Physical activity (PA) is known to decrease the risk of developing long term chronic diseases such as cardiovascular disease. Inadequate PA has long been associated with disease-related mortality and increased healthcare costs. Recent estimates in the US reported about 10% of pre-mature deaths were associated with inadequate PA, and $117 billion in annual healthcare costs (1). The current recommendation of the American Heart Association (AHA) for adults is to perform at least 150 min of moderate PA or 75 min of vigorous PA per week to have an impact on long term health (2). However, the U.S. Department of Health and Human Services (HHS) estimated that more than 80% of adults do not currently meet such guidelines (3). In such, it is essential to understand the factors associated with meeting current US guidelines among US populations.

One of the commonly accepted factors for increasing PA participation among populations is having safe and accessible recreational parks around their community (4). While it is known that expansive park networks in neighborhood-built environments are positively associated with multiple aspects of health, well-being, and quality of life (4), populations' access and PA participation in such neighborhood parks is influenced by different variables such as individuals' ability, motivation to be physically active, and parks and leisure centers' proximity to their homes (5). For example, only adolescents living in neighborhoods with available recreational facilities have reported increased frequency and duration of performing PA (6). Insufficient numbers of parks and leisure centers have also been reported for US homes, with only one of five US homes having parks and leisure centers within half a mile radius (3). Nonetheless, reported association between increased PA levels and facility numbers within a neighborhood is inconclusive (7–11), showing either statistically positive (12), negative (7), or no significant association between the two variables (8, 9, 13). For example, Stewart et al., found no association between park's proximity and PA levels among an urban, mostly white, well-educated sample population that was well-served by neighborhood parks (9), though neither their socio-economic status nor their PA access was assessed. West et al., only focused on the largest American cities whilst reporting a positive correlation between park density and PA levels, which may not therefore be generalizable to smaller cities or rural areas (10). Whether and how PA participation is determined by facility access across US populations in large cities are largely unknown.

The objective of this study was to investigate whether access to free or low-cost recreational facilities was associated with meeting the AHA PA guidelines among US adults.

Table 1 presents the characteristics of the study participants of the 2017 FLASHE survey according to access to free or low-cost recreational facilities (n = 1,750). There was no statistically significant difference in the distribution of the age groups according to whether they had access to free or low-costs facilities or whether they did not (chi-square p-value 0.119). However, there was a statistically significantly higher proportion of men in those with access to free or low-cost facilities (30.6%) compared with those without access (19.4%; p-value < 0.001). In addition, participants' race/ethnicity, health status, BMI, education, work status and household income were statistically significantly different among those with access to free or low-cost recreational facilities compared with those without access (p-values < 0.05). For instance, those with access to recreational facilities had a higher proportion of being normal weight (39.3%) than those without access (31.5%). Moreover, those with access tend to have a higher perceived excellent or very good health compared with participants without access to free or low-cost recreational facilities (59.5 vs. 52.7%). Finally, 24% of the participants who had access to recreational facilities had a household income of at least 100,000 USD/year whereas the corresponding proportion was 15.1% in those without access (p-value < 0.001).

The unadjusted and adjusted associations between respondent characteristics and meeting AHA PA guidelines, which were stratified by access to free or low-cost recreational facilities are presented in Table 2. Before adjusting for covariates, participants who had access to free or low-cost recreational facilities had an odds ratio (OR) of meeting AHA PA guidelines of 1.63 (95% CI 1.33–1.99) when compared with participants who did not. After adjustment for the covariates, participants who had access to free or low-cost recreational facilities had statistically significantly higher odds of meeting the AHA PA guidelines compared with participants who disagreed with this statement [adjusted OR (aOR) 1.42; 95% CI 1.14–1.76]. The adjusted odds of meeting the AHA PA guidelines for the 35–44 age group was 0.77 (95% CI 0.54–1.11), for the age 45–59 age group 1.01 (95% CI 0.57–1.21) and for those ≥60 years-old 0.88 (95% CI 0.31–1.27) when compared with participants age 18–34 years-old. Participants who reported being male were 1.99 times more likely to meet the AHA PA guidelines compared with females (aOR 1.99; 95% CI 1.49–2.65). Being non-Hispanic white, Hispanic (aOR 1.31; 95% CI 0.83–2.07), non-Hispanic black (aOR 0.85; 95% CI 0.64–1.14) or other (aOR 0.8; 5 95% CI 0.54–1.35) was not associated with meeting AHA PA guidelines. Regarding health status, participants who reported excellent health status were 2.42 times more likely to meet the AHA PA guidelines (aOR 2.42; 95% CI 1.66–3.52), while those who reported very good health status were 1.47 times more likely to meet them (aOR 1.47; 95% CI 1.14–1.90) when compared with those with good health status. Furthermore, obese participants compared with those having a normal BMI had 39% reduced odds to meet PA guidelines (aOR: 0.61; 95% CI 0.46–0.80). Regarding education, having an educational level of high school or less, some college (aOR 1.09; 95% CI 0.81–1.47), or 4-year college degree (aOR 1.28; 95% CI 0.94–1.75) were all not associated with meeting the AHA PA guidelines. Household income status was not associated with increased or decreased likelihood of meeting the guidelines (aOR 1.32; 95% CI 0.98–1.79).

The main finding of the present study is that access to free or low-cost recreational facilities was positively associated with meeting the AHA PA guidelines in US adults. However, such association is also affected by sex, BMI, and health status, which were all associated with complying with the AHA PA guidelines. When controlling for covariates, males were twice likely to meet AHA PA guidelines compared with females, and participants with obesity were 39% less likely to meet AHA PA guidelines compared with those with normal BMI; while those with excellent health status were 2.42 times more likely to meet AHA PA guidelines when compared with those who reported a good health.

Our findings on subjective availability of outdoor recreational facilities and higher levels of total leisure-time PA are in line with previously reported associations. For example, in a survey in five European urban regions, Mackenbach et al. found a 25% difference in weekly min of total leisure-time PA between individuals with and without availability of outdoor recreational facilities. They postulated that the availability of these facilities seemed to be an important underlying mechanism for increased populations' PA, and the proximity was the main motivator for using recreational facilities (19). Several other reports have also showed that individuals who resided in neighborhoods with higher number of public parks and recreational facilities were more likely to be regularly physically active (7–11). One study described an increased amount of park-based PA in people with two parks within one mile (aOR 2.29) and three or more parks in one mile (OR 2.53) compared with those without any parks within one mile radius (8). West et al. reported that significant, positive correlations between park density and reported PA (r = 0.37, p < 0.01), and between park density and reported performing regular exercise (r = 0.35, p < 0.01) (10). While availability of public parks is now an established determinant in meeting PA guidelines, the scientific literature is inconsistent when analyzing an association between the proximity of public parks and PA levels. Kaczynski et al. reported that distance was not significantly associated with an increased likelihood of PA at the park (8, 13). Conversely, Cohen et al. reported that people living within one mile of the park averaged 38% more regular exercise sessions per week compared to those living further (IRR 1.38; 95% CI 1.04–1.84) and were four times as likely to visit the park once a week or more than those living further away (12). Therefore, reporting on the access to free and low-cost PA facilities and its positive association with meeting PA AHA guidelines in our study provides a new approach for increasing PA and associated long term health benefits in US populations.

Our study relied on a more subjective reporting when observing the association between access to free and low-cost recreational facilities and an increased likelihood of being physically active among US adults. An important distinction between the subjective (e.g., availability dependent on factors such as cost, safety, and hygiene) and objective availability (e.g., actual access or use) of recreational facilities has been previously reported with a significant association between the subjective availability of recreational facilities and leisure-time PA, however when the analysis was based on the objective availability (or reported use) of recreational facilities the association was not statistically significant (19). This may be due in part because individuals who report access to outdoor recreational facilities do so because they use them regularly—resulting in stronger associations with the perceived measure of PA levels (20).

The secondary outcomes of our analysis suggest that the healthier a person is the more likely they are to have met AHA PA guidelines (aOR = 2.42 and 1.47 for Excellent and Good Health, respectively), which was irrespective of the participants' age (Table 1). This may be explained by increased time spent exercising which has previously been associated with better health status (21). Therefore, increased time spent and awareness among those with perceived poor health is necessary when promoting PA access across US populations. Looking at BMI specifically, individuals with obesity were significantly less likely to meet the national PA guidelines which is contradictory to Lee et al.'s finding of obese individuals (BMI 25 and above) having no difference in level of PA when compared with individuals who are not obese (22). Our results most likely differ due to a difference in definition of obesity (over 25 BMI Asian cutoff point vs. over 30 BMI in US) but can also be explained by various reasons including lack of social support, lack of time, choosing a sedentary lifestyle, or lack of motivation to use PA facilities (23, 24). Studies that integrated similar BMI stratification such as Hemmingsson et al. found similar results to ours of a clear association between BMI and level of PA (25). Sex had the largest impact on the odds of meeting PA guidelines where men were twice at odds of meeting PA guidelines than women. This finding is in line with previous studies that describe increased PA in males compared to females (26). It has been proposed in past studies that societal influences are stronger on males than females regarding PA which can explain the increased likelihood of meeting guidelines for men (27).

Naturally, our study has some limitations. First, our cross-sectional study design lacks the ability to implement causality. While we can illustrate an association between two variables, we are unable to correlate the two due in part to the possibility of reverse causality. The study design also introduces the possibility of various types of bias. Our study measured PA by a self-reported questionnaire, which may over- or underestimate true PA behavior. Thus, there is potential for social acceptability biases. This may be illustrated in part by the larger than expected percentage of individuals that met requirements and the few impossible and few possible but improbable outcomes reported. Nevertheless, the PA questions in this study were validated against an objective PA accelerometer data (r = 0.52, p < 0.01) (28). Similarly, while this study makes an important distinction from past studies in that it reports people's access to free or low-cost facilities, we recognize that it is somewhat vague in its definition of accessibility. While it is important to recognize that there is an association between access and PA, there is no concrete quantitative data to be used by local governments to best implement new policies. A strength of this study was that it included a national sample from a large, regionally diverse sample of the U.S. population, although not nationally representative. The national sample allowed taking into consideration variation in environmental contexts, socio-demographics, and behaviors. For example, access to recreational facilities vary between most U.S. states. Therefore, using a national sample allows for more generalizable results than a study located in a specific city or state.

In conclusion, our data provides various recommendations that can be extrapolated for use by health professionals, public health officials and the public. We recommend increasing the availability of facilities such as parks, trails, fields, and courts in various neighborhoods, and to increase awareness of the availability of these facilities, perhaps via targeted social media, newspapers, magazines, and local television networks so that PA is promoted across wider populations especially females and those with poorer health conditions including those with obesity. Future studies could focus on improving access to free or low-cost recreational PA facilities by understanding individuals' barriers and facilitators to using such facilities and using more objective PA assessment approaches.

Publicly available datasets were analyzed in this study. This data can be found here: https://cancercontrol.cancer.gov/brp/hbrb/flashe-study.

LA, RG, MM, AA, and NB contributed to the conception and design of the study. GC and PR supervised data collection. LA, RG, and MM organized the dataset and wrote the first draft of the manuscript. LA, RG, MM, GC, and PR performed the statistical analysis. AA, GC, PR, and NB revised the manuscript. All authors contributed to manuscript revision, read and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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