A Community Approach to Target Inactivity

Introduction

During the past few decades, the prevalence of obesity has grown to epidemic proportions, and this condition is now known to be a major contributor to the global burden of disease. That physical inactivity is a key public health issue (U.S. Department. of Health and Human Services, 1996) is brought into even sharper focus by recent attention to the obesity epidemic (World Health Org. 1997; Cameron, Welborn, & Zimmet, 2003). The high and still increasing prevalence of obesity in U.S. children, adolescents, and adults poses a major economic and health threat to our society.

What is causing this obesity epidemic? At one level the cause is obvious, Americans are changing their eating and exercise habits. Although there is some controversy about the details, data clearly suggest that Americans are eating substantially more now than they were 15 to 20 years ago (Harnack, Jeffery, & Boutele, 2000). They are exercising less. The map in Figure 1 displays the prevalence of people in each state meeting physical activity recommendations. (Recommended physical activity is defined as at least 5 days a week for 30 minutes a day of moderate intensity or at least 3 days a week for 20 minutes a day of vigorous intensity activity.)

Figure 1.
U.S. Physical Activity State Summary Data. 2003 Prevalence of Recommended Physical Activity.

Healthy Community Initiative

A Partnership for Health (PFH) is Hunterdon County's Healthy Communities initiative. This project demonstrates how Extension can be a lead collaborative partner of a coalition or partnership to implement effective behavior change to improve the physical health of community members. The partnership represents Hunterdon Medical Center, The Hunterdon County Department of Health, and over 20 concerned community service providers, with a common goal to make the Hunterdon County Community as healthy as it can be.

The Office of Disease Prevention and Health Promotion, Department of Health and Human Services has a Healthy People 2010 Initiative called "Healthy People in Healthy Communities." Healthy People 2010 identified a set of health priorities that reflect 10 major public health concerns in the United States. Physical activity and overweight and obesity are the top two leading health indicators intended to increase the importance of health promotion and disease prevention (U.S. Department of Health and Human Services, 2001).

Two of Healthy People 2010's goals are to: 1) "Reduce the proportion of adults who engage in no leisure-time activity" and 2) "Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day," (U.S. Department of Health and Human Services, 2001).

Methodology

In 2001 and 1995, a Behavioral Risk Factor Surveillance Survey (BRFSS) was conducted in Hunterdon County. The survey was based on one developed by the Centers for Disease Control and Prevention (CDC) with additional questions added that are relevant to Hunterdon County. One thousand adult Hunterdon residents took part in this health-focused, telephone survey, assuring a representative sample of the total population. The goal of the survey was to capture a "snapshot" of the health status of the Hunterdon residents, so that community health education, promotion and treatment programs may be targeted to appropriate groups.

The BRFSS for Hunterdon County in 2001 showed some comparative differences to the BRFSS done in 1995. Table 1 and Figures 2 and 3 show some of the comparative survey results.

Figure 2.
During the past month, how many times per week or month did you take part in this activity?
Respondents who have participated in a physical activity

Figure 3.
When you took part in this activity, how long did you usually keep at it?
Repsondents who have participated in a physical activity

Program Planning

The Partnership for Health addresses health issues in the community through Action Teams, such as the Cardiac Action Team, Cancer Action Team, Substance Abuse Action Team, Lyme Action Team, etc. Armed with the data from the recent 2001 BRFSS, the Partnership asked the Cardiac and Nutrition Action Team to come together to develop a community action plan to increase physical activity.

The PFH Cardiac and Nutrition Action Team Chairs identified a strategy for developing a community health plan to increase physical activity and improve cardiac health and weight. Healthy People 2010 recommends to "MAP-IT": Mobilize, Assess, Plan, Implement, and Track. After a review of the literature on physical activity, it was decided to plan a walking program using pedometers as a motivating and tracking device. Pedometers are inexpensive motion sensors that track each step the wearer takes. A value of 10,000 steps/day is gaining in popularity with the media and in practice and can be traced to Japanese walking clubs and a business slogan 30+ years ago. Ten thousand steps/day appears to be a reasonable estimate of daily activity for apparently healthy adults and studies are emerging documenting the health benefits of attaining similar levels (Locke & Bassett, 2004).

The Cardiac and Nutrition Action Team chairs took the lead to mobilize a coalition of diverse community individuals and agencies to plan the community-walking program. Several community physicians were invited to participate, as were cardiac nurses, community nutritionists, exercise physiologists, school nurses, and representatives from the Office on Aging, American Heart Association, the Department of Education, and the Parks Department.

Members met over several months as they planned what a community walking program would look like, identifying a slogan and logo, exploring what would motivate community residents to register for a walking program and what would keep them engaged to continue walking, and how participants would be tracked.

Once the community had been assessed for the need of a walking program, a list of strengths and resources was developed. Determination was made as to who in the coalition may be a link to some of those resources. Those resources would not necessarily have a monetary value. Developing a logo and slogan took creative effort from several people on the coalition. The program was called "Step Out Hunterdon." In-house technical staff were used to begin to develop marketing materials for the project. Various members were assigned responsibilities to assist in realizing the vision of the program. The walking program used the design of a successful walking program already in existence from Health Partners Insurance Company in Minnesota with their approval.

Program Implementation

With funding received from Rutgers Cooperative Research & Extension and the Hunterdon Medical Center Foundation, a coordinator from the Medical Center was assigned to the day-to-day operation of Step Out Hunterdon. Participants were recruited from the community, the hospital, county employees, and local groups and through ads in the newspaper and word of mouth.

The program was launched at a local park in the spring. The date was advertised in the weekly newspaper, at libraries, newsletters, local municipalities, etc. Local dignitaries were invited, e.g., the CEO of the hospital, Director of the Department of Health, local politicians, Celebrity Striders (some physicians and directors of local agencies who were asked to be Celebrity Striders) and the local newspaper.

The walking program included registration of walkers. Participants received a Yamax 200 Digiwalker for a nominal fee of $5, a T-shirt listing local sponsors, incentives, educational information on walking, an 8-week tracker, and a fruit and fruit juice snack donated by the local grocery chain. Eventually, participants were added to an email list serve so they could receive email updates related to walking, nutrition, and tracker information.

As an ongoing part of the program, participants received a mailed monthly postcard for 6 months with valuable tips and information related to walking and health. Participants had a number to call for information and to receive a new tracker.

Within approximately four months, 1,800 people were registered for Step Out Hunterdon. There was a great deal of interest in the program. There were two sites where people could register for the program, at the Cooperative Extension Office and Hunterdon Medical Center. After 1 year, we randomly choose 200 participants to receive a year-end survey. Of the 200 surveys sent out, there was a return of 94. Table 2 shows some of the survey results.

Discussion

While our survey results were positive, a notable limitation to this walking program was the need for a more defined method to track participants and their steps. It seemed that a significant number of participants did not follow through in continuing to record steps on their tracker, while they did remain very enthusiastic about walking and using the pedometer as a motivating tool. A program such as this requires continual follow-up and incentives to maintain motivation and interest.

References

Cameron, A.J., Welborn, T.A., & Zimmet, P.Z. et al, (2003). Overweight and obesity in Australia: the 1999-2000 Australian diabetes, obesity and lifestyle study (AusDiab), Med J Aust 178:427-432.

Harnack, L., Jeffery, R.W., & Boutelle, K.N. (2000). Temporal trends in energy intake in the United States: an ecological perspective. Am J Clin Nutr 71:1478-1484.

Tudor-Locke, C., & Bassett, D.R. (2004). How many steps a day are enough? Preliminary pedometers indices for public health. Sports Med 34(1), 1-8.

U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General. Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

U. S. Department of Health and Human Services. (2001). Healthy people in healthy communities. Washington, D.C.

World Health Organization. (1997). Obesity: Preventing and managing the global epidemic. Geneva: World Health Organization.