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INTRODUCTION

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Despite the clear and consistent evidence that regular physical activity (PA) is an important component of healthy lifestyles (1), more than 75% Americans are not meeting the PA guidelines (2). Lower PA participation rates among women, racial/ethnic minorities, individuals experiencing socioeconomic disadvantage, persons with disabilities, and adults ages 65 years and older (3) highlight some of the important disparities that exist. Many health-related outcomes, including obesity, type 2 diabetes, and cardiovascular disease, follow a similar pattern (1), suggesting that PA is fundamental to preventing disease and for reducing health disparities.

In an effort to reduce disparities, comprehensive programs, policies, and practices have been implemented to increase opportunities for all Americans to engage in health-enhancing PA. As an example, the U.S. Congress reauthorized the Elementary and Secondary Education Act, known as the Every Student Succeeds Act (4), which increased funding for health and physical education programming in public schools across the country. The Americans with Disabilities Act (5) ensures individuals with disabilities have equal access to fitness facilities. The American College of Sports Medicine’s Exercise is Medicine® (6) campaigns to make PA assessments a standard of clinical care, connecting health care with evidence-based PA resources for people of all abilities. Finally, Silver Sneakers® (7) provides health and fitness programming at no cost to adults ages 65 years and older through select Medicare plans. These initiatives have been deemed successful in increasing PA opportunities for children, adults, and seniors across the country. Yet, disparities in PA participation persist.

Moving beyond equality-based, “one-size-fits-all” approaches to increasing PA participation is needed to close the disparities gap. In this context, equality refers to interventions that are disseminated with similar educational, informational, and economic resources to increase PA levels in diverse communities, irrespective of the needs each community has to help individuals change their behavior (8). Persistent disparities in PA participation highlight the need to couple equality-based approaches with equity-based solutions. Equity in this case refers to providing different types of PA resources to increase and maintain PA participation in diverse communities (8). In essence, this approach amounts to giving communities what they need rather than giving everyone the same thing. By joining equality- and equity-based approaches, eliminating disparities in PA participation becomes an attainable goal (3).

PRIORITIZING EQUITABLE ACCESS TO PA FACILITIES AND PROGRAMMING

The Centers for Disease Control and Prevention estimates that approximately 26% of U.S. adults have some type of disability (9); therefore, it is likely that health and fitness professionals will interact with a client who has a disability. A client’s ability level is the first step to ensuring equity, and to do so, it is recommended that exercise professionals consider and address any barriers that limit PA participation (1), with a major barrier being lack of accessibility. A recent evaluation of more than 220 fitness facilities determined that access routes and entrance areas, equipment, information and signage, locker rooms, showers, bathrooms, and swimming accessibility have all improved since the passage of the American Disabilities Act (10), yet only programs and water fountains had acceptable accessibility scores (10).

Health and fitness professionals can overcome this barrier by using a universal design approach, which focuses on accommodating the greatest number of individuals, in the widest possible range of situations, without the need for alterations (11). Universal design does not negatively affect those within other groups. An example from the field of urban planning is curb cuts, which are ramps graded down from the top surface of a sidewalk to the surface of an adjoining street. Curb cuts allow those using assisted walking devices or wheelchairs to cross the street and also help individuals pushing a stroller or a shopping cart to more easily transition from the street to the sidewalk (11). However, the curb cut does not have a negative effect on any group. The same concept can be applied to fitness facilities, as universally designed equipment, access routes, and facilities are all equality-based approaches to improving accessibility to all clients, irrespective of ability level (Figure).

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Figure 1:

One size does not fit all: Visualizing the difference between equality and equity. Image courtesy of the Robert Wood Johnson Foundation.

Although universal design strategies help to close the gap in access and usability, there is a continued need to adapt PA and fitness programming to meet the specific needs of clients with disabilities. Lack of tailored programming has been cited as another common barrier to PA in this population (12). One approach is for exercise professionals to conduct an activity analysis for each client, which is the systematic process that breaks down an activity into its component parts. This includes any physical, cognitive, social, and affective skills needed to complete the activity (13). For example, when completing an activity analysis for a shoulder press exercise, the exercise professional may want to consider the physical (e.g., muscle groups needed for the shoulder press), cognitive (e.g., having the cognitive ability to follow shoulder press instruction), social (e.g., the ability to engage in physical contact with the spotter), and affective (e.g., the client’s ability to handle possible muscle soreness) skills needed to perform the task (13). The exercise professional can use the activity analysis to consider the client’s needs in tailoring the prescribed exercise plan and implementing modifications for the activity. In the case of a client having difficulties following instructions (cognitive), for example, tailoring can include extra familiarization sessions or behavior modeling. Likewise, if a client has difficulties in a group setting (social), program tailoring may encompass using an alternative location within the fitness facility. Finally, if a client is overwhelmed by the difficulty of an exercise (affective), a different type of exercise may be used. By tailoring the PA programming to the specific needs and skill levels of the client, this is an effective equity-based approach to increasing PA and fitness (see Table 1 for additional suggestions).


TABLE 1 -
Lessons Learned while Working with Clients of Varying Ability Levels








Lessons Learned Examples
Be patient • Not every movement or exercise technique is going to be “ideal” or “perfect”

• Take the time to learn the client’s preferences and implement them into the program
Perception is reality • Two people can perceive something differently; neither are wrong

• Consider the client’s point of view
Don’t be afraid to step outside of your comfort zone • Alternative methods (e.g., dancing) to engage your clients may be necessary

• Do not be afraid to try things, sometimes they work and sometimes they do not
No two clients are the same • Just because two clients have the same disability does not mean that they are the same

• Some clients may be more successful with another trainer and that is okay

PROVIDING LOW AND NO COST PA PROGRAMMING TO ENHANCE EQUITY

According to the U.S. Department of Agriculture, approximately 13% of U.S. adults live in low-income communities and do not have access to affordable indoor places to exercise (14). Fitness classes, equipment, and clothing all tend to cater to the wealthy, with costs ranging from $34 for one exercise session to $2,000 for exercise equipment (15). Access to outdoor spaces for walking, running, or cycling is also limited. Individuals living in low-income communities are more likely to experience high crime rates, heavy policing, and perceive their neighborhoods as less safe (16). Broken windows, litter, graffiti, loitering, and public drinking are also more prevalent in low-income neighborhoods, all of which are barriers to outdoor PA (17). As a result, fitness has become unaffordable and inaccessible to many Americans experiencing socioeconomic disadvantage. To overcome these barriers, low or no cost equality-based PA programs have been developed to allow anyone in the community to participate, irrespective of socioeconomic status. Most notably, the YMCA, with 2,700 locations across the United States, offers subsidized memberships to lower-income members, with 51% of their facilities located in low-income neighborhoods (15). Other equality-based approaches that have been implemented in local communities include offering free weekly classes that take place both indoors and outdoors. Programs have also included free giveaways, including running shoes and sporting equipment, to promote PA participation (15). Although these programs have reduced barriers related to affordability, additional barriers beyond the financials of exercise exist for clients experiencing socioeconomic disadvantage, which can often vary from client to client. Hence, equity-based approaches are needed to effectively tailor programs to meet the needs of all clients.

Availability of fitness facilities can be a salient barrier as most facilities are not located in low-income communities (18). To overcome this barrier, health and fitness professionals can develop programs to train community leaders on how to teach exercise classes in their local communities (e.g., SportsBackers’ Fitness Warriors Program in Richmond, Virginia). Another barrier to PA participation for individuals experiencing socioeconomic disadvantage is work-related stress. Although all jobs can be stressful, leaving limited time to exercise, many low-wage jobs are considered hectic and psychologically demanding. These high-stress jobs have limited flexibility in terms of work pace and hours and provide few opportunities to interact with and receive support from coworkers, all of which carry an increased risk of cardiovascular disease (19). Health and fitness professionals should consider developing flexible programming with flexible facility hours to accommodate these occupational constraints. Moreover, identifying feasible and affordable stress management strategies will be important to include in any client’s personalized exercise program, particularly when individuals exhibit symptoms of chronic stress. Finally, it is possible that your client experiencing socioeconomic disadvantage also may be experiencing food insecurity and limited access to healthy foods. If “food fuels a workout,” then modification will need to be made when developing exercise programs (e.g., lighter intensity, shorter duration bouts) (20) to reduce fatigue and injuries. Nutritional recommendations also should include identifying food programs within the local community. By using an equity-based approach to identify and reduce barriers to PA participation, health and fitness professionals can more effectively promote exercise in clients experiencing disadvantage (see Table 2 for additional suggestions).


TABLE 2 -
Lessons Learned while Working with Low-Income Clients








Lessons Learned Examples
Offer subsidized memberships • Offer subsidized memberships and free giveaways (e.g., apparel or equipment) as incentive for achieving exercise goals and return visits to your fitness facility
Offer free weekly exercise classes and transportation to your facility • Provide all of your clients, irrespective of income status, opportunities to try new exercise classes for free both in your facility and in the local community

• If your fitness facility is located on a public transportation route offer a free bus/subway token as an incentive to return for another exercise class
Train community leaders to teach exercise classes • Empower area residents who are committed to improving the health of their community by giving them the skills to be a professional fitness instructor
Tailor exercise programming to fit the occupational demands and nutritional needs of clients • Fully consider the social, economic, occupational, and environmental barriers that may impede your clients’ PA behaviors

• Work with your client to tailor exercise and nutrition recommendations to meet their specific needs

PROMOTING EQUITABLE PA PRACTICES THROUGH CULTURAL AND LINGUISTIC TAILORING

As an industry, fitness has largely been focused on White-European standards of beauty and health (21). Yet, Hispanic, African American, Asian American, and Native American communities all together comprise close to 40% of the total population (22). Hispanics are the fastest-growing ethnic group in this country, accounting for about half (52%) of all U.S. population growth over the last 10 years (23). With the rapid increase in racial/ethnic diversity of the U.S. population, equality-based approaches, including cultural competency training for staff, has increased inclusivity in health care settings; however, these efforts have not been broadly extended to fitness facilities (3). Moreover, health and fitness professionals need to apply an equity lens rooted in the culture, resources, and knowledge of the communities they serve to effectively reduce disparities in PA and health.

A client’s PA behaviors are shaped by the cultural context (e.g., family, neighborhood, institutions, society) within which they live, move, and play (24). This cultural context includes the experiences, norms, values, behavioral patterns and beliefs of your client, their family, and community (24). As such, any approach to behavior change or PA promotion should incorporate the cultural context of the client into the design, delivery, and evaluation of the personalized exercise program developed (25). For example, a culturally and linguistically tailored approach should consider both the shared group-level characteristics of the community (e.g., language, social norms) as well as individual characteristics of each client (e.g., barriers, facilitators) (26). Another effective strategy for tailoring your services or facility is to include community members in the planning and development process. Fostering genuine and equitable partnerships with community members and creating shared goals are both evidence-based strategies to promote equity and inclusion in your fitness facility (27,28). Another strategy that can help to reduce barriers to PA participation is “going where the people are” to bring your services into the community via shared-use agreements. Finally, identifying and leveraging supportive community assets (i.e., highlighting existing community groups who are already doing the work of addressing the social determinants of health and promoting PA in their communities) can extend your equity and inclusion efforts beyond your fitness facility. By fostering inclusive community partnerships and intentionally focusing on the needs, culture, and history of the communities you serve, this is an effective equity-based approach to increasing PA and fitness (see Table 3 for additional suggestions).


TABLE 3 -
Lessons Learned while Working with Clients of Diverse Cultural Backgrounds













Lessons learned Examples
Do an equity audit of your practice • Do not assume your space is welcoming to all

• Start small and make meaningful and impactful changes

• Examine demographics of your current clientele and determine whose voices/needs are being included versus whose are being overlooked

• Consider hiring staff from the surrounding community who are passionate about active living, have a desire to serve the community, and understand the community’s preferences and needs
Apply motivational interview techniques • Pay attention to contextual PA barriers/facilitators

• Actively work to see and know your clients as individuals rather than stereotypes
Understand the historical injustices committed against marginalized groups • Recognize your own implicit biases and work against them

• Develop policies to mitigate the effects of racism and discrimination within your organization
Partner with the community and go where the people are • Look for opportunities to bring your services to where the community is most comfortable (e.g., community center, park, church)

Summary

The value of promoting equity in PA programming, policies, and practices is nicely illustrated in the classic Haudenosaunee tale of the first stickball (also known as lacrosse) match, which was between the four-legged animals and the winged birds (29). The four-legged animals were captained by the colossal-strong bear, the immovable-sturdy tortoise, and the nimble-lively deer. Their opponents, the winged birds, were captained by the wise-sharp-eyed owl, the swift-strong hawk, and the galvanizing leader, the eagle. Legend has it that when the mouse and the squirrel, both known for their small stature, asked to play on the four-legged team, they were mocked and rejected. Not to be deterred, the mouse and the squirrel asked to be part of the winged birds’ team. One forward-thinking bird gathered drum leather and sticks and affixed it to the mouse creating a new animal, which they called the bat. Although they had run out of drum materials for the squirrel, they decided that the animal could stretch, creating the flying squirrel. As fate would have it, the winning goal was scored by the newly created bat animal.

This classic fable is applicable to the health and fitness profession as it teaches every creature (i.e., individual) has importance. When working with clients, our primary goal should be to develop and implement equitable exercise programs with universal access afforded to everyone. Like the winged birds, it is our job to consider our client’s abilities, background, context, culture, and history to develop tailored programming allowing all our clients to meet their personal fitness goals. By merging equality- and equity-based approaches, we have the potential to create a life-long commitment to PA in each of our clients, as these activities are self-determined and intrinsically motivating. Thus, when a client enters your facility for the first time, the question you have to ask is, are we planning and implementing our exercise programs with an open mind, inclusive and equitable, like the winged birds, to help our clients succeed? If not, then it is time to reconsider our approach.

References

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2. National Center for Health Statistics. [cited 2021 July 4]. Available from: https://www.cdc.gov/nchs/nhis/releases/released201905.htm.

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4. Every Student Succeeds Act of 2015, Pub. L. No. 114–95 § 114 Stat. 1177 (2015–2016).

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14. Rhone A, Ver Ploeg M, Dicken C, Williams R, Breneman V. Low-income and low-supermarket-access census tracts, 2010–2015, EIB-165. U.S. Department of Agriculture, Economic Research Service; 2017.

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19. Johnson JV, Hall EM. Job strain, work place social support, and cardiovascular disease: a cross-sectional study of a random sample of the Swedish working population. Am J Public Health. 1988;78(10):1336–42.

20. To QG, Frongillo EA, Gallegos D, Moore JB. Household food insecurity is associated with less physical activity among children and adults in the U.S. population. J Nutr. 2014;144(11):1797–802.

21. US Census Bureau Quick Facts: United States. [cited 2021 July 5]. Available from: https://www.census.gov/quickfacts/fact/table/US/PST045219.

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27. Brownson RC, Kumanyika SK, Kreuter MW, et al. Implementation science should give higher priority to health equity. Implement Sci. 2021;16(1):28.

28. Lee RE, Joseph RP, Blackman Carr LT, et al. Still striding toward social justice? Redirecting physical activity research in a post-COVID-19 world. Transl Behav Med. 2021;11(6):1205–15.

29. Oneida Indian Nation. A lacrosse legend. [cited 2021 July 5]. Available from: https://www.oneidaindiannation.com/a-lacrosse-legend/.

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