Background
Chronic disease prevention is a leading global public health issue [
1]. There is strong evidence that a lack of sufficient physical activity is independently associated with an increased risk of several major chronic diseases including coronary heart disease, type 2 diabetes, colon and breast cancer, depression, and Alzheimer’s disease as well as all-cause mortality [
1,
2]. For the prevention of chronic diseases, The World Health Organization (WHO) recommends that adults participate in (i) at least 150 min/week of moderate (e.g. walking) or 75 min/week of vigorous-intensity aerobic physical activity (e.g. jogging), or an equivalent combination of both, and (ii) 2 or more days per week of muscle strengthening activity involving major muscle groups [
3]. In addition, other health organisations, such as the American College of Sports Medicine, recommend that adults should engage in specialised exercises to enhance neuromotor fitness, (e.g. coordination, agility and balance) by doing exercises on unstable surfaces, such as balance beams or wobble boards and flexibility-related activities (e.g. passive and active stretching, tai chi, yoga) [
4]. While the current evidence base is limited to support the health benefits of these activity modes among apparently healthy adults, engagement in neuromotor fitness and flexibility training are likely to be beneficial for older adults at risk of falling.
Despite of the promotion of existing physical activity recommendations, population adherence remains low. Recent estimates based on self-reported data suggest that globally between 40 and 60 % of adults meet the moderate to vigorous-intensity aerobic physical activity guidelines [
5], 15–30 % meet the strength training guidelines [
6‐
10], whilst only 10–20 % meet the combined moderate to vigorous-intensity aerobic physical activity-strength training guidelines [
6,
11,
12]. Given these low levels, physical activity adherence is considered one of the biggest challenges in health promotion [
13].
It has been recently proposed that fitness trainers, such as personal trainers, gym or group instructors, have a potentially important and underutilised role in promoting and supporting physical activity and exercise [
14,
15]. Qualified fitness trainers should be trained in the principles of exercise prescription, such as pre-screening, goal setting, assessment and monitoring and program design [
16]. Moreover, fitness trainers have access to exercise equipment to deliver a wide range of exercise modalities (e.g. stationary bikes, strength training equipment, stability balls). However, the effectiveness of fitness trainers in reaching the most inactive populations remains unknown. Research into factors associated with physical activity shows that those who experience socioeconomic disadvantage are consistently among the most inactive population subgroups [
17]. Encouragement to engage in physical activity may be more limited amongst socioeconomically disadvantaged individuals since the engagement of a fitness trainer is contingent upon the ability to afford this service.
Another potential factor limiting engagement with fitness trainers may be a lack of availability of professionals within an individual’s immediate environment, such as a neighbourhood. This is consistent with the emerging research describing the role of area-level disadvantage on physical activity levels [
18]. In brief, after controlling for individual factors (e.g. age, gender, health-status), low physical activity levels observed among disadvantaged populations are partly explained by several area-level factors including real and perceived access to recreation facilities [
18,
19].
Fitness trainers work in a variety of indoor settings (e.g. large fitness centres, health clubs, small studios) and outdoor settings (e.g. local parks, recreation reserves) [
20]. At present, research on access to exercise facilities have mostly examined structured (e.g. gyms, health clubs, outdoor exercise stations) [
21,
22] and unstructured exercise facilities (e.g. parks) [
23]. Studies have shown that fitness centre density are distributed by area-level disadvantage, with more advantaged areas having more facilities [
21]. While these studies provide insights into the distribution of exercise facilities, little is known on where the services provided by fitness trainers are currently distributed within the community.
In 2011, it was estimated that ~30,000 adults in Australia were employed full-time, part-time or casually as fitness trainers [
24], highlighting a great potential for a wide reach of fitness service provision. Fitness trainers are simply a service provided for community members to help them engage in correctly monitored physical activities. Whilst individuals can maintain fitness simply through the presence of a path (which they can walk or jog on) there are many other facets of the environment that can lead to greater participation in physical activity. Local provision of fitness trainers may be one such factor that to date has not been explored with regards to location.
Using a large sample of Australian fitness trainers, the primary aim of this study was to examine if training locations (e.g. large fitness centres, small studios, local parks) are distributed by area-level disadvantage. A secondary aim was to examine whether characteristics of trainers (e.g. qualifications, years of experience) were associated with area-level disadvantage.
Discussion
To our knowledge, this study is the first to describe Australian fitness trainer’s usual training locations and characteristics of trainers by area-disadvantage. Findings revealed areas with high levels of socioeconomic disadvantage had fewer and lower qualified fitness industry professionals training within them.
Previous research from the UK, US and Europe has shown a comparable gradient in area-level disadvantage for aspects of the built environment related to physical activity, such as distribution of fitness centres and outdoor exercise facilities [
19,
21‐
23]. However, our study is the first to explore fitness trainer’s usual training locations. This is an important service thus far overlooked. While it is only possible to speculate on the causes of the gradient we observed, it may be due to market force and economic factors. Fitness trainers choose to work in areas in which they encounter clients who pay for their services. It may also be because facilities such as fitness centres and open space less prominent and of lower quality in the most disadvantaged areas limiting the locations where training could be undertaken. Further research is required to determine the reasons behind the observed socioeconomic patterning. Nonetheless, from a public health and social inequality perspective, a lack of fitness trainers currently working in the most disadvantage areas warrants attention.
Our finding that higher qualified fitness trainers were less likely to work in areas of greater disadvantage also deserves consideration. It is plausible that higher educated fitness trainers may charge higher fees for services which in turn affect their choice of location. Further research needs to determine whether a higher level qualification is related to better delivery of fitness services. However, trainers with university qualifications are educated on specific exercise treatment plans for managing and reducing the risk of many chronic illnesses including neurological and neuromuscular disorders, metabolic disorders, cardiopulmonary pathologies, specific musculoskeletal disorders and mental illnesses [
27]. Whilst the prevalence of many chronic disease higher in more disadvantaged areas [
17], further work is required to determine whether having higher qualified fitness trainers in disadvantaged areas would provide benefits to those communities.
Several approaches can be implemented to address the inequalities observed in this paper. First, government health departments may provide financial incentives for more and higher qualified fitness trainers to work in the most disadvantaged areas. Additionally, incentives such as subsidised access to fitness professionals could be provided to inactive individuals within disadvantaged areas. It would be useful to assess if subsided use of trainers in these areas encouraged more trainers to work in these location and encouraged inactive individuals to engage in exercise. Further, the building of fitness facilities for professionals to work from and that cater to people’s needs is important [
14]. Some may not feel comfortable in large community fitness centres, and may favour outdoor or small group settings or vice versa. Our results indicate group training may be more likely in disadvantaged areas (perhaps to share the cost amongst participants) and it is important to ensure these areas have adequate facilities to accommodate group training.
Engagement with fitness trainers and the fitness industry will not be suitable or desired by all individuals. However, given the substantial benefits associated with increasing physical activity levels among the least active [
30], the ‘downstream’ public health consequences of providing support to promote physical activity (e.g. reduction in the burden of chronic disease and improvements in quality of life) among populations from disadvantaged areas are likely to be considerable. The pioneering Finnish Diabetes Prevention Study is an example where fitness trainers were effectively utilised in community health promotion [
31]. The success of that comprehensive intervention in preventing diabetes among a ‘high-risk’ population was partly credited to the fact that participants were given with free access to community centres and fitness trainers who prescribed individualised exercise programs [
31].
Limitations and strengths
This study has several limitations. First when compared to the most recent demographic data on fitness trainers [
20,
24], we appear to have recruited greater proportions of female and older trainers (Additional file
1: Table S1). Therefore, there are restrictions on the generalisability of the findings. It is possible that male and younger trainers work in more disadvantaged areas, thus potentially leading to an overestimation of proportions working in less disadvantaged areas. It is also possible that fitness professionals may work in more than one setting. For practicality, we chose to have trainers report the postcode of setting in which they usually work. Future studies should include an option to report more than one postcode. Finally, we are not able to assess in this study the community benefits of having additional or more highly qualified fitness trainers working in an area. Despite these limitations, our study of the training location of fitness professional contributes to the body of evidence on factors that may be associated with inequalities in physical activity levels. We are not aware of a comparable study that has sampled such a large number of fitness trainers.
Acknowledgements
JAB wishes to thank Fitness Australia for part funding his research fellowship. All authors wish to thank staff at Fitness Australia for the invaluable support with recruiting fitness professionals for this study. We wish to thank all study participants for their contribution to this paper.