Perceptual & Motor Skills: Exercise & Sport 2012, 115, 2, 661-675. © Perceptual & Motor Skills 2012
PHYSICAL ACTIVITY AND PERCEPTIONS OF NEIGHBORHOOD WALKABILITY AMONG TURKISH WOMEN IN LOW AND HIGH SOCIO-ECONOMIC ENVIRONMENTS: AN EXPLORATORY STUDY1 G. YILDIRIM, M. L. INCE, AND M. MUFTULER Middle East Technical University Summary.—The purpose of this study was to compare the levels of physical activity, exercise stages of change, and perceptions of neighborhood walkability among Turkish women who were living in low and high socio-economic (SES) environments. The participants included 188 women in low SES and 206 in high SES environments, between the ages of 18 and 65 years. The Low SES group had a higher rate of inactivity, and relative to the High SES group, was less likely to rate the neighborhood environment as promoting and supportive of physical activity. Intervention programs for women living in low SES areas should be developed and administered while taking the level of physical activity, exercise stages of change, and perceptions of neighborhood walkability into consideration.
There is extensive research evidence that supports the positive effects of regular physical activity on an individual’s health and well being [U.S. Department of Health and Human Services (USDHHS), 2000; World Health Organziation (WHO), 2008]. There have also been studies indicating that people are not active enough to achieve the health benefits of physical activity (Turkish National Burden of Disease, 2004; Sjostrom, Oja, Hagstromer, Smith, & Bauman, 2006). Globally, physical inactivity is ranked as the fourth leading risk factor for all deaths, with a contribution of 1.9 million deaths per year (WHO, 2008). Therefore, promoting regular physical activity has become a public health priority in many developed and developing countries (USDHHS, 2000; Turkish National Burden of Disease, 2004; WHO, 2008). The first step toward solving the problem of inactivity appears to be understanding the variables that predict a person’s likelihood of engaging in and maintaining regular physical activity. According to Mullineaux, Barnes, and Barnes (2001), these variables include age, educational level, motivation, the perceived benefits of physical activity, lifestyle, and opportunities to participate in physical activity. Studies examining physical activity in different populations found the lowest rates of leisure-time physical activity in women, people with low socio-economic status (SES), older adults, and people living in poor neighborhood settings (Cassidy, 1996; Jones, Ainsworth, Croft, Macera, Lloyd, & Yusuf, 1998; Crespo, Ainsworth, Keteyian, Heath & Smit, 1999). Address correspondence to Mustafa Levent Ince, Physical Education and Sports Department, Faculty of Education, Middle East Technical University, 06800, Ankara, Turkey or email (
[email protected]).
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DOI 10.2466/06.15.PMS.115.5.661-675
ISSN 0031-5125
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Recently, the research on physical activity adherence has shifted its focus to understanding the intentions that motivate people to engage in exercise and identifying the opportunities in the neighborhoods where people live (Marcus & Forsyth, 2009; Sallis, Bowles, Bauman, Ainsworth, Bull, Craig, et al., 2009). Applying stages of change, a construct of the Transtheoretical model, to our understanding of exercise may enable further insight into people’s intention to exercise (Prochaska, DiClemente, & Norcross, 1992; Marcus & Forsyth, 2009). The original version of the Transtheoretical Model describes the ways in which individuals achieve behavioral changes by focusing on the cognitive, behavioral, and temporal aspects of behavior change. The model classifies individuals by their readiness to change and adopt a healthy behavior and includes three main constructs that include the stages of change, the process of change, and the levels of change (Prochaska, et al., 1992). Only the stages of change construct was within the scope of this study. Based on the Transtheoretical Model, people’s attitudes toward exercise are classified into five different stages of change: people “with no intention to exercise” (Pre-contemplation), people “with the intention to exercise but not in action” (Contemplation), people who “intend to take action in the next month” (Preparation), people who “participate in regular exercise for a period of less than six months” (Action), and people who “participate in regular exercise for more than six months” (Maintenance; Marcus & Forsyth, 2009). Exercise stages of changes have been studied in different populations (Ronda, Assema, & Brug, 2001; Riebe, Garber, Rossi, Greaney, Nigg, Lees, et al., 2005; Spencer, Adams, Malone, Roy, & Yost, 2006; Umstattd & Hallam, 2006). A meta-analysis by Spencer, et al. (2006) showed that people in developed nations tended to be at higher stages of change compared to people in developing nations. Cengiz, Ince, and Cicek (2009) found that women, relative to men, were more likely to be at lower exercise stages of change. Studies examining neighborhood characteristics reveal the effects of built environment on physical activity (Sallis, et al., 2009; Inoue, Murase, Shimomitsu, Ohya, Odagiri, Takamiya, et al., 2009). Specifically, levels of physical activity appear associated with the walkability attributes of the neighborhood. These attributes include residential density, proximity to nonresidential land uses, ease of access to nonresidential uses, street connectivity, walking/cycling facilities, aesthetics, pedestrian traffic safety, and safety from crime (Cerin, Saelens, Sallis, & Frank, 2006; Inoue, et al., 2009; Sallis, et al., 2009). Franzini, Taylor, Elliot, Cuccaro, Tortolero, Gilliland, et al. (2010) also suggest that residents in low SES neighborhoods may have a higher risk of inactivity due to the conditions for outdoor activity being less safe, less comfortable, and less pleasurable.
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Although the level of physical activity, intention to exercise, and neighborhood opportunities have been studied extensively in many developed countries in both the West and the East (Cerin, et al., 2006; Inoue, et al., 2009; Sallis, et al., 2009; Franzini, et al., 2010; Sallis, Slymen, Conway, Frank, Saelens, Cain, et al., 2011), the effects of these variables have not been well documented in developing countries, including Turkey. In the Turkish context, evidence related to the level of physical activity comes mostly from studies conducted among the school-aged population (Savci, Ozturk, Arikan, Inal-Ince, & Tokgozoglu, 2006; Cengiz, et al., 2009; Kin-Isler, Asci, Altintas, & Guven-Karahan, 2009; Ince & Ebem, 2009). A few studies have examined physical activity among the adult population in Turkey (Turkish National Burden of Disease, 2004; Aktener, Dulger, Erkayhan, Gormeli, Kafadar, Yildiz, et al., 2006; Hasil-Korkmaz & Arabaci, 2008). The findings from both the school-aged population and the adult population converge to show a higher risk of inactivity among women, as previously found in other countries. Apparently, this study is the first to examine the exercise stages of change or perceptions of neighborhood walkability among the adult population in the Turkish context. Examining the levels of physical activity and exercise stages of change among Turkish women living in low SES and high SES environments can provide important data for understanding the specific needs of the female population. Similarly, understanding the perceptions of neighborhood walkability by women living in low SES and high SES neighborhoods provides critical information for the identification of specific needs of neighborhoods by SES and allows cross-cultural comparisons. Therefore, the goals of this study were to compare the levels of physical activity, the exercise stages of change and perceptions of neighborhood walkability among Turkish women residing in low and high SES environments. Three research questions examined whether: (1) women living in low and high SES neighborhood environments differed in their levels of physical activity, (2) women living in low and high SES neighborhood environments differed in terms of their exercise stages of change, and (3) women living in low and high SES neighborhood environments differed in terms of their perceptions of neighborhood walkability. Method Design and Sampling A cross-sectional study design based on survey methodology was chosen. Self-reported survey data were collected from the selected low and high SES neighborhood environments in the Yenimahalle county of the city of Ankara, Turkey. Yenimahalle county includes 65 neighborhoods with 668,586 people. Of the total population, 340,619 were women. Six of the neighborhoods in this region were identified by SES classification of
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Turkish Statistical Institute addressing households as low and high SES. Three low SES neighborhoods (Burc, Guventepe, Cigdemtepe) and three high SES neighborhoods (Prof. Dr. Ahmet Taner Kislali, Umitkoy, Cayyolu) were selected randomly for data collection.
Participants The participants included 394 women (Low SES group, n = 188; High SES group, n = 206) between the ages of 18 and 65 years who were living in low SES or high SES neighborhoods, respectively. The mean age of participants was 38.9 yr. (SD = 13.5; Low SES M = 37.7, SD = 0.98; High SES M = 40.0, SD = 0.93).
Data Collection Procedure The approval of Middle East Technical University Research Ethics Committee was obtained before the study commenced. Upon the identification of low and high SES neighborhoods, every seventh consecutive home in the target areas was visited on weekdays and weekends. If a resident was at home, the study was explained to them, and women between the ages of 18 and 65 living in the home were invited to participate. If no one was at home, the next chosen home was visited. Participants completed the questionnaires and returned them to the researchers immediately.
Data Collection Instruments The survey used in this study included four parts: (1) demographic questions, (2) the International Physical Activity Questionnaire-Short Form (IPAQ; Craig, et al., 2003; Saglam, Arikan, Savci, Inal-Ince, BosnakGuclu, & Karabulut, 2010), (3) the Physical Activity Stages of Change Questionnaire (PASCQ; Marcus, Selby, Niaura, & Rossi, 1992; Marcus & Lewis, 2003; Cengiz, Asci, & Ince 2010), and (4) the Neighborhood Environment Walkability Scale–Abbreviated (NEWS–A; Cerin, et al., 2006). Demographic questions.—Questions related to the following demographic variables were included into the survey: age, educational status, occupational status, marital status, number of children, height, weight, family income, length of residence in the neighborhood, and reason for moving to the neighborhood. Body Mass Index (BMI) values were calculated by using the self reported weight and height values of the participants [weight (kg)/height (m)2]. International Physical Activity Questionnaire–Short Form (IPAQ).—The IPAQ is a validated instrument developed by Craig, et al. (2003) for assessing the level of participants’ physical activity. In this study, the validated Turkish short version of the IPAQ was used (Saglam, et al., 2010). The testretest reliability and criterion validity for the IPAQ (Turkish version) compared against accelerometers were r = .69 and r = .30, respectively (Saglam, et al., 2010). Test-retest reliability and criterion validity correlations of the
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Turkish IPAQ were in line with the reliability and criterion validity findings in other studies using self-report physical activity measures (Craig, et al., 2003). The IPAQ measures the frequency, duration, and level of intensity of physical activity on the preceding seven days across all contexts and allows the calculation of metabolic equivalents (METs). METs in terms of min. per week (MET-min./wk.) were calculated with regard to physical activity according to the existing guidelines (See IPAQ, 2005). Based on the self-reported METs and frequency and intensity of the physical activity, individuals can be classified as engaging in low, moderate, or high levels of physical activity. Physical Activity Stages of Change Questionnaire (PASCQ).—The PASCQ evaluates individuals’ exercise stages of change based on their physical activity behaviors (Marcus, et al., 1992; Marcus & Lewis, 2003). In this study, the participants’ exercise stages of change were evaluated with a validated Turkish version of PASCQ (Cengiz, et al., 2009, 2010). The testretest intraclass correlation of the Turkish version was ICC = .80 (Cengiz, et al., 2010). The criterion validity of the Turkish version against physical activity levels was also confirmed by Cengiz, et al. (2010). Based on participants’ responses to binary type (yes/no) questions, the instrument uses a scoring algorithm to classify individuals into five different stages of change, namely Pre-Contemplation, Contemplation, Preparation, Action, and Maintenance (Marcus & Lewis, 2003). Participants answer each question with either “yes” or “no” based on their participation in physical activity. Neighborhood Environment Walkability Scale–Abbreviated (NEWS–A).— The Neighborhood Environment Walkability Scale-Abbreviated (NEWS– A) questionnaire measures a resident’s perception of the neighborhood environment (Cerin, et al., 2006). NEWS–A has 8 sections: residential density, land use mix-diversity, land use mix-access, street connectivity, infrastructure and safety for walking, aesthetics, traffic hazards, and crime. Participants responded to questions on a 4-point Likert-type scale with anchors 1: Strongly disagree and 4: Strongly agree in all subscales with the exception of residential density and land use mix-diversity. Residential density items are rated on a 5-point Likert-type scale, and ratings are weighed relative to the average residential density that a specific item represents. Land use mix-diversity is assessed by the perceived walking proximity from home to various types of destinations, such as a convenience/ small grocery store, supermarket, or hardware store, with responses ranging from 1- to 5-min. walking distance to > 30-min. walking distance (Cerin, et al., 2006). The NEWS–A was translated into Turkish for the current study. The permission of the scale developers was obtained before the translation
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process. Two independent translators translated the English version of the NEWS–A into Turkish. After reaching a consensus on each item, another translator translated the questionnaire back into English to ensure the quality of the translation, and the final version of the questionnaire was prepared. Then, the questionnaire was administered to 20 women (10 low SES, 10 high SES) from different neighborhood SES to ensure face validity. In addition, the Turkish version was administered to another 15 people for test-retest reliability with a 10-day interval. Intra-class coefficient (ICC) analyses yielded the following ICC values for each subscale of the NEWS– A: Residential density = 0.85, Land use mix-diversity = 0.90, Land use mixaccess = 0.71, Street connectivity = 0.77, Infrastructure and safety for walking = 0.71, Aesthetics = 0.83, Traffic hazards = 0.72, and Crime = 0.94.
Data Analysis The demographic variables were first analyzed using descriptive statistics (e.g., means, standard deviations, and frequencies). To evaluate the similarities and differences between the low and high SES neighborhood groups in age, Body Mass Index (calculated based on self-reported weight and height), number of children, monthly family income, and length of residence in the neighborhood, independent t tests were used. The Pearson’s chi-squared test was used to compare educational status of the groups. Normality assumptions were not met for the levels of physical activity and Neighborhood Walkability to support the use of parametric methods. Therefore, Mann Whitney U tests were used to compare the levels of physical activity and perceptions of Neighborhood Walkability between Low and High SES groups for the first and third research questions, respectively. Analyses of exercise stages of changes were performed using the Pearson’s chi-square test for the second research question.
Results Demographic Characteristics of Participants Table 1 presents the descriptive statistics corresponding to participants’ age, Body Mass Index (BMI), number of children, monthly family income, and length of residence in the neighborhood area. Based on independent t tests, there was no significant difference in terms of age (t392 = 1.71, p = .09, d = 0.17) or length of residence (t390 = 1.35, p = .18, d = 0.14) between the low SES and high SES neighborhood groups. However, independent t test findings indicated significant differences in terms of BMI (t389 = −3.23, p = .001, d = 0.33), number of children (t392 = −6.83, p = .001, d = 0.69), and monthly family income (t392 = 25.48, p = .001, d = 2.57) between the low SES and high SES neighborhood groups. The low SES neighborhood group had a higher mean BMI and more children on average. However, the mean monthly family income of the
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PHYSICAL ACTIVITY AND NEIGHBORHOOD WALKABILITY Table 1 Descriptive Characteristic of the Participants Variable
Neighborhood SES High (n = 206) M
SD
Low (n = 188)
Range
Age (yr.) 40.0 13.3 18–65 24.6 4.1 17.3–38.5 BMI [weight (kg)/height2 (m)]* Number of children* 1.3 1.1 0–5 Family Income (month/TL)* 5,734.2 2,581.4 1,200–20,000 Length of residence (yr.) 6.4 4.7 1–22
M
SD
37.4 26.5 2.1 884.0 5.6
13.4 7.2 1.5 385.5 6.9
Range
18–65 15.2–73.8 0–6 350–2,000 1–40
Note.—SES = socio-economic status; n = number of participants; SD = standard deviation; BMI = Body Mass Index; kg = kilogram; m = meter; TL = Turkish lira.
Table 2 Demographic Characteristic of the Participants Neighborhood SES
Marital status Married Single Educational level Elementary school High school University Occupation Unemployed Retired Officer Worker Student Other Home Ownership Rental Owner The reason for living in neighborhood Near to school Near to work Near to sport facilities Safety Near to park and recreational areas Other
High (n = 206)
Low (n = 188)
f
%
f
%
149 57
72.3 27.7
169 19
89.9 10.1
22 85 99
10.7 41.3 48.0
132 39 17
70.2 20.7 9.1
84 30 35 13 35 9
40.8 14.6 17.0 6.3 17.0 4.3
159 3 8 6 11 1
84.6 1.6 4.3 3.2 5.8 0.5
101 105
49.0 51.0
79 108
42.2 57.8
32 11 1 114 21 26
15.6 5.4 0.5 55.6 10.2 12.7
15 20 0 47 0 105
8.0 10.7 0 25.1 0 56.2
Note.—SES = socio-economic status; f = frequency.
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high SES neighborhood group was significantly higher than that of the low SES neighborhood group (Table 1). Other demographic characteristics of the participants, including marital status, educational level, occupation, home ownership, and the reason for living in the neighborhood are presented in Table 2. Among these variables, educational level was compared between the low SES and high SES neighborhood group using Pearson’s chi-squared test. The findings indicated a significant difference on educational level between the groups (χ22 = 153.09, p = .001, φ = 0.62). Specifically, the educational level for the high SES group was significantly higher. Further analysis of the other characteristics indicate that the percentage of married women, percentage of elementary school graduates, percentage of those unemployed, and percentage of home ownership were higher in the low SES neighborhood group. A high percentage of the high SES neighborhood group cited safety (55.6%) as their reason for living in the neighborhood, whereas a high percentage of the low SES neighborhood group responded to the same question with “Other” (56.2%; Table 2).
First Research Question A Mann-Whitney U test revealed no significant differences in walking (z = −0.09, p > .05) and the amount of vigorous physical activity (z = 0.46, p > .05) by neighborhood SES group. However, there was a significant difference in moderate (z = −5.45, p = .01; mean rank for high SES = 221.94, for low SES = 168.90) and total (z = −3.96, p = .01; mean rank, high SES = 219.19 and low SES = 173.73) physical activity scores in favor of the high SES neighborhood group (p
