Motivation is minute - Addressing physical activity within a population

Introduction: Multi-level models of health

Understanding an individual’s health-related behavior requires a comprehensive assessment and multi-level perspective. The social ecological model (SEM) of health arose from Bronfenbrenner's ecological systems theory, which is one of the most accepted models pertaining to the influence of the social environment on human development (Ettekal & Mahoney, 2017). The SEM is a broader framework for understanding levels of influence, and the personal and environmental factors that determine behaviors (Shefner­‐Rogers, 2013). It consists of five tiers: individual, interpersonal, community, organizational, and policy (Figure 1). Each level consists of factors that influence health behavior, as shown in Table 1. It is important to note that the SEM is a framework, which should be altered and developed based on the health behavior and population. The factors that influence newborn care in East Asia will be different from the factors that influence physical activity in Canada. The SEM is adaptable and should be specific to the given topic. The levels of influence should start at the individual, and gradually broaden to national or global factors, but the tiers themselves are not rigid, and Figure 1 is just an example of one SEM.

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Figure 1. The social ecological model (Shefner­‐Rogers, 2013).

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Table 1. Description of the levels of the SEM.

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The SEM can and should be used by public health agencies and organizations to identify effective strategies for health promotion (Shefner­‐Rogers, 2013). It has been shown that public health interventions that consider multiple levels of influence and target upstream levels such as media advocacy and policy change are more successful, but less prevalent, than interventions that focus on individual and interpersonal factors (Stellefson, 2019). This is supported by the study outlined in the following video by Stellefson (2019).

In this post, I will focus on the significance of physical activity as it relates to public health, the field of orthopaedics, and the SEM in the context of physical activity.

Physical Activity and Public Health

Physical inactivity accounts for an estimated 200,000 deaths annually in the United States (Dishman et al., 2012) and is the fourth leading risk factor of global mortality (World Health Organization, 2010). In 2012, obesity became a bigger world health problem than malnutrition, causing a significant public health burden (Dishman et al., 2012). Physical inactivity is associated with poor mental health and increased rates of depression, which is the second leading cause of death in 15-29-year-olds (Dishman et al., 2012; Win et al., 2011; World Health Organization, 2020).

An estimated 25-40% of American adults do not participate in leisure-time physical activity, and less than 10% meet the recommended level of physical activity per day for general health (Dishman et al., 2012). Physically activity has a proven impact on morbidity and mortality, which raises the question- why are individuals not exercising enough? ( Glanz et al., 2015). Answering this question requires a broad view of the multi-level influences that determine one’s behaviour. Motivation and willpower are only minute, individual-level factors when it comes to physical activity.

Physical Activity and Orthopaedics

Physical activity not only prevents, but also treats a wide range of physical and psychological disorders (Dishman et al., 2012). Obesity is strongly associated with elective orthopaedic procedures such as hip and knee replacements (Harms et al., 2007). Regular physical activity may prevent or delay the development of type 2 diabetes and has substantial health benefits for individuals with type 1 diabetes (Colberg et al., 2016). In the field of orthopaedics, diabetes is one of the most common comorbidities. It is associated with several lower extremity conditions including fractures, Charcot neuroarthropathy, plantar ulcers, and infection (Gehling et al., 2016). While suboptimal bone mass and bone quality increase the risk of fractures in diabetic patients, it also impairs fracture healing (Jiao et al., 2015). Fracture healing in diabetic patients is prolonged by 87% and has a 3.4 fold increased risk of complications such as delayed union, non-union, re-dislocation or pseudoarthrosis (Loder, 1988; Retzepi & Donos, 2010).

Additionally, physical activity in the form of pre- and post-operative rehabilitation can improve outcomes of orthopaedic surgery. This includes faster recovery, fewer complications, reduced pain and swelling, and improved circulation (Peak to Shore Physiotherapy, 2020). Physical activity is pertinent to orthopaedic conditions, care, and intervention.

SEM in the Context of Physical Activity

Sallis, Owen & Fisher (2008) developed an ecological model of the determinations of physical activity, which was adapted by Bauman et al., 2012 (Figure 2). The levels of influence, adapted from the SEM framework, start with individual level factors, and gradually expand to global factors. As depicted by the arrow along the bottom of Figure 2, individual level factors have a greater influence on youth than older adults and higher-level factors had a progressively stronger influence with age (Bauman et al., 2012). In the next section, I will take a deeper look at the five tiers of the adapted ecological model of the determinants of physical activity: individual, interpersonal, environment, regional or national policy, and global.

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Figure 2. Adapted ecological model of the determinants of physical activity (Sallis et al., 2008; Bauman et al., 2012)

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Individual

Individual level influences on physical activity include biological factors such as genetics and evolutionary physiology, psychological factors such as cognition, beliefs, and motivation, as well as knowledge and skills (Bauman et al., 2012; Sallis et al., 2008, 2012). An individual with more knowledge and education about the benefits of physical activity, and the best ways (techniques, methods) to be physical active will be positively influenced. In most cases, independent level factors are modifiable, so an individual’s knowledge, education, attitude and behaviours can change over time.

Interpersonal

Interpersonal factors include social supports and cultural norms. Social supports include an individual’s closest relationships, such as family, friends and social networks that know the most about the individual and have the strongest impact on their knowledge, beliefs, and attitudes. If an individual’s family members or roommates are consistently inviting them to play recreational sports, going on long walks, or doing at-home workouts they may feel positively influenced to be physically active. Conversely, if an individual is surrounded by people who live sedentary lifestyles, it may negatively influence their activity level.

Environment

Environmental factors are sub-categorized into the social, natural, and built environment. The social environment includes level of crime, traffic, and seeing others in the community active. An individual living in a high-traffic, high-crime neighbourhood may be influenced to stay inside and, thus, be less physically active.

The natural environment includes factors such as the weather, topography, national parks, trails and walking routes. An individual may choose to walk to work if there are natural trails throughout the route. This is more likely to occur year-round in environments with appropriate weather for walking.

The built environment includes influences such as neighborhood walkability, pedestrian crossings, and recreational facilities. The built environment also includes home and building design (stairs, parking placement) and location of workplaces and schools (access to transit, sidewalks, and bike paths) (Sallis et al., 2012). An individual who is required to walk a longer distance from their car to their office, without access to an elevator, may be more physical active simply due to their built environment.

Regional or National Policy

Regional and national policy includes urban planning and architecture, national physical activity advocacy, and organized sports sector. Other examples include building codes, transportation funding, tax treatment of exercise equipment, and zoning and development codes (Sallis et al., 2012). Affordable recreational sports programs such as youth and adult basketball or soccer leagues would be a positive influence on physical activity.

Global

Finally, the global influences include global media, global advocacy, urbanization, and economic development. These influences can be at the national or supernational level and include laws and norms that govern our behaviour. The World Health Organization promoting the importance of physical activity and recommendations surrounding physical activity is an example of a global influence (World Health Organization, 2018).

Conclusion

All levels of influence can promote positive or negative changes in behaviour. They can also cause barriers to change. In order to be successful, public health policies and interventions need to use multi-level, ecological approaches to promote and encourage healthful decisions (Sallis et al., 2008). It is essential to not only focus on an individual, but how individuals interact with their environment. Creating environments and policies that make it convenient, attractive, and economical to increase physical activity will be more effective than targeting individual-level influences, such as knowledge, willpower, and motivation (Sallis et al., 2008). Increased physical activity on a population level will decrease the burden on public health and create a healthier community.

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References

Bauman, A. E., Reis, R. S., Sallis, J. F., Wells, J. C., Loos, R. J. F., & Martin, B. W. (2012). Correlates of physical activity: why are some people physically active and others not? The Lancet, 380(9838), 258–271. https://doi.org/https://doi.org/10.1016/S0140-6736(12)60735-1

Colberg, S. R., Sigal, R. J., Yardley, J. E., Riddell, M. C., Dunstan, D. W., Dempsey, P. C., Horton, E. S., Castorino, K., & Tate, D. F. (2016). Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care, 39(11), 2065 LP – 2079. https://doi.org/10.2337/dc16-1728

Dishman, R. K., Heath, G. W., & Lee, I.-M. (2012). Physical Activity Epidemiology (2nd ed.). Human Kinetics. https://books.google.ca/books?id=qu56DwAAQBAJ&lr=&source=gbs_navlinks_s

Ettekal, A. V., & Mahoney, J. L. (2017). Ecological Systems Theory. In K. Peppler (Ed.), The SAGE Encyclopedia of Out-of-School Learning (1st ed.). SAGE Publications, Inc. https://doi.org/10.4135/9781483385198.n94

Gehling, D. J., Lecka-Czernik, B., & Ebraheim, N. A. (2016). Orthopedic complications in diabetes. Bone, 82, 79–92. https://doi.org/10.1016/j.bone.2015.07.029

Glanz, Karen, Rimer, B. K., & Viswanath, K. (2015). Theory, research, and pract ice in health behavior. In Karen Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health Behavior: Theory, Research, and Practice (5th ed., pp. 23–41). Jossey-Bass. https://www.wiley.com/en-

ca/Health+Behavior:+Theory,+Research,+and+Practice,+5th+Edition-p-9781118628980

Harms, S., Larson, R., Sahmoun, A. E., & Beal, J. R. (2007). Obesity increases the likelihood of total joint replacement surgery among younger adults. International Orthopaedics, 31(1), 23–26. https://doi.org/10.1007/s00264-006-0130-y

Jiao, H., Xiao, E., & Graves, D. T. (2015). Diabetes and Its Effect on Bone and Fracture Healing. Current Osteoporosis Reports, 13(5), 327–335. https://doi.org/10.1007/s11914-015-0286-8

Loder, R. T. (1988). The influence of diabetes mellitus on the healing of closed fractures. Clinical Orthopaedics and Related Research, 232, 210–216. https://pubmed.ncbi.nlm.nih.gov/3289812/

Peak to Shore Physiotherapy. (2020). What Are the Benefits of Pre and Post-Surgical Rehab? https://peaktoshorephysiotherapy.com/benefits-of-pre-and-post-surgical-rehab/

Retzepi, M., & Donos, N. (2010). The effect of diabetes mellitus on osseous healing. Clinical Oral Implants Research, 21(7), 673–681. https://doi.org/10.1111/j.1600-0501.2010.01923.x

Sallis, J. F., Floyd, M. F., Rodríguez, D. A., & Saelens, B. E. (2012). Role of built environments in physical activity, obesity, and cardiovascular disease. Circulation, 125(5), 729–737. https://doi.org/10.1161/CIRCULATIONAHA.110.969022

Sallis, J. F., Owen, N., & Fisher, E. B. (2008). Ecological models of health behavior. In K Glanz, B. Rimer, & V. K (Eds.), Health behavior and health education: Theory, research, and practice (pp. 465–485). Jossey-Bass. https://psycnet.apa.org/record/2008-17146-020

Shefner­‐Rogers, C. (2013). Regional Communication Strategy Development Guide for Newborn Care and the Prevention and Control of Childhood Pneumonia and Diarrhoea in East Asia and the Pacific Region. In UNICEF/EAPRO Regional Communication Guide. UNICEF/NYHQ. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwikuaWC2e7sAhXhj3IEHbAKBz4QFjAAegQIBRAC&url=http%3A%2F%2Fprofessorcarlson.net%2Fc4dcourse%2Fmodule_1%2Fm1_unit3%2Fm1_u3_required%2FM1U3_UNICEF_RegionalCommStrategyDevelopmentGuideFor.pdf&usg=AOvVaw1Gz7kQK2_Tg3kuIM_gaMwj

Stellefson, M. (2019). Social Ecological Model. [Video]. Youtube. https://www.youtube.com/watch?v=1fJfZI5wlt0

Win, S., Parakh, K., Eze-Nliam, C. M., Gottdiener, J. S., Kop, W. J., & Ziegelstein, R. C. (2011). Depressive symptoms, physical inactivity and risk of cardiovascular mortality in older adults: the Cardiovascular Health Study. Heart, 97(6), 500 LP – 505. https://doi.org/10.1136/hrt.2010.209767

World Health Organization. (2010). Global recommendations on physical activity for health. https://www.who.int/publications/i/item/9789241599979

World Health Organization. (2018). Physical activity. https://www.who.int/news-room/fact-sheets/detail/physical-activity

World Health Organization. (2020). Depression. https://www.who.int/news-room/fact-sheets/detail/depression