pme02659_prn 330..333 Preventive Medicine 49 (2009) 330–333 Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed Commentary “Pushing” physical activity, and justice Robert García a, America Bracho b, Patricia Cantero b, Beth A. Glenn c,⁎ a The City Project, Los Angeles, CA, USA b Latino Health Access, 1701 N. Main Street, Suite 200, Santa Ana, CA, USA c School of Public Health, and Jonsson Comprehensive Cancer Center, University of California, Los Angeles, 650 Charles Young Dr. South, Room A2-125, CHS, Los Angeles, CA 90095-6900, USA 0091-7435/$ – see front matter © 2009 Elsevier Inc. A doi:10.1016/j.ypmed.2009.07.016 ⁎ Corresponding author. Fax: +1 310 206 3566. E-mail address: bglenn@ucla.edu (B.A. Glenn). a b s t r a c t Objective. There has been an increasing realization of the need for environmental interventions to a r t i c l e i n f o Available online 29 July 2009 Keywords: Physical activity Obesity Fitness Racial or ethnic minority African American Black Latino Hispanic Disparities Civil rights Justice Built environment Education Law increase physical activity levels in the population. Although promising, the impact of these strategies in reducing obesity-related disparities will be limited by the presence of inequities in the distribution of activity-related resources in the community. Advocacy efforts are critically needed to ensure that all communities benefit from environmental strategies being implemented. Method and results. This paper describes two activist community-based organizations in Southern California, The City Project and Latino Health Access, and their successful efforts to mandate equitable access to public resources critical for reducing obesity-related disparities. Conclusion. Principles for equitable development of public land are also presented as well as lessons learned that can inform future advocacy efforts. © 2009 Elsevier Inc. All rights reserved. Introduction Increasing the availability of safe-space for physical activity (Babey et al., 2008), opportunities to engage in physical activity during the school day (Cawley et al., 2007), and access to and use of public trans- portation (Lachapelle and Frank, 2009) are environmental strategies that have been found to be related to increased physical activity levels. Low-income, ethnic minority families are less likely to have access to parks or other space for physical activity (Estabrooks et al., 2003), less likely to engage in physical activity during leisure time (Brown et al., 2005) and are more dependent on public transportation (Mather, 2009).Evidence isaccumulatingthat promotingmass transit use may be a promising strategy to increase physical activity levels (Lachapelle and Frank, 2009). However, low-income and minority communities, those most likely to need public transit and who may be more likely to benefit from its use from a physical activity standpoint often have poorest access to these resources. Thus, these environmental change approaches hold the promise of being particularly beneficial for socioeconomically marginalized groups. Therefore, we propose that efforts should be made to mandate the equitable distribution of public resources that will ultimately increase physical activity levels in the population. The purpose of this article is to propose steps that may be neces- sary to bring about population-wide increases in physical activity ll rights reserved. level and ultimately to reduce obesity-related disparities. California, the only “majority minority” state in the continental U.S. and a leader in health promotion, is host to a number of activist community-based organizations engaged in grassroots advocacy. Case studies of two such agencies, The City Project and Latino Health Access, are included to illustrate how these organizations have spearheaded efforts to mandate equitable access to public resources critical for reducing obesity-related disparities. Finally, we put forth principles of equitable development to guide others in their efforts to advocate for the health of their respective communities. Steps in public health advocacy First, there is a need to bring people together through coalition building and a shared vision based on diverse values. Grassroots engagement is a necessity, and may require the development of coalitions with broad agendas and working across multiple issues as has been noted by others (Tajik and Minkler, 2007). The composition and nature of the coalition that are likely to be successful will depend on the timeline for achieving the goal, characteristics of the affected community and the health topic of concern among other factors. Second, sophisticated analytic approaches and broad frameworks are needed when conducting research to understand the relationship between obesity and its multiple environmental determinants including the implications of laws and public policies as well as the built environment (Sacks et al., 2009). Health Impact Assessments can 331R. García et al. / Preventive Medicine 49 (2009) 330–333 be valuable tools in assessing both the intentional and unintentional effects of public policies and programs (Dannenberg et al., 2008). Community-based participatory research (CPBR) approaches should be used to ensure that results are meaningful to the community and provide the foundation for future advocacy efforts (Tajik and Minkler, 2007). CBPR methods can be used to systematically study the process of advocacy (e.g., assessing quality and nature of partnerships and coalitions) as well as the outcomes of advocacy efforts (e.g., im- provements in perceived and objective health). Evaluation of health outcomes is particularly important in ensuring that programs and policies that improve health are sustained. Third, strategic media campaigns can focus attention on the need for systemic change and increase your likelihood of success (Tajik and Minkler, 2007). Taking advantage of traditional media and new social media (including GIS mapping, blogs, flickr, YouTube, and podcasts) can lead to increased visibility and support for your cause. Fourth, taking advantage of available policy and legal advocacy resources outside the courts may be effective in persuading public officials to take action. For example, the Robert Wood Johnson Foundation-funded National Policy and Legal Action Network (NPLAN) provides legal and policy analyses as a national resource to policymakers and advocacy groups seeking to change physical activity and nutrition environments to address childhood obesity. Finally, access to justice through the courts is available as a last resort if all else fails in the context of an overall campaign (García and White, 2006). Lessons learned from tobacco litigation in the U.S. may have application to other areas, and indeed, many grassroots advocates “cut their teeth” on public health tobacco control efforts. The following case studies illustrate efforts undertaken by The City Project and Latino Health Access to ensure equitable access to public resources relevant to physical activity in Southern California. Case studies The City Project The City Project, located in Los Angeles, California, is a non-profit policy and legal problem solving organization whose work includes specific strategies to build healthy, livable communities for all, and principles for equitable development to achieve systemic change and real choice. In Los Angeles County, children of color and those living in poverty have the highest levels of obesity. These children also have the least access to parks, to schools with at least 5 acres of playing field, and to mass transit (García and White, 2006). Thus, the City Project has engaged in a number of initiatives that have laid the groundwork for reducing obesity disparities in the county and throughout California. Creation of safe-space for physical activity Activists and attorneys worked with the community through policy and legal advocacy to help create the forty-acre Rio de Los Angeles State Park on a former rail yard in one of the most park- starved communities in the region and stop a commercial project there. This is part of a broader campaign in what is now known as the Urban Park Movement to revitalize the 52-mile Los Angeles River (which was lined with concrete as flood control measure in the 1930s) with parks, schools, affordable housing, local green jobs, and multi-use green spaces that help clean the air and water and promote climate justice. The parks and school fields should provide places for physical activity to alleviate obesity and promote physical and mental health of the people (García and White, 2006). Ensuring opportunities for PA during school for low-income and minority children More than half of the public school districts in California do not enforce physical education requirements (California Center for Public Health Advocacy, 2006). In response, The City Project is working with the United Teachers of Los Angeles (the teachers' union) and others to enforce the physical education laws in the Los Angeles Unified School District, the second largest in the nation with more than 700,000 students—91% are children of color and 74% are low income. The teachers' union launched a physical education campaign to build public support among teachers, parents, students and the public. The City Project filed an administrative (Williams) complaint under civil rights and education laws. The board of education passed a resolu- tion to enforce the physical education and civil rights laws. Teachers, lawyers, and school officials are working together to draft a far- reaching plan to implement the resolution, enforce the law, and resolve the complaint. Each of these elements is based, in part, on evidence from studies investigating public school physical education inequities commissioned by The California Endowment (García and Fenwick, 2009). Increasing access to public transportation In 1994, lawyers and organizers working together filed a historic civil rights and environmental justice lawsuit against the Los Angeles County Metropolitan Transportation Agency (MTA) on the grounds that it operated separate and unequal bus and rail systems that discriminated against the working poor with little or no access to a car. MTA agreed to settle the case in 1996 and invested over $2 billion to improve transit throughout the county and keep fares low over the next ten years (García and Rubin, 2004). Latino Health Access Latino Health Access (LHA) is a non-profit public health organiza- tion founded in 1993. It assists in improving the quality of life of underserved Latino residents in Orange County, California. The majority of the services (66%) are provided to residents of Santa Ana, one of the poorest and densest cities in the state. LHA was one of the early innovators in the development of the Promotor (Community Health Worker) model of community outreach and health education. One of the focuses of LHA's work is creating an environmental change to support responsible personal and family food choices and physical activity participation. For example, as one of six Healthy Eating Active Communities sites in California, LHA engages the community, city officials, the Orange County Health Care Agency, and the Santa Ana Unified School District in discussions on wellness policies, often involving their youth Promotores in door-to-door outreach, hosting town hall meetings and forums, and testifying before school boards and city councils. LHA has been focused, for the past six years, on addressing the inequity in park distribution in Santa Ana. They partnered with Trust for Public Land to conduct a feasibility study demonstrating that Santa Ana has roughly 1 acre of park land per 1120 residents compared with 7.9 acres per 1000 residents for other large California communities (Fig. 1). As shown in Fig. 1, the darkest areas on the map surrounding the 92701 zip code represent the highest park poor area in Santa Ana with only 0.5 acres of land per 1000 residents (Trust for Public Land, 2005). They organized residents to identify a vacant lot central to the 92701 zip code. The identified parcels had three owners, the city, a community redevelopment agency and a private market. Advocacy efforts included: (1) prominent media engagement—an exposé feature article in La Opinión, a leading Spanish-speaking newspaper; (2) collecting and disseminating local surveillance data, where the overweight rate was 85% among children and youth living in a large condominium complex adjacent to the park construction site; and (3) leveraging resources—space for health promotion activities at the condominium complex home to an estimated 1000 residents. The market donated and transferred the ownership of their parcel to LHA at no cost. LHA negotiated a 40-year leasing agreement with the city 4 th St F a ir v ie w R d 1st St Chapm an Ave E l l i s A ve Ja m bo r e e R d 1st St B ri st o l S t M ain St T u st in S t B r i st o l S t M ichelson D r T h e C it y D r Gar den Gr ove Blvd H a rv ar d A ve La V eta Ave G ra n d A v e F a ir v ie w S t M a i n S t 1st St F a ir v ie w S t Talber t Ave San t a An a Blv d Bar r anca Pky M acar thur Blvd T u st in A v e H a rb o r B lv d 17th St G r a n d A v e Alton Pky Adam s Ave G ra n d A v e H a rb o r B lv d M acar thur Blvd F a ir v ie w S t 1st St Euclid S t E u cl id S t T o w n A nd Cou ntr y Rd D yer R d G la ss e l l S t R ed H i l l Ave W ar ner Ave M em or y Ln Chapm an Ave Baker St Edinger A ve 5th St H a rb o r B lv d M ac ar th u r B lv d W estm i n ster Ave B ri st o l S t W ar n er Ave W ar n er Ave Edi n ger Ave 17th St M a in S t P a rk e r S t 55 22 55 55 57 73 5 405 Colonel W.C. Eldridge Park Friendship Park Jerome Mabury Park Birch Park Logan ParkFrench Park Angels Park Sasser Park Prentice Park Windsor Park Edna park Centennial Regional Santa Ana Memorial Madison Park Delhi Park Adams Park Campesino Park Spurgeon Park El Salvador Park Lowell Park Heritage Park Santa Anita Park Bomo Koral Park Sandpointe Park Carl Thorton Park Lillie King Park River View Park Griset Park Santiago Park Sarah May Downie Fisher Park Portola Park Cabrillo Park Rosita Park Morrison Park Park Deficit Analysis Special thanks to the following data providers: Thomas Brothers, ESRI, and the CA Department of Education Map created by The Trust for Public Land on October 3, 2006 Created in ESRI ArcMap 9.1® Map Projection: NAD 1983 State Plane California VI FIPS 0406 Feet TPL, Trust for Public Land, and The Trust for Public Land logo are trademarks of The Trust for Public Land. Copyright © 2006 The Trust for Public Land. www.tpl.org Information on this map is provided for purposes of discussion and visualization only. Legend Number of Park Acres per 1,000 Kids 0.195 - 1.000 1.001 - 3.000 3.001 - 5.000 5.001 - 7.000 7.001 - 9.121 City of Santa Ana Parks and Open Space Waterbodies Transportation Interstate Highway Major Road Local Road Railroads This map shows the results of The Trust for Public Land’s Park Deficit Model. The park deficit model calculates how many acres of park or open space exist per 1,000 children under the age of 18 within city council districts. It then identifies those districts where there is an insufficient amount of parkland. Santa Ana, California 0 0.5 10.25 Mile Fig. 1. Park deficit analysis. 332 R. García et al. / Preventive Medicine 49 (2009) 330–333 333R. García et al. / Preventive Medicine 49 (2009) 330–333 for the remaining parcels at a cost of $2 per year, for a combined open space of 0.5 acres. In conjunction with a local hospital, LHA secured the pro bono services of two Southern California-based firms to build a safe, environmentally conscious and LEED-certified community center and park. The park will feature a basketball half-court, toddler playground, adolescent jungle gym, and walking path. Security features include wrought iron gates surrounding the park area, safety night lighting, and rest points for elderly users. These features and amenities were included to increase physical activity opportunities for children and their families, and promote community mobilization for a healthy community. Discussion These case studies illustrate how advocacy efforts have resulted in increased access to public resources related to physical activity in several Southern California communities. Given the current inequities in access to public resources in poor and ethnic minority commu- nities, continued advocacy efforts are vital. With regard to the development and use of public lands, we have proposed ten principles to guide policy makers, which we summarize here (See full text of principles in García and White, 2006). The process of decision-making regarding investment of public monies in the built environment need to be transparent and fair and guided by a comprehensive vision for promoting the health of the entire community. Policy-makers should prioritize projects that can meet multiple community needs as well as promote community health such as establishing public parks within the campuses of new and remodeled schools that can provide safe-space for physical activity and potentially remove pollutants from the water and mitigate runoff. Resources should first be allocated to low-income and ethnic minority communities in order to overcome the legacy of inequities in access to high quality public parks and schools. Standards for measuring equity must be established for agencies in order to track progress in building healthy and livable communities for all. Increased attention should be paid to ensuring that recipients of public funds comply with federal and state laws designed to achieve equal access to all public resources including Title VI of the Civil Rights Act of 1964 (i.e., prohibits discrimination on basis of race, color, or national origin for programs and activities conducted with federal funding) and parallel state laws. Finally, the community needs to be engaged and empowered to take part in all aspects of infrastructure decision-making and prepared to engage in advocacy efforts if the outcome of the decision-making process is not satisfactory. Given the agenda of the new federal administration and availability of stimulus funds, many transportation infrastructure projects are underway. These projects must focus attention on ensuring that the low-income and ethnic minority communities benefit at least equally, and efforts should be made to redress past inequities. The subgroups most likely to benefit from increased access are low-income men and women living in resource-poor commu- nities. They have likely devoted their scarce resources to car ownership given the significant obstacles faced in accessing reliable public transport. Individuals in these same communities likely have little leisure time to spend in physical activity and reduced access to recreational facilities, parks or walking trails. Existing educational laws (i.e., “No Child Left Behind” and similar state laws) developed to primarily improve standard academic metrics should be amended to mandate the inclusion of physical education in federal monitoring and accountability. These efforts are likely to have the most benefit for low-income and ethnic minority populations for whom the childhood obesity epidemic is most severe and opportunities for physical activity outside of school are limited. Integration of physical activity into the school day is a prime example of a “push” strategy designed to make the healthy choice easier and unhealthy choice (i.e., remaining inactive) more difficult. Such strategies rely less on individual motivation and choice and thus may be more successful in engaging populations who typically do not participate in physical activity and who may be more likely to benefit (Yancey et al., 2007). Realization of the severity of the obesity and chronic disease epidemics and failure of individually focused interventions has led to heightened interest in implementing environmental interventions to increase physical activity. Although promising, the impact of these strategies in ultimately reducing the obesity epidemic will be limited by the presence of continued inequities in the distribution of physical activity-related resources in the community. Advocacy efforts are critically needed to ensure that all communities benefit equally from infrastructure projects designed to build healthy communities, effective public schools and safe and reliable transportation. Without continued advocacy efforts, the environmental strategies being implemented to increase physical activity levels in the population will lead to a widening versus narrowing of the gap between the health status of the wealthy and poor in this country. Conflict of interest statement The authors declare that there are no conflicts of interest. Acknowledgments The preparation of this paper was funded in part through a grant from the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI) cooperative agreement for the Cancer Prevention and Control Research Networks (CPCRN) 1-U48- DP000056. References Babey, S., Hastert, T., Yu, H., Brown, E.R., 2008. Physical activity among adolescents when do parks matter? Am. J. Prev. Med. 34 (4), 345–348. Brown, E.R., Babey, S.H., Hastert, T.A., Diamant, A.L., 2005. Half of California adults walk less than one hour each week. Health Policy Res. Brief (PB2005-9), 1–8. California Center for Public Health Advocacy, 2006. Dropping the ball: California schools fail to meet physical education mandates. Available at http://www. publichealthadvocacy.org/droppingtheball.html. Accessed November 1 2008. Cawley, J., Meyerhoefer, C., Newhouse, D., 2007. The impact of state physical education requirements on youth physical activity and overweight. Health Econ. 16, 1287–1301. Dannenberg, A.L., Bhatia, R., Cole, B.L., Heaton, S.K., Feldman, J.D., Rutt, C.D., 2008. Use of health impact assessment in the U.S.: 27 case studies, 1999–2007. Am. J. Prev. Med. 34 (3), 241–256. Estabrooks, P.A., Lee, R.E., Gyurcsik, N.C., 2003. Resources for physical activity participation: does availability and accessibility differ by neighborhood socio- economic status? Ann. Behav. Med. 25 (2), 100–104. García, R., Fenwick, C., 2009. Social Science, equal justice, and public health policy: lessons from Los Angeles. J. Public Health Policy 30, S26–S32. García, R., Rubin, T., 2004. Cross Road Blues: transportation justice and the MTA consent decree. In: Lucas, K. (Ed.), Running on Empty, pp. 221–256. García, R., White, A., 2006. Healthy parks, schools, and communities: mapping green access and equity for the Los Angeles Region. The City Project Policy Report 8–9. Available at www.cityprojectca.org/ourwork/mappinggreenaccess/documents/ Healthy_Parks_Schools_Communities_textonly.pdf, accessed 31 October 2008. Lachapelle, U., Frank, L., 2009. Transit and health: mode of transport, employer- sponsored public transit pass programs, and physical activity. J. Public Health Policy 30 (SI), S73–S94. Mather, M. 2009. Most U.S. workers still driving alone. Population Reference Bureau. Accessed at http://www.prb.org/Articles/2008/commuting.aspx?p=1. Sacks, G., Swinburn, B., Lawrence, M., 2009. Obesity policy action framework and analysis grids for a comprehensive policy approach to reducing obesity. Obes. Rev. 10, 76–86. Tajik, M., Minkler, M., 2007. Environmental justice research and action: a case study in political economy and community-academic collaboration. Int. Q. Community Health Educ. 26 (3), 213–231. Trust for Public Land, 2005. City of Santa Ana Feasibility Study. Yancey, A.K., Fielding, J.E., Flores, G.R., Sallis, J.F., McCarthy, W.J., Breslow, L., 2007. Creating a robust public health infrastructure for physical activity promotion. Am. J. Prev. Med. 32, 68–78.