Defining Exercise in Contrast to Physical Activity

During health examinations, patients are often asked about the frequency and amount of exercise undertaken. When most health providers ask about exercise, they are referring to the modern societal notion of exercise events that are planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is recommended or prescribed for patients to improve their health, maintain fitness, and as an important means of physical rehabilitation (The Free Dictionary, n. d.). Exercise is recommended also for its psychological benefits: decreasing feelings of anxiety and depression, improving self-esteem and mental alertness, and decreasing tension, frustration, and fatigue (Schaefer & Brennan, 2009). Assessing levels of exercise and encouraging it in our patients is an important part of health care.

A problem arises when there is a miscommunication between patients and health providers over what is meant by exercise. We may ask patients about how much “exercise” they get, when what we really may want to assess is the amount of total physical activity engaged in each day. In response to our questions about structured exercise, older patients from traditional heritages may indicate that they participate in limited exercise (e.g., do not engage in aerobics, go to the gym). In reality these patients may engage in a fair amount of physical activity but we may not regard such activities as exercise because they are not “structured exercise.” This may be the case especially when providers interact with older adults from traditional populations. For such populations of elders, engaging in physical activity is often a characteristic of their daily life rather than a structured event like using a gym or exercise equipment. For example, a Filipino older adult, who grew up in his or her traditional homeland may spend a large proportion of the day physically mowing the lawn, hand washing the laundry, scrubbing the floors, walking to the bus and so forth. All of these types of physical activities may come to mind when the individual answers the question, “How much exercise do you get every day?” However, we may not consider these activities to be exercise because they are not part of structured exercise.

A significant need exists for nurses to be able to accurately communicate with our patients. Based on the responses of an elderly Filipino population who immigrated later in life to the US, we discuss lessons learned from a study that attempted to be culturally responsive and measure the notion of exercise in this population. Using a descriptive qualitative method, our study was conducted to describe the health beliefs about exercise of a convenience sample of 47 traditional Filipino adults, at least 65 years old, living on the island of Oahu, Hawaii. This setting was selected because it included a large proportion of traditional older Filipino adults engaged in a lifestyle characteristic of their traditional homeland in the Philippines. All of the participants spoke Ilocano, and were born in the Philippines. Eighty-five percent did not complete high school, and only 2.1% lived alone.

The study was interested in the participants’ responses to questions about perceived benefits and barriers to exercise, preferences of types of exercise activities, and assessment of their own confidence to exercise on a weekly routine basis (three or more times/week). The interview guide was forward- and back-translated by the researchers and health center staff using Brislin’s (1970, 1980) method in order to standardize the expression of the questions. Data were analyzed using thematic analysis. Thematic analysis involves the search for and identification of common threads throughout an entire interview or set of interviews (Morse & Field, 1995).

The responses to open-ended questions by participants about exercise described both unstructured physical activity (e.g., performing activities of daily living) and structured physical activity (performing scheduled and regimented exercise). Although the participants discussed their problems in balancing barriers and benefits, engaging capabilities, and intervening factors, an interesting finding was how they defined exercise. The focus here is a discussion of the divergence between the Western definition of exercise (i.e., structured exercise, used by the researchers) and the traditional notion of exercise as total physical activity (provided by the respondents).

The researchers’ conceptualization of exercise clearly influenced the study questions:

1. Tell me about the kind of exercises you normally do.

2. How often do you usually engage in the types of exercise that you just told me about?

3. How often did you exercise last week?

4. Tell me, why do you think you exercise?

5. How confident are you that you could exercise vigorously? Like working up a sweat for 30 minutes three or more times per week?

6. If you are not exercising as often as you want or should, what are the reasons?

7. Tell me what you think would happen if you exercised vigorously three or more times per week?

FINDINGS

Although respondents answered the interview questions with honesty, the responses were limited and many indicated barriers to engaging in structured exercise activities, such as having limited time or an interfering health conditions. However, we noted that they also began to describe unstructured physical activity (e.g., performing activities of daily living, child care, house cleaning or gardening) as exercise.

The majority of participants reported some form of walking as the most common kind of exercise they engaged in while five indicated gardening-related activities. Walking was incorporated with activities of daily living, such as household chores and family obligations (walking grandchildren to school). A distinctive finding from this study was how most participants considered physical activities of daily living to be forms of exercise.

Doing household chores, going to the market, gardening, raking leaves, walking to the store, walking the kids to school, walking around the house, washing cars, and cleaning the yard and garage were all answers to the question of what constitutes exercise, and they reflect the perception of many of these participants. Several participants also reported that in addition to work inside the home, a number of them were still working outside their homes and referred to their work activities as part of their exercise activities. For instance, they would refer to the following forms of physical activities as exercise: walking to go to work, walking to serve my customers, and walking as I sell my vegetables.

DISCUSSION

Consideration must be paid to the term “exercise” and the way it was used and understood by the participants to include physical activity. Most of the participants identified walking as the most common form of exercise or physical activity. For older adults from traditional populations, walking may not mean light recreational walking but walking for a few miles to accomplish errands on a daily basis. Some participants also described activities of daily living such as doing household chores, which could include scrubbing the floors on one’s hands and knees, or gardening, which could include raking and pulling out weeds.

The participants’ comments open the door to the notion of classifying unstructured physical activity as forms of exercise. In a study conducted by Atienza and King (2005), it was reported that the two most frequently mentioned physical activities from the older Filipino American women were light housework and leisure walking. Prior research suggests that these types of activities must be explored in more culturally sensitive ways (Fischbacher, Hunt, & Alexander, 2004) as some cultures regard activities of daily living as “exercise.” Hawkins et al. (2009) suggests that total activity, including light intensity and unstructured activities such as activities of daily living, should be included in the measure of physical activity; total activity may be a better predictor of health outcomes than structured exercise activity alone.

Is there a need to differentiate between exercise and physical activity, especially among older adults from traditional populations such as the Filipino elderly? Should we be asking research participants and our clients about both exercise and physical activity in order to get a better perspective on their total activity (combination of physical activity and exercise)? These two concepts may have different meanings to lay groups and heath professionals. Health care providers, their clients, and researchers and their participants must share a consistent conceptualization of exercise and physical activity if our assessments are to be accurate. For example, the participants in our study included caring for grandchildren and walking the kids to school as part of daily unstructured physical activity, which in their minds constituted “exercise.” This is in contrast to Western society’s definition of only structured activities as constituting exercise. More research is needed to recognize what actually constitutes “exercise” from the perspective of the respondents rather than from the perspective of the researchers alone. Alignment of the researchers’ perspective with that of the respondents is essential for achieving reliable and relevant findings in future empirical studies. Awareness of the respondents’ cultural perspectives will provide a more accurate assessment of the quality and quantity of physical activity in traditional populations—especially for those who come from agricultural backgrounds, such as the older Filipino adults. To view phenomena from a specific population’s perspective is essential to provide a culturally relevant basis for developing meaningful interventions.

To be consistent with the goals of Healthy People 2020, “to increase the proportion of older adults and who engage in light, moderate or vigorous leisure-time physical activity” (US Department of Health and Human Services, 2009), it is important that our assessments accurately portray the realities of physical activity levels in all populations. The best way to accomplish this is to be sensitive to the generational and societal differences in terminology specific to each population with which we interact.