Understanding the Self - The Physical Self Part 1

The preceding chapter documented many long-term trends in the way the U.S. population lives, works, and travels that have sharply reduced the physical demands of daily life. The persuasive scientific evidence on the importance of physical activity for health presents a challenge: to increase physical activity in a highly technological society with a built environment that is already in place and has evolved over a long period of time. This chapter explores the socioeconomic and institutional context that has resulted in the current situation and holds the key to change. It starts with a discussion of the various factors that affect the individual’s choices about engaging in physical activity. The chapter then turns to the institutional and regulatory forces behind the decisions of planners, engineers, developers, elected officials, and others over the years that have shaped the built environment in place today.

FACTORS AFFECTING INDIVIDUAL CHOICE

As discussed in Chapter 1 (Figure 1-1), physical activity behavior is influenced by both individual characteristics and the social environment. Whether an individual is physically active depends on demographic characteristics such as gender, age, and ethnic background, and on socioeconomic characteristics such as education and income level. It also depends on at least three other factors, the latter two of which are external to the individual: (a) attitudes,

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Suggested Citation:"4 Contextual Factors Affecting Physical Activity." Transportation Research Board and Institute of Medicine. 2005. Does the Built Environment Influence Physical Activity?: Examining the Evidence -- Special Report 282. Washington, DC: The National Academies Press. doi: 10.17226/11203.×

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preferences, motivations, and skills related to the behavior; (b) opportunities or constraints that make the behavior easier or more difficult to perform; and (c) incentives or disincentives that encourage or discourage the desired behavior relative to competing activities. Each of these factors is discussed in turn in this section. Much of the discussion is based on self-reported survey data and focus groups. Relative to observational surveys, self-reported data often provide unreliable estimates because of problems with recall or the well-established tendency of survey respondents to give socially desirable rather than completely truthful answers (see Chapter 2). Results from focus groups cannot be generalized to the population at large. Nevertheless, self-reports and focus groups are the only way to obtain insight into attitudes and motivations that help explain behavior. This type of information is particularly important because the determinants of physical activity behavior are not well understood.

Socioeconomic Characteristics

The Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (NHIS) have revealed that physical activity levels of U.S. adults decline with age and are lower among women, ethnic and racial minorities, those with less education and low income levels, the disabled, and those living in the southeastern region of the United States (see Chapter 2).1 These results have been corroborated by numerous other studies.2 For example, younger age is positively associated with physical activity, as are university education and higher income levels. Although comparisons by race are often obscured by socioeconomic variables, some studies have shown that ethnic minorities, particularly African American and Hispanic women, are less likely to adopt and maintain active lifestyles. Other personal barriers to walking

The BRFSS is discussed in detail by Brownson and Boehmer (2004) and the NHIS by Barnes and Schoenborn (2003).

Understanding the Self - The Physical Self Part 2 (Body Image and Concept of Beauty)

See the commissioned paper by Loukaitou-Sideris (2004), which references several relevant studies on the effect of individual characteristics on the propensity to engage in physical activity.

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and an active lifestyle cited in the literature include state of personal health and physical disability; lack of time, motivation, and energy; and lack of self-esteem. Further elaboration is not provided here because the committee has chosen to focus its discussion on physical activity behaviors linked with the built environment, such as nonmotorized travel and attitudes toward walking and cycling.

Attitudes, Preferences, Motivation, and Skills3

Several national surveys have been conducted in recent years to determine the public’s attitudes toward walking and cycling, as well as the frequency and purpose of these behaviors. Two of the surveys were sponsored by organizations that advocate walking and cycling—the Surface Transportation Policy Project and America Bikes. They found positive attitudes among respondents toward both walking and cycling and strong support for investments that would make communities more friendly to these modes (BR&S 2003; America Bikes 2003).

A national survey of walking and cycling sponsored by the National Highway Traffic Safety Administration and the Bureau of Transportation Statistics (BTS) and administered by the Gallup Organization during summer 2002 found that 8 of 10 respondents aged 16 or older had taken at least one walk of 5 minutes or longer in the past 30 days; fewer than 30 percent, however, reported having ridden a bicycle at least once (DOT 2003). When asked the primary purpose for walking trips, respondents most commonly cited exercise or health reasons (27 percent), personal errands (17 percent), and recreation (15 percent). The primary purposes for cycling trips were recreation (26 percent) and exercise or health reasons (24 percent).4 Survey results

Sexual Self - Understanding the Self

The following subsections draw heavily on the commissioned paper prepared for the committee by Kirby and Hollander (2004).

Although only the primary trip purpose was recorded, the responses can be misleading. For example, the respondent may have indicated commuting to school or work as the primary trip purpose but may also have walked or cycled to work for exercise. Thus, there is likely to be overlap among some of these responses.

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should be interpreted with caution because of low response rates.5

Physical Self - Understanding the Self

Another survey, conducted as part of the BTS monthly Omnibus Household Survey (BTS 2003), queried adults aged 18 and older about walking and cycling, among other forms of transportation, during 2001–2002.6 [These results should also be interpreted with caution because of problems with response rates and sampling as detailed in a TRB report (2003).] Approximately 72 percent of those interviewed reported having walked, run, or jogged outside for 10 minutes or more at least once during the month prior to the survey (BTS 2003). Nearly 60 percent of those who walked, ran, or jogged (about 40 percent of all respondents) reported spending about 30 minutes on these activities an average of 13 days per month, as compared with the recommended minimum of 30 minutes per day of moderate-intensity activity on 5 or more days per week (see Chapter 2). Nearly 20 percent of respondents reported a longer duration of activity, but 40 percent reported no outside walking, running, or jogging (BTS 2003).7 Only 16 percent of adult U.S. residents reported cycling outside during the month prior to the survey—spending just over 1 hour per day cycling on an average of 6 days per month (BTS 2002).

The Omnibus survey also inquired about the reasons for walking and cycling. Slightly more than three-quarters of those respondents who walked, ran, or jogged reported that they did so

The survey was conducted by telephone and used a random sample of listed and unlisted numbers in the 50 states and the District of Columbia, which yielded 9,616 interviews with respondents aged 16 years or older, a 27 percent response rate. The results were then weighted to reflect the national population of this age group, with an estimated sampling error of about ±1.5 percentage points at the 95 percent confidence level.

In 2000, BTS began a monthly national telephone survey to ascertain the public’s satisfaction with the transportation system. Approximately 1,000 randomly selected households are telephoned each month, and the results are weighted to allow inferences about the U.S. population aged 18 or older. Periodically, questions are added for specific purposes, such as this survey of walking and cycling behavior. The walking survey was conducted from January to November 2002 and the cycling survey from October 2001 to September 2002.

Factors Affecting Physical Activity Performance

Nearly 30 percent of those who walked, ran, or jogged (20 percent of the total) reported spending an hour or more on these activities on about 13 days during a month.

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primarily for exercise or recreation. Another 15 percent walked for personal errands, and only 7 percent to get to work or as part of their job (BTS 2003, 1).8 Similarly, the primary reasons for cycling were for recreation (54 percent) or exercise (33 percent); only 6 percent reported commuting by bicycle to get to school or work or as part of their job (BTS 2002).

In sum, the surveys indicate that walking is more prevalent than cycling, but reported levels of walking appear to fall short of recommended daily guidelines. To the extent that Americans report walking and cycling, the primary reasons appear to be for exercise and recreation. These results correspond with the behavioral data from public health surveys discussed in the previous chapter showing a trend toward increased leisure-time physical activity.

Market research has also been conducted to probe the reasons for engaging in physical activity. Several studies cited by Kirby and Hollander (2004)9 found that adults’ dominant beliefs about moderate physical activity were that it results in feeling better or more energetic, helps reduce stress, and improves physical condition (e.g., feeling less out of breath, stronger). Focus groups with older Americans revealed similar beliefs.10 Notably absent from the survey and focus group results is any mention of the longer-term benefits of physical activity identified by the health community and summarized in Chapter 2, such as disease prevention. The positive health effects of physical activity may have been assumed by the survey and focus group respondents, but the results may also reflect the value placed by many people on more immediate benefits, such as those enumerated above. In any event, the market research

The Physical Self- Understanding the Self

As with the Gallup surveys, the respondents were asked their primary trip purpose. However, there can be an overlap in the responses between travel for exercise and for utilitarian purposes.

Fridinger et al. 1996; Collette et al. 1994; Wankel and Mummery 1993; Brown 1992; Kotler et al. 2002.

For midlife adults, the focus groups revealed that physical activity was perceived as a way to fight aging, to continue to look good, and to cope with a changing life. Older preretired adults mentioned having more energy, prolonging an active life, and protecting their quality of life as benefits of physical activity. Retired adults said they engaged in physical activity to ensure a high quality of life, maintain connections in the community, and maintain everyday functions and independence (Sloan 2001 in Kirby and Hollander 2004).

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results underscore the importance of understanding the beliefs and attitudes of those whose behavior one wishes to reinforce or change. As marketers are well aware, beliefs and attitudes are likely to differ across subpopulations. For example, a single mother holding two jobs is likely to be motivated to become more physically active by information showing how physical activity can be fit into her busy daily routine, whereas a teenager is likely to be more motivated by information that physical activity will make her more fit and attractive. Thus, tailoring interventions to specific groups is likely to prove more effective than delivering mass messages about the benefits of being physically active.

Finally, while beliefs, attitudes, and preferences have a role in determining a person’s physical activity habits, cognitive and behavioral factors come into play as well. To become more physically active, for example, individuals can self-monitor the target behavior, learn how to set realistic and achievable goals, monitor progress toward those goals, identify barriers to achieving the goals, use problem-solving techniques to overcome those barriers, and identify and use peer and family social support to help achieve lasting behavioral change. Interventions using these methods, which are based on psychosocial theories and models such as social cognitive theory and motivational readiness, have been applied successfully in randomized, controlled clinical trials to evaluate methods of helping sedentary adults become more active (Kohl et al. 1998; King et al. 1998; Dunn et al. 1999). The committee is unaware, however, of published reports in which cognitive and behavioral interventions have been incorporated into designs that also encompass environmental and socioeconomic factors.

Lecture No. 4 Factors Affecting Physical Fitness For Class 12th (PHE) By Priyanka Mam #HarshNiketan

Opportunities and Constraints

The results of the surveys reviewed in the previous section and those of other large health surveys presented in Chapter 2 indicate that the majority of Americans are not acting sufficiently on their inclinations to meet recommended levels of total daily physical activity. Personal motivation is one likely explanation, but it is instructive

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to examine other possible factors—real or perceived—that may be preventing the desired behavior, with particular attention to the built environment as a potential barrier. It should be noted that, although walking and cycling are discussed together here, they generally involve different infrastructure and user characteristics. For example, in urban areas, cycling typically is forbidden on sidewalks and confined to certain streets or bicycle lanes that share the right-of-way with automobiles. Cycling on pedestrian paths can pose a danger for those who are walking. These differences should be kept in mind in interpreting survey results. For example, these differences are likely to make cyclists more concerned with infrastructure facilities for safety.

The Gallup survey discussed above revealed that the primary reasons for not walking or cycling were personal (disabilities or other health impairments), weather- or time-related, or equipmentrelated (did not own or have access to a bicycle) (DOT 2003). Environmental factors (no safe place to ride or walk) were mentioned by only a small fraction of respondents (approximately 3 percent) (DOT 2003). Three of four adults reported being “very” or “somewhat satisfied” with the design of their communities for pedestrian safety. Nevertheless, when asked to recommend changes in their communities, presumably to make walking safer, about one-third of those polled suggested providing pedestrian facilities, such as sidewalks, traffic signals, lighting, and crosswalks. Satisfaction with the cycling environment was considerably lower. Only half of those polled were “very” or “somewhat satisfied” with their communities’ designs for cycling safety. Nearly one-half of all respondents recommended new bicycle facilities, such as bicycle trails, paths, lanes, racks, traffic signals, lighting, and crosswalks. The survey results suggest that, even for those favorably disposed to walking and cycling, changes to the physical environment that would enhance the safety and ease of engaging in these activities could make a difference.

Factors Effecting Physical Fitness and Wellness

Results of other surveys suggest that environmental factors may play a more dominant role depending on the activity—for example, transporting children to school. As noted earlier, the private

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vehicle has become the primary mode of school travel (Dellinger and Staunton 2002). Long distances, dangerous traffic, and crime have been mentioned as the main barriers to children walking and cycling more to school (Dellinger and Staunton 2002; BR&S 2003).11 In fact, children (aged 5 to 18) of parents who reported no barriers [16 percent of all respondents to the Centers for Disease Control and Prevention’s (CDC’s) HealthStyles Survey reported by Dellinger and Staunton] were six times more likely to walk or bicycle to school than those whose parents cited one or more barriers.

Interventions to mitigate such barriers can be effective. For example, the California Safe Routes to School Program has provided more than $40 million to municipalities and counties to improve the safety and viability of walking and cycling to school. Typical projects include sidewalk construction and improvements, pedestrian and bicycle crossings, and traffic controls to improve the safety of street crossings (Boarnet 2004). A before-and-after evaluation of projects associated with 10 schools across the state found that walking and cycling had increased, with larger effects if the project was along the child’s usual route to school (Boarnet et al. 2004).12 The Marin County Safe Routes to School Program is a good example of a comprehensive approach to reducing barriers for children walking and cycling to school that appears to be working (see Box 4-1).

Constraints and barriers to physical activity are perhaps best illustrated in those low-income neighborhoods where crime, disinvestment, and isolation can be major deterrents to walking and cycling for many residents. Low-income urban populations

The HealthStyles 1999 Survey, analyzed by CDC and reported by Dellinger and Staunton (2002), found that major reported barriers to walking and cycling to school included long distances (55 percent), traffic danger (40 percent), adverse weather conditions (24 percent), and crime (18 percent). The BR&S 2003 survey found distance to be the primary barrier (mentioned by 66 percent), followed by traffic danger (17 percent), fear of child being abducted (16 percent), inconvenience (15 percent), and neighborhood crime (15 percent). For both surveys, multiple responses were accepted; hence the percentages do not add up to 100.

FACTORS AFFECTING DEVELOPMENT

Survey respondents reported an increase of 10.5 percent in walking and cycling to school associated with the construction improvements. A slightly higher percentage—15.4 percent—was reported if the improvements were along the child’s usual route to school.

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BOX 4-1

The Marin County, California, Safe Routes to School Program

The Safe Routes to School Program in Marin County is one of the programs funded by the California Safe Routes to School Program. Marin County has established a grassroots program that is getting more children to walk and bicycle to school.

Program components include mapping of routes and infrastructure improvements to improve access to schools by walking or bicycling, special events and contest promotions, new concepts such as “walking school buses” and “bike trains” to generate and maintain the interest of the community, and a well-integrated communication and promotion strategy. Safe Routes task forces collaborate with public works and law enforcement staff to develop and implement an improvement plan, apply for funding, and effect improvements such as crosswalks and signage to make it easier and more convenient to walk and cycle to school. The California headquarters for the Safe Routes to School Program also provides materials, tips, and tools for community volunteers and organizations. These include a walkability checklist, sample letters to parents in 13 languages, a “guide to success” with instructions on how to create a walking school bus and a bike train, and a guide on how to create safe drop-off points for children walking to school (see www.cawalktoschool.com/dropoff_zones.php). In addition, the California headquarters partners with the state health department’s injury control center to give its safety messages even more credibility with parents.

UNDERSTANDING THE SELF: UNPACKING THE PHYSICAL SELF | Magallen Fam

Most important, the program appears to be working. At the second-year mark of the commencement of the program in Marin County, 15 participating public schools reported an increase in walking (64 percent), bicycling (114 percent), and carpooling (91 percent) and a decrease in private vehicles carrying only one student (39 percent) (Staunton et al. 2003).

SOURCE: Kirby and Hollander 2004.

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exhibit the highest levels of walking and bus transit use13 for utilitarian travel out of necessity (Pucher and Renne 2003), but they engage in much less discretionary physical activity than other groups (see Chapter 2). Interventions such as the Sisters Together Program (see Box 4-2), which attempt to address issues of regaining control over one’s environment (e.g., safe walk routes) and combating isolation (e.g., walking buddies), may help overcome barriers to recreational physical activity for some low-income urban populations. Not all low- or moderate-income neighborhoods are affected by fears of crime, however. Physical inactivity of their residents must derive from other causes.

Concern for personal safety can also play a role in the use of pathways for walking and jogging in urban and regional parks. Surveys and focus groups have shown that adults, particularly older adults and female minorities, perceive unsafe footpaths and other recreational areas for exercise as deterrents to walking and other physical activity (Hahn and Craythorn 1994; King et al. 2000; Booth et al. 2000).

Factor Affecting Physical Fitness

Crime and deteriorated neighborhoods are less likely to be an issue in rural settings, where natural scenery (open fields) and lightly traveled rural roads provide opportunities for walking and cycling. For the rural poor, however, isolation and long distances between destinations may limit these activities (Brownson et al. 2000 in Kirby and Hollander 2004).

Providing opportunities for walking and cycling may not be sufficient to change behavior, however, particularly for certain types of travel, such as commuting. Time constraints, long distances between destinations, and the mobility afforded by the automobile make traveling by personal vehicle the preferred option for many commuters. A recent study of commuting behavior in three neighborhoods in the San Francisco Bay Area—one urban and two suburban—attempted to separate the effects of household location preferences from the spatial characteristics of residential neighbor-

As noted earlier, transit, particularly bus transit, requires some walking to access the bus stop. Rail transit can also induce walking and cycling, but in suburban locations, park-and-ride facilities make driving an option.

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BOX 4-2

The Sisters Together Program

This obesity prevention pilot program supported by the National Institutes of Health (NIH) and the National Institute of Diabetes and Digestive and Kidney Diseases (www.niddk.nih.gov/health/nutrit/pdf/SisPrmGuide2.pdf) began by targeting young black women in three inner-city neighborhoods of Boston. The campaign focused on creating positive messages to generate normative change and involving existing community programs to build sustainability.

Factors Affecting Fitness

The Sisters Together initiative developed a coalition of programs and people in the community, targeting both healthy eating and moving more (www.hsph.harvard.edu/sisterstogether/move.html). In an effort to suggest activities that would resonate with their target audiences, program staff developed tips on dancing, not just walking: “Turn on your favorite music and dance to three songs a day three times a week. It gets your heart pumping, your body moving, and your mind feeling great.” A web page and brochure provided safe walking routes around the city. Radio public service announcements offered women a chance to sign up for a neighborhood walking group if they came to a 2-mile warm-up walking event. Making it easier for women to locate a walking buddy helped promote a positive social norm with regard to walking. The program’s Why Walk cites the top three benefits of walking validated by research—“Walking will … give you more energy, make you feel good, and help you relax.”

A traditional method—the bounce-back card—was used to obtain feedback from the target audience and partners on how the program was working and what could be improved. Community partners were engaged to be the sustaining force behind the program once NIH funding for the pilot project ended. Rudd et al. (1999) describe the community development model employed in this project, but no longer-term evaluation data could be located.

SOURCE: Kirby and Hollander 2004.

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hoods that help shape travel patterns (Schwanen and Mokhtarian 2004). The researchers found that, even after controlling for sociodemographic characteristics, mobility limitations, personality and lifestyle types, and travel attitudes, suburban-minded residents of the urban neighborhood (i.e., urban dwellers who preferred lower-density environments) commuted by private vehicle far more than their urban-minded neighbors (those who preferred higher-density environments such as the one in which they lived). Similarly, urban-minded suburban dwellers commuted by car about as often as their suburban-minded neighbors. However, the differences in commuting behavior across neighborhoods were greater than those within neighborhoods, which indicates that neighborhood structure itself has an autonomous effect on travel choices. Commuting by personal vehicle strongly prevails in suburban neighborhoods in which residents have fewer mode choices, longer distances to travel, and lifestyle preferences for low-density living. In urban neighborhoods where densities are higher, travel distances are often shorter, and travel options are greater, transit achieves a higher commute mode share than in suburban neighborhoods (Schwanen and Mokhtarian 2004).

Incentives and Disincentives

Lowering the cost of a desired behavior and raising the price of an undesired behavior can be an effective strategy for motivating behavior change. The choice to walk, bicycle, or combine either with transit may require such incentives and disincentives. For example, a combination of providing transit fare subsidies through the workplace and either cashing out14 or raising parking fees could help level the playing field between driving and taking transit and encourage greater transit use (Shoup 1994; Shoup 1997).15 (Of course, the

Factors Affecting Physical Fitness

“Cashing out” refers to employers offering employees the cash equivalent of any employee parking subsidy. The idea is that at least some commuters who previously drove alone to work might take the cash and choose an alternative mode, such as ridesharing (Shoup 1997).

These strategies, however, are complex. Care must be taken to consider distributional issues, for example, in their implementation. A more detailed discussion of equity issues is given in Special Report 242 (TRB 1994).

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workplace must be accessible to transit for the employee to take advantage of the transit fare subsidy.)

In addition to monetary incentives, such strategies as reducing the time cost of physical activity—making it easier and more convenient to be physically active—can be effective. In the previously cited national survey conducted by BR&S on Americans’ attitudes toward walking, inconvenience (destinations being too far) and time were the primary reasons cited for not walking more (BR&S 2003). Likewise, a community intervention in Wheeling, West Virginia,targeting sedentary adults aged 50 to 65 found that time and schedule were the major stated deterrents to being physically active (see Box 4-3) (Reger et al. 2002 in Kirby and Hollander 2004). With the tagline “Isn’t it time you started walking?” the intervention attempted to make the case that walking is an activity easily accommodated and integrated into one’s daily routine. Similarly, one of CDC’s earliest campaigns to promote the benefits of moderate physical activity—with the slogan “Ready, Set, It’s Everywhere You Go”—sought to underscore that moderate-intensity activities could easily be part of the daily routine (see Box 4-4) (Kirby and Hollander 2004). Lack of evaluation of such projects for their effects on physical activity levels, however, makes it impossible to predict the benefits of such approaches.

Improving access by shortening distances between destinations is more difficult to address. Such a strategy requires moving one’s residence or employment or both, or locating facilities in closer proximity to one another—a topic discussed in the following section.

To create incentives for physical activity, one must also consider the competition for the desired behavior. For example, a competitor for engaging in recreational physical activity might be watching television (Kirby and Hollander 2004), although this need not be the case. Many individuals watch television, or could be encouraged to do so, as they walk a treadmill either in their homes or at sports clubs. Another, more challenging competitor is the car, particularly for utilitarian physical activity. As Schwanen and Mokhtarian (2004) found, improving nonautomobile mode choice options can help encourage transit use and related walking, but these modes

Factors that influence self concept

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BOX 4-3

Wheeling, Virginia, Intervention for Sedentary Adults Aged 50–65

The work of Reger et al. (2002) is a good example of using marketing principles to design a behavior change effort. First, the researchers decided on a specific behavior—walking—for a specific target audience—sedentary adults aged 50 to 65 in Wheeling, West Virginia.

Initially, most of the programmatic effort was focused on promotion and price variables. Formative research had found that sedentary and irregularly active people and regular walkers share similar attitudes and normative beliefs but exhibit strong differences related to their perceived control over time and scheduling. The major “price” of walking for the sedentary adult was “time.” Thus, the ensuing promotional strategy was focused on perceived control issues and positioned walking as an activity that was easy to accommodate and integrate into one’s daily routine. A pithy tagline was developed to address the time issue: “Isn’t it time you started walking?”

The formative research also identified optimal promotional channels for reaching the intended audience. A combination of paid advertisements on television and radio and in newspapers was developed. In addition, non–mass media channels were tapped, such as the Wheeling Medical Society, physician prescriptions, work site wellness challenges, and community walking events. After initial campaign efforts, the researchers remained in contact with community participants, who suggested various improvements in community walking facilities. The mayor was engaged; a community task force was established; and collaboration with the National Park Service, the state Department of Transportation, and a local Rails-to-Trails group was initiated.

The following quotation illustrates the power of addressing perceived behavioral control:

My biggest surprise about walking was the fact that I actually could do it. When my brother found out how far I was going he talked me into racing. I didn’t think I could do it, but luckily I won my first race and from then on I was hooked. I loved the people, the atmosphere, and the challenge.

Psychological Factors Affecting Physical Conditions Like Hypertension & Asthma Video & Lesson Tran

SOURCE: Kirby and Hollander 2004.

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BOX 4-4

CDC’s “Ready, Set, It’s Everywhere You Go” Campaign

CDC launched one of the earliest campaigns to encourage moderate physical activity as opposed to “exercise,” which had a more high-intensity, time-demanding connotation. CDC’s “Ready, Set, It’s Everywhere You Go” campaign relied mainly on communication techniques to introduce the notion of moderate-intensity activity that could be part of an adult’s routine daily life. Formative research was conducted to validate audience segmentation and develop materials and promotional messages.

CDC produced a marketing kit for use by community-based organizations in their local efforts. It comprised three parts: (a) marketing strategies for physical activity, (b) ways to work with the media, and (c) the development of physical activity programs and events. The kit included a colorful poster and print ad emphasizing that people can be active doing routine activities such as yard work and walking the dog. The kit was designed to help health professionals and community-based organizations identify adults who wanted to become physically active and reach them with accurate and positive messages that had been tested with the same target audience. Target audiences specifically wanted materials that were family-friendly and conveyed the idea of having fun and being energetic.

By analyzing market research data and conducting focus groups and interviews, CDC developed a detailed picture of the intended audience. Research revealed that the majority of the intended audience was 18 to 45 years old, educated, middle-income, and female. Since 71 percent were married, 74 percent were employed, and 58 percent had live-in children, it was not surprising that these adults reported having little time for themselves after meeting their household, job, and family demands. Few of them considered themselves rugged or athletic; rather, they described themselves as interesting, friendly, caring, mature, fun, smart, honest, and content. As a whole, the target group members reported that they did not enjoy vigorous

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“exercise.” However, they did view “physical activity” as fun and enjoyable and were pleased to learn that it is important to their health and well-being. Participants believed that internal motivation, pleasant and manageable activities, support from family and friends, and convenience would help them become more physically active.

Factors Affecting Growth and Development

A variety of other barriers stood in the way of physical activity. Participants in the research cited such barriers as long work hours, being tired at the end of the day, lack of confidence in their athletic ability, and family priorities. Program planners reasoned that helping people understand that physical activity is “everywhere” they go and easy to do could help them become more active. The “Ready, Set, It’s Everywhere You Go” materials, community kit, radio spots, and posters were audience tested—an important step in formative evaluation for marketing. The project has not been evaluated for its impact on changing behavior related to physical activity or healthy eating, however.

SOURCE: Kirby and Hollander 2004.

cannot always compete with the mobility and convenience afforded by the personal vehicle. Fortunately, total levels of physical activity matter, not whether an individual drives rather than walks or cycles to work, and even modest increases in total physical activity levels can have a positive effect on health (see Chapter 2). Nevertheless, it must be acknowledged that some individuals may view physical activity—even in small amounts—as unpleasant.

INSTITUTIONAL AND REGULATORY CONTEXT

Whereas the previous section examined the demand for physical activity, this section looks at the supply side of the link between the built environment and physical activity. Specifically, it examines

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the institutional and regulatory arrangements and policies that, over time, have created the built environment in place today.16

Zoning and Land Use Ordinances

In the United States, local governments are responsible for developing comprehensive plans and establishing land use regulations that determine how a community will develop. The authority to create zoning and subdivision controls and building regulations, which have the force of law, is a powerful tool in establishing the design requirements and physical context of a community’s development. Most zoning regulations and subdivision controls regulate two factors thought to be closely linked to a community’s walkability and bikeability—development densities and mixing of land uses.

Zoning was introduced by urban reformers in the United States in the early twentieth century to help alleviate the impacts of urban overcrowding on disease and illness. New York’s Zoning Ordinance of 1916—the first enacted in the nation—was created for the express purpose of limiting development densities and thereby improving public health (Jurgensmeyer and Roberts 1998 in Meyer and Dumbaugh 2004). Early zoning regulations prohibited mixing of land uses to segregate those that would be incompatible, such as residential and high-polluting industrial uses. As they evolved, zoning laws also operated to reinforce economic and racial separation. Exclusionary zoning in wealthier communities restricted certain types of development, such as multifamily housing construction, and established stringent standards, such as minimum lot sizes or housing square footage, that had the effect of keeping housing prices high and thus excluding lower-income families (NRC 1999). Once such zoning limits were in place, they tended to be reinforcing. Households that moved to a community with single-family zoning viewed efforts to incorporate more affordable multifamily housing as a threat to their property values (Fischel 1999 in NRC 1999).

FACTORS INFLUENCING PHYSICAL DEVELOPMENT OF A CHILD|CTET|B.ED|

The following subsections draw heavily on the commissioned paper prepared for the committee by Meyer and Dumbaugh (2004).

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Municipal street designs and zoning requirements regarding parking have also had an important impact on the development of communities. Early municipal street designs incorporated in guidelines issued by the U.S. Federal Housing Administration in 1935 recommended that residential streets be designed to “discourage through traffic, have a minimum paved width of 24 feet, use cul-de-sacs17 as much as possible, and avoid excessive planting in the front yards to have a ‘more pleasing and unified effect along the street’ ” (FHA 1935). Municipal street design standards were also developed to take into account requirements for providing emergency services. Wide streets were believed necessary to accommodate the worst-case scenario—two high-rise ladder trucks jockeying for position on a dead-end street (Duany et al. 2000 in Meyer and Dumbaugh 2004).

Most community zoning codes require that a minimum number of parking spaces be provided per unit or per 1,000 square feet to accommodate the maximum demand for parking (Meyer and Dumbaugh 2004). In most cases, this number is greater than what is needed to handle “normal” demand and results in an oversupply of parking, particularly in suburban areas.

Taken together, zoning and land use controls can make it difficult to provide many of the characteristics associated with walkable and bikeable communities today (Meyer and Dumbaugh 2004). For example, low-density development often results in long distances between destinations, and research suggests that walking and cycling are highly sensitive to distance as compared with automobile travel, particularly travel for utilitarian purposes. Walking speeds are about 3 miles per hour (mph), and average bicycle speeds are about

A cul-de-sac is a street, lane, or passage closed at one end. Its primary use, which is encouraged by traffic engineering and subdivision standards, has been to control through traffic in residential developments (Southworth and Ben-Joseph 2004). The cul-de-sac and its close cousin—the longer-loop street with two access points—have been criticized by the new urbanists for their lack of connectedness and their adverse effect on congestion, since all traffic must enter and exit the development through a limited number of access points. On the other hand, one could argue that families who live on cul-de-sacs feel safer letting their children play outdoors than those who live on through streets. And in some communities, connections to bicycle paths and greenbelt systems exist.

Factors affecting physical fitness by Sarita bandral

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8 mph, depending on topography. Some planners suggest that walkable communities should have destinations within roughly ¼ to ½ mile of the point of origin (Seneviratne 1985). Bicycle destinations can be located slightly farther—2 to 3 miles from the point of origin (Meyer and Dumbaugh 2004). These guidelines are simply rules of thumb—individuals may well be willing to walk and cycle longer distances—but they underscore the competition posed by faster transport modes.

Separation of land uses also tends to increase the distances between destinations and creates a monotonous environment that may not be conducive to walking or cycling. In today’s economy, the rationale for separating land uses is less compelling; many service-related work places are compatible with residential uses. Minimum parking requirements accommodate driving to most destinations and take up space that could be used for neighborhood amenities, such as parks and green spaces. Finally, wide residential streets with long straight sight lines and few trees contribute to vehicle speeding, creating a potentially dangerous environment for pedestrians and cyclists (Meyer and Dumbaugh 2004).

Urban Design Features

Design features are also thought to affect the form of community development and travel choices. Such features refer to both the aesthetic appeal and the function of buildings, streetscapes, and public spaces, which can be designed in ways that can encourage walking and transit use, particularly in the neighborhood, but also around work sites. Table 4-1 lists five such urban design features—density of development, land use mix, street connectivity, street scale, and aesthetic qualities—and describes how they can be measured.

The writings of Jane Jacobs in the 1960s (Jacobs 1961) and Kenneth Jackson in the 1980s (Jackson 1985) critiqued the loss of neighborhood scale and community life in the automobile-dependent suburbs created largely after World War II. Whyte and Appleyard’s studies of public spaces and livable streets in the early 1980s (Whyte 1980; Appleyard 1981) and architect Peter

PSYCHOLOGICAL FACTORS EFFECTING PHYSICAL PERFORMANCE ( DR Harvinder Bajwa)

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TABLE 4-1 Examples of Design Features of the Built Environment

Design Element

Description and Possible Measures

Density

The amount of activity found in an area—usually defined as population, employment, or building square footage per unit of area and measured as people per acre or jobs per square mile. Floor–area ratio, the ratio between the floor space in a building and the size of the parcel on which the building sits, is another density measure.

Land use mix

The relative proximity of different land uses (e.g., homes, stores, offices, parks) within a given area—no standard measure.

Street connectivity

The directness and availability of alternative routes from one point to another within a street network—measured by the number of intersections per square mile, average block length, and so forth.

Street scale

The three-dimensional space along a street as bounded by buildings or other features—typically described as “human-scale” or “automobile-scale”—measured by the average building setback or by the ratio between building heights and street widths.

Aesthetic qualities

THE FACTORS AFFECTING HUMAN BEHAVIOR by the Professor

The qualities that contribute to the attractiveness or appeal of a place, such as the design of buildings (size and orientation of windows), landscaping, lighting and benches—the most intangible of the design features—more often described than measured.

SOURCE: Adapted from Handy et al. 2002, 66.

Calthorpe’s vision of more walkable and livable communities (Calthorpe 1993) gave rise to a set of design concepts collectively known as the “new urbanism.” The movement emerged in the late 1980s through architects who designed smaller, people-oriented communities with a small-town feel and a village scale. The goal was to establish a sense of community—often missing in newly developed neighborhoods—by creating human-scale housing and streets, mixing land uses, providing vibrant public spaces, and getting people out of their cars (Boarnet and Crane 2001). New-urbanist developments emphasize such design elements as front porches, sidewalks, and common public spaces as gathering places for community activities.

The claim is made that walking will increase if the activities of daily living (e.g., parks, neighborhood shopping) are within walk-

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ing distance and linked to where people live and work by an interconnected network of streets, sidewalks, and paths (Handy et al. 2002). These goals can be achieved by straightening of streets to improve connectivity (i.e., use of grid street patterns), “calming” of traffic, more compact land uses with a diversity of destinations, and inviting street environments with amenities such as street furniture and plantings (Boarnet and Crane 2001). Transit use should also increase with more compact land use and clustering of shopping and housing near rail or bus nodes. The evidence supporting the effects of urban design features on walking, including walking to access transit facilities, is reviewed in the paper by Handy commissioned for this study (Handy 2004) and summarized in Chapter 6.

Developers’ Response18

Private developers and lenders are ultimately responsible for the development and construction of local residences and commercial facilities. Recent surveys (Levine and Inam 2004; Smith-Heimer and Golem 2001 in Kirby and Hollander 2004) have revealed that real estate developers perceive considerable market interest in walkable communities and support developments with greater density and more mixed uses than regulations allow, particularly in inner-suburban areas. A panel discussion with California developers yielded evidence of good market support for transit-oriented development projects that involve mixed-use development near transit stations (Smith-Heimer and Golem 2001).

In view of these findings, why are there not more walking- and cycling-friendly developments—often called neotraditional or new-urbanist developments—and transit-oriented development projects in response to market demand, particularly since such developments are in short supply? Levine and Inam (2004) suggest that a large majority of developers perceive local zoning controls and the related costs of pursuing variances as the primary obstacles to neotraditional developments. For example, among developers

Factors That Influence the Growth and Development of a Child

This discussion of real estate developers also draws on the commissioned paper by Kirby and Hollander (2004).

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who proposed neotraditional developments for which variances were granted, the density was reduced by the community planning process for approximately 80 percent, mixed-use characteristics were reduced for nearly 50 percent, the housing types were changed for nearly 30 percent, the share of mixed-use development was changed for one-third, and changes were made in pedestrian or transit orientation for nearly 20 percent (Levine and Inam 2004). Other surveys have revealed that public resistance to densification and neighborhood opposition to mixed-use development are significant barriers to neotraditional projects (Logan et al. 2001 in Kirby and Hollander 2004). These findings indicate that, when faced with accepting higher densities or mixed-use development—changes that may be perceived as negatively affecting property values—not all consumers are as supportive of more walking-, cycling-, and transit-friendly communities as their survey responses would suggest.

Financial institutions can also be a barrier. Despite some developers’ perception that neotraditional developments can be profitable and the findings of studies confirming that this is in fact the case (Eppli and Tu 1999 in Kirby and Hollander 2004),19 institutional lenders are risk averse. Typically, they look for projects that are compatible with other developments in the local market (i.e., that meet local zoning and subdivision controls). Financing of mixed-use developments can be particularly problematic because many lenders have experience in dealing with only one type of development (Meyer and Dumbaugh 2004; Kirby and

Eppli and Tu (1999) examined neotraditional developments from a housing market perspective. They compared sales transactions and characteristics of homes in four regionally diverse new-urbanist developments with those of homes in nearby conventional neighborhoods. Properties in Kentlands, a new-urbanist development, were found to be selling for $30,000 to $40,000 more, on average, than homes in the surrounding conventional suburbs, even after controlling for site traits, housing characteristics, unit quality, neighborhood, and other market factors. In view of survey data revealing positive attitudes toward walking and the barriers posed by distance, inconvenience, and time constraints, it would appear that developments such as Kentlands could motivate and support increases in neighborhood walking and cycling. The fact that residents appear to be willing to pay a premium for living in such a community should hold some appeal for real estate developers.

Xl Physical Education chapter 3 factors affecting physical fitness

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Hollander 2004). An informal survey of institutional lenders in the Atlanta, Seattle, and Boston markets conducted by Meyer and Dumbaugh (2004), for example, revealed that lenders are not averse to neotraditional developments as long as such developments are not expressly prohibited by local zoning and are not the first such development in an area. The presence of profitable existing neotraditional developments in a local market and evidence of other public and private investment in a transit-oriented development, of course, increase the acceptability of similar new projects (Smith-Heimer and Golem 2001).

Relaxing zoning and financing barriers to enable more neotraditional development for those who would like to locate in such communities would require changes on many fronts—not the least of which would be to educate the public, elected officials, and the real estate community in how these communities can work and be implemented. The more it can be shown that such communities can be profitable and not reduce surrounding property values, the more acceptable they will become (Meyer and Dumbaugh 2004). In addition, instead of overturning long-standing zoning regulations and ordinances, it may be easier to win support through more targeted approaches, such as overlay districts20 and incentives (Meyer and Dumbaugh 2004; see Box 4-5 for two examples).

School Design and Location

Decisions about school design and location are largely independent of the processes that drive other forms of community development. Planning for educational facilities is the responsibility of local school boards, which are typically composed of elected representatives. Because nearly all school boards are semiautonomous, they—not local governments that have a strong interest in the

Overlay districts are a planning tool providing for special zoning requirements that are an exception to the underlying zoning and are tailored to the characteristics of a particular area (e.g., special architectural character) or complementary to a particular public policy (e.g., higher-density building near rail transit stations).

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BOX 4-5

Physical and Mental Health

Two Approaches to Relaxation of Zoning Regulations and Controls

Overlay districts. Changing a community’s land use zoning is often a difficult political undertaking. One of the approaches used to provide a higher level of urban design while maintaining the underlying zoning is to use overlay zones targeting specific development characteristics. A good example is Portland, Oregon’s, Light Rail Transit Station Zone (Portland Metro 2000). This overlay zone “allows for more intense and efficient use of land at increased densities for the mutual reinforcement of public investments and private development. Uses and development are regulated to create a more intense built-up environment, oriented to pedestrians, and ensuring a density and intensity that is transit supportive.” Actions include prohibition of parking garages within a specified distance of a station, a 50 percent reduction in the minimum number of parking spaces required within 500 feet of a light rail alignment, and the requirement of a high level of streetscape landscaping.

Neotraditional development incentives. Restructuring long-standing land use ordinances that have been the basic approach to community development is also difficult. A more appealing approach for encouraging neotraditional development and use of nonmotorized transportation is to provide incentives to both developers and communities. For example, in specified districts, developers could receive income tax credits for certain types of development, reductions in permit fees and other procedural requirements, and relaxation of other zoning requirements that might save the developer money. Regional planning agencies could reward communities that provided approvals for neotraditional developments. In the San Francisco Bay Area, for example, the metropolitan planning organization provides a certain amount of money to a community for every bedroom constructed within a certain distance of a transit station. These funds can be used by the community for any purpose. By using incentives, policy makers participate in the development market, but not in the traditional regulatory way.

SOURCE: Meyer and Dumbaugh 2004.

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overall development of a community—make decisions about school design and location.

The trend in school design has been to develop bigger schools to lower costs through economies of scale. The large land requirements recommended by the standards-setting organization for school facilities21 make incorporating these schools into existing communities difficult. The trend is to locate the facilities on large suburban tracts, which necessitates driving or busing students from surrounding communities. Because local school boards are responsible only for on-site circulation and not for access from the surrounding street network, means of accommodating walking and cycling to school are rarely planned as part of a school construction project. Similarly, school bus routes and safe access to bus stops are under the purview of local school boards; little coordination with local community planners is involved (Meyer and Dumbaugh 2004).

Some states and communities have begun to reevaluate the desirability of requirements that encourage the building of large new school campuses (EPA 2003). For example, South Carolina recently eliminated state-mandated acreage requirements for new schools that may make it easier for existing schools to be renovated. Neighborhood school initiatives in Wisconsin and Minnesota have resulted in retaining many elementary schools within walkable neighborhoods.

More coordination between local school boards and local government planners could help in addressing issues of school access and optimum school location. At a minimum, initiatives such as the previously discussed Safe Routes to School Program could help encourage more walking and cycling to school or walking to school bus stops.

Modeling of Transportation Needs

All major metropolitan areas are required by the federally supported planning process to have a regional transportation model

Factors Affecting Perception

A professional organization, the Council for Educational Facilities Planners International, provides guidance on school design and construction.

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for analyzing network investment needs and alternatives (Meyer and Dumbaugh 2004). These models provide a very aggregate picture of regional travel and were not intended to handle the level of detail required to analyze or predict pedestrian or cycling trips. Major roads, such as freeways and arterials, are represented by network links in the models, but most local roads where pedestrians walk and bicyclists ride are not. Many walking and cycling trips are relatively short in distance, occurring within a traffic analysis zone. Statistical averages are normally used to represent intrazonal travel. This can understate the impact of mixing land uses or improving pedestrian ways within a city block in promoting walking because averages ignore any variation around the mean. Overall, regional transportation models generally do a poor job of representing non-motorized travel, which can understate the potential role of pedestrian facilities and bicycle paths as well as land use strategies in promoting walking and cycling trips (Meyer and Dumbaugh 2004).

The typical regional transportation forecasting model consists of four major steps: trip generation, trip distribution, mode choice, and trip assignment. The first step, trip generation, is a function of exogenously determined demographic patterns and economic activity in a region. The remaining three steps, which are followed sequentially, simply allocate trips among alternative destinations in trip distribution, alternative travel modes in mode choice, and alternative highway (and transit if appropriate) routes in trip assignment (TRB 1995). Trip assignment is based primarily on minimizing travel time through an iterative process that feeds back to mode choice, and sometimes to trip distribution, in an effort to equate initial with final travel time estimates. The outputs of the model are vehicle and passenger volumes on highway and transit routes, respectively.

The recent interest in policies supporting pedestrian and bicycle travel has led some metropolitan areas, such as Portland, Oregon, and the San Francisco Bay Area, to make advances in incorporating pedestrian and bicycle travel into their transportation models. They are still the exception rather than the norm, however. Furthermore, few metropolitan areas have integrated land use and travel demand

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models, so that the effects of changes in urban form and design on travel behavior cannot be determined (Meyer and Dumbaugh 2004).

Models are important inputs to policy makers, but they represent only one element in the policy process. European cities typically have better bicycle and pedestrian facilities than most of their U.S. counterparts, but this is not an outcome of better models. Other policies, such as higher gasoline prices that discourage automobile travel, have likely played a far greater role in investment in nonmotorized facilities.

Factors Affecting Physical Fitness

Roadway Infrastructure Design

A highly standardized approach to roadway infrastructure design has also played a major role in determining the design and development of communities (Meyer and Dumbaugh 2004). The design manuals used by highway and traffic engineers—the “Green Book” of the American Association of State Highway and Transportation Officials (AASHTO), which provides guidance on roadway design,22 and the Manual on Uniform Traffic Control Devices, which contains uniform standards for traffic control devices—date back as far as the late 1920s and 1930s. The primary focus was, and continues to be, on automobile and truck travel (Meyer and Dumbaugh 2004), although highway engineers are being encouraged by AASHTO and the Federal Highway Administration to interpret the guidelines more flexibly to better accommodate nonmotorized travel.

Design guidelines have evolved over the years, and many can accommodate the designs advocated for nonmotorized travel (Meyer and Dumbaugh 2004). The primary barrier appears to lie in how the standards have been implemented. The methods used to evaluate facility design requirements and performance, which are described in the following paragraphs, often tend to emphasize the needs of motorized travel at the expense of other modes (Meyer and Dumbaugh 2004).

The Green Book is entitled A Policy on Geometric Design of Highways and Streets (AASHTO 2001).

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Roadway design starts with a functional classification of highways into two environments—urban and rural—with three classes of roads under each—local roads, collectors, and arterials (AASHTO 2001).23 Embedded in this framework are the competing concepts of access—the ability to travel to and from properties located adjacent to the travel way—and mobility—the ability to travel with a reasonable level of performance (i.e., at uncongested and reliable speeds) (Meyer and Dumbaugh 2004). Both of these concepts are oriented to vehicular travel with little attention to the nonmotorized traveler, who typically travels at low speeds for short distances.

Once a road has been classified, the design speed, or the speed at which motorized vehicles can travel safely on the road, is prescribed (Meyer and Dumbaugh 2004). The design speed then determines the other geometric elements of the road, such as its curvature. With the exception of local streets, the AASHTO Green Book exhorts the engineer to “use as high a design speed as practical” (AASHTO 2001, 67). Thus, many features compatible with pedestrian and bicycle travel, such as lower vehicle speeds and trees adjacent to the travel way, are viewed as limiting vehicular throughput and creating potentially dangerous obstacles should a vehicle leave the road, particularly on higher-speed roads (Meyer and Dumbaugh 2004).

Another decision involved in road design is determination of the “design vehicle,” or the vehicle type that requires the greatest amount of maneuverability on a road. For example, if buses or trucks are expected to use a road, lane widths, turning radii, traffic signal timing, and the like will be oriented to these vehicle types. The resulting design facilitates higher operating and turning speeds for smaller passenger vehicles, which escalate the danger for pedestrians and cyclists who share the roads, and increases street-crossing distances for pedestrians and bicyclists (Meyer and Dumbaugh 2004).

Unpacking the Self: The Physical Self (UTS)

Local roads provide access to land with little or no through movement. Collectors collect traffic from local roads and connect them with higher-speed arterials. Arterials provide the highest level of service at the greatest speed for the longest uninterrupted distance, with some degree of access control (AASHTO 2001).

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The demands placed on municipal street design to accommodate emergency vehicles and the implications for walking and cycling have already been discussed.

Vehicle-oriented performance measures affect both facility design and planned improvements. The level of service (LOS) is used to describe how a transportation facility is performing. It ranges from LOS A, defined as free flow where traffic volumes are low and there is little or no restriction on traffic flow, to LOS F, characterized as highly congested with stop-and-go traffic (AASHTO 2001). A desired LOS is used as a performance criterion in designing a facility and is then incorporated into development site guidelines, local comprehensive plans, and state policies. Existing roads that perform at or below the desired LOS are candidates for capacity enhancements whose primary objective is improved vehicular performance.

It is difficult to change both the vehicular orientation of road design and performance evaluation that favors higher ranges of design standards, which are equated with “better” and “safer” performance, and standardized approaches perceived by engineers as reducing liability claims (Meyer and Dumbaugh 2004). Nevertheless, AASHTO and the Federal Highway Administration have encouraged engineers to take advantage of existing guidelines by designing more flexibly to accommodate such objectives as nonmotorized travel on certain types of roads (see Meyer and Dumbaugh 2004 for further detail). Targeted approaches, such as context-sensitive design24 and special design districts, make it possible to design roads to accommodate adjacent land uses and incorporate nonmotorized users for specific areas and projects without changing the entire underlying system of road classification and design criteria (see Box 4-6 for examples). Care must be taken to implement such projects with the safety of all users—motorized and nonmotorized—in mind so as not to increase the risk of crashes.

Context-sensitive design is a project development process, including geometric design, that attempts to address safety and efficiency while being responsive to or consistent with a road’s natural and human environment.

Factors Influencing Physical fitness and Wellness

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BOX 4-6

Two Examples of More Flexible Transportation Infrastructure Design Approaches

Context-sensitive design. Many state transportation departments are moving toward a more flexible project design process known as context-sensitive design or, more broadly, context-sensitive solutions. This movement began in the late 1990s, when several states launched initiatives to define better ways of designing roadways. Perhaps one of the best definitions of context-sensitive design is found in a technical memorandum from the Minnesota Department of Transportation: “Context sensitive design is the art of creating public works that are well accepted by both the users and the neighboring communities. It integrates projects into the context or setting in a sensitive manner through careful planning, consideration of different perspectives and tailoring designs to particular project circumstances” (Minnesota Department of Transportation 2000). Such efforts are beginning to focus attention on those aspects of infrastructure design in sensitive community contexts that enable greater flexibility in implementing design standards.

Special design districts. Rather than relying on the ability of design professionals to arrive at the desired design ranges, some areas have attempted to circumvent the standardized roadway classification system through the creation of special design districts that indicate the desired dimensions for specific roads. Portland, Oregon, known for its progressive pedestrian orientation, included pedestrian districts as part of its original 1977 Arterial Streets Policy. These districts include special design criteria specifically addressing pedestrian travel (City of Portland 1998).

SOURCE: Meyer and Dumbaugh 2004.

CLASS 12th Unit 1 Topic Factors Affecting Physical Fitness

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Another common approach to accommodating nonmotorized travel is traffic calming. Originating in Europe, these measures are designed to slow traffic speeds in residential neighborhoods and near schools and pedestrian ways through self-enforcing physical devices. Examples are vertical deflections (speed humps and bumps and raised intersections); horizontal deflections (serpentines, bends, and deviations in a road); road narrowing (via neckdowns and chokers); and medians, central islands, and traffic circles (Loukaitou-Sideris 2004). The Institute of Transportation Engineers has developed suggested design guidelines for traffic calming measures encompassing applications, design and installation issues, potential impacts, and typical costs (ITE 2004).

Finally, more creative use of the cul-de-sac could be considered. Cul-de-sac patterns providing greater connectivity could achieve more of the benefits of the street grid pattern while retaining the cul-de-sac’s higher levels of privacy, safety, and quiet and lower construction costs (Southworth and Ben-Joseph 2004). For example, designing residential communities that connected cul-de-sacs and loop streets through a system of pedestrian and bicycle paths would provide better access to parks, schools, and neighborhood shops (Southworth and Ben-Joseph 2004). Retrofitting existing suburban cul-de-sac developments could prove more difficult,25 but “safe pathways” could be designed by using a combination of existing public rights-of-way, sidewalks, and street space in some closer-in suburbs.26

Transportation Infrastructure Financing

Transportation infrastructure financing has been a major factor in the development of the current transportation system. In particu-

Building a pathway system to connect cul-de-sacs in a low-density suburban development would probably require building on private rights-of-way along lot lines. Single-use development limits the variety of destinations, although such paths could be used for exercise (Southworth and Ben-Joseph 2004).

Locating community facilities and services on secondary streets should also improve traffic access for walking and cycling. Care must be exercised, however, not to congest residential areas or create a safety hazard for pedestrians and bicyclists.

Self concept, self identity, and social identity | Individuals and Society | MCAT | Khan Academy

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lar, funding restrictions on use, matching shares, procedural requirements, and design standards all have had important influences on project outcomes. In general, nonmotorized transportation modes and, to a lesser extent, transit have not fared well in traditional programs and policies (Meyer and Dumbaugh 2004).

Funding arrangements differ across transportation modes. Highways have a well-established financing system with a long history of federal assistance, primarily from gas tax revenues set aside in the Highway Trust Fund. Local street and county road improvements, however, are financed from local revenues. Transit funding is a federal and local, and increasingly a state, responsibility. Nonmotorized transportation modes are primarily locally financed.

Different funding arrangements provide different incentives and constraints. For example, for many years the emphasis of federal-aid transportation programs was on highways, and matching requirements for state and local funds mirrored this emphasis. Federal funds financed 90 percent of Interstate highway construction, but only 50 to 80 percent of the cost of constructing transit facilities. In addition, projects using federal funds had to incorporate federally required design criteria. For many projects, this meant building an improved facility—adding more capacity for vehicular travel, for example—rather than simply replacing the existing facility as it was.

State and local funding arrangements vary widely by jurisdiction. For example, state constitutions restrict the majority of state gas tax revenues to highway expenditures. These projects rarely include pedestrian-oriented improvements, such as sidewalks, which are considered the responsibility of local governments or individual landowners (Meyer and Dumbaugh 2004).

Local governments have assumed many responsibilities for transportation financing, including nonmotorized modes. For example, many larger communities finance transit operations with sales tax set-asides approved by voter referendum. Bicycle paths and pedestrian facilities (e.g., street overpasses) are largely a local responsibility or the responsibility of individual landowners (e.g., sidewalks). Local governments can finance such improvements through local taxes or impact fees on new developments but are often reluctant to

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do so because of political backlash. These strategies shift costs directly to local residents (Meyer and Dumbaugh 2004).27

Factors affecting physical Fitness (Environmental conditions)

Since passage of the Intermodal Surface Transportation Efficiency Act of 1991 (ISTEA), the playing field between highways and transit has been leveled significantly. Certain highway funds can be “flexed” for transit and other nonhighway uses, and project matching shares for transit and highways are the same. In addition, several new programs were created that can help finance pedestrian and bicycle projects. One of the principal new funding sources for nonmotorized transportation is the Transportation Enhancements Program, which restricts 10 percent of Surface Transportation Program funds allocated to the states to such improvements as pedestrian and bicycle facilities and roadway beautification (Meyer and Dumbaugh 2004). The Congestion Mitigation and Air Quality Improvement (CMAQ) Program, also created by ISTEA, is aimed at improving metropolitan air quality. Projects such as bicycle, pedestrian, and transit improvements that encourage shifts from single-vehicle travel, thereby reducing vehicle emissions, are eligible for CMAQ funding (Meyer and Dumbaugh 2004). Another source of funding, particularly for enhancing bicycle and pedestrian safety, is the 402 program administered by the National Highway Traffic Safety Administration. Because sidewalks, intersection markings, and bicycle facilities can all be used to improve transportation safety, such projects are eligible for 402 funding (Meyer and Dumbaugh 2004). Finally, opportunities exist to incorporate pedestrian facilities and bicycle paths as part of other projects eligible for federal funding at minor additional cost.

What are physical factors?

Physical factors refer to fitness, skills and tactics. Fitness covers agility, CRE, flexibility and power. These can impact performance in different ways.

In this study note we explain the three related ideas of self-concept, self-image and self-esteem and how emotional development changes through the life stages.

Self-Concept

Self-concept is how someone sees themselves and the perception that they hold about their abilities. There are various factors that can affect self-concept, these include: age, sexual orientation, gender and religion. The self-concept is also made up of a combination of self-esteem and self-image.

Self-esteem refers to a person’s feelings of self-worth or the value that they place on themselves.

There are a number of characteristics of high and low self-esteem.

Characteristics of high self-esteem

Willing to try new things in their life
Can cope well under pressure
Emotionally stable and confident
Happy to share their ideas and experiences

Characteristics of low self-esteem

Feels worthless
Reluctant to try new things
Struggles in new or challenging circumstances
Do not value their own opinions and sensitive to the opinions of others

Factors affecting self esteem

Parents/carers teaching problem solving skills from a young age (so that a child feels a sense of achievement) can lead to a positive self-esteem.
Learning difficulties at school can lead to a child struggling to complete work or maintain friendships, which can lead to negative self-esteem.

Self-Image

Self-image refers to the way an individual sees themselves, both physically and mentally. An individual’s self-image is developed over time and influenced by the experiences they have encountered.

There are a number of characteristics of a positive and negative self-image.

Characteristics of a positive self-image

Feels confident
Compares themselves positively with peers
Content with how they look and has belief in their own ability
Positive feedback received from friends and family on looks and abilities

Characteristics of a negative self-image

Doubts own ability
Compares themselves negatively with peers and images on social media/TV/magazines
Received negative comments from friends and family on physical appearance or mental ability

Factors affecting self-image

Early childhood experiences and social interactions eg parents who pass positive comments to a child can help contribute to a positive self-image.
Life events or roles eg a child who is captain of the rugby team is more likely to have a positive self-image that a child who is bullied at school

Emotional Development through the life stages

Infancy

During this stage, infants develop a sense of self and positive self-esteem through secure attachments with their caregivers. This starts with their basic needs being met as a baby.

Early Childhood

By the age of four, the child’s self-esteem develops further through the support they receive outside of the family. Being able to solve problems through puzzles will enhance self-esteem, as will involving the children in scenarios where their opinion is sought. Children who do not receive these experiences may develop low self-esteem.

Adolescence

Several factors affect self-esteem during adolescence. These can include stress within the home, or at school, or a combination of the two. Coupled with the changes that occur during puberty, these can all have an impact on self-image too.

Being bullied or not being accepted by your peers can have detrimental effects on a young person’s self-esteem and can feed into way they feel about themselves. This can lead to anxiety and depression and a sense of not belonging, all characteristics of having low self-worth. This can be intensified by peer pressure, the use of images in the media, social media and the increase in cyberbullying.

Adulthood

Self-esteem continues to develop through adulthood and an individual’s self-esteem may increase through the achievements they have made which, in turn, increases self-worth. During adulthood a person develops a real understanding of who they are and how to deal with situations more effectively and with more confidence.

UTS Chapter 6 - Physical Self

Heredity: Heredity and genes certainly play an important role in the transmission of physical and social characteristics from parents to off-springs. ...
Sex: Sex is a very important factor which influences human growth and development. .
Socioeconomic: Socioeconomic factors definitely have some affect…

Our physical development is definitely affected due to ,lack of excercise and physical activity,sedentary life style, laziness ,unhealthy careless food habits, self indulgence ,lack of zeal for living .

But the most important is the state of our mind and emotional health, as emotions are what that keep us in motion. Emotions are energy in motion , all our lack of activity ,stem from the state of our emotions .Positive emotions and feelings that emanate from healthy and growth oriented beliefs ,and thoughts ,are what ,create the momentum ,to be in motion and active ,as well as curb ,self indulgence and laziness.Negative emotions manifest as laziness, and unhealthy life styles and attitudes .

The body is lifeless ,if there are no positive emotions to run the wheel s and prime movers in us .

Emotional development is what stimulates physical development .physical activity without emotions is just , movement forced out without any purpose or intent.

What Personal factors can affect your choice of physical?

Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, we now turn to the some of the factors that can affect physical activity. Similar to the factors that can affect ingestive behaviour, there are a host of factors that can significantly affect physical activity:

Socio‐cultural factors

A wide range of socio‐cultural determinants of physical activity exist. These range from factors related to the built environment (e.g. urban sprawl, walkability, street connectivity), neighbourhood safety, social networks, and public transportation to socioeconomic limitations as well as customs and beliefs that can influence vocational or recreational physical activity. For example, being promoted from a physically active outdoor job to a sedentary indoor job, moving from a dense urban location to a rural or suburban residence, immigration to a Western country, pregnancy and change in familial status or time constraints can all promote sedentariness and increase the risk of weight gain. Indentifying and addressing the socio‐cultural barriers to physical activity can be a key to successful weight management. Patients facing significant socio‐cultural barriers to activity may specifically benefit from counselling by an occupational and/or recreational therapist.

Biomedical factors

Numerous medical conditions can lead to a reduction in or inability to engage in physical activity. These include musculoskeletal pain or immobility resulting from injury, osteoarthritis or fibromyalgia as well as any other condition that can affect physical performance such as cardiorespiratory disease, obstructive sleep apnoea, chronic fatigue, stroke or urinary incontinence. Alleviating these factors and thereby reducing immobility may be the first step in addressing weight management in these patients. Given the predominant role of musculoskeletal disorders and pain as a barrier to mobility and physical activity, these patients may benefit most from physiotherapeutic interventions and pain management.

Psychological factors and mental health

Lack of motivation, low energy levels and disinterest in exercise (especially in a previously active individual) can be a symptom of depression. Social anxiety disorder, agarophobia, sleep disorders or substance abuse can all affect physical activity levels. Body image issues and self‐efficacy can likewise pose important psychological barriers that may require specific professional counselling and intervention to promote a more active lifestyle.

Medications

Although published research on this issue is limited, it is reasonable to assume that medications, which reduce energy levels, promote drowsiness, impair coordination or limit cardiorespiratory function can pose significant barriers to physical activity.

Now that we have discussed why it is important to asses the many factors that can affect energy metabolism, ingestive behaviour, and physical activity, in coming posts, we can explore how to apply this framework to patients presenting with weight gain.

@DrSharma

Edmonton, AB

What are five physical factors?

Hey friend here is your answer......⛄⛄

Answer :-

Factors Affecting The Distribution Of Population :

➡️ No single factor can explain the uneven distribution of population in the world .

➡️ It can only be explained through the interaction of different Physical, social, cultural and economic factors .

➡️ The Physical factors include relief, climate natural vegetation, soil and availability of water .

➡️ Other factors include mineral deposit, Industries, transportation, urbanization and migration .

The Five Factors Affecting The Distribution Of Population :

✳️ Relief :

➡️ The Plains support more population than the mountains . This is because the steep mountain slopes restrict the availability of agriculture land and the growth of industries, transportation and settlement .

➡️ Thus, the Ganga Brahmaputra Plains of India are densely populated than the Himalayas .

✳️ Climate :

➡️ Temperature and rainfall influence the concentration of population in any area . Extreme climate discourages concentration while Moderate and severe human settlement .

➡️ Thus , most of the population of Canada lives in a narrow belt in the southern part which is relatively warm climate .

✳️ Soil :

➡️ The fertile Alluvial and black soils are suitable for agriculture as compared to the desert, mountain and Laterite soil .

➡️ Thus , Alluvial and black soils can support more population . The development of ancient civilizations in the River Palace was due to the fertile soil . At present, the introduction of new farming techniques and fertilizers have changed the impact of soil in some areas to some extent .

✳️ Availability of water :

➡️ Rivers are an important source of freshwater . They supply water for domestic uses, agriculture industries and transport .

➡️ Thus, people tend to settle in the river valleys . Even in deserts, permanent settlements are found around oases due to the availability of water .

✳️ Mineral deposits :

➡️ The areas rich in mineral deposits attract people . This results in higher density of population in the mining areas .

➡️ For example, the gold mines in Australia attractive people to this otherwise Barren desert land .

✳️ Transportation :

➡️ The economic activities flourish in those areas which have an adequate and efficient network of transportation . Most of the cities are located in the plains or along the coast, which provide adequate transportation facilities .

➡️ Thus, such places are thickly populated .

✳️ Natural Vegetation :

➡️ Dense and inaccessible forest grow in hot and humid areas . Such dense vegetation discourages human habitation .

➡️ Therefore , the Amazon and the Congo river basins or sparsely populated and have no large settlements .

Hope it helps you if it so please make it as brainliest...... ❤✨❤✨❤

What are the three factors affecting physical fitness?

Exercise Regularity. Depending on the regularity and intensity of the exercises, fitness is promoted.
The diet. Proper nutrition comes from a good diet.
Proper training.
Relaxation and rest.
Illness.
Environment.
Gender and Age.
Lifestyle.

What are the four factors that influence physical fitness?

(i) Heredity. (ii) Nutrition. (iii) Regular exercises. (iv) Body type.

What are the 4 key factors that influence physical activity?

[Purpose] Physical activity influences the prognosis of chronic obstructive pulmonary disease and is influenced by exercise tolerance, and environmental, psychological, and many other factors, but the influence of these factors on physical activity levels in each stage of chronic obstructive pulmonary disease is unknown. This study aimed to clarify this matter. [Participants and Methods] Seventy-one male patients with chronic obstructive pulmonary disease (aged 72.2 ± 4.5 years) participated in this study. We compared physical activity levels (determined as daily steps), presence or absence of daily routine (e.g., housework or hobby), 6-minute walking distance, psychological factors (using the Hospital Anxiety and Depression Scale), and health-related quality of life (Physical and Mental component summary of the 36-item short-form health survey) between patients in different stages of chronic obstructive pulmonary disease. [Results] When examined at each stage of chronic obstructive pulmonary disease, physical activity levels correlated with the presence or absence of daily routine, 6-minute walking distance, and Physical component summary in all stages, but the scores in the anxiety and depression components of the Hospital Anxiety and Depression Scale and Mental component summary correlated only with stage 4. [Conclusion] Physical functioning was related to physical activity levels at any stage of chronic obstructive pulmonary disease, although psychological functioning was related to the progress of disease severity. The approach to promote an active lifestyle must be selected depending on the stage of chronic obstructive pulmonary disease.

Key words: Chronic obstructive pulmonary disease, Physical activity, Daily routine

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INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a progressive airflow limitation that causes air trapping and lung hyperinflation. Airflow limitation causes dyspnea on exertion and exercise intolerance, reduced health-related quality of life, physical inactivity, and impaired psychological functioning. Recently, physical activity has been recognized as a predictor of mortality and a key target for treatment in patients with COPD1,2,3,4). The physical activity of patients with COPD is lower than that in healthy participants5,6,7,8), and it decreases as the disease severity progresses9,10,11,12,13). However, physical activity varies in patients of the same disease stage; some demonstrate high activity levels even in the very severe stage, while others have low activity even when the disease is still mild. Physical activity is influenced by environmental factors, exercise tolerance, psychological factors, and many other factors. However, it is unclear how these different factors influence physical activity in each stage. In addition, no study has examined the factors that influence the physical activity at each stage. This information is necessary to improve physical activity in patients with COPD. We hypothesized that factors affecting physical activity differ at each COPD stage. For example, the treatment methods for improving physical activity at Stage 2 and 4 may be different.

Therefore, the purpose of this study was to clarify the factors affecting physical activity at each stage of COPD, and to clarify their difference.

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PARTICIPANTS AND METHODS

Participants were COPD patients referred to the out-patient clinic of the Komaki City Hospital (Aichi, Japan) between May 2012 and June 2013. However, the season affects physical activity. Therefore, summer and winter were excluded from entry period of this study. The diagnosis of COPD was based on the following criteria: 1) a post-bronchodilator forced expiratory volume in 1 second (FEV1) /forced vital capacity (FVC) ratio ≤0.7; 2) FEV1<80% of predicted.

Inclusion criteria were: 1) stable clinical condition at inclusion, with no infection or exacerbation for at least the previous 3 months; 2) no clinical diagnosis of asthma; 3) absence of other pathological conditions that could impair physical activities in daily life; and 4) no enforcement of pulmonary rehabilitation prior to the investigation.

This study was approved by the ethics committee of the Komaki City Hospital (approval No.091039), and written informed consent was obtained from all of the participants.

Study participants were classified into three groups of stages 2 to 4 using Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification of severity of COPD14). The factors that affect physical activity were examined for each stage.

We collected general information about participants from the medical records and by interviewing participants and their families. Body anthropometry was performed, and measurements of resting lung function were obtained. Physical activity was measured as daily steps using a uniaxial acceleometer sensor. We evaluated physical activity in daily life, living environment factors, exercise tolerance, psychological factors, and health-related quality of life by the following methods. The outcome of this study was the correlation between physical activity and other variables at each stage. In addition, the measured variables were compared between stages.

Spirometry was assessed using the CHESTAC-7800 (Chest Corporation, Tokyo, Japan), according to the American Thoracic Society/European Respiratory Society guidelines15). The parameters evaluated were FVC, FEV1, and the FEV1/FVC. Recorded values were compared with the values predicted for the adult Japanese population.

The physical activity in daily life was evaluated as daily steps using a Lifecorder, a uniaxial accelerometry sensor (Suzuken Corporation, Nagoya, Japan). We instructed the participants about how to use the device by means of a document. The device was attached at the left anterior superior iliac spine using a belt. Participants were required to wear the device throughout the day, except when sleeping or bathing, for 14 consecutive days. The average of the number of steps in 14 consecutive days was used for analysis.

Most of the daily physical activities for COPD patients are related to daily living rather than sports or work. Therefore, it is necessary for physical activity enhancement to follow a daily routine (e.g., housework or hobby). We evaluated the daily routine as a living-environment factor during the baseline personal interview. The daily routine was defined as the doing of housework every day, or doing of work or practicing a hobby for more than 3 days per week, and was classified into 2 categories (presence or absence of daily routine) for analysis.

We evaluated exercise tolerance using the 6-minute walking test (6MWT). The 6MWT was conducted using the protocol described by American Thoracic Society (ATS)16). The 6-minute walking distance (6MWD) was used for analysis.

Anxiety and depression were measured using the Japanese Version of the Hospital Anxiety and Depression Scale (HADS). The HADS consists of anxiety and depression subscales, each of which contains 7 items17). These subscales provide anxiety and depression scores (range: 0−21). It has been reported that increase or decrease of 1 point in these scores is related to the steps per day18). Therefore, anxiety and depression scores were used for analysis. In addition, a score ≥8 on either scale indicates clinically relevant anxiety or depression17). We examined the proportion of patients with anxiety or depression score >8 points for each stage.

HRQL were measured using the medical outcome study short-form 36-item health survey (SF-36). The SF-36 is a self-administered questionnaire comprising 36 questions. The SF-36, with eight scales, can be summarized by the physical (PCS) and mental (MCS) component summary scores. The scores of these 2 summary components were calculated using a Japanese version of the scoring program. PCS and MCS were used for analysis.

Data analysis was performed using statistical software (SPSS 23.0, SPSS, Armonk, NY, USA). Data are presented as mean and standard deviation (SD). All variables were compared among the stages of COPD using the Kruskal-Wallis test. When differences were detected, Scheffe’s method was used for making multiple comparisons. The proportion of patients with a daily routine and depression of HADS were compared using the χ2 test. Daily steps were compared between patients with and without a daily routine using the Mann-Whitney U test. The correlation between the daily steps and other variables at each stage was determined by calculating the Spearman’s rank correlation test. A p-value <0.05 was considered to be significant for all statistical analyses.

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RESULTS

Patient characteristics are summarized in Table 1. Seventy-one patients were included in this study and no patients dropped out. All the patients were males. Participants were grouped into 3 disease stages, based on the Global Initiative for Chronic Obstructive Lung Disease spirometry classification14): stage 2: 17 patients (23.9%), stage 3: 28 patients (39.4%), stage 4: 26 patients (36.7%). There were no significant differences in the age, body mass index (BMI), and pack-years of smoking (p=0.06, 0.09, 0.45, respectively).

Table 1.

Patient characteristics

Stage 2(n=17) Stage 3(n=28) Stage 4(n=26)

Age (yrs) 73.7 ± 4.4 73.1 ± 3.7 70.4 ± 4.9

Height (cm) 158 ± 7.1 160 ± 5.8 160 ± 5.8

Weight (kg) 54.0 ± 8.4 53.2 ± 8.8 50.1 ± 6.4

BMI (kg/m2) 21.1 ± 2.8 20.5 ± 3.1 19.0 ± 2.2

Pack years of smoking 60.7 ± 23.2 62.2 ± 22.5 68.0 ± 25.9

FVC (l) 3.26 ± 0.87 2.86 ± 0.6 2.58 ± 0.48 ‡

FVC % predicted (%) 100.9 ± 24.6 86.0 ± 18.5 78.2 ± 15.4 ‡

FEV1 (l) 1.76 ± 0.35 1.09 ± 0.19 † 0.68 ± 0.14 ‡§

FEV1 % predicted (%) 62.4 ± 7.7 40.0 ± 6.1 † 23.3 ± 4.8 ‡§

FEV1 / FVC (%) 55.1 ± 11.0 40.0 ± 5.5 † 29.4 ± 4.0 ‡§

All data are presented as mean ± SD, †p<0.05 stage 2 vs. stage 3, ‡p<0.05 stage 2 vs. stage 4, §p<0.05 stage 3 vs. stage 4.

BMI: Body mass index; FVC: Forced vital capacity; FEV1: Forced expiratory volume in one second.

The comparison of measurements among COPD stages are shown in Table 2. Daily steps tended to decrease with a progression of COPD severity; however, there was no significant difference among the 3 stages (p=0.08).

Table 2.

Comparison of measurements between stage of COPD

Stage 2 (n=17) Stage 3 (n=28) Stage 4 (n=26)

Steps/day 5,138 ± 2,098 4,480 ± 1,684 3,779 ± 2,062

Daily routine Presence: 10 Presence: 21 Presence: 13

Absence: 7 Absence: 7 Absence: 13

6MWD (m) 417 ± 77.2 410 ± 79.8 359 ± 75.0 ‡§

HADS

Anxiety score 1.6 ± 1.4 2.2 ± 1.5 4.8 ± 2.9 ‡§

Anxiety score ≥8, n (%) 0 (0%) 0 (%) 7 (27%)

Depression score 3.6 ± 2.3 4.7 ± 3.0 7.0 ± 3.2 ‡§

Depression score ≥8, n (%) 2 (12%) 7 (25%) 12 (46%)

SF-36

PCS 41.2 ± 6.6 38.9 ± 7.9 30.8 ± 8.0 ‡§

MCS 54.4 ± 3.7 53.0 ± 2.6 46.2 ± 6.3 ‡§

All data are presented as mean ± SD, ‡p<0.05 stage 2 vs. stage 4, §p<0.05 stage 3 vs. stage 4.

6MWD: Six-minute walk distance; HADS: Hospital Anxiety and Depression Scale; SF-36: Short-form 36-item health survey; PCS: Physical component summary; MCS: Mental component summary.

The percentages of the presence of a daily routine were as follows: COPD stage 2, 58%; stage 3, 75%; stage 4, 50%; these did not differ significantly among the stages (p=0.16).

The 6MWD tended to decrease with the progress of COPD severity. The 6MWD was significantly lower in individuals with COPD stage 4 than in those with stages 2 and 3 (both p<0.05). However, there was no significant difference in 6MWD between stages 2 and 3 (p=0.97).

The HADS anxiety and depression scores tended to increase with the progress of disease severity. The anxiety and depression scores were significantly higher in individuals with COPD stage 4 than in those with stages 2 and 3 (both p<0.05). However, there was no significant difference in anxiety and depression scores between stage 2 and 3 (p=0.61, 0.49, respectively). The number of patients with an anxiety score ≥8 points was 0 (0%) at stage 2, 0 (0%) at stage 3, and 7 (27%) at stage 4. The number of patients who had a depression score ≥8 points was 2 (12%) at stage 2, 7 (25%) at stage 3, and 12 (46%) at stage 4. These differences among the stages were significant (p<0.01).

The PCS and MCS of the SF-36 were significantly lower in patients with COPD stage 4 than in those with stage 2 and 3 (both p<0.05). However, there was no significant difference in PCS and MCS between stage 2 and 3 (p=0.78, 0.56, respectively).

The relationship between the daily steps and a daily routine is shown in Table 3. At all stages, the group with a daily routine had a significantly higher level of daily steps than the group without a daily routine (p<0.01, respectively).

Table 3.

Comparison with the daily physical activity between presence and absence of daily routine

Presence Absence

Stage 2 6,215 ± 1,865 3,597 ± 1,344 *

Stage 3 5,155 ± 1,340 2,454 ± 620 *

Stage 4 5,274 ± 1,846 2,284 ± 781 *

All data are presented as mean ± SD, *p<0.01.

Presence: presence of daily routine; Absence: absence of daily routine.

The relationship between the daily steps and other variables at each stage are shown in Table 4. When examined in all patients, daily steps were correlated with all variables (r=−0.5 to 0.75, p<0.01, respectively). When examined at each stage of COPD, these were different among the stages.

Table 4.

Relationship between daily physical activity and 6MWD, HADS and SF-36 scores

All patients(n=71) Stage 2 (n=17) Stage 3 (n=28) Stage 4 (n=26)

6MWD (m) r=0.75 ** r=0.54 * r=0.75 ** r=0.86 **

HADS

Anxiety r=−0.5 ** r=−0.32 r=−0.32 r= −0.62 **

Depression r=−0.61 ** r=−0.23 r=−0.54 * r= −0.85 **

SF-36

PCS r=0.72 ** r=0.84 ** r=0.63 ** r=0.76 **

MCS r=0.44 ** r=0.13 r=0.12 r=0.82 **

All data are presented as mean ± SD, *p<0.05, **p<0.01.

6MWD: Six-minute walk distance; HADS: Hospital Anxiety and Depression Scale; SF-36: Short-form 36-item health survey; PCS: Physical component summary; MCS: Mental component summary.

In patients with COPD stage 2, daily steps were significantly correlated only with 6MWD and PCS (r=0.54, p<0.05, r=0.84, p<0.01). In patients with COPD stage 3, daily steps were significantly correlated with 6MWD, PCS and depression of HADS (r=0.75, p<0.01, r=−0.54, p<0.05, r=0.63, p<0.01). In patients with COPD stage 4, daily steps were significantly correlated with all variables (r=−0.62 to 0.86, p<0.01, respectively).

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DISCUSSION

Physical activity is an important determinant of the clinical condition, progression, and outcome of patients. Physical activity is influenced by environmental factors, exercise tolerance, psychological factors, and many other factors. However, it is unclear how these different factors influence physical activity at each stage. In addition, no study has examined the factors that influence the physical activity at each stage. Therefore, the purpose of this study was to examine the factors affecting physical activity at each stage of COPD and their characteristics.

The results of this study show that there was no significant decrease in physical activity among the stages of COPD. Many studies have reported that physical activity decreases as COPD severity increases9,10,11,12,13). However, the level of physical activity was not significantly different among the stages of COPD in this study. We hypothesize that this may be attributed to an equal distribution of patients with and without a daily routine across all stages of COPD. Most daily physical activities for patients with COPD are related to daily living rather than sports or work. Therefore, we considered that the presence of a daily routine was related to the level of physical activity at any stage of the disease.

Another result was that the variables related to psychological function did not decrease in stage 2, but there was a strong decline in stage 4. van Manen et al.19) have reported that patients with severe COPD had an increased risk of depression compared with non COPD, while those with mild to moderate COPD were not at an increased risk. In addition, it has been reported that psychological function is related to physical activity12, 18, 20). The results of this study indicated that it is more important to treat psychological functioning in patients with COPD stage 4 than in those with less severe COPD.

When examined in all patients, physical activity was correlated with all variables. However, when examined at each stage of COPD, variables correlated with physical activity were different among the stages.

Across all stages of COPD, daily physical activity was greater when a daily routine was present. These results suggest that the existence of a daily routine is very important for ensuring an active life. Housework can enhance physical activity in life by the performance of routine work, while a hobby can enhance physical activity by extending the range of activities. It is likely that these activities are not easily influenced by disease severity, as they can be performed at the patient’s own pace. This result suggests that establishing daily routine may be more effective in improving physical activity than exercise training.

Physical activity level was related to 6MWD and PCS at any stage of COPD in this study. Many studies have reported on the relationship between exercise tolerance and physical activity. Pitta et al.5) have reported that there is a strong association between functional capacity and physical activity. Sewell et al.21) stated that the improvement of physical functioning is important in the improvement of domestic functioning and physical activity levels. Physical activity levels were related to physical functioning in this study. These results suggest that, although the daily routine provides motivation for an active life, exercise tolerance is required for active life.

The prevalence of depression in COPD is higher than in normal participants, and is associated with COPD severity22). Recently, many studies have reported that depression is the main factor for daily inactivity23,24,25,26). However, these reports did not investigate this per stage of COPD. In the present study, we found that physical activity was related to anxiety and depression in stage 4, to depression in stage 3, and was not related to any psychological factors in stage 2 COPD patients. In addition, the results of the MCS were the same. These results suggest that psychological factors had a greater influence on physical activity as COPD severity progressed. Di Marco et al.25) have reported that the depressed COPD patients have a reduced daily and maximal exercise capacity compared to non depressed patients. Miravitlles et al.26) have reported that adequate treatment of depressed COPD patients could help to increase adherence to physical activity recommendations and improve the HRQOL and functional status.

For the above reasons, we recommend a change to the approaches taken to encourage an active life according to the disease stage. Exercise training and a daily routine would be better for motivating patients to live an active life at all stages. Pulmonary rehabilitation as well as activity goal setting using a pedometer may be effective for making behavioural changes27,28,29,30). In stage 4 COPD, it would be better to include mental support in addition to conventional treatment. Understanding and controlling breathlessness during activities may help to relieve their anxiety and depression, and lead to increased physical activity31). The use of social support and participation in community activities may be a benefical methods for improving motivation to activities. However, at present, we do not know the effective treatment methods for such patients. We consider that the further research is required.

There were some limitations to consider in this study. First, since the sample only included male patients, we cannot apply the results to the female patients. Although the prevalence of COPD is increasing in female, in Japan, it is still much more prevalent in male. Therefore, we could not recruit female patients with COPD. Another limitation of the study was the relatively small sample size. We need further studies involving larger sample size.

In conclusion, factors influencing physical activity were different at each stage of COPD. We found that physical functioning is related to physical activity levels at any stage of COPD, although psychological functioning was related to the progress of disease severity. We recommend that the approach for promoting an active life be modified according to the stage of COPD.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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Conflict of interest

The authors report no conflicts of interest in this work.

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What are physical factors affecting health?

The previous chapters of this report focused on health systems and individual and household-level risks that might explain the U.S. health disadvantage, but it has been increasingly recognized that these health determinants cannot be fully understood (or influenced) in isolation from the environmental contexts that shape and sustain them. In contrast with traditional environmental health approaches that focus primarily on toxic substances in air, water, and soil, this more recent approach conceptualizes the environment more broadly to encompass a range of human-made physical and social features that are affected by public policy (Frumkin, 2005). These economic, social, urban or rural, transportation, and other policies that affect the environment were not traditionally thought of as relevant to health policy but are now attracting greater attention because decision makers are beginning to recognize their health implications (Cole and Fielding, 2007).

By definition, environmental factors affect large groups that share common living or working spaces. Thus, they are key candidates as explanatory factors for health differences across geographic areas, such as countries. Indeed, a major motivation for the research on environmental determinants of health has been the repeated observation that many health outcomes are spatially patterned. These patterns are present across countries and across regions within countries, as well as at smaller scales, such as across urban neighborhoods (Center on Human Needs, 2012b; Kawachi and Subramanian, 2007). Strong spatial variation is present for a large range of health outcomes, including many of the outcomes for which there are cross-national health differences, such as noncommunicable diseases, associated risk factors, injuries, and violence.

Understanding the reasons for the spatial patterns of health within countries may shed light on environmental factors that may contribute to differences across countries. Several factors may explain the strong spatial patterns that are observed within countries. A key contender is the spatial sorting of people based on their socioeconomic position, race, or ethnicity. However, evidence suggests that regional and neighborhood differences in health persist even after adjusting for these socioeconomic and demographic factors (Diez Roux and Mair, 2010; Mair et al., 2008; Paczkowski and Galea, 2010; Pickett and Pearl, 2001). This evidence suggests that broad environmental factors may play an important role in health. Moreover, environmental factors linked to space and place may in turn contribute to and reinforce socioeconomic and racial or ethnic health disparities (Bleich et al., 2012; Laveist et al., 2011). Thus, individual and environmental factors may be part of a reinforcing cycle that creates and perpetuates health differences. These reinforcing processes by which environmental factors and individual-, family-, and community-level factors reinforce each other over time may also play an important role in generating cross-national differences in health.

This chapter focuses on both the physical and social environment in the United States as potential contributors to its health disadvantage relative to other high-income countries. This chapter, like others before it, focuses on three questions:

Do environmental factors matter to health?
Are environmental factors worse in the United States than in other high-income countries?
Do environmental factors explain the U.S. health disadvantage?

QUESTION 1. DO ENVIRONMENTAL FACTORS MATTER TO HEALTH?

Many aspects of the physical and social environment can affect people’s health.1 Spatial contexts linked to regions or neighborhoods are among the most frequently studied,2 but other contexts may also be important for certain segments of the population.3

Physical Environmental Factors

The factors in the physical environment that are important to health include harmful substances, such as air pollution or proximity to toxic sites (the focus of classic environmental epidemiology); access to various health-related resources (e.g., healthy or unhealthy foods, recreational resources, medical care); and community design and the “built environment” (e.g., land use mix, street connectivity, transportation systems).

The environment can affect health through physical exposures, such as air pollution (OECD, 2012b). A large body of work has documented the effects of exposure to particulate matter (solid particles and liquid droplets found in the air) on cardiovascular and respiratory mortality and morbidity (Brook et al., 2010; Laumbach and Kipen, 2012; Mustafić et al., 2012; Tzivian, 2011). Research has identified specific physiologic mechanisms by which these exposures affect inflammatory, autonomic, and vascular processes (Brook et al., 2010; Tzivian, 2011).

The effects of particulate matter on mortality appear to be consistent across countries. For example, a recent review of studies from the late 1990s to mid-2000s found a consistent inverse relationship between airborne particulate matter and birth weight in Australia, Brazil, Canada, France, Italy, the Netherlands, South Korea, the United Kingdom, and the United States (Parker et al., 2011a). Another notable example is the evidence linking lead exposures to cognitive development in children (Bellinger, 2008; Levin et al., 2008). The evidence of environmental effects of air pollution and lead has been reflected in legislation in many countries directed at reducing levels of these pollutants in the environment.

Increasing attention has focused on the implications for health behaviors and social interactions that are created by the built environment. The built environment refers to the presence of (and proximity to) health-relevant resources as well as to aspects of the ways in which neighborhoods are designed and built (including land use patterns, transportation systems, and urban planning and design features). An important example is evidence that links proximity to healthy or unhealthy food stores with dietary behaviors and related chronic disease outcomes (Babey et al., 2008; Larson et al., 2009; Moore et al., 2008; Morland et al., 2006).4 Food availability and food advertising influence energy intake and the nutritional value of foods consumed (Grier and Kumanyika, 2008; Harris et al., 2009; Institute of Medicine, 2006a).

Another large body of work has documented how walking and physical activity levels are affected by access to recreational facilities, land use mix, transportation systems, and urban planning and design (Auchinloss et al., 2008; Diez Roux et al., 2001; Ding et al., 2011; Durand et al., 2011; Gordon-Larsen et al., 2006; Heath, 2009; Kaczynski and Henderson, 2008; McCormack and Shiell, 2011; Transportation Research Board, 2005). Studies conducted in the United States and other high-income countries have found that “walkability” (which is measured by such proxies as building density, land use mix, and street connectivity) predicts walking patterns (Durand et al., 2011; Inoue et al., 2009; Sundquist et al., 2011; Van Dyck et al., 2010). Across countries, studies have also shown that physical activity by children is associated with features of the built environment, including walking-related features, and physical activity resources (Bringolf-Isler et al., 2010; Davison and Lawson, 2006; Galvez et al., 2010; Sallis and Glanz, 2006).5

Although more definitive evidence is needed (see Feng et al., 2010), it has been hypothesized that these environmental features may contribute to the obesity epidemic (Galvez et al., 2010; Papas et al., 2007; Sallis and Glanz, 2009). The importance of residential environments to obesity and related conditions, such as diabetes, was recently highlighted by a randomized housing intervention: low-income participants who were randomly assigned to move into low-poverty areas experienced significant improvements in weight and diabetes indicators (Ludwig et al., 2011). Unfortunately, the study was not designed to identify the specific environmental features responsible for the observed effect.

A range of other physical environmental features have been linked to other health outcomes. For example, the density of alcohol retail outlets has been linked to alcohol-related health complications (Campbell et al., 2009; Popova et al., 2009), including injury and violence (Cunradi et al., 2012; Toomey et al., 2012). Transportation systems and other aspects of physical environments that influence driving behaviors are also related to injury morbidity and mortality (Douglas et al., 2011). Living in socioeconomically disadvantaged neighborhoods (as a proxy for a range of environmental exposures) has been linked to higher rates of injury in both adults and children (Cubbin et al., 2000; Durkin et al., 1994).

Social Environmental Factors

Factors in the social environment that are important to health include those related to safety, violence, and social disorder in general, and more specific factors related to the type, quality, and stability of social connections, including social participation, social cohesion, social capital, and the collective efficacy of the neighborhood (or work) environment (Ahern and Galea, 2011).6 Social participation and integration in the immediate social environment (e.g., school, work, neighborhood) appear to be important to both mental and physical health (DeSilva et al., 2005). What also seems important is the stability of social connections, such as the composition and stability of households7 and the existence of stable and supportive local social environments or neighborhoods in which to live and work.

A network of social relationships is an important source of support and appears to be an important influence on health behaviors. Work on the “transmission” of obesity through social networks has highlighted the possible importance of social norms in shaping many health-related behaviors (Christakis and Fowler, 2007; Hruschka et al., 2011; Kawachi and Berkman, 2000).8 A long tradition of sociological research links these social features not only to illness, but also to risks of violence (Morenoff et al., 2001; Sampson et al., 1997). Social environments may also operate through effects on drug use, which also has consequences for violence and mental-health-related outcomes.9

Neighborhood conditions can create stress (Cutrona et al., 2006; Do et al., 2011; Merkin et al., 2009), which have biological consequences (see Chapter 6). Features of social environments that may operate as stressors (including perceptions of safety and social disorder) have been linked to mental health, as have factors that could buffer the adverse effects of stress (e.g., social cohesion, social capital) (DeSilva et al., 2005; Mair et al., 2008).

One mechanism through which the social environment can enhance health is through social support. Social support has appeared in many (but not all) studies to buffer the effects of stress (Cohen and Wills, 1985; Matthews and Gallo, 2011; Ozbay et al., 2007, 2008). Resilience to the adverse health effects of stress has also been tied to factors that could influence how one perceives a situation (threat versus challenge) and how one responds to stressors (Harrell et al., 2011; Hennessy et al., 2009; Matthews and Gallo, 2011; Ziersch et al., 2011). One theory for the tendency of some immigrant groups to have better health outcomes than might be expected on the basis of their incomes and education (see Chapter 6) is the social support immigrants often provide one another (Matthews et al., 2010).

Social capital refers to “features of social organization, such as trust, norms, and networks, that can improve the efficiency of society by facilitating coordinated actions” (Putnam, 1993, p. 167). Studies have shown consistent relationships between social capital and self-reported health status, as well as to some measures of mortality (Barefoot et al., 1998; Blakeley et al., 2001; Kawachi, 1999; Kawachi et al., 1997; OECD, 2010c; Schultz et al., 2008; Subramanian et al., 2002). Social capital depends on the ability of people to form and maintain relationships and networks with their neighbors. Characteristics of communities that foster distrust among neighbors, such as neglected properties and criminal activity, can affect both the cohesiveness of neighbors as well as the frequency of poor health outcomes (Center on Human Needs, 2012b).

Spatial Distribution of Environmental Factors

In addition to considering differences between the United States and other countries in the absolute levels of environmental factors, it is also important to consider how these factors are distributed within countries. Levels of residential segregation shape environmental differences across neighborhoods (Reardon and Bischoff, 2011; Subramanian et al., 2005). Neighborhoods with residents who are mostly low-income or minorities may be less able to advocate for resources and services. Perceptions and stereotypes about area reputation, local demand for products and services, and the purchasing power of residents may also influence the location of health-relevant resources. Physical environmental threats (such as proximity to hazardous sites) may be more prevalent in low-income or minority neighborhoods, a concern of the environmental justice movement (Brulle and Pellow, 2006; Evans and Kantrowitz, 2002; Mohai et al., 2009; Morello-Frosch et al., 2011). These neighborhoods may also lack the social connections and political power that can help remedy adverse conditions.

Other Environmental Considerations

The panel focused its attention on the role of local physical and social environments as potential contributors to the U.S. health disadvantage and did not systematically examine whether other contexts, such as school or work environments, differ substantially across high-income countries. Nor did the panel examine whether neighborhood conditions exert a greater influence on access to health care in the United States than in peer countries. However, these conditions are important to health. For example, the school environments of children, adolescents, and college students can affect diet, physical activity, and the use of alcohol, tobacco, and other drugs (Katz, 2009; Wechsler and Nelson, 2008). Dietary options on cafeteria menus and in vending machines, opportunities for physical activity, and health education curricula are all important to children’s health.

Workplaces have also long been recognized as important determinants of health and health inequalities, occupational safety, and access to preventive services (Anderson et al., 2009; Schulte et al., 2011). Physical working conditions (e.g., exposure to dangerous substances, such as lead, asbestos, mercury), as well as physical demands (e.g., carrying heavy loads), human factors, and ergonomic problems can affect the health and safety of employees. Stressful psychosocial work environments and “job strain”—which refers to high external demands on a worker with low levels of control or rewards—have become recognized as prominent determinants of health and have been linked to self-reported ill health (Stansfeld et al., 1998), adverse mental health outcomes (Clougherty et al., 2010; Low et al., 2010; Stansfeld and Candy, 2006), and markers of chronic disease (Fujishiro et al., 2011). Exposure to job strain exhibits a strong social gradient, which influences inequalities in the health of workers (Bambra, 2011).10

Although the panel did not undertake a systematic comparison of workplace conditions in the United States and other countries, it did note that U.S. employees work substantially longer hours than their counterparts in many other high-income countries. In 2005, annual hours worked in the United States were 15 percent higher than the European Union average (OECD, 2008a). Other working conditions and work-related policies for U.S. employees often differ from those of workers in peer countries. For example, U.S. workers have a larger gender gap in earnings, which could potentially affect the health of women, and U.S. workers spend more time commuting to work (OECD, 2012g), which decreases cardiorespiratory fitness (Hoehner et al., 2012). Other important differences in work-related policies include employment protection and unemployment benefits, as well as family and sickness leave (see Chapter 8). However, cross-national comparisons of workplace safety, other occupational health characteristics, labor market patterns, and work-related policies were beyond the scope of the panel’s review.

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QUESTION 2. ARE ENVIRONMENTAL FACTORS WORSE IN THE UNITED STATES THAN IN OTHER HIGH-INCOME COUNTRIES?

There is scant literature comparing social and physical environmental features across countries. Here we provide selected examples of the ways in which levels or distributions of physical and social environments relevant to health might differ between the United States and other high-income countries.

Physical Exposures

Few data are available to make cross-national comparisons of exposure to harmful physical or chemical environmental hazards. There is, for example, little evidence that air pollution is a more severe problem in the United States than in other high-income countries (Baldasano et al., 2003; OECD, 2012a; Parker et al., 2011a).11 Although cross-national comparisons of the volume of emissions and carbon production per gross domestic product show that the United States is a major emitter, this finding does not provide a basis for comparing the cleanliness or healthfulness of air, water, or other resources. The heavy reliance on automobile transportation in the United States is linked to traffic levels, which contribute to air pollution and its health consequences (Brook et al., 2010; Laumbach and Kipen, 2012). Data on population exposures to air pollution across countries are relatively scarce (OECD, 2008b). One available measure is the concentration of particulate matter less than 10 micrometers in diameter (PM-10):12 in the United States, the concentration of PM-10 levels is 19.4 micrograms per cubic meter, lower than the OECD average of 22 micrograms per cubic meter (OECD, 2012a).

An important factor that influences a range of environmental features relates to patterns of land use and transportation. In general, U.S. residential environments are highly dominated by Americans’ reliance on private automobile transportation. This characteristic has promoted dispersed automobile-dependent development patterns (Transportation Research Board, 2009) with consequences for population density, land use mix, and walkability (Richardson, 2004), all of which may have health implications. In 2008, the United States had 800 motor vehicles per 1,000 people compared with 526 in the United Kingdom, 521 in Sweden, 598 in France, and 554 in Germany (World Bank, 2012b). Cities in the United States tend to be less compact and have fewer public transportation and nonmotorized travel options and longer commuting distances than cities in other high-income countries (Richardson and Bae, 2004). Many European countries have strong antisprawl and pro-urban centralization policies that may contribute to environments that encourage walking and physical activity as part of daily life (Richardson and Bae, 2004).13

Social Factors

International comparisons of the social environment are complicated by difficulties in obtaining comparable measures of social environments. For example, aside from their direct links to injury mortality (see Chapter 1), violence and drug use may be indirect markers of social environmental features that affect other health outcomes. As noted in Chapters 1 and 2, homicide rates in the United States are markedly higher than in other rich nations. There are fewer data to compare rates of other crimes across countries. As noted in Chapter 5, certain forms of drug use (which is often linked to other social environmental features) also appear to be more prevalent in the United States than in other high-income countries.

Although Chapter 6 documented a long-standing trend of greater poverty and other social problems in the United States than in peer countries, evidence is more limited to compare these countries in terms of social cohesion, social capital, or social participation. For example, OECD data indicate that the United States has the highest prevalence of “pro-social behavior,” defined as volunteering time, donating to charities, and helping strangers (OECD, 2011e). At least one study of cross-national differences in social capital found that the United States ranked at an intermediate level compared with other high-income countries in measures of interpersonal trust; the study also found that the United States ranked higher than many other countries on indicators of membership in organizations (Schyns and Koop, 2010). A previous National Research Council (2011) report and a paper prepared for that study (Banks et al., 2010) did not find much evidence that the United States had unique social networks, social support, or social integration. However, the focus of that paper was on the social isolation of individuals rather than on social cohesion or social capital measured as a group-level construct. Other data indicate that nearly 3 percent of people in the United States report “rarely” or “never” spending time with friends, colleagues, or others in social settings. This figure is one of the lowest in the OECD (2012a).

On another measure, OECD data suggest that levels of trust14 are lower in the United States than the OECD average and than in all peer countries but Portugal, with Nordic countries showing the highest levels (OECD, 2011e). According to the World Gallup Poll, people in the United States are less likely than people in other high-income countries to express confidence in social institutions, and Americans also have the lowest voting participation rates of OECD countries.

In an interesting link between physical and social environments, Putnam (2000) has argued that increasing sprawl could contribute to declining social capital in the United States because suburban commutes leave less time for social interactions. However, it remains unclear whether sprawl helps explain differences in levels of social capital, or health, across countries.

Spatial Distribution of Environmental Factors

Research in the 1990s demonstrated that people of low socioeconomic status were more likely to experience residential segregation in the United States than in some European countries (Sellers, 1999). More recent evidence also suggests that residential segregation by income and neighborhood disadvantage has been increasing over time in the United States (Reardon and Bischoff, 2011). Given the established correlation between neighborhood, race, and socioeconomic composition and various health-related neighborhood resources in the United States, this greater segregation could also result in greater exposure of some population sectors to harmful environments (Lovasi et al., 2009). Although studies of residential segregation do not directly assess environmental factors, to the extent that segregation is related to differences in exposure to environmental factors, countries with greater segregation may also experience greater spatial inequities in the distribution of environmental factors, resulting in greater health inequalities and possible consequences for overall health status. Studies that use measures of area socioeconomic characteristics as proxies for environmental features have generally reported similar associations of area features with health in both the United States and other countries (van Lenthe et al., 2005), but there is some evidence that area effects may be greater in countries, like the United States, which have relatively greater residential segregation (Moore et al., 2008; Stafford et al., 2004).

At least two studies have suggested that spatial variation in health-related resources may have very different distributions in the United States than in other countries. A review of spatial variability in access to healthy foods found that food deserts—areas with limited proximity to stores that sell healthy foods—were more prevalent in the United States than in other high-income countries (Beaulac et al., 2009). A New Zealand study found that area deprivation was not always consistently associated with lack of community resources (including recreational amenities, shopping, educational and health facilities) (Pearce et al., 2007). This finding is in sharp contrast to studies of the United States, which have found associations between neighborhood socioeconomic disadvantage and the absence of resources that are important to public health (Diez Roux and Mair, 2010).

Large geographic disparities in toxic exposures to environmental hazards and in healthy food access have been repeatedly noted in U.S. communities (Diez Roux and Mair, 2010; Mohai et al., 2009; Pastor et al., 2005). Similar geographic disparities may exist for other environmental features. For example, the distribution of walkable environments may be more variable in the United States than in other countries, creating “unwalkable” islands, where walking is not a viable transportation alternative to driving. These barriers may inhibit physical activity for parts of the population, resulting in worse overall health. Levels of safety and violence may also be more strongly spatially segregated in the United States than in other countries, resulting in areas with greater exposure to violence and its harmful health consequences.

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QUESTION 3. DO ENVIRONMENTAL FACTORS EXPLAIN THE U.S. HEALTH DISADVANTAGE?

Although no studies have collected the necessary data to determine directly the contribution of the environment to the U.S. health disadvantage, existing evidence on the health effects of environmental factors and on differences in levels and distributions of environmental factors between the United States and other high-income countries suggest that environmental factors could be important contributors to the U.S. health disadvantage. Below we review the possible contributions of the environment to major conditions for which U.S. health disadvantages have been documented.

Obesity, Diabetes, and Cardiovascular Disease

Environmental factors that affect physical activity (primarily through their effect on active life-styles, including walking) and access to healthy foods (rather than calorie-dense foods) may help explain differences in obesity and related conditions between the United States and other high-income countries. As noted above, land use patterns and transportation systems differ starkly between the United States and other high-income countries (Richardson and Bae, 2004; Transportation Research Board, 2009). Transportation behavior also differs between the United States and other high-income countries, with U.S. residents walking and cycling substantially less than Europeans (Bassett et al., 2008; Buehler et al., 2011; Hallal et al., 2012). For example, analyses of comparable travel surveys show that between 2001–2002 and 2008–2009, the proportion of “any walking” was stable in the United States, at 18.5 percent, while it increased in Germany from 36.5 to 42.3 percent. The proportion of “any cycling” was extremely low and stable in the United States, at 1.8 percent, while it increased in Germany from 12.1 to 14.1 percent. There was also less variation in active travel among socioeconomic groups in Germany than in the United States (Buehler et al., 2011). Although the precise effects of these transportation differences on people’s energy expenditure is difficult to quantify, it seems reasonable to expect that different transportation patterns would have important implications for U.S. levels of obesity (Pucher et al., 2010a).

The food intake of the U.S. population is influenced by both supply and demand, particularly food availability, advertising, and other aspects of the way in which meals are socially produced, distributed, and consumed (including mass production and marketing of cheap calorie-dense foods and large portion sizes) (Institute of Medicine, 2006a; Nestle, 2002; Story et al., 2008).15 In addition, there is evidence that food access is more inequitably distributed in the United States than in other high-income countries (Beaulac et al., 2009; Franco et al., 2008; Moore and Diez Roux, 2006), which may create problems of food access for vulnerable populations.

Importantly, these various features of the physical environment may act synergistically, reinforcing their effects and creating an “obesogenic” environment that affects all U.S. residents, at least to some extent. In addition, these environmental effects may contribute to the development of social norms regarding behaviors and weight (Christakis and Fowler, 2007), which then reinforce certain features of the physical environment, making them increasingly difficult to modify. This reinforcement creates a vicious cycle in which the environment contributes to the development of social norms (such as reliance of automobile transportation) and the behavior resulting from the norm reinforces the environmental features (such as absence of bicycle lanes or public transportation) that sustain it.

Injuries

The dominant land use and development pattern espoused in the United States for decades (Richardson and Bae, 2004) has created dependence on private automobile transportation, with important implications for traffic volume and associated traffic injuries and fatalities (Transportation Research Board, 2009). Once established, the land use patterns and transportation systems are self-reinforcing and may in turn hinder the development of efficient and inexpensive public transportation alternatives. A physical environment that promotes and incentivizes automobile transportation also reinforces social norms regarding travel, which complicates efforts to modify the patterns. The existing land use patterns and reliance on private automobile transportation not only contribute to traffic volume and injury fatalities, but probably also contribute to physical inactivity, air pollution, and carbon emissions. In this way, a common physical environmental feature may explain the coexistence of the U.S. health disadvantage on apparently unrelated health domains (obesity and injuries).

Homicides, Violence, Drug-Related Deaths, and HIV Risk

Environmental factors, broadly defined, may also contribute to at least part of the U.S. health disadvantage in homicide, violence, and drug-related deaths. As noted above, residential segregation by income in the United States is associated with violence and related outcomes (Sampson et al., 1997; U.S. Department of Justice, 2007). Residential segregation by income and race have also been linked to drug use (Cooper et al., 2007) and HIV/AIDS risk (Poundstone et al., 2004), other contributors to the U.S. health disadvantage. Neighborhood violent crime has in turn been linked to low birth weight (Morenoff, 2003) and childhood asthma (Wright, 2006), two other health conditions that appear to be more common in the United States than in other high-income countries. Residential segregation (and its many social and physical correlates) may be another environmental factor that affects multiple, seemingly unrelated health domains in which the United States has a health disadvantage.

Another important environmental influence on homicide and suicide rates is the ease of access to firearms, which has a strong association with homicide rates (Hepburn and Hemenway, 2004). Legislative policies in other countries limit circulation and ownership of firearms by civilians. As stated in a thorough review by Hepburn and Hemenway (2004, p. 429):

High-income countries outside the United States have much lower rates of handgun ownership than the United States, and the licensing, registration, and safe storage regulations they have make it much harder for known criminals to obtain firearms. Thus, relatively few of the homicides in these countries are firearm homicides.

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CONCLUSIONS

There is some evidence that environmental factors that could affect the U.S. health disadvantage are worse or are more inequitably distributed in the United States than in other high-income countries. It is plausible to hypothesize that factors in the built environment related to low-density land development and high reliance on automobile transportation; environmental factors related to the wide availability, distribution, and marketing of unhealthy foods; and residential segregation by income and race (with its social and economic correlates) may be important contributors to the U.S. health disadvantage in many domains.

It is noteworthy that these environmental factors may interact with other factors at both “higher” levels of broad social policy and “lower” levels that operate at the individual level. For example, high levels of residential segregation may create large social inequalities across neighborhoods that, in the presence of easy access to guns, may result in high gun violence and homicide rates. Easy access to unhealthy foods may interact with personal sources of stress (e.g., from work) in promoting the consumption of calorie-dense foods. Environments that discourage physical activity may also limit social interactions, with potential implications for violence and drug use.

Environments also help to create and reinforce social norms (Hruschka et al., 2011) that influence health outcomes. In this way, environmental factors are undoubtedly part of a self-perpetuating cycle that operates across multiple domains, but delineating exactly how this occurs—and how this may differ across place and time—will require further research.

Many of the environmental factors relevant to health are directly amenable to policy. Therefore, identifying which of these factors are important contributors to the U.S. health disadvantage could point to policy interventions that might reduce the disadvantage. For example, cross-national comparisons show that levels of active transportation, such as walking or cycling, can be effectively modified by specific land use and transportation policies (Pucher and Dijkstra, 2003; Pucher et al., 2010b). Although many of the data reviewed in this chapter are highly suggestive of an important role for environmental factors, more empirical evidence is needed to draw definitive conclusions. Important areas for future cross-national research on environmental factors and health include (1) characterizing levels and distributions of environmental risk factors using comparable measures across countries; (2) documenting inequalities in the distribution of these environmental factors; (3) identifying the extent to which these environmental factors affect health and the extent to which their effects are modulated by individual-, community-, or country-level factors; (4) examining directly the contribution of environmental factors to health differences between the United States and other high-income countries; and (5) studying national, regional, and local country policies that may curb levels of adverse environmental exposures, reduce the extent to which they are inequitably distributed, or buffer their effects.

The contribution of environmental factors to the U.S. health disadvantage is likely to result from dynamic and reinforcing relationships between environmental and individual-level factors. Environmental factors also operate over a person’s life course, so that the environments one experiences early in life may influence health trajectories over time. Environmental factors are in turn linked to upstream social and policy determinants. In many ways, the environment can be thought of as the mid- or “meso-” level of influence linking macrolevel factors (e.g., economic and social policy) and microlevel processes (e.g., individual behavior). A comprehensive understanding of the causes of the U.S. health disadvantage will require recognizing how the environment interacts with these other factors and helps perpetuate or mitigate the disadvantage across a broad set of health domains.

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Footnotes

1: Although analytically distinct, physical and social environments may also influence and reinforce each other: for example, physical features related to walkability may contribute to social norms regarding walking, which may in turn promote more walkable urban designs and community planning.
2: Much early work on the spatial patterns of health used variables such as aggregate summaries of area socioeconomic or race/ethnic composition or measures of residential segregation by various attributes as proxies for a range of broadly defined environmental factors that may be relevant to health (see, e.g., Diez Roux and Mair, 2010). The identification of causal effects using these aggregate summaries raises a number of methodological challenges and does not allow one to identify the specific environmental attributes that may be relevant. More recent work has attempted to identify the specific environmental factors that may be important to specific health outcomes, as well as the pathways through which these factors may operate.
3: The environment can also be considered on a larger geographic scale, especially in seeking explanations for cross-national health differences. For example, the health of some nations is affected by their geography or climate.
4: Although in the U.S. context a number of studies have reported associations of local access to healthy foods with diet, some studies have not detected such associations (Cummins et al., 2005; Pearce et al., 2008). An important difficulty in comparing results across countries is that the proxy measure for the local food environment is often the type of food stores or restaurants available (such as supermarkets or fast food outlets), but the extent to which these typologies reflect relevant differences in the foods actually available to consumers may differ significantly across countries.
5: Studies that compare the effects of built environment features across countries are limited and inconclusive. One recent review found that access to open space (parks and other green spaces) in neighborhoods was associated with physical activity levels in both the United States and Australia (Pearce and Maddison, 2011).
6: Other factors that are also frequently discussed, such as social norms, have been more difficult to study because of a variety of methodological and data challenges.
7: As noted in Chapter 6, divorces and single-parent households have become more prevalent in the United States over time than in other high-income countries.
8: Analytical complexities make the isolation of these effects difficult in observational studies.
9: Although findings have not always been consistent, levels of safety, violence, and other social environmental features have also been found to be associated with walking and physical activity (Foster and Giles-Corti, 2008).
10: Findings on job strain have not been consistent, raising the question of whether these are primarily markers of socioeconomic position, which can influence health through other plausible material or psychosocial pathways (Eaker et al., 2004; Greenlund et al., 2010).
11: Averages could mask important spatial heterogeneity in air pollution, and this heterogeneity could have important implications for differences in aggregate health if some populations are systematically exposed to high levels of pollution.
12: Particulate matter less than 10 micrometers in diameter (PM-10) poses a health concern because it can accumulate in the respiratory system. In particular, particles that are less than 2.5 micrometers in diameter (“fine” particles) are thought to pose the largest health risks (U.S. Environmental Protection Agency, 2007).
13: Even in these countries, however, automobile use is rising quickly.
14: Trust data are based on the question: “Generally speaking would you say that most people can be trusted or that you need to be very careful in dealing with people?” Data come from two different surveys: the European Social Survey (2008 wave 4) for OECD European countries and the International Social Survey Programme (2007 wave) for non-OECD Europe (OECD, 2011e).
15: Advertising also plays an important role in promoting alcohol and tobacco use (Chuang et al., 2005; Kwate and Meyer, 2009; Mosher, 2011; Primack et al., 2007).

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What are the factors affecting physical self?

Understanding the Self - The Physical Self Part 1

QUESTION 1. DO ENVIRONMENTAL FACTORS MATTER TO HEALTH?

Physical Environmental Factors

Social Environmental Factors

Spatial Distribution of Environmental Factors

Other Environmental Considerations

QUESTION 2. ARE ENVIRONMENTAL FACTORS WORSE IN THE UNITED STATES THAN IN OTHER HIGH-INCOME COUNTRIES?

Physical Exposures

Social Factors

Spatial Distribution of Environmental Factors

QUESTION 3. DO ENVIRONMENTAL FACTORS EXPLAIN THE U.S. HEALTH DISADVANTAGE?

Obesity, Diabetes, and Cardiovascular Disease

Injuries

Homicides, Violence, Drug-Related Deaths, and HIV Risk

CONCLUSIONS

Footnotes

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