Critical Review Of The Bio-psycho-social Factors Which Impact On The Normal Optimum Levels Of Fitness And Functioning: In Coronary Artery Disease Patients  

Abstract Category: Science
Course / Degree: Physiotherapy
Institution / University: Anglia Ruskin University, United Kingdom
Published in: 2011

Paper Abstract / Summary:

Physical activity has taken centre stage in the health care community, due to its preventive and rehabilitative benefits. However, in spite of the growing knowledge of the effects of exercise and series of recommendations by the American College of Sports Medicine (ACSM), physical inactivity still remains a burden in public health. Generally, fewer adults, women than men, and blacks than whites engage in physical activity. This may be caused by several factors such as technological innovations which discourage activity by decreasing the energy needed for daily activities; economic incentives / fiscal dynamics which pay more for sedentary than manual work and educational status. Also, disabilities, personal and programmatic factors play a role resulting in low fitness levels leading to poor physical functioning and vice versa (Schutzer & Graves, 2004).

Moreover, modern medicine in its quest for effectiveness and evidence based practice to underpin professional decisions in patient management has come to terms with the role of the integrated sub-systems of man in determining the state of health and the health behaviours adopted. Therefore, in an effort to promote health by ‘increasing the well-being and self-actualization of an individual’ as distinct from disease prevention, the concept of health as it relates to the cultural definition of quality of life and well-being must be explored and understood (Saylor, 2004). This implies that optimal health as a way of living despite existing diseases (coronary artery disease, CAD) can be improved upon.

Health comprises of a ‘state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’. Although WHO popularized the concept of holistic health, the definition faced some criticisms due to the difficulty in objectively measuring other dimensions other than the physical component. Other criticisms included the variation in the concept according to culture and the impracticality of setting a ubiquitous standard of health which would inevitably categorise most people as unhealthy.
Nonetheless, the difficulties and complexities posed by this multidimensional concept of health still allows for greater meaning, validity and appropriate adaptation to diverse cultures. This model of medicine is a paradigm of patient management that considers the importance of the interplay of all factors in the outcome of health or illness in contrast to the biomedical model which focuses on biological factors. With regard to the bio-psycho-social (BPS) theory various lifestyle and behavioural affects have been related to health with exercise being one of the sturdiest lifestyle interventions.

Whereas the fitness-related cognitive benefits and affirmative positive effects on mental health of exercise remain, a gap between theory and practise exists (McAuley, et al., 2011). This is possibly due to paucity of accurate knowledge and poor clinical reasoning skills which is dependent on the successful integration and application of new concepts with previous knowledge. A proper understanding of its role in the evaluation of CAD patients is prerequisite in the achievement of this purpose (Jones, Edwards, & Gifford, 2002). This essay critically examined fitness and functions in Nigerian CAD patients using the BPS theory and proposed recommendations for the future holistic management of these patients.

These patients are mostly advanced or advancing in age and plagued with a myriad of other co-morbidities. Therefore, it is imperative to understand and draw inferences from the effects of BPS factors in the achievement of effective rehabilitation to optimal functioning.
CAD involves the narrowing of the coronal arterial lumen caused by the advancement of atherosclerosis and thrombosis. The fatality rates remain low in individuals who are < 35 years and increases exponentially afterwards (Buckley & Doherty, 2008). The major modifiable factors linked to CAD are physical activity, dietary habits and smoking. Physical activity exerts the greatest influence on CAD mortality across both sexes and most ethnic groups.

Nonetheless, inactivity is still widely reported amongst adults with a higher prevalence of inactivity amongst Africans. Also, a rising burden of the CAD in developing countries and an inactivity level of 25—57% among Nigerians has been reported (Abubakari & Bhopal, 2008). Though under representation could have influenced this result as poor documentation frameworks and diagnostic equipment plagues reports. Optimal health in CAD patients can be achieved through a critical examination of the related BPS factors impeding function and consequently fitness.

To begin with, a detailed assessment of their physical activity and fitness levels can be performed with the aid of heart rate measurements. It is an objective means of assessing present fitness levels due to its strong positive association with energy expenditure. It can be used to assess the level of activity as well as design an individualized exercise program for patients. This is to ensure that the level of physical activity engaged in is safe and reaches the threshold of energy expenditure required to confer benefits on the autonomic system.
Fitness level is influenced by age, gender and ethnicity which are immutable parts of an individual. Physical disabilities prevalent in the aging population also hinder participation in exercise. Also, genetic and cultural differences in physical activity levels were reported from family and twin studies.
The role of poor health such as chronic or joint pain in limiting function has been reported, with a higher participation in physical activity among pain free adults than their counterparts. Also, more functional disabilities and depressive symptoms were reported in women than men that showed maladaptive responses to pain by demonstrating high pain catastrophising, perceived helplessness and low self-efficacy, possibly due to psychosocial factors (Campbell, Clauw & Keefe, 2003).

This shows a relationship between the sensory-physiologic, motivational-affective and the cognitive-evaluative dimensions of pain along with the existing environmental factors in influencing patient’s interpretation of health. In addition, functional disabilities encourage sedentary lifestyles which predispose individuals to obesity. This accounts for about 8.8% of Nigerian adults (Abubakari & Bhopal, 2008).

Patients with better mobility and balance are more likely to report greater neighbourhood satisfaction with perceptions of these factors operating as mediators of higher self-efficacy levels than otherwise. Also, the increased risk of musculoskeletal injury associated with exercise may result in inactivity among CAD patients. There is a higher incidence of leisure-time and sport related injuries in physically active adults than their less active counterparts who report more injuries during non-sport and non-leisure time activities. However, the recent recommendation of the ACSM (Haskell, et al., 2007) which emphasizes intensity and duration of moderate levels results in an overall injury rate similar to that obtained in inactive individuals while producing health benefits.

A definite interaction exists between physiological states and psychosocial variables in influencing physical functioning and fitness. However, an adjustment for physical disabilities may not result in higher activity levels or exercise adherence. The prevalence of inactivity documented to be 13% in West Africa (Abubakari, et al., 2009) which is strongly associated with being older, the female gender and urban residence supports this view. Therefore, the identification of the psychosocial limitations of activity which are usually linked in a mesh work and difficult to determine due to complex and dynamic nature of exercise is paramount. This suggests that human behaviour can be viewed as an ‘interactive model of triadic reciprocal determinism’ where behaviour, personal and environmental factors determine each other interactively.

Conn (1998) outlined a number of plausible psychosocial variables affecting functioning and fitness levels which include personal traits, systems of support, community settings, environmental circumstances, economic status, occupation, educational level and opportunities for healthcare. Further, is the prevalent perspective of exercise among older adults as a time-consuming activity, rather than a therapeutic or prophylactic regimen in comparison to pharmacological or dietary interventions? This is propagated by the vague exercise prescription patterns executed by Physicians during the routine visits of ethnic patients who usually hold the opinion of Physicians with high regard. In addition is the lack of referral to the appropriate health care professional for specific management owing to the poor awareness level of Physiotherapy in West Africa (Frantz, 2007).
Besides, the cultural concept of respect which relates wisdom to old age creates an atmosphere where adult’s ≥ 40 years do not engage in recreational activities as they are related to youthful exuberance. Likewise, the associated symptoms of exercise such as sweating, laboured breathing are perceived to be negative and ‘un-ladylike’ by women in Nigeria. The general culture also associates women with marital and domestic affairs with bias over the involvement in recreational activities such as swimming or dancing (Seefeldt, Malina & Clark, 2002). This is even more prevalent in the northern parts of Nigeria where cultural and religious affiliations relegate physical activity for the acquisition of skills needed for ‘jihad’ (holy war).

Therefore, engaging in physical activities may promote dress patterns which are perceived to be immodest. On the other hand, other West African religious beliefs which may not have such restrictions uphold perspectives which relate higher body mass to economic affluence. This encourages the acquisition of high abdominal fat, consumption of fast foods and diets rich in cholesterol while associating physical activities such as walking, cycling or jogging to poverty (Adegoke, 2010).

Although, this paradigm seems to be more prevalent amongst individuals with low educational training as health behaviours tend to improve with knowledge. The proper understanding of the role of physical activity on health among literates is still low. In support, the elimination of the racial and ethnic differences in exercise patterns when comparisons were made among men of high educational and socioeconomic status was insignificant. In a related vein, low socio-economic status associated with care-giver responsibilities, inflexible work schedules or hard labour well recognised for impeding exercise levels is prevalent in West Africa (Adegoke, 2010). This makes it difficult for patients to access adequate health-care much less travel to largely unavailable fitness centres or recreational facilities for exercise.

An alternative for alleviating this factor would have been to encourage activities around the neighbourhood. However, Morris, McAuley, & Motl, (2008) discussed how concerns about the safety of the environment, neighbourhood satisfaction as well as embarrassment, though more applicable to women would pose as a hindrance to the achievement of this goal. Safety hindered by the risk of been harassed during public physical activity due to the religious perceptions or crime rates are compounded by the unavailability of convenient resources for exercise such as sidewalks and parks. Also, the common unstructured housing plans may predispose an individual to road accidents.

A resultant effect is the gender difference of lower physical activity levels in women further constrained by their social and religious roles. This supports the findings of Seefeldt, Malina & Clark (2002), who reported higher levels of leisure-time physical activity among men than women. In addition, lack of social support by a spouse, family or the community at large, plays a major role on the perceived individual self-efficacy levels which has been linked to the initiation and maintenance of physical activity.

CAD patients tend to demonstrate lower self-efficacy as related to their decline in physical and social function. An in-depth screening of the BPS factors which simultaneously co-exist via various pathways needs to be evaluated. A multivariate design that accounts for the factors that affect health status and improvement through initiation and adherence to positive health behaviours in relation to their health beliefs should be used (Adegoke, 2010).

CAD is associated with disability, decreased health-related quality of life, premature death and increased medical care costs (Whooley, et al., 2009). Adjustment of factors such as increased awareness of the vital role of physiotherapist in healthcare practice; referral for exercise by Physicians; National public health campaigns for health promotion strategies such as good housing plans and physically active transport systems; Cultural re-education within religious boundaries and establishment of exercise community centres may foster exercise participation.

However, adherence was reported as higher when individualised programs were integrated with medical and psychological care models. In the absence of a one-size-fits-all approach, systematic evaluation and planning is crucial in the designing of effective management for patients who vary in their biological, psychological and social characteristics.

Paper Keywords/Search Tags:
review, bio-psycho-social factors, coronary artery disease, physical activity

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Submission Details: Paper Abstract submitted by Jacqueline Thompson from United Kingdom on 19-Jun-2013 23:48.
Abstract has been viewed 2415 times (since 7 Mar 2010).

Jacqueline Thompson Contact Details: Email: jacqwued7@gmail.com

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