Physical Activity Promotion in the Community

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Original Editor - Karen Wilson

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Introduction

Physical inactivity is a public health issue affecting communities worldwide. With increasing mechanization and use of motorized transport, unplanned urbanization and an aging population, physical inactivity is on the rise, even in low- and middle-income countries. This trend is worrisome as physical inactivity has negative implications for general health.

Evidence shows that physical inactivity puts people at increased risk for obesity, decreases life expectancy and increases the risk for noncommunicable diseases (NCDs) such as coronary heart disease, type 2 diabetes and breast and colon cancer. Lee et al estimate that 6-10% of the aforementioned NCDs and 9% of premature mortality can be attributed to sedentary behavior. Likewise, the World Health Organization sites physical inactivity as the 4th leading risk factor for global mortality.

In light of these circumstances, the potential gains of promoting physical activity at the community level are great. If all inactive persons became active, 6% of the global burden due to coronary heart disease could be eliminated. For type 2 diabetes and breast and colon cancers, this translates to a 7% and 10% decrease in their global burden, respectively. Even with a 25% decrease in physical inactivity, 1.3 million global deaths could be averted annually. These figures make physical activity promotion a global health imperative.

Strategies to Promote Physical Activity In the Community

Physical activity is a complex behavior with multiple determinants. Effective promotion at the community level requires the implementation of culturally sensitive, multi-component interventions that make it easier for people to stay active. The following is a summary of selected, evidence-based strategies supported by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO):

• Community-wide campaigns: Community-wide campaigns utilize mass media, environmental changes (see below for policy and environmental supports) and community outreach (ex. screenings, health fairs, walking groups) to promote physical activity.To be effective, such campaigns require strategic partnerships with local agencies and organizations,(CDC) simple messaging that can be adapted to different sectors of the community (what works) and frequent exposure over an extended period of time.(CDC, what works)  The UNC Center for Health Promotion and Disease Prevention, Center for Training and Research Translation provides additional resources regarding the nature and tips for implementing this strategy.

• Policy and environmental supports: Policy and environmental supports are what set the stage for "downstream " health promotion activities and and individual behavior change. In the realm of physical activity, this involves employing town/street design, land-use policies and local regulations in a way that enables active living. Sample interventions include building sidewalks and bike lanes for active transport to school and work, enacting zoning policies that ensure easy access to parks and play facilities and establishing regulations that institutionalize robust physical education requirements in schools.

• Community-based programs: Community-based programs target neighborhoods, families and other relevant social groups to increase physical activity. Effective programs often utilize peer-support or group-based classes to encourage a more active lifestyle among relatively homogenous groups. Religious communities, work sites, recreation centers and older adult groups are settings in which physical activity promotion has been integrated into existing social networks with success. The program itself should have a strong educational component, be based on theory and focus on facilitating behavior change through multiple activities.

• Individually adapted health behavior change programs: The focus of individually adapted behavior change programs is to provide tailored information regarding physical activity promotion. In diverse populations, these programs permit for the consideration of personal interests, special needs and readiness for change in way that community-based programs cannot. Individually adapted programs are often implemented in clinical or health/fitness settings amongst a small group of people or one-on-one. Personal advice/counseling from a health coach or primary care provider fall into this category.

• School-based programs: Schools provide a built-in platform for reaching children and adolescents regarding physical activity. Enhanced physical education (PE) classes can help youth meet physical activity guidelines and teach skills that lay the foundation for physically active lifestyles in adulthood. Improving PE not only involves increasing the frequency and duration of classes, but also addressing quality issues regarding curriculum content. These efforts should be complemented by parental involvement and diet/physical activity curriculum taught by trained school staff.

Special Considerations for Program Development

No two communities are the same. The focus and messaging of physical activity promotion should vary based on key characteristics of the target audience and environment. Among the most important factors are the target audience's age, culture and country setting.

Age

Physical activity recommendations vary depending on stage of life. For children 5-17 years old, physical activity promotion should emphasize the adoption of active community transport, enhanced physical education and leisure time play, games and sports. Expansion of physical activity promotion into occupational activities, household chores and planned exercise is more appropriate for adults between the ages of 18 and 64 years old. In this age range, education should stress low-risk, moderate-intensity activities with a progressive increase in dose. In adults 65 and older, physical function can vary widely. For individuals with low fitness levels, moderate-intensity activities can be divided into shorter bouts to help meet recommendations for time spent being active.

Culture

Culture plays a huge role in social norms, language, religious values, gender roles and existing patterns of participation in physical activity. All of these factors are important for successful program development. For example, in communities with significant gender inequality, physical activity programming may need components specifically tailored to the needs and barriers faced by women. In multi-ethnic communities, educational materials may need to be translated into multiple languages to adequately reach all sectors of the target audience. Likewise, if religion plays a large role in community life, messaging should be sensitive to relevant values and social norms.

Country setting

Outside of culture, effective physical activity promotion should to be adapted to the country setting. The  security situation, stage of development, geography, role of municipalities/local leadership, seasons and climate should all be accounted for during program planning and implementation. For instance, in low- and middle-income countries, physical activity is more common during occupational and transportation tasks in comparison to leisure time. In this scenario, policy and environmental changes that reduce the former should be used with caution.

Implications for Physical Therapist Practice

Physical Therapists (PTs) have the capacity to contribute to various components of physical activity promotion. Considering the paucity of health promotion in current physical therapist practice, the first step may be to seek continuing education opportunities in public health skills such as motivational interviewing and behavior change theory. In the clinic, PTs can complement routine care with advice/counseling regarding the following:

1. The benefits of physical activity and recommended guidelines.
2. How to perform exercise, set goals and monitor outcomes.
3. Resources for being physically active in the community.
4. Building social support.
5. Strategies to cope with setbacks and barriers to physical activity.

In particular, PTs possess the clinical expertise to apply these competencies to persons with musculoskeletal conditions caused by and/or exacerbated by sedentary behavior and the special needs of persons with chronic conditions (ej. cardiovascular disease, diabetes), individuals with disability and older adults.

Outside of the clinic, PTs can help with the development and implementation of environmental changes, policies and programs that promote active living. Bezner advocates PTs being involved in community events and serving as consultants for the design of accessible public spaces. On an organizational level, she recommends participation in government initiatives, creation of resources to help PTs add promotion to their professional practice and better integration of health promotion competencies into PT education curriculum. In light of the current global health landscape, there's no better time for physical therapists to embrace the primary prevention of physical inactivity than now.

Resources

• The Motivate2Move website, created by Wales Deanery, sedentary behaviour.
• The CDC Guide to Strategies to Increase Physical Activity
• Interventions on Diet and Physical Activity: What Works