Exercise is Medicine! Why are People not Buying into the Prescription?

Purpose and methods: Despite decades of research documenting the numerous health benefits of exercise, most people are not buying into the “Exercise is Medicine” prescription and making the commitment to exercise regularly. The purpose of this study was to examine: 1) Participants’ perceptual association with descriptive statements and certain activities relating to exercise and physical activity (PA); 2) Participant’s attitudes towards the gym environment; and 3) The overall relationship between participants’ associations with PA and exercise, and their preferences for how they want to be physically active. Adults ages 18 years and older representing diverse groups from rural and urban communities in Guelph and Wellington County in Southwestern Ontario, Canada and groups from Cherokee County, South Carolina were participated in this mixed methodology study. Focus group facilitated discussions were conducted with 234 people from Southwestern Ontario and 175 people from South Carolina. Using the themes that emerged from the focus group interviews, a research-generated survey was created to validate the findings of the initial focus group interviews. Results: Overall, regardless of geographical region, most people felt that there was a difference between PA and exercise, and that national guidelines for activity could be met through lifestyle PA. Most respondents also felt that lifestyle PA was preferable to traditional exercise and easier to incorporate into their daily activity, particularly when goal oriented. Generally, participants associated exercise with being structured or planned. However, several inconsistencies were also evident. Adults from South Carolina indicated a greater association of exercise with being painful and boring, impractical, difficult to begin, and a chore. However, most South Carolinians, as well as Southern Ontarians, also indicated exercise as being a stress reliever, and that they felt happy and a sense of accomplishment afterwards. Not surprisingly, such activities included walking, playing with children, and other activities commonly done around the house (gardening, cleaning, carrying groceries, walking the dog) were associated with lifestyle PA. Generally, with only a few exceptions, about half the participants indicated that they had gym memberships. Interestingly, South Carolinians were more inclined to believe that going to gym was necessary to take care of themselves. Ironically, participants from South Carolina also were more likely to find getting started to be a problem, but also found typical gym exercises to be more enjoyable than those from South Ontario. Perhaps most surprising to us was that, regardless of geographic location, participants did not indicate strong feelings towards being embarrassed, intimidated, or feeling judged at the gym, or having any perception of a negative environment. However, most participants still indicated a preference towards activities which could be done outside of the gym environment. Conclusion: Most participants, despite recognizing the health benefits of traditional exercise, prefer to incorporate physical activity into everyday activities. “Exercise is Medicine”, but if the majority of adults will not partake in traditional activities, the medical community must consider what is most meaningful for their patients and the public at large instead of preaching a “one size fits all” narrative. ReseaRCh aRtiCle


Introduction
Exercise is Medicine (EIM), an American-based global health initiative, has substantiated the importance of exercise as a means of treating and preventing chronic diseases, and improving quality of life. EIM primarily targets the medical and health care community, who seek to inform patients and the public at large about the importance of engaging in exercise [1]. Most Americans and Canadians do not meet national Physical Activity (PA) guidelines of 150 minutes of Moderate to Vigorous the staff from the Guelph YMCA/YWCA, and the Italian Canadian Club of Guelph. Focus groups from Cherokee County in South Carolina included members from a United Methodist and Baptist church, the Board of Public Works, the City of Gaffney staff, Rotary Clubs, City of Gaffney firefighters and schoolteachers from a rural elementary school. The exclusion criteria were any health conditions that precluded a participant from exercising.

Procedures
Phase I: Phase I of the research study concentrated on the phenomenological, qualitative approach to gathering data through facilitated focus group discussions and took place in Guelph Wellington County (234 people) from December of 2014 to May of 2015, and in Cherokee County (175 people) from December of 2016 to May of 2018. Focus groups included 6-15 participants and were held in a preferred meeting place to facilitate a relaxed discussion. Conversations were not recorded, and each participant was reassured that the discussions would be kept confidential. Participants were urged to share their associations and perceptions of exercise versus PA, as well as their perceptions of the gym environment.
Participants complete a short demographic questionnaire regarding their gender, age, and residence. The focus group discussions lasted 45 to 60 minutes. Participants were free to leave at any time. The same, trained investigator facilitated each group discussion. Guiding questions included: What do you think of when you hear the word exercise? What comes to your mind when you hear the words physical activity? How do you compare your perception of exercise to PA? Is PA more realistic, enjoyable and doable to accomplish as a part of your day? What is your perception of the gym environment? Do you feel judged while working out in the gym? Do you think the recommended PA guidelines of 150 minutes of MVPA can be met in lifestyle PA? Are you intimidated when using the equipment in the gym? Further probing questions followed and were dependent upon the participants' initial responses. Focus group discussions were observed by 1 or 2 university students who made notes of the conversation as well as an interpretation of what they heard. The group facilitator thoroughly examined all of the focus group notes gathered from the student note takers as well as their own notes to identify recurring themes, which could ultimately be incorporated into the survey questionnaire (Phase II). From the feedback given in phase I, it became clear that many participants were cognizant of the benefits of exercise, but from a practical standpoint, lifestyle PA was preferred.
Phase II: A survey was created to validate the findings of the initial focus group interviews. Common themes and trends that emerged regarding PA, exercise and the gym environment from the interviews were identified by three experts with backgrounds in physical education Physical Activity (MVPA) plus 2 or more strengthening activities per week [2][3][4][5]. Despite years of emphasizing the multiple benefits of exercise through research, images of the gym and muscular, lean fit individuals, most people still are not making the commitment to exercise regularly and taking their "Exercise is Medicine" prescription. With the rise of obesity, sedentary living, and the most recent COVID-19 virus pandemic which has prompted a health reality check, it has become more vital than ever to evaluate the needs of the public to promote PA in a more compelling way.
More recent studies have indicated a preference for lifestyle PA rather than traditional exercise, including activities such as walking, mowing the grass, riding a bike, active transporting to and from work, and fulfilling everyday tasks and chores around the home [6][7][8].
Many people have expressed that lifestyle PA is a more natural, doable and enjoyable way to achieve the national PA guidelines [9].
Educating the public on the importance of a more customized, person-centered approach to PA can give people confidence to want to move more, and in a way that makes substantial sense to them. Motivating people to embrace PA should not be a "one size fits all" approach. The prospective PA participant needs to understand their personal inclinations to what they like or do not like and act on these.

Objectives
Adults from Southern Ontario and South Carolina were included in this study. The purpose of this study was: 1) To examine participants' perceptual association with descriptive statements and certain activities relating to exercise and PA; 2) To examine participant's attitudes towards the gym environment; and 3) To examine the overall relationship between participants' associations with PA and exercise, and their preferences for how they want to be physically active.

Participants
Studies in Guelph Wellington County in Ontario, Canada and Gaffney and Cherokee County in South Carolina received Research Ethics Board (University of Guelph) and Institutional Review Board (Limestone College) clearance respectively. Males and females ages 18 years and older representing 13 diverse groups from rural and urban communities in Guelph and Wellington County in Southwestern Ontario, Canada and 13 groups from Cherokee County, South Carolina participated in this study. Informed consent was obtained from all participants. Some examples from Guelph Wellington County included members of the following groups: A rural Parks and Recreation Department, Lion's Club from a rural community, a rural Mennonite church, a women's advocacy group called Zonta International of Guelph, possible. Participation in the focus group discussions was not required for completion of the survey. Survey questions are indicated in Table 1, Table 2 and Table 3.

Results
The responses to various attitudes and opinions to-and exercise. These themes were used to construct a series of descriptive statements related to peoples' preferences for PA, and views of exercise, PA and the gym environment. Survey administration was scheduled at a convenient time and location suitable for each group with the objective of obtaining as many participants as For each of the following statements, please choose either yes or no for your response.

Yes No
Is there a difference between physical activity and exercise? Do you think the Canadian/USA's guidelines of 150 minutes of moderate to vigorous physical activity each week can be achieved by physical activity alone, or is it necessary to "exercise?" Would you prefer to engage in more vigorous physical activity such as energetic yard work, brisk walking or forcefully raking leaves than exercise? Do you think exercise has greater health benefits than physical activity?
Is physical activity or exercise easier for you to do when it's goal-oriented (i.e. gardening) or when there's a destination/purpose (i.e. walking to work)?
When you are physically active or exercise, is it important to have one or more friends or colleagues to be physically active or exercise with?
Would you be interested in learning HOW to be more vigorously active in your everyday activities such as when walking the dog, cleaning around the house, running errands or playing with your kids?
Is engaging in physical activity a more natural, realistic and enjoyable part of your day than exercise?
Is moderate to vigorous physical activity easier to incorporate into your day than exercise?  Table 3: Gym membership and perceptions.

Yes No
Are you a gym member?
If yes, is going to the gym a necessary part of life in order to take care of yourself?
If yes, do you enjoy the exercise you do (treadmill, weights, group fitness class, etc.)?
for activity could be met through lifestyle PA. Most respondents also felt that lifestyle PA was preferable to traditional exercise and easier to incorporate into their wards PA and exercise are shown in Table 4 and Table  5. Overall, most people felt that there was a difference between PA and exercise, and that national guidelines Using the equipment in the gym can be intimidating 1 2 3 4 5 I feel judged in a gym environment The gym environment is intimidating 1 2 3 4 5 The gym makes me feel vulnerable and exposed Women are more likely than men to exercise to look good 1 2 3 4 5 found typical gym exercises to be more enjoyable than those from South Ontario. Regardless of geographic location, participants did not indicate strong feelings towards being embarrassed, intimidated or feeling judged at the gym, or having any perception of a negative environment. However, most participants still indicated a preference towards activities which could be done outside of the gym environment.

Discussion
Overall, participants viewed exercise as "planned, structured, regimented and repetitive", which likely accounts for the fact that most participants preferred lifestyle PA over traditional exercise. Yet, one of the more interesting results reflected that the majority of Southern Ontarians who did belong to a gym, did not think going to the gym was a necessary part of life to take care of themselves. The majority of South Carolinians indicated the contrary. This could be due to the influence of a highly organized sport culture that exists in the US which can form a mindset that an exercise workout is ultimately the way to engage in PA. The general public daily routine, particularly when goal oriented.
Common associations with exercise, rather than lifestyle PA, are indicated in Table 6. Generally, participants associated exercise with being structured or planned. However, several inconsistencies were evident. Adults from South Carolina indicated a greater association of exercise with being painful and boring, impractical, difficult to begin, and a chore. However, most South Carolinians, as well as Southern Ontarians, also indicated exercise as being a stress reliever, and that they felt happy and a sense of accomplishment afterwards.
Activities commonly associated as being part of lifestyle PA, rather than traditional exercise, are shown in Table 7. Table 8 and Table 9 show participants' associations with the traditional gym culture. About half the participants indicated that they had gym memberships. Interestingly, South Carolinians were more inclined to believe that going to gym was necessary to take care of themselves; ironically, South Carolinians were more likely to find getting started to be a problem, but also     7: Male and female responses to survey questions related to the association of certain activities with physical activity rather than exercise. Numbers represent the percentage of total respondents associating a word or phrase with physical activity.    responses from adults across all ages from South Carolina revealed that they associated exercise with "painful, tiring and boring" as well as "impractical, takes too long to drive to the gym, exercise and shower" while these descriptors were not as significant with Southern Ontarians. In addition, other than the females in the 18 to 34-year-old group (53%), South Carolinians also indicated it was hard to get motivated to participate in exercise while the majority of the respondents from Southern Ontario did not find it difficult to overcome inertia to achieve PA. Overall, both Southern Ontario and South Carolinians associated exercise as being a stress reliever. Notably among the females in both regions, a feeling of happiness and a sense of accomplishment after engaging in exercise was expressed. Some of the results indicate most adults do understand physiological and affective benefits to exercise but for all practical purposes, still prefer lifestyle PA.
There is definitely a consensus across both groups and among all ages with what they associate with physical activity: Walking, playing with children, taking the needs to be convinced that lifestyle PA truly is a viable way to keep physically active, and that people should not feel compelled to move in a formal, structured environment if not attracted to this type of PA.
Previous research has shown that those who do favor exercise tend to have a higher level of self-efficacy, outcome expectation, and place an important priority on exercise [10,11]. However, since lifestyle PA can be incorporated throughout the day, it is possible that anxiety and stress levels are lowered. It could also be that the perception of traditional exercise hinders people from feeling like they can accomplish PA without having to go to the gym. By the time many people return home after a long day of work, they are too tired to think about a formal workout and change into gym clothes and then dash off to the gym. In addition, women found that other matters are more important and require their time and energy [12].
There were some distinct differences between the descriptive associations of exercise from the South Carolina participants and those from Southern Ontario. The ercise and PA with a persuasive tone and convincing enthusiasm. Considering our current Covid-19 pandemic environment, and knowing the role PA plays in overall health, one's life may literally depend on adhering to a meaningful PA relationship in order to combat chronic diseases and improve quality of life.

Limitations and Conclusion
Limitations of the current study include a lack representation of certain ethnic groups, as the vast majority of participants identified as White/Caucasian. There were also very few smokers. While we attempted to include many diverse community groups, we cannot exclude the possibility that responses from other regions of either country could be different. The current study also does not include responses from the elderly population i.e. 65 years and older. Since the majority of adults prefer lifestyle PA, perhaps health and medical professionals should consider a paradigm addition of "Lifestyle Physical Activity is Medicine" in order to support peoples' preferences for movement that is more meaningful to them. More importantly, the medical community must become more educated about the benefits of lifestyle PA and exemplify accordingly in their own day to day activities while supporting and encouraging their communities to be lifestyle physically active. The scores of years spent overwhelmingly advocating mainly a more traditional way of moving has done our populations a disservice due to lack of adherence. Exercise is respected by many but only partaken by few. Therefore, let's broaden the approach to helping people help themselves be more successful in meeting our PA guidelines. stairs, gardening, raking leaves, shoveling snow (and other yard work), walking the dog, and cleaning the house or washing the car. The health benefits of these physical activities are well documented [13][14][15]. Knowing that most adults prefer lifestyle PA and largely associate, identify, and agree on various lifestyle physical activities, the medical community and health professionals have an obligation to educate themselves and the public on the importance of promoting lifestyle PA. Furthermore, practitioners should help their patients and the public at large to feel comfortable and confident fulfilling their PA in and around the home and work, and not necessarily at the gym. "Exercise is Medicine", but if the majority of adults will not partake in traditional activities, even though they appreciate exercise, nor have any desire to want to participate in exercise, the medical community must consider what is most meaningful for their patients instead of preaching a "one size fits all" narrative. Furthermore, medical and health practitioners must welcome lifestyle PA into their own lives before teaching and supporting others to include lifestyle PA in their own day to day life. This study points to the direction that many people want to be supported to embrace their own PA world, unique to each person, and not necessarily include organized exercise.
The descriptions that adults associate with exercise are important because, overall, this outlook can affect one's attitude towards exercise and the frequency it is engaged in [16]. In the larger picture, one's exercise frequency has a direct impact on overall exercise adherence and therefore, general health outcome. Some of the responses, indicated in Table 6 to descriptors associated with exercise, underscore the variability in terms of how well people "buy in" to the exercise prescription. Generally, fewer than half of the participants found exercise to be fun or enjoyable. However, there was a wide range of responses in terms of associating exercise with being "painful…", "not rewarding…", and "impractical…". Therefore, it is paramount for individuals to realize that it is natural to not enjoy more formal exercise, and more importantly, to understand that incorporating PA into their lifestyle in a more natural way can be impactful on their health. Because some of the exercise descriptive associations potentially pose as obstacles towards participation in exercise and PA, the fewer the obstacles, the higher the intrinsic motivation to customize PA to each individual realizing individuality and uniqueness [17].
Physicians and health professionals must also understand that many patients prefer a home-based PA program (especially if they are recovering) primarily reflecting lifestyle PA, and a patient-centered approach, emphasizing what is best for that person. In addition, most patients understand the value of PA and how it relates to their well-being and lifelong health [18]. As a result, the time is ripe for the medical community as educators to support peoples' preferences towards ex-