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Introduction : Public Health Policy

According to WHO (2019), physical activity in its truest sense is described as the movement of the body produced by skeletal muscles that require spending of energy which includes activities like running, jumping, daily household activities, activities carried out while working and playing. Physical activity is of prime importance and provides a multitude of health benefits. It helps in improving the overall health and health outcomes for people of all age groups. The benefits in terms of a healthy outcome of increasing the levels of physical activity in individuals who are either not active physically or those who show a low level of activity are much higher than the ones gained by increasing the level of activity in pre-existing active individuals (Hagstormer & Franzen, 2017).

There are a number of factors underlying and highlighting the importance of physical activity and how physical inactivity plays an important role in the development of non-communicable, life-style associated disorders, and poses an economic burden as well. Physical inactivity in itself is a pandemic and is one of the leading causes of death in the world right now. It is explicitly one of the four pillars of a strategy for handling the burden of non-communicable diseases. However, its role is not valued as much despite its cost-effective benefits and protective benefits against the economic burden put forward by the current levels of people being physically inactive around the world. The occurrence of physical inactivity is high and increasing by the day, and the available trends do not show any kind of reversal at all. The undervaluing of the importance of physical inactivity as a major public health issue and threat can be best explained as a "stealth pandemic" (Booth et al., 2017) This report consists of a brief description of the existing public health problem of physical inactivity amongst the population and the identification of evidence base surrounding it for advocating a public health policy for the same.

Description of Public Health problems

Physical activity is being increasingly shoved out of people’s social as well as working lives. It is essential to maintaining good health, both psychological and physical as well. It helps in reducing the occurrence of non-communicable diseases and moderates risk factors to health like cholesterol, obesity, hypertension and diabetes. Compelling evidence shows that a walk for half an hour every day, for five days a week helps in increasing the expectancy of life to 1.5-3 years based on the intensity of walk and exercise (Cadilhac et al., 2011). However, there still exist barriers to pursuing physical activity in terms of time limitations and dissatisfaction with exercise amongst people (Meltzer et al., 2010).

The public health issue of physical inactivity is a pandemic, global in nature. Every year, it leads to more than 5 million deaths and puts an economic burden of billions of dollars on societies around the world (Ding et al., 2017). It was noted globally in the year 2016, that more than a quarter of all adults were not physically active enough. According to estimates worldwide, around 1.4 billion people were at risk of developing diseases and conditions related to physical inactivity in 2016. Previously it was observed that there existed a global prevalence of around 23.3% of physical inactivity in 2010 (Guthiold et al., 2018). Insufficient physical activity and its prevalence were highest in the high-income group of western nations and the Asia Pacific, followed by Latin America and the Caribbean in 2016. High-income countries showed a greater prevalence of physical inactivity in comparison with low-income countries. The trends in physical inactivity worldwide showed that there existed variations in terms of inactivity, based on income groups and countries. There has been a large increase in physical inactivity in high-income countries whereas, a similar decrease in physical inactivity was noted in the eastern and southeast regions of Asia, especially China (Guthold et al., 2018).

There exists a whole lot of evidence explaining how inactivity makes a contribution to mortality and morbidity that can be avoided and there is also accumulated data about how physical activity is an economically effective way as well to prevent diseases. Still, a lot of research and efforts and trend data show that the prevalence of physical inactivity in Australia has mainly remained stable for the past 22 years and the past 15 years in the world (Nau et al., 2019). The total prevalence of adults in Australia who reported low or sedentary levels of physical activity was around 66.9% in the year 2011–12 (Montgomerie et al., 2014). The absence of physical activity is associated with a huge number of non-communicable diseases and conditions such as obesity, hypertension and high blood sugar. It was reported in 2009 that around 27% of the adults reporting physical inactivity were also found to be obese in Australia (Montgomerie et al., 2014). Also reported by the WHO, it was shown that physical inactivity causes around 2 M deaths in a year in the entire world; and has been ranked second after smoking as a cause of disease and poor health in Australia (Govt. of South Australia 2020).

Comparing the population groups within Australia, it has been found that every 1 in 2 adults did not meet the guidelines on physical activity in 2017-2018 and more indigenous children met the criteria of required physical activity as compared to non-indigenous children in the age group 5-17 years(AIHW,2019). Only 3 in every 10 pregnant women met the required physical activity criteria in 2017-2018. Most affected population groups with inactivity or most vulnerable to inactivity would be considered women, people of older age group and younger children and adolescents. Associated disease burden with physical inactivity was also noted at 2.5% overall and around 10-20% of the individual burden of disease from bowel cancer, diabetes, uterine cancer, breast cancer, dementia, stroke, and coronary artery disease in 2015 (AIHW, 2019). Coming to adults, comparison between indigenous and non-indigenous people showed lower levels of physical activity amongst the indigenous people if there were changes in setting- cultural and socio-economical. Also, noted was the fact that there existed a gender gap in terms of indigenous women not doing as much physical activity as non-indigenous women. Cultural connotations were ascribed to the problem (Dahlberg et al., 2018).

Pie chart showing Proportion of Adults, aged 15-64  meeting Physical activity Guidelines

Causes of physical inactivity and quality of evidence

The levels of physical inactivity noted nowadays are attributed to increasing sedentary lifestyle and behavior while carrying out occupational and domestic activities and partly due to decreased participation in carrying out any kind of activity- physically, during leisure or free time as well (Meltzer et al., 2010 ). Changing modes of transport from "active" to "passive" also contribute to a decline in the physical activity levels of the population. WHO (2019) in its paper as a part of its strategy to handle diet and physical activity mentioned that changing lifestyles and increasing urbanization has led to the development of a number of environmental factors like air pollution, low air quality index, violence, lack of walking space, parks, side-walks and recreational places which have led to poor physical activity among people. Also, it has been mentioned that increased traffic also poses a threat to physical activity.

Other barriers to not pursuing physical activity are time limitations and dissatisfaction with exercise (Meltzer et al., 2010). Other factors responsible for physical inactivity include old age. There are lesser chances of elderly exercising or being able to do physical activity. They are increasingly prone to living a sedentary lifestyle. Also, socio-economic factors also play a major role along with age and lifestyle in determining physical activity levels. More economically better elderly showed better physical activity levels than elder people coming from an economically weaker background (McPhee et al., 2016). A sedentary lifestyle and socioeconomic factors also act as a major factor in determining the measures of physical inactivity in individuals (Konevick et al., 2015).

The use of mobile phones and cell phones was also linked with a more sedentary lifestyle and physical inactivity (Fennel et al., 2019). Lack of proper and accurate awareness and knowledge about the importance and benefit of physical activity amongst people is also a major factor for rising physical inactivity (Fredriksson et al., 2018). It was also found that there existed an association between gender and levels of physical activity along with the socio-economic status of people. Lack of sufficient and adequate awareness about the importance of physical activity was also one causative factor for physical inactivity (Goje et al., 2014). The risk of rising physical inactivity among individuals is being identified especially the older population due to the ongoing epidemic of COVID-19 (Roschel et al., 2020). Co-morbidities associated with diseases such as COPD also acted as a major hindrance to physical activity (Yoshida et al., 2018).

A study is done on the causes of physical inactivity which revealed that gender also plays a significant role in determining levels and causes of physical inactivity. Women tend to do less in their leisure-time and be less involved in intense exercises as compared to men (Guthold et al., 2018). It has been shown that certain factors like their cultural norms, the roles they play traditionally, lack of community and social support also leads to a reduction in physical activity of women (Guthold et al., 2018). Although, it is a cross-sectional study which lies on the fifth position in the hierarchy of evidence but still it is s quality evidence because the researchers have collected data from 358 different surveys for a total of 168 countries. Also, the results of the study can be applied to the local population which makes it more reliable.

A systematic review which is at the top of the hierarchy of evidence done on physical activity and its implications on public health stated that economic and social transitions affecting populations can elicit a substantive effect on people’s health and their behavior towards health. The review also discussed the trend of development of over-nutrition and obesity in the population of many Latin American countries trending rapidly away from under-nutrition and micronutrient deficiencies. It also mentioned the rapid growth of a population that is ageing with an increase in the prevalence of non-communicable diseases as well due to the rapid economic development in the countries (Kohl et al., 2012). The review was done to summarize and list the current global efforts being carried out to deal with the issue of physical inactivity. More than 250 articles and data from more than 100 countries were collected by the Lancet Physical Activity observatory. The review is a part of a five-part series on physical activity by the observatory to help collect substantial evidence to act as an evidence base.

In the international context, a study showed that an increase in urbanization and a rapidly developing economy in China are related to a reduction in physical activity linked to occupation in adults along with some amount of increase in television viewing by children. Africa also shows a similar trend with the rural to urban migration showing association with an increase in the prevalence of physical inactivity (Abubakari et al., 2009). A systematic review was conducted along with a Meta-analysis as well, which comes at the top of the hierarchy of evidence and is quality evidence and used around 21 articles on physical activity to establish the findings. This can be considered for evidence-based practice in the field of public health both locally and globally.

A study using the method of a cross-sectional sample collection was done to evaluate the effects of co-morbidities of COPD on physical activity and showed that physical inactivity was affected by a variety of factors such as skeletal muscle pain, pulmonary hypertension, etc. The study is on the fifth position of the hierarchy of evidence still acts as quality evidence due to the large sample size and measurement of activity carried out(Yoshida et al., 2018). An online survey on the use of cell phones and association with a sedentary lifestyle and physical inactivity revealed that increased usage leads to physical inactivity (Fennel et al., 2019). Although an online survey would stand at the last position in the hierarchy of evidence, it still acts as quality evidence due to the large sample size and the fact that the study can be extrapolated to different countries and the local population as well.

Physical Activity Policy : The Australian Context

There exists both local and international evidence outlining the significance and importance of being physically active and the burden that physical inactivity puts in terms of disease and economic both. A study done in Australia on the economic benefits of being physically active, developed compelling simulation models to show the effect of a reduction of around 10% in the levels of physical inactivity in people on opportunity cost savings. Simulation models are effective ways of prediction in research (Cadihillac et al., 2011).

A cross-sectional survey with around 615 participants in the Australian context revealed that a lack of proper knowledge and awareness about physical activity leads to a sedentary lifestyle and physical inactivity. The study is good quality evidence because of its local context and the sample size as well (Fredriksson et al., 2018). A qualitative systematic review done in the Australian context on the indigenous population showed that cultural and gender preferences were existent in them when it came to their idea of physical activity and its importance. The review provided compelling evidence to establish that population type and region, both play an important role in determining the measures of physical activity in the people in terms of an Australian context (Dahlberg et al., 2018).

In the Australian context, it has been found that the physical activity policy of the country has been developing since 1996 and undergone many changes since then (Nau et al., 2019). A cross-sectoral analysis of the same reveals that Australia's physical activity policy is based on country's guidelines on physical activity and sedentary behavior. The guidelines talk about increasing regular physical activity for everyone in order to decrease all-cause mortality and prevent life-style associated non-communicable diseases such as diabetes, obesity, hypertension, cardiovascular diseases, certain cancers, etc. They recommend the physical activity required in terms of its amount and intensity from moderate to vigorous so as to optimise health outcomes across the course of life of people (PHAA Policy Statement, 2019).

It was also observed that the guidelines need more robust considerations taking into account the cultural and socioeconomic characteristics of the different kinds of the population residing in the country to promote physical activity among them. Culturally-appropriate ways of promotion would help in effective changes (Dahlberg et al., 2018). The evidence discussed shows that researchers and independent stakeholders, both are involved in making and actively driving the country’s public health policy on physical activity. The government organizations, Public health association of Australia and independent researchers are all involved in designing a policy framework for the same.

Data visualization format

The research done by Abubakari et al. (2009) has been presented in data visualization format which is a systematic review with Meta-analysis and served as great evidence for developing the relationship between chronic illnesses like diabetes with adult’s physical inactivity.

systematic review with Meta-analysis

Conclusion

The report discussed the importance of being physically active for people and the burden that physical inactivity imposes as an important public health pandemic, both globally and in the Australian context as well. It also discussed the factors leading up to physical inactivity in populations and the evidence base to support it as well. Lack of interest and motivation, environmental factors, old age, socio-economic factors, sedentary lifestyle, and use of cell-phones are some of the factors responsible for lack of physical activity. Also, the type of population and rural-urban migration are certain other contextual factors as well. The researchers and stakeholders involved in collecting evidence base for the issue were also mentioned.

References

Abubakari, A. R., Lauder, W., Jones, M. C., Kirk, A., Agyemang, C., & Bhopal, R. S. (2009). Prevalence and time trends in diabetes and physical inactivity among adult West African populations: the epidemic has arrived. Public Health, 123(9), 602-614.

Bellew, B., Bauman, A., Bull, F. C., & Schoeppe, S. (2008). The rise and fall of Australian physical activity policy 1996–2006: A national review framed in an international context. Australia and New Zealand Health Policy, 5(1), 1-10.

Blair, S. N. (2009). Physical inactivity: The biggest public health problem of the 21st century. British Journal of Sports Medicine, 43(1), 1-2.

Booth, F. W., Roberts, C. K., Thyfault, J. P., Ruegsegger, G. N., & Toedebusch, R. G. (2017). Role of inactivity in chronic diseases: Evolutionary insight and pathophysiological mechanisms. Physiological Reviews, 97(4), 1351-1402.

Cadilhac, D. A., Cumming, T. B., Sheppard, L., Pearce, D. C., Carter, R., & Magnus, A. (2011). The economic benefits of reducing physical inactivity: An Australian example. International Journal of Behavioral Nutrition and Physical Activity, 8(1), 1-8.

Dahlberg, E. E., Hamilton, S. J., Hamid, F., & Thompson, S. C. (2018). Indigenous Australians perceptions’ of physical activity: A qualitative systematic review. International Journal of Environmental Research and Public Health, 15(7), 1492.

Ding, D., Kolbe-Alexander, T., Nguyen, B., Katzmarzyk, P. T., Pratt, M., & Lawson, K. D. (2017). The economic burden of physical inactivity: A systematic review and critical appraisal. British Journal of Sports Medicine, 51(19), 1392-1409.

Fennell, C., Barkley, J. E., & Lepp, A. (2019). The relationship between cell phone use, physical activity, and sedentary behavior in adults aged 18–80. Computers in Human Behavior, 90, 53-59.

Fredriksson, S. V., Alley, S. J., Rebar, A. L., Hayman, M., Vandelanotte, C., & Schoeppe, S. (2018). How are different levels of knowledge about physical activity associated with physical activity behaviour in Australian adults?. PLoS One, 13(11), e0207003.

Goje, M., Salmiah, M. S., Ahmad Azuhairi, A., & Jusoff, K. (2014). Physical inactivity and its associated factors among university students. IOSR Journal of Dental and Medical Sciences, 13(10), 119-130.

Guthold, R., Stevens, G. A., Riley, L. M., & Bull, F. C. (2018). Worldwide trends in insufficient physical activity from 2001 to 2016: A pooled analysis of 358 population-based surveys with 1· 9 million participants. The Lancet Global Health, 6(10), 1077-1086.

Hagströmer, M., & Franzén, E. (2017). The importance of physical activity and health for physical therapy. Physical Therapy Reviews, 22(3-4), 116-123.

Kohl 3rd, H. W., Craig, C. L., Lambert, E. V., Inoue, S., Alkandari, J. R., Leetongin, G., & Lancet Physical Activity Series Working Group. (2012). The pandemic of physical inactivity: global action for public health. The Lancet, 380(9838), 294-305.

Konevic, S., Martinovic, J., & Djonovic, N. (2015). Association of socioeconomic factors and sedentary lifestyle in Belgrade’s suburb, working class community. Iranian Journal of Public Health, 44(8), 1053.

McPhee, J. S., French, D. P., Jackson, D., Nazroo, J., Pendleton, N., & Degens, H. (2016). Physical activity in older age: Perspectives for healthy ageing and frailty. Biogerontology, 17(3), 567-580.

Meltzer, D. O., & Jena, A. B. (2010). The economics of intense exercise. Journal of Health Economics, 29(3), 347-352.

Montgomerie, A. M., Chittleborough, C. R., & Taylor, A. W. (2014). Physical inactivity and incidence of obesity among South Australian adults. PLoS One, 9(11), e112693.

Nau, T., Lee, K., Smith, B. J., Bellew, W., Reece, L., Gelius, P., & Bauman, A. (2019). Toward whole-of-system action to promote physical activity: A cross-sectoral analysis of physical activity policy in Australia. Journal of Physical Activity and Health, 1(aop), 1-10.

PHAA Policy Statement (2019).Immediate policy priority. Retrieved from https://www.phaa.net.au/documents/item/3373

Roschel, H., Artioli, G. G., & Gualano, B. (2020). Risk of increased physical inactivity during covid‐19 outbreak in older people: A call for actions. Journal of the American Geriatrics Society.

WHO. (2019). Global strategy on diet, physical activity and health. Retrieved from https://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf?ua=1

Yoshida, M., Moriwaki, A., Osoreda, H., Hiramoto, T., Iwanaga, T., & Inoue, H. (2018). Effects of comorbidities on physical activity in chronic obstructive pulmonary disease. Europe Respiratory Journal, 52(3), 4033.

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