C3EN is delighted to announce that Activity and Recreation in Communities for Health (ARCH), led by Brad Appelhans, Professor of Family and Preventive Medicine at Rush University Medical Center and C3EN Investigator Development Core co-director, in partnership with Paris Thomas, executive director of Equal Hope, a Chicago not-for-profit organization focused on eliminating health inequities, has received funding from NIH to study a novel approach to reducing depressive symptoms and lowering cardiometabolic risk.

The project also features partnerships with several Chicagoland organizations that provide recreational programming, including the Chicago Park District, YMCA of Metropolitan Chicago, West Cook YMCA, New Life Centers of Chicagoland, Greater Auburn-Gresham Development Corporation’s Healthy Lifestyle Hub, and the Salvation Army’s Ray and Joan Kroc Corps Community Center.

An intervention for people with depression and physical inactivity or extra weight in underresourced communities, ARCH will supply funding for recreation, partly through community organizations that support recreational activities, and partly as funds free to be used by participants to support recreation of their choice, such as purchasing supplies for art, cooking, or gardening. By increasing access to rewarding activities, the study aims to reduce unhealthy behaviors such as consuming junk food and using electronic devices that contribute to obesity and depression. A comparison group will receive a traditional health outreach program that includes screening for social determinants of health and referrals to mental health care and social care resources. Over a four-month study period, researchers will monitor changes in depressive symptoms, activity levels, and weight.

“The communities that C3EN has engaged with through town halls have said that mental health and access to care are the two areas they need the most help with,” says Appelhans. “ARCH does that in two ways: it’s a depression treatment, and it also overcomes the barriers to accessing care because it’s delivered as an outreach program by community health workers so people will never have to come to a medical center.”

ARCH will be incorporated into the an outreach, education, and patient navigation program at advocacy organization Equal Hope, which was initially established 16 years ago to address the 62% higher rate of mortality for Black women with breast cancer in Chicago and now serves patients of all genders who need primary care. “We hire community health workers and patient navigators from the west and south side of Chicago and give them the tools to be able to go out and spread education throughout the community,” says Thomas. “They are individuals with lived experiences, who are trusted by and able to connect to the community.” Because Equal Hope patient navigators and community health workers keep patients engaged with care as they lose or gain benefits and other forms of access, they will stay in contact with patients throughout the intervention. “I’m hoping that Equal Hope can help not only get people involved in the project but also be a resource by providing additional support that patients need, whether it be resources for depression or cardiometabolic health,” she says.

The ARCH intervention is based on behavioral activation, a therapy that involves practicing activities that promote pleasure, mastery, social connection, and personal values to improve how patients feel. “Recreation is really important in behavioral activation,” says Appelhans. “Behavioral activation focuses on helping people with depression re-engage with rewarding experiences in their daily lives. With depression, people tend to withdraw from social activities and things they like. A symptom of depression is finding things less enjoyable, so there’s a vicious cycle of withdrawing from the world—then your brain’s reward circuits get suppressed, so people withdraw further. Behavioral activation tries to help people take baby steps to rekindle that reward circuit in the brain and support them as they start to do rewarding activities again to break through the barrier of being unmotivated. It’s very much about doing activities that are rewarding. That can include activities that are just enjoyable, like seeing a movie or getting a massage, but they can also be activities that provide a sense of accomplishment or mastery, so that might be something like cleaning out a closet or painting a fence.”

Mustering the energy to participate in fulfilling activities is challenging for many with depression, but behavioral activation therapy includes strategies to combat counterproductive patterns and set goals. “Part of the therapy is helping people talk back to self-defeating thoughts like, ‘Oh, this will be annoying!’ ‘I’m not going to enjoy it,’ and so on,” says Appelhans. “We give people things to say to themselves when they notice those thoughts. And we try to help them identify activities that align with their values and possibly other areas like their career goals.”

The project is part of a longstanding interest in the relationship between rewarding activities, physical activity, and obesity. While conducting a childhood obesity trial (CHECK – Creating Healthy Environment for Chicago Kids) early in the COVID-19 pandemic, Appelhans and collaborators found that children homebound during the quarantine increased their consumption of junk food and screen time. “They really just didn’t have access to the other types of rewarding activities that would usually pull them away from those things—all the kids gained weight, the parents gained weight. Kids that had been previously losing weight started gaining weight at a pretty high rate,” he says. “A lesson that extends beyond the pandemic is that high-value rewarding activities might be important for pulling people away from food and sedentary activities.”

Engaging in rewarding activities not only promotes weight loss but also contributes to emotional satisfaction. “People are overeating, drinking, and watching TV not because they really love those things, but because it’s the most accessible and most convenient form of reward compared to things that are more rewarding but take a little effort,” he says. “Imagine you’re really into bird watching. To do that, you have to wait for the right time, make a plan, clear your schedule, pack a little lunchbox, and then go do it—but you could just fire up your phone and scroll through TikTok. I think when people realize they’re doing a lot of things not because they really want to but because they’re just available, and if they put a little effort in, they can get a higher payoff, that’s when we can help ease them into those things.”

If ARCH proves effective, making the intervention accessible to more people is the next step for C3EN—potentially by integrating the program into the existing education and outreach programs at Equal Hope or by delivering the program through the recreational centers currently partnering on the project. “The Chicago Park District and the YMCA already have a lot of health programming,” notes Appelhans, citing the Diabetes Prevention Program at the YMCA and the wellness program at CPD. “Part of this project is dedicated to sustainability planning in parallel to running the actual study. We are measuring some implementation-related variables, including cost and fidelity (the degree to which programs can be delivered as designed in real world settings). A big goal of ours is for ARCH to survive past the life of the project and past the grant.”

While ARCH seeks to reduce barriers to recreation by providing education and funding for people to explore opportunities for fulfilling activities, ultimately the success of the program depends on a strong connection with communities and the community health workers that serve them through Equal Hope and other partners. “Community health workers have a lot more on the ground knowledge about their communities—we’re hoping that their local knowledge will really facilitate this work,” says Appelhans.