February 2016 City Voices: New Yorkers on Health Physical Activity: NYC on the Move By Elisa Fisher, MSW, MPH | Lindsey Realmuto, MPH | Sharon A. Abbott, PhD Dona Green, MBA, MAgS, MA | Linda Weiss, PhD INSTITUTE FOR URBAN HEALTH FELLOWS LIBRARY Physical Activity: NYC on the Move CITY VOICES This data brief is part of a series—“City Voices: New Yorkers on Health”—developed to give a voice to the health needs of people in the city who are oftentimes invisible or unheard. “Physical Activity: NYC on the Move” does this by highlighting informative personal experiences of primarily low-income New Yorkers in the Bronx, Brooklyn, Manhattan, and Queens. PHYSICAL ACTIVITY NEARLY THREE QUARTERS OF SURVEY RESPONDENTS REPORTED THAT THEY HAD ADEQUATE ACCESS TO PLACES TO ENGAGE IN PHYSICAL ACTIVITY. This collection of voices provides a direct glimpse inside the health issues and needs of New Yorkers to help inform the many decisions that are being made on a daily basis by community service and health care providers, as well as policy makers. For more insights and perspectives directly from New Yorkers, visit NYAM.org to download the full “City Voices: New Yorkers on Health” series of reports. NYAM.org “... I can only speak for Coney Island. Well, [a local non-profit’s gym] is there for people who can afford to go. You have a great membership there. ... It comes up at our community meetings about how people would love to go but they can’t afford it because they’re on a set income.” – FOCUS GROUP PARTICIPANT, BROOKLYN Table of Contents 1Abstract 2Overview 4Findings 11Conclusions 13 Design & Methodology 15References NYAM.org ABSTRACT This data brief is part of a series—“City Voices: New Yorkers on Health”— developed to give a voice to the health needs of people in the city who are oftentimes invisible or unheard. “Physical Activity: NYC on the Move” does this by highlighting informative personal experiences of primarily low-income New Yorkers in the Bronx, Brooklyn, Manhattan, and Queens. Physical activity improves health and reduces risk for chronic illnesses, like diabetes and hypertension, and research suggests that living in an urban environment is associated with a more active lifestyle. Although some evidence indicates that New York City residents are more physically fit than the average American, data also imply that New Yorkers have differential opportunities for physical activity and exercise, suggesting areas for intervention. In 2014, a mixed-method community needs assessment (CNA) was conducted based on 2,875 surveys and 81 focus groups with primarily low-income New Yorkers, as well as 41 interviews with key community leaders. This report explores the perspectives of these community members and key informants on physical activity as reported in this CNA. Our findings are consistent with existing research on the habits of New Yorkers; City residents frequently participate in physical activity facilitated, in large part, by the urban environment in which they live. Formal exercise, however, occurs less regularly due to a number of community and personal factors, including a lack of quality, safe, affordable and culturally-appropriate recreation spaces or programs, and a lack of time or energy after addressing other priorities, such as work, childcare and school. Focus group participants and key informants offer suggestions to reduce barriers and support community members in exercising more consistently. Physical Activity: NYC on the Move 1 OVERVIEW Physical activity can significantly lower one’s risk for chronic diseases, like heart disease, cancer and diabetes, which are responsible for half of all premature deaths (before age 75) in New York City (NYC).1,2 Among low-income New Yorkers, these conditions are even more prevalent; for example, those with the lowest incomes are nearly three times more likely to have been diagnosed with diabetes than those with the highest incomes.3 Physical activity includes actions that are a part of everyday life, such as walking for transportation, climbing subway stairs, and jobs that involve physical labor, as well as exercise, which is the intentional engagement in activities that require physical effort, such as jogging or fitness classes, often for the purposes of improved health or general well-being.4 Both types of physical activity have been linked to health and a reduced risk for chronic diseases.5 In general, New York City residents are more physically active than the average adult in the United States; 67 percent of New Yorkers report engaging in the recommended amounts of physical activity, compared to just 50 percent of Americans.6 Studies suggest that the higher rates of physical activity are due to the characteristics of an urban environment common in New York City, such as easy access to public transportation, sidewalks, and mixed residential/commercial zoning, which encourage walking and other forms of active transportation.7 Still, one-third of New Yorkers report that they do not engage in the recommended amounts of physical activity, and participation varies by neighborhood. Low-income communities, such as the South Bronx and some neighborhoods in Southeast Brooklyn and Queens, have lower rates of participation in physical activity in addition to high burdens of chronic disease. Research indicates that engagement in physical activity varies according to a wide range of individual, social and environmental factors, such as the availability of places to exercise (e.g., parks, recreational facilities), perceived community safety and neighborhood walkability—all less likely to be present in low-income communities. These neighborhood differences may contribute to persistent health disparities. NYAM.org 2 This report, part of a series describing findings from a comprehensive CNA conducted in four NYC boroughs, explores the perspectives of low-income New Yorkers on physical activity and the factors that support or hinder engagement across communities in NYC. Our findings are consistent with existing research on the habits of New Yorkers; City residents frequently participate in physical activity facilitated, in large part, by the urban environment in which they live. Intentional exercise, however, occurs less consistently, due to a number community and personal factors. Community residents offer suggestions for interventions and programs that might reduce barriers and improve participation in exercise. Physical Activity: NYC on the Move 3 FINDINGS Physical activity in everyday life Nearly three quarters of survey respondents reported that they had adequate access to places to engage in physical activity. Many participants reported that they are regularly active as part of their everyday life. Caring for young children, jobs that require physical labor, and an urban environment that encourages walking and climbing stairs, enabled participants to stay active without engaging in formal exercise programs. I do a lot of walking only because of the job we do, we visit people’s houses and stuff like that. So that’s how I get my [exercise]–I even got the app on my phone. So it lets me know how much I walk every day. (Focus Group Participant, Bronx] Sometimes I feel good, sometimes I don’t. But I don’t per se, exercise– you know, say that I do this every day, but I do exercise. I’m always walking, and I realize that that’s exercise; walking, climbing stairs. (Focus Group Participant, Brooklyn) I chase grands all day, chasing grandchildren is enough exercise. Two want to go down this hallway and the other two like this one. Grandma can’t catch all of them. (Focus Group Participant, Bronx) NYAM.org 4 Exercise In addition to discussing physical activity as part of daily life, many described participation in exercise, including walking, running, playing sports, and taking fitness classes. They also discussed facilities and programs located within their communities, citing parks, basketball courts, gyms, swimming pools, and senior centers. Still, some reported that their communities lacked adequate access to places for exercise that were appealing and accessible to all community members. Participants also described the differences in the quality and availability of recreational spaces across NYC neighborhoods and noted that a lack of high-quality parks and facilities discourages exercise. Comments representing the range of responses include: I know my consumers that live in the Chinatown area. They became members of the senior centers. They do a lot of dancing. I’ve been to one to do outreach and I can see them ballroom dancing. They have Tai Chi and people who play Mahjong, which is good for the brain–my mom goes there every day. (Focus Group Participant, Manhattan) It’s easy to talk about exercising if I live in Battery Park. They just made the whole garden thing, you can walk, run, do anything you want. It’s beautiful. … How do you do that in Flatbush? (Community Health Professional, Brooklyn) A better gym [would help me exercise], because the gym I go to here is small and it is limited in the amount of workout equipment. A better gym would help. (Focus Group Participant, Manhattan) Physical Activity: NYC on the Move 5 Affordability Community members indicated that use of recreational facilities and programs was significantly impacted by affordability. Some described available low or no cost options, such as free access to swimming pools on certain days; free fitness classes in the city parks, senior centers and recreational facilities; and gym memberships covered by insurers. However, low cost options were not available to all residents or in all communities, and several viewed the high price of exercise programs, such as organized sports or gym memberships, as a major barrier to participation. I have my insurance, and it lined me up with a gym where I don’t have to pay, or it’s very low. And I can go, and I can do the swimming. I can work out. I can play ball. And I can go anytime I want to go. If I don’t exercise at home, I can go to the gym. I can do yoga. (Focus Group Participant, Manhattan) I can only speak for Coney Island. Well, [a local non-profit’s gym] is there for people who can afford to go. You have a great membership there. ...It comes up at our community meetings about how people would love to go but they can’t afford it because they’re on a set income. (Focus Group Participant, Brooklyn) On 92nd Street and Columbus Avenue they used to have free calisthenics, aerobics, you name it, but they don’t have it anymore. When they had it I used to go and they had … free swimming in Trinity. (Focus Group Participant, Manhattan) Safety Perceived safety of streets and parks also impacted willingness and ability to exercise. Some participants reported that the safety of their community facilitated exercise routines, but those living in communities with more violence felt opportunities for exercise outdoors—for adults and children—were limited due to safety concerns. NYAM.org 6 Parks, I’m sorry to say, are dirty shooting galleries because they don’t care if there’s a child, a dog, a baby, a disabled person like me they will shoot up the park. (Focus Group Participant, Bronx) Physical activity makes me think of Hunts Point and the big effort put out there by a lot of the community residents about building safe spaces. ... I think safety is a big component that sometimes people don’t think about with social determinants. Safety from violence; that you can go to the park and you are going to be safe and that your kids are going to be okay playing outside. … You have to feel safe in your environment. I think that’s lacking in ours. (Health Care Provider, Bronx) Accessibility for all Participants indicated that existing recreational programs and facilities were not necessarily accessible to all, with barriers reported by those with disabilities, those identifying as transgender, and those with cultural dictates regarding modesty and/ or separation of genders. Well, I think I’d like to do much more exercise, but I can’t find a gym with accessible equipment in my neighborhood. … in Bushwick, in Brooklyn. (Focus Group Participant, Manhattan) We can’t dress the same way and go to a gym where men are present. (Focus Group Participant, Queens) Individual factors that influence exercise frequency Despite a clear appreciation of the positive health impacts of physical activity, participants described personal barriers to exercising that went beyond access, including a lack of motivation and time. While several felt that “laziness” contributed to limited exercise participation, others reported that competing commitments and priorities, such as work, school and childcare, often make it difficult to dedicate time and energy to exercise. To address these barriers, participants felt that improved social support, increased education, and/or a reduction in other commitments might contribute to increased exercise. Physical Activity: NYC on the Move 7 I used to do it every day but I stopped because I needed support, like, ‘Come on, girl. Let’s get out there and go. …’ And I didn’t have that. Since I didn’t have that and no one was knocking on my door, I thought it didn’t make sense for me to go. I don’t mind going if I have a little push…Once I get that push, I don’t mind doing it. (Focus Group Participant, Brooklyn) So I believe that a lot of people in the neighborhood are aware of physical activity and the importance of it, but I believe certain people, and I’m speaking on behalf of me when I say, with me, I think with having to work two jobs it limits my ability to work out to where I’ve just been eating and gaining weight, but I’m trying. (Focus Group Participant, Bronx) If they paid us more and we worked less to have more time for our children, because we’re single mothers. ... I don’t have time to do exercise, I’d prefer to be in my bed when I get home. (Focus Group Participant, Bronx) Participant recommendations Participants offered several recommendations to support physical activity in NYC. For instance, they expressed the need to improve or rehabilitate existing neighborhood facilities or residential buildings to create safe places to exercise. Participants also recognize that financial incentives and/or staffing may be needed to facilitate increased access and engagement. As far as facilities to actually offer classes and workshops and training, that’s on all of us to set those up and make them available … you’ve just got to keep on doing it until people, until the community understands that you are there to stay. (Social Service Provider, Bronx) In addition, participants noted that community exercise programs and facilities need to be culturally and physically appropriate. Residents have a broad range of abilities, restrictions, and preferences, which vary by age, health status, gender, ethnicity, and other personal characteristics. Diverse programming is necessary to engage all members of the community. NYAM.org 8 “I look at the buildings and I know there are a lot of community basements, there are community centers. You can even get the landlords involved. Say, look, we’ll give you some tax credit if you open an area that is for people to exercise. There is light; it’s secure; they can walk around… So those are the kind of things I think that … they are not putting enough resources [into]. – COMMUNITY HEALTH PROFESSIONAL, BROOKLYN Physical Activity: NYC on the Move 9 The groups that we work with that have those programs, what I’ve actually found is that if it’s neighborhood-based, they’re very successful. They can bring folks together. Also, in thinking about those exercises that are, I want to say culturally competent. So if this particular community loves dancing, let’s do a program around that. If they come from a culture where they want to do walking or let’s think about those issues. (Health Policy Professional, Manhattan) And the women, there’s no way they’re going to exercise there, especially women with the hijab. One time we brought a lady who does yoga, so we put them in a closed room. They could take off their hijab and do some yoga and exercise with the lady. It was great. I would love to see them doing that more often. (Health Care Navigator, Brooklyn) I’d like to see more services adaptable to people with mobility issues. For example, if there’s an exercise program, there’s a part of it that can be delivered to people who have mobility issues like people who use wheelchairs and are limited in doing certain things. (Focus Group Participant, Manhattan) 10 CONCLUSION The benefits of physical activity are well-understood among community members and interest in participation is high. Many focus group participants reported engaging in physical activity as part of their everyday life, such as when they walk for transportation or work at jobs that require them to be active, which is consistent with literature suggesting that urban environments and access to public transport support active living. Still, intentional participation in exercise varied among participants. Although some reported regularly engaging in exercise activities like sports and fitness classes, others discussed both environmental and individual-level factors that prevent them from exercising regularly, such as the limited availability of safe, clean and affordable recreational spaces or a lack of time due to other commitments. Participants also offered suggestions for interventions that could increase exercise participation in their communities, such as encouraging the development of new recreation centers or tailoring programs to meet the cultural needs of the community they serve. Many city-led efforts to increase opportunities for exercise and address some of the pressing concerns of community members are already underway. For example, the NYC Department of Parks and Recreation offers free exercise classes through Shape Up NYC and recently launched the Community Parks Initiative, a multi-faceted program focused on ensuring that all New Yorkers have equitable access to clean and safe park space. The initiative will engage local community members in the redesign of 35 parks in low-resource neighborhoods. Despite these promising efforts, our findings suggest that equitable access to exercise opportunities will require a more detailed understanding of each community’s needs and resources. Considerations may include subsidizing access to recreational programs, facilities, and child care, creating accessible and culturally- appropriate facilities and services, and implementing programs focused on social support and education. Physical Activity: NYC on the Move 11 This collection of voices provides a direct glimpse inside the health issues and needs of New Yorkers to help inform the many decisions that are being made on a daily basis by community service and health care providers, as well as policy makers. For more insights and perspectives directly from New Yorkers, visit NYAM.org to download the full “City Voices:New Yorkers on Health” series of reports. NYAM.org 12 DESIGN & METHODOLOGY The New York Academy of Medicine led a four-borough community needs assessment during the summer and fall of 2014. This report uses data from the CNA to better understand engagement in physical activity as well as perceptions of facilitators and barriers, and recommendations for increasing daily exercise. The CNA included 41 key informant interviews, 81 focus groups, and 2,875 community surveys. Key informants were selected for their expertise across a broad range of issues including aging, immigrant health, behavioral health, homelessness, incarceration, disabilities, and environmental health. Focus groups and surveys targeted diverse, low-income New Yorkers. The CNA was conducted to inform the design of health care service transformation through the Delivery System Reform Incentive Payment programs. For more information, please refer to “Findings from a New York City Community Needs Assessment: An Overview” (November, 2015). Physical Activity: NYC on the Move 13 Acknowledgements We are sincerely grateful to focus group participants for their time and for sharing their personal experiences. We would also like to thank the key informants, health care providers, and other partners who were involved in participant recruitment and provided insights on physical activity. We would like to particularly express our gratitude to those organizations that provided venues for the focus groups. Authors Elisa Fisher, MSW, MPH* Senior Policy Associate, Center for Health Policy and Programs The New York Academy of Medicine Lindsey Realmuto, MPH* Project Director Center for Evaluation and Applied Research The New York Academy of Medicine Sharon A. Abbott, PhD Assistant Director of Strategic Program Development, Division of Corporate Planning Services NYC Health + Hospitals Dona Green, MBA, MAgS, MA Chief Operating Officer Queens Hospital Center for NYC Health + Hospitals Linda Weiss, PhD Director, Center for Evaluation and Applied Research The New York Academy of Medicine The views presented in this publication are those of the authors and not necessarily those of The New York Academy of Medicine, or its Trustees, Officers or Staff. *Authors Elisa Fisher and Lindsey Realmuto contributed equally to this report. NYAM.org 14 References Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans: Be 1 Active, Healthy, and Happy! [Internet]. Washing (DC): HHS. Last accessed September 10, 2015. Available from: http://health.gov/paguidelines/pdf/paguide.pdf. 2 New York State Department of Health, Bureau of Biometrics and Health Statistics. Leading Causes of Premature Death (Death before age 75), New York City, 2003-2012, Vital Statistics Data. Last accessed July 21, 2015. Available at: https://www.health.ny.gov/statistics/leadingcauses_death/ pm_nyc_by_year.htm. Calculation based on 2012 data. 3 New York City Department of Health and Mental Hygiene. Epiquery: NYC Interactive Health Data System - Community Health Survey 2013. [November 16, 2015]. http://nyc.gov/health/epiquery 4 U.S. Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 5 American Heart Association. American Heart Association Physical Activity Recommendations for Adults. Available at: http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/ FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_ UCM_307976_Article.jsp. Last accessed December 23, 2015. 6 Centers for Disease Control and Prevention. (2013). Nutrition, Physical Activity and Obesity Data, Trends and Maps. Division of Nutrition, Physical Activity and Obesity. Available at https://nccd.cdc. gov/NPAO_DTM/. Last accessed January 29, 2016. Fingerhut, L. and Lovasi, G. Supporting evidence-based investment in public spaces: A literature 7 review. February 13, 2015. Available at: https://behcolumbia.files.wordpress.com/2015/03/ nyrplitreview_feb13_final.pdf. Last accessed December 21, 2015. 8 NYC Department of Parks and Recreation. NYC Parks: Framework for an Equitable Future. http:// www.nycgovparks.org/about/framework-for-an-equitable-futureUN-13/Presentations/9_Jim_ Hester.pdf. Physical Activity: NYC on the Move 15 About the Academy The New York Academy of Medicine advances solutions that promote the health and well-being of people in cities worldwide. Established in 1847, The New York Academy of Medicine continues to address the health challenges facing New York City and the world’s rapidly growing urban populations. We accomplish this through our Institute for Urban Health, home of interdisciplinary research, evaluation, policy and program initiatives; our world class historical medical library and its public programming in history, the humanities and the arts; and our Fellows program, a network of more than 2,000 experts elected by their peers from across the professions affecting health. Our current priorities are INSTITUTE FOR URBAN HEALTH healthy aging, disease prevention, and eliminating health disparities. FELLOWS LIBRARY NYAM.org The New York Academy of Medicine 1216 Fifth Avenue | New York, NY 10029 212.822.7200 © 2016 The New York Academy of Medicine. All rights reserved.