Part A CBS Natl Survey_12 04 2013

The Division of Nutrition, Physical Activity, and Obesity of the Centers for Disease Control and Prevention (CDC) requests approval for a new data collection called National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living to be conducted over the period of 1 year. This data collection effort is a new national survey to assess local governments’ policies and practices that support healthy eating and active living among their residents. This national survey will provide nationally representative data and has the potential to serve as the baseline for tracking data across time for CDC.

A.1.a. Study Background

According to the Dietary Guidelines for Americans and Physical Activity Guidelines for Americans, both published by the Federal government, the consumption of a healthful diet and regular physical activity are important behaviors for the prevention of obesity and other chronic diseases (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2010; U.S. Department of Health and Human Services, 2008). Although behavior change is made at the individual level, the socioecological model suggests that health and behavior are determined by many factors that extend beyond the individual (Breslow, 1996). There is growing consensus among experts that the environment plays a critical role in promoting or discouraging these behaviors (Hill & Peters, 1998; Sallis & Glanz, 2006, 2009). For example, when communities lack full-service grocery stores, residents may be less likely to consume fresh fruits and vegetables (Morland, Wing, & Diez Roux, 2002). In addition, poor street design and neighborhood planning may limit the use of active forms of transportation, such as walking and biking (Frank, Engelke, & Schmid, 2003). Local governments have been targeted for the study because of their central role in establishing local policies and practices that can make the environments in which people live more supportive of healthy eating and active living. The establishment of policies, practices, and standards enacted by local governments is therefore an important first step to ensuring environments support healthful diets and physical activity within a community.

Currently, little is known about the environmental and policy supports for healthful diets and regular physical activity within a community and how these supports change across time. Data have not been collected in a systematic way with regard to these supports at a community level. Most surveys and surveillance systems measure health and behavioral factors at the individual level. Integrating environmental and policy factors that contribute to health and disease into surveys and surveillance is an important step in effectively preventing disease (Kyle, Balmes, Buffler, & Lee, 2006; Story et al., 2009).

Assessment of these policies, practices, and standards that support healthful eating and physical activity at the local level is important to public health programs because it helps them identify areas for interventions and track progress in changing those supports. CDC’s current data collection efforts mainly focus on individual behaviors; however, the proposed data collection extends the breadth of CDC’s activities and fills a critical gap by documenting community-level policies, practices, and standards that support the behaviors of physical activity and healthful eating. This proposed information collection is authorized under Section 301(a) of the Public Health Services Act (42. U.S.C. 241) to “…cooperate with, and render assistance to other appropriate public authorities, scientific institutions, and scientists in the conduct of, and promote the coordination of, research, investigations, experiments, demonstrations, and studies related to the causes, diagnosis, treatment, control, and prevention of physical and mental diseases and impairments of man…” (Appendix A).

Efforts in Assessing Community-Level Policy Supports. This effort to develop a community-based national survey to measure policy and environmental supports for healthy eating and active living is influenced by previous work CDC conducted on recommended community strategies and measurements to prevent obesity in the United States (Kettel Khan et al., 2009) and a methodological pilot study conducted in 2012. Foundational work for this study included the identification of 24 recommended strategies for local communities to implement that would encourage healthy eating and active living to address the obesity epidemic and decrease the incidence of chronic diseases. The proposed national survey content and data collection procedures incorporate lessons learned during an initial pilot study (Pilot Study of Community-Based Surveillance and Supports for Healthy Eating/Active Living, OMB No. 0920-0934, exp. 5-31-2013). This pilot provided valuable information to inform the sample design, the most effective recruitment strategies for maximizing response rates, and tested the feasibility of proposed survey items for the new national survey.

This current effort seeks to build upon previous work by conducting a nationally representative survey of communities to document the current prevalence of policies, practices, and standards under the purview of local governments. Data from this survey are valuable because they will provide the current status of communities. They also have the potential to be used to establish a baseline for tracking these activities across time.

A.1.b. Study Overview

This study consists of a nationally representative survey of municipalities in the United States to document community-based policy and practice supports for healthy eating and active living. Information from this survey will provide data on the policies and practices municipal governments have in place to support healthy eating and active living for their residents and can serve as a baseline to assess progress made in changing these policies and practices across time. The national survey is designed to yield 95% confidence intervals within ± 3 percentage points for all study estimates, taking into account the anticipated design effect and response rate of 70%. The national study will also detect a 5% difference in prevalence estimates between subgroups of approximately equal sample sizes with an alpha of 0.05.

The national study’s sample will use a single-stage selection approach to recruit municipalities, which will then be stratified by a number of relevant dimensions including region, population size, and urban status. The sampling frame will include 4,484 municipalities to ensure a sample size large enough to obtain the desired response rate and to generate subgroup comparisons with 80% power and detect differences as small as 5%, as required by CDC. The key respondent for each sampled municipality will be the city or town manager or planner or a person with similar responsibilities for the sampled municipality. To recruit them, each sampled municipality will receive a study invitation packet. Respondents will be able to complete the self-administered survey via a Web-based data collection system or hard copy, depending on their preference. Sampled entities will receive e-mail and telephone reminders at set intervals over the duration of the proposed 16-week data collection window. The data collection window for the study is 12 weeks, with an additional 4 weeks of time allotted for nonresponse survey follow-up activities. As municipalities complete the survey, they will be removed from future nonresponse follow-up procedures. A case management system (CMS), an integrated database developed by the contractor, will be used to carefully track and update the survey completion status for each community.

A.1.c. Privacy Impact Assessment Information

This study will collect information on policies, standards, and practices that local governments have in place to support healthy eating and physical activity among residents within the communities. The national survey will be conducted with a national sample of 4,484 municipalities. The national survey questionnaire is a self-administered instrument that consists of self-report for 24 questions. Questions focus on municipal-level public policies, standards, and practices rather than on information about the key respondents themselves. More specifically, the questionnaire obtains data on local-level planning documents, such as policies that support changes in the built environment to encourage physical activity, policies that support access to healthful food and beverages, and policies on breast-feeding. Data sources for answering the survey items are the existing public documents within the local governments, which are generally regarded as being no greater than minimally sensitive. No sensitive information is being collected; therefore, the proposed data collection will have little or no effect on the respondents’ privacy. Nevertheless, safeguards will be put in place to ensure that all collected data remain private. To facilitate the distribution of study invitation materials, the respondents’ names, e-mail addresses, mailing addresses, and telephone numbers will be collected as a part of the sampling frame. However, this information will be captured in a separate system and will never be part of the study data set.

A.1.d. Overview of the Data Collection System

The questionnaire will be administered to a key informant representing each of the 4,484 sampled municipalities. The key informants (city or town managers or planners or persons with similar responsibilities for the sampled municipality) were identified as the individuals possessing the broadest knowledge of the healthy eating and active living policies and practices being implemented within the municipalities. The questionnaire was designed to allow for collaboration with other employees of the sampled municipality, should a respondent need additional information to provide the most accurate information.

Questionnaires will be self-administered via paper forms (Appendix C1) or the Internet (Appendix C2). Respondents have the ability to respond to the questionnaire at a time and place of their choosing from any Internet-connected computer, as well as the option to complete the questionnaire in hard copy by printing it out and mailing it in. Respondents who wish to use a paper survey can choose to print a specially formatted paper questionnaire from the Web-based data collection system, complete the questionnaire, and return it to project headquarters using instructions that will be attached to the invitation letter.

A.1.e. Items of Information to be Collected

No individually identifiable information is being collected as part of the questionnaire. Sources of information for the survey items are the existing public documents within the local governments. The questionnaire consists of 38 items divided into three sections. The first section, Communitywide Planning Efforts, asks questions about the planning documents local municipalities may have in place that support healthy eating and active living. The next section asks respondents to indicate what policies, standards, and practices they have in place to support aspects of the built environment that support physical activity. The third section of the survey asks about policies, standards, and practices in place to support access to healthy food and beverages, as well as breast-feeding.

A.1.f. Identification of Web Site(s) and Web Site Content Directed at Children 13 Years of Age

The national survey will use a Web-based data collection to obtain responses from key informants from sampled municipalities. Access to the Web-based system is limited to those with valid access codes or tokens, which will be created, assigned, and managed by the study team. The study team will also have access to the Web site. The Web site does not include content directed at children younger than 13 years of age. No links or references to outside Web sites will appear on the study Web site. The log-in page for the Web-based survey will present the rules of conduct and the privacy policy for the data collection.

A.2. Purpose and Use of Information Collection

Results from this study uphold the goals of several key CDC agency priorities. In 2009, CDC issued recommendations for actions that communities could undertake to alter local environments to support healthful diet and physical activity (Kettel Khan et al., 2009). The proposed study project builds on those recommendations by assessing the extent to which communities have some of the recommended strategies in place.

This effort also strengthens one of CDC’s 10 Winnable Battles in the area of obesity, nutrition, and physical activity. Winnable Battles are public health priorities with large-scale impact on health and with known, effective strategies to address them. Communities are one setting in which strategies to lower obesity rates through improved nutrition and greater levels of physical activity are being implemented, and this survey will support those efforts. This project also bolsters three of the five strategic directions for CDC as identified by the CDC Director. These three are:

Excellence in surveillance, epidemiology, and laboratory services
Strengthening support for State, tribal, local, and territorial public health
Advancing evidence-based health policies

The national survey will assist the work of CDC programs that provide support to States and communities to address environmental and policy supports for healthy eating and physical activity. These major programs include the following:

Community Transformation Grants (CTG)
State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors, and Promote School Health

There is limited systematically collected information on the types of policies and practices of local governments that encourage their residents to consume healthful diets and participate regularly in physical activity. This study will help fill this data gap. Information obtained will be relevant to multiple CDC initiatives and to other stakeholders. CDC will further use this information to evaluate the extent to which local communities are implementing strategies consistent with its recommended measures for communities and recommendations from expert groups, such as the Institute of Medicine (IOM) and the U.S. Surgeon General. Results will also help CDC learn about the characteristics of municipalities that have specific policy and practice supports for diet and physical activity and whether their implementation clusters with other supports. Local agencies may use the data collected to evaluate how they compare nationally or with other sampled municipalities of a similar geography, population size, and urban status. From this information, communities may learn which policy supports are being enacted by their peers and better understand what is most feasible toward policy and environmental interventions or solutions for healthy behaviors or choices. The disseminated information among the local jurisdictions can also serve as validation of municipalities’ efforts toward improving healthy eating and active living supports in the community.

CDC will share these data with other Federal agencies and additional colleagues. CDC has contacted U.S. Department of Housing and Urban Development (HUD), U.S. Department of Agriculture (USDA), and the National Institutes of Health (NIH) to make them aware of the study and has offered to provide the summary of findings and methodology, if requested. Aggregate data will be shared with other Federal agencies upon request. CDC will also share aggregated information on the findings through Webinars, scientific papers, and presentations. Sampled municipalities will receive individualized reports presenting findings for the municipality.

A.2.a. Privacy Impact Assessment Information

This study will collect information on policies and practices that local governments have either enacted or support that provide environmental supports for healthy eating and physical activity among community residents. The national survey questionnaire is a self-administered instrument that consists of 24 questions to obtain data on the planning documents local municipalities have; policies that are in place to support changes in the built environment that encourage physical activity; and policies that are in place to support access to healthy food and beverages, as well as breast-feeding. Sources of information for the survey items are the existing public documents within the local governments. These are generally regarded as being no greater than minimally sensitive. No sensitive information is being collected; therefore, the proposed data collection will have little or no effect on the respondents’ privacy. To facilitate the distribution of study invitation materials, the respondents’ names, e-mail addresses, mailing addresses, and telephone numbers will be collected as a part of the sampling frame. This information will be captured in a separate system and will never be part of the study data set.

A.3. Use of Improved Information Technology and Burden Reduction

The data collection uses a secure Web-based data collection and CMS as the primary method for implementing the national survey. This technology offers a number of advantages in the collection of these data. First, a Web-based methodology permits more complex routings in the questionnaire compared to a paper-and-pencil method. The Web program can implement complex skip patterns based on answers previously provided by the respondent. Errors made by a respondent due to faulty implementation of skip instructions are virtually eliminated. Thus, this approach will reduce respondent burden insofar as they will only be asked questions relevant to their situation based on previous responses and will not need to navigate complex skip patterns by hand. Second, the Web-based survey will be programmed to identify inconsistent responses and attempt to resolve them through respondent prompts. This reduces the need for most manual and machine editing, thus saving both time and money and resulting in more consistent data. In addition, it is likely that respondent-resolved inconsistencies will result in data that are more accurate than when inconsistencies are resolved using editing rules. Third, a Web-based questionnaire offers greater flexibility over other paperless survey programs, such as computer-assisted telephone interviews (CATI), because respondents can elect to do the survey from any Internet-connected computer at the time of their choosing.

Web-based technologies also permit greater efficiency with respect to data processing and analysis (e.g., a number of data processing steps, including editing, coding, and data entry, become part of the data collection process). These efficiencies save time because of the speed of data transmissions, as well as receipt of the data in a format suitable for analysis. Tasks formerly completed by clerical staff will be accomplished by the Web-based programs. In addition, the cost of printing paper questionnaires and associated shipping to respondents is eliminated. On the basis of the pilot study, approximately 1-2% of respondents are expected to elect using paper format.

All data will be electronically uploaded as surveys are completed. Security measures will be put in place to only allow respondents to enter an access ID into the Web-based survey that the system expects to receive and that has not already been used. CDC is committed to complying with the E-Government Act, 2002 to promote the use of technology.

A.4. Efforts to Identify Duplication and Use of Similar Information

CDC contacted several other Federal agencies with interests in healthy eating and active living to discuss the scope and intent of this data collection and identify any possible existing duplication of efforts, particularly the collection of data on policy and environmental supports that exist at the local or community levels. The Federal agencies that were contacted were HUD, USDA, and NIH. CDC has verified that there are no other Federal data collections that duplicate the data collection tools and methods included in this request.

CDC reviewed its own national program, CTG, to determine whether or not there was potential duplication of data collection efforts and determined that no such duplication of efforts existed (see Monitoring and Reporting System for Community Transformation Grant Awardees, OMB No. 0920-0946, exp. 8/31/2015; and Targeted Surveillance and Biometric Studies for Enhanced Evaluation of Community Transformation Grants, OMB No. 0920-0977, exp. 8/31/2016). The CTG program funds approximately 100 grantees including state and local government agencies, tribes, territories, non-profit organizations and small communities. Data collection efforts for the CTG program primarily focus on the selected communities receiving grants and do not provide a national baseline set of prevalence estimates for the policy supports of interest to CDC.

CDC also carefully reviewed the intent of NIH’s National Heart, Lung and Blood Institute (NHLBI) Healthy Communities Study, which also collects some information on community level policies (OMB No. 0925-0649, exp. 8/31/2016). However, the NHLBI study is a 5-year observational research study that focuses on determining the associations between community programs and policies and body mass index (BMI), diet, and physical activity in children and if community, family, and child factors that modify or mediate those associations. The NIH’s study collects specific data on the attributes of programs and policies most likely to impact childhood obesity, such as duration of program or policy and amount of funding tied to it. In addition, Healthy Communities Study collects children’s behaviors and weights to answer specific research questions related to childhood weight status.

In contrast, the national survey proposed by CDC focuses on the presence or absence of policies, standards, and practices under the jurisdiction of local governments that are important to monitor because of their potential to impact environments and associated behavioral and health outcomes within communities and that are consistent with recommendations of expert groups. Subsequently, a national baseline of prevalence estimates for these policy and environmental supports will be established. Although the NIH and CDC studies will collect some similar but limited data, CDC has determined that the purposes and objectives of the NIH effort do not make it feasible to use the data for CDC’s objectives. The NIH study would not provide the necessary information to satisfy CDC’s need for national and regional estimates with the desired level of precision on the selected policy supports nor provide the designated data elements for the specific types of policy and environmental supports that CDC wants to document.

Persons contacted from other federal agencies are listed below.

Sonia Arteaga

Scientific Program Specialist

National Institutes of Health

National Heart, Lung, and Blood Institute

6701 Rockledge Drive, MSC 7936

Bethesda, Maryland 20892

Type of Respondent	Data Collection Instrument	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in Hours)	Total Burden (in Hours)
City or Town Planner or Manager	National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living	3,139	1	30/60	1,570
City or Town Planner or Manager	Telephone Non-response Follow-up Contact Script	4,484	5	5/60	1,868
	TOTAL				3,438

Type of Respondent	Data Collection Instrument	Total Burden (in Hours)	Hourly Wage Rate	Respondent Cost
City or Town Planner or Manager	National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living	1570	$51.26	$80,479
City or Town Planner or Manager	Telephone Non-response Follow-up Contact Script	1,868	$51.26	$95,754
			TOTAL	$176,233

Data Collection, Analysis, and Reporting Activities	Timeline
OMB clearance received	January 2014
Data collection	January/February–April/May 2014
Preparation of SAS data file (data cleaning, processing, tabulation, and analysis using SAS software)	June–July 2014
Final data dissemination reports	June–July 2014
Final report summarizing procedures, findings, and lessons learned	July–September 2014

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Part A CBS Natl Survey_12 04 2013