Comment on: “Equity in Physical Activity: A Misguided Goal”

Abstract

As three self-identified ‘equity advocates’, we read “Equity in Physical Activity: A Misguided Goal” [1] with great interest. Nuzzo argues equity in physical activity promotion is misguided and, therefore, interventions should aim to “increase physical activity in groups that are most sedentary and/or at greatest health risk to a level that is as high as is feasible and possible, irrespective of how that new level compares with other groups”. Here, we demonstrate that the influence of social inequalities means achieving Nuzzo’s goal actually relies upon equitable intervention. Far from misguided, equity is fundamentally misconstrued in Nuzzo’s commentary. We begin by clarifying the central tenets of equity and then respond to Nuzzo’s three key claims that equity approaches are (1) aimed at achieving equal physical activity levels across demographic groups; (2) characterised by flawed underlying assumptions; and (3) bettered by more objective and less politically motivated goals. Equity is not about ensuring everyone is equal. Rather, an equity agenda emphasises health is strongly influenced by social factors: health outcomes largely follow a social gradient, evidenced by a linear relationship between socioeconomic privilege and health [2]. Equity advocates consider health inequalities deriving from relative privilege to be unjust and thus aim to ensure everybody, irrespective of social position, can expect to benefit from social conditions that seek to support, promote and maximise health and wellbeing. Consequently, equity advocates recognise the limits of promoting health primarily through physical activity [3, 4] because the significant influence of social factors on health and strategies of individual behaviour change is ineffective without more fundamental changes to the structures, values and processes of societies at large [5, 6]. Equitable physical activity intervention thus begins by identifying and supporting those who face relative social disadvantage to overcome barriers to participation. With regards to Nuzzo’s claims, first, he asserts physical activity initiatives designed to address inequities “seek to create equal levels of physical activity across demographic groups” and this is “meant to be taken literally” [1]. This is false. We are unaware of any initiatives operating according to this logic, nor does Nuzzo provide examples. Rather than ensuring everyone is equally physically active, health promotion seeks to support people to meet minimum levels of physical activity recommended for health [7]. Like Nuzzo, equity advocates highlight that decisions should be made to maximise effect. Unlike Nuzzo, who relies on hypothetical examples, equity advocates use epidemiological evidence and sociocultural studies to guide targeting of resources to groups tending to fall below the minimum physical activity guidelines for health. As such, intervention success is assessed against compliance with set levels of—not uniformity in—physical activity. Said differently, Nuzzo’s claim that uniformity in activity levels between groups is equity advocates’ metric of success not only misses the point of health recommendations but also misrepresents the goals of equity advocates. Secondly, Nuzzo argues that underlying assumptions of equity-based initiatives are flawed by using interrelated claims that individuals belong to more than one demographic group, differences in physical activity are not solely attributable to (limited) opportunity, and causal relationships between initiatives and changes in activity are unknowable. We agree with aspects of these premises, yet Nuzzo’s ensuing arguments are spurious and contradict his call to focus on sedentary/at-risk groups. For one, any number of reasons can be explored for why people are physically (in)active; (in)activity is multi-causal and complex [8]. This leads Nuzzo to posit that activity is ultimately reducible to individual differences because group differences can be “explained away” through stepwise introduction of demographic variables to show people fit * Kass Gibson [email protected]