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Shared Responsibility: California's State andCommunity Partnerships to Promote Physical Activityamong Diverse PopulationsSora Park Tanjasiri DrPH aa Department of Environmental Analysis and Design , School of Social Ecology, University ofCalifornia , Irvine , USAPublished online: 22 Feb 2013.

To cite this article: Sora Park Tanjasiri DrPH (1999) Shared Responsibility: California's State and Community Partnershipsto Promote Physical Activity among Diverse Populations, Journal of Health Education, 30:sup2, S64-S71, DOI:10.1080/10556699.1999.10603435

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Shared Responsibility: California‘s State and Community Partnerships to Promote Physical

Activity Among Diverse Populations

Sora Park Tanjasiri

ABSTRACT

This article discusses the models and implementa t ion strategies used b y the California Depar tment of Health Services’ ON T H E MOVE! program and the conimuni ty projects to p lan and inzpletizent physical act iv i ty programs in ethnically and soc iodernograp~icul~y diverse populations. Despite diffrrences in conzmunity settings rind target populations, urii-

versa1 needs guided state health program consultants in their provision of technical assistance and support to local c o m m u n i t y agencies. However, unique approaches were used to tailor physical activities to each populat ion, requiring flexibility in the consideration of ethnic, cultural, geographic, a n d socioeconotnic differences. Lessons learned f r o m the success o f th i s shured partnership between the state lzeriltli department and local coinnrunities hold impor tant irnplica- tions for health planners and educators striving to meet the challenges of health promotion in diverse populations.

Ample scientific literature documents the link between physical inactivity and chronic diseases (Powell & Blair, 1994). The landmark Surgeon General’s report on physi- cal activity and health (U.S. Department of Health and Human Services, 1996) provided an in-depth summary of the available epide- miological and behavioral research data and helped to spotlight physical inactivity as the second leading cause of death in this coun- try. Of particular concern are the higher rates of inactivity and cardiovascular and other chronic diseases among ethnically diverse populations, as described by Cassady, Jang, Tanjasiri, and Morrison (1999).

Primary prevention of cardiovascular disease has traditionally employed commu- nity-based interventions that aim to change not only individual behaviors but also poli- cies and environments of entire populations (Fawcett et al., 1995). Studies such as the Min- nesota Heart Health Study, the Stanford Five

City Project, and the Pawtucket Heart Health Program provide ample evidence of the benefits of community-based health promo- tion projects (Luepker et al., 1994). However, they do not describe the nuances of imple- ment ing programs in ethnically and sociodemographically diverse segments of their target populations.

The Surgeon General’s report highlights the potential for collaborations between state and local governments, community groups, and businesses to reduce risk factors among employees and residents (U.S. Department of Health and Human Services, 1996). The Cali- fornia Department of Health Services’ ON THE MOVE! program represented just such a partnership between a state health department and local communities. The state health de- partment was concerned with how to foster physical activity promotion programs success- fully in diverse community settings. The par- ticipating communities were dedicated to re-

ducing the burden of chronic disease for such ethnically and socioeconomically diverse populations as rural American Indians, South- east Asian immigrants, urban African Ameri- cans, and low- to moderate-income Latinos. This article focuses on how the many respon- sibilities for accomplishing the ON THE MOVE! program were differentiated between the state department of health and the local participating communities, and the approaches employed by each partner to tailor physical xtivity programs to nine unique populations.

Methods Information included in this article was

obtained from several sources. Printed mate-

Sora Pork Tanjasiri, DrPH, is a postdoctoral fellow in the Departnierzt of Environmental Analysis and Design, School of Sociul Ecology, Lhi iws i ty of Ciilifornia, Irvinc.

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rials and reports were the main sources of information on the state’s role in the ON THE MOVE! program, including the original re- quest for applications, printed program de- scriptions, and state progress and evaluation reports. In addition, staff from the California Department of Health Services were con- sulted for descriptions of the underlying phi- losophies and strategies used in the state’s ef- forts. Information on the diverse strategies and experiences of the participating commu- nities came from contractors’ progress re- ports, final reports, program educational materials, supporting program information (e.g., newspaper reports), and articles writ- ten by the contractors. Thus, the information contained in this article represents an induc- tive collection of experiences and lessons learned from the state and the partnering communities.

Differentiating Responsibilities in State and Local Partnerships

Developing physical activity interven- tions that were appropriate and relevant to diverse communities in California presented enormous challenges for staff at the state and community levels. A framework previously proposed by Pasick, D’Onofrio, and Otero- Sabogal (1996) provides a basis for under- standing the relative contribution of cultural concerns to program planning and imple- mentation. According to the authors, cultural concerns are relatively less influential than other factors (such as staff expertise and avail- able resources) in identifying problems and setting objectives, approximately equally in- fluential in identifying relevant theories, and relatively more influential in designing and implementing interventions. This framework helps to differentiate the roles of the state and local community partners in the ON THE MOVE! program, with each partner assum- ing primary responsibility for guiding differ- ent phases of program planning based on their experience in cultural tailoring.

Since there is little research on how be- havioral theories differentially influence sub- group populations, program planning is driven by more universal perspectives from commu- nity health promotion. The same could be said for the selection of intervention approaches,

which in ethnically diverse communities usu- ally involve lay leader training, individual communication strategies, mass media in- volvement, and changes in the broader com- munity to support physical activity (Fawcett et al., 1995). However, the ways in which these approaches are specifically designed and implemented undoubtedly depend on the unique characteristics of the target populations. For instance, an urban African American pro- gram may involve churches as sites for aerobic instructor recruitment and classes, while a ru- ral Southeast Asian refugee community may respond to clan-based outreach strategies that recruit entire families into community garden- ing efforts. This highly tailored implementation represents what Pasick et al. (1996) refer to as “the emics of individual groups.”

This framework is helpful in describing the differentiation of efforts and responsibili- ties between state and local communities for conducting California’s ON THE MOVE! program. At the state level, by design, the planning process undertaken by all commu- nities created uniform guidelines and bench- marks for physical activity in each commu- nity. Such a systematic approach to health promotion planning is reflected in models proposed by numerous researchers (Green & Kreuter, 1991; Hiatt et al., 1996) that maxi- mize comparability of outcomes between di- verse interventions. For local communities implementation of interventions required flexibility in response to ethnic, cultural, geo- graphic, and socioeconomic differences. The entire planning, implementation, and evalu- ation processes involved members of the com- munities, thereby helping to maximize efforts for capacity building and institutionalization of physical activity values and programs.

State Approaches for Universal Planning Planning for changes in physical activ-

ity in ethnically diverse communities repre- sented an enormous challenge, particularly in communities so burdened with other prob- lems that physical activity is not viewed as a priority issue. Numerous planning models for health promotion exist that guide the identi- fication of health status goals, levels of inter- vention, targets of interventions, and strate- gies for change (Green & Kreuter, 1991; McLeroy, Bibeau, Steckler, & Glantz, 1988;

Pasick et al., 1996). In terms of cultural con- siderations, as described by Pasick et al., mod- els such as Green and Kreuter’s PRECEDE- PROCEED do not explicitly prescribe cultur- ally relevant interventions. Rather, they are generic steps to follow that require tailoring at specific stages. According to Pasick and her colleagues, while the goals and objectives of a health promotion problem (e.g., increasing physical activity) are likely to be similar across cultures, the intervention designs and strate- gies (e.g., specific outreach strategies and fit- ness activities) will differ considerably based on cultural appropriateness. The notion of universal planning processes could also be said to hold for other factors, such as eco- nomic resources and language limitations.

Similarly, the ON THE MOVE! program provided planning guidelines that all commu- nity contractors had to accomplish, while leaving other aspects of specific program de- sign and implementation to be tailored by the communities. The state required that the lo- cal projects utilize two specific health promo- tion planning approaches. The first approach was the Spectrum of Prevention (Swift, 1987), which represents an ecological approach that targets multiple levels for health promotion. The coalition level of the spectrum was fur- ther developed by a coalition-building ap- proach, which took the concept of commu- nity mobilization explored in the 1-year Cali- fornia Community Action and Mobilization Project (C-CAMP) and institutionalized it into the contractor work plans. In general, these two approaches were selected because of their appropriateness to community-level work, their recognition of community power structures and processes, and their fostering of capacity building for long-term commu- nity change for physical activity.

Spectrum of Prevention The ON THE MOVE! program was fun-

damentally based on the notion of multiple targets of change for community-wide in- creases in physical activity. According to McLeroy et al. (1988), health behavior affects, and is affected by, multiple levels of influence from micro (face-to-face) to macro (cultural beliefs and values that influence the different systems). Thus, an ecological model for health promotion contains strategies targeting

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I Table 1. Levels of Prevention at which Contractors Conducted Physical Activity Work

Asian Health Services Walk for Hralrh

Pirrsburg Active Living Project

Fitness Fmatic,

La Vida Bcrena

Contra Costa County

Drew University

Escondido Community Health Cntr

LEVEL OF PREVENTION Individual Community Provider Coalition Organizational Poky Skills Education Education Practice

X X X X X

X X X X X

X X X X X

X X X X X

Fresno County

St Mary Medical Center

San Joaquin County

La Vida Comirando

Families if ’ Good qealth

Africa1 Arr’rirar tiypertmsion Rick Reducr on

Southern Indian Health Council Work Out lo Lovw Fdt (WOLF)

United Indian Health Service CUitLJral hmlth ard

1 Mobilizamn Project KHAMPI

intrapersonal, interpersonal, institutional, community, and public policy factors. Indeed, program institutionalization derives from consideration of organizational factors (e.g., whether the sponsoring agency has a high fit between its mission and the health promo- tion program) and policy factors (e.g., whether the community uses brokers as in- termediaries between funders and program implementers) (Steckler & Goodman, 1989). The ecological model for health promotion planning represents a widely accepted ap- proach in physical activity interventions (Stokols, 1992; U.S. Department of Health and Human Services, 1996).

ON THE MOVE! recognized the impor- tance of such an approach for ethnically di- verse and low-income communities and em- braced the Spectrum of Prevention as a framework for multilevel physical activity promotion in California. Like other planning frameworks, it could be modified to the cul- tural and sociodemographic factors of differ- ent ethnic and racial populations. As de- scribed by Cassady et al. (1999), the model prescribes intervention on six levels: strength- ening individual knowledge and skills, pro-

X X X X X

X X X X X

X X X X

X X X X

X X X X X

moting community education, educating pro- viders, fostering coalitions and networks, changing organizational practices, and influ- encing policy and legislation.

A review of the projects’ work plans over the 3 years of funding indicated a combina- tion of activities representing at least four lev- els of the spectrum (Table 1 ) . All projects sought to incorporate coalition building into their work plans. In addition, traditional indi- vidual and community-level outreach activi- ties were proposed and implemented by all.

Eight of the projects also conducted pro- vider educational activities, which target health professionals and advocates who have regular contact with large numbers of at-risk people. Changes involving organizational practices and community policies were more difficult for contractors to anticipate. While five of the nine contractors chose intervention strategies targeting organizational behaviors, no shared notion of what such work entails emerged from the contractors’ work plans.

Clearly, the most difficult area for con- tractors was the level of policy change. Only a few contractors incorporated policy change work in their efforts. Issues of cost and time

created challenges to policy development. Unfortunately, a past article by King and her colleagues (1995) on policy change in physi- cal activity programs did not describe any direct efforts that can take place in the com- munity setting. Thus, while an ecological model for program planning may represent the current trend in physical fitness and health promotion, the lack of documented successes and failures points to glaring gaps in both health promotion research and practice.

Coalition-Building Approach The coalition level of the Spectrum of

Prevention was further developed in the department’s coalition-building approach. All contractors were required to use coalition building as a component of their interven- tions. Stemming from community develop- ment models of health promotion, coalition development calls for participation of a broad cross-section of people in a community work- ing on a common goal. Best described by Rothman and Tropman (1979), community development relies on consensus building among diverse community and interest groups, with d coordinator functioning as a facilitator of group discussions and progress.

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Community coalitions represent a key com- ponent of such an approach because they bring together different sectors (e.g., business, health, education, and religion) to address common problems (Thompson & Kinne, 1990). Community coalitions can also ensure that cultural themes and socioeconomic bar- riers are considered in program planning.

Community development partnerships between community coalitions and external facilitators are used to orchestrate planned change. Such was the case for the department’s Health Promotion Section, which believed that capacity-building processes could address a broad range of health promotion issues of immediate concern to local communities. Thus was conceived C-CAMP, described by Cassady et al. (1999). Of the 15 original community mobilization projects, six agencies successfully competed in the ON THE MOVE! request for applications. Through C-CAMP, these agen- cies had 1 year’s worth of coalition organizing under their belt and could“hit the ground run- ning” for physical activity programs. For in- stance, San Joaquin’s C-CAMP coalition initi- ated walking club activities for Afiican Ameri- cans even before notification of ON THE MOVE! funding.

Of the three ON THE MOVE! projects that did not have C-CAMP funding, two projects experienced challenges in mobilizing a broad cross-section of community partici-

I . Individual knowledge and skills

pants on their coalitions. For instance, the Contra Costa County Department of Health Services was not unsuccessful in mobilizing an advisory board to advocate for policy change and rely instead on preexisting coali- tions for networking contacts and guidance. Asian Health Services’ health education staff faced the difficulty of working within a clini- cal setting that did not consider coalition- building work as part of their priority activi- ties. In contrast, Escondido Community Health Center’s La Vida Buena Project suc- cessfully convened a coalition of Latino com- munity activists, health care providers, and health service organizations that continues to meet because of their shared need to mobi- lize Latinos for improvements in health sta- tus and health promotion. Experiences of ON THE MOVE! projects point to the need for time and resources to successfully engage in community development and coalition mo- bilization processes, particularly in low-in- come communities of color.

Bilingual materials, incorporation of physical activity into traditional practices

Free physical activity programs, child care

Local Community Approaches for Intervention Tailoring and Implementation

In contrast to the broad planning ap- proaches used to guide the projects, the task of tailoring basic physical activity interven- tion approaches to the unique cultural and sociodemographic characteristics of local

2. Promoting community education

communities fell to each contractor. Several factors informed the design and implemen- tation of contractors’ activities, which can be broadly broken down into two categories: (1) ethnicity and culture, including language, nativity, traditional beliefs and practices, and cultural community structures; and (2) eco- nomics, including individual income, fees for services, organizational budgets, and utility costs. Other environmental factors included community structure (urban versus rural), geography (contiguousness of targeted popu- lations), and community resources (presence of parks and other physical activity facilities).

How did the projects tailor their pro- grams to the unique characteristics of their communities and target populations? As shown in Table 2, programs were tailored to cultural and economic factors at nearly every level of the Spectrum of Prevention. Specific examples of program tailoring are described below. While most examples rep- resent tailoring of programs to characteris- tics of the targeted populations, some ex- amples describe experiences that arose within the contracting agency in their efforts to pro- mote physical activity to underserved ethnic minority communities.

Tailoring Programs to Ethnic and Cultural Factors

At the individual level of prevention, many well-established strategies were used to

Bilingual and bicultural staff, lay leader training volunteers and businesses

In-kind support from community

1 Levels of Prevention I Ethnic and/or Cultural Considerations I Economic Considerations I

4. Fostering coalitions and networks Traditional tribal activities, conferring with tribal elders prior to coalition development

Fund-raising benefits for collaborating community orqanizations

5. Changing organizational practice

6. Influencing policy and legislation Providing support to reticent Southeast Asian community members testifying at

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tailor programs to the ethnicity and culture of the targeted populations. As described by Sabogal, Otero-Sabogal, Pasick, Jenkins, and Perez-Stable (19961, health education mate- rials have the potential to reach diverse popu- lations with important health messages. De- velopment of culturally specific materials holds the greatest potential for heightened relevance for the most isolated groups (i.e., nonacculturated immigrants) within any eth- nic population. In communities where En- glish was a second language, ON THE MOVE! projects developed and distributed bilingual materials promoting their program and de- scribing the importance of physical activity for their populations, In addition to bro- chures, some contractors developed colorful posters with traditional images to promote physical activity or created music tape cas- settes with messages about physical activity and other cardiovascular health topics inter- spersed between traditional songs.

At the community education level of prevention, tailoring of health education ap- proaches begins with the beliefs and charac- teristics of a specific population and devel- ops unique interventions for those elements. Two ON THE MOVE! projects developed unique physical activity programs based on the cultural beliefs and practices of the com- munities they served. St. Mary Medical Cen- ter considered cultural values of family and self-reliance in their Families in Good Health program for the Cambodian, Lao, a n d Hmong refugee populations of Long Beach. Before the advent of war that transplanted these refugees from their homelands, these were agrarian populations that depended on farming for subsistence. Thus, community gardens were initiated on three plots of land; the gardening activities promoted physical fitness while preserving cultural concepts of self-esteem and self-reliance. The United In- dian Health Service went beyond exercise goals to embrace cultural beliefs of respect for elders and the importance of oral histories for cultural continuation. For instance, Oh- Welth-Per (stick game) tournaments were taught by tribal elders to young men as a way of physical and spiritual training as well as a way to pass down the history of “old ways.”

Several contractors also incorporated

culture into specific physical fitness activities in their communities. These agencies adapted standard physical fitness strategies (e.g., dance classes, aerobics) to include culturally themed activities. For instance, the San Joaquin County Public Health Services conducted well-at- tended Afro-Haitian dance classes at a coni- munity center in their target region of South- east Stockton. Further evidence of the dance classes’appeal could be seen in dance class per- formances at the Black Family Day Celebra- tion and the state and county fair. Similarly, Escondido Community Health Center initiated Latin aerobic classes in their community.

At the level of educating service provid- ers, the ethnic match of staff to the target populations was a common concern of con- tractors. Ideally, participation and communi- cation are maximized when program staff and community participants share cultural char- acteristics and language abilities. All ON THE MOVE! projects employed health education and outreach staff that spoke the same lan- guages as their target populations. In the case of St. Mary Medical Center and Escondido Community Health Center, the health edu- cators were recruited directly from the com- munities and served as role models and pro- moters for physical activity. While ideal, in- volvement of community members as edu- cators was not always possible. In the case of Charles R. Drew University, language capa- bility was not an issue for their African Ameri- can population; however, in the first 2 years of the project a connection between program staff and community participants may not have been made because of differences be- tween the academic environment and the community setting. Finally, outreach to mul- tiple ethnic populations posed a unique prob- lem to Asian Health Services. In their case, bilingual staff were hired from the Chinese, Korean, and Vietnamese communities. How- ever, budget considerations limited their em- ployment to half time, which proved challeng- ing to program planning and implementation in all three communities.

Beyond project staff, ethnic matching between community service providers and populations arose as an important concern in the case of St. Mary Medical Center’s Fami- lies in Good Health. Original plans to promote

YMCA exercise classes to Cambodian families were changed after the community revealed their desire for more Cambodian staff at the YMCA to provide language access and posi- tive role models for their families. A change in staffing was undoubtedly successful, as evi- denced by the enrollment of over 50 South- east Asian youths in the summer program.

At the coalition level of prevention, cul- tural considerations formed the organizing core of work by the United Indian Health Ser- vice. Their project served a 4,500-square-mile area and took on the difficult task of orga- nizing coalitions of American Indians in seven urban and rural communities. Many tribes were represented within each Community, and members were often descendants of several tribes. Project staff considered cultural issues by soliciting the involvement of elders from different tribes in order to understand the most culturally relevant and respectful ways to in- corporate physical activity into the communi- ties. This process resulted in the identification of traditional activities played by all tribes, such as the stick game, that enabled tribes to com- pete against each other within a community.

Finally, with regard to the policy level of prevention, St. Mary Medical Center faced considerable challenges in getting Cambo- dian, Lao, and Hmong refugees to speak out for policy changes in Long Beach. At first, they found that the cultural values of Southeast Asian populations promoted harmony and discouraged individuals from disrupting community life. To encourage individuals to testify at public hearings of the city council, project staff ensured that all policy activities had the support of Southeast Asian families and mainstream organizations. This step al- lowed individuals to testify with feelings of legitimacy and collectivism.

Tailoring Programs to Economic Factors While there are fewer examples of tai-

loring programs to economic factors than to cultural factors, contractors tailored many of their individual, community, coalition, and organizational activities to the socioeconomic levels of their targeted populations. At the individual level of prevention, projects used a variety of approaches. All projects limited financial costs to individuals, often offering activities for free. Escondido Community

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Health Center improved access to individuals by offering classes at nearby nonfitness-related locales, such as schools, churches, and hous- ing complexes. San Joaquin County Public Health Services incorporated a different aspect of economics into their walking clubs. Beyond offering all of their clubs at no cost, they also partnered with a local community coalition that wanted to reduce crime in the neighbor- hood. Thus, the walking club offered an in- crease in physical activity for participants while monitoring neighborhood crime in this low- socioeconomic area.

At the community level of prevention, an interesting example of the economics of health promotion programs was the fact that many of the projects were successful in obtain- ing considerable in-kind support and contri- butions to supplement funding for the promo- tion of physical activity. According to a depart- mental analysis, the value of in-kind contri- butions varied from $475, representing less than 1% of the contract award, to $98,400, repre- senting 89% of the award. Examples of in-kind support included volunteer labor, facility space, physical activity equipment, and incen- tive items such as bottled water and fruit. The types of in-kind support varied by the projects, and the impact of these items on the project and the individual participants is unclear.

With regard to both facilitating coali- tions and changing organizational practices, Asian Health Services discovered the need to

address financial resources in their attempt to involve nonhealth-specific community- based organizations in the cosponsorship of a community walkathon. While their goal was to introduce the benefits of physical activity via the walkathon, staff found that other mainstream Chinese community organiza- tions valued a walkathon as a potential fund- raiser for themselves. During the 3 years of the program, the walkathon fulfilled both needs. Unfortunately, after the conclusion of their ON THE MOVE! project, Asian Health Services transferred primary sponsorship to another organization, which ultimately dis- continued the event because of its poor fund- raising ability.

Examples of Efective Program Tailoring in Reaching Diverse Populations

What was the net effect of program tai- loring, including consideration of cultural and socioeconomic factors, on the recruit- ment of diverse populations? As shown in Table 3, the characteristics of ON THE MOVE! program participants at recruitment attest to the success of program tailoring efforts. With regard to recruiting people of diverse ethnicities and cultures, the over- whelming majority of participants were people of color. A little less than half of the participants spoke a language other than En- glish at home. With regard to understanding the socioeconomic characteristics of program participants, data are limited to educational

Table 3. Characteristics of Participants at 6, Recruitment into the ON THE MOM!

Ethniciy/Culture American Indian African American Asian American Hispanic/Latino White Other

Language Non-English-speaking at home English speaking at home

Education Less than high school diploma High school diploma or more

N=3,706 (%)

351 (10%) 949 (26%) 913 (25%)

1,022 (28%) 203 (6%) 176 (5%)

1,405 (44%) 1,805 (56%)

1,681 (46%) 2,012 (54%)

level only. However, nearly half of all partici- pants possessed less than a high school di- ploma. This proportion also varied by project, ranging from a low of 13% among urban Af- rican American clients at Charles R. Drew University of Medicine and Science to a high of 91% among primarily Southeast Asian refugee clients at St. Mary Medical Center.

Discussion Overall, what can be learned from the

experiences of the state and local partners in the ON THE MOVE! program? Clearly, the delineation of roles and responsibilities be- tween the state health department and the local community projects facilitated the uni- form planning of multilevel, coalition-driven physical activity programs in all nine partici- pating communities. However, the nuances of unique populations mandated the unique tai- loring of programs, particularly to the eth- nic, cultural, and socioeconomic factors within each community. The concerted yet tailored approach succeeded in reaching a vast diversity of adults, with over three-quarters of participants being African American, Asian American, or HispanidLatino. While some past studies have suggested ways to adapt physical activity programs to ethnically di- verse populations, we know of no cross-cul- tural research that has synthesized the expe- riences into similarities and differences in approaching community-based planning and implementation. The ON THE MOVE! pro- gram represented an ideal opportunity to iden- tify key models or model components neces- sary for attaining the universal goal of physical activity within diverse populations.

Implications for State Health Department Planners

How can state departments of health 1

foster and support community-based physi- cal activity programs for diverse populations? State agencies possess several tools that, when directed toward community capacity-build- ing processes, can represent valuable inputs into state-community partnerships. First, the availability of well-established planning mod- els conducive to fostering community capac- ity building for physical activity points to the need for a shift in state allocations for health promotion. Funding initiatives based on

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disease-specific categories of need often limit the health promotion goals to health status improvements . The O N THE MOVE! program’s successes at the local level were in large part the result of a community-based approach that emphasized the development of coalitions to identify community needs, strategize funding requests, and develop com- munity-based interventions. When the deci- sion was made to spearhead a statewide physi- cal fitness campaign, communities were given guiding principles (the Spectrum of Preven- tion) rather than prescribed educational ac- tivities to include in their interventions. The success of ecologically minded programs can be seen in the continuation of physical activi- ties in some communities after the conclu- sion of state funding. Evidence of the timeli- ness of the ON THE MOVE! initiative can be seen in the inclusion of activity in California’s 5-A-Day and Project LEAN nutritional pro- grams, as well as in the youth initiative of a major private California foundation.

The introduction of universal program planning models and community mobiliza- tion processes early in the ON THE MOVE! initiative was crucial to the uniform approach made by nine diverse contracting agencies. The California Department of Health Services staff provided support to the projects via in- tensive technical assistance and training in program planning, evaluation, and basic prin- ciples of physical activity for local commu- nity organizations and staff. This assistance was supplemented with biannual training for ON THE MOVE! projects in physical activity instruction, media advocacy, and evaluation survey administration. Such intensive work requires effort beyond basic contract moni- toring roles, and the state department of health staff saw themselves as not only bu- reaucratic officers but also community part- ners in nine physical activity efforts.

Implications f o r Communi ty Health Educators

In contrast to the discussion and appli- cation of well-established planning models, little guidance can be found in the research literature for models of ethnically diverse physical activity programs. Wha t was uniquely cultural about the experiences of ON THE MOVE! projects, and could they

help in the planning of future programs and research? As opposed to multicultural research studies, our observations arose from the ex- periences of implementing health promotion in each community. Local projects employed a variety of means of adapting physical fit- ness messages to the cultural and geographic nuances of their communities. Rather than promoting physical activity as a health issue, they made it relevant to other social values and traditions of their target communities.

All of the local projects tackled the chal- lenge of making physical activity a priority goal in their communities by selecting strate- gies they felt would attract their populations. However, the difficulties many projects faced in their communities point to the need for ongoing needs assessments. In the case of Asian Health Services, physicians resisted pro- viding referrals to walking club programs, possibly because of their lack of belief in walk- ing as an effective health regimen or their lack of time to provide basic walking education to their patients. Needs assessment should not be limited to the planning phase of programs. In the case of St. Mary Medical Center, origi- nal plans to promote YMCA exercise classes to Cambodian families were changed after community members revealed their desire for more Cambodian staff at the YMCA. Such flexibility is an important asset for commu- nity health educators.

While the 1996 Surgeon General’s report stressed the need for environmental and policy approaches for physical activity inter- ventions, the experiences of ON THE MOVE! projects highlight the many barriers in low- income, ethnically diverse communities. Con- tra Costa County’s health promotion staff faced numerous difficulties in promoting a sliding-scale fee structure for their city’s rec- reational activities, in part because of prior- ity pressures brought on by managed care, welfare reform, and possibly anti-immigrant issues. Budgetary constraints on public parks and recreation departments provide further barriers to promoting geographic, financial, and language access for low-income and non- English-speaking populations.

In summary, perhaps ON THE MOVE! made the greatest contribution to health pro- motion by modeling a shared partnership

between the state and local communities for physical activity. Such a mutually beneficial approach holds the key to long-term commu- nity capacity building. Rather than fuel the debate about how to reach thel‘hard to reach,” this shared partnership relied on the wisdom of communities to create their own uniquely tailored strategies. While not all of the pro- grams succeeded, all of the communities ben- efitted from the experiential learning inher- ent in community mobilization processes.

Acknowledgments I am grateful to Lisa Hershey for her con-

t r ibut ion to this paper, a n d to Lourdes Baezconde-Garbanati, Diana Cassady, Sigrid Deeds, Virginia Jang, and Cynthia Morrison for their comments on earlier drafts.

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omoting Phy ical Activit “We need to get up,

we need to speak out, we need to do

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