Using qualitative methods to challenge public health policy discourse:

Physical activity, noncommunicable disease and wellbeing in a South African township

Emer Brangan Centre for Development Studies, University of Bath /

School of Social and Community Medicine, University of Bristol

e.brangan@bristol.ac.uk

“I think that the only effective way of fighting against national and international technocracy is by confronting it on its own preferred terrain….and putting forward, in place of the abstract and limited knowledge which it regards as enough, a knowledge more respectful of human beings and of the realities that confront them” (Bourdieu 1998: 27-28).

What I’m going to talk about

Research background & panel aim

Methods

Some results– Concepts of physical activity

– Relationship between physical activity, and health and wellbeing

– Inactivity and its consequences

Discussion

Research background

NCDs: Cardiovascular diseases, diabetes, cancers and chronic respiratory diseases

4 out of 5 deaths from NCDs are in low and middle income countries (WHO 2008)

4 shared risk factors — tobacco use, physical inactivity, unhealthy diets and the harmful use of alcohol (WHO 2007)

Research overwhelmingly based in high income countries, and using quantitative methods

Today’s panel

Ultimate aim:

– “to advance the use of qualitative methods in the assessment of public policy” (White & Thin 2012)

Illustrate potential contributions to policy:– Providing new knowledge

– Engagement with key stakeholders

What I did

Ideas about physical activity and inactivity, and their relationship with wellbeingThematic analysis of two sets of data:

i) Ethnographic research in Langa township

ii) WHO policy literature on the prevention of NCDs in low and middle income countries

Why qualitative research using a wellbeing framework?

– Exploratory

– Gaps

– Engagement

Concepts of physical activity – WHO policy documents

“Lifestyle factor”, “Risk factor”, “Health behaviour”

Term “exercise” sometimes used interchangeably

Types – aerobic, strength, flexibility, balance

Domains – recreational / leisure-time, transportation, occupational, household chores, play, games, sports or planned exercise

Dimensions – frequency, intensity, volume

Concepts of physical activity – Langa respondents

Going to the gym or whatever but I don’t do that because I am active in my own house; I clean my house and I do that so... That is my training. (Cebisa*, 57 year old female)

I can say that it is being busy all the time; doing anything to help keep your blood circulating. I can say that it is exercising. (Mnyamezeli, 51 year old male)

It means that the person is not lazy, like all the time the person feels her body and you are coping, the mood that you are in. (Zimkhitha, 37 year old female)

Being physically active means that you can do things on your own, without being assisted by anyone. (Unathi, 59 year old female)

* Note: All names have been changed

Health from, or for, physical activity?

Physical activity is a fundamental means of improving the

physical and mental health of individuals (WHO 2004)

When adults of this age group cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow (WHO 2010)

Health from, or for, physical activity?

My health is pulling me back. (Nkosazana, 39 year old female)

I cannot go outside the house. If I go outside the house, the sun burns this metal and that is not good. I do not go out of the house; I have to stay inside the house. (Mangaliso, 61 year old male)

Someone told me that I can see there isn’t a light job there because I could not walk very fast; I would have a short breath. (Mandisa, 69 year old female)

Now I am recycling empty bottles but I am struggling with that because I have to lift up the bottles and my body is not good. (Lubabalo, 41 year old male)

Cost / benefit analysis?

Possible costs:

Overall, the benefits of being physically active and implementing the above recommendations outweigh the harms. Activity-related adverse events such as musculoskeletal injuries are common but are usually mild (WHO 2010)

Ensure that walking, cycling and other forms of physical activity are accessible and safe (WHO 2004)

In the literature reviewed, only minimal information was available on the unintended impact of [physical activity] interventions. (WHO 2009)

Cost / benefit analysis

Unpleasant feelings: Hunger, fatigue and pain

Benefit: Physical activity is a key determinant of energy expenditure, and thus is fundamental to energy balance and weight control. (WHO 2004: 4)

Cost: The only thing you do there is to play and at the end of the day you go to sleep hungry. Playing is just a waste of time because you have to have something to eat; how can you play with an empty stomach? (Sandile, 47 year old male)

Feeling good

I walk, I love walking so that I do not sit down for a long time (Luxolo, 57 year old male)

Cost / benefit analysis?

Cost: Risk from crime and violence

Benefit: Preventing crime and violence

Cost: Time and money

Benefit: Earning or saving money

Cost? Behaving appropriately

– Age, gender, race and size

It’s so weird – my Mum in a tracksuit, running, people would think ‘what is she taking? Is she ok?’ [Laughs] It’s so bizarre. It’s just one of those things. You don’t actually see it in our community. (Key informant working in health)

Cost / benefit analysis?

Benefit: Forgetting troubles

At the same time, keeping myself active helps me to forget the things that happened to me. When I am not exercising, everything becomes too much for my brain but when I am exercising, it becomes easier. (Malusi, 38 year old male)

Yes, exercising is very good and you should not stress yourself by thinking too much. You see now I am concentrating on this because I know that I must do this work. I forget about other things you see. (Nombeko, 55 year old female)

Inactivity and its consequences

Engaging in less than 30 minutes of moderate activity five times per week or less than 20 minutes of vigorous activity three times per week, or the equivalent. (WHO 2010/2011)

…provide leadership in combating physical inactivity (WHO 2007)

…elimination of these modifiable risk factors (WHO 2009)

…by means of essential public health action and health-promoting and disease preventing measures (WHO 2004)

Physical inactivity has been identified as the fourth leading risk factor for global mortality (6% of deaths globally). (WHO 2010)

Just sitting

The opposite of being active

I: Are they keeping themselves active and healthy?

R: No they do not that; the ones that I know are just sitting. They are not doing anything. (Vuyani, 60 year old male, speaking about people in Langa)

Being unemployed

And then I stopped working, I didn’t want to sit around and I was wondering why I got asthma at such an age, my children were young, what was I going to do? …they were sleeping on the floor, the house is small and there was no fresh air, I would sit outside and weep. (Mandisa, 69 year old female)

Just sitting

We sit in the house and stare at each other.(Thandiwe, 46 year old female, unemployed after an accident at work and talking about how she spends her day with her sister.)

If you just sit here in the township, you will not get anything. (Malusi, 38 year old male)

Being physically active is also good for your health, because if you are always sitting at one place, you get sick. But if you keep yourself busy, you don’t sit around and think…when you are doing nothing you think a lot and that adds to your stress. (Boniswa, 43 year old female)

We need things to keep people away from just sitting at home or in the shebeen and standing in corners, you see. (Thembani, 43 year old male)

Discussion

Epistemology

– Search for more complete forms of evidence, and Bourdieu’s “more respectful” knowledge

Setting objectives for public policy

The nature of engagement

References (only those directly quoted)

Bourdieu, P. (1998). Acts of resistance: against the new myths of our time. Cambridge, Polity press.

White, S. and Thin, N. (2012). "Happiness and wellbeing: Going to scale – integrating qualitative methods in wellbeing and happiness assessment." from http://www.devstud.org.uk/wellbeing_and_the_psychosocial_in_international_development-137.html.

WHO (2004). Global strategy on diet and physical activity. Geneva, World Health Organisation

WHO (2007). Guide for population based approaches to increasing physical activity. Geneva, World Health Organisation.

WHO (2008). Review of best practice in interventions to promote physical activity in developing countries. Geneva, World Health Organisation.

WHO (2009). Intervention on diet and physical activity: What works. Geneva, World Health Organisation.

WHO (2010). Global recommendations on physical activity for health. Geneva, World Health Organisation.