Exercise is medicine: critical considerations in the qualitative research landscape

Abstract

Since the American Medical Association and the American College of Sports Medicine partnered to launch Exercise is Medicine® (EIM) in 2007, the program has gained traction in 43 countries. The EIM discourse has been fruitful for framing exercise/physical activity as a form of disease prevention and/or symptom management for chronic conditions and mental health. This editorial ‘sets the stage’ for the articles within the special issue that coalesce a critical inquiry dialogue on EIM, by outlining taken for granted assumptions inherent in EIM. Assumptions include that people’s inactivity (and poor health) necessitates quick/planned intervention, exercise is positive/good for everyone and that the connection of exercise to medicine enhances credibility. Assumptions are problematized through grounding them in a neoliberal discourse of healthism, which emphasizes individual responsibility and/or experts as gatekeepers and facilitators of risk management through exercise. Three challenges to each of the assumptions are offered to explore EIM as socially, culturally and politically constructed, expanding the critical EIM dialogue. An overview of each of the articles within the special issue is then outlined to show ‘examples in use’ of critical theories and methodologies grounded broadly in interpretivist forms of inquiry and social constructionism. We conclude with noting the impetus and goal of this special issue--to spark further interest, dialogue and critical qualitative research on EIM –bringing forward the personal, socio-cultural, political iterations and potential of EIM.

Exercise is Medicine® (EIM), an initiative formed by a partnership between the American Medical Association and the American College of Sports Medicine (Sallis 2009), was launched in 2007. Since that time, there has been widespread interest and adoption of the brand, across many health jurisdictional settings in 43 countries, speaking to the local and global reach of this initiative (Neville 2013). Importantly, EIM has become a highly influential and powerful perspective and practice orientation in the disciplines of kinesiology, public health and behavioural medicine. On the surface, the EIM brand appeals to those who advocate for exercise/physical activity as a form of disease prevention and/or symptom management for chronic conditions (e.g. hypertension) and mental health (e.g. depression, anxiety). Messages such as ‘exercise is as effective as medications for the treatment of mild depression’, or ‘exercise has many health enhancing effects without the negative side-effects of medications’, promote the idea that intentional use of exercise is therapeutic for all and may even be preferable to other forms of allopathic medicine, which often carry risks that are iatrogenic. Quite often, the effect of exercise on total health is described as a ‘panacea’ or ‘magic pill’, to be delivered by medical and/or health service providers, because of the ostensible impact it has on so many chronic conditions and diseases (Sallis 2009, 2015).

At the same time, the EIM philosophy and social movement is certainly not without its critics (Berryman 2010; Neville 2013). Indeed, by virtue of the impact the EIM movement has had in shaping professional, patient and scholarly discourses, as well as practice itself, it should be the focus of critical inquiry. Such a focus was the impetus for this special issue, the goal of which was to expand the critical inquiry dialogue into the qualitative landscape through papers highlighting original qualitative methods/methodologies and theoretical excavations of EIM. From our perspective, EIM is predicated on several often taken for granted assumptions that deserve critical attention.

The first of these assumptions concerns the social mandate of EIM, espousing that individuals in society are inactive – at least not active enough to reap the health benefits of exercise – and this necessitates quick and decisive intervention. Conceived this way, inactivity is a wicked and pervasive problem, one that has resisted amelioration for some time. Despite well-known sociological patterns pertaining to who ‘plays’ and who does not along class, race, gender, ethnicity, sexual orientation and other lines, inactivity is distilled to individual failings, with the solution being to ‘uptake’ and adhere to ‘good physical activity’ behaviour (Wiest, Andrews, and Giardina 2015). Rates of physical inactivity in Western or developed nations are high (e.g. Kohl et al. 2012) and health promoters and advocates of physical activity have been largely unsuccessful in finding the right mix of marketing and behavioural interventions at the population level to increase physical activity participation. For proponents of EIM, connecting exercise to medicine is the best solution to this ‘problem’. Framing exercise as medicine draws attention simultaneously to the large scientific literature base that supports physical activity for disease prevention, while appealing to a (so-called) individualised motivation to live long and well by one’s own (neoliberal) doing, which can be achieved through the science and practice of medicine (Crawford 1980; Lupton 1995; Cheek 2008). Framed in this manner, using and/or promoting EIM as a tool to attain good or ‘best’ health, is in fact, a practice of faith grounded in morality. Simply put, if exercise can come to be viewed as an effective means to achieve health and longevity by coupling it to a belief in the power of allopathic medicine to prevent and cure disease, then all individuals will, and must, surely be(come) active. Importantly in this context, the onus for disease prevention is placed squarely on the individual, whose behaviour (or failure to behave correctly) becomes, itself, a cause of disease. Such messages are bound up in a moral imperative and neoliberal discourse of healthism, that places the onus (or blame) squarely on the individual with clinicians and experts often positioned as the means by which individual risk management through exercise, is realised/attained/enacted (Hallowell 1999; Cheek 2008; Wiest, Andrews, and Giardina 2015; McGannon et al. 2016). As a result of privileging healthism and neoliberal values, fundamental social and economic conditions which are known to influence mortality and morbidity and so-called individual choices (Raphael et al. 2003; Phelan, Link, and Tehranifar 2010), fade into the background as cultural noise, relegated to the category of non-modifiable risk factors in epidemiological parlance – outside the practitioners’ scope of practice.

A second taken for granted assumption of the EIM movement is that exercise is inherently good for everyone – sometimes accompanied by the recognition that the response to it varies between individuals, but always in the positive – and as such, more is always preferable. In the pursuit of ever increasing daily step counts as one example of this, one of the authors once heard a comedic skit wherein the protagonist celebrated the fact he had finally surpassed 80,000 steps a day, but then expressed grave concern that he might not be able to better his record now that he is forced to rely only on the bloody stumps that now occupy the place of his feet. Viewing disablement not as a cause of a pathological preoccupation with walking but an impediment to sustaining the behaviour may be humorous. However, it reveals a logical inconsistency that accompanies the push to increase physical activity and a push that is exclusionary of a range of bodies and abilities (Richardson, Smith, and Papathomas 2017). Public health messages (e.g. sit less, stand more) reproduce the notion that exercise is something everyone can do, reinforcing normative assumptions about human bodies (e.g. all people can stand, all people can move in certain spaces or places) Such messages discriminate against certain bodies, further obscuring social, physical ability and cultural (dis)advantages (Wiest, Andrews, and Giardina 2015). While exercise can be for all, the foregoing messages as framed potentially close down more inclusive social and cultural adaptations to exercise promotion, that consider a range of preferences, bodies and abilities (Richardson, Smith, and Papathomas 2017). This pursuit of a limited view of ‘exercise for all’ can partly be seen to infiltrate all spheres of human endeavours and aspects of everyday life. In the case of treadmill desks, for example, we see a curious bridging of work for punishment (the treadmill used for mindless, useless energy expenditure as torture, created as a mechanism of control and punishment in prisons) with work for pay, which for increasing numbers of individuals is precarious in nature. The rationale being, why should there be any limits on how much time you can devote to exercise? What other practices follow a logic that suggests you can never get too much and there are no consequences to excess? Whose interests, ultimately, does this perspective of exercise as a constant and/or moral imperative in people’s lives serve? And perhaps more importantly, who might be excluded from these sorts of messages and ideals concerning the promotion and framing of exercise and EIM for (supposedly) all global citizens?

The final taken for granted assumption concerning EIM is that the connection of exercise to medicine is also for the purpose of credibility enhancement. Advocates argue that allopathic medicine and its practitioners, medical doctors, are respected, credible sources of ‘expert’ information and most people in the population rely on their physicians to provide advice and care for a range of health concerns. In connecting exercise to medicine, exercise is now backed by the weight of this institution, and all the associated benefits of the alliance, behind it. Part of this assumption continues to rest on the values of healthism and neoliberalism, which place ‘responsible use of exercise’ for, and by, individuals to prevent and/or manage physical and mental health, in the hands of medical professionals as the gatekeepers of the message and its meaning (Wiest, Andrews, and Giardina 2015; McGannon et al. 2016). This assumption implies of course that when exercise is promoted outside of the medicine frame and meanings – through fitness advocates or physical educators – the message is no longer imbued with the same power and gravitas (Berryman 2010; McGannon et al. 2016). Medicine, unlike these disciplines, is extolled as an all-powerful institution that can influence (and control) health behaviour in ways other professions cannot in the light of the historical power of the discipline grounded in physicians’ socially sanctioned role to ‘help’ people regulate and/or manage health risks (Lupton 1995; Robertson 2001; Foucault 2003; Sulik 2009). It is, therefore, both expedient and pragmatic for exercise and sport science (broadly defined) to align with medicine to promote exercise in this context and gain legitimacy. Besides the subordination of exercise and physical education professionals trained in the prescription and promotion of exercise in the EIM discourse, there may be other (un)intended consequences potentially impacting the individual uptake and long-term engagement exercise. One consequence of promoting exercise as being in the hands of medical professionals may be that the meaning of exercise emerges as a ‘thing’ to be consumed, and (potential) exercisers emerge positioned as ‘consumers’ (Sulik and Eich-Krohm 2008; McGannon and Spence 2012; Wiest, Andrews, and Giardina 2015). In turn, the concept of EIM emerges as a means to an end – as a ‘thing’ and object to be prescribed, and a particular intensity to be met – and the intrinsic value, pleasure and enjoyment of exercise may be lost or downplayed (Ekkekakis, Parfitt, and Petruzzello 2011; Wiest, Andrews, and Giardina 2015).

To expand critical dialogues on EIM, we offer three challenges to the foregoing assumptions. First, while there is evidence that Western societies may indeed be obsessed with the pursuit of some vague notion of health (Cheek 2008; Wiest, Andrews, and Giardina 2015; Cinquegrani and Brown 2018), exercise ranks low as a preferred remedy; one need only look at rates of physical activity participation by almost any measure or method. Connecting this notion more reflexively to allopathic medicine as a strategy to combat the ‘exercise participation problem’ fails to consider how EIM and its practices are actually experienced by individuals (Phelan, Link, and Tehranifar 2010). Indeed, the strategy is predicated on a naïve conception of the influence of medicine to affect significant and permanent behaviour change. Take, for example, the analogy of exercise to taking medications – there is similar rationale with aligning EIM as being ‘like a pill’ or the meaning of it within a narrow medical, prescription discourse. This strategy simply does not hold under any reasonable scrutiny. Moreover, there is in fact no rational basis for comparison; particularly considering differences in the effort required for both actions alone render the comparison problematic and simplistic. Perhaps more pointedly, the comparison rests on a fiction that denies actual adherence to prescription medications in Western society. The World Health Organization estimates that the prevalence of non-adherence to prescriptions in developed countries is about 50% (Sabaté 2003; Lee, Grace, and Taylor 2006), and as many as half of these are intentional. In Canada, a country where access to health care is supposedly universal, 10% of individuals are non-complaint with medications because they cannot afford to purchase to them (Law et al. 2012). Apparently, prescription from a physician is not enough. Why would we expect rates of adherence to ‘prescribed exercise’, knowing how effortful and complex that behaviour is, would by any different, if not much worse? While it is beyond our scope to answer this complex question, the answer in part, lies in the taken for granted discourses and history of medicine that places power within the hands of medical professionals and institutions (Foucault 2003; Gearity and Mills 2012; Sulik 2009).

Next, exercise and physical activity simply cannot be reasonably viewed as a completely benign activity; exercise is socially, culturally and politically constructed (Gearity and Mills 2012; McGannon and Spence 2012). In addition to arguments outlined earlier concerning meanings of exercise promoting versus excluding certain persons and bodies, the promotion of exercise a risk reduction tool has additional and complicated meanings and consequences (Cinquegrani and Brown 2018; Wiest, Andrews, and Giardina 2015). For example, the flip side of exercise and physical activity reducing risk in EIM discourse is that long-term participation in any exercise or sport regime carries a risk of injury, running the gambit from the relatively non-serious (aches and minor sprains) to fractures or even long-term impairments – physical and psychological (Gearity and Mills 2012; Mosewich, Crocker, and Kowalski 2014). While EIM practitioners may be cautious about the ‘prescription’, and dispense generic advice about not ‘overdoing it’, for those embarking on an exercise regime or for those requiring modifications (Richardson, Smith, and Papathomas 2017), this approach may not be useful. In this regard, the adage ‘more is better’ or even the notion of ‘exercise in moderation’ seems to never accompany a serious consideration about what is too much, too little or ‘just right’ and for whom, nor whether this exponential growth curve of activity can be truly taken up and/or sustained over the entire life course. Moreover, when exercise meanings are framed around notions of risk and/or in relation to particular dosages to reduce risk, the intrinsic value and psychological benefits may be downplayed or eclipsed (Ekkekakis, Parfitt, and Petruzzello 2011; Mosewich, Crocker, and Kowalski 2014).

Finally, medicine is a powerful institution in our society and is also very hierarchical, with the top positions and esteem almost exclusively held by physicians (Foucault 2003). While there may be some credibility gained for the value and promotion of exercise through alignment with this profession due to such power and prestige, non-medical practitioners (e.g. exercise https://hub.taylorandfrancis.com/ – my-draft physiologists, exercise psychologists, physiotherapists, kinesiologists) should reflexively consider what the cost of aligning exercise with medicine might be, within the EIM programme and framework. The obvious cost is professional autonomy and potentially perpetuating, a narrow meaning of what ‘exercise’ can mean in practice, promotion and in people’s everyday lives. If exercise truly is medicine, and physicians control medicine which is further bound up in some of the aforementioned assumptions, then the practice and implications are clear. At the very time universities and professional bodies are attempting to legitimise and expand the practice of kinesiology and the use of exercise science within the health promotion landscape, EIM proponents, convinced they are doing right by their professions, may very well be ‘selling the farm’ or downplaying their own contributions, autonomy and power in the movement.

Our arguments above, however, are insufficient to truly understand and critique the complexity of EIM as an institutional, social and political movement. That is, in part, the purpose of this scholarly collection of articles. For this special issue, we invited qualitative researchers to consider EIM using critical theoretical, interpretative and social constructionist frameworks. By focusing on the institutional, narrative and cultural framings of personal experiences of individuals in everyday life, the inconsistencies and contradictions inherent in the logic and practice of EIM are revealed and the emerging critical dialogue on EIM expanded. Each contribution is briefly reviewed next, in relation to its focus and contributions a critical EIM dialogue.

EIM qualitative contributions: an overview of articles

In some ways, Nicholls et al. (2018) set the stage for this collection by considering through social theory the ideas (experiences) and bodies that are marginalised and/or altogether excluded when exercise is narrowly confined to the therapeutic realm of meanings and practice. Noting as they do that ‘exercise as therapy’ is certainly not a new social construct, EIM as a contemporary practice, can best be understood as a series of ‘biopolitical and biopedagogical strategies’ that fix individuals within a ‘web of micropolitical rationalities’, which privilege the practices and knowledges of one power form – medicine (p. XX). In other words, drawing heavily on Foucauldian theory, through the enactment of exercise within this system of rationality, only very limited forms of experience and expression are permitted. To emancipate the embodied subject from this kind of prison (e.g. the gymnasium), they turn to the works of Deleuze and his ‘ontology of affect and desire’ (p. XX), which the authors argue liberates the subject from the narrow confines of EIM to consider movement as freedom: freedom to experience new modes of being and expression, to express oneself and to commune in meaningful ways with other bodies. In doing so, they explore a theme that will be revisited throughout this collection – the tension between exercise as instrumental versus experiential practice. By connecting the two, it can be seen that the systems of power that are implicitly (and often hidden) within the practice and logic of EIM can indeed be turned on themselves by the pleasure and meaning that can be personally derived from authentic pursuit of the activity itself. Importantly, their essay is not a wholesale rejection of the therapeutic qualities of exercise, but rather an expose on what can be lost and found when the practice is viewed in overly constrictive and reductionist terms.

Williams and Gibson (2018) next focus on an institutional analysis of EIM and how it has given rise to a class of ‘movement intellectuals’ (sic exercise physiologists, physical activity public health promoters) whose attempts to align with medicine serve to legitimise their practice. Through the use of social constructionist qualitative research methodologies, duoethnography and the construction of non-fiction stories that exemplify their own experiences of fieldwork and emersion in the literature, two tales of frustrated sociologists engaging with EIM proponents are offered. In both tales, we see a failed attempt to convince the proponents that by being constrained within a paradigm that views exercise (i.e. lifestyle modification) as the means by which health is achieved, they refuse or fail to see the larger social conditions and forces that constrain not only individual behaviour, but which themselves give rise to the production of illness. Frustrated, but not without hope, Williams and Gibson are optimistic that through the invocation of these stories, deeper, cross-disciplinary collaborations become possible (in both tales, neither protagonist ends up on top; instead, we are left feeling the cross-talk resulted in a missed occasion to arrive at a deeper of understanding of a commonly shared problem). Indeed, like many authors in this collection, they do not deny the potential health benefits of exercise or the contribution of movement intellectuals in this tradition. They seek to promote a contextualised understanding of the use of exercise as therapy. To that end, they land on an alternate framework – the Behavioural Justice Movement – one that motivates behaviour change without blaming victims; one that shifts exercise from a moral imperative (i.e. the responsibility of the neoliberal citizen) to a social right and justice – the right for all to live a healthy lifestyle as a matter of social justice, not individual responsibility.

Several articles in this collection explore EIM within the context of specific conditions or clinical outcomes (i.e. Adamson et al.; Caddick & Smith; Smith-Tran; Williams et al.). In doing so, they explore many of the aforementioned core themes, while at the same time providing useful information that could be used for specific interventions and policies connected to specific disease states. Caddick and Smith (2018), for example, also question the individualism and discourse of healthism and neoliberal values (i.e. exercise as personal responsibility) inherent in EIM as others do, but in the context of the use of exercise in the treatment of trauma for military veterans. Noting the compelling, emergent evidence form clinical research (read RCTs) on the positive effects of exercise in the abetment of PTSD symptoms, the authors make a specific case for the need for qualitative inquiry in this field. In doing so, they make a compelling argument for how interpretative social constructionist inquiries can shed light on the possible gaps between the wants, desires and needs of the ‘patient’ and those who both plan and administer the therapy: in particular, the disjuncture between viewing exercise as medicine, versus exercise/physical activity as enjoyable, distracting and social. Responding to calls within medicine to make therapies more relevant by centring them around the patient, the authors make a pragmatic case for qualitative inquiry as a crucial adjunct to clinical research and its reliance on quantitative, post-positivistic methods, by showing the utility of the approach for evaluating both the quality of interventions and for the study of knowledge exchange with funders.

Also in the tradition of focusing on specific populations, Williams et al. (2018) present findings from qualitative studies of two clinical populations – those with spinal cord injuries and individuals with arthritis. Through their interpretive, narrative approach, their findings challenge post-positivistic research characteristic of EIM discipline – research that seeks to confirm that exercise is indeed medicine. Importantly, their work reveals ‘collateral damages’ that arise from a blinded, de-contextualised adoption of EIM. The first is narrative containment or the blockage of narrative reconstructions of the self, following illness and disability. In the context of chronic diseases for which there are no cures, conceiving of exercise as a magic pill can trap individuals in what the authors call a ‘narrative of restitution’. While a restitution narrative could be framed as hopeful, it can also be potentially delusional, preventing acceptance of one’s situation and the formation of a new narrative identity. Importantly, the restitution narrative promotes a commodity – exercise – that itself is not equally distributed in these populations. Consistent with a social model of disability, access to affordable, quality exercise programmes for persons with disabilities is a real problem that when perceived through this narrative structure, perpetuates a belief that only a privileged few can indeed be restituted. Many of the stories presented in the article also reveal exercise has a painful and sometimes debilitating experience. The authors quite rightly question the broad-spectrum approach of EIM, which fails to consider the unique, condition-specific symptoms of chronic conditions or the simple fact that exercise can be medically contraindicated, either by the condition itself, or the treatment (e.g. medications). Here again, the authors point out how narrative can be used to create patient-centred models of care, including recommendations about physical activity – what Charon (2006) calls ‘narrative medicine’. Finally, the narratives presented by the authors highlight the pleasures of exercise, be it the sensual pleasures that arise from the bodily experience of movement, the fact that many forms of exercise take the form of normative activities (standing, walking) that are no longer part of daily routines following injury, or by pleasure from immersion in an environment that provides a means of escape or distraction from everyday struggles and challenges; this latter pleasure can become habitual in the sense that exercise can help provide structure to one’s daily experience. Existentially, exercise as pleasure is at odds with exercise for utilitarian purposes – or at least it can be. The authors worry that exercising for health undermines a view of movement activity for fun and enjoyment. Through their discursive analysis of exercise stories, their work ultimately challenges the unified and simplified grand narrative that EIM promote, viz., exercise is always good and good for all.

Adamson et al. (2018) too focus on a clinical population – persons with multiple sclerosis (MS) – which allows them to explore a unique case of ‘disability’. Specifically, the nature of MS is such that symptoms ‘come and go’, which affects one’s identity as person with the condition. Like Williams et al. (2018), the tension between benefit and cost, the contradictions that arise from EIM, are identified. For example, the authors noted their participants’ stories of exercise as both a source of empowerment – the sense of accomplishment that comes from meeting ones’ goals – to feeling of guilt, when at times, participants felt they were not doing enough or not being compliant with prescriptions. Because participants viewed exercise as important in preventing relapse and in maintaining general health and personal autonomy, failure to practice exercise as medicine, whether arising from internal or external constraints, meant future disability or impairment was ‘their fault’. Again, and again, we see the potential negative consequence of narrowly conceptualising health behaviours in strictly individualistic terms. The contradictions in EIM in this context warrant careful messaging and promotion to persons with MS.

In a deeply personal, interpretive self-infused methodology of auto-ethnography, Smith-Tran (2018) explores the intersections of gender (femininity/masculinity), expert medical diagnosis and treatment and process of identity transformation also in the context of a specific condition – polycystic ovarian syndrome. Smith-Tran’s diagnosis came with specific advice regarding diet and exercise, specifically, strength training, as an important adjunct to her medical treatments. In her analysis, experiences of entering a hyper-masculine space where weight training to gain muscle is viewed as not feminine are explored. Her own ‘success’ in losing weight, while uncertain if it was diet, exercise or both, forces her to confront the double-edged sword of EIM – one can experience the positive effects from it but also recognise that its individualising tendencies can also lead to a source of frustration, feelings of failure and inadequacy. Her identity as a sociologist allows her to see these contradictions, while expressing to ‘others’ a very accessible and captivating account of her experiences with diagnosis and treatment in the context of EIM.

Following along the same path of iatrogenic effects that were observed in the previous articles, Pullen and Malcolm (2018) also build on the analogy of ‘exercise as pill’ and consider its side effects in a global context. They do so through adopting a critical constructionist lens, questioning the utility and ethics of the individualising of health concerns, which they view as logically consistent with neoliberalism. Their focus, however, is to critique the premise that exercise, as a seemingly ‘never-ending journey’, is not without consequences. To accomplish this critique, they connect sport to exercise, arguing that many of the strongest adherents to EIM are engaged not in light or moderate activity, but also pursue sport including its higher risk forms (e.g. contact sport). Specifically, they argue that injuries arising from physical activity and sport in particular are common and costly, economically (direct medical costs for treatment; lost productivity at work), socially (lost connections during time out for injury) and psychologically (sense of personal loss, alienation, stress, etc.). In fact, through their qualitative inquiries, they are able to show how injury arising from exercise can deleteriously effect identity, particularly for those who ‘buy-in’ to the exercise as moral imperative perspective promoted through EIM. Pullen and Malcolm question why a more balanced discussion about the health trade-offs of EIM are not at the centre of policy conversations, concluding finally and perhaps ironically, that the iatrogenic effects of EIM may indeed be diametrical to a medical/health orientation.

The final paper in this collection by Henderson et al. (2018) uses a figurational sociological approach to examine the interactions of stakeholders involved in the provision of exercise referral schemes (ERS) in the United Kingdom – a process connecting primary care providers to exercise professionals in the community. Their data reveal the tensions across disciplinary pillars that define the ‘figuration’ of ERS. Importantly, as we identified at the outset, mutual professional respect between exercise providers and primary care clinicians turned out to be a contested space. The exercise providers expressed concerns that primary care clinicians did not truly see the value in EIM, and often expressed that their roles were not respected professionally, a sentiment that was not confirmed (nor shared) in interviews with the primary care providers themselves. Another interesting finding was the differing ways in which stakeholder groups perceived the role of ERS, and how this lead to conflict. From an evaluation perspective, the authors argue that focusing solely on programme impact and end-user experience obscures the messy reality of programme delivery that arises within the complex web of multidisciplinary providers and programme administration structures.

Final reflections

In reviewing the articles that comprise this collection, several common themes emerge, consistent in large part with the critique of taken for granted assumptions concerning EIM that began this editorial. We also see shared theoretical frameworks and critical methodologies grounded broadly in interpretivist forms of inquiry and social constructionism, whereby the meanings of EIM are formed and framed by discourses made socially, culturally and institutionally available. By exploring EIM in a variety ways, across multiple contexts, the papers in this collection draw attention to such meanings and the implications of the EIM concept. In so doing they have identified the inherent- sometimes hidden, sometimes overt – power structures that construct and legitimate EIM as a practice, as well as through using specific theories that position the sociocultural realm as a necessary counterbalance to an overly individualised, depoliticised conceptualisation of disease and health behaviour. What we also see in this collection is that a plurality of interpretative methods across contexts can open up rich understandings of EIM’s own assumptions, inconsistencies and inherent contradictions.

At the same time, we do not see outright rejection of the EIM paradigm, nor do we seek to downplay the uptake, use and significance of EIM within the context of disciplines and institutions (e.g. medicine, exercise science, behavioural medicine) that seek to promote and use EIM. Instead, we see a collective desire to further problematise the EIM concept, recognising its limitations and possibilities. Ultimately, the articles in the present qualitative collection open up new dialogues in this regard, with the intent to show additional ways of thinking and conversations as to when, where, why and for whom, EIM can be effective.

This is the first collection of qualitative papers to explore the complexity and use of EIM in this manner – and these papers offer a range, albeit limited perspectives – when one considers the complex and highly contextualised relationship between exercise (physical activity) and health. In this sense, the co-editors and authors in this volume and collection of articles neither seek to praise, nor bury, EIM but instead try to understand the linked practice and outcomes in multiple forms – intended and unintended. We believe the collection, particularly as it is positioned within a qualitative frame of inquiry, provides a much needed, insightful and informative critical examination of EIM. We hope that these articles spark further interest and research on EIM – particularly from a qualitative research perspective – and continue to bring forward the personal, social, cultural and political iterations and potential of EIM.

Disclosure statement

No potential conflict of interest was reported by the authors.