Physical Activity: Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends the creation of or enhanced access to places for physical activity based on strong evidence of their effectiveness in increasing physical activity and improving physical fitness.

The full CPSTF Finding and Rationale Statement and supporting documents for Environmental and Policy Approaches to Increase Physical Activity: Creation of or Enhanced Access to Places for Physical Activity Combined with Informational Outreach Activities are available in The Community Guide Collection on CDC Stacks.

Intervention

Creation of or enhancing access to places for physical activity involves efforts of worksites, coalitions, agencies, and communities to change the local environment to create opportunities for physical activity. Such changes include creating walking trails, building exercise facilities, or providing access to existing nearby facilities.

These multicomponent programs were evaluated as a “combined package” because it was not possible to separate out the effects of each individual component.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 10 studies (search period 1980-2000).

Study Characteristics

  • Evaluated interventions provided access to weight and aerobic fitness equipment in fitness centers or community centers, created walking trails, or provided access to nearby fitness centers
  • In addition to promoting access, many studies incorporated components such as training on equipment, health behavior education and techniques, seminars, counseling, risk screening, health forums and workshops, referrals to physicians or additional services, health and fitness programs, and support or buddy systems
    • Multicomponent interventions evaluated together because it was not possible to separate out the incremental benefits of each component
  • All studies conducted in the United States
  • Conducted at worksites including industrial plants (automotive, brewing, printing), universities, and federal agencies (8 studies), or in low-income communities (2 studies)

Summary of Results

Ten studies qualified for the review.

  • In all 10 studies, creating or enhancing access to places for physical activity was effective in getting people to exercise more:
    • Aerobic capacity: median increase of 5.1% (Interquartile interval 2.8% to 9.6%; 8 study arms)
    • Energy expenditure: median increase of 8.2% (3 study arms)
    • Percentage reporting some leisure-time physical activity: median increase of 2.9% (4 study arms)
    • Exercise score: median increase of 13.7% (6 study arms)
  • Most studies also reported weight losses or decreases in body fat among program participants

Summary of Economic Evidence

Two studies were included in the economic review.

Study 1: 4-year cost benefit analysis of structured physical fitness program for insurance company employees providing exercise classes and health seminars

  • Benefits included savings in major medical costs, reduction in disability days, and reduction in direct disability costs
  • Costs included personnel, non-salary operating expenses, and medical claims
  • Adjusted estimates for 1 year: benefits $1,106 and costs $451

Study 2: 5-year study with 10-year projections among 36,000 insurance company employees and retirees. Cost benefit analysis of company-sponsored health and fitness program using health promotion centers, newsletters, medical reference texts, videotapes, and quarterly media blitzes

  • Benefits included cost savings from healthcare costs averted, absenteeism reduction, deaths averted, and increased productivity
  • Costs included personnel, overhead, capital equipment, materials, and rent, but not employee time away from the job
  • Adjusted estimates: benefits $139 million and costs $43 million

Applicability

Given the diversity of settings and populations, results should be applicable to diverse settings and populations, provided appropriate attention is paid to adapting the intervention to the target population.

Evidence Gaps

  • What characteristics of a community are necessary for the optimal implementation of policy and environmental interventions?
  • Does the effectiveness vary by type of access (e.g., worksite facility or community facility) or socioeconomic group?
  • How can the necessary political and societal support for this type of intervention be created or increased?
  • Does creating or improving access motivate sedentary people to become more active, give those who are already active an increased opportunity to be active, or both?
  • If you build it, will they come? In other words, is enhanced access to places for activity sufficient to create higher physical activity levels, or are other intervention activities also necessary?
  • What are the effects of creating new places for physical activity versus enhancing existing facilities?
  • Which neighborhood features (e.g., sidewalks, parks, traffic flow, proximity to shopping) are the most crucial in influencing activity patterns?
  • How does proximity of places such as trails or parks to residence affect ease and frequency?

General Research Issues

The following outlines evidence gaps for reviews of the following interventions to increase physical activity:

Effectiveness

Several crosscutting research issues about the effectiveness of all of the reviewed interventions remain.

  • What behavioral changes that do not involve physical activity can be shown to be associated with changes in physical activity?
    • For example, does a decrease in time spent watching television mean an increase in physical activity or will another sedentary activity be substituted?
    • Does an increase in the use of public transportation mean an increase in physical activity or will users drive to the transit stop?
  • Physical activity is difficult to measure consistently across studies and populations. Although several good measures have been developed, several issues remain to be addressed.
    • Reliable and valid measures are needed for the spectrum of physical activity. Rationale: Current measures are better for vigorous activity than for moderate or light activity.
    • Sedentary people are more likely to begin activity at a light level; this activity is often not captured by current measurement techniques.
    • Increased consensus about “best measures” for physical activity would help to increase comparability between studies and would facilitate assessment of effectiveness.
  • Note: This is not intended to preclude researchers’ latitude in choosing what aspects of physical activity to measure and to decide which measures are most appropriate for a particular study population. Perhaps a useful middle ground position would be the establishment of selected core measures that most researchers should use which could then be supplemented by additional measures. The duration of an intervention’s effect was often difficult to determine.

Applicability

Each recommended and strongly recommended intervention should be applicable in most relevant target populations and settings, assuming that appropriate attention is paid to tailoring. However, possible differences in the effectiveness of each intervention for specific subgroups of the population often could not be determined. Several questions about the applicability of these interventions in settings and populations other than those studied remain.

  • Are there significant differences in the effectiveness of these interventions, based on the level or scale of an intervention?
  • What are the effects of each intervention in various sociodemographic subgroups, such as age, sex, race, or ethnicity?

Other Positive or Negative Effects

The studies included in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

  • Do informational approaches to increasing physical activity help to increase health knowledge? Is it necessary to increase knowledge or improve attitudes toward physical activity to increase physical activity levels?
  • Do these approaches to increasing physical activity increase awareness of opportunities for and benefits of physical activity?
  • What are the most effective ways to maintain physical activity levels after the initial behavior change has occurred?
  • Are there other benefits from an intervention that might enhance its acceptability? For example, does increasing social support for physical activity carry over into an overall greater sense of community?
  • Are there any key harms?
  • Is anything known about whether or how approaches to physical activity could reduce potential harms (e.g., injuries or other problems associated with doing too much too fast)?

Economic Evidence

The available economic data were limited. Therefore, considerable research is warranted on the following questions:

  • What is the cost-effectiveness of each of these interventions?
  • How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
  • How can the cost benefit of these programs be estimated?
  • How do specific characteristics of each of these approaches contribute to economic efficiency?
  • What combinations of components in multicomponent interventions are most cost-effective?

Barriers

Research questions generated in this review include the following:

  • What are the physical or structural (environmental) barriers to implementing these interventions?
  • What resource (time and money) constraints prevent or hinder the implementation of these interventions?

Implementation Considerations and Resources

Creation of or enhanced access to facilities is time and resource intensive. It requires careful planning and coordination, as well as resources sufficient to carry out the construction.

Success is greatly enhanced by community buy-in, which can take a great deal of time and effort to achieve.

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