Outcomes Associated With Social Distancing Policies in St Louis, Missouri, During the Early Phase of the COVID-19 Pandemic.

Importance: In the absence of a national strategy in response to the COVID-19 pandemic, many public health decisions fell to local elected officials and agencies. Outcomes of such policies depend on a complex combination of local epidemic conditions and demographic features as well as the intensity and timing of such policies and are therefore unclear. Objective: To use a decision analytical model of the COVID-19 epidemic to investigate potential outcomes if actual policies enacted in March 2020 (during the first wave of the epidemic) in the St Louis region of Missouri had been delayed. Design, Setting, and Participants: A previously developed, publicly available, open-source modeling platform (Local Epidemic Modeling for Management & Action, version 2.1) designed to enable localized COVID-19 epidemic projections was used. The compartmental epidemic model is programmed in R and Stan, uses bayesian inference, and accepts user-supplied demographic, epidemiologic, and policy inputs. Hospital census data for 1.3 million people from St Louis City and County from March 14, 2020, through July 15, 2020, were used to calibrate the model. Exposures: Hypothetical delays in actual social distancing policies (which began on March 13, 2020) by 1, 2, or 4 weeks. Sensitivity analyses were conducted that explored plausible spontaneous behavior change in the absence of social distancing policies. Main Outcomes and Measures: Hospitalizations and deaths. Results: A model of 1.3 million residents of the greater St Louis, Missouri, area found an initial reproductive number (indicating transmissibility of an infectious agent) of 3.9 (95% credible interval [CrI], 3.1-4.5) in the St Louis region before March 15, 2020, which fell to 0.93 (95% CrI, 0.88-0.98) after social distancing policies were implemented between March 15 and March 21, 2020. By June 15, a 1-week delay in policies would have increased cumulative hospitalizations from an observed actual number of 2246 hospitalizations to 8005 hospitalizations (75% CrI: 3973-15 236 hospitalizations) and increased deaths from an observed actual number of 482 deaths to a projected 1304 deaths (75% CrI, 656-2428 deaths). By June 15, a 2-week delay would have yielded 3292 deaths (75% CrI, 2104-4905 deaths)-an additional 2810 deaths or a 583% increase beyond what was actually observed. Sensitivity analyses incorporating a range of spontaneous behavior changes did not avert severe epidemic projections. Conclusions and Relevance: The results of this decision analytical model study suggest that, in the St Louis region, timely social distancing policies were associated with improved population health outcomes, and small delays may likely have led to a COVID-19 epidemic similar to the most heavily affected areas in the US. These findings indicate that an open-source modeling platform designed to accept user-supplied local and regional data may provide projections tailored to, and more relevant for, local settings.

Disrupted and Restored Patient Experience With Transition to New Electronic Health Record System.

Transitioning from one electronic health record (EHR) system to another is of the most disruptive events in health care and research about its impact on patient experience for inpatient is limited. This study aimed to assess the impact of transitioning EHR on patient experience measured by the Hospital Consumer Assessment of Healthcare Providers and Systems composites and global items. An interrupted time series study was conducted to evaluate quarter-specific changes in patient experience following implementation of a new EHR at a Midwest health care system during 2017 to 2018. First quarter post-implementation was associated with statistically significant decreases in Communication with Nurses (-1.82; 95% CI, -3.22 to -0.43; P = .0101), Responsiveness of Hospital Staff (-2.73; 95% CI, -4.90 to -0.57; P = .0131), Care Transition (-2.01; 95% CI, -3.96 to -0.07; P = .0426), and Recommend the Hospital (-2.42; 95% CI, -4.36 to -0.49; P = .0142). No statistically significant changes were observed in the transition, second, or third quarters post-implementation. Patient experience scores returned to baseline level after two quarters and the impact from EHR transition appeared to be temporary.

Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

PURPOSE: Substantial reductions in inpatient episodes of severe hypoglycemia achieved by a large healthcare system through enhanced use of technology and sustained quality-improvement initiatives are described. SUMMARY: After internal data collection and analysis revealed that severe hypoglycemia accounted for 75% of all systematically monitored adverse drug events in its hospital network, St. Louis-based BJC HealthCare designed and executed a multifaceted approach to reducing hypoglycemia events. Initiated by a pharmacist-led task force, the project entailed (1) automated event detection and creation of dashboards for comparing hypoglycemia rates among at-risk patients at 11 BJC facilities, (2) implementation of evidence-based and internal best practices in use at BJC's top-performing hospitals, (3) development of an online "Hypoglycemic Event Analysis Tool" (HEAT) to support event investigation and collection of data on causative factors, and (4) the assembly of targeted interventions at a "Hypoglycemia Facility Strategy Tracking" (H-FaST) intranet site. As a result of the launch of the HEAT and H-FaST tools and associated provider education activities, the systemwide rate of hypoglycemia events in the specified at-risk patient population declined from 6.45 per 1000 patient-days during a preimplementation baseline period (July-December 2009) to 1.32 per 1000 patient-days during a designated postimplementation period (January-June 2014), an 80% overall reduction in hypoglycemia (p < 0.01); reductions in severe hypoglycemia events ranging from 70% to 100% were observed at all 11 hospitals. CONCLUSION: A multifaceted, evidence-based, data-driven approach enabled a large healthcare system to markedly reduce the frequency of severe hypoglycemia events.

Review of measures of worksite environmental and policy supports for physical activity and healthy eating.

INTRODUCTION: Obesity prevention strategies are needed that target multiple settings, including the worksite. The objective of this study was to assess the state of science concerning available measures of worksite environmental and policy supports for physical activity (PA) and healthy eating (HE). METHODS: We searched multiple databases for instruments used to assess worksite environments and policies. Two commonly cited instruments developed by state public health departments were also included. Studies that were published from 1991 through 2013 in peer-reviewed publications and gray literature that discussed the development or use of these instruments were analyzed. Instrument administration mode and measurement properties were documented. Items were classified by general health topic, 5 domains of general worksite strategy, and 19 subdomains of worksite strategy specific to PA or HE. Characteristics of worksite measures were described including measurement properties, length, and administration mode, as well as frequencies of items by domain and subdomain. RESULTS: Seventeen instruments met inclusion criteria (9 employee surveys, 5 manager surveys, 1 observational assessment, and 2 studies that used multiple administration modes). Fourteen instruments included reliability testing. More items were related to PA than HE. Most instruments (n = 10) lacked items in the internal social environment domain. The most common PA subdomains were exercise facilities and lockers/showers; the most common HE subdomain was healthy options/vending. CONCLUSION: This review highlights gaps in measurement of the worksite social environment. The findings provide a useful resource for researchers and practitioners and should inform future instrument development.

Change in Neighborhood Socioeconomic Status and Weight Gain: Dallas Heart Study.

INTRODUCTION: Despite a proposed connection between neighborhood environment and obesity, few longitudinal studies have examined the relationship between change in neighborhood socioeconomic deprivation, as defined by moving between neighborhoods, and change in body weight. The purpose of this study is to examine the longitudinal relationship between moving to more socioeconomically deprived neighborhoods and weight gain as a cardiovascular risk factor. METHODS: Weight (kilograms) was measured in the Dallas Heart Study (DHS), a multiethnic cohort aged 18-65 years, at baseline (2000-2002) and 7-year follow-up (2007-2009, N=1,835). Data were analyzed in 2013-2014. Geocoded addresses were linked to Dallas County, TX, census block groups. A block group-level neighborhood deprivation index (NDI) was created. Multilevel difference-in-difference models with random effects and a Heckman correction factor (HCF) determined weight change relative to NDI change. RESULTS: Forty-nine percent of the DHS population moved (263 to higher NDI, 586 to lower NDI, 47 within same NDI), with blacks more likely to move than whites or Hispanics (p<0.01), but similar baseline BMI and waist circumference were observed in movers versus non-movers (p>0.05). Adjusting for HCF, sex, race, and time-varying covariates, those who moved to areas of higher NDI gained more weight compared to those remaining in the same or moving to a lower NDI (0.64 kg per 1-unit NDI increase, 95% CI=0.09, 1.19). Impact of NDI change on weight gain increased with time (p=0.03). CONCLUSIONS: Moving to more-socioeconomically deprived neighborhoods was associated with weight gain among DHS participants.

Behavior-over-time graphs: assessing perceived trends in healthy eating and active living environments and behaviors across 49 communities.

CONTEXT: In the evaluation of the Healthy Kids, Healthy Communities initiative, investigators implemented Group Model Building (GMB) to promote systems thinking at the community level. As part of the GMB sessions held in each community partnership, participants created behavior-over-time graphs (BOTGs) to characterize their perceptions of changes over time related to policies, environments, collaborations, and social determinants in their community related to healthy eating, active living, and childhood obesity. OBJECTIVE: To describe the process of coding BOTGs and their trends. DESIGN: Descriptive study of trends among BOTGs from 11 domains (eg, active living environments, social determinants of health, funding) and relevant categories and subcategories based on the graphed variables. In addition, BOTGs were distinguished by whether the variables were positively (eg, access to healthy foods) or negatively (eg, screen time) associated with health. SETTING: The GMB sessions were held in 49 community partnerships across the United States. PARTICIPANTS: Participants in the GMB sessions (n = 590; n = 5-21 per session) included key individuals engaged in or impacted by the policy, system, or environmental changes occurring in the community. MAIN OUTCOME MEASURES: Thirty codes were developed to describe the direction (increasing, decreasing, stable) and shape (linear, reinforcing, balancing, or oscillating) of trends from 1660 graphs. RESULTS: The patterns of trends varied by domain. For example, among variables positively associated with health, the prevalence of reinforcing increasing trends was highest for active living and healthy eating environments (37.4% and 29.3%, respectively), partnership and community capacity (38.8%), and policies (30.2%). Examination of trends of specific variables suggested both convergence (eg, for cost of healthy foods) and divergence (eg, for farmers' markets) of trends across partnerships. CONCLUSIONS: Behavior-over-time graphs provide a unique data source for understanding community-level trends and, when combined with causal maps and computer modeling, can yield insights about prevention strategies to address childhood obesity.

Bridging the gap between research and practice: an assessment of external validity of community-based physical activity programs in Bogotá, Colombia, and Recife, Brazil.

For more than a decade, physical activity classes have been offered in public places at no cost to the participants in some Latin American cities, however, internal and external validity evidence of these programs is limited. The goals of this study were to assess, report, and compare the external validity of the Recreovia program (RCP) in Colombia, and the Academia da Cidade program (ACP) in Brazil. Interviews to assess external validity of the RCP and ACP were conducted in 2012. The interview guide was developed based on the RE-AIM framework. Seventeen key informants were selected to participate in the study. Interviews were recorded and transcribed verbatim. Transcripts were analyzed using a constant comparative qualitative method and experts validated common themes. RCP and ACP key informants reported that both programs reach underserved population. There is no information available about effectiveness. Both programs take place in public spaces (e.g., parks and plazas), which are selected for adoption mainly based on community demand. RCP and ACP offer free physical activity classes with educational and cultural components, have a strong organizational structure for implementation, and differ on schedule and content of classes. Funding sources were reported to play an important role on long-term maintenance. Facilitators and barriers were identified. Programs are similar in the reach and adoption elements; the main differences were found on implementation and maintenance, whereas information on effectiveness was not found. Reporting external validity of these programs is useful to bridge the gap between research and practice.

Neighborhood-level socioeconomic deprivation predicts weight gain in a multi-ethnic population: longitudinal data from the Dallas Heart Study.

OBJECTIVE: The aim of this study is to examine a relationship between neighborhood-level socioeconomic deprivation and weight change in a multi-ethnic cohort from Dallas County, Texas and whether behavioral/psychosocial factors attenuate the relationship. METHODS: Non-movers (those in the same neighborhood throughout the study period) aged 18-65 (N=939) in Dallas Heart Study (DHS) underwent weight measurements between 2000 and 2009 (median 7-year follow-up). Geocoded home addresses defined block groups; a neighborhood deprivation index (NDI) was created (higher NDI=greater deprivation). Multi-level modeling determined weight change relative to NDI. Model fit improvement was examined with adding physical activity and neighborhood environment perceptions (higher score=more unfavorable perceptions) as covariates. A significant interaction between residence length and NDI was found (p-interaction=0.04); results were stratified by median residence length (11 years). RESULTS: Adjusting for age, sex, race/ethnicity, smoking, and education/income, those who lived in neighborhood >11 years gained 1.0 kg per one-unit increment of NDI (p=0.03), or 6 kg for those in highest NDI tertile compared with those in the lowest tertile. Physical activity improved model fit; NDI remained associated with weight gain after adjustment for physical activity and neighborhood environment perceptions. There was no significant relationship between NDI and weight change for those in their neighborhood ≤11 years. CONCLUSIONS: Living in more socioeconomically deprived neighborhoods over a longer time period was associated with weight gain in DHS.

Effects of buffer size and shape on associations between the built environment and energy balance.

Uncertainty in the relevant spatial context may drive heterogeneity in findings on the built environment and energy balance. To estimate the effect of this uncertainty, we conducted a sensitivity analysis defining intersection and business densities and counts within different buffer sizes and shapes on associations with self-reported walking and body mass index. Linear regression results indicated that the scale and shape of buffers influenced study results and may partly explain the inconsistent findings in the built environment and energy balance literature.

Scaling up of physical activity interventions in Brazil: how partnerships and research evidence contributed to policy action.

The global health burden due to physical inactivity is enormous and growing. There is a need to consider new ways of generating evidence and to identify the role of government in promoting physical activity at the population level. In this paper, we summarize key findings from a large-scale cross-national collaboration to understand physical activity promotion in Brazil. We describe the main aspects of the partnership of Project GUIA (Guide for Useful Interventions for Activity in Brazil and Latin America) that sustained the collaborative effort for eight years and describe how the evidence gathered from the collaboration triggered political action in Brazil to scale up a physical activity intervention at the national level. Project GUIA is a cross-national multidisciplinary research partnership designed to understand and evaluate current efforts for physical activity promotion at the community level in Latin America. This example of scaling up is unprecedented for promoting health in the region and is an example that must be followed and evaluated.

Understanding the independent and joint associations of the home and workplace built environments on cardiorespiratory fitness and body mass index.

This observational study examined the associations of built environment features around the home and workplace with cardiorespiratory fitness (CRF) based on a treadmill test and body mass index (BMI) (weight (kg)/height (m)(2)). The study included 8,857 adults aged 20-88 years who completed a preventive medical examination in 2000-2007 while living in 12 Texas counties. Analyses examining workplace neighborhood characteristics included a subset of 4,734 participants. Built environment variables were derived around addresses by using geographic information systems. Models were adjusted for individual-level and census block group-level demographics and socioeconomic status, smoking, BMI (in CRF models), and all other home or workplace built environment variables. CRF was associated with higher intersection density, higher number of private exercise facilities around the home and workplace, larger area of vegetation around the home, and shorter distance to the closest city center. Aside from vegetation, these same built environment features around the home were also associated with BMI. Participants who lived and worked in neighborhoods in the lowest tertiles for intersection density and the number of private exercise facilities had lower CRF and higher BMI values than participants who lived and worked in higher tertiles for these variables. This study contributes new evidence to suggest that built environment features around homes and workplaces may affect health.

Designing for dissemination among public health researchers: findings from a national survey in the United States.

OBJECTIVES: We have described the practice of designing for dissemination among researchers in the United States with the intent of identifying gaps and areas for improvement. METHODS: In 2012, we conducted a cross-sectional study of 266 researchers using a search of the top 12 public health journals in PubMed and lists available from government-sponsored research. The sample involved scientists at universities, the National Institutes of Health, and the Centers for Disease Control and Prevention in the United States. RESULTS: In the pooled sample, 73% of respondents estimated they spent less than 10% of their time on dissemination. About half of respondents (53%) had a person or team in their unit dedicated to dissemination. Seventeen percent of all respondents used a framework or theory to plan their dissemination activities. One third of respondents (34%) always or usually involved stakeholders in the research process. CONCLUSIONS: The current data and the existing literature suggest considerable room for improvement in designing for dissemination.

Development and reliability testing of the Worksite and Energy Balance Survey.

CONTEXT: Worksites represent important venues for health promotion. Development of psychometrically sound measures of worksite environments and policy supports for physical activity and healthy eating are needed for use in public health research and practice. OBJECTIVE: Assess the test-retest reliability of the Worksite and Energy Balance Survey (WEBS), a self-report instrument for assessing perceptions of worksite supports for physical activity and healthy eating. DESIGN: The WEBS included items adapted from existing surveys or new items on the basis of a review of the literature and expert review. Cognitive interviews among 12 individuals were used to test the clarity of items and further refine the instrument. A targeted random-digit-dial telephone survey was administered on 2 occasions to assess test-retest reliability (mean days between time periods = 8; minimum = 5; maximum = 14). SETTING: Five Missouri census tracts that varied by racial-ethnic composition and walkability. PARTICIPANTS: Respondents included 104 employed adults (67% white, 64% women, mean age = 48.6 years). Sixty-three percent were employed at worksites with less than 100 employees, approximately one-third supervised other people, and the majority worked a regular daytime shift (75%). MAIN OUTCOME MEASURES: Test-retest reliability was assessed using Spearman correlations for continuous variables, Cohen's κ statistics for nonordinal categorical variables, and 1-way random intraclass correlation coefficients for ordinal categorical variables. RESULTS: Test-retest coefficients ranged from 0.41 to 0.97, with 80% of items having reliability coefficients of more than 0.6. Items that assessed participation in or use of worksite programs/facilities tended to have lower reliability. Reliability of some items varied by gender, obesity status, and worksite size. Test-retest reliability and internal consistency for the 5 scales ranged from 0.84 to 0.94 and 0.63 to 0.84, respectively. CONCLUSIONS: The WEBS items and scales exhibited sound test-retest reliability and may be useful for research and surveillance. Further evaluation is needed to document the validity of the WEBS and associations with energy balance outcomes.

The 2011-2016 Transdisciplinary Research on Energetics and Cancer (TREC) initiative: rationale and design.

PURPOSE: Recognition of the complex, multidimensional relationship between excess adiposity and cancer control outcomes has motivated the scientific community to seek new research models and paradigms. METHODS: The National Cancer Institute developed an innovative concept to establish a center grant mechanism in nutrition, energetics, and physical activity, referred to as the Transdisciplinary Research on Energetics and Cancer (TREC) Initiative. This paper gives an overview of the 2011-2016 TREC Collaborative Network and the 15 research projects being conducted at the centers. RESULTS: Four academic institutions were awarded TREC center grants in 2011: Harvard University, University of California San Diego, University of Pennsylvania, and Washington University in St. Louis. The Fred Hutchinson Cancer Research Center is the Coordination Center. The TREC research portfolio includes three animal studies, three cohort studies, four randomized clinical trials, one cross-sectional study, and two modeling studies. Disciplines represented by TREC investigators include basic science, endocrinology, epidemiology, biostatistics, behavior, medicine, nutrition, physical activity, genetics, engineering, health economics, and computer science. Approximately 41,000 participants will be involved in these studies, including children, healthy adults, and breast and prostate cancer survivors. Outcomes include biomarkers of cancer risk, changes in weight and physical activity, persistent adverse treatment effects (e.g., lymphedema, urinary and sexual function), and breast and prostate cancer mortality. CONCLUSION: The NIH Science of Team Science group will evaluate the value added by this collaborative science. However, the most important outcome will be whether this transdisciplinary initiative improves the health of Americans at risk of cancer as well as cancer survivors.

Physical activity interventions in Latin America: expanding and classifying the evidence.

CONTEXT: Systematic reviews of public health interventions are useful for identifying effective strategies for informing policy and practice. The goals of this review were to (1) update a previous systematic review of physical activity interventions in Latin America which found that only school-based physical education had sufficient evidence to recommend widespread adoption; (2) assess the reporting of external validity elements; and (3) develop and apply an evidence typology for classifying interventions. EVIDENCE ACQUISITION: In 2010-2011, community-level, physical activity intervention studies from Latin America were identified, categorized, and screened based on the peer-reviewed literature or Brazilian theses published between 2006 and 2010. Articles meeting inclusion criteria were evaluated using U.S. Community Guide methods. External validity reporting was assessed among a subset of articles reviewed to date. An evidence rating typology was developed and applied to classify interventions along a continuum based on evidence about their effectiveness in the U.S. context, reach, adoption, implementation, institutionalization, and benefits and costs. EVIDENCE SYNTHESIS: Thirteen articles published between 2006 and 2010 met inclusion criteria and were abstracted systematically, yet when combined with evidence from articles from the previous systematic review, no additional interventions could be recommended for practice. Moreover, the reporting of external validity elements was low among a subset of 19 studies published to date (median=21% of elements reported). By applying the expanded evidence rating typology, one intervention was classified as evidence-based, seven as promising, and one as emerging. CONCLUSIONS: Several physical activity interventions have been identified as promising for future research and implementation in Latin America. Enhanced reporting of external validity elements will inform the translation of research into practice.

Commuting distance, cardiorespiratory fitness, and metabolic risk.

BACKGROUND: Limited evidence exists on the metabolic and cardiovascular risk correlates of commuting by vehicle, a habitual form of sedentary behavior. PURPOSE: To examine the association between commuting distance, physical activity, cardiorespiratory fitness (CRF), and metabolic risk indicators. METHODS: This cross-sectional study included 4297 adults who had a comprehensive medical examination between 2000 and 2007 and geocoded home and work addresses in 12 Texas metropolitan counties. Commuting distance was measured along the road network. Outcome variables included weekly MET-minutes of self-reported physical activity, CRF, BMI, waist circumference, triglycerides, plasma glucose, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, and continuously measured metabolic syndrome. Outcomes were also dichotomized using established cut-points. Linear and logistic regression models were adjusted for sociodemographic characteristics, smoking, alcohol intake, family history of diabetes, and history of high cholesterol, as well as BMI and weekly MET-minutes of physical activity and CRF (for BMI and metabolic risk models). Analyses were conducted in 2011. RESULTS: Commuting distance was negatively associated with physical activity and CRF and positively associated with BMI, waist circumference, systolic and diastolic blood pressure, and continuous metabolic score in fully adjusted linear regression models. Logistic regression analyses yielded similar associations; however, of the models with metabolic risk indicators as outcomes, only the associations with elevated blood pressure remained significant after adjustment for physical activity and CRF. CONCLUSIONS: Commuting distance was adversely associated with physical activity, CRF, adiposity, and indicators of metabolic risk.

Page Avenue health impact assessment: building on diverse partnerships and evidence to promote a healthy community.

The Page Avenue health impact assessment (HIA) was focused on a redevelopment in Missouri. This case study describes a comprehensive HIA led by an interdisciplinary academic team with community partners, as well as compliance with North American HIA Practice Standards. Some of the key lessons learned included: (1) interdisciplinary teams are valuable but they require flexibility and organization; (2) engaging community stakeholders and decision-makers prior to, during, and following the HIA is critical to a successful HIA; and (3) HIA teams should not be too closely affiliated with decision-makers. It is hoped that this case study will inform future HIAs.

Association between neighborhood walkability, cardiorespiratory fitness and body-mass index.

Many studies have found cross-sectional associations between characteristics of the neighborhood built environment and physical activity (PA) behavior. However, most are based on self-reported PA, which is known to result in overestimation of PA and differential misclassification by demographic and biological characteristics. Cardiorespiratory fitness (CRF) is an objective marker of PA because it is primarily determined by PA. Furthermore, it is causally related to long-term health outcomes. Therefore, analyses of the association between CRF and built environment could strengthen arguments for the importance of built environment influences on health. We examined the association between neighborhood walkability and CRF and body-mass index (BMI). This cross-sectional analysis included 16,543 adults (5017 women, 11,526 men) aged 18-90 years with home addresses in Texas who had a comprehensive clinical examination between 1987 and 2005. Outcomes included CRF from total duration on a maximal exercise treadmill test and measured BMI. Three neighborhood walkability factors emerged from principal components analyses of block-group measures derived from the U.S. Census. In multilevel adjusted analyses, the neighborhood walkability factors were significantly associated with CRF and BMI among men and women in the expected direction. An interaction between one of the neighborhood factors and age was also observed. The interaction suggested that living in neighborhoods with older homes and with residents traveling shorter distances to work was more strongly positively associated with CRF among younger adults and more strongly negatively associated with BMI among older adults. In conclusion, neighborhood characteristics hypothesized to support more PA and less driving were associated with higher levels of CRF and lower BMI. Demonstration of an association between built environment characteristics and CRF is a significant advance over past studies based on self-reported PA. Nevertheless, stronger causal evidence depends on more robust study designs and sophisticated measures of the environment, behavior, and their physiological consequences.

Perceived environmental correlates of physical activity for leisure and transportation in Curitiba, Brazil.

BACKGROUND: Physical activity (PA) has consistently been associated with perceived environmental characteristics. OBJECTIVE: To examine the association between perceived environmental attributes and various forms of PA in Curitiba, Brazil. METHODS: A cross-sectional phone survey of adults was conducted in 2008 (n=2097). The questionnaire included environmental perceptions and PA. Principal components analysis was used to identify groups of perceived environmental attributes. Multivariate methods tested the associations of PA with perceived environment characteristics. RESULTS: Perceptions of moderate and high personal safety were positively associated with walking for transportation (53.0%, 53.1% vs. 47.3%, both adjusted ORs [aOR]=1.5). Number of destinations within a 10-minute walk (4 and >6 vs. <3) was positively associated with bicycling for transportation (7.8%, 9.9% vs.4.8%, aOR=2.5). Perception of high accessibility was positively associated with MVPA during leisure time (35.1% vs. 19.1, aOR=1.7) and meeting recommendations for total PA (58.7% vs. 45.1%, aOR=1.4). Perception of high quality of the pedestrian space (57.3% vs. 46.5%, aOR=1.4) and moderate levels of personal safety (54.3% vs. 47.6%, aOR=1.3) were also positively associated with meeting recommendations for total PA. CONCLUSIONS: Different environmental attributes were associated with different PA outcomes, suggesting that these relationships are complex and may differ from those in high-income countries.

Promoting physical activity through community-wide policies and planning: findings from Curitiba, Brazil.

BACKGROUND: Community programs have been suggested to be an important and promising strategy for physical activity (PA) promotion. Limited evidence is available regarding knowledge of and participation in these programs in Latin America. OBJECTIVE: To describe participation in and knowledge of community PA programs and to explore associations with leisure-time PA in the city of Curitiba, Brazil. METHODS: A cross sectional telephone survey was conducted among adults in Curitiba, Brazil (n = 2097). The International Physical Activity Questionnaire was used to determine levels of PA, and specific questions were used to evaluate the extent to which respondents knew about or participated in the programs conducted by the municipality. Logistic regression was used to assess the meeting of PA recommendations in leisure time based on program knowledge and participation. RESULTS: Knowledge of PA programs was high (91.6%) and 5.6% of population participated in the programs. After adjusting for individual characteristics, exposure to Curitiba's PA community programs was associated with leisure-time PA (POR = 2.9, 95% CI = 2.9-3.0) and walking for leisure (POR = 2.4; 95% CI = 2.3-2.4). The associations were stronger among men than among women. CONCLUSIONS: Knowledge and participation in Curitiba's community PA programs were associated with meeting recommended levels of PA in leisure time.