Citation
Child's play

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Title:
Child's play community solutions for increasing youth physical activity in distinct safety contexts
Creator:
Phibbs, Stephanie L. ( author )
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
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1 online resource (225 pages). : ;

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Subjects / Keywords:
Physical fitness for youth ( lcsh )
Participant observation ( lcsh )
Observation (Psychology) ( lcsh )
Observation (Psychology) ( fast )
Participant observation ( fast )
Physical fitness for youth ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Review:
ABSTRACT Amid the uniformly low physical activity rates among children in the United State, practical solutions for increasing physical activity (PA) are needed. Whether interventions to increase PA need to account for individual demographic characteristics or safety context is unknown. Methods: Study Design: This community based participatory research project used mixed methods, including secondary data analyses and concept mapping. Setting: Five demographically diverse, geographically contiguous, urban neighborhoods in Colorado, including one of the largest redevelopments in the United States designed for active living. Measures: Secondary data identified neighborhood safety contexts. Concept mapping participants identified, sorted and rated interventions to increase youth PA. Population: Participants were purposefully sampled households, including equal numbers of black, white and Latino adults from each safety context, and their 10-14 year-old children. Analysis: Cluster analysis using measures of social cohesion, incivilities, discrimination, and fear of crime and traffic safety identified homogenous safety subgroups. ANOVA, multivariable analyses and concept mapping pattern matching were used to compare ratings between safety contexts and demographic groups. Results: Cluster analyses identified three distinct safety contexts. Concept mapping elicited 330 ideas, 100 of which were randomly selected for participants to sort and rate. Three intervention groupings were identified: 1) activity interventions, 2) safety interventions, and 3) infrastructure/access interventions. Participants residing in less safe contexts, and black and Latino adults, rated all interventions as more needed than participants from the safest context and white adults. Adults residing in the safest context thought infrastructure/access interventions were most needed, while adults from less safe contexts rated safety interventions as most needed. Youth across all contexts thought safety interventions were least needed; activity and infrastructure/access interventions were most needed. Community-led analyses identified that all youth across all contexts wanted safe, free and fun physical activity resources and opportunities. Discussion: Safety context is an indicator of community need for youth physical activity interventions. Communities recommend framing and implementing interventions that are simultaneously safe, free and fun, rather than focusing exclusively on safety intervention needs that stigmatize neighborhoods. Top rated interventions are consistent with nationally recommended interventions.
Thesis:
Thesis (Ph.D.)--University of Colorado Denver. Health and behavioral sciences
Bibliography:
Includes bibliographic references.
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Stepahnie L. Phibbs.

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Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
868701889 ( OCLC )
ocn868701889

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CHILDS PLAY: COMMUNITY SOLUTIONS FOR INCREASING YOUTH PHYSICAL ACTIVITY IN DISTINCT SAFETY CONTEXTS by Stephanie L. Phibbs B.A., University of Redlands, CA, 1993 M.P.H., University of Nottingham, England, 1995 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences Program 2013

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2013 STEPHANIE L. PHIBBS ALL RIGHTS RESERVED

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This thesis for the Doctor of Philosophy degree by Stephanie L. Phibbs has been approved for the Health and Behavioral Sciences Program by Deborah S. Main, Dissertation Chair Ronica N. Rooks, Chair of Examination Committee L. Miriam Dickinson Richard Allen Miech Jean N. Scandlyn April 19, 2013 ii

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Phibbs, Stephanie, L. (Ph.D., Health and Behavioral Sciences) Childs Play: Community Solutions for Increasing Youth Physical Activity in Distinct Safety Contexts Thesis directed by Professor Deborah S. Main. ABSTRACT Amid the uniformly low physical activity rates among children in the United States, combined with epidemic rates of childhood obesity, practical solutions for increasing physical activity (PA) are needed. Whether interventions to increase PA need to account for individual demographic character istics or safety co ntext is un known. Methods: Study Design: This community based participat ory research project used mixed methods, including secondary data analyses and concept mapping. Setting: Five demographically diverse, geographically contiguous, urban neighborhoods in Colorado, including one of the largest redevelopments in the United States designed for active living. Measures: Secondary data identified neighbor hood safety contexts. Concept mapping participants identified, sorted and rated interventions to increase youth PA. Population: Participants were purposefully sampled households, including equal numbers of black, white and La tino adults from each safety context, and their 10-14 yearold children. Analysis: Cluster analysis using measures of social cohesion, incivilities, discrimination, and fear of crime and tra ffic safety identified homogenous safety iii

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subgroups. ANOVA, multivariable analyses an d concept mapping pattern matching were used to compare ratings within and between safety contexts and demographic groups. Results: Cluster analyses identified three distin ct safety contexts. Concept mapping elicited 330 ideas, 100 of which were randomly sele cted for participants to sort and rate. Three intervention groupings were identified: 1) activity interventions, 2) safety interventions, and 3) infrastru cture/access interventions. Participants residing in less safe contexts, and black and Latino adults, ra ted all interventions as more needed than participants from the safest context and white adults. Adults residing in the safest context thought infrastructure/access interventions were most needed, while adults from less safe contexts rated safety interventions as most needed. Youth acro ss all contexts thought safety interventions were least needed; activity and infrastructure/access interventions were rated as most needed. Community-led an alyses identified that all youth across all contexts wanted fun, free and safe physical activity opportunities. Discussion: Safety context is an indicator of co mmunity need for youth physical activity interventions. Communities recommend fram ing and implementing interventions that are simultaneously fun, free and safe, rather than focusing exclusively on safety intervention needs that stigmatize neighborhoods. Top in tervention needs are consistent with nationally recommended intervention s and also suggest a role fo r grassroots participants. The form and content of this abstract are approved. I recommend its publication. Approved: Deborah S. Main iv

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ACKNOWLEDGEMENTS This project would not have been possible without the work and support of numerous people. Debbi Main took th e initiative to start Taking Neighborhood Health to Heart, finding excel lent community organizers such as Charlene Barrientos Ortiz, Patricia Iwataki Iwasaki and Alic ia Brown to bring and keep community members together. The chair of Taking Ne ighborhood Health to Heart, George Ware, has dedicated countless hours to maintaining this CBPR effort through the years. The Society of the Youth, a working group of TNH2H, included beautiful people dedicating time each month making this disserta tion part of a social change project, where research played one part. Adul t leaders of that group included LaShonn Billingsley, Carmen Miranda, Francisco Subiadur, Olga Martinez, Cat Santos and Daniel Armijo. These adults were extremel y generous, sharing so much to create a true community. Many youth brought fun and vitality to the group as well. Silvia Gutirrez Raghunath, Rebecca Slaughter, Heather Kennedy, Nicole Tuitt, Ira Gorman, Rosario Montoya, Kate Walk er and Samuel Wood all contributed significantly to various phases of the project. Thank you all! My family has been incredibly suppor tive, really understand ing and loving me even in my constant busyness, supporting me in believing that together we can make a difference. I am also very grateful fo r my supportive colleague s at Denver Health. This study would not have been possibl e without the generous funding from the Active Living Research Program of Th e Robert Wood Johnson Foundation. Results would not have become actions without the funding of The Denver Foundation. v

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TABLE OF CONTENTS CHAPTER I. INTRODUCTION........................................................................................................1 Project Significance................................................................................................8 Study Aims............................................................................................................10 II. LITERATURE AND THEORY REVIEW................................................................11 Understanding Physical Activity among Youth through a Social Ecological Approach...............................................................................................................11 Combining CBPR and Recommended Interventions for Action..........................14 Rationale for Safety Construct Selection..............................................................16 Understanding Racial and Ethnic Disparities.......................................................21 A View from a Broad Theoretical Lens................................................................24 Chapter Summary.................................................................................................29 III. METHODOLOGY.....................................................................................................30 Research Design....................................................................................................30 Research Setting....................................................................................................30 Aim 1 Methods.....................................................................................................32 Measures...................................................................................................33 Cluster Analytic Methods Used to Identify Unique Safety Contexts.......34 Aim 2 Methods.....................................................................................................35 Concept Mapping Sampling and Recruitment Methods...........................36 Steps in Concept Mapping........................................................................37 Concept Mapping Data Analysis..............................................................41 vi

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IV. RESULTS...................................................................................................................44 Aim 1 Results........................................................................................................44 Aim 2 Results........................................................................................................46 CBPR and the Community-Advisory Counsel.........................................46 Concept Mapping Recruitment Efforts.....................................................50 Participant-Suggested Interventions.........................................................52 Concept Map of Suggested Interventions.................................................54 Multivariable Analyses to Evaluate How Ratings by Different Demographic Subgroups Vary within and between Safety Contexts.......58 Comparisons of Safety Intervention Needs. .................................59 Comparisons of Infrastructu re/Access Intervention Needs..........60 Comparison of Activity Intervention Needs .................................61 Summary of Multivariable Analyses. ...........................................62 Concept Mapping Analyses......................................................................62 Concept Maps by Context and Demographic Groups. .................62 Comparing Intervention Needs amon g Adults within and between Safety Contexts .............................................................................64 Comparing Intervention Needs amon g Youths within and between Safety Contexts.............................................................................67 Comparing Intervention Needs am ong Ethnic Groups within and between Safety Contexts...............................................................70 Summary of Concept Mapping Need Analysis Comparisons......76 Concept Mapping Adult Possibility Comparisons........................76 vii

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Community-Generated Analyses for Action........................................................81 V. DISCUSSION.............................................................................................................85 Review of Study Findings.....................................................................................85 Interpretation of Study Aim 1 Findings................................................................88 Interpretation of Study Aim 2 Findings................................................................91 Revised Socio-Ecological Framework......................................................91 Perceived Needs Influenced by Individual Factors..................................95 CBPR as a Social Change Project.............................................................98 Correspondence of Study Intervention Recommendations with National Efforts .............................................................................................................................102 Reflections..........................................................................................................107 Limitations..........................................................................................................109 Limitations of Study Aim 1....................................................................109 Limitations for Aim 2.............................................................................109 Conclusions and Implications for Future Research............................................112 REFERENCES...............................................................................................................115 APPENDICES................................................................................................................134 1: Participant Recruitment Flyer.........................................................................135 2: CAC Facilitation Training Materials..............................................................137 3: Brainstorming Protocol and Packet................................................................153 4: Sorting Protocols.............................................................................................167 5: Rating Protocols..............................................................................................174 6: Community Fair Flyers...................................................................................181 viii

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7: Comprehensive List of Intervention Suggestions...........................................187 8: Pattern Match: Similar Ratings am ong Context 2 and Context 3 Adults.......195 9: Community Feedback Presentation................................................................197 10: Physical Education Policy Brief...................................................................208 ix

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LIST OF TABLES TABLE II.1 Recommendations for Combating Obesity................................................................15 II.2 Sample of Study Populations, Meas ures of Safety and Outcomes............................17 III.1 Socio-Demographic Characteristics of Catchment Area..........................................31 III.2 Summary of Clustering Variables.............................................................................34 III.3 Sampling Frame for Concept Mapping Efforts.......................................................37 IV.1 Summary of Brainstorming and Sorting Phase Participants.....................................51 IV.2 Rating Participant Recruitment Effort......................................................................52 IV.3 Summary of Rating Phas e Study Participants..........................................................52 IV.4 Summary of Safety-Related Interventions by Context.............................................53 IV.5 Statements Sorted into Th ree Intervention Clusters.................................................56 IV.6 Average Need for Safety Interventions by Safety Context......................................59 IV.7 Mean Need for Safety Interventions.........................................................................60 IV.8 Mean Need for Infrastructure/Access Interventions.................................................61 IV.9 Mean Need for Activity Interventions......................................................................61 IV.10 Go-Zone Ideas Listed in Order of Highest to Lowest Youth Needs.....................83 IV.11 Go-Zone Ideas Listed in Categor ies of Fun, Free and Safe Needs.........................84 V.1 Nationally Recommended Strategies for Youth Obesity Reduction.......................103 V.2 Go-Zone Ideas Listed in Categories of Fun, Free and Safe Needs..........................106 x

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LIST OF FIGURES FIGURE II.1 Social Ecological Framework for Physical Activity Interventions............................11 II.2 Constructs Used in Cluster Analysis..........................................................................19 IV.1 Data from Three-Cluster Solution, with Data Normalized to 0-1 Scale...................45 IV.2 Point Map Resultant from Sorting Activity..............................................................54 IV.3 Three Cluster Solution..............................................................................................55 IV.4 Adult Rating of Relative Need for Different Intervention Clusters.........................63 IV.5 Youth Rating of Relative Need for Different Intervention Clusters.........................63 IV.6 Relative Need for Interventi ons by Adults in Context 1..........................................65 IV.7 Relative Need for In terventions by Adults in Contexts 2 and 3...............................65 IV.8 Pattern Match of Adult Intervention Needs Context 1 v. Contexts 2 & 3................67 IV.9 Relative Need for Interventions by Youth in Safest Context...................................67 IV.10 Relative Need for Interventions by Yout h in Second-Safest Context (Context 2).68 IV.11 Relative Need for Interventions by Y outh in Least Safe Context (Context 3).......68 IV.12 Pattern Match of Youth Intervention Needs Context 1 v. Contexts 2 & 3.............69 IV.13 Relative Intervention Needs for Wh ite Adults in Safest Context...........................70 IV.14 Relative Intervention Needs for La tino Adults in Safest Context..........................70 IV.15 Relative Intervention Needs for Bl ack Adults in Safest Context...........................71 IV.16 Relative Intervention Needs for White Adults in Two Least Safe Contexts..........71 IV.17 Relative Intervention Needs for Black Adults in Two Least Safe Contexts..........72 IV.18 Relative Intervention Needs for Latino Adults in Two Least Safe Contexts.........72 IV.19 Pattern Match Comparing Latino (lef t) and Black (right) Adult Ranking of Intervention Needs............................................................................................................73 IV.20 Pattern Match Comparing Latino (lef t) and White (right ) Adult Ranking of Intervention Needs............................................................................................................74 xi

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IV.21 Pattern Match Comparing Black (left) and White (right) Adult Ranking of Intervention Needs............................................................................................................75 IV.22 Relative Intervention Feasibility Rating Among All Adults..................................77 IV.23 Relative Intervention Feasibility Rating Among All Youths.................................77 IV.24 Relative Intervention Feasibility Rating Among All White Adults.......................78 IV.25 Relative Intervention Feasibility Rating Among Black Adults..............................78 IV.26 Relative Intervention Feasibility Rating Among Latino Adults.............................79 IV.27 Relative Intervention Feasibility Rating Among Adults in the Safest Context......80 IV.28 Relative Intervention Feasibility Ra ting Among Adults in the Second Safest Context..............................................................................................................................80 IV.29 Relative Intervention Feasibility Rating Among Adults in the Least Safe Context. ...........................................................................................................................................81 IV.30 Go-Zones Examining What Youth Say is Needed and What Adults Say is Possible. ...........................................................................................................................................82 V.1 Social Ecological Framework for Physical Activity Interventions............................89 V.2 Revised Social Ecological Framework for Physical Activity Interventions.............93 xii

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xiii LIST OF ABBREVIATIONS ABBREVIATION BMI BRFSS CAC CDC CBPR MVPA NHANES NHLBI PA SAY SES SOY TNH2H Body Mass Index Behavior Risk Factor Surveillance System Community Advisory Council Centers for Disease Control and Prevention Community-Based Participatory Research Moderate to Vigorous Physical Activity National Health and Nutrition Examination Survey National Heart, Lung and Blood Institute Physical Activity Shaping Americas Youth Socio-Economic Status The Society of the Youth Taking Neighborhood Health to Heart

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CHAPTER I INTRODUCTION Rising rates of obesity in our nation constitute a public health crisis.1 Measured as > 95% body mass index (BMI),2-4 obesity rates increased between 1974 and 2004, doubling among children aged 6-11 and tripling among teens.5 Most recent national data show 18.0% of children 6-11 years of age a nd 18.4% of children 12-19 years of age are obese, representing a recent le veling off in obesity rates.6, 7 Including overweight and obese children, nearly one-thir d of youth nationally have a BMI > 85%.8 In Colorado, 27.3% of 5-17 year-olds have a BMI > 85%,9 a figure that ranks the state as one of the leanest, though the disparity between non-Hispanic white and Hispanic rates of childhood obesity is among the highest.10 Though BMI may not equate to the same level of body fat in all racial/ethnic groups,11 corresponding national data show a persistent12 disparity in obesity rates among 6-11 year old Hispan ic, Mexican American and non-Hispanic black girls, when compared with non-Hispanic white girls.6 Overweight and obese children are more likely to become adults with costly8 chronic health conditions such as cardiovascular disease, diabetes, a nd cancer with poorer health outcomes.13, 14 Additionally, national costs of childhood obesity are estimated at $3 billion for children with Medicaid,15 and two authors extrapolate that additional national medical health care expenditures for emergent, drug and outpatient visits associated with elevated BMI stands at $14.1 billion.16 While the direct linkage between obesity and physical activity is not as clear among youth as it is in adults,17, 18 developing physical activity patterns early in life helps establish behaviors for later life, and improves a range of health outcomes such as aerobic 1

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fitness, blood lipids, blood pressure skeletal and psychological health.19,20, 21 The national recommendation is for youth to get 60 minutes of moderate physical activity every day. 22 National Healthy People 2020 goals call for improving adolescent physical activity levels 10%, and increasing the per centage of schools requiring daily physical education and recesses.23 So how much exercise are youth getting? In the Youth Risk Behavior Survey youth were asked to report thei r physical activity that increas ed their heart rate and made them breathe hard some of the time for a tota l of at least 60 minutes, i.e., moderate to vigorous physical activity (MVPA), 18.4% of high school students reported that they were active for one hour on all 7 days; 37% met the recommendation on 5 days; and 23.1% were not active any day in th e 7 days preceding the survey.24 These data also show boys are more active than girls, and activity rates d ecrease with age.24 Recognizing the limitations of self-report data, the Nationa l Health and Nutrition Examination Survey (NHANES) survey, a nationally representative survey of youth 6-19 year olds, measured MVPA objectively using accelerometers.25,26 In these 2003-2004 data, which measured whether children met national recommendati ons, 42% of children 6-11 years, 8.0% of youth 12-15, and 7.6% of 16-19 year olds me t the national recommendation for physical activity, with large disparitie s between girls and boys under 16 years of age. In 20052006, children 6-11 years old were found to ge t on average 90.1 minutes MVPA/day and 12-19 year old youth averaged 29.3 minutes/day.26 But, similar to the YRBS survey, males averaged more physical activity (P A) than females in both age groups. 26 Findings regarding socio-economic, ethnic or racial disparities in physical activity among children are mixed. Earlier studies using self-report data indicated white children 2

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had higher rates of MVPA compared to their Latino and black counterparts.24 Yet, more objective accelerometer data ca ll this disparity into ques tion. NHANES data from 2003 and 2006, using accelerometers for the first tim e, showed non-Hispanic black youth have the highest levels of MVPA.27 26 28 These same data showed no difference in activity levels among 6-15 year olds according to income.27 So what do we know about physical activity -related trends over time? Between 1999 and 2010, obesity rates among youth were leveling for all but adolescent boys.7 Self-reported levels of modera te to vigorous physical act ivity among youth stabilized between 2003 and 200626 and the percentage of youth m eeting national physical activity recommendations between 2005 and 2009 was unchanged.29 A recent national telephone survey found that 7.1% of children 5-15 year s old walk 30 minutes per day and 1.6% of children bike 30 minutes or more per day, re presenting a significant decrease in cycling compared to 2001.30 Youth are spending mo re time with media, increasing from 6 hours and 19 minutes in 1999 to 7 hours and 38 minutes in 2009. 31 After an initial decrease in daily physical educati on between 1991 and 1995, 32 daily attendance rates have not decreased.33 Together these data show physical activity levels have decreased since 1991, but, along with obesity rates, may be leveling out. Another relevant question is what other variables are associated with physical activity (PA) in children? Researchers curr ently use a social ecological framework to organize the multiple influences on physical activity.34 This framework recognizes that individual behaviors are embedded in a cont ext that has multiple dimensions, including intrapersonal, interpersonal, institutional, community, and policy-related influences. In their extensive 2000 review, Sallis, Prochask a and Taylor found that correlates of 3

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physical activity varied between children and adolescents.21 Among children 6-11 years of age, time outdoors, program facility access, having an overweight parent, eating a healthy diet, participating in previous physical activity, preferring PA, intending to participate in PA, and being male, were consis tently related to higher levels of physical activity. More variables were associat ed with PA among adolescents than among children, including: psychological (achievement orientat ion, depression, competence, intention), behavioral (community sports, prev ious PA), social cultural issues (parent support, direct help from pare nts, sibling PA), as well as opportunities to exercise, being male, younger age, and white, showing a ssociations with physical activity. Ding et al. 35 conducted a review of a databa se developed for Active Living Research, focusing on associations betw een the neighborhood environment and youth physical activity. They found that the most consistent environmental supports for childrens (ages 6-11) phys ical activity were: neighborhood walkability, traffic speed/volume, access/proximity to recreation facilities, land-use mix and residential density. For adolescents the associations between environmental supports and physical activity were most consistent for land -use mix and residential density. Individual factors related to obesity include: income,36 genetics, knowledge regarding diet and physical activity, health status psychology, self-efficacy,37 and perceptions of obesity and healthy weight.38, 39 Interpersonal fact ors include social support.40 Broader environmental factors includ e opportunities for physical activity or sedentary behavior such as school physical activity,41, 42 social and economic systems in which these behaviors take place,8 and the more global social norms and cultural concordance with intervention messages.43-47 4

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Based on the vast amounts of active living35 and related research, the IOM,8 Healthy People 2020,23 The Robert Wood Johnson Foundation48, the Centers for Disease Control and Prevention (CDC)49 and others50 have recommended environmental changes, strategies and polic y interventions for improving physical activity levels among youth.51 Yet, the question remains: which of these s uggested interventions would be considered useful by the target communities? Do interventions need to be tailored for specific ethnic groups as some authors suggest?52 Might some interventions be more efficacious in some, but not other environments? How can unintended consequences of interventions be avoided? Although research can inform policy and environmental changes, sustainable interventions to improve physical activity be nefit from engaging th e target communities themselves to take ownership of the solutions.53, 54 Intervention areas that the community might suggest could fall anywhere w ithin the social-ecological framework.46, 55-63 The need for community engagement is made clearer as more research has shifted its focus on examining the effects of the physical and social context on physical activity among ethnically diverse youth in lower income ne ighborhoods. In fact, in its most recent report, the IOM has said: It is important to recognize as well that not all individuals, families, and communities are similarly situ ated. In many parts of the United States, low-income individuals and families live, learn, work, and play in neighborhoods that lack sufficien t health-protectiv e resources such as parks and open space, grocery stores, walkable streets, and highquality schools. In any given community, the relative mix of community-level resources and risk factors is determined primarily through democratic local and regional decision-making processes; consequently, organized participatio n in these processes influences where these community resources an d risks are located. Because of such factors as poverty, language ba rriers, and immigration status, low-income, minority, and other disadvantaged population groups 5

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often are underrepresented and their concerns marginalized in these decision-making processes. These gr oups are therefore less likely to benefit from access to health-protec tive resources. To change this situation, robust and long-term co mmunity engagement and civic participation among these disadvantaged populations become essential. 8, pg.7 Amid the various correlates of physical activity, communities and public health entities agree safety is a ba rrier to physical activity,64, 65 66, 67 especially in urban contexts.64, 65 For instance, parental concerns ab out traffic safety can keep youth from walking to school.66, 67 As the Institute of Medicine states, Local governments, in partnership with private developers and community groups, should ensure that every neighborhood has safe and well-designed recr eational facilities and other places for physical activity for children and youth.46, p.211 Improving neighborhood safety may lead to more outdoor time and less sedentar y behaviors that place children at risk for obesity,68, 69 such as watching television or videos, using computers and/or playing video and other electronic games.70, 71 Indeed, intervention studies have shown safe spaces may encourage higher activity levels.72 The qualities that confer a sense of safe ty and support physical activity, however, are not clear. Perceptions of safety and neighborhood attractiveness have been shown to differ among racial, 73, 74gender,75 ethnic and economic groups.76-78 Authors of one review concluded there is insufficient evid ence linking crime-related safety and adult physical activity.79 Neighborhood incivilities and hazar ds, an objective measure of the physical environment including graffiti and tras h, are thought to signal feelings of being Note the term Race is used throughout with the understanding this is a socially constructed category, consiste nt with statements from an thropological associations referenced here. 6

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unsafe,80 yet in one study more hazards were correlated with increased levels of youth physical activity.81 Also, children from lower economic gr oups are more likely to walk to school than their more affluent counterparts,82 despite the fact that these lower socioeconomic environments are associated wi th more crime, which is also associated with feeling unsafe.76 Safety concerns are not limited to fear of crime but can also include objective and perceptual measures of traffic, light ing, loose dogs, strangers and sidewalk maintenance.47, 76 Aspects of the social environmen t, such as collective efficacy and social cohesion are also related to safety83, 84 and to obesity.85 Taken together, the association between physical activ ity and safety has been inco nsistent, with some studies showing positive, 69, 71, 86-90 some negative,86 and some insignificant81, 91-95 correlations. These inconsistencies point possibly to the different measures,96,76 or analytic methods used,79, 86 but also suggest the unique ways social and physical environments interact to influence physical activity. Wh ether interventions need to be tailored to specific safety environments is not known. For example, might interventions to improve safety actually impede informal social control and social cohesion?84 Specifically, the intervention often brought to violent situations is increased pol icing, which may unintentionally reduce informal social control, the thing most needed.97 As one concept mapping proj ect has shown, a barrier to physical activity may include police misjudge [ing] black men outsideassum[ing] they are getting into trouble [and] people are arrested when playing outside. 98, p.292 Thus, increasing police presence may have the unintended consequence of decreasing a communitys sense of safety and their physical activity. 7

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Therefore, it is not clear whether interventions need to be tailored for different safety contexts, and whether such tailored interventions would be related to safety or to other components of the social ecological model. To understand whether and how interventions to increase physical activity might need to be tailored for distinct safety conditions, this study uses extensive secondary data, and concept mapping with parents and middl e-school-aged children from different safety contexts to identify contextually relevant solutions for increasing physical activity among youth. Project Significance The significance of this project lies in its engagement of community stakeholders in a unique socio-ecological context. In 2006, a grant funded by the National Heart, Lung and Blood Institute (NHLBI) funded the initiation of a community-based participatory research (CBPR) project, na med Taking Neighborhood Health to Heart. Taking Neighborhood Health to Heart (TNH2 H) formalized a CBPR process and collected observational data to understand the influen ce of the built and social environments on health and health disparities in five distinct, geogr aphically contiguous neighborhoods in urban areas of Colorado.99 The setting is uni que because it includes Stapleton, one of the largest urban renewa l projects in the United States, which was designed especially for active living, includ ing green space, pocket parks, walking and bicycling trails, wide sidewalks and r ecreation amenities. Beginning in 2001, this redevelopment replaced the former Denver airpor t and its associated noise, traffic and air pollution which had impacted four adjacent neighborhoods: Northeast Park Hill, Greater Park Hill, East Montclair, and Original Aurora. 99 8

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While the initial NHLBI study focused on adult health, TNH2H members also expressed interest in youth issues and agreed to participate in this research project to learn what interventions are appropriate fo r increasing youth physical activity. Thus the groundwork established in TNH2H provided the relationships and basic framework for forming a TNH2H sub-committee called The Societ y of the Youth. With The Society of the Youth, we explored whether as hypothesize d, participants in less safe neighborhoods would suggest interventions to accommodate the safety environment, and if so, we wanted to know what types of interventi ons would be appropriate. The study also compared how different racial and ethnic grou ps within the same safety context rate the same intervention recommendations to see if different groups have different perceptions of what is needed. Combining the grassroots support for this study from TNH2H and the favorable policy climate related to physical activity, resu lts of this study could be translated to action. There is great political support at the national, state and local levels for increasing physical activity. Additionally, among all 50 states, Colorado has passed the largest percentage of introduced bills regarding childhood obesity prevention.100 Also, the Colorado Society for Public Health Educati on and Colorado Public Health Association work together with their l obbyist and other public health organizations to advocate for relevant policy changes. This confluen ce of grassroots and political support for improving environments to support physical activity seemed timel y for achieving the following study aims. 9

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Study Aims Aim 1: Identify homogenous block group clusters by known physical and social correlates/measures of safety, including: fear of crime, traffic safe ty, social cohesion, discrimination and incivilities. Aim 2: Within a community-based participatory research context, use concept mapping methodologies to examine how solutions for increasing pediatric physical activity vary within and between different safety contexts. H01: People in environments defined as be ing safe, having high levels of perceived safety and social cohesion and low measures of incivilities a nd discrimination will offer more solutions for increasing physical activity that are unrelated to the safety environment. H02: Ratings of solutions suggested by different demographic subgroups within safety environments will be more similar th an the ratings of solu tions offered between different safety environments. 10

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CHAPTER II LITERATURE AND THEORY REVIEW Understanding Physical Activity among Youth through a Social Ecological Approach Understanding the childhood obesity epidemic in the United States -and the role that physical activity plays-requires a social -ecological perspectiv e that recognizes the multi-level influences on human behavior; a model that has been extensively used and lends well to environmental and policy interventions.34, 56, 101 For the current research study, these concepts are integrated into th e social ecological framework adapted from Elder et al. 2007, Figure I.1.102 Figure II.1 Social Ecological Framework fo r Physical Activity Interventions. The multi-level targets for change in the middle section of the diagram suggest that individual attributes, su ch as race or ethnicity, gender, age and socio-economic 11

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status, might influence physical activity. The model also shows that the social and physical environment can influence physical activity. Noticeably, these three domains can influence one another, e.g., individuals can shape social and physical environments and these environments can also impact indivi duals. Lastly, the model demonstrates that interventions to impact physical activity can be in the form of policy and organizational changes that impact the environment, while cues, messages and incentives can impact the environment and individuals directly. Related to this framework, the first aim of this study identifies safety contexts from secondary data by combining social a nd environmental variables. The second aim of this study includes using concept ma pping methods, a multi-step process where residents from the different safety contexts suggest, sort and rate interventions for improving physical activity among youth. Together the two aims of this study allow for a deeper exploration of the relative influen ce of individual and environmental attributes on individuals perceived needs for interventions relevant to youth physic al activity. The current study is consistent with a growing body of research showing the influence of what is termed the built or physical environment on health, and specifically, on physical activity.21, 103-105 The built environment has been defined as the neighborhoods, roads, buildings, food sources, and recreational facilities in which people live, work, are educated, eat, and play,106, p.90 For instance, research has shown that children and adolescents with access to r ecreation centers and amenities for physical activity near their homes were more activ e than same-aged youth without such access.95 Although not uniformly true, 107 some researchers have s hown there are unfortunately fewer parks, athletic fields and trails in low-income neighborhoods, and this unequal 12

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access has been related to lower levels of physical activity and increased rates of overweight among youth of color living in lower socio-economic status (SES) communities.108-111 Relevant interventions to address these disparities elicited in concept mapping groups might include construction of walk ing or bike trails that reduce barriers related to cost, conveni ence, and accessibility,112, 113 interventions particularly effective among less active populations.114 Other interventions fo cusing on designing built environments to promote more active lifestyles, healthy eating, and social interactions and to reduce substance abuse and violence may also be pertinent to the communities included in the present research study.115 In addition to individual factors and the physical environment, the social environment also influences physical activity. The social environment includes cultural and social influences that shape how people vi ew their environments and their relation to physical activity. Physical activity is inhere ntly shaped by ones social environment in that most activity occurs within th e bounds of families, communities and neighborhoods.116, p.1012 117 Clearly, advising individuals to be more physically active without considering social norms for activity, resources and opportuni ties for engaging in physical activity, and environmental constraints, is unlikely to produce behavior change. Other research has confirmed this by showing that access to safe and appealing, proximate spaces and facilities enco uraged higher levels of walking.72 62 By using the social ecological framewor k for this study, I recognize how solutions for increasing physical activity may fall within any of these levels of the social ecological framework. 13

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Combining CBPR and Recommende d Interventions for Action This dissertation research adopted a co mmunity-based participatory research (CBPR) approach, extending an existing CBPR process formed for a National Heart Lung and Blood Institute study involving community members from five demographically diverse neighborhoods. When done well, CBPR involves all partners equitably in a topic that is important to the community and combines knowledge and action to achieve social changes to im prove health and e liminate disparities.118, 119 This project is a logical extens ion of the groups progress, building on recent reports of neighborhood-level health data, moving towards action. While engaging community re sidents in CBPR, it is important to simultaneously consider evidence related to effective physical activity interventions. Community suggestions supported by the literature can be forwarded to policy-makers with information about the evidence base. Commun ity solutions unique from the literature can suggest other avenues of research or intervention. Environmental and policy interventions thought to disrupt the obesogenic environment (and the strength of evidence for that intervention) were summarized by Brownson, Haire-Joshu and Luke (2006)50 as: 1) access to facilities (strong evidence, e.g., fitness centers walking, biking trails), 2) urban planning and policy (sufficient eviden ce, e.g., zoning regulati ons, street lighting and sidewalk continuity), 3) transportation policy (insufficient evid ence), 4) school-based physical education (strong evidence, e.g., lengthening classes or encouraging more activity in a given period ha s been shown to increase phys ical activity), 5) economic incentives (promising evidence, e.g., making funding available for community improvements, giving employees cash for not using parking), and 6) points of decision 14

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prompts (sufficient evidence, e.g., signs on elevat ors to encourage people to use stairs or exercise messages).50, 120 Kumanyika et al. (2008) 121 further describe possible environmental and policy interventions. A nother study has shown that providing children access to a supervised and safe afterschool space to play outdoors can increase physical activity.71 Local and informal policies and interventions that may be relevant to this issue have also been summarized by the Robe rt Wood Johnson Foundation in its publication, F as in Fat 48 with their suggestions shown in Table II.1. Thes e recommendations could correspond with interventions suggested by the community, and can be used as a reference for policy briefs. The Robert Wood Johnson Foundation (RWJF) funded the F as in Fat study, demonstrating their interest especi ally in creating polic y interventions. Together, CBPR methods and awareness of evidence-based interventions provide a strong foundation for policy and other intervention changes. Table II.1 Recommendations for Combating Obesity. The F as in Fat report concludes with a recomme ndation that the country set a national goal of reversing the childhood obesity epidemic by 2015. Some key policy recommendations include: Investing in effective community-based disease-prevention programs that promote increased physical activity and good nutrition; Increasing the amount and quality of physical education and activity in schools and childcare programs; Increasing access to safe, acces sible places for physical activity in communities. Examples include creating and maintaining park s, sidewalks and bike lanes and providing incentives for smart growth designs that make communities more livable and walkable; Encouraging limits on screen time for childre n through school-based curricula and media literacy resources; Providing people with the information they need about nutrition and activity to make educated decisions, including point-of-purchase information about the nutrition and calorie content of foods. 48 Similarly the recent IOM report, Acceler ating Progress in Obesity Prevention, recognizes the multi-level interventions needed to address obesity rates at a population 15

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level and suggests the following physical activity (PA) interventions: Strategy 1-1: improving the physical and built environm ent, and Strategy 1-2: providing and supporting community programs to increas e physical activity. The IOM further recommends Strategy 5-1: requiring quality PE and other physical activity opportunities in schools.8 Rationale for Safety Construct Selection Because the central goal in th is study is to learn whethe r interventions to increase physical activity need to be tailored to the safety context, I next review literature regarding the conceptuali zation of safety and its relation to physical activity. Safety is thought to figure into the decision of whether ca re-takers allow children to play outside or walk to school, with unsafe environments l eading to more obesity-related behaviors, ones that are more prevalent among et hnic minority or low income youth.22, 93, 122 While this trail of logic makes intuitive sense, the rela tionship between safety and physical activity is more complex. First, the construct of safety is conceptualized and measured in very different ways in the empirical literature. Safety can be measured from a single question, such as the question from the Behavior Risk Factor Surveillance System (BRFSS) that asks, How safe from crime do you c onsider your neighborhood to be?78 Romero et al. (2001) used a neighborhood hazards scale to determine the problem-level that traffic, trash, litter, crime, noise, gangs, prejudice, drugs and park access posed to neighborhoods.81 Burdette and Whitaker (2005) used a similar scale to measure social disorder defined as loitering, gang activit y, drug dealers, disorderly behavior.93 Weir, Etelson and Brand (2006) used a scale that asks parents about their level of anxiety 16

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concerning gangs, child aggression, crim e, traffic and personal safety.123 Fish et al. used a single question to i nquire about direct e xperiences of crime. 86 All but the BRFSS and Fish studies used scales to meas ure hazards and incivilities. Perhaps owing to these different appro aches to measuring safety or perhaps because different subpopulations perception of safety varies, studies present inconsistent associations between physical activity and safety (Table II .2). Data from the BRFSS survey show that physical activity is lowe r in adult populations that report being less safe.78 Yet, in Burdette and Whitakers study, safety and obesity were not associated among 3-year olds, but parents of these three year olds were more likely to be obese if they were in a less safe environment. One author has noted that the association between environmental hazards and physical activity found in two studies of middle class primarily European American populations, was contradicted in his study including largely lower income Mexican and Viet namese populations in the U.S., where more hazards were related to more physical activity .81 Table II.2 Sample of Study Populations, Measures of Safety and Outcomes. Study Population; study design Measure of Safety Outcome Centers for Disease Control, 1999 78 Representative adult sample; cross-sectional Behavioral Risk Factor Surveillance System (BRFSS), How safe from crime do you consider your neighborhood to be? Safety related to report of physical activity in last month Romero et al, 2001 81 Fourth-grade students from diverse economic and ethnic backgrounds in Arizona; crosssectional Neighborhood Hazards, a 3point Likert rating of how big of a problem the following eight items are in your neighborhood: traffic, trash and litter, crime, too much noise, gangs, lack of access to parks, prejudice, and drugs; adapted scale with alpha=0.76 Contrary to expectations, increased hazards were associated with increased selfreported rates of PA measured with the adapted Selfadministered Physical Activity Checklist Burdette Three-year old children Neighborhood Environment No association between 17

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Study Population; study design Measure of Safety Outcome and Whitaker, 2005 93 part of the Fragile Families and Child Wellbeing Study from 20 large US cities in 15 states; cross-sectional for Children Rating Scale, contains eight items designed to measure social disorder asked if they saw events such as loitering, gang activity, drunks or drug dealers hanging around, disorderly or misbehavior youths or adults. safety and time spent outdoors or BMI >95th percentile in 3-year old children. Burdette, Wadden, Whitaker, 2006 92 Mothers three years post-partum, part of the Fragile Families and Child Wellbeing Study from 20 large US cities in 15 states; crosssectional Neighborhood Environment for Children Rating Scales (see above) BMI related to safety measures, but not to measures of collective efficacy Kelly, et al., 2007 98 Seventy-four African American community members participating in concept mapping; qualitative study Inductive coding and labeling of data from qualitative methods Barriers to PA different for high and low income AA participants, safety concerns included concerns about crime and police mistreatment Weir, Etelson, Brand, 2006 123 Parents of children 5-10 years of age from suburban and inner-city neighborhoods; crosssectional Level of anxiety concerning gangs, child aggression, crime, traffic, and personal safety in their neighborhood Inner-city children engaged in less physical activity and had parents who had more safety concerns Fish et al., 2010 86 Random, stratified sample of adults living in 65 census tracts in Los Angeles County; cross-sectional Collective efficacy and household crime, i.e., while in the neighborhood whether the respondent or anyone in their household had anything stolen or damaged inside or outside Ordinary least squares analysis showed no association of BMI with safety, while instrumental variable analysis did show an association These seemingly inconsistent associations between safety and physical activity in different studies may, in part, be due to the incomplete conceptualization of safety. The present study builds from these methods by combining multiple constructs associated with safety. A summary of the safety construc ts included in the cluste r analysis to define safety contexts in this study is shown in Fi gure II.1. The exact measures used for these 18

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constructs are described in the methods s ection, and a rationale for including social cohesion and discrimination constructs follows. Fear of Crime Perception Safety of Traffic Incivilities Social Cohesion Discrimin ation Safety Figure II.2 Constructs Used in Cluster Analysis. Collective efficacy is described as mutual trust and the willingness to intervene for the common good 84, p.919 or as the norms and networks that enable collective action. 85, p.770 Collective efficacy is strongly asso ciated with neighborhood violence, with authors explaining that collective efficacy is a method of guaranteeing shared norms and exerting social control within the community.84 This reasoning suggests that a relationship between safety and physical activity may be medi ated by collective efficacy.97 Yet, research examining the relationship between collective efficacy and obesity has resulted in mixed findings. For instance, BMI among adults was not 19

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associated with collective efficacy in one study,92 but collective efficacy was associated with obesity in one study of adolescents.85 Collective efficacy is measured using a scale by Sampson et al., 84 92, 124 that includes subscales of informal social control and social cohesion. Whereas informal social controls asks if neighbors would intervene in the cases of children skipping school, spray-pain ting, fighting, etc., social cohesion and trust measures whether people help, trus t and get along with one another.84 The secondary data source provided the social cohesion subscale of collectiv e efficacy, so I included this construct in the cluster analysis. Another construct that may be associated with feelings of safety is discrimination. Concept mapping findings from at least one African American community showed that police interventions that are often meant to in crease safety may instead lead people to feel less safe and to a decrease in physical activity.98 Thus, an intervention such as policing may engender a sense of safety for some pe ople, but may contribute to fear among other people.97 Romero et al., 2001 81similarly included prejudice in his neighborhood hazards scale. Including discrimination in the cluster analysis allows for different solutions that may implicitly or explicitly address this i ssue. The discrimination measure I used asked whether people have ever experienced discrimi nation from the police or in the courts, or on the street or in a public settings.125 Within this section I have described how safety is a complex concept and that the linkage between safety and physical activity is inconsistent. The various correlates of safety used in other studies provide a rationale for incl uding perceptual and objective measures of safety, as well as social cohesion and discrimination in th e cluster analysis to 20

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identify distinct safety contexts within the catchment area, which is the first Aim of this study. Understanding Racial and Ethnic Disparities Previous sections in this chapter have described the multi-level influences on physical activity, and suggested safety is a co mplex construct with a complex relationship to physical activity. Researchers often describes disparities by racial/ethnic group,126 but less research has described health dispari ties by safety context. By purposefully sampling different ethnic or r acial groups within each of the safety contexts, this study helps disentangle race/ethnicity from safety context, to look more closely at a potential mechanism behind racial/e thnic disparities. Disparities research is founded on various theories explaining the relationship between social inequality and disease. The Black Report describes four possible theoretical explanations for inequalities: the artifact explanation (a problem of measurement), theories of natural or soci al selection (sick people become poor), cultural/behavioral theories ( poor people have poor health ha bits), and material/structural factors aka social causation (life circumstances associated with poverty make people more vulnerable to disease). 127 128, p.780 Additional, but relate d, theories of health disparities at an ecological level include one proposed by LaVeist (2005), who posits that racial segregation influe nces health through 1) the re latively higher prevalence of social and environmental health risk s and 2) through resource deprivation. Schultz and Other disparity theories focus at other levels of the socioecological model, such as the psychosocial and behavioral theories (weathering hypothesis, John Henryism, Immigration and Acculturation, Racial Discrimination [ biopsychosocial model ] and the individual biogenetic and physical theories of disparities [ biological differences among 21

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Mullings (2006) note a number of critical theo retical approaches to health disparities, including the ecological model, social capital, community-based participatory research and social justice, while at the same tim e making a case for the use of intersectional theory, developed most prominently by black feminist social scie ntists emphasizing the simultaneous production of race, class and ge nder inequality such that in any given situation, the unique contribu tion of one factor might be difficult to measure. 129, p.5 As an example of this intersectiona l effect, Kumanyika (2008) noted how differences in obesity rates among children could be related to differences in foodrelated beliefs, preferences and behaviors a nd should not be studied in isolation [of] demographic, socio-structural, and environmental variables.130, p.61 The author notes that the ethnic and racial differences in obesity rates may be manifest ed through numerous pathways, including high rates of maternal diabetes in pregnancy, parental attitudes and practices related to overfeed ing children, over-eating of high calorie foods and inadequate physical activity. Environmental variables in clude lower than aver age availability of healthy foods, and higher than average availability of fast food, and marketing efforts that target these specific social and cultural groups.131 Kumanyinka, for one, recognizes the interwoven nature of cultural and contextual factors that influence behaviors associated with racial and ethnic disparities in obesity rates.130 Intersectional theory is also supported by research showing that the physical body actually represents the manifestations of troubles in the social body such as racism, sexism and classism.132, p. 239-240 In this analysis, researchers hypothesize that groups, biogenetic-environmental interactions, and the sl avery hypertension hypothesis [ disproven ] ]) 22

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overeating may be used as a coping mech anism to deal with multiple forms of oppression, or a way of countering white conceptions of beauty.132 133 Indeed black and white women hold different conceptions of ideal body images, with black women reporting more satisfaction with their we ight and overall appearance than white women.132 Black women also self-report less ne gative pressure when obese, so some authors propose that weight reduction and ma intenance efforts may less interesting to black women.132 134 Thus, producing the same behavior change in black and white women might require tail ored interventions. The above research and theory, in addition to others129, 135-138 supports the idea posited by Frohlich, Corin and Potvin (2001), who argue the associations between social factors and health outcomes are more comple x than the simple principles derived from social epidemiology.128 While social ecological models ha ve taken a step forward to help researchers consider the ways in which the environment impacts individual behaviors, these environmental variables still do not de scribe how or why the environment functions to impact an outcome,128, 139 and therefore have limited ability to inform effective interventions. More in-depth work by aut hors noted above and Dre ssler et al. suggests that approaching culture through its complexities, and thus at a deeper level, may help overcome the limitations of social epidemio logy because; if we understand the culture, the mechanisms linking culture and health can be better understood.140, 141 Race and/or ethnicity in this study is unde rstood as a variable associat ed with a host of different experiences, beliefs and percep tions in line with the theories described above. 23

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A View from a Broad Theoretical Lens In addition to the discussion above, it is also beneficial to take a step back in order to view the association between safety, physi cal activity and racial/e thnic disparities and the role of CBPR in this study from a broader th eoretical lens. In pa rticular, theory from Pierre Bourdieu, is helpful in understandi ng the complex, multi-factorial relationships that may help explain physical activity in pediatric populations. Theory from Paulo Friere and Jrgen Habermas provide a lens for understanding the role of CBPR in this study. Bourdieus concepts provide a framewor k for understanding how different views and behaviors are constituted by different groups within a so ciety. Bourdieu defines the social space in which we live as the field. This field can be visualized as a grid composed of an x and y axis. The grid is th e social space characterized by different types of capital, the x and y axes of the grid. Th e types of capital that create the field depend on what type of capital is associated with power in a specific system.142 For most industrialized countries, Bourdieu noted economic capital and cultural capital (e.g., competencies, skills, and qualifications) were the forms of capital most relevant in forming the social space, or field For example, a doctor likely has higher levels of both cultural and economic capital compared to some one like a health clinic clerk, owing to differences in educational and economic resour ces. These individuals inhabit different areas of the field or social space and a particular space on the field is termed a habitus 143 In Bourdieus description, a habitus is associated with a number of different tastes143 as well as a certain doxa the pre-reflexive, shared but unquestioned opinions and 24

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perceptions the apparently natural beliefs or opinions that are intimately linked to field and habitus.144, p.120 Viewed from this theoretical vantag e point, different communities inhabit different areas of the social space. People in these spaces have particular behaviors, beliefs and ways of understanding the way thin gs are. For example, one community may have facilities and resources afforded to it by economic capital that are unavailable to other communities, which influences tastes and behaviors. In terms of physical activity, people from different habitus pos ition themselves on a social field as they participate, or choose not to participate, in different activ ities. Playing polo would be an extreme marker of very high economic status and capit al compared to bask etball, which confers status for adolescent urban males especially in African American communities. Within each habitus different activities confer different levels of status. In similar ways, these contexts reproduce different perceptions and practices, including what would be considered a safe environment, and al so how exercise would be perceived.145,146 Bourdieus concept of habitus also provide s a way to view the measures used in this dissertation study. In the work of Sampson, Raudenbush and Earls (1997), social cohesion plus a measure called informal social control form a concept called collective efficacy. Sampson defines co llective efficacy as social cohesion among neighbors combined with their willingness to intervene on behalf of the common good.84, p.19 At face value, Sampsons definiti on suggests that increasing collective efficacy will decrease neighborhood violence. While this might be true, it is important to note that the questions used in Sampsons measure are rooted in a certain doxa with its associated norms and values as defined by B ourdieu. Sampsons measure emanates from 25

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a positive conceptualization of social c ohesion and a specific assumption of which behaviors should receive social control. In Sampsons work, collective efficacy (and the subscale social cohesion) is only associated with positive outcomes, namely, reduced violence.84 Rather than being a measure of soci al cohesion, that is either positive or negative, I argue that Sampsons model ac tually measures the concordance of a community with a certain doxa, a doxa that contains certain norms: shared values, trust, getting along, being close-knit, being able to help their neighbors, controlling children who skip school, spray paint, or disrespect adul ts and care about fire stations' closing. This measure is not necessarily the same measure that someone from a different habitus would use to measure informal social cont rol. For instance, the character Cesar, a drug dealer, in Bourgoiss book, In Search of Respect 147 might view someone interrupting a child painting graffiti as someth ing that disrupts Cesars informal social control of the neighborhood. Sally Engle Merr y suggests interpersonal violence may be a form of informal social control, adapted for an economi cally poor, culturally diverse environment she researched. 148 Thus, Sampsons measure of collective efficacy is collective efficacy embedded within a certain habitus The measure of social cohesion used in this study, therefore, is treated both as a measure of safety as conceptualized by the dominant society, and as a marker of a dominant habitus endowed with social and cultural capital, i.e., cult ural practices, knowledge, and demeanors learned through exposure to role models in the family and other environments. 149 150, p.5 This theoretical lens provides perspective fo r interpreting results that mi ght come from the different concept mapping groups. 26

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Turning now to the theories of Paulo Frie re and Jrgen Haberm as, it is interesting to examine how CBPR links with their broader theoretical lens. With increased research funding available for CBPR, many researcher s claim to use CBPR, but there are a number of theoretical and practical differences in the wa y CBPR is done. Wallerstein and Duran have helped show how the various fo rms of CBPR have r oots in one of two traditions, the Global Northern tradition or the Global Southern tradition. Broadly, the Northern tradition corresponds more with a pr oblem-solving utilitari an approach used more by practitioners from the North, while th e Southern tradition takes an emancipatory and critical consciousness approach, emanating from practitioners from the South.151-154 The anthropological version of community deve lopment, focusing less on the process and more on the efficient achievement of economic development in native cultures, is an example of the Northern approach. 151 In contrast, the Southern tradition places more emphasis on process, engaging in reflexive di alogues in line with the work of Paulo Freire and Augusto Boal and the critical theory of Habermas.151, 155, 156, 157 Wallerstein and Duran argue that the emancipatory, rather than the utilitarian, st rain of CBPR holds greater promise for alleviating health disparities.151 In the present study the use of CBPR and concept mapping is theoretically aligned with the empowerment education of Paulo Friere and also Habermass communicative th eories and the concept of the lifeworld, the context-forming background of pr ocesses of reaching understanding.157, p.204 158, p.444 To Habermas, capitalist societies have created two distinct worlds: the systems worlds of highly differentiated legal, economic and political systems and the life world, the resour ce in which individuals form their identity and reproduce th eir culture. Increa singly people define themselves by their role within system sthey become objectsclients and consumersrather than subjects or democratic members of civil society who reproduce themselves as so cial and cultural beings. 159, p.32-33 27

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Habermas saw that the indivi dual had agency and that the lifeworld could be shaped and changed through communicative di scourse. In a sense, the process of engaging in CBPR bridges peopl e that inhabit different habitus This is certainly the case among the researchers and participants in th e advisory group who begin to see issues from each others viewpoints, reflecting on thei r own norms and values. This is a process that can lead to what Paulo Friere term s, conscientizao, when people engage in praxis (a combination of reflection and action) to move from being objects to subjects.160 Concept mapping is a tool consistent with conscientizao, allowing the community members complete control over th e grouping and rating of ideas, a way of reflecting peoples thinking processes back to them. This method sa tisfies the objectivity needed in studying a subjective matter, consistent with Habermass grounding as a student of Husserl, the father of Phen omenology. As a philosophical movement, phenomenologys primary objective is the di rect investigation and description of phenomena as consciously experienced. 161 Through the lens of phenomenology we can make sense of how or why an environment full of objective hazards appears unsafe to one group and safe to another. Rather than investigate what differe nt groups term or view as safe and unsafe, this study inves tigates how people who exist in different habitus with different influences shaping their life-wo rld, suggest and rate different solutions. Overall, this study approach es the problem of physic al inactivity by engaging community members to propose solutions for improving physical activity among children. By so doing, the researcher enga ges individuals from different communities from different doxas to provide contextually releva nt solutions. This study moves 28

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beyond a social-epidemiological approach and places residents and researchers on equal footing to say what interventions make sense to communities within distinct safety environments, which are also now understood to represent different habitus As the community advisory council engages in the CBP R process, at a theoretical level, our dialogue allows for a degree of conscienti zao that results from reflecting on the different solutions emanating from different people. Chapter Summary In this study, physical activity is under stood to be the product of multi-level influences described in the socio-ecologi cal framework. From that framework an individual variable (race/ethni city) and an environmental vari able (safety) used in this dissertation study were explored in more depth, evidencing the complex phenomenon these variables represent. Next turning to the theory of Bourdieu, safety and race/ethnicity are seen as markers of locations on a social field, or different habitus with associated doxas. Therefore the differences in percep tions of needed interventions by safety context and race/ethnicity explored in this study are underst ood as perceptions and beliefs emanating from different doxas CBPR and concept mapping methods used for this study are used as a means of engaging people from different habitus and doxa in communicative discourse and praxis. This engagement is consistent with the S outhern approach to CBPR and conscientizao, that some authors claim holds promise as a method for alleviating health disparities. 29

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CHAPTER III METHODOLOGY Research Design This mixed methods study includes two phases. In the first phase, cluster analysis of secondary data from representative hous ehold surveys and block audits from the catchment area identified distinct safety cont exts. The second phase involves engaging residents from the identified safety cont exts in concept mapping efforts. The study protocol was approved by the Colorado Mu ltiple Institutional Review Board. Research Setting This research builds from a community -based participatory research study initiated in 2006 to examine th e impact of the built and soci al environment on health and health disparities.99 The setting is unique because it includes Stapleton, one of the largest urban renewal projects in the United States, which was designed especially for active living, including green space, pocket parks, wa lking and bicycling trails, wide sidewalks and recreation amenities. Beginning in 2001, this redevelopment replaced the former Denver airport and its associated noise, traffi c and air pollution which had impacted four adjacent neighborhoods: Northeast Park Hill, Greater Park Hill, East Montclair, and Original Aurora.99 Data describing the neighborhoods (Table III.1) demonstrate large variations within these contiguous neighborhoods. In line with the social ecological framework, these contextual differences and similarities are important in unders tanding how residents conceptualize solutions for increasing physical activity am ong neighborhood children. 30

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Table III.1 Socio-Demographic Characteristics of Catchment Area. Neighborhood Population (#households, #households with 10-14 year-olds) Ethnicity % persons in Poverty** At current address <1 yr** Crime Rates Burglary and Violent Crime (per 1000 households) NE Park Hill **2000 Census ***2010 Census 8,729 (2744, 671) 7,821(2760, 518) 69% Afr.Am 24% Latino 5% White 51% Afr.Am 30% Latino 14% White 24% 22.9 41.3 9.8 Greater Park Hill **2000 Census ***2010 Census 19,118 (7522, 755) 17,972 (7308, 950) 36% Afr.Am 10% Latino N & S Park Hill* 28% and 75% White 24% Afr.Am 12% Latino N & S Park Hill* 44% and 77% White 9% 16.1 & 15.6 (N & S Park Hill) 23.5 & 17.2 3.2 & 4.6 (N & S Park Hill) East Montclair **2000 Census ***2010 Census 7,506(4218, 671) 10,191(4276, 701) 32% Afr.Am 32% Latino 31% White 24% Afr.Am 28% Latino 32% White 22% 30.3 30.2 13.3 NW Aurora 2000 Census ****2009 ACS 24,400 (7773, 2763) 36,461 (NA, 3053 15% Afr.Am 58% Latino NA White 17% Afr.Am 58% Latino NA White 27% N/A N/A Stapleton *Piton estimate ***2010 Census 5,296 (1871, NA) 13,948 (2543, 235) NA 10% Afr. Am 13% Latino 67% White 0% N/A 47.6 6.5 *Data provided by www.piton.org ** US Census 2000, *** US Census 2010, ****2009 ACS, Piton Foundation Participants from Taking Neighborhood Hea lth to Heart were invited to join a community advisory council (CAC) to guide the research efforts, which ultimately included English, and Spanish-speaking adults and youth. Youth par ticipants chose the 31

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name The Society of the Y outh and chose as the groups vision: The Society of the Youths dream is to have a safe and clean playground. A clean playground that has green grass, no graffiti, and where all kids come together to play. In total 26 people (15 adults, 11 children) participated and there wa s consistent attendan ce by a dozen people (6 adults and 6 children), a size that encouraged pa rticipation, relatedness and ownership in the process.162 Adults were given a $15 gift card and children a $7 gift card for their participation in monthly meetings, though the co nsistent participants continued to come after funding ran out and incentives were no lo nger offered. Participants were mainly responsible for guiding and re fining research materials, facilitating concept mapping sessions and providing feedback re garding analyses. Youth also created a play to present the study results. In these ways, we tried to achieve the nine principles of CBPR described by Israel et al, prin ciples that align with the Southern emancipatory approach of engaging community. These principles in clude: acknowledging the community as a unit of identify, building on community strengths, engaging commun ity in each phase of the research, developing mutual co-learning, ba lancing research and action, and emphasizing local relevance and action. This co-learni ng process focused both on group process and research products. The following two sections detail the met hods used to address each of the two study aims. Aim 1 Methods Aim 1: Identify homogenous bl ock group clusters by known physical and social correlates a nd measures of safety, including: 32

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fear of crime, traffic safety, social cohesion, discrimination and incivilities. Measures. Data from the original Taking Neighborhood Health to Heart study were collected using standard methods for achieving a representative sample.163-166 A detailed description of the data measures and collection procedures are provided in the paper by Main et al., 2012.99 The household survey in cluded 950 randomly selected households representing the five neighborhoods and a neighborhood audit measure that was collected from randomly selected blocks in the catchment area. These instruments provided the data for the cluster analysis, i.e., social cohesion,84 discrimination,125 perceptions of safety,167 and incivilities.168, 169 Race, ethnicity, language and presence of youth in the home were also collected in the household survey, data that were later used for concept mapping sampling efforts. I previously outlined the safety-related constructs in Figure II.1 and provide the details of their measurement below in Table III. 2. These constructs include fear of crime and perceived traffic safety, both of which are related to parental c oncerns. Incivilities are also theorized to sign al danger and create fear.80 Social cohesion, a subscale of collective efficacy may have protective effects from violence. A measure of discrimination was also include d as discrimination could infl uence a sense of safety as well as the interventions appropr iate to improving safety. 33

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Table III.2 Summary of Clustering Variables. Construct (data source) Questions Scoring Social Cohesion 84 (household survey) 1) this is a close-knit neighborhood, 2) people around here are willing to help their neighbors, 3) people in neighborhood generally dont get along with each other, 4) people in neighborhood dont share same values, 5) people in neighborhood can be trusted. Scale ranges from 525, with 25 being most cohesive Perception of crime subscale167 (household survey) 1) there is high crime rate in my neighborhood 2) the crime rate in my neighborhood makes it unsafe to go on walks during the day 3) the crime rate in my neighborhood makes it unsafe to go on walks at night Scale ranges from 14, with 4 being the least safe, the mean of three questions Perception of traffic safety subscale167 (household survey) 1) so much traffic along streets it makes it difficult or unpleasant to walk in neighborhood 2) the speed of traffic on most nearby streets is usually slow 3) most drivers exceed the posted limits while driving in my neighborhood Scale ranges from 14, with 4 being most traffic, the mean of three questions Experiences of Discrimination125 (household survey) 1) school 2) getting hired 3) at work 4) getting housing 5) getting medical services 6) getting services in a store or restaurant 7) getting credit, bank loans or a mortgage 8) on the street or in a public setting 9) from the police or in the courts? This scale totals the number of situations in which a person has experienced discrimination, from 1-9. I used the mean experiences of 8 and 9. Incivilities 168, 169 A walking block audit was conducted including observations for graffiti, litter, overall condition of grounds or landscaping, overall condition of buildings, condition of vacant lots, and broken windows or abandoned houses.170 Cluster Analytic Methods Used to Identify Unique Safety Contexts. In order to identify distinct safety contexts from which concept mapping participants could be recruited and intervention needs compared, I combined the survey measures described in the previous section, into a cluster analysis. Initial analysis showed variability in the measures used among the five neighborhoods; then to allow for intra-neighborhood variability, household and audit data were aggregated to the block group level, totaling 57 block groups. After inspecting the frequencie s, mean, median, range and variability of 34

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each measure, I normalized the data to the ra nge of 0 and 1. This was done by examining the range of values for each variable. The lowest value in the range was subtracted from each value and then each value was divided by th e highest number in the revised range. Then, I entered these data into hierarchical agglomerative cluster analysis (average link with Euclidean distance) in SAS 9.1 to identify homogeneous subgroups. After inspecting the frequencies, means, and central tendencies of each cluster and reviewing correlations between the constructs, the best-fit cluster soluti on was selected, identified by the cubic clustering cr iterion, or CCC statistic. 171, 172 The face validity of the clusters was tested by mapping the clusters in GIS, showing the data correspond closely to distinct neighborhoods. Aim 2 Methods Aim 2: Within a community-based participatory research context, use concept mapping methodologies to examine how solutions for increasing pediatric physical activity vary w ithin and between different safety contexts. Consistent with community-based part icipatory research, I worked with a community advisory council (C AC) originating from Tak ing Neighborhood Health to Heart to address this a im. We used concept mapping, a method that can help communities develop locally relevant interv entions it obtains information regarding group level definitions and perceptions as opposed to individual conceptualizations and it obtains information on social and st ructural influences on outcomes.11, p.284 Specifically, this method involves a number of structured steps: 1) preparing the focus prompt, 2) brainstorming solutions, 3) refining the solution set, 4) sorting the solutions, 5) rating the 35

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solutions, and 6) interpreting th e results and sharing the data.98 The remainder of this section includes a description of the sa mpling frame used to draw concept mapping participants and details about the six steps outlined above including related analytic methods. Concept Mapping Sampling and Recruitment Methods. Participants from the original TNH2H adult study and from a subsequent Kids Study173 used the same randomly selected blocks to recruit partic ipants. Both studies asked permission to contact participants in the future. My sampling frame included participants who participated in either of these studies and ag reed to future contact. Then I stratified the samples by safety context, race/ethnicity and language (English/Spanish), and randomly ordered these stratified samples for recrui tment. Society of the Youth members participated in the sorting pha se of the study and contributed some brainstormed ideas. After recruiting for and conducting the idea generating and sorting sessions with inperson meetings, the Society of Youth CAC a nd I realized our part icipation rates were insufficient for the rating phase and agreed to conduct the rating phase of the study by phone. At that time, a third study, the Apart ment Survey within the same footprint, was completed and we included a few of thes e participants so we would have equal numbers of people from each ra cial/ethnic group from each safety context. The origins of the sampling frame and correspondence to each concept mapping step is provided in Table III.3. 36

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Table III.3 Sampling Frame for Concept Mapping Efforts. How Initial Sample Recruited Sampling Frame Steps of Concept Map where Participants were Included TNH2H Adult Survey Every fourth house on the randomly selected block was approached. Data from 82% of 950 adults agreeing to contact after the TNH2H survey were reviewed. Those who reported children in the household were included in the sampling frame for the current study. Brainstorming, Sorting, Rating The Kids Study Every house on each of the randomly selected block was approached. Households with 10-14 year-old youth were included. Brainstorming, Rating, Sorting The Apartment Survey Inaccessible apartments for the initial adult survey were approached. Six households from this study were included in the rating step of concept mapping. Rating Steps in Concept Mapping Concept mapping methods follow prescribed steps, the overview of which, as well as the CAC involvement in each of these steps, are described below, while the more detailed data collection protocols are provided in Appendices 3-5. 1) Defining the focus prompt The original Taking Neighborhood Health to Heart council members were interested in focusing research on youth. Knowing this, I wrote a grant proposal, including the associated hypot heses and a letter of support from TNH2H members. The specific phrasing of the focus prompt emerged from interactions with The Society of the Youth community advisory c ouncil (CAC) and was piloted. After piloting and revising the statement, we chose the focus prompt, What changes would increase physical activity among 10-14 year old ch ildren in your neighborhood? 2) Idea generating phase. The sampling frame (combined participants of the household survey and kids study who agreed to future contact) was stratified by race/ethnicity, context and la nguage and put in random order. CAC members and I called 37

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the randomly-ordered participant list and sent a flyer to invi te their participation. The phone call provided an introduction and the flyer reinforced details such as time, location, $10 incentive, and date for the group-discussion formatted sessions. When people could not be located by phone, we mailed a flyer. Th e flyer included original art work designed by the youth to create a fun, inviting feel (Appendix 1). Participation rates were relatively low in this step, suggesting other methods would be needed for the rating phase of the study. Besides helping to recrui t, CAC members were also trained using materials adapted from other Taking Neighborhood Health to Heart efforts (Appendix 2). They were then hired as contractors to facilitate and take notes for brainstorming groups. Each group followed a common protoc ol (Appendix 3), and was a udio recorded, with a notetaker documenting notes as a backup. In most circumstances youth and adults generated their ideas for solutions in separate gr oups that lasted two hours or less. 3) Refining the solution set. Two University researcher s independently took notes from the available recordings (or session notes) of the idea generating sessions to capture specific participant suggesti ons. A CAC member subsequently reviewed the two resaerchers notes; ideas listed on both note-takers lists were included in the final list of community ideas. This final list was translat ed so each idea appeared in English and Spanish. To condense the list of ideas to a manageable set, the advisory group reviewed each idea on individual cards, and attempte d to identify duplicate ideas for the purpose of reducing our set of ideas. We attempted this task twice a nd were unsuccessful. Ultimately, I proposed that the least biased wa y to narrow the statements was to put the 38

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ideas in random order and select the firs t 100 ideas; the committ ee and my dissertation chair agreed. Next, the advi sory group members independently reviewed the first 100 ideas and identified duplicate or similar ideas In the CAC, each member discussed the duplicates they identified and the group came to a consensus on which ideas were to be eliminated and whether and how statements n eeded to be edited. As duplicates were eliminated, we included lower ordered ideas and the list was checked to assure that evidence based ideas, e.g., reducing television time, making facilitie s accessible, were included. The final set of 100 ideas was tran slated and back-translated by different translators. 4) Sorting the solutions The sorting phase also followed a standard protocol where, within a two hour session, individuals were given 100 cards with each of the randomly selected interventions and asked to so rt the cards into piles that made sense to them and then to name the piles (Appendi x 4). Despite low attendance in the brainstorming phase, we attempted to have sorting and rating efforts conducted in person with the same recruitment methods, with the exception that th e incentive was doubled ($20). Even with the larger incentive, few people participated, so CAC members also participated in sorting the ideas. From these efforts, it became evident that some people could not understand the written materials in their native English or Spanish language. I had to discard data from two Spanish-speaki ng participants whose sorting efforts were incomplete and incoherent. This experience also reinforced the need to find alternate recruitment and administration methods for the rating phase. 5) Rating the solutions Because there was relatively low attendance in the brainstorming and sorting study phases, th e CAC and I redesigned the rating phase 39

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materials to be administered by phone. The standard protocols for the rating phase were amended, a related COMIRB amendment was submitted and the final materials used are in Appendix 5. I hired indivi dual contractors with survey administration experience (2 bilingual in Spanish and English; 1 English only) to collect the needed ratings by phone. Because we conducted individual interviews we didnt need the sample stratification to include language, so I restratif ied the sample by safety cont ext and race/et hnicity alone and again randomly ordered the newly stratified samples. Th e recruiters sent formal letters describing the study and/or called participants, leaving a maximum of three messages. If phones were disconnected or the person was not c ontacted after three attempts by phone, recruiters made a home vi sit where they met the person, explained the study and provided a letter describing the study. If nobody was reached, recruiters left the study letter and wrote a not e explaining that the phone num ber we had did not work. Up to two home visits were made for each pa rticipant. After all attempts to contact a participant were exhausted, we then attempte d to reach the next person in the randomly ordered stratified sample. Adults were interviewed by phone first and then asked if they had a 10-14 year old youth in th e house they would permit to complete the same survey. Thus adult and youth intervention ratings were collected independent of one another. The CAC and I chose how to ask participants to rate the solutions. First we asked, To increase physical activity among 10-14 y ear olds in your neighborhood, how needed would you say it is to (read statement); 1 is no t at all needed, 5 is most needed: We chose a second rating that read: And how possible would that be? 1 is not at all possible and 5 is most possible. A CAC member was al so employed to record these results in the concept mapping software. 40

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6) Interpreting the results and sharing the data I analyzed data to answer the study hypotheses and presented that to the CA C. The CAC reviewed the analyses and suggested other analyses to present. Th e CAC rejected the concept mapping format for sharing study results because it seemed relatively difficult to understand, and instead created a skit to repres ent the top results. Concept Mapping Data Analysis. The Concept Systems Software ( www.conceptsystems.com ) and SAS 9.1 were used for concept mapping analyses. The Concept Systems Software allows users to en ter sorting and rating responses, as well as a set of questions for each respondent, e.g., de mographics, safety context. Kane and Trochim (2007)174 describe the analytic methods utilized within the concept mapping software. Sorting information from participants is put into a binary symmetric similarity matrix which represents how many people put di fferent ideas into the same pile. Then, this similarity matrix is used for nonmetric multidimensional scaling, which creates a two-dimensional point map where ideas that were more commonly put in the same pile are placed closer together than those not often in the same pi les. According to Kane and Trochim174, in multidimensional scaling the stress index is the key diagnostic test to determine if the point map is a good fit for th e participant sorts. Stress measures the degree to which the distances on the map are discrepant from the values in the input similarity matrix. 174, pg.97 The smaller the stress test valu e, the better the map fits the data. A meta-analysis by Trochim (1993) showed that across a variety of concept mapping projects, the average stress test sc ore was 0.285 with a standard deviation of 0.04. So 95% of concept mapping projects would have a stress test in the range of 0.2050.365. 174 41

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Once the concept mapping software esta blishes x and y coordinates through multidimensional scaling analyses, these coordi nates are used for hierarchical cluster analysis which creates the c oncept groupings seen in concept mapping. The more often participants sorted the ideas together the smaller area of the cluster, and larger area clusters represent broader groupings of id eas. Concept Systems uses agglomerative cluster methods, using the Ward algorithm th at works well with distance-based data. 174 Authors note any number of clusters can be c hosen and no specific number of clusters is better than another, and often this choice is made by the researcher rather than study participants The hypotheses for this second study aim include: H01: People in environments defined as being safe, having high levels of perceived safety and social cohesion and low measures of incivilities and discrimination will offer more solutions for increasing physical activity that are unrelated to the safety environment. H02: Ratings of the solutions suggest ed by different demographic subgroups within safety environments will be more similar than the ratings of solutions offered between different safety environments. To test these hypotheses I exported data from Concept Systems Software into SAS 9.1 and then used one-way ANOVA for bi variable analyses and Proc GLM for standard multivariable linear regression. I complemented these standard analytic techniques with concept mappi ng pattern matching in order to illustrate the ratings of intervention solutions within and between safety clusters. 175 Pattern mapping graphs 42

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resulting from this method allow visual inspect ion of cluster agreement. For example, in this study, separate group ratings of interven tion clusters are represented on separate vertical axes, with higher rated intervention clusters placed hi gher on the vertical axis and lower rated interventions placed lower on the vertical axis. To compare two different groups cluster ratings, the vertical axis rati ngs of one group are shown next to a second groups ratings. For these comparisons, the concept mapping software produces a Pearson Product-Movement correlation coeffi cient (r), representing the degree of statistical correspondence between the data from the two groups. The r coefficient can range in value from -1 to 1, with 1 repres enting a perfect correl ation. This would be depicted by the clusters being listed in the same order on bot h axes with horizontal lines drawn from each cluster to its corresponding cluster on the opposite axis. An r of 0 represents a poor correlati on, and an r of -1 represen ts a perfectly inversed relationship.175, p.531 For example, if all safety cluste rs indicate that the same concepts are similarly important or actionable, then the Pearson product coefficient would measure 1. If the solutions proposed are rated in inverse order then the Pearson correlation coefficient would measure -1. 43

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CHAPTER IV RESULTS Aim 1 Results Aim 1: Identify homogenous block group clusters by known physical and social correlates/measures of safety, including: fear of crime, traffic safe ty, social cohesion, discrimination and incivilities. The five variables included in the cluster analysis to model safety included: fear of crime, traffic safety, social cohesion and discrimination, as well as an objective measure of incivilities. This analysis resu lted in a three cluste r solution, depicted in Figure IV.1 revealing different neighborhood bloc k groups having low, medium and high levels of safety. Because discrimination did not follow the pattern of the other four variables and has not traditionally been included as a measure of safety, the cluster analysis solution was tested to both include and exclude discrimina tion, but the original conceptualization, including disc rimination, was selected as a better fit for the data. Oneway ANOVA analysis comparing block groups in the 3 clusters rejected the null hypothesis of no difference between the cluste rs for each of the variables measured (Figure IV.1). 44

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Three Cluster Solution0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1most safe mid safe least safeClusterStandardized Clustering Variable 0 least safe, 1 most safe crime safety traffic safety free from incivil have soc_cohesion free from discrim Cluster crime safety traffic safety freedom from incivilities have social cohesion free from discrimination Most safe 0.84 0.85 0.76 0.82 0.83 Mid safe 0.56 0.51 0.38 0.54 0.5 Least safe 0.24 0.3 0.2 0.22 0.61 Figure IV.1 Data from Three-Cluster Solution with Data Normalized to 0-1 Scale. A GIS student then mapped the block-group sa fety scores to allow visual review of the cluster solution, resulti ng in a map where red, yellow and green colors signified least, middle and most safe areas, respec tively. Broadly, these maps provided face validity for the safety clusters for people who know the neighborhoods. The CAC requested this map of safety contexts not be distributed because it could stigmatize neighborhoods and I agreed, recognizing that this preliminary anal ysis is similar to conducting univariable distribut ion graphs to prove the ap propriateness of different statistical techniques. That is, the map was simply used to confirm that the cluster analysis had face validity. This map can be requested for specific purposes by contacting 45

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the author. With the safety contexts identi fied, I was able to stratify the sampling frame accordingly and begin recruiting re sidents from each of these contexts to participate in concept mapping. Aim 2 Results Aim 2: Within a community-based participatory research context, use concept mapping methodologies to examine how solutions for increasing pediatric physical activity vary within and between different safety contexts. CBPR and the Community-Advisory Counsel. What distinguishes community based participatory research (CBPR) from ot her research has been articulated as nine principles of CBPR.176 How this study intersected with each of these principles is described next. First the community was the unit of id entity, including residents of five geographic neighborhoods engaged in a pare nt research project, Taking Neighborhood Health to Heart (TNH2H). Second the present study built on strengths of the community, including the TNH2H study where community members had participated in research, had built trust with one another and were vocal about their community needs. TNH2H included community members already r ecognized as community leaders in their neighborhoods. A third aspect of CBPR is facilitating collaborative, equitable partnership in all phases of th e research. Researcher and residents contributed to the different phases of the research study as described below: Problem definition: The interest in working on youth-related issues was prompted by the original Taking Ne ighborhood Health to Heart Advisory Committee, while I offered the specif ic focus on youth physical activity and related hypotheses in response to an available funding mechanism. 46

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Data collection: I chose concept ma pping methods because it necessitates community engagement; CAC members refined the focus prompt, collaboratively designed recruitment me thods, chose rating scales and refined study materials; CAC members were trained and then contracted as facilitators and recorders for the brainstorming and sorting phases of the research. One community member was hired to record data collected from the rating phase of the study. Interpretation of results : I presented the study hyp othesis results to CAC members for review and in terpretation. They were also given the primary variables available for analysis, e.g., youth and adult need ratings; youth and adult feasibility ratings; neighborhood sa fety contexts. CAC members chose which way they wanted data to be an alyzed for community presentations. These analyses are included as part of the results, complimenting the hypothesis testing initially proposed for the academic research aims. Application of the results to addr ess community concerns: CAC members specifically chose not to show a map of the different neighborhood safety environments as that could stigmatize neighborhoods, focused on unifying themes of the results for presentations to policy makers and decided the results should be presented as a play or skit rather than an academic presentation alone. Members chose to focus on results that youth across communities supported, rather than looking at differences in solutions by safety context. The community group was able to use the study results to obtain a $500 grant that helped the group participate in one activity fair and build partnerships to 47

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create a second activity fa ir attended by hundreds of community members in second part of the catchment area (Appendix 6). Fourth Israel et. al., have described CBPR as promoting co-learning and capacity building among all partners. As a resear cher, I helped the community group gain research experience in group f acilitation, recruitment, data entry, data analysis and introduced advocacy principles. Four peopl e received recommendations for jobs or scholarships. Two youths wrote a grant that was not funded, and then adults worked together to write a second small grant that did receive funding. Wh en we were offered the opportunity to present our st udy results as part of an annual meeting where the U.S. Surgeon General was scheduled to speak, the community group brought a new idea to me, suggesting we present the st udy results in the form of a play, ra ther than as an academic-oriented PowerPoint presentati on. The older youth in the group took over writing and directing the play. In the end, an actor working with Kaiser Permanente's Educational Theatre Program taught the youth ho w to stage their skit and some basics of acting. I learned the importance of incorpor ating community engagement through each phase of the study, including study design and an alysis: if left to myself, I could have unnecessarily stigmatized the included neighbo rhoods without necessarily adding value. While the group focused on the presentation, in retrospect, we didnt strategize sufficiently about how we would build on the presentation, where the audience included policy makers and linkages to funding opportunities. All the CAC participants worked toge ther to help addr ess one anothers hardships: money for food, lack of health insurance, disengaged parents, depression, issues related to trust. In one instance, a CAC member led the rest of the group in 48

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praying for one of our members. I didnt have a lot of the knowledge and skills community members shared, and I also learne d how little expertise I have in creating youth-led initiatives, de spite previous community organi zing and youth-le d evaluation experience. I belatedly brought in help, which was rejected because the group had already formed an identity and was sensitive to outside input. All these experiences, from simple things like choosing what f ood to bring to meetings, to acceptance of professional outside help, wa s all part of the communicative discourse, the mixing of different doxa that challenged us as a community, but it may be these very challenges that gave us the gift of deep transformative community experience. Below are a few illustrative quotes to understand the nature of the group: In the past when I did attend meetings it wasnt the communitys word it was the citys wordbut they dont live in this neighborhood so they dont know what the neighborhood needs. I think the program is great because it allows community members, people who may never show up at other places or other meetings to voice their opinions about what they want for thei r kids or the youth in the community. Im very proud of what is going on. ..the whole purpose is to find something that they (youth) want so that they can become more physically active and if they put their ideals into it and they create it then theyll participate in it. A fifth principle of CBPR is that it integr ates and achieves a balance between research and action for the mutual benefit of a ll partners. As this research is completed so are actions in the community. For example, we decided to meet one of the expressed 49

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needs, by offering activities in a local park once a mont h during the summer, including swimming pool entrance coupons for participan ts. Later, the group received a Denver Foundation Strengthening Communities grant th at resulted in participation in two community fairs. Two hundred people visited our table at a Get Outdoors Colorado fair in City Park, and about 500 people attended a family activity fair we organized with partner organizations in Aurora. We anticipate this Aurora fair will be an annual event. A sixth principle of CBPR is that it emphasizes local relevance of public health problems and attends to the multiple determinants of health and disease. By using concept mapping methods, community member s contributed their ideas for improving their neighborhood outside any one fr amework, allowing them to group and conceptualize their so lutions within a grounded framew ork. We did not address the seventh principle of CBPR, involving systems de velopment through cyclical and iterative processes. The eighth principle of CBPR is disseminating findings and knowledge gained to all partners, with all partne rs involved in the dissemination process. Results were interpreted and disseminated with the CAC members at a neighborhood health summit. Lastly, CBPR is described as involving a long-term process and commitment (even when funding is not available). This partnership has extended years beyond funding availability, with the group continuing to meet with plans to convene yearly to create a family activity fair in Aurora. As Randy Stoecker suggests, this was a social change project, of which research is only one piece. 177, p. 102 Concept Mapping Recruitment Efforts. People who participated in one of the three surveys described in the methods sect ion were eligible to participate in the 50

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brainstorming, sorting and/or rating phas es of the concept mapping project. CAC members also contributed data to the brainstorming and sorti ng steps of this project. A description of the participants in these phases is provided in Tables IV.1 and IV.2 below. To elicit community solutions for incr easing physical activity among youth aged 1014, we held idea generating sessions between 11/14/09 and 2/13/10. A total of eleven groups with 62 participants (Table IV.1) ge nerated 318 ideas in these sessions. The advisory group added twelve ideas and then the list of 330 soluti ons (Appendix 7) were put in random order and the first 100 unduplicated ideas were chosen for the solution set. The next step in concept mapping efforts was to engage the community to pile sort the ideas. Between 6/19/10 and 8/28/10, we held 5 groups with 17 people (See Table IV.1) contributing pile sorting data for the 100 solutions. Individual pa rticipant pile sorts were combined in the concept mapping softwa re, producing data or concept clusters. Table IV.1 Summary of Brainstorming and Sorting Phase Participants Participants Total Black Latino* White Adult Child Brainstorming 62 15 32 15 31 31 Sorting 17 4 5 8 12 5 *Nineteen of these participants did not complete th e demographic survey, but participated in Spanishspeaking group or were child of parents in Spanish-speaking groups and therefore assigned to the Latino/Hispanic category or could have been designated unknown. In addition to the 62 participants, CAC members contributed 12 intervention ideas. To assure better representation of the study population, between 8/8/10 and 12/20/10, the study team conducted the rating phase by phone or in-p erson. We asked participants to rate the solutions in terms of need and possibility (feasibility). The summary of rating phase recruitment efforts by context and ethnicity is shown in Tables IV.2 and IV.3. 51

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Table IV.2 Rating Participant Recruitment Effort. RATING PARTICIPANTS # Homes Attempted Declined No response to multiple attempts Moved Adult Raters Youth Raters Context 1 black 15 6.3% (1) 6.3% (2) 12.5% (2) 10 4 Context 1 white 15 0 20.0% (3) 6.7% (1) 11 3 Context 1 Latino* 14 0 7.1% (1) 7.1% (1) 11 4 Context 2 black 19 0 10.5% (2) 36.8% (7) 10 3 Context 2 white 21 4.8% (1) 14.3% (3) 28.6% (8) 9 4 Context 2 Latino 22 4.5% (1) 9.1% (2) 40.9% (9) 10 3 Context 3 black 24 4.2% (1) 8.3% (2) 45.8% (11) 10 3 Context 3 white 16 0 18.8% (3) 18.8% (3) 10 4 Context 3 Latino 20 0 20.0% (4) 30.0% 6 10 4 Totals* 166 2.4% (4) 12.6%( 22) 27.5% (48) 91 32 The reason for one persons non -inclusion was not recorded Table IV.3 Summary of Rating Phase Study Participants. Race/Ethnicity Context Participants Total black Latino White 1 2 3 Adult 91 30 31 30 32 29 30 Youth 32 10 11 11 11 10 11 Total 123 40 42 41 43 39 41 Participant-Suggested Interventions. The first study hypothesis is: People in safer environments (having hi gh levels of perceived safety and social cohesion and low measures of incivilities and discrimination) will offer more solutions for increasing physical activity that are unrelated to the safety environment. To evaluate this hypothesis, solutions fr om each of the brainstorming groups were listed and categorized as related or unrelated to safety. Any idea related to traffic safety, police, gangs, need for youth supervision, or sa fety stated in some other explicit way was considered related to safety. The ideas were categorized twice, once in July 2011 and again in May 2012; only eight di screpancies in categorization occurred between the first and second categorizations of the 330 ideas. Those 8 ideas were reviewed and given a final categorization in May 2012. 52

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Reviewing all brainstormed ideas, 23% (74/ 318) were related to safety. To be consistent with later analyses, interventions suggested by participants from the middleand leastsafe contexts were combined and compared to interventions suggested by participants in the safest cont ext. Results show that 30% of the solutions suggested by participants in less safe cont exts and 13% of solutions sugge sted by participants in the safest context were related to safety, rejecting the null hypothesis of no difference between the groups. Interestingly, only 5% of solutions suggested in youth-only groups were related to safety, compared to 39% of solutions from th e adult-only groups. Of the ideas added by the community advisory council, three or 25% of the ideas were safety-related. Table IV.4 Summary of Safety-Relat ed Interventions by Context. Context Participants Language Date Total Ideas Safety Ideas % of Ideas = Safety 2&3 Adults Spanish 11/14/09 15 7 47% 2&3 Adults Spanish 2/6/10 13 9 69% 2&3 Youth and Adults English 2/6/10 44 5 11% 2&3 Youth English 11/14/09 12 2 17% 2&3 Adults English 11/14/09 13 5 38% 2&3 Adults English 12/5/09 16 1 6% 2&3 Youth and Adults English 2/13/10 26 11 42% 2&3 Youth English 12/5/09 22 0 0% 2&3 Adults English 12/5/09 32 18 56% Subtotal 2&3 193 58 30% 1 Youth English 12/12/09 82 4 5% 1 Adults English 12/12/10 43 12 28% Subtotal 1 125 16 13% Youth total 126 6 5% Adult total 132 52 39% Grand Total 318 74 23% CAC Youth and Adults Bilingual 12 3 25% 53

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Concept Map of Suggested Interventions. After the brainstormed solutions were reduced to 100 ideas and community members sorted the solutions, these data could be represented as a point map (Figure IV.2) The map had a stress test value of 0.314, which is within the average range for concept mapping projects.174 Each point on the map represents a different idea. The clos er any two points are together, the more frequently the two ideas were sorted in the same pile. For instance, ideas 39 and 98 were sorted in the same pile by nearly all the so rting participants, whereas idea 98 was hardly ever (if ever) put in the same pile with idea 13. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 4 9 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 8 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Figure IV.2 Point Map Resultant from Sorting Activity. Like cluster analysis, any number of c oncept clusters could be generated from these data. But on inspection, the 3 cluster so lution was chosen to best fit the data and address the research question. The three clus ter solution included the following concepts: safety interventions, infrastructure/access improvements, and activity interventions (Figure IV.3). Using these thre e clusters, including a distinct safety cluster, I examined 54

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the main research question of whether the relative perceived n eed for safety interventions differed between safety contexts and de mographic groups. The points on the map correspond to the statements shown in Table IV.5. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.3 Three Cluster Solution. 55

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Table IV.5 Statements Sorted in to Three Intervention Clusters. INFRASTRUCTURE/ACCESS 1. Have more mentors to encourage physical activity 9. Make more places to lift weights, do aerobics, and play sports 10. Have parents get their children involved 11. Use the park at Fitzsimmons 14. Provide a multi-sport facility where children can participate in tournaments, sports camps 19. Make playgrounds better with different e quipment, like zip lines and more creative staff 20. Make the parks prettier with flowers and trees 21. Set up more biking paths to places you want to go, like school and the mall 22. Make a closer skating rink 23. Have chaperones (adult volunteers) take kids out of the city for fieldtrips 24. Have more stretching and warm up for sports 26. Have a football field close to home 32. Have more recreation centers around the neighborhood 34. Have more organized sports in elementary schools 47. Have less expensive instruments, uniforms, equipment 50. Have parents take children to the park 51. Reduce costs of recreation centers 53. Provide more physical activities in schools 60. Create more parks, playgrounds, and open places to play 63. Vote to be sure programs, like PE classes, are not cut from schools 64. Have a recreation center with free activities 65. Have students get up and walk or do some activity every 20 minutes at school 71. Have people talk at back-to-school night to tell others about opportunities to be active 83. Build more walking paths and trails nearby 92. Give money to schools to supervise kids after school enrichment activities and physical activity, especially for girls 93. Reduce sport fees, especially for families with multiple kids 95. Build more businesses, restaurants and other places in the neighborhood that people can walk to 96. Unlock school playgrounds so they can be used after school hours and during breaks 97. Have more public restrooms and drinking fountains in parks SAFETY 2. Improve safety in recreation centers 3. Have older youth watch younger kids outside to create safety 4. Have responsible parents and adults in the park and neighborhoods to watch over kids 5. Get a group of people to commit to report bad activities to the police 6. Have adults pay more attention to their children and check on them 25. Have parents volunteer to staff the school playgrounds after school 30. Put in traffic bumps to slow traffic 31. Give people a way to report crime anonymously 36. Educate people on how to report crime and what to look for 38. Add security cameras around the recreation center to keep it safe 39. Have fences to keep kids from running in streets 40. Have community members report license plates of people doing bad thingsso reports are anonymous 43. Make police more visible 56

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Table IV.5 contd Statements Sorted into Three Intervention Clusters. 54. Provide more security and protection for the kids and youth 57. Get rid of unproductive businesses, because they are crime magnets 59. Make a safe place for kids to go during summer or spring breaks 67. Put a fence around the playground area so kids feel safer 68. Protect children from traffic 72. Clean up the litter and graffiti in your neighborhood and neighborhood parks 74. Give kids freedom to be outside and let them know not to talk to strangers 75. Make travel safer to parks, recreation centers, and schools 77. Protect kids from gang members and bullies 81. Put in new street lights 82. Organize everyone to turn on porch lights to make the neighborhood safer 88. Enforce curfew laws 98. Have emergency telephones in th e parks and in the neighborhood YOUTH ACTIVITIES 7. Have a volleyball court close to home 8. Open/unlock tennis courts for things like roller-skating 12. Have snowman building competitions 13. Take and teach children to ski or snowboard 15. Go to the pool 16. Have a scavenger hunt where you go to look for different things like pine cones and birds with your family 17. Have kids do activities like sports 18. Youth having season passes to amusement parks, like Elitches or Water World, where they can be active 27 Make basketball tournaments 28. Teach kids about everyday fitness (like walking to school, the grocery store, walking the dog) 29. Have a dog to walk or other animals to interact with 33. Train or educate adults to facilitate youth physical activities 35. Have snowball fights 37. Have geogames (where people use a map and compass to find different treasures) 41. Take students on a free snowboarding trip with school 42. Open the paddle boats in the parks more often 44. Have more skate parks for kids on wh eels, like skateboards, rollerblades, etc 45. Take kids out walking with lunches and hy giene kits to give to the homelesskids contributing to the community 46. Parents ride bikes with kids, have a family ride 48. Have music and more affordable after-school activities 49. Make available free or reduced price rentable sports or activity equipment 52. Have a walk-a-thon 55. Have a gym for dance competitions 56. Go for a field trip snow shoeing or ice skating 58. Have more kids walk or bike to school 61. Create a game of urban survivor 62. Take students on backpacking, hiking or camping trips 66. Create more sports and activities for kids 69. Set up different activities and stations in the park for the whole family 57

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Table IV.5 contd Statements Sorted into Three Intervention Clusters. 70. Give youth something positive to do, a program to clean up neighborhood, help the elderly, make them feel worthwhile, like th ey have a purpose, like they count 73. Have hopscotch, hula hoops, jump ropes, four square tournaments after school 76. Provide more interesting activiti es to involve the whole community 78. Have a community history trivia contest 79. Have bungee jumping 80. Have free youth activity time at the rec cente rs for swimming, basketball and other activities 84. Jump rope at home 85. Have kids involved with after-school activities because they are safe 86. Dance in class or at school 87. Give prizes to encourage physical activity 89. Have music, block parties to draw people out 90. Have teachers give less work over the weeke nds so students have more time to play and do activities 91. Go to summer camp 94. Encourage kids to spend less time watching TV and using computers 99. Support having mobile playgrounds, a semi-truc k of toys that can be taken to different places 100. Get a group of kids together to organize and advertise youth events (with flyers or word-ofmouth) Multivariable Analyses to Evaluate How Ratings by Different Demographic Subgroups Vary within and between Safety Contexts. The second study hypothesis is: Ratings of solutions suggested by differe nt demographic subgroups within safety environments will be more similar than the ratings of solutions offered between different safety environments. To address the first study hypothesis, I first used ANOVA anal yses to compare the average ratings of need for safety interv ention combining youth and adult participants living in the three geographic safety contexts. This analysis (Table IV.6) shows for all participants in the rating phase of the study, participants liv ing in the safest geographic context rated the need for safety interventions lower than participants from the other two contexts, supporting the study hypothesis, F=17.5, p<0.001. 58

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Table IV.6 Average Need for Safety Interventions by Safety Context. Geographic Context Participants (N) Mean Std Dev Min Max Safest 43 3.23 0.60 1.46 4.50 Medium Safe 39 3.93 0.66 2.19 4.96 Least Safe 41 3.94 0.63 2.19 4.96 Comparisons of Safety Intervention Needs. The previous ANOVA results showed the rated need for safety interventions was hi gher in the two least safe contexts compared to the safest context. To examine the re lative influence of envi ronmental context and individual characteristics on need for safety interventions, I expanded the ANOVA analysis to a multivariable regression analysis including ethnic/racial groups and adult or youth age group as covariates. In the adjust ed analysis, the R-square value was 0.38. Adults were more likely than youth to see a need for safety interventions; and black and Latino participants (who were in equal numbers in all safety contexts) were more likely to see a need for safety interventions compared to white participants (Table IV.7). There were differences in the rating of safety in tervention needs by geogra phic safety context, but also by ethnic group, and age group (youth v. adult). These results show the geographic context was the stronge st correlate of perceived need for safety interventions, but there were also signifi cant differences by ethnic and age group. This finding supports the hypothesis that safety context, more than individual characterist ics, is related to participant perception of wh at interventions are needed to increase youth physical activity. Because this higher re lative need for safety interv entions could be indicative of a higher need for all interventions gene rally, the perceived needs for the other intervention clusters are examin ed in the next sections. 59

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Table IV.7 Mean Need for Safety Interventions. Parameter Estimate Standard Error t Value p Value F value Intercept 3.37 0.15 23.08 <0.01 Black Latino White 0.59 0.48 0.0 0.13 0.13 4.68 3.70 <0.01 <0.01 12.07 Safest Medium Safe Least Safe -0.73 -0.05 0.00 0.13 0.13 -5.85 -0.39 <0.01 0.69 21.33 Adult Child 0.30 0.00 0.12 2.50 0.01 6.25 Comparisons of Infrastructu re/Access Intervention Needs. Similar analyses were conducted to see how different demogra phic groups rated infrastructure/access improvement needs, with similar findings (Table IV.8). In this model the R-square value was 0.20. Adults in the two least safe contexts thought in frastructure/access improvements were more needed than adults in the most-safe context. Black and Latino participants thought infrastru cture/access improvements were more needed than white participants. Children and adults rated the need for infrastructure/access improvements similarly. Again, the absolute value for the safety context estimate was larger than any other estimate, showing context, more than individual characteristics, shape the perceived need for infrastructure/access improvement interventions to incr ease physical activity among youth. 60

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Table IV.8 Mean Need for Infras tructure/Access Interventions. Parameter Estimate Standard Error t Value p Value F value Intercept 3.86 0.11 35.67 <0.01 Black Latino White 0.23 0.22 0.0 0.09 0.10 2.51 2.33 <0.01 0.02 3.88 Safest Medium Safe Least Safe -0.40 -0.06 0.00 0.09 0.09 -4.33 -0.64 <0.01 0.52 10.89 Adult Child -0.03 0.00 0.09 -0.40 0.69 0.16 Comparison of Activity Intervention Needs Finally, I analyzed the data to determine whether different groups rated ac tivity intervention n eeds similarly, with results indicating some consistent and other un ique findings (Table IV.9). In the adjusted analysis, the R-square value was 0.18. Agai n, people in the two least safe contexts thought activity interven tions were more needed than the participants in the safest context. Black and Latino participants thought activities were more needed than white participants. Youth thought act ivities were more needed than adults. The estimate for ethnic group was larger than that for context, suggesting that ethnic group had a stronger influence than context on the perceive d need for activity interventions. Table IV.9 Mean Need for Activity Interventions. Parameter Estimate Standard Error t Value p Value F value Intercept 3.73 0.11 Black Latino White 0.29 0.29 0.0 0.10 0.10 3.01 2.94 <0.01 <0.01 5.85 Safest Medium Safe Least Safe -0.24 -0.03 0.00 0.10 0.10 -2.54 -0.26 0.01 0.80 3.83 Adult Child -0.19 0.00 0.09 -2.10 0.04 4.41 61

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Summary of Multivariable Analyses. Together, the three multivariable analyses suggest that context and indi vidual characterist ics all influence i ndividuals perceived needs for interventions. Participants in less safe contexts thought all interventions were needed more than those living in safer neighborhood contexts. Yet the multivariable analysis showed there were no differences betw een the ratings of participants in the two least safe contexts. Context (most safe v. two less safe contexts) had a larger independent association with safety and infrastructure /access needs than individual factors, e.g., race/ethnicity or age group. In activity intervention analyses, race/ethnicity had a larger relative influence on perceive d needs than context. Concept Mapping Analyses. Concept Maps by Context and Demographic Groups. Above, the multivariable analyses examined how independent variable s influenced the perceived need for each intervention cluster separately, e.g., sa fety, infrastructure/access and activity interventions. By comparison, concept mappi ng analyses provide a pictorial comparison of the relative importance of different inte rvention clusters within specific groups. Though these analyses could be accomplis hed with multiple ANOVA analyses, the graphic concept mapping represen tation was chosen instead. In the maps provided in this section, th e intervention clusters are shown. Each cluster has a specific number of layers, which represent the ra ting, where a greater number of layers correspond to a higher relati ve need. For example, the title of the first map (Figure IV.4) indicates this is a cluster rating map for adults ove rall. There are four layers associated with the infrastructu re/access intervention gr ouping, showing adults 62

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thought this intervention cluster was the most needed, followed by safety interventions (2 layers) and youth activities were least needed (1 layer). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.4 Adult Rating of Relative Need for Different Intervention Clusters. Figure IV.4 (Adults) contrast s considerably with the cluster rating map of youth (Figure IV.5). Youth thought infrastructure/acces s and activity interventions were most and equally needed (4 layers per group), while safety interventions were least needed (1 layer). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.5 Youth Rating of Relative Need for Different Intervention Clusters. 63

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Thus, while the multivariable analyses s howed how the need for each intervention cluster was influenced by i ndividual and contextual vari ables, these concept mapping analyses show the relative need for the different interventions by selected characteristics. Among the overall adult and youth populations, safety interventions are perceived as less needed than other interventions. Comparing Intervention Needs among Adults within and between Safety Contexts This and the next section breaks down the adult map above to show how adult ratings of intervention needs differ by safety context. Analyses separated youth from adults because results in the previous section showed youth and adults had clear differences in their perceived intervention needs. Also, because earlier multivariable analyses showed nearly identical ratings am ong the two least safe clusters, and concept mapping pattern matching analyses confirmed these results (Appendix 8), these populations are combined in these concept mapping analyses. Among the adults in the safest contex t (Context 1), infrastructure/access improvements were most needed, followed by youth activity interventions; safety interventions were perceived as least needed (Figure IV.6). 64

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.6 Relative Need for Interventions by Adults in Context 1. In contrast to the relatively low need fo r safety interventions in Context 1, among adults in the two least safe contexts, safe ty interventions are among the most needed interventions (Figure IV.7). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.7 Relative Need for Interventi ons by Adults in Contexts 2 and 3. We can more formally compare the cluste r rating maps for the adults in these different contexts with pattern matching. As described in the methods section, with 65

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pattern matching each groups intervention cl uster ratings are shown on a separate vertical axis. A vertical axis representing th e first groups responses is positioned next to a second vertical axis representing the sec ond groups responses. The concept mapping software calculates a Pearson correlation coe fficient to compare the ratings, where an r value of 1 corresponds to perfect agreement in the ratings among the two groups and an r value of -1 represents a complete disagreement. In the pattern match shown below (Fi gure IV.8), the cluster rating map of participants from the safest context is repres ented on the left vertical axis. The cluster rating map from adults in the two less safe c ontexts is represented on the right vertical axis. In cluster rating maps, higher ratings are represented with la yers and in pattern matching the higher rated interventions are show n higher on the vertical axis. The labels on the axis show the relative rating of the interventions. For context 1 participants, infrastructure/access interventions are rated as most needed, whereas safety interventions are rated as most needed for context 2 and 3 adults. The lines between the left and right axis show the difference between the group rating s of the same intervention cluster. In the pattern match below, the average ratings ranged from 3.28 to 4.04. Participants in the two least safe contexts rated every intervention cluster as more needed than even the highest needed intervention in context 1. The Pearson Correlation coefficient for the pattern match -.47 indicates disagreement be tween the groups on the need for different interventions. 66

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r = -.47 4.04 3.28 4.04 3.28 Youth Activities Safety Infrastructure and Acces s Youth Activities Safety Infrastructure and Access Figure IV.8 Pattern Match of Adult Interven tion Needs Context 1 v. Contexts 2 & 3. Comparing Intervention Needs among Youths within and between Safety Contexts. Similar to the analyses just shown for a dults, cluster maps were also created to compare the relative ratings among youth betwee n safety contexts. These analyses show youth in the safest contex t rated safety interventi ons as least needed and infrastructure/access and activity interventions as equally and most n eeded (Figure IV.9). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.9 Relative Need for Interven tions by Youth in Safest Context. 67

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Youth in contexts 2 and 3 showed nearly identical patterns in their cluster rating map as youth in context 1, i.e., safety inte rventions were rated as least needed and infrastructure/access and activ ity interventions were most needed (Figures IV.10 and IV.11). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.10 Relative Need for Interventi ons by Youth in Second-Safest Context (Context 2). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.11 Relative Need for Interventions by Youth in Least Safe Context (Context 3) 68

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The similarly perceived intervention n eeds among youth across safety contexts contrasts with the different needs perceived by adults across these same contexts. The more formal comparison of youth ratings between clusters is again achieved with the pattern match. In the pattern match shown below (Figure IV.12), the cluster rating map of youth from the safest context is represented on the left vert ical axis. The cluster rating map from youth in the two less safe contexts is represented on the right vertical axis. For all youth, activity and infrastruc ture/access interventions were rated as the highest needs, while safety interventions were considered least needed. Similar to their adult counterparts, youth in the two least safe contex ts rated every intervention cluster as more needed than even the highest needed intervention in contex t 1. The Pearson Correlation coefficient for the pattern match 0.98 indicate s nearly complete agreement between the two groups of youth. r = .98 4.07 3.1 4.07 3.1 Safety Safety Youth Activities Infrastructure and Access Infrastructure and Acces s Youth Activities Figure IV.12 Pattern Match of Youth Interven tion Needs Context 1 v. Contexts 2 & 3. 69

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Comparing Intervention Needs among Et hnic Groups within and between Safety Contexts. As the relative rating of intervention needs were shown for adults and youth in different safety contexts, the relative need for interventions by racial/ethnic group were also of interest. Below, the first three cluster rating maps (IV.12-IV.14) show that within the safest cluster, white, black and Latino pa rticipants have similar relative ratings of what interventions are needed, with safety interventions ranked lowest. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.13 Relative Intervention Needs for White Adults in Safest Context. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.14 Relative Intervention Needs for Latino Adults in Safest Context 70

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.15 Relative Intervention Needs for Black Adults in Safest Context. In contrast to the similar ratings of safe ty intervention needs in the safest context shown in the previous 3 figures, there is a difference in need for safety interventions between white, black and Latino participants in contexts 2 and 3 (F igures IV.16-IV.18). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.16 Relative Intervention Needs for White Adults in Two Least Safe Contexts. 71

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.17 Relative Intervention Needs for Black Adults in Two Least Safe Contexts. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.18 Relative Intervention Needs for Latino Adults in Two Least Safe Contexts. Because equal numbers of black, white and Latino participants were sampled from each cluster, it is possible to combine th e ratings of ethnic groups between contexts and examine whether there are differences by ethnic group. Three pattern matches are 72

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shown below comparing all Latino and black ad ult ratings (Figure IV.19), then all Latino and white adults (Figure IV.20) and then all black and white adults (Figure IV.21). r = .96 4.01 3.76 4.01 3.76 Youth Activities Youth Activities Infrastructure and Acces s Safety Safety Infrastructure and Access Figure IV.19 Pattern Match Comparing Latino (left) and Black (right) Adult Ranking of Intervention Needs. In this pattern match, the Pearson correl ation coefficient is 0.96, representing near complete agreement between Latino adult and black adult intervention ratings. Both groups rated youth activities as least needed, and safety and infrastructure/access interventions as highly needed. The black adult participants expressed a slightly higher need for safety and infrastructure/access interventions compared to their Latino counterparts. 73

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r = .29 4.01 3.38 4.01 3.38 Safety Youth Activities Youth Activities Safety Infrastructure and Acces s Infrastructure and Access Figure IV.20 Pattern Match Comparing La tino (left) and White (right) Adult Ranking of Intervention Needs. In the pattern match shown in Figure IV .20, the Pearson correlation coefficient is 0.29, suggesting a low level of agreement in the intervention ratings between Latino and white adults. Latino adults expressed a grea ter need for every cluster of interventions compared to white adults. Both Latino a nd white adults thought Infrastructure/access were most needed interventi ons, but among Latino adults, safe ty and infrastructure/access interventions were rated sim ilarly high. Among white adults safety interventions were rated least needed of all the interventions. 74

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r = .03 4.01 3.38 4.01 3.38 Safety Youth Activities Youth Activities Infrastructure and Access Infrastructure and Acces s Safety Figure IV.21 Pattern Match Comparing Black (left) and White (right) Adult Ranking of Intervention Needs This third pattern match (Figure IV.21) co mpares black and white adult ratings of the different intervention clusters, showi ng nearly no agreement (Pearson Correlation coefficient 0.03) between perceived interventi on needs. Black adults thought safety was most important and youth activities leas t important. White adults thought Infrastructure/access interventions were most important and safety interventions least important. Together, the last three patte rn matches show although equal number of Latino, black and white adult participants were sampled from each of the three safety contexts, Latino and black participants had similar ratings of what was needed, while white participants thought all interventions we re less needed, and that safety interventions were least needed. Latino and black adults thought safety interventi ons were relatively more needed. 75

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Summary of Concept Mapping Need Analysis Comparisons. Within the safest context, each demographic group examined, you ths as well as black, white and Latino adults, agreed safety interventions are least of the needed interventions. Youth in the least safe contexts also rated safety interven tions as least needed. However adults within the least safe contexts rated safety interv entions as most needed, but black and Latino adults thought safety interventi ons were more needed than wh ite adults in these contexts. Another notable difference between the adult cluster ratings is that Latino and black participants rated all interventions as more needed than any interv ention need rating of the white participants. Participants in the less safe contexts rated all interventions as more needed than any of the interventions rated by adults in the safest context. Concept Mapping Adult Po ssibility Comparisons. In addition to the need rating, participants were also asked to rate ho w possible it would be to implement each intervention. Below there is a cluster rating map for each of the follo wing: all adults, all children, all white adults, all black adults, all Latino adults, all context 1 adults, all context 2 adults and all contex t 3 adults. Overall, adults thought safety interventions would be the most possible (i.e., feasible ) interventions to implement, with youth activities second most feasible, and infras tructure access interventions as the least possible set of interventions to implement (Figure IV.22). In terestingly, the interventions adults thought were most needed, infrastruc ture access interventions, were reported here as the least feasible to implement. 76

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.22 Relative Intervention Feas ibility Rating Among All Adults. Youth ratings contrasted w ith adult ratings of what was feasible. Youth thought activity interventions would be most possibl e to implement, and safety interventions would be least feasible to implement (Figure IV.23). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.23 Relative Intervention Feasibility Rating Among All Youths. 77

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Breaking down the adult population into different racial/ethnic groups, each ethnic racial group rated safety interventions as the most feas ible, of all the intervention clusters to implement (Figures IV.24-IV.26). 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.24 Relative Intervention Feasib ility Rating Among All White Adults. Figure IV.24 shows white adults thought both safety and activity interventions were most feasible to implement. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.25 Relative Intervention Feas ibility Rating Among Black Adults. 78

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Black adults thought safety interventions were most feasible to implement, followed by youth activities (Figure IV.25) 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.26 Relative Intervention Feasib ility Rating Among Latino Adults. Figure IV.26 shows Latino adults, simila r to black adults thought safety interventions were the most feasible to impl ement, with youth activity interventions next most possible to implement. Next, the following three maps (Figures IV.27-IV.29) show the relative feasibility of implementing the three intervention clusters by safety context. In the two safest contexts (contexts 1 and 2), safety interven tions are seen as among the most feasible interventions to implement. Adults in the safest cont ext also thought youth activity interventions were feasible to implement. In the least safe context safety interventions were seen as slightly less feasible to imp lement than youth activity interventions. 79

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.27 Relative Intervention Feasibil ity Rating Among Adults in the Safest Context. 1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.28 Relative Intervention Feasibil ity Rating Among Adults in the Second Safest Context. 80

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1. Infrastructure and Access 2. Safety 3. Youth Activities Figure IV.29 Relative Intervention Feasibilit y Rating Among Adults in the Least Safe Context. Perhaps most notable about these feasibility ratings is that the overall most needed intervention, infrastructure/access interventi ons were perceived as least feasible to implement. While taking the survey several people commented that in the current economic climate, infrastructure/access in terventions would not be a priority. Community-Generated Analyses for Action The CAC participants were not interest ed in separating out the needs of the adjacent communities by safety context or race/ethnicity. Instead, the consistent intervention ratings by youth across contexts were noted by the CAC and they asked, What do children across the different contexts say is needed to increase physical activity? The CAC also wanted to honor th e perceptions of what adults thought were feasible interventions in their analyses. So instead of using concept maps or pattern matches that were relatively difficult to interp ret, they were interest ed in looking at data by go-zones. Go-zones are a third type of analysis available in the concept mapping 81

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software. Go-zone analyses need not use interv ention clusters at all, but can instead plot each individual intervention using an x-y coordinate plane. In Figure IV.30 below the youth intervention need rating is on the x axis and the adult feasibility rating is on the y axis. The x and y axis intersect at the mid-point of the range for each respective scale. So inte rventions to the right of the y-axis are interventions youth rated as ha ving an above-average need. Similarly, the interventions above the x-axis were rated by adults as having a higher than average feasibility rating. Therefore the green zone or the go-zone includes the ideas that are rated as above average in need according to youth and above average feasibility according to adults. 3.44 1.6 4.33 2.37 4.66 Possible Need 3.79 1 11 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 98 99 100 Figure IV.30 Go-Zones Examining What Yout h Say is Needed and What Adults Say is Possible. The CAC examined the ideas in the go-zone, especially the top twenty needs identified by youth that were still thought feasible by the adults (Table IV.10). Similar ideas were combined and grouped into the them es of fun, free and safe (See Table IV.11). 82

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The community group also decided that rath er than showing the go-zones, it could present the top themes in the fo rm of a play or skit. Two yout h led the effort to write the script and the youth practiced for several months. Just prior to the neighborhood health summit held by Partners for Health 2040, who had scheduled the U.S. Surgeon general to speak, the group was invited to present their skit to this large a udience (Appendix 9). A colleague then introduced the group to an act or with Kaiser Permanente's Educational Theatre Program, Samuel Wood, who offered to help stage the skit. Another colleague, Ira Gorman, offered data from his study to compliment the skit, slides underlining the need for fun, free and safe opportunities fo r youth. A summary of the methods and results were presented in a PowerPoint s lide, followed by the skit with all the CAC participants. The presentation was attended by both the head of the Colorado Department of Public Health and the Environment, as well as one of our state representatives. Table IV.10 Go-Zone Ideas Listed in Ord er of Highest to Lo west Youth Needs. 49. Make available free or reduced price rentable sports or activity equipment 64. Have a recreation center with free activities 17. Have kids do activities like Sports 80. Have free youth activity time at the rec cente rs for swimming, basketball and other activities 87. Give prizes to encourage physical activity 96. Unlock school playgrounds so they can be used after school hours and during breaks 4. Have responsible parents and adults in the park and neighborhoods to watch over kids 15. Go to the pool 19. Make playgrounds better with different e quipment, like zip lines and more creative stuff 50. Have parents take children to the park 53. Provide more physical activities in schools 59. Make a safe place for kids to go during summer or spring breaks 10. Have parents get their children involved 100. Get a group of kids together to organize and advertise youth events (with flyers or word-ofmouth) 68. Protect children from traffic 85. Have kids involved with after-school activities because they are safe 89. Have music, block parties to draw people out 27 Make basketball tournaments 66. Create more sports and activities for kids 71. Have people talk at back-to-school night to tell others about opportunities to be active 83

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Table IV.11 Go-Zone Ideas Listed in Cate gories of Fun, Free and Safe Needs. Fun 17. Have kids do activities like sports 87. Give prizes to encourage physical activity 15. Go to the pool 19. Make playgrounds better with different e quipment, like zip lines and more creative stuff 53. Provide more physical activities in schools 100. Get a group of kids together to organize and advertise youth events (with flyers or wordof-mouth) 89. Have music, block parties to draw people out 27 Make basketball tournaments 66. Create more sports and activities for kids 71. Have people talk at back-to-school night to tell others about opportunities to be active Free/Accessible 49. Make available free or reduced price rentable sports or activity equipment 64. Have a recreation center with free activities 80. Have free youth activity time at the rec centers for swimming, basketball and other activities 96. Unlock school playgrounds so they can be used after school hours and during breaks Safe 4. Have responsible parents and adults in the park and neighborhoods to watch over kids 50. Have parents take children to the park 59. Make a safe place for kids to go during summer or spring breaks 10. Have parents get their children involved 68. Protect children from traffic 85. Have kids involved with after-school activities because they are safe 84

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CHAPTER V DISCUSSION In the ensuing discussion I first review the study findings and then interpret these results within the background theory and the cont ext of previous research. Finally I offer limitations and reflections on this study. Review of Study Findings This study set out to answer the question of whether interven tions to increase youth physical activity need to be tailored for different safety contexts. To answer this question, I used secondary data, sp ecifically combining fear of crime, traffic safety, social cohesion, discrimination and incivi lities in a cluster analysis. This analysis identified three geographic safety contexts, fulfilling the first study aim and providing the needed safety context variable for the second study aim. The second aim of the study was to use a community-based participatory research approach, and concept mapping methodologies to examine how solutions for increasing pediatric physical activity vary within and between different safety contexts. The first hypothesis of this aim was: people in envi ronments defined as being safe, having high levels of perceived safety and social cohesion and low m easures of incivilities and discrimination will offer more solutions for in creasing physical activity that are unrelated to the safety environment. A community ad visory counsel was formed to advise and facilitate concept mapping within a community based participatory research framework. Residents from the three safety contexts were purposefully recruited to engage in concept mapping. Eleven groups were held incl uding 62 participants who generated 330 suggestions, answering the question, What changes would increas e physical activity 85

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among 10-14 year old children in your neighbor hood? Thirty percent of the intervention ideas suggested by participants in the two le ss safe contexts addressed safety, whereas only thirteen percent of the id eas from the participants in the safest context addressed safety, thus supporting the first study hypothesis. Safety was mo re relevant to the people from the less than more safe contexts. Next, one-hundred of these 330 solutions we re randomly selected for the sorting and rating concept mapping phases. The randomly selected solutions were sorted by 17 people. Then the solutions were rated by 132 participants who were sampled from each of three safety contexts, with equal numbers of white, black and Latino adults from each safety context, and their children. Sorting th e ideas resulted in three intervention clusters: 1) safety interventions, 2) infrastructure/access interventions and 3) activity interventions. The second study hypothesis was that th e geographic safety context would account for more variability in the need for interventions than would individual demographic differences. Multivariable anal yses showed safety interventions were perceived as more needed by participants in le ss safe contexts compared to participants in more safe contexts. Analyses also showed safety interventions were perceived as more needed by adults than children and more needed by black and Latino participants compared to white participants. Results ther efore showed that cont ext, ethnicity and age group each independently influenced the percei ved need for safety interventions. Yet context accounted for more variability in the rating of safety interventions than race/ethnicity or age. Thus the second study hypothesis was also confirmed, showing that context, more than ethnicity or age group, accounts for perceived safety intervention needs. 86

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Because safety context may have been an indicator of a more general need for all types of interventions, similar multivariable analyses of the two other intervention clusters were conducted. These analyses show ed that context had an independent effect on the need for each type of intervention. Par ticipants from less safe contexts described each cluster of interventions as more needed than the participants from safer contexts. Considering these fairly complex findings, the CAC chose to focus community feedback on a simpler go-zone analysis that emphasized the needs expressed by youth, the ultimate intervention target In their analys is, they looked at the concept mapping go-zone examining what children say is mo st needed across contex ts, and what adults say is possible or feasible. The go-zone s howed needed and feasib le interventions to increase youth physical activity could be categ orized as interventions that make physical activity fun, free and safe. Notably these go-zone categor ies are essentially synonymous with the concept mapping clusters where the go-zone safe theme approximates the safety concept mapping cluster. The free theme approximates infrastructure access, and fun approximates the activity in terventions cluster. These results were summarized in a play created and presented by the CAC. Of primary importance to this CBPR solu tion-oriented project is how to apply these results to interventions that make a difference for youth in the neighborhoods. The CAC chose the theme of fun, free and safe interv entions that applied to all contexts rather than singling out or stigmatizing specific neighborhoods by pointing out their greater needs, or by focusing especially on safety in tervention needs. CAC participants have repeatedly shown more interest in worki ng in less safe compared to more safe neighborhoods because they acknowledge more needs there. Yet they dont want to 87

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present data, especially maps that would s tigmatize neighborhoods as less safe or focus on safety interventions alone. As one CAC member put it: In order for kids to get more active you have to addre ss the safety issue, but you really are focused on getting them activ e. There are other issues like making things free that are important. If you get parents together to take equipment to the park you take care of all three things, providi ng fun, free and safe activities. Or if you create more activities for people to participate i n, like a basketball tournament, you address all three concepts at the same time. This creates more focus on the positive (getting kids active), but you are still in a subtle way addressing safety too. If you get more pos itive things happening it will push out negative things. We dont need police lining the parks. If there are people always playing sports in the parks, then people doing negative things will find somewhere else to go. This seems to encapsulate the difference between a problem-oriented (stopping something negative) and solution-oriented approach (promoting something positive). Both interventions might improve neighborhood sa fety. The difference is that unlike the solution-oriented approach, the problem-or iented approach leaves in its wake a stigmatized neighborhood. The go-zone themes, fun, free and safe, frames a solutionoriented approach that recognizes safety as an issue, but doesnt make it the exclusive focus of attention. The remainder of this chapter will explor e these findings in more detail, including how these results can be app lied to intervention efforts to improve physical activity among youth. Interpretation of Study Aim 1 Findings While other studies have examined wh ether individual activity levels are associated with individual perceptions or contextual measures of safety, 92,78, 123, 86 this is the first study to define safety context in ex actly this way, using fear of crime, traffic safety, social cohesion, discrimination and inci vilities. This con ceptualization blends 88

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perceptual and objective measures of sa fety, building on other studies that use perceptions 87 178 92, 123 81, 179 or objective measures of safety. 88, 180 Social cohesion, a subscale of collective efficacy was included a nd varied with the other factors in the expected direction. Also, similar to Romero s inclusion of prej udice as a neighborhood hazard, this study also included discrimina tion as an aspect of safety. Because discrimination didnt follow the expected ti ered pattern in the analyses, the cluster analysis was run with and without discrimi nation included in the analysis. Including discrimination in the conceptualization of safety strengthened the model, and was therefore included. As it relates to the social ecological fra mework for this study (Figure V.1), this analysis combined aspects of th e physical environment, i.e., in civilities and traffic safety, with the social environment, i.e., fear of crime, social cohesion and discrimination. Figure V.1 Social Ecological Framework fo r Physical Activity Interventions. 89

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As this first study aim was designed as a requisite step for defining distinct geographic areas with distinct safety ratings and was not associated with any specific hypotheses, the most relevant issue for this fi rst aim is whether the identified geographic safety contexts have face validity. Context 1 had the highest level of all the variables, freedom from: fear of crime, discriminati on, incivilities and traffic concerns, and the highest level of social cohesi on. Context 2 enjoyed the next highest levels of all these variables, except freedom from discriminati on, and Context 3 had th e lowest levels of these variables, except freedom of discriminatio n. Thus all variables followed expected trends with the exception of discrimina tion, where there was more freedom from discrimination in Context 2 than in C ontext 3. Although the cluster analysis distinguished Context 2 from Context 3, bot h clusters rated all intervention groupings similarly and were collapsed in most of the later analyses. The validity of the contex ts identified in this st udy is supported by their consistency with two correlates of safety: tr ansience and cultural heterogeneity. Safety and transience are correlated,96 and recruitment data from this study showed the safest context was associated with the least amount of transience, where only 9.1% (4/44) of attempted households had moved, compared to 38.7% (24/62) in context 2 and 33.3% (20/60) in context 3. Thus, rates of transience support th e finding that Context 1 was seen by its residents as safer than contexts 2 and 3. Cultural heterogeneity is also thought to relate safety. Merry suggests people feel safer in culturally homogenous neighborhoods because they understand and can navigate social norms and threats more easily.148 In a more critical analysis of why cultural Transience is defined as the percentage of people who had moved newly into the neighborhood in the last year. 90

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heterogeneity is related to lower perceptions of safety, Blalock proposes a social threat effect.181 According to Blalock, majority (wh ite, male, powerful groups in whatever context) populations are threatened by mi nority (especially black male) populations and will impose means of formal control to keep minority populations from threatening their power. This is consistent with other authors descriptions of a raci alized fear of crime.182 183 While analysis of the representative de mographic data for each block group was outside the scope of this study, another researcher using data from this same catchment area confirmed people living on blocks that are more diverse repor ted lower perceptions of safety. 170, pg. 115 In the present st udy, Context 1 overlap ped primarily with neighborhoods with majority white residents and Contexts 2 and 3 overlapped with more ethnically diverse neighborhoods. Thus, the ge ographic safety contexts were consistent with expected trends in transience and cultural heterogeneity suggesting distinct neighborhood safety contexts were identified by the cl uster analysis condu cted here. Interpretation of Study Aim 2 Findings This is the first study to purposefully compare how resi dents within and between different safety contexts pr ioritize resident-suggested interventions to increase youth physical activity. These findings are consistent with, but offe r important contributions to a broad range of literature suggesting the importance of safety in improving physical activity among youth.65, 70, 123, 184-186 Revised Socio-Ecological Framework. The initial socioecological framework used to conceptualize this st udy is revised to be consistent with study findings, as shown in Figure V.2. In this figure the physical a nd social environments combine to comprise 91

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the safety context. The wide solid arrow be tween safety context and perceived need for safety interventions represents the larges t independent association found in this study, that between safety contexts and perceived need for different interventions. The more narrow solid line between indivi dual factors and perceived ne eds represents the relatively smaller association between these attributes. The dotted line between safety context and individual factors suggests a modifying effect of individu al characteristics by safety context, a result suggested by the concept mapping results but not formally tested in statistical analysis. Though untested, the broader social/economic/ political context is shown to embed each of the model components. This model suggests that interventions need to be tailored for the socio-ecologic c ontext, especially the safety context. 92

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Broader Social/ Economic/ Political Factors Individual Factors Race/ethnicity Age Safety Context Physical Environment Incivilities Perception of traffic safety Social Environment Social cohesion Fear of crime Exp.of discrimination Intervention Needs Safety Activity Infrastructure / Access Multi-level Influences on Perceptions of Intervention Needs Interventions Needed to Increase Youth Physical Activity Youth Physical Activity Figure V.2 Revised Social Ecological Framew ork for Physical Activity Interventions. These results suggest interventions for increasing physical activity need to account for the safety context. But why? One pa rticipant from a less safe context, when reminded to use the entire range of the scale while rating the need for different interventions, in a sense e xplaining why she was not using the lower range of the scale said, we just need everything so much. This is especially in teresting because the different contexts are adjacent to one another; there are three recrea tion centers in the less safe contexts and one recently-built recreation center in the sa fest context. While some 93

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literature shows people in lower income areas have fewer activity opportunities, this may not be the case in all areas.107 Also perceptions of access do not necessarily match material facts, for instance GIS measures of sidewalks, recreation f acilities, and crime did not match perceptions of these attributes.76 Additionally, Suminski et al. found lower income neighborhoods in their catchment area had more locations, but similar quantities of amenities, more faith-based locations and court, trail/path, event and water-type amenities. Higher income neighborhoods had more for-profit businesses offering physical activity opportunities.107, p.599 Therefore a deeper exploration of these per ceptions would be of interest. Might the safety context be associated with the invi sible lines separating the communities in the present study, lines that correspond roughly to neighborhood socio-ec onomic status? If that were true, people sharing in frastructure can still have different levels of accessibility. There is anecdotal support fo r this hypothesis because in conversations with activity organizers at the local recreation center, they explained that youth can get a free membership to the recreation center, but activ ity fees can be cost-p rohibitive for some families. Underlining this economic difference, people from the safest context, both children and adults suggested children need time free from structured extra-curricular activities, while participants from less safe contexts talked about costs and transportation as barriers to extra-curricular engagement. Though the soci o-economic associations with safety context were not formally tested in th is study, this contrast would be consistent with intersectional theory that describes how race, class, and gender inequities intersect, such that shared infrastructure would not guarantee equitable access. 94

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While adults in the least sa fe context thought each intervention cluster was more needed than adults in the safest context, adul ts in the least safe context also thought safety interventions were relatively more important than activity interventions. When asked to interpret why adults in the least safe contexts were le ast likely to support activity interventions, CAC members talked about how some neighbors were untrustworthy and so in some cases it was not appropriate to create more activities for their children to interact with neighbors. In fact one CAC member talked ab out developing strategies to be sure her child did not play with ot her children in their neighborhood. This interpretation is similar to findings by others,187 suggesting parents may limit childrens outdoor activity because of their safety concer ns. Thus the independent effect of safety context on perceived intervention needs is further clarified. Perceived Needs Influenced by Individual Factors The revised framework in Figure V.2 also shows that individual charac teristics influenced perceived intervention needs. In this study youth, adults, black, white and Latino participants within similar contexts had some differences in perceived intervention needs. While adults ratings of needed interventi ons varied by safety context, youth from all safety contexts ranked intervention needs similarly. Youth uniformly rated activity and infrastructure/access interventions as most and equally needed, and safety interventions as least needed. Yet, in the community-suggested analyses, some of the top youth-rated interventions included parental or adult supervisi on. When these results were reviewed by the CAC, youth pointed out th at having parents in the parks, something included in both the infrastructure/access and ac tivity solution clusters confers a sense of safety. So safety may be important, but in the minds of youth it may be accomplished 95

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through more informal social control. Th is method of ensuring personal safety is consistent with routine activity theory wher e guardians (who protect potential victims, e.g., parents) or place managers (who are in terested in smooth operations, e.g., park and recreation center attendants) and handlers (p eople who discourage potential offenders, e.g., coaches)188 ensure safety. Importan tly, this type of informal social control, provided by afterschool supervision in playgrounds ha s been shown to increase youth physical activity. 71 While we can understand that youth thought formal safety interventions were less relevant than their adult counterparts, the differences in percei ved intervention needs between racial or ethnic groups, require s deeper examination. In many studies, differences in perceptions and outcomes be tween racial, ethnic and socio-economic groups might be attributed to these groups living in different environments due to residential segregation along ec onomic and ethnic/racial lines.52 77 Related research can use multivariable analyses to control for some differences in the environments, e.g. quality of the recreation centers width of sidewalks, etc. Yet differences in racial or ethnic group perceptions and outcomes might still be attributed to an unmeasured confounding environmental factor. The present study overcomes this important limitation by purposefully sampling equal numbers of adults from three different ethnic groups within each safety context so the pr esence of ethnic tastes or intervention preferences could be explored within a nd between common geogra phic contexts. Yet still, there were differences in perceived intervention needs by racial/ethnic group with white participants expressing less need for sa fety interventions compared to their black and Latino counterparts. 96

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These analyses highlight the different pe rceptions of people from different age groups, ethnic/racial groups and safety cont exts. Yet as Frohlich, Corin and Potvin (2001) suggest,128 stopping there, does little to help address the issues. Therefore I turn now to the deeper theory undergirding this study, including Bourdieus theory of habitus. At the outset of this study I recognized that my measure of safety, or at least the specific measures used therein, might be a measure of a certain type of habitus. For example the measure of social cohesion used here is cons istent with dominant so cietal conceptions of what pro-social cohesion is. Additionally experiences of discrimination, which could be interpreted as a lack of dominant societys cultural capital, would separate people who do and dont experience discrimination in our societ y. Indeed, the safest context identified in this study overlaps consider ably with the more economically privileged portions of the included catchment area and with the most homogeneous white population in the catchment area, which may have the most cultural capital, e.g., competencies, skills and qualifications that are rewarded in the existi ng social structures. Therefore it does seem that the cluster analysis using safety-related measures, including fear of crime, traffic safety, incivilities, a pro-social measur e of social cohesion and discrimination, differentiated this economically/socially privileged section of the catchment area from its neighbors. Yet the safety context al one did not fully capture the unique doxa s or ways of understanding the ways that things just are, it didnt fully identify distinct habitus These findings also underline the limitations of using race or ethnicity as a social epidemiological variable w ithout further understanding. In this study being white contributed to a different way of seeing things. White adults thought safety interven tions were less needed than Latino and black participants 97

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living in the same contexts. White adults, re lative to black and Lati no adults, thought all interventions were less needed, even living in the same contexts. It may be these groups have different levels of social support, economic advantage, coping skills or resiliency, or it may be a deeper sociological phenomenon. Futu re research to closer explore the lived experiences of residents from different ethnic backgrounds in the same context, a phenomenological exploration, may poi nt to various ways the group doxas are constructed. Unde rstanding these doxas much like understanding the need this community expressed to address safety more subtly within the context of positive activities, opens doors to mo re effective interventions to address disparities. CBPR as a Social Change Project. This study is consistent with third generation disparities research189 and a solution-oriented rese arch paradigm that focuses on which interventions should be prioritized for whom, instead of identifying causes and correlates of diseases and risk factors.190 Compared to a Northern CBPR process, this study was also more theoretically aligned w ith the Southern, emancipatory, approach. The results of this CBPR process are discus sed contrasting how th e study process and results would have differed if the process ha d been completed within a more Northern approach. Unlike a Global Northern approach that would have included grass-tops people, e.g., heads of services and policy makers,191 except for University researchers and a Kaiser Permanente theater professional, this study included grassroots residents exclusively. Community members living in mo re and less safe contexts engaged in a communicative discourse,157 working together to improve skills and understanding of research and community needs. One of the community members from this group was 98

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very vocal in not wanting to engage grasstops participants, essentially knowing that grass-tops stakeholder priori ties could drown out the gra ssroots. This group wanted resident voices to be heard. This is important as grass-tops and grassroots constituencies have been known to have different priorities. 192-194 195, 196 197 Given the opportunity to choose how to analyze the research data the CAC chose not to focus community presentations on the differences between nei ghborhoods, especially th e differential need for safety interventions that could stigmatize neighborhoods. Instead this group conducted analyses that could unite ne ighborhoods for action by focusing on what children say is needed. The importance of this contribution cannot be underestimated because it speaks to a certain level of political astuteness, recognizing that by allowing results to reify perceptions of neighborhood safe ty, they could in fact adversely impact physical activity, the very beha vior this research seeks to ultimately improve. Rather they were interested in addressing safety through more comprehensive strategies that provide positive things that could unite the community, e.g., parents in parks, open playgrounds (where safety would also need to be assured). Had this CAC included more grass-tops participation, I am not sure thei rs concern would have been expressed by the residents, or that the resident s would have been able to decide how the study results were presented. Therefore this more Southern CBPR appro ach demonstrated th e clear strength and ownership of residents in this process, even choosing how to analyze and present data. Research has shown that engaging members of target communities in designing and owning policy solutions results in more sustainable interventions to improve physical activity.53, 54 While grass-tops participants e.g., school administrators, recreation center 99

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staff, other relevant non-profits, have been shown to focus more on policy and environmental changes, parents focus on mo re tangible needs, e.g., creating accessible activities. 193 198 On its own initiative the CAC wanted to provide for tangible needs, first pursuing a $500 community grant to get kids active during the summer. The group, this time headed by youth, wrote a grant that wasn t funded, but still the group showed up each month in a local park to play with kids and offer prizes for their participation. After that experience, recognizing the group wasn t trained or really experienced in youth development/activity coordination, the group wrote another grant that was funded for $500 to create an activity fair bringing toge ther different activity providers in the neighborhoods to publicize the fun, free and safe activities that were available for youth. Thus the grassroots CAC did ultimately work on addressing tangible needs, rather than policy interventi on changes. Still one of the top solutions in the go -zone was especially related to policy change. Residents were intere sted in assuring physical educ ation in schools. Had grasstop participants such as policy makers been included in the CAC, one wonders whether the results of the study ma y have moved more effici ently into policy changes.199 Coincidentally, when our results came out th ere was a bill in the state legislature concerning physical education in schools. A policy brief th at was created (Appendix10) and shared with an RWJF policy consultant, was then shared with one of the coalitions favoring Colorado HB11-1069, CONCER NING MEASURES TO INCREASE PHYSICAL ACTIVITY IN PUBLIC SCHOOLS, a bill that was signed into law in April 2011. The coalition for the bill was fairly confident their efforts would result in its passage, so the policy brief was not distributed further. The bi ll was recognized as a first 100

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step in getting physical education requirement s in the school, but is recognized as not sufficiently strong. Recognizi ng the opportunity to engage in policy change, the CAC partnered with various people to submit a grant proposal that would have provided additional advocacy training and experience fo r our group, but it was not funded. Thus it may not be that grassroots groups are uninter ested in advocacy efforts, it may be more that these constituencies need skills (cultural capital) to engage and further their empowerment consistent with the Southern CBPR tradition. Experience from tobacco advocacy efforts have shown the efficacy of engaging youth as policy change agents, funding to engage youth to address obes ity-related policies se ems promising. A core group participating in this effo rt has been extremely dedicated, coming with and without incentives to participat e, investing their own time and money to contribute to the group. Despite this high level of dedi cation within the group, it is important to note that there was attrition in the group, espe cially in the last year, particularly when the team began to act to implement intervention priorities identified by the study. In this phase there was a percep tion by one family that not everyone was helping sufficiently, and that family chose to take a break, which turned into a long, if note permanent, break from the group. That fa mily had been very motivated and did a lot to engage and celebrate the ch ildrens involvement so their departure affected the entire group. Also, some of the children moved fr om the area or graduated high school and without funding to pursue a specific goal, it was more difficult to provide as clear a focus. The group has committed to a yearly activity fair, and is considering with the parent body other policy-related effort s it could pursue. 101

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So which is betterthe Southern or Nort hern approach to CBPR? This is a question that is untested in this study. Yet I can make several observations. While engaging the grass-tops as pa rt of the CAC may have help ed speed results into policy changes, it may be that these changes woul d have left out true grassroots opinions. Together, this discussion hi ghlighted the drawbacks and benefits of a CBPR process consistent with the Southern approach focusi ng more on grassroots rath er than grass tops participation. Correspondence of Study Intervention Recommendations with National Efforts The interventions identified in this dissertation study are both similar to CDCrecommended strategies for increasing physical activity,49 and also suggest a broader role for grassroots participation. Building from another artic le demonstrating how funding links to CDC strategies,200 this section compares CDC-recommended strategies to the dissertation findings. CDC, similar to other previously reviewed strategies, 8, 50, 121, 48 recommends three strategies, strategies to: 1) encourage physi cal activity or limit sedentary activity among children and youth, 2) create safe communities that support physical activity, and 3) encourage co mmunities to organize for change. 49 These strategies represent national efforts to address pediatric obesity, efforts recognizing the up-stream, social determinan ts of health, including the social, physical, economic, cultural and community environments that shape health.201 102 202 In lowincome communities where discriminatory policies have been a fundamental cause of poor health,203, 204 environmental and policy interventions have received considerable support.34, 56, 101, 205 In the first column of Table V.1 CDC-recommended strategies for 102

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increasing physical activity are shown. The second column indicates which CDCrecommended strategies were supported by findings from this dissertation study. The third column of the table describes how RW JF funding has recently been allocated in relationship to CDC-recomm ended strategies. Table V.1 Nationally Recommended Stra tegies for Youth Obesity Reduction. CDC Interventions Categories49 Dissertationsupported CDC Interventions RWJF-Funded, Health Kids Healthy Communities200 Encourage physical activity or limit sedentary activity among children and youth 1. Require physical education in schools 2. Increase the amount of physical activity in PE programs 3. Increase opportunities for extracurricular physical activity 4. Reduce screen time in public service venues. 1, 2, 3 15/41 RWJF grantees used this CDC strategy. All four CDCsuggested areas were addressed by grantees, but most common areas were increasing physical activity opportunities outside of school, e.g., joint-use agreements with schools for expanded use and after-school program physical activity standards setting Create safe communities that support physical activity 1. Improve access to outdoor recreation facilities, 2-3 Enhance infrastructure to support cycling and walking, 4. Support locating schools within easy walking distance of residential areas, 5. Improve public transportation access 6. Zone for mixed use, 7. Enhance personal safety in areas where people are or could be physically active, and 8. Enhance traffic safety. 1, 2-3, 5, 6, 7, 8 35/41 grantees included this strategy. Efforts included improving walking and cycling infrastructure and access to parks; revitalizing parks, and enhancing community awareness of these facilities; Safe Routes to Schools. Personal and traffic safety focused on increased police presence, improved lighting, traffic calming and crossing aids. Encourage communities to organize for change. Part of CBPR design Most grantees engaged communities, esp. grass-tops Many interventions suggested by participants in this di ssertation research focused on increasing opportunities for physical activity. Like RWJF-funded strategies, participants alluded to join t-use agreements, e.g., unlocking school playgrounds so they can be used after school hours and during brea ks. Similar to the CDC, a recent IOM 103

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report also suggests improving access to amenities, e.g., opening playground and requiring physical education in schools. 8 A core concern among participants in the present study was making facili ties and extra-curricular activ ities cost-accessible. One related strategy suggested by dissertation study participants was to stress the importance of civic participation to maintain physical education in schools. In addition to making activities cost accessible, participants also pointed to the need for activities to be safe, with many interventions in this area focusing on providing appropria te supervision for youth, including grassroots participation by parents, mentors and chaperones. These ideas overlap with CDC-recommended safety interventions that are explored next in more detail. The next category of interventions su ggested by the CDC and reviewed for consistency with RWJF funding,200 was creating safe commun ities that support physical activity. The strategies identified in the current study have some similarities and differences with CDC recommendations. CDC, RWJF grantees, and participants in this study agreed on the need for traffic safety interventions, improved infrastructure to support safety, and some formal safety inte rventions. Again, the notion of improving adult supervision of youth was a comm on recommendation among dissertation study participants, something that may be embedded in the enhancing personal safety strategy recommended by the CDC, but seems worthy of highlighting. The last strategy recommended by the CD C and reviewed relative to RWJF funding is encouraging communities to organi ze for change, including local government participation in community coalitions or part nerships to address obesity. This strategy seems geared specifically for grass-tops constituencies, similar to creating CBPR 104

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partnerships comprised predominantly of agency and organizational heads. The limitations and benefits of this approach were discussed in the previous section. While the CDC and RWJF-grantees focused on fo rmal organized activities and improving physical infrastructure, local grassroots partic ipants in this dissert ation study pointed to a large group of informal, creative, low cost activities that could engage youth to be active. Dissertation participants seemed to suggest a larger role of informal networks, consistent with the importance of the social environment,206 a strategy that might enhance CDCs strategy of encouraging communities to organize for change. As the CDC grouped its strategies for in creasing physical activities, the CAC for this dissertation independently grouped their top-rated interventions (Table V.2). The specific interventions placed in each the fun, free and safe categories are described below. Youth had a specific category of activ ities they categorized as fun. In this category are interventions to provide more access to activities, including broadening existing opportunities and let ting people know about existing opportunities. Free and accessible interventions dealt especially with making activity opportunities cost accessible, providing reduced cost sports a nd activity equipment and opportunities, and increasing access to playgrounds after-school hours. Youth also suggested a number of strategies for keeping youth safe, including traffic safety interventions and appropriate supervision for various activities. Notably, these intervention characteristics were integrated in the communitys minds. Interventions needed to be simultaneously fun, free AND safe. As discussed previously, the CAC didnt support framing interventions exclusively related to safety, but they did fully support framing interventions as a positive opportunity that would also be safe. Thus, results from this dissertation study show 105

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community suggestions for increasing physic al activity are consistent with many CDC strategies, but also suggest more informal or ganization within grassr oots social networks holds promise for improving physical activities. Table V.2 Go-Zone Ideas Listed in Categories of Fun, Free and Safe Needs. Fun 17. Have kids do activities like sports 87. Give prizes to encourage physical activity 15. Go to the pool 19. Make playgrounds better with different e quipment, like zip lines and more creative stuff 53. Provide more physical activities in schools 100. Get a group of kids together to organize and advertise youth events (with flyers or wordof-mouth) 89. Have music, block parties to draw people out 27 Make basketball tournaments 66. Create more sports and activities for kids 71. Have people talk at back-to-school night to tell others about opportunities to be active Free/Accessible 49. Make available free or reduced price rentable sports or activity equipment 64. Have a recreation center with free activities 80. Have free youth activity time at the rec centers for swimming, basketball and other activities 96. Unlock school playgrounds so they can be used after school hours and during breaks Safe 4. Have responsible parents and adults in the park and neighborhoods to watch over kids 50. Have parents take children to the park 59. Make a safe place for kids to go during summer or spring breaks 10. Have parents get their children involved 68. Protect children from traffic 85. Have kids involved with afte r -school activities because they are safe This discussion has shown the similaritie s and differences between resident and national conceptualizations of intervention ac tivities. Youth provided a very memorable framework for communicating strategies for increasing physical activity, providing opportunities that are fun, free and safe. Thes e resident-led intervention suggestions are strikingly consistent with national initiative s. Shaping Americas Youth (SAY) is the only other example I have found where rigor ous methods were applied to engaging 106

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community in identifying physical activity intervention suggestions. 193 194 198 Consistent with the interventions proposed by participants in this study, th e top barriers identified in the SAY project included safety and appr opriate spaces for physical activity, time, parental knowledge about physical activity, and parent al motivation/skills; top interventions suggested by families included encouraging physical activity and connecting children to available activities.193 Similar to the SAY study, 198 this dissertation confirms grassroots residents, especially youth, ca n be essential partners in identifying intervention needs. Expanding CDCs strategy of encouraging communities to organize for change to purposefully engage grassroots residents in forums similar to SAY or this study, holds promise for improving youth physical activity. Reflections This CBPR project has provided a mirror to me as a researcher. I live in the study catchment area, but before working on this project, I lived in my neighborhood, but was not part of my neighborhood in the same wa y. Through this study I was able to meld CBPR methods, community orga nizing and social justice and a love for children. Through this research I experienced at a very personal and profound way that still I approached issues of social ju stice from a genuine heart-felt, but also very privileged, and reasoned lens. Going into this study I also assumed that disparities in obesity rates between white, black and Latino youth were related to physical activity. Thus improving physical activity could help reduce obesity rates. I hypothesized safety contex ts, that would likely correspond to socio-economic differences I know about the neighborhoods, would be evident from the cluster analyses. Then I assumed that where a person lives, more than 107

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the color of their skin, would determine how needed they thought interventions were, corresponding to a materialis t analysis. Evidencing these disparities within a CBPR context would mean that then the grassroots group formed to do the research could use the study results to advocate for the changes they want to see, advocating for more resources as needed. Or, I thought, maybe people at the gr assroots level would say, No, we dont need more buildings, we want to get together with our neighbors and forge tighter connections with each other because we are powerful people who dont need the latest buildings to have healthy kids, an emancipation from the capitalist framework altogether. So those were some of my assumptions going in. As I was rewriting the introduction to my di ssertation, I looked for the latest data on obesity and physical activity, and looked again. Obesity rates were stabilizing overall, still with some disparities. Yet physical act ivity rates, now measured objectively rather than through self-report, showed physical activity deficits didnt mirror obesity rates. When I came into the field I took at face valu e that there would be fewer physical activity amenities in lower income neighborhoods compared to higher income neighborhoods. Then I read that at least in one large city the reverse was tr ue, that public physical activity facilities were more prevalen t in lower income neighborhood s, while private facilities were more available in higher income neighborhoods. These facts challenged my previous unde rstanding of the literature and my assumptions. This helped me realize again th at I am imbedded in a field that makes its living by finding problems, especially pr oblems among the most marginalized. The literature seems to focus on the problems minority youth have, even when they dont exist. For instance, even in the article that debunked previous research and showed 108

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higher rates of physical activity among black rather than white children, still the discussion focused on the change in PA, how PA was decreasing among black children while increasing among white children. The authors found a problem among black children, though the white kids were shown to get less exercise overall. You might even say that when the disparity is a black person s disparity that it can be appropriated, i.e., funded so we can highlight and examine the underprivileged persons problem. It is a slippery slopebecause my social justice bent says yes we want to make sure resources go to an area if there is a problem, but on the other hand the constant reinforcement of disparities, even when the raw facts are oppos ite the conclusion, just makes me realize how much benefit I deri ve from disparities, and especi ally how CBPR projects that focus on grass-tops organizing can capitalize on disp arities, without challenging themselves to truly emancipatory processes. Though CAC pa rticipants would readily admit a need to improve community safety, they refused to stigmatize different safety contexts, suggesting safety needs to be integrated into other more positive-or iented interventions, making me question the tendency of research to reify perceptions of problem-areas. Limitations Limitations of Study Aim 1. Limitations of the cluster analysis conducted here are consistent with the orig inal study data limitations.99 Additionally, data collected in 2007 from Stapleton represents th e people who lived in that co ntext at that time, but not all the people who moved there between 2008 and 2010. Limitations for Aim 2. Important limitations in inte rpreting results from the first aim is that there were only two intervention generating groups from the safest context, one adult and one child group. Also in the Spanish-speaking groups and one youth 109

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group, friends or neighbors were invited to the group so not all the participants were part of our random survey sample. Also, at least one of the Spanish-speaking groups was led by a facilitator who was somewhat leading in his discussion, which may have solicited more safety intervention suggestions than wh at would have happened otherwise. Another limitation as well as strength of the study was that the concept generating sessions were not all conducted by the same facilitator so di fferences in the percen tage of brainstormed interventions related to safety may be related to different facilitato r styles or biases. Though these are important limita tions of the brainstorming pha se, in the rating phase of concept mapping these limitations were not present. Together these two study phases provide consistent results, suggesting black and Latino adult reside nts and adults from less safe contexts think safety and infrastructu re/access interventions are most needed. Another limitation of this st udy was that the initial study design intended to engage a consistent group of people in each concept mapping phase, and thereby build investment in the study results among a larger constituenc y. Because our recruitment efforts did not yield a sufficient number of people to come to community meetings, we chose to do the rating phase of the study through individual interviews. Though study participants were invited to a large community forum to learn the results of the research, it didnt seem that many of the rating participants participated. So feedback about the results and offers to help implement the solutions came from peopl e outside the grassroots. But internal group dynamics flared at that time and we didn t have a solid plan for how to incorporate more grass-tops participation. Therefore the process did not benefit from the consistent, developing engagement of a large group of study participants, and instead the CAC served this role. Larger grants to suppor t policy implementation efforts were not funded 110

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and the instead, the group focused on smaller projects in an effort to begin partnering with grass-tops organizations. Results of this study are not generalizable outside this urban environment, but results do provide one example of both contex t and ethnicity indepe ndently relating to residents views of what interventions are ap propriate in different safety environments. Another limitation of this study is that the concept mapping efforts only included participants who agreed to be contacted after completing an earlier household survey. Those who did not agree to future participa tion and those who moved since agreeing to participate in future studies, were not re presented in the concept mapping efforts. Because there were differential transience rate s within the three contexts, this may have biased the results. If, however the theory that transience is related to experiences of being less safe, it would have biased the results toward th e null hypotheses, because the most stable of the residents w ould be those feeling safest a nd would have been present to participate. Additionally, not all of the 330 brainstormed ideas were included in the sorting and rating phases of the study. The community gr oup tried twice with different efforts to manually reduce the 330 ideas to 100 ideas and failed, so the random selection of solutions was thought the best way to select solutions without bias ing the results. A fourth limitation is that this study focuse s on perceptions of what is needed in the neighborhoods and studies would be need ed to test whether implementing these interventions would actually result in be havior changes, or if standard CDCrecommended interventions absent the CBPR process would be equally effective. Grassroots groups could select interventions that have mi nimal long-term impact, but 111

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they may also select interventions that are much more relevant and appropriate to the community doxa. Prospective studies to test the re lative benefit of engaging grassroots participation in intervention selection and implementation would be of interest. Another limitation is that these data were analyzed at the block group level which may have been too gross an anal ytic unit to identify different doxa For instance, residents living at opposite ends of the block group might have perspectives more similar to those of the adjacent block group rather than each other. If this were th e case, because the sampling frame for identifying safety contex ts provided the bulk of the sample for the rating phase, the safety of the context and the rating of the interventions would have been biased in similar fashions. 207 Lastly, this effort did not benefit from the knowledge and engagement of a fulltime youth policy development specialist. Wh en one was invited to sessions, the CAC had already developed and the value of an outside specialist was not sufficiently appreciated. Had such a person been part of the process, the group would have gained additional skills. Conclusions and Implications for Future Research Increasing physical activity among youth is part of a national comprehensive plan for reversing the obesity epidemic.49 The factors influenc ing physical activity are complex and varied. Engaging grassroots comm unities to identify their priorities for improvements can help tailor evidence-based national strategies for the local context. This study challenges the typical problem-orie nted research paradigm and research done without community participation. It simila rly highlights the tension between academic hypothesis testing and using research as one piece of a social change project.177 While 112

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the study results could have focused exclusivel y on the differential need for interventions between safety contexts, community members preferred focusing on issues common to the communities, the needs expressed by children. If the results had been done using a traditional, top-down research paradigm, community presentations would have run the danger of stigmatizing neighborhoods by publicizi ng different safety contexts and their disparate needs. Instead, grassroots participants guided each phase of the study, and suggested many interventions consistent with nationally-recommended, evidence-based interventions. Their insistence on focusing on the go-zone analyses showing that youth want interventions that are fun, free and safe, seems simple, but it is has a deep rationale. Community members from less safe neighborhoods in this study were acutely aware of the impact of safety context on their children s activity. They also worked especially in the less safe contexts to bring more opportunities to children there. To address the safety environment, however, the CAC didnt want to focus on safety interventions alone which could stigmatize communities. Instead, it recommended framing interventions as fun, free and safe so the intervention would be seen as positive and the stigmatizing safety issues could be more subtly addressed. This subtle, but important lesson in framing interventions to address disp arities seems to hold lessons for the broader field of disparities research. While earlier generati ons of disparities research focused on the differences in health outcomes and needs, ne wer disparities research focuses on solutions, where paying attention to how solutions ar e framed takes on increasing importance. This study highlights a number of interesti ng questions worthy of future research. Results presented here suggest that diffe rences in perceived community needs are 113

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associated with safety context differences, and that in less safe contexts people from different racial/ethnic groups have different perspectives. One interesting question is, why do people from different ethnic backgrounds have different perceptions of need when they live in the same geographic cont ext? Especially, why would white people see less need for safety interventions compar ed to their black and Latino counterparts? How do systems, policies, and interpersonal and intrapersonal beha viors contribute to these differential perceptions? What perpetua tes the perception of different levels of need? Is it a socio-economic disparity that a ffords differential access to physical activity opportunities inside and outside th e geographic context, or might it also be another facet of disparate doxa in these contexts? Perhaps these questions could be explored through the lens of white privilege. Also of interest would be research on how the strengths of grassroots and grasstops participation can be ma ximized. Whereas grassroots co uld identify priorities they thought most needed, grass-tops could help ma ke residents aware of available resources to meet their needs. The primary question he re is whether a Northern or Southern CBPR process, or blend of the two, would be more effective in improvi ng physical activity, and in challenging dominant doxa that may only perpetuate disparities. Given similar resources (including paid time to do this work ), what leadership structure would produce changes in youth physical activ ity most efficiently? 114

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strategies to increase physical activity. Eval Program Plann. Aug 2007;30(3):282-293. 99. Main DS, Ware G, Iwasaki PG, et al. Taking Neighborhood Health to Heart (TNH2H): building a community-based participatory data system. Prev Chronic Dis. Jan 2012;9:E41. 100. Boehmer TK, Luke DA, Haire-Joshu DL, Bates HS, Brownson RC. Preventing childhood obesity through state policy. Predictors of bill enactment. Am J Prev Med. Apr 2008;34(4):333-340. 101. Sallis JF, Cervero RB, Ascher W, Henderson KA, Kraft MK, Kerr J. An ecological approach to creating active living communities. Annu Rev Public Health. 2006;27:297-322. 102. Elder JP, Lytle L, Sallis JF, et al. A description of the social-ecological framework used in the trial of activity for adoles cent girls (TAAG). Health Educ Res. Apr 2007;22(2):155-165. 103. Giles-Corti B, Donovan RJ. The relative influence of individual, social and physical environment determinants of physical activity. Soc Sci Med. Jun 2002;54(12):1793-1812. 104. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal factors affect food choice and physical activ ity: rationale, influences and leverage points. Nutr Rev. Mar 2001;59(3 Pt 2):S21-39; discussion S57-65. 105. Saelens BE, Sallis JF, Frank LD. Envi ronmental correlates of walking and cycling: findings from the transportati on, urban design, and planning literatures. Ann Behav Med. Spring 2003;25(2):80-91. 106. Sallis JF, Glanz K. The role of built e nvironments in physical activity, eating, and obesity in childhood. Future Child. Spring 2006;16(1):89-108. 107. Suminski RR, Ding D, Lee R, May L, To ta T, Dinius D. Youth physical activity opportunities in lower and higher income neighborhoods. J Urban Health. Aug 2011;88(4):599-615. 108. Powell LM, Slater S, Chaloupka FJ. The relationship between community physical activity settings and race, ethnicity and socioeconomic status. Evidencebased Preventive Medicine. 2004;1:135-144. 124

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166. Pikora TJ, Bull FC, Jamrozik K, Knuiman M, Giles-Corti B, Donovan RJ. Developing a reliable audit instrument to measure the physical environment for physical activity. Am J Prev Med. Oct 2002;23(3):187-194. 167. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-based differences in physical activity: an environment scale evaluation. Am J Public Health. Sep 2003;93(9):1552-1558. 168. Caughy MO, O'Campo PJ, Patterson J. A brief observational measure for urban neighborhoods. Health Place. Sep 2001;7(3):225-236. 169. Laraia BA, Messer L, Kaufman JS, et al. Direct obser vation of neighborhood attributes in an urban area of the US s outh: characterizing th e social context of pregnancy. Int J Health Geogr. 2006;5:11. 170. Hill JL. Examining the potential relationshi ps between social capital, built environment and physical activity: A mixed methods study Denver: School of Health and Behavioral Sciences University of Colorado; 2009. 171. Everitt BS. Cluster analysis New York: John Wiley & Sons; 1994. 172. RK B. Mixture model tests of cluster analysis: accuracy of four hierarchical agglomerative methods. Psychological Bulletin. 1976;83:377-385. 173. Gorman I. Childhood obesity: parents vs. envi ronment, who has the greater influence? Denver: Health and Behavioral Sc iences, University of Colorado; 2012. 174. Kane M, Trochim WMK. Concept Mapping for Planning and Evaluation Thousand Oaks, CA: Sage Publication; 2007. 175. JaMuir MR, Trochim WMK. An ex amination of community members', researchers' and health professionals' perceptions of barriers to minority participation in medical research: an application of concept mapping. Ethnicity and Health. 2007;12(5):521-539. 176. Israel BA, Schulz AJ, Parker EA, Beck er AB, Allen AJ. Critical issues in developing and following community based participatory research principles. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health San Francisco: Jossey-Bass; 2003. 130

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177. Stoeker R. Are academics irrelevant? Approaches and roles for scholars in community based participatory research. In: Minkler M, Wallerstein N, eds. Community-based participatory research for health San Francisco: JosseyBass; 2003. 178. Timperio A, Ball K, Salmon J, et al. Pe rsonal, family, social, and environmental correlates of active commuting to school. Am J Prev Med. Jan 2006;30(1):45-51. 179. Bacha JM, Appugliese D, Coleman S, et al. Maternal perception of neighborhood safety as a predictor of child weight status: The moderating e ffect of gender and assessment of potential mediators. Int J Pediatr Obes. 2010;5(1):72-79. 180. Rossen LM, Pollack KM, Curriero FC, et al. Neighborhood incivilities, perceived neighborhood safety, and walking to school among urban-dwelling children. J Phys Act Health. Feb 2011;8(2):262-271. 181. Blalock HM. Toward a Theory of Minority-Group Relations,. New York: John Wiley & Sons; 1967. 182. Covington J, Taylor RB. Fear of cr ime in urban residential neighborhoods: implications of betweenand within-n eighborhood sources for current models. Sociological Quarterly. 1991;32(2):231-249. 183. Weitzer R, Kubrin CE. Breaking news : How local TV news and real-world conditions affect fear of crime. Justice Quarterly. 2004;21(3):497-520. 184. Miles R, Panton L. The influence of the perceived quality of community environments on low-income wo men's efforts to walk more. J Community Health. Oct 2006;31(5):379-392. 185. Cecil-Karb R, Grogan-Kaylor A. Childhood body mass index in community context: neighborhood safety, television view ing, and growth tr ajectories of BMI. Health Soc Work. Aug 2009;34(3):169-177. 186. Lindsay AC, Sussner KM, Greaney ML, Pete rson KE. Influence of social context on eating, physical activity, and sedentary behaviors of Latina mothers and their preschool-age children. Health Educ Behav. Feb 2009;36(1):81-96. 187. Olvera N, Smith DW, Lee C, et al. Hispanic maternal and children's perceptions of neighborhood safety related to walking and cycling. Health Place. Jan 2012;18(1):71-75. 131

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188. Loukaitour-Sideris A, Eck JE. Crime prevention and active living. Am J Health Promo. 2007;21(4 [Supplement]):380-389. 189. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities resear ch to achieve health equity. Annu Rev Public Health. 2011;32:399-416. 190. Robinson TN, Sirard JR. Preventing childhood obesity: a solution-oriented research paradigm. Am J Prev Med. Feb 2005;28(2 Suppl 2):194-201. 191. Green LW, Mercer SL. Can public health researchers and agencies reconcile the push from funding bodies and pull from communities? Am J Public Health. 2001;91(12):1926-1929. 192. Kessel SS, McCarron DA. Future directions: a community-based approach. Pediatrics. Nov 2010;126 Suppl 2:S98-100. 193. McCarron DA, Richartz N, Brigham S, White MK, Klein SP, Kessel SS. Community-based priorities for impr oving nutrition and physical activity in childhood. Pediatrics. Nov 2010;126 Suppl 2:S73-89. 194. McCarron DA, Kessel SS. Shaping America's Youth initiative: implementation and assessment of a community-based approach to improving childhood nutrition and physical activity. Introduction. Pediatrics. Nov 2010;126 Suppl 2:S71-72. 195. Vander Stoep A, Williams MV, Jones R, Green L, Trupin E. Families as full research partners: what's in it for us? the Journal of Behavioral Health Services & Research. 1999;26(3):329-344. 196. Travers KD. Reducing inequities through participatory research and community empowerment. Health Educ Behav. 1997;24(3):344-356. 197. McKenna SA, Iwasaki PG, Stewart T, Ma in DS. Key informants and community members in community-based participatory research: one is not like the other. Prog Community Health Partnersh. Winter 2011;5(4):387-397. 198. Kopell MR. Civic engagement: bringing in the real experts --a commentary on the Shaping America's Youth initiative. Pediatrics. Nov 2010;126 Suppl 2:S90-94. 199. Katz DL, Nawaz H, Jennings G, et al Community health promotion and the randomized controlled trial: appr oaches to finding common ground. J Public Health Management Practice. 2001;7(2):33-40. 132

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200. Ohri-Vackaspati P, Leviton L, Bors P, Brennan L, Brownson RC, Strunk S. Strategies proposed by Healthy Kids, Healthy Communities partnerships to prevent childhood obesity. Prev Chronic Dis. 2012;9: http://www.cdc.gov/pcd/issues/2012/2010_0292.htm 201. The Joint Center for Political and Ec onomic Studies, Prevention Institute. Reducing Inequities in Health and Safety through Prevention http://www.preventioninstitute.org/com ponent/jlibrary/article/id-201/127.html Accessed April 28, 2013. 202. Robert Wood Johnson Foundation, Commi ssion to Build a Healthier America. Beyond Health Care: New Directions for a Healthier America. April; http://www.commissiononhealth.org/PDF/779d4330-8328-4a21-b7a3deb751dafaab/Beyond%20Health%20Care%20%20New%20Directions%20to%20a%20Healthier%20America.pdf Accessed April 29, 2013. 203. Williams DR, Collins C. Racial reside ntial segregation. In: LaVeist TA, ed. Race, ethnicity and health San Francisco, CA: Jossey-Bass; 2002:369-390. 204. Cohen L, Iton A, Davis R, Rodriguez S. A time of opportunity: Local solutions to reduce inequities in health and safety. Minneapolis, MN: The Prevention Institute; May 2009. 205. Dankwa-Mullan I, Rhee KB, Williams K, et al. The science of eliminating health disparities: summary and analysis of the NIH summit recommendations. Am J Public Health. Apr 1 2010;100 Suppl 1:S12-18. 206. Franzini L, Elliott MN, Cuccaro P, et al. Influences of physical and social neighborhood environments on children's physical activity and obesity. Am J Public Health. Feb 2009;99(2):271-278. 207. Handwerker WP. Quick Ethnography. Walnut Creek, CA: AltaMira; 2001. 133

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APPENDICES 134

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Appendix 1: Participant Recruitment Flyer 135

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Society of the Youth We are the Society of the Youth and you are invited! Join us an d help the youth in our neighborhoods be ab le to play more! So join us in helping the youth! Where: Come on down to the Local Library What: Sit down with a small group and share your ideas about how we can make the neighborhood better for youth When: Saturday, June XX, 2009, 10 am And one of the be st parts is that you get a gift certificate fo r helping out This is part of a re search project run by University of Co lorado Denver Questions? Call Stephanie at 303-724-1080 to learn more Stephanie Phibbs COMIRB #08-1388 136

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Appendix 2: CAC Facilitation Training Materials 137

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Facilitation What a good facilitator doesConnection. Leadership. Motivation. Explains things thoroughly. Gets people to participate. Call and give group members a reminder of the next coming up meeting. Makes sure that the communitys voices are heard. Keeps other/off-topic ideas in a parking lot. Lets people know about agendas/provide minutes. Facilitacin Conexin Liderazgo Motivacin Explicar las cosas minuciosamente Hacer que la gente participe Llame a sus miembros del grupo para recordarles sobre la prxima reunin. Asegurar que las voces de la comunidad sean escuchadas. Mantener las ideas que no estn relaciona das con el tema fu era de la reunin. Informar a los dems sobre las agenda/proporcionar las minutas. Ideas brainstormed by The Society of the Youth working group, June 27, 2009 138

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YOUR ROLE AS A FACILITATOR (From Taking Neighborhood Health to Heart) 139

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140

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Su Papel como Facilitador (From Taking Neighborhood He alth to Heart Materials) Papel y responsabilidades: Su papel es ayudar a los particip antes a discutir sus experiencias relacionadas al propsito de la reunin. Esto se puede hacer de di ferentes formas: manteniendo una conversacin activa, validando el conocimiento de los participantes cuando sea posible, haciendo preguntas despus de un comentario para acla rar las respuestas de los participantes, afirmando las ideas principales que ha escuch ado, hablando con los participantes para clarificar que lo que escuch como la idea principal es correcto, conectando la discusin con los objetivos de la reunin, alentando a todos los participantes para que participen, escuchando atentamente a todo momento, ayuda ndo a los participantes a mantenerse enfocado en la conversacin y tambin mantener orden con el uso del tiempo. Su papel es obtener informacin y experienci as de los participantes para poder cumplir los objetivos de la reunin. No hay ni ngn problema en compartir informacin o ejemplos personales para ayudar al progreso de la conversacin, sea breve. Si usted se da cuenta que est hablando ms que los partic ipantes de la reunin, se dar cuenta que usted est compartiendo ms ideas personales que en vez de crear oportunidades para que los participantes expresen sus ideas. Su papel no es ser un particip ante, ni hacer decisiones pa ra el grupo. No haga ninguna promesa. Este Preparado! Diferentes puntos de vista Hay muchas posibilidades que en la reunin existan diferentes puntos de vista. La dinmica del grupo es muy importante. Su tr abajo consiste en apoyar al grupo con un dilogo justo y relacionado a la conversacin, ayudar a los participan tes a que se sientan seguros compartiendo sus perspectivas con el grupo. Haga entender al participante que la idea de la reunin no es llegar a un acuerdo si no al contrario la idea es escuchar todas diferentes opiniones. Recomiendo que los acuerdos de grupo se presenten antes de comenzar el dilogo. Sino se usa el acuer do, usted como facilitador debe de compartir con los participantes la importancia de la regla de estar de acuerdo con los desacuerdos. El facilitador debe de hablar con los miembros del grupo ac erca de lo que se puede y no se hablar fuera de la reunin sobre las ideas compartidas en el grupo. Principios Por motivos de consistencia es recomendado que el facilitador haga lo siguiente: sepa sus lmites, sea respetuoso, se mantenga enfocado, interacte honestamente, evite situaciones de conflictos de inters, se enfoque en el objetivo y en la auten ticidad del proceso. Pautas 142

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Los participantes necesitan estar sentados para la discusin, lo mejor sera sentarse en crculo o hacer una media luna. Al momento de hablar mire a todos lados hable con todos no solo con algunos. Sea consciente de su lenguaje corporal Sea usted mismo Haga que los participantes se sientan cmodos Mire a todos Hable con todos por lo menos una vez Mantngase en el tema, use Socie ty of the Youth Discussion Guide. Tenga buen uso del tiempo Este preparado Sea flexible Cudese Una forma de comenzar la discus in es hacer preguntas abiertas Preste mucha atencin al lenguaje corporal no as uma que usted sabe lo que el participante esta pensando o sintiendo basado en su lenguaje corporal o expresin facial. Tenga una mente abierta para escuchar persp ectivas que son diferentes a las de usted. Cuando aclare las ideas de los partic ipantes evite desafiar las mismas. Consejos Avsele a los participantes que el registra dor estar escribien do y esto es para estar seguros de obtener la mayor info rmacin posible. Al explicar esto el registrador prender la grabadora. Preste atencin al tiempo y a la agenda. Ajuste el tiempo sin comprometer la agenda. El Hablador: cuando una persona este ha blando y tome un descanso breve para agarrar un poco de aire, es un buen moment o para intervenir y decir gracias por su intervencin, ahora escuchemos la opinin de otros. El Callado: dirjase a persona que no ha hablado y pregntele, usted qu piensa sobre lo que se dijo? qu agregara la lo que se dijo? Si el grupo de participantes empieza a re petir lo mismo, intervenga y vuelva a enfocar al grupo en los objetivos de la reunin. Por ejemplo puede decir, este es un asunto importante y me gustara hablar de ese tema pero despus de la reunin puede llamar al (nmero), si usted quiere Terminar la conversacin, pregunte si alguien tiene comentarios finales y agradezca a todos por su participacin. Recurdeles que tan importante es su participacin y explqueles que se va hacer con la informacin obtenida en la reunin. Ejercicio Lets go for it Materiales necesarios: Grupo 1: Tarjetas con rol de faci litador, el anfitrin y el re gistrador y Grupo 2: Tarjetas con rol de los participantes. Un buen humor y diversin. Tarjetas: Cada tarjeta tiene una desc ripcin de su rol y que es lo que tiene que hacer. 143

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Instrucciones: Formen grupos de seis, tres participantes necesitan tomar una tarjeta del grupo 1 y los otros tres necesitan tomar una tarjeta de l grupo 2. Cada persona tendr un rol y una tarjeta. Se debe de asumir que todos ya se cono cen, y tienen los datos de su vecindario. El facilitador comenzar la discusin con la pregunta en la tarjeta del facilitador, todos los dems asumirn sus papeles como si estuvieran en una reunin hogarea. Usted tendr 5 minutos para asumir ese pa pel. La persona que lleva el tiempo se encargar de avisarle cua ndo tiene que parar (usted tie ne que parar), la persona actuando como facilitador tendr un minuto pa ra compartir su experiencia y como se sinti, lo que hicieron bien y lo que tienen que mejorar. La persona con el rol de anfitrin le dir al fac ilitador en una oracin lo que hizo bien y en otra lo que puede mejorar. Cada tarjeta se va a pasar hacia la der echa y el ejercicio se repetir hasta que todos los participantes de su grupo experimenten con cada papel. Aviso Legal El contenido de la facilitaci n no es substituye el entrenam iento como facilitador. Es recomendado que si usted quiere continuar co mo facilitador reciba entrenamiento en otras reas de facilitacin. Este documento fue adaptado usando C. Barrientos Capacity Building and Technical Assistance Tools. Editado por George Ware. Traducido por Andrea Clinger. 144

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GROUP PROCESSING: LEV ELS OF HELPING (From Taking Neighborhood He alth to Heart Materials) WAYS OF HELPING A GROUP PROCESS A) DO NOTHING a. Takes no action b. May force group members to be independent, self responsible, handle own challenges c. Allows space to think about what should follow if nothing doesnt work d. Can raise tension, prompt beha viors that may not be de sired but stem from members need for inclusion B) DESCRIBE WHAT YOU SEE a. Only describes your pe rception, does not interpret or suggest action b. Reflects both verbal and nonverbal observtions c. Observation as a proces s comment [meaning: te ntative, data-based, does not evaluate & may be risk-taking ] d. Example, Ive noticed seve ral in this group began talking but stopped C) DESCRIBE YOUR FEELINGS a. Report what you perceive is occurring and the associated feeling b. Move from content or task to feeling level c. Depending on phase of group, can isolate you or precede turning point d. Eg: Im uncomfortable proceeding since X is not present and voiced concerns D) POSE A QUESTION a. State what you see happening, shifts in interest/disintere st, ask group, discuss b. Consult others, check perceptions c. Verify if the ques tion raised addresses collective concerns d. Eg: When you raised genetics, did anyone else feel the trust dropped? E) STRONG ACTION a. Impose direction on group b. Risky behavior for facilitator; use cautiously c. Suggest a facilitative structure or action d. Provide a helping hand instruct on group theory or teach why e. Refer back to operating agreements; group norms f. Allow for thorough debriefing 145

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PROCESAMIENTO DE GRUP O: NIVELES DE AYUDA (From Taking Neighborhood He alth to Heart Materials) FORMAS DE AYUDAR UN PROCESO GRUPAL A) NO HACER NADA a. No toma accin b. Puede forzar a los miembros del gr upo a ser independiente s, responsables, y cargar con su propios desafos. c. Permite dar un espacio para pensar acerca que es lo que sigue si nada funciona. d. Puede incrementar la tensi n, para provocar un comportamiento no deseado, un impulso para que los miembros comiencen incluir a los dems. B) DESCRIBE LO QUE VES a. Solo describa su percepcin, que no sugiera una accin. b. Refleja las observaciones verbales y no verbales. c. Comentario sobre La observacin como proceso [signi fica: tentativo, que es resultado de datos, no evala y puede ser riesgoso] d. Ejemplo, He notado que mucho miembros del grupo comenzaron hablando pero despus pararon... C) DESCRIBE SUS SENTIMIENTOS a. Reporte lo que usted percibe que esta ocurriendo y el sentimiento asociado con esto. b. Muvase del nivel de tarea al nivel de sentimientos. c. Dependiendo en la fase en la que se encuentre el grupo, usted se puede aislar o llegar a un punto de retorno. d. Ejemplo: Estoy incomoda con el proceso porque X no esta y no puede expresar su preocupaciones D) PLANTEE UN PREGUNTA a. Diga que ve que esta pasando, un cambi o de inters, o desi nters, pregunte al grupo, debata. b. Consulte con otros, revise las percepciones. c. si las preguntas que se ha n realizado tratan de las preocupaciones del grupo. d. Ejemplo: Cuando se hablo de la gentica, alguien mas sinti que se perdi la confianza? E) ACCION FUERTE a. Imponga un rumbo en el grupo. b. Comportamiento ries goso para los facilitadores, use precaucin. c. Sugiera una estructura facilitativas o una accin. d. Otorgue una mano de ayudaensee una teora grupal o ensee porque e. Consulte con los sistemas de acuerdo, normas de grupo. f. Permita un cuidadoso informe. 146

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FACILITATION AND RECORDING TRAINING CARDS Facilitator Lets get started, how long have you lived in this neighborhood and what specific actions do you think could be taken to increase phys ical activity among youth aged 10-14 in your neighborhood? Recorder Start the recorder and take notes duri ng the discussion, including writing peoples ideas on a white pad. Have an extra battery and check that the red light is on Talker Be a know-it-all and answer all the ques tions. If someone else talks, start where they left off. Repeat yourself Quiet Person Do not give eye cont act. Dont answer questions unless called on. Respond very quietly and briefly answer, if called on. Be Yourself! Disagreeable Disagree with others opinions and give your idea as a better idea 147

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FACILITATION AND RECORDING TRAINING CARDS (Spanish) Facilitador Comencemos, Cunto tiempo ha vivido en este vecindario? Qu acciones especfica que se necesita para que los jovenes entre las edades de 10 a 14 aos del vecindario practi quen mas actividades fsicas? Registrador Prender la grabadora y tomar not as durante la discusin, esto tambin incluye escribir las ideas de los participantes en la pizarra. Tene r una batera de repuesto y verificar que la luz roja de la grabadora este prendida. Hablador Actue como un sabelo todo, y responde todas las preguntas Si alguien mas habla, empiece por conti nuar con la idea. Repita lo que dice. Persona Callada No haga contacto visual. No responda ninguna preguntas al menos que se lo pidan. Responda bien calmado y que su respue sta sea corta, si se lo piden. SEA USTED MISMO Persona Ingrata No acepte las ideas de los dems y ofrezca sus propias ideas como si fueran mejor que las ideas de los dems 148

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RECORDER RESPONSIBILITIES Before the Participants Arrive: Put paper on the wall Put sitting area in a circle Set out food, nametags, sign-in sheet, tape recorder, pens Introductions and Consent Process Help welcome people Ask people to sign in (name) Help people to get a name tag After facilitator has explained consent pr ocess, walk around and be sure people are putting their initials on every page and signing the forms in the correct place Collect consents and HIPAA forms and be sure they ar e all filled out correctly During Discussion after Consents Collected: Turn on the recorder Take notes on the easel paper so people know they are heard When the group is over Pass out incentives and get correct numbers from incentives recorded 149

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RESPONSABILIDADES DEL REGISTRADOR Antes que los participantes lleguen: Poner el papel en la pared Acomodar el rea donde los particip antes se sentaran en un crculo. Acomodar la comida. Instrucciones y Procedimiento de consentimiento Ayudar a recibir a las personas Asegrese que los participantes firmen la hoja de asistencia con su nombre. Ayudar para que las personas reciban una identificacin con su nombre. Despus que el facilitador explico el pr oceso de consentimiento, revise que las personas pongan sus iniciales en todas las pginas y que firmen las formas en el lugar correcto. Asegrese de recolectar los documento s de consentimiento y las formas de HIPPA, y revise otra vez que todo este correcto. Despus de recolectar la formas de consentimiento y durante la discusin. Prenda la grabadora. Tome notas en el papel que esta en la pared para que as lo s participantes vean que sus opiniones son escuchadas. Cuando el encuentro grupal termina Reparta los incentivos y escriba correctamen te los nmeros de los incentivos que esta entregando a lo s participantes. 150

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FACILITATION RE-TRAINING 11/21/2009 Leading Tension between research and communityPersonal informationwe are not allowed to ask people for their phone numbers or tell them we will contact them laterI have a protocol that says how I will contact people and what I can contact them foryou are all research assistants contracted by the unive rsity we are not allowed to contact them outside this studyAt the e nd of the study we can give people an opportunity to be involved with a group or to form a group, but you cannot ask people if they want to be called, etc. You are in a position of authority an d that violates ethical research standards. FIDELITY Role of recorder: Support to the facilitatorto listen and record. You trust and respect the facilitator that they will ask the right que stions and they will lead the session well. Your job is very important to ma ke sure the recorder stays on and that you listen for everything the people say AND to write it up on the paper. Tape recorder The tape recorder turn ed itself off in two out of the three sessionsRebecca noticed it and turned it back onKat yours went off but it wasnt turned back on. Reminderch eck the recorder, but dont be too obvious about it. The recorder should also be writing the groups ideas on the chart paperat least 15 different ideas should be on the paper at the end of the session. Role of facilitatorTwo new concepts Leading and FidelityFidelitycollecting the data we set out to collect using the same methods, flow, and questions in every group, every time LeadingAny time you saysomething like, do you think it would be a good idea to. And they say yesthat is leadingI cant use that information. If you judge their response seven if you just say oh that is a good ideathat is leading. It makes people wonder if what they said earlier is not a good idea or if there is a right answer. Be really curious about themyou should avoid offering opinions or comments. We are so accustomed as a culture to seeing the problems and sometimes we dont feel powerful enough to think we can create solutions. This project is about daring ourselves and our communities to come up with solutions. Therefore we really need to help people think in a new way. We are looking for SOLUTIONS and ACTIONS read the focus question. So for instance if someone says safety is a problem. If I am looking for a solutionwhat would the facilitator say? If someone says there is not enough equipment in 151

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the playground. How should a you need to ask what should be put in the playground People talking over one anothercan not hear what they said on the recording Facilitator:what could be done to improve the youth physical activity. Participant: It think the parks are good; I am always with th e kids so, but there are kids who go by themselves. I talked to my kids about all the dangers; I know there are kids that need more communication. Facilitator: What could you do to improve this? Participant:.. This is hard to help with because people dont trust each other. Facilitator: This is true and sometime ne ighborhood parties work in order to create a relationship between neighbors. Participant: I think we need this beca use it has not been done before. Changes needed Does the focus prompt work? Does the guide provide an overview of the what will happen? Is there a good introduction question ready? Is confidentiality assured? 152

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Appendix 3: Brainstorming Protocol and Packet 153

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The Society of the Youth Each packet has a Label with Society of the Youth, facilitators name, space for the facilitators name, the group number (1-4) and meeting number (1-3) Adult Packets: First Handout Folder 10 copies of the consent, HIPAA, Survey Second Handout Folder 10 copies of consent and HIPAA for participants to take home Facilitators Folder Sign-in sheet with facilitators name a nd group number and place to enter gift card information for first two meetings Sign-in sheet with facilitators name a nd group number for third meeting with each group Facilitation guide for your meeting Sample group agreements, facilitation handouts Facilitators be sure to have with you for each meeting: Tape recorder, extra battery Notepad with pen for recorder 12 Pens for participants 2 markers to write on chart paper Post-it pages chart paper Name tags Gift Cards 154

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La Sociedad de la Juventud Cada paquete tiene una etiqueta de Sociedad de jvenes, el nombre del facilitador, el nmero del grupo (1-4) y el nm ero de la reunin (1-3). Paquetes de adultos: Primera carpeta de folletos 10 copias de documentos de consentimiento, la forma HIPAA y la encuesta. Segunda carpeta de folletos 10 copias de documentos de consentimiento y la forma de HIPPA para que los participantes lleven a casa. Carpeta del facilitador Una hoja de asistencia con el nombre del facilitador y el nmero de grupo y un lugar donde se pueda apuntar la informacin sobre las tarjetas de regalo de las dos primeras reuniones. Una hoja de asistencia con el nombre del facilitador y el nmero de grupo para la tercera reunin para cada grupo. Una gua de facilitacin para su reunin. Ejemplos de acuerdos de grupo, folletos de facilitacin. Los facilitadores necesitan tener lo siguiente para cada reunin: Una grabadora, con una batera de repuesto Un cuaderno con una pluma para el registrado. 12 plumas para los participantes 2 marcadores para escribir en la pizarra (bloc de papel) Hojas de un bloc de papel adheridles Etiqueta con su nombre Certificodo 155

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Society of the Youth Discussion GuideMeeting #1 WELCOME / OVERVIEW 1. Welcome guests and introduce yourself, saying Welcome. Thank you for coming today to talk about what can be done to improve the neighborhoods for youth, especially so they can play more. 2. We are going to be here about 2 hours t oday to have this discussion, including time for us to gather, get some snacks, do some paperwork, share our ideas, and get a gift certificate. So it will be a full two hours. We wont take a break in that time, but feel free to get more food and drink or go to the bathroom as you like. The bathrooms are located.. 3. We are going to invite you to introd uce yourself, the neighborhood you live in, and the number of children you have (f or adult groups) (or for the youth group ask what is one of the things you like to do the most, and how long they have lived in the neighborhood PAPERWORK 1. Facilitator lets group know that we have some paperwork we need to review before the discussion beginsit is paperwork to be sure that everyone knows about the project and knows th eir rights while participati ng in this projectthis paperwork is for YOU, for you to know your rights. 2. Note taker and facilitator ha nd out packets from folder called First Handoutlet people know that they dont need to sign with their real name if they rather not. 3. Facilitator reads the consent form, stoppi ng occasionally to ask people if they have questions 4. Facilitator asks everyone willing to part icipate to sign the consent form, and put their initials on the bot tom of each page where initials are requested. 5. Facilitator reads the HIPAA form (summari ze) and asks if there are any questions 6. Facilitator asks everyone willing to part icipate to sign the HIPAA form and put initials on the bottom of the first page. 7. Facilitator tells people this is the last page of paperwork before they get started and asks them to fill out the questionnaire about me 8. Note taker and/or facilitat or collects all three docu ments from each personpaperclips documents from each person together and then puts a large paperclip on all the documents. 9. Facilitator hands out copies of consent a nd HIPAA forms for participants to keep (in Handout 2 folder) DISCUSSION Again thank you all for being here. Each of you have been invited because you have an important voice, you are the expe rt. You know about your community in a way that only community members do. You know what works and doesnt work for you and the children in your community. 156

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Your participation builds on prev ious work done in your neighborhood Residents of five neighborhoods and th e University of Colorado Denver have been partnering for the last two years All of you may have taken a survey so we can learn about the health of the community The purpose of todays meeting is to learn how to improve the neighborhoods for youth, so they can get outside and play more. Today we are going to start a conversation that will take place over three different meetings. If you cannot participate in othe r meetings, your work here will be very valuable. If you can participate in other m eetings that will be very helpful to the community. The first meeting today will be about brainstorming, this means we share our ideas without critiquing or challenging each other's ideaswe just offer our own ideas and listen to others. _______ (the recorders name) will write down your ideas as you say them and we area al so recording this so we are sure to get all your ideas. Again feel free to get up and help yourself to food or to go to the restroom. Are there any questions? We have found as part of group discussions it is helpful for the group to come up with group agreements. For instance one request we have is that people speak one at a time so the microphone will record what you are saying, other agreements we have seen include respect for each persons ideas, are there other agreements you think will help the discussion go smoothly? Write up the agreements.. First we will talk about some of the things that keep kids from playing outside. Later we will talk about how we can get kids out playing more. So to start us out, why dont kids who ar e 10-14 years old get out and play more in this neighborhood? (spend about 15 minutes on this) Now we are going to shift the conversation to solutions. So please write down or think of 3 ideas you have for the following question: What changes would you like to see to in crease physical activity among 10-14 year old youth? [start general, then move to in schools in parks in neighborhoods in households] 157

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(NOTE TO FACILITATOR Give the group a few minutes and then ask them to shareyou can go around the table asking for a volunteer and when someone gives an idea spend some time with that ideabe interested in their ideafor example if they say something like ma ke the neighborhood saferask something like, how could that be done? or if they say improve the parks, ask something like what specifically would you want to see improved?) or if they say they want to lessen traffic, you could ask w hat could be done to make the traffic safer? If people get stuck some questions you can ask: 1. What could we do as a community to get kids to be more active outside? 2. What actions would you take if you had several million dollars? What if you didnt have any money at all? 3. Talk about particular places or times when you notice children being active. What do you think is different about these places from others? OR 4. Why do you think kids are more active in some places and not others? whats present, whats not? 158

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Sociedad de jvenes gua de discusin BIENVENIDA/ INTRODUCCIN 1. Recibir a los invitados y hacer una intr oduccin personal, diciendo Bienvenidos. Gracias por estar aqu el da de hoy para conversar acerca de lo que podemos hacer para mejorar los vecindarios, esp ecficamente para que los jvenes puedan jugar mas. 2. El da de hoy nosotros vamos ha estar aqu alrededor de 2 horas para tener esta conversacin, este periodo de tiempo in cluye, tiempo para reunirnos, tener un refrigerio (comer algo), hacer papeleo, co mpartir algunas ideas, y al final darles un certificado. As que utilizaremos las 2 horas completas. Nosotros no vamos a tener descansos, pero por favor sintanse con la libertad de servirse ms refrigerio o ir al bao. Los baos estn localizados en .. 3. Nosotros queremos invitarles a que nos conozcamos diciendo su nombre, el nombre del vecindario en el que usted vive y el numero de nios que usted tiene [o algo que a usted le guste hacer (para los grupos de jvenes)], y como tiempo lleva viviendo en el vecindario PAPELEO 1. El organizador le explica al grupo que tenemos unos documentos que se tienen que revisar antes de comenzar la discus in. Estos documentos es para asegurarse que todos sepan acerca del proyecto y tamb in saber cuales son sus derechos como participantes del proyecto mientras estn participando este papeleo es para USTED, para que usted conozca sus derechos. 2. La persona que va ha tomar notas y el or ganizador entregaran los papeles de la carpeta llamados First Ha ndout (primer folleto) e inform aran a los participantes que no tienen que firmar con su nombre real sino lo desean. 3. El organizador lee el docum ento de consentimiento y debe de parar de vez en cuando para preguntar si alguno de los particip antes tiene preguntas. 4. El organizador pide a los participantes que estn inte resados en participar que firmen el documento de consentimiento y que pongan sus iniciales en la parte posterior de cada pgina co mo lo indica el documento. 5. El organizador lee la forma HIPPA ( un resumen) y pregunta si hay alguna pregunta. 6. El organizador pregunta a los participantes que si estn de acuerdo en participar firmen la forma HIPPA y escriban sus inicia les en la parte de abajo de la primera pagina. 7. El organizador le dice a los participantes que esta es la ultima pagina de los documentos antes de empezar y les pide que completen el cuestionario questionnaire about me (cuestionario sobre mi). 8. El registrador y/ el organizador recoge los tres documentos de cada personala persona que los recoge debe de separa r los paquetes de cada persona con un sujetador de papeles, y despus pone todos los documentos juntos con un sujetador de papel grande. 159

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9. El organizador entrega las copias del documento de consentimiento y de la forma HIPPA a los participantes (estos se encuentran en la carpeta del Handout 2). CONVERSACION Gracias por estar aqu otra v ez. Cada uno de usted ha sido in vitado porque su opinin es importante y ustedes son los expertos. Ustede s conocen su comunidad de la forma que solo los miembros de esta lo hacen. Ustedes saben lo que funciona y lo que no funciona para usted y sus hijos en su comunidad. Su participacin en el da de hoy se basa en trabajo anterior que se ha hecho en su vecindario Residentes de cinco vecindarios y la Un iversidad de Colorado Denver han trabajado juntos en los ltimos dos aos Todos ustedes pudieron haber contestado un cuestionario por el cual nosotros aprendimos sobre de la salud de la comunidad El propsito de la reunin de hoy es para aprender cmo mejo rar las condi ciones del vecindario para que la juventud salga a jugar. Hoy vamos a comenzar la conversacin que se va a extender a tres reuniones, su contribucin es valiosa. Su participacin en las otras re uniones ayudara mucho a su comunidad. En esta primera reunin vamos a concentrarnos en producir ideas, esto significa compartir opiniones e ideas sin crti cas ni enfrentamientos entre los miembros del grupo. Ofreceremos nuestras ideas y escucharemos a los dems. Antonio anotara sus ideas conforme usted las exprese, esta discus in tambin ser grabada para garantizar que todas las ideas sean escuchadas. Alguna pregunta? Una vez mas sintase libre de levantarse y se rvirse algo de comer o para ir al bao. Hay alguna pregunta? Como parte de grupos de discusin, nosotros hemos encontrado que es bueno poner reglas o acuerdos. Por ejemplo una petic in que tenemos es que las personas que participen hablen una a la vez, as el mi crfono registrar lo que usted dice, otros acuerdos que hemos visto incluyen respeto para las ideas de cada persona; todas las ideas son importante aunque algunas veces usted no este de acuerdo. Hay otros acuerdos que usted piense ayudaran para que la conversacin del grupo sea amena? Escriba los acuerdos. Bueno comencemos con la produccin de ideas. Primero hablaremos de las cosas que impiden a los nios jugar afuera y luego conversaremos de los cosas que creemos que puedan ayudarlos a jugar afuera. 160

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Porque los nios que la edad entre diez y catorce aos no salen a jugar ms a menudo? (spend about 15 minutes with this) Ahora vamos a conversad sobre soluciones. Po r favor piense en tres ideas con respecto a la pregunta anterior: (NOTE TO FACILITATOR Give the group a few minutes and then ask them to shareyou can go around the table asking for a volunteer and when someone gives an idea spend some time with that ideabe interested in their ideafor example if they say something like ma ke the neighborhood saferask something like, how could that be done? or if they say improve the parks, ask something like what specifically would you want to see improved?) or if they say they want to lessen traffic, you could ask w hat could be done to make the traffic safer? Qu cambios les gustara a hacer para in crementar la actividad fsica entre nios de diez a catorce anos de edad? (Empiece hablando de forma general y de ah contine con los siguientes temas: En la escuela En los parques En los vecindarios En los hogares Si los participantes se estancan en alg una de las pregunta, usted puede hacer las siguientes preguntas: 1. Qu podemos hacer como comunidad para incrementar la actividad fsica de los nios? 2. Qu accin tomara usted si tuviera muchos millones de dlares disponibles? Y si no tuviera nada de dinero? 3. Hable de lugares en particular o un tiem po en especfico donde usted cree que los nios son ms activos. Cual es la diferencia de estos lugares comparados a otros? O 4. Por que piensa que los nios son mas act ivos en estos lugares en comparacin con que en otros lugares? Qu es los que tienen o lo que no tienen? 161

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Consent MaterialsOne Example of Many Consent Forms. There were consent forms for Advisory Group Members and Concept Mapping Participants, each with Adult, Child, English and Spanish Versions Date: Valid for Use Through: Study Title: The Society of the Youth Principal Investigator: Stephanie L. Phibbs COMIRB No: 08-1388 Version Date: 4/6/09 Version #: 4/6/09 In this form, we use the words you and y our. If you are reading this form and deciding for your child, the words you and y our refer to that other person, not to you. You are being asked to be in a research study. This form provides you with information about the study. A member of the research team will describe this study to you and answer all of your ques tions. Please read the information below and ask questions about anything you don t understand before deciding whether or not to take part. Why is this study being done? This study plans to learn more about what community members think is needed to improve our communities for y outh, especially how to increase physical activity among youth in our neighborhoods. You are being asked to be in this research study because you live in Aurora, Park Hill, Stapleton, or East Montclair neighborhoods. Other people in this study Up to 500 people from your area will participate in the study. What happens if I join this study? If you join the study, you will be in one or more group discussions where you provide ideas about what can be done to improve our neighborhoods for youth. 162

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Your participation will last 2 hours for eac h discussion. You can participate in up to 3 discussions. What are the possible discomforts or risks? Discomforts you may experience while in this study include discomforts of talking in groups with peopl e from your neighborhood. What are the possible be nefits of the study? This study is designed for the researc her to learn more about what changes to the neighborhood would benefit youth. This study is not designed to treat any ill ness or to improve your health. Also, there may be risks, as discussed in t he section describing the discomforts or risks. Who is paying for this study? This research is being paid for by The Robert Wood Johnson Foundation. Will I be paid for being in the study? You will be paid $ 15 for participating in a group m eeting to provide ideas of how to improve the neighborhood. You will be paid $15 to rate ideas. The last meeting will be a comm unity meeting with results and you will not be paid to participate in that study. If you leav e the study early or only participate in the last meeting, or if we have to ta ke you out of the study, you will be paid only for the meeting you have completed. It is important to know that payments for participation in a study is taxable income. Will I have to pay for anything? It will not cost you anything to be in the study. 163

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Is my participation voluntary? Taking part in this study is voluntary. You have the right to choose not to take part in this study. If you choose to take part, you have the right to stop at any time. If you refuse or decide to withdraw later, you will not lose any benefits or rights to which you are entitled. Can I be removed from this study? The study doctor may decide to stop your participation without your permission if the study doctor thinks t hat being in the study may cause you harm, or for any other reason. Who do I call if I have questions? The researcher carrying out this study is Stephanie Phibbs. You may ask any questions you have now. If you have question s, concerns, or complaints later, you may call Stephanie Phibbs at 303724-1080. You will be given a copy of this form to keep. You may have questions about your rights as someone in this study. You can call Stephanie Phibbs with questions. You can also call the Colorado Multiple Institutional Review Board (COMIRB). You can call them at 303-724-1055. What Will Happen to my Recorded Information? In this study we will be recording the group discussion. We will use digital audio recordings and notebooks. We will keep this information secure and private. We will store it for up to 50 years At the end of that time, we will destroy it. Things That Must be Reported to The Authorities We respect your right to privacy. But there are some things we cannot keep private. If you give us information about child neglect or child abuse, we have to report that to Social Services. If y ou give us information about someone hurting someone else, we have to report that to t he police. If a court orders us to hand over your study records, we have to hand them over to the court. Who will see my research information? We will do everything we can to keep your records a secret. It cannot be guaranteed. Both the records that identify you and the consent form signed by you may be looked at by others. They are: 164

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People at the Colorado Multiple Institutional Review Board (COMIRB) The study doctor and his/her team of researchers. The Robert Wood Johnson Foundation who is the organization paying for this research study. Officials at The University of Colo rado, Denver who are in charge of making sure that we follow all of the rules for research. We might talk about this research study at meetings. We might also print the results of this research study in relev ant journals. But we will always keep the names of the research subjec ts, like you, private. We will ask you to sign a different fo rm that talks about who can see your research records. That form is called a HIPAA form. It will mention companies and universities who will s ee your research records. You have the right to request access to your personal health information from the Investigator. This authorization does not expire. However, you may withdraw this authorization for use and disclosure of your personal health information by providing written request to the Investi gator. If you withdraw this authorization, the Institution, the Investigator, the re search staff, and the research Sponsor will no longer be able to use or disclose your personal health information from this study, except so far as that they have already relied on this information to conduct the study. Agreement to be in this study I have read this paper about the study or it was read to me. I understand the possible risks and benefits of this study. I know that being in this study is voluntary. I choose to be in this study : I will get a copy of this consent form. Signature: Date: Print Name: Consent form explained by: Date: Print Name: 165

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Investigator: Date: [If Applicable, Signature Line for studies w ith children ages 13-18 who can read this form (children 7-13 should sign a SEPARATE assent form; for children 0-7, the parents are consented.) __________________ _________________________ Date_________ Child Consent form explained by: _____________Print Name _________ Date________ Investigator ______________________________ Date ______________ 166

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Appendix 4: Sorting Protocols 167

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Recruitment Script If they did participate in a previous discussion: Hello. My name is ____ and Im calling with th e Society of the Youth. May I talk with _______? If they are not home is there a good time when I could reach them or a better number I could use to reach them? Thank you. Hi mam/sir. You came to an earlier meeting where you ga ve your ideas about how to make the neighborhoods better for youth. No w we have collected ideas from multiple neighborhoods and are ready to invite you back to one mo re session to sort out the different ideas and to rate the different idea s. If you can make it to this session you will be given a $20 gift card. We would like to m eet this weekend, on Saturday, at the Martin Luther King Library at x:00 ? Would you be available? If they are not available : you can sayyour opinion really counts so we would be willing to meet at a time that works for you if you can t make this Saturdaywe would even be willing to come to your house if you prefer. If they didnt participate in a previous discussion say: Hello, My name is x can I please talk with y? Thank you. If they are not home is there a good time when I could reach them or a better number I could use to reach them? Thank you. Hello mam/sir, my name is x and Im with the Society of the Youth. We received your name and phone number fr om an earlier survey you did with the University of Colorado and taking neighborhood health to heart. On the survey you completed you said it would be okay to call you back for other projects. Your name has been randomly selected to represent opinions in your neighborhoodto tell us what you think are the most important things to do for youth in our neighborhoods. We would like to give you a $20 gift card to Ki ng Soopers or Target to meet at the MLK library and participate in a group that so rts and ranks different ideas from the neighborhood. Would you be able to meet with us this weekend on Saturday? If they say they are not available say: If not, well your opinion is rea lly so important that we woul d be willing to meet with you at a time and place that works for you, wed even come to your house if youd like. Could we arrange a time to come meet with you? Thanks, 168

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Participant Materials Instructions Overview This packet has complete instructions and data coll ection forms for three key activities: Activity 1: Participant questions Activity 2: Sorting Statements into groups and recording results Activity 3: Rating how need and po ssible each of the statements is For Activity 1 : Participant questions, you should have: Survey about me For Activity 2 : Sorting and Recording, you should have: InstructionsSorting and Recording For Step 1, the statemen ts in a deck of cards For Step 2, Sort recording sheet For Activity 3 : Rating, you should have: Needed rating recording sheets Possible rating recording sheets Please follow the instructions given very carefully; a few small errors can change the final results. Please return this packet to the facilitator when you are done. 169

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Activity 2Instructions for Sorting and Recording Step 1Sorting the Task Statement Cards. You will be gi ven a deck of cards with one statement on each card. Each card has a statement in English and Spanish and an ID number. We woul d like you to group the statements in piles that make sense to you, following these guidelines: Group the statements for ho w similar in meaning they are to one another. Do not group the statements by how important they are, how much you like them, etc. You will do so me of that in later steps There is no right or wrong way to group statements. You will probably find that you could grou p the statements in seve ral different sensible ways. Put cards in piles in a way that feels best to you. People differ on how ma ny piles they wind up with. In most cases, anywhere from 10-20 piles works well. A statement can be put alone in its own pile. If you think it is not related to all the other statements or it stands alone as a un ique idea put it alone. Do not have any piles of misce llaneous or other statements. Make sure every statement is put somewh ere. Do not leave any statements out. Step 2Recording the Results. You also have in this packet a Sort Recording Sheet for recording the results of your groupings. On that sheet please write the results as described below. An example of how to record a pi le is shown in the first box on the So rt Recording Sheet Pick up any one of your pile statem ents. It does no t matter which pile you start with. Quickly read the statements in the p ile, and then write down a short title that describes the pile on the line provided after Pile Title or Main Topic in the first available box on the Sort Recording Sheet. In the space under the pile name, writ e the statement iden tification (ID) number of each card in that pile. Separate th e numbers with commas. When you finish with the pile, put it aside so you dont record it twice by mistake. Move on to your next pile and repe at the three steps above, recording the statement numbers in the next availabl e box on the Sort Recording Sheet. Continue in this way until all your piles have been na med and recorded Your Sort Recording Sheet has room fo r you to record up to 20 piles or groups of cards. As mentioned ab ove, any number of piles (usually 10-20 is fine. If you have more than 20 piles, ask for more Recording Sheets 170

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Please write clearly. Most of the errors we have are made at this stage and are due to data that is hard to read. When you have recorded al l the piles, please go to Activity 3Rating. 171

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Activity 2Step 2 Sort Recording Sheet continued This sheet is to be used to record your resu lts. Remember you do not have to have as many piles as there are boxes on this sheet. Th ere are many boxes because different people will create different numbers of piles. The first box (example pile) is filled out to be a guide for you. Start recording your piles here: Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Example Pile Title or Main Topic : ___Playground Changes __________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas 1 4 29 34 50 Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas 172

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Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas Pile Title or Main Topic: ______________ ____________________ Record here each of the ID numbers for the ideas in this pile, separating the numbers with commas 173

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174Appendix 5: Rating Protocols

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Society of the Youth Activity 3: Ratings for Phon e and In-Person Interviews ENGLISH: Packet #___________ To increase physical activity among 10-14 year olds in your neighborhood, how needed would you say it is to (read statement ) ; 1 is not at all needed, 5 is most needed; And how possible would that be? 1 is not at all possible and 5 is most possible? (record response, repeat) SPANISH: Para aumentar la actividad fsica entre los jovenes de 10-14 aos de edad en su vecindario, qu tan necesario es ..(read statement, record response); 1 no es necesario, 5 es loms necesario. Y que tan posible sera que (leer la idea de ms arriba ) ? 1 no es posible y 5 es muy posible. (record, repeat) 1 Need____ Poss_____ Have more mentors to encourage physical activity/Tener ms mentores para promover la actividad fsica 2 Need____ Poss_____ Improve safety in recreation centers/Mejorar la seguridad en los centros de recreacin 3 Need____ Poss_____ Have older youth watch younger kids outside to create safety/Tener jvenes afuera cuidando a los ms pequeos para crear seguridad 4 Need____ Poss_____ Have responsible parents and adults in the park and neighborhoods to watch over kids/Tener padres y adultos responsables en parques y vecindarios para cuidar a los nios 5 Need____ Poss_____ Get a group of people to commit to reportin g bad activities to the police /Conseguir un grupo de personas que se comprometan a repo rtar actividades malas en el vecindario a la polica 6 Need____ Poss_____ Have adults pay more attention to their children and check on them/Que los padres les presten ms atencin a sus hijos y los chequen 7 Need____ Poss_____ Have a volleyball court close to home/Tener un parque para jugar volleyball cerca a la casa 8 Need____ Poss_____ Open/unlock tennis courts for things like roller-skating/Abrir el accesso a campos de tenis para practicar otras actividades como por ejemplo, el patinaje 9 Need____ Poss_____ Make more places to lift weig hts, do aerobics, and play sports/Construir ms lugares para levantar pesas, hacer ejercicios aerbicos, y hacer otros deportes 10 Need____ Poss_____ Have parents get their children involved/Que los padres apoyen a sus hijos para que se involucren en mas actividades 11 Need____ Poss_____ Use the park at Fitzsimmons/Utilizar el parque en el campo Fitzsimmons 12 Need____ Poss_____ Have snowman building competitions/Hacer competencias de construccin de hombres de nieve 13 Need____ Poss_____ Take and teach children to ski or snowboard/Llevar y ensear a los nios a esquiar o snowboard 14 Need____ Poss_____ Provide a multi-sport facility where ch ildren can participate in tournaments and sports camps/Proveer lugares donde los nios pued an participar en torneos y campamentos di

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deportivos 15 Need____ Poss_____ Go to the pool/Ir a la alberca/piscina 16 Need____ Poss_____ Have a scavenger hunt where you go to look for different things like pine cones and birds with your family/Organizar una bsque da de tesoros en un parque donde uno busque diferentes cosas como bellotas y pjaros con la familia 17 Need____ Poss_____ Have kids do activities like sports/Hacer que los nios hagan actividades, como deportes 18 Need____ Poss_____ Give youth season passes to amusement park s, like Elitches or Water World, where they can be active/ Entregarle a los jvene s pases de temporada a parques de diversin como Elitches o Water World donde pu edan mantenerse fsicamente activos 19 Need____ Poss_____ Make playgrounds better with different eq uipment, like zip lines and more creative stuff/Mejorar los parques infantiles con dife rente equipo como tirolinas y cosas ms creativas 20 Need____ Poss_____ Make the parks prettier with flowers an d trees/Poner los parques ms bonitos con rboles y flores 21 Need____ Poss_____ Set up more biking paths to places you want to go, like schools or shopping/ Crear ms rutas de ciclismo para ir a lugares donde uno quiera ir, como la escuela y el centro comercial 22 Need____ Poss_____ Make a closer ice skating rink/Hacer una pista de patinaje ms cercana 23 Need____ Poss_____ Have chaperones (adult volunteers) take kids out of the city for fieldtrips /Conseguir chaperones (adultos voluntarios) para llevar a los nios a excursiones fuera de la ciudad 24 Need____ Poss_____ Have more stretching and warm up for sports /Aumentar los ejercicios de estiramiento y calentamiento antes de hacer deportes 25 Need____ Poss_____ Have parents volunteer to staff the school playgrounds after school/Tener padres voluntarios para supervisar los parques infantiles despus de la escuela 26 Need____ Poss_____ Have a football field close to home/Tener un campo de football futbol cerca a la casa 27 Need____ Poss_____ Make basketball tournaments/Hacer torneos de baloncesto 28 Need____ Poss_____ Teach kids about everyday fitness, like walking to school or the grocery store; walking the dog)/Ensear a los nios que se puede incorporar ejercicio a las actividades de la vida diaria, como por ejemplo ir caminando a la escuela, al supermercado; sacar al perro a caminar) 29 Need____ Poss_____ Have a dog to walk or other animals to in teract with/Tener un perro para sacar a caminar u otros animales con quien interactuar 30 Need____ Poss_____ Put in traffic bumps to slow traffic/Poner topes para reducir la velocidad del trfico 31 Need____ Poss_____ Give people a way to report crime anonymou sly/ Ofrecer una opcin annima para que la gente pueda reportar crmenes 32 Need____ Poss_____ Have more recreation centers around th e neighborhood/Constru ir ms centros de recreacin en los vecindarios 33 Need____ Poss_____ Train or educate adults to facilitate youth physical activities/Capacitar o educar a los adultos para que puedan guiar o dirigir las actividades fsicas entre los jvenes You are Doing Great! 34 Need____ Poss_____ Have more organized sports in elementary schools/Implementar deportes en equipo en

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las escuelas primarias 35 Need____ Poss_____ Have snowball fights/Tener peleas de nieve 36 Need____ Poss_____ Educate people on how to report crime and what to look for/Educar a la gente en como reportar crimenes y como detectarlo 37 Need____ Poss_____ Have geogames (where people use a map and compass to find different treasures)/Hacer juegos ge ogrficos conocidos como geos o geojuegos (Juegos donde se usa un mapa y comps para encontrar diferentes tesoros) 38 Need____ Poss_____ Add security cameras around the recreation center to keep it safe/Poner cmaras alrededor de los centros de recr eacin para mejor la seguridad 39 Need____ Poss_____ Have fences to keep kids from running in streets/Poner cercas para prevenir que los nios corran a las calles 40 Need____ Poss_____ Have community members report license plates of people doing bad thingsso reports are anonymous/ Que los miembros de la com unidad reporten las placas de las personas que esten haciendo cosas malas, y que los reportes sean annimos 41 Need____ Poss_____ Take students on a free snowboarding trip with school/Llevar a los estudiantes a un viaje gratuito para practicar snowboarding 42 Need____ Poss_____ Open the paddle boats in the parks more of ten/Abrir los botes de pedal en los parques ms seguido 43 Need____ Poss_____ Make police more visible/Que la polica este ms visible 44 Need____ Poss_____ Have more skate parks for kids on wheels, like skateboards, rollerblades, etc/Construir ms parques para los nios que les gust an las bicicletas, patines y patinetas 45 Need____ Poss_____ Take kids out walking with lunches, hygiene kits to give to the homelesskids contributing to the community/Salir a pi e con los nios llevando almuerzos y kits higinicos para dar a los desamparados, asi los nios pueden contribuir a la comunidad 46 Need____ Poss_____ Parents ride bikes with kids, have a family ride/Que los padres salgan a paseos familiares de bicicleta con los nios 47 Need____ Poss_____ Have less expensive band instruments, un iforms, equipment/Proporcionar instrumentos de bandas musicales uniformes y equipo deportivo ms econmicos 48 Need____ Poss_____ Have music and more affordable after-sch ool activities/Tener clases de msica y actividades extracurriculares mas econmicas 49 Need____ Poss_____ Make available free or rentable sports or activity equipment/Ofrecer equipos deportivos para usar de forma gratuita o para alquilar 50 Need____ Poss_____ Have parents take children to the park/Que los padres lleven a sus hijos a los parques 51 Need____ Poss_____ Reduce costs of recreation centers/Reduci r el costo de los centros de recreacin Great we are over 1/2 way donethanks for helping prio tize activities for your community! Bueno! Ya hemos hecho ms de la mitad. Gracias por ayudarnos a priorizar las actividades en su comunidad! 52 Need____ Poss_____ Have a walk-a-thon/ Organizar una camina ta en la que participe mucha gente

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53 Need____ Poss_____ Provide more physical activities in school s/Ofrecer ms actividades fsicas en las escuelas 54 Need____ Poss_____ Provide more security and protection for the kids and youth/Otorgar ms seguridad y proteccin para los nios y jvenes 55 Need____ Poss_____ Have a gym for dance competitions/Tener un gimnasio para hacer competencias de baile 56 Need____ Poss_____ Go for a field trip snow shoeing or ice skating/Ir de paseo a patinar sobre hielo o a caminar en la nieve con zapatos especiales para la nieve 57 Need____ Poss_____ Get rid of unproductive businesses, because they are crime magnets /Deshacerse de negocios malos que atraigan el crimen 58 Need____ Poss_____ Have more kids walk or bike to school/Incrementar el nmero de nios que caminen o vayan en bicicleta a la escuela 59 Need____ Poss_____ Make a safe place for kids to go during su mmer or spring breaks/Hacer lugares seguros donde los nios puedan ir durante las vacaciones 60 Need____ Poss_____ Create more parks, playgrounds, and open places to play/Crear ms parques, parques infantiles y lugares al aire libre donde puedan ir a jugar 61 Need____ Poss_____ Create a game of urban survivor/Crea r un juego de sobre vivencia urbana 62 Need____ Poss_____ Take students on backpacking,hiking or camp ing trips/Llevar a los estudiantes a viajes de exploracin para acampar y escalar 63 Need____ Poss_____ Vote to be sure programs like PE clas ses are not cut from schools/Votar para asegurarse de que no corten las clases de educacin fsica en las escuelas 64 Need____ Poss_____ Have a recreation center with free activities/Tener un centro de recreacin donde se ofrezcan actividades gratis 65 Need____ Poss_____ Have students get up and walk or do some activity every 20 minutes at school/Que los estudiantes se levanten y caminen, o hagan algn tipo de actividad cada 20 minutos en la escuela 66 Need____ Poss_____ Create more sports and activities for kids/ Crear ms deportes y actividades para los nios 67 Need____ Poss_____ Put a fence around playgrounds so kids feel safer/Cercar alrededor de los parques infantiles 68 Need____ Poss_____ Protect children from traffic/Proteger a los nios del trfico 69 Need____ Poss_____ Set up different activities and stations in th e park for the whole family/Crear diferentes actividades y diferentes estaciones en los parques para toda la familia 70 Need____ Poss_____ Give youth something positive to do, a pr ogram to clean up neighborhood, help the elderly, make them feel worthwhile, like th ey have a purpose, like they count/Dar a la juventud tareas positivas, como un programa para limpiar el vecindario, ayudar a los ancianos, algo que los haga sentirse que va len la pena, que tienen un propsito, que cuentan 71 Need____ Poss_____ Have people talk at back-to-school night to tell others about opportunities to be active/Traer personas en el dia de la matricula escolar para que hablen sobre oportunidades para mantenerse activos 72 Need____ Poss_____ Clean up the litter and graffiti in my neighborhood and neighborhood parks/Recoger la basura de mi vecindario y los parques de mi vecindario y limpiar las paredes pintadas.

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73 Need____ Poss_____ Have hopscotch, hula hoops, jump ropes, four square tournaments after school/Hacer torneos de rayuela, aros de hula (hula hoops), o de saltar cuerdas, o de cuatro cuadras despus de escuela 74 Need____ Poss_____ Give kids freedom to be outside and let th em know not to talk to strangers/Darle libertad a los nios para que estn afuera y ensearles que no deben hablar con extraos 75 Need____ Poss_____ Make travel safer to parks, recreation centres, and schools /Poner medidas de seguridad en las calles para que sea ms seguro ir a los parques, centros de recreacin, y escuelas 76 Need____ Poss_____ Provide more interesting activities to involve the whole community/Ofrecer ms actividades interesantes para qu e toda la comunidad participe 77 Need____ Poss_____ Protect kids from gang members and bullie s/Proteger a los nios de pandilleros y abusivos 78 Need____ Poss_____ Have a community history trivia contest/Hacer un concurso de trivia sobre la historia de la comunidad 79 Need____ Poss_____ Have bungee jumping/Practicar el salto de cada libre o bungee jumping 80 Need____ Poss_____ Have free youth activity time at the rec centers for swimming, basketball and other activities/Tener actividades pa ra los jvenes de forma gratuita en los centros de recreacin, como natacin, beisbol, baloncesto y otras actividades 81 Need____ Poss_____ Put in new street lights/ Poner ms postes de luz en las calles 82 Need____ Poss_____ Organize everyone to turn on porch lights to make the neighborhood safer/Organizar a todos para poner luces en la fachada de las casas para hacer los vecindarios ms seguros 83 Need____ Poss_____ Build more walking paths and trails nearby/Construir ms veredas y caminitos para salir a caminar 84 Need____ Poss_____ Jump rope at home/Saltar cuerda en casa 85 Need____ Poss_____ Have kids involved with after-school activities because they are safe/Que los nios se involucren en actividade s especiales (despus de escuela) porque son mas seguras 86 Need____ Poss_____ Dance in class or at school/Ofrecer clases de baile en la escuela durante en dia o despus de la escuela 87 Need____ Poss_____ Give prizes to encourage physical activity/Da r premios para fomentar la actividad fsica We're almost done; thanks for taking the time to have your voice heard. Ya casi hemos terminado. Gracias por dar su opinin 88 Need____ Poss_____ Enforce curfew laws/Hacer cumplir las leyes de toque de queda, que prohiben que los nios anden solos en las calles por la noche 89 Need____ Poss_____ Have music, block parties to draw people out/Tener msica, fiestas de vecindario para atraer a la gente 90 Need____ Poss_____ Have teachers give less work over the weekends so students have more time to play and do activities/Que los maestros den menos tareas los fines de semana para que los estudiantes tengan mas tiempo para jugar y hacer otras actividades 91 Need____ Poss_____ Go to summer camp/Ir a campamentos de verano 92 Need____ Poss_____ Give money to schools to supervise kids after school enrichment activities and physical activity, especially for girls/Incrementar el di nero a las escuelas para que supervisen a los nios despus de la escuela y ofrecer programas/actividades de enriquecimiento y actividad fisica, especialmente para las nias

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93 Need____ Poss_____ Reduce sport fees, especially for families with multiple kids/Reducir el precio de los deportes, especialmente para familias con varios nios 94 Need____ Poss_____ Encourage kids to spend less time watching TV and using computers /Fomentar a los nios el que pasen menos tiempo mirando TV y usando la computadora 95 Need____ Poss_____ Build more businesses, restaurants and other places in the neighborhood that people can walk to/Construir ms negocios, restaura ntes, y otros lugares en los vecindarios donde la gente pueda ir caminando 96 Need____ Poss_____ Unlock school playgrounds so they can be used after school hours and during breaks/ Abir los parques infantiles de las escuelas para que se puedan usar despus de la escuela y durante las vacaciones 97 Need____ Poss_____ Have more public restrooms and drinking fountains in parks/Tener mas baos pblicos y bebederos de agua en los parques 98 Need____ Poss_____ Have emergency telephones in the parks an d in the neighborhood/Tener telfonos de emergencia en los parques y en el vecindario 99 Need____ Poss_____ Support having mobile playgrounds, a semi-truck of toys that can be taken to different places/Apoyar los parques infantiles mviles, que son una troca o camin con juguetes que se pueden llevar a diferentes lugares 100 Need____ Poss_____ Get a group of kids together to organize and advertise youth events (with flyers or word-of-mouth)/ Formar un grupo de nios para organizar y anunciar eventos (con panfletos y hablando con la gente) 101 Yes____ No_____ Our final question is, can we contact you to share the results of this project with you? /Nuestra ultima pregunta es: podemos contactarla para darle los resultados de este proyecto?

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Appendix 6: Community Fair Flyers 181

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Appendix 7: Comprehensive List of Intervention Suggestions 1 Put restrictions on t.v. 2 Put teen mentors in the parks 3 Have 'Dance Dance Revolution' at schools 4 Have a low-income or free recreation center 5 Make a safe place for kids to go during breaks 6 Need transportation to safe places 7 Rotate transportation with other families 8 Address transients in abandoned homes 9 Provide homeless a homeless shelter 10 Use the park at Fitzsimmons 11 Get a place where infants can crawl over things in parks 12 Get a dog park 13 Build more walking paths nearby 14 Make more places to play basketball 15 Have cops do something about gangs 16 Have more recreation centers around the neighborhood 17 Have more commercials advertising kids to go outside and play 18 Have a petting zoo 19 Have a dog to walk or other animals to interact with 20 Have bikes and scooters we can ride for free 21 Have basketball tournaments, 3 on 3 basketball 22 Have restaurants by school so y ou can walk to them and get exercise 23 Make travel safer to parks 24 Have more social sport-oriented events 25 Have more competitions to motivate kids to be actives 26 Provide more security and protection for the kids and youth 27 Have adults pay more attention to their children 28 Entertain kids with anythingwith wood or tiny carsit doesn't take a lot of money 29 Have neighbors cooperate to take care of each other's children 30 More security so kids can feel good about being outside 31 Provide more games 32 Provide more physical activity 33 Provide more competitions running and jumping 34 Provide more interesting activites to involve the whole community 35 Have more activities with them (children) 36 Take them to the library 37 Children could do more sport activities 38 Create more sports and activities for kids 39 Divide schools into elementary, middle and high schoolsnot K-8 40 Get parents to want the children to be involved 41 Help make parents aware of what is available (for kids) 42 Get parents to patrol around the neighborhood 43 Have parents report license plates of people doing bad thingsso people don't know who is reporting 44 More education, knowledge that 'this is YOUR community 45 Need more fathers in the home 187

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46 Communicate and discipline youth to behave well 47 Have representatives talk at back-to-sch ool night to tell parents about opportunities 48 Engage men in The Fatherhood Initiative 49 Vote to be sure programs are not cut from schools 50 Longer recesseseven if it extends the school day 51 Take back the parks 52 Get a group of people to commit to doing your daily activities and reporting bad activities to the police 53 Need number to report to the police and what to look forlook for the license plate 54 Need safe way for children to get from home to the recreation center 55 Train PTA members so they can report activity 56 Get active in your neighborhood and watch out for kids 57 Change the YMCA into a Boys and Girls Club 58 $10 sports clubs 59 Marital Arts or Kapoeira (Brazilian martial art) 60 Get donations from Chauncy or others to get a Boys and Girls Club 61 Security cameras need to go in around the recreation center 62 Put lights around the park at nightbig bright lights 63 Put in new street lights 64 Get rid of unproductive businesses 65 Parents take children to the park 66 Make recreation center safe 67 Confront mentality that being an acti ve participant is not being a snitch 68 Take kids out walking with lunches, hygiene kits to give to the homelesskids contributing to the community 69 Parents volunteering 70 Take children to ski 71 Make skiing affordable 72 Make clubs, sports affordable 73 Have older kids help the younger kids 74 Have a closer amusement park 75 Improve the playground in the neighborhood, by adding more equipment for older kids, like a rock climbing wall 76 Improve the playground in the neighborhood, add an outdoor pool 77 Have a place to learn to cook or bake 78 Provide other classes teaching people sports 79 Provide other classes teaching people how to fix things 80 Offer yoga classesa 81 Need more stretching and warm up for sports 82 Have dancing (jerking?) competitions at school 83 Have a gym for dance competitions 84 Make a closer skating rink 85 Make more events, concerts 86 Make basketball tournaments 87 Give prizes to encourage physical activity 88 Give prizes like water bottles, ipods, cell phones, CDs, cash prizes, visa gift cards, gift cards to TARGET 89 Have a dodgeball tournament 90 Have a walk-a-thon 188

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91 Plant trees and give prizes by the number of trees planed 92 Have a community history trivia contest 93 Have geogames (where people use a map and compass to find different treasures) 94 Have a family bike event 95 Give out prizes to places like Jump Street a place with a lot of trampolines 96 Give out passes to Jungle Quest a place with zip lines and other fun things for kids 97 Give out passes to Elitches 98 Give out Water World passes 99 Go sledding on the hill at City Park 100 Snowball fights should be encouraged 101 Tomato fights should be encouraged 102 Cheese rolling (rolling a huge wheel of cheese) should be encouraged 103 User flyers to organize people to go out and play 104 Have Chauncey Billups (a famous Denver ba sketball player) or ot her celebrities encourage people to get out and play 105 Use a sky writers (airplanes that tow signs) to advertise outdoor activities 106 Play leaf tagwhere you use leaves to make a pac-man type route 107 Create life-size games of board games like Candy Landmaybe get in the Guiness Book of World Records for the largest board game 108 Go biking 109 Play in the sprinklers 110 Go to Congress Park pool 111 Make a huge pile of leaves to jump into wi th all the leaves collected from the leap drop 112 Encourage hiking in the mountains as a group 113 Have a bus to shuttle people to the mountains 114 Do a survivor show 115 Create a game of urban survivor 116 Plant more flowers and trees 117 Create more parks and open places to play 118 Have parks more isolated from traffic 119 Open the paddle boats in City Park more often 120 Go and observe the fish from the paddle boats 121 There could be a City Park scavenger hunt wher e you go to look for different things like pine cones and birds with your family 122 Have a kids obstacle course in the park 123 Make the zoo cheaper 124 Make the parks prettier with flowers and trees 125 Make playgrounds better with different equipment, like zip lines and more creative staff 126 Make playgrounds larger with more equipment 127 Put more swings in parks 128 Put in circular round-abouts (play equipment t hat is a tilted circle that you can run on) 129 Replace rusty equipment and repaint things 130 Put giant swings in a hexagon shape so everyone swings towards each other 131 Make physical education curriculum more fun 132 Have more playgrounds at the middl e schools, not just basketball courts 133 Lower the price on trampolines 134 Have trampolines in public places that people can use for free 135 Set up more biking paths to places you want to go, like school and the mall 136 Set up different activities and statio ns in the park for the whole family 189

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137 Have less homework on the weekends so children have more time to play 138 Every 20 minutes at school students should get up and walk or do some activity 139 Make sure students have recess 140 Need more space for kids to play at school 141 If you get into trouble at school, people should have to be active outside picking up trash instead of writing sentences 142 Go to summer camp 143 Go to art camp in the summer 144 Go swimming in the summer 145 Get a season pass to Water World 146 Free skiing offered in 5th gradeand it should be offered to more grades 147 Go for a field trip show shoeing, ice skating 148 Go to field trip to DU to do gymnastics, LaCross, ice skating and swimming 149 Take students on a camping trip 150 Take students on a canoeing trip 151 Take students on a backpacking trip 152 Take students on a snowboarding trip 153 Put drinking fountains along trails in the mountains 154 Put drinking fountains in the parks 155 Make more programs for kids to get out of the city and go for hikes 156 Have chaperones (adult voluntee rs) take kids out of the city 157 Need more safety, more security 158 Have parents go out with kids and watch over them 159 Kids could do activities like sports 160 Send kids to different schools so they are safe 161 Send kids to camps 162 Involve kids in Boy Scouts and Girl Scouts 163 Improve safety in parks 164 Improve safety in schools 165 Improve safety in recreation centers 166 Clean up the neighborhood 167 Instead of allowing bars and liquor stores, there should be recreation centers 168 Have kids get together, and have adults present with them 169 Parents should organize activities for their kids 170 When there are dangers, bad areas, you need to teach kids how to handle it or take safe route 171 Doesnt have to be planned, organized. Just have a place to play (school facilities), with light adult supervision 172 Have a parents night out, using school grounds, fa cilities for kids to play; teachers volunteer to supervise 173 Have hopscotch, hula hoops, jump ropes, four square tournaments after school 174 Have free youth activity time at the rec centers, swimming, basketball 175 Need a place for the skateboar ders/Se necesita un lugar para los patinadores (skateboarders) 176 Use school grounds, hoops, swings after hours/ utilizar las escuelas, los aros y columpios despus de escuela 177 Use the schools after hours/utilizar la escuela despus de horas regulares 178 More resources for kids to participate/Mas recursos para que los nios participen 179 Have the government pay to let kids participat e, basketball, summer camp/Que el gobierno page campamentos de verano o de baloncesto, para que los nios participen 180 Have more basketball courts/Tener ms canchas de baloncesto 181 Have more playgrounds/Tener ms patios de juego 190

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182 Have more safety 183 Have more trails 184 Have more areas for bikes and skateboards 185 Have an urban skate park 186 Have more adults outside to create safety 187 Need more crosswalks 188 Need fences to keep kids from running in streets 189 Have emergency telephones in the parks and in the neighborhood 190 Have music and more affordable extracurricular activities 191 Need less expensive instruments, uniforms, equipment 192 Parents go outside and play with the kids, make it a family thing 193 Play soccer 194 Play tag 195 Have music, block parties 196 Put up flyers for a flag football game and f ood and drink at the park, kids would come 197 Have snowball fights 198 Have snowman building competition 199 Organize outdoor free movies with physical activity before the movie starts 200 Dance 201 Jump rope 202 Hang out 203 Party 204 Go Walking 205 Put in Basketball hoops, courts in the park at 17th & Montview 206 Upgrade the playground 207 Build tennis court 208 Make track field, baseball & football field improvements 209 Have a recreation center with free activities 210 Help the homeless 211 Have incentives for sports events with incentives: laptops, iPods 212 Have free classes: music, dance lesson s, free gym, yoga, pilates, tae kwan do 213 Make police visible so gangs go away 214 Need positive male role models 215 Need more mentors 216 Need cheaper organized sports 217 Reduce costs of recreation centers 218 Curfew laws should be enforced 219 Neighborhood watch would be good; people will talk to police 220 Traffic bumps to slow traffic 221 Enforcement of stop signs 222 Police should be out in the nei ghborhood where they can be seen 223 Have more friendly kids (to get kids outside) 224 Have fewer not-nice kids around 225 More playground equipment 226 Need responsible parents in the park to watch over kids 227 People should take responsibility for themselves 228 Fence around the playground area 229 Make police more visibleit would change a lot quickly 191

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230 Youth need something positive to do, a program to clean up neighborhood, help the elderly, make them feel worthwhile, like they have a purpose, like they count 231 Have community gathering for youth, feed them, and show them that youre willing to do something for them 232 Let youth know they can make a difference, like one Saturday a month 233 Pay kids to help in the neighborhood; prizes 234 Create a program Hip Help where youth help el derly and get a prize like all school supplies and clothes for next school year 235 Walk around the neighborhood 236 Need a recreation center to hang out with friends 237 Have more security to proect against having property, like bikes, stolen 238 Take children to the park to avoid traffic 239 Reduce sport prices, especially for families with multiple kids 240 Make anonymous reporting of crimeand let people know it is legitimate 241 Everyone put on porch lights 242 Teach children to ski 243 Increase physical activity in K-8 schoolsin everyday curriculum and field trips 244 Get signs in parks that say no smoking for the health of kids 245 Have kid-friendly events in the parkask kids what they want 246 Get a group of kids together to advertise youth events (with flyers or word-of-mouth) 247 Get kids together to feed the homeless 248 Get kids togheter to have a roller-fest (include skates, skateboards, bikes) 249 Have competitions with prizes to get kids interested 250 Ask kids what they want to see or participate in with a friend 251 Have children play sports at school 252 Have a football field close to home 253 Have a volleyball court close to home 254 Have adults teach kids how to play sports 255 Parents need to put energy into getting kids active making them do it even if they don't want to 256 Elementary school needs more organized sports 257 Have neighbors that you like, neighbors who are active 258 Have more sports and fewer video games 259 Have a schedule where kids and parents exercise together, like jumping jacks, crunches, stretches 260 Dance in class or at school 261 Have a tetherball court 262 Have a dodge ball tournament in a park 263 Have schools host a dodgeball tournament with incentives to encourage people to come 264 Go to Waterworld and get exercise by going to different rides 265 Plant more trees next to raods around parks to protect kids from traffic 266 Clean up the pollution and litter in parks 267 Improve the school grounds 268 More families shouls have things like trampolines to be active 269 Have bungee jumping 270 Give kids more education about physical activity and nutrition 271 Keep the attitude that kindergartners have in the playground, no matter how old you are 272 Have kids involved with after-school activities because they are safe 273 Have faster police response times 274 Don't over-schedule kids 192

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275 Help people distinguish between real and perceived safety risks 276 Give kids freedom to be outside and let them know not to talk to stranger 277 Have better, more interactive teachers 278 Have better parents being role models 279 Teachers should give less work so students have more time to do activities 280 Need to add music back into schools 281 Add in more extra-curricular activities 282 Have activities like music to draw people out 283 Have parents volunteer to staff the school playground after school 284 Have more kids walk or bike to school 285 Protect children from traffic 286 Create a way to get kids safely through tr affic when they bike or walk to school 287 Need people to be present in the neighborhoods 288 Participate in neighborhood watch programs and teach kids about stanger dangers 289 People need to be more active and involved 290 There has to be a critical mass of kids out for them to get together 291 Have older youth watch younger kids in the parks, maybe for their school service requirement 292 Look at pre-programmed activities, clubs like tennis after school that can be free 293 Have block captains encourage interactionsmay be athey could organize a group activity every 3 weeks, or block parties so people get to know each other 294 Need to train or educate adults to facilitate youth physical activities 295 Have youth supervise youth in schools as parent helpers 296 Go to the recreation centers, t hey provide plenty of activities 297 If girls are not in sports they need to have parents schedule things for them to do 298 Open/unlock tennis courts for things like roller-skating 299 Better utilize existing school facilitieskeep them open during after-school hours and the summer 300 Need parents who have time to take them out, non-working parents 301 Go to after-school enrichment programs and get scholarships to go 302 Have Wii's for kids in the homes 303 Have kids play in the backyard with a trampoline or basketball 304 Jump rope at home 305 Be outside building forts 306 Sled on snowy days at the park 307 Need kids to have free time together and live close to together 308 Teach kids about lifestle fitness (walking to sch ool, the grocery, walking the dog)instead of sports fitness 309 Send kids to the store to get milk 310 Parents ride bikes with kids, have a family ride, go get ice-cream 311 Give money to schools to supervise kids after sc hool enrichment activities and physical activity, especially for girls 312 School playgrounds should be unlocked so t hey can be used after school hours 313 Have snacks to encourage people to come together and be active 314 Once a monthhave groups that go hiking, ca mping, whitewater rafting, horseback riding 315 Have a bus to take kids skiing, camping, rock climbing, fishing, hiking 316 Give youth a purpose and let them know they countmake them feel worthwhile 317 Figure out how to have youth have goo d feeligns doing things for others 318 Have youth do things for othersone Saturday a month 319 Thank youth for their contributi on by giving them a meal and making them know they make a difference 193

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320 Create monthly birthday celebrations for kids that involves physical activity 321 Keep your eye out to witness and keep the neighborhood safe for children 322 Provide a mulit-sport facility where children can par ticipate in tournaments, sports campslike the Gold Crown that has facilities for golf, basketball, computers, volleyball, soccer, football 323 Have teens help elderly in the neighborhood for a stipend 324 Throw community events 325 Have open houses at existing facilities, like the Gold Center 326 Add more security cameras 327 Make clean places to play 328 Make available free or rentable sports or activity equipment 329 Support having mobile playgrounds, a semi-truck of toys that can be taken to different places 330 Have more public restrooms in parks 194

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Appendix 8: Pattern Match: Similar Ratings among Context 2 and Context 3 Adults 195

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The pattern match, displayed in the ladder diagram below shows intervention ratings among adults in context 2 on the left and rati ngs among adults in context 3 are shown on the right. These results show the participants in these two clusters rated intervention cluster needs identically and these groups were combined. Pattern match with all adults contex t 2 on left and context 3 on right r = 1 4.05 3.72 4.05 3.72 Youth Activities Youth Activities Infrastructure and Acces s Infrastructure and Access Safety Safety Thus the combined ratings from adults in clusters 2 and 3 are shown in the cluster rating maps. 196

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Appendix 9: Community Feedback Presentation 197

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198

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The Society of The YouthA Project of Taking Neighb orhood Health to HeartSolutions for Getting Youth Active in Our NeighborhoodsPresenter: Stephanie L. Phibbs, MPH University of Colorado, Denver Community-Based Participatory Research (CBPR) Effort•CBPR is a way for community members and researchers to learn together and contribute equally to a project •When communities shape research they can own and act on the results Academic PartnersStephanie L. Phibbs, MPH Rebecca Slaughter, Student Intern Deborah S. Main, PhDDepartment of Health and Behavioral Sciences University of Colorado, Denver Neighborhood PartnersYouth •Lissette Acevedo •Daniel Armijo •Lavaris Billingsley •Chris Brooks •Jalil Jefferson •Alandra Ibarra •Jesus Ibarra Adults •Teresa Acevedo •Lashonn Billingsley •Olga Martinez •Carmen Miranda •Cat Santos •Francisco Subiadur Two Aims•Aim 1: Identify different neighborhood safety environments using data collected by Taking Neighborhood Health to Heart •Aim 2: Work with neighbors to find solutions for increasing physical activity among 10-14 year old youth Aim 1: How We Did ItAnalyzed data to identify safety environments using the Taking Neighborhood Health to Heart data:Household survey measures: discrimination, social cohesion, perception of traffic safety, perception of personal safety, Audit data: neighborhood incivilities, e.g., graffiti

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Aim 1: What We Learned•We identified three different safety environments within the five neighborhoods •Advisory Committee members did not want to present these data as a map because it could stigmatize neighborhoods •Data were used to be sure equal numbers of people from each safety environment were involved in Aim 2 Aim 2-How We Worked with Neighbors to Identify Solutions•Formed a Community Advisory Committee in early 2009 •Used “Concept Mapping” to identify solutions,“Concept mapping is a method that can help communities develop locally relevant interventions...” Concept Mapping Process•Trained and hired community facilitators •Selected a question:“What changes would you like to see to increase physical activity among 10-14 year old youth in your neighborhood?”•Neighbors brainstormed 300 solutions •We reduced the 300 solutions to 100 solutions•Neighbors sorted the 100 solutions Concept Mapping Process •Recruited equal numbers of neighbors from each of the three safety environments (30 adults and 10 youth aged 10-14) •Participants rated solu tions (How needed? How possible?) •Analyzed data with Community Advisory Committee •Now sharing results with the, you, the community Youth Engagement•Meeting monthly •Youth named the group •Created a vision and art work •Received an introduction to advocacy •Run some meetings •Excited to present the results you will see today Community Partner Thoughts“I’m very proud of what is going on.” “..the whole purpose is to find something that they (youth) want so that they can become more physically active and if they put their ideals into it and they create it, then they’ll participate in it.”

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More Community Thoughts“I think the program is great because it allows community members, people who may never show up at other places or other meetings to voice their opinions about what they want for their kids or the youth in the community.” Aim 2: What we Learned•Youth in different safety environments had similar ideas about what was needed •The Advisory Committee decided to focus on what the youth said was needed •The Advisory Committee decided to take into account what adults thought was possible Fun Make playgrounds better with different equipment, like zip lines and more creative stuff Have kids do activities like sports Give prizes to encourage physical activity Safe Have “responsible”parents and adults in the park and neighborhoods to watch over kids Free •Have a recreation center with free activities •Make available free or reduced price rentable sports or activity equipment •Unlock school playgrounds so they can be used after school hours and during breaksTOP SOLUTIONS: Health Strikes Back! Safe, Free and Fun(A youth-adult partnership skit) MAKE IT SAFE Not feeling safe keeps me from playing outdoorsOne quarter of 10-14 year-old youth agree:Data from the Kids’Study

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I worry that my child will be hurt by gangs if he/she plays outside I worry that my child will be hurt by other children if he/she plays outsideOne-third of parents say: One-half of parents say:Data from the Kids’Study MAKE IT FREE Of the 10-14 Year-olds in our Neighborhoods, less than half:used the recreation center last week participated in after-school sports or dance programs run by the school Data from the Kids’Study MAKE IT FUN Fun Make playgrounds better with different equipment, like zip lines and more creative stuff Have kids do activities like sports Give prizes to encourage physical activity Safe Have “responsible”parents and adults in the park and neighborhoods to watch over kids Free •Have a recreation center with free activities •Make available free or reduced price rentable sports or activity equipment •Unlock school playgrounds so they can be used after school hours and during breaksTOP SOLUTIONS: Play ParticipantsActors/Actresses Lissette Acevedo Daniel Armijo Lamar Billingsley Lavaris Billingsley Chris Brooks Jalil Jefferson Alandra Ibarra Jesus Ibarra Erika Solis Narrarators: Daniel Armijo Rebecca Slaughter Director Sam Wood

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Acknowledgements•2040 Partners for Health for the invitation to present to you here today! •Principle Investigators Ira Gorman and Debbi Main; Taking Neig hborhood Health to Heart; 2040 Partners for Health; The Colorado Health Foundation •Heather Kennedy for youth engagement consultation •Sam Wood and Erika Solis from Kaiser Permanente’s Teens Take it On Programthank you for directing the play!!! They are a youth-adult partnership that has brought healthy school lunches to 184,000 students! Acknowledgements•Community residents who participated in this study and Advisory Committee •Translators/Interpreters: Silvia Gutierrez Raghunath, Andrea Clinger, Rosario Montoya •Study recruiters: Michael Garcia, Kate Walker, Rosario Montoya •This study was funded by an Active Living Research Program grant from The Robert Wood Johnson Foundation Audience ParticipationWhich would be the best thing to do to get youth 10-14 years old more physically active in our neighborhoods? 1. Make the neighborhoods safe 2. Make things free 3. Make things more fun Audience ParticipationWhich would you say you are? 1.A youth 10-24 years old 2.An adult who mostly speaks English 3.An adult who mostly speaks Spanish Join Us for Breakout Groups!Later today we will get in break-out groups We invite you to join in the groups to talk about making things safe, free and fun in our neighborhoods Small Group Discussion Questions•Did anything surprise you about the safe, free and fun results? (have slide with all solutions) •What do you think it would take to make this happen? •Who should be involved? •What are the next steps? •Would you like to be involved? •Next meeting SOY date, time

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Narrators Script: Fun, Free and Safe (a.k.a. Health Strikes BACK(!) By: Rebecca Slaughter/Daniel Armijo 204

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Scene 1: Outside of the re c. center on a weekend morning. After they get the ball from the rec. they proceed outdoors. As one attempts to make a shot a bully co mes out of left, and snatches the rebound. (Bully) (Kids) Whad up B?! This yo basketball? Yeah man, its my ball. Not anymore its not! The bully proceeds to get a friend and play monkey in the middle with the ball. While doing so, he is teasing the original kid that had the ball. Hey! Give me my ball back! NOW Get your own! This courts no t big enough for all of us! End Scene Scene 2: Another day at the same rec. center the children try to play again, but this time they ar e accompanied by their parents. With all of the confidence in the world they rent another basketball, and proceed outside. Lets play! Na man, remember what happened last time? Yeah, just forget abou t it, lets go play. In the center of the basketball court, they see th e same bullies. Fortunately, before the bullies ha ve a chance to wr eak havoc they see the parents and kick dirt. End Scene 205

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Scene 3: A group of kids walk to the rec. center in hopes to play some ball. As they walk past the sign of admission they try to get in, but the guy points at the sign. They pull out their pockets and find that their broke! (Worker) (Kid) Hey man, didnt you see the sign? What sign? The one that says you cant get in for free. As he points at the sign that says 3$, the kids have a very saddened look in their eyes. So they walk back home. End Scene Scene 4: Same scene, different sign. This sign says free day! (There will be more kids in this scene because its free!) Hey man, didnt you see the sign? What sign? The one that says FREE DAY! A lot of yeahs and screaming! End Scene Scene 5: The kids are at the park, standingbored. So they walk back home with nothing to do. (Kids) Man, Im just so bored! Me too! This sucks 206

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End scene Scene 6: Were at the park and now it has lots of cool things to play on Hey, look at all the fun stuff to do! Yeah lets play!. The kids go crazy with all of the stuff to play on. End Scene Scene 7: Kids walk to the school playground that is locked. They walk up and hold the lock and look sad saying Man this sucksI wish we could get in there to play Yeah this is a bummer Scene 8: Kids walk to school playground that is unlocked and they run in and start playing, then say It is great we can get in here to play Yeah good thing we worked with the schools to get this unlocked 207

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Appendix 10: Physical Education Policy Brief 208

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Physical Education in Colorado Schools Background The Colorado State Legislature is currently cons idering legislation related to physical activity requirements in schools. What the Research Shows Why does this matter? In Colorado, 57.1 percent of school-age children participated in vigorous physical activity for four or more days per week, ranking 37th of all states in United Statesi A 2008 report from The Colorado Health Foundation cited obesity-related medical expenditures cost Colorado $874 million annually.7 Though Colorado is the leanest state in the nation, childhood obesity in Colorado increased 23 percent between 2003 and 2007 the second-fastest rate of increase in the nation behind Nevada.8 In 2005-2007 an estimated 14 percent of Colorado children ages 2-14 were considered obese. The Healthy People 2010 objectives call for no more than 5 percent of children and adolescents to be overweight.8 Highest rates of obesity among 2-14 year olds are seen in Hispanic (24%), followed by black (18%), Asian (12%) and white children A study of local school wellness policies from districts in lower-income, rural Colorado communities found that ratings of policy strength ranged on average from 3 to 31 on a scale of 1 (weakest) to 100 (strongest). Physical education guidelines had the weakest rating of 3 on average.ii iii Research suggests physical education does not diminish school academic performance.iv v Neighborhood safety may limit opportunities for outdoor play among the youth at highest risk for obesity. vi ixrates) Policy Implications 8 ( 11 %) requiring physical activity in schools will improve the health outcomes in children without diminishing academic performance; physical education curricula should adhere to evidence-based curricula encouraging maximal physical activity; offer regular professional development opportunities to physical education teachers which are specific to the field and require teachers to keep aware of emerging technologies, model programs, and improved teaching methods; x require that students are active in moderate-vigorous physical activity for at least 50% of class time; x What do Coloradoans Think? 95% of Colorado parents of school children support or strongly support having recommended levels of PE in schoolsxi In a recent survey where re presentative adult and youth residents in 5 neighborhoods from Denver and Aurora were asked to rate 100 solutions for increasing youth physical activity, residents said voting to be sure physical education is not cut from schools received the highest rating.vi 209

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Conclusion Colorado has enjoyed its status as one of the leanest state in the nation for some time, but with the fastest rise in obesity rates among children in the nation, our trajectory is clear and expensive. Physical education is a recommended strategy for improving youth physical activity, will not likely diminish test scores and may be especially necessary for children living in neighborhoods that are unsafe for afterschool outdoor activity. i The Colorado Health Foundation, The Colorado Health Report Card 2008. Accessed 2/25/11: http://www.coloradohealthreportcard.org/ ReportCard/2008/subdefault.aspx?id=3302 ii Belansky E, Cutforth N, Delong E, et al. Early Impact of the Federally Mandated Local Wellness Policy on Physical 1 Activity in Rural, Low Income Elementary Schools in Colorado. Journal of Public Health Policy 30(1): S141S160, January 2009 iii Local School Wellness Policies: How Are Schools Implementing the Congre ssional Mandate? Robert Wood Johnson Foundation Policy Brief 2009. http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RWJFBriefLocalSchoolWellnessPolicies2009.pd f iv Sallis, JF, McKenzie, TL, Kolody, B., Lewis, M., Marshall, S., Rosengard P. Effects of Health-Related Physical Education on Academic Achievement: SPA RK. Research Quarterly for Exercise and Sport. 1999. Vol. 70, No.2, pp. 127-134. v Coe DP, Pivarnik JM, Womack CJ, Reeves MJ, Malina RM. Effect of physical education and activity levels on academic achievement in children. Medicine and Science in Sports and Exercise Vol. 38, No. 8, 1515-1519, 2006. vi Phibbs, S, Main D. Solutions for increasing physical activity in diverse safety contexts, doctoral dissertation, unpublished. 2011 vii The Colorado Health Foundation, Inco me Education and Obesity A Closer Look at Inequities in Colorados Obesity Problem. 2008 Supplement to the Colorado Health Report Card, 2008. Accessed 2/25/11: http://www.coloradohealthreportcard.org/ ReportCard/2008/subdefault.aspx?id=3302 viii Colorado Childrens Campaign. 2010 KIDS COUNT in Colorado, http://www.coloradokids.org/facts /kids_count/publications.html accessed February 25, 2011. x American Heart Association. Physical Education in Schools Both Quality and Quantity are Important. http://www.americanheart.org/downloadable/h eart/1204662840069Policy%20Positi on%20Statement%20on%20Phy sical%20Education%20in%20Schools.pdf Accessed 2/25/11. 210

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211 xi Colorado Child Health Survey 2006, cited in https://www.livewellc olorado.org/assets/pdf/resources/factsheets/cdphe-child-obesity-factsheet-revised09.pdf