Physical activity and nutrition are essential behavioral factors that contribute to overall health and well-being of individuals. Health promotional activities target these behavioral aspects often singularly when aiming to improve health and related quality of life of the population. Previous research has shown the benefits of integrated interventions with focus on both physical activity and nutrition given that food choices are frequently altered in the context of exercise. Further, studies show that individuals tend to choose unhealthy snack directly after exercise thus it was considered important to include nutrition education in physical activity intervention programs [1]. Despite the fact that the World Health Organization (WHO) recommends leisure time physical activity of 150 minutes of moderate intensity aerobic activity per week for adults aged 18–64 years nearly 30% of adults over the age of 15 years are considered to be physical inactive [2]. Evidence suggests that physically inactive individuals are at an increased risk of premature death compared to active individuals [3]. According to a study on the Global Burden of Disease, nearly 4.4% of the overall burden of disease in populations from European countries was a result of poor nutrition specifically low intake of fruits and vegetables. Issues related to nutrition exist despite the WHO’s recommendation of at least five servings of fruits and vegetables as a part of daily routine [4, 5]. Physical inactivity on the other hand happens to be the fourth largest cause for death globally, owing to the magnitude of chronic diseases associated with this risk behavior. Aside of its impact on mortality rates, morbidity of health disorders associated with physical inactivity, together with its impact on the health-related quality of life, exerts a substantial economic burden on health systems. Physical inactivity alters body composition and impairs glucose regulation [6]. Previous research also shows that physical inactivity alters rate at which blood circulates in the body, distorts metabolic processes and affects the immune system [7].
However, regular physical activity has an impact on controlling body weight and helps regulate blood flow and oxygen saturation in blood [8]. Studies demonstrated that physical activity and healthy diet may help in the reduction of both systolic and diastolic blood pressure up to 5–7 mmHg of especially in otherwise inactive individuals with hypertension [9–11]. Aside of its impact on physical health, prior studies with various cohorts of population, particularly with some form of diagnosis such as different forms of cancer, hypertension, obesity and chronic pain have shown that physical activity helps improve subjective well-being and health related quality of life [12–14]. However, studies addressing the long-term impact of physical activity interventions on the perceived quality of life at a community level are dearth.
The developing countries have been undergoing rapid social and economic transition due to globalization, urbanization, increase in ageing population and most importantly migration, which has benefitted economy through trade exchange and tourism. However, the inevitable results of these structural changes have led to more unhealthy environments; consumption transition and nutritional transition [15]. These transitions particularly have had an impact on socioeconomic factors such as poverty, lack of access to education, which has in turn led to the development of risk behaviors including physical inactivity, as well as, low fruit and vegetable consumption. Interventions targeting such risky behaviors were unable to cope with the pace of the rapidly increasing prevalence of health risk behaviors contributing to the growing prevalence of chronic disease [15].
According to the Swedish national health monitoring and surveillance system nearly 65% of the Swedish adult population reported to be highly physically active as they followed the recommendation of 150 min of moderate-intensity physical activity per week since several forms of sports were part of the native Swedish culture [16, 17]. In addition, studies on perception related to physical activity in adult Swedish men showed that there was a general presumption among Swedish natives that being physically active was health, and they also believed that it was associated with good mental health and happiness [18]. However, populations living in low socioeconomic areas in larger cities in Sweden, exhibited low fitness levels due to prolonged sitting owing to lack of access to physical activity, such as sport or training [16]. While physical activity levels is known to differ by age, gender, and disability[19], research also suggests a social gradient associated to it, in that those who are less advantaged often tend to lead a sedentary lifestyle and experience adverse health outcomes related to inactive lifestyle compared to their more advantaged peers [20–22]. The unequal distribution of physical activities both in Sweden and elsewhere is owing lack of access to preventive health care and most importantly lack of access to affordable leisure time physical activity centers or gyms in the neighborhood [23].
Citizens living in socially disadvantaged neighborhoods are often ethnic minorities who differ from the general population by language, cultural beliefs, education levels, and access to the labor market. Lack of adequate efforts towards integration of these communities has led to low social contact, segregation and mental suppression among them. They also face issues such as unemployment and those few that are employed are less informed about employment rights in the host country and tend to have poor work-life balance leading to lack of time for self-care or physical activity [24]. Women belonging to these disadvantaged groups frequently experience more challenges than their male counterparts owing to being financially dependent together with social and traditional values they carried from their country of origin apparently influencing their view of their current context. The rate of chronic disease seemed higher particularly among these women due to their lack of access to knowledge regarding behavioral risk factors and the lack of access to health care services owing to financial and language barriers, resulting in delay in access to primary care, late diagnosis and treatment [17, 24–26].
Interventions targeting the general population fail to reach or rather are not to full advantage to citizens living in socially disadvantaged neighborhoods since their needs in relation to their cultural and contextual factors are seldom considered in the design of these interventions [27]. Thus, there is a need to identify alternate strategies to make otherwise unheard voices heard through directly involving citizens from these community in the design, development and implementation of intervention both globally [24], as well as, in Sweden [28].
Several physical activity interventions targeting this part of the population has been implemented earlier however, their effectiveness in improving health of communities remains uncertain [29]. It has been much debated that such interventions are not customized to the needs of the population in concern and therefore have been unsuccessful [28]. Most of the existing intervention have failed to take into account the views of the target population as done in participatory research informed interventions used in health promotional work aiming to reduce health disparities where community members have an active part in developing and implementing interventions [30–33]. Prior research indicates that the participatory research process has the ability to foster productive interaction and multiple impacts since research is co-produced with citizens in concern together with academic, public, and private actors [34–37].
Although participatory research has been the most preferred design in promoting health among citizens residing in socially disadvantaged neighborhoods, assessing the effectiveness of participatory interventions, also calls for appropriate evaluation approaches, considering the resources and time dedicated to develop and implement these interventions [32]. There do exist several physical activity interventions informed by participatory research [30–33]. However, most of these studies were focused on a particular community and were faith-based interventions, where participants were those attending a particular church on selected days of the week [33, 38, 39]. In addition, in most of these studies the level of participation by the target groups in the design and development of the intervention were also not clearly described. Studies evaluating participatory research informed health promotional interventions in the Swedish context is relatively dearth. This may be of particular interest since in a context such as Sweden, a welfare state whose health system has been regarded as a role model for the rest of the world, health inequalities do exists [40]. The health promotional initiatives implemented at a general population level have failed to reach a select group of citizens who live in disadvantaged neighborhoods. Thus, there is a need to apply and evaluate alternative approaches in such context in order to address the remnant health needs of select citizens living in disadvantaged neighborhoods. Previous research also suggests that such health promotional interventions or initiatives aiming to reduce health inequalities must have a cross sectorial approach with the continuous input from the citizens that suffer the most and require help [41], as it is done in participatory research.
One such physical activity intervention program was developed together with the citizens built on a community based participatory research program for strategic planning in a socially disadvantaged neighbourhood in Southern Sweden and tested for its feasibility by the research team [42].The intervention program included both training and physical activity, as well as, reflection, counselling and dialogue regarding healthy diet. The intervention program aimed at introducing gradual change in the lifestyles of the participants beginning with simple bodily movements to more advance exercises in the absence of complex gadgets, which were replaced by everyday objects. The activities were customized based on individual capabilities. The feasibility study gave insights into the development of a contextually appropriate physical activity program. The results of the feasibility study showed that participants perceived an improvement in their health related quality of life after participation. This was also expanded on during the discussions where they associated the sense of happiness to their improved mental health. From the feasibility study, it was also understood that the community members enjoyed physical activity when it was organized in a group where the participants could draw motivation from other members within the group. The participation also increased their sense of security while moving around in the neighborhood since they made new acquaintances through their participation, which in turn extended their social networks within the community. Participation in the intervention program also made participants self-confident and urged them further to share their knowledge with others in their network through becoming coaches themselves. Aside of this all participants were certified as health ambassadors who could spread the intervention to others in the neighborhood [42].
It also appeared that community members preferred training for men and women to be organized separately. The study also brought to light that women in the neighborhood were isolated and there was a need for activities primarily targeting women. In addition, the uptake of interventions were better when offered in a group, as participants perceived that it promoted social bonding and minimized isolation thereby helped building community together with improving health of the citizens. Participants in the feasibility study welcomed the possibility to assess their health using biomedical tests and believed that such tests gave them a realistic evidence of the health impact of the intervention, which further motivated them to be physically active. They were particularly more curious about appearance, body weight and body mass index.
The feasibility study which presented the initial evaluation of the intervention where citizens who were part of the core team for strategic planning and development of the intervention were only included. However, an evaluation of the intervention applied to other citizens who initially participated in the initial Future Workshops and expressed the need for such an activity but were not involved in the development of the physical activity intervention was also warranted. However, the feasibility study lacked clarity on the sustainability aspects of the intervention since only the short-term follow-up of the perceptions relating to health related quality of life and some of the biomedical parameters were assessed directly after the end of the intervention.
The aim of the current study was to evaluate the effects of a participatory research informed physical activity intervention on the health and related behaviors of women living in socially disadvantaged neighborhoods in an urban quarter of Southern Sweden.