Texas Childhood Obesity Prevention Policy Evaluation (T-COPPE Project): Baseline data from Safe Routes to School Policy evaluation Co-Leads: Deanna Hoelscher, PhD, RD, LD Marcia G. Ory, PhD, MPH

Presentation Overview

¨  Why are we doing TCOPPE? ¨ Background and rationale

¨  What are we doing? ¨ Methods

¨  What did we find? ¨ Results

¨  What does it all mean? ¨ Discussion

The Rule of “2s” ¨  Two policies to evaluate

¤ Both aspects of the energy equation: activity and nutrition •  Safe Routes to Schools (SRTS) •  WIC

¤ Two environments •  School/home environment •  Grocery stores/home

¤ Two functional timelines •  School year •  Year round

Slide “2” of “2s” ¨  Two state universities in a unique and effective

working relationship… ¤ The University of Texas School of Public Health ¤ Texas A&M (Health Science Center School of Rural

Public Health)

¨  Two rivalries……

National impact…

starts with evidence of local impact

¨  Robert Wood Johnson Foundation is committed to reducing childhood obesity by 2015

¨  There are a number of national policies identified as aimed at reducing childhood obesity (i.e., SRTS)

¨  Which of these national policies are actually shown to be effective in reducing childhood obesity?

¨  What is the impact of implementing these national policies locally?

Why Evaluating Childhood Obesity & Prevention Policies?

How did we select our policies?

¨  Potential for evidence of effectiveness

¨  Political feasibility ¤  Potential for leadership engagement ¤ Champions identified in Texas

Legislature and State Government

¨  Public Acceptability ¤  Readiness and feasibility in implementation ¤ Documented history of obesity efforts during last decade

How did we select our policies? (cont.)

¨  Partnership support ¤ Live Smart Texas coalition development/support ¤ Partnership for a Healthy Texas

¨  Policy sustainability

Standardized Mode of Transportation Trips to School, 1965-2005

Source: McDonald, N.C. 2007. American Journal of Preventive Medicine

Walking/Biking by Distance to School, 1965-2005

Source: McDonald, N.C. 2007. American Journal of Preventive Medicine

Active Commuting to School

¨  Current childhood obesity epidemic

¨  Children are not meeting current recommendations for physical activity

¨  One strategy to increase physical activity among children: ¤  Walking or biking to and from school (Active Commuting to

School or ACS)

¨  Currently, approximately less than 16% of children use ACS

Survey

¨  And now…..let us hear from you!

Safe Routes to School Policy

¨  SAFETEA-LU ¤  2005 Federal Transportation Bill ¤  % of nation’s total children K-8 to offer increased physical activity

through health alternatives to bus and car school transportation ¤  Texas received about $40 million in Safe Routes to School (SRTS) funding

between 2005 and 2009

¨  State support for SRTS ¤  In September 2007, The Texas Transportation Commission approved

$24.7 million for 244 projects in 66 communities throughout the state ¤  Supplemented by revenue from the God Bless Texas and God Bless

America specialty license plates ¤  Funds administered through grant process

Source: Tx DOT, 2008

Texas SRTS Policy

SRTS

Education

Enforcement

Encouragement

Evaluation

Engineering

¨  For Texas, two major types of grants were awarded: ¤ Construction (Infrastructure) grants, which

include ‘brick and mortar’ type projects, such as construction of crosswalks, sidewalks, etc. n Schools need to have a SRTS plan in place

first ¤ Planning grants, which include a SRTS

plan, which may or may not include potential infrastructure changes or implementation of the plan.

Methods

Measures: • Student (4th grade) survey • Parent survey • ACS • School Checklist • Campus Policy • School Audit

¨  Purpose ¤  To determine the effects of differing

allocation methods of funding (construction versus planning grants) from the Texas Transportation Commission on parent attitudes & behaviors.

¨  Natural experiment ¤ Quasi-experimental

¨  Initial study assumptions ¤  For active commuting to schools (ACS),

construction (infrastructure) schools > planning schools > comparison schools

Methods

Baseline data collected in 2009

¨  Funded schools were selected for measurement based on funding type, location (urban/rural), race/ethnicity, and socioeconomic status (SES); comparison schools had similar characteristics but received no funding.

¨  Data were analyzed using mixed linear regression and controlled for random and fixed effects, and other independent variables.

School Sample – Where We are in Texas

SRTS Baseline Data

School Survey Status Infrastructure Schools

Planning Schools

Control Schools

Total

Measured Spring 2009 11 13 13 37

Measured Fall 2009 14 9 21 44

Total 25 22 34 81

Survey Activity Total (to date)

Student Survey 3315

Parent Survey 2057

Parent/Student Survey Combination

1653

Active Transport Count 12,167

Environmental Audit 79 *

* Two school environmental audits were not done due to safety concerns for the auditors

Demographic Variables by School Condition (n = 81)

Variable Construction Schools (n = 25)

Planning Schools (n = 22)

Comparison Schools (n = 34)

Student Male (%) 49.9 51.9 47.5

Parent race/ethnicity

White (%) 19.8 30.3 24.3

Other (%) 80.2 69.7 75.7

Economically disadvantaged (%)

75.5 65.8 68.3

All family members born in USA (%)

64.1 55.3 57.7

Mean time to school

<5 m (%) 27.0 28.5 20.6

5-10 m (%) 38.5 39.3 36.2

11-20 m (%) 20.9 20.3 25.5

>20 min (%) 13.6 11.9 17.6

Baseline Rates of Active Commuting to School (ACS), n = 79

*Means  are  significantly  different    from  comparison  schools  (p<0.05)  Ac>ve  Commu>ng  is  2-­‐day  self-­‐reported  walking  or  biking  to  or  from  school  Analyses  are  controlled  for  %  economically  disadvantaged,  %  white,  mean  precipita>on,  mean  heat,  mean  wind  speed.  

Mea

n %

AC

S

ACS in 1969 (48%)

Mean Active Commuting to School

Before School n=79

After School n=79

Mean ACS n=79

10.4% 17.1% 13.8%

Analyses were conducted using Mixed Effects Linear Regression

School Environment (Rural)

¨  School in rural area.

¨  Only 2 segments indicated on audit tool. ¤ One was a one-lane

gravel road that separated school property from a corn field.

School Environment (Urban)

Planning school Planning school

Environment Comparisons

¨  Construction school with gate

¨  Planning School with

crosswalk, sidewalks, signage

Environmental Comparisons

¨  Comparison School

¨  Planning School

Differences in Parent Attitudes & Behaviors by School Types at Baseline Variable   Construc0on  Schools  

Mean  (SD)*  n  =  25  

Planning  Schools  Mean  (SD)  n  =  22  

Comparison  Schools  Mean  (SD)  n  =  34  

Asking  Behavior  Scale   1.11  (.09)   1.29  (.10)a   .98  (.08)a  

Parent  Self-­‐Efficacy  Scale   18.6  (.4)a   20.4  (.5)ab   18.7  (.4)b  

Parent  Outcome  Expecta>ons  

13.9  (.2)  a   14.7  (.2)  ab   13.7  (.2)  b  

Student  Self-­‐Efficacy  Scale   27.2  (.5)  a   27.2  (.6)  b   24.7  (.5)  ab  

Arrived  Walking  (%)   10.5  (1.5)  a   9.1  (1.7)  b   4.6  (1.3)  ab  

Arrived  Biking  (%)   0.5  (0.6)  a   2.5  (0.6)  ab   0.5  (0.5)  b  

Arrived  by  School  Bus  (%)   16.4  (4.1)  a   14.0  (4.5)  b   26.9  (3.5)  ab  

TV  on  during  evening  meal   3.51  (.11)  a   3.14  (.12)  ab   3.58  (.09)  b  

TV  >me  on  weekends   4.49  (.07)   4.32  (.08)  a   4.59  (.06)  a  

0

School level analyses using weighted UNIANOVA

What Factors are Associated with Walking or Biking to School (Child)?

Factors NOT Associated with ACS:

• Screen time

• Days PA

• Safety

• Social support

• Attitude

¨  Students who walked or biked to school were more likely to: ¤ Have a friend who walked or biked to

school ¤ Have self-confidence that they could walk

to school ¤ Feel that they could ask their parents to

walk or bike to school

What Factors are Associated with Walking or Biking to School (Parent)? ¨  Parents more likely to let their children commute to

school: ¤ Had higher self-efficacy (self-confidence) in letting their

child walk to school ¤  Perceived better walkability around their house and their

child’s school ¤ Were more likely to let their children walk to other places

from school ¤  Reported better outcomes associated with walking to school (e.g., children would be healthier) ¤  Reported fewer barriers to commuting

Does weather influence ACS?

¨  Students decrease ACS in the morning due to precipitation (marginally significant, p-value=0.099)

¨  When the morning temperature was warmer, ACS was higher (p-value=0.019) ¤ Morning temperature range = 10.4-89.6 degrees

Fahrenheit

¨  Analysis ¤ Covariates in the Mixed Effects Linear Regression

Modeling of ACS

¨  Number of children walking or riding a bike to school was low

¨  We need policies that promote environments that are conducive to walking and biking

¨  We need safety and perception of safety

Implications

¨  Many parent-related variables were consistent with ACS ¤ Parents are highly motivated to participate and be

engaged ¤ Parents made a point to contact both PI and Project

Director to express interest and ask how else to be involved

¨  Need programs that focus on parent education ¨  Need programs that make neighborhoods safer (e.g.,

benefits of complete streets)

Policy Implications

¨  Significant differences were seen in ACS between planning/construction and comparison schools ¤ Outcome expectations, self-efficacy, TV ¤ Grant application process encouraged schools to collect

pilot data n  Smaller grants (planning grants) may be as effective in getting

ACS as larger grants (construction grants) initially n  Grant processèAwarenessèMore likely to engage in ACS? n  More likely to have a program champion? n  Planning schools had greater percentage of children who biked

¨  Allocation of resources may be given to schools who are already working on SRTS ¤ How do we reach other schools?

Conclusions

¨  Child behaviors associated with walking & biking to school included asking behaviors & having friends commute

¨  Programs like SRTS increase walking and bike riding

Conclusions

T-COPPE: Environmental Audit

Why School Audits?

¨  Important role of the built environment in promoting WTS.

¨  Recognition of the many micro-scale and modifiable barriers at/around schools.

¨  Importance of the context-specific and detailed environmental features in changing school travel behaviors

à  Lack/shortage of instruments designed to capture school environments systematically and comprehensively

z

School Audit Components

FORMAT: Letter-size sheets with checklist, rating, closed-end choices, and mapping items

COMPONENTS: A. STREET AUDIT B. SCHOOL SITE AUDIT C. MAP AUDIT – sidewalk, bike lane, drainage ditch, buffer, tr

ail, crosswalk, and bus stop

§  Land Uses §  Street/traffic/parking conditions §  Lighting , other amenities, and sigs § Unattractive items § Perceptual rating items (surveillance, maintenance, cleanliness, vis

ual quality, safety and attractiveness)

Audit Components and Items

Street Segment Audit

•  Audit Items

- For objective

observations

•  Audit info.

- Auditor info.

- Date, weather

- Start/end time

- Street name

•  Segment Image

- Indicating each

segment

- North up

•  Perceptions

•  Map Audit Indicators

- If related items

present, go to

Map Audit(s)

•  Frontage

- Street facing

- Vehicular and

pedestrian entries

•  School Site Image

- Indicating

School site and

property line

- Maine entry

•  On-site facilities

- Physical features

- Amenities, etc. •  Main entry

- Amenities around

main entry

•  D/P Area

- Location, types,

and capacity

School Site Audit

Map Audit Example

Map audit A : sidewalk & informal path

•  Exact locations

•  Detailed conditions slope, shade, width, holes & cracks

, bumps & uneven surface , weed

s , litter , drainage problems, etc.

•  Obstructions poles , parked cars, mail boxes,

etc.

•  Connections

z

Analyzing School Audit Data Preliminary Results

Descriptive Findings from 79 TCOPPE Schools audited across Texas

Street & Map Audit Elements Requiring Improvements:

¤  Bike lanes (98% lacked)

¤  Benches and trash cans (96%)

¤  Traffic calming devices (85%)

¤  Unattractive items/social disorder (75% with 1+)

¤  Street lights (25% lacking)

¤  Sidewalk obstructions (many with poles, parked cars, mail boxes, etc.)

Descriptive Findings from 79 TCOPPE Schools audited across Texas

School Site Audit Elements Requiring Improvements:

¤  Designated drop-off/pick-up area (21 lacked)

¤  Adjacency to vacant/abandoned/undeveloped areas (19 schools)

¤  Lack of walkway connections to school buildings (14 lacked)

¤  Trails/paths within campus (73 lacked)

Frontage Street Audit Items Correlated with % Walkers

Variables B Sig. Presence of sidewalks 10.996 0.001 Presence of street parking 7.143 0.012 Presence of vacant areas -6.999 0.022 Presence of unattended/stray dogs

-8.358 0.050

Presence of drainage ditches -6.853 0.047 Surveillance* 2.030 0.058 Safety in walking* 3.033 0.013 Safety in bicycling* 3.453 0.008 Attractiveness in walking* 2.459 0.048 Attractiveness in bicycling* 2.451 0.047

*likert-type scale item (1 being poor to 5 being excellent)

Other Street Audit Items Correlated with % Walkers

Variable B Sig. Number of intersections*

4 – 10 7.090 0.055 11+ 6.194 0.064

Number of street lights**

1 - 3 6.854 0.037 4+ 4.202 0.247

Presence of street parking 4.628 0.094 Presence of street calming devices

-7.178 0.019

Presence of safety/child crossing sign

7.943 0.006

Presence of landscaped buffer 7.642 0.008

Presence of drainage ditch -5.094 0.096 Presence of crosswalk 6.308 0.081

* The reference category is 0-3 driveways. ** The reference category is 0 street light.

School Site Audit Items Correlated with % Walkers

Variable B Sig. Number of school bus only entry & exit -2.717 0.051 Number of pedestrian only entries & exits 1.562 0.028 Presence of vacant area -7.179 0.029 Presence of sidewalk/walkway connection 9.234 0.016 Presence of private car area -7.163 0.050 Presence of basketball/tennis/volleyball court 7.147 0.006 Presence of baseball/football/soccer field -6.616 0.016 Presence of outdoor swimming pool 5.427 0.056 Presence of bench / seating 6.411 0.019 Presence of picnic table 7.604 0.015

* The reference category is none of evergreen tree.

Photograph by Yang Mi Kim

¨  This School Audit Instrument is a tool that can provide effective and efficient assessments of street and school site environments, focusing on those attributes related to children’s active transportation to school.

¨  The instrument’s three components help objectively identify many easily modifiable elements, facilitating policy development toward creating safe and walkable communities.

¨  With proper training, this audit can be used for education, research, intervention, and policy-support purposes.

¨  The instrument can be shortened and customized, once more data are collected from diverse communities.

Conclusion

T-COPPE: Policy Implications

Multi-pronged Support and Dissemination System… ¨  Partnership with Texas Health Institute part of initial funding proposal with

expectation of ¤  Legislative policy forums in years 1, 2, 3 and 5 of the grant ¤  Sharing activities and findings in “real time”

¨  Support and advisement from Texas Obesity Policy Research Advisory Council (TOPRAC) whose mission is ¤  To provide health policy research, translation, evaluation, and dissemination

support to TCOPPE and Live Smart Texas

¨  Regular feedback to Live Smart Texas (LST) collaboration ¤  Texas coalition working collaboratively on obesity prevention efforts and the

development of resources to fund it ¤  TCOPPE is LST’s first major research project

¨  Respond to opportunities as they arise and are appropriate

Additional opportunities…

¨  Testimony to the Institute of Medicine on Childhood Obesity Prevention workshop in Texas, February 2009

¨  Annual participation in the Texas Obesity Awareness Week events at the Texas Capital

¨  Invited testimony to Texas legislative committees on the state of obesity in Texas

¨  Development of a Strategic Communications Plan ¤  Intensive communications workshop provided by RWJF to

selected individuals ¤  To provide focus and benchmarks for monitoring success and

outlining timely policy forum opportunities

Conclusions

¨  Close collaboration and communication with stakeholders at multiple levels

¨  Dissemination throughout the project ¨  Establish team of credible experts who can inform

and educate legislators—the “go to” team ¨  Policy makers knowledgeable about

issue before research conclusions are made/available

It takes more than a ‘Village’ to do this Texas-sized project…

¤  Roy Allen ¤  Heather Atteberry ¤  Chester Bryant ¤  Arthur Castro ¤  Yichen Cheng ¤  Diane Dowdy ¤  Sandra Evans ¤  Kyna Farmer ¤  Selina Guerra ¤  Emily Hines ¤  Deanna Hoelscher ¤  Leah Kolar ¤  Pat Koym ¤  Chanam Lee ¤  Kris Lykins ¤  Jay Mendoza ¤  Ann Mesaros

¤  Jingang Miao ¤  Lisako McKyer ¤  Hyung Jin Kim ¤  Deb Kellstedt ¤  Tiffni Menendez ¤  Marcia Ory ¤  Courtney Peterson ¤  Mike Pomeroy ¤  Donna Nichols ¤  John Reilly ¤  Tina Simms ¤  Carolyn Smith ¤  Christine Tisone ¤  Suojin Wang ¤  Pete Walton ¤  Jerri Ward ¤  Cheryl Brien-Warren

It takes a TEXAS-sized team…

Contact Information

Live Smart Texas ¤  Tiffni Menendez, MPH

512-391-2512 Tiffni.Menendez@uth.tmc.edu

T-COPPE ¤ Diane Dowdy, PhD

979-458-4249 Dowdy@srph.tamhsc.edu

Acknowledgements

This work was partially supported by three Robert Wood Johnson Foundation grants (64634, 63755, 65539).

We would like to thank: n Arthur Casto for his help with the audits.

n  Jun Hyun Kim, Carolyn Smith, Ashley Wilson, and Chelsea Mounce for the valuable inputs during the instrument development phases.

n Dr. Woosung Lee for his help with the data analyses.

To request a copy of the instrument & manual, please contact Diane Dowdy, PhD, TCOPPE Project Director:

Dowdy@srph.tamhsc.edu

Current Stats: The Walking School Bus and Children's Physical Activity Study

¨  Objective: Evaluated a walking school bus program on active commute and moderate to vigorous physical activity (MVPA)

¨  Intervention: Walking school bus (a group of children led by an adult to and from school )

¤  Intervention group: n=4 schools; 70 4th graders

¤  Control group: n=4 schools; 79 4th graders

¤  76% of total students from low-income families (<= $30,000)

¤  91% of students Hispanic; 47% of students Black

¨  Measures: self-questionnaire and accelerometry at Time 1 and Time 2

¨  Results:

¤  Intervention group increased daily minutes of MVPA from 46.6 +/- 4.5 at Time 1 to 48.8 +/- 4.5 at Time 2

¤  Control group decreased daily minutes of MVPA from 46.1 +/- 4.3 at Time 1 to 41.3 +/- 4.3 at Time 2

Source: Mendoza JA, et al. Pediatrics, 2011.

The Walking School Bus and Children's Physical Activity Study: continued

¨  Objectives:

¤  Evaluate the feasibility of a protocol to measure changes to children’s pedestrian safety behaviors

¤  Evaluate the potential influence of the WSB program, neighborhood safety, and intersection characteristics on children’s pedestrian safety behaviors at the school-level

¨  Intervention group: Taught and modeled safe pedestrian behaviors during walks from trained staff members

¨  Control group: Received usual information from school district about school transportation

¨  Results: impact on pedestrian behaviors is unknown ¤  Child pedestrians at the intervention schools had a five- fold higher odds of

crossing at the corner or crosswalk compared to pedestrians at control schools

¤  Child pedestrians at the intervention school also had five-fold lower odds of stopping at the curb versus control schools

Source: Mendoza JA, et al. Health Place, 2012.

Methods

¨  Baseline data collected for T-COPPE Study ¨  4th grade students and parents were recruited

through 81 schools ¨  Active Transport Survey/Counts

¤ Collected in classrooms ¤ 2-day self-report ¤ Validated instrument