Promoting the Health Benefits of Walking and Bicycling to Work: A Qualitative Exploration of the Role of Healthcare Providers in Addressing Barriers to Active Commuting

Rebecca Wallace, MD, CCFP

Don Mills Family Health Team 20 Wynford Drive, Suite 200 Toronto, ON M3C 1J4, Canada Tel. 416-444-6161 Fax. 416-444-5849 E-mail: rebecca.wallace@medportal.ca

INTRODUCTION

Physical inactivity adds a disease burden to society comparable with smoking.¹ Though physical activity has far-reaching benefits on health and disease,^2,3,4 many adults and children do insufficient physical activity to maintain good health.⁵ Walking or bicycling to work (active commuting) represents one approach to encourage the population to be more active.⁶ At an individual level, active commuting is correlated with numerous positive health outcomes, including cardiovascular benefits,^7,8,9 a reduction in all-cause mortality,^10,11 and reduced obesity.¹²

In spite of these health benefits, in North America only a small proportion of individuals use walking and bicycling as a mode of transport. In Canada in 2006, 6.4 percent of workers walked to work, and just 1.3 percent of workers bicycled to work.¹³

Factors determining whether a person participates in active commuting are complex; variables such as improved esthetics, the presence of sidewalks and bicycle lanes, and workplace supports are associated with an increased likelihood of active commuting.^14-18

Other studies have reported that personal and psychological factors play a more important role than environmental factors.^19,20 High self-efficacy,²¹ positive intentions, and strong habits^22,23 are all associated with active commuting. Barriers include lack of fitness, lack of confidence in abilities²⁴ and perceived time and distance.²⁵

Given the health benefits, healthcare providers are well positioned to recommend and promote active commuting. Yet, there have been no studies to our knowledge that assess the role of primary healthcare providers in increasing population levels of this physical activity. Quantitative studies focus on individual variables and are limited in their ability to address all of the complex and interrelated factors associated with the behavior of active commuting.²⁶ To address these many interrelated variables, we conducted a study that qualitatively explored the barriers to active commuting and how healthcare providers could be involved in addressing these barriers for their patients. The study was done in a primary care population who were under the care of a healthcare provider (and therefore within reach of a healthcare intervention).

METHODS

We conducted a qualitative research study using 5 separate onehour focus groups of up to 5 people over a period of 4 months at McMaster Family Practice in Hamilton, Ontario, Canada. Approval was obtained from the McMaster University Research Ethics Board.

Sampling

Participants were recruited from a list of current patients aged 18 to 65 years old that had been randomly generated by the electronic medical record (EMR) system within the practice. Possible participants were telephoned by a member of the research team (RW, SG) to assess eligibility and willingness to participate, and to clarify status as an active or non-active commuter. Patients were informed that if they did not wish to participate in the focus group, their medical care would be unaffected. To be eligible for the study, participants had to be patients at McMaster Family Practice, currently working or attending school, and residing within a 10 kilometre distance to walk or bicycle to their place of work. Exclusion criteria were if patients had any selfidentified physical limitation to walking or bicycling.

The active commuters and the non-active commuters were given separate focus groups to allow for adequate space and time for the unique viewpoints of each group. Focus groups were carried on until theme saturation was met. We aimed for up to 5 participants per focus group.

Facilitation Process

The focus groups were held in a semi-structured format to allow for free discussion within defined topics. Our focus group questions were developed to inspire discussion in an open-ended manner:

• Why do you choose driving to work instead of bicycling or walking (or vice versa)?
• What barriers do you face in bicycling or walking to work?
• How could you overcome those barriers?
• How can healthcare providers help you to start or continue walking or bicycling to work?

Data Collection and Analysis

Focus groups were facilitated by RW and SG. The focus groups were recorded using a digital recorder and transcribed. A grounded theory approach was used to analyze the data because it allowed for data collection and analysis to occur simultaneously and for theories to be generated freely from the data without a preconceived hypothesis.²⁷ All 3 authors read the transcripts independently and devised an initial list of themes and subthemes. These themes were closely examined, negotiated, and consolidated at a series of meetings involving all members of the research team. Upon further analysis, these themes and subthemes were then organized into broader themes upon re-application with the original transcripts. Consensus was obtained a final list of coding themes was generated. Recruitment for new focus groups concluded when a saturation point for all themes was reached and no new themes were being generated.

RESULTS

A total of 5 focus groups took place between May and August 2012. Three groups for active commuters and 2 groups for nonactive commuters were held with 3 to 4 participants at each session. A total of 17 participants were recruited (11 active commuters and 6 non-active commuters) before a saturation point was met.

Participant Characteristics

Most of our participants were Caucasian and between 27 and 65 years old with a mean age of 56 (Table 1). Women comprised 47% of the overall sample and made up 33% of active commuters and 66% of non-active commuters. Participants had high levels of education with 16 out of 17 participants (94%) having achieved a college education or higher.

Table 1: Characteristics of study participants (n=17).

Barriers to Active Commuting

The research team organized the barriers identified by participants into 3 main thematic categories: internal, external, and cultural.

Barriers such as inconvenience were labeled as internal barriers during the thematic analysis if they occurred at the individual and psychological level. External barriers were defined as those that happened outside in the built environment, such as bicycle lanes and workplace accommodations. A barrier was categorized as cultural if it occurred on a larger, societal level. Table 2 summarizes the barriers identified above.

Table 2: Patient-identified barriers to active commuting

THE ROLE OF HEALTHCARE PROVIDERS IN ADDRESSING THESE BARRIERS

Participants outlined several opportunities for physician intervention, including (1) individualized education around the health benefits of active commuting, (2) problem-solving around barriers to active commuting, (3) motivational interviewing, and (4) advocacy. These are outlined in further detail below.

PATIENT EDUCATION ON THE BENEFITS OF ACTIVE COMMUTING

Participants who actively commuted brought up numerous benefits that motivated them to actively commute. These benefits included mental and physical health benefits, financial savings, and enjoyment of the community and environment. Participants thought that learning about active commuting from their family physician during a clinical encounter would be an effective way to increase physical activity. In particular, patients suggested they would be receptive to hearing about the non-physical health benefits. The key points regarding how physicians could approach these conversations are outlined in Table 3.

Table 3: Summary of benefits of active commuting for patient education

PROBLEM-SOLVING AND MOTIVATIONAL INTERVIEWING

Even though both non-active and active commuters identified similar barriers, active commuters were much better equipped to problem-solve logistical issues. Participants suggested that physicians might be well positioned to help patients problemsolve. Active commuters suggested that simple solutions such as bringing a spare change of clothes, watching the weather report, and leaving five minutes earlier would solve common concerns people have about work clothes.

To motivate patients, apart from discussing the benefits of active commuting, study participants proposed that healthcare providers could encourage small behavioral changes. Participants suggested that physicians could highlight that patients could choose to walk or bicycle to work just a few days a week and still reap health benefits.

The representative quotes that illustrate these themes are found in Table 4.

Table 4: Themes for problem-solving and motivation

ADVOCACY

Finally, participants suggested that physicians could act as community advocates to promote safe cycling infrastructure, better work and school accommodations, and greater education. One participant suggested that active commuting could be approached in the same manner that public health, government agencies, and individual healthcare providers have approached smoking cessation. In addition to individual healthcare interventions, there could be a role for workplace incentives for active commuters and for increased media attention around the benefits of active commuting.

Participants brain stormed large-scale societal changes for which physicians could advocate. Participants suggested that if cities were designed better, it would be more convenient to actively commute. One participant suggested that doctors focus on pressuring governments to make a more walk and cycle-friendly environment before asking patients for individual change.

These themes and representative quotes are further explored in Table 5.

Table 5: Themes for physician advocacy

DISCUSSION

Through this qualitative study, we identified 3 main kinds of barriers to active commuting in attendees of a family practice—internal, external, and social. The patient-identified barriers helped shape and inform the discussion of healthcare provider intervention. Indeed, the types of interventions participants identified could be categorized into the same main categories. The barriers cited by members of a family practice in this study were consistent with barriers cited by members of the general public in prior studies.^24-28 Our study population was different in that all participants were known to have easy access to a physician. The relationship between barriers and other determinants of active commuting is complex. Ogilvie et al²⁹ have developed a framework to understand the relationship between the multiple determinants of active commuting. Up until now, the role of healthcare providers in assisting patients in overcoming these barriers to start active commuting has not been studied. We sought to bring a patient-centered approach to healthcare provider intervention. Based on the themes of barriers and interventions, we have developed a framework to suggest the ways in which healthcare providers might intervene on modifiable barriers (Figure 1). We discuss the framework in detail below.

Figure 1: Barriers to active commuting and corresponding healthcare interventions

Healthcare Intervention on Internal Barriers

Participants proposed that they would be open to hearing from their physician one-on-one about active commuting. Physicians could address the internal barriers on an individual basis through education, support, and motivational interviewing. Motivational interviewing can be defined as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change”.³⁰ It may include educating patients in a clinical encounter to consider active commuting as a form of exercise; helping patients become motivated; or problem-solving solutions to patient-identified barriers. As an example, if a patient would like to actively commute for exercise but feels that he or she does not have the motivation nor the time, it may be helpful to use motivational interviewing to challenge his or her way of thinking. Motivational interviewing has been shown to be effective in changing health behavior,^31,32 and this form of intervention is the most readily accessible intervention to primary care physicians.

Increasing physical activity through active commuting could be part of a comprehensive management plan for patients with diabetes, hypertension, or obesity. Above and beyond the physical health benefits of active commuting, there were numerous other benefits discussed by participants including mental health improvements, financial savings, and interaction with the community and the environment. Participants were receptive to hearing about the “non-physical” benefits of active commuting and this information could be discussed in various clinical encounters.

Healthcare Intervention on External Barriers

Intervening on external barriers has the potential for a large population health impact. Healthcare providers can act as advocates to promote safe cycling infrastructure and better work and school accommodations. The Ontario Medical Association (OMA) is an example of a physician-led organization doing such advocacy work. The OMA has recommended that the Ontario government increase separated bicycle lanes and make cyclistvehicle education a component of the Ontario Drivers’ Manual.³³ Family physician-led organizations could perform similar advocacy work, as they are a well-respected source of information for policy makers and already do such work on other issues.³⁴

The voice of individual family physicians may be beneficial in their community of practice where they have specific insight into their patient population needs. For example, family physicians could speak to their city council in support of bicycle lane additions. Being a health advocate for their patients and communities is one of the seven roles of a family physician identified by the Canadian College of Family Physicians.³⁵ Healthcare providers can also provide information and research to encourage private companies to invest in workplace active commuting infrastructure.

Much like the campaign for smoking cessation, a variety of stakeholders are needed to fully address systemic issues. These stakeholders may include citizen groups, employers, city councils, and government officials.

Healthcare Intervention on Cultural Barriers

Creating a culture of walking and bicycling requires not only the removal of barriers, but also a re-imagining of city layout to make active commuting an easier option. Physicians could advocate to city councils for an urban design that makes walking to work and other important destinations such as the grocery store logistically possible.

Physicians can also intervene to promote an active commuting culture through public health education campaigns Media advertising could be used to promote the health benefits of active commuting on a large scale and to improve safety on the road. One such initiative is the “Share the Road” campaign³⁶ that creates television ads to improve the relationship between drivers and cyclists. Media campaigns can be important tools but they need to be done while addressing internal and external barriers. As illustrated by the success story of the anti-tobacco movement, multi-pronged interventions are likely needed to prime the public so that they are open to receiving information from media campaigns.³⁷

LIMITATIONS AND STRENGTHS

The study provides an in-depth exploration of the barriers that family practice patients face in active commuting. In addition to providing the first qualitative information about the role of primary healthcare providers in active commuting, we provide a framework of possible areas of intervention.

This study has several limitations. The nature of qualitative studies makes it difficult to generalize the results to a larger population. The number of active commuters participants and non-active commuters participants were not equal in the study. Since all participants were patients at McMaster Family Practice, problems and solutions that are specific to other jurisdictions would not have been captured. The majority of participants were Caucasian and barriers of other ethnic groups may not have been represented. Further qualitative research is required with an emphasis on reaching out to ethnically mixed communities. In addition to soliciting more patient perspectives, it would be helpful to gain information through the lens of healthcare providers or other agencies involved in promoting active commuting. Quantitative studies assessing patient barriers to active commuting and areas of physician intervention would help confirm the patient-identified barriers and proposed physician interventions.

Next steps after identifying interventions would then be to assess their efficacy. This research may include studies that look at the outcome of promoting active commuting through education, counseling, and motivational interviewing. Previous studies have looked at motivational interviewing for increasing physical activity in general and this avenue seems to be a promising wayto promote health behavior change.^31,32

CONCLUSION

The patient-identified barriers to active commuting fell into 3 main categories: internal barriers, external barriers, and cultural barriers. Correspondingly, there were physician solutions found for each type of barrier. Participants suggested numerous opportunities for healthcare provider intervention, including individualized education regarding the health benefits of active commuting, problem-solving around barriers, motivational interviewing, andadvocacy. Physicians can use the information provided in this study to help guide a one-on-one discussion with a patient to address internal barriers. Physicians can also use this information to advocate for the removal of external and cultural barriers.

Healthcare providers are one of the many stakeholders required to create a comprehensive strategy to get the population more physically active through active commuting.

ACKNOWLEDGEMENTS

The authors wish to thank the study participants, supporters, and funders. Mountain Equipment Co-op (MEC) and the Ontario Public Interest Group (OPIRG)–McMaster provided study funding, and the McMaster Department of Family Medicine provided support for the project.

FUNDING SOURCES

Mountain Equipment Co-op (MEC) and the Ontario Public Interest Group (OPIRG)-McMaster funded the study. The funding bodies had no part in the study design; data collection, analysis, or interpretation; writing of the manuscript; or in the decision to submit the manuscript for publication. Funding for manuscript publication was provided by MEC. This project was completed as part of a research project for the Family Medicine Residency Program, Department of Family Medicine, McMaster University.

AUTHOR CONTRIBUTIONS

RW conceived of the study and its design, participated in the data collection, interpretation, and analysis, and drafted the manuscript. SG participated in data collection, interpretation, and analysis and helped to draft the manuscript. GA contributed to study design and participated in data interpretation and analysis, and drafting of the manuscript. All authors read and approved the final manuscript.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONSENT

The participants has provided written permission for the manuscript publication.

1. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273: 402-406. doi: 10.1001/ jama.1995.03520290054029

2. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA, USA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.

3. McAuley E, Rudolph D. Physical activity, aging, and psychological well-being. J Aging Phys Act. 1995; 3: 67-96.

4. Knoops KTB, de Groot LCPGM, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: The HALE project. JAMA. 2004; 292(12): 1433-1439. doi: 10.1001/jama.292.12.1433

5. Hallal PC, Andersen LB, Bull FC, et al. Global physical activity levels: Surveillance progress, pitfalls, and prospects. The Lancet. 2012; 380(938): 247-257. doi: 10.1016/S0140- 6736(12)60646-1

6. Tannahill A. You don’t have to …: Walking to a healthier nation. Br J Sports Med. 2000; 34(2): 79-80. doi: 10.1136/ bjsm.34.2.79-a

7. Gordon-Larsen P, Boone-Heinonen J, Sidney S, Sternfeld B, Jacobs DR Jr, Lewis CE. Active commuting and cardiovascular disease risk: The CARDIA study. Intern Med. 2009; 169(13): 1216-1223. doi: 10.1001/archinternmed.2009.163

8. Kwaśniewska M, Kaczmarczyk-Chałas K, Pikala M, et al. Commuting physical activity and prevalence of metabolic disorders in Poland. Prev Med. 2010; 51(6): 482-487. doi: 10.1016/j. ypmed.2010.09.003

9. Hamer M, Chida Y. Active commuting and cardiovascular risk: A meta-analytic review. Prev Med. 2008; 46(1): 9-13. doi: 10.1016/j.ypmed.2007.03.006

10. Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med. 2000; 160(11): 1621-1628. doi: 10.1001/archinte.160.11.1621

11. Rojas-Ruedam D, de Nazelle A, Tainio M, Nieuwenhuijsen MJ. The health risks and benefits of cycling in urban environments compared with car use: Health impact assessment study. BMJ. 2011; 343: d4521. doi: 10.1136/bmj.d4521

12. Lindström M. Means of transportation to work and overweight and obesity: A population-based study in southern Sweden. Prev Med. 2008; 46(1): 22-28. doi: 10.1016/j. ypmed.2007.07.012

13. Martin T. Commuting to work: Results of the 2010 General Social Survey. Statistics Canada. 2011. Website. http://www. statcan.gc.ca/pub/11-008-x/2011002/article/11531-eng.pdf. Accessed June 28, 2016.

14. Craig CL, Brownson RC, Cragg SE, Dunn AL. Exploring the effect of the environment on physical activity: A study examining walking to work. Am J Prev Med. 2002; 23(Supp 2): 36-43. doi: 10.1016/S0749-3797(02)00472-5

15. Parker KM, Gustat J, Rice JC. Installation of bicycle lanes and increased ridership in an urban, mixed-income setting in New Orleans, Louisiana. J Phys Act Health. 2011; 8(Supp 1): S98-S102. Website. http://prc.tulane.edu/uploads/13_parker_ JPAH_2010_0102-1294247947.pdf. Accessed June 28, 2016.

16. Wahlgren L, Schantz P. Exploring bikeability in a metropolitan setting: Stimulating and hindering factors in commuting route environments. BMC Public Health. 2012; 12: 168. doi: 10.1186/1471-2458-12-168

17. Badland HM, Schofield GM, Garrett N. Travel behavior and objectively measured urban design variables: Associations for adults traveling to work. Health Place. 2008; 14(1): 85-95. doi: 10.1016/j.healthplace.2007.05.002

18. Kaczynski AT, Bopp MJ, Wittman P. Association of workplace supports with active commuting. Prev Chronic Dis. 2010; 7(6): A127.

19. Ogilvie D, Mitchell R, Mutrie N, Petticrew M, Platt S. Personal and environmental correlates of active travel and physical activity in a deprived urban population. Int J Behav Nutr Phys Act. 2008; 5: 43. doi: 10.1186/1479-5868-5-43

20. Lemieux M, Godin G. How well do cognitive and environmental variables predict active commuting? Int J Behav Nutr Phys Act. 2009; 6: 12. doi: 10.1186/1479-5868-6-12

21. de Geus B, De Bourdeaudhuij I, Jannes C, Meeusen R. Psychosocial and environmental factors associated with cycling for transport among a working population. Health Educ Res. 2008; 23(4): 697-708. doi: 10.1093/her/cym055

22. de Bruijn G, Kremers SP, Singh A, van den Putte B, van Mechelen W. Adult active transportation: Adding habit strength to the theory of planned behavior. Am J Prev Med. 2009; 36(3): 189-194. doi: 10.1016/j.amepre.2008.10.019

23. Panter JR, Jones AP, van Sluijs EM, Griffin SJ, Wareham NJ. Environmental and psychological correlates of older adult’s active commuting. Med Sci Sports Exerc. 2011; 43(7): 1235-1243. doi: 10.1249/MSS.0b013e3182078532

24. Heesch KC, Sahlqvist S, Garrard J. Gender differences in recreational and transport cycling: a cross-sectional mixed-methods comparison of cycling patterns, motivators, and constraints. Int J Behav Nutr Phys Act. 2012; 9: 106. doi: 10.1186/1479-5868- 9-106

25. Engbers LH, Hendriksen IJ. Characteristics of a population of commuter cyclists in the Netherlands: Perceived barriers and facilitators in the personal, social and physical environment. Int J Behav Nutr Phys Act. 2010; 7: 89. doi: 10.1186/1479-5868- 7-89

26. Ogilvie D, Egan M, Hamilton V, Petticrew M. Promoting walking and cycling as an alternative to using cars: Systematic review. BMJ. 2004; 329: 763. doi: 10.1136/bmj.38216.714560.55

27. Charmaz KC. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. London, UK: SAGE Publications Ltd; 2006: 5-6.

28. Guell C, Panter J, Jones NR, Ogilvie D. Towards a differentiated understanding of active travel behavior: Using social theory to explain everyday commuting. Social Science and Medicine. 2012; 75: 233-239. doi: 10.1016/j.socscimed.2012.01.038

29. Ogilvie D, Bull F, Powell J, et al. An appliedecologicalframework for evaluatinginfrastructure to promotewalking and cycling: The iConnectstudy. Am J Public Health. 2011; 101(3): 473-481. doi: 10.2105/AJPH.2010.198002

30. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, USA: Guilford Press; 2013: 12.doi:10.1093/alcalc/agt010

31. Vanbuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: A systematic review and metaanalysis. J Behav Med. 2014; 37(4): 768-780. doi: 10.1007/ s10865-013-9527-4

32. Hardcastle SJ, Taylor AH, Bailey MP, Harley RA, Hagger MS. Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: A randomised controlled trial with a 12-month post-intervention follow-up. Int J Behav Nutr Phys Act. 2013; 10: 40. doi: 10.1186/1479-5868-10-40

33. Ontario Medical Association. Enhancing Cycling Safety in Ontario. 2011. Website. https://www.oma.org/Resources/Documents/OMACyclingPaper09-08-2011.pdf. Accessed June 28, 2016.

34. Abelsohn A, Rachlis V, Rosen D, Kasperski J. Addressing the Health Effects of Climate Change: Family Physicians Are Key. Ontario College of Family Physicians. 2008. Website. http://www.ocfp.on.ca/docs/publications/addressing-thehealthimpacts-of-climate-change-family-physicians-are-key. pdf. Accessed June 28, 2016.

35. Tannenbaum D, Konkin J, Parsons E, et al. CanMEDS-Family Medicine: A Framework for Competencies in Family Medicine. College of Family Physicians of Canada 2009. Website. http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20 FM%20Eng.pdf. Accessed June 28, 2016.

36. Share the Road Cycling Coalition. Website. http://www. sharetheroad.ca/. Accessed June 28, 2016.

37. Hersey JC, Niederdeppe J, Ng SW, Mowery P, Farrelly M, Messeri P. How state counter-industry campaigns help prime perceptions of tobacco industry to promote reductions in youth smoking practices. Tob Control. 2005; 14(6): 377-383. doi: 10.1136/tc.2004.010785