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STRATEGIES FOR ACTION: INTEGRATING NUTRITION AND PHYSICAL ACTIVITY PROMOTION TO REACH LOW-INCOME CALIFORNIANS Also available as PDF Prepared for the Cancer Prevention and Nutrition Section California Department of Health Services by Prevention Institute Oakland, CA, October 2001 Acknowledgments The Strategies for Action report was prepared by Prevention Institute for the Cancer Prevention and Nutrition Section (CPNS) of the California Department of Health Services (DHS). The principal authors were Leslie Mikkelsen, Manal Aboeleta, and Larry Cohen. Emily Gordon, Katherine Keir, Chris Schmidt, and Alia Udhiri provided support with editing and research. Gil Sisneros and Michelle Oppen of CPNS contributed valuable content and editorial assistance. The authors would like to thank the participants in the key informant interviews and the Physical Activity and Nutrition Integration Committee (PANIC) members, listed in the appendices, who generously contributed their time and wisdom to the development of this framework. We would also like to acknowledge Sue Foerster and Gil Sisneros for their vision and leadership in including physical activity as a vital complement to promoting healthy eating. This report was made possible by funding from the United States Department of Agriculture (USDA). Prevention Institute is a national non-profit organization established to advocate for prevention by developing methodology and strategy to strengthen and expand primary prevention practice. The organization provides training and technical assistance to a variety of public and private organizations in the areas of injury and violence prevention, fitness and nutrition, child and adolescent health, and strategy development for city and county governments. Such strategy is essential to save lives and money, reduce individual suffering, and enhance community well-being. The Cancer Prevention and Nutrition Section was established in 1986 and operates large-scale social marketing campaigns to increase healthy eating, physical activity, sun safety, and other protective behaviors. CPNS is striving to prevent obesity and promote good health through the California Nutrition Network for Healthy, Active Families and the California 5-a-Day Plus Physical Activity Campaign.

Executive Summary The Strategies for Action report describes the results of a planning process, initiated by the Cancer Prevention and Nutrition Section (CPNS) of the State of California Department of Health Services, to integrate physical activity promotion into existing efforts to improve eating habits among California families with low incomes. The executive summary briefly summarizes the seven sections of the report. I. Introduction "We are dealing with a life and death situation. The statistics are getting worse and worse. Can we turn it around? We can do this!" (PANIC member) Recent research confirms that there are many benefits from the dual promotion of regular physical activity and healthy eating.i Together, these behaviors significantly lower the risk of chronic disease and reduce complications for those who are already experiencing illness. While the majority of people in California do not meet the U.S. Dietary Guidelines or the Surgeon General's recommendations for levels of regular, moderate physical activity, people with low incomes face particular challenges in achieving these goals. The Cancer Prevention and Nutrition Section of the State of California Department of Health Services is committed to playing a role in addressing these challenges. In June 2000, CPNS established the Physical Activity and Nutrition Integration Committee (PANIC) to identify key strategies for increasing physical activity among families with low incomes. Through the California Nutrition Network for Healthy, Active Families, CPNS funds over 160 local public and community-based organizations to support educational activities, food security projects, and faith-based initiatives. The planning process was designed to inform CPNS statewide efforts and assist Network members by identifying key actions that could complement and strengthen current nutrition-related activities. CPNS retained Prevention Institute, a national non-profit organization committed to forging effective prevention strategies, to facilitate the planning process and develop the written framework. II. Methods The planning process included several steps: Establishment of PANIC Synthesis of the research literature Key informant interviews Two planning sessions with PANIC members Planning session with state staff Review and development of a final strategy framework III. Background According to the United States Surgeon General, leading a sedentary lifestyle is linked to five percent of all cancer deaths and is a contributing factor to premature deaths from a variety of serious diseases, including heart disease and diabetes. The Surgeon General and the Centers for Disease Control and Prevention recommend that adults get at least 30 minutes of moderately intense physical activity on most and preferably all days of the week.ii Despite California's reputation as a health-conscious state, most adults are not regularly active. People with low incomes are even less likely to be active. Over the last five years, there has been gradual improvement in levels of vigorous activity and leisure time activity for higher-income adults but the trend has moved in the opposite direction among those with lower incomes.iii Moreover, the Behavioral Risk Factor Surveillance survey shows that over 52 percent of California adults are classified as overweight or obese. Rates of being overweight and obese in low-income individuals and adults of color are even higher. It is vitally important that efforts to promote physical activity reach the state's low-income residents, since on average they engage in less physical activity and are at a higher risk for chronic disease. In California, disproportionately more people of color live in poverty than whites. Given the alarming diabetes rates among Latinos, Native Americans, and African Americans as well as higher risk for cardiovascular disease and some kinds of cancer, effective physical activity promotion is also a means to begin to reduce health disparities between these ethnic groups and whites.iv To date most of the published research literature on physical activity initiatives has focused on middle- and higher-income, predominately white, able-bodied populations.v Physical activity promotion as a whole is a relatively new state priority. There is only one state program devoted exclusively to physical activity promotion and only a few programs that include physical activity promotion as one of their goals. IV. Physical Activity and Nutrition Integration Committee (PANIC) Findings PANIC was charged with outlining the major strategies that should be implemented in California to increase physical activity among families with low incomes. In order to determine these strategies, they had to first develop a common understanding of the major barriers that lead to inactivity and the most promising approaches for promoting an active lifestyle. This section represents a compilation of the major themes contained in the background materials and the reflections of PANIC members. A key purpose of this plan was to look for opportunities to include physical activity in existing nutrition promotion efforts. PANIC members generally agreed that there is an interrelationship between nutrition and physical activity promotion. There were some differences of opinion about whether the same practitioners could promote both behaviors, since each discipline has its own expertise and the environmental changes needed to support the behaviors are different. Despite these differences, there was fairly wide agreement that there was value in bringing the two fields together. PANIC members felt that the public stood to achieve significant gains through mutual support, streamlined messages, and strategies developed in tandem. Barriers to Physical Activity The committee and formative research indicates that major barriers to activity for low-income people could be linked to a variety of environmental and economic factors, including: Lack of formative research for promoting physical activity among low-income populations Lack of time and resources Negative attitudes toward physical activity Absence of role models and social support Unsupportive physical environments Limited opportunities at school Limited opportunities in workplaces Inadequate recreational facilities and programs Unfriendly to walkers and bicyclists Safety concerns Key Principles for Physical Activity Promotion After outlining the major barriers to activity, PANIC discussed what was needed to improve the rates of physical activity among low-income families. Action at both the state and local level is important for changing the picture of physical activity in California. Some key principles were identified for forging a comprehensive physical activity promotion plan: Build on community assets Involve the community Utilize comprehensive strategies Foster collaboration Conduct ongoing evaluation V. Tools for Designing Comprehensive Physical Activity Initiatives PANIC made use of two tools to assist with the planning process: the Social-Ecological Model and the Spectrum of Prevention. The Social-Ecological Model is a theoretical framework for understanding the multiple factors that influence behavior. The model suggests that interventions that are designed to impact more than one sphere of influence will have a greater impact. The Spectrum of Prevention provided PANIC with a framework for developing such a multifaceted intervention. The Spectrum identifies six levels of intervention that encourage practitioners to move beyond a primarily educational or individual skill-building approach to a more community-wide, systems change focus. VI. Recommendations PANIC members delineated overarching strategies and potential action steps along the Spectrum of Prevention for increasing physical activity among low-income California families. While the Spectrum provided general guidelines for the types of strategies that are needed, the specific concepts evolved from PANIC members' discussion about barriers and principles for physical activity promotion. There will need to be ongoing monitoring and evaluation to provide information about the quality of implementation and outcomes. This data can then be used to modify implementation strategies and action steps. Level of Spectrum Recommendations 6. Policies That Support Prevention A. Enact policies at the state and local level that promote positive physical environments and organizational practices. B. Increase government support for physical activity and nutrition programming, training, and evaluation. C. Simplify state contracts to make it easier for localities to target funds for local needs. 5. Changing Organizational Practices D. Promote school and workplace practices that support physical activity. E. Build the capacity of community-based organizations to incorporate physical activity into their programming. 4. Fostering Coalitions and Networks F. Develop collaboration among agencies anddepartments at the state level. G. Support collaboration and planning at the local level. H. Engage community organizations and the private sector. 3. Educating Providers I. Develop the skills of community residents from low-income communities. J. Educate local, state, and national legislators and government administrators to build support for physical activity and nutrition. K. Train managers in the public and private sector in physical activity and nutrition promotion. L. Teach doctors, allied health care professionals, social workers, and WIC and other service providers how to include physical activity promotion in current practices. 2. Promoting Community Education M. Utilize a neighborhood focus; work where people are. N. Refine media approaches to physical activity promotion in diverse populations. 1. Strengthening Individual Knowledge and Skills O. Teach life-long skills. P. Support current healthy behaviors; enhance what people already do. Q. Encourage and provide social support for family and peers. VII. Next Steps for CPNS The recommendations outlined in section VI are general for promoting physical activity among low-income Californians statewide. This section outlines specific activities that CPNS will conduct with USDA funding in the next two years. Additional sources of funding will be necessary to fully implement the recommendations identified in section VI. Year 1 Form advisory group (PANIC) comprised of physical activity experts and key partners to provide recommendations to CPNS for promoting and integrating physical activity among low-income Californians. Define mission, objectives, membership, etc. (4-G) Collaborate with other PA programs funded by the Department of Health Services to develop a statewide physical activity coordination team (PACT). (4-F, 6-A, B, C) Conduct additional formative research (e.g., literature review, focus groups, and partner surveys). Develop a statewide marketing plan for promoting physical activity and nutrition among low-income adults in California. Develop a resource kit for CPNS contractors. Pilot marketing activities in 1-2 regions of the state. Develop a database of research-based physical activity resources for promoting physical activity among low-income communities. Year 2 Identify other sources of categorical funding to expand physical activity campaign statewide. Develop additional partnerships with business partners and other non-traditional partners to expand campaign. Based on results from Year 1 pilot campaign, expand the campaign to include other regions of the state. Based on availability of additional funding, provide resources to community-based organizations to conduct interventions at the local level. VIII. Conclusion The recommendations contained in this report provide direction for a multi-year effort to improve physical activity levels among low-income California residents. It has taken decades for our current sedentary culture to develop and reversing this trend will require perseverance. Yet there is no question that the "epidemic" of obesity and the scourge of related chronic diseases makes action an absolute necessity. As one PANIC participant summed it up, "I didn't imagine that I'd run into the people here that are doing the things I want to do. I feel relieved that there are more people working towards the same goal. This really encouraged me." The development of the strategy framework is not the final step in this important work, but is a vital beginning. I. Introduction This report describes the results of a planning process, initiated by the Cancer Prevention and Nutrition Section (CPNS) of the State of California Department of Health Services, to integrate physical activity promotion into existing efforts to improve eating habits among California families with low incomes. Recent research makes it clear that there is much to be gained from the dual promotion of these healthy behaviors.vi Together, regular physical activity and healthy eating significantly lower the risk of chronic disease and reduce the complications of those who are already experiencing illness. While the majority of people in California do not meet the U.S. Dietary Guidelines or the Surgeon General's recommendations for levels of regular, moderate physical activity, people with low incomes face particular challenges in achieving these goals. Food choices and activity options are frequently limited in low-income neighborhoods. There are many needs competing for scarce dollars in the family budget. Family members with special dietary needs or physical disabilities have even greater difficulties finding adequate resources. Recognizing these challenges, CPNS is committed to playing a role in addressing them. In June 2000, CPNS established the Physical Activity and Nutrition Integration Committee (PANIC) to identify key strategies for increasing physical activity among families with low incomes. Through the Nutrition Network for Healthy, Active Families, CPNS funds over 160 local public and community-based organizations to support educational activities, food security projects, and faith-based initiatives. The planning process was designed to inform CPNS statewide efforts and assist Network members by identifying key actions, which could complement and strengthen current Network nutrition-related activities. CPNS retained Prevention Institute, a national non-profit organization committed to forging effective prevention strategy, to facilitate the planning process and develop the written framework. This document describes the activities and primary findings of PANIC. The final strategy framework reflects some of the best thinking in the state about what action is needed to make a real difference in the health of families with low incomes. From the onset, CPNS recognized that there was a great deal of knowledge about effective physical activity promotion throughout California, but much of this knowledge had not yet been fully understood and shared among people working in the field. The planning process provided the opportunity to synthesize the learning's to date from academic researchers and the experience of practitioners at the local, state, and national levels. PANIC members drew on their experiences in health promotion and sensitivity to issues facing families with low incomes to distill this information and translate it into specific action steps for California. Their collective wisdom and hard work has led to the recommendations, which are presented at the conclusion of this report. II. Methods Strategies for Action is the result of a year-long planning process beginning in June 2000. The process included eight primary steps: Establishment of the Physical Activity and Nutrition Integration Committee (PANIC) CPNS, with assistance from Prevention Institute, convened individuals representing organizations and sectors with an influence and interest in promoting positive physical activity and nutrition behavior. These groups included public health organizations, parks and recreation, voluntary health organizations, grassroots and faith-based organizations, media, advocacy groups, business, and private funders. State staff from CPNS as well as other Department of Health Services programs served as ex-officio members of PANIC (see Appendix I for list of participants). Synthesis of Research Literature In order to capture what had already been learned about increasing physical activity among people with low incomes, James F. Sallis, Ph.D. of San Diego State University was commissioned to prepare a document "Community Interventions and Communities as Interventions" that discussed findings from the research literature (see Appendix II). Key Informant Interviews Prevention Institute conducted key informant interviews with a range of researchers and experienced practitioners at the local, state, and national levels. The primary purpose of the interviews was to include the expertise of practitioners outside of California and to learn from the perspectives of other state and national policy organizations. The key informants were primarily selected through the recommendations of California Department of Health Services staff. (Appendix III) First Planning Session On July 13-14, 2000, PANIC members attended a meeting in San Diego, California. Members heard a review of the key informant interviews and presentations by an expert panel (Appendix IV). Drawing on their personal knowledge, the background papers, and the panel, participants outlined the major barriers to physical activity in low-income communities and a strategy framework for improving the prevalence of physical activity. Draft Strategy Framework The major outcome of the first meeting was a broad set of strategies for promoting physical activity among low-income families that could be integrated into healthy eating promotion efforts. In addition to the key strategies, the PANIC members made recommendations for particular actions that could be carried out to implement the strategies. Second Planning Session The draft framework was reviewed and refined by PANIC members at two one-day working sessions (one in Northern California and one in Southern California). The final set of recommendations in this report synthesizes the results of these two meetings. Session with State Staff A meeting was held with state staff to review the final recommendations and establish a process for collaboration among state programs to most effectively carry out elements of the plan. Review and Final Framework The final report summarizes the major influences on physical activity among families with low incomes identified throughout this process and outlines specific strategies for promoting physical activity among low-income families throughout the state. Before publication, the draft recommendations were distributed to PANIC members for review and comments. III. Background Physical Activity Benefits According to the United States Surgeon General, leading a sedentary lifestyle is linked to five percent of all cancer deaths and is a contributing factor to premature deaths from a variety of serious diseases, including heart disease and diabetes. Further, physical activity fosters healthy muscles, bones, and joints, and helps maintain function and preserve independence in older adults.vii Physical activity is simply any movement of the body that results in some energy expenditure.viii A combination of cardiovascular or aerobic, strength, and flexibility training is highly recommended for everyone. Cardiovascular activity includes activities such as walking, running, or bicycling that increase one's heart rate, usually followed by an increase in breathing. Strength training consists of activities that develop the musculoskeletal system, such as weight lifting or push-ups. Flexibility exercises increase the ability to move around and are especially important as the population ages. Such activities include stretching, yoga, and t'ai chi. Cardiovascular exercise is most related to the prevention of chronic conditions such as cancer, heart disease, and Type II diabetes. It is also the most widely measured on local, state, and national levels. Therefore, it will be the primary focus of physical activity programming in conjunction with nutrition education and social marketing through CPNS for California. However, programs that combine the promotion of aerobic activity with other types of activity will be encouraged as well. Physical activity has also been shown to have benefits that go beyond reducing the risk of disease. New research suggests that regular participation in physical activity is linked to better academic performance among school-aged children.ix Further, participating in organized physical activity programs, such as midnight basketball or after school sports teams, has been shown to increase a sense of mastery and self-esteem among youth. Recent findings indicate an "association between involvement in physical activity and sport and well-being. Physical activity is associated with lower levels of mental health problems, and seems to promote self-esteem."x This effect reduces the likelihood teens will participate in risk-taking behavior. Having the ability to walk and play freely in one's neighborhood also helps children develop key cognitive skills. "Independent play and mobility by school-aged children in their neighborhoods have been found to contribute to their social and spatial development."xi Physical Activity Recommendations The Surgeon General and the Centers for Disease Control and Prevention recommend that adults get at least 30 minutes of moderately intense physical activity on most and preferably all days of the week. Most people in the United States do not meet this requirement.xii In fact, the National Health Interview Survey in 1997 found that only 15 percent of the population exercises regularly at least 5 days a week, at least 30 minutes per session. Given that physical activity levels in the United States are relatively low, the U.S. Department of Health and Human Services established, within Healthy People 2010, fifteen physical activity objectives in four categories (Physical Activity in Adults, Physical Activity in Children and Adolescents, Muscular Strength/Endurance and Flexibility, and Access). CPNS has adopted the following Healthy People 2010 objective for the Physical Activity campaign, Increase the proportion of adults who engage regularly in moderate physical activity for at least 30 minutes per day. Presently only fifteen percent of Americans meet this objective; the 10-year goal is thirty percent. Additionally, Healthy People 2010 has set targets for people at the extremes of the activity spectrum - those with no leisure time activity and those with vigorous activity at least 3 times per week. The national goal is to increase the percentage of individuals engaging in vigorous activity from 23 percent (in 1997) to 30 percent in 2010. The goal is to reduce the percentage of people not participating in leisure time activity from 40 percent in 1997 to no more than 20 percent (see Appendix V for a complete listing of the Healthy People 2010 physical activity objectives).xiii Despite California's reputation as a health-conscious state, most adults are not regularly active. People with low incomes are even less likely to be active. According to the 1998 California Behavior Risk Factor System (BRFS), only 17 percent of all adults reported partaking in vigorous physical activity three or more times per week, and 24 percent reported no leisure time activity. Participation rates are lower for people with lower incomes (those with household incomes less than $20,000 annually). Eleven percent of the low-income population engaged in vigorous activity for the recommended length of time (see Figure 1). Thirty-five percent of the low-income population in California did not participate in any leisure time physical activity (see Figure 2). Over the last five years, there has been gradual improvement in levels of vigorous activity and leisure time activity for higher-income adults but the trend has moved in the opposite direction among those with lower incomes.xiv Figure One 1: Those that engage in vigorous activity at least 3 days a week, at least 20 minutes per session. Figure Two Healthy People 2010 Goal: No more than 20% of adults participate in no leisure time activity It is important to note that organized classes, sports teams, or scheduled daily walks or runs are not the only approach to increasing cardiovascular exercise. There is growing recognition of the value of incidental physical activity. Benefits may accrue through actions such as taking the stairs instead of an elevator, walking more frequently to run errands, using bicycles for transportation, or adding small bits of activity throughout the day.xv Reaching Low-Income Californians The California BRFS data demonstrate that there is a need to promote physical activity to Californians at all income levels. It is vitally important that these efforts reach the state's low-income residents, since on average they engage in less physical activity and are at a higher risk for chronic disease. In California, disproportionately more people of color live in poverty than whites (see Figure 3). Given the alarming diabetes rates among Latinos, Native Americans, and African Americans as well as higher risk for cardiovascular disease and some kinds of cancer, effective physical activity promotion is also a means to begin to reduce health disparities between these ethnic groups and whites. Figure Three There are several reasons why physical activity promotion targeted to the general population may not be effective in increasing physical activity among low-income families: Low-income families have limited disposable income for purchasing physical activity goods and services. Work demands may mean parents have less free time to be active with their children. It is more likely that both parents are working, or that there is a single parent in the home. Low-wage earners are more likely to work longer hours or work two jobs. Further, parents may have jobs that are more physically exhaustive than higher-income workers, making it more difficult to engage in exercise after work or on weekends. Low-income neighborhoods frequently lack well-maintained facilities such as community recreation centers and parks. Safe environments are not always available. People with lower incomes are more likely to be victims of crime and children especially are more likely to be hit by motor vehicles.xvi, xvii This discourages families from being active outside and parents from permitting children to walk to school. The spokespersons selected for physical activity promotion to the general population may not be suitable role models that reflect the faces and preferred activities of the diverse low-income residents in the state. This project was designed to develop a deeper understanding of these barriers and identify opportunities for increasing physical activity among low-income families. As specified by USDA Nutrition Network funding, low-income is defined as anyone living in a household that is eligible for food stamps, with income at approximately 130 percent of the federal poverty level or less. To date most of the published research literature on physical activity initiatives has focused on middle- and higher-income, predominately white, able-bodied populations.xviii Therefore there is a need to build a body of knowledge about how to effectively increase physical activity among low-income, ethnic minority, and disabled populations. Physical activity promotion as a whole is relatively new as a priority of the state. There is only one state program devoted exclusively to physical activity promotion, the Physical Activity and Health Initiative (PAHI). Several programs including the California Nutrition Network, California 5-a-Day Campaign, Project LEAN, and the California Heart Disease and Stroke Prevention Program (CHDSPP) include physical activity promotion as one of their goals. An overview of state efforts can be found in Appendix VII. California was home to one nationally recognized physical activity initiative, On The Move!, which funded nine local projects, primarily serving ethnically and sociodemographically diverse communities.xix In 1992, On The Move! devoted $1 million annually for three years to promote community-based physical activity programs using an ecological approach, with a focus on coalition building. This program was successful in working with local projects and showed that there can be a strong link between state and local programs. Most local programs increased participants' awareness of the importance of physical activity and succeeded in creating partnerships, as well as coalition and community building. These things are key to maintaining physical activity programming in the future. Policy change appeared to be the most difficult aspect of the Spectrum of Prevention (the health planning framework used for On The Move!) to strongly affect during the 3-year grant period. However, according to Dr. Steve Hooker, when policy change did occur it seemed to be the most sustainable aspect of the program.xx Many lessons can be taken from On The Move! when planning the Cancer Prevention and Nutrition Section's future in physical activity. Further state efforts will build on the knowledge gained from this experience as we continue to look deeper at how to create effective initiatives to make an impact on levels of physical activity in low-income communities. IV. The Physical Activity and Nutrition Integration Committee Findings "We are dealing with a life and death situation. The statistics are getting worse and worse. Can we turn it around? We can do this!" (PANIC member) PANIC was charged with outlining the major strategies that should be implemented in California to increase physical activity among families with low incomes. At their first session, PANIC heard presentations from three experts in the field of physical activity promotion. These presentations provided background information to inform the strategy development process. Along with pre-meeting reading materials, including the results of the key informant interviews, this information set the stage for strategy development. In order to determine these strategies, they had to first develop a common understanding of the major barriers that lead to inactivity and the most promising approaches for promoting an active lifestyle. This section represents a compilation of the major themes contained in the background materials and the reflections of PANIC members. It is based on the discussion and opinions of PANIC members and the key informants, rather than specific research findings. Integrating Nutrition and Physical Activity A key purpose of this plan was to look for opportunities to include physical activity in existing nutrition promotion efforts. PANIC members generally agreed that there is an interrelationship between nutrition and physical activity promotion. As one PANIC member described, they are "co-dependent," because the health implications of the two are intertwined. Good nutrition is essential for improving physical performance, and at the same time being physically active improves how the body utilizes nutrients. Because of the synergistic health effects, it made sense to many PANIC members to promote the behaviors together. In fact, people interested in one are frequently interested in the other. At the same time, there are related reasons that people do not adopt these healthy behaviors such as limited time and access. There were some differences of opinion about whether the same practitioners could promote both behaviors, since each discipline has its own expertise and the environmental changes needed to support the behaviors are different. Despite these differences, there was fairly wide agreement that there was value in bringing the two fields together. PANIC members felt that the public stood to achieve significant gains through mutual support, streamlined messages, and strategies developed in tandem. Barriers to Being Physically Active Lack of Time and Resources There are many competing priorities for household time and resources which make it difficult to participate in physical activity. Basic survival issues, such as managing finances or coping with health problems, may take precedence over physical activity. Heads of households from low-income families are more likely to work more than one job. They are also more likely to be engaged in occupations such as janitorial services, light manufacturing, housekeeping, and retail work, which leave them physically exhausted at the end of the day without providing sufficient health benefits. Reliance on public transportation and less access to automobiles also cut into available time. Unlike more affluent families, low-income parents cannot afford to pay the cost of gym memberships or class fees for themselves and their children. Nor can they pay for extra childcare to permit them to participate in leisure time activity. In fact, many adults feel that time taken for physical activity interferes with time spent with their children and fulfilling other family responsibilities. Negative Attitudes Towards Physical Activity People do not think of physical activity as something enjoyable. As one PANIC member stated, "Adults treat physical activity as anything that is not fun. This is not true; we have to find enjoyable activities that make physical activity congruent with people's personality types and lifestyles." There are many ways that people can add moderate-intensity physical activity to the things that they already do, but there is a lot of misunderstanding about what 'qualifies' as physical activity, and even less knowledge about how to include these activities into already busy lifestyles. Attitudes need to shift so that walking, biking, and being active are seen as positive. Absence of Role Models and Social Support An absence of role models and social networks emerged as an obstacle for people from households with low incomes. Images that reflect real people of all shapes and sizes, both able-bodied and physically challenged, taking part in a wide range of fun activities are missing. There are limited images of women and people of color engaging in diverse activities. Media portrayals of professional athletes and amateur enthusiasts send the message that only those with perfect bodies and a willingness to engage in rigorous activity meet the descriptor of physically active. They also imply that engaging in physical activity requires expensive shoes, clothing, and equipment. PANIC members asked, "What does it take to get people to see their own lives reflected in our physical activity efforts, so that they resonate and have impact?" Sallis notes that "social support is a powerful correlate of physical activity" and that "enjoyment encourages activity."xxi People are more likely to stay in an active routine if they find it fun and enjoyable and if they have support from family members and friends. Given the lower levels of physical activity in low-income communities, there is less of a support network already in place. The lack of structured opportunities for women in particular makes being physically active a challenge. PANIC members noted that many women face resistance from their families when considering getting involved in physical activity routines. When a woman is the primary caretaker or meal planner in the home, families are concerned that an exercise routine would keep her from this work. Unsupportive Physical Environments: Limited Opportunities at School Children and youth spend a great deal of time at school and learn many lifestyle habits related to physical activity there. Schools can be key allies in activity promotion, but many do not enforce existing standards for physical activity. If students do have physical education (P.E.) sessions, they may spend more time standing on the sidelines waiting their turn than actually participating in activity. Schools in low-income neighborhoods are least likely to have facilities and well-trained teaching staff devoted to physical activity promotion. Team sports frequently alienate less athletically inclined students who are picked last. These situations could be improved through better training for physical activity instructors. However, despite research showing the positive link between physical activity and learning, limited budgets lead school resources to be devoted to more traditional academic skills.xxii Limited Opportunities in Workplaces Most adults spend their workday indoors, sitting or standing for long periods of time. As mentioned earlier, many adults who are low wage earners are engaged in the service industry. These employers thus far have not invested in encouraging physical activity among their personnel. Lack of showers, locker facilities, and expectations for business dress discourage people from riding bikes to work or engaging in activities on their breaks. Few workplaces have on-site exercise facilities. The general work culture does not promote even incidental activity. While elevators are centrally located, the stairways are often difficult to find and appear unpleasant. Inadequate Recreational Facilities and Programs Low-income communities generally have fewer recreational facilities and programs available. The costs of participation may be prohibitive. Frequently equipment is missing or in disrepair, and playgrounds and gyms are not maintained. Programs may not meet the needs of both able-bodied and disabled participants, nor be appropriate for the cultural backgrounds of the participants. One PANIC member noted that "local streets used to be the playgrounds for city kids in America." There is potential to design neighborhood streets to recapture some of the 25-40 percent of the street space, which makes up American cities. While this would help alleviate the problem of inadequate recreational facilities in low-income communities, at this point street space in many areas is not viewed as safe for recreational use. Unfriendly to Walkers and Bicyclists Communities with high rates of poverty are often designed without attention to walkability or bikeability. According to one key informant, streets in many low-income neighborhoods are designed to provide access for suburban commuters rather than serve the needs of community residents. These wide multi-lane streets are not conducive to walking and biking. High poverty neighborhoods are more likely to have limited commercial activity, absence of trees and bike lanes, and abandoned buildings that make it unappealing to be out on the street. Safety Concerns Safety concerns rank high as a reason low-income residents choose not to be physically active outdoors. Violence and the perception of vulnerability to violence are very real barriers to people's use of their neighborhood, along with dangerous high-speed traffic. Parents are afraid to let their children play on the street or walk to school. These concerns have led an increasing number of parents to drive their children to school. This understandable response means that children are losing access to important opportunities for physical activity. Key Principles for Physical Activity Promotion After outlining the major barriers to activity, PANIC discussed what was needed to improve the rates of physical activity among low-income families. Action at both the state and local level is important for changing the picture of physical activity in California. Some key principles were identified for forging a comprehensive physical activity promotion plan. Build on Community Assets There are many important community assets to bring to bear on promoting physical activity. Successful initiatives should incorporate existing institutions such as faith-based organizations, community-based organizations, schools, and local businesses, as well as input from community leaders. PANIC members felt strongly that there is a need for local role models, real people who have figured out how to regularly integrate healthy eating and physical activity into their lives. Therefore an important strategy is to find the natural helpers in the community and provide training and support to develop their skills as leaders and advocates. Involve the Community Each community is unique. There is no single way of making effective change. Every locale must assess its unique characteristics, assets, and barriers for physical activity. PANIC members and the key informants agreed that it is critically important that community members are involved in planning and program development. Low-income communities are too often the recipients of programs imposed from the outside, which are frequently destined to failure. As one PANIC member described it, "You can quickly see a program you thought was good go down the tubes if you don't engage community and community role models." Community members have important knowledge about what is needed to successfully promote healthy behaviors and they need to be a part of planning and implementation. Utilize Comprehensive Strategies There are many influences on whether an individual is physically active. Traditional approaches to health promotion have tended to rely on individual education as the sole means for encouraging the adoption of healthy habits. This technique has been somewhat effective with educated, higher-income individuals but has not contributed to widespread improvement in healthy eating or activity levels. Sallis, along with the PANIC key informants, calls for a combination of strategies that includes environmental and policy interventions." There is emerging evidence that the structure of the community itself and the transportation infrastructure have profound effects on the physical activity habits of the residents. If we can identify the most important community characteristics, we may be able to guide the construction of communities that naturally stimulate physical activity."xxiii An effective initiative requires a multifaceted approach that includes a wide range of strategies - from individual education, to community promotion, to environmental changes and policy. Foster Collaboration Collaboration provides the opportunity to strengthen the impact of physical activity promotion efforts. PANIC identified some "natural allies." These include organizations and individuals from the fields of public health, nutrition, traffic safety, violence prevention, urban planning, transportation, and environmental design, as well as community-based service and social organizations. Each discipline can contribute its unique expertise to the development of a holistic strategy. By identifying and building on common areas of interest, more can be achieved together than by any one organization alone. Physical activity proponents are well advised to reach out to existing networks and organizations to build strategic alliances. Finally, in order to successfully advance physical activity promotion within California, it is essential that collaboration occur within government as well. This collaborative effort needs to begin with the state. Currently, there are several programs (Project LEAN, Active Aging, Worksite Health Promotion, and Active Community Environments) aimed at addressing physical activity that operate largely in isolation from one another. One priority for PANIC community members was greater uniformity in applications, contract periods, and reporting requirements among state agencies. These changes would reduce the paperwork burden and allow grantees more time to carry out program activities. The PANIC meetings provided an opportunity for staff to begin to share their approaches and consider how their efforts can be complementary. In this way, resources can be maximized and better support can be provided to local public and private partners. Conduct Ongoing Evaluation One of the concerns of PANIC was "How will we know if we are being effective?" As new strategies and initiatives are put into place, it is important to assess whether they are being implemented in a high quality manner and whether they are having the impact that was intended. This information is essential for building a body of knowledge about the most effective approaches. Evaluating the results of multifaceted approaches is a challenge. To date, most evaluation methods have tended toward single focus and quantitative models, measuring programs and initiatives in isolation, and measuring only certain outcomes. Given the complexity of environmental approaches to reduce health risks, we cannot expect that simple or linear models for evaluation will illustrate the relative value of comprehensive efforts. The challenge to evaluation, as seen with other health issue initiatives, is making sure all aspects of the effort are accounted for during evaluation. The process requires that we involve all of the key stakeholders, especially community members, in developing evaluations that are useful in helping us to answer the questions, "What are all of the impacts of this effort?" and "How has the low-income population been affected by these efforts?" in a substantive manner. V. Tools for Designing Comprehensive Physical Activity Initiatives After outlining the barriers to being physically active and identifying principles for physical activity promotion, PANIC members began the process of developing specific recommendations for increasing levels of physical activity among low-income families in California. PANIC made use of two tools to assist with the planning process: the Social-Ecological Model and the Spectrum of Prevention. The Social-Ecological Model is a theoretical framework for understanding the multiple factors that influence behavior. The model conceptualizes the social world in five spheres, or levels, of influence (see Figure 4).xxiv CPNS has adopted this model as an evaluation tool for the social marketing campaigns conducted through the California Nutrition Network for Healthy, Active Families. The Social-Ecological Model was presented to PANIC members to provide an underlying explanatory model for how different spheres of influence might affect physical activity behaviors at the individual level. The spheres of influence are not separate and distinct categories but they represent the range of influences that affect behavioral change. The Social-Ecological Model suggests that interventions that are designed to impact more than one sphere of influence will have a greater impact. Figure Four Social Structure, Public Policy: Local, State and Federal policies and laws that regulate or support healthy actions. Community: Social networks, norms, or standards (e.g. public agenda, media agenda) Institutional/Organizational: Rules, regulations, policies, and informal structures (worksites, schools, religious groups) Interpersonal: Interpersonal processes and primary groups (family, peers, social networks, associations) that provide social identity and role definition Individual: Individual characteristics that influence behavior such as knowledge, attitudes, beliefs, and personality traits 1: McLeroy, K.R., Bibeau, D., Steckler, A., Glanz, K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988. The Spectrum of Prevention provided PANIC with a framework for developing such a multifaceted intervention.xxv The Spectrum identifies six levels of intervention that encourage practitioners to move beyond a primarily educational or individual skill-building approach to a more community-wide, systems change focus (Figure 5). Each level of the Spectrum targets successively broader arenas for change, beginning with a focus on the individual and family, on community norms, institutional practices, and finally laws. By carrying out action steps at each level of the Spectrum, interventions have the potential to produce greater change than would be possible by implementing a single strategy. Figure Five 6. Influencing Policy Legislation Developing strategies to change laws and policies to influence health outcomes 5. Changing Organizational Practices Adopting regulations and shaping norms to improve health and safety 4. Fostering Coalitions and Networks Bringing together groups and individuals for broader goals and greater impact 3. Educating Providers Informing providers who will transmit skills and knowledge to others 2. Promoting Community Education Reaching groups of people with information and resources to promote health and safety 1. Strengthening Individual Knowledge and Skills Enhancing an individual's capability of preventing injury or illness and promoting safety VI. Recommendations PANIC members delineated overarching strategies and potential action steps along the Spectrum of Prevention for increasing physical activity among low-income California families. While the Spectrum provided general guidelines for the types of strategies that are needed, the specific concepts evolved from PANIC members' discussion about barriers and principles for physical activity promotion. There will need to be ongoing monitoring and evaluation to provide information about the quality of implementation and outcomes. This data can then be used to modify strategies and action steps. Strategies along the Spectrum of Prevention* Level of Spectrum Recommendations 6. Policies That Support Prevention A. Enact policies at the state and local level that promote positive physical environments and organizational practices. B. Increase government support for physical activity and nutrition programming, training, and evaluation. C. Simplify state contracts to make it easier for localities to target funds for local needs. 5. Changing Organizational Practices D. Promote school and workplace practices that support physical activity. E. Build the capacity of community-based organizations to incorporate physical activity into their programming. 4. Fostering Coalitions and Networks F. Develop collaboration among agencies anddepartments at the state level. G. Support collaboration and planning at the local level. H. Engage community organizations and the private sector. 3. Educating Providers I. Develop the skills of community residents from low-income communities. J. Educate local, state, and national legislators and government administrators to build support for physical activity and nutrition. K. Train managers in the public and private sector in physical activity and nutrition promotion. L. Teach doctors, allied health care professionals, social workers, and WIC and other service providers how to include physical activity promotion in current practices. 2. Promoting Community Education M. Utilize a neighborhood focus; work where people are. N. Refine media approaches to physical activity promotion in diverse populations. 1. Strengthening Individual Knowledge and Skills O. Teach life-long skills. P. Support current healthy behaviors; enhance what people already do. Q. Encourage and provide social support for family and peers. * Recommendations are not in order of priority LEVEL 6: POLICIES THAT SUPPORT PREVENTION Strategy Actions A. Enact policies at the state and local level that promote positive physical environments and organizational practices B. Increase government support for physical activity and nutrition programming, training, and evaluation C. Simplify state contracts to make it easier for localities to target funds for local needs Develop model ordinances for localities, based on investigation of best practices, to create environments supportive of physical activity for able-bodied and disabled residents. Target particular jurisdictions such as school districts, zoning, housing, parks, street engineering, public transportation, and workplaces. Healthy Cities' livability measures and Safe Routes to School are examples. (A) Based on model ordinances, seek increased legislative flexibility and support for change (tax credits, subsidies, reimbursements, etc.). (A) Identify and reduce barriers to utilization of public space. Examples of underutilized public space include sidewalks, public parks, school grounds, and university campuses. (A) Research and evaluate the enforcement of existing standards related to nutrition and physical activity and take corrective action; utilize information to improve future policymaking. (A) Assess transportation routes and identify mechanisms for encouraging physical activity (i.e., free shuttles to public parks). (A) Fund pilot projects to support collaborative planning and implementation of model ordinances and programs at the local level. Monitor outcomes to build the knowledge base about effective approaches. (A, B) Work with the California delegation to Congress to change federal requirements in order to better meet local and state needs. (A, B) Build on previous programmatic experience (e.g., On The Move!); fund successful organizations to document what contributed to their successes, and fund studies of what happened in failed efforts. Disseminate findings. (B) Allocate funds for physical activity and nutrition programming, training, and evaluation. (B) Track federal government funding opportunities to ensure that all available funds are utilized. (B) Make State of California contracts longer-term and streamline reporting requirements. (C) Develop uniform applications, scopes of work and progress reports between state programs to simplify work by local agencies receiving multiple State of California funding streams. (C) Make State of California grant goals more flexible to apply to a community's specific needs. To retain accountability, set standards for an appropriate needs assessment and allow funds to be targeted based on needs assessment results. (C) LEVEL 5: CHANGING ORGANIZATIONAL PRACTICES Strategy Actions D. Promote school and workplace practices that support physical activity E. Build the capacity of "non-traditional" organizations to incorporate physical activity into their programming Implement and evaluate practices that promote physical activity and nutrition in government workplaces (i.e., physical activity breaks and healthy food) and share findings with other organizations. (D) Adopt norms and practices at work and faith-based and community-based organizations that encourage physical activity such as casual dress, walking meetings, and exercise breaks. (D, E) Create workplace and community organization environments that are designed for physical activity, including inviting stairways, bike racks, lockers, showers, gardens, recreational facilities, and meditation/relaxation rooms. (D, E) Identify legal barriers to including physical activity promotion in work sites and community organizations, such as insurance liability issues. (D, E) Develop physical activity task forces at schools and worksites. (D) Develop physical activity and nutrition report cards. (Possible model is San Mateo County Health Department grading of restaurant sanitation.) Grades could be provided for the degree to which schools and businesses enable healthy practices among employees and students, and to what extent the food offered is nutritious. Improvements could be recognized and celebrated. (D, E) Provide incentives, such as comp time, physical activity-related memberships or discounts, or paid exercise breaks, to individuals for participating in health risk assessments and physical activity at work. Consider utilizing EAP programs for health risk assessments. (D) Include requirements for physical activity/nutrition standards in government contracts with service providers (e.g., P.A. Breaks). (D) Provide model, court-tested MOU (Memorandum of Understanding) language templates to incorporate work-site safety and physical activity into contracts. (D) Disseminate model organizational practices, such as the American Cancer Society's Meeting Well documents. Gather information on best practices, hold a symposium to present and review various ideas, and produce a manual of best practices. (D,E) Link farmers' markets, flea markets, swap meets, community gardens, and supermarkets to physical activity and nutrition promotion. (E) Provide funding to community-based and faith-based organizations to pay staff to lead physical activity and nutrition promotion efforts. (E) LEVEL 4: FOSTERING COALITIONS AND NETWORKS Strategy Actions F. Develop collaboration among agencies and departments at the state level G. Support collaboration and planning at the local level H. Engage community organizations and the private sector Assess the current and potential role of state agencies/ departments in physical activity and nutrition promotion. Set specific objectives for collaboration. (F) Devote ongoing commitment of staff/resources to ensure that physical activity and nutrition promotion will play a role in existing related coalitions. (F, G) Identify and share information on barriers, lessons learned, best practices, and models in California and other states that exemplify cross-departmental collaboration with state and local groups (e.g., Walk Your Kids to School). (F, G) Invest in local identification of existing coalitions, physical activity assets, needs, and objectives. (G) Develop a cadre of local facilitators who can provide leadership and bridge state/local planning efforts. (G) Invest in local strategy development for communities to identify and prioritize local needs. (G) Engage independent living and other organizations that address the needs of people with disabilities. (F, G, H) Initiate interdisciplinary collaboration, emphasizing issues that cross disciplines and engage all relevant sectors and key stakeholders. (F, G, H) Reformulate the CPNS Physical Activity and Nutrition Integration Committee to reflect a broader cross-section of disciplines that have an influence on physical activity (e.g., poverty programs/social services infrastructure, city and county planning advisors). (F, G, H) Increase the number of community-based organizations represented in strategic planning processes for physical activity. (H) Explore opportunities to involve local agencies that work with dogs to develop programs to encourage walking (i.e., buddy programs that match up dogs with seniors for a walk). (H) LEVEL 3: EDUCATING PROVIDERS Strategy Actions I. Develop the skills of community residents from low-income communities J. Educate local, state, and national legislators and government administrators to build support for physical activity and nutrition K. Train managers in the public and private sector in physical activity and nutrition promotion L. Teach doctors, allied health care professionals, social workers, and WIC and other service providers how to include physical activity promotion in current practices Identify community members who serve as opinion leaders, role models, and community change agents. (I) Develop skills of low-income community residents to teach classes in nutrition and lead physical activity programs; provide certification, underwrite costs, and offer continuing education and support. (I) Develop a government relations committee to plan and organize educational activities. (J) Train advocates, including low-income residents, to promote physical activity to relevant state and local governing boards (such as City Councils, Boards of Supervisors, School Boards, and relevant commissions, special districts, and authorities) as well as relevant professional and community organizations. (J) Identify existing organizations and councils that advocate around physical activity or related issues and build collaborative ties. (J) Attend political debates and forums and raise issues related to physical activity promotion; prepare factual materials to support this activity. (J) Conduct outreach to individual providers and make presentations to relevant organizations to motivate providers to participate in physical activity promotion. (I, J, K, L) Locate existing materials, or develop as needed, factsheets that detail the benefits of physical activity and nutrition, including cost and quality of life "savings" relevant to workplaces, education, health care, and communities and that are appropriate for various provider audiences. (I, J, K, L) Recruit, train, and mentor community providers to serve as champions of organizational change. Teach state-of-the-art nutrition and physical activity promotion strategies; provide effective outreach materials that are appropriate for their target audience, as well as easy-to-use models for incorporating changing organizational practices and education into their sphere of influence. Continue to provide coaching, evaluate impact, and provide feedback to help providers be more successful. (I, K, L) Develop public policy advocacy skills among providers, especially leaders in low-income communities. (I, K, L) Conduct state and community level training on the importance of cross-disciplinary collaboration for physical activity and nutrition promotion. (I, K, L) Present at or co-sponsor key conferences (i.e., Annual California Injury Prevention Conference) that include physical activity or nutrition promotion in their agendas. (K, L) Train managed care/Medi-Cal eligibility/enrollment workers to promote physical activity as part of their wellness presentations to potential enrollees. (K, L) Develop tools and models for incorporating physical activity into existing health care and service provision settings, e.g., quick health and fitness assessments, and appropriate on-site activities. (L) LEVEL 2: COMMUNITY EDUCATION Strategy Actions M. Utilize a neighborhood focus -- work where people are N. Refine media approaches to physical activity promotion in diverse populations Channel physical activity and nutrition information through key community organizations that regularly interact with neighborhood residents. (M) Create and support forums for defining and addressing community needs and wants (e.g., focus groups, neighborhood planning councils). (M) Develop and distribute neighborhood maps that show opportunities for physical activity; include environmental features (parks) and organizations that support activity and nutrition. (M) Provide support/funding to existing community programs (not primarily doing physical activity promotion) for development/expansion of physical activity components. (M) Promote a simple, broader, more cohesive health message that includes a definition of physical activity as both exercise and incidental activity; work with community leaders. (M, N) Utilize social marketing principles/practices to develop culturally and geographically appropriate materials; emphasize diversity and use a diversity of role models. (M, N) Use local media including radio, local columnists, public television (in-kind media support), and other sources of information for local news and events. (N) Use national entertainment media, mainstream TV, Latino/a broadcast channels, ethnic cable channels, and trend-setting music channels to communicate new images of physical activity. (N) LEVEL 1: INDIVIDUAL SKILL BUILDING Strategy Actions O. Teach life-long skills P. Support current healthy behaviors; enhance what people already do Q. Encourage and provide social support for family and peers Emphasize strategies and programs that incorporate a 'lifestyle perspective' by acknowledging that behavior change takes time, encouraging long-term planning (plan ahead) and teaching youth skills early. (O) Promote activities that are accessible (i.e., do not require costly equipment and are locally available). (O) Clarify health messages; integrate and coordinate between government departments and disciplines. (O) De-emphasize rigid guidelines and broaden definition of physical activity to encourage activities people are already doing. (O, P) Provide incentives for those who get others to participate as well as for those who get support through monetary donations. (O, P) Utilize youth as mentors and role models for physical activity. (O, P) Ensure that opportunities exist for buddy, group, and family participation in physical activity through funding and/or expanded programming. (Q) VII. Next Steps The recommendations outlined in this report for promoting physical activity (PA) among low-income Californians are not agency-specific. This section of the report identifies recommendations that CPNS can conduct with USDA funding. Funding from USDA is provided to CPNS primarily for conducting nutrition education activities. However, USDA allows the integration of some physical activity promotional activities. Activities congruent with USDA guidelines are outlined below. CPNS will continue to work with PANIC to set priorities and plan future implementation steps. The Department of Health Services has formed an internal Physical Activity Collaboration Team (PACT) to determine how state staff can best work together to promote physical activity. CPNS Objective 1: Increase the percentage of low-income Californian adults engaging in 30 minutes of physical activity on a daily basis. Baseline: 25% Target: 30% Data: CABRFSS, 1998 Healthy People 2010 Objective (22-2): Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day. Baseline: 15% Target: 30% Data: NHIS, CDC, NCHS, 1997 CPNS Objective 2: Increase the proportion of adolescents in California's low-resource schools who report engaging in 30 minutes of (moderate level) physical activity on a daily basis. Baseline: 22% Target: 30% Data: YRBS, CALTEENS, 1999 Healthy People 2010 Objective 22-9: Increase the proportion of adolescents who engage in moderate physical activity at least 30 minutes on 5 or more of the previous seven days. Baseline: 20% Target: 30% Data: YRBS, CDC, NCCDPHP, 1997 Action Steps - Year 1 (2001 - 2002) Foundational Activities LEAD AGENCY KEY PARTNERS Form advisory group (PANIC) comprised of physical activity experts and key partners to provide recommendations to CPNS for promoting and integrating physical activity among low-income Californians. Define mission, objectives, membership, etc. CPNS Physical Activity partners (see appendix) Identify and collaborate with other DHS-funded physical activity programs to develop a statewide physical activity coordination team (PACT). Review mission, goals, and objectives of programs. Develop a coordination plan for promoting physical activity among Californians. Specifically, identify programmatic activities conducted by other DHS agencies that support recommendations outlined in this report and CPNS objectives. Identify strategies to support PACT efforts. Identify or conduct research-based surveys to determine base-line data for Objectives 1 and 2. Physical Activity Health Initiative (PAHI) PACT, CPNS CPNS, PANIC advisory group PANIC Promotional Activities LEAD AGENCY KEY PARTNERS Conduct formative research on physical activity promotion among low-income populations. CPNS CPNS Research Unit Based on formative research, develop a marketing plan for promoting physical activity and nutrition among low-income Californians statewide. CPNS PANIC Pilot a marketing campaign in selected communities. CPNS PANIC, CPNS contractors Resource Development LEAD AGENCY KEY PARTNERS Identify and catalog research-based educational resources for promotional physical activity among low-income populations. Develop a database and system for disseminating information to CPNS contractors. Based on the pilot marketing campaign, develop a marketing resource kit for CPNS contractors to integrate and promote physical activity among low-income populations. Pilot the marketing kit with 2-3 CPNS contractors. CPNS PACT, CDC One-Time Demonstrations LEAD AGENCY KEY PARTNERS Develop a written plan for providing CPNS contractors with "one-time" demonstrations/trainings on promoting physical activity. CPNS PANIC Conduct 1-3 pilot "one-time only" demonstrations/trainings with selected CPNS contractors. CPNS CPNS contractors Action Steps - Year 2 (2002 - 2003) Foundational Activities LEAD AGENCY KEY PARTNERS Identify other sources of categorical funding to expand physical activity campaign beyond promotional activities. Depending on funding, use the Strategies for Action framework to develop a comprehensive 2-3-year strategic plan for developing and implementing statewide physical activity interventions that include community, environmental, and systems approaches. Identify and develop partnerships with for-profit, private partners to support and fund physical activity activities. CPNS PANIC, PACT Promotional Activities LEAD AGENCY KEY PARTNERS Based on results from the pilot project (marketing campaign), implement and evaluate a statewide physical activity promotional campaign. CPNS PANIC Resource Development Activities LEAD AGENCY KEY PARTNERS Based on pilot phase (marketing kit) in Year 1, provide funding for additional CPNS contractors to implement and evaluate physical activity resource kit. CPNS PANIC VIII. Conclusion The recommendations contained in this report provide direction for a multi-year effort to improve physical activity levels among low-income California residents. It has taken decades for our current sedentary culture to develop and reversing this trend will require perseverance. Yet there is no question that the "epidemic" of obesity and the scourge of related chronic diseases makes action an absolute necessity. As one PANIC participant summed it up, "I didn't imagine that I'd run into the people here that are doing the things I want to do. I feel relieved that there are more people working towards the same goal. This really encouraged me." The development of the strategy framework is not the final step in this important work, but is a vital beginning. Appendices I-VIII Footnotes i Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 ii Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 iii California Dietary Practices Survey: Overall Trends in Healthy Eating Among Adults 1989-1997, A Call to Action, Part 2, Cancer Prevention and Nutrition Section, California Department of Health Services, Public Health Institute, September 1999. iv US Department of Health and Human Services, Press Release, 12.28.99, "New National Health Goals Target Racial and Ethnic Health Disparities." v Taylor WC, Baranowski T. "Physical Activity Interventions in Low-Income, Ethnic Minority, and Populations with Disability," American Journal of Preventative Medicine, 1998. vi Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 vii Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 viii Caspersen CJ, Powell KE, Christenson GM. "Physical activity, exercise, and physical fitness: Definition and distinctions for health-related research," Public Health Reports, 1985; 100:126-131. ix Foerster S. California Teen Eating, Exercise and Nutrition Survey: Also Profiling Body Weight and Tobacco Use. Public Health Institute, September 2000. x Ommundsen Y. [Can sports and physical activity promote young people's psychosocial health]? Tidsskr Nor Laegeforen, November 2000; 120(29):3573-3577. xi Jacobsen P, Anderson CL, Winn DG, Moffat J, Agran PF, Sarkar S. "Child Pedestrian Injuries on Residential Streets: Implications for Traffic Engineering." Institute of Traffic Engineers Journal, February 2000. xii Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 xiii Physical Activity and Health: A Report of the Surgeon General, US Department of Health and Human Services, 1996 xiv California Dietary Practices Survey: Overall Trends in Healthy Eating Among Adults 1989-1997, A Call to Action, Part 2, Cancer Prevention and Nutrition Section, California Department of Health Services, Public Health Institute, September 1999. xv US Department of Health and Human Services. Healthy People 2010. (Conference edition, in two volumes). Washington, DC: January 2000. xvi Rennison CM. National Crime Victimization Survey: Criminal Victimization 1998: Changes 1997-1998 with Trends 1993-1998, Bureau of Justice Statistics, US Department of Justice, July 1999. xvii Ohland G, Nguyen T, and Corless J, Dangerous by Design: Pedestrian Safety in California, Surface Transportation Policy Project. Sacramento, September 2000. xviii Taylor WC, Baranowski T. "Physical Activity Interventions in Low-Income, Ethnic Minority, and Populations with Disability," American Journal of Preventative Medicine, 1998. xix Journal of Health Education Supplement. March/April 1999; 30(2). xx Presentation by Dr. Steve Hooker, Physical Activity and Nutrition Integration Committee. xxi Sallis JF. "Community Interventions and Communities as Interventions," Background Paper for California Nutrition Network and Five-a-Day Programs Physical Activity Planning Meeting, San Diego, CA, July 13-14, 2000. xxii Sallis JF. "Community Interventions and Communities as Interventions," Background Paper for California Nutrition Network and Five-a-Day Programs Physical Activity Planning Meeting, San Diego, CA, July 13-14, 2000. xxiii Sallis JF. "Community Interventions and Communities as Interventions," Background Paper for California Nutrition Network and Five-a-Day Programs Physical Activity Planning Meeting, San Diego, CA, July 13-14, 2000. xxiv McLeroy KR, Bibeau D, Steckler A, Glanz K. "An Ecological Perspective on Health Promotion Programs," Health Education Quarterly, 1988; 15:351-377. xxv Cohen L, Swift S. "The Spectrum of Prevention: Developing a Comprehensive Approach to Injury Prevention." Injury Prevention, 1999; 5:203-207. For more information, contact Prevention Institute. Phone: 510-444-7738; Fax: 510-663-1280; E-Mail prevent63.134.213.124 Return to top of page Putting Prevention at the Center of Community Well Being preventioninstitute.org