this workshop, and this time when the children were picked up, they were taken to child protective services. Pate did not express his opinion about who was right or wrong in this situation. He did say, however, that regardless of who was right, the situation was sad. It was unfortunate if the police were right, and it was not safe for these children to be walking a few blocks from their home to a park to play. And it was unfortunate if the parents were right—if the neighborhood was safe, and the police were intervening because of a misperception.
Pate’s second anecdote was that just a couple of days before the workshop, John Hancock announced that it would be providing financial incentives for its life insurance clients to adopt and maintain a level of physical activity that meets the national guidelines. The company would be providing its clients with Fitbits, uploading the data, and monitoring compliance. If that development catches on and is adopted by other life insurance companies, Pate said, it could have a powerful positive impact on the behavior of millions of people.
The third anecdote was relayed to Pate by a friend who coaches boys’ and girls’ high school cross-country teams. Girls in the high school were posting pictures of their prom dresses on the Internet, with some girls commenting that they had to go on a diet and lose weight so they could fit into their dresses. The captain of the girls’ cross-country team asked her classmates whether, instead of going on a diet, it would be better to run to improve their fitness, lose weight, and fit into their prom dresses. This anecdote struck Pate because not only did this girl have the right idea, but she took the initiative to advance it. Despite policies that operate at a macro level, in the end, Pate believes, there is nothing as powerful as what is taking place in one’s immediate social group.
