Friday, 7 October 2011

#30: Revolution 9

Two in one day; I'm on a roll...

Kass Gibson is one of the smartest people I know. He's also among the funniest. Those traits together, intelligence and humour, create an effective and winning combination that is surely absent in far too many academic-types. Anyway, I am extremely fortunate to get to hang out with Kass quite often, and today during a regular graduate student-style coffee break (long and often) on a simply sensational Friday afternoon, I was once again humbled and inspired by his wisdom and thoughtful insight.

I was talking to him about my most recent blog post: About what types of interventions might be most successful for increasing physical activity (PA) levels and the importance of offering incentives to increase physical activity (since persuasion and regulation are unlikely to work). The first question he asked was:

"Why is it so important that people be physically active? Why should we tell them this is important in the first place?"

It might seem ignorant but it's an excellent point. “You live your life; I'll live mine!” I would normally agree, HOWEVER in Canada, we support a ("free") publicly funded health care system. This essentially means that when you or I get sick, everyone else pays for it (literally). In theory, it's a great idea: We all help each other out in their time of need. But what happens when certain types of people benefit more from the system than others? I'm talking of course about a population that is becoming increasingly (and overwhelmingly) unhealthy. Although you could debate it; heart disease, stroke, hypertension, diabetes, metabolic syndrome, many cancers, mental illness, and dementia all affect a disproportionate amount of people: People who I would argue are less healthy and who are often personally responsible for their lack of health. To make my point: I don't feel I should be paying for the millions of Canadians now developing diabetes and heart disease because they choose to be sedentary.

Without much fuss, Kass eventually agreed that was a fair point. However, rather than offer the financial incentives and tax credits (that far too often benefit the already advantaged middle and upper classes); why not remove the barriers that undoubtedly prevent so many people from becoming active in the first place (adoption) or maintaining activity in the long term (adherence). At first I brushed the idea off as far too simple-minded. "If I can overcome these said 'barriers'; then why can't others?!" But the more I got to thinking, the more one must acknowledge that barriers do exist (or perhaps more importantly...are perceived to exist).

I then began coming up with a list of potential "barriers" to physical activity and as you will see, there are a lot of them! These barriers are not necessarily physical barriers (there isn't a giant wall blocking the entrance to the park), but can be anything that limits access or opportunity to be active.

Here are but a few (mostly adapted from Trost et al., 2002) organized into different types:

Demographic and biological factors: age, sex, gender, education, working class occupation, children, genetics, income/socioeconomic status (SES), injury/illness, disability, marital status, race/ethnicity, religious affiliation, being overweight or obese

Psychological, cognitive and emotional factors: attitudes, control, enjoyment, expectancy beliefs, intension, mood/affect, normative beliefs, knowledge/understanding of health, time, locus of control, perceived current health, personality, body image, psychological/mental health, self-efficacy, self-motivation, stress, susceptibility to illness

Behavioural attributes and skills: activity during childhood, youth and adolescence, activity during adulthood, alcohol, dietary habits, coping skills, processes of change, school sports, smoking, mental illness, sports media use, Type A behaviour pattern

Social and cultural factors: exercise group size, exercise/PA models, group cohesion, family influence, physician influence, social isolation, social support from family, spouse, friends, peers, staff, instructor

Physical/built environment factors: access to facilities (actual and perceived), lighting, climate/season, cost of programs, disruption of routine, scenery, traffic, home equipment, crime rates, hilly terrain, neighbourhood safety, sidewalks, dogs, urban vs rural locations, noise

Physical activity characteristics: mode, duration, frequency and intensity of activity, perceived effort.

WOW! That's quite a list. When reading it, many barriers (perhaps better called factors, variables, correlates or determinants), will NOT seem modifiable which is true. So it then must be determined which factors CAN be changed and what the overall effect of changing those factors will be (in order to increase PA levels). We must also consider things like the feasibility, timeline, cost, and many practical considerations. This can (and should) seem pretty overwhelming.

I might be a bit of an idealist (picturing a perfect world where everyone is physically active and healthy) but I am also a realist. We can't change the world (I'm also a pessimist) all at once; rather we need to make small, gradual steps to affect meaningful change over time. Currently, I might argue that rather than change anything 'for the better'; we should simply attempt to 'stop the bleeding' and try and ensure that we don't change 'for the worse'. Either way, it's a tall order.
Okay, so I realize that I've been rambling on for quite a bit and I fear I haven't really made a point so should probably attempt to do so. Here's the take home message:

I think that 'asking' that people be physically active and healthy (as a direct result of this) is a necessary and important 'request.' The health care system is designed in such a way that we all end up paying for those who are inactive and unhealthy (here I assume that increased physical activity equates to better overall health, and am supported heavily by the literature). And rather than simply offer incentives for individuals to be active; we also need to consider removing or altering the 'barriers' that exist to prevent PA. Some of these barriers cannot be changed but many can. Demographic and biological factors cannot be changed per se, but they can be overcome. Psychological and behavioural barriers are those being addressed by myself and other exercise/PA psychologists and ultimately require "changing" the individual. Changing the build/physical environment will likely come from policy (government) and will take time. We can’t change the nature of PA: it’s physically (and mentally) tough to do and can be unpleasant; but we can change our attitudes toward it. We can embrace it.

What are your thoughts? What factors and barriers are most important and in most needing of change?! For now, I plan to stick with my monumental (and perhaps foolish) task of trying to change individuals (whether they know it or not)...

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