My place through my eyes : a social constructionist approach to researching the relationships between socioeconomic living contexts and physical activity

There is a growing evidence-base in the epidemiological literature that demonstrates significant associations between people’s living circumstances – including their place of residence – and their health-related practices and outcomes (Leslie, 2005; Karpati, Bassett, & McCord, 2006; Monden, Van Lenthe, & Mackenbach, 2006; Parkes & Kearns, 2006; Cummins, Curtis, Diez-Roux, & Macintyre, 2007; Turrell, Kavanagh, Draper, & Subramanian, 2007). However, these findings raise questions about the ways in which living places, such as households and neighbourhoods, figure in the pathways connecting people and health (Frolich, Potvin, Chabot, & Corin, 2002; Giles-Corti, 2006; Brown et al, 2006; Diez Roux, 2007). This thesis addressed these questions via a mixed methods investigation of the patterns and processes connecting people, place, and their propensity to be physically active. Specifically, the research in this thesis examines a group of lower-socioeconomic residents who had recently relocated from poorer suburbs to a new urban village with a range of health-related resources. Importantly, the study contrasts their historical relationship with physical activity with their reactions to, and everyday practices in, a new urban setting designed to encourage pedestrian mobility and autonomy. The study applies a phenomenological approach to understanding living contexts based on Berger and Luckman’s (1966) conceptual framework in The Social Construction of Reality. This framework enables a questioning of the concept of context itself, and a treatment of it beyond environmental factors to the processes via which experiences and interactions are made meaningful. This approach makes reference to people’s histories, habituations, and dispositions in an exploration between social contexts and human behaviour. This framework for thinking about context is used to generate an empirical focus on the ways in which this residential group interacts with various living contexts over time to create a particular construction of physical activity in their lives. A methodological approach suited to this thinking was found in Charmaz’s (1996; 2001; 2006) adoption of a social constructionist approach to grounded theory. This approach enabled a focus on people’s own constructions and versions of their experiences through a rigorous inductive method, which provided a systematic strategy for identifying patterns in the data. The findings of the study point to factors such as ‘childhood abuse and neglect’, ‘early homelessness’, ‘fear and mistrust’, ‘staying indoors and keeping to yourself’, ‘conflict and violence’, and ‘feeling fat and ugly’ as contributors to an ongoing core category of ‘identity management’, which mediates the relationship between participants’ living contexts and their physical activity levels. It identifies barriers at the individual, neighbourhood, and broader ecological levels that prevent this residential group from being more physically active, and which contribute to the ways in which they think about, or conceptualise, this health-related behaviour in relationship to their identity and sense of place – both geographic and societal. The challenges of living well and staying active in poorer neighbourhoods and in places where poverty is concentrated were highlighted in detail by participants. Participants’ reactions to the new urban neighbourhood, and the depth of their engagement with the resources present, are revealed in the context of their previous life-experiences with both living places and physical activity. Moreover, an understanding of context as participants’ psychological constructions of various social and living situations based on prior experience, attitudes, and beliefs was formulated with implications for how the relationship between socioeconomic contextual effects on health are studied in the future. More detailed findings are presented in three published papers with implications for health promotion, urban design, and health inequalities research. This thesis makes a substantive, conceptual, and methodological contribution to future research efforts interested in how physical activity is conceptualised and constructed within lower socioeconomic living contexts, and why this is. The data that was collected and analysed for this PhD generates knowledge about the psychosocial processes and mechanisms behind the patterns observed in epidemiological research regarding socioeconomic health inequalities. Further, it highlights the ways in which lower socioeconomic living contexts tend to shape dispositions, attitudes, and lifestyles, ultimately resulting in worse health and life chances for those who occupy them.

Relationship over time between psychological distress and physical activity in colorectal cancer survivors

Purpose Increased physical activity in colorectal cancer patients is related to improved recurrence free and overall survival. Psychological distress after cancer may place patients at risk of reduced physical activity; but paradoxically also act as a motivator for positive lifestyle change. The relationship between psychological distress and physical activity after cancer over time has not been described. Methods A prospective survey of 1966 (57% response) colorectal cancer survivors assessed the psychological distress variables of anxiety, depression, somatisation, cancer threat appraisal as predictors of physical activity five, 12, 24 and 36 months post-diagnosis 978 respondents had valid data for all time points. Results Higher somatisation was associated with greater physical inactivity (Relative risk ratio (RRR) =1.12; 95% CI=[1.1, 1.2]) and insufficient physical activity (RRR=1.05; [0.90, 1.0]). Respondents with a more positive appraisal of their cancer were significantly (p=0.031) less likely to be inactive (RRR=0.95; [0.90, 1.0]) or insufficiently active (RRR=0.96). Fatigued and obese respondents and current smokers were more inactive. Respondents whose somatisation increased between two time periods were less likely to increase their physical activity over the same period (p<0.001). Respondents with higher anxiety at one time period were less likely to have increased their activity at the next assessment (p=0.004). There was no association between depression and physical activity. Conclusions Cancer survivors who experience somatisation and anxiety are at greater risk of physical inactivity. The lack of a clear relationship between higher psychological distress and increasing physical activity argues against distress as a motivator to exercise in these patients.

Cost-effectiveness of a telephone-delivered intervention for physical activity and diet

Background: Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined. Methodology/Principal Findings: A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective ($78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective ($29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective ($12,153 per quality adjusted life year gained). Conclusions/Significance: This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile.

What works elsewhere? A review of physical activity intervention studies

Obesity and type 2 diabetes mellitus (T2D) have reached epidemic proportions in many parts of the world with numbers projected to rise dramatically in coming decades (Wang and Lobstein, 2006; Zaninotto et al., 2006). In Australia, and consistent with much of the developed world, the problem has been described as a ‘juggernaut’ that is out of control (Zimmet and James, 2007). Unfortunately the burgeoning problem of non-communicable diseases, including obesity and T2D, is also impacting developing nations as populations are undergoing a nutrition transition (Caballero, 2005). The increased prevalence of overweight and obesity in children, adolescents and adults in both the developed and developing world is consistent with reductions in all forms of physical activity (Brownson et al., 2005). This brief paper provides an overview of the importance of physical activity and an outline of physical activity intervention studies with particular reference to the growing years. As many interventions studies involving physical activity have been undertaken in the context of childhood obesity prevention (Lobstein et al., 2004), and an increasing proportion of the childhood population is overweight or obese, this is a major focus of discussion.

Parental physical activity : exploring the role of social support

Objectives: To explore the influence of social support on parental physical activity (PA). Methods: Forty parents (21 mothers, 19 fathers) participated in semistructured individual or group interviews. Data were analyzed using thematic content analysis.---------- Results: Instrumental (eg, providing child care, taking over chores), emotional (eg, encouragement, companionship), and informational support (eg, ideas and advice) as well as reciprocal support (eg, giving as well as receiving support) and autonomy support (eg, respecting one’s choices) are important for parents’ PA behavior. However, having support for being active is not straightforward in that many parents discussed issues that inhibited the facilitative nature of social support for PA performance (eg, guilt in getting help). Conclusions: Results highlight the complex nature of social support in facilitating parental PA.

The contribution of physical activity and sedentary behaviours to the growth and development of children and adolescents : implications for overweight and obesity

The obesity epidemic is a global trend and is of particular concern in children. Recent reports have highlighted the severity of obesity in children by suggesting: “today's generation of children will be the first for over a century for whom life expectancy falls.” This review assesses the evidence that identifies the important role of physical activity in the growth, development and physical health of young people, owing to its numerous physical and psychological health benefits. Key issues, such as “does a sedentary lifestyle automatically lead to obesity” and “are levels of physical activity in today's children less than physical activity levels in children from previous generations?”, are also discussed. Today's environment enforces an inactive lifestyle that is likely to contribute to a positive energy balance and childhood obesity. Whether a child or adolescent, the evidence is conclusive that physical activity is conducive to a healthy lifestyle and prevention of disease. Habitual physical activity established during the early years may provide the greatest likelihood of impact on mortality and longevity. It is evident that environmental factors need to change if physical activity strategies are to have a significant impact on increasing habitual physical activity levels in children and adolescents. There is also a need for more evidence-based physical activity guidelines for children of all ages. Efforts should be concentrated on facilitating an active lifestyle for children in an attempt to put a stop to the increasing prevalence of obese children

Cross talk between physical activity and appetite control: does physical activity stimulate appetite?

Physical activity has the potential to modulate appetite control by improving the sensitivity of the physiological satiety signalling system, by adjusting macronutrient preferences or food choices and by altering the hedonic response to food. There is evidence for all these actions. Concerning the impact of physical activity on energy balance, there exists a belief that physical activity drives up hunger and increases food intake, thereby rendering it futile as a method of weight control.

Ghrelin and obestatin concentrations during puberty: Relationships with adiposity, nutrition and physical activity

Ghrelin and obestatin are two peptides associated with appetite control and the regulation of energy balance in adults. It is intuitive that they have an important role in growth and development during puberty. Therefore, it is acknowledged that these peptides, in addition to others, form part of the substrate underlying energy homeostasis which in turn will contribute to body weight regulation and could explain changes in energy balance during puberty. Both peptides originate from the stomach; hence, it is intuitive that they are involved in generating signals from tissue stores which influence food intake. This could be manifested via alterations in the drive to eat (i.e. hunger), eating behaviors and appetite regulation. Furthermore, there is some evidence that these peptides might also be associated with physical activity behaviors and metabolism. Anecdotally, children and adolescents experience behavioral and metabolic changes during growth and development which will be associated with physiological changes.

Physical activity and obesity.

The authors explore our understanding of the part played by physical activity in preventing obesity through suitable activity or fostering obesity through reduced levels of activity. The international group of authors review physical activity as an important part of obesity on the one hand and appropriate weight on the other. The role of physical activity and exercise in those age-groups, and the natural history of weight and overweight during growth and development, are among essential public health topics under review here

Effect of physical activity and other stressors on appetite: Overcoming underconsumption of military operational rations revisited.

Recognizing the importance of good nutrition for physical and mental status, the Department of Defense asked the Institute of Medicine to guide the design of the nutritional composition of a ration for soldiers on short-term, high-stress missions. Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations considers military performance, health concerns, food intake, energy expenditure, physical exercise, and food technology issues. The success of military operations depends to a large extent on the physical and mental status of the individuals involved.

Concurrent and prospective associations between physical activity, walking and mental health in older women

Background Leisure-time physical activity (LTPA) shows promise for reducing the risk of poor mental health in later life, although gender- and age-specific research is required to clarify this association. This study examined the concurrent and prospective relationships between both LTPA and walking with mental health in older women. Methods Community-dwelling women aged 73–78 years completed mailed surveys in 1999, 2002 and 2005 for the Australian Longitudinal Study on Women's Health. Respondents reported their weekly minutes of walking, moderate LTPA and vigorous LTPA. Mental health was defined as the number of depression and anxiety symptoms, as assessed with the Goldberg Anxiety and Depression Scale (GADS). Multivariable linear mixed models, adjusted for socio-demographic and health-related variables, were used to examine associations between five levels of LTPA (none, very low, low, intermediate and high) and GADS scores. For women who reported walking as their only LTPA, associations between walking and GADS scores were also examined. Women who reported depression or anxiety in 1999 were excluded, resulting in data from 6653 women being included in these analyses. Results Inverse dose–response associations were observed between both LTPA and walking with GADS scores in concurrent and prospective models (p<0.001). Even low levels of LTPA and walking were associated with lowered scores. The lowest scores were observed in women reporting high levels of LTPA or walking. Conclusion The results support an inverse dose–response association between both LTPA and walking with mental health, over 3 years in older women without depression or anxiety.