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在我国,随着社会经济的发展,工业化、城镇化、老龄化进程的加快,以及人们生活方式的快速转变,心血管疾病、糖尿病、恶性肿瘤、肥胖病和慢性呼吸系统疾病等慢性非传染性疾病(以下简称“慢性病”)已成为危害我国人民健康和生命的头号因素,《2010年全球疾病负担评估》结果显示,我国由慢性病造成的疾病负担(伤残调整寿命年)占总负担的77%。体力活动不足会使这些慢性疾病发生的危险性增加,每年由于体力活动不足导致全球190万人死亡。据预测到2020年,全球将有70%的疾病是由于缺乏体力活动引起的。经常性、规律性的体力活动对于降低心血管疾病、肥胖病、糖尿病、一些癌症(结肠癌、乳腺癌等)及骨质疏松症等慢性病的风险都有非常明显的益处。
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然而,体力活动是受个人、社会和环境等因素影响的复杂行为,国外许多学者普遍认为人口学和社会学因素已经不能完全解释体力活动不足比例上升的原因,研究或实践中应充分考虑个体因素和外在环境因素的综合影响及其相互作用机制,这方面的研究成果引起了一些国家政府部门的关注,成为其制定体力活动干预方案的重要依据。在发展中国家(包括我国)却很少有人涉及该领域的研究,国内有关体力活动影响因素的综述类文献只有少量几篇,研究内容侧重于体力活动影响因素的研究方法、体力活动测量方法或研究阶段变化等,鲜有对国内外体力活动影响因素进行系统的梳理分析。本文立足社会生态学视角,对国内外体力活动影响因素的相关研究进行系统的梳理和分析,了解和探索国内外体力活动影响因素的共性和差异,为我国进一步探索和干预国民体力活动和健康问题提供有益的借鉴和启示。
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1 概念界定
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体力活动[1]是指任何由骨骼肌收缩引起的导致能量消耗的身体运动。它既包括在闲暇时间动员大肌肉群、为增进或维持身体健康而进行的有计划、有组织的重复性的体育锻炼(如跑步、打球等),也包括较小的身体移动(如用电脑等)和日常生活中各类非运动性、休闲性的及一般生活性的活动(如步行、做家务、搬东西等)。换句话说体力活动是由职业类、交通类、家务类和休闲类四类体力活动组成的[1]。
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2 主要影响因素
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体力活动的研究始于上世纪60年代,到了20世纪80年代,大量的研究成果证明体力活动与健康存在关系。近三十年来,公共卫生学与流行病学、环境学、行为学和体育学等学科相联系一起对体力活动进行交叉学科研究,实现了从单门学科研究到跨学科交叉研究的质的飞跃。1996年以来,公共卫生、体育科学和行为科学的研究者使用社会生态学模型理论极大地提高了与体力活动相关的个体和外在环境方面的研究水平。研究发现,影响体力活动的因素是很复杂的,也是多维的[2]。体力活动影响因素主要包括人口学和生物学、心理、认知和情感、行为属性和技巧、社会文化和物质环境等[3]。
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2.1 人口学和生物学因素
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随着时间的推移,人口学和生物学因素中的年龄、职业、婚姻状况、肥胖、吸烟行为等变量与体力活动的相关性越来越强。随着年龄的增长,65岁以上老年人的体力活动水平会逐渐下降[4],静坐的可能性也会增加[5]。80岁以上老年人以低等强度体力活动为主,用于满足基本的生理和生活需求,健身活动所占比例不高,内容相对单一[6]。男女体力活动水平、类别和参与率不同[7],男性体力活动参与率高于女性[8],以职业活动和交通出行类的中等体力活动为主[9],且比女性更为活跃[3,9-11];女性则以轻度体力活动为主[12],家务体力活动占总体力活动的52.5%[13],职业体力活动对总体力活动量的贡献较小[14]。许多研究表明社会经济地位、收入、职业、受教育程度与体力活动水平呈正相关[13,15-16],这与国内的研究结果相互印证[17-18]。
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婚姻状况对体力活动的影响在不同国家研究结果不同。有的研究认为婚姻状况与体力活动水平差异均无统计学意义[19-21],而有的研究认为已婚男性成年人体力活动水平高于其他婚姻状态的成年人[22-23],已婚女性比未婚女性的体力活动水平要低[24]。
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健康状况为体力活动影响因素研究的常用变量。BMI小于或等于18.5或大于24是体力活动不足的保护性因素[25-26],体重偏瘦、超重或肥胖的人应成为体力活动健康教育的重点人群[25]。自评健康状况好/极好和一般的老年人达到世界卫生组织体力活动推荐量的发生比分别是自评健康状况差/很差老年人的1.65倍和1.95倍,说明健康状况是老年人从事体力活动的基础,良好的健康状况有助于达到世界卫生组织体力活动的推荐量[27]。儿童时期的自评健康状况是老年时期体力活动水平的一个预测器[28],15岁以前身体健康状况与老年时期体力活动水平呈负相关[29],这与15岁以前身体健康状况差的人更注重体育锻炼并养成健身习惯有关。
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2.2 心理、认知和情感因素
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自我效能感是社会认知理论的一个核心组成部分,高水平的自我效能感能使人们更好地作出参与体力活动的决定、制定健身计划,以及充分利用他们的认知资源来有效应对困难和实现目标。大量研究证实,人的自我效能感与体力活动水平呈显著的正相关[30-32],自我效能感越高的人体力活动水平高的可能性越大[33],这一现象在高龄人群中尤为明显,自我效能感的丧失是高龄人群体力活动水平下降的深层因素[6],但可以通过监督或激励机制提高老年人的自我效能感知基线,增强老年人体力活动的可持续性[34]。心理健康、运动动机、体力活动预期效益与休闲体力活动水平呈正相关[35],缺少时间、感觉很累、缺少组织、缺少资金成为发达或发展中国家成年人参加体力活动的障碍[22,36]。
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从表1中发现,身体外形与体力活动呈显著负相关,但健康和锻炼知识与体力活动不具有关联性,换句话说,人们仅了解健康和锻炼的知识还不够,在今后的体力活动干预中在注重健康锻炼知识宣传普及的同时,更应督促人们参加体育锻炼,实现知和行的统一。
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注:++为在文献中反复出现的与体力活动成正相关的变量;+为和体力活动相关性弱或者混合证据证明的变量;0为和体力活动没有关联的变量;-为在文献中反复出现的与体力活动成负相关的变量;-*为和体力活动有较弱的负相关或者混合证据证明的变量。下表同。
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2.3 行为属性和技能因素
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健身行为、看电视、吸烟、喝酒逐渐成为体力活动影响因素研究领域的新增变量[37-39]。青少年时期健身行为是成年时期参加体力活动的一个很好的预报器[40],青少年时期越爱健身的成年人达到世界卫生组织体力活动推荐量的可能性越大。中、美老年人看电视的行为会降低其体力活动水平,而法国老年人看电视和体力活动水平则无关联性[41],拥有宠物狗的老年人比没有宠物狗的老年人体力活动水平要高[42-43]。吸烟、酗酒和体力活动呈负相关[44-45],有可能会降低其体力活动的水平[46]。
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2.4 社会文化因素
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国外学者对来自过去家庭、医生的影响,配偶、朋友、同伴的支持,以及社会隔离等社会文化因素对体力活动影响的研究相对成熟。来自家庭、朋友或同伴的支持与不同年龄段人的体力活动水平均呈正相关[3,40,47]。体力活动行为往往建立在生命初期,父母对孩子儿童时期体力活动行为的支持对其后期体育运动方面的发展有着直接的推动作用。获得社会支持的女性每周从事高水平体力活动的可能性大约是获得很少社会支持女性的2倍。丈夫对妻子体力活动越支持,妻子达到世界卫生组织体力活动水平推荐量的可能性越大(比如一起体育锻炼、自己照顾孩子让配偶去锻炼)[48]。在发达国家,医生支持对成年人参加体力活动的影响越来越显著。如果老年人周围的朋友经常规律地参加体力活动,她(他)参加体力活动的积极性会更高[40]。社会隔离与体力活动水平相关性从不明确的负相关发展到了显著负相关,所以应重视社会隔离对人体力活动的影响。
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2.5 物质环境
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友好的社区物质环境在促进社区居民从事体力活动中扮演着非常重要的角色[49-50]。若社区的休闲设施不充足、日常生活目的地的可及性差、缺少前往设施或目的地的交通工具、可步行性差、社区安全性差、社区光线弱、使用设施成本高等[3,51],将会引起居民心理紧张和害怕,影响居民产生消极的健康行为[52],减少居民从事体力活动的机会。
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社区的可步行性、交通容量、距离最近绿地的距离与居民散步(以休闲为目的)的频率呈显著性差异[53-54],建议根据人们步行或骑自行车去附近目的地的能力进行社区设计,从而提高居民的交通类活动水平[31,55-57]。如欧洲一些国家将便利的公共交通设施作为城市积极生活干预的重要内容后,城市居民从事休闲类体力活动水平显著提高[58]。
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因各个国家的经济发展程度、文化和健身习惯不同,家庭或社区的休闲娱乐设施便利程度对居民休闲体力活动水平的影响也是不同的。美国人体育锻炼的频次和社区的密度、有偿使用的健身设施的密度呈强正相关,免费的健身设施和体育锻炼水平无关[59];波兰社区无偿使用体育设施的便利程度与波兰人体育锻炼水平呈正相关[60-61];有无便利优美的公园与澳大利亚人休闲体力活动水平呈显著正相关[40];家中有无健身器材与比利时成年人的休闲体力活动呈正相关[61]。但无论是哪个国家,社区休闲设施的可及性对青少年体力活动的影响均具有显著的统计学意义[62-64];普遍存在现有休闲娱乐设施并不能满足老年人体力活动的需求、体育设施和老年人体力活动不具有相关性的现象,所以在社区休闲娱乐设施设计时应考虑老年人的特殊性[65]。
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前期的许多研究成果证明物质环境对提高体力活动水平的影响越来越显著,在体力活动干预与健康促进的实践中,通过改善社区的物质环境提高了居民的体力活动水平。但不可忽略具有调和物质环境作用的社会和心理环境因素,社会和心理环境的调整,会削弱物质环境对体力活动的作用,体力活动和物质环境之间有可能没有明显的关联性[66],因此社会、心理和社区物质环境相结合将会更好地掌握提高人们体力活动水平的决定性变量[67]。最大限度地发挥社区环境的作用来改善或提高人们的体力活动水平,培养积极健康的生活方式,显得尤为重要。
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2.6 自然环境
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室外体力活动是体现体力活动水平的一个重要预测变量[68],越来越多的学者关注天气和季节对体力活动水平的影响。研究发现,白昼时间的长短、温度和降水等有可能影响体力活动行为,白昼时间较短人们的体力活动水平就较低。下雨一天就会对个体当天的体力活动水平产生负面影响,持续降水就会降低体力活动的水平[69],建议反复降雨或者气候比较恶劣的地区提供额外的室内活动场地或设施,以维持或提高居民全年的体力活动水平[69]。体力活动水平是随着季节的变化而变化的,生活在季节和气候适宜地区的人们达到世界卫生组织体力活动推荐量的比例相对较高[70],暖和的月份提高了中—高等强度的体力活动水平的可能性[71],与冬天相比,夏天人们的体力活动水平要高。如何根据当地的气候条件,因地制宜地提供适宜进行体力活动的设施或场所显得尤为关键[72]。
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3 建议
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通过对文献的梳理和分析发现,随着时间的推移,职业、婚姻状况、心脏病风险、肥胖(BMI)、医生对病人的康复运动的建议和自我效能感等个体变量与体力活动的相关性越来越强;儿童时期的健康状况、过去的健身行为、吸烟和喝酒逐渐成为研究领域的新增变量,这应引起国内学者或政策制定者的关注。改善或提高人们体力活动水平不仅需要考虑个体的行为选择,还要充分关注社会环境、社区物质环境和自然环境的综合影响,建议今后的研究中应加强分层线性回归分析研究,探索个体层面和更高层面变量对体力活动影响的解释力度及其相互作用机制。当前国内外的研究大部分采用横截面数据探讨体力活动与影响因素的相关性,并不能发现体力活动与影响因子之间的因果关系及方向,建议今后研究中应加强生命历程中体力活动的纵向跟踪研究,探索影响体力活动的决定性因素,实现有针对性的体力活动干预和健康促进。
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摘要
通过梳理和分析国内外近30年有关体力活动影响因素的研究文献发现:随着时间的推移,职业、心脏病风险、婚姻状况、肥胖、家庭支持、医生对病人的康复运动建议等与体力活动的相关性越来越强;儿童时期自评健康状况、过去的健身行为、吸烟逐渐成为研究领域的新增变量;体力活动水平的提高不仅需要考虑个体的行为选择,还要充分关注社会环境、社区物质环境和自然环境的综合影响。今后研究中应加强对生命历程中体力活动跟踪的纵向研究,探索影响体力活动的决定性因素,实现有针对性的体力活动干预和健康促进。
Abstract
By combing and analyzing the literature of the influencing factors on physical activities in China and abroad in the past three decades, it is found that with the time goes by, there is bigger correlation between physical activities and occupational, risk of heart diseases, marital status, obesity, family support, rehabilitation and exercise recommendations from physicians. The self-rated health status in childhood, fitness behaviors in the past, and smoking have gradually become new variables in this research field. The improvement of physical activity levels needs to consider individual behavior option, and it also needs to concern about society environment, material environment of the community and the natural environment as the comprehensive factor. In the future study, the longitudinal study of the physical activity tracked in the life course shall be strengthened, decisive factors influencing the physical activities shall be further explored, and the targeted physical activity intervention and health promotion shall be realized.
Keywords
physical activity ； influencing factors ； social ecology ； research progress