- Email: [email protected]
Physical Activity Preferences, Preferred Sources of Assistance, and Perceived Barriers to Increased Activity among Physically Inactive Australians
26, 131–137 (1997) PM960116
PREVENTIVE MEDICINE ARTICLE NO.
Physical Activity Preferences, Preferred Sources of Assistance, and Perceived Barriers to Increased Activity among Physically Inactive Australians1 MICHAEL L. BOOTH, PH.D.,*,2 ADRIAN BAUMAN, PH.D.,† NEVILLE OWEN, PH.D.,‡
AND
CHRISTOPHER J. GORE, PH.D.§
Department of Public Health and Community Medicine, University of Sydney, Sydney, New South Wales 2006; †School of Community Medicine, University of New South Wales, Kensington, New South Wales 2033; ‡School of Human Movement, Deakin University, Barwood, Victoria 3125; and §Australian Sports Commission, Adelaide, South Australia, Australia
Background. Participation in regular moderate or vigorous physical activity substantially reduces risk for all-cause and cardiovascular-disease mortality and confers other health benefits. Efforts to decrease the population prevalence of inactivity will have a greater impact if they are tailored to the needs and preferences of the community. Methods. In the Pilot Survey of the Fitness of Australians, a questionnaire was administered to a randomlyselected sample of 2,298 adults and included questions on the preferred sources of assistance or support to become physically active, preferred activities, and barriers to regular participation. The responses of those who were identified as insufficiently physically active (n = 1,232; 53.6%) were examined for men and women separately and for those aged 18 to 39, 40 to 59, and 60 to 78 years. Results. The most-preferred activity was walking (38 and 68% of the youngest and oldest age groups, respectively). The most frequently cited barriers to moreregular participation in the youngest age group were insufficient time, lack of motivation and child care responsibilities. Among those aged 60 to 78 years, injury or poor health were the most frequently cited barriers to activity. The most-preferred source of advice or assistance changed with age: more than 50% of the oldest age group wanted advice from a health professional (compared with 22% of the youngest group) and the opportunity to exercise with a group was the most preferred source of support for the youngest age group. Conclusions. The physical activity-related attributes of men and women and of younger and older age 1 The 1990–1991 Pilot Survey of the Fitness of Australians, from which the data reported here were drawn, was funded by the Commonwealth Department of Art, Sport, the Environment, Tourism and Territories. The authors conceived the present study and conducted the analyses. 2 To whom reprint requests should be addressed at the Department of Public Health and Community Medicine A27, University of Sydney, New South Wales 2006, Australia. Fax: 61-2-351-7420; Email: [email protected].
groups described in this study may be used to provide more relevant and appealing options for those who might otherwise be missed by ‘‘one-size-fits-all’’ physical activity promotion strategies. © 1997 Academic Press Key Words: exercise, physical; health promotion; health behavior.
INTRODUCTION
Efforts to promote participation in physical activity are likely to be most effective if they address the needs and interests of particular target groups. Health promotion planning models emphasize the importance of using such information systematically [1]. Knowledge of the types of activities in which people would prefer to participate is of value in planning communication campaigns, in planning intervention programs (for example, in worksites), in town planning and urban design, and in the development of specific facilities. It is important to know the type of advice or support that people would prefer to assist them to initiate or maintain habitual physical activity, for informing the training of professionals and for determining priorities in service provision and public policy. Regardless of how firmly people may believe that physical activity is beneficial to their health, there are many barriers that may limit or prevent regular activity. Whether these barriers are real or perceived, they represent significant potential obstructions to the adoption, maintenance, or resumption of participation in physical activity. More comprehensive understanding of preferred activities, preferred sources of assistance, and barriers to increased activity will improve efforts to foster increased participation in physical activity. There do not appear to be any reports in the literature on the preferred activities of sedentary people. Similarly, little is known about people’s preferred sources of assistance for becoming more physically active. Public health approaches to increasing participation aim to activate the sedentary, but the very inac-
131 0091-7435/97 $25.00 Copyright © 1997 by Academic Press All rights of reproduction in any form reserved.
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tive are less likely to want to attend structured or group-based programs [2] and may be more interested in self-help or home-based methods [3]. Research on other health behaviors is particularly informative: for example, a study of Australian’s preferences for assistance with smoking cessation found that physician advice was strongly preferred and that women were more likely than men to want to attend group-based programs [4]. There exists a modest literature on the barriers to increased physical activity. Sallis and colleagues, in a large community-based study, examined 24 potential determinants of physical activity, including a measure of the frequency with which different factors prevented people exercising (barriers) [5]. They found that ‘‘barriers to activity’’ was most strongly and negatively associated with selfreported vigorous activity among younger men and women and among older men, and was the second most strongly associated variable among older women. However, when the same data were examined for correlates of walking for exercise, barriers to activity was not a significant factor [6]. Two years later the same researchers resurveyed the initial respondents and found that barriers to activity was strongly related to the adoption of vigorous activity over that period [7]. These findings suggest that barriers to activity represents an important determinant of participation in vigorous activity, but that barriers may be of less relevance to walking for health or exercise. Four studies, conducted on samples from three developed countries, have attempted to identify the prevalence of specific barriers to physical activity participation. Godin and colleagues examined the relative importance of five barriers in a community sample of adults [8]. They found that the order of importance of the barriers was finding time, finding a partner to exercise with, physical health problems, the financial cost, and lack of access to appropriate facilities. Another Canadian study of barriers to activity compared women who were sedentary, but who wanted to start exercise, with active women who wanted to do more [9]. There were no substantial differences between the two groups. Lack of time was the most frequently cited barrier to activity, followed by physical health reasons, lack of energy/motivation, child care responsibilities, and, finally, cost/access to facilities. A similar study among a sample of women in the United States found that lack of time was the most frequently identified barrier followed by lack of money, lack of facilities, and lack of an exercise partner [10]. Using pooled data from 17,053 participants in three population surveys conducted in the mid-1980s, an earlier Australian study identified 29.7% of the sample as sedentary in their recreational physical activity habits [11]. The three most commonly reported reasons for inactivity were no time (35%), physically unable (24%), and ‘‘don’t want to exercise’’ (13%). Such data sug-
gested different subgroups of the inactive, as a function of age and gender, who may require different strategies to encourage them to adopt regular physical activity. No time, being physically unable, and not wanting to exercise were more likely to be reported by those who were older and who had lower incomes; the only exception was that being 55 years or older was not associated with having less time. Women were more likely to report being physically unable to exercise. Lower income was associated with being physically unable and with not wanting to exercise. Those with children, while wanting to exercise, were more likely to report having no time. The results of these studies suggest that perceived lack of time, poor health or injury, lack of motivation, and lack of facilities are the most prevalent barriers. The results also suggest that the prevalence of different barriers may vary across age groups and between genders. The 1990–1991 Pilot Survey of the Fitness of Australians asked respondents to a population survey (N 4 2,298) to identify the physical activities in which they would prefer to participate, the sources of support or assistance they would prefer to become more active, and the barriers they perceived as preventing them from becoming more active [12]. A self-report measure of leisure-time physical activity was used to classify respondents as sufficiently active (to gain the health benefits associated with physical activity) or as insufficiently active [12,13]. We examined the activity preferences, the preferred sources of support, and the barriers to regular participation in physical activity reported by insufficiently active respondents to the Australian survey, separately for men and women and for those aged 18 to 39, 40 to 59, and 60 to 78 years. METHODS
Survey Methods A sample of Australian adults was drawn from metropolitan Adelaide, South Australia, using a two-stage systematic random sampling procedure generated by the Australian Bureau of Statistics (ABS) and designed to oversample older people. Stage 1 was a computerized random selection of Census Collectors’ Districts. Stage 2 comprised random selection of a start point and a predetermined skip between dwellings. Within a chosen dwelling every individual age 45 years and older and every second person age 18–44 years was selected. A more detailed description of the sampling methods has been published elsewhere [14]. Informed consent was obtained from all participants. The questionnaire was administered in the respondents’ homes by trained interviewers employed by the ABS. The project was approved by the University of Adelaide Human Ethics Committee.
PHYSICAL ACTIVITY PROMOTION
Measures For the measure of leisure-time physical activity, respondents were presented with a list of 20 common leisure-time activities and asked to identify up to 5 activities in which they had participated over the previous 2 weeks, state the frequency, average duration, and perceived intensity (on a 4-point scale) of participation in each activity. The rate of energy expenditure for each intensity of participation for each activity, in metabolic equivalents, was multiplied by the total time engaged in the activity over the past 2 weeks. The resultant values were expressed as kcal z day−1 z kg−1. These values were summed to yield a total energy expenditure which was used to classify respondents into one of two categories: sufficiently (ù1.8 kcal z day−1 z kg−1) and insufficiently (<1.8 kcal z day−1 z kg−1). This measure of physical activity has been found to have acceptable reliability and validity [15,16]. The insufficiently active group did not meet the criterion of an equivalent of 30 min per day of moderateintensity activity such as walking [17,18]. Respondents were asked what activities they would most like to do if they were to exercise (or to exercise more if they were already active). A list of nine activities (walking, swimming, team sports, racquet sports, jogging, gym, aerobics, cycling, and other) were available to choose from and multiple choices could be made. These activities had been found to account for most leisure-time physical activity in earlier Australian surveys [19]. Respondents were also asked what type of help they would prefer if they were to exercise more or to take up exercise, based on the findings of an earlier Australian study of smokers’ preferred sources of assistance to quit [4] and following pretesting by the ABS. Eight alternate responses were offered (abbreviations used in the figures are shown in parentheses): Advice from doctor or other health professional (med advice), a group of other people to exercise with (group), advice over the telephone (telephone), a videotape on exercise (video), a book on how to exercise (book), an exercise ‘‘kit’’ with pamphlets and practical tips (help kit), a course sent through the mail (mail), and no form of assistance (none). Finally, respondents were shown a list of 19 reasons for not exercising (more) than they did currently and asked which applied to them. The barrier response options were based on those used in an earlier Australian study [11] and were modified and extended following pilot testing of the questionnaire, during which respondents were encouraged to identify barriers to physical activity participation. More than one reason (barrier) could be selected. RESULTS
The data are presented for all respondents, for men and women and for 20-year age groups (18 to 39 years, 40 to 59 years, and 60 to 78 years) for those who were
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insufficiently active (n 4 1,232; 53.6% of the sample) to achieve most of the health benefits associated with regular physical activity. Preferred Activities Figure 1 (left) illustrates preferred activities for all insufficiently active respondents and for insufficiently active men and women separately. More than half of the respondents said that their most preferred activity was walking. The next two most popular choices were swimming (nominated by 14% of respondents) and team sports (nominated by 7% of respondents). Of the remaining activities, none was nominated by more than 4% of the respondents. More women than men tended to nominate walking and aerobics and more men than women nominated each of the other activities, although the differences were not large for any particular activity. Figure 1 (right) illustrates the same data for the three age groups. A large proportion (38%) of the youngest age group selected walking as the preferred activity, but substantial proportions also identified swimming (19%) and team sports (15%). Eight percent of the youngest age group nominated jogging or going to a gym and less than 5% nominated any of the remaining activities. Of those aged 40 to 59 years, 67% nominated walking and 10% nominated swimming. Less than 5% nominated the remaining activities. In the oldest age group, 68% preferred to walk for exercise and 13% preferred swimming. Preferred Sources of Support Figure 2 (left) illustrates preferred sources of support for all insufficiently active respondents and for men and women separately. The two most preferred sources of help were to receive advice on appropriate activities from doctors or other health professionals (38% of all respondents) or to have the opportunity to exercise with a group (31% of all respondents). Although slightly more women than men wanted to exercise with a group and slightly more men than women wanted professional advice on appropriate activities, the differences were small. Approximately 20% of all respondents did not want any advice or support. Figure 2 (right) illustrates the preferred sources of support among the insufficiently active for three age groups. Among those aged 18 to 39 years, more than 40% wanted to be able to exercise with a group, but this was the case for only 27% of 40- to 59-year-olds and for fewer than 20% of those aged 60 to 78 years (x2 4 65.4, df 4 2, P < 0.01). More than 50% of those ages 60 or more years wanted professional advice, 41% of 40- to 59-year-olds wanted professional advice, but only 22% of the youngest age group preferred advice from a health professional (x2 4 68.6, df 4 2, P < 0.01).
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FIG. 1. Preferred activities for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right).
Barriers to Activity Figure 3 (left) shows the barriers for all insufficiently active respondents and for men and women separately. The most frequently cited barrier to participation was lack of time (almost 40% of all respondents) and almost 30% felt that they lacked motivation to exercise. Approximately 20% of respondents had an injury or disability that prevented them from being active and a similar proportion perceived themselves as not being ‘‘the sporty type.’’ Between 10 and 20% preferred to rest, lacked company for exercise, cared for young children, had poor health, felt that they lacked persistence, lacked sufficient energy, or couldn’t afford to exercise. Each of the remaining barriers was nominated by less than 10% of the respondents. Substantially more men than women wanted to rest and relax in their free time, but more women than men nominated each of the other barriers. Figure 3 (right) shows the barriers among insufficiently active respondents for three age groups. The figure illustrates large differences between different age groups in the perceived barriers to participation in physical activity. Approximately 45% of the two youngest age groups felt they did not have enough time for physical activity, but only 20% of the oldest age group felt time to be a barrier (x2 4 70.6, df 4 2, P < 0.01). Similarly, 35% of the youngest age group and 30% of 40- to 59-year-olds felt unmotivated to become active,
but only about 16% of the oldest group lacked motivation (x2 4 32.3, df 4 2, P < 0.01). An injury prevented less than 20% of the youngest groups from being active, but it was a barrier for nearly 40% of the oldest age group (x2 4 57.4, df 4 2, P < 0.01). Similarly, a higher proportion of the oldest group (27%) reported poor health as a barrier to activity, compared with about 10% of the two younger groups (x2 4 56.6, df 4 2, P < 0.01). One-third of the youngest group reported that responsibility for child care was a barrier for them, but only a small proportion of the two older groups was constrained by responsibility for children. Only 20% of those aged 60 to 78 years felt they were too old to be active. DISCUSSION
The most-preferred activity among those respondents who were insufficiently active was walking, even in the youngest age group. Swimming was the next most-preferred activity for all age groups, followed by team sports. None of the remaining activities were nominated by more than 10% of any group of respondents. Given these findings and the recent evidence that regular walking (about 30 min per day) provides most of the cardiovascular health benefits associated with physical activity it is clear that any public health approach to promoting greater participation in physical activity would do well to focus on walking [18]. The
PHYSICAL ACTIVITY PROMOTION
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FIG. 2. Preferred sources of support to initiate activity for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right).
very low proportions of respondents who nominated gym, racquet sports, or aerobics as their preferred activity and that nominated lack of facilities or equipment as important barriers to participation indicates that increased public health investment in the provision of such specific indoor exercise facilities may not be warranted, at least in Australia. In countries with more extreme climatic conditions (particularly very cold winters) this may be less likely to be the case. With regard to potential sources of assistance or support to become active, preference for advice from a doctor or health professional increased with increasing age and the preference to be able to exercise with a group was common among younger people, decreasing with increasing age. Older people were significantly less likely to want to exercise in a group. This finding may be of some public health importance. Group-based approaches for inactive older people may be a strategy which is not generally appealing. We would even offer the speculation that groups may attract only those older people who already are active. With regard to barriers to participation in physical activity, the younger age groups were more likely to report that time, motivation, and child care responsibilities were barriers, whereas a much greater proportion of older people reported that injury or poor health were barriers to becoming active. These findings may usefully
inform the development of strategies to promote higher levels of participation in physical activity. Any strategy would do well to place an emphasis on walking, regardless of whether it involves social marketing, environmental change, or policy development. Although having insufficient time to be active appears to be a difficult barrier to overcome, people may be encouraged to integrate walking with other daily activities such as work, commuting, and child care. The promotion of swimming and team sports may be worthwhile, but are likely to have a smaller impact. Strategies which target younger people could promote walking and other activities and should seek to create opportunities for group activities. Strategies which target older people may best be promoted through general medical practitioners with an emphasis on walking, but with the provision of advice on activities appropriate to the individual’s health status [20]. For example, many older people with arthritis may believe that they should remain sedentary, whereas supervised activity in warm water may be beneficial. Comprehensive, community-wide exercise promotion strategies are likely to have a greater impact if they are tailored to the attributes of key target groups [21]. Our findings particularly highlight how different older people are from those who are younger, on a num-
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FIG. 3. Barriers to participation in leisure-time physical activity for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right). The list of barriers is shown in the Appendix.
ber of attributes relevant to prompting and providing appropriate opportunities to be active. An earlier study found older people were much more likely to be precontemplators (not active and no intention to become active) for exercise [22]. But it should not be assumed that these attributes of older people mean that they are not likely to be responsive to activity campaigns or programs. For example, a nationwide physical activity campaign in Australia in 1990 had its most significant impact on people who were older and less well educated, although no such effects were apparent in a follow-up campaign in 1991 [23,24]. The physical activity-related preferences and barriers of men and women and of younger and older age groups we have described here should not be interpreted primarily as constraints or inherent limitations. Rather, they help to identify modifiable preferences and perceptions, which may be used to provide more relevant and appealing options for those who might otherwise be missed by ‘‘one-size-fits-all’’ strategies [13,21]. APPENDIX
List of reasons (barriers) provided to respondents (abbreviations used in the figures are shown in parentheses): I haven’t got time (no time). My health is not good enough (poor health). There’s no one to do it with (no company). I can’t afford it (can’t afford). I’m too old (too old). I have an injury or disability that stops me (injury).
I’m too shy or embarrassed (too shy). I’m not the sporty type (not sporty). There’s no suitable facilities nearby (no facilities). I need to rest and relax in my spare time (need rest). I’ve got young children to look after (children). I’m too lazy/not motivated/can’t get started (no motivation). I might get injured or damage my health (fear injury). I don’t enjoy physical activity (don’t enjoy). I haven’t got the right clothes or equipment (no equipment). I’d never keep it up (lack persistence). I’m too fat (too fat). I haven’t got the energy (no energy). Other (other). REFERENCES 1. Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. London: Mayfield Pub., 1991. 2. King AC. Clinical and community interventions to promote and support physical activity participation. In: Dishman RK, editor. Advances in exercise adherence. Champaign (IL): Human Kinetics, 1994:183–212. 3. King AC, Haskell WL, Taylor CB, Kraemer HC, DeBusk RF. Group- versus home-based exercise training in healthy older men and women: a community-based community trial. JAMA 1991;266:1535–42. 4. Owen N, Davies N. Smokers’ preferences for assistance with cessation. Prev Med 1990;19:424–31. 5. Sallis JF, Hovell MF, Hofstetter CR, Faucher P, Elder JP, Blanchard J, et al. A multivariate study of determinants of vigorous exercise in a community sample. Prev Med 1989;18:20–34.
PHYSICAL ACTIVITY PROMOTION 6. Hovell MF, Sallis JF, Hofstetter CR, Spry VM, Faucher P, Caspersen CJ. Identifying correlates of walking for exercise: an epidemiologic prerequisite for physical activity promotion. Prev Med 1989;18:856–66. 7. Sallis JF, Hovell MF, Hofstetter CR, Barrington E. Explanation of vigorous physical activity during two years using social learning variables. Soc Sci Med 1992;34:25–32. 8. Godin G, Desharnais R, Valois P, Lepage L, Jobin J, Bradet R. Differences in perceived barriers to exercise between high and low intenders: observations among different populations. Am J Health Promot 1994;8:279–85. 9. Yoshida KK, Allison KR, Osborn RW. Social factors influencing perceived barriers to physical exercise among women. Can J Public Health 1988;79:104–8. 10. Johnson CA, Corrigan SA, Dubert PM, Gramling SE. Perceived barriers to exercise and weight control practices in community women. Women Health 1990;16:177– 91. 11. Owen N, Bauman A. The descriptive epidemiology of a sedentary lifestyle in adult Australians. Int J Epidemiol 1992;21:305–10. 12. Department of Art, Sport, the Environment and Territories. Pilot Survey of the Fitness of Australians. Canberra: Australian Govt. Publishing Service, 1992. 13. Department of Environment, Sport and Territories. Active and inactive Australians: assessing and understanding levels of physical activity. Canberra: Australian Govt. Publishing Service, 1995. 14. Gore CJ, Owen N, Bauman A, Booth M. Methods of the Pilot Survey of the Fitness of Australians. Aust J Sci Med Sport 1993; 25:80–3. 15. Booth ML, Owen N, Bauman AE, Gore CJ. Retest reliability of recall measures of leisure-time physical activity in Australian adults. Int J Epidemiol 1996;25:153–9.
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16. Booth ML, Bauman A, Owen N, Gore CJ. Relationship between a fourteen-day recall measure of leisure-time physical activity and a submaximal test of physical work capacity in a population sample of Australian adults. Res Q Exerc Sport. In press. 17. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402–7. 18. Blair SN, Kohl HW, Gordon NF, Paffenbarger RS Jr. How much physical activity is good for health? Annu Rev Public Health 1992;13:99–126. 19. Bauman A, Owen N, Rushworth RL. Recent trends and sociodemographic determinants of exercise participation in Australia. Community Health Studies 1990;XIV:19–26. 20. Long BJ, Calfas KJ, Wooten WJ, Sallis JF, Patrick K, Goldstein M, et al. A multisite field test of the acceptability of physical activity counselling in primary care—Project PACE. Am J Prev Med 1996;12:73–81. 21. Donovan RJ, Owen N. Social marketing and population interventions. In: Dishman RK, editor. Advances in exercise adherence. Champaign (IL): Human Kinetics, 1994:249–90. 22. Booth ML, Macaskill P, Owen N, Oldenburg B, Marcus B, Bauman A. Population prevalence and correlates of stage of change in physical activity. Health Educ Q 1993;20:431–40. 23. Booth M, Bauman A, Oldenburg B, Owen N, Magnus P. Effects of a national mass-media campaign on physical activity participation. Health Promo Int 1992;7:241–7. 24. Owen N, Bauman A, Booth M, Oldenburg B, Magnus P. Serial mass-media campaigns to promote physical activity: reinforcing or redundant? Am J Public Health 1995;85:244–8.
PREVENTIVE MEDICINE ARTICLE NO.
Physical Activity Preferences, Preferred Sources of Assistance, and Perceived Barriers to Increased Activity among Physically Inactive Australians1 MICHAEL L. BOOTH, PH.D.,*,2 ADRIAN BAUMAN, PH.D.,† NEVILLE OWEN, PH.D.,‡
AND
CHRISTOPHER J. GORE, PH.D.§
Department of Public Health and Community Medicine, University of Sydney, Sydney, New South Wales 2006; †School of Community Medicine, University of New South Wales, Kensington, New South Wales 2033; ‡School of Human Movement, Deakin University, Barwood, Victoria 3125; and §Australian Sports Commission, Adelaide, South Australia, Australia
Background. Participation in regular moderate or vigorous physical activity substantially reduces risk for all-cause and cardiovascular-disease mortality and confers other health benefits. Efforts to decrease the population prevalence of inactivity will have a greater impact if they are tailored to the needs and preferences of the community. Methods. In the Pilot Survey of the Fitness of Australians, a questionnaire was administered to a randomlyselected sample of 2,298 adults and included questions on the preferred sources of assistance or support to become physically active, preferred activities, and barriers to regular participation. The responses of those who were identified as insufficiently physically active (n = 1,232; 53.6%) were examined for men and women separately and for those aged 18 to 39, 40 to 59, and 60 to 78 years. Results. The most-preferred activity was walking (38 and 68% of the youngest and oldest age groups, respectively). The most frequently cited barriers to moreregular participation in the youngest age group were insufficient time, lack of motivation and child care responsibilities. Among those aged 60 to 78 years, injury or poor health were the most frequently cited barriers to activity. The most-preferred source of advice or assistance changed with age: more than 50% of the oldest age group wanted advice from a health professional (compared with 22% of the youngest group) and the opportunity to exercise with a group was the most preferred source of support for the youngest age group. Conclusions. The physical activity-related attributes of men and women and of younger and older age 1 The 1990–1991 Pilot Survey of the Fitness of Australians, from which the data reported here were drawn, was funded by the Commonwealth Department of Art, Sport, the Environment, Tourism and Territories. The authors conceived the present study and conducted the analyses. 2 To whom reprint requests should be addressed at the Department of Public Health and Community Medicine A27, University of Sydney, New South Wales 2006, Australia. Fax: 61-2-351-7420; Email: [email protected].
groups described in this study may be used to provide more relevant and appealing options for those who might otherwise be missed by ‘‘one-size-fits-all’’ physical activity promotion strategies. © 1997 Academic Press Key Words: exercise, physical; health promotion; health behavior.
INTRODUCTION
Efforts to promote participation in physical activity are likely to be most effective if they address the needs and interests of particular target groups. Health promotion planning models emphasize the importance of using such information systematically [1]. Knowledge of the types of activities in which people would prefer to participate is of value in planning communication campaigns, in planning intervention programs (for example, in worksites), in town planning and urban design, and in the development of specific facilities. It is important to know the type of advice or support that people would prefer to assist them to initiate or maintain habitual physical activity, for informing the training of professionals and for determining priorities in service provision and public policy. Regardless of how firmly people may believe that physical activity is beneficial to their health, there are many barriers that may limit or prevent regular activity. Whether these barriers are real or perceived, they represent significant potential obstructions to the adoption, maintenance, or resumption of participation in physical activity. More comprehensive understanding of preferred activities, preferred sources of assistance, and barriers to increased activity will improve efforts to foster increased participation in physical activity. There do not appear to be any reports in the literature on the preferred activities of sedentary people. Similarly, little is known about people’s preferred sources of assistance for becoming more physically active. Public health approaches to increasing participation aim to activate the sedentary, but the very inac-
131 0091-7435/97 $25.00 Copyright © 1997 by Academic Press All rights of reproduction in any form reserved.
132
BOOTH ET AL.
tive are less likely to want to attend structured or group-based programs [2] and may be more interested in self-help or home-based methods [3]. Research on other health behaviors is particularly informative: for example, a study of Australian’s preferences for assistance with smoking cessation found that physician advice was strongly preferred and that women were more likely than men to want to attend group-based programs [4]. There exists a modest literature on the barriers to increased physical activity. Sallis and colleagues, in a large community-based study, examined 24 potential determinants of physical activity, including a measure of the frequency with which different factors prevented people exercising (barriers) [5]. They found that ‘‘barriers to activity’’ was most strongly and negatively associated with selfreported vigorous activity among younger men and women and among older men, and was the second most strongly associated variable among older women. However, when the same data were examined for correlates of walking for exercise, barriers to activity was not a significant factor [6]. Two years later the same researchers resurveyed the initial respondents and found that barriers to activity was strongly related to the adoption of vigorous activity over that period [7]. These findings suggest that barriers to activity represents an important determinant of participation in vigorous activity, but that barriers may be of less relevance to walking for health or exercise. Four studies, conducted on samples from three developed countries, have attempted to identify the prevalence of specific barriers to physical activity participation. Godin and colleagues examined the relative importance of five barriers in a community sample of adults [8]. They found that the order of importance of the barriers was finding time, finding a partner to exercise with, physical health problems, the financial cost, and lack of access to appropriate facilities. Another Canadian study of barriers to activity compared women who were sedentary, but who wanted to start exercise, with active women who wanted to do more [9]. There were no substantial differences between the two groups. Lack of time was the most frequently cited barrier to activity, followed by physical health reasons, lack of energy/motivation, child care responsibilities, and, finally, cost/access to facilities. A similar study among a sample of women in the United States found that lack of time was the most frequently identified barrier followed by lack of money, lack of facilities, and lack of an exercise partner [10]. Using pooled data from 17,053 participants in three population surveys conducted in the mid-1980s, an earlier Australian study identified 29.7% of the sample as sedentary in their recreational physical activity habits [11]. The three most commonly reported reasons for inactivity were no time (35%), physically unable (24%), and ‘‘don’t want to exercise’’ (13%). Such data sug-
gested different subgroups of the inactive, as a function of age and gender, who may require different strategies to encourage them to adopt regular physical activity. No time, being physically unable, and not wanting to exercise were more likely to be reported by those who were older and who had lower incomes; the only exception was that being 55 years or older was not associated with having less time. Women were more likely to report being physically unable to exercise. Lower income was associated with being physically unable and with not wanting to exercise. Those with children, while wanting to exercise, were more likely to report having no time. The results of these studies suggest that perceived lack of time, poor health or injury, lack of motivation, and lack of facilities are the most prevalent barriers. The results also suggest that the prevalence of different barriers may vary across age groups and between genders. The 1990–1991 Pilot Survey of the Fitness of Australians asked respondents to a population survey (N 4 2,298) to identify the physical activities in which they would prefer to participate, the sources of support or assistance they would prefer to become more active, and the barriers they perceived as preventing them from becoming more active [12]. A self-report measure of leisure-time physical activity was used to classify respondents as sufficiently active (to gain the health benefits associated with physical activity) or as insufficiently active [12,13]. We examined the activity preferences, the preferred sources of support, and the barriers to regular participation in physical activity reported by insufficiently active respondents to the Australian survey, separately for men and women and for those aged 18 to 39, 40 to 59, and 60 to 78 years. METHODS
Survey Methods A sample of Australian adults was drawn from metropolitan Adelaide, South Australia, using a two-stage systematic random sampling procedure generated by the Australian Bureau of Statistics (ABS) and designed to oversample older people. Stage 1 was a computerized random selection of Census Collectors’ Districts. Stage 2 comprised random selection of a start point and a predetermined skip between dwellings. Within a chosen dwelling every individual age 45 years and older and every second person age 18–44 years was selected. A more detailed description of the sampling methods has been published elsewhere [14]. Informed consent was obtained from all participants. The questionnaire was administered in the respondents’ homes by trained interviewers employed by the ABS. The project was approved by the University of Adelaide Human Ethics Committee.
PHYSICAL ACTIVITY PROMOTION
Measures For the measure of leisure-time physical activity, respondents were presented with a list of 20 common leisure-time activities and asked to identify up to 5 activities in which they had participated over the previous 2 weeks, state the frequency, average duration, and perceived intensity (on a 4-point scale) of participation in each activity. The rate of energy expenditure for each intensity of participation for each activity, in metabolic equivalents, was multiplied by the total time engaged in the activity over the past 2 weeks. The resultant values were expressed as kcal z day−1 z kg−1. These values were summed to yield a total energy expenditure which was used to classify respondents into one of two categories: sufficiently (ù1.8 kcal z day−1 z kg−1) and insufficiently (<1.8 kcal z day−1 z kg−1). This measure of physical activity has been found to have acceptable reliability and validity [15,16]. The insufficiently active group did not meet the criterion of an equivalent of 30 min per day of moderateintensity activity such as walking [17,18]. Respondents were asked what activities they would most like to do if they were to exercise (or to exercise more if they were already active). A list of nine activities (walking, swimming, team sports, racquet sports, jogging, gym, aerobics, cycling, and other) were available to choose from and multiple choices could be made. These activities had been found to account for most leisure-time physical activity in earlier Australian surveys [19]. Respondents were also asked what type of help they would prefer if they were to exercise more or to take up exercise, based on the findings of an earlier Australian study of smokers’ preferred sources of assistance to quit [4] and following pretesting by the ABS. Eight alternate responses were offered (abbreviations used in the figures are shown in parentheses): Advice from doctor or other health professional (med advice), a group of other people to exercise with (group), advice over the telephone (telephone), a videotape on exercise (video), a book on how to exercise (book), an exercise ‘‘kit’’ with pamphlets and practical tips (help kit), a course sent through the mail (mail), and no form of assistance (none). Finally, respondents were shown a list of 19 reasons for not exercising (more) than they did currently and asked which applied to them. The barrier response options were based on those used in an earlier Australian study [11] and were modified and extended following pilot testing of the questionnaire, during which respondents were encouraged to identify barriers to physical activity participation. More than one reason (barrier) could be selected. RESULTS
The data are presented for all respondents, for men and women and for 20-year age groups (18 to 39 years, 40 to 59 years, and 60 to 78 years) for those who were
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insufficiently active (n 4 1,232; 53.6% of the sample) to achieve most of the health benefits associated with regular physical activity. Preferred Activities Figure 1 (left) illustrates preferred activities for all insufficiently active respondents and for insufficiently active men and women separately. More than half of the respondents said that their most preferred activity was walking. The next two most popular choices were swimming (nominated by 14% of respondents) and team sports (nominated by 7% of respondents). Of the remaining activities, none was nominated by more than 4% of the respondents. More women than men tended to nominate walking and aerobics and more men than women nominated each of the other activities, although the differences were not large for any particular activity. Figure 1 (right) illustrates the same data for the three age groups. A large proportion (38%) of the youngest age group selected walking as the preferred activity, but substantial proportions also identified swimming (19%) and team sports (15%). Eight percent of the youngest age group nominated jogging or going to a gym and less than 5% nominated any of the remaining activities. Of those aged 40 to 59 years, 67% nominated walking and 10% nominated swimming. Less than 5% nominated the remaining activities. In the oldest age group, 68% preferred to walk for exercise and 13% preferred swimming. Preferred Sources of Support Figure 2 (left) illustrates preferred sources of support for all insufficiently active respondents and for men and women separately. The two most preferred sources of help were to receive advice on appropriate activities from doctors or other health professionals (38% of all respondents) or to have the opportunity to exercise with a group (31% of all respondents). Although slightly more women than men wanted to exercise with a group and slightly more men than women wanted professional advice on appropriate activities, the differences were small. Approximately 20% of all respondents did not want any advice or support. Figure 2 (right) illustrates the preferred sources of support among the insufficiently active for three age groups. Among those aged 18 to 39 years, more than 40% wanted to be able to exercise with a group, but this was the case for only 27% of 40- to 59-year-olds and for fewer than 20% of those aged 60 to 78 years (x2 4 65.4, df 4 2, P < 0.01). More than 50% of those ages 60 or more years wanted professional advice, 41% of 40- to 59-year-olds wanted professional advice, but only 22% of the youngest age group preferred advice from a health professional (x2 4 68.6, df 4 2, P < 0.01).
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FIG. 1. Preferred activities for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right).
Barriers to Activity Figure 3 (left) shows the barriers for all insufficiently active respondents and for men and women separately. The most frequently cited barrier to participation was lack of time (almost 40% of all respondents) and almost 30% felt that they lacked motivation to exercise. Approximately 20% of respondents had an injury or disability that prevented them from being active and a similar proportion perceived themselves as not being ‘‘the sporty type.’’ Between 10 and 20% preferred to rest, lacked company for exercise, cared for young children, had poor health, felt that they lacked persistence, lacked sufficient energy, or couldn’t afford to exercise. Each of the remaining barriers was nominated by less than 10% of the respondents. Substantially more men than women wanted to rest and relax in their free time, but more women than men nominated each of the other barriers. Figure 3 (right) shows the barriers among insufficiently active respondents for three age groups. The figure illustrates large differences between different age groups in the perceived barriers to participation in physical activity. Approximately 45% of the two youngest age groups felt they did not have enough time for physical activity, but only 20% of the oldest age group felt time to be a barrier (x2 4 70.6, df 4 2, P < 0.01). Similarly, 35% of the youngest age group and 30% of 40- to 59-year-olds felt unmotivated to become active,
but only about 16% of the oldest group lacked motivation (x2 4 32.3, df 4 2, P < 0.01). An injury prevented less than 20% of the youngest groups from being active, but it was a barrier for nearly 40% of the oldest age group (x2 4 57.4, df 4 2, P < 0.01). Similarly, a higher proportion of the oldest group (27%) reported poor health as a barrier to activity, compared with about 10% of the two younger groups (x2 4 56.6, df 4 2, P < 0.01). One-third of the youngest group reported that responsibility for child care was a barrier for them, but only a small proportion of the two older groups was constrained by responsibility for children. Only 20% of those aged 60 to 78 years felt they were too old to be active. DISCUSSION
The most-preferred activity among those respondents who were insufficiently active was walking, even in the youngest age group. Swimming was the next most-preferred activity for all age groups, followed by team sports. None of the remaining activities were nominated by more than 10% of any group of respondents. Given these findings and the recent evidence that regular walking (about 30 min per day) provides most of the cardiovascular health benefits associated with physical activity it is clear that any public health approach to promoting greater participation in physical activity would do well to focus on walking [18]. The
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FIG. 2. Preferred sources of support to initiate activity for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right).
very low proportions of respondents who nominated gym, racquet sports, or aerobics as their preferred activity and that nominated lack of facilities or equipment as important barriers to participation indicates that increased public health investment in the provision of such specific indoor exercise facilities may not be warranted, at least in Australia. In countries with more extreme climatic conditions (particularly very cold winters) this may be less likely to be the case. With regard to potential sources of assistance or support to become active, preference for advice from a doctor or health professional increased with increasing age and the preference to be able to exercise with a group was common among younger people, decreasing with increasing age. Older people were significantly less likely to want to exercise in a group. This finding may be of some public health importance. Group-based approaches for inactive older people may be a strategy which is not generally appealing. We would even offer the speculation that groups may attract only those older people who already are active. With regard to barriers to participation in physical activity, the younger age groups were more likely to report that time, motivation, and child care responsibilities were barriers, whereas a much greater proportion of older people reported that injury or poor health were barriers to becoming active. These findings may usefully
inform the development of strategies to promote higher levels of participation in physical activity. Any strategy would do well to place an emphasis on walking, regardless of whether it involves social marketing, environmental change, or policy development. Although having insufficient time to be active appears to be a difficult barrier to overcome, people may be encouraged to integrate walking with other daily activities such as work, commuting, and child care. The promotion of swimming and team sports may be worthwhile, but are likely to have a smaller impact. Strategies which target younger people could promote walking and other activities and should seek to create opportunities for group activities. Strategies which target older people may best be promoted through general medical practitioners with an emphasis on walking, but with the provision of advice on activities appropriate to the individual’s health status [20]. For example, many older people with arthritis may believe that they should remain sedentary, whereas supervised activity in warm water may be beneficial. Comprehensive, community-wide exercise promotion strategies are likely to have a greater impact if they are tailored to the attributes of key target groups [21]. Our findings particularly highlight how different older people are from those who are younger, on a num-
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FIG. 3. Barriers to participation in leisure-time physical activity for insufficiently active respondents: All respondents and men and women separately (left) and 20-year age categories (right). The list of barriers is shown in the Appendix.
ber of attributes relevant to prompting and providing appropriate opportunities to be active. An earlier study found older people were much more likely to be precontemplators (not active and no intention to become active) for exercise [22]. But it should not be assumed that these attributes of older people mean that they are not likely to be responsive to activity campaigns or programs. For example, a nationwide physical activity campaign in Australia in 1990 had its most significant impact on people who were older and less well educated, although no such effects were apparent in a follow-up campaign in 1991 [23,24]. The physical activity-related preferences and barriers of men and women and of younger and older age groups we have described here should not be interpreted primarily as constraints or inherent limitations. Rather, they help to identify modifiable preferences and perceptions, which may be used to provide more relevant and appealing options for those who might otherwise be missed by ‘‘one-size-fits-all’’ strategies [13,21]. APPENDIX
List of reasons (barriers) provided to respondents (abbreviations used in the figures are shown in parentheses): I haven’t got time (no time). My health is not good enough (poor health). There’s no one to do it with (no company). I can’t afford it (can’t afford). I’m too old (too old). I have an injury or disability that stops me (injury).
I’m too shy or embarrassed (too shy). I’m not the sporty type (not sporty). There’s no suitable facilities nearby (no facilities). I need to rest and relax in my spare time (need rest). I’ve got young children to look after (children). I’m too lazy/not motivated/can’t get started (no motivation). I might get injured or damage my health (fear injury). I don’t enjoy physical activity (don’t enjoy). I haven’t got the right clothes or equipment (no equipment). I’d never keep it up (lack persistence). I’m too fat (too fat). I haven’t got the energy (no energy). Other (other). REFERENCES 1. Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. London: Mayfield Pub., 1991. 2. King AC. Clinical and community interventions to promote and support physical activity participation. In: Dishman RK, editor. Advances in exercise adherence. Champaign (IL): Human Kinetics, 1994:183–212. 3. King AC, Haskell WL, Taylor CB, Kraemer HC, DeBusk RF. Group- versus home-based exercise training in healthy older men and women: a community-based community trial. JAMA 1991;266:1535–42. 4. Owen N, Davies N. Smokers’ preferences for assistance with cessation. Prev Med 1990;19:424–31. 5. Sallis JF, Hovell MF, Hofstetter CR, Faucher P, Elder JP, Blanchard J, et al. A multivariate study of determinants of vigorous exercise in a community sample. Prev Med 1989;18:20–34.
PHYSICAL ACTIVITY PROMOTION 6. Hovell MF, Sallis JF, Hofstetter CR, Spry VM, Faucher P, Caspersen CJ. Identifying correlates of walking for exercise: an epidemiologic prerequisite for physical activity promotion. Prev Med 1989;18:856–66. 7. Sallis JF, Hovell MF, Hofstetter CR, Barrington E. Explanation of vigorous physical activity during two years using social learning variables. Soc Sci Med 1992;34:25–32. 8. Godin G, Desharnais R, Valois P, Lepage L, Jobin J, Bradet R. Differences in perceived barriers to exercise between high and low intenders: observations among different populations. Am J Health Promot 1994;8:279–85. 9. Yoshida KK, Allison KR, Osborn RW. Social factors influencing perceived barriers to physical exercise among women. Can J Public Health 1988;79:104–8. 10. Johnson CA, Corrigan SA, Dubert PM, Gramling SE. Perceived barriers to exercise and weight control practices in community women. Women Health 1990;16:177– 91. 11. Owen N, Bauman A. The descriptive epidemiology of a sedentary lifestyle in adult Australians. Int J Epidemiol 1992;21:305–10. 12. Department of Art, Sport, the Environment and Territories. Pilot Survey of the Fitness of Australians. Canberra: Australian Govt. Publishing Service, 1992. 13. Department of Environment, Sport and Territories. Active and inactive Australians: assessing and understanding levels of physical activity. Canberra: Australian Govt. Publishing Service, 1995. 14. Gore CJ, Owen N, Bauman A, Booth M. Methods of the Pilot Survey of the Fitness of Australians. Aust J Sci Med Sport 1993; 25:80–3. 15. Booth ML, Owen N, Bauman AE, Gore CJ. Retest reliability of recall measures of leisure-time physical activity in Australian adults. Int J Epidemiol 1996;25:153–9.
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16. Booth ML, Bauman A, Owen N, Gore CJ. Relationship between a fourteen-day recall measure of leisure-time physical activity and a submaximal test of physical work capacity in a population sample of Australian adults. Res Q Exerc Sport. In press. 17. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402–7. 18. Blair SN, Kohl HW, Gordon NF, Paffenbarger RS Jr. How much physical activity is good for health? Annu Rev Public Health 1992;13:99–126. 19. Bauman A, Owen N, Rushworth RL. Recent trends and sociodemographic determinants of exercise participation in Australia. Community Health Studies 1990;XIV:19–26. 20. Long BJ, Calfas KJ, Wooten WJ, Sallis JF, Patrick K, Goldstein M, et al. A multisite field test of the acceptability of physical activity counselling in primary care—Project PACE. Am J Prev Med 1996;12:73–81. 21. Donovan RJ, Owen N. Social marketing and population interventions. In: Dishman RK, editor. Advances in exercise adherence. Champaign (IL): Human Kinetics, 1994:249–90. 22. Booth ML, Macaskill P, Owen N, Oldenburg B, Marcus B, Bauman A. Population prevalence and correlates of stage of change in physical activity. Health Educ Q 1993;20:431–40. 23. Booth M, Bauman A, Oldenburg B, Owen N, Magnus P. Effects of a national mass-media campaign on physical activity participation. Health Promo Int 1992;7:241–7. 24. Owen N, Bauman A, Booth M, Oldenburg B, Magnus P. Serial mass-media campaigns to promote physical activity: reinforcing or redundant? Am J Public Health 1995;85:244–8.