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Stress, Fatigue, Health, and Risk of Road Traffic Accidents Among Professional Drivers: The Contribution of Physical Inactivity

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Strategies to achieve ambitious targets for reducing road accidents ( 34 ) have largely focused on engineering and technological advancements, the modification of occupational demands, and, to a lesser extent, human factors. These factors include stress and psychological states; sleep, fatigue, and alertness; and health status. Physical activity appears to influence all these human factors but has not previously been systematically considered as a direct or indirect risk factor for driver accidents. This chapter provides an overview, within an evidence-based framework, of the impact each of these human factors has on driver performance and risk of at-work road traffic accidents and then examines how physical (in)activity may moderate and mediate these relationships. Finally, we consider practical implications for work site interventions. The review aims to offer an evidence base for the deployment of resources to promote physical activity, manage stress, facilitate sleep, reduce fatigue, and enhance alertness to improve physical and psychological health among professional drivers.
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Annu. Rev. Public Health 2006. 27:2.1–2.21
doi: 10.1146/annurev.publhealth.27.021405.102117
Copyright
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2006 by Annual Reviews. All rights reserved
STRESS,FATIGUE,HEALTH, AND RISK OF ROAD
TRAFFIC A
CCIDENTS
AMONG PROFESSIONAL
D
RIVERS
: The Contribution of Physical Inactivity
Adrian H. Taylor
1
and Lisa Dorn
2
1
School of Sport and Health Sciences, University of Exeter, Exeter, EX1 2LU,
United Kingdom; email: a.h.taylor@exeter.ac.uk
2
Driving Research Group, Department of Human Factors, School of Engineering,
Cranfield University, Cranfield, Bedfordshire, MK43 0AL, United Kingdom;
email: l.dorn@cranfield.ac.uk
KeyWords driver, occupational health, exercise, health promotion, stress
management
Abstract Strategies to achieve ambitious targets for reducing road accidents (34)
have largely focused on engineering and technological advancements, the modifica-
tion of occupational demands, and, to a lesser extent, human factors. These factors
include stress and psychological states; sleep, fatigue, and alertness; and health status.
Physical activity appears to influence all these human factors but has not previously
been systematically considered as a direct or indirect risk factor for driver accidents.
This chapter provides an overview, within an evidence-based framework, of the impact
each of these human factors has on driver performance and risk of at-work road traffic
accidents and then examines how physical (in)activity may moderate and mediate these
relationships. Finally, we consider practical implications for work site interventions.
The review aims to offer an evidence base for the deployment of resources to promote
physical activity, manage stress, facilitate sleep, reduce fatigue, and enhance alertness
to improve physical and psychological health among professional drivers.
INTRODUCTION
Professional drivers make a significant contribution to road traffic accident statis-
tics (8, 50) at an extraordinary human and financial cost (49a). A number of studies
have shown that workers who drive as part of their occupation have a higher acci-
dent risk than does the general driving population, even when a greater exposure to
risk is factored out (8, 18, 77). An understanding of the antecedents of accidents, for
different kinds of organizations with different kinds of professional drivers, is es-
sential to designing effective interventions to reduce fatalities and serious injuries.
Indeed, both the United Kingdom and the United States have set national targets to
reduce accident involvement [40% reduction in the United Kingdom by 2010 (16);
0163-7525/06/0421-0001$20.00 2.1
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2.2 TAYLOR
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41% reduction in large truck fatalities from 1996 to 2008 in the United States (34)].
Efforts to do so have focused largely on in-situ driver-assisted technologies, drug
and alcohol testing, regulation of working conditions (e.g., length of shift), and
advice on prescribed and over-the-counter medication. A number of other factors,
including stress and emotions, fatigue, sleep deprivation, and health status, have
been independently linked to increased risk of at-work accidents. Although driver
stress and fatigue appear to be major contributors to at-work road traffic accidents
(11, 78), it is less clear which factors contribute to driver stress and fatigue.
Physical activity has been reported to effectively influence stress and psycho-
logical states, fatigue, sleep, and health status (17, 113), but less scholarly focus has
been given to the effects on work-place safety (102). In the driving context, only
one study (105) has reported a direct connection. Drivers engaging in more than
one weekly session of exercise had 0.78 accidents per driver, whereas less-active
drivers had 1.05 accidents over a two-year period. This was not, however, a main
element of the Dutch study of long-distance bus drivers, and there were inherent
limitations with the methods used (e.g., measure of physical activity). In contrast,
other studies have attempted to consider if heavy exercise causes commercial driver
accidents (86) as a result of fatigue. Clearly there is a need both to understand the
effects of exercise directly and indirectly on accident antecedents (e.g., stress,
fatigue, and health status) and also to develop and examine the effectiveness of
physical activity interventions on risk of driver accidents.
Definitions
It is first important to define the terms physical fitness, physical activity, and
exercise within the context of chronic and acute exercise (12).
1. Physical fitness is a set of attributes that people have or achieve that relates
to their ability to perform physical activity.
2. Physical activity is any bodily movement produced by skeletal muscles that
results in energy expenditure.
3. Exercise is planned, structured, and repetitive bodily movement purposefully
done to improve or maintain one or more components of physical fitness or
health.
Both the chronic and acute effects of physical activity (or exercise) have been ex-
amined. Chronic exercise involves regular participation over time (e.g., 10 weeks,
at least 3 days a week for 20 min at vigorous intensity at a level that would make
talking difficult, or at least 5 days a week for an accumulated 30 min at moderate
intensity, such as a single session or three brisk 10-min walks at a level that would
still permit talking). Acute exercise involves a single period of exercise.
In the present context, chronic exercise may enhance fitness and coping re-
sources and result in improvements in or reduce the risk of ill health. There is
reason to suppose that acute exercise may have short-term effects that have an
impact on driver behavior and cognitive performance (e.g., increased alertness).
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PHYSICAL ACTIVITY AND ROAD ACCIDENTS
2.3
Purpose
This review provides a framework (see Figure 1) founded on relevant literature pub-
lished in diverse areas of scientific inquiry, which will help guide future research,
synthesis, and interventions. Complex links clearly exist between stress, fatigue,
sleep, health status, and driver accident risk, but the purpose of the review is to
Figure 1 A framework for linking chronic and acute exercise to driver stress, fatigue,
health status, and performance.
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consider critically the possible impact of physical (in)activity on these relation-
ships as both a moderating (individual difference in response to chronic exercise)
and mediating [a temporary period of (in)activity] variable. Finally, we consider
the effectiveness of interventions to promote physical activity among professional
drivers.
STRESS, PSYCHOLOGICAL STATES, AND DRIVER
PERFORMANCE: EFFECTS OF (IN)ACTIVITY
Driving requires sustained attention in complex dynamic tasks and detection
of changes in the task environment to search for potential hazards. Perception
of hazards may be affected by driver stress, especially for professional drivers
who often have to adhere to strict schedules and timetables (21). Driver stress
results from a continual interaction of intrinsic and extrinsic factors, e.g., life
events and daily hassles (100) of driving moderated by a number of individual
differences.
Driver stress vulnerability relates to cognitive processes of appraisal and cop-
ing specified by transactional models of stress (76, 79). Demands may exceed
perceived capability or resources: Stress factors (and outcomes including fatigue)
were associated with performance impairments primarily in underload conditions
(78). The main intrinsic sources of professional driver stress vary according to
the type of vehicle being driven and the nature of the work. Among company
car drivers (18), heavy goods vehicle drivers (114, 117), and long-distance pub-
lic service vehicle drivers (69, 83, 98), time pressures (particularly on congested
roads) are a common factor, combined with long hours spent driving. In an in-
dustry with a shortage of skilled drivers, poor health status and a consequential
high absenteeism (121), and low profit margins, inevitably some employers may
place excessive demands on drivers. For example, in the operation of buses in
urban areas workload has high demands with little control over ability to make
decisions to help cope with the demands of the job (22, 42). Driving buses can also
be socially isolating and involve dealing with difficult passengers. It also requires
heightened alertness to deal with inconsiderate road users who may miscalculate
the operational capabilities of large vehicles and behave aggressively in response to
a slow-moving bus making frequent stops. Occupational stress can also spill over
into home life because of split schedules and rotating shifts. For other professional
driver groups, there may be different issues: For example, with emergency service
drivers, additional stress can arise from high-speed driving in pursuit of offend-
ers or to reach an accident scene (21). Although we may view the framework in
Figure 1 as causal, undoubtedly there are reciprocal and interacting relationships.
Forexample, an accident history, inadequate sleep and fatigue, poor health status,
and negative psychological states may all independently and in combination have
an impact on how occupational events are interpreted (i.e., perceived demands)
and on their associated perceived resources for coping.
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So how does driver stress affect the health and safety of the professional driver?
Greater traffic congestion and time pressures predicted aggression, irritability, frus-
tration, and negative mood (53). The acute and chronic nature of daily work strain
and driving events leads to heightened psycho-physiological responses (106, 114).
Drivers often experience symptoms of driver stress such as worry, irritation, and
anxiety. The cognitive interference model for adverse effects of stress has been for-
mulated from extensive research on test anxiety. The diversion of resources away
from the task resulting from interference becomes increasingly detrimental to per-
formance as task demands increase. Attentional overload can occur when resources
become inadequate for the total processing load imposed on the cognitive system.
Forexample, a high-anxiety condition during a simulated drive resulted in slower
and less accurate identification of peripheral lights and significant performance
decrements in central and peripheral tasks when compared with a low-anxiety
condition (60). However, this model neglects a person’s active attempts to cope
with stress-related demands through compensation and task-focused strategies.
Therefore stress-related impairment may be a function of failure to match effort
with workload rather than with resource insufficiency. The driver stress inventory
(DSI) (80) has been used to show that more severe stress reactions may disrupt
driver performance and reduce safety (23).
With repeated exposure to stressful driving contexts over the course of a journey,
fatigue symptoms may develop (73). Although driver fatigue has been conceptu-
alized as a consequence of circadian disruption and sleep deprivation (56) leading
to reduced alertness and impaired performance (4), driver stress has hiterto not
been linked with circadian disruption or sleep deprivation.
Driving for a sustained period can increase fatigue and alter cardiovascular
and neuroendocrine function (104). Ambulatory studies of professional drivers
have demonstrated cortical deactivation in response to continuous driving over
monotonous and repetitive environments (7). Therefore, arousal is important for
maintaining the vigilance and phasic alertness to stimuli required for safe driving.
Quantity and quality of sleep can inevitably be affected by overstimulation of
the neuro-endocrine system, as a compensatory coping mechanism for dealing
with driver-related fatigue, and compounded by overuse of legal stimulants (e.g.,
caffeine products). Psycho-physiological recovery from driving shifts has recently
been monitored (106) to investigate in situ responses to fatigue debt, but we know
little about how drivers use different coping strategies and whether exercise can be
used to influence chronobiological responses among drivers. However, a measure
of need for recovery as an indicator of the level of work-related fatigue among coach
drivers has been used to demonstrate that this variable can predict psychosomatic
complaints, sleep disorders, and occupational burnout (104).
Stress and Health Status
Stress-related disorders have been widely recognized: the Department of Health
in the United Kingdom estimated that 80 million working days are lost annually
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owing to anxiety and depression at a cost of £5.3 billion ($9.31 billion) (15).
In addition, health care expenditure for the treatment of anxiety and depression
has been estimated at more than £1 billion ($1.76 billion). Stress has been
linked with cancer, coronary heart disease/stroke, accidents, and poor mental health
(16, 108). The mechanisms have been considered both indirect, through effects of
stress on health behaviors such as diet (120) and smoking (61), and direct, through
biological changes including neuroendocrine changes and adaptations (1), devel-
opment of the metabolic syndrome and insulin resistance, disturbances of blood
coagulation, and disruption of immune responses (2, 10). Recent research has also
focused on psycho-physiological measures of recovery from work as an indicator
of effective coping (104), which mediates the link between a demanding work
environment and health status. Stress-induced fatigue may also increase the use of
caffeine, which in turn may disrupt coping and adversely affect sleep and health
status.
The role of personality in moderating the effects of stress on driver accidents
has received some attention (23), but little consideration has been given to the role
of an individual’s level of physical fitness and physical activity as an individual
difference factor.
Chronic and Acute Exercise, Stress, and Psychological States
Chronic and acute exercise may help to reduce stress and its psychological and
physical responses in a number of ways (84). First, from a cognitive perspective,
being more physically active may increase resilience, hardiness, physical self-
perceptions and self-concept (see 111), and perceived energy, and reduce fatigue;
these attributes influence how we initially cognitively appraise events that are
intrinsic and extrinsic to the occupation. Physical fitness, as a coping resource,
may also enable a more positive secondary appraisal of stressors (65). Engage-
ment in acute exercise can also provide a distraction away from rumination about
stressors, particularly if it involves social interaction with others. Second, from
a psycho-physiological perspective, improved aerobic capacity or ability to deal
with a physical stressor may attenuate our physical response to a psychological
stressor (stress reactivity). Attenuated physiological responses (e.g., heart rate,
blood pressure, etc.) to, and more rapid recovery from, stressors may leave peo-
ple feeling less fatigued and more able to cope with events that are intrinsic and
extrinsic to the occupation (48).
The past 30 years has resulted in a large volume of literature on physical activity
and stress and anxiety, including 29 reviews (74) and 57 (40) reviews, respectively.
Recently, an overview (109) was published of systematic qualitative (without meta-
analyses) reviews (articles and book chapters) and six quantitative (with meta-
analyses) reviews. In summary, the findings point to the following conclusions:
1. Chronic exercise can result in lower subjective (e.g., anxiety) and objective
(e.g., blood pressure) indicators of stress responses. When stressors are
presented, the evidence for absolute reductions in cardiovascular response
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to stress is more consistent than it is for reduced reactivity (or change) to
stressors.
2. Single sessions of moderate intensity exercise, particularly aerobic and
rhythmic in nature, can result in lower subjective (e.g., anxiety) and objec-
tive (e.g., blood pressure) indicators of stress responses. This evidence has
focused almost exclusively on changing anxiety and arousal under normal
rather than enhanced stressful conditions, when the effects may be even
greater.
3. A single session of moderate intensity exercise may reduce physiologi-
cal reactivity to a variety of mostly laboratory stressors (48) and enhance
recovery after the stressor. Further research is needed for driving-related
stressors.
Both chronic and acute exercise can improve subjective tension, depression,
and anger/hostility (3). Very vigorous exercise may reduce coping assets (e.g.,
lower feelings of control, self-confidence, elation, etc.) and increase coping deficits
(e.g., easily irritated, feeling run down and drained, feeling less calm, etc.) (87). In
contrast, moderate intensity exercise (e.g., at a level that enables continued talking)
may enhance coping assets, reduce coping deficits, and provide a sense of physical
well-being.
SLEEP, FATIGUE, ALERTNESS, AND DRIVER
PERFORMANCE: EFFECTS OF (IN)ACTIVITY
Driver fatigue has been identified as a major cause of serious accidents (14, 56, 81)
owing to reduced driving performance efficiency. Over a quarter of long distance
lorry drivers reported falling asleep at the wheel at some time during the previous
12 months of driving (81). However, fatigue-related accidents are complex, and
numerous factors have been proposed for the causes of fatigue and low alertness
implicated in increased driver risk. These causes include (a) stress and task de-
mands, (b) hours on task, (c) sleep deprivation and disorders, (d ) time of day and
circadian variation, and (e)effort investment and motivation.
Earlier we considered the role of stress as a cause of fatigue, but clearly other
causes exist and there is a need for further conceptual clarity. Driver stress and
fatigue are dependent on both driving-related and nondriving-related factors, often
in different ways. Many investigators prefer to discuss the multifactorial concomi-
tants of both driver stress and fatigue. For fatigue, there is a circadian variation in
adrenaline excretion, noradrenaline, performance, and fatigue ratings (36). Peak
of circadian variation for each of these variables was at a different time of day (37),
and adrenaline excretion was not significantly correlated with performance (36).
In terms of stress physiology and fatigue, this suggests that driver stress and fatigue
are conceptually distinct but related processes that both interact with chronobio-
logical changes.
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Professional driver fatigue may result from the occupational requirement of
driving for long hours, with progressive withdrawal of attention from the road and
traffic demands particularly in familiar environments (9) involving cognitive un-
derload rather than excessive information-processing demands. Some researchers
believe that prolonged driving in monotonous conditions should be characterized
as a demanding task that is associated with effort costs, even though working mem-
ory load and controlled information processing demands are low (115). However,
the contribution of time on task in the development of fatigue may be small in
comparison to time of day, poor sleep, and individual differences (e.g., the point at
which aversion to invest effort and stop driving because of subjective fatigue symp-
toms begins to develop) (90). Also, prolonged driving will not necessarily cause
serious problems if drivers can choose the speed and safety margins they prefer
and if they can stop driving if they so desire (9, 115). Yet with strict occupational
scheduling demands disrupting the adoption of safety margins in prolonged driv-
ing, detriments to central task components such as steering have been observed,
although performance in high-priority subtasks such as hazard avoidance remained
intact. Fatigued drivers can also maintain adequate performance and protect task
priorities (54) through compensatory strategies such as driving slower (if organi-
zational demands permit). The combination of being in a hurry (driver stress) and
prolonged driving may be particularly dangerous.
Chronic and Acute Exercise, Sleep, Fatigue, Alertness,
and Accident Risk
The potential role of exercise in reducing work-related fatigue (and accident risk)
is complex, and any brief discussion is in danger of oversimplifying the interre-
lationships. In the previous section on stress, a link between stress and psycho-
physiological response and sleep was suggested. Long-distance coach drivers who
did more than one session of exercise per week (to increase physical condition)
reported lower scores on their need-for-recovery scale (107), but the study did not
consider if chronic or acute exercise facilitated psycho-physiological indicators
of recovery or ability to sleep. In contrast, others (93) have attempted to deter-
mine if physical exertion (e.g., cargo loading) causes fatigue and reduced driver
alertness.
Two research questions of significance to driver safety research are
1. does chronic and acute exercise result in improved quality and quantity of
sleep? and
2. does chronic and acute exercise result in enhanced psychological states
such as vigor, alertness and activation, reduced fatigue, drowsiness, and
deactivation?
The five recent reviews highlighted in Table 1 largely draw the same conclusions
that chronic and acute exercise can influence quality and quantity of sleep. Also,
subjectively, people report that exercise is an important behavior for sleep hygiene.
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TABLE 1 Review papers on effects of chronic and acute exercise on sleep
Reference Type of paradigm Type of review Main results
(71) Acute and chronic Meta-analysis:
Acute—32 studies (828 ESs);
Chronic—12 studies (274 ESs)
Acute ex positive effects on 7 key sleep measures
(ES = 0.14–0.75).
Chronic exercise positive effects on 5 key sleep measures
(ES = 0.40–0.94).
Effects greater for females, less fit, older, and when exercise is
longer, aerobic, not late in evening.
(24) Acute Narrative Positive effect of exercise in
A.M. and of moderate intensity in P.M.
Sleep-disruptive effect of exercise if high intensity, long duration,
or unaccustomed.
(92) Cross-sectional;
acute; chronic; bed
rest
Mainly narrative and also
meta-analysis (with few details)
Consistency across epidemiological, acute, and chronic studies for
low-moderate effect of exercise but methodological limitations
(e.g., limited mainly to good sleepers).
(123) Acute Meta-analysis: 38 studies
(211 effects)
Moderate ES on 4 sleep measures (0.18–0.52). Effects greater for
longer exercise and not late in the day. ES limited by exclusive
focus on good sleepers.
(122) Cross-sectional,
acute and chronic
Systematic, narrative People believe that exercise is an important sleep-promoting
behavior.
Individuals who exercise regularly have a lower risk of disturbed
sleep.
Chronic exercise may elicit improvements in sleep in individuals
with disturbed sleep.
Acute exercise (particularly of longer duration) elicits modest
improvement in sleep among good sleepers. Fitness, exercise
intensity, or time of day have minimal moderating influence.
ES = effect size.
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The most recent review (122) highlights the complexity of exercise and sleep
research and the quest to identify moderating factors and mechanisms.
Studies involving often unreliable, self-reported measures of physical activity
and sleep are limited. However, in a recent relatively rigorous trial (67), investiga-
tors reported that 16 weeks of community-based exercise consisting of 67 males
and females between 50 and 76 years of age resulted in significant net improve-
ments per night in sleep duration (42 min) and sleep-onset latency (11.5 min).
Separating out the chronic and acute effects is challenging; these effects may have
resulted from an increase in dose of daily exercise due to training. Also, the small
sample sizes that typify the more rigorous studies do not allow full analysis for
moderating effects of variables such as dose of exercise (e.g., frequency, inten-
sity, duration), timing of exercise, and initial sleep status. One of the key issues
to address is not the acute effects of a single session of exercise in a day, which
is what most of the literature has considered, but what the effect of total daily
energy expenditure on sleep is (122). This is more difficult to assess, but the use
of accelerometers should advance the field. Those in sedentary occupations, such
as driving, may be particularly prone to sleep disorders unless they compensate
with regular exercise when not driving. Also, further understanding of the mecha-
nisms by which exercise influences sleep is needed to prescribe exercise for sleep
enhancement (122).
If inadequate sleep and stress (intrinsic and extrinsic to work-related driving)
can result in fatigue, drowsiness, and deactivation, can chronic and acute exercise
influence these psychological states? In a review of 20 studies (82) designed to
investigate the effects of chronic aerobic exercise, significant increases in vigor
[Effect Size (ES) = 0.40] and reductions in fatigue (ES =−0.27) were reported.
An extensive narrative review confirmed that less-active people report greater fa-
tigue, and chronic exercise results in greater levels of perceived vigor and alertness
and less fatigue (3).
There is a general perception that acute exercise will induce fatigue and physical
exhaustion, which may be detrimental to driver performance, rather than increase
activation and alertness (see 93). As a result, individuals may seek to regulate
psychological states (e.g., fatigue) by avoiding exercise in favor of stimulants such
as sugar snacks and caffeine. An accumulation of inactivity would result in further
deconditioning and reduced energy. It is therefore critical to consider, within a
conceptually clear framework, the actual relationship between acute exercise and
these psychological states (27, 28).
Laboratory-based studies suggest that moderate- to high-intensity (vigorous)
acute exercise can lead to increased levels of fatigue and exhaustion in the later
parts of an exercise session, and it takes some time (depending on the length of
exercise and an individual’s fitness level) before these feelings return to normal. In
contrast, feelings of revitalization occur during and after low-moderate intensity
exercise and last some time (depending on the length of exercise) (26).
Fairly rigorous field-based studies (e.g., involving pagers and other sampling
methods) have shown that low-moderate intensity exercise (e.g., walking) results
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in significantly higher levels of revitalization, with the effects lasting throughout
the day, hours after the exercise bout occurred (38, 39). Indeed, 10-min walks were
associated with increases in self-rated energy lasting for 2 h, whereas a sugar snack
condition was associated with significantly higher energy and reduced tiredness
for 1 h, followed1hlater by increased tiredness and reduced energy (112). In
another study that involved walking (in both laboratory and natural settings) (25),
the circumplex model (99) was used to investigate the effects of exercise on valence
and arousal. Across 4 experimental studies, the results consistently showed that
short (10–15-min) bouts of walking was associated with increased activation (and
a state of calmness and relaxation).
A study to compare exercise and behavior typically used by drivers for mood
regulation (i.e., sugar snacking) has been conducted (112). However, further re-
search is needed to understand the effects of brief periods of moderate inten-
sity exercise in comparison with other popular stimulants used by drivers. For
example, another study showed that coach drivers consumed an average of
12 cups of caffeine per day on long-distance trips and, perhaps not surprisingly,
also showed signs of sleep disturbance, unwanted daytime sleepiness, and ele-
vated stress hormones to compensate for fatigue debt (106). Exercise may com-
pare favorably with a progressive increasing use of such stimulants to reduce
fatigue.
Other research has used performance measures, such as reaction time, visual
tracking, and other cognitive tasks, as indicators of fatigue and alertness. In a
unique study involving haulage drivers (reference 34 cited in 93), investigators
reported that after 90 min of manual lifting and moving boxes, instead of causing a
detrimental effect on performance as hypothesized, there was an initial invigorating
positive effect on vigilance and response time to likely simulated crash situations.
The effect faded with time. Following an afternoon manual loading/unloading
session, performance deteriorated discernibly but returned to baseline near the
end of the day. This suggests that exercise may have different effects at different
times of the day within a circadian cycle. The daily manual tasks (morning and
afternoon) took place within a daily schedule of 14 h on/10 h off (with 12 h of
driving), with a weekend rest/recovery period of 58 h between successive weeks
following the study protocol. The researchers reported that following the manual
routine, the drivers tended to sleep longer on the first night of the weekend. The
study should be replicated with more careful monitoring of exercise intensity
by using heart rate monitors and fitness measures to determine relative physical
workload.
Finally, aging research on the protective role of exercise on cognitive decline
and impairment is rapidly gaining momentum (6, 31, 44, 75, 97). The transfer
of evidence to the context of driving would be speculative at present, but several
plausible mechanisms may explain how inactivity results in cognitive impairment:
Exercise may improve cerebral blood flow and neuronal growth and positively
affect other risk factors for cognitive decline such as stress hormones, lipids, insulin
levels, and immune function.
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HEALTH STATUS AND DRIVER PERFORMANCE:
EFFECTS OF (IN)ACTIVITY
Health status has an impact on the safety of drivers (46). More than 300 fatal two-
vehicle trailer-truck accidents were investigated in one study (47). The probability
of being principally responsible for an accident increased by a factor of 3.5 if the
driver had a chronic illness. One study (62) reported that drivers with cardiovascular
disease were twice as likely to have an accident and be at fault than were healthy
drivers. In other studies, diabetic heavy goods vehicle (HGV) drivers were more
likely to have an accident than were nondiabetic HGV drivers (19, 72). Chronic
medical conditions have also been associated with increased accident involvement
among older drivers (52). There is no research on the effects of depression on
driver risk, although recent evidence suggests that depression influences cognitive
functioning (i.e., attentional processes) (32).
Further work is needed to understand how physical and mental health statuses
influence risk of driver accidents. In a cohort study of 10,525 New Zealand men and
women, obese drivers were twice as likely to have an accident (120a), although in
considering the public health impact of obesity, these effects have typically not been
considered (e.g., 13, 116). Much has been written about sleep apnea syndrome and
driver safety, and a reduction in obesity, through lifestyle management (including
physical activity), could reduce the problem (91). Another possibility may be
through pharmacological mechanisms that impair driver alertness and information
processing. There is also the potential for unwanted sleepiness in drivers using
certain over-the-counter medicines such as antihistamines, opioid analgesics, and
muscarinic antagonists (55), but little is known about the effects of physical activity
on pharmokinetics (66).
Finally, in the United Kingdom, a figure of more than 18 million days of sickness
absence is attributable to obesity and its consequences. The National Audit Office
(89) has estimated that obesity-related costs are £135 million ($237 million)
for hypertension, £127 million ($223 million) for coronary heart disease, and
£124 million ($218 million) for Type 2 diabetes. Diabetic employees are likely
to use 32 days per year of sickness absence, whereas nondiabetic employees used
17 days (103). We are not aware of any attempt to estimate the implications of
absenteeism (or indeed premature retirement due to ill health) on occupational
stress (resulting from greater work demands placed on those remaining at work);
this probably has significant consequences for driver safety in the transport industry
where there is often a shortage of skilled workers.
Chronic and Acute Exercise, Health Status, and Accident Risk
More than 50 years ago, it was first reported that less-active London bus drivers
had a higher risk of coronary heart disease (CHD) than did more-active bus con-
ductors (85, 94). It is now clear that regular physical activity is beneficial for many
dimensions of health, well-being, and quality of life, with a particular concern for
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2.13
physical inactivity and obesity (17, 113). Inactive and less-fit people, compared
with physically active and more-fit people, are almost twice as likely to die from
cardiovascular disease (5). From a public health perspective, the greatest protec-
tive effects are likely to be seen from an increase in physical activity among the
least active and least fit. Physical activity at an intensity of 4–6 METS (1 unit of
metabolic energy expenditure is equivalent to sleeping) (equivalent to brisk walk-
ing) is adequate for reducing the risk of CHD (88) and stroke (119). This can be
achieved from an accumulation of short sessions (i.e., 3 × 10 min per day) on
most days of the week.
Physical inactivity is a major risk factor for the development of Type 2 diabetes
(64). Regular walking and cycling is sufficient to reduce the risk for Type 2 dia-
betes (59, 119) with each increment of 500 kcal in weekly energy expenditure (e.g.,
90 min of brisk walking) associated with a 6% decrease in the age-adjusted risk (up
to 3500 kcal/week
1
). The number of hours of inactivity, such as television watch-
ing (independent of exercise), is strongly associated with risk of diabetes (58).
This finding places those in sedentary occupations such as driving at considerably
greater risk. Indeed, physical activity may be a more important contributor to Type 2
diabetes prevention than dietary change alone, but both are important.
Chronic low back pain (CLBP) is a major reason for absenteeism. Inactivity,
particularly with poor posture (96), is a major risk factor for the development of
CLBP, and chronic exercise (involving flexibility, strengthening, endurance, and
core stability activities) appears to have a protective effect (118).
In summary, physical inactivity has become so endemic in industrialized coun-
tries, and particularly among certain occupational groups such as professional
drivers (49, 70), that the overall population attributable risk for CHD in particular
(and possible other conditions) is greater than any other lifestyle risk factor. The
contribution of physical inactivity on driver health status as an important risk factor
for accidents has not previously been considered in the literature (13).
IMPLICATIONS FOR INTERVENTIONS
Increasing physical activity may be particularly challenging among professional
drivers owing to variable shift work, demanding occupational schedules and stress-
induced fatigue, lethargy from being sedentary, and a social culture that often rein-
forces physical inactivity (35). Physical activity interventions, aimed at changing
predisposing factors (e.g., attitudes, beliefs, and values), reinforcing factors (e.g.,
attitudes of line managers, union representatives, and occupational health workers),
and enabling factors (e.g., opportunities to cycle, leave bikes and shower at work,
use an exercise facility while traveling, have flexible shifts to facilitate more phys-
ical activity, and provide financial incentives for more active lifestyles) (41, 110),
can be effective (63). Yet there has been a conspicuous absence of interest in the
role of exercise in work place health and accident risk among professional drivers
(20, 43, 101).
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In a Swedish study, counseling by physicians led to significant increases in phys-
ical activity after 6 months among 69 professional drivers (29, 30). The drivers
ranked exercise first among several lifestyle changes as a way in which they could
influence their own well-being (51). Both a health profile assessment (including in-
dividualized counseling) and a health examination were associated with increases
in aerobic fitness and physical activity and a reduction in total cholesterol and per-
ceived stress up to the 18-month follow-up. Availability of variable working hours
was the most common obstacle to changing a health habit. Finally, a review of 13
studies was conducted that involved stress prevention interventions for bus drivers
(68). Physical activity was identified as a major component (within a multifaceted
intervention) in only two studies, both involving bus drivers. Fitness training and
an informational course, respectively, appeared to reduce absenteeism, but it is im-
possible to apportion effects to any specific component of the intervention. Driver
wellness programs are emerging for both small and large companies (33), and the
systematic evidence reviewed here can help underpin their scope and implemen-
tation. Certainly, drivers have identified physical inactivity, weight, fatigue, poor
diet, and stress as priority concerns.
CONCLUSIONS
In conclusion, there are several ways in which increased physical activity may
improve driving performance and potentially reduce accident risk. These include
effects on the following: stress and psychological and physiological responses;
enhanced sleep and alertness, reduced fatigue, and improved cognitive functioning;
and enhanced psychological and physical health status. There is sufficient global
evidence that professional drivers are less active than is the general population. To
test the beneficial effects of physical exercise, research is needed at four levels:
1. Epidemiological studies are needed to identify relationships between phys-
ical activity levels and driver stress, fatigue, sleep, health status, and ac-
cidents among specific subgroups of professional drivers (e.g., local bus
drivers, long-distance coach drivers, HGV drivers, company car drivers,
etc.). An economic evaluation of the potential financial implications of
physical (in)activity among specific professional drivers would follow.
2. Intervention studies are needed to examine the effects of chronic exercise
on driver performance in natural and controlled settings (e.g., using driving
simulators), particularly for drivers who report high stress, poor sleep, and
poor health status.
3. Studies are needed that examine the acute effects of exercise (in different
doses, intensity, and duration, but particularly behaviours such as walking,
which are convenient and likely to be adopted) on simulated driving per-
formance, particularly among drivers who report high stress, poor sleep,
and poor health status.
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4. There is a need for research that examines the effectiveness of driver work
site interventions (to promote physical activity) to determine how best to
promote physical activity to groups of professional drivers through multi-
level interventions (at the organizational structure, work site environments,
and individual levels).
ACKNOWLEDGMENTS
The authors thank the U.K. government’s Department for Transport (Road Safety
Division) for their support of this work. Project title: The potential of physical
exercise to reduce driver stress and fatigue (S301H).
The Annual Review of Public Health is online at
http://publhealth.annualreviews.org
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... Existe acuerdo en que la fatiga afecta seriamente la tarea de conducción, y que la merma en el desempeño del conductor se manifiesta en un mayor riesgo de accidentes y violaciones de normas viales -especialmente en conductores profesionales- (Shams et al., 2011;Firestone & Gander, 2010, Taylor & Dorn, 2006, Amundsen & Sagberg, 2003, Dalziel & Job, 1997 y violaciones de tránsito (Zhang et al., 2013). Existe evidencia de que la fatiga disminuye los niveles de alerta y vigilancia del conductor, alterando parámetros psicofisiológicos que son relevantes para la actividad de conducir (Lal & Craig, 2001, Taylor & Dorn, 2006, Williamson, 2011, y que reduce la capacidad de procesar la información del entorno vial y de responder frente a las situaciones dinámicas del tránsito ( Van der Linden et al., 2003). ...
... Existe acuerdo en que la fatiga afecta seriamente la tarea de conducción, y que la merma en el desempeño del conductor se manifiesta en un mayor riesgo de accidentes y violaciones de normas viales -especialmente en conductores profesionales- (Shams et al., 2011;Firestone & Gander, 2010, Taylor & Dorn, 2006, Amundsen & Sagberg, 2003, Dalziel & Job, 1997 y violaciones de tránsito (Zhang et al., 2013). Existe evidencia de que la fatiga disminuye los niveles de alerta y vigilancia del conductor, alterando parámetros psicofisiológicos que son relevantes para la actividad de conducir (Lal & Craig, 2001, Taylor & Dorn, 2006, Williamson, 2011, y que reduce la capacidad de procesar la información del entorno vial y de responder frente a las situaciones dinámicas del tránsito ( Van der Linden et al., 2003). Además, tiene consecuencias a nivel motivacional y emocional, afectando los niveles aceptados de riesgo y produciendo estados afectivos adversos. ...
... Asimismo, los choferes de taxi/remise obtuvieron puntuaciones más altas en una escala de severidad de la fatiga, indicando un mayor nivel de interferencia en su vida personal. Este resultado está en línea con estudios previos del grupo y con la literatura sobre el tema que indican que la ocupación tiene un fuerte impacto sobre la vida personal y familiar, debido entre otras cosas a la falta de tiempo de libre y descansos adecuados(Taylor & Dorn, 2006).Estos problemas vinculados a la organización del trabajo -tales como la excesiva carga de trabajo y los tiempos reducidos de descanso-generan fatiga y problemas de sueño(Lam, 2004).La fatiga suele ser resultante de aspectos relacionados con el estilo de vida y a su vez con presiones vinculadas a la actividad laboral(ERSO, 2006). En relación a esta última, se pueden mencionar las posibilidades de tener un sueño reparador, el tiempo total de trabajo y el tiempo dedicado a conducir. ...
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... Due to varying operational demands and working environments in the industry, some of the work stressors can be assumed to be rather commonplace, whereas others may apply only to specific groups (Useche et al., 2018). To better understand the complex aetiology of stress in terms of different negative outcomes, previous work has concentrated on professional drivers' perceptions of what makes them stressed at work (Murphy, 1996;Taylor and Dorn, 2006). Reported work stressors among professional drivers include time pressure, adverse driving conditions, and traffic (Crizzle et al., 2017;Filtness et al., 2019;Hege et al., 2019;Shattell et al., 2010;Tse et al., 2006). ...
... Future research should include objective as well as subjective measurements of work stress and aim to quantify the duration of and exposure to the stressors. Considering the effect of the work shift schedule, or examining the coping strategies (Hennessy and Wiesenthal, 1997), crash history (Hill and Boyle, 2007), chronotype (Langford and Glendon, 2002;Manfredini et al., 2017), level of physical activity (Föhr et al., 2017;Taylor and Dorn, 2006), or other moderating individual factors would also be beneficial. The role of passengers as a cause of stress deserves further investigation. ...
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Work stress may compromise professional drivers' health and driving capacity. Differences between driver groups in terms of on-duty stress are understudied. Therefore, we examined self-reported stress (Stockholm University Stress Scale) of shift-working tram and long-haul truck drivers (n = 75) across 2-3 weeks. Furthermore , stressors were self-reported retrospectively and categorised as related to the job, driving conditions, personal, or other causes. Stress levels were generally low, but moderate to high stress (≥6) was more frequently reported among the tram drivers. Stressors related to the job (54%) and driving conditions (19% of all shifts) were frequently reported among the tram and truck drivers, respectively. Moderate to high stress was associated with categorised stressors related to the job and other causes among the tram drivers, and all categorised stressors among the truck drivers. Altogether, self-reported stress and stressors differ by driver group, but the role of shift type is less significant.
... Several studies have identified road accidents as a global problem due to the number of deaths and injured individuals resulting from this phenomenon. In addition, it is also worrisome that for many years increased road congestion has been detected in many cities of the world (Kurzhanskiy & Varaiya, 2015), via the expansion in the vehicle fleet and an increase in driving times, with consequent health risks (Tse, Flin, & Mearns, 2006;Taylor & Dorn, 2006;Liu, Ettema, & Helbich, 2022). ...
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The aim of this investigation is to show the relationships between the use of Mobile Driving Applications and Devices (mdad) with self-reported road accidents, anger, physical health, and subjective wellbeing, in three types of Colombian drivers. The sample is non-randomized (n = 1149) and 93.2% are male drivers. Results showed that (a) for professional drivers, there is an inverse correlation between the use of mdad with lower driving frequency during weekdays and a higher educational level, (b) for occasional drivers, gps use was directly associated with fatal road accidents and low driving frequency during weekdays, (c) for private drivers, correlations were found between mdad broader usage, higher levels of both aggression and perceived driving difficulty as well as physical health problems mainly hypertension and diabetes. It is necessary to conduct in-depth research on mdad uses, health, and driving styles, by controlling social desirability.
... Environmental factors include a monotonous road surface, traffic flow and unchanging road conditions, and time of the day (Farahmand & Boroujerdian, 2018;Larue, Rakotonirainy, & Pettitt, 2011). Physical features that can enhance drowsiness include age and sex, a lack of physical fitness, or the presence of an injury or illness (Alonso, Esteban, Useche, & Serge, 2017;Claret et al., 2003;Deery, 1999;Herman et al., 2014;Taylor & Dorn, 2006). Psychophysiological factors that can have a large influence on alertness and attention include emotional stress, anxiety, depression, use of anti-doze stimulation (gum, coffee, naps), and the use of medications or drugs (Aidman et al., 2018;Behnood & Mannering, 2017;Lal & Craig, 2001;Tse, Flin, & Mearns, 2006). ...
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Introduction: Whole-body vibration has direct impacts on driver vigilance by increasing physical and cognitive stress on the driver, which leads to drowsiness, fatigue and road traffic accidents. Although sleep deprivation, sleep apnoea and alcohol consumption can also lead to driver drowsiness, exposure to steady vibration is the factor most readily controlled by changes to vehicle design, yet it has received comparatively less attention. Methods: This review investigated interrelationships between the various components of whole-body vibration and the physiological and cognitive parameters that lead to driver drowsiness, as well as the effects of vibration parameters (frequency, amplitude, waveform and duration). Vibrations transmitted to the driver body from the vehicle floor and/or seat have been considered for this review, whereas hand-arm vibration, shocks, acute or transient vibration were excluded from consideration. Results: Drowsiness is affected by interactions between the frequency, amplitude, waveform and duration of the vibration. Under optimal conditions, whole-body vibration can induce significant drowsiness within 30 min. Low frequency whole-body vibrations, particularly vibrations of 4–10 Hz, are most effective at inducing drowsiness. This review notes some limitations of current studies and suggests directions for future research. Conclusions: This review demonstrated a strong causal link exists between whole-body vibration and driver drowsiness. Since driver drowsiness has been established to be a significant contributor to motor vehicle accidents, research is needed to identify ways to minimise the components of whole-body vibration that contribute to drowsiness, as well as devising more effective ways to counteract drowsiness. Practical Applications: By raising awareness of the vibrational factors that contribute to drowsiness, manufacturers will be prompted to design vehicles that reduce the influence of these factors.
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The causes of traffic accidents include sudden cardiovascular disease events of drivers that go undetected in routine physical examinations of their health. While increased attention has been paid to proactive driver management by the frequent monitoring of drivers’ mental and physical condition to avoid such events, very few studies have examined the deeper risk factors that influence the cardiovascular health of bus drivers represented by workload and scheduling. To fill this knowledge gap, this study adopts a data mining approach to exploring the factors influencing the cardiovascular health of intercity bus drivers using their daily cardiovascular measurement data along with their schedules and routine physical examination results. Ten influencing factors were identified, including medical history, late-night habits and afternoon and evening driving schedules. The present findings will be useful for preventing accidents where cardiovascular disease is involved, which in turn will help improve transit safety.
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Book
The book presents the state of the art of the Internet of Things (IoT), applied to Human-Centered Design (HCD) projects addressed to ageing users, from the perspective of health, care and well-being. The current focus on the ageing population is opening up new opportunities for the development of niche solutions aimed at the niche category of older users who are beginning to experience physical and cognitive decline but are still independent and need to maintain their autonomy for as long as possible. The combination between the needs expressed by older users and the opportunities offered by the recent innovative technologies related to the Internet of Things allows research institutions, stakeholders, and academia to target and design new solutions for older users, safeguarding their well-being, health, and care, improving their quality of life. This book discusses and analyses the most recent services, products, systems and environments specifically conceived for older users, in order to enhance health, care, well-being and improve their quality of life. This approach is coherent with the percept of AAL or enhanced living environment, looking to the users’ comfort, autonomy, engagement and healthcare. The book describes and analyses aspects of HCD with older users looking to the emerging technologies, products, services, and environments analysed in their actual application in different areas, always concerning the design for the elderly related to the IoT, just as the development of biomonitoring devices, tools for activity recognition and simulation, creation of smart living environments, solutions for their autonomy, assistance and engagement enhancing health, care and wellbeing. The book is intended for researchers, designers, engineers, and practitioners in healthcare to connect academia, stakeholders, and research institutions to foster education, research and innovation.
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Train drivers work long hours on 24 h schedules and many factors impact their fatigue risk at work, creating a clear imperative for good rostering practice. Adopting a systems approach, this study investigated the relationship between multiple interrelated factors (train drivers’ schedule, sleep, wellbeing, and fatigue) and the perceived influence of these factors on train driving performance and safety using an online survey distributed in Australia and New Zealand. In addition to demographics and work schedule, passenger and freight train drivers ( n = 751) answered questions about: (1) Sleep duration; (2) wellbeing, including physical and mental health, the extent to which shiftwork causes sleep, social, domestic, and work problems, and (3) the extent to which ten fatigue, health and wellbeing factors in the work and home environment negatively impact their driving performance. The key factor that emerged from analyses, with the largest and most consistent negative effects (and controlling for other factors) was schedule irregularity. Approved rosters were ranked as having the most important impact on day-to-day driving performance, followed by physical and mental health, and outside work factors. Results also suggested that schedule irregularity may amplify the negative impacts of the roster, impaired physical and mental health, and outside work factors on driving performance. As shift variability and schedule irregularity are often poorly represented in existing industry guidance, these results provide evidence for increased reflection on current fatigue management guidelines for train drivers and suggest a need for greater focus on schedule irregularity through the lens of a systems approach.
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80 subjects high and low in vulnerability to driver stress participated in a study of simulated driving performance. Subjects completed the Driving Behaviour Inventory, which assesses vulnerability through a Dislike of Driving scale. Half the subjects performed in a ‘stress’ condition, in which they frequently lost control of vehicle steering, the remainder in a non-stressful control condition. Two performance measures were analyzed: response time (RT) on a secondary attentional task, and a measure of lateral tracking. The stress manipulation was more strongly related to longer RTs in high Dislike of Driving subjects than in low Dislike subjects. However, slowing of response was more pronounced on straight than on curved road sections, i.e. when the driving task is relatively undemanding. This finding suggests that stress-related impairment is not simply due to overload of attention. Instead, the stress-vulnerable driver may have difficulties in matching effort to task demands, with under-mobilisation of effort when the task appears relatively easy. Lateral tracking data were also consistent with this hypothesis. Self-report data suggested that the manipulation was generally effective in inducing subjective stress symptoms. However, high Dislike subjects tended to react to the manipulation with particularly high levels of intrusive thoughts and ‘cognitive interference’.
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One of the assumptions underlying recent physical activity recommendations is that lower doses of activity (i.e. intensity and duration) are more enjoyable for the average person, thus leading to higher involvement and adherence rates. However, the veracity of this hypothesis can be questioned, since little is actually known regarding the association between activity doses and affective responses. The few preliminary attempts at the conceptual delineation of the dose-response relationship, all centred around an ‘inverted-U’notion, are reviewed and criticised as lacking empirical foundation. Available meta-analyses, as well as the empirical literature on the role of exercise intensity and duration, are examined. Increased intensity appears to be associated with reduced positivity of affect during and immediately following an exercise bout. Intensity effects appear to be attenuated during recovery. Fitness and training status appear to become significant mediators of the exercise-affect relationship only at high intensities. With intensity being kept constant, different exercise bout durations have not been shown to have a differential impact on pre- to post-exercise affective changes. Recommendations for future research include: (i) a shift from categorical to dimensional conceptualisations and operationalisations of affect; (ii) the examination of psychological theories on the association between activation and affect (e.g. extraversion-introversion, sensation seeking, type A behaviour pattern and related self-evaluative tendencies, reversal theory, optimal stimulation theory, multidimensional activation theory and self-efficacy); (iii) the systematic and theory-based examination of in-task and post-exercise affective responses; (iv) the incorporation of the parameter of fitness and/or activity status in research designs; and (v) the re-evaluation of methods for selecting exercise intensity levels.
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Numerous provocative studies on the psychological effects of aerobic fitness training are available today, and more are appearing almost on a daily basis. This book reviews and evaluates the research, and it asks and attempts to answer significant background questions: What are the various motivating factors that have contributed to the emergence of the national fitness movement? What are the public health considerations con- cerning the relationship between physical fitness and coronary heart disease? What exactly do we mean by "physical fitness," especially "aerobic" fitness? This book contains essential, in-depth data for everyone interested in the most solid and reliable information on the psychology of aerobic fitness.
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Physical activity (PA) is healthy, and it offers a practical and safe means to decrease substantially the burden of diseases. However, due to lack of sufficient PA in most populations, this potential is in partial use only. The health care system should support the patients and the population at large to increase their PA to sufficient level for health. The largest and most sustainable increase in PA would be gained by developing and implementing wide-ranging health promotion policies adapted to PA. However, currently the health care system and the primary health care (PHC) provide mainly individual services, e.g. counseling on PA. Even these services are not, however, used widely by the PHC due partly to attitudes but mainly to practical obstacles. PA counseling can be incorporated in the routine work of the PHC, and there are feasible means to improve the quality and increase the use of PA counseling. However, in order to get PA promotion services offered widely by the PHC, two fundamental changes are needed. First, PA and especially systematic exercise training should be considered as a means belonging to the repertoire of PHC, comparable to pharmaceuticals. The Exercise is Medicine ™Initiative is working towards this goal. Second, the leading medical experts as well as the major scientific and professional organizations within the health sector should accept PA as an inherent and effective means to further their goals.
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Objective: To encourage increased participation in physical activity among Americans of all ages by issuing a public health recommendation on the types and amounts of physical activity needed for health promotion and disease prevention. Participants: A planning committee of five scientists was established by the Centers for Disease Control and Prevention and the American College of Sports Medicine to organize a workshop. This committee selected 15 other workshop discussants on the basis of their research expertise in issues related to the health implications of physical activity. Several relevant professional or scientific organizations and federal agencies also were represented. Evidence: The panel of experts reviewed the pertinent physiological, epidemiologic, and clinical evidence, including primary research articles and recent review articles. Consensus process: Major issues related to physical activity and health were outlined, and selected members of the expert panel drafted sections of the paper from this outline. A draft manuscript was prepared by the planning committee and circulated to the full panel in advance of the 2-day workshop. During the workshop, each section of the manuscript was reviewed by the expert panel. Primary attention was given to achieving group consensus concerning the recommended types and amounts of physical activity. A concise "public health message" was developed to express the recommendations of the panel. During the ensuing months, the consensus statement was further reviewed and revised and was formally endorsed by both the Centers for Disease Control and Prevention and the American College of Sports Medicine. Conclusion: Every US adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week.
Article
Nearly 200 studies have examined the impact that either acute or long-term exercise has upon cognition. Subsets of these studies have been reviewed using the traditional narrative method, and the common conclusion has been that the results are mixed. Therefore, a more comprehensive review is needed that includes all available studies and that provides a more objective and reproducible review process. Thus, a meta-analytic review was conducted that included all relevant studies with sufficient information for the calculation of effect size (W = 134). The overall effect size was 0.25, suggesting that exercise has a small positive effect on cognition. Examination of the moderator variables indicated that characteristics related to the exercise paradigm, the participants, the cognitive tests, and the quality of the study influence effect size. However, the most important finding was that as experimental rigor decreased, effect size increased. Therefore, more studies need to be conducted that emphasize experimental rigor.
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