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RESEARCH to PRACTICE

Breaking Barriers to Increased Physical Activity

Melissa A. Napolitano, PhD; Bess H. Marcus, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2021


Physical activity has been identified as one of the leading health indicators, and inactivity is among the major public health concerns in the United States. As such, increasing physical activity becomes an important building block for promoting public health and is a prominent part of the Healthy People 2010 report. Currrently, 60% of all Americans do not participate in regular physical activity, and 25% of Americans report being completely inactive (1). One way to address this problem is to identify and address existing barriers to exercise.

Barriers to Exercise

Individuals report that certain events, pressures, and situations impede their ability to become and remain physically active. Barriers to physical activity are diverse and include issues of environment, psychosocial factors, health, physician lack of emphasis, and program type.

Environment. There is increasing recognition that environmental factors play an important role in promoting and supporting physically active lifestyles. Neighborhood safety, convenient and accessible facilities, and proximity to facilities have been noted as factors that influence physical activity (2).

Psychosocial milieu. Time. Lack of time, including work and family demands, has been reported as a barrier to being active, particularly for women (3). Women who are employed and have young children are less likely to exercise than women who do not have children (4).

Patient perceptions. Self-efficacy, or the degree of confidence for performing a behavior, can be a barrier to activity. Physical activity history may influence self-efficacy and perceptions of ability to be active. Patients who had participated in activities at some time in their lives are more likely to become active than those who have never been active (5).

Personal. Lack of interest and enjoyment of activity also are barriers (6). Patients may fail to understand that tasks other than jogging, weight training, and the like will meet activity needs. Activities such as brisk walking, vigorous household chores, and heavy gardening can be done instead.

Health. For some patients, musculoskeletal ailments or chronic diseases such as diabetes or osteoarthritis may constitute barriers to activity and may require additional preparation (eg, modifying exercises, using different equipment).

Physician lack of emphasis. Physicians can influence patients' behavior and may inadvertently be reinforcing a sedentary lifestyle. By not asking patients about physical activity, physicians can give the impression that exercise is unimportant.

Program accessibility. Another barrier to participation can be the exercise program itself. For some, a group-based program may not meet their needs because of time, work, transportation, or family demands. Dunn et al (7) have shown that lifestyle approaches (eg, accumulating at least 30 minutes of activity per day) are an effective and important addition to traditional program offerings. Some strategies for accumulating daily activity include: (1) Set a timer to signal when to go for a short 10-minute walk; (2) walk during lunch hours or after work at a shopping mall; and (3) do more physical activities with children or take a brisk walk when children are participating in organized sports. Group-based programs may not be tailored to individuals' preferences. Some research (8) has indicated that men are more likely to adopt vigorous activity, while women prefer moderate-intensity exercise.

Overcoming Barriers: Stages of Change

Motivation level can be a significant barrier to participation in physical activity (9,10). Individuals engaging in a new behavior move through a series of stages: precontemplation (not intending to make changes), contemplation (considering a change), preparation (making small changes), action (actively engaging in the behavior) and maintenance (sustaining the change over time) (7). Many interventions target that small segment of the population (10%) who are ready to become active. However, to reach more patients effectively, it is important to tailor interventions to participants' motivation level. Physicians can help by asking simple questions about lifestyle and exercise.

Physician Counseling: Five A's

The physician's office can be an important location for addressing potential barriers to physical activity. Marcus et al (11) describe the "five A's" of patient-centered counseling based, in part, on psychological theory and existing research. (See also, "How to Counsel Patients About Exercise," page 53.)

  • Address the agenda. Bring up the issue of physical activity only after the patient's agenda for the visit has been addressed.
  • Assess. Determine patients' current level of physical activity and stage of motivational readiness.
  • Advise. Give the patient specific, personalized feedback on recommendations, such as physiologic data.
  • Assist. Provide support, understanding, praise, and reinforcement. Negotiate intermediate steps and help patients set small goals.
  • Arrange follow-up. Once a plan is developed, it is useful to establish a follow-up visit or telephone call.

Future Directions, Resources

Research goals include assessing the importance of tailoring and targeting to the barriers addressed. Barriers should be measured by a comprehensive assessment tool (eg, questionnaire, telephone, face-to-face meeting). Future research should use existing technologies, such as the Internet, to promote and support physical activity (eg, the Centers for Disease Control and Prevention's Web site on physical activity: https://www.cdc.gov/health/physact.htm). Finally, additional research should continue to focus on how to incorporate the physician and the physician's office in the counseling process.

References

  1. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion: Physical Activity and Health: A Report of the Surgeon General. Atlanta, Centers for Disease Control and Prevention, 1996
  2. Sallis JF, Bauman A, Pratt M: Environmental and policy interventions to promote physical activity. Am J Prev Med 192021;15(4):379-397
  3. Ainsworth BE: Issues in the assessment of physical activity in women. Res Q Exerc Sport 2021;71(2 suppl):S37-S42
  4. Marcus BH, Pinto BM, Simkin LR, et al: Application of theoretical models to exercise behavior among employed women. Am J Health Promot 1994;9(1):49-55
  5. Dunlap J, Barry HC: Overcoming barriers in older adults. Phys Sportsmed 1999;27(11)69-75
  6. Sallis JF, Hovell MF, Hofstetter CR, et al: A multivariate study of determinants of vigorous exercise in a community sample. Prev Med 120219;18(1):20-34
  7. Dunn AL, Marcus BH, Kampert JB, et al: Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999;281(4):327-334
  8. Sallis JF, Haskell WL, Fortmann SP, et al: Predictors of adoption and maintenance of vigorous physical activity in a community sample. Prev Med 120216;15(4):331-341
  9. Prochaska JO, DiClemente CC: Stages and processes of self-change in smoking: toward an integrative model of change. J Consult Clin Psychol 120213;51(3):390-395
  10. Marcus BH, Pinto BM, Clark MC, et al: Physician delivered physical activity and nutrition interventions. Med Exerc Nutr Health 1995;4:325-334
  11. Marcus BH, Selby VC, Niaura RS, et al: Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport 1992;63(1):60-66

Dr Napolitano is a postdoctoral fellow and Dr Marcus is professor of psychiatry and human behavior at the Brown University Center for Behavioral and Preventive Medicine in the Miriam Hospital in Providence, Rhode Island. Address correspondence to Bess H. Marcus, PhD, Division of Behavioral Medicine, The Miriam Hospital, Brown University, 164 Summit Ave, Providence, RI 02906; e-mail to [email protected].


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