Physical Activity and Health

self-monitoring group had significantly better
adherence over 12 weeks than those in the self-
monitoring plus attention or control groups; how-
ever, adherence over the last 6 weeks of the study was
significantly better in the self-monitoring plus atten-
tion group. Actual differences were not large, amount-
ing to 4 to 5 days of gym attendance over 3 weeks,
compared with about 3 days among controls. In all
three groups, adherence dropped off most sharply
during the first 6 weeks of the study.
  Classes, health clubs, and fitness centers are
resources to promote physical activity, and numer-
ous studies have been undertaken to improve atten-
dance (Table 6-2). However, many people prefer to
exercise on their own. Several studies have used
behavioral management techniques to encourage
people to do so on their own (Table 6-2). In some
studies, training in behavioral management tech-
niques has occurred in a group setting before the
participants began exercising on their own; in oth-
ers, information has been provided by mail. Results
have been equivocal. King, Haskell, and colleagues
(1995) assigned 50- through 6%year-old partici-
pants to one of three conditions: a vigorous, group-
based program (three 60-minute sessions); a
vigorous, home-based program (three 60-minute
sessions); and a moderate, home-based program
(five 30-minute sessions). At 1 year, a'dherence was
significantly greater in both home-based programs
than in the group-based program. At 2 years, how-
ever, the vigorous, home-based program had higher
adherence than the other two programs. Research-
ers hypothesize that it was more difficult for the
moderate group to schedule 5 days of weekly physi-
cal activity than for the vigorous group to schedule
3 days. Another study encouraged self-monitoring
and social support (walking with a partner) and
also tested a schedule of calling participants to
prompt them to walk. Frequent calls (once a week)
resulted in three times the number of reported
episodes of activity than resulted from calling every
3 weeks (Lombard, Lombard, Winett 1995). Cardi-
nal and Sachs (1995) randomly assigned 133 women
to receive one of the three packets of information
promoting physical activity: self-instructional pack-
ages that were based on stage of change and that
provided tailored feedback; a packet containing a
standard exercise prescription; and a packet pro-
vidingminimal information about health status and

exercise status. No significant differences were
observed among the three groups at baseline, 1
month, or 7 months.

The advent of interactive expert-system com-
puter technologies has allowed for increased indi-
vidualization of mailed feedback and other types of
printed materials for health promotion (Skinner,
Strecher, Hospers 1994). Whether these technolo-
gies can be shown to be effective in promoting
physical activity at low cost is yet to be determined.

Insummary, behavioral management approaches
have been employed with mixed results. Where an
effect has been demonstrated, it has often been small.
Evidence of the effectiveness of techniques like self-
monitoring, frequent follow-up telephone calls, and
incentives appear to be generally positive over the
short run, but not over longer intervals. Evidence on
the relative effectiveness of interventions on adher-
ence to moderate or vigorous activity is limited and
unclear. Because of the small number of studies, the
variety of outcome measures employed, and the di-
versity of settings examined, it is not clear under what
circumstances behavioral management approaches
work best.

In a number of studies, methodological issues,
such as high attrition rates, short follow-up, small
sample sizes, lack of control or comparison groups,
incomplete reporting of data, or lack of clarity about
how theoretical constructs were operationalized.
also make it difficult to determine the effectiveness
of behavioral management approaches or to general-
ize results to other settings or population groups.
Stages of change theory suggests that people move
back and forth across stages before they become able
to sustain a behavior such as physical activity. The
relatively short time frame of many studies and the
use of outcome measures that are not sensitive to
stages of change may have limited the ability to
determine if and to what extent possessing behav-
ioral management skills is useful in the maintenance
of regular physical activity.

Interventions in Health Care Settings
Health care settings offer an opportunity to indi-
vidually counsel adults and young people about
physical activity as well as other healthful behaviors,
such as dietary practices (U.S. Preventive Services
Task Force 1996). Approximately 80 percent of the

226


U.S. population see a physician during a l-year
period (National Center for Health Statistics 1991),
but the extent to which physicians counsel their
patients to be physically active is unclear. One survey
of physicians found 92 percent reporting that they or
someone in their practice counseled patients about
exercise (Mullen and Tabak 1989), but in a more
rcccnt study, only 49 percent of primary care physi-
cians stated they believed that regular daily physical
nctivity was very important for the average patient
c\Vechsler et al. 1996). Counseling is likely to be
brief, often less than 2 minutes (Wells et al. 1986),
.tnd ineffective counseling approaches are often
cmpfoyed (Orleans et al. 1985). Physicians may be
\css likely to counsel patients about health habits if
their own health habits are poor (Wells et al. 1984).
Only three studies attempting to improve the
physical activity counseling skills of primary care
physicians have been reported in the literature; the
rcsufts suggest small but generally positive effects on
patients, with from 7 to 10 percent of sedentary
l,crsons starting to be physically active (Table 6-2).
( )nc feasibility trial ofmultiple risk factorreduction-
IIK Industrywide Network for Social, Urban, and
Rural Efforts (INSURE) Project-indicates that con-
ttnuing medical education seminars, combined with
rclmbursement for prevention counseling and re-
rntndcrs to providers, can increase the.percentage of
I lrcsc physicians' patients who subsequently start exer-
t 151ng (Logsdon, Lazaro, Meir 1989). The Physician-
`j.t~d Assessment and Counseling for Exercise (PACE)
l)rogram incorporated social cognitive theory and the
trnnstheoretical model to individualize brief (2-5
Inlnutcs) counseling messages for patients. Com-
p;u-cd with patients who did not receive the program
c,ounseling, those who did had significantly greater
Improvements at 4-6 weeks in their reported stage of
i~h!sical activity readiness, their reported amount of
: ,rlking for exercise, and their scores from an activity
,n0nitor (Calfas et al. in press).

The Canadian Task Force on the Periodic Health
Examination (1994) cited insufficient evidence as
the reason for not making a recommendation regard-
ing physical activity counseling. However, several
other professional organizations have recently rec-
ommended routine physical activity counseling. The
`~mcrican Heart Association (Fletcher et al. 1992),
`Jc American Academy of Pediatrics (1994), the
.`mcrican Medical Association (1994)) the President's

227

Understanding and Promoting Physical Activity

Council on Physical Fitness and Sports (1992), and
the U.S. Preventive Services Task Force (1989,1996)
all recommend including physical activity counsel-
ing as part of routine clinical preventive services for
both adults and young people.
In summary, many providers do not believe that
physical activity is an important topic to discuss with
their patients, and many lack effective counseling
skills. The studies that have attempted to increase
provider counseling for physical activity demonstrate
that providers can be effective in increasing physical
activity among their patients. It is not known what
alternative approaches to provider counseling can be
used effectively in health care settings, although the
work of Mayer and colleagues (1994) suggests that
well-trained counselors conducting health education
classes with patients may help older adults make
changes in their stage of physical activity.

Community Approaches

Communitywide prevention programs have evolved
from the concept that a population, rather than an
individual, approach is required to achieve primary
prevention of disease through risk factor reduction
(Luepker et al. 1994). Behaviors and lifestyle choices
that contribute to an individual's risk profile are
influenced by personal, cultural, and environmental
factors (Bandura 1977b). Much of the current knowl-
edge regarding community-based prevention strate-
gies has been gained over the past 20 years from three
U.S. research field trials for community-based health
promotion-including physical activity promotion-
to reduce cardiovascular disease (Table 6-2).
These three trials, which were funded by the
National Heart, Lung, and Blood Institute during the
198Os, were the Minnesota Heart Health Program
(MHHP) (Luepker et al. 1994), the Pawtucket Heart
Health Program (PHHP) (Carleton et al. 1995), and
the Stanford Five-City Project (SFCP) (Farquhar et al.
1990). The MHHP advocated regular physical activity
as part of its broad effort to reduce risk for CHD in
whole communities in the upper Midwest (Crow et al.
1986; Mittelmark et al. 1986). Three intervention
communities received a 5- to 6-year program designed
to reduce smoking, serum cholesterol, and blood
pressure and to increase physical activity; three other
communities served as comparison sites. Mass media
were used to educate the public about the relationship


Physical Activity and Health

between regular physical activity and reduced risk for
CHD and to increase opportunities for physical activ-
ity. Health professionals promoted physical activity
through their local organizations, through their advi-
sot-y committees on preventive practice. and through
serving as role models and opinion leaders. Systematic
risk factor screening and education provided on-site
measurement, education, and counseling aimed in
part at increasing to 60 percent the prevalence of
physical activity among the residents in the three
intervention communities. The adult education com-
ponent made available personal, intensive, and mul-
tiple-contact programs to increase physical activity;

this strategy focused on self-management and in-
eluded changes in existing behaviors, in the meaning
of those behaviors, andin the environmental cues that
supported them. Direct education programs forschool-
aged children promoted physical activity in young
people and their parents. The MHHP investigators
reported small but significant effects for physical
activity in the first 3 years among people in the cross-
sectional study group; that effect disappeared with an
increasing secular trend in physical activity in the
comparison groups. The cohort group (followed over
time) showed no intervention effect until the last
follow-up survey (Figure 6-l).
                       .

Figure 6-l. Results of the Minnesota Heart Health Program on physical activity. Graph compares the
   percentage of respondents reporting regular physical activity in intervention cities and the
     secular trend estimated from control cities

I         I         I        I        I

-4      -2       0        2       4       6       8
            Education year
75                     I
                      I               1

Panel 1: Cross-sectional
Fitted secular trend
and MHHP education
program effect estimates

m-v- Education effect
I  95% Confidence
   bounds
- Secular trend

                      I
45 -                   I
                      I
     Baseline       I
                      I         Follow-up
                      I
35         I          I         I         I        I
-4       -2       0       2        4       6       8
             Education year

Panel 2: Cohort

Fitted cohort levels
and MHHP education
program effect estimates

---- Education effect
I  95% Confidence
   bounds
- Cohort levels

Sours e: Luepker RV et Ji. American ]ourna/ oi PuOlic Health 1994 (reprinted with permission).
Note: Adjusted for age, sex. and education.

228


  The PHHP fostered communiry involvement in
heart healthy behavior changes in Pawtucket, Rhode
\s\and(Carletonetal. 1995).Thefocuswasongrassroots
organizing, volunteer delivery, and partnerships with
existing organizations rather than on using electronic
media (Lasater et al. 1986). In the area of physical
.Ictlvity promotion, the emphasis was on environmen-
t,ll and policy change through partnerships with city
oo\,ernment and others. Working with the Department
I-
of Parks and Recreation, the PHHP was instrumental in
establishing cardiovascular fitness trails in both of the
c~t).`sparks. Earlyin itsexistence, the PHHPalso helped
that department place on the ballot and pass a large
bond issue in return for renovations (e.g., lights, fenc-
ing to keep stray dogs out, resurfacing) to an existing
c,ciarter-mile track for walking. The Pawtucket 6-
Lvcck Imagine Action Program, designed around the
stages of change model, enrolled more than 600
participants, who subsequently reported being more
.IC`~IVC as a result of the program (Marcus, Banspach, et
,11. 1992). Results of this uncontrolled study suggest
I 11`11 ;I stage-based approach may be effective in moving
people toward regular physical activity.
  The SFCP included two intervention and two
comparison communities in northern California (only
morbidity and mortality data were monitored in the
hfth city, and those results were not reported in this
ytucly). This project was designed to increase physical
~cr~viry and weight control and to reduce plasma cho-
Icstcrol levels, cigarette use, and blood pressure
l'nrquhar et al. 1990). Greater emphasis was placed on
rlutrition, weight control, and blood pressure than on
physical activity. The program used concepts from
\ocial learning theory, diffusion theory, community
organization, and social marketing in combination
\vlth a communication and behavior change model
(Flora, Maccoby, Farquhar 1989). The program relied
heavily on the use of electronic and print media for the
Jchvery of health education information. General edu-
.ition was supplemented by four to five annual educa-
IIon campaigns targeting specific risk factors. Direct
face-to-face activities included classes, contests, and
school-based programs (Farquhar et al. 1990). Overall,
Ihe educational intervention had no significant im-
pact on physical activity levels, knowledge, self-
efficacy, or attitudes toward physical activity (Young
ct al. T in press). In the cross-sectional sample, men in
`he experimental communities were significantly more

Understanding and Promoting Physical Activity

likely than those in the control communities to engage
in at least one vigorous activity. For women in both the
cross-sectional and cohort studies, a small but signifi-
cant increase was observed in the number of moderate
activities engaged in (Young et al., in press).
Among smaller-scale community studies, the re-
sults of efforts to promote physical activity have been
mixed (Table 6-2). One exception was the community-
based cardiovascular disease prevention program
aimed at black residents in rural communities in the
Missouri "Bootheel" (Brownson et al. 1996). In this 5-
year, low-cost intervention project, educational ef-
forts were combined w,ith environmental changes.
Local coalitions formed walking clubs, built walking
trails, started exercise classes in churches, and orga-
nized special events to promote both physical activity
and good nutrition. Although no difference in levels of
physical inactivity was observed between the Bootheel
and the rest of the state at follow-up, physical inactiv-
ity declined an average of 3 percent in Bootheel
communities that had coalitions and increased an
average of 3.8 percent in those without, for a net
improvement of 6.8 percent.

In summary, results of community-based inter-
ventions to increase physical activity have been
generally disappointing. Measurement of physical
activity has varied across studies, making compari-
sons difficult. The presence of active communiry
coalitions, widespread community involvement, and
well-organized community efforts appear to be im-
portant, however, in increasing physical activity
levels.

Worksite Programs

Physical activity programs conducted on the worksite
have the potential to reach a large percentage of the
U.S. population (Bezold, Carlson, Peck 1986; Na-
tional Center for Health Statistics 1987). As settings
for physical activity promotion, manyworksites have
easy access to employees and supportive social net-
works and can make changes in the environment to
help convey physical activity as an organizational
norm (Shephard, in press).

The proportion of worksites offering physical
activity and fitness programs has grown in recent
years, from 22 percent in 1985 to 42 percent in 1992
(Table 6-3). For two groups of employers, those
with 50-99 employees and those with loo-249

229


Physical Activity and Health

Table 6-3. Summary of progress toward Healthy People 2000 objective 1 .lO
        "Increase the proportion of worksites offering employer-sponsored
           physical activity and fitness programs as follows:"

Year 2000 objective                 1985            1992        Year 2000 target
Physical activity and fitness
worksites with:
SO-99 employees                 14%             33%              20%
loo-249 employees               23%            47%              35%
250-749 employees               32%             66%              50%
750+ employees                 54%             83%              80%
Source: U.S. Department of Health and Human Services, 1992 National Survey of Worksite Health Promotion Activities, 1993.

r

employees, the percentage with exercise programs
more than doubled over that time period. In each
worksitesize category, the percentage with exercise
programs had already (i.e., in 1992) exceeded the
year 2000 national objective for worksite health
promotion listed in Healtlly People 2000 (USDHHS
1993). Generally, the extent of participation, effec-
tiveness, and quality of those programs is unknown,
for only a few worksite physical activity programs
have been evaluated (Table 6-2).
In the Johnson 6;r Johnson Live for Life program
(Wilbur 1983), employees at four experimental sites
participated in lifestyle seminars, contests, and exer-
cise programs and received newsletters on health
issues and other health communications. Experi-
mental and control sites both received an annual
health assessment. Overall, at the end of 2 years, 20
percent of women and 30 percent of men in the
experimental sites reported beginning a vigorous
exercise program; the prevalence at three compari-
son sites was 7 percent for women and 19 percent for
men (Blair et al. 1986).

Fries and associates (1993) evaluated the effec-
tiveness of a health promotion program that included
physical activity for Bank of America retirees. In one
intervention group, each participant paid $30 for a
personalized. mail-delivered program that included a
health risk appraisal and behavioral management
books and other materials. A second group received a
risk appraisal and nothing else for the first 12 months,
after which it received the full intervention. A control
group was monitored for claims data only. The first

intervention group did not differ from the second in
self-reported physical activity at the end of year 1 but
was significantly different in year 2.

Worksite programs less often attract sedentary,
blue-collar, or less-educated employees, but interven-
tions that are tailored to these persons' needs and
interests (King, Carl, etal. 1988) and provide counsel-
ing and peer support (Heirich et al. 1993) show
promise. In a controlled study, Heirich and colleagues
(1993) compared different programs at four automo-
tive manufacturing plants of like size and employee
populations. The three approaches tested were 1) a
staffed physical fitness facility, 2) one-to-one counsel-
ingandoutreachwith high-riskemployees (i.e., those
who had hypertension, were overweight, or smoked
cigarettes), and 3) one-to-one counseling and out-
reach to all employees, peer support, and organiza-
tional change (e.g., the institution of nonsmoking
areas). The fourth site, which served as a control,
offered health education classes and special events.
After 3 years, exercise prevalence at the four sites was
lowest at the plant with the exercise facility _ In the two
counseling and outreach sites, nearly half of the
employees reported exercising 3 times a week.

In summary, considerable progress has been
made in meeting the Healthy People 2000 goals for
worksite physical activity programs. Too few studies
exist to clearly determine what elements are required
for physical activity programs at work to be effective
in increasing physical activity levels among all em-
ployees, attracting diverse employee groups (such as
blue-collar workers), or maintaining exercise levels


over time. However, the limited research available
suggests that widespread employee involvement and
support coupled with organizational commitment
evidenced by the presence of policies and programs
may be important factors in increasing levels of
physical activity. Existing controlled studies have
been done in larger worksites; studies have not yet
shown what might work in smaller worksites and in
diverse worksites (e.g., where many employees travel
or facilities may not exist).

Communications Strategies

Communications strategies, both electronic and print,
\lave the potential for reaching individuals and com-
munities with a rapidity unmatched by other inter-
ifcntion strategies. For the general population, media
can play several roles: to increase the perceived
importance of physical activity as a health issue, to
communicate the health and other benefits of physi-
cal activity, to generate interest in physical activity
;md awareness about available programs, to provide
role models for physically active lifestyles, and to
provide cues to action, such as getting people to
request further information on physical activity,
\,isit an exercise site, or begin exercising (Donovan
and Owen 1994).

The effectiveness of different forms of media
alone, including broadcast and print media, for
promoting either initial adoption or subsequent
maintenance of physical activity remains unclear
hccause the few systematically evaluated interven-
I [(Ins employing communications strategies have
\hown mixed results (Osler and Jespersen 1993;
liooth et al. 1992; Owen et al. 1995; Luepker et al.
1994; Farquhar et al. 1990). The SFCP, discussed
cnrlier, resulted in small increases in the number of
moderate activities engaged in by women and vig-
orous activity engaged in by men. Two national
mass media campaigns to increase physical activity,
i~nrticularly walking, to prevent cardiovascular dis-
I"KC were conducted in Australia in 1990 and 1991
(Booth et al. 1992). Drawing on social marketing
`lnd social learning theories, both campaigns in-
cluded paid advertisements on national television,
Pllblic service announcements on radio, scripted
episodes on two nationally broadcast television
clrarnas, posters and leaflets, stickers, T-shirts and
-\\,catshirts, magazine articles, distribution of a

Understanding and Promoting Physical Activity

professional article, soap operas specially scripted
to feature physical activity, and publicity tours by
two experts in heart health. The budgets and paid
television coverage for the 1990 and 1991 cam-
paigns were similar. Both campaigns were evalu-
ated by one-on-one, home-based interviews with
structured cross-sectional random samples of ap-
proximately 2,500 people 2 weeks before and 3 to 4
weeks after each campaign. Both campaigns re-
sulted in significant differences in message aware-
ness (46 percent vs. 71 percent in 1990; 63 percent
vs. 74 percent in 1991). The 1990 postcampaign
survey revealed significant increases in walking for
exercise (p < 0.01) compared with the precampaign
period, although the actual percentage increase was
small (73.9 percent vs. 70.1 percent). In particular,
adults over 50 years of age were nearly two times
more likely to report walking at follow-up than
before the campaign. The 1991 campaign produced
different results. Evaluation showed that the per-
centage of persons reporting walking in the previ-
ous 2 weeks declined from precampaign levels
among all adult age groups except people over 60
years of age. Intention to become more active also
declined overall, from 26.3 percent to 24.8 percent
(Owen et al. 1995).

  Communications intended to serve as cues to
action have been tested at places where people can
choose whether to walk or ride. This approach in-
volves placing signs to use the stairs near escalators
in public places like train and bus stations or shop-
ping malls (Brownell, Stunkard, Albaum 1980;
Blarney, Mutrie, Aicchison 1995). For example, signs
that said "Stay Healthy, Save Time, Use the Stairs"
increased the percentage of people using stairs in-
stead of an adjacent escalator from 8 percent to 1%
17 percent (Blarney, Mutrie, Aitchison 1995). Twelve
weeks after the sign was removed, the increase in
stair use remained significant but showed a trend
toward baseline.

In summary, communications strategies have
had limited impact. It is not clear if communications
approaches would be more effective in getting people
to be regularly active if they were linked with oppor-
tunities to act on messages or if messages were
tailored to stages of change or to the needs of sub-
groups in the population (Carleton et al. 1995;
Donovan and Owen 1994; Young et al. in press).

231


physical Activity and Health

Appropriately placed communications that serve as
cues to action appear to increase the decision to use
the stairs instead of ride the escalator.

Special Population Programs

Racial and Ethnic Minorities

The few interventions studies that have been con-
ducted with racial and ethnic minorities have pro-
duced mixed results. The Bootheel Project referred
to earlier in this chapter found increased levels of
physical activity in black communities with coali-
tions. The Physical Activity for Risk Reduction project
(Lewis et al. 1993) was undertaken in black commu-
nities in Birmingham, Alabama, using a combination
of behavioral management and community organi-
zation approaches. In the intervention groups, com-
munity members played roles in defining needs,
identifying strategies, and conducting interventions.
In those communities where strong organization,
leadership, and commitment to the project were
observed, statistically significant increases in physi-
cal activity were also noted.

Results of two family-based health promotion
programs that used behavioral management ap-
proaches to promote physical activity showed no
greater increase in physical activity among those
participating in the programs than among those in a
control group. Nader and colleagues (1989) con-
ducted a nutrition and physical activity program for
Anglo-American and Mexican American families with
children in fifth and sixth grades; the program im-
proved dietary habits but did not succeed in increas-
ing physical activity levels, although participation in
the program was high. Another family-based pro-
gram, a 14week intervention for African American
families that included educational sessions and twice-
weekly fitness center activities, had low attendance
and did not increase physical activity (Baranowski et
al. 1990).

The Indian Health Service undertook the
community-based Zuni Diabetes Project to increase
physical activity and decrease body weight among
Zuni Indians in New Mexico who had non-insulin-
dependent diabetes mellitus (NIDDM) (Leonard,
Leonard, Wilson 1986). The exercise program con-
sisted of several l-hour aerobic sessions offered during
the week. Zuni Indians who were trained in exercise
and group leadership methods helped coordinate the

program and build community ownership. After par-
ticipating in aerobic sessions through the program, 43
percent of the participants began and maintained an
at-home exercise program, whereas only 18 percent
of a comparison group of previously sedentary non-
participants with NIDDM did so (Heath et al. 1987).

People Who Are Overweight

Being overweight increases the risk of developing
chronic diseases (see Chapter 4). Results of inter-
ventions to promote physical activity for weight loss
have been mixed (Perri et al. 1988; Jeffery 1995;
King et al. 1989).

The MHHP , one of the large community inter-
vention trials discussed earlier in this chapter
(Luepker et al. 1994), developed a series of compo-
nent programs containing strategies to increase physi-
cal activity for losing weight or preventing weight
gain Ueffery 1995). The Building Your Fitness Fu-
tures program was a 4-week adult education class
that focused on how to develop a regular exercise
program. The Wise Weighs programs was an g-week
adult education class that emphasized weight man-
agement strategies related to diet and exercise. The
third MHHP intervention, a correspondence course,
addressed diet and exercise through monthly news-
letters and tested two levels of financial contract
incentives ($5 and $60 dollars). Each of these pro-
grams was evaluated in the MHHP randomized trial.
The Building Your Fitness Futures and the Wise
Weighs programs resulted in only small weight loss
that was not significant after 1 year. The correspon-
dence course resulted in significantly greater weight
loss among participants with $60 incentives than
among those with $5 incentives.
Preventing weight gain may be easier than promot-
ing weight loss. Wing (1995) suggests that there are
three time periods during which interventions to pre-
vent weight gain might be most effective: in the years
between ages 25 and 35 years, in the peri-menopausal
period for women, and in the year following successful
weight loss. A fourth MHHP program that addressed
physical activity, the Weight Gain Prevention Pro-
gram, was a randomized trial of 211 communityvolun-
teers. The participants (approximately two-thirds
women) were randomly assigned to either the inter-
vention group (n = 103) or the no-contact control
group (n = 108). This program was for normal-weight
adults and included monthly newsletters and four


classes emphasizing diet and regular exercise as well
as a financial incentive component linked to weight
maintenance. The intervention group lost 2 pounds
on average over the course of the year and were
significantly less likely to gain weight than the control
group (82 percent vs. 56 percent) (Jeffery 1995).

Older Adults

\lany of the diseases and disabling conditions asso-
elated with aging can be prevented, postponed, or
ameliorated with regular physicalactivity (see Chap-
tcr 4). The few interventions that have been tested to
Increase physical activity levels among older adults
,how generally positive results. The 1990 Australian
ticart Week campaign reviewed earlier resulted in a
t\vofold increase in walking among adults over 50
\`ears of age (Owen et al. 1995). Retirees in the study
by Fries (1993), also discussed earlier, showed sig-
nlficantly greater improvements in physical activity
In year 2 than did persons in the control group.
Pnrricipants in a longitudinal study of Medicare
rcclpients (n = 1,800) who belonged to a health
maintenance organization were randomly assigned
10 a preventive care or a control group (Mayer et al.
1094). The intervention employed information and
hchavior modification approaches. Participants re-
ccived recommended immunizations, completed a
health risk appraisal, received face-tq-face counsel-
~ng that included goal setting, received follow-up
rclcphone counseling, and participated in educa-
~lonal sessions on health promotion topics. A focus
~III physical activity was a priority in goal-setting
dIscussions; 42 percent of participants selected in-
creasing physical activity as their goal. Members of
both groups were largely white, well educated, and
~~enerally had above-average incomes. The preva-
r cnce of physical activity was high in both groups at
llaseline; approximately 60 percent reported get-
llng regular exercise. At 1 year, the intervention
croup showed a significant 7 percent increase in
yell-reported physical activity.

Much of the published research on physical activ-
I$ describes researcher-initiated interventions. How-
ever, individuals and small groups of people often
Imtiate physical activity on their own, independent of
nny formal program. A qualitative research study by
Duncan, Travis, and McAuley (1995) used observa-
`ions and in-depth interviews to examine motivation

Understanding and Promoting Physical Activity

for initiating and maintaining mall walking by older
persons in rural West Virginia. Most participants in
this study reported becoming physically active at the
urging of their physicians; several others were moti-
vated by personal interest in health maintenance, and
some were encouraged by family members. Mall walk-
ers maintained a regular routine, showing up at the
same time each day, walking in pairs or small groups,
and then adjourning to a mall eatery for coffee or
breakfast. Interviews revealed that participants per-
ceived mall walking as meaningful "work" to be doing
during retirement. A need for socializing with others,
a sense of belonging to a community of mall walkers,
and the safe environment of the mall were other
factors contributing to adherence. Study researchers
recommended that community-based physical activ-
ity programs try to replicate various aspects of work,
such as keeping attendance records and providing
occasional recognition or acknowledgment of a job
well done (such as pins, certificates, or celebrations).

People with Disabilities

People with disabilities have similar health promo-
tion and disease prevention needs as persons with-
out disabilities. Interventions to promote physical
activity for risk reduction among persons with mo-
bility, visual, hearing, mental, or emotional impair-
ments are largely absent from the literature. Physical
activity interventions for managing chronic condi-
tions, on the other hand, have led to enhanced
cardiorespiratory fitness and improved skeletal
muscle function in persons with multiple sclerosis
(Ponichtera-Mulcare 1993), increased walking ca-
pacity and reduction in pain for patients with low
back pain (Frost et al. 1995), and improvements in
endurance among patients with chronic obstructive
pulmonary disease (Atkins and Robert 1984).

In summary, interventions that have been suc-
cessful in increasing physical activity among minori-
ties have employed community organization
strategies, such as coalition building and community
engagement at all levels. Family-oriented interven-
tions in community centers that have employed
behavioral management approaches have not re-
sulted in increases in physical activity. Physical
activity interventions incorporating incentives show
promise for promoting weight loss or preventing
weight gain. Although there are a limited number of

233


Physical Activity and Health

studies, positive effects have been shown for inter-
ventions and communications strategies promoting
physical activity in older adult populations, at least
among older white adults with moderate incomes
and education levels. What is not well known is what
interventions may be effective with racial or ethnic
minority older adults who may face barriers such as
language, transportation, income, education, or dis-
ability. It is not clear what interventions might be
effective to promote physical activity. other than for
disease management, among people with disabili-
ties, or what strategies might assist with the manage-
ment of pain, periods of illness, environmental
barriers, or other circumstances to improve adher-
ence with physical activity recommendations.

Summary

The review of adult intervention research literature
provides limited evidence that interventions to pro-
mote physical activity can be effective in a variety of
settings using a variety of strategies. Controlled
interventions that have been effective at the work-
place, in health care settings, and in communities
have resulted in increased physical activity, although
effects have tended to be small, in the range of 5-10
percent, and short-lived. Multiple interventions con-
ducted over time may need to be employed to sustain
physical activity behavior. Most experimental and
quasi-experimental intervention research has been
theory-based, much if not most relying largely on
behavioral management strategies, often in combi-
nation with other approaches, such as communica-
tions and social support. Mixed results have made it
impossible to determine what theory or theories
alone or in combination have most relevance to
physical activity. Research strategies that appear
promising include the tailoring of interventions to
people's needs, experiences, and stages of change;
the timing of intervention strategies to reinforce new
behaviors and prevent relapse (such as through
frequent follow-up telephone calls); peer involve-
ment and support; and an engaged community at all
levels. It is not known if interventions could be
strengthened by combining them with policy ap-
proaches (Luepker 1994; Winkleby 1994).
  Intervention studies with adults were often con-
ducted over a brief period of time, had little or no
follow-up, and focused on the endpoint of specified
vigorous physical activity rather than on moderate-

234

intensity physical activity or total amount of activity.
Studies used different endpoints, such as class par-
ticipation versus specified changes in behavior, mak-
ing them difficult to compare. Because physical
activity interventions were often only one compo-
nent of an intervention to reduce multiple risk fac-
tors, they may not have been robust enough to result
in much or any increase in physical activity. Few if
any studies compared their results to a standard of
effectiveness, such as recommended frequency or
duration of moderate or vigorous physical activity,
or clearly stated the extent of stage-based change.

Behavioral Research on Physical
Activity among Children and
Adolescents

Behavioral research in this area includes studies on
the factors influencing physical activity among
young people as well as studies examining the effec-
tiveness of interventions to increase this behavior.
This research, however, is more limited than the
determinants and interventions literature for adults.

Factors Influencing Physical Activity among
Children and Adolescents

The emphasis in this section is on factors that influ-
ence unstructured physical activity during free time
among youths rather than on supervised physical
activity, such as physical education classes. Studies
of organized youth sports have also been excluded.
Only studies with some measure of physical activity
as the outcome, however, are included in this re-
view. For example, studies that investigated atti-
tudes toward physical activity and did not relate
those to a measure of physical activity were ex-
cluded. As was the case in the adult section, this
section focuses on studies that address modifiable
determinants of physical activity, such as self-
efficacy, rather than on studies that examine factors
that cannot be altered to influence participation in
physical activity, such as age, sex, and racejethnicity.

Modifiable Determinants

The modifiable determinants of youth physical ac-
tivity include personal, interpersonal, and environ-
mental factors (Table 6-l). Self-efficacy, a construct


from social cognitive theory, has been positively
associated with physical activity among older chil-
dren and adolescents (Reynolds et al. 1990; Trost et
al. 1996; Zakarian et al. 1994). Similarly, perceptions
of physical or sports competence (Biddle and
Armstrong 1992;BiddleandGoudas 1996; Dempsey,
Kimiecik, Horn 1993; Ferguson et al. 1989; Tappe,
Duda, Menges-Ehrnwald 1990) also have been posi-
tively associated with physical activity among older
children and adolescents.

Expectations about the outcomes of physical
activity are associated with physical activity among
preadolescents and adolescents. Perceived benefits
have been positively associated (Ferguson et al.
1989; Tappe, Duda, Menges-Ehrnwald 1990;
Zakarian et al. 1994), whereas perceived barriers
have been negatively associated (Stucky-Ropp and
DiLorenzo 1993; Tappe, Duda, Menges-Ehrnwald
1990; Zakarian et al. 1994). Intention to be active, a
construct from the theory of reasoned action and the
theory of planned behavior, has been consistently
und positively related to physical activity among
older children and adolescents (Biddle and Goudas
1996; Ferguson et al. 1989; Godin and Shephard
1986; Reynolds et al. 1990) .

Enjoyment, the major reason young people en-
gage in physical activity (Borra et al. 1995), has been
positively associated with physical activity among
both children and adolescents (Stucky-Ropp and
DiLorenzo 1993; Tinsley et al. 1995). Favorable
,Ittitudes toward physical education also have been
llositively related to adolescent participation in
physical activity (Ferguson et al. 1989; Zakarian et
111. 1994).

Social influences-such as physically active role
models and support for physical activity-are im-
portant determinants of physical activity among
\`onng people (Tinsley et al. 1995). Parental activity
i Moore et al. 1991; Poest et al. 1989; Sallis, Patterson,
`ilcKenzie et al. 1988) is positively related to physical
.\ctivity among preschoolers. Studies reveal no rela-
[ionship between parental physical activity and physi-
cal activity among elementary school children
(McMurray et al. 1993; Sallis, Alcaraz, et al. 1992),
and either no relationship (Biddle and Goudas 1996;
Garcia et al. 1995; Stucky-Ropp and DiLorenzo 1993;
jallis, Patterson, Buono, et al. 1988) or positive
:efationships (Anderssen and Wold 1992; Butcher

Understanding and Promoting Physical Activity

1985; Gottlieb and Chen 1985; Stucky-Ropp and
DiLorenzo 1993; Sallis, Patterson, Buono, et al.
1988) to the physical activity of middle school stu-
dents (grades 5-8). Parental physical activity is posi-
tively related to physical activity among older
adolescents (Reynolds et al. 1990; Zakarian et al.
1994). The physical activity of friends (Anderssen
and Wold 1992; Stucky-Ropp and DiLorenzo 1993;
Zakarian et al. 1994) and siblings (Perusse et al.
1989; Salhs, Patterson, Buono, et al. 1988) also is
positively associated with physical activity among
older children and adolescents.

Parental encouragement is positively related to
physical activity among*preschoolers (McKenzie,
Sallis, et al. 1991; Klesges et al. 1984, 1986; Sallis et
al. 1993), and parental or adult support for physical
activity is positively associated with physical activity
among adolescents (Anderssen and Wold 1992;
Biddle and Goudas 1996; Butcher 1985; Zakarian et
al. 1994). Friends' support for physical activity
(Anderssen and Wold 1992; Zakarian et al. 1994)
also is positively related to physical activity among
adolescents.

Direct help from parents, such as organizing
exercise activities (Anderssen and Wold 1992) or
providing transportation (Sallis, Alacraz, et al. 1992>,
is positively related to physical activity among older
children and younger adolescents. Access to play
spaces and facilities (Garcia et al. 1995; Sallis et al.
1993; Zakarian et al. 1994) is positively related to
physical activity among youths of all ages. The avail-
ability of equipment has been positively related to
physical activity among preadolescent and adoles-
cent girls (Butcher 1985; Stucky-Ropp and DiLorenzo
1993). Further, two studies of young children have
demonstrated that time spent outdoors is a positive
correlate of physical activity level (Klesges et al.
1990; Sallis et al. 1993).

Determinants for Population Subgroups
Among the limited number of subgroup-specific
determinants studies, sex-specific differences are
investigated most frequently. In two studies of ado-
lescents (Kelder et al. 1995; Tappe, Duda, Menges-
Ehrnwald 199O), competition motivated boys more
than girls, and weight management motivated girls
more than boys. Additionally, boys have higher
levels of self-efficacy than girls (Trost et al. 1996)

235


physical Activity and Health

and higher levels of perceived competence (Tappe,
Duda, Menges-Ehrnwald 1990) for physical activity.

Summary

Few studies of the factors that influence physical
activity among children and adolescents have applied
the theories and models of behavioral and social
science. The research reviewed in this section, how-
ever, has revealed that many of the factors that influ-
ence physical activity among adults are also
determinants of physical activity among children and
adolescents. Older children's and adolescents' inten-
tions to engage in physical activity, as well as their
perceptions of their ability to engage in such activity
(i.e., self-efficacy and perceived competence), are
positively related to their participation in physical
activity. Social influences, such as parental and peer
engagement in, and support for, physical activity, also
are positively related to physical activity among young
people. Further, exercise enjoyment and positive atti-
tudes toward physical education have been positively
associated with physical activity among older chil-
dren and adolescents. Research is limited, however,
on patterns of determinants for population subgroups,
such as girls, ethnic minorities, and children with
disabilitiesorchronic healthconditions (e.g.,asthma).

Interventions to Promote Physical Activity
among Children and Adolescents
The most extensive and promising research on in-
terventions for promoting physical activity among
young people has been conducted with students in
schools, primarily at the elementary school level.
Although many school-based studies have focused
on short-term results, a few studies have also exam-
ined long-term behavioral outcomes. There is lim-
ited evidence concerning the effectiveness of
school-community programs, interventions in health
care settings, family programs, and programs for
special populations. In this section, the emphasis is
on interventions designed to promote both unstruc-
tured physical activity during free time and super-
vised physical activity, such as physical education
classes. Interventions designed to increase participa-
tion in, or adherence to, organized youth sports have
been excluded from this review. The review places
special emphasis on experimental studies, which
feature random assignment of individuals or groups

to intervention (experimental) or comparison (con-
trol) conditions, or quasi-experimental studies, which
feature intervention and comparison groups.

School Programs

Because most young people between the ages of 6 and
16 years attend school, schools offer an almost
populationwide setting for promoting physical activ-
ity to young people, primarily through classroom
curricula for physical education and health educa-
tion. The CDC (in press) recommends that compre-
hensive school and community health programs
promoting physical activity among children and ado-
lescents be developed to increase knowledge about
physical activity and exercise, develop behavioral and
motor skills promoting lifelong physical activity, fos-
ter positive attitudes toward physical activity, and
encourage physical activity outside ofphysical educa-
tion classes. CDC's 1994 School Health Policies and
Programs Study (Kann et al. 1995) examined the
current nationwide status of policies and programs
for multiple components of a school health program.
The study examined kindergarten through 12th-grade
health education and physical education at state,
district, school, and classroom levels (Errecart et al.
1995). Results from the health education component
of this study revealed that physical activity and fitness
instruction were required in 65 percent of states and
82 percent of districts and were included in a required
health education course in 78 percent of schools.
Only 41 percent of health education teachers pro-
vided more than one class period of instruction on

these physical activity topics during the school year
(Collins et al. 1995).

Results from the physical education component
of the School Health Policies and Program Study
revealed that physical education instruction is re-
quired by most states (94 percent) and school dis-
tricts (95 percent) (Pate, Small, et al. 1995). These
policies, however, do not require students to take
physicaleducationeveryyear. Forinstance,although
most middle and junior high schools (92 percent)
and most senior high schools (93 percent) require at
least one physical education course, only half of
these middle and junior high schools and only 26
percent of these senior high schools require the
equivalent of at least 3 years of physical education.
Additionally, only 26 percent of all states require

236


Understanding and Promoting Physical Activity

schools to offer a course at rhe senior high school
level in lifetime physical activity (i.e., physical activ-
it!, that can be practiced throughout one's lifetime)
(Pate. Small, et al. 1995). The School Health Policies
.Ind Programs Study also revealed that instructional
practices in physical education often do not reflect
the emphasis on lifetime physical activity that is
recommended in the national objectives in Healrl~y
Pcoplc 2000 (USDHHS 1990), in the National Physi-
cal Education Standards (National Association for
Sport and Physical Education 1995), and in the
CDC's Guiddincs for Schwa and Community Health
Proyrams to Promote Physical Activity Among Youth
(In press). More than half of physical education
teachers devoted multiple class periods to traditional
bports activities, such as basketball (87 percent),
volleyball (82 percent), and baseball/softball (82
percent), whereas much smaller proportionsof teach-
ers devoted multiple class periods to lifetime physi-
cal activities, such as jogging (47 percent), aerobic

dance (30 percent), and swimming (14 percent)
(Pate, Small, et al. 1995) (Table 6-4). Additionally,
only 15 percent of all physical education teachers
required students to develop individualized fitness
programs (Pate, Smail, et al. 1995). Despite current
guidelines' emphasis on lifetime physical activity,
during the 2 years preceding the study only 22
percent of physical education teachers received in-
service training on developing individualized fitness
programs, and only 13 percent received training on
increasing students' physical activity outside of
physical education class (Pate, Small, et al. 1995).
Detailed findings from the School Health Poli-
cies and Programs Study are important because
school-based physical education may be the most
widely available resource for promoting physical
activity among young people in the United States.
For physical education to meet public health goals,
it should provide all students with recommended
amounts of weekly physical activity (USDHHS 1990).

Table 6-4. Percentage of all physical education courses in which more than one class period was devoted to
    each activity, by activity, School Health Policies and Programs Study, 1994
Activity                Percentage of all courses           -
Uasketball                               86.8

Volleyball                              82.3

lL~seball/soitball                          ai .5

Flag/touch football                        68.5

Soccer                                65.2

logging                              46.5*
Weight lifting or training                     37.3*

Tennis                               30.3*

Aerobic dance                            29.6*
LYalking quickly                           14.7*
Swimming                             13.6*

Handball                              13.2*
Racquetball                            4.9+
HikinGackpacking                        3.0'
Bicycling                               1.3*
hxe: Adapted from Pate RP et al. School physical education. /ournal oikhool Healfh 1 Y95 (reprinted with permission).
`LIfetIme physical activities

237


Physical Activity and Health

Ironically, observations of physical education classes
indicate that insufficient class time is spent actually
engaging in physical activity (McKenzie et al. 1995;
McKenzie et al., in press; Simons-Morton et al. 1991,
1993, 1994).

The School Health Policies and Programs Study
provided a national overview of the status of school
health programs (Kann et al. 1995). Intervention
research has been reported from several studies
(Table 6-5). Most of the early research in schools
focused on knowledge-based health education class-
room lessons; these studies generally reported posi-
tive changes in knowledge and attitudes but not in
behaviors. Summarized in review articles (Sallis,
Simons-Morton, et al. 1992; Simons-Morton, Parcel,
O'Hara et al. 1988), these studies suffered from
methodological problems, such as small samples and
measurement limitations. Contemporary programs
emphasize the importance of multicomponent inter-
ventions that address both the individual and the
environmental level to support engagement in physi-
cal activity among youths (Kelder, Perry, Klepp
1993; Luepker et al. 1996; McKenzie et al., in press;
Perry et al. 1990, 1992; Simons-Morton, Parcel,
O'Hara 1988; Stone et al. 1995).
The Know Your Body (KYB) program (Williams,
Carter, Eng 1980) has been the focus of three school-
based cardiovascular risk reduction studies (Bush,
Zuckerman, Taggart, et al. 1989; Bush, Zuckerman,
Theiss, etal. 1989; Resnicowetal. 1992; Walter 1989).
This program includes health screening, behavior-
oriented health education curricula, and special
interventions for students with one or more cardio-
vascular disease risk factors (e.g., hypercholester-
olemia, hypertension, obesity, lack of exercise,
cigarette smoking) (Williams, Carter, Eng 1980).
Although this program was designed to improve
students' knowledge, attitudes, and behaviors re-
lated to physical activity, nutrition, and cigarette
use, the measurement and reporting of physical
activity behavior has been inconsistent among the
three studies. In the first study, the measure for self-
reported physical activity was found to be unreliable,
and the results related to this measure were not
reported (Walter 1989). In the second KYB study,
students' physical activity behavior was not assessed
(Resnicow et al. 1992). The third study was a 5-year,
randomized cardiovascular risk reduction trial among
1,234 African American students in grades four

through six from nine schools stratified for socio-
economic status (Bush, Zuckerman, Taggart, et al.
1989; Bush, Zuckerman, Theiss, et al. 1989). This
project included the KYB health education curricu-
lum, health screening, parent education, and KYB
advisory boards for parents, community members,
students, and physicians. After 4 years, students
from both the intervention and control schools had
significant increases in health knowledge at posttest,
and intervention students had significantly better
gains in health knowledge (Bush, Zuckerman, Theiss,
et al. 1989). Physical activity, however, decreased
significantly amongstudents f&m both the interven-
tion and control schools, and there was no difference
in physical activity between the intervention and
control schools.

The Stanford Adolescent Heart Health Program
(Killen et al. 1988) was a classroom-based random-
ized cardiovascular disease risk reduction trial for
1,447 tenth graders from four matched high schools
within two school districts. One school within each
district was designated at random to receive a 20-
week risk reduction intervention, and the other
school served as the control. The classroom-based
intervention focused on three cardiovascular risk
factors, including physical activity. At the 2-month
follow-up, students from the intervention schools
had significantly higher gains in knowledge about
physical activity than did students in the control
schools. Among students not regularly exercising at
baseline, those in the intervention schools had sig-
nificantly greater increases in physical activity than
did those in control schools. Additionally, students
who received the intervention had significantly lower
resting heart rates and subscapular and triceps
skinfold measures. The long-term effectiveness of
this program was not reported.

An Australian study (Dwyer et al. 1979, 1983)
was one of the first randomized trials that investi-
gated the effects of daily physical activity on the
health of elementary school students. The study
included 513 fifth-grade students from seven
Adelaide metropolitan schools. Three classes from
each school participated in the study and were ran-
domly assigned to one of three conditions: fitness,
skills, or control. Students in the control condition
received the usual three 30-minute physical educa-
tion classes per week. The students in both interven-
tion conditions received 75 minutes of daily physical

238


Understanding and Promoting Physical Activity

education: one condition emphasized fitness activi-
ties featuring high levels of physical activity, and the
other emphasized skill development activities with-
out special emphasis on the intensity or duration of
physical activity. With the class as the unit of analy-
sis, the fitness condition led to significantly greater
Increases in endurance fitness and decreases in
skinfold measurements. Although this study did not
evaluate the impact of increased physical education
on students' engagement in physical activity outside
of class, it showed that academic test scores did not
differ between the intervention and control groups,
despite the additional 275 minutes of class time the
intervention groups spent on physical education
rather than on traditional academic subjects.
Go For Health (GFH) was a 3-year school health
project designed to promote healthful diet and exer-
cise behaviors among elementary school students
(Parcel et al. 1987; Simons-Morton, Parcel, O'Hara
1988; Simons-Morton et al. 1991). This project in-
volved four elementary schools (kindergarten
through fourth grade) from the Texas City Indepen-
clcnt School District. Two schools were assigned to
serve as controls, and the other two were designated
JS GFH intervention schools. The intervention was
hased on social cognitive theory and included a GFH
health education curriculum, physical education
classes that focused on vigorous physical activity,
and lower-fat school lunches. The physical activity
results revealed a significant increase from pretest to
posttest (2 years) in the percentage of physical edu-
cation class time that students in the intervention
schools were engaged in moderate-to-vigorous physi-
cal activity. Additionally, posttest values were sig-
nificantly greater than those for the control schools
(Simons-Morton et al. 1991). Although this study
did not examine changes in physical activity outside
of physical education classes, it highlighted the im-
portance of organizational changes to promote physi-
cal activity among students.

The Sports, Play, and Active Recreation for Kids
(SPARK) study, conducted in San Diego, California,
tested the effects ofcombininga health-related physi-
cal education curriculum and in-service programs
on the quantity and quality of physical education
classes in elementary schools (McKenzie et al. 1993).
In a single school district, 28 fourth-grade classes in
jeven schools were randomly assigned to one of

three conditions: 10 classes were taught in their
usual manner by classroom teachers (control group);
10 classes were taught the SPARK program by cfass-
room teachers who had received in-service training
and follow-up consultations; and 8 classes were
taught the SPARK program by physical education
specialists hired by the research project. Direct ob-
servation found that students assigned to either of
the two intervention groups engaged in significantly
more weekly physical activity during physical edu-
cation classes than did controls. Teachers who re-
ceived the new physical education curriculum and
in-service training provided significantly higher-
quality instruction than did teachers in the control
group, although the trained classroom teachers' in-
struction did not match the quality of the instruction
provided by the physical education specialists. This
study demonstrated that an improved physical edu-
cation curriculum, combined with well-designed
training for physical education specialists and class-
room teachers, can substantially increase the amount
of physical activity children receive in school
(McKenzie et al. 1993) and can help ensure that the
resulting physical education classes are enjoyable
(McKenzie et al. 1994).

  The Child and Adolescent Trial for Cardiovas-
cular Health (CATCH) study was a multicenter,
randomized trial to test the effectiveness of a cardio-
vascular health promotion program in 96 schools in
four states (Luepker et al. 1996; Perry et al. 1990,
1992; Stone 1994). A major component of CATCH
was an innovative health-related physical education
program, beginning at the third grade, for elemen-
tary school students. For 2.5 years, randomly assigned
schools received a standardized physical education
intervention, including new curriculum, staff de-
velopment, and follow-up consultations. In these
intervention schools, observed participation in
moderate-to-vigorous activity during physical
education classes increased from 37.4 percent of
class time at baseline to 51.9 percent (Luepker et al.
1996). This increase represented an average of 12
more minutes of daily vigorous physical activity in
physical education classes than was observed among
children in control schools (Luepker et al. 1996;
McKenzie et al. 1995). Figure 6-2 shows the effect of
CATCH on physical activity during physical educa-
tion class. The CATCH study showed that children's

239


Physical Activity and Health

Table 6-5. Studies of interventions to increase physical activity among children and adolescents
---
study             Design         Theoretical approach    Population

School programs

Bush, Zuckerman,
Taggart, et al. (1989),
Bush, Zuckerman,
Theiss, et al. (1989)
(Know Your Body)

4 year
experimental

Social learning theory

1,234 students initially
in grades 4-6, follow-up
in grades 7-9

Killen et al. (1988)         7 week
(Stanford Adolescent      experimental
Heart Health Program)     2-month follow-up

Dwyer et al. (1983)

14 week
experimental

Social cognitive theory

1,447 students in grade 10

None

513 students in grade 5

Simons-Morton et al.
(1991) (Go For Health)

3 year
quasi-experimental

Social cognitive theory

409 grades 3 and 4
PE classes

McKenzie et al.
(1993) (SPARK)

Luepker et al. (1996);
McKenzie (in press);
Edmundson et al.
(1996) (CATCH)

8 month
experimental

3 year
experimental

112 PE lessons

Social cognitive theory

96 schools; 3,239 students
initially in grade 3,
follow-up at grade 5

School-community programs

Kelder, Perry, Klepp
(1993) (Minnesota
Heart Health Program:
Class of 1989 Study)

7 year
quasi-experimental

Social learning theory

Students in grade 6 from
2 Minnesota Heart Health
Program communities

I = tnterventlon; C = control or comparison; HE = health education; PE = physical education.

240


Understanding and Promoting Physical Activity

Intervention
.----

Findings and comments

t-1 : -I5 minutes, 2 times/week, Know Your Body
HE curriculum; health screening and results
t-2: -t5 minutes, 2 times/week, Know Your Body
HE curriculum; health screening
C: Health screening

I:  20 classroom PE sessions, 50 minutes each,
3 times/week, HE risk reduction curriculum
(1: No intervention

I-I : 75 minutes daily PE, fitness curriculum    Physical activity not assessed; no differences in academic
I-?: 75 minutes daily PE, skill curriculum      achievement between intervention and control
C: 30 minutes PE 3 times/week, standard     groups despite additional 275 minutes of time
  curriculum                 spent in PE by intervention groups

I:  6 behaviorally based HE modules; five 6- to
8-week modules of PE, children's active PE
curriculum; reduced fat and sodium school
  lunch

C: No intervention

I-1 : PE provided by PE specialists
I-J: PE provided by "specially trained" classroom
  teachers

(1: PE provided by classroom teachers

I-1 : HE curricula; PE featuring enjoyable
moderate-to-vigorous physical activity;
  EAT SMART school food service intervention
I-2: Same as I-1 with family involvement
(1: No intervention

I:  Peer-led physical activity challenge at grade 8;
10 lesson Slice of Life HE curriculum at grade 10
(1: No intervention

Decrease in physical activity for both groups between pretest
and follow-up. No difference in physical activity between
groups at posttest. Increase in posttest knowledge by each
group. Great increases in knowledge by intervention groups
at posttest, 18% response rate at 4-year follow-up

Intervention groups compared with control had a higher
proportion of nonexercisers at baseline exercising at
follow-up

Increase from pretest to posttest in the percent of PE class
time intervention school students spent in moderate-to-
vigorous physical activity; higher percentage of PE class
time spent in moderate-to-vigorous physical activity by
intervention schools compared with controls in posttest

At posttest PE specialists spent more minutes per lesson on
very active physical activity and fitness activities than
specially trained classroom teachers and classroom
teachers; specially trained classroom teachers spent more
minutes per lesson on very active physical activity and fitness
activities than classroom teachers

Intervention schools compared to control schools provided a
greater percentage of PE time spent in moderate to vigorous
physical activity at posttest; family involvement had no
effect on physical activity and psychosocial outcomes; data
from the intervention groups combined for comparison with
the control groups; intervention students were not different
from control students in total daily physical activity at posttest;
intervention students spent 12 more minutes per day engaged
in vigorous physical activity than controls; pretest-to-posttest
increases in students' perceptions of self-efficacy for
exercise and positive social reinforcement for exercise
among both intervention and control students; intervention
students' posttest scores on these and other psychosocial
measures were not different from those of control students

At 7-year follow-up students from schools in intervention
community had higher levels of physical activity than
students from schools in control community, particularly
among girls; 45% response rate at 7-year follow-up

241


Physical Activity and Health

Figure 6-2. Moderate-to-vigorous and vigorous
    physical activity observed during Child
     and Adolescent Trial for Cardiovascular
    Health (CATCH) physical education classes
   60

                      Intervention

Intervention

  --- -__L -L------/H
            Vigorous
lo-

Ol       I        I        I        I        I
      2      3      4      5     6
           Semester

Source: Luepker RV et al. journal of the American Medical
Association 1996 (reprinted with permission).

Note: Observed at six time points, 1991 through 1994. The CATCH
intervention, introduced during semester 2. increased the percentage
of time spent in moderate-to-vigorous and vigorotis activity JS
measured by the System for Observtng Fitness Instruction Time
classroom observation system. Intervention and control curves
diverged significantly according to repeated-measures analysis of
variance with the class session as the unit of analysis: ior moderate-
to-vigorous activity, P = 2.17, df = 5, 1979, P = .02; for vigorous
activity, F = 2.95, df = 5, 1979, P = 04. Analysts controlled for CATCH
site, the location of the lesson, the specialty of the teacher, and random
variation among schools and weeks of observation.

physical activity can be increased by a standardized
intervention applied to existing physical education
programs in four geographically and ethnically di-
verse regions. Although the intervention students
showed significant pretest to follow-up increases in
their perceptions of positive social reinforcement
and self-efficacy for exercise (Edmundson et al.
1996), these psychosocial determinants were not
significantly more prevalent than those observed
among the control groups at follow-up (Luepker et
al. 1996). Although the family intervention compo-
nent produced no additional increase in physical
activity among students (Luepker et al, 1996), the

CATCH physical education and classroom programs
successfully increased moderate-to-vigorous physi-
cal activity in physical education class and increased
students' daily participation in vigorous physical
activity.

School-Community Programs

The Class of 1989 Study (Kelder, Perry, Klepp 1993;
Kelder et al. 1995), an ancillary study of the MHHP
(Luepker et al. 1994), tested the efficacy of a school-
based health promotion program. One of three
MHHP intervention communities and its matched
pair were involved in the Class of 1989 Study. The
intervention cities were engaged in an extensive
communitywide intervention program designed to
improve eating, exercise, and smoking patterns for the
entire population. The physical activity intervention
included a peer-led physical activity challenge, in which
students were encouraged to engage in out-of-school
exercise activities. The program's assessment included
annual measurements collected from a large number of
students (baseline n = 2,376) for 7 years, beginning in
the sixth grade. Throughout most of the follow-up
period, physical activity levels were significantly higher
among female students in the intervention community
than among those in the control community. For male
students, the levels did not differ significantly between
the communities. Results suggest that at least among
female students, a multicomponent intervention that
includes peer-led behavioral education in schools and
complementary communitywide strategies can increase
levels of regular physical activity (Kelder, Perry, Klepp
1993; Kelder et al. 1995).

Interventions in Health Care Settings
Health professionals also have a potential role in
promoting physical activity, healthy eating, and other
health behaviors among children and adolescents
(American Medical Association 1994; U.S. Preventive
Services Task Force 1996). Results of a national sur-
vey of pediatricians showed that one-half of respon-
dents believed that regular exercise during childhood
is important in preventing cardiovascular disease in
adulthood (Nader et al. 1987). However, only one-
fourth believed they would be effective in counseling
their young patients to get regular vigorous exercise.
The American Medical Association's Guidelines for
Adolescent Preventive Health Services (1994) is one

242


example of practical counseling recommendations
that have been developed for those who provide
health services to adolescents.

Special Population Programs

Physical activity can assist in the treatment or reha-
bilitation of several diseases that occur during youth
(Rowland 1990; Greenan-Fowler 1987); however,
relatively few interventions have been conducted to
examine how to promote physical activity among
young people with special needs. The most extensive
study is a series of randomized investigations of
children who are overweight (Epstein, Wing, Valoski
1985; Epstein, McCurley, et al. 1990; Epstein, Valoski,
et al. 1990; Epstein et al. 1994). In this series, family-
based treatments of 5- to 12-year-old obese children
incorporated both physical activity and nutrition in-
terventions, and the programs were based specifically
on principles of behavior modification. Parents were
trained to improve their children's physical activity by
setting behavioral change goals with their children, by
identifying effective reinforcers (e.g., spending time
with parents), and by reinforcing children when goals
were met. Ten-year follow-ups of children in these
four randomized studies revealed that 30 percent of
children receiving family-based interventions were
no longer obese, and 20 percent had decreased their
percentage overweight by 20 percent or more (Epstein
ct al. 1994). The lo-year follow-up investigation also
revealed that the percentage of overweight children in
each study decreased most when the intervention
involved both the parent and the child or when a
change in lifestyle exercise was emphasized. Epstein
and colleagues (1994) also compared the effective-
ness of three forms of physical activity interventions:
lifestyle physical activity, in which activity was incor-
porated into daily routines; structured aerobic exer-
cise; and calisthenics. At the lo-year follow-up, the
lifestyle group had lost the most weight, and both the
lifestyle group and the aerobic exercise group had
greater weight-loss results than the calisthenics group
(Epstein et al. 1994).

Summary

The preceding review of the research literature on
interventions among young people reveals that
school-based approaches have had consistently
strong effects on increasing physical activity in

Understanding and Promoting Physical Activity

elementary school students when the intervention
orients the physical education program toward de-
livering moderate-to-vigorous physical activity.
Further, social learning theory appears to have had
the widest application to this interventions re-
search. Much research has taken place at the el-
ementary school level; very little is known about
increasing children's physical activity in middle
and high school physical education classes or in
settings other than school physical education classes.
It seems likely that these interventions would be
strengthened by designing programs that combine
school and community policy with health educa-
tion and physical education. Data are lacking on
ways to tailor interventions to the needs and inter-
ests of young people and to prevent the rapid
decline in physical activity that occurs during late
childhood and adolescence, especially among girls.
Additionally, few physical activity interventions
and research studies encompass populations par-
ticularly characterized by race/ethnicity, socioeco-
nomic status, risk factor status, disabilities, or
geographic location.

Promising Approaches, Barriers,
and Resources

Many questions remain about how best to pro-
mote physical activity in the general population of
young people and adults, as well as in clinical
populations and other subgroups. Policy initia-
tives, the provision of more physical activity facili-
ties and programs, and media campaigns are
promising, but studies testing their effects are
limited. The following two sections describe exist-
ing policy and program approaches' that have the
potential to increase population levels of physical
activity but have received little or no evaluation.
They are reviewed separately from the previously
discussed, better-documented research studies.

`Descriptions of specific physical activity programs across the
United States can be found in the Combined Health Information
Database, a computerized bibliographic database of health infor-
mation and health promotion resources developed and managed
by several federal agencies, including the CDC, the National
Institutes of Health, the Department of Veterans Affairs, and the
Health Resources and Services Administration. Intended for all
health professionals who need to locate health information for
themselves or their clients, this resource is available in many
libraries, state agencies, and federal agencies.

243


Physical Activity and Health

Environmental and Policy Approaches
Most interventions that have been evaluated in re-
search studies are discrete programs targeting popu-
lation subgroups (e.g., employees, schoolchildren)
or communities. Interventions have shown some
success in promoting physical activity, but their
results have been inconsistent. A possible reason for
limited results is a lack of concomitant support from
the larger environment within which such interven-
tions take place. Many physical activity researchers
believe that environmental and policy interventions
must occur to complement interventions that focus
on behavior change among individuals or small
groups. This larger perspective recognizes the pow-
erful moderating effect that environment has on
individual volition. As King, Jeffery, and colleagues
(1995) observe, "Environmental and policy inter-
ventions are based on the recognition that people's
health is integrally connected to their physical and
social environments" (p. 501).
Two premises underlie environmental and policy
approaches. First, interventions addressing chronic
disease risk factors, such as physical inactivity, re-
quire comprehensive, population-based approaches
that incorporate both individual and societal-level
strategies (Green and Simons-Morton 1996; Schmid,
Pratt, Howze 1995). Second, strategies should not
rely solely on active approaches requiring individual
initiative, such as enrolling in exercise classes, but
should also incorporate passive approaches, such as
providing walking trails or policies that permit em-
ployees to exercise during work hours (Schmid,
Pratt, Howze 1995). An example of intervention
elements combining passive and active approaches is
a school board policy that permits school facilities
to remain open before and after school for commu-
nity use, together with health communications that
make citizens aware of these facilities and encour-
age their use.

As presented previously, ecological models of
health behavior (McLeroy et al. 1988; CDC 1988;
Stokols 1992) provide frameworks for conceptualiz-
ing what the role of policy approaches is to health
promotion and how individuals interact with their
social, institutional, cultural, and physical environ-
ments. The concept of the health-promoting envi-
ronment suggests that communities and other settings
can facilitate healthy behaviors by providing envi-
ronmental inducements to be active, such as by

244

offering safe, accessible, and attractive trails for
walking and biking.

National objectives and recommendations have
encouraged the development of policies, programs,
and surveillance strategies that would help create
an environment that promotes physical activity
(USDHHS 1990; Pate, Pratt, et al. 1995; National
Association for Sport and Physical Education 1995;
U.S. Department OfTransportation [USDOT] 1994).
Increasing national levels of physical activity and of
cardiorespiratory fitness has also been targeted as a
priority health objective in Healthy People 2000
(USDHHS 1990) and the Dietary Guidelines far
Americans (U.S. Department of Agriculture and
USDHHS 1995).

Many efforts to raise public awareness and pro-
mote physical activity are under way. In 1994, the
American Heart Association, the American College
of Sports Medicine, and the American Alliance for
Health, Physical Education, Recreation and Dance
formed a National Coalition for Promoting Physical
Activity. The coalition's goals are to increase public
awareness of the benefits of physical activity, pro-
vide an opportunity for forming effective partner-
ships, and enhance delivery of consistent messages
about physical activity (National Coalition for Pro-
moting Physical Activity 1995). The CDC has estab-
lished guidelines for promoting physical activity and
healthy eating among young people (CDC 1996;
CDC in press) and has initiated a public education
effort to encourage active lifestyles and healthy eat-
ing among Americans. The National Institutes of
Health (NIH) has used national campaigns to pro-
mote messages to both the general public and pa-
tients on the importance of physical activity and a
heart healthy diet. The NIH also sponsors research
on physical activity in special populations, includ-
ing women from diverse economic backgrounds,
and in various settings, such as worksites, schools,
and health care institutions. In 1995, the NIH spon-
sored the Consensus Development Conference on
Physical Activity and Cardiovascular Health, which
recommended regular physical activity for most
persons aged 2 years and older (see Appendix B in
Chapter 2). The President's Council on Physical
Fitness and Sports works with a broad range of
partners in private industry, voluntary organiza-
tions, and the media to promote physical activity,
fitness, and sports participation by Americans of all


ages. As part of the midcourse review of the physical
activity and fitness objectives of Healtlry People 2000,
the council presented a synopsis of ongoing grassroots
activities by Healthy People 2000 Consortium mem-
bers in support of increasing participation in physi-
cal activity and improvement in fitness (USDHHS
1995). The President's Council on Physical Fitness
and Sports is also an advisory body to the President
and to the Secretary of the DHHS on matters involv-
ing physical activity, fitness, and sports that enhance
and improve health. Thirty-nine Governor's Coun-
cils on Physical Fitness and Sports stimulate state
;rnd local activities and program development; these
efforts target fitness promotion for school-aged
),ouths, older adults, working adults, and families
(National Association of Governor's Councils on
Physical Fitness and Sports 1996).

Community-Based Approaches
Community-based programs can be tailored to meet
the needs of their specific populations. More col-
laborative work is under way between state and local
governments, community groups, and businesses to
reduce risk factors among employees and residents.
Two-year follow-up data from one such effort in
Smyth County, Virginia, suggested that 40 percent of
school system employees had increased their physi-
cal activity participation during the program period
(CDC 1992).

Two large subpopulations may be especially im-
portant to address in community-based programs:
)`oung people and older adults. Communities will face.
a growing need to provide a supportive environment
for their children and adolescents. Between 1995 and
2020. the number of young people under 18 years old
will increase by an estimated 13 percent, from 69
million to 78 million (Bureau of the Census 1996).
The framework for community-level physical activity
programs for young people is already in place: mil-
lions of American youths participate in sports spon-
sored by community leagues, religious organizations,
social service organizations, and schools. In addition
to organized sports, communities need to provide
recreational programs and opportunities for all young
people in a community, because such programs may
encourage a lifetime habit of physical activity as well
~1s other immediate community benefits. According to
The Trust for Public Land, arrests among young
people in one community decreased by 28 percent

Understanding and Promoting Physical Activity

after the community instituted an academic and rec-
reational support program for teenagers (National
Park Service 1994). In another community, juvenile
crime dropped 55 percent when community recre-
ational facilities stayed open until 2 a.m. (National
Park Service 1994).

  Communities will also need to meet the chal-
lenges of a growing population of older adults. Be-
tween 1995 and 2020, the number of people over the
age of 60 will increase by 43 percent, from 44 to 63
million (Bureau of the Census 1996). Programs and
facilities designed to meet the needs of aging baby
boomers and older adultscan help ensure that these
rapidly growing segments of the population obtain
the health benefits of regular, moderate physical
activity. In one community, 35 age-peer exercise
instructors for older adults were recruitedand trained
by a local university as volunteers to conduct age-
appropriate physical activity programs on a regular
basis at sites such as libraries, senior centers, and
nursing homes in their neighborhoods. Because they
were age peers, the instructors were sensitive to
many of the concerns that older adults had about
physical activity, such as fear of falling and fracturing
a hip. Over the following year, instructors conducted
more than 1,500 half-hour exercise programs for
more than 500 older adults at 20 sites (DiGilio,
Howze, Shack 1992 >.

Places of worship represent a potentially effec-
tive site for physical activity promotion programs in
communities, since these settings can provide the
impetus for starting-and the social support for
maintaining-behavioral regimens (Eng, Hatch,
Callan 1985; Eng and Hatch 1991) such as regular
physical activity. Among the advantages of such
settings are a history of participating in a range of
community health and social projects; large mem-
berships, including families; a presence in virtually
every U.S. community; and connections to minority,
and low-income communities typically underserved
by health promotion programs (King 1991). The
Fitness Through Churches Project promoted aero-
bic exercise in conjunction with other health behav-
iors to African American residents of Durham, North
Carolina (Hatch et al. 1986). The results from this
pilot program suggest that physical activity pro-
grams offered at places of worship are feasible and
attractive to clergy and their congregations. Another
project, the Health and Religion Project (HARP) of

245


Physical Activity and Health

Rhode Island (Lasater et al. 1986), found that volun-
teets can be trained to provide heart health pro-
grams, including physical activity, in church settings
(DePue et al. 1990).

Societal Barriers

The major barrier to physical activity is the age in
which we live. In the past, most activities of daily
living involved significant expenditures of energy. In
contrast, the overarching goal of modern technology
has been to reduce this expenditure through the
production of devices and services explicitly de-
signed to obviate physical labor. From the days of
hunting and gathering to turn-of-the-century farm-
ing practices and early industrial labor, the process
of earning a living was once a strenuous activity.
Today, many Americans engage in little ot no physical
activity in the course of a working day typically spent
sitting at a desk or standing at a counter or cash
register. A large part of many people's time is spent
inside buildings where elevators or escalators are
prominent features and stairs ate difficult to find and
may seem unsafe. Motorized transportation carries
millions of Americans to and from work and on
almost every errand. These inactive daily expedi-
tions occur virtually door-to-door, with the help of
parking lots built as neat to destinations as possible
to minimize walking and increase convenience and
safety. Whereas older cities and towns, were built on
the assumption that stores and services would be
within walking distance of local residents, the design
of most new residential areas reflects the supposition
that people will drive from home to most destina-
tions. Thus work, home, and shopping ate often
separated by distances that not only discourage walk-
ing but may even necessitate commuting by motor-
ized transportation.

Television viewing, video games, and computer
use have contributed substantially to the amount of
time people spend in sedentary pursuits (President's
Council on Physical Fitness and Sports and Spotting
Goods Manufacturers Association 1993). Next to
sleeping, watching TV occupies the greatest amount
of leisure time during childhood (Dietz 1990).
Preschoolers exhibit the highest rate of TV watching
(27-28 hours per week). By the time a person gradu-
ates from high school, he ot she will likely have spent

15,000-18,000 hours in front of a television-and
12,000 hours in school (Strasburger 1992).

In the face of these powerful societal induce-
ments to be inactive, efforts must be made to encour-
age physical activity within the course of the day and
to create environments in communities, schools,
and workplaces that afford maximum opportunity to
be active. Policy interventions can address public
concerns about safety, financial costs, and access to
indoor and outdoor facilities. Such interventions
also can address the concerns of employers and
governments about liability in the event of injury. At
the state and local level, governments determine
building codes and public safety, traffic, and zoning
statutes that have potential bearing on physical ac-
tivity opportunities in communities.

Concerns about crime can be a major barrier to
physical activity for both adults and young people. In
a national survey of patents, 46 percent believed
their neighborhood was not very safe from crime for
their children (Princeton Survey Research Associates
1994). Minority parents were about half as likely as
white parents to report that their neighborhoods
were safe. Successful implementation ofpolicy inter-
ventions may help address such concerns. For ex-
ample, decisions to put more police on a beat in a
high-crime area may help residents feel safer going
outside to walk. Similarly, neighborhood watch
groups formed to increase safety and reduce crime
may be a vehicle for promoting physical activity.
Opening schools for community recreation and malls
for walking can provide safe and all-weather venues
that enable all members of the community to be
active.

Transportation, health, and community plan-
ners as well as private citizens can help ensure that
children living in areas near schools can safely walk
or bike to school and that adults can walk or bike to
work. Fear of traffic is one of the most frequently
cited reasons for not bicycling (USDOT 1993). Adult
pedestrians and bicyclists account for 14 percent of
yearly traffic fatalities (USDOT 1994). In a survey of
adults, those who rode a bicycle in the preceding year
were asked whether they would commute to work by
bicycle under specific conditions. Fifty-three per-
cent said they would do so if safe, separate, desig-
nated paths existed; 47 percent would if their

246


employer offered financial or other incentives; 46
percent would if safe bike lanes were available; and
45 percent would if their workplace had showers,
lockers, and a secure area for bike storage (USDOT
1994). More than half the respondents indicated
they would walk, or walk mote, if there were safe
pathways (protected from automobile hazards) and
if crime were not a consideration. A majority also
wanted their local government to provide better
opportunities to walk and bicycle.

These percentages stand in sharp relief against
current practice: only 4.5 percent of Americans com-
mute to work by bicycle or on foot (USDOT 1994).
Even in such comparatively small numbers, these
people are estimated to save as much as 1.3 billion
gallons of gasoline yearly and to prevent 16.3 million
metric tons of exhaust emissions (USDOT 1994).
Every mile walked or cycled for transportation saves
5 to 22 cents that would have been spent for a mile
by automobile, including reduced cost from pollu-
tion and oil imports (USDOT 1994). The Intermodal
Surface Transportation Efficiency Act, passed in
1991, promotes alternatives to automobile use by
making funds available for states to construct or
improve bicycling facilities and pedestrian walkways
(USDOT 1993). Decisions on how these funds are
used ate made locally, and organizations such as
local transportation, health, and parks departments
can promote the use of these funds in ways that
increase the prevalence of physical activity in their
communities.

In a growing number of communities, concerns
nbout environmental quality have led to zoning
restrictions that protect open spaces and other areas
that can subsequently be used for recreational pur-
suits. Such greenways, or linear open space, can
connect neighborhoods and foster the use of bicy-
cling and walking for transportation (Indianapolis
I)cpartment of Parks and Recreation 1994).

Societal Resources

.Jlthough there is no comprehensive listing of physi-
cal activity resources in the United States, such
a document would be extensive. Millions of
,Jmericans have sports supplies, bicycles, and exercise
lnachines in their homes or have access to public and
private resources such as tennis courts, parks, play-
<rounds, and health clubs. Numerous organizations

247

Understanding and Promoting Physical Activity

promote physical activity as part of their mission ot
in fund-raising efforts such as walks or runs. In
addition, TV programs, magazines, books, videos,
and CD-ROMs on physical activity are marketed.
Although using a computer is a sedentary activity,
physical activity interest and advocacy groups are on
the Internet, and the World Wide Web contains
information about many organizations and resources
related to physical activity. The multitude of physi-
cal education teachers, aerobics instructors, dance
instructors, recreation leaders, coaches, and per-
sonal trainers constitute an energetic pool of physi-
cal activity advocates and role models.
Ensuring the availability and accessibility of
environments and facilities conducive to exercise
is central to seeing that the public has the oppot-
tunity to obtain regular physical activity. Facili-
ties should be convenient, affordable, comfortable,
and safe (King et al. 1992). Many communities
offer sufficient facilities, but unless they are also
accessible and affordable, people may not use
them (Sallis et al. 1990). Walking for exercise
needs no more equipment than a comfortable pair
of shoes, but it does require a safe environment.
Other activities vary widely in the resources they
require-specialized clothing and equipment, play-
grounds, bicycle lanes, swimming pools, fields for
outdoor games, courts for indoor games, fitness
facilities for weight lifting and aerobic exercise,
studios for dancing, to mention a few.
Proximity of resources to home or worksites is
particularly important (Sallis et al. 1990). In a tele-
phone survey, 72 percent of respondents indicated
that there was a park ot playground within walking
distance of their home, and 75 percent of these
persons had used them (Godbey et al. 1992). Rural
residents are less likely to have such access (Godbey
et a1.1992), but they may have open spaces of other
kinds. In addition, large indoor areas, such as shop-
ping malls and schools, have become popular venues
for individuals and for walking groups and clubs. In
some communities, schools stay open before or after
the school day so community residents can use them
for hall walking (King, Jeffery, et al. 1995). Results
from a survey of exercise facilities in San Diego,
California, suggest that schools may be the most
available yet least-used resource for physical activity
among community residents (Sallis et al. 1990).


physical Activity and Health

Summary

The scope, quality, and effectiveness of the wide
range of policies and programs described in this
section have the potential to foster more physically
active lifestyles in the U.S. population. These efforts
could be targeted to meet the needs of population
subgroups and could be designed to use effective
strategies. Public health goals for physical activity
and fitness are more likely to be achieved if policies
and programs are guided by approaches known to be
effective and tailored to meet the needs of all mem-
bers of the community. Policies and programs should
be periodically evaluated to learn how they can be
improved to promote physical activity.
The discussion of existing barriers and resources
makes it clear that attention should be given to
addressing not only the challenges of individual
behavior change but also the environmental barriers
that inhibit a populationwide transition from a sed-
entary to an active lifestyle. Expenditure of resources
for bike paths, parks, programs, and law enforce-
ment to make playgrounds and streets safer will
encourage physical activity in daily living and should
thus be viewed as contributing to the health of all
Americans. At the same time, evaluations of such
changes can occur and more research accordingly
conducted to clarify how much the availability of
community spaces, facilities, and programs might
encourage physical activity. Such information would
better inform specific public policy decisions about
providing environmental supports and resources to
promote physical activity.

Behavioral and social scientists, exercise special-
ists, recreation specialists, health professionals, ar-
chitects, city planners, and engineers-all these
disciplines need to work together to engage commu-
nities, schools, and worksites in creating opportuni-
ties and removing barriers to physical activity. To
create lasting behavior change in communities, poli-
cies as well as individuals must change. Interven-
tions that simultaneously influence individuals,
community organizations, and government policies
should lead to greater and longer-lasting changes.

Chapter Summary

This chapter has reviewed approaches taken by re-
searchers to understand and encourage physical ac-
tivity among adults, children, and adolescents living

in a technologically advanced society. Behavioral and
social science research on physical activity is a rela-
tively recent endeavor, and many questions remain to
be answered about not only increasing but also sus-
tainingphysical activity. Several factorsseem to be key
influences on physical activity levels for both adults
and young people. Having confidence in one's ability
to be active (self-efficacy); enjoying physical activity;
receiving support from family, friends, or peers; and
perceiving that the benefits of physical activity out-
weigh its barriers or costs appear to be central deter-
mining factors influencing activity levels across the
life span.

For adults, some interventions in communities,
in health care settings, in worksites, and at home
have resulted in small increases in physical activity,
which if widely applied could create significant pub-
lic health benefits. Among young people, school-
based programs are the most widely available resource
for promoting physical activity and have the poten-
tial for reaching large numbers of children and ado-
lescents. Research indicates that children's levels of
physical activity in physical education class are greater
when physical education teachersare specially trained
in methods to increase the time their students spend
engaging in moderate-to-vigorous physical activity.
Few studies, however, have been conducted at middle
and high school levels-a time when most adoles-
cents decrease their physical activity.
Only limited information exists about the needs
of population subgroups of all ages and how determi-
nants of physical activity may change over the life span
because of puberty, the normal aging process, health
conditions, type of occupation, and other biological,
social, and environmental influences. Effective ap-
proaches for weight gain prevention are few, espe-
cially in light of the recently observed trend of
increasing weight among U.S. adults and children
(Kuczmarski et al. 1994; Troiano et al. 1995). Al-
though recommendations given by health care pro-
viders can increase physical activity among adults, a
similar effect of counseling for children and adoles-
cents has not been examined. It is unclear what
approaches can help people recover from relapses into
inactivity-whether from illness, the weather, de-
mands at work or at home, or other reasons-and
sustain the habit of regular physical activity over time.
Questions also remain about how to address barriers
to physical activity and how to more effectively use

248


resources in communities, schools, and worksites to
increase physical activity. Recent research and prom-
ising approaches have begun to address some of these
questions and provide direction for future research
and interventions to promote physical activity among
all Americans.

Conclusions

Consistent influences on physical activity pat-
terns among adults and young people include
confidence in one's ability to engage in regular
physical activity (e.g., self-efficacy), enjoyment
of physical activity, support from others, posi-
tivc beliefs concerning the benefits of physical
activity, and lack of perceived barriers to being
physically active.

For adults, some interventions have been suc-
cessful in increasing physical activity in commu-
nities, worksites, health care settings, and at
home.

Interventions targeting physical education in el-
ementary school can substantially increase the
amount of time students spend being physically
active in physical education class.

Research Needs

Determinants of Physical Activity
1. Assess the determinants of various patterns of
physical activity among those who are sedentary,
intermittently active, routinely active at work,
and regularly active.

1. Assess determinants of physical activity for
various population subgroups (e.g.? by age,
  sex, race/ethnicity, socioeconomic status,
health/disability status, geographic location).

3. Examine patterns and determinants of physical
activity at various developmental and life transi-
tions, such as from school to work, from one job
or city to another, from work to retirement, and
from health to chronic illness.

-t. Evaluate the interactive effects of psychosocial,
cultural, environmental, and public policy influ-
ences on physical activity.

Understanding and Promoting Physical Activity

Physical Activity Interventions

1.





2.

Develop and evaluate the effectiveness of inter-
ventions that include policy and environmental
supports.

3.

Develop and evaluate interventions designed to
promote adoption and maintenance of moderate
physical activity that addresses the specific needs
and circumstances of population subgroups, such
as raciauethnic groups, men and women, girls
and boys, the elderly, the disabled, the over-
weight, low-income groups, and persons at life
transitions, such as adqlescence, early adulthood,
family formation, and retirement.

Develop and evaluate the effectiveness of inter-
ventions to promote physical activity in combi-
nation with healthy dietary practices that can be
broadly disseminated to reach large segments of
the population and can be sustained over time.

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