the dimensions of health promotion applied to physical

THE DIMENSIONS OF HEALTH PROMOTION APPLIED TO PHYSICAL ACTIVITY’

Kenneth E. Powell,’ Marshall W Kreuter,3 Thomas Stephens,4 Bernard Marti,” & Lothar Heinemann 6

INTRODUCTION

Regular physical activity has many healthy benefits. Coronary heart disease is approxi- mately twice as common among physically inactive individuals as among active ones (1). Regular physical activity can also help prevent hypertension, non-insulin dependent diabetes mellitus, osteoporosis, obesity, and mental health problems. It is associated with lower rates of colon cancer and stroke, and with increased longevity. Furthermore, evidence is accumulat- ing that physical activity of low to moderate in-

Source: JourMalofPublic Health Policy 1991; lZ(winter): 492-508. Reprinted with permission from the Journal of Public Health Policy Inc., South Burlington, Vermont, United States of America.

‘Paper presented at the World Conference on Sport for All, Tampere, Finland, June 4,199O.

2Medical Epidemiologist, Intentional Injuries Section, Epidemiology Branch, Division of Injury Control, Center for Environmental Health and Injury Control, Public Health Service, Atlanta, Georgia, United States of America.

‘Director, Health 2000, Atlanta, Georgia, United States of America.

Consultant in Social Epidemiology and Survey Research, Manotick, Ontario, Canada.

‘Acting Chief, Department of Epidemiology and Prevention of Noncommunicable Diseases, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland.

“Director, Center for Epidemiology and Health Research, Zepernick, Federal Republic of Germany.

tensity is sufficient to produce many of these benefits (2, 3). Modern life, however, has re- moved the necessity of a physically active lifestyle. Mechanization of occupational work, housework, and transportation has markedly reduced overall energy expenditure through physical activity. The surfeit of modern conve- niences in industrialized nations makes physical activity often unnecessary and vigorous activity almost totally voluntary. Inactivity, long the prerogative of the rich and powerful, is now within the grasp of nearly everyone in the industrialized world. Its allure is seductive and many are firmly within its embrace.

This paper is written because of the common misperception that health promotion cannot or, at the very least, has not appreciably increased participation in leisure-time physical activities. Our conclusion is that health promotion can, and probably has, increased participation in leisure-time physical activities. However, our efforts to evaluate it empirically have been frustrated by a paucity of adequate population-based data and by the very nature of health promotion itself. In this paper we (1) describe the characteristics of health promotion, (2) provide examples of successful site-specific efforts to increase physical activity, and (3) consider the policy and research implications of our arguments.

316

Powell et al. 317

DIMENSIONS OF HEALTH PROMOTION

Health promotion is a combination of educational and environmental supports that encourage behaviors or actions conducive to health (4). It accomplishes its goal through a broadly based combination of activities designed to shape the normal behaviors of individuals and populations. Health promotion encompasses two recognizable and occasion- ally feuding schools of thought: one school fo- cuses on personal choice and responsibility; the other, on social and environmental change. Both elements are important. In physical activity promotion, the area of social and environmental change has, so far, received less emphasis.

Health promotion is not synonymous with health education. Health education, often confused and used interchangeably with health promotion, is a more limited concept. Health education strives to inform people about health issues; it provides information on which motivated people can act. Health promotion strives not only to inform but also to persuade, motivate, and facilitate action. Although imparting information is an important component, health promotion is successful only when action has been taken.

In order to accomplish its goals, health promotion applies a variety of complementary strategies in various settings to different target groups. The strategies encompass information dissemination; skill building; and legislative, regulatory, environmental, and technological change. Each of these strategies can be applied in different settings, such as in homes, schools, worksites, medical care facilities, and other places within the community. In each setting, these strategies need to be applied to a variety of target populations based on gender, age, resources, and interests. These three dimensions-strategies, settings, and target groups-might be envisioned as a large cube with each axis representing a dimension of health promotion (Figure 1). The most effective health promotion programs are those which in- volve the most boxes within the cube (46). Finally, each of the boxes can be implemented by one or more groups, for example, a health department, a school system, or a service club. Health promotion encourages the formation of coalitions by engaging various public, private, and voluntary agencies to participate in a common cause. This “fourth dimension” of health promotion is not easily presented pictorially, but calls further attention to the conceptual complexity of health promotion.

SE TTINGS

,/ ” Community ,-‘“- t--l-

Health Care Delivery

TARGET GROUPS

FIGURE 1. The Health Promotion Cube

318 Promoting Physical Activity

Target Groups and Stages of Behavior Change

Interventions that are effective for one group may not succeed with another because values, knowledge, attitudes, skills, behaviors, and opportunities vary among individuals and groups. Therefore, research and evaluation efforts must be directed to specific target groups. Health promotion programs intended to influence the entire population must combine target-group-specific activities into a broader effort.

Stage of behavioral change is an underap- preciated and less commonly considered target group characteristic. Prochaska and DiClemente have described five stages of behavioral change: precontemplation, contemplation, readiness for action, action, and maintenance (7, 8). Precontemplation is the stage in which people are not thinking about changing their behavior. Contemplation means that they are thinking about doing something but probably not immediately, perhaps within the next six months. Individuals who are ready for action not only think about changing but expect to take some action soon, such as within the next month. Those in the action stage have actually begun the behavior, but the behavior is still experimental and relapse is common. For those in the maintenance stage, the behavior has been fully incorpo- rated into their daily living habits. Questions have been developed to categorize individuals into these categories in terms of their exercise behavior (Beth Marcus, personal com- munication, May, 1991).

The model contains two important con- cepts, one static and one dynamic. The static concept calls attention to the fact that there are different levels of readiness for change. People differ in their readiness to change just as they do by gender, age, or resources. Many efforts in the area of exercise have focused on moving people from the ready-for-action group to the action group. These efforts have pertained to a limited segment of the population and have had little effect on those who are in other

stages. Programs targeted at one level of behavioral change need to be evaluated based on the number of people in that level and not on the entire population. For example, if the objective of a single intervention is to move individuals from precontemplation to contemplation, then change in physical behavior is not the appropriate measure of evaluation.

The dynamic concept emphasizes that the condition is the least stable just after a shift to a new stage. Conscious effort to continue the desired behavior is frequently necessary and relapse is common. Eventually, however, a certain number of people achieve maintenance where conscious and specific efforts to prevent relapse are no longer needed. Data from studies of smoking behavior suggest that the first and last stages of behavioral change are the most stable, whereas the mid- dle three stages are more dynamic. Smoking cessation literature also suggests that the av- erage smoker enters and leaves the action stage 34 times over a 7-10 year period before reaching maintenance (8). This helps explain the finding that one of the better predictors of long-term participation in an exercise program is whether or not the person has been in a similar program before (9).

EXAMPLES OF SUCCESSFUL PHYSICAL ACTIVITY PROMOTION

The format and availability of descriptions of successful physical activity promotion programs need to be improved. Existing reports tend to carefully document changes in physical activity or physical fitness in experimental and comparison groups. Unfortunately, the programs that presumably led to the changes are not systematically described. Meaningful changes have occurred, but the activities that caused the changes are only briefly sketched and, therefore, are not replicable. The failure to describe programs adequately has several causes: (1) a system, or taxonomy, for describ- ing health promotion programs has not been agreed upon; (2) promotion programs are

Powell et al. 319

complex and difficult to describe, in part because they are often “organic” in nature- growing and developing as they progress; (3) scientists often focus on the outcome without sufficient regard for the information necessary to repeat the experiment.

Nevertheless, some successful programs have been well described. We have selected the examples to represent different settings, and, for each, we have tried to describe the promotion program systematically.

Worksites

The Johnson & Johnson LIVE FOR LIFE campaign is one of the better documented worksite efforts (10, 21). Begun in 1978, the program encouraged increased exercise, smoking cessation, proper nutrition, weight loss, and stress management. The research de- sign compared the effects of the full campaign in four Johnson & Johnson companies with three whose employees received only the health screening and one-time counseling portion of the program.

The LIVE FOR LIFE program provides three important messages. First, the program worked. It successfully increased the physical activity and fitness levels of a diverse population of workers within a single company (20). Second, the program used the full array of interrelated and mutually supportive strategies of health promotion to inform, to persuade, and to facilitate change (Table 1). Third, the program was promoted by marketing experts. Successful health promotion programs require health promotion experts.

Schools

A number of physical activity programs in schools have led to improved fitness among students (12, 13). Because schoolchildren are a captive audience, appropriate changes in physical education (PE) classes will produce increased physical fitness. A more important

question is: How does a new program get into the school system?

The Go for Health Project in Texas successfully increased the time that third and fourth grade children spent in enjoyable moderate to vigorous physical activity in PE classes (24). To have the new PE program adopted by the schools, several of the strategies of health promotion were used with teachers as the target group (Table 1).

A more difficult and fundamental question concerns the effect, if any, a school PE program has on children’s physical activity out- side of school and in the future. Childhood physical fitness test scores, participation in ex- tracurricular sports, and grades in school PE have been associated with increased exercise in adulthood (25, 26). However, we have no empirical evidence that the content and qual- ity of school PE programs influence lifetime physical activity patterns.

Health Care System

A third important setting in the health promotion cube is the health care system. The medical system can influence exercise behavior in two ways. First, and potentially most important, health care providers can influence their patients’ attitudes and behaviors by directly counseling them about health-related behaviors (17). When asked, patients in the United States and Canada say that their physi- cian’s advice is an important factor in their physical activity practices (18,19).

The U.S. Preventive Services Task Force rec- ommends physical activity counseling by physicians as a primary preventive intervention to increase physical activity levels (2). Preliminary data from a single study indicate that patients are more likely to begin a regular physical activity program if their physi- cian encourages them to do so (2). However, many physicians feel poorly trained to coun- sel patients about physical activity (20-22).

Second, the medical care institution can be used as the focal point for exercise promotion.


TABLE 1. Health Promotion Strategies of Selected Exercise Promotion Programs

Program

Setting

Target Population

Leadership Commitment

Educational Methods Public media Printed matter Electronic

Classroom

Other personal educational methods

Policy Change

Environmental Change

LIVE FOR LIFE

Worksite

All workers with special attention to women and blue-collar workers

Company management committed resources

- Brochures, reading material Audio and video tapes,

computer-aided instruction

Formal classroom instruction

Trained fitness instructors, health screening, individual counseling

Attendance rules changed to facilitate participation

Locker and fitness rooms, exercise equipment, special events

Go For Health

School

Teachers

Key administrators involved in early planning, letters of support from principals

In-service training

Health screening, for teachers and staff

Easy to use teaching modules

Community Health Assessment and Promotion Project

Outpatient clinic

Hypertensive, obese, low income, urban women

Coalition of community leaders planned the program

- Brochures, recipes

-

Evening classes

Health screening, home visits

Program sessions changed to meet suggestions of participants

Transportation and babysitting aid, police protection, new steps in pool, blinds for privacy

Space is set aside for the program, instructors are provided by the hospital or clinic, and participants are drawn from the patient population. Cardiac rehabilitation programs have used this model for many years. A more un- usual example of exercise promotion through a health clinic is the Community Health Assessment and Promotion Project (CHAPP) (23). A medical clinic in an impoverished section of Atlanta developed an exercise and nutrition program for obese, hypertensive women, many of whom also had adult-onset diabetes mellitus. Using an array of educational and environmental strategies (Table l), CHAP participants lost weight and reduced their blood pressure (23). This program was successful despite the fact that it was conducted in one of Atlanta’s poorest neighborhoods and directed toward a population generally de-

scribed as “difficult to reach.” A detailed de- scription of the program is available (24).

Community-wide and International Programs

Worksites, schools, and medical care delivery systems are all components of a broader community. The greater diversity of the community means that the intervention and evaluation will be more complex. Several efforts have been made to increase physical activity on a community-wide basis. Three large demonstration projects in the United States of America to prevent cardiovascular disease- Stanford, Minnesota, and Pawtucket-have included physical activity in their interventions. Final data are not yet available, but early reports are consistent with increased regular

Powell et al. 321

physical activity among the experimental groups (25,26). Descriptions of the programs indicate that a variety of strategies were applied to specific target groups in different settings. Therefore, many “cubelets” of the health promotion cube have been used. At the community level the effort to plan, implement, and evaluate the intervention program is compli- cated and expensive because the full range of strategies needs to be applied to the full range of settings and target groups.

Moving from the community to the nation adds yet another layer of complexity. At the national level an even greater variety of settings, target groups, and organizational groups exist. Few data are available on either national trends or nationwide efforts to increase physical activity. Identifiable expendi- tures specifically directed toward nationwide efforts to promote physical activity for a few countries indicate that the per capita effort is small. Approximate annual per capita expen- ditures (US$) are: President’s Council on Physical Fitness and Sports in the USA, 0.6 cents; “Look After Your Heart!” program in

England, 3.1 cents; “Life. Be in it” program in Australia (ended in 1980), 4.1 cents, and PARTICIPaction in Canada, 7.0 cents.

The few available data about trends in leisure-time physical activity in four countries--Canada, Finland, the United States (USA), and the German Democratic Republic (GDR)-suggest that leisure-time physical activity has increased over the past 20-25 years (27) (Figure 2). The heights of the lines in Figure 2 cannot be meaningfully compared because each represents a different definition of “active,” but the general trend is upward for each country.

Among these four countries for which we have information about trends in leisure-time physical activity, only Canada has had a highly visible effort to promote leisure-time physical activity. PARTICIPaction is a private, nonprofit company created in 1971 with government seed money Its mission is to promote physical recreation and to encourage Canadians to as- sume greater personal responsibility for their health and well-being. The major strategy of PARTICIPaction is to spread humorous mes-

70

60 I

t 5o I

10

/?USA-Gallup Poll

./ &A-BRFS’

0 ’ I I I I I I

1960 1965 1970 1975 1980 1985 1990

Year

‘Behavior Risk Factor Survey.

FIGURE 2. Percent of Adults Considered Physically Active in Their Leisure-Time in

Canada, Finland, the United States of America, and the German Democratic Republic


sages about the benefits of a physically active lifestyle via public service advertising. PARTICIPaction’s campaigns have concen- trated on moving Canadians from precontemplation to contemplation, and from readiness for action to action. An example of the latter is the slogan used a few years ago: “Don’t just think about it. Do it!”

PARTICIPaction is very well known in Canada. Over 80% of the population recognize its logo and symbol. PARTICIPaction has been more closely identified with the promotion of physical activity than any other agency in Canada for at least a decade. So per- vasive is the PARTICIPaction logo and mes- sage that a whole generation of Canadians is confused about the proper spelling of the word “participation!”

More importantly, 95% of Canadians believe that PARTICIPaction’s efforts are useful, and 82% believe it is working, in the sense that it has caused people to become more active. Whether or not this is really true is a deeper question, but the existence of the belief is im- pressive in itself.

The promotion of leisure-time physical activity in the USA is decentralized. A 1982 report noted that “fitness promotion (is not) a distinct matter of governmental concern” (28). This report indicated that governmental promotion of sports, and by extension leisure- time physical activity, in the USA is less active and less successful than promotional efforts in either Australia or Canada. During the 198Os, national health objectives have called attention to the importance of regular physical activity but few resources have been provided. The President’s Council on Physical Fitness and Sports, which has a per capita budget al- location one-tenth that of PARTICIPaction, and the Centers for Disease Control and Prevention, are the only two Federal agencies with established programmatic interests in the promotion of physical activity, and neither has received sufficient funding to specifically and appreciably augment their programs in this area. The activities of “grass roots” organizations, marketing efforts by sports equipment

and fitness industries, and coverage by the media have provided the subject a continuing forum. At this juncture, the promotion of leisure-time physical activity in the USA ap- pears more haphazard than coordinated.

In Finland, there have been several infor- mational campaigns and national events by several sports organizations. Some worksite and community-wide programs have also taken place. There is no national effort, however, to coordinate or keep track of these various efforts. Thus, the role of these activities in the rise in leisure-time physical activity is unknown.

Over the past two decades the German Democratic Republic (GDR) has become fa- mous because of its success in the Olympics. In 1968, athletes from the GDR won 30 Olympic medals; in 1988 they won 127. Changes in leisure-time physical activity among the general population in the GDR have been more modest (Figure 2). In spite of the temporal relationship between the four- fold increase in the number of Olympic medals won by athletes from the GDR and the relatively modest increase in self-reported leisure-time physical activity, it seems un- likely that the program to develop elite athletes is also responsible for the population changes. The population change in the GDR is no greater than that in Canada, Finland, or the USA, where there has been no marked increase in the number of Olympic medals won. In addition, the athletic program in the GDR identified the most gifted athletes and provided them with special and separate training facilities which were not available to the general public.

The similarities in patterns and trends among the four countries suggest that, inspite of some differences, they apparently share some important influences on physical activity practices. In the USAand Finland, multiple promotional messages have emanated in an uncoordinated fashion from various sports organizations, the fitness industry, and lay and scientific publications. For the most part, the emphasis has been on sports and high-

Powell et al. 323

intensity exercise. The promotional efforts in Canada have been similar to those in the USA and Finland with the addition of PARTICIPaction, a widely recognized organ- ization that encourages recreational physical activities. In spite of significant political and economic differences and efforts to control public access to information from the West, residents of the GDR have been subject to many of the same messages about physical activity via the Western media. The obviously successful program to develop elite athletes provided no additional opportunities for leisure-time physical activity to the general population, but may have increased their sen- sitivity to other information sources.

There are several possible explanations for the general rise in leisure-time physical activity over the past 20-25 years in these four-and presumably other-industrialized countries. One is reporting artifact. People may be an- swering the same questions differently over time. The current population may be thinking more about their physical activity practices and, as a result, recalling, or perhaps fabricat- ing, more activities than in the past.

We think it is more likely that the trends are real. They could be the spontaneous ex- pression of an innate need for physical activ-

60 -

55 -

50 -

45 -

40 -

,35 -

:30 - 2

225 -

20:

15 -

10 -

i: 1972 1977 i 982 1987

Year

FIGURE 3. Minutes per Day in Walking or

Cycling to Work by Adult Men, Finland

ity that is expressed increasingly through leisure-time physical activity because work, transportation, and other forms of required physical activity have declined. The trends could be the effect of the publicity generated by the growing number of scientific reports about the benefits of regular physical activity or the planned effects of promotional efforts of various fitness-related businesses or organizations. Finally, in Canada, some of the change may well be due to PARTICIPaction. Although an increase in activity has occurred in all of the countries, the rate of increase in Canada seems to be the greatest.

In contrast to the uplifting observation about the general trend in leisure-time physical activity are three disheartening observations. First, the increase in leisure-time physical activity seems to be more than coun- terbalanced by the decrease in occupational and transportational physical activity. Data from Finland, the USA, and the GDR indicate a downward trend in occupational activity (27). In Eastern Finland, for example, surveys indicate that the proportion of men who spend 30 minutes or more walking or cycling to work has markedly declined (Figure 3). Second, most of the population remains insufficiently active. Although all of the surveys shown in Figure 2 used different definitions for “active” individuals, in all of the surveys except the Gallup poll the majority of the respondents were classified as inactive. Third, those who stand to benefit the most from increased physical activity appear to be the slowest to participate. Data from Canada, Finland, and the USA all indicated that those who are poor or poorly educated and those who have other risk factors for cardiovascular disease are the least active (27,29,30).

IMPLICATIONS FOR POLICY AND RESEARCH

There is clear and persuasive evidence that regular physical activity maintains and im- proves health. Evidence from several coun-


tries shows increasing but still low and un- even participation in leisure-time physical activity. Comprehensive health promotion programs in worksites, schools, and health care delivery settings have increased physical activity participation. These observations have important implications regarding national leisure-time physical activity promotion programs.

First, national physical activity promotion policy should be based upon established health promotion principles. Comprehensive, population-based health promotion includes a broad array of educational and environmental strategies applied in various settings and targeted at selected populations. Educational strategies to improve knowledge and skills need to be delivered via multiple channels to specific target groups. Knowledge about the multiple benefits of physical activity and the ease, if not pleasure, with which these benefits can be achieved needs to be disseminated. For largely sedentary populations such as ours, the necessary behavioral and physical skills may need to be taught as well. Given that many of the health benefits accrue from low to moderate intensity activities such as walking or gar- dening, essentially allmembers of our societies already possess the physical skills to be more active. The behavioral skills necessary to in- corporate physical activity into everyday practice will be more difficult to inculcate.

Environmental strategies need to facilitate being physically active. Programs should strive to make it easier rather than more difficult for people to be active. Safe trails, paths, and sidewalks for walking would be a rea- sonable beginning. More complete utilization of existing facilities is an inexpensive and available opportunity. Tax modifications could also be used to encourage business to encourage their workers to be more physically active.

It is important to note that the principles of health promotion, as exemplified by the “health promotion cube” (Figure l), indicate that the most successful effort requires a bal- anced, multifaceted approach. Each of nu-

merous target groups needs to be addressed via multiple strategies applied in multiple and appropriate settings. In the USA, the Physical Activity and Fitness objectives of the U.S. Department of Health and Human Services provide appropriate goals but lack sufficient recommendations about how to achieve them (3). Specific recommendations for a national physical activity promotionpro- gram such as those recently prepared for Australia would be helpful (32).

National physical activity promotion poli- cies need also to recognize the limits of the scientific method while exploiting its power. The important limits are at least three. In the first place, each nation is an experiment of one for which there is no truly adequate comparison. Therefore, experimental science is unable to reach statistically supported causal conclusions about any national changes that occur. In addition, the effect of any single effort will be impossible to distinguish from secular trends or background noise. At the national level, a well-planned and well-implemented health promotion program encompasses too many variables for any one component to be adequately isolated and studied. The many types of and locations for physical activity; the plethora of target group characteristics in- cluding the stages of behavioral change; the educational and environmental strategies; and the many settings in which they are applied create too many variables to be managed as a research project. Finally, the very nature of health promotion frustrates efforts to evaluate it empirically. Awell-designed large-scale health promotion effort becomes so inter- twined in the fabric of society that it is impossible to distinguish from secular trends. It is, in fact, a major determinant of the secular trends from which we try to distinguish it. An evaluation that tries to isolate the effects of the essential components of a national health promotion program and to distinguish the effects from secular trends fails to appreciate the nature of the program it seeks to evaluate.

Nevertheless, scientific methods are essential to the conduct and evaluation of national

Powel I et al. 325

health promotion programs of physical activity. The experimental evaluation of the individual components of physical activity promotion programs in selected settings and limited populations is necessary. What, for example, are the most effective methods for moving individuals from the stage of precontemplation to the stage of contemplation? What kinds of school programs have the greatest positive influence on physical activity patterns during subsequent adulthood? How can physicians and other medical providers have the greatest influence on their patients’ physical activity patterns? These and many other specific questions canbe and need to be addressed via specifically designed research projects.

As part of these research efforts, a stan- dardized and systematic format for the de- scription of physical activity promotion programs, in fact, of health promotion programs in general, is needed. Programs cannot be repeated if they have not been described. Efforts to measure the outcomes of health promotion programs are important but are only half the task. Adequate descriptions of the programs are also necessary. This will be aided by efforts to identify and cod- ify the individual elements of health promotion programs.

Finally, surveys and surveillance systems of current physical activity practices are essential. Subsequent health promotion activities and subsequent focused research will be largely directed by the overall and group- specific trends. Presently available information about current and past physical activity practices suggests that leisure-time physical activity is increasing in industrialized nations. More information, regularly collected with valid and accurate instruments, is necessary. Ongoing surveillance, such as the Canada Fitness Survey, the Behavioral Risk Factor Study in the USA, and the North Karelia and National Health Behavior Sur- veys in Finland, should be continued. No national programs should be started without the means to measure changes in the population.

The health benefits of physical activity are great, but less than half of our populations are receiving these benefits. Comprehensive health promotion programs can increase physical activity in inactive populations. The most desirable situation for any nation would be to have a large-scale, coordinated health promotion effort that is tracked in the aggre- gate by surveillance systems, evaluated by how well the individual pieces are implemented, and supported and molded by existing and current research focused on specific issues.

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