Recreation and health agencies: working together to promote physical activity.

Cardiovascular disease (CVD) is the leading cause of death in the United States. And a sedentary lifestyle is a primary risk factor for CVD. In fact, it is listed as the most common risk factor by the Centers for Disease Control and Prevention (CDC). At the same time, moderate levels of activity are associated with significant reduction in risk for CVD as well as diabetes, some cancers, osteoporosis, osteoarthritis, and depression(1)(2) and will play an increasingly important role in enhancing quality of life and life span. Recent studies show that CVD rates are seven to eight times higher in unfit individuals than in those who are fit.(3) However, despite research supporting the health benefits of physical activity, nearly 60% of Americans remain sedentary.(4)

But how can we get people to change? That is a question that Health People 2000 seeks to answer. Healthy People 2000 National Health Promotion and Disease Prevention Objectives (HP 2000), developed by the U.S. Public Health Service, is a nationwide effort to significantly reduce the incidence and mortality rates from CVD in the U.S. by the year 2000.

To compliment this program, the Colorado Department of Health (CDH) formed the Cardiovascular Disease Prevention Coalition in 1989 to address the problem of CVD in Colorado. The Coalition is comprised of individuals from public, private, professional, voluntary organizations, and media and consumer groups. Combining the knowledge and experience of these individuals, the Coalition developed The Colorado Strategic Plan to Improve Cardiovascular Health 1991-2000 to support the HP 2000 objectives.

Physical Activity Subcommittee 

The Physical Activity Subcommittee is one of four the Coalition developed to address a specific area of the HP 2000 objectives relating to CVD. The Physical Activity Subcommittee believes that a partnership involving parks and recreation and health agencies in each community is needed to maximize the heart health of residents and accelerate achievement of the HP 2000 objectives. The CDH involved parks and recreation professionals early on in the development of the strategic plan and related activities. And members of the Colorado Parks and Recreation's (CPRA) Fitness and Wellness Committee joined the Coalition and have been major contributors, CPRA has promoted and endorsed the project.

As one of its objectives, the Physical Activity Subcommittee developed a tool, EXER-DECK, to promote increased physical activity in the adult population. As a result of this tool, a three-year collaborative effort was formed involving NRPA, the CDH, and several local recreation departments. NRPA's objective for this collaborative effort is "to form, demonstrate, and advance a community-based CVD health promotion effort through collaboration of local recreation and health agencies." NRPA has increased its emphasis on recreation's relationship to national health and fitness objectives. In 1991 NRPA adopted a "Statement of Endorsement For a Leisure Professional Health and Fitness Commitment" and encouraged all state agencies to adopt this statement. NRPA also has organized the National Fitness and Wellness Coalition and encourages public health authorities to recognize the health and fitness potential of recreation and park facilities and services and to include such systems in public health and fitness strategies. This is being accomplished by the collaborative efforts of the CDH and NRPA with the EXER-DECK project.

The CDH and NRPA recognize the importance of collaborative efforts for effective and successful community-based program planning. Some of the benefits of collaboration include: greater impact, increased resources, bridging gaps in existing community programs, not duplicating efforts, credibility, networking opportunities, enhanced communication between agencies, enhanced relationships, and increased access to the media. Collaboration of efforts benefits both park and recreation and health agencies. It provides park and recreation with increased credibility, access to disease prevention and health promotion data and services, medical expertise and additional resources and contacts. Health agencies benefit from recreation's resources such as facilities, staffing, experience in marketing and program development, name recognition, and experience in serving communities.

EXER-DECK is a book of removable cards containing three sections. The first section is a progress check for the user, providing easy self-administered measurements to determine current level of fitness. It offers the user a chance to be his or her own personal trainer. This section also helps the user over the hurdles of beginning and maintaining an active lifestyle and allows them to develop personal fitness goals. Section two contains fitness facts, information about pacing, nutrition, weight control, resources, and options. The final section takes the user through a variety of physical activities. Each card highlights appropriate stretches, safety tips, program guidelines, a sample program, and options for fitting the activity into daily routines. A six-month log is included at the end of EXER-DECK to record physical activity progress, and recreation activities and opportunities are referred to throughout.

EXER-DECK has many uses in both park and recreation and health agencies, including as a counseling tool for clients interested in starting a physical activity program; as an adjunct for beginning fitness classes, personal training, and assessments; and for employee wellness and fitness programs. Agencies also have used various cards from EXER-DECK, such as the fitness blackout card and the exercise log for fitness challenges and as an additional means to motivate clients to exercise. EXER-DECK is a versatile tool and can be used separately or in conjunction with many programs and services.

Laying Foundation for Collaborative Efforts

This project began with a training program, "Promoting Physical Activity Among Adults", conducted by the CDH in conjunction with CDC at a CPRA conference in April 1991. It provided training and tools to enhance physical activity in local communities and across the state and promoted collaborative efforts between park and recreation and health agencies. Park and recreation and health professionals attending this program began identifying needs in their respective communities and considering strategies for working together to meet these needs. As a result of this workshop, several agencies began to work together on health promotion activities. And this program was the first step in the journey to link park and recreation and health agencies in collaborative program planning efforts throughout Colorado. EXER-DECK would be the future catalyst to continue this journey.

Building on the Foundation

The Physical Activity Subcommittee of the Cardiovascular Disease Prevention Coalition continued to work on the development of EXER-DECK with support from the National Recreation Foundation. This tool was a means to link park and recreation and health agencies together to promote physical activity in their communities. Development of EXER-DECK was a three-year process and included two pilot studies to evaluate its effectiveness.

In the first study, EXER-DECK was distributed to a convenience sample of 43 adults who reviewed EXER-DECK and expressed their opinion on the appropriateness of its goals, design, content, and utilization. This group included exercisers and non-exercisers, as well as professionals with art and editing background; several modifications were made to EXER-DECK based on recommendations from this group. However, 88% of study subjects felt that EXER-DECK was a valuable educational tool.

The second pilot study was conducted to test the ability of EXER-DECK to increase the number of adults who participate in regular physical activity. Pilot sites--park and recreation and health agencies--were chosen in both urban and rural settings throughout Colorado. A total of 127 subjects received EXER-DECK with instructions on its use and were asked to complete a pre-survey. Subjects were asked to use EXER-DECK for a 10-week period. Sixty-nine participants (54%) completed the post survey at the end of this period. Of these, 22% began and continued a regular physical activity program for the duration of the study. An additional 23% stated they "exercised some," representing a slight change from a sedentary lifestyle. Results also showed that the participants increased knowledge relating to physical activity and its benefits and adopted a more realistic approach to exercise and an increase in readiness to start a physical activity program.

Encouraging Collaboration Training

Training professionals to work collaboratively and use EXER-DECK was a priority objective of this project and of the Colorado 10-year CVD strategic plan. CDH staff reviewed data from the park and recreation survey and a survey of public health agencies statewide regarding their communities' physical activity needs and current collaborative efforts. Nursing consultants who were familiar with county nursing service staff and community dynamics provided useful insights during this planning phase. Local health and park and recreation agencies throughout the state were contacted to host these training sessions.

Training sessions lasted from 2-4 hours depending on the needs of the participants. Both park and recreation and health professionals were invited to participate in these training sessions. Trainings were conducted by staff from the CDH and from park and recreation agencies. Topics included the impact of CVD and its relationship to physical activity, a review of EXER-DECK and how to use it, the benefits of collaborative efforts, and participant activities in collaborative program planning.

Participants came from urban and rural settings and from communities with populations of less than 1,000 to communities with populations over 100,000. For many participants, this was their first contact with either park and recreation or health agencies. It was a chance for these two professions to view each other as a resource in their community and to learn what types of programs and services each had to offer. During the participant exercise, park and recreation and health professionals worked together to develop hypothetical physical activity programs for their communities, examined ways they could act as resources to each other, and identified other community resources. At the end of the session, participants were asked to write a self-addressed letter stating what their goals for collaborative efforts would be for the next three months. These letters were mailed to participants three months after the workshop to be used as a self-evaluation tool for progress.

Several collaborative efforts were identified by workshop participants, many in small communities with a population of less than 2,000, where community professionals need to be especially resourceful. Some of these included:

* a community nursing service working with a local hotel to allow community seniors to use the hotel's pool two times per week for aqua exercise classes at the cost of one dollar per class;

* park and recreation working with the high school Future Homemakers of America Club, who provides pot lucks for seniors who complete fitness challenges;

* a senior walking club, formed by the recreation department, using the perimeter of the elementary school gym during physical education classes so the seniors can continue walking during the harsh winter months;

* multi-generation walking clubs developed by the recreation department linking seniors with elementary-aged children;

* and health agencies providing blood pressure, cholesterol and other screenings at recreation centers.

These and other program ideas provided valuable information to others who were attempting to begin programs in their communities. This networking/information sharing seemed to be one of the most important aspects of the training sessions.

These training sessions provided a wealth of information for parks and recreation and the health profession. Many barriers to providing community programs relating to physical activity were identified by the participants. The most common barriers cited were lack of resources, (including funding), staff limitations, and lack of time. By combining the resources of both the park and recreation and health agencies many of these barriers can be overcome. Collaboration also allows agencies to impact more people, strengthen their programs, maximize their power, broaden community support, and strengthen the community's trust in your program.

Future Plans

Future plans include the coordination of a national focus group of park and recreation and health leaders to develop a national model and development of materials to advocate the combined efforts of park and recreation and health agencies in promoting physical activity as well as other activities, events, and services. Materials developed as a result of this focus group then will be disseminated to park and recreation and health agencies nationwide. Other national organizations, such as the President's Council for Physical Fitness and Sports and the National Governor's Council will be approached for support, endorsement, and promotion of the materials and for advocacy of collaborative efforts within their organizations.

A task force of the Physical Activity Subcommittee is in the process of developing a disability section for EXER-DECK. This section will focus on program modifications, concerns, and safety issues for persons with physical disabilities.

Funding sources are being sought to develop a youth version of EXER-DECK. This version, appropriate for elementary school aged children, would contain games and fun motivating activities that would build on individual success. This tool would be designed to reach the large number of children who are not athletic or involved in sports and motivate them to adopt an active lifestyle that they will carry into their adult years.

It is the intent of the CDH to continue working with park and recreation agencies and other community organizations to reduce CVD and promote an active and healthy lifestyle. Only through collaborative efforts will we make the impact necessary to reach the HP 2000 objectives for the nation. By working together, everyone benefits.

(1.)Summary Statement. Workshop on Physical Activity and Public Health. Sponsored by: U.S. Centers for Disease Control and Prevention and the American College of Sports Medicine in conjunction with the President's Council for Physical Fitness and Sports. July 29, 1993.

(2.)Blair SN, Kohl HW, & Gordon NF, How much physical activity is good for health? Ann Re Pub Health, 1992. 13: 99-126.

(3.)Blair SN & Kohl HW III, Paffenbarger RS, Jr, Cooper KH, and Gibbon LW. Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA, 1989. 262:2395-2401.

(4.)Prevalence of Sedentary Lifestyle--Behavioral Risk Factor Surveillance System, United States, 1991. Centers for Disease Control and Prevention. MMWR, Volume 42, No. 29, July 30, 1993.