PACES: a Physical Activity Campus Environmental Supports Audit on university campuses.

For individual use only. Duplication or distribution prohibited by law.

Health Promoting Community Design; Measurement Issues

PACES: A Physical Activity Campus Environmental Supports Audit on University Campuses Tanya M. Horacek, PhD; Adrienne A. White, PhD; Carol Byrd-Bredbenner, PhD; Melissa M. Reznar, MPH, PhD; Melissa D. Olfert, DrPH; Jesse S. Morrell, MS; Mallory M. Koenings, PhD; Onikia N. Brown, PhD; Karla P. Shelnutt, PhD; Kendra K. Kattelmann, PhD; Geoffrey W. Greene, PhD; Sarah E. Colby, PhD; Carrie A. Thompson-Snyder, MPH

Abstract Purpose. This study evaluated the policy and built and recreation environmental supports for physical activity on 13 university campuses. Design. Environmental audit survey. Setting. Thirteen U.S. universities, 2009. Subjects. University policies, recreation programs and facilities, and at least five additional buildings per campus. Measures. The Physical Activity Campus Environmental Supports Audit was developed for this study. Analysis. Analysis of variance with post hoc Tukey’s B and v2 assessed differences by institution and building type. Results. The mean obesogenic policy score was significantly lower than the desired score, 7 (p ¼ .002), with only one campus scoring 10. The mean built environment audit score (5.4 6 1.7) was low, with significant differences between institutions (p , .001) and only three campuses scoring above the desired score, 7. Although generally stairwells were clean and well lighted, there was a lack of signage to encourage stair use (p , .001). Overall, recreation programs (7.1 6 .7) and facilities (7.1 6 1.2) scored well, but amenities scores were lower for satellite (2.8 6 1.6) versus main (4.1 6 1.8) recreation facilities (p ¼ .04). Conclusion. On these 13 university campuses, recreation programs and facilities were supportive of healthful lifestyles for obesity prevention, but policies and the built environment were not. This physical activity environmental audit survey requires testing in a wider sample of postsecondary institutions to corroborate its utility and provide evidence to support initiatives to improve campus environments for physical activity. (Am J Health Promot 2014;28[4]:e104–e117.) Key Words: College Campus, Built Physical Activity Environment, Recreation Services Programs and Facilities Obesogenic Policies, Audit, Prevention Research. Manuscript format: research; Research purpose: description/evaluation; Study design: survey; Outcome measure: physical activity environmental support scores; Setting: university/postsecondary campuses; Health focus: physical activity built environment quality/accessibility; Strategy: built environment; Target population: buildings, recreation services, policies; Target population circumstances: size/population of postsecondary campuses

PURPOSE Obesity and its comorbidities are prevalent in the United States1 and are major contributors to health care costs and decreased quality of life.2,3 The transitional nature of early adulthood puts individuals aged 18 to 24 years at particularly high risk for unhealthy weight gain,4–11 which has been associated with metabolic syndrome in this population.12–14 Whereas the average American adult gains 4 pounds over a 2-year period,15 college students gain 4 to 9 pounds in their first 2 years of school.5–7 Approximately half of all college students have poor eating habits5,16 and do not consider healthful eating a priority.5 They get insufficient exercise,17–20 which also decreases as they age.21,22 Behavioral patterns formed during this life stage

Tanya M. Horacek, PhD, is with the Department of Public Health, Food Studies and Nutrition, Syracuse University, Syracuse, New York. Adrienne A. White, PhD, is with the Department of Food Science and Human Nutrition, University of Maine, Orono, Maine. Carol Byrd-Bredbenner, PhD, is with the Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey. At the time of this research, Melissa M. Reznar, MPH, PhD, was with the Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan; she is currently with the School of Health Sciences, Oakland University, Rochester, Michigan. Melissa D. Olfert, DrPH, is with the Division of Animal and Nutritional Sciences, West Virginia University Davis College of Agriculture, Natural Resources, and Design, Morgantown, West Virginia. Jesse S. Morrell, MS, is with the Department of Molecular, Cellular, & Biomedical Sciences, University of New Hampshire, Durham, New Hampshire. At the time of this research, Mallory M. Koenings, PhD, was with the Department of Nutritional Sciences, University of Wisconsin– Madison, Madison, Wisconsin; she is currently with the Division of Animal and Nutritional Sciences, West Virginia University Davis College of Agriculture, Natural Resources, and Design, Morgantown, West Virginia. At the time of this research, Onikia N. Brown, PhD, was with the Department of Nutrition Purdue University, Lafayette, Indiana; she is currently with the Department of Nutrition, Dietetics, and Hospitality Management, Auburn University, Auburn, Alabama. Karla P. Shelnutt, PhD, is with the Department of Family, Youth & Community Sciences, University of Florida, Gainesville, Florida. Kendra K. Kattelmann, PhD, is with the Nutrition, Food Science and Hospitality Department, South Dakota State University, Brookings, South Dakota. Geoffrey W. Greene, PhD, is with the Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island. At the time of this research, Sarah E. Colby, PhD was with the Department of Nutrition Science, East Carolina University, Greenville, North Carolina; she is currently with the Department of Nutrition, University of Tennessee, Knoxville, Tennessee. Carrie A. Thompson-Snyder, MPH, is with the Department of Research and Extension-Human Nutrition, Kansas State University, Manhattan, Kansas. Send reprint requests to Tanya M. Horacek, PhD, Department of Public Health, Food Studies and Nutrition, Syracuse University, 426 Ostrom Avenue, Syracuse, NY 13244-3240; [email protected]. This manuscript was submitted December 12, 2012; revisions were requested May 9, and July 2, 2013; the manuscript was accepted for publication July 5, 2014. Copyright Ó 2014 by American Journal of Health Promotion, Inc. 0890-1171/14/$5.00 þ 0 DOI: 10.4278/ajhp.121212-QUAN-604

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American Journal of Health Promotion

March/April 2014, Vol. 28, No. 4

For individual use only. Duplication or distribution prohibited by law. affect health throughout adulthood.10,23,24 Being overweight this early in life increases the likelihood of being overweight or obese and/or developing chronic diseases later in life.4,25 Therefore, prevention of excess weight gain during young adulthood is important to improve quality of life and potentially lower health care costs for these future adults. Helping adults adopt healthy lifestyle behaviors is a daunting challenge. Researchers have extensively examined strategies for facilitating and encouraging behavior changes to prevent and treat obesity.26 Reviews and meta-analyses of clinical interventions using behavioral and motivational techniques alone provide evidence of the difficulty in creating significant and long-term changes to prevent excess weight gain,27,28 especially in young adults.29,30 These findings, along with evidence that environments favoring excess caloric intakes and inadequate physical activity are a causal factor of obesity,31–36 highlight the need to take a more ecological view that considers how the environment promotes or inhibits healthy diet and exercise behaviors. Environments like university campuses are vital to encouraging healthful lifestyles that promote healthy weights.36–41 University campus environments, which may promote or inhibit healthful choices regarding food and physical activity,40–46 are particularly important because many individuals live and work there. There are 4495 postsecondary degree–granting U.S. institutions,47 which enroll more than 19 million young adults, employ over 3.7 million staff/faculty,48 and serve between one-third and onehalf of the U.S. population at some point during their lives. To make informed decisions regarding changes to be made on campus environments to support healthful choices, as recommended by the Institute of Medicine,49 thorough objective evaluations of the obesogenic environments are necessary.49–52 However, the obesogenic environmental influences on campus environments that could be modified to encourage healthier diets and physical activity levels remain understudied,51,53,54 perhaps because of the environmental complexity. Dual


student and employee populations use the campus residential and work environments, where environmental factors (infrastructure and policies) influence health behavior. Eating behavior is affected by campus dining, restaurant, store, and vending machine options, and physical activity behavior is shaped by the campus walkability and bikeability, recreation programs and facilities, and the built environment. University policies that inform and encourage students and employees to use available campus infrastructure are also important factors in maximizing the beneficial influence of the campus environment on health behavior. In response to the need to evaluate obesogenic environments at universities, university partners of the United States Department of Agriculture Multistate Research Project NC1028, Promoting Healthful Eating to Prevent Excessive Weight Gain in Young Adults (multistate project), engaged in a multifaceted study to assess campus food environments (i.e., dining , food stores and vending) and walkability/bikeability that has been described elsewhere.54–57 Given that this multistate research group has already reported significant differences in one dimension of the supports for physical activity on campuses, walkability and bikeability,54 the purpose of the current study is to describe and evaluate the policy, recreation, and built environmental supports for physical activity on 13 U.S. university campuses.

METHODS Design In fall 2009, the community-based participatory research (CBPR) model PRECEDE-PROCEED31 was used to assess the environmental supports for physical activity in the campus environment using a newly developed and tested comprehensive audit tool. Based on this model, campus-specific steering committees of students, faculty, and staff worked together to select the most representative buildings and recreation facilities to include in the study sample and to interpret results.

Sample Each campus team identified the academic, residential, support (i.e., union, library), and recreational buildings most frequently used by students using the CBPR approach. They evaluated at least six buildings, including one library, one student union, 20% of the residence halls and academic buildings (or a minimum of two each), the main recreation facility, and a satellite recreation facility (if one existed). Each campus researcher identified and trained between two and five students to collect data through direct observation. Institutional review board approval was not necessary, because no human subjects were involved. Data were collected in October and November 2009. Measures Instrument. A thorough review of the literature revealed that no tools existed to evaluate an environment as diverse as a university campus. Thus the Physical Activity Campus Environmental Supports (PACES) audit was developed using the literature, primarily the Checklist of Health Promotion Environments at Worksites58 and the Environmental Assessment Tool.59 The phase 1 prototype of the PACES Audit was modeled upon these existing worksite audit tools assessing the physical and information supports for physical activity. The PACES Audit was a combination checklist indicating presence (yes/no) of health promoting items (stairwell characteristics, programs, etc.) and a tally or count of signs, exercise equipment and classes, showers, bike stalls, etc. Collaborating with campus recreation and student life professionals, extensive additions were created to assess campus policies and the recreation facilities and programs to reflect the more comprehensive nature of these aspects on college/ university campuses. Recreation services professionals were pivotal in these later revisions, because no detailed/ objective evaluation audit of recreation type facilities was available at that time. Questions to assess objective demographic data regarding the campus and community population, weather, crime, parks, etc. were also included. Clear definitions were developed to evaluate the physical condition (PC)


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Table 1 Physical Activity Healthy Campus Audit Components and Point Ranges

Audit Survey Components Built environment Bike racks Health promotion signage Stairwells Built environment total scores (mean/campus) Ecological facilitators Campus safety features Weather effect on activities Public transportation Community socioeconomic and crime Ecological facilitators total score: subcategories/2 Policy Policy topics

Possible Minimum and Maximum

Description Categorized access (rack/building entrance) and sufficiency of parking spots 25% of total No. of signs in a high traffic area encourage healthy habits Average of two stairwells: tally cleanliness, lighting, floors numbered, doors labeled (beyond ‘‘emergency exit only’’), stairwell direction prompts

0, 4 0, 1 0, 5 0, 10

Tally of existence of police, safety education, programs, and systems Categorized campus accommodations for physical activity given typical weather (indoor track/swimming) Categorized extensiveness of transportation—effect on pedestrian traffic Compared local violent/property crime statistics* and income† to national averages

0, 5 0, 3 0, 6 0, 6 0, 10

Tally of documented policies: physical education requirements, degree of car access restriction, advisory boards, etc. Rated ease of access (internal use only to extensive campus distribution–Web)

Accessibility of policies Policy total score Campus recreation program (overview of full program on campus) Equipment/intramural programs available Total No. and variety: equipment, intramurals, club sports, fitness classes Exercise spaces available Free weight, aerobic, cardio, track swimming pool, skating rink, other Courts/fields available Racquetball, basketball, volleyball, tennis, multipurpose (indoor/outdoor) Health education programs Topics/features: weight management, wellness education, high risk programs Prompts: campus and community walking paths exist, labeled; program marketing Program characteristics: outcome/satisfaction evaluations, incentives offered, personalized counseling Campus recreation program total score: subcategories/5 Recreation facility (quality and accessibility of main and satellite facilities) Hours of operation/trained staff Weekday and weekend hours; No. of trained staff in cardio/weight area Equipment: physical‡ 3 working§ condition Average of sample evaluated: treadmill, bike, stepper, etc. Exercise space: physical condition 3 usage/ Average of sample evaluated: weight, aerobic, cardio, etc. availability|| Courts: physical condition 3 usage/ Average of sample evaluated: basketball, volleyball, etc. availability Amenities physical 3 working condition Average of sample evaluated: showers, TV, music Minimal components available factor No. of equipment, spaces, courts, amenities available/facility Recreation facilities total score subcategories/3

0, 8 0, 2 0, 10 0, 0, 0, 0,

22 7 7 14

0, 10

0, 2 0, 6 0, 6 0, 6 0, 6 0, 4 0, 10

* Violent and property crime statistics secured for each institution from the Bureau of Justice Crime Statistics Database61 for 2007 (or 2006). The 2006 national average U.S. violent crime rate was 473.6/100,000, and the property crime rate was 3334.5/100,000. † Median income for zip code census tract for each institution evaluated according to 2009 census data and compared to 2009 national averages from the Factfinder Census Web site.62 ‡ Physical condition: rated poor, moderate, or good/excellent (to evaluate equipment, exercise spaces, courts, and amenities). § Working condition: rated not working, poor or good/excellent (to evaluate equipment and amenities). || Usage/availability: rated limited, restricted, or sufficient (assessed at the busiest times of the day to assess exercise spaces and courts/fields).

and working condition (WC) of equipment, courts, and amenities. This phase 1 prototype was pilot tested on five campuses and revised for

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clarity. In 2008, the phase 1 prototype tool was implemented on the 13 campuses. This prototype required each campus team to evaluate every

exercise machine/class, intramural/ club sport, and court/field; and for each building evaluated, it required a detailed evaluation of every stairwell



Table 2 Data Collected, Survey Logistics, and Overall Interrater Reliability (IRR)*

Venues Assessed

Mean No. Venues Assessed/Campus

Range Assessed/ Campus

Total Data Sample

No. of Audit Items

Mean Time Assessed/ Venue, min

8.6 2

6–18 1–2

113 21

16 67 12

20 60 60

Buildings/stairwells Recreation facilities and programs Policies

Mean IRR

IRR Range

.95† .98

.80, 1 .83, 1

* IRR is the proportion of items concordantly scored. † IRR for buildings/stairwells completed on a subsample (n ¼ 29) of buildings on each campus at the end of training as a pretest prior to implementing the audit.

and bike rack. This phase 1 prototype audit was overly complicated and made it too difficult to summarize the obesogenic nature of a campus. Nonparametric statistics (percentages, means, ranges) were applied to summarize each question, comparing appropriate questions in reference to campus/ community population statistics (data not shown). As a result, the phase 1 prototype was revised to create the current PACES audit, which assesses a sample of the environment (exercise machines, courts, etc.) and uses scoring based upon categorical classifications (rather than tally/count) devised from the range of responses from the data as well as the literature. A panel of five experts reviewed the revised audit questions to determine the appropriateness of the categorical classifications. The resulting PACES Audit was a mix of yes/no and categorical questions regarding the buildings/bike racks, stairwells, recreation services and facilities, health-related policies, and demographic questions. The 13 campus co–principal investigators and their steering committees and field experts (e.g., recreation and student services personnel) reviewed the PACES Audit and refined it for use as the study instrument. All components of the 2009 PACES Audit were thoroughly field tested before data collection commenced. A description of the final components comprising the PACES Audit and possible point ranges for each component are summarized in Table 1. The number of assessment items in each PACES Audit component and time to complete can be found in Table 2.


The Built Environment component of the PACES Audit was used to assess three aspects of buildings: bike racks, healthy signage, and stairwells. Bike rack availability and accessibility were evaluated by assessing the number of racks by each entrance and the adequacy of parking spots for bikes in the area. Adequacy was determined by the number of bikes parked beyond the racks. Examples of health promotion signs were clearly defined in the procedure manual. The extent of health signage was evaluated by determining the number of signs in a hightraffic area and the percentage of healthy to total signage (minimum of 25% desired, based upon 2008 pilot data). Two stairwells per sampled building were assessed by rating the presence of directional signage prompts, lighting, cleanliness, and floor/door labels. The stairwell score was the average of the two sampled stairwells’ ratings. The built environment audit score, a maximum of 10 points, was the mean of the built environmental evaluations of all buildings sampled for a campus. The ecological facilitators component of the PACES Audit was used to assess campus safety, public transportation, and climate. Although not a direct environmental indication of support for physical activity, each of these variables were determined to be moderating factors between the actual environmental supports and a community’s activity level.45,60 Campus safety consisted of an evaluation of the availability of campus police and the extent of safety education programs and resources. A categorical score was assigned for the total number of

campus safety features present. Because the nearby (noncampus) community may affect the perception of a supportive environment for physical activity, a community socioeconomic and crime aspect was included to rate the level of community violent and property crime61 and community mean income62 using Web sites that published national comparisons. Climate was categorized by its effect on outdoor activities. Public transportation was evaluated based on its extensiveness and encouragement of pedestrian traffic. Each question was summed for a possible ecological facilitators audit total of 10. The policy component was used to evaluate published health-related policies on eight topics and determine the accessibility of those policies to students and staff. A policy is a documented statement, rule, or regulation issued by the institution that clarifies the institution’s position on a topic and guides decision making; ideally it should require specific actions and be enforceable (Dr. Melissa Laska, personal communication, January 2013). Example policy topics included requirement of healthy food options at campus meetings/events, car use on campus, and core curriculum requirements of health or physical education courses. Polices for each campus were retrieved from official university documents and Web sites. Policy ‘‘ease of access’’ was assessed by determining how readily available it was to the campus community via the Internet. The policy audit score was the sum of the policy topics covered, plus the access score, for a possible total of 10.


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Table 3 Participating Campus (N ¼ 13) Institutional and Community Demographics Mean (SD) Institution Student population (enrollment), No. Students live on campus policy, % Undergraduates, % White, % Black, % Hispanic/Latino, % Native American, % Asian, % Community City population, No. residents Median income, $/y* Violent crime rate, incidents per 100,000 residents†

28,195 35.2 77.0 77.3 5.7 4.4 0.7 4.4

Range

(13,712) (19.4) (5.3) (10.9) (4.0) (3.3) (0.7) (6.2)

11,687/52,112 16.0/84.0 67.4/87 52.6/90.6 1.0/14.8 1.0/12.0 0.03/2.0 0.1/23.6

71,551 (68,831) 37,798.5 (10,071) 314.4 (240.5)

9,670–218,915 24,251–55,096 74–953

* Median income for zip code census tract for each institution evaluated according to 2009 census data and compared to 2009 national averages from the Factfinder Census Web site.62 † Violent and property crime statistics secured for each institution from the Bureau of Justice Crime Statistics Database61 for 2007 (or 2006). The 2006 national average U.S. violent crime rate was 473.6/100,000, and the property crime rate was 3334.5/100,000.

The recreation program component was used to review the comprehensiveness of the entire recreation services program. Using a combination of Webbased and site visits, the total equipment, programs, and exercise spaces were tallied. Treadmills, cardio equipment, club sports, intramurals, fitness classes, and the variety of fitness classes were counted and given a categorical score based upon the pilot study. The

availability of various exercise spaces, courts/fields, and health programs was also documented. The recreation program audit points were additive with a maximum 50 points total, and the total score was proportionally scaled to the range of zero to 10. The recreation facilities component included a quality assessment of the main recreation facility, and, if available, a second satellite facility. Based

on site visit reviews, facilities management (hours of operation, trained/ certified staff) and the condition of a sample of the exercise equipment, spaces and courts, and amenities (lockers, showers, TV/music) were assessed. Categorical scores were assigned based upon pilot data. The quality scoring criteria used was developed for this study. A PC score rated from poor to good/new was applied to all samples. A WC score rated from not working to good condition was applied to equipment and amenities, and a usage/availability (UA) score rated limited, restricted, or sufficient was applied to exercise spaces and courts/ fields. The quality score for each sample was the PC 3 (WC or UA) score. Each subcategory (equipment, exercise space, etc.) was the mean of the included sample scores. The recreation facilities audit score was the total of all subcategories with a maximum of 30 points, scaled proportionally to the range of zero to 10. Evaluator Training. College student evaluators were identified and trained by the PI for each institution. The lead PI designed and distributed a procedures manual and training module with examples. All evaluators also participated in a 2-hour national Web conference PowerPoint presentation/ discussion. The evaluators on each campus practiced using the entire tool at different times with two to three buildings and recreation facilities not

Table 4 Environmental Supports for Physical Activity Healthy Campus Audit Scores by Institution Audit Number Buildings assessed Mean (SD) Built Environment per campus* Score per campus Ecological facilitators Policy Recreation programs Main recreation facilities Secondary recreation facilities

NE1

NE2

NE3

NE4

NE5

MW1

MW2

MW3

NW4

NW5

(n ¼ 6)

(n ¼ 9)

(n ¼ 6)

(n ¼ 7)

(n ¼ 11)

(n ¼ 7)

(n ¼ 6)

(n ¼ 10)

(n ¼ 6)

(n ¼ 6)

3.4(1.5)a 4.7(1.2)ab 5.7(1.3)abcd 5.5(2.2)abcd 5.6(1.9)abcd 5.9(2.0)bcd 7.1(1.8)cde 5.5(1.0)abcd 8.1(0.9)e 7.4 (.5)de 6.8 5.0 7.2 7.9

6.0 6.0 6.8 6.2 6.3

8.5 5.0 7.4 7.8

5.3 4.0 6.6 7.5

9.75 10.0 8.9 7.4

7.8

8.5 1.0 5.4 6.1

5.5 6.0 6.6 6.7

6.0 3.0 7.6 9.1

9.0 3.0 7.6 7.3

8.7

4.8

7.9

6.0 2.0 7.4 8.6

* Institutions with similar a-e subscripts are not significantly different, F ¼ 5.625, p , .000. † Significant difference of mean score from desirable benchmark score of 7, p ¼ .002.

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For individual use only. Duplication or distribution prohibited by law. included in this study. Each campus team reviewed their results and followed procedures to clarify any misperceptions/differences. An interrater reliability (IRR) pretest was conducted prior to implementing the audit. On each campus, IRR (Table 2) was determined by having each trained evaluator independently assess a building or recreation facility on the same day. The IRR score was the proportion of the items concordantly scored for each audit component between a pair of evaluators. Coordinated IRR evaluations were repeated on a campus if IRR was not greater than 80% for all evaluators. Each campus specifically assessed the built environment and the recreation facilities audits. Analysis SPSS 19.0 (SPSS, Inc., 2012) was used for data analysis. To enhance interpretation of the audit results, and equalize the contribution of various aspects on a campus, each component was standardized to a scaled score ranging from 1 to 10. Total scores, subscores for audit components, and ranges and mean scores with standard deviations were calculated for each PACES component. To compare mean scores against the desired benchmark score of 7 (equivalent to a grade of C)63 t-tests were used. Although this benchmark was subjectively set, it enhances interpretation of score results. Analysis of variance with post hoc

Table 4, Extended

S1

S2

S3

Total

(n ¼ 18)

(n ¼ 9)

(n ¼ 12)

(n ¼ 113)

4.6(1.4)ab 4.9(1.3)abc 4.9(0.5)abc 5.4(1.7) Score per campus 5.8 7.3 2.3 6.7 (2.0) 3.0 5.0 6.0 4.5 (2.3)† 7.2 6.6 8.4 7.1 (0.7) 8.2 7.8 6.5 7.5 (0.9) 6.2

6.3

4.6

6.6 (1.5)


Table 5 Built Environment Audit Results† Buildings Evaluated (N ¼ 112)

Overall No. (%)

v2

42 (37.5) 41 (36.6) 29 (25.8)

2.8

Bike rack accessibility 1 rack around the building or only by one entrance Racks by 50% of the entrances A bike rack by every entrance Bike rack availability No bike racks or insufficient to hold parked bikes Moderate bike rack space to hold bikes Covered/secure/sufficient bike racks Extensive health signage evident Stairwell evaluation (one set of stairs/building) (n ¼110) Cleanliness and lighting encourage use of stairs Stairwell doors labeled for consumer not just emergency Floors labeled: each door has a number Clear signage indicating stairwells

22 54 36 6

(19.6) (48.2) (32.1) (5.4)

95 79 71 57

(86.3) (71.8) (64.5) (51.8)

14.59*

† v2 analysis testing significant difference from equal distribution. * p , .05.

Tukey’s B was used to make comparisons by institution and region. For the total sample, percentage distributions to each PACES question were calculated. Chi-square tests were used to compare these nonparametric data. Spearman’s correlations were used to compare PACES Audit component scores.

RESULTS Schools in the following 13 states participated: Florida, Indiana, Kansas, Maine, Michigan, North Carolina, New Hampshire, New Jersey, New York, Rhode Island, South Dakota, Wisconsin, and West Virginia. Eleven of the 13 schools were land-grant institutions. Equal numbers of institutions were located in the Northeast and Midwest regions (38.5% each) with the remaining three schools (23%) from the Mid-Atlantic/South. The schools varied in student population and other demographic variables (Table 3). Each campus evaluated from 6 to 18 buildings according to its size and advisory team input. There were significant differences in built environment scores between institutions (Table 4), with only two schools securing a mean built environment score greater than the desired 7 or a grade of C. A significant difference (p ¼ .019) was detected by region, with the

Midwest institutions scoring significantly higher (6.7 6 1.1) than both the Northeast (4.9 6 .9) and Mid-Atlantic/ South (4.8 6 .2), but there were no statistical differences in results by building type (academic versus residential, etc.). Based on results of the built environment evaluation, 25.8% of the total buildings evaluated had bike racks by every entrance and 32.1% had covered/secured/sufficient bike racks for student use. Only 5.4% of the buildings had extensive, prominent health promotion signage. As for the stairwells, most were clean and well lit (86.3%), 71.8% of the doors were labeled for regular use (instead of emergency only), 64.5% of the floor numbers were labeled on each door, and 51.8% had clear signage to find the stairwell (Table 5). For the remaining PACES Audit components, scores for each institution are shown in Table 4. Most campuses (61.5%) scored below 7 on the ecological facilitators audit. Campuses had most safety features in place, although 31% did not have a neighborhood patrol system, and 23% did not have a free shuttle system or a student safety orientation. Weather was not a significant factor affecting activity levels, for all campuses made some or extensive accommodations (i.e., indoor temperature-controlled facilities) for their typical weather patterns. Pedestrian traffic with extensive public


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Table 6 Ecological Facilitators and Policy Audit Results† Overall No. (%) Ecological facilitators Campus safety features (n ¼ 13) Campus police Blue light system in place Safety tips made readily available Free shuttle-you-home system Walking escorts Campus alerts Neighborhood patrol Group presentations on safety Free self-defense classes offered to students Emergency procedures in place Campus alerts via e-mail, texting Siren system Emergency contact system Student safety orientation Weather Weather accommodations Some accommodations are made for typical weather: air-conditioned facilities; indoor pool/track Extensive accommodations and numerous opportunities provided regarding activities in the area Typical weather at the institution Extremely cold and/or hot temperatures, extensive precipitation (snow, rain). Too cold/warm to enjoy outdoor activities daily, precipitation often, weather is unpredictable Sunny, comfortable temperature; outdoor activities are not compromised due to weather Transportation The only means of transportation is car, discourages pedestrian traffic Pedestrian traffic is neither encouraged or discouraged Pedestrian traffic is encouraged, extensive public transportation Community violent crime rates‡ .23 national average 1–23 national average ,National average Community property damage rates‡ .23 national average 1–23 national average ,National average Community population income rates§ ,0.753 national average 0.76–13 national average .National average Policy evaluation (N ¼ 13) Promotion of physical activity Restriction of student access on campus with cars Requirement of healthy food options at campus functions Healthy food options by campus food services Labeling of foods offered by campus food services No smoking on campus Students have a reduced health fee for living a healthy lifestyle There is a student health advisory committee in place on campus Farmer’s market is provided on campus at least 13/mo during the growing season Transportation is provided to purchase healthful, cost-effective foods Policy access Policies are not well documented Policies are documented but not easily accessible to the campus community Policies are clearly documented, easily accessible to the campus community

13 12 13 10 12 12 9 12 12 13 13 11 13 10

v2

(100) (92.3) (100) (76.9) (92.3) (92.3) (69.2) (92.3) (92.3) (100) (100) (84.6) (100) (76.9)

7 (11.5) 6 (46.2)

NS

2(15.4) 10(76.9) 1 (7.7)

11.2*

0 7 (53.8) 6 (46.2)

NS

2 (15.4) 3 (23.1) 8 (61.5)

NS

2 (15.4) 4 (30.8) 7 (53.8)

NS

8 (61.5) 2 (15.4) 3 (23.1)

NS

0 8 (61.5) 2 (15.4) 3 (23.1) 3 (23.1) 13 (100) 1 (7.7) 4 (30.8) 4 (30.8) 1 (7.7) 1 (7.7) 6 (46.1) 6 (46.1)

NS

† v2 analysis testing significant difference from equal distribution. NS indicates not significant. ‡ Violent and property crime statistics secured for each institution from the Bureau of Justice Crime Statistics Database61 for 2007 (or 2006). The 2006 national average U.S. violent crime rate was 473.6/100,000, and the property crime rate was 3334.5/100,000. § Median income for zip code census tract for each institution evaluated according to 2009 census data and compared to 2009 national averages from the Factfinder Census Web site.62 * p , .01.

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For individual use only. Duplication or distribution prohibited by law. transportation support was evident on 46.2% of the campuses. Most campuses were located in lower-income areas (61.5% were classified as ,.75 times the national income average), but only 15.4% of institutions were located in high–crime rate neighborhoods (defined as both violent and property crime rates 2 times the national crime averages). These ecological demographics had no relationship to other environmental variables (Table 6). The overall mean policy score for all institutions was significantly lower than the desired score of 7, with only one school scoring 7 (Table 4). Cars were restricted on most campuses (61.5%). Only 30.8% of the schools had a student health advisory board. Most obesity prevention policies had no or limited support such as promotion of physical activity on campus or a reduced health fee for living a healthy lifestyle. Less than half of the institutions’ policies were well documented and easily accessible to the campus population. The policy evaluation and recreation programs audit scores were significantly associated (r ¼.595, p ¼ .032), although no other correlations with the policy scores were evident from these results. Only 38.5% of the campuses had a recreation program score below the desired 7 (Table 4). The total number of treadmills on campus correlated with student population (r ¼ .567; p ¼ .04), indicating the comprehensiveness of recreation services on a campus with respect to the size of its student population. All campuses had sufficient diversity of types of aerobic equipment (61.5% of institutions had .7 types). Club and intramural sports were common on all campuses, with only one campus having less than 20 club sports. All campuses offered extensive weekday exercise classes, but 23% had no classes on the weekend. Most campuses had an adequate variety of exercise classes, and 30.8% had over 25 different types of classes. The types of exercise spaces and number of courts and fields on each campus varied. Most institutions (76.9%) had a walking path or route marked on campus and in the wider community. A majority of campuses (69.7%) had oncampus weight management programs,


distributed health education materials, or offered and promoted nutrition/ health classes, but only 30.8% had programs to recruit high risk individuals to use these resources (Table 7). Less than a third (30.8%) of campuses fell below the desired score of 7 on the recreation facility quality scale (Table 4). Although there were no significant differences overall between main and secondary facilities on the campuses, 62.5% of the eight secondary facilities scored below 7. Most facilities (main and secondary) (66.7%) were open between 16 and 20 hours a day on weekdays. Only 10% of the facilities were unattended; 75% had trained staff in the cardio-weight area. Less than 10% of the exercise equipment evaluated was in poor PC or WC. However, 25% of exercise spaces (typically free weight, stretching/ dance aerobic areas) were reported as insufficient for student demand. Most amenities (lockers, towels, music, TVs) were in good condition and working order. In general, the overall score for amenities was significantly lower (p ¼ .04) for satellite/secondary facilities (2.8 6 1.6) as compared to the main facility (4.1 6 1.8) (Table 7).

DISCUSSION The period when older adolescents leave home for higher education has been identified as a time when they are particularly vulnerable to an imbalance in energy intake/output that can lead to excess weight gain.4,64,65 Although obesity rates among college-aged individuals (18–29-year-olds) are increasing,4–11 little is known about the microcosm of college campus physical activity environments.66 Researchers have provided evidence that public and private environments influence physical activity, with specific focus upon racial/ethnic disparities, rural communities, child care centers, workplaces, and school environments.33,41,67–70 The lack of literature concerning the aspects of college campus environments that influence physical activity behavior warrants a need for research using reliable and valid measures. This study is one of the first54 evaluations of the environmental supports to en-

courage physical activity for a sample of college campuses. Our study is also the first report of site visit observations of the quality and accessibility of exercise equipment, spaces, and facilities. This sample of 13 U.S. institutions had extensive recreation programs and high-scoring facilities. Although the results were generally favorable, only 30% had specific screening or programs for high risk individuals, and almost one-quarter had no exercise classes on the weekend, a time when students’ academic commitments are lighter. Additionally, 25% of the most popular exercise spaces were rated as insufficient at busy times of the day or were restricted by the athletics program. Secondary/satellite facilities had lower scores, which could be attributed to the quality of their amenities. Few survey evaluations of collegelevel recreation programs and facilities have been completed.71,72 In one survey, 40 universities were compared for program and facility capacity.72 Comparing our results to a sample of Midwest 4-year institutions,71 we found a higher percentage of institutions with health and wellness programs and exercise spaces. To evaluate their recreation programs, many institutions have focused on student satisfaction levels.73–75 A convenience sample of students surveyed at one Midwest U.S. institution73 indicated that students were happy with the recreation programs, but less satisfied with operating hours, communication, ambient conditions, facility design, and equipment. Given their findings, it appears important to compare objective evaluation of the recreation facilities environment with subjective evaluation by students/ employees. The walkability/bikeability of an environment has been related to physical activity levels.7,69,76.77 Although we previously reported good to excellent walkability scores in our sample of 13 campuses,54 unsatisfactory scores were found for bikeability.54 This study and similar evaluations of workplace environments52,78 found limited support for parking bikes on campuses, which deters people from riding their bikes. Midwest schools that had the highest built environment scores also had significantly higher walkability/bike-


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For individual use only. Duplication or distribution prohibited by law. ability scores54 as compared to the Northeast and Mid-Atlantic/Southern schools. This finding indicates a consistency in environmental supports for physical activity and could potentially be the result of planned layout and construction and terrain-friendly development. Many programs encourage the use of stairs to promote physical activity79–81; however, few studies have assessed the stairwell environment to determine if the physical nature of stairwells encourages or deters use.79–82 We found that stairwells were clean and well lit, but deficient in floor labels, door signs (beyond emergency exit), and particularly point-of-decision prompts. There is a need for accessible, inviting, clean, and safe stairwells with prominent signage identifying the location to encourage college students and staff to take the stairs. Although visibility of the stairwell is important to stair use,83 there is strong evidence that point-ofdecision prompts are effective for increasing stair use.84–86 There is insufficient evidence to know if use of stairs can be increased by additional environmental improvements (i.e., paint, music, art) or other creative methods such as the skip stop technique, where the elevators only stop on certain floors.81,82 Given that our sample represented various geographical areas of the country, it was necessary to account for differences in weather, crime, and urbanicity. For this small sample of schools, there was not enough evidence to find those factors differentiating, but they could become relevant in a wider, more diverse sampling of institutions. Although the ecological facilitators factor did not affect or relate to other parameters of this audit, crime surrounding campus was important to assess, because perceived campus safety can affect physical activity levels.45,60 Although college and university campuses have a wide variety of wellness/health promotion initiatives and programs, most campus efforts are not supported by creative obesity prevention policies. Not one campus had a policy regarding physical activity; whereas in the mid-1960s almost 90% of 4-year colleges and universities included physical education as a grad-

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Table 7 Campus Recreation Programs and Facilities Audit Results† Overall No. (%) Campus recreation programs (n ¼ 13) Treadmills 9 10–19 20–39 40 Varieties of cardio machines 5–6 7 Club sports 10–19 20–39 40 Intramurals offered 11 Intramural waitlist No Yes Yes, teams added to accommodate Fitness classes offered (weekday/weekend) 0 1–24 Varieties of fitness classes offered 5–9 10–24 25 Exercise spaces on campus Free weight areas Stretching/dance/aerobic area Cardio Area Track Swimming pool Skating rink Other spaces Courts and fields available Racquetball courts Indoor/outdoor basketball courts Indoor/outdoor volleyball courts Indoor/outdoor tennis courts Indoor/outdoor multipurpose courts Multipurpose fields Outdoor playing fields Health education programs available Distribute education information on weight management Offer on-campus weight management groups Offer prizes/incentives for students/employees as they make health improvements Offer nutrition education/health education/stress management classes Provide personalized nutrition or health education programs upon request Promote the availability of these programs Evaluate the programs by asking participants their perceptions Programs have a plan to recruit high risk individuals Walking path or route available on campus The path/route on campus is marked The path/route length on campus is communicated

2 5 4 2

v2

(15.4) (38.5) (30.8) (15.4)

NS

5 (38.5) 8 (61.5)

NS

1 (7.7) 8 (61.5) 4 (30.8)

NS

13 (100)

NS

3 (23) 4 (30.8) 6 (46.1)

NS

0/3 (23.1) 13 (100)/10 (76.9) 1 (7.7) 8 (61.5) 4 (30.8) 13 13 13 12 13 7 6

(100) (100) (100) (92.3) (100) (53.8) (46.1)

13 13 12 11 12 12 11

(100) (100) (92.3) (84.6) (92.3) (92.3) (84.6)

3.76*

NS

9 (69.2) 9 (69.2) 6 (46.1) 9 (69.2) 8 (61.5) 9 (69.2) 8 (61.5) 4 10 8 7

(30.7) (76.9) (61.5) (53.8)



Table 7, Continued Overall No. (%)

v2

Walking path or route available in the wider community 10 (76.9) The path/route in the wider community is marked 8 (61.5) The path/route length in the wider community is 9 (69.2) communicated Recreation facilities audit (main and secondary facilities combined) (n ¼21) (weekday/weekend) Hours of operation ,11 1 (4.8)/6 (28.6) 12.3**/6.0* 12–15 or 21–24 6 (28.6)/12 (57.1) 16–20 14 (66.7)/3 (14.3) Trained staff in cardio/weight area score 0 staff present 2 (10) NS Attendant only 3 (15) 1 trained staff member 6 (30) More than 1 staff member 9 (45) Equipment physical condition‡ Poor 10 (7.3) Moderate 62 (45.3) Good/excellent 65 (47.4) Equipment working condition§ Not working 4 (2.9) Poor 9 (6.6) Good/excellent 124 (90.5) Exercise spaces/courts/fields physical condition‡ Poor 8 (4.6) Moderate 71 (41) Good/excellent 94 (54.4) Exercise spaces/courts/fields usage/availability|| Limited 5 (2.9) Restricted 39 (22.5) Sufficient 173 (74.6) Amenities Showers physical condition‡ Poor 5 (17.9) Moderate 15 (53.6) Good/excellent 8 (28.5) Showers working condition§ Not working 0 Poor 5 (17.9) Good/excellent 23 (82.1) TV/music physical condition‡ Poor 1 (3.4) Moderate 6 (20.7) Good/excellent 22 (75.9) TV/music working condition§ Not working 0 Poor 3 (10.3) Good/excellent 26 (89.7) † v2 analysis testing significant difference from equal distribution unless otherwise noted. No statistics run—reporting of multiple response data. NS indicates not significant. ‡ Physical condition: rated poor, moderate, or good/excellent (to evaluate equipment, exercise spaces, courts, and amenities). § Working condition: rated not working, poor, or good/excellent (to evaluate equipment and amenities). || Usage/availability: rated limited, restricted, or sufficient (assessed at the busiest times of the day to assess exercise spaces and courts/fields). * p , .001. ** p , .01.


uation requirement,87 today less than 40% have such a requirement.88 Similarly, based on an extensive review of obesity-prevention policies in Missouri, 88% of primary/secondary schools but only 17% of worksites had obesityprevention policies.89 Primary school personnel have been leaders in assessing and developing effective health promotion policies.90–92 Model obesity prevention policies and programs are needed in higher education to facilitate and maintain healthy campus environments. Campus recreation programs and facilities are more than an avenue for students to be physically active, they are a recruitment and retention tool that universities cannot afford to ignore.93–95 A few tools have been created to evaluate the healthfulness of the worksite environment,58,59,96–102 yet none was sufficiently detailed to be readily used to evaluate the university campus environment. The tool created through this research complements the campus walkability/bikeability audit54 to provide a complete assessment of campus environmental supports for physical activity. The PACES Audit offers an objective, comprehensive review of recreation programs and facilities. Currently, it is in a paper-andpencil format that requires data transcription into Excel, and this format might be a disincentive for utilization by a large population of institutions. The PACES Audit is easy to implement; the built and recreation facilities audits showed high reliability; however, the policy and ecological facilitators audits require further testing to confirm this. The audit’s main limitation is unknown generalizability of these results, because they are based on differences between a small sample of 13 U.S. campuses and the researcher-set benchmark criteria of 7. Minimal differences existed among this nonrandomized sample of campuses, and a wider sample of institutions is necessary to explore and validate the full range of responses and benchmark score, and to secure examples of model obesity prevention policies, programs, and environmental supports for use on campuses. The methods used to scale audit sections to achieve 10 points per section made the sections comparable, but uniform weighting of each PACES


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For individual use only. Duplication or distribution prohibited by law. component may not reflect their actual relative importance. Future Research The PACES Audit will be automated to facilitate ease of administration in a field setting. It is imperative to understand the relationships between the environment and health behavior, through program evaluation generated by comprehensive outcome measures.49–51 To validate the audit, it will be administered on a wide sample of postsecondary educational institution campuses and compared to behavioral/health outcomes data and environmental perception data, which in turn can improve the benchmarking database. PACES Audit results can be compared to student/employee/administrator perceptions and satisfaction with the environment for obesity prevention.73 The audit can be expanded to assess aspects of institutional mission, vision, values, and ideally student/recreation program learning objectives and outcome data, to better determine the effect of environmental supports for physical activity on student health outcomes.103 Additionally, the PACES scores can be mapped using geographic information systems to determine the relationship between proximity, environmental supports, and physical activity.46 The results can be shared with key stakeholders, including students and employees, to advocate for changes and motivate participants through CBPR31 and grassroots efforts to change the environment to prevent obesity.103 Our work can complement other efforts in understanding and improving the link between environment and health: (1) the newly created and validated Centers for Disease Control and Prevention Worksite Health Score Card,104 which focuses primarily on health promotion/disease prevention programs in the work environment; (2) the effect of the environment on the public’s health via Health Impact Assessments67,68,105; or (3) the call for the Healthy University,106 which advocates striving for health promoting sustainable campuses through appropriate environment, policies, teaching philosophy, and practices.

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Conclusion University campuses have extensive recreation services and programs, but what other supports exist on campus for daily activities that can facilitate obesity prevention Physical infrastructure and policy59,107,108 aspects of the campus environment potentially can contribute to preventing or mitigating overweight/obesity by facilitating healthy habits and behavior regarding physical activity.18,109 Isolated or ad hoc improvements to environmental supports for healthy habits produce weak beneficial effects.50 The PACES Audit is a comprehensive tool to document the environmental supports for physical activity, and when implemented using CBPR with all populations affected, including practitioners, researchers, and decision makers, it can inform decisions to improve environmental policy and or physical infrastructure supports. Through the CBPR process,31 each campus collaborated and shared its results with its advisory team. A third of the participating states reported making progress on institut-

So What? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? Although there are numerous tools and extensive research assessing the built neighborhood environmental effects on physical activity, there is limited knowledge regarding complex environments such as a university campus. What does this article add? For this sample of 13 U.S. campuses, the built and policy environments have the potential to provide greater supports for obesity prevention. This tool provides a comprehensive environmental audit using an onsite objective assessment. What are the implications for health promotion practice or research? This audit tool will allow others to carefully evaluate and document what built environmental supports for physical activity exist on college campuses, and advocate for effective policy and environmental changes. PACES Audit results can be compared to student’s behavior and perceptions and other campus survey results.

ing environmental changes because of the extensiveness of the audit and its findings (i.e., bike racks, stairwell door labels, campus walking trails, etc.). These are encouraging and positive benefits of this research. This study provides an example for how to use community-based research results to influence campus’ decision making regarding obesity prevention. Acknowledgments We would like to thank our other state primary investigators, graduate students/staff, and all of our student data collectors for their hard work in every phase of the study.

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