The neighborhood of Old North St. Louis had over the years fallen into disrepair and blight. As a community development group spurred its revitalization, researchers Cheryl Kelly, PhD, MPH, and Michael R. Elliott, PhD, used a Robert Wood Johnson Foundation (RWJF) Active Living Research grant to study the impact of an improved built environment on children’s activity levels.
The problem. Neighborhoods with boarded up buildings, crumbling sidewalks, poorly maintained parks, and little in the way of walking destinations discourage the physical activity that is so important to children’s growth and development.
Old North St. Louis was in just such a blighted state when in 1981 a group of residents, small business owners, and community leaders formed the not-for-profit Old North St. Louis Restoration Group with a mission to revitalize the once vibrant neighborhood just north of downtown.
At first, the group focused primarily on rehabbing houses, but it then turned its attention to other factors that make for a vibrant community, such as access to healthy foods and walkability. By 2010, Old North St. Louis had eight community gardens, the Old North Grocery Co-op, a new playground, and a resurrected central park, as well as an array of new businesses.
Old North’s transformation presented a “natural experiment” for Saint Louis University researchers Cheryl Kelly, PhD, MPH, and Michael R. Elliott, PhD. They wanted to find out: Does improving the “built environment” in a neighborhood enable children to increase their physical activity? A $400,000 grant in 2010 from RWJF’s Active Living Research program helped them do that.
RWJF Approach: Robert Wood Johnson Foundation's (RWJF) Active Living Research program stimulates and supports research to examine environmental factors and policies that influence physical activity, particularly in children. Funded researchers use transdisciplinary approaches—bringing together expertise from various disciplines to create new methods of identifying environmental factors and policies that are related to physical activity. The program places special emphasis on children of color and those living in lower-income families and communities, who are at greater risk for obesity. See the Program Results Report for more information on the program.
A focus on individuals gives way to working for larger change. The researchers began their careers at the intersection of individual psychology and health—Kelly studied sports psychology and Elliott preventive medicine—but each obtained doctorates in public health because of its relevance to the health of populations and communities, and its focus on the broader social and societal determinants of health.
“In public health, we think more about how to improve population-level health as opposed to just working one-on-one,” Kelly said. “I see that as the ability to create larger change and potentially faster change.”
While at Saint Louis University, first as a graduate student and then assistant professor, Kelly focused her research on the relationship between community factors, such as the built environment, and healthy behaviors, such as physical activity and healthy eating. She also studied disparities in access to opportunities to engage in healthy behaviors. In 2012, Kelly moved to the Beth-El College of Nursing and Health Sciences at the University of Colorado in Colorado Springs, where she is continuing this work.
Elliott earned a doctorate in public health from Ohio State University, and as of 2013, is assistant professor of biostatistics at Saint Louis University College for Public Health and Social Justice. His research examines the relationship between health behaviors (nutrition and physical activity) and the intrapersonal, interpersonal, physical, and policy environments. His specialty is using geographic information systems (GIS) to study the associations between the built environment and diabetes risk and treatment effectiveness.
What makes a good neighborhood? Kelly discovered the work of Old North St. Louis Restoration Group while co-directing an evaluation of the Missouri Foundation for Health’s Healthy and Active Communities Initiative. In this role, she provided technical assistance to community organizations across Missouri that were implementing physical activity and healthy eating interventions, and she led a multisite evaluation of the initiative.
While the urban planning group did not address health specifically, “its members embraced this philosophy that part of having a good neighborhood is not just building homes and having nice homes, but having access to a park and to healthy affordable food.
“The Old North group did all the good work and hard work of opening the grocery co-op and working with the city on the park and the streets,” Kelly said. “We just led the evaluation of it.”
Measuring activity levels. To measure activity levels, the researchers recruited families in the Old North St. Louis neighborhood who consented to have their children wear accelerometers. These gadgets, worn like pedometers, measure all types of activity, including intensity and duration. “So you could say, ‘This person engaged in vigorous activity or moderate activity,’ which you can translate into the calories they expended—given their weight,” Elliott said. “It provides a richer measure than using something like a pedometer that measures steps."
For comparison, the researchers also used the devices to monitor activity levels of children in McKinley Heights, a south St. Louis neighborhood with a similar socioeconomic makeup, but one that had not undergone the same kind of environmental transformation as Old North.
As a separate component of their study researchers also surveyed about 200 parents in each neighborhood about their physical activity and their child’s activity, including how often and where they were active.
Challenges with recruitment and retention. The researchers planned to measure children’s activity levels at baseline and then again at two intervals—12 months and 18 months later. But Kelly described the recruitment of participants into the study as quite challenging. Methods that had worked well in previous research projects—hosting or attending community events, purchasing a phone list and calling individual houses—yielded a smaller-than needed number of eligible children.
Finding children through the schools proved not to be a viable option. “Many of the children who lived in the neighborhood don’t go to school in the neighborhood,” Kelly said. “They go to other schools or charter schools all over the place.”
So the research team went door to door, where they had more success finding and recruiting willing participants. “But we still didn’t get the numbers we wanted,” Kelly said. “And when we went to do the follow-up, we had a really hard time finding those families—even when we knocked on their doors. We found they did not live there anymore.”
It’s a common occurrence in low-income neighborhoods, she said. “People tend to be more transient.” In the end, the researchers were only able to reach 42 families in both communities that participated at baseline and recruit them to wear the accelerometer again at follow-up.
The researchers also had trouble getting the children to use the accelerometers, and then, to return them. The children often did not wear the accelerometer for the full week called for in the study, and a number of the devices got lost. Elliott noted that the red box worn on an elastic belt or band was “probably not the most attractive thing to wear. That’s maybe why some of the kids in the sample were not overly into wearing them to school.”
Another possible impediment, Elliott said, was that the accelerometer had no “read-out” that gave feedback to the person wearing it. “That is good from a research standpoint,” he said, “because you avoid someone trying to be more active because they are wearing the device and can see that they are more active. The downside is you don’t have the motivation to wear it. You don’t see that you are getting anything out of it.”
If you build it, will they come? In the end, the researchers were able to track the activity levels of 21 children in Old North St. Louis at baseline and one follow-up. Among that small sample, activity levels dropped slightly, a disappointing finding, but not statistically significant. “In reality, activity levels did not change,” Kelly said. “We had a really small sample size. That is a huge issue.”
To help explain the findings, Kelly and Elliott are delving into survey data they collected from the survey of some 200 people in each of the two neighborhoods. That survey asked respondents an array of questions about life in their neighborhoods, including: “Do you perceive that it is safe to walk outside?” and “Do you know your neighbors?” Such factors have been shown to influence people’s willingness to engage in physical activity. “Really, if there was not a change in perceived safety and social capital,” Kelly said, “then I am not surprised that we did not see changes in activity.”
Elliott concurs. “[In Old North] you have impacted one level—the environment. If there are still perceptions—or the reality—that it is unsafe to be physically active, then any number of parks is not going to address that issue.”
Many factors influence people’s motivation to engage in physical activity. “We have to be more creative in how we think across these different levels—individual, social, and environmental,” Kelly said.
For encouragement, Kelly points to the cultural shift that has happened in regard to tobacco use. “It took a long, long time to switch our perceptions and our culture around tobacco,” she said. “Nowadays if you smoke people look at you like, ‘Oh, you smoke.’ It took changing the environment, changing policies, education, media awareness. It took so many things. So I think there is hope in terms of physical activity. We just have to stay with it.”
RWJF Perspective: Launched in 2000, Active Living Research is a $31 million national program that supports research to examine how physical and built environments and policies influence the amount of physical activity Americans get as part of everyday life. Findings from the research are used to help inform policy, the design of the built environment and other factors necessary to re-engineer healthy levels of physical activity into everyday life for all Americans. Over the past few years, the program has focused on reversing the rise in childhood obesity, particularly in the lower-income and racial/ethnic minority communities in which childhood obesity levels are highest and rising fastest.
A recent analysis by Program Director James F. Sallis, PhD, documents dramatic growth in research to identify policy and environmental factors and interventions affecting physical activity at the population level and in high-risk populations following the program’s launch in 2001.
Active Living Research teams are required to be transdisciplinary, involving investigators from multiple disciplines and backgrounds who work together across traditional disciplinary boundaries. The researchers represent more than 20 different disciplines (e.g., public health, urban planning, architecture, behavioral science, exercise science, transportation, parks and recreation, sociology, and political science). “In addition to building an evidence base to guide physical activity policy and community design, Active Living Research is developing a vibrant, new transdisciplinary field, and a diverse network of accomplished researchers,” says C. Tracy Orleans, PhD, RWJF distinguished fellow and senior scientist.
Active Living Research seeks to translate actionable research findings into policy and practice change as rapidly as possible. Says Orleans: “For instance, if we find out that adding bike paths and sidewalks or walk-to-school programs significantly increases physical activity, we want to get this information out to local residents, decision- and policy-makers as quickly and effectively as possible, so they can start using it.”
Orleans adds, “The Active Living Research program has sparked new awareness among policy-makers and community leaders in many sectors that our everyday physical activity levels depend on the presence or absence of environmental and policy supports for physical activity. In addition, a growing number of urban planners and transportation policy-makers recognize that community design is critical for health.”