5

Community Supports for Physical Activity

INTRODUCTION

Although physical activity is an individual behavior, it occurs in built and social environmental contexts that affect individuals’ decisions about being active. There are different community attributes that can be supportive of active recreation (e.g., leisure time physical activities) and active forms of transportation (Bauman et al., 2012). Active recreation includes sports, recreational walking, and exercise, and they are discretionary and not associated with tasks required for daily functioning. By contrast, active transportation encompasses all human-powered means of travel to reach a destination, such as walking, bicycling, or wheelchair rolling. Public buses and rail systems may be frequently overlooked as forms of active transportation, but they contribute to physical activity because they often involve walking at the beginning and end of trips (Giles-Corti et al., 2016). This committee expanded its initial focus on the outcome of active transportation to include active recreation because there are significant gaps in surveillance of community supports for both categories of physical activity; therefore this chapter’s recommended strategies and actions consider community attributes that are relevant for both outcomes.

Community supports for physical activity take numerous forms, from physical infrastructure such as parks, trails, sidewalks, and bicycle facilities, to neighborhood design features such as accessibility to destinations, compactness or density, and the availability and cost of automobile parking. Policies and standards influence when and where these supports are implemented. Policies may heavily favor vehicular travel over active modes

of travel, or they may compel or incent decision makers and developers to design neighborhoods and environments that support physical activity (Giles-Corti et al., 2016). For example, policies that open school recreational facilities for community use have proven to be promising for enhancing access to recreational areas and increasing physical activity (Labarthe et al., 2016).

Topics related to community supports for physical activity overlap with topics discussed in this report’s other chapters. For example, although many community supports are relevant for all community members and visitors, such as sidewalks and parks, other supports are specific to subpopulations in the community. Schools and early childhood education facilities are particularly influential for children; whereas the built environment around workplaces and health care facilities, as well as the design of the buildings and grounds, influences the physical activity behaviors of people using those facilities. Some physical activity programs and promotions are available to communities through schools, workplaces, and health care facilities.

Evidence on the importance of community supports for physical activity has accumulated over the past two decades. For example, data indicate that street design can encourage pedestrian and bicyclist activity by increasing the connectivity of destinations, improving safety by creating safe crossings, separating bicyclists from cars, lowering vehicular speeds with traffic calming measures, and enhancing the attractiveness of the environment (Smith et al., 2017; Stappers et al., 2018). Zoning ordinances, complete streets policies, and urban design codes can influence the proximity and accessibility of land uses, which in turn help determine walking and bicycling for transportation (Choi et al., 2017). Although access is important, the design aesthetics and the visual appeal of public and private spaces also influence walking and biking activity. For example, both the availability of parks and the presence of amenities and activity facilities in parks are positively associated with park use and physical activity (Karmeniemi et al., 2018).

Extensive evidence about the importance of community supports for physical activity has led to recommendations by authoritative groups. The Surgeon General’s Call to Action to Promote Walking and Walkable Communities, the Community Preventive Services Task Force recommendation for combined built environment approaches to increase physical activity, and the World Health Organization Global Action Plan on Physical Activity 2018–2030 recognize the importance of community supports for physical activity (HHS, 2015; Barnett et al., 2017; CDC, 2017; WHO, 2018).

Social environments and community programs can enhance the usefulness and impact of the built environment. There is preliminary evidence of the interactive effects between built and social environments and physical activity (Sawyer et al., 2017). Programs such as Open Streets, which

temporarily prohibit vehicles and make city streets open only to walkers, bicyclists, roller skaters, and the like, can support physical activity by increasing awareness of opportunities, changing attitudes, and creating incentives for active leisure and transportation (Eyler et al., 2015).

Community supports for physical activity are important across the lifespan, and their relevance for active transportation and overall walking is similar across age groups. Among older adults, the presence of recreational facilities, the quality of sidewalks, and safety features are emerging as important community attributes (Barnett et al., 2017; Cerin et al., 2017). For adolescents and children, evidence suggests that improvements in the walking environment, traffic safety, transportation infrastructure, and access to sports and recreational facilities are important community supports (Bauman et al., 2012; HHS, 2012). Encouraging active travel to school through a mix of infrastructure, policy, and programs is an important support to increase physical activity and reduce pedestrian- and bicycle-related injury among children and adolescents (HHS, 2018; NPAPA, 2018).

Decisions about community supports lie primarily outside the public health sector. Thus, a multisector approach that includes decision makers and practitioners in education, parks and recreation, urban planning, transportation, and other sectors of civil society is important (Giles-Corti et al., 2016; Reis et al., 2016). Representation of these disciplines at different geographic levels is also necessary, because decisions about physical and social environments cut across neighborhood, local, county, regional, state, and national governments. Likewise, multiple sectors and government agencies have relevant expertise and data that are essential for understanding opportunities for, and influences on, physical activity. Therefore, surveillance of policies and practices regarding community supports at local, regional, state, and national levels is important.

The multisector nature of community supports offers opportunities for broader benefits of a robust surveillance system. Implementing many of the recommendations that follow will require collaboration among public health and stakeholders in diverse fields. There is the possibility that such collaboration could lead to greater integration of health goals into what are considered “non-health” sectors. To facilitate such a shift, care should be taken to make the community supports surveillance data as accessible as possible to a wide range of partners, including data access, data linkage, and data visualization. Implementation of new surveillance systems should also seek to increase the value of the data within public health. Because there is evidence that several types of community supports are inequitably distributed across communities (Taylor and Lou, 2011), improved surveillance is needed to document such inequities and use the information to plan public health actions to achieve equity goals. Improved community

supports surveillance could also be integrated within widely used public health resources, such as County Health Rankings.¹

To develop recommended strategies for surveillance of community supports for physical activity, along with specific actions to support implementation of those strategies, the committee consulted a list of 20 relevant community support constructs. The list was compiled in a 2018 discussion paper (Pate et al., 2018) and includes community design; street design; safety; policy and planning; transportation systems and infrastructure; events, resources, and programming; and public attitudes toward policies and environments (see Box 5-1). Although all 20 community support constructs are relevant to physical activity, and it would be desirable to monitor as many of them as feasible, the discussion paper, Pate et al. (2018), used a systematic process to prioritize seven constructs for surveillance systems. The eight experts on the community supports workgroup ranked all 20 constructs on three criteria: (1) level of evidence that construct relates to higher levels of physical activity, (2) relevance to active transportation as a form of physical activity, and (3) potential for change or improvement over time and change can be sustained. Those results were used to select seven constructs for further consideration. Prioritization was based on the logic that it is not feasible for surveillance systems to assess all relevant variables.

As noted in the study statement of task (see Chapter 1, Box 1-3), to meet the priority needs of the sponsor, a surveillance document was commissioned as a component of the larger study to serve as part of the range of available evidence on tools to facilitate surveillance in the area of community supports for active transportation. The sponsor requested that the surveillance document include (1) a population survey about community supports for active transportation; (2) a survey of practitioners and professionals about the presence of relevant policies in the communities where they work; (3) guidance for creating relevant measures of community supports for active transportation using geographic information systems; and (4) a guide for conducting streetscape audits using an automated system.

The commissioned document was developed in tandem with the committee’s work, and in its evaluation of the final commissioned document, the committee determined that the reports included can be considered as resources for developing more comprehensive survey materials and guidelines for surveillance purposes, particularly within the area of community supports for active transportation. The final commissioned document consists of three components, which can be found in Appendix E. Part I includes the brief questionnaires on individual perceptions of community supports for active transportation and for members of a professional organization, and an accompanying validation protocol; Part II includes the geographic

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¹ See http://www.countyhealthrankings.org (accessed April 15, 2019).

information systems (GISs) protocol; and Part III pertains to the protocol of remote collection of audit data.

For the development of the strategies and supporting actions for implementation, the committee expanded the focus from community supports for active transportation to physical activity in general, with the main additional focus being on leisure or recreational physical activity. This expansion was based on the idea that many supports for recreational physical activity such as parks, events, and programs can also increase utilitarian physical activity and can affect entire communities. Evidence and existing measures also make these types of supports promising prospects for physical activity surveillance systems. Because this expansion made a complex set of constructs even more complex, we decided not to further expand into other domains of occupational physical activity (which could be considered by the workplace group) or household activities. The following strategies and actions for implementation of surveillance of community supports for physical activity attempt to cover as many community support constructs as possible while being feasible.

STRATEGIES AND ACTIONS FOR IMPLEMENTATION OF SURVEILLANCE OF COMMUNITY SUPPORTS FOR PHYSICAL ACTIVITY

Strategy 17

Background

Self-reported surveys of population health are frequently used in public health surveillance. They can complement other measurement methods, such as GIS, direct observation of environments, and coding of policy documents. Surveys can measure constructs, such as perceived safety and public attitudes toward environments and policies, that cannot be assessed through other methods. Surveys can also provide built environment data for locations that lack GIS data.

Findings

Numerous surveys of the built and social environment constructs (e.g., perceived safety) listed in Box 5-1 have been developed and evaluated (Brownson et al., 2009). These surveys usually ask the respondent to evaluate the “neighborhood” around the home or workplace. Though other scales of assessment are possible, such as cities, smaller geographic scales are preferable because they provide more detailed, and probably more accurate, assessment. Evidence indicates that survey measures are related to physical activity outcomes in age groups ranging from children through older adults, though there are inconsistencies in the evidence (Bauman et al., 2012). Some brief measures have been developed (Brownson et al., 2009), and a few have already been used in national samples of the U.S. population (Sallis et al., 2009; Whitfield et al., 2018). Thus, it is feasible to include a small number of survey items regarding the built and social environments in existing national surveys, such as the National Health Interview Survey (NHIS) conducted by the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS), and possibly the National Household Transportation Survey conducted by the Federal Highway Administration.

By contrast, measures of events, programs, and resources, as well as measures of public attitudes toward policies and environments, are much less developed. Further development will help prepare these constructs for inclusion in national surveillance systems.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 18

Background

Objective measurement of community supports using GIS is an important component of a surveillance system for physical activity. The depth and availability of GIS data on community supports varies by sector. For instance, transportation system characteristics such as the presence of public streets and number of street lanes are collected, distributed, and regularly updated by the U.S. Census Bureau (U.S. Census Bureau, 2018). Other data

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² Available at https://www.epa.gov/smartgrowth/smart-location-mapping (accessed March 25, 2019).

such as the presence and quality of sidewalks, bicycle facilities, and parks are not collected nationally, but some municipalities and regional agencies collect, maintain, and disseminate these data. Availability of GIS data on land uses and places people visit (e.g., libraries, health care clinics, stores), building footprints, and building intensity varies considerably across cities, and no single national source exists. Some private firms commercialize GIS-related information based on administrative records, such as employment reporting and county and municipal permits, that can be used to infer land uses and destinations (e.g., National Employment Time Series, InfoUSA/ReferenceUSA). Others have recently used image processing to develop a national inventory of buildings (Microsoft, 2018), but this technique has not been applied to examine community supports relevant to physical activity. Finally, indices (e.g., WalkScore®, BikeScore®, ParkScore®) that attempt to encapsulate in a single score the degree of community support for a specific physical activity behavior have been developed and commercialized recently and are also being increasingly used in research (Hirsch et al., 2014; Braun et al., 2016).

Findings

There is no centralized repository of up-to-date and consistent GIS data on community supports. Given the large number of potential GIS measures of local community supports, it would be beneficial to identify which are key measures (starting with the constructs in Box 5-1). It is desirable that data on community supports are available at small geographic units, which helps support local decision making and enables linkage to other data such as the U.S. Census block groups, tracts, and zip codes.

EPA’s Smart Location Database makes available more than 90 indicators associated with the built environment at the Census block group level nationwide, as well as publicly available walkability and public transportation access indices. The current version of the database (2.0) has data from 2010 to 2013, but it is undergoing an update, providing continuity and opportunity for improvement. Similarly, the National Environmental Database (NED)³ provides data at the block group level for metropolitan areas. The NED has overlap with EPA’s database, but adds important new measures and constructs such as employment mixing, pedestrian fatality rates, and the presence of open space and tree canopy. Appendix E provides an introduction to GIS methods and illustrates the creation of a physical activity–related environmental indicator.

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³ Available at http://ned.ud4htools.com (accessed March 11, 2019).

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

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⁴ American Institute of Architects, American Planning Association, American Public Health Association, American Society of Civil Engineers, American Society of Landscape Architects, National Recreation and Park Association, Urban Land Institute, and U.S. Green Building Council.

Strategy 19

Background

Most (if not all) of the community support constructs are influenced by policies, either directly (e.g., community design, streetscapes, programs) or indirectly (e.g., perceptions of safety) (Giles-Corti et al., 2016). Policies can be generated in different ways, such as by legislation, by agency regulation, by professional association guidelines and standards, and by companies. Policies are made at local, state, and national levels, sometimes with relevant policies at all three levels, such as with transportation. However, few policies that affect community supports for physical activity are under the jurisdiction of public health. The professionals most knowledgeable about community support policies are in fields such as urban planning, transportation, parks and recreation, landscape architecture, education (for schools), and employers (for workplaces).

Findings

It is not feasible for one centralized group to conduct national surveillance of community support policies, given the number of sectors, involvement of multiple levels of government, and complexity of content. Multisector collaboration is imperative for developing surveillance systems for community support policies.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

• Complete Streets Coalition, which tracks adoption of policies consistent with active transportation.
• Form-Based Code Institute, which tracks adoption of zoning codes that are compatible with walkability.
• Safe Routes to School National Partnership, which tracks adoption and implementation of policies and programs.
• Vision Zero Network and the Road to Zero Coalition, which track adoption of policies that set transportation safety goals that are consistent with physical activity promotion.
• National Association of City Transportation Officials, which tracks adoption of street design standards that are consistent with active transportation.

Strategy 20

Background

Existing policies can provide valuable information about the regulatory and institutional requirements and incentives for, and possible barriers to, community supports for physical activity. Self-reported data also provide information about the perceived presence and quality of these supports. Linking these data sources with other geospatial data is critical to understanding possible underlying causes for the presence or absence of supports, examining inequities in the distribution of supports across sociodemographic groups, and identifying opportunities for further improvements.

Findings

There is variation in the relevance of spatial information as is relates to assessing policies that influence community supports. In some cases, policies cover entire jurisdictions and may not vary from one location to the next. For example, minimum sidewalk widths or design standards for curb cuts may apply uniformly in a given jurisdiction (National Association of City Transportation Officials, 2013). In other cases, policies can vary considerably across space. Zoning and maximum speed limits are policies that may

vary based on the characteristics of the neighborhood under consideration (Chriqui et al., 2016).

Linkages at smaller geographic units (e.g., tract, block group, zip code) are preferable to aggregate linkages (e.g., county) as long as confidentiality and privacy of respondents can be preserved. The U.S. Census Bureau and other U.S. federal agencies have developed a system for assigning unique numerical codes called geographic identifiers (GEOIDs) to geographic entities.⁵ These identifiers are key to organizing, presenting, and linking policies, self-reported data, and other environmental data within and across geographies. GEOIDs can be included in policies and self-reported data when geographic linkages are desired.

Supporting Action for Implementation

The committee recommends the following action to support this strategy:

Strategy 21

Background

Community design, street design, and park environment features can be assessed through direct observation, often called audits (Brownson, 2009).

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⁵ Available at https://www.census.gov/geo/reference/geoidentifiers.html (accessed March 4, 2019).

Audits generally involve a trained observer using a systematic coding protocol to identify features of streets, intersections, and parks. Observational measures of schools and buildings are less developed. Audits are often conducted in person, but comprehensive photographic records of all streets in most U.S. cities, such as Google StreetView™, allow online assessments.

An advantage of the observation method is that more detailed local data can be collected than are available through other measurement modes. Community design variables, especially land uses and macro-level street features like street connectivity, can also be quantified with GIS, but observational methods may provide more detail. Observational methods are particularly useful for assessing street design details that are rarely available in GIS databases and measured only crudely through self-reports. Most street observational measures assess key street design variables including presence and quality of sidewalks, quality of street crossings, presence of traffic controls at intersections, presence of aesthetic features like trees and well-maintained buildings, and signs of social disorder such as graffiti and boarded-up buildings. Park observations usually assess presence and quality of physical activity and sport facilities, aesthetics, and amenities such as water fountains, restrooms, benches, and parking.

Observations of streets and parks are indicators of the quality of the built environment, and they have been shown to be related to physical activity in multiple age groups even after adjusting for walkability (Cain et al., 2014). Park observation scores have also been related to number of people and overall physical activity in parks (Geremia et al., 2018). Observational data have demonstrated sensitivity to socioeconomic and race/ethnicity group inequities that exist in the quality of these community supports (Engelberg et al., 2016; Thornton et al., 2016).

Findings

There is no centralized repository to store nationwide observational data on street designs and parks. Numerous measures for observing street designs and parks have been published, with documented inter-observer reliability (Brownson, 2009). However, most observational instruments are lengthy to complete, many measures lack clear scoring guidelines, and data collection is labor-intensive and may involve travel. As a result, observational measures appear to be used infrequently for either research or practice. Conducting observations online using images such as Google StreetView™ still requires trained data collectors, but cost savings are realized by eliminating travel to the location being observed (Rzotkiewicz et al., 2018). Diverse technologies such as artificial intelligence could be leveraged to collect observational data on a broad scale within the next 5 to 10 years.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

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⁶ Also see Chapter 2 on children and Chapter 4 on workplaces.

⁷ A community of practice refers to the group of researchers and practitioners who use computer vision and machine learning to identify supports for physical activity from digital images. These individuals and organizations come together, physically or digitally, under the umbrella of a community of practice to discuss applications, analytical approaches, data sources, and results, among others.

• Investigators attend conferences and trainings to explore best practices in citizen science and crowd-sourcing.
• Investigators develop and evaluate promising methods of recruiting, training, certifying, and retaining observers, ideally those residing in the communities where data are being collected. National membership organizations could be engaged

• as partners in creating a national network for implementing this strategy.
• In a national system, trained observers are deployed to specific locations to achieve sufficient coverage of streets and parks. Methods for assigning locations for observations are developed and evaluated.
• Technology is developed to support citizen-science and crowd sourced observations, including apps for data collection and automatic geocoding of observations within GIS.
• Investigators develop and validate sampling strategies for personal observational methods to adequately characterize a neighborhood. Sampling strategies reduce the time and effort needed to characterize environments for neighborhoods. It will be important to ensure equitable inclusion of lower socioeconomic status areas, communities of color, and tribal nations in sampling strategies.

Strategy 22

Background

The underlying concept is that the diverse community supports covered in this strategy enhance the likelihood of community residents being active. It is expected that the more events, programs, social environments, and promotions, the better for physical activity, though evidence is variable. There are concerns about inequities in all these resources within and across communities. Physical activity events and programs encourage use of facilities such as parks, trails, and other public spaces. There is growing interest in the potential of physical activity programs in public settings to produce health benefits, such as exercise classes in parks and Open Streets events (Giles-Corti et al., 2017). Physical activity programs often serve specific age, sex, or race/ethnic groups, adding to the complexity of their assessment.⁸

Various aspects of the social environment are relevant for physical activity, such as social norms about being active, positive and negative responses to people being active, fear of crime, depictions of physical activity and sedentary behavior in the media, and advertising for products and

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⁸ Programs based in schools and early childhood facilities are covered in Chapter 2, and workplace programs are covered in Chapter 4.

programs that promote being active or sitting. Physical activity promotion resources refer to personnel, budgets, training programs, and advocacy efforts that enable proportionate responses to the epidemic of physical inactivity, especially by public health departments (Yancey et al., 2007).

Findings

No systematic approaches exist for monitoring physical activity events, programs, social environments, or promotion resources as they relate to community supports. Each category is complex, dynamic, and difficult to assess. Residents would likely have limited information about these resources in their community, unless they had direct contact through participation. There is likely no single person or professional group that would be informed about all aspects of any one category of supports. There are widely used measures of most of the social environment constructs, but it is unclear how suitable these would be for surveillance purposes. In the Healthy Community Study, a resource-intensive method of identifying and interviewing multiple key informants in each community was used to quantify physical activity events and programs (Collie-Akers et al., 2018), but this method does not seem feasible for national surveillance. There can be substantial difficulties in assessing physical activity promotion resources even in public health departments, because physical activity resources may not be separable from resources devoted to chronic disease control more broadly.

Although it is questionable whether methods could be developed to obtain a subset of these components of community supports in a systematic, reliable, and cost-effective way, these supports play an important role, are modifiable in the short term, and can be inequitably distributed. Thus, it is critical to attempt to develop methods that could be used for surveillance purposes.

Supporting Action for Implementation

The committee recommends the following action to support this strategy:

• Partner with the National Recreation and Park Association and the National Park Service to survey members about physical activity events and programs.
• Partner with YMCAs to survey local Ys about physical activity events and programs.
• Partner with the American Public Health Association, Association of State and Territorial Health Officials, and National Association of County & City Health Officials to survey health departments about physical activity promotion resources.
• Partner with the United Way to assess locations and characteristics of physical activity programs in its 211 system, which helps people find local resources.
• Partner with the County Extension system to develop monitoring systems for physical activity events and programs, particularly in rural areas.
• Partner with the Indian Health Service and national organizations of American Indians to develop methods for assessing resources on tribal lands.
• Partner with affinity groups such as Outdoor Afro, Girl Trek, and Girls on the Run, which are associated with individuals who are less covered through mainstream programming.

CONCLUSION

Many aspects of built and social environments influence individuals’ decisions to be active, and evidence on the effects of these community supports is mounting. Because multiple non-health sectors and government agencies have expertise and data that are integral to assessing a

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⁹ See Chapter 2 for additional recommendations about assessing physical activity programs targeting children.

community’s influences on physical activity, a multisector approach is an imperative element of surveillance of community supports. The 6 strategies and 15 implementation actions described in this chapter are expected to promote the multisector collaboration that can help achieve such surveillance, and ultimately achieve more widespread community supports for physical activity.

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