Until now, ACSM’s focus has been primarily on individual-level factors influencing physical activity behavior, partly because of the complexity of addressing social and environmental determinants of physical activity behavior. However, with the increased emphasis on social–contextual factors as key modifiable determinants of physical activity behavior, ACSM has developed a national roadmap for achieving equity in physical activity participation by promoting physically active lifestyles aimed at the community level. Figure 3 illustrates the actionable, integrated initiatives that provide the foundation of ACSM’s national roadmap, which include the following pathways: 1) communication, 2) education, 3) collaboration, and 4) evaluation. The present report provides a conceptual overview of these four core components of ACSM’s roadmap to achieving equity in physical activity participation.
A key component of ACSM’s roadmap includes community engagement. The term community refers to a group of people united by geography, social identities, shared interests, values, experiences, and/or traditions (95). Understanding these characteristics and how they affect physical activity behavior is necessary to initiate engagement efforts with different communities (65). Community engagement is the process of working collaboratively with and through individuals, community-based organizations, and institutions within each community to involve them in health decisions, physical activity promotion, and disease prevention efforts (35). Community engagement also involves partnerships and coalitions that help to empower community members to mobilize resources, influence relationships, and serve as catalysts for changing policies, programs, and practices that affect their neighborhoods (35). Hence, community engagement is at the center of ACSM’s efforts to achieve equity in physical activity participation.
In 2000, the U.S. Health and Human Services issued its strategic plan for the nation’s health, Healthy People 2010 (100), where the two overarching national health goals were the following: to “increase quality and years of healthy life and eliminate health disparities” (100); these goals were reiterated and expanded on to include achievement of health equity in Healthy People 2020 (101). In 2003, reports released by both the Agency for Healthcare Research and Quality (2) and the Institute of Medicine (89) documented widespread inequities in health care access and quality. In 2008, the PBS series Unnatural Causes … Is Inequality Making Us Sick? brought attention to racial/ethnic and socioeconomic inequities in health (103), and the Robert Wood Johnson Foundation’s Commission to Build a Healthier America also addressed the sociobehavioral determinants of health and health inequities (14,76). Despite these reports and campaigns, mainstream media coverage of health inequities declined between 1998 and 2005 (50), with a modest increase in the public’s awareness (55% in 1999 compared with 59% in 2010) (10). Hence, the first pathway of ACSM’s national roadmap is to expand on previous efforts to raise awareness of health inequities and to bring attention to the benefits of healthy lifestyles in general and physical activity in particular.
Currently, ACSM is developing a communications toolkit with meaningful and relevant contextual messaging that is designed to successfully increase the public’s awareness of health inequities through the 2008 U.S. Physical Activity Guidelines and the U.S. Physical Activity Plan. The toolkit suggests evidence-based and best practice models to incorporate physical activity into daily life through a community context. Some examples of community-wide campaigns to increase awareness of physical activity include the Stanford Heart Prevention program (108), the Wheeling Walks intervention (81), and the VERB™ campaign (41). These campaigns represent large-scale, high-visibility programming to raise awareness, to disseminate targeted health messages, and to reinforce behavior change to increase physical activity participation (39). Part of ACSM’s mission includes using these and other campaigns as a model for increasing awareness around health inequities and the benefits of physical activity. It is important to note that communication is bidirectional; as ACSM engages with communities to increase awareness of health inequities, the organization will listen to, and learn from, the communities that it serves. This exchange will enable ACSM to identify the needs of communities and members’ varied perceptions of physical activity, exercise, and health. In addition, this information will better support ACSM’s development of messages and messaging strategies that are contextually appropriate for communities and organizations affected by health inequities.
ACSM recognizes that achieving equity in health behaviors and health outcomes will require culturally competent health care. Creating a culturally competent system of care that involves valuing culture, assessing cross-cultural relations, and striving to expand cultural knowledge as a path to adapt services to meet culturally unique needs is the primary objective of the second pathway of ACSM’s national roadmap. More specifically, pathway 2 calls for the education of health care providers and fitness professionals in cultural competency and barriers to effective health care, such as patient–provider miscommunication, distrust, and lack of access to health care systems or physical activity opportunities or professionals. ACSM recognizes that in many cases, it may be easier to train community members (e.g., clergy members, salon owners, and other community leaders) about their community’s health rather than train health providers about the community. Thus, ACSM strives to develop 1) training programs specifically targeted for health care and fitness professionals, 2) “train the trainer” mentorship programs, and 3) new community-based training programs for community members.
To date, ACSM has established the American Fitness Index Diversity Workgroup and Exercise is Medicine® Underserved Populations Committee—both commissioned to review ACSM online and print materials as well as general recommendations for its appropriateness and inclusiveness for all populations.
Future ACSM education and training programs will include teaching strategies, such as webinars, podcasts, and formats such as story-telling and vignettes. Each of these programs will create a supportive infrastructure with a network of training opportunities at all levels, including certification programs and membership programs. Consequently, these programs will help to establish a network of professionals to share best practices and lessons learned. In addition, these programs will aid in the development of a resource database of evidence-based educational materials and toolkits to be used in a community setting. ACSM in collaboration with medical providers and community partners strives to create competencies and evidence-based programs that support increases in physical activity and emphasize the role of physically active lifestyles in improving health outcomes and reducing health inequities.
The third pathway of ACSM’s roadmap centers on building partnerships and programs that integrate existing infrastructures and leverage novel stakeholders from both public and private sectors. Organizations that were approached to partner on this work are described in Table 1, and the work toward establishing and/strengthening these partnerships is ongoing. Such partnerships and programs can influence environmental and social policies as well as promote physical activity behaviors at the local, state, and federal level. Additional local partners should include but are not limited to schools, churches, libraries, barbershops, beauty salons, convenience stores, and community centers.
Moving forward, ACSM plans to develop additional local, state, and federal partnerships to leverage resources from existing national programs implemented to promote physical activity and positive health outcomes such as Head Start programs and the Let’s Move campaign (47,75). As recommended by the 2016 U.S. National Physical Activity Plan, partnerships should occur across multiple sectors, including business and industry; education; health care; parks and recreation; fitness and sports; public health; transportation, land use, and community design; and volunteer and nonprofit organizations (77). Partnering with clothing manufacturers, technology and gaming industries, and entertainment and arts communities may also prove to be effective in promoting physical activity behaviors and policy change.
Another aspect of evaluation by ACSM will include the development of a database of best practices based on what has been shown to increase physical activity and reduce inequities in underserved communities. A similar strategy has been recommended for several sectors of the National Physical Activity Plan. These strategies can then be incorporated into training curricula and communication toolkits for continued success in achieving equity in physical activity participation in other communities. A clearinghouse of success stories will also be developed to showcase the successes of each community to advocates, partners, and policy makers as part of the communication strategy to increase awareness around health inequities. Major barriers to physical activity in various communities as well as major gaps and key needs for further research will be identified as a result of having the database. All information will be made freely available and easily accessible in an effort to develop novel metrics to gauge success in reducing health. ACSM will use the Equity in Physical Activity Participation Report Card and other newly developed evaluative measures to work with partnering organizations to ensure we are not maintaining, increasing, or creating inequities but instead achieving improvements in physical activity participation for people living in at-risk communities.
It is estimated that inequities in health impose costs on numerous aspects of society, both direct health care costs and indirect costs such as loss of productivity. Using data from the National Vital Statistics Reports, LaVeist et al. (53) estimated that the elimination of racial/ethnic health inequities would have reduced direct medical care expenditures by approximately $230 billion and indirect costs associated with illness and premature death by more than $1 trillion dollars for the years 2003–2006. In addition, poor health outcomes associated with physical inactivity presents a tremendous economic burden globally (29). Information on the costs associated with health inequities by gender, age, sexual orientation, education level, disability status, and geographic location is not currently available. To better address inequities in health, ACSM has developed a national roadmap for achieving equity in physical activity participation. This plan includes four actionable, integrated pathways that provide the foundation of ACSM’s national roadmap: 1) communication—raising awareness of the issue and magnitude of health inequities and conveying the power of physical activity in promoting health equity; 2) education—developing educational resources to improve cultural competency for health care providers and fitness professionals as well as develop new community-based programs for lay health workers; 3) collaboration—building partnerships and programs that integrate existing infrastructures and leverage institutional knowledge, reach, and voices of public, private, and community organizations; and 4) evaluation—ensuring that ACSM attains measurable progress in reducing physical activity disparities among population groups to promote health equity.
The authors acknowledge the editorial assistance of their colleagues on the ACSM Strategic Health Initiative on Health Equity Committee: Nailah Coleman, Eduardo Bustamante, and Sheila Ward for their constructive feedback on different versions of this article. They also thank Phil Lofton, Regenstrief Institute, Inc. Communication Specialist, for his assistance with the figures. The authors have nothing to disclose. The findings and conclusions in this article are those of the ACSM and do not necessarily represent the views or official position of the partnering organizations.
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