That parks and recreation help facilitate healthy, active lifestyles and physical activity is particularly important given that more than two-thirds of adults in the U.S. are overweight or obese, a risk factor for many chronic diseases. Since the 1990s, there has been a shift from chronic disease treatment to prevention and wellness, and a focus on developing and implementing more evidence-based practices (EBPs). Evidence-based practices are well-researched programs that have been tested broadly and demonstrate effectiveness in a variety of populations; often, programs are focused around health promotion/disease prevention. Some early examples from the 1990s include NRPA’s Hearts ‘N Parks program and CATCH (Coordinated Approach to Child Health), while current examples of EBPs include the Arthritis Foundation’s Walk with Ease program and the Stanford Chronic Disease Self-Management program. Although EBPs are becoming more widespread, there are still significant disparities regarding organizations’ knowledge and capacity to adopt EBPs.
Geographic Hurdles
Rural areas are particularly constrained by lack of human and monetary resources. According to 2013 U.S. Census data, almost 20 percent of this country’s population lives in rural areas, which have higher poverty, all-cause mortality, obesity-related chronic diseases — 39.6 percent of rural versus 33.4 percent of urban residents — inactivity and poorer access to healthy food.
While the Centers for Disease Control and Prevention (CDC) has emphasized the adoption of evidence-based health and wellness programs, many rural communities lack the knowledge, organizational capacity, funding and partnerships to implement them. Even though fewer rural residents are insured and they are more likely to smoke or be inactive than urban or suburban residents, relatively few rural counties are included in funding initiatives to target these risk factors and improve wellness and prevention in their communities. Thus, it is important to understand what is currently being done in rural communities to prevent chronic disease, assess program effectiveness and develop strategies that lead to improved capacity to make community-level changes in health behavior and health outcomes.
Case Study of a Rural Community
The authors evaluated a recreation-based wellness program in a rural Midwestern town — South Town’s (pseudonym) population is 13,000 and is 85.4 percent Caucasian and 10.2 percent African-American. The median household income is $31,905, compared to $47,367 for the state, and 14.6 percent of residents live below the poverty line, while 18 percent are uninsured. In 2009, a local hospital partnered with a recreation center and a faith-based organization to create a wellness center providing community-based programs to address chronic disease management. The resulting adult wellness program promotes weight loss through physical activity and nutrition education. More than 300 participants had completed the six-week program by 2012, meeting twice weekly at the recreation center. Each class included one hour of nutrition education and one hour of exercise instruction — including strength training, treadmill and bicycle — and walking.
A physical therapy assistant teaches the classes, with physicians, dieticians and exercise instructors serving as guest speakers or trainers. Most participants are over age 50, low- or middle-income, and have at least one chronic disease or risk factor. Although they are weighed pre- and post-program and surveyed, the limited budget and personnel prevents this data from being analyzed and leveraged for further benefit (i.e., evaluation of impact, grant funding).
The program is in some ways successful — from 2009-2012, participants lost 3.4 pounds and 0.7 body mass index (BMI) percentage points on average over the six-week program. However, only about half of the people who began the program completed it, and very few men participated, even though men have high rates of chronic diseases at younger ages than women. Participants suggested making the fitness program longer, incentivizing weight loss, increasing accountability, sending email or phone reminders, providing links to helpful websites about chronic disease self-management, adding alternative activities such as swimming, yoga and dance, plus more interactive nutrition classes involving portion size and cooking lessons and a recipe-exchange program.
How Can We Bring More EBPs to Rural Communities?
To increase EBPs in rural communities, including the wellness/chronic disease prevention program these writers worked with, we suggest leveraging more local community and park and recreation resources available, as well as basing programs on the CDC’s Understanding Evidence guide. There are several other cost-effective and easy ways to adopt more EBPs to improve chronic disease prevention and self-management programs:
Increase interest and involvement by developing a broad base of appealing activities, especially those relevant to our everyday lives (e.g. walking, gardening, household chores, playing with children/grandchildren). Emphasis on lifestyle physical activity versus exercise is optimal.
Ensure that programs are long enough to create lifestyle change (preferably 8-12 weeks or longer) and achieve changes in physical fitness/function parameters (e.g., weight, BMI, strength, flexibility). With age, it takes longer for these changes to happen.
Reformat nutrition classes to incorporate recipe sharing, healthy cooking techniques and competitions, and use community resources including gardens, garden centers and farmers’ markets as local subject matter experts and resources in the program.
Use online forums and social media (e.g. Facebook, MyFitnessPal), text messages and devices to track progress (e.g. accelerometers) and increase involvement.
Use data, surveys and outcomes to assess the impact of and tailor programs to participants and specific diseases. If personnel resources are scarce to utilize this data for the organization’s benefit, partner with a community college faculty member and/or students to leverage the data for organizational benefit.
In addition to implementing sound programs that are evidence-based, rural communities are often constrained financially from participating in continuing education where EBPs are showcased and urban areas usually benefit first from large grant-funded programs focused on diffusing EBPs. Additional education, training and resources must be channeled to rural communities to ensure quality health and wellness programming. The CDC’s Understanding Evidence guide notes that it is crucial not only to use the best available research to design programs, but also experiential and contextual evidence, which are both obtained from feedback from participants and community members. Understanding Evidence also gives suggestions of evidence-based practices that can serve as a model for programs. Instead of inventing new programs to address widespread health issues and chronic diseases, using established, evidence-based programs like Active Living Every Day can improve health and be more cost-effective overall for communities without many resources.
Using technology such as text messages or phone apps can also enhance social support and facilitate self-management behaviors, such as counting calories and physical activity, while improving program retention. Instructions for selecting and preparing healthy foods or getting involved with community gardens or farmers’ markets could increase program reach, as well as provide a community context promoting health and well-being.
Many communities are constrained by lack of both monetary and human resources, as well as lack of communication and commitment to a common cause. Programs should ideally involve previous program participants and others as volunteers, increasing program capacity and creating a culture of health and activity. Reunions and follow-up programs such as walking clubs and water aerobics classes could also help engage participants after the programs end. Building a healthier and involved community will also require the involvement of faith-based organizations, service organizations, parks and food providers including farmers and grocery retailers.
Getting feedback and assessing outcomes is also critical to program effectiveness. Rural communities like South Town continue to struggle with resources, activities, attrition and adherence to EBPs, which compromise program effectiveness and participant outcomes. Health and social service organizations should connect more with recreation centers to raise awareness and increase funding, education and training in rural areas. These steps will lead to needed program improvements, translating to better participant health outcomes.
Online Support for EBPs
Many resources are available to offer guidance on evidence-based practice and programs:
The Administration on Aging (AoA) and National Council on Aging’s list of EBPs can be found here and here.
Each division of the CDC has resources for EBPs. Physical activity program resources can be found here.
The Arthritis Foundation offers an EBP called Walk with Ease, which is appropriate for people with arthritis and the general population. More information is available here.
Mary Christoph is a doctoral student in Kinesiology and Community Health at the University of Illinois Urbana-Champaign. Laura Payne is an Associate Professor and Extension Specialist in the Department of Recreation, Sport and Tourism at the University of Illinois Urbana-Champaign.
References
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