hapter 6 understanding and promoting · pdf filetheories and models used in behavioral and...

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Theories and Models Used in Behavioral and Social Science Research on Physical Activity . . . 211

Learning Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Health Belief Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Transtheoretical Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Relapse Prevention Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Theory of Reasoned Action and Theory of Planned Behavior . . . . . . . . . . . . . . . . . . . . . . 213

Social Learning/Social Cognitive Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

Ecological Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Behavioral Research on Physical Activity among Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Factors Influencing Physical Activity among Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Modifiable Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Determinants for Population Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Interventions to Promote Physical Activity among Adults . . . . . . . . . . . . . . . . . . . . . . . . . 217

Individual Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Interventions in Health Care Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

Community Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Worksite Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Communications Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Special Population Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Racial and Ethnic Minorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

People Who Are Overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

CHAPTER 6UNDERSTANDING AND PROMOTING

PHYSICAL ACTIVITY

Contents, continued

Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

People with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Behavioral Research on Physical Activity among Children and Adolescents . . . . . . . . . . . . . 234

Factors Influencing Physical Activity among Children and Adolescents . . . . . . . . . . . . . . 234

Modifiable Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Determinants for Population Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Interventions to Promote Physical Activity among Children and Adolescents . . . . . . . . . 236

School Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

School-Community Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Interventions in Health Care Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Special Population Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Promising Approaches, Barriers, and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Environmental and Policy Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Community-Based Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

Societal Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Societal Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Determinants of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Physical Activity Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

CHAPTER 6UNDERSTANDING AND PROMOTING

PHYSICAL ACTIVITY

Introduction

As the benefits of moderate, regular physicalactivity have become more widely recognized,

the need has increased for interventions that canpromote this healthful behavior. Because theoriesand models of human behavior can guide thedevelopment and refinement of intervention efforts,this chapter first briefly examines elements of be-havioral and social science theories and models thathave been used to guide much of the research onphysical activity. First for adults, then for childrenand adolescents, the chapter reviews factors influ-encing physical activity and describes interven-tions that have sought to improve participation inregular physical activity among these two agegroups. To put in perspective the problem ofincreasing individual participation in physicalactivity, the chapter next examines societal barri-ers to engaging in physical activity and describesexisting resources that can increase opportunitiesfor activity. The chapter concludes with a sum-mary of what is known about determinant andintervention research on physical activity and makesrecommendations for research and practice.

Theories and Models Used inBehavioral and Social ScienceResearch on Physical ActivityNumerous theories and models have been used inbehavioral and social science research on physicalactivity. These approaches vary in their applicabilityto physical activity research. Some models and theo-ries were designed primarily as guides to under-standing behavior, not as guides for designinginterventions. Others were specifically constructedwith a view toward developing interventions, and

some of these have been applied extensively in inter-vention research as well. Because most were devel-oped to explain the behavior of individuals and toguide individual and small-group intervention pro-grams, these models and theories may have onlylimited application to understanding the behavior ofpopulations or designing communitywide interven-tions. Key elements most frequently used in thebehavioral and social science research on physicalactivity are described below and summarized inTable 6-1.

Learning TheoriesLearning theories emphasize that learning a new,complex pattern of behavior, like changing from asedentary to an active lifestyle, normally requiresmodifying many of the small behaviors that composean overall complex behavior (Skinner 1953). Principlesof behavior modification suggest that a complex-pattern behavior, such as walking continuously for30 minutes daily, can be learned by first breaking itdown into smaller segments (e.g., walking for 10minutes daily). Behaviors that are steps toward afinal goal need to be reinforced and established first,with rewards given for partial accomplishment ifnecessary. Incremental increases, such as adding 5minutes to the daily walking each week, are thenmade as the complex pattern of behaviors is “shaped”toward the targeted goal. A further complication tothe change process is that new patterns of physicalactivity behavior must replace or compete with formerpatterns of inactive behaviors that are often satisfy-ing (e.g., watching television), habitual behaviors(e.g., parking close to the door), or behaviors cued bythe environment (e.g., the presence of an elevator).

Reinforcement describes the consequences thatmotivate individuals either to continue or discon-tinue a behavior (Skinner 1953; Bandura 1986).

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Physical Activity and Health

Table 6-1. Summary of theories and models used in physical activity research

Theory/model Level Key concepts

Classic learning theories Individual ReinforcementCuesShaping

Health belief model Individual Perceived susceptibilityPerceived severityPerceived benefitsPerceived barriersCues to actionSelf-efficacy

Transtheoretical model Individual PrecontemplationContemplationPreparationActionMaintenance

Relapse prevention Individual Skills trainingCognitive reframingLifestyle rebalancing

Social cognitive theory Interpersonal Reciprocal determinismBehavioral capabilitySelf-efficacyOutcome expectationsObservational learningReinforcement

Theory of planned behavior Interpersonal Attitude toward the behaviorOutcome expectationsValue of outcome expectations

Subjective normBeliefs of othersMotive to comply with others

Perceived behavioral control

Social support Interpersonal Instrumental supportInformational supportEmotional supportAppraisal support

Ecological perspective Environmental Multiple levels of influenceIntrapersonalInterpersonalInstitutionalCommunityPublic policy

Source: Adapted from Glanz K and Rimer BK. Theory at-a-glance: a guide for health promotion practice, U.S. Department of Health andHuman Services, 1995.

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Understanding and Promoting Physical Activity

Most behaviors, including physical activity, arelearned and maintained under fairly complex sched-ules of reinforcement and anticipated future re-wards. Future rewards or incentives may includephysical consequences (e.g., looking better), extrin-sic rewards (e.g., receiving praise and encourage-ment from others, receiving a T-shirt), and intrinsicrewards (e.g., experiencing a feeling of accomplish-ment or gratification from attaining a personal mile-stone). It is important to note that although providingpraise, encouragement, and other extrinsic rewardsmay help people adopt positive lifestyle behaviors,such external reinforcement may not be reliable insustaining long-term change (Glanz and Rimer 1995).

Health Belief ModelThe health belief model stipulates that a person’shealth-related behavior depends on the person’s per-ception of four critical areas: the severity of a poten-tial illness, the person’s susceptibility to that illness,the benefits of taking a preventive action, and thebarriers to taking that action (Hochbaum 1958;Rosenstock 1960, 1966). The model also incorpo-rates cues to action (e.g., leaving a written reminderto oneself to walk) as important elements in elicitingor maintaining patterns of behavior (Becker 1974).The construct of self-efficacy, or a person’s confi-dence in his or her ability to successfully perform anaction (discussed in more detail later in this chap-ter), has been added to the model (Rosenstock 1990),perhaps allowing it to better account for habitualbehaviors, such as a physically active lifestyle.

Transtheoretical ModelIn this model, behavior change has been conceptual-ized as a five-stage process or continuum related toa person’s readiness to change: precontemplation,contemplation, preparation, action, and maintenance(Prochaska and DiClemente 1982, 1984). People arethought to progress through these stages at varyingrates, often moving back and forth along the con-tinuum a number of times before attaining the goalof maintenance. Therefore, the stages of change arebetter described as spiraling or cyclical rather thanlinear (Prochaska, DiClemente, Norcross 1992). Inthis model, people use different processes of changeas they move from one stage of change to another.Efficient self-change thus depends on doing the right

thing (processes) at the right time (stages) (Prochaska,DiClemente, Norcross 1992). According to thistheory, tailoring interventions to match a person’sreadiness or stage of change is essential (Marcus andOwen 1992). For example, for people who are notyet contemplating becoming more active, encourag-ing a step-by-step movement along the continuum ofchange may be more effective than encouragingthem to move directly into action (Marcus, Banspach,et al. 1992).

Relapse Prevention ModelSome researchers have used concepts of relapseprevention (Marlatt and Gordon 1985) to help newexercisers anticipate problems with adherence. Fac-tors that contribute to relapse include negative emo-tional or physiologic states, limited coping skills,social pressure, interpersonal conflict, limited socialsupport, low motivation, high-risk situations, andstress (Brownell et al. 1986; Marlatt and George1990). Principles of relapse prevention include iden-tifying high-risk situations for relapse (e.g., changein season) and developing appropriate solutions(e.g., finding a place to walk inside during thewinter). Helping people distinguish between a lapse(e.g., a few days of not participating in their plannedactivity) and a relapse (e.g., an extended period ofnot participating) is thought to improve adherence(Dishman 1991; Marcus and Stanton 1993).

Theory of Reasoned Action andTheory of Planned BehaviorThe theory of reasoned action (Fishbein and Ajzen1975; Ajzen and Fishbein 1980) states that indi-vidual performance of a given behavior is primarilydetermined by a person’s intention to perform thatbehavior. This intention is determined by two majorfactors: the person’s attitude toward the behavior(i.e., beliefs about the outcomes of the behavior andthe value of these outcomes) and the influence of theperson’s social environment or subjective norm (i.e.,beliefs about what other people think the personshould do, as well as the person’s motivation tocomply with the opinions of others). The theory ofplanned behavior (Ajzen 1985, 1988) adds to thetheory of reasoned action the concept of perceivedcontrol over the opportunities, resources, and skillsnecessary to perform a behavior. Ajzen’s concept of

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perceived behavioral control is similar to Bandura’s(1977a) concept of self-efficacy—a person’s percep-tion of his or her ability to perform the behavior(Ajzen 1985, 1988). Perceived behavioral controlover opportunities, resources, and skills necessary toperform a behavior is believed to be a critical aspectof behavior change processes.

Social Learning/Social Cognitive TheorySocial learning theory (Bandura 1977b), later re-named social cognitive theory (Bandura 1986),proposes that behavior change is affected by environ-mental influences, personal factors, and attributes ofthe behavior itself (Bandura 1977b). Each may affector be affected by either of the other two. A centraltenet of social cognitive theory is the concept of self-efficacy. A person must believe in his or her capabilityto perform the behavior (i.e., the person must possessself-efficacy) and must perceive an incentive to do so(i.e., the person’s positive expectations from perform-ing the behavior must outweigh the negative expecta-tions). Additionally, a person must value the outcomesor consequences that he or she believes will occur asa result of performing a specific behavior or action.Outcomes may be classified as having immediatebenefits (e.g., feeling energized following physicalactivity) or long-term benefits (e.g., experiencingimprovements in cardiovascular health as a result ofphysical activity). But because these expected out-comes are filtered through a person’s expectations orperceptions of being able to perform the behavior inthe first place, self-efficacy is believed to be the singlemost important characteristic that determines aperson’s behavior change (Bandura 1986).

Self-efficacy can be increased in several ways,among them by providing clear instructions, provid-ing the opportunity for skill development or training,and modeling the desired behavior. To be effective,models must evoke trust, admiration, and respectfrom the observer; models must not, however, appearto represent a level of behavior that the observer isunable to visualize attaining (Bandura 1986).

Social SupportOften associated with health behaviors such asphysical activity, social support is frequently usedin behavioral and social research. There is, how-ever, considerable variation in how social support

is conceptualized and measured (Israel and Schurman1990). Social support for physical activity can beinstrumental, as in giving a nondriver a ride to anexercise class; informational, as in telling someoneabout a walking program in the neighborhood; emo-tional, as in calling to see how someone is faring witha new walking program; or appraising, as in provid-ing feedback and reinforcement in learning a newskill (Israel and Schurman 1990). Sources of supportfor physical activity include family members, friends,neighbors, co-workers, and exercise program lead-ers and participants.

Ecological ApproachesA criticism of most theories and models of behaviorchange is that they emphasize individual behaviorchange processes and pay little attention to sociocul-tural and physical environmental influences on be-havior (McLeroy et al. 1988). Recently, interest hasdeveloped in ecological approaches to increasingparticipation in physical activity (McLeroy et al.1988; CDC 1988; Stokols 1992). These approachesplace the creation of supportive environments on apar with the development of personal skills and thereorientation of health services. Stokols (1992) andSimons-Morton and colleagues (CDC 1988; Simons-Morton, Simons-Morton, et al. 1988) have illus-trated this concept of a health-promoting environmentby describing how physical activity could be pro-moted by establishing environmental supports, suchas bike paths, parks, and incentives to encouragewalking or bicycling to work.

An underlying theme of ecological perspectivesis that the most effective interventions occur onmultiple levels. McLeroy and colleagues (1988), forexample, have proposed a model that encompassesseveral levels of influences on health behaviors:intrapersonal factors, interpersonal and group fac-tors, institutional factors, community factors, andpublic policy. Similarly, a model advanced by Simons-Morton and colleagues (CDC 1988) has three levels(individual, organizational, and governmental) infour settings (schools, worksites, health care institu-tions, and communities). Interventions that simulta-neously influence these multiple levels and multiplesettings may be expected to lead to greater andlonger-lasting changes and maintenance of existinghealth-promoting habits. This is a promising area for

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the design of future intervention research to pro-mote physical activity.

SummarySome similarities can be noted among the behavioraland social science theories and models used to un-derstand and enhance health behaviors such as physi-cal activity. Many of the theoretical approacheshighlight the role of the perceived outcomes ofbehavior, although different terms are used for thisconstruct, including perceived benefits and barriers(health belief model) and outcome expectations (so-cial cognitive theory and theory of planned behav-ior) (Table 6-1). Several approaches also emphasizethe influence of perceptions of control over behav-ior; this influence is given labels such as self-efficacy(health belief model, social cognitive theory) andperceived behavioral control (theory of planned be-havior). Other theories and models feature the roleof social influences, as in the concepts of observa-tional learning (social cognitive theory), perceivednorm (theory of reasoned action and theory of plannedbehavior), social support, and interpersonal influ-ences (ecological perspective). Most of the theoriesand models, however, do not address the influence ofthe environment on health behavior.

Behavioral Research on PhysicalActivity among AdultsBehavioral research in this area includes studies onboth the factors influencing physical activity amongadults (determinants research) and the effectivenessof strategies and programs to increase this behavior(interventions research). Although many of the keyconcepts presented in the preceding section arefeatured in both types of research presented here,neither area is limited to those concepts only.

Factors Influencing Physical Activityamong AdultsResearch on the determinants of physical activityidentifies those factors associated with, or predictiveof, this behavior. This section reviews determinantsstudies in which the measured outcome was overallphysical activity, adherence to or continued partici-pation in structured physical activity programs, ormovement from one stage of change to another (e.g.,

from contemplation to preparation). The sectiondoes not review studies in which the outcome mea-sured was an intermediate measure of physical activ-ity (e.g., intentions concerning future participationin physical activity). Although researchers have stud-ied a wide array of potential influences on physicalactivity among adults, the section focuses on factorsthat can be modified, such as self-efficacy and socialsupport, rather than on factors that cannot bechanged, such as age, sex, and race/ethnicity.

Modifiable DeterminantsThe modifiable determinants of adult physical activ-ity include personal, interpersonal, and environ-mental factors (Table 6-1). Self-efficacy, a constructfrom social cognitive theory, has been consistentlyand positively associated with adult physical activity(Courneya and McAuley 1994; Desmond et al. 1993;Hofstetter et al. 1991; Yordy and Lent 1993), physi-cal activity stage of change (Marcus, Eaton, et al.1994; Marcus and Owen 1992; Marcus, Pinto, et al.1994; Marcus, Selby, et al. 1992), and adherence tostructured physical activity programs (DuCharmeand Brawley 1995; Duncan and McAuley 1993;McAuley, Lox, Duncan 1993; Poag-DuCharme andBrawley 1993; Robertson and Keller 1992). Theevidence is less conclusive, however, for the theoryof planned behavior’s construct of perceived behav-ioral control (Courneya 1995; Courneya and McAuley1995; Godin et al. 1991, 1995; Godin, Valois, Lepage1993; Kimiecik 1992; Yordy and Lent 1993).

Several studies have found no association be-tween adult physical activity (whether physical ac-tivity, stage of change, or adherence) and either thehealth belief model’s constructs of perceived benefits(Hofstetter et al. 1991; Mirotznik, Feldman, Stein1995; Oldridge and Streiner 1990; Taggart andConnor 1995) and perceived barriers (Desmond etal. 1993; Godin et al. 1995; Neuberger et al. 1994;Oldridge and Streiner 1990; Taggart and Connor1995) or the theory of reasoned action and theory ofplanned behavior’s construct of attitude toward thebehavior (Courneya and McAuley 1995; Godin,Valois, Lepage 1993; Hawkes and Holm 1993). None-theless, the cumulative body of evidence supportsthe conclusion that expectations of both positive(e.g., benefits) and negative (e.g., barriers) behav-ioral outcomes are associated with physical activityamong adults. Expectation of positive outcomes or

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perceived benefits of physical activity has been con-sistently and positively associated with adult physicalactivity (Ali and Twibell 1995; Neuberger et al. 1994),physical activity stage of change (Booth et al. 1993;Calfas et al. 1994; Eaton et al. 1993; Marcus, Eaton, etal. 1994; Marcus and Owen 1992; Marcus, Pinto, et al.1994; Marcus, Rakowski, Rossi 1992), and adherenceto structured physical activity programs (Lynch et al.1992; Robertson and Keller 1992). Conversely, theconstruct of perceived barriers to physical activity hasbeen negatively associated with adult physical activity(Ali and Twibell 1995; Dishman and Steinhardt 1990;Godin et al. 1991; Hofstetter et al. 1991; Horne 1994),physical activity stage of change (Calfas et al. 1994;Lee 1993; Marcus, Eaton, et al. 1994; Marcus andOwen 1992; Marcus, Pinto, et al. 1994; Marcus,Rakowski, Rossi 1992), and adherence to structuredphysical activity programs (Howze, Smith, DiGilio1989; Mirotznik et al. 1995; Robertson and Keller1992). Additionally, attitude toward the behavior(outcome expectations and their values) has beenconsistently and positively related to physical activity(Courneya and McAuley 1994; Dishman andSteinhardt 1990; Godin et al. 1987, 1991; Kimiecik1992; Yordy and Lent 1993) and stage of change(Courneya 1995).

Social support from family and friends has beenconsistently and positively related to adult physicalactivity (Felton and Parsons 1994; Horne 1994; Minorand Brown 1993; Sallis, Hovell, Hofstetter 1992; Treiberet al. 1991), stage of change (Lee 1993), and adher-ence to structured exercise programs (Duncan andMcAuley 1993; Elward, Larson, Wagner 1992). Be-havioral intention, a construct from the theory ofreasoned action and the theory of planned behavior,also has consistently been associated with adult physi-cal activity (Courneya and McAuley 1994; Godin et al.1987, 1991; Godin, Valois, Lepage 1993; Kimiecik1992; Yordy and Lent 1993), stage of change (Courneya1995), and adherence to structured exercise programs(Courneya and McAuley 1995; DuCharme and Brawley1995). Conversely, the construct of subjective normfrom these theories has been both positively associ-ated (Courneya 1995; Godin et al. 1987, 1991; Hawkesand Holm 1993; Kimiecik 1992; Yordy and Lent1993) and not associated (Courneya and McAuley1995; Godin et al. 1995; Hofstetter et al. 1991) withadult physical activity, stage of change, and adherenceto structured exercise programs.

There is also mixed evidence regarding the posi-tive relationship between the health belief model’sconstruct of perceived severity of diseases and eitherphysical activity (Godin et al. 1991) or adherence tostructured exercise programs (Lynch et al. 1992;Mirotznik, Feldman, Stein 1995; Oldridge andStreiner 1990; Robertson and Keller 1992). Addi-tionally, that model’s construct of perceived suscep-tibility to illness has been unrelated to adult adherenceto structured exercise programs (Lynch et al. 1992;Mirotznik et al. 1995; Oldridge and Streiner 1990).

The cumulative body of determinants researchconsistently reveals that exercise enjoyment is adeterminant that has been positively associated withadult physical activity (Courneya and McAuley 1994;Horne 1994; McAuley 1991), stage of change (Calfaset al. 1994), and adherence to structured exerciseprograms (Wilson et al. 1994). Conversely, there hasbeen no relationship between locus of control beliefs(i.e., perceptions of personal control over health,fitness, or physical activity) and either adult physicalactivity (Ali and Twibell 1995; Burk and Kimiecik1994; Dishman and Steinhardt 1990; Duffy andMacDonald 1990) or adherence to structured exer-cise programs (Lynch et al. 1992; Oldridge andStreiner 1990). Although previous physical activityduring adulthood has been consistently related tophysical activity among adults (Godin et al. 1987,1993; Minor and Brown 1993; Sharpe and Connell1992) and stage of change (Eaton et al. 1993), historyof physical activity during youth has been unrelatedto adult physical activity (Powell and Dysinger 1987;Sallis, Hovell, Hofstetter 1992).

Determinants for Population SubgroupsFew determinants studies of heterogeneous sampleshave examined similar sets of characteristics in sub-groups. Self-efficacy is the variable with the stron-gest and most consistent association with physicalactivity in different subgroups from the same largestudy sample. Self-efficacy has been positively re-lated to physical activity among men, women, youngeradults, older adults (Sallis et al. 1989), Latinos (Hovellet al. 1991), overweight persons (Hovell et al. 1990),and persons with injuries or disabilities (Hofstetteret al. 1991). The generalizability of the self-efficacyassociations is extended by studies of universitystudents and alumni (Calfas et al. 1994; Courneyaand McAuley 1994; Yordy and Lent 1993), employed

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women (Marcus, Pinto, et al. 1994), participants instructured exercise programs (Duncan and McAuley1993; McAuley, Lox, Duncan 1993; Poag-DuCharmeand Brawley 1993), and people with coronary heartdisease (CHD) (Robertson and Keller 1992).

SummaryIdeally, theories and models of behavioral and socialscience could be used to guide research concerningthe factors that influence adult physical activity. Inactuality, the application of these approaches to deter-minants research in physical activity has generallybeen limited to individual and interpersonal theoriesand models. Social support and some factors fromsocial cognitive theory, such as confidence in one’sability to engage in physical activity (i.e., self-efficacy)and beliefs about the outcome of physical activity,have been consistently related to physical activityamong adults. Factors from other theories and mod-els, however, have received mixed support. Althoughperceptions of the benefits of, and barriers to, physicalactivity have been consistently related to physicalactivity among adults, other constructs from the healthbelief model, such as perceptions of susceptibility to,and the severity of, disease, have not been related toadult physical activity. Further, constructs from thetheory of reasoned action and the theory of plannedbehavior, including intentions and beliefs about theoutcomes of behavior, have been consistently relatedto adult physical activity, whereas there has beenequivocal evidence of this relationship for normativebeliefs and perceptions of the difficulty of engaging inthe behavior. Exercise enjoyment, a determinant thatdoes not derive directly from any of the behavioraltheories and models, has been consistently associatedwith adult physical activity.

Few studies have specifically contrasted physi-cal activity determinants among different sex, age,racial/ethnic, geographic location, or health statussubgroups. Many studies contain relatively homoge-neous samples of groups, such as young adults,elderly persons, white adults, participants in weightloss groups, members of health clubs, persons withheart disease, and persons with arthritis. Because thenumbers of participants in the studies that includethese subgroups are small, and because the studiesevaluated different factors, making comparisons be-tween studies is problematic.

Interventions to PromotePhysical Activity among AdultsThis section reviews intervention studies in whichthe measured outcome was physical activity, adher-ence to physical activity, or movement in stage ofchange (Table 6-2). It does not include interventionstudies designed to assess the effect of physicalactivity on health outcomes or risk factors (seeChapter 4). Further, this review places special em-phasis on experimental and quasi-experimental stud-ies, which are better able to control the influence ofother factors and thus to determine if the outcomeswere due to the intervention itself (Weiss 1972).

Individual ApproachesIndividual behavioral management approaches, in-cluding those derived from learning theories, relapseprevention, stages of change, and social learningtheory, have been used with mixed success in nu-merous intervention studies designed to increasephysical activity (Table 6-2). Behavioral manage-ment approaches that have been applied include self-monitoring, feedback, reinforcement, contracting,incentives and contests, goal setting, skills trainingto prevent relapse, behavioral counseling, andprompts or reminders. Applications have been car-ried out in person, by mail, one-on-one, and in groupsettings. Typically, researchers have employed thesein combination with other behavioral managementapproaches or with those derived from other theo-ries, such as social support, making it more difficultto ascertain their specific effects. In numerous in-stances, physical activity was only one of severalbehaviors addressed in an intervention, which alsomakes it difficult to determine the extent that physi-cal activity was emphasized as an intervention com-ponent relative to other components.

Self-monitoring of physical activity behavior hasbeen one of the most frequently employed behavioralmanagement techniques. Typically, it has involvedindividuals keeping written records of their physicalactivity, such as number of episodes per week, timespent per episode, and feelings during exercising. Inone study, women who joined a health club wererandomly assigned to a control condition or one oftwo intervention conditions—self-monitoring of at-tendance or self-monitoring plus extra staff attention(Weber and Wertheim 1989). Overall, women in the

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Table 6-2. Studies of interventions to increase physical activity among adults

Study Design Theoretical approach Population

Individual approaches

Weber and Wertheim 3 month Self-monitoring 55 women who joined a(1989) experimental gym; mean age = 27

King, Haskell, et al. 2 year Behavioral management 269 white adults(1995) experimental aged 50–65 years

Lombard, Lombard, 24 week Stages of change 155 university faculty andWinett (1995) experimental staff; mostly women

Cardinal and Sachs 12 week Stages of change 113 clerical staff at a(1995) experimental university; mean age = 37;

63% black

Belisle (1987) 10 week Relapse prevention 350 people enrolled inquasi-experimental beginning exercise groupswith 3-month follow-up

Gossard et al. (1986) 12 week Behavioral management 64 overweight healthyexperimental men aged 40–60 years

King, Carl, et al. (1988) 16 week Behavioral management 38 blue-collar universitypretest-posttest employees; mean age = 45

King and Frederiksen 3 month Relapse prevention, 58 college women(1984) experimental social support, aged 18–20 years

behavioral management

King, Taylor, et al. Study 1: 6 month Relapse prevention, 152 Lockheed employees(1988) experimental behavioral management aged 42–55 years

Study 2: 6 month Behavioral management Lockheed employees fromexperimental Study 1

I = intervention; C = control or comparison group.

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Intervention Findings and comments

I-1: Self-monitoring of attendance, fitness exam I-1 had better attendance than I-2 overall; interest in self-I-2: Self-monitoring, staff attention, fitness exam monitoring waned after 4 weeksC: Fitness exam

I-1: Self-monitoring, telephone contact, vigorous Better exercise adherence at 1 year in home-based groups; atexercise at home year 2 better adherence in vigorous home-based group; 5

I-2: Self-monitoring, telephone contact, moderate times per week schedule may have been difficult to followexercise at home

I-3: Self-monitoring, vigorous exercise in group

I-1: Weekly calls, general inquiry Frequent call conditions had 63% walking compared withI-2: Weekly calls, structured inquiry 26% and 22% in the infrequent condition; frequent call andI-3: Call every 3 weeks, general inquiry structured inquiry had higher rate of walking than otherI-4: Call every 3 weeks, structured inquiry groups

I-1: Mail-delivered lifestyle packet based on No difference in stage of change status among orstages of change within groups

I-2: Mail-delivered structured exercise packetwith exercise prescription

C: Mail-delivered fitness feedback packet

I: Exercise class and relapse prevention training Higher attendance in relapse prevention group over 10C: Exercise class weeks and at 3 months; high attrition and inconsistent

results across experimental groups

I-1: Vigorous self-directed exercise, staff telephone Better adherence in the moderate-intensity group at 12 weekscalls, self-monitoring compared with vigorous (96% vs. 90%) (no statistical tests

I-2: Moderate self-directed exercise, staff reported); travel, work schedule conflicts, and weathertelephone calls, self-monitoring were noted as barriers to physical activity

C: Staff telephone calls

I: 90-minute classes 2 times/week after work, Twofold increase in bouts of exercise compared withparcourse, self-monitoring, contests nonparticipants. Participants different from nonparticipants

C: None at baseline

I-1: Team building, relapse prevention training; I-2 and I-3 had twice the jogging episodes as I-1 and C atgroup exercise 5 weeks; at 3 months, 83% of I-3 were jogging compared

I-2: Team building, group exercise with 38% of I-1 and I-2 and 36% of CI-3: Relapse prevention training and jogging aloneC: Jogging alone

I-1: Home-based moderate exercise, self- No difference in number of sessions and duration reportedmonitoring with portable monitor, relapse at 6-month follow-upprevention training, telephone calls from staff

I-2: Same as I-1 without telephone calls from staff

I-1: Daily self-monitoring I-1 had more exercise bouts per month (11 vs. 7.5)I-2: Weekly self-monitoring

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Table 6-2. Continued


Marcus and Stanton 18 week Relapse prevention, 120 female university(1993) experimental social learning employees, mean

theory age = 35

McAuley et al. (1994) 5 month Social learning theory 114 sedentary middle-experimental aged adults

Owen et al. (1987) 12 week Behavioral management 343 white-collar and pro-quasi-experimental fessional workers, mean

age = 36, mostly women

Robison et al. (1992) 6 month Behavioral management, 137 university staff atquasi-experimental social support 6 campus worksites,

mean age = 40

Interventions in health care settings

Logsdon, Lazaro, 1 year None mentioned 2,218 patients from multi-Meier (1989) quasi-experimental specialty group practice(INSURE) sites

Calfas et al. 2 week Stage of change 212 patients(in press) quasi-experimental

Community approaches

Luepker et al. (1994) 5 to 6 year Diffusion of innovations, Community longitudinal(Minnesota Heart quasi-experimental; social learning theory, cohort (n = 7,097),Health Project) 3 matchedpairs community organization, independent survey

communication theory (n = 300–500)

Young et al. 7 year Social learning theory, 2 sets of paired, medium-(in press) quasi-experimental communication theory, sized cities (5th city used(Stanford Five-City Project) community organization for surveillance only)

Macera et al. (1995) 4 year None specified Community residentsquasi-experimental ≥ 18 years;(2 matched communities) 24% African American (I),

35% African American (C)

Brownson et al. (1996) 4 year Social learning theory, Rural communities; largelyquasi-experimental stage theory of innovation African American


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I-1: Relapse prevention training and exercise Better attendance in I-1 at 9 weeks; no difference atI-2: Scheduled reinforcement for attendance 18 weeks or 2-month follow-up

and exerciseC: Exercise only

I: Modeling of exercise, provision of efficacy- Better class attendance (67% vs. 55%) and more minutesbased information (mastery accomplishments, and miles walked among intervention group than controlssocial modeling, social persuasion,physiological response), walking program

C: Biweekly meetings on health information,walking program

I: Self-management instruction, exercise class No difference in activity levels at 6 monthsC: Exercise class

I: Weekly group meetings, contracts, cash Higher attendance among experimental groups thanincentives, social support, exercise comparison groups (93–99% vs. 19%)

C: Exercise, diary

I: Screening and counseling from physicians Increase in starting to exercise among intervention patientswho received continuing education; preventive (34% to 24%)visits at no charge

I: Physician counseling; booster call from Intervention patients increased walking (37 minutes vs.a health educator 10 minutes per week)

C: Nothing

I: Screening and education; mass media; com- Percent physically active higher in independent survey atmunity participation; environmental change; 3 years; higher in the cohort at 7 yearsprofessional education; youth and adults

C: Nothing

I: Print materials; workshops and seminars; Men increased participation in vigorous activities;organized walking; organized walking events; men and women in the intervention communities“Heart & Sole” groups; worksite programs; increased their overall number of physical activities;TV spots significant differences between intervention and

comparison communities at baseline

I: Community cardiovascular risk reduction No difference in physical activity prevalence, physicanactivities counseling for exercise, or exercise knowledge

C: None specified

I: Community organization; development of 6 coa- Increased physical activity levels in coalition communities,litions; exercise classes and walking classes and declining levels in communities without; net effect was 7%.walking clubs; demonstrations; sermons; news- Planned Approach to Community Health education planningpaper articles; community improvements; $5,000 modelto each coalition from the state health department

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Marcus, Banspach, et al. 6 week Stages of change 610 sample of community(1992) (Pawtucket Heart pretest-posttest residents, mean age = 42Health Program: Imagine uncontrolledAction)

Worksites

Blair et al. (1986) 2 year None 4,300 Johnson & Johnson(Live for Life) quasi-experimental employees

Fries et al. (1993) 24 month None 4,712 Bank of Americaexperimental retirees

Heirich et al. (1993) 3 year None specified 1,300 automobile plantexperimental workers

Communication

Osler and Jespersen 2 year Social learning theory, Rural communities in(1993) quasi-experimental communications Denmark (n = 8,000 [I])

(diffusion of innovations);community organization

Owen et al. (1995) 2 year Social learning theory, 2 national physical activitypretest-posttest social marketing theory campaigns in Australia

Brownell, Stunkard, Study 1: 8 week None specified 21,091 general publicAlbaum (1980) quasi-experimental observations at a mall,

train station, bus terminal

Study 2: 4 month None specified 24,603 general publicquasi-experimental observations at a train

station

Blamey, Mutrie, 16 week None 22,275 subway usersAitchison (1995) quasi-experimental observations


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Written materials, resource manual, weekly fun Participants more active after intervention with movementwalks, and activity nights toward action and low relapse to earlier stage; suggests

stage-based community intervention can result in movementtoward action; study uncontrolled

I: Screening; lifestyle seminar; exercise programs; 20% of women and 30% of men began vigorous exercisenewsletters; contests; health communications; of 2 yearsno smoking policies

C: Screening only

I-1: Health risk appraisal; feedback letter; No difference in physical activity year 1; I-1 greaterbehavioral management materials; personalized physical activity in year 2 over I-2health promotion program

I-2: Health risk appraisal; no feedback; fullprogram in year 2

C: No intervention

I-1: Fitness facility Percent exercising 3 times per week: I-1 = 30%, ,I-2: Outreach and counseling to high risk employees I-2 = 44%, I-3 = 45%, C = 37%I-3: Outreach and counseling to all employeesC: Health education events

I: Heart Week with assessments, health No difference in self-reported physical activity, buteducation, weekly community exercise, TV, intervention community expressed more interest in becomingradio, newspaper community messages active; low response rate to surveys (59%); became mainly

C: Not specified a media campaign with little community involvement

I: Messages to promote walking and readiness to 1st campaign—increase in percent who walked for exercisebecome active; modeling activity; radio and TV (70% to 74%), greatest impact on 50+ age group (twofoldPSAs; T-shirts; special scripting of soap operas increase in reported walking—not significant)

2nd campaign—small declines in reported walking andin intentions to be more active

I: Sign reading “Your heart needs exercise— Number of people using the stairs increased from 5%here’s your chance” to 14% when sign was up. Use declined to 7% when

sign was removed

I: Sign reading “Your heart needs exercise— Number of people using the stairs increased from 12% tohere’s your chance” 18%; effect remained for 1 month after sign was removed

I: Sign reading “Stay Healthy, Save Time, Baseline stair use increased to 15–17% when signUse the Stairs” was up; persisted at 12 weeks after sign removal;

larger increase among men

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Special populations: ethnic minorities

Heath et al. (1991) 2 year None specified 86 Native Americansquasi-experimental with diabetes

Lewis et al. (1993) 3 year Constituency-based African Americanquasi-experimental model residents of 6 public

housing units

Nader et al. (1989) 3 month Social learning theory 623 Mexican and Anglo-(San Diego Family experimental American families withHealth Project) 9 month 5th grade children

maintenance

Baranowski et al. 14 weeks None specified 94 black families (63(1990) adults, 64 children)

Special populations: persons at risk for chronic disease

Perri et al. (1988) 18 month Behavioral management 123 overweight adultsexperimental

Jeffery (1995) 7 year None mentioned 280 communityuncontrolled members trying

to lose weight

King et al. (1989) 2 year None mentioned 96 men trying toexperimental maintain weight

loss

Special Populations: older adults

Mayer et al. (1994) 2 year Social learning theory 1,800 Medicareexperimental beneficiaries in HMO,

mostly white, high SES


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I: Exercise class Participants in the exercise program lost 4 kg of weightC: Nonparticipants on average, compared with 0.9 kg among nonparticipants;

improvements occurred in fasting blood glucoselevels and medication requirements

I-1: Basic exercise program Communities that were better organized and had moreI-2: Basic exercise program; social; goal setting; committed leaders had better program attendance and

attention; information; barrier reduction higher physical activity levels

I: Family newsletter; telephone; mail; personal No difference in physical activity at 1 yearcontact; feedback; family behavior manage-ment; physical activity; nutrition education

C: Periodic evaluation

I: Individual counseling, small group education, No difference in energy expenditure; lowaerobic activity, incentives (babysitting, participation (20%)transportation), telephone prompts, assessment

C: Assessment only

I-1: Behavior therapy Difference adherence in high exercise groups at 6 months;I-2: Behavior therapy, maintenance no differences at 12 and 18 months; high attrition (24%)I-3: Behavior therapy, maintenance, social influenceI-4: Behavior therapy, maintenance, exerciseI-5: Behavior therapy, maintenance, exercise, social

influence

I-1: Diet management I-2 resulted in greater weight loss at end, but noI-2: Weight management, including exercise differences were observed at 1 yearI-3: Physical activity

I: Monthly mailings, advice and tips for coping, Men who exercised and received the intervention regainedstaff telephone calls less weight in year 2 than exercisers who did not get

C: No intervention the intervention or dieters who were exposed to theintervention

I: Health risk appraisal, feedback, health No change in physical activity (3+ times a week) at 1 year,education sessions, medical tests, immuniza- but 21% vs.14% moved from sedentary to activetions, goal setting, self-monitoring (no statistical test reported); attrition 16% in experimental

C: Not specified group at 1 year

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self-monitoring group had significantly betteradherence 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 wassignificantly 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 allthree groups, adherence dropped off most sharplyduring the first 6 weeks of the study.

Classes, health clubs, and fitness centers areresources to promote physical activity, and numer-ous studies have been undertaken to improve atten-dance (Table 6-2). However, many people prefer toexercise on their own. Several studies have usedbehavioral management techniques to encouragepeople to do so on their own (Table 6-2). In somestudies, training in behavioral management tech-niques has occurred in a group setting before theparticipants began exercising on their own; in oth-ers, information has been provided by mail. Resultshave been equivocal. King, Haskell, and colleagues(1995) assigned 50- through 65-year-old partici-pants to one of three conditions: a vigorous, group-based program (three 60-minute sessions); avigorous, home-based program (three 60-minutesessions); and a moderate, home-based program(five 30-minute sessions). At 1 year, adherence wassignificantly greater in both home-based programsthan in the group-based program. At 2 years, how-ever, the vigorous, home-based program had higheradherence than the other two programs. Research-ers hypothesize that it was more difficult for themoderate group to schedule 5 days of weekly physi-cal activity than for the vigorous group to schedule3 days. Another study encouraged self-monitoringand social support (walking with a partner) andalso tested a schedule of calling participants toprompt them to walk. Frequent calls (once a week)resulted in three times the number of reportedepisodes of activity than resulted from calling every3 weeks (Lombard, Lombard, Winett 1995). Cardi-nal and Sachs (1995) randomly assigned 133 womento receive one of the three packets of informationpromoting physical activity: self-instructional pack-ages that were based on stage of change and thatprovided tailored feedback; a packet containing astandard exercise prescription; and a packet pro-viding minimal information about health status and

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

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

In summary, behavioral management approacheshave been employed with mixed results. Where aneffect has been demonstrated, it has often been small.Evidence of the effectiveness of techniques like self-monitoring, frequent follow-up telephone calls, andincentives appear to be generally positive over theshort run, but not over longer intervals. Evidence onthe relative effectiveness of interventions on adher-ence to moderate or vigorous activity is limited andunclear. Because of the small number of studies, thevariety of outcome measures employed, and the di-versity of settings examined, it is not clear under whatcircumstances behavioral management approacheswork best.

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

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

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U.S. population see a physician during a 1-yearperiod (National Center for Health Statistics 1991),but the extent to which physicians counsel theirpatients to be physically active is unclear. One surveyof physicians found 92 percent reporting that they orsomeone in their practice counseled patients aboutexercise (Mullen and Tabak 1989), but in a morerecent study, only 49 percent of primary care physi-cians stated they believed that regular daily physicalactivity was very important for the average patient(Wechsler et al. 1996). Counseling is likely to bebrief, often less than 2 minutes (Wells et al. 1986),and ineffective counseling approaches are oftenemployed (Orleans et al. 1985). Physicians may beless likely to counsel patients about health habits iftheir own health habits are poor (Wells et al. 1984).

Only three studies attempting to improve thephysical activity counseling skills of primary carephysicians have been reported in the literature; theresults suggest small but generally positive effects onpatients, with from 7 to 10 percent of sedentarypersons starting to be physically active (Table 6-2).One feasibility trial of multiple risk factor reduction—the Industrywide Network for Social, Urban, andRural Efforts (INSURE) Project—indicates that con-tinuing medical education seminars, combined withreimbursement for prevention counseling and re-minders to providers, can increase the percentage ofthese physicians’ patients who subsequently start exer-cising (Logsdon, Lazaro, Meir 1989). The Physician-based Assessment and Counseling for Exercise (PACE)program incorporated social cognitive theory and thetranstheoretical model to individualize brief (2–5minutes) counseling messages for patients. Com-pared with patients who did not receive the programcounseling, those who did had significantly greaterimprovements at 4–6 weeks in their reported stage ofphysical activity readiness, their reported amount ofwalking for exercise, and their scores from an activitymonitor (Calfas et al. in press).

The Canadian Task Force on the Periodic HealthExamination (1994) cited insufficient evidence asthe reason for not making a recommendation regard-ing physical activity counseling. However, severalother professional organizations have recently rec-ommended routine physical activity counseling. TheAmerican Heart Association (Fletcher et al. 1992),the American Academy of Pediatrics (1994), theAmerican Medical Association (1994), the President’s

Council on Physical Fitness and Sports (1992), andthe U.S. Preventive Services Task Force (1989, 1996)all recommend including physical activity counsel-ing as part of routine clinical preventive services forboth adults and young people.

In summary, many providers do not believe thatphysical activity is an important topic to discuss withtheir patients, and many lack effective counselingskills. The studies that have attempted to increaseprovider counseling for physical activity demonstratethat providers can be effective in increasing physicalactivity among their patients. It is not known whatalternative approaches to provider counseling can beused effectively in health care settings, although thework of Mayer and colleagues (1994) suggests thatwell-trained counselors conducting health educationclasses with patients may help older adults makechanges in their stage of physical activity.

Community ApproachesCommunitywide prevention programs have evolvedfrom the concept that a population, rather than anindividual, approach is required to achieve primaryprevention of disease through risk factor reduction(Luepker et al. 1994). Behaviors and lifestyle choicesthat contribute to an individual’s risk profile areinfluenced by personal, cultural, and environmentalfactors (Bandura 1977b). Much of the current knowl-edge regarding community-based prevention strate-gies has been gained over the past 20 years from threeU.S. research field trials for community-based healthpromotion—including physical activity promotion—to reduce cardiovascular disease (Table 6-2).

These three trials, which were funded by theNational Heart, Lung, and Blood Institute during the1980s, were the Minnesota Heart Health Program(MHHP) (Luepker et al. 1994), the Pawtucket HeartHealth Program (PHHP) (Carleton et al. 1995), andthe Stanford Five-City Project (SFCP) (Farquhar et al.1990). The MHHP advocated regular physical activityas part of its broad effort to reduce risk for CHD inwhole communities in the upper Midwest (Crow et al.1986; Mittelmark et al. 1986). Three interventioncommunities received a 5- to 6-year program designedto reduce smoking, serum cholesterol, and bloodpressure and to increase physical activity; three othercommunities served as comparison sites. Mass mediawere used to educate the public about the relationship

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between regular physical activity and reduced risk forCHD and to increase opportunities for physical activ-ity. Health professionals promoted physical activitythrough their local organizations, through their advi-sory committees on preventive practice, and throughserving as role models and opinion leaders. Systematicrisk factor screening and education provided on-sitemeasurement, education, and counseling aimed inpart at increasing to 60 percent the prevalence ofphysical activity among the residents in the threeintervention 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-cluded changes in existing behaviors, in the meaningof those behaviors, and in the environmental cues thatsupported them. Direct education programs for school-aged children promoted physical activity in youngpeople and their parents. The MHHP investigatorsreported small but significant effects for physicalactivity in the first 3 years among people in the cross-sectional study group; that effect disappeared with anincreasing secular trend in physical activity in thecomparison groups. The cohort group (followed overtime) showed no intervention effect until the lastfollow-up survey (Figure 6-1).

Figure 6-1. Results of the Minnesota Heart Health Program on physical activity. Graph compares thepercentage of respondents reporting regular physical activity in intervention cities and thesecular trend estimated from control cities

75

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Baseline Follow-up

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

Education effect95% Confidence bounds

Secular trend

Panel 2: Cohort Fitted cohort levels and MHHP education program effect estimates

Education effect95% Confidence bounds

Cohort levels

Source: Luepker RV et al. American Journal of Public Health 1994 (reprinted with permission).

Note: Adjusted for age, sex, and education.

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The PHHP fostered community involvement inheart healthy behavior changes in Pawtucket, RhodeIsland (Carleton et al. 1995). The focus was on grassrootsorganizing, volunteer delivery, and partnerships withexisting organizations rather than on using electronicmedia (Lasater et al. 1986). In the area of physicalactivity promotion, the emphasis was on environmen-tal and policy change through partnerships with citygovernment and others. Working with the Departmentof Parks and Recreation, the PHHP was instrumental inestablishing cardiovascular fitness trails in both of thecity’s parks. Early in its existence, the PHHP also helpedthat department place on the ballot and pass a largebond issue in return for renovations (e.g., lights, fenc-ing to keep stray dogs out, resurfacing) to an existingquarter-mile track for walking. The Pawtucket 6-week Imagine Action Program, designed around thestages of change model, enrolled more than 600participants, who subsequently reported being moreactive as a result of the program (Marcus, Banspach, etal. 1992). Results of this uncontrolled study suggestthat a stage-based approach may be effective in movingpeople toward regular physical activity.

The SFCP included two intervention and twocomparison communities in northern California (onlymorbidity and mortality data were monitored in thefifth city, and those results were not reported in thisstudy). This project was designed to increase physicalactivity and weight control and to reduce plasma cho-lesterol levels, cigarette use, and blood pressure(Farquhar et al. 1990). Greater emphasis was placed onnutrition, weight control, and blood pressure than onphysical activity. The program used concepts fromsocial learning theory, diffusion theory, communityorganization, and social marketing in combinationwith a communication and behavior change model(Flora, Maccoby, Farquhar 1989). The program reliedheavily on the use of electronic and print media for thedelivery of health education information. General edu-cation was supplemented by four to five annual educa-tion campaigns targeting specific risk factors. Directface-to-face activities included classes, contests, andschool-based programs (Farquhar et al. 1990). Overall,the educational intervention had no significant im-pact on physical activity levels, knowledge, self-efficacy, or attitudes toward physical activity (Younget al., in press). In the cross-sectional sample, men inthe experimental communities were significantly more

likely than those in the control communities to engagein at least one vigorous activity. For women in both thecross-sectional and cohort studies, a small but signifi-cant increase was observed in the number of moderateactivities engaged in (Young et al., in press).

Among smaller-scale community studies, the re-sults of efforts to promote physical activity have beenmixed (Table 6-2). One exception was the community-based cardiovascular disease prevention programaimed at black residents in rural communities in theMissouri “Bootheel” (Brownson et al. 1996). In this 5-year, low-cost intervention project, educational ef-forts were combined with environmental changes.Local coalitions formed walking clubs, built walkingtrails, started exercise classes in churches, and orga-nized special events to promote both physical activityand good nutrition. Although no difference in levels ofphysical inactivity was observed between the Bootheeland the rest of the state at follow-up, physical inactiv-ity declined an average of 3 percent in Bootheelcommunities that had coalitions and increased anaverage of 3.8 percent in those without, for a netimprovement of 6.8 percent.

In summary, results of community-based inter-ventions to increase physical activity have beengenerally disappointing. Measurement of physicalactivity has varied across studies, making compari-sons difficult. The presence of active communitycoalitions, widespread community involvement, andwell-organized community efforts appear to be im-portant, however, in increasing physical activitylevels.

Worksite ProgramsPhysical activity programs conducted on the worksitehave the potential to reach a large percentage of theU.S. population (Bezold, Carlson, Peck 1986; Na-tional Center for Health Statistics 1987). As settingsfor physical activity promotion, many worksites haveeasy access to employees and supportive social net-works and can make changes in the environment tohelp convey physical activity as an organizationalnorm (Shephard, in press).

The proportion of worksites offering physicalactivity and fitness programs has grown in recentyears, from 22 percent in 1985 to 42 percent in 1992(Table 6-3). For two groups of employers, thosewith 50–99 employees and those with 100–249

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employees, the percentage with exercise programsmore than doubled over that time period. In eachworksite size category, the percentage with exerciseprograms had already (i.e., in 1992) exceeded theyear 2000 national objective for worksite healthpromotion listed in Healthy People 2000 (USDHHS1993). Generally, the extent of participation, effec-tiveness, and quality of those programs is unknown,for only a few worksite physical activity programshave been evaluated (Table 6-2).

In the Johnson & Johnson Live for Life program(Wilbur 1983), employees at four experimental sitesparticipated in lifestyle seminars, contests, and exer-cise programs and received newsletters on healthissues and other health communications. Experi-mental and control sites both received an annualhealth assessment. Overall, at the end of 2 years, 20percent of women and 30 percent of men in theexperimental sites reported beginning a vigorousexercise program; the prevalence at three compari-son sites was 7 percent for women and 19 percent formen (Blair et al. 1986).

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

intervention group did not differ from the second inself-reported physical activity at the end of year 1 butwas 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 andinterests (King, Carl, et al. 1988) and provide counsel-ing and peer support (Heirich et al. 1993) showpromise. In a controlled study, Heirich and colleagues(1993) compared different programs at four automo-tive manufacturing plants of like size and employeepopulations. The three approaches tested were 1) astaffed physical fitness facility, 2) one-to-one counsel-ing and outreach with high-risk employees (i.e., thosewho had hypertension, were overweight, or smokedcigarettes), and 3) one-to-one counseling and out-reach to all employees, peer support, and organiza-tional change (e.g., the institution of nonsmokingareas). The fourth site, which served as a control,offered health education classes and special events.After 3 years, exercise prevalence at the four sites waslowest at the plant with the exercise facility . In the twocounseling and outreach sites, nearly half of theemployees reported exercising 3 times a week.

In summary, considerable progress has beenmade in meeting the Healthy People 2000 goals forworksite physical activity programs. Too few studiesexist to clearly determine what elements are requiredfor physical activity programs at work to be effectivein increasing physical activity levels among all em-ployees, attracting diverse employee groups (such asblue-collar workers), or maintaining exercise levels

Table 6-3. Summary of progress toward Healthy People 2000 objective 1.10

“Increase the proportion of worksites offering employer-sponsoredphysical activity and fitness programs as follows:”

Year 2000 objective 1985 1992 Year 2000 target

Physical activity and fitnessworksites with:

50–99 employees 14% 33% 20%100–249 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.

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over time. However, the limited research availablesuggests that widespread employee involvement andsupport coupled with organizational commitmentevidenced by the presence of policies and programsmay be important factors in increasing levels ofphysical activity. Existing controlled studies havebeen done in larger worksites; studies have not yetshown what might work in smaller worksites and indiverse worksites (e.g., where many employees travelor facilities may not exist).

Communications StrategiesCommunications strategies, both electronic and print,have the potential for reaching individuals and com-munities with a rapidity unmatched by other inter-vention strategies. For the general population, mediacan play several roles: to increase the perceivedimportance of physical activity as a health issue, tocommunicate the health and other benefits of physi-cal activity, to generate interest in physical activityand awareness about available programs, to providerole models for physically active lifestyles, and toprovide cues to action, such as getting people torequest further information on physical activity,visit an exercise site, or begin exercising (Donovanand Owen 1994).

The effectiveness of different forms of mediaalone, including broadcast and print media, forpromoting either initial adoption or subsequentmaintenance of physical activity remains unclearbecause the few systematically evaluated interven-tions employing communications strategies haveshown mixed results (Osler and Jespersen 1993;Booth et al. 1992; Owen et al. 1995; Luepker et al.1994; Farquhar et al. 1990). The SFCP, discussedearlier, resulted in small increases in the number ofmoderate activities engaged in by women and vig-orous activity engaged in by men. Two nationalmass media campaigns to increase physical activity,particularly walking, to prevent cardiovascular dis-ease were conducted in Australia in 1990 and 1991(Booth et al. 1992). Drawing on social marketingand social learning theories, both campaigns in-cluded paid advertisements on national television,public service announcements on radio, scriptedepisodes on two nationally broadcast televisiondramas, posters and leaflets, stickers, T-shirts andsweatshirts, magazine articles, distribution of a

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

Communications intended to serve as cues toaction have been tested at places where people canchoose whether to walk or ride. This approach in-volves placing signs to use the stairs near escalatorsin public places like train and bus stations or shop-ping malls (Brownell, Stunkard, Albaum 1980;Blamey, Mutrie, Aitchison 1995). For example, signsthat 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 15–17 percent (Blamey, Mutrie, Aitchison 1995). Twelveweeks after the sign was removed, the increase instair use remained significant but showed a trendtoward baseline.

In summary, communications strategies havehad limited impact. It is not clear if communicationsapproaches would be more effective in getting peopleto be regularly active if they were linked with oppor-tunities to act on messages or if messages weretailored 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).

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Appropriately placed communications that serve ascues to action appear to increase the decision to usethe stairs instead of ride the escalator.

Special Population Programs

Racial and Ethnic MinoritiesThe few interventions studies that have been con-ducted with racial and ethnic minorities have pro-duced mixed results. The Bootheel Project referredto earlier in this chapter found increased levels ofphysical 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 combinationof 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 wereobserved, statistically significant increases in physi-cal activity were also noted.

Results of two family-based health promotionprograms that used behavioral management ap-proaches to promote physical activity showed nogreater increase in physical activity among thoseparticipating in the programs than among those in acontrol group. Nader and colleagues (1989) con-ducted a nutrition and physical activity program forAnglo-American and Mexican American families withchildren in fifth and sixth grades; the program im-proved dietary habits but did not succeed in increas-ing physical activity levels, although participation inthe program was high. Another family-based pro-gram, a 14-week intervention for African Americanfamilies that included educational sessions and twice-weekly fitness center activities, had low attendanceand did not increase physical activity (Baranowski etal. 1990).

The Indian Health Service undertook thecommunity-based Zuni Diabetes Project to increasephysical activity and decrease body weight amongZuni Indians in New Mexico who had non–insulin-dependent diabetes mellitus (NIDDM) (Leonard,Leonard, Wilson 1986). The exercise program con-sisted of several 1-hour aerobic sessions offered duringthe week. Zuni Indians who were trained in exerciseand group leadership methods helped coordinate the

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

People Who Are OverweightBeing overweight increases the risk of developingchronic diseases (see Chapter 4). Results of inter-ventions to promote physical activity for weight losshave 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 weightgain (Jeffery 1995). The Building Your Fitness Fu-tures program was a 4-week adult education classthat focused on how to develop a regular exerciseprogram. The Wise Weighs programs was an 8-weekadult education class that emphasized weight man-agement strategies related to diet and exercise. Thethird MHHP intervention, a correspondence course,addressed diet and exercise through monthly news-letters and tested two levels of financial contractincentives ($5 and $60 dollars). Each of these pro-grams was evaluated in the MHHP randomized trial.The Building Your Fitness Futures and the WiseWeighs programs resulted in only small weight lossthat was not significant after 1 year. The correspon-dence course resulted in significantly greater weightloss among participants with $60 incentives thanamong those with $5 incentives.

Preventing weight gain may be easier than promot-ing weight loss. Wing (1995) suggests that there arethree time periods during which interventions to pre-vent weight gain might be most effective: in the yearsbetween ages 25 and 35 years, in the peri-menopausalperiod for women, and in the year following successfulweight loss. A fourth MHHP program that addressedphysical activity, the Weight Gain Prevention Pro-gram, was a randomized trial of 211 community volun-teers. The participants (approximately two-thirdswomen) were randomly assigned to either the inter-vention group (n = 103) or the no-contact controlgroup (n = 108). This program was for normal-weightadults and included monthly newsletters and four

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classes emphasizing diet and regular exercise as wellas a financial incentive component linked to weightmaintenance. The intervention group lost 2 poundson average over the course of the year and weresignificantly less likely to gain weight than the controlgroup (82 percent vs. 56 percent) (Jeffery 1995).

Older AdultsMany of the diseases and disabling conditions asso-ciated with aging can be prevented, postponed, orameliorated with regular physical activity (see Chap-ter 4). The few interventions that have been tested toincrease physical activity levels among older adultsshow generally positive results. The 1990 AustralianHeart Week campaign reviewed earlier resulted in atwofold increase in walking among adults over 50years of age (Owen et al. 1995). Retirees in the studyby Fries (1993), also discussed earlier, showed sig-nificantly greater improvements in physical activityin year 2 than did persons in the control group.Participants in a longitudinal study of Medicarerecipients (n = 1,800) who belonged to a healthmaintenance organization were randomly assignedto a preventive care or a control group (Mayer et al.1994). The intervention employed information andbehavior modification approaches. Participants re-ceived recommended immunizations, completed ahealth risk appraisal, received face-to-face counsel-ing that included goal setting, received follow-uptelephone counseling, and participated in educa-tional sessions on health promotion topics. A focuson physical activity was a priority in goal-settingdiscussions; 42 percent of participants selected in-creasing physical activity as their goal. Members ofboth groups were largely white, well educated, andgenerally had above-average incomes. The preva-lence of physical activity was high in both groups atbaseline; approximately 60 percent reported get-ting regular exercise. At 1 year, the interventiongroup showed a significant 7 percent increase inself-reported physical activity.

Much of the published research on physical activ-ity describes researcher-initiated interventions. How-ever, individuals and small groups of people ofteninitiate physical activity on their own, independent ofany formal program. A qualitative research study byDuncan, Travis, and McAuley (1995) used observa-tions and in-depth interviews to examine motivation

for initiating and maintaining mall walking by olderpersons in rural West Virginia. Most participants inthis study reported becoming physically active at theurging of their physicians; several others were moti-vated by personal interest in health maintenance, andsome were encouraged by family members. Mall walk-ers maintained a regular routine, showing up at thesame time each day, walking in pairs or small groups,and then adjourning to a mall eatery for coffee orbreakfast. Interviews revealed that participants per-ceived mall walking as meaningful “work” to be doingduring 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 otherfactors contributing to adherence. Study researchersrecommended that community-based physical activ-ity programs try to replicate various aspects of work,such as keeping attendance records and providingoccasional recognition or acknowledgment of a jobwell done (such as pins, certificates, or celebrations).

People with DisabilitiesPeople with disabilities have similar health promo-tion and disease prevention needs as persons with-out disabilities. Interventions to promote physicalactivity for risk reduction among persons with mo-bility, visual, hearing, mental, or emotional impair-ments are largely absent from the literature. Physicalactivity interventions for managing chronic condi-tions, on the other hand, have led to enhancedcardiorespiratory fitness and improved skeletalmuscle function in persons with multiple sclerosis(Ponichtera-Mulcare 1993), increased walking ca-pacity and reduction in pain for patients with lowback pain (Frost et al. 1995), and improvements inendurance among patients with chronic obstructivepulmonary disease (Atkins and Robert 1984).

In summary, interventions that have been suc-cessful in increasing physical activity among minori-ties have employed community organizationstrategies, such as coalition building and communityengagement at all levels. Family-oriented interven-tions in community centers that have employedbehavioral management approaches have not re-sulted in increases in physical activity. Physicalactivity interventions incorporating incentives showpromise for promoting weight loss or preventingweight gain. Although there are a limited number of

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

SummaryThe review of adult intervention research literatureprovides limited evidence that interventions to pro-mote physical activity can be effective in a variety ofsettings using a variety of strategies. Controlledinterventions that have been effective at the work-place, in health care settings, and in communitieshave resulted in increased physical activity, althougheffects have tended to be small, in the range of 5–10percent, and short-lived. Multiple interventions con-ducted over time may need to be employed to sustainphysical activity behavior. Most experimental andquasi-experimental intervention research has beentheory-based, much if not most relying largely onbehavioral management strategies, often in combi-nation with other approaches, such as communica-tions and social support. Mixed results have made itimpossible to determine what theory or theoriesalone or in combination have most relevance tophysical activity. Research strategies that appearpromising include the tailoring of interventions topeople’s needs, experiences, and stages of change;the timing of intervention strategies to reinforce newbehaviors and prevent relapse (such as throughfrequent follow-up telephone calls); peer involve-ment and support; and an engaged community at alllevels. It is not known if interventions could bestrengthened 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 nofollow-up, and focused on the endpoint of specifiedvigorous physical activity rather than on moderate-

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 physicalactivity interventions were often only one compo-nent of an intervention to reduce multiple risk fac-tors, they may not have been robust enough to resultin much or any increase in physical activity. Few ifany studies compared their results to a standard ofeffectiveness, such as recommended frequency orduration of moderate or vigorous physical activity,or clearly stated the extent of stage-based change.

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

Factors Influencing Physical Activity amongChildren and AdolescentsThe emphasis in this section is on factors that influ-ence unstructured physical activity during free timeamong youths rather than on supervised physicalactivity, such as physical education classes. Studiesof organized youth sports have also been excluded.Only studies with some measure of physical activityas the outcome, however, are included in this re-view. For example, studies that investigated atti-tudes toward physical activity and did not relatethose to a measure of physical activity were ex-cluded. As was the case in the adult section, thissection focuses on studies that address modifiabledeterminants of physical activity, such as self-efficacy, rather than on studies that examine factorsthat cannot be altered to influence participation inphysical activity, such as age, sex, and race/ethnicity.

Modifiable DeterminantsThe modifiable determinants of youth physical ac-tivity include personal, interpersonal, and environ-mental factors (Table 6-1). Self-efficacy, a construct

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

Expectations about the outcomes of physicalactivity are associated with physical activity amongpreadolescents and adolescents. Perceived benefitshave been positively associated (Ferguson et al.1989; Tappe, Duda, Menges-Ehrnwald 1990;Zakarian et al. 1994), whereas perceived barriershave been negatively associated (Stucky-Ropp andDiLorenzo 1993; Tappe, Duda, Menges-Ehrnwald1990; Zakarian et al. 1994). Intention to be active, aconstruct from the theory of reasoned action and thetheory of planned behavior, has been consistentlyand positively related to physical activity amongolder children and adolescents (Biddle and Goudas1996; Ferguson et al. 1989; Godin and Shephard1986; Reynolds et al. 1990) .

Enjoyment, the major reason young people en-gage in physical activity (Borra et al. 1995), has beenpositively associated with physical activity amongboth children and adolescents (Stucky-Ropp andDiLorenzo 1993; Tinsley et al. 1995). Favorableattitudes toward physical education also have beenpositively related to adolescent participation inphysical activity (Ferguson et al. 1989; Zakarian etal. 1994).

Social influences—such as physically active rolemodels and support for physical activity—are im-portant determinants of physical activity amongyoung people (Tinsley et al. 1995). Parental activity(Moore et al. 1991; Poest et al. 1989; Sallis, Patterson,McKenzie et al. 1988) is positively related to physicalactivity among preschoolers. Studies reveal no rela-tionship 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;Sallis, Patterson, Buono, et al. 1988) or positiverelationships (Anderssen and Wold 1992; Butcher

1985; Gottlieb and Chen 1985; Stucky-Ropp andDiLorenzo 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 olderadolescents (Reynolds et al. 1990; Zakarian et al.1994). The physical activity of friends (Anderssenand Wold 1992; Stucky-Ropp and DiLorenzo 1993;Zakarian et al. 1994) and siblings (Perusse et al.1989; Sallis, Patterson, Buono, et al. 1988) also ispositively associated with physical activity amongolder children and adolescents.

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

Direct help from parents, such as organizingexercise activities (Anderssen and Wold 1992) orproviding transportation (Sallis, Alacraz, et al. 1992),is positively related to physical activity among olderchildren and younger adolescents. Access to playspaces and facilities (Garcia et al. 1995; Sallis et al.1993; Zakarian et al. 1994) is positively related tophysical activity among youths of all ages. The avail-ability of equipment has been positively related tophysical activity among preadolescent and adoles-cent girls (Butcher 1985; Stucky-Ropp and DiLorenzo1993). Further, two studies of young children havedemonstrated that time spent outdoors is a positivecorrelate of physical activity level (Klesges et al.1990; Sallis et al. 1993).

Determinants for Population SubgroupsAmong the limited number of subgroup-specificdeterminants studies, sex-specific differences areinvestigated most frequently. In two studies of ado-lescents (Kelder et al. 1995; Tappe, Duda, Menges-Ehrnwald 1990), competition motivated boys morethan girls, and weight management motivated girlsmore than boys. Additionally, boys have higherlevels of self-efficacy than girls (Trost et al. 1996)

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

SummaryFew studies of the factors that influence physicalactivity among children and adolescents have appliedthe theories and models of behavioral and socialscience. The research reviewed in this section, how-ever, has revealed that many of the factors that influ-ence physical activity among adults are alsodeterminants of physical activity among children andadolescents. Older children’s and adolescents’ inten-tions to engage in physical activity, as well as theirperceptions of their ability to engage in such activity(i.e., self-efficacy and perceived competence), arepositively related to their participation in physicalactivity. Social influences, such as parental and peerengagement in, and support for, physical activity, alsoare positively related to physical activity among youngpeople. Further, exercise enjoyment and positive atti-tudes toward physical education have been positivelyassociated 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 withdisabilities or chronic health conditions (e.g., asthma).

Interventions to Promote Physical Activityamong Children and AdolescentsThe most extensive and promising research on in-terventions for promoting physical activity amongyoung people has been conducted with students inschools, primarily at the elementary school level.Although many school-based studies have focusedon short-term results, a few studies have also exam-ined long-term behavioral outcomes. There is lim-ited evidence concerning the effectiveness ofschool-community programs, interventions in healthcare settings, family programs, and programs forspecial populations. In this section, the emphasis ison interventions designed to promote both unstruc-tured physical activity during free time and super-vised physical activity, such as physical educationclasses. Interventions designed to increase participa-tion in, or adherence to, organized youth sports havebeen excluded from this review. The review placesspecial emphasis on experimental studies, whichfeature random assignment of individuals or groups

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

School ProgramsBecause most young people between the ages of 6 and16 years attend school, schools offer an almostpopulationwide setting for promoting physical activ-ity to young people, primarily through classroomcurricula for physical education and health educa-tion. The CDC (in press) recommends that compre-hensive school and community health programspromoting physical activity among children and ado-lescents be developed to increase knowledge aboutphysical activity and exercise, develop behavioral andmotor skills promoting lifelong physical activity, fos-ter positive attitudes toward physical activity, andencourage physical activity outside of physical educa-tion classes. CDC’s 1994 School Health Policies andPrograms Study (Kann et al. 1995) examined thecurrent nationwide status of policies and programsfor multiple components of a school health program.The study examined kindergarten through 12th-gradehealth education and physical education at state,district, school, and classroom levels (Errecart et al.1995). Results from the health education componentof this study revealed that physical activity and fitnessinstruction were required in 65 percent of states and82 percent of districts and were included in a requiredhealth education course in 78 percent of schools.Only 41 percent of health education teachers pro-vided more than one class period of instruction onthese physical activity topics during the school year(Collins et al. 1995).

Results from the physical education componentof the School Health Policies and Program Studyrevealed that physical education instruction is re-quired by most states (94 percent) and school dis-tricts (95 percent) (Pate, Small, et al. 1995). Thesepolicies, however, do not require students to takephysical education every year. For instance, althoughmost middle and junior high schools (92 percent)and most senior high schools (93 percent) require atleast one physical education course, only half ofthese middle and junior high schools and only 26percent of these senior high schools require theequivalent of at least 3 years of physical education.Additionally, only 26 percent of all states require

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schools to offer a course at the senior high schoollevel in lifetime physical activity (i.e., physical activ-ity that can be practiced throughout one’s lifetime)(Pate, Small, et al. 1995). The School Health Policiesand Programs Study also revealed that instructionalpractices in physical education often do not reflectthe emphasis on lifetime physical activity that isrecommended in the national objectives in HealthyPeople 2000 (USDHHS 1990), in the National Physi-cal Education Standards (National Association forSport and Physical Education 1995), and in theCDC’s Guidelines for School and Community HealthPrograms to Promote Physical Activity Among Youth(in press). More than half of physical educationteachers devoted multiple class periods to traditionalsports activities, such as basketball (87 percent),volleyball (82 percent), and baseball/softball (82percent), whereas much smaller proportions of 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 teachersrequired students to develop individualized fitnessprograms (Pate, Small, et al. 1995). Despite currentguidelines’ emphasis on lifetime physical activity,during the 2 years preceding the study only 22percent of physical education teachers received in-service training on developing individualized fitnessprograms, and only 13 percent received training onincreasing students’ physical activity outside ofphysical education class (Pate, Small, et al. 1995).

Detailed findings from the School Health Poli-cies and Programs Study are important becauseschool-based physical education may be the mostwidely available resource for promoting physicalactivity among young people in the United States.For physical education to meet public health goals,it should provide all students with recommendedamounts of weekly physical activity (USDHHS 1990).

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

Activity Percentage of all courses

Basketball 86.8

Volleyball 82.3

Baseball/softball 81.5

Flag/touch football 68.5

Soccer 65.2

Jogging 46.5*

Weight lifting or training 37.3*

Tennis 30.3*

Aerobic dance 29.6*

Walking quickly 14.7*

Swimming 13.6*

Handball 13.2*

Racquetball 4.9*

Hiking/backpacking 3.0*

Bicycling 1.3*

Source: Adapted from Pate RP et al. School physical education. Journal of School Health 1995 (reprinted with permission).

*Lifetime physical activities

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Ironically, observations of physical education classesindicate that insufficient class time is spent actuallyengaging 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 Studyprovided a national overview of the status of schoolhealth programs (Kann et al. 1995). Interventionresearch has been reported from several studies(Table 6-5). Most of the early research in schoolsfocused on knowledge-based health education class-room lessons; these studies generally reported posi-tive changes in knowledge and attitudes but not inbehaviors. Summarized in review articles (Sallis,Simons-Morton, et al. 1992; Simons-Morton, Parcel,O’Hara et al. 1988), these studies suffered frommethodological problems, such as small samples andmeasurement limitations. Contemporary programsemphasize the importance of multicomponent inter-ventions that address both the individual and theenvironmental level to support engagement in physi-cal activity among youths (Kelder, Perry, Klepp1993; 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, et al. 1989; Resnicow et al. 1992; Walter 1989).This program includes health screening, behavior-oriented health education curricula, and specialinterventions 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 improvestudents’ knowledge, attitudes, and behaviors re-lated to physical activity, nutrition, and cigaretteuse, the measurement and reporting of physicalactivity behavior has been inconsistent among thethree 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 notreported (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 among1,234 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). Thisproject included the KYB health education curricu-lum, health screening, parent education, and KYBadvisory boards for parents, community members,students, and physicians. After 4 years, studentsfrom both the intervention and control schools hadsignificant increases in health knowledge at posttest,and intervention students had significantly bettergains in health knowledge (Bush, Zuckerman, Theiss,et al. 1989). Physical activity, however, decreasedsignificantly among students from both the interven-tion and control schools, and there was no differencein physical activity between the intervention andcontrol schools.

The Stanford Adolescent Heart Health Program(Killen et al. 1988) was a classroom-based random-ized cardiovascular disease risk reduction trial for1,447 tenth graders from four matched high schoolswithin two school districts. One school within eachdistrict was designated at random to receive a 20-week risk reduction intervention, and the otherschool served as the control. The classroom-basedintervention focused on three cardiovascular riskfactors, including physical activity. At the 2-monthfollow-up, students from the intervention schoolshad significantly higher gains in knowledge aboutphysical activity than did students in the controlschools. Among students not regularly exercising atbaseline, those in the intervention schools had sig-nificantly greater increases in physical activity thandid those in control schools. Additionally, studentswho received the intervention had significantly lowerresting heart rates and subscapular and tricepsskinfold measures. The long-term effectiveness ofthis 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 thehealth of elementary school students. The studyincluded 513 fifth-grade students from sevenAdelaide metropolitan schools. Three classes fromeach school participated in the study and were ran-domly assigned to one of three conditions: fitness,skills, or control. Students in the control conditionreceived the usual three 30-minute physical educa-tion classes per week. The students in both interven-tion conditions received 75 minutes of daily physical

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education: one condition emphasized fitness activi-ties featuring high levels of physical activity, and theother emphasized skill development activities with-out special emphasis on the intensity or duration ofphysical activity. With the class as the unit of analy-sis, the fitness condition led to significantly greaterincreases in endurance fitness and decreases inskinfold measurements. Although this study did notevaluate the impact of increased physical educationon students’ engagement in physical activity outsideof class, it showed that academic test scores did notdiffer between the intervention and control groups,despite the additional 275 minutes of class time theintervention groups spent on physical educationrather than on traditional academic subjects.

Go For Health (GFH) was a 3-year school healthproject designed to promote healthful diet and exer-cise behaviors among elementary school students(Parcel et al. 1987; Simons-Morton, Parcel, O’Hara1988; Simons-Morton et al. 1991). This project in-volved four elementary schools (kindergartenthrough fourth grade) from the Texas City Indepen-dent School District. Two schools were assigned toserve as controls, and the other two were designatedas GFH intervention schools. The intervention wasbased on social cognitive theory and included a GFHhealth education curriculum, physical educationclasses that focused on vigorous physical activity,and lower-fat school lunches. The physical activityresults revealed a significant increase from pretest toposttest (2 years) in the percentage of physical edu-cation class time that students in the interventionschools 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 studydid not examine changes in physical activity outsideof 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 of combining a health-related physi-cal education curriculum and in-service programson the quantity and quality of physical educationclasses in elementary schools (McKenzie et al. 1993).In a single school district, 28 fourth-grade classes inseven schools were randomly assigned to one of

three conditions: 10 classes were taught in theirusual manner by classroom teachers (control group);10 classes were taught the SPARK program by class-room teachers who had received in-service trainingand follow-up consultations; and 8 classes weretaught the SPARK program by physical educationspecialists hired by the research project. Direct ob-servation found that students assigned to either ofthe two intervention groups engaged in significantlymore weekly physical activity during physical edu-cation classes than did controls. Teachers who re-ceived the new physical education curriculum andin-service training provided significantly higher-quality instruction than did teachers in the controlgroup, although the trained classroom teachers’ in-struction did not match the quality of the instructionprovided by the physical education specialists. Thisstudy demonstrated that an improved physical edu-cation curriculum, combined with well-designedtraining for physical education specialists and class-room teachers, can substantially increase the amountof physical activity children receive in school(McKenzie et al. 1993) and can help ensure that theresulting 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 infour states (Luepker et al. 1996; Perry et al. 1990,1992; Stone 1994). A major component of CATCHwas an innovative health-related physical educationprogram, beginning at the third grade, for elemen-tary school students. For 2.5 years, randomly assignedschools received a standardized physical educationintervention, including new curriculum, staff de-velopment, and follow-up consultations. In theseintervention schools, observed participation inmoderate-to-vigorous activity during physicaleducation classes increased from 37.4 percent ofclass time at baseline to 51.9 percent (Luepker et al.1996). This increase represented an average of 12more minutes of daily vigorous physical activity inphysical education classes than was observed amongchildren in control schools (Luepker et al. 1996;McKenzie et al. 1995). Figure 6-2 shows the effect ofCATCH on physical activity during physical educa-tion class. The CATCH study showed that children’s

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Table 6-5. Studies of interventions to increase physical activity among children and adolescents


School programs

Bush, Zuckerman, 4 year Social learning theory 1,234 students initiallyTaggart, et al. (1989), experimental in grades 4–6, follow-upBush, Zuckerman, in grades 7–9Theiss, et al. (1989)(Know Your Body)

Killen et al. (1988) 7 week Social cognitive theory 1,447 students in grade 10(Stanford Adolescent experimentalHeart Health Program) 2-month follow-up

Dwyer et al. (1983) 14 week None 513 students in grade 5experimental

Simons-Morton et al. 3 year Social cognitive theory 409 grades 3 and 4(1991) (Go For Health) quasi-experimental PE classes

McKenzie et al. 8 month 112 PE lessons(1993) (SPARK) experimental

Luepker et al. (1996); 3 year Social cognitive theory 96 schools; 3,239 studentsMcKenzie (in press); experimental initially in grade 3,Edmundson et al. follow-up at grade 5(1996) (CATCH)

School-community programs

Kelder, Perry, Klepp 7 year Social learning theory Students in grade 6 from(1993) (Minnesota quasi-experimental 2 Minnesota Heart HealthHeart Health Program: Program communitiesClass of 1989 Study)

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

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I-1: 45 minutes, 2 times/week, Know Your Body Decrease in physical activity for both groups between pretestHE curriculum; health screening and results and follow-up. No difference in physical activity between

I-2: 45 minutes, 2 times/week, Know Your Body groups at posttest. Increase in posttest knowledge by eachHE curriculum; health screening group. Great increases in knowledge by intervention groups

C: Health screening at posttest, 18% response rate at 4-year follow-up

I: 20 classroom PE sessions, 50 minutes each, Intervention groups compared with control had a higher3 times/week, HE risk reduction curriculum proportion of nonexercisers at baseline exercising at

C: No intervention follow-up

I-1: 75 minutes daily PE, fitness curriculum Physical activity not assessed; no differences in academicI-2: 75 minutes daily PE, skill curriculum achievement between intervention and controlC: 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 Increase from pretest to posttest in the percent of PE class8-week modules of PE, children’s active PE time intervention school students spent in moderate-to-curriculum; reduced fat and sodium school vigorous physical activity; higher percentage of PE classlunch time spent in moderate-to-vigorous physical activity by

C: No intervention intervention schools compared with controls in posttest

I-1: PE provided by PE specialists At posttest PE specialists spent more minutes per lesson onI-2: PE provided by “specially trained” classroom very active physical activity and fitness activities than

teachers specially trained classroom teachers and classroomC: PE provided by classroom teachers teachers; specially trained classroom teachers spent more

minutes per lesson on very active physical activity and fitnessactivities than classroom teachers

I-1: HE curricula; PE featuring enjoyable Intervention schools compared to control schools provided amoderate-to-vigorous physical activity; greater percentage of PE time spent in moderate to vigorousEAT SMART school food service intervention physical activity at posttest; family involvement had no

I-2: Same as I-1 with family involvement effect on physical activity and psychosocial outcomes; dataC: No intervention from the intervention groups combined for comparison with

the control groups; intervention students were not differentfrom control students in total daily physical activity at posttest;intervention students spent 12 more minutes per day engagedin vigorous physical activity than controls; pretest-to-posttestincreases in students’ perceptions of self-efficacy forexercise and positive social reinforcement for exerciseamong both intervention and control students; interventionstudents’ posttest scores on these and other psychosocialmeasures were not different from those of control students

I: Peer-led physical activity challenge at grade 8; At 7-year follow-up students from schools in intervention10 lesson Slice of Life HE curriculum at grade 10 community had higher levels of physical activity than

C: No intervention students from schools in control community, particularlyamong girls; 45% response rate at 7-year follow-up

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physical activity can be increased by a standardizedintervention applied to existing physical educationprograms in four geographically and ethnically di-verse regions. Although the intervention studentsshowed significant pretest to follow-up increases intheir perceptions of positive social reinforcementand self-efficacy for exercise (Edmundson et al.1996), these psychosocial determinants were notsignificantly more prevalent than those observedamong the control groups at follow-up (Luepker etal. 1996). Although the family intervention compo-nent produced no additional increase in physicalactivity among students (Luepker et al. 1996), the

CATCH physical education and classroom programssuccessfully increased moderate-to-vigorous physi-cal activity in physical education class and increasedstudents’ daily participation in vigorous physicalactivity.

School-Community ProgramsThe 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 threeMHHP intervention communities and its matchedpair were involved in the Class of 1989 Study. Theintervention cities were engaged in an extensivecommunitywide intervention program designed toimprove eating, exercise, and smoking patterns for theentire population. The physical activity interventionincluded a peer-led physical activity challenge, in whichstudents were encouraged to engage in out-of-schoolexercise activities. The program’s assessment includedannual measurements collected from a large number ofstudents (baseline n = 2,376) for 7 years, beginning inthe sixth grade. Throughout most of the follow-upperiod, physical activity levels were significantly higheramong female students in the intervention communitythan among those in the control community. For malestudents, the levels did not differ significantly betweenthe communities. Results suggest that at least amongfemale students, a multicomponent intervention thatincludes peer-led behavioral education in schools andcomplementary communitywide strategies can increaselevels of regular physical activity (Kelder, Perry, Klepp1993; Kelder et al. 1995).

Interventions in Health Care SettingsHealth professionals also have a potential role inpromoting physical activity, healthy eating, and otherhealth behaviors among children and adolescents(American Medical Association 1994; U.S. PreventiveServices Task Force 1996). Results of a national sur-vey of pediatricians showed that one-half of respon-dents believed that regular exercise during childhoodis important in preventing cardiovascular disease inadulthood (Nader et al. 1987). However, only one-fourth believed they would be effective in counselingtheir young patients to get regular vigorous exercise.The American Medical Association’s Guidelines forAdolescent Preventive Health Services (1994) is one

Source: Luepker RV et al. Journal of the American MedicalAssociation 1996 (reprinted with permission).

Note: Observed at six time points, 1991 through 1994. The CATCHintervention, introduced during semester 2, increased the percentageof time spent in moderate-to-vigorous and vigorous activity asmeasured by the System for Observing Fitness Instruction Timeclassroom observation system. Intervention and control curvesdiverged significantly according to repeated-measures analysis ofvariance with the class session as the unit of analysis: for moderate-to-vigorous activity, P = 2.17, df = 5, 1979, P = .02; for vigorousactivity, F = 2.95, df = 5, 1979, P = .04. Analysis controlled for CATCHsite, the location of the lesson, the specialty of the teacher, and randomvariation among schools and weeks of observation.

Figure 6-2. Moderate-to-vigorous and vigorousphysical activity observed during Childand Adolescent Trial for CardiovascularHealth (CATCH) physical education classes

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1Descriptions of specific physical activity programs across theUnited States can be found in the Combined Health InformationDatabase, a computerized bibliographic database of health infor-mation and health promotion resources developed and managedby several federal agencies, including the CDC, the NationalInstitutes of Health, the Department of Veterans Affairs, and theHealth Resources and Services Administration. Intended for allhealth professionals who need to locate health information forthemselves or their clients, this resource is available in manylibraries, state agencies, and federal agencies.

example of practical counseling recommendationsthat have been developed for those who providehealth services to adolescents.

Special Population ProgramsPhysical 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 toexamine how to promote physical activity amongyoung people with special needs. The most extensivestudy is a series of randomized investigations ofchildren who are overweight (Epstein, Wing, Valoski1985; 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 childrenincorporated both physical activity and nutrition in-terventions, and the programs were based specificallyon principles of behavior modification. Parents weretrained to improve their children’s physical activity bysetting behavioral change goals with their children, byidentifying effective reinforcers (e.g., spending timewith parents), and by reinforcing children when goalswere met. Ten-year follow-ups of children in thesefour randomized studies revealed that 30 percent ofchildren receiving family-based interventions wereno longer obese, and 20 percent had decreased theirpercentage overweight by 20 percent or more (Epsteinet al. 1994). The 10-year follow-up investigation alsorevealed that the percentage of overweight children ineach study decreased most when the interventioninvolved both the parent and the child or when achange in lifestyle exercise was emphasized. Epsteinand 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 10-year follow-up, thelifestyle group had lost the most weight, and both thelifestyle group and the aerobic exercise group hadgreater weight-loss results than the calisthenics group(Epstein et al. 1994).

SummaryThe preceding review of the research literature oninterventions among young people reveals thatschool-based approaches have had consistentlystrong effects on increasing physical activity in

elementary school students when the interventionorients the physical education program toward de-livering moderate-to-vigorous physical activity.Further, social learning theory appears to have hadthe widest application to this interventions re-search. Much research has taken place at the el-ementary school level; very little is known aboutincreasing children’s physical activity in middleand high school physical education classes or insettings other than school physical education classes.It seems likely that these interventions would bestrengthened by designing programs that combineschool and community policy with health educa-tion and physical education. Data are lacking onways to tailor interventions to the needs and inter-ests of young people and to prevent the rapiddecline in physical activity that occurs during latechildhood and adolescence, especially among girls.Additionally, few physical activity interventionsand research studies encompass populations par-ticularly characterized by race/ethnicity, socioeco-nomic status, risk factor status, disabilities, orgeographic location.

Promising Approaches, Barriers,and ResourcesMany questions remain about how best to pro-mote physical activity in the general population ofyoung people and adults, as well as in clinicalpopulations and other subgroups. Policy initia-tives, the provision of more physical activity facili-ties and programs, and media campaigns arepromising, but studies testing their effects arelimited. The following two sections describe exist-ing policy and program approaches1 that have thepotential to increase population levels of physicalactivity but have received little or no evaluation.They are reviewed separately from the previouslydiscussed, better-documented research studies.

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Environmental and Policy ApproachesMost 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 somesuccess in promoting physical activity, but theirresults have been inconsistent. A possible reason forlimited results is a lack of concomitant support fromthe larger environment within which such interven-tions take place. Many physical activity researchersbelieve that environmental and policy interventionsmust occur to complement interventions that focuson behavior change among individuals or smallgroups. This larger perspective recognizes the pow-erful moderating effect that environment has onindividual volition. As King, Jeffery, and colleagues(1995) observe, “Environmental and policy inter-ventions are based on the recognition that people’shealth is integrally connected to their physical andsocial environments” (p. 501).

Two premises underlie environmental and policyapproaches. First, interventions addressing chronicdisease risk factors, such as physical inactivity, re-quire comprehensive, population-based approachesthat incorporate both individual and societal-levelstrategies (Green and Simons-Morton 1996; Schmid,Pratt, Howze 1995). Second, strategies should notrely solely on active approaches requiring individualinitiative, such as enrolling in exercise classes, butshould also incorporate passive approaches, such asproviding walking trails or policies that permit em-ployees to exercise during work hours (Schmid,Pratt, Howze 1995). An example of interventionelements combining passive and active approaches isa school board policy that permits school facilitiesto remain open before and after school for commu-nity use, together with health communications thatmake citizens aware of these facilities and encour-age their use.

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

offering safe, accessible, and attractive trails forwalking and biking.

National objectives and recommendations haveencouraged the development of policies, programs,and surveillance strategies that would help createan environment that promotes physical activity(USDHHS 1990; Pate, Pratt, et al. 1995; NationalAssociation for Sport and Physical Education 1995;U.S. Department of Transportation [USDOT] 1994).Increasing national levels of physical activity and ofcardiorespiratory fitness has also been targeted as apriority health objective in Healthy People 2000(USDHHS 1990) and the Dietary Guidelines forAmericans (U.S. Department of Agriculture andUSDHHS 1995).

Many efforts to raise public awareness and pro-mote physical activity are under way. In 1994, theAmerican Heart Association, the American Collegeof Sports Medicine, and the American Alliance forHealth, Physical Education, Recreation and Danceformed a National Coalition for Promoting PhysicalActivity. The coalition’s goals are to increase publicawareness of the benefits of physical activity, pro-vide an opportunity for forming effective partner-ships, and enhance delivery of consistent messagesabout physical activity (National Coalition for Pro-moting Physical Activity 1995). The CDC has estab-lished guidelines for promoting physical activity andhealthy eating among young people (CDC 1996;CDC in press) and has initiated a public educationeffort to encourage active lifestyles and healthy eat-ing among Americans. The National Institutes ofHealth (NIH) has used national campaigns to pro-mote messages to both the general public and pa-tients on the importance of physical activity and aheart healthy diet. The NIH also sponsors researchon 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 onPhysical Activity and Cardiovascular Health, whichrecommended regular physical activity for mostpersons aged 2 years and older (see Appendix B inChapter 2). The President’s Council on PhysicalFitness and Sports works with a broad range ofpartners in private industry, voluntary organiza-tions, and the media to promote physical activity,fitness, and sports participation by Americans of all

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ages. As part of the midcourse review of the physicalactivity and fitness objectives of Healthy People 2000,the council presented a synopsis of ongoing grassrootsactivities by Healthy People 2000 Consortium mem-bers in support of increasing participation in physi-cal activity and improvement in fitness (USDHHS1995). The President’s Council on Physical Fitnessand Sports is also an advisory body to the Presidentand to the Secretary of the DHHS on matters involv-ing physical activity, fitness, and sports that enhanceand improve health. Thirty-nine Governor’s Coun-cils on Physical Fitness and Sports stimulate stateand local activities and program development; theseefforts target fitness promotion for school-agedyouths, older adults, working adults, and families(National Association of Governor’s Councils onPhysical Fitness and Sports 1996).

Community-Based ApproachesCommunity-based programs can be tailored to meetthe needs of their specific populations. More col-laborative work is under way between state and localgovernments, community groups, and businesses toreduce risk factors among employees and residents.Two-year follow-up data from one such effort inSmyth County, Virginia, suggested that 40 percent ofschool 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:young people and older adults. Communities will facea growing need to provide a supportive environmentfor their children and adolescents. Between 1995 and2020, the number of young people under 18 years oldwill increase by an estimated 13 percent, from 69million to 78 million (Bureau of the Census 1996).The framework for community-level physical activityprograms 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 additionto organized sports, communities need to providerecreational programs and opportunities for all youngpeople in a community, because such programs mayencourage a lifetime habit of physical activity as wellas other immediate community benefits. According toThe Trust for Public Land, arrests among youngpeople in one community decreased by 28 percent

after the community instituted an academic and rec-reational support program for teenagers (NationalPark Service 1994). In another community, juvenilecrime dropped 55 percent when community recre-ational facilities stayed open until 2 a.m. (NationalPark 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 theage of 60 will increase by 43 percent, from 44 to 63million (Bureau of the Census 1996). Programs andfacilities designed to meet the needs of aging babyboomers and older adults can help ensure that theserapidly growing segments of the population obtainthe health benefits of regular, moderate physicalactivity. In one community, 35 age-peer exerciseinstructors for older adults were recruited and trainedby a local university as volunteers to conduct age-appropriate physical activity programs on a regularbasis at sites such as libraries, senior centers, andnursing homes in their neighborhoods. Because theywere age peers, the instructors were sensitive tomany of the concerns that older adults had aboutphysical activity, such as fear of falling and fracturinga hip. Over the following year, instructors conductedmore than 1,500 half-hour exercise programs formore 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 incommunities, since these settings can provide theimpetus for starting—and the social support formaintaining—behavioral regimens (Eng, Hatch,Callan 1985; Eng and Hatch 1991) such as regularphysical activity. Among the advantages of suchsettings are a history of participating in a range ofcommunity health and social projects; large mem-berships, including families; a presence in virtuallyevery U.S. community; and connections to minorityand low-income communities typically underservedby health promotion programs (King 1991). TheFitness Through Churches Project promoted aero-bic exercise in conjunction with other health behav-iors to African American residents of Durham, NorthCarolina (Hatch et al. 1986). The results from thispilot program suggest that physical activity pro-grams offered at places of worship are feasible andattractive to clergy and their congregations. Anotherproject, the Health and Religion Project (HARP) of

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

Societal BarriersThe major barrier to physical activity is the age inwhich we live. In the past, most activities of dailyliving involved significant expenditures of energy. Incontrast, the overarching goal of modern technologyhas been to reduce this expenditure through theproduction of devices and services explicitly de-signed to obviate physical labor. From the days ofhunting and gathering to turn-of-the-century farm-ing practices and early industrial labor, the processof earning a living was once a strenuous activity.Today, many Americans engage in little or no physicalactivity in the course of a working day typically spentsitting at a desk or standing at a counter or cashregister. A large part of many people’s time is spentinside buildings where elevators or escalators areprominent features and stairs are difficult to find andmay seem unsafe. Motorized transportation carriesmillions of Americans to and from work and onalmost every errand. These inactive daily expedi-tions occur virtually door-to-door, with the help ofparking lots built as near to destinations as possibleto minimize walking and increase convenience andsafety. Whereas older cities and towns were built onthe assumption that stores and services would bewithin walking distance of local residents, the designof most new residential areas reflects the suppositionthat people will drive from home to most destina-tions. Thus work, home, and shopping are oftenseparated by distances that not only discourage walk-ing but may even necessitate commuting by motor-ized transportation.

Television viewing, video games, and computeruse have contributed substantially to the amount oftime people spend in sedentary pursuits (President’sCouncil on Physical Fitness and Sports and SportingGoods Manufacturers Association 1993). Next tosleeping, watching TV occupies the greatest amountof 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 or she will likely have spent

15,000–18,000 hours in front of a television—and12,000 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 andto create environments in communities, schools,and workplaces that afford maximum opportunity tobe active. Policy interventions can address publicconcerns about safety, financial costs, and access toindoor and outdoor facilities. Such interventionsalso can address the concerns of employers andgovernments about liability in the event of injury. Atthe state and local level, governments determinebuilding codes and public safety, traffic, and zoningstatutes that have potential bearing on physical ac-tivity opportunities in communities.

Concerns about crime can be a major barrier tophysical activity for both adults and young people. Ina national survey of parents, 46 percent believedtheir neighborhood was not very safe from crime fortheir children (Princeton Survey Research Associates1994). Minority parents were about half as likely aswhite parents to report that their neighborhoodswere safe. Successful implementation of policy inter-ventions may help address such concerns. For ex-ample, decisions to put more police on a beat in ahigh-crime area may help residents feel safer goingoutside to walk. Similarly, neighborhood watchgroups formed to increase safety and reduce crimemay be a vehicle for promoting physical activity.Opening schools for community recreation and mallsfor walking can provide safe and all-weather venuesthat enable all members of the community to beactive.

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

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employer offered financial or other incentives; 46percent would if safe bike lanes were available; and45 percent would if their workplace had showers,lockers, and a secure area for bike storage (USDOT1994). More than half the respondents indicatedthey would walk, or walk more, if there were safepathways (protected from automobile hazards) andif crime were not a consideration. A majority alsowanted their local government to provide betteropportunities to walk and bicycle.

These percentages stand in sharp relief againstcurrent practice: only 4.5 percent of Americans com-mute to work by bicycle or on foot (USDOT 1994).Even in such comparatively small numbers, thesepeople are estimated to save as much as 1.3 billiongallons of gasoline yearly and to prevent 16.3 millionmetric tons of exhaust emissions (USDOT 1994).Every mile walked or cycled for transportation saves5 to 22 cents that would have been spent for a mileby automobile, including reduced cost from pollu-tion and oil imports (USDOT 1994). The IntermodalSurface Transportation Efficiency Act, passed in1991, promotes alternatives to automobile use bymaking funds available for states to construct orimprove bicycling facilities and pedestrian walkways(USDOT 1993). Decisions on how these funds areused are made locally, and organizations such aslocal transportation, health, and parks departmentscan promote the use of these funds in ways thatincrease the prevalence of physical activity in theircommunities.

In a growing number of communities, concernsabout environmental quality have led to zoningrestrictions that protect open spaces and other areasthat can subsequently be used for recreational pur-suits. Such greenways, or linear open space, canconnect neighborhoods and foster the use of bicy-cling and walking for transportation (IndianapolisDepartment of Parks and Recreation 1994).

Societal ResourcesAlthough there is no comprehensive listing of physi-cal activity resources in the United States, sucha document would be extensive. Millions ofAmericans have sports supplies, bicycles, and exercisemachines in their homes or have access to public andprivate resources such as tennis courts, parks, play-grounds, and health clubs. Numerous organizations

promote physical activity as part of their mission orin fund-raising efforts such as walks or runs. Inaddition, 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 onthe Internet, and the World Wide Web containsinformation about many organizations and resourcesrelated to physical activity. The multitude of physi-cal education teachers, aerobics instructors, danceinstructors, recreation leaders, coaches, and per-sonal trainers constitute an energetic pool of physi-cal activity advocates and role models.

Ensuring the availability and accessibility ofenvironments and facilities conducive to exerciseis central to seeing that the public has the oppor-tunity to obtain regular physical activity. Facili-ties should be convenient, affordable, comfortable,and safe (King et al. 1992). Many communitiesoffer sufficient facilities, but unless they are alsoaccessible and affordable, people may not usethem (Sallis et al. 1990). Walking for exerciseneeds no more equipment than a comfortable pairof shoes, but it does require a safe environment.Other activities vary widely in the resources theyrequire—specialized clothing and equipment, play-grounds, bicycle lanes, swimming pools, fields foroutdoor games, courts for indoor games, fitnessfacilities for weight lifting and aerobic exercise,studios for dancing, to mention a few.

Proximity of resources to home or worksites isparticularly important (Sallis et al. 1990). In a tele-phone survey, 72 percent of respondents indicatedthat there was a park or playground within walkingdistance of their home, and 75 percent of thesepersons had used them (Godbey et al. 1992). Ruralresidents are less likely to have such access (Godbeyet al.1992), but they may have open spaces of otherkinds. In addition, large indoor areas, such as shop-ping malls and schools, have become popular venuesfor individuals and for walking groups and clubs. Insome communities, schools stay open before or afterthe school day so community residents can use themfor hall walking (King, Jeffery, et al. 1995). Resultsfrom a survey of exercise facilities in San Diego,California, suggest that schools may be the mostavailable yet least-used resource for physical activityamong community residents (Sallis et al. 1990).

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SummaryThe scope, quality, and effectiveness of the widerange of policies and programs described in thissection have the potential to foster more physicallyactive lifestyles in the U.S. population. These effortscould be targeted to meet the needs of populationsubgroups and could be designed to use effectivestrategies. Public health goals for physical activityand fitness are more likely to be achieved if policiesand programs are guided by approaches known to beeffective and tailored to meet the needs of all mem-bers of the community. Policies and programs shouldbe periodically evaluated to learn how they can beimproved to promote physical activity.

The discussion of existing barriers and resourcesmakes it clear that attention should be given toaddressing not only the challenges of individualbehavior change but also the environmental barriersthat inhibit a populationwide transition from a sed-entary to an active lifestyle. Expenditure of resourcesfor bike paths, parks, programs, and law enforce-ment to make playgrounds and streets safer willencourage physical activity in daily living and shouldthus be viewed as contributing to the health of allAmericans. At the same time, evaluations of suchchanges can occur and more research accordinglyconducted to clarify how much the availability ofcommunity spaces, facilities, and programs mightencourage physical activity. Such information wouldbetter inform specific public policy decisions aboutproviding environmental supports and resources topromote physical activity.

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

Chapter SummaryThis 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 andsocial science research on physical activity is a rela-tively recent endeavor, and many questions remain tobe answered about not only increasing but also sus-taining physical activity. Several factors seem to be keyinfluences on physical activity levels for both adultsand young people. Having confidence in one’s abilityto be active (self-efficacy); enjoying physical activity;receiving support from family, friends, or peers; andperceiving that the benefits of physical activity out-weigh its barriers or costs appear to be central deter-mining factors influencing activity levels across thelife span.

For adults, some interventions in communities,in health care settings, in worksites, and at homehave 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 resourcefor promoting physical activity and have the poten-tial for reaching large numbers of children and ado-lescents. Research indicates that children’s levels ofphysical activity in physical education class are greaterwhen physical education teachers are specially trainedin methods to increase the time their students spendengaging in moderate-to-vigorous physical activity.Few studies, however, have been conducted at middleand high school levels—a time when most adoles-cents decrease their physical activity.

Only limited information exists about the needsof population subgroups of all ages and how determi-nants of physical activity may change over the life spanbecause of puberty, the normal aging process, healthconditions, 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 ofincreasing 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, asimilar effect of counseling for children and adoles-cents has not been examined. It is unclear whatapproaches can help people recover from relapses intoinactivity—whether from illness, the weather, de-mands at work or at home, or other reasons—andsustain the habit of regular physical activity over time.Questions also remain about how to address barriersto physical activity and how to more effectively use

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resources in communities, schools, and worksites toincrease physical activity. Recent research and prom-ising approaches have begun to address some of thesequestions and provide direction for future researchand interventions to promote physical activity amongall Americans.

Conclusions1. Consistent influences on physical activity pat-

terns among adults and young people includeconfidence in one’s ability to engage in regularphysical activity (e.g., self-efficacy), enjoymentof physical activity, support from others, posi-tive beliefs concerning the benefits of physicalactivity, and lack of perceived barriers to beingphysically active.

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

3. Interventions targeting physical education in el-ementary school can substantially increase theamount of time students spend being physicallyactive in physical education class.

Research Needs

Determinants of Physical Activity1. Assess the determinants of various patterns of

physical activity among those who are sedentary,intermittently active, routinely active at work,and regularly active.

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

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

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

Physical Activity Interventions1. Develop and evaluate the effectiveness of inter-

ventions that include policy and environmentalsupports.

2. Develop and evaluate interventions designed topromote adoption and maintenance of moderatephysical activity that addresses the specific needsand circumstances of population subgroups, suchas racial/ethnic groups, men and women, girlsand boys, the elderly, the disabled, the over-weight, low-income groups, and persons at lifetransitions, such as adolescence, early adulthood,family formation, and retirement.

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

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