In October 2005, the Commonwealth Department of Health and Ageing, the National Heart Foundation, and VicHealth joined forces with Sports Medicine Australia (SMA) to present the Fifth National Physical Activity Conference in Melbourne. Concurrent for the first time with the Australian Conference of Science and Medicine in Sport, and the National Sports Injury Prevention Conference, the event highlighted knowledge and skills in the science and art of promoting safe physical activity for all.
With the coordinating theme ‘Promoting Innovation, Measuring Success’, the Physical Activity Conference provided an opportunity to showcase innovative physical activity and public health work from Australia and overseas. The conference began with an address by Professor Roald Bahr, a Norwegian Professor of Sports Medicine who serves on his government's National Council on Nutrition and Physical Activity. His inspiring keynote address (‘Redefining sports medicine—from sprained ankles to clogged arteries’) reminded delegates that they have an important role in public health—sports medicine is no longer confined to the science and medicine of elite performance, and must now concern itself with the health of the nation.
Australia does not currently have any regular national surveillance of physical activity levels in children and adults, although there are moves by the Federal government to address this. It is therefore impossible to compare physical activity trends with health data and say with any certainty whether physical activity is primarily to ‘blame’ for the current epidemic of obesity in Australia. Nonetheless, the demonstrated role of physical activity in the prevention and management of a range of prevalent chronic health problems1 is creating an imperative for the promotion of physical activity in what appears be an increasingly sedentary population.
Although the issues are complex, and the work is difficult, a wealth of exciting physical activity intervention work is being conducted with various population sub-groups (e.g. children, older adults, women) and whole populations, in Australia and in other places around the world. The purpose of this special edition of edition of the Journal of Science and Medicine in Sport is to highlight some of the innovative formative and intervention research being conducted internationally in this rapidly growing field. Most of this work was presented at the 2005 National Physical Activity Conference.
Promoting physical activity is a complex mix of art and science. Early work in this field, such as that conducted in the Pawtucket, MRFIT, Minnesota and North Karelia projects, focused largely on the promotion of physical activity as a tool for improving cardiovascular risk in middle age ‘at risk’ populations.2, 3, 4, 5, 6 This somewhat ‘biomedical’ approach to individual behaviour change in ‘at risk’ people, based largely on the provision of information through education campaigns and individual ‘prescription’ has however, been largely unsuccessful in promoting sustained increases in population levels of physical activity.
An alternative approach is suggested by Geoffrey Rose in his book, Sick Individuals and Sick Populations,7 in which he suggests that population strategies to improve health should “attempt to control the determinants of incidence, to lower the mean level of risk factors, and to shift the whole distribution of exposure in a favourable direction” (p. 431). If we are to do this for the risk factor of physical inactivity, it is clear that we must now move beyond individual behaviour based solutions, and adopt a broader focus acknowledging the social, environmental and cultural contexts of physical inactivity.
In what has become known as the ‘ecological approach’ in creating active living communities, physical activity research has, in recent years, shown much more interest in the role of the physical environmental determinants.8 This approach emphasises that the availability of places for children to play, and for children and adults to participate in sport, and to walk or cycle safely for transport or recreation, is fundamental for people to be active. While this is important, it is essential that physical activity promotion keeps sight of the other determinant domains identified in the ecological model. Human behaviour may be understood not just by environmental factors, but by the interactions between individual, social and physical environmental factors.9 To optimise the likelihood of physical activity therefore, people not only need pleasant and safe environments to be active, but also the motivation, attitude and self-efficacy to be active, and the social circumstances and support from others that enables them to be active. The obligations of paid and unpaid work, as well as the interdependence of others (e.g. caring responsibilities) mean that for many adults, it is difficult to prioritise regular activity.
We begin with a summary of the keynote address by Professor Billie Giles-Corti who provided an overview of the ‘places’ approach to understanding and promoting physical activity, including consideration of how ‘people’ may be active in places, and are responsible for changing places.10 The paper includes results from Professor Giles-Corti's research with 1800 homemakers and workers that examined both the relative and joint influences of individual, social and environmental factors on walking. Although little of this ‘empirical contrasting’ work has been done, it is essential for identifying the factors that are most likely to result in increases in physical activity when they are targeted in intervention studies. Given the multiple influences on physical activity, Professor Giles-Corti concludes that there are “jobs for everyone” in the physical activity promotion area.
In a response to the first keynote address, Dr. Kylie Ball questions whether the ‘people’ and ‘places’ debate is a false dichotomy.11 Her paper raises issues about focusing on single domains of determinants, and restates the importance of studying multiple domains. A multi-factorial approach is more likely to reflect the diverse influences on physical activity participation, and different opportunities for intervention. Studies that focus on only one determinant domain do not optimise our ability to understand physical activity, and if the determinants are inter-related, focusing on only one domain may imply an over-importance of that domain. To support her discussion, Dr. Ball presents the results of her research with over 1500 women, and summarises other research demonstrating the role of ‘other people’ (i.e. social environments) and broader socio-cultural and socio-economic determinants of physical activity. Understanding the interplay of psychological, social and environmental influences is a key research need if we are to direct more policy attention to health promotion.12
The third paper in this edition13 is an overview of intervention research being conducted in the Netherlands; work which was presented by one of the international keynote speakers at the conference, Professor Willem van Mechelen from the Vrije University of Amsterdam. It introduces three important settings for physical activity promotion: general practice, aged care facilities and workplaces. These are settings in which we encounter the aging ‘baby boomers’, who are becoming the ‘frequent flyers’ of our health care system, as they present with chronic health problems relating to sedentary lifestyles. The paper highlights how difficult it is to achieve change in these population groups—we face the same issues with our intervention work in these settings in Australia. The Dutch work relating to workplace activity promotion, especially in relation to ‘early return to work’ for workers with low back pain, provides a model for physicians to think differently about the role of physical activity in the management of chronic health problems. This is important, because persuading clinicians to think differently about the management of a range of chronic health problems (including cardiovascular disease, type 2 diabetes, some cancers, asthma, some mental health problems and some musculoskeletal problems) will be a major challenge for those working in physical activity and public health in the near future.
With one in five children in Australia now overweight or obese14 it has been argued that children are important ‘people’ in terms of obesity prevention strategies.15 Given the amount of time that children spend there, and the ‘captive audience’ they provide, schools are clearly a very important ‘place’ for physical activity promotion. The next two papers in this edition focus on work conducted in schools.
The Australian ‘Switch-Play’ researchers worked with teachers, parents and children in disadvantaged areas of Melbourne, and examined the individual, family and environmental features that explained why some children in the intervention groups managed to decrease their television viewing and others did not.16 Such analyses demonstrate the importance of considering factors such as family dynamics, and individual and social determinants of television viewing for greater intervention effects. The Irish ‘Switch Off–Get Active’ project was an intervention study that incorporated several behavioural modification principles including self-monitoring, budgeting of television viewing time and teaching children about ‘intelligent’ or selective television viewing.17 This controlled trial was delivered by classroom teachers and incorporated into the existing health education curriculum in schools in disadvantaged areas of Ireland. The results suggest that it might be easier to change one of these behaviours (either ‘switch off’ or ‘get active’) than the other. Read the paper to see which one was more successful!
The following paper is a feasibility study from the Deakin Centre for Physical Activity and Nutrition research which incorporated both ‘place’ and ‘people’ as its foci. This innovative study used a church as the setting for a brief (8-week) intervention which aimed to increase physical activity and promote mental and spiritual health in a small group of women.18 There is consistent evidence from epidemiological studies that women are more likely to be inactive (particularly during their leisure-time) than men19 and associations between exercise and mental health have been documented repeatedly over the last two decades.20 The incorporation of mental and spiritual health outcomes in this study is another example of an innovative approach which acknowledges the additional associated benefits of physical activity.
Retirement villages offer another interesting ‘place’ for promoting physical activity. At first glance it may appear that they offer a ‘captive audience’ of older people, similar to that noted for schools and children. However, as the next paper21 shows, residents of Australian retirement villages are far from ‘captive’. The issues of participant retention, adherence and compliance are important in all physical activity interventions; and while most studies report data on retention and adherence, few report whether the participants actually do what they are asked to do (compliance). It is hardly surprising that we see such limited results from our interventions, if people do not or cannot comply with what we ask of them. In this paper, the authors identify factors associated with adherence to and compliance with a resistance training program for older people.21 Once again, we are reminded that even when the environment is safe and convenient, and the program is free of charge, social factors can be an important determinant of participation.
As physical activity intervention researchers we currently invest most of our efforts in efficacy trials, and to date, relatively few dissemination efforts have been reported in the scientific literature. The penultimate paper in this edition describes the ‘Action Schools BC!’ project which was a dissemination trial of the ‘active school’ model in BC, Canada.22 The intervention targeted changes to the curriculum and the school environment (including policies and culture) and also encouraged community links. In keeping with the dissemination approach, the authors provide a detailed presentation of process evaluation data, which are extremely valuable in determining what aspects of the intervention work or do not work when implemented under less tightly controlled (‘real world’) conditions than in an efficacy trial.
The final paper also describes the dissemination of an evaluated intervention. Following the completion of the innovative ‘10,000 Steps Rockhampton’ program,23 the Queensland government made funds available for dissemination of the materials and ideas used in the original project. The paper describes the use of the internet as a dissemination tool, and the subsequent adoption and implementation of project activities by individuals, worksites and health promotion workers.24 The authors note that there is room for much more work in the area of evaluating dissemination strategies for effective physical activity interventions.
But before such dissemination research can be conducted, we need to have interventions that work. In addition to the papers presented in this special issue, our 2005 National Physical Activity Conference highlighted a wealth of very good formative and observational work which is underpinning the development of even more innovative and creative intervention strategies for promoting physical activity to different people in a range of places. The abstracts of all the papers presented at the conference can be found in the December 2005 supplement to the journal. We are confident that by the time of our next conference, which will be held in Adelaide in October 2007, we will have even more exciting and pioneering work to report from the field of physical activity promotion in Australia and around the world.
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