dialogue on heart health

 

 

 

 

 

 

Eastern Newfoundland Health and Community Services Region

 

Local Public Health Infrastructure Development (LoPHID) Project

 

 

Rhoda Hoskins, Ann Hollett, Catherine Donovan

Health and Community Services Eastern

 

Serge Merhi, Anne Cockcroft

CIETcanada

 

March 2001

 

TABLE OF CONTENTS

ACKNOWLEDGMENTS....................................................................................................... iv

 

EXECUTIVE SUMMARY....................................................................................................... v

 

LIST OF TABLES................................................................................................................... ix

 

LIST OF FIGURES.................................................................................................................. x

 

INTRODUCTION................................................................................................................... 1

Heart Health in the Eastern Region................................................................................. 1

The Health Promotion Plan............................................................................................ 2

Eastern Heart Health Network....................................................................................... 2

Goal and Objectives...................................................................................................... 3

 

METHODS.............................................................................................................................. 4

Sample Selection........................................................................................................... 4

Instruments.................................................................................................................... 4

Ethics............................................................................................................................ 5

Data Collection.............................................................................................................. 5

Data Entry..................................................................................................................... 6

Data Analysis................................................................................................................ 6

 

FINDINGS............................................................................................................................... 7

Households and Individuals in the Survey....................................................................... 7

Physical Activity............................................................................................................ 8

Resources for active living in the community........................................................ 9

Factors related to physical activity.................................................................... 10

Eating Habits............................................................................................................... 11

Changes in diet ............................................................................................... 11

Eating fat fried food  ....................................................................................... 12

Use of salt at the table ..................................................................................... 14

Fruit and vegetables in the diet......................................................................... 14

Eating fruit and vegetables.................................................................... 14

Access to fruit and vegetables in communities....................................... 15

Factors related to eating fruit and vegetables......................................... 16

Nutrition policies.............................................................................................. 17

Weight........................................................................................................................ 17

Factors related to being overweight.................................................................. 19

Smoking...................................................................................................................... 20

Factors related to smoking............................................................................... 21

Exposure to second-hand smoke..................................................................... 21

Public health smoking policies.......................................................................... 22

Smoking within the home................................................................................. 23

Medical Conditions Related to Heart Health................................................................. 23

Blood Pressure................................................................................................ 23

Factors related to high blood pressure.................................................. 23

Other conditions.............................................................................................. 24

Multiple Risk Factors for Heart Disease....................................................................... 24

Knowledge about Heart Health.................................................................................... 25

Delivery of Services and Information............................................................................ 26

Knowledge of programs.................................................................................. 26

Service preferences......................................................................................... 27

Influences on health within the home................................................................. 28

Preferred information sources........................................................................... 28

 

DISCUSSION AND RECOMMENDATIONS FOR ACTION ........................................... 30

Physical Activity.......................................................................................................... 30

Eating Habits............................................................................................................... 30

Smoking and Environmental Tobacco Smoke............................................................... 31

Clustering of Risk Factors............................................................................................ 32

Public Knowledge and Preferences.............................................................................. 32

Socioeconomic Determinants of Heath......................................................................... 33

 

 

 

ANNEXES

 

1.                  LoPHID Methods

2.                  Instruments

3.                  Key informant summary

4.                  Focus group summary

5.                  Maps

 

 

 

ACKNOWLEDGMENTS

 

There are many people who made important contributions to this project.  We especially thank the many people who participated in the survey and discussion groups in the 20 randomly selected communities included in the project.  We would also like to thank those community representatives who participated in key informant interviews.

 

This research was supported by many staff of Health and Community Services.  A committee consisting of staff from different program areas along with representatives from other organizations collaborated on the design.  Four staff supervised the interviewing teams throughout the Region.  Several staff also facilitated and recorded focus groups.  The clerical support staff in Health Promotion and Protection helped with numerous  tasks.  We would also like to thank the interviewers that were hired for this project.

 

The regional sample of 20 representative population enumeration areas was designed by Dr. Jean Dumais of Statistics Canada, using the 1996 national census as a sampling frame. This project was funded by Health Canada, as part of the Local Public Health Infrastructure Development Project. Technical support was provided by CIETcanada.

 

Design Committee Members:

 

Donna Noseworthy, Nutritionist-Health and Community Services Eastern

Clayton Welsh, Regional Consultant- Department of Tourism, Culture, & Recreation

Alice Blundon, Member-Eastern Heart Health Network

Shirley LeCour, Member-Eastern Heart Health Network

Natalie Moody, Director of Health Promotion-Health and Community Services Eastern

Judy O=Keefe, Assistant Executive Officer-Health and Community Services Eastern

Joan Linthorne, Community Heath Nurse-Health and Community Services Eastern

Paula Pinsent, Behaviour Management Specialist- Health and Community Services Eastern

Catherine Donovan, Medical Officer of Health-Health and Community Services Eastern

Rhoda Hoskins, Research Analyst-Health and Community Services Eastern

Serge Merhi, Research Associate-CIETcanada

Anne Cockcroft, Senior Research Associate-CIETcanada

 

 

 

 

 

 

 

 

EXECUTIVE SUMMARY

 

In this project, data to support heart health activities aimed at reducing the prevalence of risk factors for heart disease was collected.  In particular, information was gathered on three topics that are the focus of the Heart Health Health Promotion Plan for the Region: physical activity, healthy eating, and smoking.  Twenty randomly selected sites within the Eastern Region were included.  Information was collected from 1269 people who completed household interviews, 1029 people who completed individual interviews, 20 key informants, and 20 focus group discussions. 

 

Physical Activity

 

Many adults (about 6 in 10) are not exercising at the recommended level for heart health, which is generally 30 minutes or more at least three times a week.  Almost a fifth reported no leisure-time exercise at all in the preceding month.  Women exercise less than men at the recommended levels and those with a post-secondary education were more likely to exercise than those with a lower education.

 

Barriers to participation in activities were identified in the focus groups.  Lack of time and lack of motivation were common themes.  Lack of time seems to be a particular problem for women.

 

In terms of community factors, lack of safe walking places and lack of facilities were commonly identified.  Although walking is the most common type of activity and many communities have walking trails, there are many issues around their safety and accessibility during the winter months.

 

Eating Habits

 

Many people (almost half) report changing their eating habits in the past two years and many of these had done so for health reasons.  This suggests that the messages about healthy eating are reaching people and having an influence.  Surprising, the amount of fat fried food consumed by people seems relatively low.  Only 18% said they ate food fried in fat or oil three or more times per week.  However, men, people in the low income category, people with less than secondary education and those under 45 are all more likely to eat food fried in fat or oil three times a week or more.

 

About half of respondents never use salt but about a fifth always add salt to their food without tasting it first.  Men were more likely to add salt without first tasting their food then women and those under 45 were more likely to do so than those older.

 

Only one in ten adults report eating five or more servings of fruit and vegetables per day.  Women and those with a post-secondary education are more likely to eat five or more fruit and vegetables per day.  Costs, along with poor quality and poor selection in the local stores, seem to play a role in deterring people from selecting fruits and vegetables.

 

Women primarily do the shopping and cooking in households, either alone or in conjunction with a male.

 

Smoking and Environmental Tobacco Smoke

 

About a third of respondents were current smokers.  Smoking was more common among those who were younger, those who were in the low income category, and those who did not have a post-secondary education. 

 

About half of the people surveyed indicated that they were exposed to second-hand smoke on a daily basis.  Four in five people (80%) supported smoke-free policies in public places and almost all (97%) supported smoke-free policies in places where there may be children.

 

Other Risk Factors

 

The Body Mass Index (BMI) is an indicator, relating height and weight to assess physical size as a risk factor for developing health problems.  The proportion of the population who have a high BMI is of significant concern.  Thirty-seven percent of respondents reported a high BMI (greater than 27). Men were more likely to report a high BMI than women.  People 45 and older were more likely to have a high BMI than those younger.

 

About six in ten respondents indicate they have been told their blood pressure in numbers.  Of those who had their blood pressure taken, 22% have been told they have high blood pressure. 

 

Eight percent of respondents have been told they have diabetes, (2% report a heart attack and 2% report angina).

 

Clustering of Risk Factors

 

It is not surprising that risk factors tend to cluster together.  People who have one risk factor for heart disease are more likely to have another.  Looking at the risk factors of smoking, high blood pressure, obesity, and physical inactivity, 85% of the sample had one or more risk factor; half have two or more risk factors.

 

Knowledge and Service Preferences

 

When asked unaided about factors that contribute to heart disease, some factors such as smoking, lack of exercise, and eating fatty foods were more commonly known, but others were less frequently identified.  Generally, people=s knowledge tends to be sporadic in terms of factors identified and knowledge varies among subgroups.  Those with a post-secondary education in particular tended to be more aware of the risk factors than those without post-secondary education.  The messages about the risk of women for heart disease seems to be having some impact as people, especially women, tend to be aware that women are at risk for heart disease as well as men.

 

Individual respondents were presented with a list of potential services and asked to indicate which ones they would be likely to use.  At least a portion said they would use each of the services presented with walking clubs being the most popular.  In terms of receiving information, most identified doctor=s offices which is not surprising since they traditionally receive health information at the doctor=s office.  Focus group discussion indicate that people are open and interested in other ways of receiving information, such as activities in their community and written messages.

 

Socioeconomic Determinants of Health

 

The role of socioeconomic determinants of health are evident in this study.  In particular, those without post-secondary education and those with lower household incomes are more likely to smoke, be inactive, to eat more fatty foods, and to eat less fruit and vegetables.

 

Recommendations

 

Based on the information collected, several recommendations were made to address the key issues identified.

 

Recommendations for increasing physical activity

<                    Provide more indoor exercise facilities to help both women and men exercise safely throughout the year.

<                    Explore exercise options that are more attractive to women and provide concrete examples of how they can fit exercise into their lives.

<                    Support communities to develop and maintain safe walking trails and to start up walking clubs.

 

Recommendations for increasing healthy eating habits

<                    Introduce more about healthy eating into the school curriculum. 

<                    Introduce healthy eating policies into schools, hospitals and other workplaces.

<                    Explore the perception of healthy eating being more costly.  Develop messages and programs which promote low cost healthy eating.

<                    Explore ways to increase access to good quality fruit and vegetables at reasonable cost.

<                    Encourage people to explore alternatives, such as frozen vegetables.

<                    Explore new ways of getting the messages about the benefits of healthy eating to people, utilizing women in their role as gatekeepers.

 

Recommendations for reducing smoking and exposure to environmental tobacco smoke

<                    Provide more support for smokers to quit and remain ex-smokers.

<                    Provide practical guidance and encourage people to make their homes smoke free.

<                    Continue to strengthen legislation and policies banning or restricting smoking in public places. There is strong support for this in the public.

 

Recommendation for addressing clusters of risks

<                    Combine messages about healthy behaviours, since they are often related.

 

Recommendations for increasing public knowledge and providing programs people will find acceptable

<                    Increase program efforts in areas where there is less awareness; the importance of fruit and vegetables in the diet is one example.

<                    Tailor health promotion efforts differently in different subgroups - the information about knowledge by demographic characteristics in this report can help.

<                    Take advantage of the knowledge that those at higher risk are more likely to avail of services and programs.

<                    Offer programs for which there is expressed interest; this may mean different programs for different segments of the population.

<                    Use the geographic information available from this survey when planning heart health activities in different parts of the region.

 

Recommendation for addressing socioeconomic determinants

<                    Issues related to heart health practices should be addressed in the context of a more general approach to health promotion and the determinants of health.

 

 

 

 

 

LIST OF TABLES

 

Table 1.  Factors associated with exercising at recommended level, from logistic regression

 

Table 2. Reported changes to eating habits in the last two years

 

Table 3.  Factors associated with eating five servings of fruit and vegetables a day, from logistic regression

 

Table 4.  Factors associated with having a high BMI (>27), from logistic regression

 

Table 5.  Factors associated with current smoking, from logistic regression

 

Table 6. Factors associated with having a diagnosis of high blood pressure, from logistic regression

 

Table 7. Factors related to heart disease as identified by respondents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIST OF FIGURES

 

Figure 1. Percentage of respondents by area

 

Figure 2. Percentage of respondents doing the weekly recommended amount of physical activity by area

 

Figure 3. Frequency of physical activity by sex

 

Figure 4. Frequency of eating fried food

 

Figure 5. Percentage of respondents who reported eating fried food more than twice a week by area

 

Figure 6. Frequency of adding salt to food at the table

 

Figure 7. Number of servings of fruit or vegetable eaten per day

 

Figure 8. Percentage of respondents in each of the BMI categories

 

Figure 9. Percentage of respondents trying to lose or gain weight in the different BMI categories

 

Figure 10. Number of cigarettes current smokers smoke per day

 

Figure 11. Smoking status by age group of respondents

 

Figure 12. Frequency of exposure to second-hand smoking

 

Figure 13.  Percentage of respondents with two or more risk factors by area

 

Figure 14. Proportion of respondents who said they will use proposed services in their community

 

Figure 15. Preferred places to get information on heart health

 

 

 

 

 

 

 

 

INTRODUCTION

 

This project is one of four research cycles being carried out in the Eastern Newfoundland Health Region through the Local Public Health Infrastructure Development Project or LoPHID (see Annex 1 for more information on LoPHID). The focus of this research project is the collection and analysis of current and actionable data related to heart health at a level that would facilitate an in-depth assessment of heart health issues for the Region. Moreover, the project builds the community voice into planning by exploring their preferences and needs for programs and services.  This project supports a continued dialogue with the community on heart health issues. 

 

Heart Health in the Eastern Region

 

Heart health has been identified as one of three health promotion priority areas to be addressed by Health and Community Services, Eastern Region over the next five years.  In addressing heart health as a health promotion priority, the goal is to reduce the prevalence of risk factors for heart disease among the residents of the Eastern Region through increased awareness and community action related to healthy eating, active living and reduced use and exposure of tobacco.

 

The selection of heart health as an area of focus is based on several key pieces of research.  Heart health was identified by key informants as one of the major health problems in the region and was attributed chiefly to socioeconomic conditions, lifestyle and lack of preventive health services (Health in Our Community: A Profile of the Eastern Region, 1997).  This concern is substantiated by existing data, including mortality and morbidity statistics.  Newfoundland compared to the rest of Canada experiences higher than average death rates for cardiovascular disease (Newfoundland and Labrador Heart Health Survey, 1988-89). Lifestyle-related diseases such as heart disease are the leading causes of death among men and women in the Eastern Region (Eastern Region: Health Status Report, 1997).  With the exception of admissions for pregnancy, lifestyle related diseases are the leading causes of hospitalization in the Eastern Region.  Hospitalizations for diseases of the circulatory system are number one (Eastern Region: Health Status Report, 1997). 

 

Survey data points to the prevalence of risk factors for heart disease among residents of the province. The Newfoundland and Labrador Heart Health Survey indicated that approximately two-thirds of the population aged 18-74 had one or more of the major risk factors: smoking, elevated blood cholesterol, or high blood pressure (Newfoundland and Labrador Heart Health Survey, 1988-89).  The Eastern Region has one of the highest rates of smoking among both males and females aged 24-49 in the province (Adult Health Survey, 1995).  Smoking is a risk behaviour that is prevalent among young people as well.  The Student Drug Use Survey (1998) indicated that one in five students smoke and that cigarette smoking increases significantly by grade level.  The first LoPHID cycle in Eastern Region collected data in late 1998 and found that over a quarter of all students in grades 7-12 smoke cigarettes daily, and over 40% of those16-18 years

 

 

old are daily smokers.  Other risks including obesity and physical inactivity are also common in the population (Newfoundland and Labrador Heart Health Survey, 1988-89 & Adult Health Survey, 1995).

 

The Health Promotion Plan

 

Within the Health Promotion plan, outcome objectives relevant to heart health programs and services have been set for 2005.  These include:

 

C                     The morbidity and mortality related to cardiovascular disease will be reduced by 5% of the 1995 rate.

C                     The rate of smoking among individuals under 19 years will be reduced by 20% of the 1998 baseline. 

C                     The rate of smoking in the population will be reduced by 20% of the 1995 baseline.

C                     Number of people reporting participation in 30 minutes of physical activity 3-5 times per week will increase by 10% of the 1997 rate.

 

The Health Promotion Plan also proposes various strategies and activities to address heart health in the Region.  The strategies include improving access to health promotion resources and services, advocacy to support the implementation and enforcement of provincial legislation related to completely smoke free spaces, and increasing the number of communities participating in heart health activities of the Eastern Heart Health Network.  Activities to support these strategies include assessment of needs and gaps in services, staff training and education, health education, community mobilization, and social marketing. 

 

Eastern Heart Health Network

 

A Heart Health Network is active in the Region and is trying to facilitate the development of community-based Heart Health initiatives.  The Network is a group of professionals and volunteers involved with various aspects of heart health such as healthy eating, active living, smoking awareness, blood pressure and stress.

 

The Network has a planning group that facilitates the promotion of heart health at the local level.  The planning group is currently involved in: follow up and training for facilitators to conduct a Stop Smoking program for Women; Women and Heart Health activity; publicity for the Network; a 3x/year newsletter; planning for Heart Smart Restaurant Program; and Provincial Heart Health evaluation program activity.  Individual members are involved in activities such as Lifestyle Clinics, a smoking cessation program for women, community walks, health fairs, aerobics groups, and public education.  The Network is affiliated with the Newfoundland and Labrador Heart Health Program and liaises regularly with the manager of this program.

 

 

Goal and Objectives

 

In keeping with the goal of the health promotion plan, this project aims to provide evidence that will help reduce the prevalence of risk factors for heart disease among the residents of the Eastern Region through increased awareness and community action related to healthy eating, active living and reduced use and exposure of tobacco.

 

The objectives of this cycle are to:

 

1.                  determine the prevalence of heart disease risk factors, particularly poor eating habits, lack of physical activity, and smoking, in the Eastern Region population.

2.                  determine the knowledge of these particular heart disease risk factors.

3.                  explore people=s current practices and preferences for services and programs related to heart health promotion.                       

4.                  assess community, geographical, gender, age and socioeconomic differences related to heart health including differences in risks, knowledge, and current practices and preferences.

5.                  share the information on heart health, produced by the project, with the community.

 

METHODS

 

The project follows an established research methodology (see Annex 1 for more information on LoPHID methods). The methods used in this LoPHID cycle include a household survey to collect individual household information.  This is complemented by key informant interviews to assess community level factors and community focus groups to discuss results and explore strategies.

 

A Steering Group was formed for the cycle, to review instruments and implementation of the survey, as well as to review the findings.  The group included people active in Heart Health in the Eastern Region, including community representatives.

 

Sample Selection

 

The sample was drawn by Statistics Canada. Twenty Enumeration Areas (EAs) were selected within the Eastern Region, after stratification into 6 sub-regions to reflect the geographic spread in the Region. EAs with a population of 0 (according to the 1996 Census) were excluded.  Six urban and 14 rural sites were selected.  After stratification by urban/rural and ordering by subregion and ascending number of households within subregions, EAs were randomly selected based on a probability proportional to the EA size. 

 

In the final sample, EA size ranged from 98 to 419 households.  A total of 5,011 households were included in the sample (see Annex 3)..

 

Instruments

 

As part of a Astandards-based approach@ existing questionnaires especially those used in the Province were reviewed as a starting point for designing the household questionnaire and existing questions were used whenever possible.  There were two parts to the household questionnaire.  A general section, that was administered once per household to an adult aged 18 or over, focussed on relevant household characteristics.  An individual section was administered to all available adults between the ages of 18 and 60 in each household.  This section focused on individual behaviours, knowledge, and preferences.  The questionnaire was pilot tested in an area outside the selected EAs and modified slightly as a result.

 

Key informant interviews were designed to collect information about community level factors including availability of recreational and fitness opportunities, types of grocery stores, and heart health activities in the community.  A section on the cost of key items in the grocery stores in the communities was included.

 

Focus group discussion guides were developed, presenting key findings from the household questionnaires and key informant interviews and guiding discussion onto areas useful for program planning. 

All instruments can be found in Annex 2.

 

Ethics

 

The project proposal was reviewed by the Ethics Committee of Health and Community Services, Eastern Region to ensure relevant ethical issues were addressed.  These issues include  the confidentiality of the information, both during and after data collection, the mechanisms for obtaining voluntary consent, the insurance that participation is not harmful, and that the information collected is valuable.

 

Confidentiality in the LoPHID initiative is a strong focus.  No record is made of the name or address of the household informant alongside any information that they provide. Thus, there is no means to trace back to any individual participant.  Personal information such as age, gender, level of education and household level of income is collected from the respondents but no identifying information is included in the records other than noting the EA where the data is collected.  At the beginning of each cycle, field workers sign a ADeclaration of Confidentiality@ form.

 

Data Collection

 

Household data collection and key informant interviews for this LoPHID cycle took place during October and early November 1999.

 

Twenty-one interviewers and 5 supervisors helped collect data in this LoPHID cycle.  All participated in a one-day training.  The purpose of the training was to ensure that interviewers had an understanding of the project, that they were familiar with the interview process and the instrument being used, that they appreciated the concepts of confidentiality and quality data collection, and that they understood the logistics involved in the cycle.

 

Interviewers were organized into five teams, each with a team supervisor.  Teams travelled to a site and conducted the interviews in sequential households.  Households where interviews were completed, those where no one was available and those where there were refusals were noted.

 

Key informant interviews were conducted in each sample community by the data collection team supervisor.  Most often the key informant was the Community Health Nurse.  The team supervisor was also responsible for collecting the costing information from a local grocery store.  Interviewers were instructed to visit the grocery store that seemed to be the largest available one in the community.

 

Focus group facilitators and recorders were trained in the techniques involved. The focus groups were set up with the help of local staff and were composed of community people including representatives of existing groups, such as service organizations, in each of the sample communities.  Each group included 4-11 participants. The focus groups were conducted during February 2000, when the main findings from the household survey and key informant interviews were available.

 

Data Entry

 

The household questionnaire was designed in a scannable format and subsequently scanned into a computer database, using the Remark software package.  Additional data entry from the household questionnaires and key informant interviews was undertaken using the Epi Info software package.

 

Data Analysis

 

Most of the analysis was undertaken using Epi Info. Basic frequencies of heart health risk factors and other indicators were calculated and weighted according to the sample weighting (see Annex 2).  Values of indicators shown in the report are weighted unless stated otherwise. The relationships between personal and community factors and heart health risk factors were examined individually and in combination.  Multivariate analysis included sequential stratification using Epi Info and multiple logistic regression using the SPSS statistical package.

 

 

FINDINGS

 

Households and Individuals in the Survey

 

In total, 3908 households were visited.  Of these, interviews were refused at 514 (13%).  Another 2125 households had no one at home, leaving 1269 (32%) households that participated in the survey.   Of the responding households, 36% (461/1269) were in urban areas and the remaining 64% (808) were in rural areas.  The distribution of the respondents in the sub-regions is consistent with the population distribution for the Region (Census 1996). (see Figure 1.)

 

From the household survey,  most (77%; 957/1241) of the people who provided information were female.  Among the respondents, 16% (198/1269) were between 18 and 34, 22% (279) were between 35 and 44, 31% (391) were between 45 and 60 and 31% (401) were over 60.

 

Among the households, 23% (222/946) had an annual gross income under $15,000, 27% (253) between $15,000 and $24,999, 20% (191) between $25,000 and $34,999, 17% (158) between $35,000 and $49,999 and 13% (122) had an income of $50,000 or more.  An index of low income was calculated taking household size into account, approximately based on the method used by Statistics Canada.  Households with one or two members fall into the low income category if they have an annual gross income of less than $15,000 and a higher income threshold applies for larger households.  In the Eastern region in 1997, nearly 50% of lone-parent families fell below the low income threshold used by Statistics Canada.  Only 10% of two-parent families fell below the low income threshold.  Nearly a third (30%; 282/946) of households in the survey sample were in the low income bracket.

 

From the individual survey, over two-thirds (71%; 726/1029) of the respondents were female.  This is higher compared to the population which has 50% women (1996 Census).  Of the people who responded, 7% (68/1029) were 24 years of age or younger, 18% (188) were between 25 and 34 years of age, 31% (317) were between 35 and 44 years of age, 29% (297) were between 45 and 54 years of age and 15% (159) were between 55 and 60 years of age.  This compares to 17% who are between 18 and 24, 24% between 25 and 34, 27% between 35 and 44, 23% between 45 and 54, and 9% between 55 and 60 in the actual population (1996 Census).  Thus, our sample tends to be somewhat older than the general adult population in the Region.

 

The majority of respondents (82%, 846/1028) were married/common-law, 12% (125) had never been married and 6% (57) were separated, divorced, or widowed.  Forty-two percent (433/1029) of respondents had at least some post-secondary education.

 

About a fifth (22%, 228/1026) of respondents worked full-time.  Another 15% (154) worked part-time, 33% (334) were unemployed or worked on a seasonal basis, and 15% (155) were homemakers.

 

Physical Activity

 

Respondents were asked to indicate how many times per week they had done any physical activity in their leisure time to make them sweat or breathe harder during the past month and how much time they spent doing the physical activity on each occasion. 

 

In response, 18% (188/1029) indicated that they had not done any activity at all, 11% (108) said less than once a week, 24% (250) said once or twice a week, 20% (201) said three or four times a week and 27% (282) said more than four times a week.  Of those exercising, almost one in ten (9%, 74/839) exercised less than 15 minutes and 20% (171) exercised for at least 15 minutes but for less than 30 minutes.  Forty percent (331) exercised for 30 minutes to an hour and 31% (263) exercised for more than one hour.

 

 

Generally the recommendation is to exercise for 30 minutes or more at least three times a week.  Four out of ten (39%; 405/1029) of the adults surveyed reported exercising as much as this. 

 

Reasons for not exercising at the recommended levels were explored in the focus groups.  Lack of time to exercise was frequently mentioned.  Participants discussed that people are busy with work and other responsibilities.  Lack of motivation, both in getting started and keeping with it, was also commonly mentioned.  Increased awareness of the benefits was mentioned in some groups as a way of increasing levels of physical activity.

 

Most people (56%, 581) reported being more active in the summer months.  Thirty-nine percent (397) reported the same level of activity year round and a few 5% (51) said they were more active in the winter.

 

The most common type of activity in the past 12 months was walking with 89% (912/1029) of respondents indicating they had walked.  Gardening and physical labour type of work was also quite common with 52% (540/1029) indicating they had done activities of this type in the past 12 months.  Other activities included gym type of activities (such as aerobics and weight lifting) (24%, 243), individual activities (such as biking, running, skating and swimming) (29%, 294), team sports (11%, 117) and hunting (10%, 99).

 

Resources for active living in the community

 

On average, communities have 6-7 indoor or outdoor recreational facilities as reported by key informants (see Annex 4 for details of community facilities).  Most (14/20) communities have one or more walking trails and people in the communities without walking trails mainly walk on old railway beds.  None of the communities have any specific cycling trails.  Only one of the twenty communities has a walking club.  Over half (11/20) of the communities have two or more physical activity classes available and most (17/20) have two or more organized sporting activities available. 

 

The most common type of additional resources for active living individual respondents felt were needed in their communities were indoor recreation facilities (30%, 381/1269) and safe walking trails (24%, 299/1269).  In the survey, very few households indicated any specific barriers to participating in activities in their community.

 

In the focus groups, lack of recreation facilities and the need for them was a common theme.  Walking trails in particular were seen as things that are needed and would be used.  Participants discussed many issues around the lack of safe places to walk including having to walk along the road as well as problems with dogs, lack of streetlights and walking conditions in winter.  The need for organized programs targeted at different levels was mentioned in some groups.  It was discussed that some programs are too difficult for those who are older or those who are not in shape.  Some people also mentioned that one of the problems with current programs is the lack of qualified instructors.  Some discussed the need to make programs more fun.  The cost associated with activities was also mentioned in some groups as a barrier to participation. 

Factors related to physical activity

 

Men are more likely than women to be exercising at the level recommended^[2].  This is mainly because men tend to exercise more often than women at the duration specified.  Women are engaging in less strenuous exercise and/or exercise that is less than 30 minutes in duration as was found in the Newfoundland and Labrador Heart Health Survey (1989-99).  The 1995 Adult Health Survey also found that men exercise more than women in their leisure time. 

 

In the focus group discussions, many had difficulty believing that men exercise more than women.  Women seem to be more visible when they exercise, i.e., they are more likely to be walking along the road.  Otherwise, many felt that women exercise less than men because they have less time.  They have the major responsibilities for childcare and housework and in addition they may be working outside of the home.

 

Overweight individuals with a Body Mass Index (BMI) of more than 27 (see below) are less likely to exercise at the recommended level than those with a lower BMI^[3].  Similarly, those who have been told they have high blood pressure are less likely to exercise at the recommended level^[4].  There is little difference between age groups (up to 44 years and 45 years plus) in the proportion of people doing the recommended amount of exercise.

 

Individuals who eat at least five servings of fruit and vegetables per day (see below) are more than twice as likely to be exercising at the recommended, compared with those who eat less fruit and vegetables^[5].

 

People from households in the low income category are less likely to exercise at the recommended level than people from households with a higher income^[6].  People with post-secondary education are more likely to exercise at recommended levels than those with less education^[7].

 

Factors related to exercising at the recommended level were considered together in a logistic regression. The factors remaining in the final model, and their relationship to exercising at the recommended level, are shown in Table 1.   Taking other factors into account, people are more likely to exercise at the recommended level if they are male, have at least secondary education, are not overweight and also eat five or more servings of fruit and vegetables per day.

 

Table 1. Factors associated with exercising at recommended level, from logistic regression

Factors	Adjusted Odds Ratio*
Male gender	1.4
Post secondary education	1.2
Eating five servings of fruit and vegetables per day	1.7
Not having a high BMI	1.3

*This is the likelihood of exercising at the recommended level among those with the factor, compared with those without it.  For example, males are 40% more likely than females to exercise at the recommended level, taking the effects of other factors into account.  This however does not imply a cause and effect relationship.  

 

Eating Habits

 

Changes in diet

 

Almost half (48%) the respondents said they had changed their eating habits in the past 2 years.  Females were more likely to have done so than males (52% vs 40%)^[8].  The age groups were similar with 47% of the 18-44 year olds and 49% of the 45-60 year olds having changed their eating habits. Reported changes to eating habits are shown in Table 2.  The most common reported change was cutting down on fat in the diet. 

 

Among those who had changed their diet, 50% (244/488) had done so for health reasons (to feel more fit or to eat Ahealthy@ foods), 29% (143) had done so for medical reasons (on doctor=s advice) and 15% (71) had done so to improve appearance.  Among those who had not changed their diet, 68% (364/535) said they saw no need to change; another 21% (114) said they preferred their usual diet.  Of those who saw no need to change, 56% (202/364) were in the age group 18-44; 36% (122/341) had a BMI over 27 (high), 23% were women with a high BMI and 13% were men with a high BMI.

 

Table 2. Reported changes to eating habits in last two years (1029 respondents)

Change in eating habit	Number (%)
	Total	Male	Female
Eat less fat	335 (33)	84 (28)	251 (35)
Eat healthier	187 (18)	45 (15)	142 (12)
Eat more fruit and vegetables	155 (15)	38 (13)	117 (16)
Eat less junk food	123 (12)	32 (11)	91 (13)
Use less salt	120 (12)	32 (11)	88 (12)
Eat more balanced diet	102 (10)	35 (12)	70 (10)
Eat less sugar	98 (10)	24 (8)	74 (10)

Figure 4. Frequency of eating fried food

 

 

Eating fat fried food 

 

People were asked how many times per week they ate food fried in fat or oil.  In response,  40% (412/1029) said they did so less than once a week, 42% (440) said they did so once or twice per week, 12% (119) said 3 or 4 times a week and 6% (58) said more than four times a week.

 

Men are more likely than women to report eating food fried in fat or oil three times a week or more (25% vs 14%)^[9].  This is also true for people in the low income category compared with those with higher incomes^[10], people with less than secondary education compared to those with secondary education or above^[11], and people under 45 years compared with older people^[12].

 

The number of people who reported eating food fried in fat or oil more than twice a week seemed rather low, based on local perceptions of eating habits in the Region.  It is possible that  people were actually only including food they fried at home themselves and did not include bought foods that had already been fried.  This issue was explored in the focus groups.  Participants predominantly felt that people had not included all types of fat fried foods.  In particular, participants indicated that people may not have thought about precooked foods bought in the grocery store.  Some thought that people may have included take-out foods but some thought that people may not have thought about those.  It is possible that the percentages reported here are an underestimate of the actual amount of fat fried food consumption.  However, the frequent reporting of reducing fat in the diet in the last two years may suggest that people really are eating less fat than popular perception would indicate.

 

How to reduce the amount of fat fried food eaten was  explored in focus groups.  Education- about the health risks of fat and about what foods are fatty- was seen by many as important to encouraging people to reduce the amount of fat fried food they eat.  Advertising to increase public awareness was also seen as a way to reduce the amount of fat fried food eaten.  In particular, some felt that more consistent messages were needed.  Several people felt that graphic displays are effective.  Some also mentioned that it cost more to eat lower fat foods.

 

Targeting younger people, children and teenagers, were seen by several people as important for changing eating habits around fatty foods.  Some people felt that the eating habits of children may be easier to change than adults.  It was indicated that healthier foods need to be offered at schools.

Use of salt at the table