Abstract
This article provides commentary on the accompanying manuscript, “Physical Activity in Latino Men and Women: Facilitators, Barriers, and Interventions” by Larsen and colleagues. A major strength of the Larsen manuscript is that it draws attention to the need for more research on the facilitators and barriers of physical activity in this population, particularly Latino men, and the need for more effective physical activity interventions. This commentary presents some additional insights surrounding the 29 physical activity interventions in Latinos that were identified and directions for future research. In order to expand the state of the science regarding physical activity in Hispanic/Latino populations, researchers should expand their investigation to identify important social determinants of health, include voices from the Latino community in the research process, and use state of the art measures to assess outcome variables.
‘…focus on the psychosocial facilitators and barriers of Latino physical activity overlooks important environmental and contextual variables at best, and risks blaming the individual at worst.’
The accompanying article “Physical Activity in Latino Men and Women: Facilitators, Barriers, and Interventions” by Larsen and colleagues presents a discussion of the psychosocial facilitators and barriers of physical activity in Latinos and a review of recent (1999-2013) interventions that aim to promote physical activity in this population. The article is timely given the growing Hispanic/Latino population in the United States and the expanding body of research on this topic. A major strength of the article is that it draws attention to the need for more research on the facilitators and barriers of physical activity in this population, particularly Latino men, and the need for more effective physical activity interventions. However, key implications of the interventions were omitted, and the focus on the psychosocial facilitators and barriers of Latino physical activity overlooks important environmental and contextual variables at best, and risks blaming the individual at worst.
While the article presented the 29 identified interventions according to the levels of the social ecological model, the presentation of the facilitators and barriers of physical activity in Latinos focused specifically on the psychosocial predictors of physical activity. This important limitation essentially narrows our understanding of the issue and our interpretation of the intervention findings and implications. While self-efficacy and social support are consistently associated with physical activity in Latinos and other groups more broadly, and thus important targets for interventions, a focus solely on these variables masks the complex and broader contextual factors that are at play to influence physical activity in Latinos. A commentary by Zambrana and Carter-Pokras in the American Journal of Public Health in 2010 stated, “Scientific assumptions that omit consideration of structural and economic factors in the study of Latino health disparities must be challenged.” 1 The approach of Larsen et al. overlooks the potential effects of socioeconomic status, neighborhood resources, historical and political context of immigration, and institutional patterns of unequal treatment, among others, which may have greater implications on the disparity in physical activity in Latinos than that which can be explained by psychosocial factors alone. Furthermore, the language adopted by Larsen and colleagues to discuss these barriers and facilitators remained culturally focused, which ultimately risks blaming the individual. Statements such as “exercise is in conflict with the cultural norms and goals for Latinas” (p. 7) or “the dearth of programs for [Latino] men may also be due to the unique challenges related to gender roles, such as limited time and interest in leisure time physical activity and other health programs” (p. 27) should be interpreted with caution. As Zambrana and Carter-Pokras submitted, “Expanding and shifting the boundaries of public health research to include social determinants of health, institutional barriers, and structural inequality will enhance our understanding of health disparities among Latinos,” 1 and ultimately help us design and implement the most effective physical activity interventions.
Following their discussion of the psychosocial predictors of physical activity in Latinos, Larsen and colleagues presented a review of 29 recent interventions that have aimed to increase physical activity in primarily Latino populations (mostly of Mexican descent). This included 3 community-based interventions, 17 interpersonal interventions, and 10 individual interventions. Ironically, only 2 of the interpersonal interventions identified were family-based despite the focus on the family in Latino culture and the fact that many of the participants were Latina women. After presenting the results of these interventions, the authors concluded that the findings were mixed and that future interventions should target culturally specific barriers in order to be more effective. They submit that cultural adaptation and tailoring is needed, especially given that Latino cultural expectations and perspectives are not favorable toward physical activity. Caution should be used when interpreting this statement. Larsen and colleagues perhaps could have focused on how the content of future interventions could be more effectively tailored in order to be more successful. For example, community-based participatory methods (CBRP), 2 a research approach that is grounded in the needs of the community and that emphasizes involvement of community members and stakeholders at all steps of the research process (eg, needs assessment, implementation planning, monitoring, and evaluation), offers one answer. The time has passed when we can simply tweak a few minor details of a successful (primarily non-Latino white-focused) intervention (eg, language, photos in brochures) and hope to see effects in outcome variables. We should include the rich data from CBPR methods to improve interventions in a variety of communities. As noted in the current literature, few interventions to date have been successful, and there is room for improvement. CBPR can provide a step in the right direction.
There is another important issue concerning about the state of the science on physical activity interventions in Latinos. A key point missing from Larsen and colleagues’ discussion is that much of the literature on Latino physical activity is based on self-report measures. A major premise of the article is that Latinos report less leisure time physical activity than non-Latino whites. However, very few studies have examined this objectively. In fact, of those studies that have used accelerometry, they have demonstrated that Latinos actually have higher physical activity levels than non-Hispanic whites and are more likely to meet recommended guidelines for physical activity.3,4 While leisure time physical activity or planned exercise may appear to be in contrast to the cultural values of the Latino population, that does not mean that physical activity necessarily is. Self-report measures may not adequately capture the types of physical activities within which Latinos regularly engage (ie, household activities, occupational activities). It is also likely that these physical activity levels differ based on other social and environmental factors including socioeconomic status, neighborhood resources, language abilities, and so on. It is of note that only 1 of the 29 interventions reviewed by Larsen and colleagues included an objective measure (pedometry) of physical activity as an outcome variable. How can we know whether the interventions we implement are truly effective if we are not using gold standards for measurement? There is a need for more research to document the physical activity levels of Latino men and women from various Hispanic subgroups and backgrounds using objective measurement of physical activity.
Hispanic/Latinos can be defined as any person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. 5 Generally, Latinos have been lumped into one group despite very different historic, sociocultural, and economic backgrounds. 6 The heterogeneity of Latino subgroups is something that cannot be underemphasized in public health research. Any Puerto Rican will tell you they are not the same as someone from Mexico or from Argentina, yet they are often grouped together for the sake of science. It is likely that physical activity levels as well as correlates will differ not only by gender but also by Latino subgroup. In order for interventions to be effective, they need to be tailored to the specific subgroup they are serving. While Larsen and colleagues presented a summary of facilitators, barriers, and interventions in Latino men and women, it is just one piece to the puzzle. Given that Latinos suffer disproportionately from obesity, diabetes, and some cancers, physical activity promotion should remain a goal and topic for future research. In order to expand the state of the science, researchers should expand their investigation to identify important social determinants of health, include voices from the Latino community in the research process, and use state-of-the-art measures to assess outcome variables.