Dr Charlie FosterThe health of the nation – older,

sicker, fatter!

The effectiveness of physical activity promotion interventions- changing attitudes and environments

Dr Charlie Foster BHF Health Promotion Research GroupDepartment of Public HealthUniversity of Oxford

Fitness Industry Association Conference 2010

So what’s in FIA’s tool box?

Research evidenceCommunication & sales skills

Behaviourstrategies

Business Skills

Exercise promotion training, knowledge & skills

Toolbox

Advocacy & Policy placement

Outline• Physical activity basics• What is the EB for

promoting physical activity?• Attitudes• Environment• Community & Individual

• Limitations of evidence base• Other options• Conclusions

% active

Age

61% of men and 71% of women do not meet the Chief Medical Officer’s minimum recommendations for physical activity in adults

Men

Women

International consensus on health benefits of physical activity• Physical activity

can reduce the risk of:

– Cardiovascular disease– Hypertension– Obesity– Some forms of cancers– Non insulin-dependent

diabetes mellitus– Strokes – Osteoarthritis, by maintaining

normal muscle strength, joint structure and joint function

– Osteoporosis

– Cognitive function– Crime reduction and community

safety– Economic impact and

regeneration of communities– Education and lifelong learning– Psychological well-being– Self esteem– Management of anxiety and

depression– Social capital and community

cohesion– Drug misuse– Carbon use

(US Dept Health & Human Sciences, 1996; CMO, 2004; Sport England, 2009)

£14.85

£14.01

£17.20

£12.95

£14.85

£14.63

£13.94

£15.96

£18.71

£15.27

Cost of physical inactivity (£/population) related disease by SHA

Foster et al, 2009

£14.85

£14.01

£17.20

£12.95

£14.85

£14.63

£13.94

£15.96

£18.71

£15.27

Cost of physical inactivity (£/population) related disease by SHA

Spend in London is 85p per head

Foster et al, 2009

Physical activity and inequalities

• Physical activity choices are socially patterned

• Individual approaches to promote physical activity have the potential to increase inequalities

• Availability of physical activity facilities declines with level of area deprivation

The density of exercise facilities by quintile ofdeprivation for the county of Kent in Southeast England

Availability of physical activity facilities declines with

level of area deprivation

Attitudes• How are attitudes constructed?

– KAB

• What is a social norm?• Change4Life• Within families not within communities

– Increase the desirability of physical activity behaviour

– Decrease the desire to be sedentary– Change attitudes to behaviour or change

environment, • places acceptable for the behaviour• More acceptable, normal

MINDSPACE: Influencing behaviour through public policy was a joint commission by the Cabinet Office and the Institute for Government.   It shows how the latest insights from the science of behaviour change can be used to generate new and cost-effective solutions to some of the current major policy challenges, such as reducing crime, tackling obesity and climate change.

So what does affect our behaviour?

MINDSPACE. Influencing behaviour through public policy. Cabinet Office & Institute for Government, 2010.

Presentation Objectives

• Physical activity basicsPhysical activity basics• What is the EB for What is the EB for

promoting physical activity?promoting physical activity?• AttitudesAttitudes• Environment• Individual Individual

• Limitations of evidence baseLimitations of evidence base• Other optionsOther options• ConclusionsConclusions

The effectiveness of environmental change interventions to promote physical activity• NICE review – physical activity and environment

• Systematic reviews have also found some evidence to support the impact of large scale environmental changes on physical activity

• A combination of changes to working practices, policies and the physical environment encouraged adults to maintain their vigorous physical activity and fitness

• Active travel interventions must contain environmental supports to sustain individual choice (i.e. public transport)

Using the environment to promote active living

• Successful active travel interventions blend changes to places, people and policies

• European examples demonstrate what can be achieved in the long term

• NICE Physical activity and Environment public health guidance offers direction

The Cycling Demonstration Towns programme• First phase: October 2005

– October 2008

• All towns funded at approx £5 per head per year, matched by the local authority

• Comprehensive evaluation

CityAnnual

increase in cycling flows

Darlington +14.2%

Exeter +9.9%

Brighton & Hove +9.0%Strasbourg +7.0%

Lanc w Morecambe +6.2%Vienna +6.4%

Graz +5.9%

Munich +5.5%

Hanover +5.4%

Annual growth rates: European cities and CDTs

Adapted from: Transport for London (2004) ‘Creating a chain reaction. The London Cycling Action Plan. February 2004. (http://www.croydon-lcc.org.uk/downloads/2004_TfL_LondonCyclingActionPlan.pdf)

CityAnnual

increase in cycling flows

Nottingham +4.8%

Freiburg +4.4%

Munster +3.6%

Aylesbury +3.6%Berlin +3.2%

Derby +2.5%Zurich +2.3%

Delft +1.2%

The effectiveness of community-based approaches using person-focused techniques to promote physical activity

• community wide campaigns using person focused techniques– Sustained changes in physical activity up to

one year post intervention– those tailored to people’s needs– targeted at the most sedentary or at those most

motivated to change– delivered either at the level of the individual (brief

advice, supported use of pedometers, telecommunications) or household (individualised marketing) or through groups

– Interventions which provide people with professional guidance about starting an exercise programme and then provide on going support

The findings of this review indicate that professional advice and guidance with continued support can encourage people to be more

physically active in the short to mid-term.

Estimated net increase in walking in general by validity and then sample size

Ogilvie D, Foster C, Rothnie H, Cavill N, Hamilton V, Fitzsimons CF, Mutrie N. Scottish Physical Activity Research Collaboration. Interventions to promote walking: systematic review. BMJ 2007;334 (7605):1204;

The effectiveness of community-based approaches using person-focused techniques to promote physical activity• community wide campaigns using person focused

techniques– Sustained changes in physical activity up to

one year post intervention– those tailored to people’s needs– targeted at the most sedentary or at those most

motivated to change– delivered either at the level of the individual (brief

advice, supported use of pedometers, telecommunications) or household (individualised marketing) or through groups

– Interventions which provide people with professional guidance about starting an exercise programme and then provide on going support

Presentation Objectives

• Physical activity basicsPhysical activity basics• What is the EB for What is the EB for

promoting physical activity?promoting physical activity?• AttitudesAttitudes• EnvironmentEnvironment• Community & Individual Community & Individual

• Limitations of evidence base• Other optionsOther options• ConclusionsConclusions

Limitations of evidence base

• Measurement• Study design• Expense• Population sample• Applicability to the UK from international

work• Differential effects on different population

groups• Very little from the fitness industry

Other options

• Reducing sedentary behaviours• Provision of free swimming and/or free sports centre

access• Discounted or free public transport provision for

children or the elderly• The use of local authority regulatory, legislative and

policy guidance on physical activity promotion• The impact of combined programmes to tackle

healthy eating and physical activity together at a community level

• The recruitment of those in most need to participate in community based physical activity programmes

• YMCA Activate England, Walking For Health Initiative, Sport Action Zones, Positive Futures

Social-ecological model of physical activity behaviour

Foster et al (2005). Understanding why adults and children participate in physical activity and sport. London, Sport England.

Law & Regulations

Fiscal

Built environment

Natural environment

Health care systems

National policies & programmes

Conclusions

• Evidence base does suffer limitations (maturity) but it offers a direction of travel

• Evidence to support smaller more individually focused activities rather than larger scale community interventions

• Recommend multiple level interventions– Environment, legislation, fiscal, policy

approaches– Support individual approaches as part of RF

prevention and management• Populate our list of options

Public Health White Paper Late 2010• Local authorities, who will employ the Director of

Public Health

• Public Health Service in place, with ring-fenced budget and local health improvement led by Directors of Public Health in local authorities– Budget allocated to reflect relative population health

outcomes, with a new health premium to promote action to reduce health inequalities.

• NICE put on a firmer statutory footing • Health and Wellbeing boards (2012)

Conclusions

• New and interesting times for physical activity promoters

• Partnerships with industry– workplace

• Partnerships with LAs• Partnership with new

NHS – Primary care fund holders