Physical Activity and Built Environment

Physical activity (PA) is defined as any bodily movement produced by skeletal muscles that requires energy expenditure.1 Physical Inactivity identified as the fourth leading risk factor for global mortality (6% of deaths globally), estimated to be the key cause for 21–25% of breast and colon cancers, 27% of diabetes and around 30% of ischaemic heart disease burden,1–3 is a global pandemic contributing to substantial disease4 and economic burden5 worldwide. The issue is societal affecting all age groups,6 requiring interventions that are population-based, multi-sectoral, multi-disciplinary and culturally sensitive.

WHO has launched a global action plan to reduce physical inactivity by a relative 10% by 2025, and 15% by 2030, with a stress on the need for “urban planning and transport policies to improve the accessibility, acceptability and safety of, and supportive infrastructure for, walking and cycling,” and to ensure, “the creation and preservation of built environments with a particular focus on providing infrastructure to support active commuting.”

Total PA (leisure-time, occupational, housework, and transport-related activity) is affected by a wide range of factors including individual, family, community, neighbourhood and physical environment, with the physical or built environment (BE) providing cues and opportunities for the activity.

8 Inactivity rises with age, is higher in women than in men, and is increased in high-income countries. Community design influences human behaviour, as does design of the BE on the type of behaviour, PA and health outcomes associated through passive design,9–11 and active influences by providing opportunities that are accessible, convenient, safe and appealing,10,11 towards impedance or promotion of PA.

BE constructs are important but limited, and include neighbourhood barriers (lack of green spaces/parks, traffic, trash, crime, noise, gangs, prejudice, and drugs) and facilitators (walking distances, infrastructure for walking and biking, safety, aesthetics, recreation facilities, mixed use with shops and convenience stores nearby).

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Development of the international PA questionnaire (IPAQ) and work leading to the global PA questionnaire (GPAQ)13 provides the measurements to support monitoring and the inclusion of physical inactivity in risk factor surveillance systems.

The main theories used in PA research have been the health belief model, theory of planned behaviour, social cognitive theory, and the transtheoretical model. This paper will address walking, a common, accessible and inexpensive form of PA among adult populations in a neighbourhood scale; with interventions to increase population levels of walking to 150 min/week, the recommended guideline, through the lens of two established social theories; the Social Cognitive Theory and the Health Belief Model. The topic is significant as in addition to health benefits it improves mental well-being and quality of life.

The social cognitive theory (SCT) developed by Bandura explains behaviour in terms of reciprocal relationships between the person’s characteristics, behaviour and the environment, and the concept of self-efficacy (the confidence that a person feels about performing a particular activity, including confidence in overcoming the barriers to performing that behaviour) in understanding health behaviour; that it is not a simple linear relationship, the person and the environment influence each other. Outcome expectations play an important role in this theory: individuals learn that outcomes occur as a result of their behaviour, then expect them to occur again.

The BE consists of three dimensions: land use patterns, transportation system and design, with the first two being functional dimensions. Environmental factors include: destination, functional, aesthetic and safety. Factors that constrain or decrease PA include environmental stressors such as crowding, noise, traffic congestion, violence, crime etc., physical features, incivilities, information overload and distraction, excessive participation in sedentary activities; while restorative or stress-reducing features such as natural elements, water, foliage, vistas, recreational facilities such as parks, gyms, playgrounds, bike trails etc, social capital or cohesion among community members, electronic networks that disseminate information on health benefits promote PA.

The hypothesis is that adults who perceived the BE as more facilitative of PA, with fewer barriers, would report more PA. The proposed intervention is a 2 phase mixed methods research design that includes a feedback guided intervention development process for the target population, as studies show adults expressed need for more individualized program interventions. Phase 1 is formative research (focus groups) conducted on PA levels, PA barriers, including those related to the BE, and intervention preferences based on existing intervention materials. Phase 2 is a single arm, pre-post-test demonstration trial will then be conducted to vet the resulting theory-based individually tailored PA intervention with the target population with assessments at baseline, 1-month and 6 months.

The 7-day PAR interview will serve as the primary outcome measure25,26 as it provides an estimate of weekly min of PA, and is sensitive to changes in moderate intensity PA over time; the Neighbourhood Environment Walkability Scale (NEWS) will serve to assess the BE. Psychosocial assessments (processes of change, self-efficacy and perceived disadvantages, here BE barriers, to participating in physical activity) will be conducted to address self-efficacy and monitor achieved PA levels and change behaviour.

The health belief model (HBM) constructed by social psychologists Hochbaum, Rosenstock and Kegels, contains six key constructs that address why people will take an action or modify their behaviour to achieve a health benefit, what influences people’s decision in their health motivation behaviour: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. This model explains the relationship between socio-demographic, intrapersonal factors, and walking behaviour. Walking is an individual behaviour with an internal motive for people including being able to exert personal control; people’s behaviour is influenced through intrapersonal factors such as knowledge, attitudes, beliefs, and personality traits that are reflected by their surroundings, and found to be one of the important intervention strategies to increase walking behaviour.A past study on HBM and walking behavior30 showed ethnic differences between the groups for the different sets of constructs, with the health beliefs only explaining a part of the walking behaviour; but motivations and constraints were two main themes of influence, with the strongest relationship found between PA and self-efficacy.31

Interventions include a multi-dimensional approach through a framework for behaviour change (social support and self-efficacy), individualized goal setting, positive reinforcement, and management of risk motivation through knowledge and awareness on health benefits gained from walking through communication through media, government agencies, and non-government organizations with stories from the local community to serve as cues for action, including availability of programs that encourage walking (strongest cue to action). Constraints were perceived as limited free time, weather, safety, negative attitude towards walking and having a disability due to a health condition. Design of the BE can address some of the issues through community-scale and street-scale urban design to address weather and safety by providing street connectivity and linkages for respite from harsh weather, well-lit walkways, paths and signage that will encourage people to use them.

Conclusion

Design of urban environments has the potential to contribute nearly 90min/week of PA, which is 60% of the 150 min/week recommended in PA guidelines. While the individual is important, efforts beyond the health sector through social and environmental change is necessary for boosting healthy behaviour through PA. It is critical for public health proponents to collaborate with other sectors, including environmental groups, to promote PA supportive development to reduce energy consumption, greenhouse gas emissions and air pollution, while achieving health and economic benefits.9,11 societies that are more active demonstrate reduced use of fossil fuels, cleaner air and less congested, safer roads. outcomes that are interconnected with the shared goals, political priorities and ambition of the Sustainable Development Agenda 2030.

Strategies need to address scale of the development especially when we move to scales larger than a neighbourhood, as land use policies and transportation system are critical due to the association to walking and/or biking from home or work to other destinations.