Prioritizing a research agenda on built environments and physical activity: a twin panel Delphi consensus process with researchers and knowledge users.

BACKGROUND: The growth of urban dwelling populations globally has led to rapid increases of research and policy initiatives addressing associations between the built environment and physical activity (PA). Given this rapid proliferation, it is important to identify priority areas and research questions for moving the field forward. The objective of this study was to identify and compare research priorities on the built environment and PA among researchers and knowledge users (e.g., policy makers, practitioners). METHODS: Between September 2022 and April 2023, a three-round, modified Delphi survey was conducted among two independent panels of international researchers (n = 38) and knowledge users (n = 23) to identify similarities and differences in perceived research priorities on the built environment and PA and generate twin 'top 10' lists of the most important research needs. RESULTS: From a broad range of self-identified issues, both panels ranked in common the most pressing research priorities including stronger study designs such as natural experiments, research that examines inequalities and inequities, establishing the cost effectiveness of interventions, safety and injuries related to engagement in active transportation (AT), and considerations for climate change and climate adaptation. Additional priorities identified by researchers included: implementation science, research that incorporates Indigenous perspectives, land-use policies, built environments that support active aging, and participatory research. Additional priorities identified by knowledge users included: built environments and PA among people living with disabilities and a need for national data on trip chaining, multi-modal travel, and non-work or school-related AT. CONCLUSIONS: Five common research priorities between the two groups emerged, including (1) to better understand causality, (2) interactions with the natural environment, (3) economic evaluations, (4) social disparities, and (5) preventable AT-related injuries. The findings may help set directions for future research, interdisciplinary and intersectoral collaborations, and funding opportunities.

Rural libraries implementing walking groups or walking groups plus civic engagement for walkability in rural communities: a comparative effectiveness trial study protocol.

BACKGROUND: Rural residents generally lack adequate physical activity to benefit health and reduce disparities in chronic diseases, such as cardiovascular disease and certain cancers. The Socioecological Model describes physical activity as involving a dynamic and reciprocal interaction between individual, social, and community factors. Community group-based walking programs and civic engagement interventions aimed at enhancing physical activity have been successful in rural communities but have not targeted all three socioecological levels. Public libraries can act as innovative public health partners in rural communities. However, challenges remain because rural libraries often lack the capacity to implement evidence-based health promotion programming. The goals of this study are (1) build the capacity for rural libraries to implement evidence-based health promotion programs, (2) compare changes in physical activity between a group-based walking program and a combined group-based walking and civic engagement program with rural residents, and (3) conduct an implementation evaluation. METHODS: We will conduct a comparative effectiveness study of a group-based walking (standard approach) versus a group-based walking plus civic engagement program (combined approach) aimed at enhancing walkability to increase physical activity among rural adults. Key mediators between the program effects and change in outcomes will also be identified. Finally, we will evaluate program implementation, conduct a cost effectiveness evaluation, and use a positive deviance analysis to understand experiences of high and low changers on key outcomes. Twenty towns will be matched and randomized to one of the two conditions and our aim is to enroll a total of 350-400 rural residents (15-20 per town). Study outcomes will be assessed at baseline, and 6, 12, and 24 months. DISCUSSION: This study will build the capacity of rural libraries to implement evidence-based walking programs as well as other health promotion programs in their communities. The study results will answer questions regarding the relative effectiveness and cost effectiveness of two multilevel physical activity interventions targeting rural communities. We will learn what works and how these multilevel interventions can be implemented in rural populations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05677906.

COVID-19 Related Protocol Considerations and Modifications within a Rural, Community-Engaged Health Promotion Randomized Trial.

Rural communities are at higher risk for physical inactivity, poor dietary behaviors, and related chronic diseases and obesity. These disparities are largely driven by built environment, socioeconomic, and social factors. A community-based cluster randomized controlled trial of an intervention, the Change Club, aims to address some of these disparities via civic engagement for built environment change. Baseline data collection began in February 2020, only to be paused by the COVID-19 pandemic. In this context, the investigators evaluated multiple approaches for collecting data when the study resumed, focusing on Life's Simple 7, and additional anthropometric, physiologic, and behavioral outcomes in rural and micropolitan (<50,000 population) communities in Texas and New York. Life's Simple 7 includes fasting blood glucose, total cholesterol, blood pressure, weight, physical activity, diet, and smoking. Rigor and feasibility were considered across a variety of in-person versus at-home measurement options. After a comprehensive input from participants, partners, staff, researchers, and the funding liaison, the study team chose self-measurement and use of validated questionnaires/surveys to measure the Life's Simple 7 components. This case provides an example of how a study team might adjust data collection protocol during unexpected and acute events while giving consideration to rigor, feasibility, stakeholder views, and participants' health and safety.

Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial.

BACKGROUND: Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors. METHODS: This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation. DISCUSSION: Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

Social and Structural Determinants of Health Inequities: Socioeconomic, Transportation-Related, and Provincial-Level Indicators of Cost-Related Forgone Hospital Care in China.

Despite near universal health insurance coverage in China, populations with low incomes may still face barriers in access and utilization of affordable health care. We aimed to identify the likelihood of forgone medical care due to cost by surveying individuals from the community to assess: (1) The percent with forgone medical care due to cost; and (2) Factors associated with forgone medical care due to cost. Surveys conducted (2016-2017) in Mandarin included demographic and medical care utilization-related items. Theoretically-informed, fully-adjusted analyses were employed. Approximately 94% of respondents had health insurance, which is somewhat similar to national estimates. Overall, 24% of respondents resided in rural areas, with 18% having less than a high school education, and 49% being male. More than 36% reported forgone medical care due to cost in the past 12 months. In fully-adjusted analyses, having lower education, generally not being satisfied with the commute to the hospital, and being a resident of a province with a lower density of physicians were associated with forgone medical care. Cost-related disparities in the access and utilization of needed medical care persist, even with near universal health insurance, which may be due to one's satisfaction with travel time to healthcare and other community assets.

Association Between Social Isolation and Eating Alone on Foods Consumed by Chinese Adolescents.

Obesity is increasingly affecting Chinese adolescents due to trends in unhealthy eating, including lower fruit and vegetable consumption and increased consumption of processed foods. A cross-sectional study of adolescents was conducted in Wuhan, China, in October 2019 that included measurements of perceived social isolation, eating when anxious or depressed, diet composition, body weight, and height. Social isolation, eating when sad or anxious, and eating alone were significant predictors of processed food and sugar-sweetened beverage consumption, although only eating when sad or anxious was a significant predictor of fruit and vegetable consumption. Eating when anxious or depressed did not mediate these relationships. Social isolation was associated with consumption of processed foods and sugar-sweetened beverages by boys, but not by girls, and only eating home-cooked dinner was associated with fruit and vegetable consumption by female adolescents. Eating when sad or anxious, eating alone, and eating home-cooked meals were all associated with fruit and vegetable consumption among male adolescents. The effects of social isolation, anxiety, and depression could act to increase unhealthy eating through several mechanisms potentially mediated by chronic stress, while eating alone could also act to increase unhealthy eating due to effects of self-efficacy and food availability. The interplay between diet and outside factors, including environment, social factors, and personal psychology specific to Chinese adolescents needs to be better understood to develop comprehensive interventions for this population.

A Scoping Review of Bikeability Assessment Methods.

Bicycling holds promise as a healthy and sustainable means of transportation and physical activity. Despite the growing interest in community-based environmental approaches to promoting physical activity, bikeability has received relatively little attention. This paper provides a scoping review of the instruments developed to measure bikeability along with practice-based analyses of the tools related to user expertise, estimated cost, and required time to implement. The review summarizes the literature, identifies research gaps, and informs stakeholders with articles from EBSCO and transportation databases published after 2003 when the previous bikeability instrument review paper was published. Data extraction included the tool name, data collection method, study location, data collection scale, type of measure, and description. Two reviewers independently reviewed articles included in the full text review, and the inter-rater agreement exceeded 90%. The database search yielded 388 unique articles, and 17 met the inclusion/exclusion criteria. Most of the studies, 11 of 17, were applied to settings outside of the U.S. Five studies employed a self-report survey, and five studies examined bikeability using geospatial data, like GIS. Seven studies used a direct observation audit tool-one specifically using a mobile app and another using virtual observation techniques with Google Street View. Bikeability tools are useful for assessing communities and their supports for bicycling. Our primary finding is that advances in technology over the past two decades have driven innovative and useful methodologies, in a variety of disciplines, for assessing the environment, but more consensus is needed to provide a universal definition of bikeability.

Comparisons of social and demographic determinants of tobacco use in the Democratic Republic of the Congo.

BACKGROUND: Worldwide, tobacco use has caused over 100 million deaths in the twentieth century and is projected to cause death in up to one billion people in the twenty-first century. It is a leading cause of early death and disability in over 100 countries and accounts for over 11% of global deaths, disproportionately affecting low- and middle-income countries. The purpose of the study was to examine a variety of social determinants of tobacco use in the Democratic Republic of the Congo, including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights with regard to tobacco use among sub-national groups. METHODS: This project was a secondary data analysis of the 2013-2014 Demographics and Health Survey (DHS) for the Democratic Republic of the Congo. Logistic regressions predicting smoking, use of snuff and smoking cigars or natural tobacco as dichotomous variables were conducted. Independent variables included age, educational level, religion, rurality, literacy, wealth index, occupation and ethnicity. RESULTS: Tobacco use is highest among those with less education and low literacy. It was also highest among the working poor. Older age and living in larger cities were predictive of smoking, although the relationship between age and smoking was not linear. There was a strong linear effect for wealth. Being in a professional, technical or managerial position was highly protective against smoking while being engaged in services, skilled and unskilled manual labor, and the army had significantly greater odds of smoking. CONCLUSIONS: Data indicate that tobacco use in the DRC, as is common in the developing world, is heavily concentrated in the working poor with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. Additionally, examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions that can lead to inefficient and ineffective allocation of resources aimed at controlling tobacco use.

The Healthy Hawai'i Initiative: insights from two decades of building a culture of health in a multicultural state.

BACKGROUND: The Healthy Hawai'i Initiative was created in 2000 with tobacco settlement funds as a theory-based statewide effort to promote health-supporting environments through systems and policy change. Still active today, it is imbedded explicitly in a multi-sectoral, social ecological approach, effectively striving to build a culture of health before this was the name for such an ambitious effort. METHODS: From interviews with key informants, we analyze two decades of the Healthy Hawai'i Initiative (HHI) in the context of the Robert Wood Johnson Foundation (RWJF) Culture of Health Action Framework (CHAF). We list HHI accomplishments and examine how the Initiative achieved notable policy and environmental changes supportive of population health. RESULTS: The Healthy Hawai'i Initiative started with an elaborate concept-mapping process that resulted in a common vision about making "the healthy choice the easiest choice." Early on, the Initiative recognized that making health a shared value beyond the initial stakeholders required coalition and capacity building across a broad range of governmental and nonprofit actors. HHI coalitions were designed to promote grassroots mobilization and to link community leaders across sectors, and at their height, included over 500 members across all main islands of the state. Coalitions were particularly important for mobilizing rural communities. Additionally, the Initiative emphasized accessibility to public health data, published research, and evaluation reports, which strengthened the engagement to meet the shared vision and goals between diverse sector partners and HHI. Over the past two decades, HHI has capitalized on relationship building, data sharing, and storytelling to encourage a shared value of health among lawmakers, efforts which are believed to have led to the development of health policy champions. All of these factors combined, which centered on developing health as a shared value, have been fundamental to the success of the other three action areas of the CHAF over time. CONCLUSIONS: This evidence can provide critical insights for other communities at earlier stages of implementing broad, diverse, multifaceted system change and fills a key evidence gap around building a culture of health from a mature program in a notably multicultural state.

An Observational Assessment of Park-based Physical Activity in Older Adults in Nanchang, China.

Objectives: Parks are more widely used by older adults in East Asia than in the United States. Parks are an important community asset for healthy aging; yet, little is known about park usage and features among older adults in China. Methods: The Community Park Audit Tool and the System for Observing Play and Recreation (SOPARC) were used to assess park features, PA levels and primary activities among 40,469 older adults in Nanchang, China. Results: None of the 8 parks observed had basketball courts or baseball fields and only one had a playground. Results indicated that about half of older adults were active in parks, with women, cooler temperatures, weekdays, and morning hours being related to higher levels of activity. Conclusions: Lessons from the construction of parks in China may be useful in increasing park use in older adults in western countries. Features such as exercise equipment, water features, and small exercise areas were common where western parks are often designed with features for teens and youth including basketball courts, baseball fields, and playgrounds.

Effect of the treatment-before-deposit policy on trust in physicians and perceived service quality among patients in 12 hospitals in China.

This study examined effects of the treatment-before-deposit policy on Chinese patients' trust in physicians and perceived service quality. This study included 3313 patients recruited from 12 hospitals in China. The research team used cross-sectional survey to examine Chinese patients' experience with the treatment-before-deposit policy, perceived service quality, and trust in their physicians. Using mediation analysis, we estimated direct and indirect effects of the treatment-before-deposit policy on patients' perceived service quality and trust in their physicians. Patients who benefitted from the treatment-before-deposit policy reported greater service quality and higher trust in their physicians. The impacts of whether patients benefitted from the policy on trust in physicians were fully mediated by perceived service quality with statistically significant indirect effect. The results support the hypothesis that the treatment-before-deposit policy improves patients' perceived service quality and trust in physicians.

Qualitative Exploration of Cross-Sector Perspectives on the Contributions of Local Health Departments in Land-Use and Transportation Policy.

INTRODUCTION: Transportation and land-use policies can affect the physical activity of populations. Local health departments (LHDs) are encouraged to participate in built-environment policy processes, which are outside their traditional expertise. Cross-sector collaborations are needed, yet stakeholders' perceptions of LHD involvement are not well understood. The objective of this study was to describe the perceived value of LHD participation in transportation and land-use decision making and potential contributions to these processes among stakeholders. METHODS: We analyzed qualitative data from 49 semistructured interviews in 2015. Participants were professionals in 13 US states and 4 disciplines: land-use planning (n = 13), transportation/public works (n = 11), public health (n = 19), and other (municipal administration and bike and pedestrian advocacy [n = 6]). Two analysts conducted directed content analysis. RESULTS: All respondents reported that LHDs offer valuable contributions to transportation and land-use policy processes. They identified 7 contributions (interrater agreement 91%): 1) physical activity and health perspective (n = 44), 2) data analysis and assessment (n = 41), 3) partnerships in the community and across sectors (n = 35), 4) public education (n = 27), 5) knowledge of the public health evidence base and best practices (n = 23), 6) resource support (eg, grant writing, technical assistance) (n = 20), and 7) health equity (n = 8). CONCLUSION: LHDs can leverage their strengths to foster cross-sector collaborations that promote physical activity opportunities in communities. Our results will inform development of sustainable capacity-building models for LHD involvement in built-environment decision making.

The Association between Family and Parental Factors and Obesity among Children in Nanchang, China.

BACKGROUND: With rapid economic development in China, traditional patterns of health behaviors are changing, concurrent with a rise in childhood obesity. While the home environment and parenting behaviors are modifiable factors that could be targeted for intervention, little is known about their relationship with children's health behaviors. Therefore, the purpose of this study was to investigate the relationship between obesity and home and parenting factors in Chinese children. METHODS: A cross-sectional survey was conducted in Nanchang, China in 2013 with caregivers (N = 470) of a child between the ages of 2 and 10 years. Regression analyses were conducted to determine risk factors for childhood obesity. RESULTS: Obesity prevalence (21.7%) did not differ by demographic variables. Eight physical activity, nutrition, and sedentary variables had significant relationships to obesity status. Logistic regression analysis revealed three significant predictors of obesity: the number of days the family eats meals together (odds ratio = 0.84, 95% CI 0.73-0.96) and parental home computer use time (odds ratio = 0.83, 95% CI 0.72-0.96) were related to lower levels of obesity, while parental television time (odds ratio = 1.25 95% CI 1.07-1.47) was related to higher levels of obesity. CONCLUSION: The prevalence of obesity among children is high in Nanchang. Family and environmental risk factors are significantly related to obesity.

Priorities of Municipal Policy Makers in Relation to Physical Activity and the Built Environment: A Latent Class Analysis.

OBJECTIVE: To examine policy makers' public policy priorities related to physical activity and the built environment, identify classes of policy makers based on priorities using latent class analysis, and assess factors associated with class membership. DESIGN: Cross-sectional survey data from municipal officials in 94 cities and towns across 6 US states were analyzed. PARTICIPANTS: Participants (N = 423) were elected or appointed municipal officials spanning public health, planning, transportation/public works, community and economic development, parks and recreation, and city management. MAIN OUTCOME MEASURES: Participants rated the importance of 11 policy areas (public health, physical activity, obesity, economic development, livability, climate change, air quality, natural resource conservation, traffic congestion, traffic safety, and needs of vulnerable populations) in their daily job responsibilities. Latent class analysis was used to determine response patterns and identify distinct classes based on officials' priorities. Logistic regression models assessed participant characteristics associated with class membership. RESULTS: Four classes of officials based on policy priorities emerged: (1) economic development and livability; (2) economic development and traffic concerns; (3) public health; and (4) general (all policy areas rated as highly important). Compared with class 4, officials in classes 1 and 3 were more likely to have a graduate degree, officials in class 2 were less likely to be in a public health job/department, and officials in class 3 were more likely to be in a public health job/department. CONCLUSIONS: Findings can guide public health professionals in framing discussions with policy makers to maximize physical activity potential of public policy initiatives, particularly economic development.

Analysis of residents' willingness to pay to reduce air pollution to improve children's health in community and hospital settings in Shanghai, China.

BACKGROUND: Shanghai, along with many major cities in China, faces deterioration of air quality and increases in air pollution-related respiratory diseases (RDs) in children due to rapid industrialization and urbanization. The Contingent Valuation Method (CVM) was used to qualitatively and quantitatively measure the willingness to pay (WTP) for reducing children's RDs through air quality improvement. METHODS: Between April and May, 2014, 975 face-to-face interviews were collected from parents in a community-based and a hospital-setting in Shanghai. Multiple imputation and the Probit model were used to determine the relationship between the WTP and the related environmental factors, child health factors and the socio-economic status. RESULTS: Most respondents reported being willing to make a financial contribution to improve air quality in both the community (52.6%) and hospital (70.2%) samples. Those in the hospital setting were willing to pay significantly more ¥504 (USD$80.7) compared to the community sample ¥428 ($68.5) as expected. Reasons for those not being willing to pay included lack of disposable income and believing that responsibility of the air quality was a community issue. These did not differ by sample. Annual household income and education were related to WTP. CONCLUSION: This study indicated that parents in Shanghai would be willing to pay for improved air quality. Children's health can be the incentive for the citizens' participation and support in the air quality improvement, therefore, hospital settings may present unique places to improve education about air quality and enhance advocacy efforts. This study also suggested that future environmental policies be addressed more rigorously for targeted populations.

Attitudes of Policy Makers in Hawaii toward Public Health and Related Issues before and after an Economic Recession in the United States.

INTRODUCTION: Legislation and regulation at the state and local level can often have a greater impact on the public's health than individual-based approaches. Elected and appointed officials have an essential role in protecting and improving public health. Despite this important role, little systematic research has been done to assess the relative importance of public health issues compared to other policy issues in times of economic hardship. This study assessed attitudes of elected and appointed decision makers in Hawaii in 2007 and 2013 to determine if priorities differed before and after the economic recession. METHODS: Elected and appointed state and county officials were mailed surveys at both time points. Respondents rated the importance of 23 specified problems, of which 9 asked about specific public health issues. RESULTS: The survey was completed by 126 (70.4%) respondents in 2007 and 117 (60.9%) in 2013. Among the public health issues, five saw significant mean decreases. These variables included climate change, pedestrian safety, government response to natural disasters, access to healthcare, and pandemic influenza. Obesity was the only public health issue to increase in importance across the two time points. In terms of relative ranking across the time points, only drug abuse and obesity were among the top 10 priorities. Lack of public health training, pandemic influenza, and government response to natural disasters were among the bottom five priorities. CONCLUSION: After the economic recession, many public health issues have a lower priority among Hawaii's policy makers than before the downturn. Additional education and advocacy is needed to keep public health issues on the minds of decision makers during tough economic times.

Insights from an observational assessment of park-based physical activity in Nanchang, China.

Internationally, parks have been shown to be an important community asset for physical activity (PA), but little is known about the relationship between park usage and physical activity in China. The purpose of this study was to determine the association between park user characteristics and PA in Nanchang, China. In June 2014, 75,678 people were observed in eight parks over 12 days using SOPARC, a validated systematic observation tool. A logistic regression analysis was used to determine the association between PA and park user characteristics. Most park users were older adults (53.5%) or adults (34.6%). Overall, 55% of park users engaged in moderate-to-vigorous physical activity (MVPA). Fewer women were observed in parks than men, but were 66% more likely to be engaged in MVPA than men. Park users were more likely to be observed in MVPA between 6-9 am and when the temperature was below 30 °C. Chinese park users were more active (55%) than US studies in Tampa (30%), Chicago (49%), and Los Angeles (34%). More research is necessary to identify features of parks that are associated with greater PA so that effective interventions can be developed to promote active park use in Chinese citizens.