Building a Public Health Infrastructure for Physical Activity Promotion

Physical inactivity is an important contributor to most of the leading chronic diseases and an independent primary risk factor for cardiovascular diseases, similar to smoking and hyperlipidemia in importance.¹ Physical inactivity also contributes to the risk of obesity,² type 2 diabetes,^3,4 osteoporosis,⁵ breast and colon cancer,^6,7 and other chronic physical and mental health problems.8 At least 200,000 deaths in the United States⁹ and 2 million deaths worldwide¹⁰ each year can be attributed to inactive lifestyles. Inactivity-related US health care costs have been estimated at $78 billion or more annually.¹¹ 

Healthy People 2010 sets 15 objectives for physical activity and identifies it as a leading health indicator.¹² However, the majority of US adults and children do not meet federal recommendations for regular physical activity.^2,8 Certain sociodemographic characteristics are associated with particularly low prevalence of sufficient physical activity: female gender, older age, lower socioeconomic status, and racial/ethnic minority background.⁸ Indeed, physical inactivity has become so prevalent1^3,14 that the costs imposed on society by people with sedentary lifestyles may be greater than those imposed by smokers and heavy drinkers and are similar to those imposed by overweight and obesity.^15–19 Regular activity, compared with sedentary status, even in late middle age, is linked to substantially decreased health care costs^20,21 and may ameliorate the adverse health consequences of less severe levels of obesity.^22–24 

Despite widespread understanding by health professionals and the lay public of the importance of physical activity for health, there is little indication the situation is improving. Leisure time physical activity (PA) levels have remained fairly constant since 1985,²⁵ but walking for transportation has declined substantially since the 1970s.²⁶ Thus, current public health efforts to promote physical activity have not been effective, which is in part due to the lack of a public health infrastructure needed to plan and implement effective physical activity promotion.

The cornerstone of health promotion, embodied in successful tobacco control policy efforts led by public health professionals, is making the healthy choices the easy choices^27–29 and the unhealthy choices increasingly difficult. Consistent with its roots and its Institute of Medicine-defined (IOM) role of ensuring the conditions necessary for good health,³⁰ US public health is appropriately positioned to take the lead in instigating the structural change necessary to restore adequate population levels of physical activity. 

Several conditions have been met that generally precipitate government intervention to change personal behavior. First, there is evidence of a “market failure,” that is, lack of rationality in making choices, stimulated in part by extensive marketing of products that lead to sedentary behavior (e.g., automobiles, TV viewing, computer games, spectator sports) and comparatively little marketing or promotion of products consistent with physical activity (e.g., health clubs, walking for exercise). Second, there are economic externalities, meaning production or use of sedentary entertainment- and transportation-imposed external costs on society.³¹ Third, there are inequities in distribution of public goods and services, for example, fewer recreational facilities and poorer sidewalk and park maintenance in low-resource communities.^32–35 Ethnic disparities in physical activity and chronic disease, linked to these adverse environmental conditions, provide another compelling impetus for public health leadership in this arena.^36,37 

Although the role of individual choice in and personal/familial responsibility for health-constructive behavior change is undisputed, individual motivation and effort to be physically active are increasingly difficult to sustain in a society characterized by a proliferation of step- and labor-saving devices, along with fragmented public transportation services, inadequately funded and poorly regulated school physical education, and aggressive and pervasive commercial marketing of sedentary entertainment and discretionary transportation.^38,39 Public health professionals and agencies need to become more engaged with these diverse sectors of society to find solutions to the public health problem of unhealthfully low physical activity levels. Changing environments by influencing organizational practice and legislation, while the emerging evidence base is promising, has yet to permeate health policy in a way that is likely to engage the majority of Americans in regular physical activity.^40–43 

One of the most successful and significant public health advances of the past 50 years has been tobacco control. There are many lessons from the strategies used to achieve today’s level of tobacco control that can be applied to physical activity promotion. Of the lessons described by Yach et al.,⁴⁴ several seem to be particularly applicable:

1. The more comprehensive the approach is, the more impact it is likely to have.
2. Multilevel interventions are needed that target changes in individuals, environments, and policies for optimal impact.
3. The public health community should be continually updated about the latest evidence concerning public health strategies shown to have an impact on community levels of physical activity.
4. Evidence-based programs should be fully implemented to make the most efficient use of resources.
5. Broad-based coalitions that unite all relevant partners and are present in every locale are critical to affecting the social norms that are a prerequisite to societal change.
6. Creative use of mass media, social marketing, and effective political leadership and advocacy are essential for ensuring widespread adoption of new, more healthful social norms.
7. Modest well-spent funds can be the leverage to substantial impact.

But who will advocate for and implement such complex and far-reaching intervention approaches? Again, the tobacco control movement provides both inspiration and data. ASSIST was a massive study in which 17 states were supported to change policy, environmental, economic, and cultural factors related to smoking, with statewide smoking changes compared with all other states.⁴⁵ Intervention states received modest funding to develop a tobacco control infrastructure and advocate for changes in access to minors, taxes, smoke-free environments, and tobacco counteradvertising. After 8 years, smoking prevalence and tobacco sales decreased more in ASSIST states, indicating populationwide behavior change. A key finding was that “strength of tobacco control” was the best predictor of statewide changes in smoking. Strength of tobacco control was an index of budget and personnel, staff experience, interagency relationships, strength of statewide coalitions, and percentage of effort focused on policy and environmental change. A critical lesson from the ASSIST experience is that “strength of physical activity promotion” needs to be developed in public health departments.⁴⁶

At present, a very limited public health infrastructure exists to promote physical activity.⁴⁷ Physical activity promotion did not explicitly appear among the core functions of public health until the introduction of the Health Security Act of 1993.⁴⁸ The establishment of a physical activity unit at the Centers for Disease Control and Prevention (CDC) in 1996 marked an elevation in priority, helping to legitimize parallel structural foci at state and local health departments. However, in public health departments, physical activity promotion has often been relegated to nutrition, tobacco control, or health education staff, with few additional resources and highly variable levels of interest or training. These staff members sometimes view physical activity promotion as competition for scarce resources. Each state health department has at least 1 staff member responsible for physical activity, but most are funded through the CDC. Very few dedicated positions exist in local health departments, and no professional or training standards have been developed for these positions. In a 1999 local public health agency infrastructure survey, respondents did not even identify an occupational classification for exercise scientists or physical activity promotion specialists, whereas an average of 3 to 5 full-time equivalent positions were reported in nutrition, occupational safety and health, policy analysis, and health education. Thus, the infrastructure for physical activity promotion is not proportionate to the public health burden of physical inactivity nor to the challenge of implementing interventions. The American Public Health Association (APHA) recognizes the need to build a public health infrastructure for physical activity promotion within academic institutions, local health departments, and community-based organizations that will implement more effective physical activity promotion to improve public health.

Several effective physical activity interventions that target individuals, social groups, communities, and built environments are recommended by the US Task Force on Community Preventive Services.⁴⁹ The effectiveness of building the public health infrastructure for physical activity promotion is unproven, but this goal is consistent with epidemiological and intervention evidence. Commercial industry stakeholders may argue that “push” strategies that emphasize environmental and policy change compromise individual freedom and could potentially harm some individuals more than they help them. However, a comprehensive public health approach would include efforts to motivate and educate individuals as well as strategies to change environments and policies so they support and facilitate choices to be physically active.

A particularly important arena for physical activity promotion in youth is school physical education (PE), which is a major system that can reach all youth for current and future physical activity. However, public health has limited involvement with the education sector about PE. There are evidence-based recommendations from CDC that need to be implemented more fully.

Therefore APHA—

1. Calls for support for the design and implementation of educational curricula, courses, training certificates, and degree programs in schools of public health to prepare practitioners and researchers to develop and appropriately utilize the evidence needed to increase population physical activity and to disseminate effective physical activity promotion approaches within the wide variety of fields relevant to physical activity policy and systems, for example, communications, organizational development and management, education, public policy, law, youth development, exercise science, urban planning, architecture, and public administration. Scholarships and other financial support mechanisms should be created for targeted recruitment of students and professionals from sociodemographic groups experiencing physical inactivity-related health disparities, such as from ethnic minority, low-income, and Southern regional and rural backgrounds.
   
2. Calls for courses or programs in physical activity promotion to be recommended (and eventually required) for accreditation for schools of public health.
3. preferably as an independently funded program area from nutrition but programmatically interdependent with nutrition.
4. Calls for small state taxes to be levied on sedentary-promoting products to fund state and local health departments’ physical activity intervention efforts and to support grassroots state and local policy advocacy.
5. Calls for federal food and nutrition agencies to provide resources for physical activity promotion.
6. Calls for efforts to engage private industry partners with business interests in increasing population physical activity levels, which may provide new product development, media exposure, dissemination venues, political support, and funding for physical activity interventions. 
7. Calls for efforts to improve collaboration with national and state education departments, school districts, and related organizations to improve the quantity and quality of school PE and widely implement evidence-based PE.

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