Equitable Access to Exercise Facilities Melvyn Hillsdon, PhD, Jenna Panter, BSc, Charlie Foster, PhD, Andy Jones, PhD Background: Leisure-time physical activity patterns are low and socially patterned. Ecologic studies of the provision of exercise facilities indicate that in areas of deprivation, there is a trend toward reduced availability of exercise facilities compared with more affluent areas. Existing studies are restricted to single geographic areas or regions. In this study, national-level data were used to examine the relationship between neighborhood deprivation and the density of physical activity facilities in England. Methods:
A database of all indoor exercise facilities in England was obtained, and facilities were linked to administrative areas and assigned a deprivation score. Census data were used to calculate the density of physical activity facilities per 1000 people per quintile of deprivation. The exercise facilities data were collected in 2005, and the analysis was conducted in 2006.
Results:
When all 5552 facilities were considered, there was a statistically significant negative relationship (p⬍0.001) between area deprivation score and the density of physical activity facilities. A similar relationship was observed when public and private facilities were examined separately. When only swimming pools were examined, a negative association was observed for public pools (p⬍0.0001) but not those that were private (p⫽0.50), which were more evenly distributed among quintiles of area deprivation.
Conclusions: The availability of physical activity facilities declines with level of deprivation. Areas in most need of facilities to assist people live physically active lifestyles have fewer resources. (Am J Prev Med 2007;32(6):506 –508) © 2007 American Journal of Preventive Medicine
Introduction
A
physically active lifestyle is associated with a range of beneficial health outcomes,1 and reducing the number of people engaging in low levels of physical activity would lead to significant reductions in premature morbidity and mortality rates.2 In England, leisure-time physical activity levels are low and are lowest in adults from lower socioeconomic positions.3 It has been observed that in areas of deprivation, the availability of local exercise facilities that may assist people to live physically active lifestyles is poorer than more affluent areas.4 In the U.S., a population study reported that high–socioeconomic status (SES) areas were more likely to have at least one physical activity facility than low-SES areas. Furthermore, the number of physical activity facilities in an area was associated with levels of physical activity.5 Also, a study in a midwestern U.S. city found that low-SES areas had fewer free-for-use facilities compared to highFrom the Department Exercise and Health Sciences (Hillsdon), University of Bristol, Bristol, UK, School of Environmental Sciences, University of East Anglia, Norwich, Norfolk, UK (Panter, Jones), and BHF Health Promotion Research Group, Department of Public Health, University of Oxford, Headington, Oxford, UK (Foster) Address correspondence and reprint requests to: Melvyn Hillsdon, PhD, Senior Lecturer Department Exercise and Health Sciences, University of Bristol, Tyndall Avenue, Bristol, UK, BS8 1TP. E-mail:
[email protected].
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SES areas.6 However, there are exceptions. In a relatively wealthy Australian city, access to recreational facilities was higher in lower-SES areas compared with higher-SES areas.7 Apart from one U.S. study, existing ecologic studies of the availability of physical activity facilities according to area socioeconomic position or deprivation are restricted to single geographic areas or regions.8,9 In this study, national-level data were used to examine the relationship between neighborhood deprivation and the density of physical activity facilities in England.
Methods An educational research license was taken out with a commercial company (Leisure Database Company, London, UK) that supplied a database of physical activity facilities. The company carries out an annual telephone survey of all operational sports/recreational facilities in England that have public access. Cross-checks to ensure the robustness of the data are conducted with leisure management contractors and private health club operators as well as comparisons with published directories such as the Yellow Pages. The exercise facilities data were collected in 2005, and the analysis was conducted in 2006. Sites were categorized as either “private,” referring to commercial health clubs requiring membership that have at least a gym and an element of public access (e.g., monthly membership fees but not pay per session) or “public,” referring to sports centers owned/managed by a local
Am J Prev Med 2007;32(6) © 2007 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/07/$–see front matter doi:10.1016/j.amepre.2007.02.018
Table 1. Type of physical activity facility by sector Sector Type of facility
Public
Private
Gym only Swimming pool only Sports hall only Gym and swimming pool Gym and sports hall Pool and sports hall Gym, swimming pool, and sports hall Total
114 259 522 312 799 121 692 2819
1460 1 0 1156 47 0 69 2733
authority/council containing at least a sports hall or swimming pool or gym, with public access through pay per session (not requiring membership), membership (pay monthly), or club (sports) usage. To be classified as a gym, a facility must contain stand-alone fitness equipment. To be classified as a sports hall, a facility must have a room of at least 18 m ⫻ 10 m in size and have court markings for at least one basketball, badminton, or volleyball court. No facilities were free to use. The database included the full ZIP code for each facility that was used to locate it in one of 32,482 Super Output Areas (SOAs) in England and assign an Index of Multiple Deprivation 2004 (IMD 2004) score.10 Super Output Areas11 are a geographic hierarchy designed to improve the reporting of small area statistics in England. They are relatively homogeneous in size and demographic structure (minimum population 1000, mean 1500). The IMD score is a weighted area level aggregation of specific dimensions of deprivation including income, employment, health, education, housing, environment, and crime. The higher the IMD score is, the higher the deprivation will be. Quintiles of IMD score were generated as 1 ⫽ least deprived and 5 ⫽ most deprived. Population data for each SOA were obtained from the 2001 English census.12 It was used to calculate the density of physical activity facilties per 1000 people per quintile of deprivation. The association between neighborhood deprivation and the density of physical activity facilities was examined using one-way analysis of variance with the statistical software STATA version 8.0 (Stata Corp LP, College Station, TX) and conducted in 2006.
Results Table 1 shows the type of physical activity facility by sector. There were slightly more public than private
Figure 1. The density of exercise facilities by quintile of deprivation for the county of Kent in Southeast England.
facilities with a greater variety in type of provision in the public sector facilities, and private facilities comprised mainly gyms and swimming pools. When all facilities were considered, there was a statistically significant negative relationship (p⬍0.001) between quintile of area deprivation and the density of physical activity facilities (Table 2). A graphic example of this distribution is shown for one English county (Figure 1). This figure indicates that deprived neighborhoods had fewer facilities than less deprived neighborhoods. A similar relationship was observed when public and private facilities were examined separately. When only swimming pools were examined, a negative association was observed for public pools (p⬍0.0001) but not those that were private (p⫽0.50), which were more evenly distributed among quintiles of area deprivation.
Discussion This geographic study has revealed that the availability of physical activity facilities is associated with area deprivation. The absolute difference in the density of facilities between the least- and most-deprived areas is equivalent to four facilities per 100,000. In Kent (Figure 1), the mostdeprived neighborhoods currently share just six facilities,
Table 2. Mean number of exercise facilities overall and by type per 1000 people by index of multiple deprivation quintile All
Public
Private
Public pools
Private pools
IMD quintile
Mean
n
Mean
n
Mean
n
Mean
n
Mean
n
1 (least deprived) 2 3 4 5 (most deprived) Total p value (analysis of variance)
0.136 0.119 0.117 0.107 0.093 0.114 ⬍0.0001
1324 1146 1127 1037 918 5552
0.069 0.061 0.058 0.054 0.050 0.058 ⬍0.0001
670 596 538 524 491 2819
0.068 0.057 0.061 0.052 0.044 0.056 ⬍0.0001
653 551 589 513 427 2733
0.038 0.032 0.028 0.023 0.020 0.028 ⬍0.0001
374 306 275 228 201 1384
0.025 0.025 0.026 0.027 0.023 0.025 0.50
246 241 252 266 221 1226
June 2007
Am J Prev Med 2007;32(6)
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whereas if the density of facilities were equivalent to the least-deprived quintile in the population, they would have 10. Perhaps more surprisingly, public sector swimming pools were more available in affluent areas, whereas swimming pools in private sector gyms, which might be expected to cluster in more affluent areas, were more evenly distributed across quintiles of deprivation. Our observations are consistent with those of other studies that also show that deprived neighborhoods have fewer affordable resources for physical activity.5,6,8 In addition, it has also been shown that people in deprived neighborhoods have a reduced capacity to travel to facilities as a consequence of less access to cars and public transport.13 However, one study from Australia reported better access to recreational facilities in low-socioeconomic neighborhoods compared with high-socioeconomic neighborhoods, although residents of these neighborhoods were less likely to use them.7 The location of this study was a relatively wealthy city that may not have had the same degree of variability in SES compared with the other studies cited. This highlights the need for future studies to have data not only on the availability or proximity of facilities but also accessibility, including the cost-perexercise session. This study was limited because information on only the location of the facilities was available, and it was consequently not possible to examine the effects of deprivation on patterns of usage. In addition, only specific indoor recreational facilities are reported, and it may be that other places for physical activity such as parks and open green spaces are less socially distributed. Furthermore, existing administrative areas were used as the spatial unit for this analysis, whereas other zonal definitions, such as buffer zones around peoples’ homes, may more accurately reflect the availability of physical activity facilities. Other attributes of the built environment, including greenery and general upkeep, are associated with physical activity and may influence the relationship between the availability of facilities and levels of physical activity.14 There is considerable evidence that interventions that are limited to modifying intrapersonal variables such as attitudes, knowledge, and personal skills are unlikely to resolve the inequalities observed in rates of physical activity.15 Our findings suggest that a more equitable distribution of opportunities to participate in physical activity is also likely to be required. Expenditure by local authority leisure departments in recent years has remained relatively static, when at the same time, there has been a rapid growth in private sector provision.16 If this trend continues, it is possible that the private sector could become the major provider of recreational facilities, which in turn may increase the inequitable distribution of resources.
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Conclusion The study has shown that the availability of physical activity facilities declines with the level of deprivation. Areas in most need of facilities to assist people to live physically active lifestyles have fewer resources. If the government is to meet its targets for improving levels of physical activity and reducing inequalities,17 it may need to consider the way in which market forces might be creating an inequitable distribution of facility provision in England. The authors thank the Leisure Database Company for kindly preparing and supplying the data on physical activity facilities. Ethical approval was not required for this work, as patients were not involved. Funding for this study was provided by the British Heart Foundation Core Funding PPC/JUL05/5B BHF. No financial conflict of interest was reported by the authors of this paper.
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