Get out Live, Love Life: Park 30

Get out Live, Love Life: Park 30
Evidence-Based Practice Proposal
Tasha Chenoweth
Grand Canyon University: HCA 699
October 8, 2014

What does going to the park mean to you? When you look at this beautiful landscape do
fond memories of being outdoors enjoying nature come to mind?

Central Park, New York
The daily stresses
of life often leave
us yearning for an
escape. A jog in the
park can provide
our mind and body
with a healthy way
to deal with this
built up stress.

In stark contrast to a beautiful park...

JUNGLE OF CONCRETE KILLERS and SNAKES
“CONCRETE JUNGLE is a slang term for rough, inner-city areas, as
they represent the violent nature of a wild jungle, but filled with
concrete roads and buildings” (“Nas – Star Wars,” 2014).

Section A: Problem Description
• The World Health Organization ranked
inactivity as the sixth leading cause of
premature death in the U.S. and a
contributing factor of several health problems,
such as “obesity, cancer, diabetes, heart
disease, osteoporosis, and depression”
(Jerrett et al., 2013, p. 386).

• This public health issue
disproportionately impacts poor urban
communities and creates economic
losses from lost productivity and high
health care costs (Geneau et al., 2010).

• Evidence-based interventions have
shown that smart-growth initiatives
could be implemented, with the help of
community partnerships, to boost the
accessibility of safe places for at-risk
individuals to engage in physical
activity.

PICOT
Patient Population
• Due to a higher prevalence of obesity and
chronic diseases in poor urban communities
that lack access to affordable nutritional
foods and safe places for physical activity,
researchers have been seeking solutions to
resolve this public health crisis.

PICOT
Intervention
• Through the development of community
environments with infrastructure supporting
healthy eating and active living, research has
shown health outcomes can be improved
within low socio-economic (SES) urban
populations.

PICOT
Intervention
• Studies have identified a dramatic decrease in
levels of physical activity due to unsafe walking
and biking routes between students’ homes and
their schools.
• However, prevention or delay of the
development of type 2 diabetes within high-risk
adults with minimal weight loss of five to 10% of
body weight.

PICOT
Comparison Intervention
• While there are numerous health advantages
of weight loss for overweight and obese
populations, whole neighborhoods can
benefit from increased access to convenient
urban parks that facilitate physical activity
and socialization.

PICOT
Comparison Intervention
• According to Jarrett et al. (2013) physical
activity behavior has been shown to be
influenced by the built environment, such as
access to sidewalks and parks which would
contribute to health benefits for the whole
community.

PICOT
Outcome of Interest
• Strategies for building healthier communities
that enable safe physical activity can be
developed and implemented through the use
of community-based participatory research
and partnerships at the community and state
government levels.

PICOT
Time of Intervention to Achieve the Outcome
• An initial baseline of physical activity surveillance will
be measured in the target and control parks prior to
the proposed interventions over a three month
period.
• Building trust is crucial for community participation in
this project.

PICOT
• Over a five year period, these community
health programs will measure physical
activity indicators in the areas where
environmental improvements have been
made.

PICOT
• These environmental infrastructure
improvements can include park community
activities and sporting events as well as
street redesigns for pedestrian and bicycle
safety (Division of Nutrition, Physical Activity,
2014b).

PICOT
• The combined strategy of improving recreational
facilities with an evidence-based physical
activity intervention study and health
promotional outreach activities will enable the
success of this proposal to reduce health
disparities within a low SES urban community
within the proposed five year period.

Section B: Literature Support
• With the growing body of evidence-based
physical activity intervention studies, the
transition into clinical application aims to
address this public health issue of chronic
illnesses related to inactivity and obesity.
• The increased incidence of these chronic
conditions has created a strain on health care
resources (Brownson et al., 2007).

• As public health professionals are fighting the
battle to combat the obesity epidemic, the
Brownson et al. (2007) study sought to
specify several approaches these
practitioners could effectively implement to
promote physical activity within the
populations they serve.

The most notable of research on the subject was from
the Task Force on Community Preventive Services (the
Task Force) that produced several evidence-based
physical activity promotion guidelines including:
• informational approaches to increase knowledge of
physical activity benefits
• behavioral and social approaches to enhance
behavioral change
• environmental and policy approaches for improved
accessibility of physical activity areas (Brownson et al.,
2007).

• Evaluation of the cost-effectiveness of
interventions to increase physical activities and
the lifetime path of disease incidence is meant
to guide health policy in order to increase
implementation at the population level.
• The literature review for the Roux et al. study
included seven intervention studies aimed at
promoting physical activity (Roux et al., 2008).

• The two most applicable intervention studies
were focused on a combination of enhanced
access to places for physical activity blended
with informational outreach activities.
• By increasing accessibility of places that enable
physical activity, these interventions are strongly
recommended by the Task Force as well, due to
their overall health benefits ("Recommendations
to Increase Physical Activity in Communities,"
2002).

• The disproportionate rates of overweight,
obesity, cardiovascular disease and diabetes in
black populations compared to whites have
rapidly escalated, which this community-based
participatory research (CBPR) project addressed
through examination of the underlying social
environment.
• The literature review discussed public health
and medical literature findings of a correlation
between environmental factors and disease
(Sloane et al., 2006).

• With the continuation of poor health
outcomes in underprivileged urban
communities, the literature showed a shift to
CBPR to address the change of focus from an
individual to a social model.
• The literature regarding these urban
communities’ lack of access to exercise
including proximity to parks and recreational
facilities was discussed (Sloane et al., 2006).

• In order to evaluate the strength of evidence
for weight loss and physical activity
intervention studies through 2012, Stephens,
Cobiac, and Veerman (2014) utilized an
evidence-based reporting system for
systematic reviews and meta-analyses,
known as the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses
(PRISMA) framework as well as a hierarchy
and evidence level classification analysis.

• This overview of the current research
literature focused on meta-analyses and
systematic reviews obtained by a thorough
search strategy within several medically
relevant databases and strict eligibility
criteria (Stephens, Cobiac, & Veerman, 2014).

• Although 73% of the reviews designated the
effectiveness of interventions to be
statistically significant, the outcomes were
highly variable especially regarding weight
loss maintenance and follow-up timeframes
which ranged between eight weeks and
seven years (Stephens, Cobiac, & Veerman,
2014).

• The fact that obesity prevalence continues to
be a problem reveals the need for more of
these evidence-based interventions focused
on high risk populations, as is planned by the
Get out, Live, Love Life: Park 30 proposal
(Stephens, Cobiac, & Veerman, 2014).

Section C: Solution Description
• Inequitable access to parks within low SES
minority communities was revealed in a study
by the Harvard School of Public Health.
• Similar findings by the National Recreation and
Park Association (NRPA) confirm how numerous
urban parks have not received the funding
needed for appropriate maintenance
(Community Development Block Grants and the
Urban Park and Recreation Recovery Program,
n.d.).

• As the health care system costs spiral out of
control, health reform advocates have begun
to understand the cost savings that can be
attributed to reducing the obesity epidemic
through community-wide physical activity
interventions in urban parks (National
Recreation and Park Association, 2014).

Proposed Solution
• A 2011 study revealed Seattle residents’ physical
activity in parks led to a $64 million savings in
medical costs (NRPA, 2014).
• The correlation of inactivity and costly poor
health outcomes clearly indicates the utility of
community-based participatory physical activity
interventions for the disproportionately
unhealthy low SES residents of urban cities.

• Under the guidance of the CDC’s evidence-based
measures to reduce obesity prevalence and
eliminating health disparities, a baseline survey
would steer researchers toward culturally appropriate
goals for the community park enhancement strategy
of the Get out, Live, Love Life: Park 30 proposal.
• The survey will be used to engage community
members to build partnerships and determine what
would encourage them to increase their level of
physical activity within their neighborhood parks.

The community building needed to facilitate more physical
activity within inner city parks would be determined by
gathering relevant data, including:
• who uses the park
• how people use the park
• why community members do/do not use the park
• what park features are valued most in the community
(Walker, 2004)
• Safety concerns have been widely reported as a significant
barrier to inner city community members’ use of parks for
physical activity (Bedimo-Rung, Mowen, & Cohen, 2005;
Obesity Prevention Source, 2014).

Culture
• Dependent on the budget, the type of
amenities the park will incorporate will be
voted on through the various partnerships
developed in the first year of community
building.

Culture
• These partnerships could include churches
since they are a significant aspect of family-
oriented minority communities and have
been shown to be an effective tool for health
outreach programs, utilizing this partnership
will help the team determine the diverse
needs of the community at large in the parks’
amenities and design.

Expected Outcomes
• The enhancement of the designated neighborhood
park and the community outreach campaign, Get out,
Live, Love Life: Park 30, will help community members
appreciate their improved access to pleasant green
space for increased physical activity.
• Through a variety of outreach community
partnerships for beautification and improved safety,
sedentary high risk community members can begin to
partake in walking for improved physical and mental
health.

• With community involvement in organizing a
neighborhood watch program, including
cooperation and gaining endorsement by
police or the sheriff’s office, problem-
oriented policing can identify hot spots more
effectively.

• Studies of crime in cities revealed that most
crime was concentrated to certain areas due
to features such as, “poor lighting, blind
alleys, abandoned buildings, gathering spots
for unsupervised youth, and concentrations
of illicit business” (Capowich, 2013).

• Over the five-year multi-faceted project with
a combination of informational outreach,
environmental and policy strategies, the
heightened community involvement will
foster community building, greater social ties
and collaboration.
• The project will thus create a positive
attitude toward utilizing parks to improve
physical activity levels.

• This program will educate the
community on the importance of
physical activity for all age groups with
an emphasis on high risk populations
through community leaders and several
marketing outreach strategies.

• Through various support measures, such
as formation of committees, church
groups, neighborhood watch, and
walking groups the community-wide
physical activity interventions will
enhance the health and livability of the
community.

Method to Achieve Outcomes
• In order for the research team to be well rounded,
recruitment of public health researchers, faculty and
students from the nearby colleges and universities will be a
priority.
• Even though a significant amount of the project would be
dependent on volunteers and unpaid community leaders,
the staffing and operational expenses for this project will
dictate how much funding is left for actual park
enhancements.
• Recruitment of volunteers for the park clean-up and
landscaping will begin simultaneously within the first year of
the project while gaining community and financial support.

Outcome Impact
• The community-wide Get out, Live, Love Life: Park 30
campaign aims to enhance the target inner city
community through numerous partnerships to strengthen
social networks for a supportive environment of increased
access to safe, aesthetically pleasing places for physical
activity.
• Through various community outreach collaborations and
marketing within inner city minority communities, the
community members will gain an understanding and
appreciation for how their neighborhood parks can lead to
community building and improved mental and physical
health.

Section D: Change Model
In order to attain the goal of a healthier
community, there will be several years of
preparation starting with community building
activities to form partnerships with community
leaders and existing advocacy groups.

• Once the target park has been revitalized and
the outreach marketing program has publicized
the community enhancement, the next phase of
the project can begin.
• The three year process leading up to the
exercise intervention study will help educate the
community about the 30 minutes of moderate-
intensity physical activity (MPA) at least five
days per week recommendation by the U.S.
Surgeon General.

Baseline
• The collaboration of community leaders,
members, and churches will be a crucial aspect
of this project for recruiting volunteers for
several facets of the project.
• The preliminary survey data will be analyzed to
ensure the target and control groups have
comparable demographics, including
race/ethnicity, age, sex, education, and income.

Change Model
• The change model of choice is the Transtheoretical
Model (TM) questionnaire of which the test-retest
method has been indicated as valid and reliable by
several studies.
• The participants will be sent the first questionnaire
immediately in which they will indicate their level of
activity by denoting which sentence is most
applicable within the five stages of change:
precontemplation, contemplation, preparation,
action, and maintenance.

First Intervention
• After the first month the target group will be
mailed an active living informational
pamphlet.
• This intervention is a physical activity
promotion indicating the health benefits of
the recommended 30 minutes of physical
activity for five days per week that could be
effective in 10 minute episodes.

TM Survey Follow-up
• Following a three month period after the
health promotional pamphlet has been sent
to the target group, the post-test TM
questions, identical to the pre-test questions,
will be sent to both the target and the control
groups to verify if any of the participants
have changed their physical activity level
according to the stages of change.

• The last mailing will be identical to the previous
post-test TM questionnaire for consistency in
order to gauge the long-term effectiveness of
the TM for physical activity promotion.
• Additionally, for the research team to determine
if the TM study participants increased their
activity level to the nationally recommended
150 minutes per week, an extra question will be
included in the final post-test.

Section E: Implementation Plan
• The local churches and community centers that
service the diverse urban neighborhood will be the
setting for obtaining and meeting with the
intervention participants for both the target and
control groups.
• Once the project is introduced to the church
members, the congregation will be asked for their
cooperation and if anyone would volunteer to be
participants in the five year intervention study meant
to improve the health of their community.

Timeline
• The project will involve four phases over a five year
timeframe.
• The first phase during the first year revolves around
community building, forming partnerships and
identifying the community needs, fundraising, and
recruitment of volunteers for clean-up, landscaping,
study participants, and a neighborhood watch
committee.
• The second phase involves marketing and park
restoration.

Timeline
• The exercise intervention takes place in the final year
of the project after the environmental barriers have
been removed and marketing has highlighted the
accessibility of a safe and pleasant green space to
facilitate physical activity within the community.
• Finally, the evaluation phase should show the
successful maintenance of the interventions with
more community members being active in the park
and the preservation of the improved park condition.

Resources and Feasibility of the
Implementation Plan
• The expertise of a knowledgeable research
team, consultants, and consulting firms will
be necessary to ensure accuracy, reliability,
and validity for widespread application of
this evidence-based pilot study.

Resources and Feasibility of the
Implementation Plan
• There will be significant costs for construction,
labor, supplies and equipment which will
include materials for a new bathroom, benches,
picnic tables, barbeques, exercise and
playground equipment, and grass, trees, and
plants for a basic park refurbish with a
basketball court and walking paths.

Resources and Feasibility of the Implementation
Plan
• The funding for the park restoration, outreach
marketing program, and pilot research study will be
partly funded by several sources, including federal,
state, and private grants and city funding (2012–2016
Capital Improvement Plan, n.d.).
• Public-private partnerships have become more
commonplace to raise enough funds for the creation
or refurbishment of urban parks with the cost of
creating new parks over $100 million (Newcombe,
2013).

Methods and Instruments
• Criteria for potential participants will be
determined through analysis of the baseline
survey, including demographics, residency
near the target park, and exercise status with
the ability to walk for 30 minutes.

Methods and Instruments
• A before and after assessment of the target and
control parks’ activity using the System for
Observing Play and Recreation in Communities
(SOPARC) will be performed by the field
research team (Cohen et al., 2013).
• Cohen et al. (2013) described this test as, “a
validated method using momentary time-
sampling to assess the characteristics of parks
and their users, including their physical activity
levels” (p. 592).

Training
• Due to the nature of the project involving several
disciplines, there will need to be transdisciplinary
collaboration (Marcus et al., 2006).
• In order to study physical environments and policy,
Marcus et al. (2006) explained the need for a wide range
of disciplines for the research study, such as researchers
from public health, behavioral science, exercise science
who will collaborate with several consultants in disciplines
including urban planning, transportation, civil
engineering, recreation and leisure study, geography,
landscape architecture, economics, marketing,
environmental and policy lobbying.

Data Collection Plan
• The research team will perform data collection
from the various surveys which will be
supervised by the senior research scientists with
consultation from NORC.
• Once the senior staff approve of the data’s
validity, the data management and maintenance
will be entrusted to NORC within their secure
Data Enclave (NORC, 2014).

Barriers
• Due to the reportedly inaccurate self-reporting
problems on surveys and invalidating missing
answers, the research team will perform face-to-face
interviews in addition to the mail-in surveys.
• Since it can be difficult to find people willing to
participate in surveys, the research team will rely on
community leaders to assist in this challenging
process.
• The criminal element will likely be a significant barrier
once the neighborhood watch committee begins
working with the police department.

Maintenance
• Expanding the intervention to include more
parks and surrounding areas for improved
access to pedestrians and bicycles will be a
significant challenge.
• The continuation of funding for maintenance
requirements will be a top priority that the
research team will address with community
leaders for future grant applications to continue
improving the community and surrounding
areas.

Section F: Evaluation
• The outcome goal of this pilot study is to
investigate if an environment facilitating regular
exercise in the community leads to improved
health outcomes among a population which
may be at a higher risk of developing various
chronic conditions due to inactivity.
• The results of these surveys at the end of the
intervention period will be compared to results
from surveys at baseline.

Project Objectives
• After the last TM post-tests are mailed for
the maintenance stage of the intervention
study, the research team will perform the
follow-up observational studies, the SOPARC
and the BRAT-DO at the target and control
parks for comparison of the BRFSS data to
determine the effectiveness of the
intervention at the population level.

Project Objectives
• It has been noted that lengthy and time
consuming surveys can reduce response rates
of participants therefore a streamlined brief
PAAT survey will be used for baseline and
follow-up data.
• The brevity of the PAAT allows it to be
completed within a shorter time frame of five
to seven minutes for higher compliance.

Evidence
• On receiving the completed TM post-test
surveys, the research team will do a preliminary
analysis of the outcome data and compare it to
results from the NORC Data Enclave (NORC,
2014).
• Due to a high non-response rate that is expected
with the TM survey, we will start with 400
participants to ensure that we have an adequate
sample size to obtain valid results.

Evidence
• Several baseline and follow-up measures will
be used for test-retest comparison in order to
establish clinical significance.
• Data for demographic variables will be
collected and used to control for confounding
in the final analysis for internal validity.

Evidence
• Each study participant’s physical activity level
will be recorded as a numerical variable and
subsequently a t-test will be used to compare
the physical activity levels between the two
groups and also compared to baseline.
• A before and after assessment of the target and
control parks’ activity using the System for
Observing Play and Recreation in Communities
(SOPARC) will be performed by the field
research team.

Root Cause Analysis
• This intervention study will not only provide
a refurbished neighborhood park that will
offer a recreational atmosphere for the
whole family, but it will also provide social
support and increased safety through the
cooperation of community leaders and a
neighborhood watch committee working
with police.

• As with any behavioral intervention, however, there is
a risk of not achieving the expected outcomes.
• Therefore, any negative results will be thoroughly
evaluated to determine where the intervention went
wrong and if any measures can be undertaken to
improve it.
• A root cause analysis will guide the research team to
“determine what happened; determine why it
happened; and figure out what to do to reduce the
likelihood that it will happen again” (Root Cause
Analysis: Tracing a Problem to Its Origins, 2014).

• In case the intervention does not yield the
expected results during the study, a number of
strategies can be employed to increase
community participation.
• This includes an increase in outreach activities
and marketing using radio, newspapers and the
internet.
• Community members can also be offered
various incentives such as discount coupons and
free prizes to join the walking groups and join
the intervention.

Future Practice and Research
• The success of this project may incentivize
other neighborhoods to seek funding for
revitalizing their parks and the surrounding
environment.
• Our research team will provide
encouragement and support for establishing
partnerships and help generate funding
needs for maintenance of the park.

• Community leaders will also be encouraged to seek
grants for their community and the surrounding
communities with a goal to increase access to safe
places for physical activity.
• The results of this project will provide evidence to
city, state, and federal officials towards the
significance of parks and other recreational facilities
in improving the health of the residents.
• Furthermore, it will show how the goal of promoting
a healthy lifestyle can be achieved through
partnerships and community involvement within
established frameworks.

References
Adams, J., & White, M. (2005). Why don't stage-based activity promotion
interventions work? Health Education Research, 20(2), 237-243. doi:
10.1093
A prescription for physical activity [Center for Active Design]. (n.d.). Retrieved
from
http://centerforactivedesign.org/prescriptionforphysicalactivity
Bedimo-Rung, A. L., Mowen, A. J., & Cohen, D. A. (2005). The significance of
parks to physical activity and public health: A conceptual model.
American Journal of Preventive Medicine, 2(2), 159-168. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/15694524
Blanck, H. M., Allen, D., Bashir, Z., Gordon, N., Goodman, A., Merriam, D., &
Rutt, C. (2012). Let's go to the park today: The role of parks in
obesity prevention and improving the public's health. Childhood
Obesity, 8(5), 423-428. Retrieved from
http://www.nrpa.org/uploadedFiles/nrpa.org/Publications_and_Res
earch/Research/Papers/Role-Parks-Obesity-Prevention.pdf

Adams, J., & White, M. (2005). Why don't
stage-based activity promotion interventions
work? Health Education Research, 20(2),
237-243. doi: 10.1093
A prescription for physical activity [Center for
Active Design]. (n.d.). Retrieved from
http://centerforactivedesign.org/pre
scriptionforphysicalactivity
Bedimo-Rung, A. L., Mowen, A. J., & Cohen, D.
A. (2005). The significance of parks to
physical activity and public health: A
conceptual model. American Journal of
Preventive Medicine, 2(2), 159-168.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/156945
24
Blanck, H. M., Allen, D., Bashir, Z., Gordon, N.,
Goodman, A., Merriam, D., & Rutt, C. (2012).
Let's go to the park today: The role
of parks in obesity prevention and improving
the public's health. Childhood Obesity,
8(5), 423-428. Retrieved from
http://www.nrpa.org/uploadedFiles/
nrpa.org/Publications_and_Research/Research
/Papers /Role-Parks-Obesity-Prevention.pdf

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