This is an archive copy of a document originally located at http://www.nphp.gov.au/sigpah/gaa/index.htm. All copyright remains with the creator.
This chapter is concerned with equity issues in our approach to physical activity for special populations. Some people with chronic illnesses or with disabilities may benefit from physical activity but may find it difficult to access relevant and appropriate programs. People from a non-English-speaking cultural background and Indigenous Australians appear to be among the least active groups in the community. Specific community-developed approaches may be required to engage these population groups in the design and delivery of culturally-appropriate and relevant physical activity programs.
It is well established that several population groups are less likely to be adequately active for health benefit. These include people with chronic illness or disability and people from some non-English-speaking backgrounds (Taylor et al. 1998). There is some evidence to suggest that women may be less active than men at some life stages (see chapters 1.3 and 3.4, and Appendix 4). The aim of this chapter is to review the current Australian recommendations and initiatives for the promotion of physical activity among these groups with special needs.
Physical activity plays a role in both the prevention and management of many chronic illnesses, including cardiovascular disease, diabetes, lung disease, obesity, osteoporosis and some forms of arthritis (Carlson et al. 1999). Most of the research into the role of physical activity in the management of, and rehabilitation from, chronic illness has focused on heart disease.
Primary prevention studies have clearly identified the protective effects of regular physical activity for people with coronary artery disease. These include increased efficiency of oxygen extraction in skeletal muscles and reduced myocardial ischaemia (Schuler et al. 1992). The results of coronary angiography studies suggest that the minimum level of leisure time physical activity required to improve cardiorespiratory fitness in these patients is about 1400 kcal/week (or about 40 minutes walking daily for an 80-kg person) (Hambrecht et al. 1993). However, work by Hambrecht et al. suggests that considerably more activity, about 2200 kcals per week, is required to achieve regression of coronary artherosclerotic lesions - this equates with at least one hour of moderate-intensity walking exercise every day of each week. In this study, it was achieved by having patients exercise on a cycle ergometer six times a day for 10 minutes, and attend at least two one-hour group activity sessions each week (Hambrecht et al. 1993).
While regular physical activity is the central focus of many cardiac rehabilitation programs, most published studies are compromised by 'drop-out' and short periods of follow-up data collection. 'Drop-out' is a perpetual problem - 50 per cent of patients typically leave programs before the end of the first six months (Marcus et al. 2000). In a review of intervention studies that have included collection of follow-up data at least six months after the end of the intervention, Simons-Morton et al. (1998) located 14 studies involving cardiac rehabilitation patients. Factors associated with improved adherence were:
Two studies have shown very good longer-term maintenance. In the 'Treatment of mild hypertension study' (Elmer et al. 1995), 900 men and women were randomised to lifestyle plus placebo or drug treatment. The lifestyle intervention began with group sessions that were followed by newsletters, outings and competitions during follow-up. Increases in energy expenditure of over 50 per cent above baseline were maintained after four years of follow-up. In the MULTIFIT trial (MULTIFIT trial 1997), nurses provided education and counselling (for multiple risk factors) by mail and telephone. After 12 months, 71 per cent of the study group was still exercising an average of five times per week. More studies like these, with longer-term active maintenance strategies, are required.
In the NSW Health funded 'Heart moves' project, National Heat Foundation researchers are aiming to build partnerships between key stakeholders who have the opportunity or the responsibility to provide modified physical activity programs to individuals who have heart disease or risk factors for heart disease. Group programs are delivered by specially trained and accredited fitness leaders. They are designed specifically to be safe for people with, or at risk of, heart disease and diabetes, and to be acceptable to health professionals who are likely to refer 'at-risk' clients. The main outcome indicator in this project is a change in the proportion of 'at-risk' clients who participate in exercise classes in commercial fitness centres.
The term 'disability' refers to problems or difficulties experienced by a person as a result of a health condition. Most commonly these problems include locomotion, sensory and/or cognitive impairment. The International classification of impairment, disability and handicap (ICIDH, WHO 1999) defines disability at three levels:
For example, a child with spina bifida has structural impairment of the spinal cord, which may limit function in terms of the child's personal ability to walk, as well as participation in societal activities such as the local junior sports club.
In considering the promotion of physical activity for people with disabilities it is important to recognise the great diversity of health problems faced by this population group. Nevertheless, it is acknowledged that most people with disabilities will gain the same health benefits from physical activity as the general population (Heath and Fentem 1997). In general, however, people with disabilities have lower rates of participation than the able bodied population, and most perceive their disability to be a barrier to physical activity. People with disabilities who are physically active have lower rates of hospital admission and fewer secondary health complications, and there is evidence that physical activity may ameliorate some of the psychological sequelae associated with disability. Measures of independence and quality of life in this group are also improved by participation in physical activity (Heath and Fentem 1997).
In relation to disability discrimination and duty of care, health promotion professionals must take all reasonable steps to ensure that services and facilities take account of the needs of people with disabilities. The Disability Discrimination Act 1992 (Commonwealth) aims to 'eliminate, as far as possible, discrimination against persons on the grounds of disability, in the areas of work, accommodation, education, access to premises, clubs and sport' (DDA 1992). This has clear implications for health promotion programming. In addition, in all cases where a service provider has a duty of care, all reasonable steps must be taken to ensure the safety of the participants. People with disabilities may be more vulnerable to injury if they have a specific, relative or absolute contraindication to physical activity resulting from their disability, or if they are less able to understand safety instructions as a result of their disability. Consequently, practitioners should ensure that they establish a risk management plan which incorporates appropriate pre-participation screening tools. If in doubt, seek specialist advice from healthcare providers who are familiar with the needs and activity limitations of specific disabilities.
In the United States, the 'Strong for life' program in Boston has found that home-based resistance exercise programs show promise as an effective public health strategy for people with disabilities (Jette et al. 1999). Participants in this program followed a home-based, video-taped exercise routine, with elastic bands for resistance training. There were modest improvements in strength, balance, and mobility among older people with a disability (Jette et al. 1999).
A home-based approach is particularly attractive for this group, who often face difficulties with access and transport, as well as psychological barriers to exercise (King et al. 1994).
There appear to have been few population-based strategies to encourage Australian people with disabilities to be more physically active. The Australian Sports Commission and relevant State-based lead agencies provide information and programs for people with disabilities, as well as information about educational opportunities for encouraging participation, such as 'Willing & able' and 'Coaching athletes with disabilities.' States' and Territories' departments of sport and recreation and local government offices may also have strategies (including financial incentives) to encourage community groups and sporting bodies to cater for people with disabilities.
There is a need for more research into the development of physical activity measures, and the role of physical activity in the maintenance of function and independence among people with disabilities. There is also a need for improved understanding of the environmental and social barriers to physical activity, and the feasibility and efficacy of activity promotion for this population group.
The available data suggest that Australians from some non-English-speaking backgrounds have consistently lower levels of self-reported physical activity than their Australian-born counterparts. These population groups have been the focus of health promotion action in the last decade. For example, in Central Sydney, the 'Andiamo' project aimed to encourage activity among Italo-Australians and preliminary data suggest that there were changes in intention to exercise (Health Promotion Unit, Central Sydney Area Health Service 1999). In Western Sydney, there is an ongoing project with migrants from Croatia - 'Get up, have a go, and be active' (Blacktown, WSAHS) - and in South Eastern Sydney, health workers are collaborating with TAFE to develop bilingual, bi-cultural fitness leader training, and to evaluate the success of classes for older, non-English-speaking people. In many areas, culturally specific program development is required, for example to preserve cultural values and traditions. Physical activity programs may range from a segregated pool class for Muslim women, to programs that foster traditional dance and recreation, as a forms of energy expenditure.
In the Hunter region of NSW, women from Polish, Dutch, Greek and Macedonian backgrounds participated in a quasi-experimental study to evaluate the efficacy of a 12 week minimal intervention combined activity and nutrition program. Women in the intervention groups showed significant decreases in BMI and blood pressure, and improvement in fitness (Brown et al. 1996, Brown et al. 1997). This study has similar limitations to those described above - the samples were relatively small and the intervention and follow-up periods were short. Nevertheless, adherence and maintenance were greatest when programs were conducted by bilingual community educators in culturally appropriate and accessible venues, such as local church halls, and where there was strong community support for the initiative (Lee and Brown 1998).
The higher burden of illness due to chronic diseases in Indigenous communities is a cause for great concern. Higher rates of cardiovascular disease, diabetes, hypertension, and renal disease are particularly alarming and both diet and physical inactivity play a role in the aetiology of these problems (Mathers et al. 1999). Mass-media promotion campaigns may be of little benefit in remote communities because of limited communication technology and, possibly inappropriate language and messages.
There have been few carefully evaluated intervention studies in Aboriginal communities, but, as is the case for people from other culturally diverse backgrounds, there is some evidence that strategies are more likely to be effective when local communities are responsible for their development, implementation and direction (Simmons et al. 1997). The Looma Healthy Lifestyle Programme in the Kimberley region of Northwest Australia has developed during the period since 1994, and is using multiple interventions including participation in sports and walking groups, as well as several innovative dietary change strategies, to promote changes in risk factors for diabetes. This program shows promise in terms of sustainability and long-term increases in physical activity over time (White et al. 1997).
Other interventions in Indigenous populations include youth sport programs, particularly in rural communities, which have engaged Indigenous youth. A range of similar programs is offered throughout Australia by the Australian Sports Commission and States' and Territories' departments of sport and recreation. Despite these initiatives, few evaluations have been carried out, and the recommended 'best practice' programs, using evidence-based approaches, remain difficult to define.
'Populations with special needs' is a term used in this report to define a broad range of population groups. While population data can be used to describe physical activity patterns in these special groups, there is little scientific evidence of effective interventions for promoting physical activity among these groups. An equity approach to physical activity would require that such evidence be accumulated. Most of the available research has focused on small convenience samples, and most studies have been descriptive. Research and evaluation resources should be provided to better define 'best practice' programs for special populations.
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Brown WJ, Lee C, Nasstasia YN. (1997). Heart health for migrant women: a short intervention with Macedonian Australian women. Health Promotion Journal of Australia 7(2):134-37.
Carlson JE, Ostir GV, Black SA, et al. (1999). Disability in older adults 2: physical activity as prevention. Behavioral Medicine 24 (4):157-78.
Disability Discrimination Act 1992 (Commonwealth) (DDA), http://www.austlii.edu.au/do/disp.pl/au/legis/cth/consol_act/dda1992264
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White GA, Skinner K, Skinner M, et al. (1997). A community based intervention program for the prevention and treatment of obesity and diabetes in Aboriginal people - the Looma Diabetes program. Proc 4th National Rural Health Conference. Perth: National Rural Health Alliance, pp 653-7.
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Next: Part 3 (cont.) - 3.6 Social disadvantage and inactivity
Previous: Part 3 - 3.4 Older people
This is an archive copy of a document originally located at http://www.nphp.gov.au/sigpah/gaa/index.htm. All copyright remains with the creator.
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