Evaluating communitywide walking interventions

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Evaluation and Program Planning 29 (2006) 251–259 www.elsevier.com/locate/evalprogplan

Evaluating communitywide walking interventions Bill Reger-Nasha,, Adrian Baumanb, Linda Coopera, Tien Cheyb, Kenneth J. Simona a

Department of Community Medicine, School of Medicine, West Virginia University, Morgantown, WV 26506 9190, USA b Center for Physical Activity and Health, School of Public Health, University of Sydney, Sydney, Australia Received 15 October 2005; received in revised form 8 November 2005; accepted 15 December 2005

Abstract Public health evaluation funding is limited, and hence optimal evaluation principles and methods should be applied to the assessment of communitywide programs. Since sedentary lifestyles and insufficient physical activity contribute to the overall burden of disease, efforts to encourage more walking at the whole population level are an important prevention strategy. This article describes the evaluation methods used and principles learned from four communitywide walking programs conducted by the authors. The application of evaluation design principles, formative and process evaluation, and participatory planning can contribute to the lessons of such community level interventions. Impact evaluation, optimizing research design and examination of mediators, policy, and environmental changes contribute to the scientific base for describing program effectiveness and understanding the mechanisms through which these interventions may work. r 2006 Elsevier Ltd. All rights reserved. Keywords: Social marketing; Physical activity; Mass media; Intervention study; Evaluation; Walking; Population based

1. Public health programs to address physical inactivity Approximately 60% of the population of the US, the UK, and Australia are insufficiently active, that is, they do not regularly attain the recommended standard of 30 min of moderate intensity physical activity 5 days per week or 20 min of vigorous activity 3 days per week (Bauman, Ford, & Armstrong, 2001; CDC, 2001; Health Development Agency England, 2000). Among all the behavioral risk factors, poor diet and physical inactivity pose the greatest health threats (Mokdad, Marks, Stroup, & Gerberding, 2004). Both have high prevalence and strong association with a range of adverse health outcomes. Effective public health approaches to physical inactivity have used broad theoretical frameworks, such as social ecological models (Sallis & Owen, 2002). Multiple levels of influence contribute to establishing and maintaining health-enhancing behaviors. Community behaviors are associated with supra-individual level factors such as social capital, and the built environment (Leyden, 2003) as well as intra-individual factors such as motivational readiness to Corresponding author. Tel.: +1 304 293 0763; fax: +1 304 293 6685.

E-mail address: [email protected] (B. Reger-Nash). 0149-7189/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.evalprogplan.2005.12.005

become active (Marcus, Rossi, Selby, Niaura, & Abrams, 1992). Community interventions require multiple intervention components, including mass media, media relations, and community-based activities, which enhance social networks and social support. Engagement with community members, participatory planning, and the development of community partnerships are optimal health promotion strategies (Brenes, Strube, & Storandt, 1998; Sallis & Owen, 2002; Trafimow & Trafimow, 1998). These ideas have been reinforced through international consensus documents for community health promotion (Ashton, Grey, & Bernard, 1986; WHO, 1986). Bartholomew, Parcel, Kok, and Gottlieb (2001) suggests that social capital and the concepts of community affiliation are enhanced by promoting linkages among individual community members, stakeholders, and organizations. 2. Community program evaluation Walking remains accessible, affordable and achievable as the physical activity behavior of choice among the inactive (Wright, 1999). Effecting small changes across a large number of people in a community is more effective than

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making larger changes in a few high-risk people. Individual change programs, in net sum, have not contributed to overall population-level changes in physical activity and walking. By contrast, evaluation of community physical activity programs may demonstrate population-level impacts (Cavill & Bauman, 2004; Kahn et al., 2002; Reger et al., 2002; Reger-Nash, Bauman, et al., 2005; RegerNash, Cooper, Orren, & Cook, et al., 2005; Reger-Nash, Fell, et al., 2006) and those that build in components designed to be self-sustaining to address underlying environmental and policy aspects that support activity hold promise to reduce physical inactivity prevalence over time. Community health promotion programs are most comprehensively evaluated by utilizing multiple levels of evaluation, from defining the problem, developing interventions (formative evaluation), implementing them (process evaluation) and assessing their short- and long-term effects (impact and outcome evaluation). Central challenges include using reliable and valid outcome measures, maximizing generalizability of the findings and using the best possible and most feasible research designs. The latter issue is problematic in community interventions, where random allocation at the community level requires many communities to be assembled (Bauman & Koepsall, 2005). Usually, few or single communities are assessed, before and after an intervention, with some attempt at measuring matched comparison or control communities. This paper will review the evaluation of four single community interventions that promoted communitywide walking, each with at least one matched control community. Examples of the evaluation techniques used and the lessons learned across four community interventions in different locations forms the central theme of this paper. 3. The evaluation of community walking interventions The authors developed and evaluated four communitywide physical activity interventions that promoted regular walking. Three intervention communities were in West Virginia, with matched controls; the fourth and its control community, in New York State. Selection criteria for the comparison communities included similar demographics and physical activity levels, a location in the same region but far enough away to have a separate and distinct media market, and comparable walkability. A social ecologic approach encouraged community members to begin with 10 min, increase to 20 min, then 30 min or more of daily moderate intensity walking (Reger et al., 2002; Reger-Nash, Bauman, et al., 2005; RegerNash, Cooper, et al., 2005; Reger-Nash, Fell, et al., 2006). The ‘‘intervention’’ describes the overall sets of activities which summate to the community effort to promote walking. All four programs (1) were communitywide, (2) had an equivalent comparison community, (3) promoted 30 min or more of moderate intensity daily walking, (4) included an 8-week multiple strategies mass media-

based campaign, (5) targeted insufficiently active residents, (6) were conducted in small US cities or counties, (7) had Human Subject Committee approval, and (8) were evaluated using random-digit-dial population telephone surveys in intervention and comparison communities, using a cohort design with individuals surveyed before and after the 8-week mass media campaigns. Telephone surveys were conducted by the Survey Research Center of the University of North Texas (Denton, TX) for Wheeling Walks and West Virginia (WV) Walks and by TNS Intersearch Corporation (Westchester, IL) for Broome County (BC) Walks. Trained community volunteers conducted the surveys for Welch Walks. The telephone survey questions assessed demographic characteristics and walking as well as other moderate and more vigorous physical activities reported each week (CDC, 2005; Jones, Ainsworth, Pratt, Kimsey, & Morgan, 1999; Reger et al., 2002; Reger-Nash, Bauman, et al., 2005; Reger-Nash, Cooper, et al., 2005; Reger-Nash, Fell, et al., 2006). Measurements of recalled mass media exposure, prompted and unprompted recall of the campaign message, and stages of change were also asked (Marcus et al., 1992; Reger et al., 2002). Components of the four interventions are illustrated in the Table 1(a). All had paid media and publicity campaigns and community activities. The Wheeling and WV Walks programs had the greatest number of additional elements, namely participatory planning and policy/environmental changes. Population, total budget, media budget, campaign duration, and cost per complete telephone survey questionnaire are listed in Table 1. The overall per capita costs of the intervention were greatest for Wheeling Walks and WV Walks, which were the most comprehensive based on data in Table 1. The costs of telephone surveys varied, with the least expensive for Welch Walks, which were not carried out by a private company (Table 1). 3.1. The four community interventions The first campaign was the most intensive intervention. Wheeling Walks (Reger-Nash, Bauman, et al., 2006; RegerNash, Cooper, et al., 2006; Reger-Nash, Fell, et al., 2006) began in September 1999 with a community health participatory planning process (Reger-Nash, Smith, Cooper, & Holmstrand, 2003). Participants meeting once weekly for 12 weeks were asked to incorporate and evaluate personal wellness behaviors while assisting with community needs assessment, planning, and implementation of a proposed community walking intervention. Participatory planning group members were subsequently invited to join the project’s Community Advisory Board. Post-campaign, the mayor of Wheeling established the Walkable Wheeling Task Force to advocate for policy and environmental change. Intensive paid and unpaid mass media promoted walking to 50–65-year-old residents during the 8 weeks April/May 2001 and again during a 4-week booster

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Table 1 Comparison of four communitywide walking interventions Campaign characteristics

Wheeling Walks

WV Walks

Welch Walks

BC Walks

a. Intervention components 12-week participatory planning Paid media Media relations Community activities Website Policy changes Environmental changes

X X X X X X X

X X X X X X X

X X X

X X X X

b. General Intervention community populations Campaign duration (weeks)

31,420 8

26,806 8

27,329 8

200,540 8

c. Associated costs Total campaign budgeta ($) Budget per person ($) Media budget ($) Telephone survey costs per completed questionnaire ($)

125,000 14.3 80,000 20

132,000 7.6 70,800 16

43,500 2.3 7704 6

155,676 7.6 127,000 30

d. Paid elements of the media campaigns Network TV GRPb 30-s ad purchased

5104 683

2316 356

NA 340

4835 953

Cable TV GRP 30-s ad purchased

NA 1164

1159 4256

0 0

NA 1314

Radio GRP 60-s ads purchases Print—1/8 page ads purchased

3450 1988 28

1876 1763 39

NA 600 38

3245 1645 10

e. Self-reported walking and website activity Walkers enrolled Minutes walked Website hits

2248 864,810 1530

5406 6,862,771 4310,000

2875 NA NA

10,800 31,944 11,360

f. Campaign reception (self-reported) Any message recall (%) Television ads (%) Radio ads (%) Worksites (%) Speakers’ bureau (%) Educational programs (%)

92 76 32 6 5 5

89 57 44 38 25c 25c

84 — — — — —

81 62 28 5 4 4

a

Without evaluation or development costs for campaign materials such as the television ads. Gross ratings points. c For WV Walks, Speakers Bureau and Educational program were 25% combined. b

campaign in March 2002. One of the authors (BRN) wrote a weekly column for the Sunday newspaper for 12 months. In addition to the before and after telephone surveys, follow up surveys were conducted at 6 and 12-months post. The flow chart for the intervention process is summarized in Figure 1 (Fig. 1). In 2002, Welch Walks targeted the promotion of walking among 35–65-year-old residents of McDowell County, WV, the sixth poorest county in the US (Reger-Nash, Cooper, et al., 2005). A local physical activity coalition and the McDowell County Rural Health Advisory Council collaborated with the authors to implement an 8-week campaign. Limited funding was invested. Local campaign

stakeholders remade the television, radio, and print advertisements with prominent community members. The ads emphasized walking for at least 10 min per day. The New York State Department of Health Cardiovascular Program and United Hospital Services joined the authors in developing, implementing, and evaluating BC Walks, which targeted 40–65-year-old residents of Broome County, NY (Reger-Nash, Fell, et al., 2006). The 8-week campaign was conducted April/May 2003. One additional print message featuring African American actors was developed to appeal to the regional minority population. WV Walks began in 2003 with a 12-week Community Health Participatory Planning program, similar to Wheeling

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PHASE I Community Empowerment

PHASE II Formative Research & Resource Development

PHASE III Mass-media campaign

PHASE IV Policy & environmental changes

•Initial Steering Committee •Participatory Planning (12 week)

•Specific population and message identification •Fundraising and other resource development

8-week mass media-based campaign with: •Paid prime-time television, cable TV, radio and print ads •Staged press events to garner earned media •Community activities involving diverse sectors Optional: -website -worksite component

•Self-sustaining, legitimized local stakeholders organization •Effective structure Fig. 1. Flow chart of Wheeling Walks/WV Walks process.

Walks. Emphasis was placed on evaluating existing and needed resources, including funding. More than 75 Morgantown community stakeholders and members-at-large assisted with the needs assessment, planning, design, implementation, and evaluation of the 8-week campaign conducted in March–May 2005. The intervention targeted 40–65-year-old residents of Morgantown, WV. A concerted effort was made to collaborate with and strengthen existing walking programs, such as West Virginia On the Move and the Wellness Council of West Virginia’s 100 Miles in 100 Days. One of the authors wrote a weekly column for the Sunday newspaper for 8 weeks. Booster campaigns and follow up surveys are scheduled for 6 and 12 months post program. 3.2. Evaluation compared across the four walking interventions 3.2.1. Needs assessment A needs assessment defines the behavioral, social and epidemiological characteristics of a community and dictates campaign direction and components (Green & Kreuter, 1999). In Wheeling and WV Walks, the participatory planning groups expressed the communities’ interest in addressing community problems related to obesity and sedentary lifestyles. State-level Behavioral Risk Factor Survey data indicated that 55–64-yearold residents had the highest prevalence of insufficient activity and the highest levels of obesity (WV Department of Health

and Human Resources, 2003) providing evidence to include this age group in an intervention. County physical activity coalitions and cardiovascular representatives in the state departments of health determined that high levels of physical inactivity in McDowell and Broome Counties suggested a need for a targeted physical activity intervention using the Wheeling Walks model (Reger-Nash et al., 2002). 3.2.2. Formative evaluation Once the program focus is determined, formative research can help to develop a best practice intervention. In Wheeling Walks, the participatory planning members assisted with formative research. Qualitative formative research was conducted with 30 regular walkers and 34 insufficiently active targeted population members (convenience sample) to identify Theory of Planned Behavior beliefs about regular moderate-intensity walking (Fishbein & Ajzen, 1975). Research participants identified: (1) good and/or bad things related to walking (behavioral beliefs), (2) people who support and/or disapprove of regular walking (normative beliefs), and (3) what makes it easier and/or harder to walk (control beliefs). The responses were categorized and incorporated into a 41-item quantitative survey, which was administered to a convenience sample of 411 regular walkers and irregularly active 50–65 years-ofage participants from our target community. The goal was

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to identify the beliefs that distinguished walkers from the insufficiently active. The perceived control item of ‘‘finding time in daily schedule’’ was overwhelmingly the largest single factor that differentiated walkers from non-walkers (Booth-Butterfield, Reger, Middlestadt, & Cooper, 2004; Hausenblas, Carron, & Mack, 1997). An advertising agency that specialized in low cost hardhitting mass-media campaigns was contracted; three sets of storyboard illustrations showing the sequence of proposed messages were created. These messages contained information about time for walking, energy, reduced stress, and heart disease reduction. We recruited a convenience sample of 139 insufficiently active target age participants from the Wheeling community and worksite groups to test the storyboards. Each participant was exposed to one of three randomly selected storyboard ads and asked open- and close-ended questions. There were statistically significant differences on the perception of the ads as believable, interesting, relevant and liked, but not for the time barrier. Information from this formative evaluation was used to develop two 30 s television ads, two 60 s radio ads, and two 1/8-page print ads that addressed the time barrier. The advertising message models were Caucasian to reflect the 96% white Wheeling and WV populations (Reger et al., 2002; Reger-Nash, Bauman, et al., 2005; Reger-Nash, Cooper, et al., 2005; Reger-Nash, Fell, et al., 2006). In Welch Walks and BC Walks, program advocates worked with existing physical activity coalitions to assist with campaign needs assessment. Feedback from the Welch Walks and BC Walk physical activity coalitions indicated a preference that the target population should be 35–65-yearold residents of McDowell County and 40–65-year-old residents of Broome County, respectively. The reasoning behind this appeared to be an interest in reaching a broader cross section of the community. After consideration and consultation with other physical activity experts, the authors concluded that the materials appeared to be relevant to this expanded age range. However, no additional formative evaluation was conducted, as this built on the earlier Wheeling campaign development. 3.2.3. Process evaluation Process evaluation provides a detailed record of program implementation against planned program delivery. Process evaluation permits implementation staff to monitor the program dose as a means of explaining impact. The information can be detailed by campaign staff, community volunteers, contractors, as well as reported in the pre and post telephone surveys. In Wheeling Walks, the 37-member participatory planning group assisted with grant applications and local fund raising. In WV Walks, similar efforts generated resources from state and local sources. It has been thought that there is a dose-response effect for mass media campaigns to change knowledge and behavior (McAlister & Fernandez, 2002; Snyder & Hamilton, 2002). We tracked television and radio gross

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rating points (GRPs) and the number of television, radio, and print ads purchased. For television, 100 television gross rating points suggests that the target audience is exposed to the message at least one time (See Bauman & Smith, 2006, this issue). Similarly for radio, each 100 gross rating points suggests that the target audience is exposed to the message at least two times. We purchased adequate television, radio, and newspaper advertising to reach all members of the community with the campaign message numerous times, independent of socioeconomic status. Our goal for Wheeling, BC, and WV Walks was to achieve a 90% market penetration. As part of process evaluation, Table 1(d) details the message purchase of 30 s network and cable television ads, 60-s radio ads, and 1/8 page newspaper ads as well as GRPs for network television and radio. The Welch Walks campaign had the least funding and the local media were unwilling or unable to provide GRP information on the media purchases. Local adaptation of the standard walking messaging occurred. In the Welch Walks campaign, the local physical activity coalition modified the messages to include locally recognizable talent. Feedback from the BC Walks physical activity coalition indicated a need for ethnic diversity in the advertising campaign, and a supplementary print ad was produced featuring African American talent. 3.2.3.1. Media relations. Media relations activities are focused toward the generation of ‘‘earned’’ unpaid media. This is also identified as behavioral journalism (McAlister & Fernandez, 2002). The goal of behavioral journalism is to ‘‘earn’’ media news coverage. During the 8 weeks of each community walking campaign, we scheduled five or six media relations activities to generate coverage, such as a campaign kickoff, physician press conference, the Mayor’s Walking Cup, an Intergeneration Walk. We then assessed our success with these events by asking telephone survey respondents if they observed ‘‘none’’, ‘‘a little’’, or ‘‘a lot’’ of the media campaign coverage. There were 170, 19, 168, and 144 media stories for Wheeling Walks, Welch Walks, BC Walks, and WV Walks, respectively, suggesting that the media relations strategies were effective. Telephone survey data indicated that 81%, 43%, and 65% of the Wheeling, BC, and WV Walks respondents, respectively, observed ‘‘a little’’ or ‘‘a lot’’ of the community walking program in any of the news coverage. The media question was not asked of Welch Walks survey respondents. 3.2.3.2. Website. One component of community participation was tracked through access to the campaign websites for Wheeling Walks, BC Walks, and for WV Walks. Participants were encouraged to log on the websites for information about the campaigns, to register with the campaign, and to record their minutes walked. Table 1(e) indicates the number of walkers enrolled online, minutes of walking that were recorded, and website hits. The greatest amount of web access was in the WV Walks website; this

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campaign accessed the largest proportion of the total population reached, although these estimates are limited as website hits could occur from non-local residents or from repeat website attendees merely logging minutes walked. With each campaign, we learned how to better use the website component. For example, all worksite components for WV Walks were provided through an interactive website (www.wvwalks.org). This methodology was adapted from national programs such as America On The Move (www.americaonthemove.org). 3.2.3.3. Public health activities. Efforts were made to establish ongoing public health activities in the communities to support walking by providing social networks and social support for walking. Mass events included an intergenerational walk (102, 75, and 57 participants for Wheeling, Welch, and WV Walks, respectively), walking with a local celebrity (98 participants for BC Walks and 74 participants for WV Walks), special walks in parks or on rail-trails (161 participants for WV Walks), and a Mayor’s Walking Fitness Cup (123, 98, 89 participants for Wheeling Walks, Welch Walks, WV Walks, respectively). Participants attending Speakers’ Bureau activities in the four campaigns were 900 for Wheeling Walks, 600 for Welch Walks, 1492 for BC Walks, and 267 for WV Walks. Weekly lecture series, established in Wheeling and WV Walks, were attended by 302 and 42 people, respectively. 3.2.3.4. Policy and environmental change. In Wheeling and WV Walks, volunteer community advisory committees were formed. These met monthly to assist with campaign implementation and evaluation. Some members then joined the Policy and Environment Task Force to advocate for changes in the community, which would enable and sustain walking. The West Virginia University Department of Civil Engineering conducted a Walkable Wheeling workshop, attended by 36 stakeholders. After this workshop, the Mayor of Wheeling established the Walkable Wheeling Task Force, and charged this group to advocate for improved walkability and programs to promote walking. The chair of this group reports to the mayor two times per year. A convenience sample survey of 1167 Morgantown (WV Walks) residents was conducted by the Participatory Planning Policy Task Force. A charrette (National Charrette Institute, 2005), a planning process which capitalizes on the talents and energies of a community, also generated information about desired changes in walkability in Morgantown. The West Virginia University Hospitals has allocated $15,000 to fund an engineering study of the priority projects to promote walkabilty in and around the West Virginia University Health Sciences Center, setting the stage for ongoing infrastructure changes. 3.2.4. Impact evaluation Impact or outcome evaluation provides evidence of the effectiveness of interventions; this is the ‘‘bottom line of an

intervention.’’ Community walking campaigns are focused toward behavioral change. However, there are also intermediary outcomes or impacts that will inform the success of an intervention. 3.2.4.1. Telephone survey. Complete baseline telephone survey calls were made to 72%, 68%, and 54% of eligible intervention and comparison community telephone respondents in Wheeling Walks, BC Walks, and WV Walks, respectively. No baseline completion data was available for Welch Walks. Follow-up phone calls were successfully made to 72% and 76%, 61% and 54%, 68% and 55%, and 79% and 72% for intervention and comparison communities for Wheeling Walks, Welch Walks, BC Walks, and WV Walks, respectively. The baseline survey sample sizes were 719 for Wheeling and 753 for the comparison community in Wheeling Walks, 152 for McDowell and 149 for the comparison community in Welch Walks, 575 for Broome County and 374 for the comparison community for BC Walks, and 611 for Morgantown and 611 for the comparison community in WV Walks. 3.2.4.2. Campaign component dose. As illustrated in Table 1, high percentages of telephone survey respondents reported any campaign recall, especially through the channel of paid television advertisements. 3.2.4.3. Short-term impact on walking behaviors. Thirtytwo percent of insufficiently active persons in Wheeling reported meeting the criteria for regular walking immediately post campaign, compared to an 18% increase in the comparison community. This represents a twofold increase in the likelihood of walking in the intervention community (OR ¼ 2.12, CI: 1.41–2.24) (Reger et al., 2002). An increase in reaching criterion for regular walking was observed for the most sedentary group in WV Walks (po0:05). No similar categorical changes from insufficiently active to regular walker were observed for Welch or BC Walks. There were significant increases in walking for Welch and BC Walks. The intervention community in Welch Walks demonstrated a twofold (OR ¼ 2.0, CI: 1.01–3.97) gain in weekly walking by at least 30 min, versus the comparison community. Forty-one percent of intervention respondents increased walking by 30 min per week in BC Walks, compared to 30 percent for the comparison community (OR ¼ 1.56, CI: 1.07–2.28). There were no changes in any of the communities for moderate or vigorous activity. (1) Social capital: An intermediate measure of a health promotion program might assess changes in stakeholders’ commitment to a planning process, during the several years that it takes to develop sustainable community programs. A ‘‘social capital’’ inventory was created for completion by the Wheeling Task Force, in order to examine changes in commitment to shared planning. Items asking about perceived

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Table 2 Assessment of social capital (among Wheeling Walks community task force members)

Commitment Enjoyment Confidence Shared purpose Contribution valued Trust

November 1999 (n ¼ 32) Mean [sd]

February 2001 (n ¼ 33) Mean [sd]

February 2002 (n ¼ 29) Mean [sd]

4.10 4.47 4.16 4.25 4.20 4.28

4.27 4.38 4.36 4.44 4.52 4.45

4.66 4.66 4.66 4.69 4.55 4.72

[0.75] [0.73] [0.79] [0.72] [0.85] [0.58]

[0.78] [0.75] [0.90] [0.62] [0.57] [0.79]

[0.48] [0.55] [0.55] [0.54] [0.78] [0.45]

Data were analyzed as pairwise independent comparisons of means; significance was set at po0:01 due to multiple testing.  po0:01 comparing 1999–2002 and ‘‘Commitment’’ in 2001–2002.

‘‘Commitment to the process’’, ‘‘Enjoyment of the process’’, ‘‘Confidence that process will achieve outcomes’’, ‘‘Shared purpose among group members’’, ‘‘Your contribution is valued’’, and ‘‘You tend to trust the process’’ were rated on 5-point Likert scales, with 5 being the highest. The ratings of perceived participation and affiliation with the planning taskforce increased over time in Wheeling, with four of these showing significant improvements (Table 2). These kinds of data are uncontrolled observations, but do point to some intermediate indicators of relevance to an increased sense of cohesion and common purpose in this community physical activity taskforce. (2) Policy and environmental change: Two of the interventions had the goal of improving walkability in the community by engaging community members and resources toward policy and environmental changes. Documenting these outcomes represents a challenge and no systematized methodology was used to audit the changes. For Wheeling Walks, the Task Force successfully encouraged the Mayor to capture a small parcel of land so that a key link in the rail trail system might be completed. A five-mile extension of the rail trail has been made north from Wheeling into the neighboring county. The Ohio Valley Runners Club changed their name to the Ohio Valley Runners and Walkers Club, and added a walking division to all monthly competitions in Wheeling. A local hospital and West Virginia Attorney General have provided community grants to promote walking and physical activity. For WV Walks, the Monongalia County Commission has now contracted to maintain the 30-mile countywide rail trail network. The Morgantown City Council is considering banning truck traffic in the downtown area as a means of enhancing walkability. A subsidiary evaluation element here is to conduct pre and post surveys of 100 policy makers in Morgantown to determine how much of a change in walking priorities is evident among this group.

4. Lessons learned To effectively engage with communities, participatory planning is an essential initial step. Once one has the investment of a wide cross section of the community, it is easier to conduct the various aspects of program implementation and a thorough evaluation. Using a social ecologic approach sets the stage for multi-component evaluation. At every step of the process, solid theoretical basis and evaluation data help to define the health needs of the community, the target population, the message, the community program resources needed, and the implementation strategy for the total program. The participatory planners helped us to decide on using the Transtheoretical Model, the Theory of Planned Behavior, and the McGuire Cascade (McGuire, 1981) media approach to campaign impact. Coordinated media approaches and staying on message are central to the community capacity to understand and engage with the message. If there is a substantial paid mass media component to the campaign, it is our recommendation to work with professional media buyers who have knowledge about health media purchases in order to obtain a quality product and to obtain the process data. Having established targeted campaign materials and a short campaign time period (8 weeks) enable local paid staff and volunteers to remain focused, otherwise it would be less likely to affect the desired changes. Know your media market. The media market for WV Walks is split between Pittsburgh and North Central WV making adequate purchase of network television and satellite television very expensive. Understanding the need for sufficient media exposure is a critical step, which often requires media purchase; GRPs form a useful index of media density. For print media, column inches and the number of stories carrying the main campaign message could also be used. In Wheeling Walks, our ad buyer was able to obtain two television gross rating points for each one purchased. For Welch Walks, the ads were placed by a member of the local community coalition. For WV Walks, we decided to use the established media buyer at the university health

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sciences center. We did obtain a better buy for our local cable and radio purchase, but one of the two local network television stations promised us two for one gross rating points, but never delivered. We believe that one receives a better service and better data by working with professional media buyers. First community walking programs require more resources as one is developing a justification for every aspect. For example, our formative research suggested that walking behavior change would be mediated through control beliefs. Further exploration identified the role of the environment and policy makers on making and sustaining community walking behavior changes. Both individual and environment-level variables need to be influenced in these community campaigns. Funding and the garnering of resources becomes a major time commitment; funders need to be persuaded to invest in quasi-experimental evaluations of organic and flexible programs that evolve over time and in partnership with community members. In order to conduct comprehensive process and impact evaluation, advocacy to funding agencies is required, so that more time could be spent in community programming, rather than fundraising. Engaging with communities requires a local community organizer, who maintains links to stakeholders, encourages media interest and reporting of the project, and supports the process evaluation monitoring. Close co-operation across agencies and groups, and with health and other program staff is essential, further reinforcing the central organizer’s role. The Welch and BC Walks physical activity coalition determined that the community walking campaign emphasis should be on walking at least 10 min per day. Our outcome evaluation data indicate that there were more respondents who made some increase in walking, as opposed to the Wheeling and WV Walks, where the message remained consistent with the recommendation of the Surgeon General for moderate intensity physical activity, that is, walk at least 30 min daily. For Wheeling and WV Walks, there were statistically significant changes for categorical change from insufficiently active to meeting the Surgeon General’s recommendation. We learned that there is added value in remaining faithful to the more established public health recommendation. This is not to suggest that one ignore local preferences, but public health leadership can help local coalitions to see and utilize all the data. However, if local coalitions still decide to modify the message to suit their perceived needs, their efforts should be supported. The BC Walks and Welch Walks physical activity coalitions determined a need for the ad campaign actors to be more representative of the local population. This local adaptation is part of the process of effectively replicating community interventions in different settings (Hawe, Shiel, Riley, & Gold, 2004). For BC Walks, this resulted in a print ad featuring African American actors. For Welch Walks, the television, radio, and print ads included locally recognized personalities.

Once a program planning begins, it is easy for program staff to not devote efforts to recording the complex myriad of program activities The BC Walks staff developed a useful worksheet for staff to inventory events and actions in the program, which facilitated better process evaluation. Monitoring the sustainability of programs for the years following the intervention is important, as many changes may take years to develop, such as policy and environmental improvements. Having set up monitoring systems, then taskforces and coalitions should be encouraged to use them for post-program long-term monitoring. In summary, community-level walking interventions appear able to produce short-term changes in walking behavior at the population level. Supported by environmental changes, and by ongoing taskforce commitment, these are able to generate sustainable public health interventions. The evaluation tasks to track and monitor these diverse activities is much more complex than the relatively straightforward research design issues in assessing the effectiveness of interventions in closed systems. However, an understanding of the process and effects of community interventions has greater promise for generalizing these interventions to other settings, and to make greater improvements in sedentarism in America. References Ashton, J., Grey, P., & Bernard, K. (1986). Healthy cities—WHO’s new public health initiative. Health Promotion, 319–324. Bartholomew, L., Parcel, G., Kok, G., & Gottlieb, H. (2001). Intervention mapping: Designing theory- and evidence-based health promotion programs (p. 206). Mountain View, CA: Mayfield Publishing. Bauman, A., Ford, I., & Armstrong, T. (2001). Trends in population levels of reported physical activity in Australia 1997, 1999 and 2000. Australian Sports Commission. Bauman, A., & Koepsall, T. D. (2005). Epidemiologic issues in community interventions (Chapter 6) in applied epidemiology. In R. C. Brownson, & D. B. Petitti (Eds.), Theory to practice (2nd ed.). New York: Oxford University Press. Bauman, A., & Smith, B. (2006). Evaluation of mass media campaigns for physical activity. Evaluation and Program Planning, this issue. Booth-Butterfield, S., Reger, B., Middlestadt, S., & Cooper, L. (2004). Using the cascade model for message development in the ‘‘Wheeling Walks’’ mass media campaign. Paper presented at the annual convention of the National Communication Association, Chicago, IL. Brenes, G., Strube, M., & Storandt, M. (1998). An application of the theory of planned behavior to exercise among older adults. Journal of Applied Social Psychology, 28(24), 2274–2290. Cavill, N., & Bauman, A. (2004). Changing the way people think about health- enhancing physical activity: Do mass media campaigns have a role? Journal of Sports Sciences, 22, 771–790. Centers for Disease Control and Prevention (CDC). (2001). Physical activity trends—United States, 1990–1998. Morbidity and Mortality Weekly Report, 50(9), 166–9. Available at URL: http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm5009a3.htm. Centers for Disease Control and Prevention (CDC). (2005). Behavioral risk factor surveillance system prevalence data 2004. Retrieved 26 January 2005 from http://www.cdc.gov/brfss. Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Green, L. W., & Kreuter, M. W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View, CA: Mayfield Publishing Company.

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