Promotion of physical activity guidelines and behavior change

J Phys Fitness Sports Med, 4(1): 9-15 (2015)DOI: 10.7600/jpfsm.4.9

JPFSM: Review Article

Promotion of physical activity guidelines and behavior changeKazuhiro Harada1* and Yoshio Nakamura2

Received: December 20, 2014 / Accepted: January 22, 2015

Abstract Physical activity guidelines have been published by governments to increase physical activity at a national level. Such guidelines commonly include behavior change techniques. To allow guidelines to contribute to physical activity promotion, it is necessary to enhance peo-ple’s awareness of these physical activity guidelines. The present article reviews trends regard-ing studies on the prevalence and socio-demographic correlates of the awareness of physical activity guidelines, and on the relationship between the awareness of guidelines and physical activity behavior change. Compared with the awareness of physical activity guidelines in Can-ada (20.7-37.3%) and the United States (32.0-36.1%), awareness of physical activity guidelines was less prevalent in Japan (6.1-12.3%). More intensive campaigns promoting physical activ-ity guidelines are necessary in Japan. Regardless of country, those with higher socioeconomic status (higher educational background or household income level) were more likely to be aware of physical activity guidelines. Promotion campaigns targeting those with low socioeconomic status are needed to reduce inequalities in the awareness level of such guidelines. Positive relationships between guideline awareness and physical activity levels have been reported in cross-sectional studies. However, longitudinal studies have not revealed any such positive re-lationships. Moreover, intervention studies have failed to show any effects of the guidelines on physical activity behavior change. Thus, the awareness of physical activity guidelines appears to have limited influence on physical activity behavior change. Unlike physical activity guide-lines, the promotion of Japanese dietary guidelines has been successful in increasing healthy eating behaviors in Japanese adults.Keywords : health communication, health policy, information dissemination, health promotion,

awareness, physical activity

Introduction

The health benefits of physical activity are now well known. Physical inactivity increases the risk of major non-communicable diseases and causes 9% of premature mortality1). Nevertheless, on a global scale, one-third of adults are physically inactive2). In Japan, the Ministry of Health, Labour and Welfare reviewed epidemiological studies of the relationships between physical activity and health outcomes. Based on the review, the Ministry3,4) rec-ommends that Japanese adults should undergo at least 23 METs (metabolic equivalents)-hours of physical activity per week for health promotion. However, only 26.6% of Japanese adults met this recommended physical activity level in 20075), and the amount of physical activity among Japanese adults has decreased over time from a peak around 1998–20006). Thus, physical activity promotion is a public health priority7). The governments of some countries have published

guidelines to increase physical activity at a national level. In Canada, the Public Health Agency of Canada pub-lished Canada’s Physical Activity Guide to Healthy Active Living in 19988), and new guidelines were published in 20119). In the United States, Physical Activity and Health: a report of the Surgeon General10) was released in 1997, and the 2008 Physical Activity Guide for Americans11) was released in 2008. Make your move – Sit less – Be ac-tive for life!12) outlines the current physical activity guide-lines in Australia, and Start Active, Stay Active13) is the equivalent in the United Kingdom. In Japan, the Ministry of Health, Labour and Welfare published the Exercise and Physical Activity Guide for Health Promotion 200614) in 2006 and the Active Guide - Japanese Official Physical Activity Guidelines for Health Promotion15) in 2013. Notably, common physical activity guidelines explain behavior change techniques as well as the health benefits and recommended level of physical activity. For example, the Exercise and Physical Activity Guide for Health Pro-motion 200614) includes information about goal setting, self-monitoring, and self-evaluation. Similarly, the 2008 *Correspondence: [email protected]

1 Section for Motor Function Activation, National Center for Geriatrics and Gerontology, 35 Gengo, Morioka, Obu, Aichi 474-8511, Japan

2 Faculty of Sport Sciences, Waseda University, 2-579-15 Mikajima, Tokorozawa, Saitama 359-1192, Japan

10 JPFSM : Harada K and Nakamura Y

Physical Activity Guide for Americans recommends goal setting and using social support to increase physical activ-ity levels11). Make your move – Sit less be active for life!12) provides information about the action planning of physi-cal activity. To allow such guidelines to contribute to the promotion of physical activity, it is necessary to enhance people’s awareness of physical activity guidelines. According to the impact model of communication campaigns for pro-moting physical activity16), communication campaigns initially increase the awareness of campaign elements, and then awareness has an influence on physical activity behavior, mediated by psychological factors (e.g., knowl-edge and attitude). Previous studies have employed this model16) to evaluate the effects of physical activity cam-paigns on behavior change (e.g., the VERB campaign17) and the COMMUNICATE study18)). Fig. 1 shows the impact model of the promotion of physical activity guide-lines on physical activity behavior change, modified from Cavill & Bauman16). The effects of promotion of physical activity guidelines can be evaluated by 1) who and how many people become aware of physical activity and 2) whether the awareness of physical activity guidelines lead to changes in physical activity behavior. Although previ-ous studies have evaluated the effects of the promotion of physical activity guidelines, no review articles are avail-able on this topic. It would be useful to have an overview of the effects of the promotion of physical activity guide-lines on physical activity behavior change. The present article looked at trends regarding studies on the prevalence and socio-demographic correlates of the awareness of physical activity guidelines, and on the

relationship between the awareness of physical activity guidelines and physical activity behavior change.

Prevalence of awareness of physical activity guidelines

Increasing the awareness of physical activity guidelines is the initial outcome of the promotion of the guidelines. Previous studies have examined how many people were aware of physical activity guidelines in each country (Table 1). As shown in Table 1, compared with the aware-ness of physical activity guidelines in Canada (20.7-37.3%19,23,24)) and in the United States (32.0-36.1%21,22)),

Awareness of physical activity guidelines

Physical activity behavior change

Knowledge

Belief/attitude

Promotion of physical activity guidelines

Fig. 1 Impact model for promotion of physical activity guide-lines and behavior change (modified from Cavill & Bau-man16).

Author(s) Year Country Guidelines Participants Prevalence of

awareness

Cameron et al.19 2007 Canada Canada’s Physical Activity Guide 8892 adults 37.3%

Harada et al.20 2009 Japan Exercise and Physical Activity Guide for

Health Promotion 2006

1613 adults 12.3%

Kay et al.21 2014 United States 2008 Physical Activity Guide for

Americans

4281 adults 36.1%

Morrow et al. 22 1999 United States Physical Activity and Public Health: a

report of the Surgeon General

2002 adults 32%

Plotnikoff et al.23 2011 Canada Canada’s Physical Activity Guide 2803 adults 27.3%

Spence et al.24 2002 Canada Canada’s Physical Activity Guide 2719 adults 20.7%

Tsuji et al.25 2014 Japan Active Guide 1800 adults 6.1%

Table 1. Prevalence of awareness of physical activity guidelines

11JPFSM : Promotion of physical activity guidelines and behavior change

the prevalence of awareness of physical activity guide-lines was lower in Japan (6.1-12.3%20,25)). Therefore, more intensive campaigns promoting physical activity guidelines are necessary in Japan. In Canada, three studies19,23,24) have reported the preva-lence of awareness of Canadian physical activity guide-lines (Canada’s Physical Activity Guide to Healthy Ac-tive Living8) published in 1998). Spence et al.24) revealed that among 2719 respondents of a mailed questionnaire, 20.7% were aware of the guidelines. Plotnikoff et al.23) also targeted randomly-sampled people living in Alberta. Among 2803 respondents of a telephone survey, the prevalence of awareness was 27.3%23). Cameron et al.19) examined a nationally and provincially representative sample. They used the data (n = 8892) from the 2003 Physical Activity Monitor survey, and showed that 37.3% of respondents were aware of the guidelines. In the United States, Morrow et al.22) investigated the prevalence of awareness of Physical Activity and Health: a report of the Surgeon General10) published in 1996. Morrow et al.22) conducted a national telephone survey targeting randomly-sampled American adults in 1997. Of 2002 respondents, 36.1% were aware of this report10). To examine the awareness of the 2008 Physical Activity Guide for Americans11) Kay et al.21) analyzed the data of HealthStyles, which is an annual consumer mail-panel survey that targets a nationally representative sample in the United States. Of the available 4281 respondents, 36.1% were aware of the 2008 Physical Activity Guide for Americans11). In Japan, the Exercise and Physical Activity Guide for Health Promotion 200614) was released by the Ministry of Health, Labour and Welfare in 2006. In the year follow-ing its release, Harada et al.20) examined the prevalence of awareness of the guidelines using a web-based survey. Among 5667 potential respondents, 1613 were analyzed by Harada et al.20) The results showed that 12.3% of re-

spondents were aware of the guidelines. After publication of Active Guide15), Tsuji et al.25) conducted a telephone survey on 1800 adults by using the random digit dialing method. Tsuji et al.25) found that the prevalence of aware-ness of Active Guide15) was 6.1%. Additionally, some previous studies have examined how many people accurately know the recommended level of physical activity. In the United States, previous stud-ies revealed that 25.6%26) to 33.0%27) of adults knew the accurate duration and frequency of moderate-intensity physical activity recommendations. A study28) in the United Kingdom also showed that the rates of those who accurately knew the recommended level of physical activ-ity were 11.0% in 2007 and 18.0% in 2013 (not shown in Table 1).

Socio-demographic correlates of awareness of physical activity guidelines

Identifying the socio-demographic correlates of the awareness of physical activity guidelines is helpful when considering what kinds of subpopulations should be tar-geted to promote physical activity guidelines. As shown in Table 2, previous studies19-25) have investigated the so-cio-demographic characteristics of those with awareness of physical activity guidelines. In particular, regardless of country, higher socioeconomic status (educational back-ground or household income) has been repeatedly iden-tified as a correlate of awareness19-24). Thus, promotion campaigns targeting those with low socioeconomic status are needed to reduce the inequality of awareness level of physical activity guidelines. In Canada, all studies19,23,24) have consistently reported that higher educational background and gender (women) were socio-demographic correlates of the awareness of Canada’s Physical Activity Guide to Healthy Active Liv-ing8). Cameron et al.19) and Spence et al.24) also revealed

+: positively associated with awareness of guidelines–: negatively associated with awareness of guidelines0: not significantly associated with awareness of guidelines

Table 2. Socio-demographic correlates of awareness of physical activity guidelines

Cameron et al.19

(Canada)

Harada et al.20

(Japan)

Kay et al.21

(the United States)

Morrow et al.22

(the United States)

Plotnikoff et al.23

(Canada)

Spence et al.24

(Canada)

Tsuji et al.25

(Japan)

Age (older) 0 + + + ‒ 0 0

Gender (women) + 0 + 0 + + 0

Higher education + 0 + + + +

Higher household income + + + 0

Race/ethnicity (white) + + 0

Living in large community ‒

Awareness of other guidelines +


that ethnicity was not significantly associated with aware-ness. Further, Cameron et al.19) reported that community size was related to awareness. While Cameron et al.19) found a significant relationship between awareness and household income, Spence et al.24) found no significant relationship. Regarding age, Plotnikoff et al.23) found that younger adults were more likely to be aware of the guidelines. However, two other studies19,24) did not find a significant relationship between age and awareness. In the United States, Kay et al.21) examined the socio-demographic correlates of awareness of the 2008 Physi-cal Activity Guide for Americans11), and Morrow et al.22) examined that of Physical Activity and Health: a report of the Surgeon General10). Both studies21,22) revealed that older adults, those with higher education, and those who were white tended to be more aware of physical activ-ity guidelines. Kay et al.21) also reported a significant relationship between higher household income and the awareness of the guidelines. For gender, Kay et al.21) showed that women were more likely to be aware of the guidelines. However, Morrow et al.22) did not find gender differences in the awareness of the guidelines. In Japan, Harada et al.20) examined the socio-demo-graphic correlates of awareness of the Exercise and Phys-ical Activity Guide for Health Promotion 200614). Harada et al.20) found that older age, higher household income, and awareness of other guidelines were associated with awareness. Although Tsuji et al.25) examined the effects of age and gender on the awareness of the Activity Guide15), significant relationships were not found. Additionally, socio-demographic correlates of accurate knowledge of recommended physical activity level were also examined. In the United States, older adults27), wom-en26,27), those in employment27), foreign-born individu-als27), married people26), those with a higher educational background26), and non-black people26) were more likely to accurately know the recommended physical activity level. Knox28) showed that marital status, gender, age, education and employment status were associated with accurate knowledge in the United Kingdom (not shown in Table 2).

Relationship between awareness of physical activity guidelines and physical activity

Table 3 shows a summary of previous studies examin-ing whether the awareness of physical activity guidelines leads to physical activity behavior change. Positive rela-tionships between awareness of the guidelines and physi-cal activity levels have been reported in cross-sectional studies19,23,29,30). However, longitudinal studies23,30) have not revealed positive relationships, and intervention stud-ies31,32) have failed to show any effects of providing the guidelines on physical activity behavior change. Thus, the awareness of physical activity guidelines appears to have limited influence on physical activity behavior change.

Analyzing the cross-sectional data of a telephone inter-view (n = 8892), Cameron et al.19) revealed that awareness (unprompted recall) of Canada’s Physical Activity Guide to Healthy Active Living8) was positively associated with physical activity. Higo et al.30) conducted a cross-sectional web-based survey on 1436 adults and revealed that those with awareness of the Exercise and Physical Activity Guide for Health Promotion 200614) were more likely to have walking habits (self-reported ≥ 10000 steps per day) than those without awareness of it. Harada et al.29) and Plotnkikoff et al.23) examined the longitudinal relationship between the awareness of physi-cal activity guidelines and physical activity. Harada et al.29) analyzed the data of 1100 adults and completed both baseline and follow-up (13 months later) web-based sur-veys. At baseline, awareness of the Exercise and Physical Activity Guide for Health Promotion 200614) was posi-tively associated with physical activity29). However, in longitudinal examinations, a positive relationship between awareness of the guidelines and physical activity was not found (Fig. 2)29). From a telephone survey, Plotnkikoff et al.23) showed similar results to Harada et al.29) Plotnkikoff et al.23) revealed that those with awareness of Canada’s Physical Activity Guide to Healthy Active Living8) tended to be physically active at baseline, but that awareness of it was not significantly associated with a longitudinal change in physical activity. Two intervention studies31,32) have examined the effects of the distribution of physical activity guidelines. How-ever, neither study31,32) showed significant effects. Kliman and Rhodes31) allocated 130 randomly-sampled adults into an intervention or a control group. Canada’s Physical Ac-tivity Guide to Healthy Active Living8) was provided to the intervention group, and a post-test was implemented after 1 month. In the results, no effect of providing the guide-lines on physical activity was found31). Plotnkikoff et al.32) conducted a secondary analysis of the Physical Activity Workplace Study33). Long and short versions of Canada’s Physical Activity Guide to Healthy Active Living8) were provided to 202 adults at baseline and at 6 months, with a post-test carried out at 12 months. The results showed that participants did not significantly change their moderate or vigorous physical activity32).

Other health behaviors: Japanese dietary guidelines

As mentioned above, the effects of physical activity guidelines on behavior change are not supported in longi-tudinal or interventional studies23,29,31,32). However, unlike the case of physical activity guidelines, the effectiveness of promoting dietary guidelines on behavior change for healthy eating is better supported. Takaizumi et al.35) conducted a web-based longitudinal survey (n = 1012) to examine the longitudinal change of awareness of the Japanese Food Guide Spinning Top34). Takaizumi et al.35) revealed that 56.3% of respondents


were aware of it in 2007 and 60.4% were aware of it in 2008, and that the awareness of it increased particularly among those with health risk factors. Next, Takaizumi et al.36) conducted a follow-up survey to the participants of the baseline survey in Takaizumi et al.35) Then, changes in healthy eating behaviors were compared among three groups (group 1, aware of it in 2007; group 2, unaware of it in 2007 but had become aware by 2009; group 3, unaware of it in both 2007 and 2009). The results showed that healthy eating behaviors did not change from 2007 to 2009 in group 1 or group 3. In contrast, healthy eating be-haviors in group 2 were significantly improved from 2007 to 200936). Compared with the prevalence of the awareness of

physical activity guidelines in each country19-25), the prevalence of awareness of the Japanese Food Guide Spinning Top34) was remarkably higher35). This might be because the ministries implemented nation-wide promo-tion campaigns of the Japanese Food Guide Spinning Top34). Moreover, while the awareness of physical activity might not increase behavior change, a longitudinal study indicates that the awareness of the Japanese Food Guide Spinning Top34) does have an influence on healthy eat-ing behaviors35). Therefore, it can be concluded that the promotion of Japanese dietary guidelines has succeeded in increasing healthy eating behaviors among Japanese adults.

Table 3. Relationship between Awareness of Physical Activity Guidelines and Physical Activity

Author(s) Year Study design Country Guidelines Participants Procedures Findings

Cameron et

al.19

2007 Cross-sectional Canada Canada’s Physical

Activity Guide

8892 adults Telephone interview Both awareness (unprompted recall) of

guidelines and knowledge about

recommended level of physical activity were

positively associated with physical activity.

Harada et

al.29

2011 Longitudinal Japan Exercise and

Physical Activity

Guide for Health

Promotion 2006

1100 adults

completed

both baseline

and follow-up

survey

Web-based survey at

baseline and 13

months later

At baseline, awareness of guidelines was


However, a positive longitudinal relationship

between awareness of guidelines and physical

activity was not found.

Higo &

Nakamura30

2008 Cross-sectional Japan Exercise and

Physical Activity

Guide for Health

Promotion 2006

1436 adults Web-based survey Awareness of guidelines was positively

associated with walking habits.

Kliman &

Rhodes31

2008 Randomized

experimental

design

Canada Canada’s Physical

Activity Guide

130 adults Intervention group:

providing the

guidelines

Control group: not

providing

An effect of providing the guidelines on

physical activity was not found.

Plotnkikoff

et al.23

2011 Longitudinal Canada Canada’s Physical

Activity Guide

2803 adults at

baseline, of

which 1423

completed

follow-up

Telephone interview at

baseline and 1 year

later

At baseline, awareness of guidelines was


However, awareness of guidelines was not

significantly associated with longitudinal

change of physical activity.

Plotnkikoff

et al.32

2012 Single-arm

analysis

Canada Canada’s Physical

Activity Guide

202 adults Participants received

the guidelines at

baseline and 6 months

later

An effect of providing the guidelines on

moderate or vigorous physical activity was not

found.


Conclusions

Compared with the awareness of physical activ-ity guidelines in Canada (20.7-37.3%19,23,24)) and in the United States (32.0-36.1%21,22)), the prevalence of aware-ness of physical activity guidelines was lower in Japan (6.1-12.3%20,25)). Regardless of country, those with higher socioeconomic status (higher educational background or household income level) were more likely to be aware of physical activity guidelines19-24). Positive relationships between awareness of the guidelines and physical activity level have been reported in cross-sectional studies. How-ever, according to longitudinal and interventional studies, the awareness of physical activity guidelines has limited influence on physical activity behavior change. Unlike the case of physical activity guidelines, the promotion of Japanese dietary guidelines is successful in increasing healthy eating behaviors in Japanese adults.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this article.

17.7

10.7

10.8 9.9

0

5

10

15

20

25

Baseline 13 months

Med

ian

of p

hysi

cal a

ctiv

ity(M

ETS*

hour

s)

Unaware at baseline but aware at 13 months (n = 74)Unaware at both baseline and 13 months (n = 898)

Fig. 2 Longitudinal relationships between awareness of Exercise and Physical Activity Guide for Health Promotion 2006 and physical activity in Japan (Harada et al., 2011).

Group difference of change in physical activity was not significant (p = 0.096). METs: Metabolic equivalents

Acknowledgments

This work was supported by a Grant-in-Aid for Scientific Research from Japan Society for the Promotion of Science (24500763).

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Promotion of physical activity guidelines and behavior change