Population-based studies note that 33% of American Indians report not engaging in any leisure-time physical activity, compared with 28% of all other racial/ethnic groups (6). Objective measures of physical activity indicate that most American Indian adults do not meet the national benchmarks for recommended physical activity levels, and further reductions in physical activity are associated with advancing age and increasing body mass index (7). Previous investigations of American Indians have found that older age, poor social support, unsafe neighborhoods, lack of access to places to exercise, and competing caregiver responsibilities are also associated with lower activity levels (2,8-11). These studies do not generalize well to older American Indians because they investigated younger (11) and female cohorts (8-11), with small sample sizes (2,9). Older American Indians are at an even greater risk of physical inactivity than younger cohorts (12) and may face unique challenges in establishing healthy routines. Furthermore, many of these studies did not investigate factors that may be associated with promoting increased engagement in leisure-time physical activity.

Consistent with previous studies (2), personal facilitators to walking largely involved health and social reasons. Both physical and aesthetic features of the built environment are consistently associated with physical activity and walking (22-24). American Indian elders also frequently endorsed many of these built-environment facilitators to walking. Furthermore, they regarded the availability of benches and places to rest as an important environmental feature, a finding that could be helpful in planning built environments that can assist older and medically compromised populations in pacing their physical activity.

Lack of recreational resources was also reported by elders as a significant barrier. Previous studies have noted that racial/ethnic minority and economically disadvantaged communities are 3 to 4.5 times less likely to have available recreational and exercise facilities compared with predominately white and higher-income communities (25). Basic physical features of the neighborhood environment, such as sidewalks, lighting, green space, and aesthetics, are associated with higher levels of physical activity (23,24,26), and community interventions that modify the built environment to promote physical activity can lead to objective increases in walking (27). Indeed, respondents in our study reported a 5-fold increase in self-reported walking preference when sidewalks were present in both residential and commercial areas. The integration of objective measures of both the built environment and physical activity levels is an area for future research. Advances in global positioning technology offer a potential tool for further inquiry (28).

On the Barriers to Being Physically Active Quiz, lack of willpower emerged as the most highly and frequently reported subscale, whereas fear of injury was the lowest-rated subscale. This contrast underscores the importance of using motivational enhancement strategies to bolster physical activity levels in medically ill populations. Previous studies have also found that low motivation is a commonly voiced reason for physical inactivity among older, racial/ethnic minority populations (2,19). In an adult sample of American Indian women, those reporting higher levels of self-efficacy in their ability to be physically active were approximately 2 to 3 times more likely to meet physical activity requirements outlined by the Centers for Disease Control and Prevention and the American College of Sports Medicine (11). Further, another independent sample of American Indian elders similarly noted that low motivation and low self-esteem were common reasons for not walking (2). Interventions to promote exercise that incorporate motivational enhancement are effective in increasing physical activity levels among sedentary adults, and these principles can be easily integrated into primary care (29). The finding that people with higher self-efficacy perceive fewer personal, social, and environmental barriers to physical activity underscores the importance of enhancing self-efficacy in at-risk populations, as this may help to compensate for objective barriers to physical activity (26). Future research should address the efficacy of motivational enhancement and confidence-building interventions to assist elders in reaching and maintaining nationally recognized physical activity guidelines.

Our study has several limitations. First, we assessed urban-dwelling American Indian elders, so our findings may not generalize to other American Indian populations. Second, we conducted within-group, cross-sectional analyses that limit statements regarding the directionality of the relationships. It remains unclear if self-reported barriers and facilitators to walking are stable over time, or if physical activity interventions can produce desirable changes in these outcomes. Third, we did not collect neighborhood data that could have provided a more objective measure of built-environment features that either promote or inhibit physical activity. Fourth, although the data were collected 9 months after enrollment in the randomized activity trial, participation in a study specifically designed to increase walking behavior could have influenced our current findings. Assessing these domains in a new community sample of American Indians might address this uncertainty. Fifth, CHAMPS and the Barriers Quiz have not been previously validated with older American Indians, and therefore questions arise about the cultural relevance of these measures. Finally, many of the built-environment items assessed were not frequently reported by the elders, so we may have missed other barriers.

Craig N. Sawchuk, Dean Health System. 1313 Fish Hatchery Road, Madison, WI 53715, Phone: 608-252-8226, Email: sawchuk/at/u.washington.edu.