Prevalence of Physical Activity and Barriers to Physical Activity Among Yerevan Adult Population

PHYSICAL ACTIVITY PREVALENCE PHYSICAL ACTIVITY PREVALENCE AND BARRIERS TO PHYSICAL ACTIVITYAND BARRIERS TO PHYSICAL ACTIVITYAMONG YEREVAN ADULT POPULATIONAMONG YEREVAN ADULT POPULATION

(2007)(2007)

Liana Hakobyan, MD, MPHCRRC Publication Research Fellowship

June, 3 2008

OUTLINE OUTLINE

IntroductionIntroduction

Objectives of the studyObjectives of the study

MethodologyMethodology

Results & Discussion Results & Discussion

RecommendationsRecommendations

Comments, questionsComments, questions

INTRODUCTIONINTRODUCTION

Meanwhile, regular Meanwhile, regular physical activityphysical activity provides provides people of both genders, of all ages and people of both genders, of all ages and

conditions with a wide range of physical, conditions with a wide range of physical, social and mental health social and mental health benefits benefits

Physical ActivityPhysical Activity DefinitionDefinition

Physical activityPhysical activity - - any bodily movement any bodily movement produced by skeletal muscles that produced by skeletal muscles that increases increases energy expenditure energy expenditure

Physical fitnessPhysical fitness - - set of attributes a person has in set of attributes a person has in regards to regards to his/her his/her ability to perform physical activitiesability to perform physical activities

ExerciseExercise - - repetitive bodily movement done to improve repetitive bodily movement done to improve or maintain the components of physical fitnessor maintain the components of physical fitness - - muscular strength,muscular strength, endurance, flexibility, endurance, flexibility, as well as as well as body body compositioncomposition**

*Surgeon General*Surgeon General

Regular physical activity: BenefitsRegular physical activity: Benefits

Reduces the risk of:Reduces the risk of: Cardiovascular DiseaseCardiovascular DiseaseObesityObesityType II Diabetes mellitusType II Diabetes mellitusColon and Breast cancerColon and Breast cancerFracture / OsteoporosisFracture / OsteoporosisMental health disorders (Alzheimer’s disease)Mental health disorders (Alzheimer’s disease)

Additional benefits Additional benefits Weight reduction, reduced feelings of stress, Weight reduction, reduced feelings of stress, improved psychological well-being and physical improved psychological well-being and physical

function, enhanced self-esteem… function, enhanced self-esteem… The European Health ReportThe European Health Report 2002 WHO Regional Publications, European Series No. 97 2002 WHO Regional Publications, European Series No. 97

Physical inactivity: DangerPhysical inactivity: Danger

2 million deaths2 million deaths worldwide annually worldwide annually

Significant contributor to the global burden of Significant contributor to the global burden of chronic chronic diseasedisease

Less healthy pattern of Less healthy pattern of eating behavioreating behavior

Economic cost: Economic cost: ◊ ◊ higher health care higher health care costs costs ((30%30% more more hospital days hospital days & & 41%41% more more likely annual claims over $5,000 likely annual claims over $5,000))◊ ◊ more more absenteeismabsenteeism◊ ◊ value of value of future earningsfuture earnings lost by lost by premature deathpremature death

Keeler, et al. (1989) Keeler, et al. (1989) The external cost of a sedentary lifestyleThe external cost of a sedentary lifestyle Am J of PH, 79, 975-981 Am J of PH, 79, 975-981

NEW !!!NEW !!!

Health-related benefits could accrue from a minimum Health-related benefits could accrue from a minimum of of 30 minutes30 minutes of of moderate-intensitymoderate-intensity activity, such as activity, such as carrying light loads, brisk walk, bicycling at a regular carrying light loads, brisk walk, bicycling at a regular

pace or washing windows, on pace or washing windows, on most, preferably all, most, preferably all, days of the week days of the week

American American JJ of Sports and Medicine & General Surgeon Recommendation of Sports and Medicine & General Surgeon Recommendation

Situation in Situation in ArmeniaArmeniaCardiovascular Disease: Cardiovascular Disease: morbidity in 2000 - 20.1, while in 2004 - 25.7 (per 1,000) and 58% morbidity in 2000 - 20.1, while in 2004 - 25.7 (per 1,000) and 58% of all deaths in 2003of all deaths in 2003

Hypertension:Hypertension: ¼ of adults ¼ of adults (DHS Armenia 2005, WHO 2006)(DHS Armenia 2005, WHO 2006)

Breast cancer:Breast cancer: the the incidence increased up to 73%, and mortality increased up to 143%incidence increased up to 73%, and mortality increased up to 143% from from 1980 to 2000 1980 to 2000 ((HH. . M. GM. Galstyan et al.,alstyan et al.,Short reportShort report; ; Archive of Oncology 2003;11(1):31-3Archive of Oncology 2003;11(1):31-3))

Diabetes:Diabetes: mortality rate increased nearly four-fold from 1981-1998mortality rate increased nearly four-fold from 1981-1998 ( (Hovhannisyan, S.G., Tragakes, et al. Hovhannisyan, S.G., Tragakes, et al. Armenia: Health Care Systems in Transition 2001)Armenia: Health Care Systems in Transition 2001)

DataData onon ArmeniaArmenia

H. Armenian et al. Leninakan-43.3% of cases and 70% of controls active (1988)

Hakobyan et al. – 73% of sedentary lifestyle in Yerevan in 2005

World Vision Armenia & American University of Armenia:

• Tashir (Lori marz) and Vardenis (Geghharkunik marz) – 50% of women is sedentary (2004)

Study AimStudy AimPrevention of severe diseases directly related to physical Prevention of severe diseases directly related to physical

inactivity, such as coronary heart disease, diabetes, inactivity, such as coronary heart disease, diabetes, obesity, colon and breast cancerobesity, colon and breast cancer

Study ObjectivesStudy Objectives– Estimation of prevalence of PA among Yerevan 18-65 yr- Estimation of prevalence of PA among Yerevan 18-65 yr-

old adultsold adults– Identification of groups with escalated health risks due Identification of groups with escalated health risks due

to sedentary life-style to sedentary life-style – Understanding major barriers to PAUnderstanding major barriers to PA

Secondary ObjectivesSecondary Objectives– To reveal the knowledge of target population on benefits To reveal the knowledge of target population on benefits

of PA and concept of “enough” level of PA and concept of “enough” level – To reveal subjective perception (satisfaction) of people To reveal subjective perception (satisfaction) of people

by their level of activity by their level of activity – To identify the current and desired source of To identify the current and desired source of

information about PA information about PA

Dependent Variable: physical activity level Mode of Measurement Scale

1=Health Enhancing Physical activity levelAny of the following two criteria: - Vigorous-intensity activity on at least 3 days and accumulating at least 1500 MET-minutes/ week OR- 7 or more days of any combination of walking, moderate-intensity or vigorous-intensity activities achieving a minimum of at least 3000 MET-minutes/week. 0= Inactive/Minimally active - No activity is reported OR- Some activity is reported but not enough to meet category 1

Dichotomous

1=Health Enhancing Physical activity level

0=Inactive/Minimally active

Independent Variables Variable Mode of Measurement Scale

1. Gender Dichotomous1=Female, 0=Male

2. Age What was your age on your last birthday?

Continuous

3. Educational level

What is your level of education?

Ordinal 1= Incomplete / complete secondary 2= College 3= University/Postgraduate

Independent Variables (cont.)Variable Mode of Measurement Scale

4. Income level(proxy- monthly household expenditures)

On average how much money does your household spend monthly?

Ordinal 1= Below 35, 000 AMD2= 35,000 to 70,000 3= 70, 001 to 130, 000 4=130, 001 to 200,000 5= More than 200 001

5. Occupation Are you occupied? Dichotomous1=Yes, 0=No

6. Marital status

What is your marital status? Nominal 1= Single2= Married3= Divorced 4=Widowed

Methods: 1. Methods: 1. Study DesignStudy Design

Cross-sectionalCross-sectional analytical analytical Population-based telephone surveyPopulation-based telephone survey

Reason:Reason:1.1. Objectives to achieve Objectives to achieve 2.2. Efficiency in timeEfficiency in time3.3. Efficiency in resources Efficiency in resources

Limitations:Limitations: Inability to provide causal relationship: only Inability to provide causal relationship: only

test association between variables test association between variables

Methods: 2. SamplingMethods: 2. Sampling

Probability sampling by Probability sampling by RDDRDD technique technique

Sampling unit - telephone numberSampling unit - telephone numberThe first two digits are correspond to the area The first two digits are correspond to the area codes (54,56-codes (54,56-KentronKentron), and the remaining four ), and the remaining four digits are randomly generated: Ms Excel digits are randomly generated: Ms Excel (Function: =RANDBETWEEN (999, 9999)) (Function: =RANDBETWEEN (999, 9999)) Phone numbers are proportionately divided Phone numbers are proportionately divided according to the number of 18-65 yr-old people according to the number of 18-65 yr-old people living in each living in each HamaynkHamaynk (2001 census data) (2001 census data) The method is unrestricted by the problem of missing people with unlisted or new numbers and the sample represents the households from different areas of Yerevan

# Quarter Community (Hamaynk)

# of people aged 18-65 year-old living in Hamanynk

# of people aged 18-65 year-old according to sample size

1 Malatia-Sebastia 93,041 61

2 Nor-Nork 90,848 61

3 Shengavit 87,646 56

4 Arabkir 84,330 51

5 Kentron 82,651 51

6 Erebuni 75,326 46

7 Achapnyak 67,517 41

8 Kanaker-Zeytun 49,567 31

9 Avan 31,403 26

10 Davidashen 26,026 20

11 Nork-Marash 7,078 10

12 Nubarashen 5,783 6

Total 701,216460

Methods: 3. Study PopulationMethods: 3. Study PopulationTarget population - general population of YerevanSurvey population - Yerevan adult population

Inclusion criteria: residency in Yerevan, age between

18-65 years old at the start of the survey, willingness to participate, and ability to speak Armenian

Sample frame - all telephone households in YerevanSample units were selected by Random Digit Dialing

Random selection was used to enroll only one participant per household: Kish technique (“next birthday” ) to ensure randomization at all stages

Methods: 4. Sample Size CalculationFormula: n=z2*pq/d2, where

p - proportion of individuals who have the desired characteristic (enough activity level for a healthy lifestyle)q (1-p)- proportion of those who do not have the desired characteristic d - desired level of precision

For 95% CI type I error is α =0.05; Zα= 1.96 (two-sided)Maximum % difference we are willing to accept between true population rate and sample rate is 5%: d = 0.05To get the maximal sample size, the ratio of active and inactive people is assumed to be 50:50

n = 1.96²*0.5*0.5/0.05²= 38420% non-response from the previous RDD surveys (1999,2005) the sample size is increased to (384*0.2+384) 460

Methods 5. Data Collection Phone interviews (September - November 2007)

(time period has been selected to control for seasonal variations)Time: during the week-end days and/or in usual working days after 7PM to avoid sampling bias toward non-working peopleLanguage: Armenian since 96% of the population speaks the language Interviewer Training Manual was developed which includes general information about the survey, information about the procedures for gaining cooperation and establishing rapport with respondentsTwo interviewers previously trained using the Manual

Methods: 6. Study Instrument Methods: 6. Study Instrument

International Physical Activity QuestionnaireInternational Physical Activity Questionnaire (short –form)(short –form)

RationaleRationale::~~ Comparable data across countries (designed for Comparable data across countries (designed for

International Prevalence StudyInternational Prevalence Study))~~ ReasonableReasonable reliability & reliability & vvalidityalidity ((Spearman’s Spearman’s RhoRho: 0.8; : 0.8;

criterion validity: median criterion validity: median rhorho of 0.3 against the accelerometer) of 0.3 against the accelerometer)

DomainsDomains: : 1. 1. screening questions, 2. oral consent screening questions, 2. oral consent form, 3. PA questions (behavior, knowledge, form, 3. PA questions (behavior, knowledge, attitude, barriers, motivators), 4. behavioral, health attitude, barriers, motivators), 4. behavioral, health status, demographicsstatus, demographics

Translation, adaptation, pilot testingTranslation, adaptation, pilot testing

Methods 7. Data Coding Metabolic equivalents Metabolic equivalents (METs)(METs) were assigned to each were assigned to each activity for categorization according to three degrees of activity for categorization according to three degrees of physical activity – inactive, minimally active and Health physical activity – inactive, minimally active and Health Enhancing physical activity levelEnhancing physical activity level

((www.ipaq.ki.se)www.ipaq.ki.se) MET is the amount of oxygen used by body as person sits quietly, MET is the amount of oxygen used by body as person sits quietly,

f.e. talking on the phone, reading a book, i.e. METs represent the f.e. talking on the phone, reading a book, i.e. METs represent the ratio of energy expended during a physical activity to the metabolic ratio of energy expended during a physical activity to the metabolic rate of sitting quietly rate of sitting quietly

For statistical analysis data were recoded to two degrees For statistical analysis data were recoded to two degrees of physical activity – of physical activity – 1. inactive/minimally1. inactive/minimally activeactive and and 2. 2. HEPA activeHEPA active

Although minimally active category is more than the minimum level Although minimally active category is more than the minimum level recommended, it is not enough for “total physical activity” when all recommended, it is not enough for “total physical activity” when all domains are considered. IPAQ measures total physical activity, but domains are considered. IPAQ measures total physical activity, but recommendations are based on activity over and above usual daily recommendations are based on activity over and above usual daily activitiesactivities

Calculation of Metabolic Equivalents TYPE OF

ACTIVITYMET AMOUNT

Walking 3.3

Moderate intensity activity

4.0

Vigorous intensity activity

8.0

Total MET-min/week = (Walk METs x min x days) + ( Mod METs x min x days) + (Vig METs x min x days)

*To calculate the weekly physical activity (MET-hours), we multiplied the number of hours, dedicated to each activity by the specific MET score of each activity. Ainnsworth et al.Ainnsworth et al. (1993) (1993)

Methods: 8. Statistical Analysis Methods: 8. Statistical Analysis

SPSS 11,0 SoftwareSPSS 11,0 Software

Descriptive statisticalDescriptive statistical analysisanalysis- - categorical variablescategorical variables: absolute & relative frequencies : absolute & relative frequencies - - continuous variablescontinuous variables: mean values ± standard : mean values ± standard

deviationdeviation

StepwiseStepwise logistic regression logistic regression to assess the to assess the association between physical activity level association between physical activity level and sociodemographic indicators & and sociodemographic indicators & Chi Chi squaresquare test to test the association between test to test the association between PA and satisfactionPA and satisfaction

P-P-values based on two-sided tests and compared to 5% values based on two-sided tests and compared to 5% significance levelsignificance level

Methods: 8. Statistical Analysis Methods: 8. Statistical Analysis (cont.)(cont.)

Three types of logistic regression models:

1. Model with single variable

2. Model with all variables

3. Model with all variables excluding income

The final model is the model with all variables excluding income, since only 64% percent of respondents reported their income, i.e. 36% of data is missing

Ethical ConsiderationsNo risk for participants, not sensitive topic Each interview lasted on average 12 minutesConsent form in Armenian: objectives of the study, its importance, risk/benefit and voluntary nature Participants were aware that responses were coded and the anonymity of all provided information was insured.Names of the participants were not registered: identifiers were phone numbers, which were not written on the questionnaires. ID numbers were given to each phone number and were registered in a separate form: Interviewer Report Form The results of the survey are displayed in an aggregate form.

Results:Results: 1. 1. Response to the surveyResponse to the survey

Number Percent

Persons Interviewed (Completed interviews)

369 80%

Persons Interviewed (Partial interviews)

0 0

Persons Refused 61 13

Non-reached* * people of unknown eligibility who theoretically could be reached during the period of the survey

30 7

Total 460 100

Results: 2. Distribution of Sample CharacteristicsCharacteristics Category % of sample representatives

Age Mean ± standard deviation

39 yrs-old ± 14

Gender Male : female 24 : 76Education Secondary 19

College 32

University / postgrad 48

Occupation Unoccupied : occupied 62 : 38

Expenditures per month(as a proxy for income), AMD

< 70,000 8

70,001-130,000 17

130,001-200,000 22

>200,001 17

Marital status Single 24

Married 69

Divorced 3

Widowed 3

Results: 2. Distribution of Sample Characteristics (cont.)Characteristics Category % of sample

representatives

Health status Excellent 6

Very good 5

Good 36

Moderate 48

Poor 4

Weight Too skinny 4

Normal 68

Slightly overweight 23

Overweight 4

Smoking status Smoking : not smoking 20 : 79

# of cigarettes Mean ± st. deviation (range)

20 ± 16 (2-99)

# of people in the household

Mean ± st. deviation (range)

4 ± 2 (1-13)

Results: Results: 3.3. Physical Activity Level Physical Activity Level

CategoryCategory of of physical activityphysical activity

Sample Sample populationpopulation

Inactive / Inactive / MinimMinimally activeally active 53%53%

HEPA activeHEPA active

(Health Enhancing Physical (Health Enhancing Physical Activity level) Activity level)

47%47%

Results: 4. ORs for Logistic Regression of association between PA & socio-demographic indicators

A.Single factor modelIndependent

VariableOR 95% CI p value

1 Age 0.997 0.983-1.012 0.734

2 Gender 1.082 0.671-1.746 0.747

3 Education 1.403 0.880-2.238 0.155

4 Income level 1.719 0.885-3.338 0.110

5 Occupation* 3.047 1.951-4.758 0.000

6 Marital status* 0.425 0.255-0.710 0.001


B. Model with all demographic variables

Independent Variable

OR 95% CI p value

1 Age 0.982 0.959-1.006 0.142

2 Gender 0.683 0.341-1.368 0.282

3 Education 0.941 0.484-1.828 0.857

4 Income level 1.719 0.819-3.608 0.152

5 Occupation* 4.078 2.140-7.769 0.000

6 Marital status 2.278 0.967-5.364 0.06


C. Model with all variables excluding income

Independent Variable

OR 95% CI p value

1 Age* 0.979 0.960-0.997 0.026

2 Gender 0.716 0.415-1.234 0.229

3 Education 0.995 0.565-1.614 0.864

4 Occupation* 3.324 2.007-5.505 0.000

5 Marital status* 3.369 1.781-6.372 0.000

Results: 5. Knowledge on benefits of Results: 5. Knowledge on benefits of physical activity physical activity

“Physical activity is beneficial for health”“Physical activity is beneficial for health”

Strongly agree 87%

Agree 10%

Uncertain 2%

Disagree 1%

Results: 6. 1. Knowledge on the diseases to be prevented by PA

Disease (Nosology)

Spontaneous answer

Answer after interviewer clarification

YES YES Don’t know NO

# (%) # (%) # (%) # (%)

Cardiovascular diseases

90 (24%) 265 (72%) 60 (16%) 24 (7%)

Hypertension 46 (13%) 219 (59%) 90 (24%) 39 (11%)

Diabetes 8 (2%) 133 (36%) 143 (39%) 73 (20%)

Obesity 37 (10%) 294 (80%) 44 (12%) 10 (3%)

Colon cancer 2 (1%) 95 (26%) 198 (54%) 55 (15%)

Breast cancer 2 (1%) 77 (21%) 204 (55%) 68 (18%)


Disease (Nosology)

Spontaneous answer


YES YES Don’t know

NO

# (%) # (%) # (%) # (%)

Stress 27 (7%) 220 (60%) 87 (24%) 42 (11%)

Pneumonia 3 (1%) 80 (22%) 156 (42%) 113 (31%)

Tuberculosis 0 37 (10%) 177 (48%) 134 (36%)

HIV/AIDS 0 17 (5%) 140 (38%) 192 (52%)


Disease (Nosology)

Spontaneous answer


YES YES Don’t know NO

# (%) # (%) # (%) # (%)

Osteoporosis 2 (1%) 2 (1%)Arthritis 2 (1%) 29 (8%)Vertebral diseases 6 (2%)Influenza 4 (1%)Metabolic syndrome

2 (1%)

Thymus diseases 2 (1%)Muscles diseases 2 (1%)Rheumatic diseases

2 (1%)

Bronchitis 1

Results: 7. Knowledge on the concept Results: 7. Knowledge on the concept of “enough” physical activityof “enough” physical activity

Only Only 14%14% of participants reported correct of participants reported correct amount of physical activity for a healthy amount of physical activity for a healthy lifestyle lifestyle

Median days reported: Median days reported: 77

Median minutes reported: Median minutes reported: 6060

Correct answer: Correct answer:

3030 minutes of moderate activity for minutes of moderate activity for 5-75-7 days days per weekper week

Results: 8. Desire to have additional Results: 8. Desire to have additional information about physical activityinformation about physical activity

45% 45% of participants definitely want to of participants definitely want to have more information about physical have more information about physical activityactivity

16%16% probably want probably want

30%30% probably do not want probably do not want

5%5% definitely do not want to have definitely do not want to have more information about physical more information about physical activityactivity

Results: 9. Source of Information about Physical Activity: current and desirable

SOURSEHeard about

physical activityWant to know about physical

activity # (%) # (%)

1 TV

257 70 200 54

2 Radio 76 21 108 293 Medical literature 56 15 34 94 Physician, medical office

22 6 27 7

5 Newspapers, magazines

57 15 48 13

6 Internet 15 4 25 77 Relatives, friends,

neighbors37 10 40 11

8 Workplace 8 2 13 49 Brochures 5 1 4 1

10 School, college 4 1 - -

Results 10. Subjective Perception vs. Objective Level of PA: cross-tabulation

Category of activity

Inactive/min active

HEPA active

Total

Satisfaction status

No 101 57 158

Yes 93 (48%)

118(33%)

211

(57%)

Total 194 175 369

Pearson Chi-square 15.4 P value .000

Results: 11. Desire to be more activeResults: 11. Desire to be more active

64% of participants reported that they 64% of participants reported that they want to practice more activity want to practice more activity

Results: 12. Reported Barriers to Physical ActivityBarriers # of people (%)

Lack of time because of working/studying 111 30Lack of time because of family responsibilities 106 29Lack of energy/tiredness 17 5Lack of money/high cost of sport gyms 30 8Feeling of shame - -Fear to be injured 2 1Overweight, obesity 2 1Lack of companionship 4 2No person to take care for children 7 2Poor health status 39 11Bad mood/depression 9 3Lack of safe places - -I do not like to be active - -Lack of strong will 21 6Sitting occupation 2 1Old age 5 2Being unemployed 8 4

Results: 13. Motivating Factors to Physical Activity

# FACTOR

Spontaneous Answer

Answer after Interviewer Clarification

# (%) # (%)

1 Family member/wife, husband exercising with me

17 5 89 24

2 Friend exercising with me 10 3 86 23

3 Family member/wife, husband encouraging me

9 2 80 22

4 Friend encouraging me 8 2 76 21

5 Employer paying for sport club/gym

11 3 75 20

6 Gym in the workplace 5 2 42 11

Results: 13. Motivating Factors to Physical Activity #

FACTOR

Spontaneous Answer

Answer after Interviewer Clarification

# (%) # (%)7 Flexible working hours 5 1 49 138 Advice from a doctor 17 5 123 339 Sport club/gym close to

home2 1 37 10

10 Sport club membership 2 1 29 811 Person to take care of

children5 1 28 8

12 Availability of inexpensive sport facilities

12 4

13 Availability of green places 2 1

Results: 14. Suggestions:

“what should be done in your area to motivate people to practice more activity”

Suggestions # of persons answered

Create good places (parks) 3

Educate people 4

Establish non-expensive sport facilities 2

Organize meetings with famous sportsmen and sport events

2

Discussion: 1. PA Prevalence Discussion: 1. PA Prevalence Yerevan, Armenia: 5Yerevan, Armenia: 53 % sedentary3 % sedentaryFinland: Finland: 8.1%8.1% sedentarysedentaryBrazil: Brazil: 41%41% sedentary (IPAQ) sedentary (IPAQ)Greece: Greece: 48-53%48-53% sedentary sedentaryBaltic countries: Baltic countries: 43-60%43-60% sedentary sedentaryUSA: USA: 60%60% sedentary (leisure-time) sedentary (leisure-time)Portugal: Portugal: 60%60% France: France: 50-70%50-70% sedentary (leisure-time) sedentary (leisure-time)RussiaRussia: : 73-81%73-81% are sedentary (IPAQ) are sedentary (IPAQ)

• Conclusion: Yerevan population is more active than US, Conclusion: Yerevan population is more active than US, Portugal, Lithuanian, French, Israel & Russian Portugal, Lithuanian, French, Israel & Russian population & less active than most European countries population & less active than most European countries population, Estonian, Australian, Brazilian and Greek population, Estonian, Australian, Brazilian and Greek female populationfemale population

Discussion: 1. PA PrevalenceDiscussion: 1. PA PrevalenceHowever !However !

1.1. The majority of the mentioned studies assessed not all The majority of the mentioned studies assessed not all life domains, but only leisure-time physical activity. We life domains, but only leisure-time physical activity. We assessed all life domains.assessed all life domains.

2.2. From those 47% HEPA active people, 38 (22%) reported From those 47% HEPA active people, 38 (22%) reported jobs requiring heavy physical endeavor: builders, jobs requiring heavy physical endeavor: builders, laborers, technicians, etc. Therefore, these people are laborers, technicians, etc. Therefore, these people are active as part of their job. active as part of their job.

3.3. CDC’s recommendations based on the recreational CDC’s recommendations based on the recreational (leisure-time) activity above usual daily activity(leisure-time) activity above usual daily activity

Conclusion: the prevalence of sedentary life-style in Conclusion: the prevalence of sedentary life-style in Armenia is even higher, if only leisure-time activity is Armenia is even higher, if only leisure-time activity is taking into consideration. taking into consideration.

Discussion: 2. Association between variables & PA: Discussion: 2. Association between variables & PA: AGEAGE

InIn France France meeting the recommended physical meeting the recommended physical activity levels wasactivity levels was more likely in subjects aged more likely in subjects aged 60 years and older60 years and older

A A direcdirect relationship between PA and age was t relationship between PA and age was found also in found also in IsraelIsrael

In the In the USUS and and BrazilBrazil the association between the association between physical activity and age was physical activity and age was negativenegative

This study This study also found also found negativenegative association association between age and PA between age and PA

Discussion: 2. Association between variables & Discussion: 2. Association between variables & PA: PA: GENDERGENDER

Women tend to be Women tend to be less actless actiiveve than men in some than men in some European countries, Greece, Australia.European countries, Greece, Australia.

In In FranceFrance females tend to be females tend to be moremore active than active than males. males.

NoNo significant association was found between significant association was found between gender and physical activity in gender and physical activity in RussiaRussia. .

This study This study also did not found any statistically also did not found any statistically significant association between physical activity significant association between physical activity level and gender.level and gender.

Discussion: 2. Association between Discussion: 2. Association between variables & PA: variables & PA: EDUCATIONEDUCATION

Physical activity was Physical activity was inverselyinversely related to related to educational level in the educational level in the US, Israel, Baltic US, Israel, Baltic countries. countries.

PositivePositive relationship was found between relationship was found between physical activity and education in the physical activity and education in the pooled pooled European European data and in data and in AustraliaAustralia..

This studThis study did not found any statistically y did not found any statistically significant association between physical significant association between physical activity level and education.activity level and education.

Discussion: 2. Association between Discussion: 2. Association between variables & PA: variables & PA: INCOMEINCOME

Physical activity was Physical activity was inverselyinversely related to related to income level in the income level in the US, Israel, & BrazilUS, Israel, & Brazil

PositivPositive relationship was found between e relationship was found between physical activity and income in physical activity and income in Baltic Baltic countries, Australiacountries, Australia

This study This study failed to obtain data on failed to obtain data on association between physical activity level association between physical activity level and income, since only 64% of and income, since only 64% of respondents reported their incomerespondents reported their income

Discussion: 2. Association between Discussion: 2. Association between variables & PA: variables & PA: MARITAL STATUSMARITAL STATUS

GreekGreek study showed that physically active study showed that physically active people were more likely to be unmarried.people were more likely to be unmarried.

In In US US the change from a married to a single the change from a married to a single state did not affect PA relative to remaining state did not affect PA relative to remaining married, while the transition from a single to a married, while the transition from a single to a married state resulted in significant positive married state resulted in significant positive changes in PA relative to remaining single.changes in PA relative to remaining single.

In this studyIn this study, married individuals are more , married individuals are more likely to be active. likely to be active.

Discussion: 2. Association between Discussion: 2. Association between variables & PA: variables & PA: OCCUPATIONOCCUPATION

GreekGreek study showed that physically active study showed that physically active people had higher occupation skillspeople had higher occupation skills

In this study In this study occupied individuals are occupied individuals are moremore likely to be active likely to be active

This finding is probably due to the This finding is probably due to the assessment of all domains physical assessment of all domains physical activity, including work-relatedactivity, including work-related

Discussion: 3. BenefitsDiscussion: 3. Benefits

The overwhelming majority of the The overwhelming majority of the participants agree that physical activity is participants agree that physical activity is beneficial for their health. beneficial for their health.

The same percentage of American people The same percentage of American people knows that exercise is beneficial for their knows that exercise is beneficial for their health.health.

Although Although 87%87% of surveyed population of surveyed population aware that PA is beneficial for health, only aware that PA is beneficial for health, only 47%47% are HEPA active. are HEPA active.

Discussion: Discussion: 4.Knowledge on the diseases 4.Knowledge on the diseases

1.1. A very low % of people answered spontaneously that A very low % of people answered spontaneously that PA is beneficial for CVD (24%), even lower- for PA is beneficial for CVD (24%), even lower- for hypertension (13%), and for obesity (10%)hypertension (13%), and for obesity (10%)

2.2. When the options were read, much more respondents When the options were read, much more respondents gave right answers gave right answers

3.3. 24% of the respondents believe that PA is not 24% of the respondents believe that PA is not beneficial for hypertension, 17%- for CVD, 39%- for beneficial for hypertension, 17%- for CVD, 39%- for diabetes, 54%-for colon cancer, 55% -for breast cancerdiabetes, 54%-for colon cancer, 55% -for breast cancer

4.4. 22% said that PA is beneficial for the pneumonia, 10%- 22% said that PA is beneficial for the pneumonia, 10%- for the tuberculosis, and 5% - for the HIV/AIDS for the tuberculosis, and 5% - for the HIV/AIDS

5.5. Conclusion: there is a lack of concrete knowledge on Conclusion: there is a lack of concrete knowledge on benefits of physical activity among Yerevan adult benefits of physical activity among Yerevan adult population population

Discussion: 5. Knowledge on the Discussion: 5. Knowledge on the concept of “enough” activityconcept of “enough” activity

Only Only 14%14% of the participants reported of the participants reported correct amount of physical activity for a correct amount of physical activity for a healthy lifestyle healthy lifestyle

Some respondents reported more extreme Some respondents reported more extreme amount of daily PA amount of daily PA minutes-120 minutes minutes-120 minutes (22%)(22%) or even or even 180 minutes (7%)180 minutes (7%)

Conclusion: For the majority physical Conclusion: For the majority physical activity sounds as a very intimidating activity sounds as a very intimidating conceptionconception

Discussion: Discussion: 6. Source of information 6. Source of information

The majority of the participants heard The majority of the participants heard about PA from about PA from TV and radioTV and radio. .

The disappointing finding of this survey is The disappointing finding of this survey is that only that only 6% 6% of people heard about the PA of people heard about the PA from from physician or medical officephysician or medical office

More than a half of the participants want to More than a half of the participants want to have more information on PA and mostly have more information on PA and mostly from the same source from the same source - TV and radio- TV and radio

Discussion: 7. SatisfactionDiscussion: 7. SatisfactionAlmost Almost halfhalf of inactive people are satisfied by the activity they of inactive people are satisfied by the activity they practice practice

Our findings are consistent with US data, where 52% of the Our findings are consistent with US data, where 52% of the respondents were generally satisfied with the amount of respondents were generally satisfied with the amount of exercise they get, while 58% of them were classified as exercise they get, while 58% of them were classified as sedentarysedentary

In Israel only 17.5% of the sample population considered In Israel only 17.5% of the sample population considered themselves physically active while in reality being sedentary themselves physically active while in reality being sedentary according to sport intensity calculationsaccording to sport intensity calculations

Two possible explanations for this unexpected result: Two possible explanations for this unexpected result:

1.1. such a question may have sounded unclear to the participantssuch a question may have sounded unclear to the participants

2.2. this can be due to the limited knowledge on the concept of this can be due to the limited knowledge on the concept of “enough” PA level“enough” PA level

Discussion: 7. Willingness Discussion: 7. Willingness

The majority of survey sample are willing The majority of survey sample are willing to expand their level of activity (64%)to expand their level of activity (64%)

This is important, since pro-physical This is important, since pro-physical activity campaigns should not be tailored activity campaigns should not be tailored to population subgroups apparently to population subgroups apparently unwilling to be activeunwilling to be active

Discussion: 8. BarriersDiscussion: 8. BarriersThe main reported barriers: lack of time because of The main reported barriers: lack of time because of working/studying (30%) & lack of time because of family working/studying (30%) & lack of time because of family responsibilities (29%)responsibilities (29%)

In Israel: lack of time and/or energy; smoking habitsIn Israel: lack of time and/or energy; smoking habits

In Baltic countries - lack of time (54%) and laziness In Baltic countries - lack of time (54%) and laziness (46.7%) (46.7%)

These are types of psychological and behavioral barriersThese are types of psychological and behavioral barriers

It is not clear, to what extent mentioned barrier “lack of It is not clear, to what extent mentioned barrier “lack of time” is dictated by person’s life circumstances, or by time” is dictated by person’s life circumstances, or by his/her lack of time-management skillshis/her lack of time-management skills

While only 4% of the participants reported poor health, While only 4% of the participants reported poor health, 11% mentioned poor health as a barrier to PA11% mentioned poor health as a barrier to PA

Discussion: 9. MotivatorsDiscussion: 9. MotivatorsA very low % answered spontaneously to this question, but when the A very low % answered spontaneously to this question, but when the options were read, people became more actively to answer options were read, people became more actively to answer

33% of the respondents would practice more physical activity, if doctor 33% of the respondents would practice more physical activity, if doctor advice them to do itadvice them to do it

Family member (wife, husband) exercising with, would motivate 24% of Family member (wife, husband) exercising with, would motivate 24% of respondents; family member/wife, husband encouraging would motivate respondents; family member/wife, husband encouraging would motivate 22% of respondents22% of respondents

Friend, exercising with, would motivate 23%; and friend encouraging would Friend, exercising with, would motivate 23%; and friend encouraging would motivate 21% of peoplemotivate 21% of people

20% of the respondents would practice more exercise if employer pay for 20% of the respondents would practice more exercise if employer pay for the sport club.the sport club.

13% of the respondents mentioned flexible working hours and 11%-13% of the respondents mentioned flexible working hours and 11%-availability of the gym at the workplace.availability of the gym at the workplace.

The most important agents are physicians, The most important agents are physicians, family and friends, as well as employers family and friends, as well as employers

Study StrengthsStudy Strengths

High generalizability: high coverage of High generalizability: high coverage of Yerevan households by phones – 95% Yerevan households by phones – 95% (www.armentel.am)(www.armentel.am)

Randomized design: RDD and Kish Randomized design: RDD and Kish technique to ensure randomization at all technique to ensure randomization at all stagesstages

High response rate: 80% High response rate: 80%

Internationally valid and reliable instrument Internationally valid and reliable instrument designed for phone interviewsdesigned for phone interviews

Study LimitationsStudy Limitations

Cross-sectional designCross-sectional design

Self-reported data Self-reported data

Recall biasRecall bias

Failure to obtain data on Income Failure to obtain data on Income

Seasonal variations (last 7 days recall)Seasonal variations (last 7 days recall)

Impossibility to generalize to the whole population of Impossibility to generalize to the whole population of Armenia, especially ruralArmenia, especially rural

Assessment of all life domains: those who were Assessment of all life domains: those who were physically active as part of their job, may bias the study physically active as part of their job, may bias the study findingsfindings

Recommendations: 1. Research Recommendations: 1. Research

Further research is recommended to Further research is recommended to assess all life-domains separately, assess all life-domains separately, focusing especially on leisure-time activity focusing especially on leisure-time activity

Use long-form IPAQ instrument Use long-form IPAQ instrument

Exclude those reporting energy Exclude those reporting energy expenditure of 10,000 METs or more to expenditure of 10,000 METs or more to avoid measurement error due to over-avoid measurement error due to over-reportingreporting

Recommendations: Recommendations: 2. Awareness raising 2. Awareness raising

Educational programs in different settings Educational programs in different settings

Mass Media programs Mass Media programs • Involve politicians, starsInvolve politicians, stars• Pauses by TV like adds of healthy behavior Pauses by TV like adds of healthy behavior

Promo actions, campaigns at national level Promo actions, campaigns at national level (health walks, health runs), day of activity (health walks, health runs), day of activity “Get “Get active”active”

Brochures with the information on benefits of Brochures with the information on benefits of PA, concept of “enough" activity, ways of PA, concept of “enough" activity, ways of overcoming barriersovercoming barriers

Special calendars and diaries for daily planning Special calendars and diaries for daily planning

Recommendations: Recommendations: 3. Establishment of environments 3. Establishment of environments

Establish attractive and low-cost health clubs Establish attractive and low-cost health clubs

Encourage sport clubs to provide child care facilities, to offer Encourage sport clubs to provide child care facilities, to offer activities for adults and children at the same place and time, activities for adults and children at the same place and time, to provide special family packages with discount for families to provide special family packages with discount for families and companionships of two or more peopleand companionships of two or more people

Have several attractive sport facilities in each Hamaynk Have several attractive sport facilities in each Hamaynk

Promote the use of existing sport facilities: give free Promote the use of existing sport facilities: give free advertisement possibilities or provide a discount on advertisement possibilities or provide a discount on advertisement of sport- and fitness-centers, dance clubs, advertisement of sport- and fitness-centers, dance clubs, swimming pools, etc. swimming pools, etc.

Create safe and pleasant informal places for people to be Create safe and pleasant informal places for people to be active and to increase access to walking and bicyclingactive and to increase access to walking and bicycling

Construct walking roads with sidewalks and bike lanes, Construct walking roads with sidewalks and bike lanes, comfortable parks, etc. comfortable parks, etc.

Recommendations: Recommendations: 4. P 4. Promotion of the activity by employersromotion of the activity by employers

Encourage employers to give special packages for Encourage employers to give special packages for employees, pay for the sport clubemployees, pay for the sport club

Establish ongoing health education program at the Establish ongoing health education program at the workplace workplace

Motivate employers by giving special tax benefits to Motivate employers by giving special tax benefits to those organizations which encourage healthy life-stylethose organizations which encourage healthy life-style

Inform employers with the report of Surgeon General, Inform employers with the report of Surgeon General, according to which workplace physical activity programs according to which workplace physical activity programs can reduce short-term sick leave by 6 to 32%, health can reduce short-term sick leave by 6 to 32%, health care costs by 20-55%, and increase productivity by 2-care costs by 20-55%, and increase productivity by 2-52%52%

Recommendations: Recommendations: 5. I5. Improvement of physicians’ counseling mprovement of physicians’ counseling

skillsskills• Objectively assess physicians’ counseling skills on Objectively assess physicians’ counseling skills on

healthy lifestyle, including physical activityhealthy lifestyle, including physical activity• Improve physicians’ counseling practices:Improve physicians’ counseling practices:

- provide GPs, cardiologists and nurses with the - provide GPs, cardiologists and nurses with the additional trainings on healthy-lifestyle counseling, with additional trainings on healthy-lifestyle counseling, with the evidence based information on the amount, type and the evidence based information on the amount, type and duration of physical activity required for maintaining and duration of physical activity required for maintaining and improving health, with the knowledge, skills and improving health, with the knowledge, skills and resources to assess current PA level and prescribe resources to assess current PA level and prescribe appropriate amounts and types of physical activity, appropriate amounts and types of physical activity, based on age, skills, fitness level and health status to based on age, skills, fitness level and health status to prevent injury prevent injury

Recommendations: Recommendations: 5. I 5. Improvement of physicians’ counseling mprovement of physicians’ counseling

skillsskills

Improve counseling protocols and supervise Improve counseling protocols and supervise the compliance with protocols and policy the compliance with protocols and policy guidelines guidelines

Give additional incentives for lifestyle Give additional incentives for lifestyle counselingcounseling

Provide physicians with educational materials Provide physicians with educational materials to disseminate them among patientsto disseminate them among patients

Present the results of this study to doctors Present the results of this study to doctors

Recommendations Recommendations

Establishment of the network of Establishment of the network of organizationsorganizations

Monthly newsletters with up-to-date Monthly newsletters with up-to-date information dedicated to PAinformation dedicated to PA

Establishment of regular surveillance Establishment of regular surveillance system to monitor lifestyle factors, collect system to monitor lifestyle factors, collect data on the whole Armenia to have data on the whole Armenia to have nationally representative data, not limited to nationally representative data, not limited to the capital city the capital city

Programs’ requirementsPrograms’ requirements

• population-basedpopulation-based• involve multiple sectors and various stakeholders - involve multiple sectors and various stakeholders -

ministries of health, sport, education, transport and ministries of health, sport, education, transport and culture; public and private sector groups and NGOs; culture; public and private sector groups and NGOs; urban planners and local governments, municipalities urban planners and local governments, municipalities

• culturally relevant culturally relevant • promote PA in all life settings making use of major promote PA in all life settings making use of major

sport, health and cultural eventssport, health and cultural events• be supported at the governmental level. be supported at the governmental level.

Conclusion Conclusion

Improving physical activity practice will bring with it Improving physical activity practice will bring with it compliance to more healthy dietary patterns as well as to compliance to more healthy dietary patterns as well as to recommended annual health screening; will discourage recommended annual health screening; will discourage the use of tobacco, alcohol and drugs, will help to reduce the use of tobacco, alcohol and drugs, will help to reduce violence, and will promote social interaction and violence, and will promote social interaction and integrationintegration

Establishing good relationships between environment, Establishing good relationships between environment, behavior, and health, investment of time, energy and behavior, and health, investment of time, energy and money to this will contribute to better health of population money to this will contribute to better health of population and decreased health care costs in the long-term and decreased health care costs in the long-term

AcknowledgmentsAcknowledgments

Eurasia Partnership Foundation and Eurasia Partnership Foundation and CRRCCRRC

CRRC–Armenia staff CRRC–Armenia staff

Ms. Inessa Asmangulyan and Dr. Levon Ms. Inessa Asmangulyan and Dr. Levon DallakyanDallakyan

Ms. Lilit Grigoryan Ms. Lilit Grigoryan

Dr. Maria SevoyanDr. Maria Sevoyan

Results:Results: 1. 1. Response to the surveyResponse to the surveyTwo types of RR: based on known eligible respondents and based on known and unknown (estimated) eligible respondents. 1) RR based on known eligible respondents

RR= # of completed interviews / eligible= # of completed interviews / completed interviews + partial interviews + unavailable for duration + refused to participate = 369/369+0+30+61= 369/460 = 80%2) RR based on known and unknown (estimated) eligible respondents

Proportion of eligible respondents = eligible / all screened = completed interviews + partial interviews + unavailable for duration + refused interview + other screened / completed interviews + partial interviews + unavailable for duration + refused interview + other screened + ineligible + business number + refused screening =369+0+30+61+0/369+0+30+61+0+37+46+15=460/558= 0.82RR= # of completed interviews / eligible = # of completed interviews / completed interviews + partial interviews + unavailable for duration + refused to participate + other screened + refused to screen (estimate) + busy number (estimate) + no answer (estimate)= 369/369+0+30+61+0+15*0.82+26*0.82 +98*0.82 = =369/369+0+30+61+12.3+21.3+80.36 = 369/ 574= 64%

Health & Medicine

Prevalence of Physical Activity and Barriers to Physical Activity Among Yerevan Adult Population