Sunday, December 10, 2006

Effects of Community and Culture on Physical Activity: The lack of focus on social barriers in educational public health interventions-Laura Carlton

A multitude of health problems have been attributed in part to leading a sedentary lifestyle. In our society, many physical activity campaigns by public health officials focus on education and awareness of risks associated with inadequate physical activity. According to the Massachusetts Department of Public Health, almost 70% of the commonwealth’s population is physically inactive (1). MassMoves, a physical activity campaign run by the Massachusetts Department of Public Health, offers information for adults, children, and seniors on how exercise reduces the risk of many diseases and gives recommendations on how often to exercise (2). Many states have programs similar to MassMoves that base their campaign on educating the public on the benefits of physical activity and providing guidelines or suggestions on exercising. This educational approach, however, fails to address some of the root causes of inactivity, such as lack of access to a safe place to exercise, inability to afford expensive gym memberships or exercise equipment, and differences in social and cultural perceptions on physical activity.

Many campaigns focus primarily on walking or bicycling as easy ways to incorporate physical activity into a daily schedule. According to the National Center for Bicycling and Walking, the number of trips the average American takes on foot decreased 42% between 1975 and 1995 (3). The organization also notes that about 25% of all trips made are less than one mile in length, but 75% of these short trips are made by car. While walking and bicycling tend to be convenient and relatively inexpensive forms of exercise, the structure of many of our communities is not conducive to walking or bicycling. Cities are often designed around automobile use and don’t provide safe routes for walking or biking. Heavy traffic may make walking or biking too uncomfortable for people, as well. A study on neighborhood-based differences in physical activity levels rated neighborhoods according to their “walkability,” which included factors such as residential density, street connectivity, aesthetics and safety, and compared activity levels in high and low walkability neighborhoods. The authors found that residents of high-walkability neighborhoods had 70 more minutes of physical activity per week and a lower prevalence of obesity than residents of low-walkability neighborhoods (4).

In addition to structural barriers, perceptions on neighborhood safety may affect levels of outdoor activity in a community. Campaigns that suggest outdoor activities fail to address the fact that some people may not feel safe or comfortable being outside in their neighborhood. In an article from the Chattanooga Times, residents of an Alabama public housing project named safety or the perception of safety as the main barrier to their use of the gym that was constructed for residents and the sidewalks of the complex (5). Similarly, a study looking at perceptions of environmental supports for physical activity found that white adults who perceived less crime in their neighborhood were more likely to report meeting recommendations on walking than those who perceived more crime in their neighborhoods (6). People who want to be more physically active but do not feel safe walking or bicycling around their community may need to travel outside of their own neighborhoods to exercise. The increase in effort caused by having to travel may decrease self-efficacy, which is the best known predictor of a health behavior (7). Increased motivation would be necessary for people to change or maintain physical activity levels if they felt they had to go out of their way in order to exercise.

Apart from walking, participating in exercise usually requires some financial investment. Gym memberships, bicycles, exercise classes such as dance or martial arts, and indoor exercise equipment can be expensive. For families or individuals without much expendable income, access to exercise is limited. This is particularly true for people who don’t feel comfortable walking in their neighborhood. In a report on older adult perspectives on physical exercise, one of the environmental barriers to being physically active was program costs and lack of affordable transportation (8). Increased suggestions on activities that can be done within the home that do not require spending extra money may improve the effectiveness of public health interventions by reducing both financial and environmental barriers.

Cultural factors may also play a role in levels of physical activity and are often overlooked by exercise interventions. Physical activity levels differ across race, with Hispanics having the highest percentage of inactivity at 22.1%, compared to African-Americans at 21.5%, and whites at 11.4% (9). Different cultural values may affect physical activity levels through perceptions of exercise, prioritizing of personal health or exercise, and social acceptance of exercise. The study on environmental supports for physical activity in white and African-American adults found differences in the perception of exercise in the two groups. A large proportion of white adults identified exercise as structured physical activity performed in their leisure time, while African-American adults considered physical activity as being busy at home or work, or caring for children (6). Another study found that African-American women had trouble incorporating physical exercise into their routine because of heavy family or community responsibilities (10), which may suggest different cultural priorities. Public health interventions for exercise often suggest activities of a structured nature that require a set time out of someone’s schedule, such as walking groups. By also suggesting less structured activities that can be incorporated more easily into a daily schedule, interventions could potentially better serve the entire population. Michigan Steps Up, a state-wide health campaign, suggests activities that may reach a wider population, such as getting on or off the bus several blocks away, parking and going into businesses rather than using the drive-up window, and playing actively with children or pets (11). These activities could be accomplished within a normal daily schedule and provide a less structured alternative to increasing physical activity levels.

Social support is associated with increased physical activity (8), and different cultural or community perceptions may affect social acceptance of exercise. The study by Hooker et al. found that white adults who perceived their neighbors as physically active were more likely to be physically active themselves compared to those who did not perceive their neighbors as being physically active. In African-Americans, however, physical activity was not related to perceptions about physical activity levels of neighbors (6). In a study on physical activity in older adults, Native Americans reported that they felt strengthened and motivated by being around other Native Americans, and tended to avoid fitness facilities because of the lack of other Native Americans there (8). African-Americans tend to view a wider range of body sizes as acceptable, and may not experience as much social pressure to exercise (12).

The theory of planned behavior states that attitude, self-efficacy, and perception of the social norm of a behavior determine whether a person will perform that behavior. Different cultures and communities may have different perceptions on social norms of physical activity. For non-hispanic African-Americans and Mexican-Americans, dancing and sports like basketball and soccer are some of the top reported activities, while non-Hispanic white men favor golf (13). By offering programs that promote a diverse range of physical activity or by tailoring programs to reflect socially acceptable forms of exercise in specific neighborhoods, exercise campaigns may engage more of the population. Societal factors may also influence attitudes about physical activity. Groups that experience discrimination, such as Native Americans or African-Americans, may have lower self-esteem, and this is associated with less motivation for self-care, including exercise (8). Medical mistrust exists in minority cultures due to unethical practice and unequal treatment, and this mistrust may extend to guidelines and recommendations for physical activity. For educational physical activity interventions to be effective, public health practitioners may need to recruit community members to provide a trust-worthy source of education in their neighborhoods.

Overall, “one-size-fits-all” educational physical activity interventions by public health agencies can not be effective because of social and environmental differences in target populations. In order for a physical activity intervention to be successful, a collaborative effort must be made to address underlying causes of inactivity on a community level, such as neighborhood structure and the cultural background of the population. Efforts that directly address these causes, such as improving the walkability of a community or offering exercise programs suited to the cultural background of a neighborhood, should be the new focus of physical activity interventions in public health.


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