Attitude adjustment: How to work it so you can work out more
Struggling to start strength training, slay the cardio combat class, or even prioritize a walk on a sunny day through flowering meadows? Weâve all been there. Many of us are there right now (as in: on the couch, wondering how weâll ever get up again). How and why we think about physical activity, and how we decide or plan to incorporate it into our lives, has a lot to do with whether or not weâre successful in staying active, research shows.
Our quiz helps you figure out how to maximize your workout successâand your friendsâ (if they want it maximized). Check out the scenarios below and pick the option(s) you think might work. For each question, at least one of the options is a YAAASSS. Some options may not help much (NOOOOOO). Others arenât ideal, but arenât hopeless either (NOT REALLY BUT). CLICKÂ on your answer to find out how it ranks and why.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]Youâve been inactive for a year and want to start working out again. You struggle with negative body image and tend to take an all-or-nothing approach to nutrition and working out (super-healthy vs. whatever). What might help you make physical activity an ongoing thing?[/vc_column_text][vc_tta_accordion shape=”square” c_icon=”chevron” active_section=”” collapsible_all=”true”][vc_tta_section title=”A. Make this about your general well-being, not your weight or body shape. Find stuff to like about your body. Itâs harder to take care of yourself if youâre self-shaming.” tab_id=”1489612665015-1d8327ba-1152″][vc_column_text]
YAAASSS
Looking after ourselves gets easier when our goals are feeling good and being healthier in general. When we focus on our body weight and shape, thereâs usually an element of shame and stigmaâand this tends to backfire, studies show. In contrast, when our goals are health and well-being, healthy behaviors are more accessible and sustainable, according to 2014 review of studies in the Journal of Obesity.
âThere is this cultural belief that people have to be dissatisfied with themselves in order to make behavioral changes to improve their health,â says Sara Stahlman, marketing and communication coordinator of Campus Health Services at the University of North Carolina at Chapel Hill. âIn fact, the opposite has been shown; people take better care of their bodies when they hold their bodies in high regard.â
Student perspective
âAs someone who has struggled with body image, I understand the temptation to push my limits in a negative sense. Physical exercise forces you to come to terms with the fact that your body is a miracle.â
âName and college withheld[/vc_column_text][/vc_tta_section][vc_tta_section tab_id=”1489612665048-92030fea-9b91″ title=”B. Commit for the long term: Find a six-month training program for a marathon or triathlon.”][vc_column_text]
NOT REALLY BUT
Big goals work great for some people, when theyâre ready. Right now, weâre thinking this may not be the best approach for you. The bigger the goal, the higher the chance of not getting there. Your all-or-nothing history (which isnât unusual) shows the pitfalls. Try looking for ways to have fun with working out first (see Q2).
That includes racking up some small successes. How does 2 percent sound? Two percent lifestyle change is the key to full-on success, says Dr. Edward Phillips, director of the Institute of Lifestyle Medicine at Harvard Medical School, Massachusetts. Thatâs because small steps are realistic and sustainable, and can lead to big results.
âIf your goal is to go to the gym every day of the week for two hours a day, ask how confident you are that youâll stick to that plan for the next three to four weeks,â says Dr. Phillips. âIf your confidence level is low, think about dialing it back and going to the gym three times a week for an hour, or going to a Zumba class once a week as a start. Whatâs your confidence level in that? Itâs easier and probably more attainable to achieve the smaller goal first.â
If you keep getting stuck, try talking with a personal trainer; you may be able to get a free session or two at your campus gym. Another option for some: Cognitive behavioral therapy (CBT) can help us reframe the thinking thatâs holding us back.
Intro to cognitive behavioral therapy: PsychCentral[/vc_column_text][/vc_tta_section][vc_tta_section title=”C. Spend more time with friends who are active. Physical activity is contagious.” tab_id=”1489612770242-b8b48bd4-6c3c”][vc_column_text]YAAASSS
Hanging out with active people helps us get active. âIf our friends work out regularly and support our exercise goals we are more likely to exercise,â says Dr. Xiaomeng Xu, professor of psychology at Idaho State University. Arrange with your friends to join them for the bike ride or that cardio groove class.
In a 2015 study, finding a new workout partner made people more physically active, especially when the partner was emotionally supportive (British Journal of Health Psychology). Another bonus: Working out with others means we work out longer or harder, a 2012 study suggests (Annals of Behavioral Medicine).
Student perspective
âJust the other day I didnât want to go run but I had told my friend that I would run with him. Once I made that commitment I know that I was going to do it no matter what. I hate backing out.â
âFifth-year undergraduate, Midwestern State University, Texas
Friends not in the mood? Look for groups and communities that exist specifically to get active, such as the November Project and Meetup groups.
Meetup[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]You know physical activity is the greatest thing you can ever do for yourself bar not much. But for you, the gym is a soulless wasteland. In high school you enjoyed track, but youâre having a hard time seeing yourself getting back into that kind of shape. Whatâs a good way to get moving anyway?[/vc_column_text][vc_tta_accordion shape=”square” c_icon=”chevron” active_section=”” collapsible_all=”true”][vc_tta_section title=”A. Get tough on yourself. Use your self-perceived flaws and weaknesses for motivation.” tab_id=”1495559443115-fcafea5e-c146″][vc_column_text]
NOOOOOO
As a motivational strategy, beating yourself up doesnât work long term. Life rule: Shaming ourselves or others does not work, and studies prove it. Stigmatizing body size makes people âsicker, poorer, lonelier, and less secure,â says Dr. Deb Burgard, a psychologist in California who specializes in body image, weight, and health issues. For more on this backfire effect, see Q1.
There are far more effective (and less demoralizing) tactics than this. Keep reading.
[/vc_column_text][/vc_tta_section][vc_tta_section tab_id=”1495559443309-b5737a0c-d24c” title=”B. Make this so not about fitness. Look for physical activities that donât feel like exercise, with its icky clinical associations. Focus on how getting active can help you feel good right now.”][vc_column_text]YAAASSS
Moving isnât just about moving. Itâs also about being with friends, letting go of your stress and angst, or even the task of getting from your residence hall to downtown. What works is doing stuff you like, at a pace you like, in places you like.
Try loosening up your thinking in general. âToss out any rules you might have about how to exercise, because research shows you wonât keep it up [if those rules donât reflect your feelings],â says Dr. Michelle Segar, author of No Sweat: How the Simple Science of Motivation Can Bring You a Lifetime of Fitness (Amacom, 2015).
Physical activity actually feels better than we expect, studies show. And recognizing this may help us do it. For example, in a 2016 study, participants ran for 30 minutes on a treadmill. Some were told in advance that running helped people feel refreshed and relaxed (Health Psychology). The participants were asked to keep up their runs through the week. Those whoâd been primed to feel good about the run reported that the treadmill workout was less fatiguing, and intended to run more, than those who had not been primed this way.
In a recent survey by Student Health 101, many students described fitness as a mind game. âI usually trick myself into thinking I am just having fun, even though I am getting a lot of physical activity in,â says a second-year undergraduate at the University of WisconsinâPlattville.
For more on reframing the way you think about this, see Q5.
Student Perspective
âRealize life is short and you might as well spend it feeling good and alive.â
âEthan G., second-year undergraduate, University of Maryland, Baltimore County
NOT REALLY BUT
Swimming is awesome. Learning new stuff is awesome. Walking 10 blocks is awesome. So why are we hesitating about this plan? Because building healthier habits has to be as easy as possible. The 10-block schlep to the pool is an ideal excuse to not follow through. Itâs too hot. Itâs raining. The hamster ate your shoes. Plus, learning to swim is a major prerequisite for getting more activeâand if you struggle, your planâs dead in the water.
Think about activities that (a) you already know you can enjoy, and (b) you can work into your day conveniently. Maybe thatâs running or biking the route back to your residence hall after the lecture. Maybe you can go to on-campus yoga or high-intensity cardio with a friend twice a week. Alsoâdonât forget to track your steps and factor in the value of what youâre already doing. That counts too.
When setting goals and planning, bear in mind that adults aged 18â64 should get at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, according to the World Health Organization. You can substitute at least 75 minutes of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate and vigorous activity.
- Moderate aerobic activity requires some effort and makes your heart beat fasterâe.g., brisk walking, yard work, and dancing.
- Vigorous aerobic activity requires a lot of effort; it causes rapid breathing and ramps up your heart rateâe.g., running, climbing hills, and fast cycling.
App and tracker comparisons (Wellocracy)
[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]
YAAASSS
This plan is practical, social, and could work well for both of you. Some disabilities and other pre-existing conditions have implications for working out. Your friend knows her own body and can seek medical clearance if needed. This is her call.
As for making a plan you can stick withâeffective strategies are flexible, research shows. Expect your fitness approach to change over time. As we adopt new behaviors and try to turn those into habits, we benefit from evolving messages, strategies, and tools. The same motivational messages that got us up off the sofa in the first place may not be exactly what we need six weeks later (this idea is sometimes known as âstages of changeâ). In the liveWell wellness program for students, the messages and tools shift appropriately as you make progress.
liveWell program (Pro-Change Behavior Systems, Inc.)[/vc_column_text][/vc_tta_section][vc_tta_section title=”B. Suggest she invests in basic fitness equipment so she can exercise alone without self-consciousness. Alternatively, help her search online for a special needs gym.” tab_id=”1489681625462-001c0d08-2092″][vc_column_text]
NOOOOO
Self-consciousness can be a barrier to working out, yes. Candy hasnât said thatâs a problem for her, though. Many people with disabilities are marginalized and excluded. We all do better when weâre socially integrated into our communities. For example, people with robust social networks (supportive friends and family) experience lower rates of chronic disease and longer lives, and more job opportunities, according to a 2011 report from the National Research Council.
This isnât just about being nice (though being nice is nice). A more inclusive, accessible environment is good for many people besides those with disabilities: older adults, pregnant women, parents with small children, people with less education, and speakers of a second language, says a 2011 report by the World Bank and World Health Organization. Weâll all be in at least one of those groups some day.[/vc_column_text][/vc_tta_section][vc_tta_section title=”C. Let her know how inspirational she is for even thinking about it. Turn her photo into an Instagram meme, adding a quotation about the human spirit.” tab_id=”1489681625607-8182b29a-b482″][vc_column_text]
NOOOOO
Disability advocates call this âinspiration porn.â Itâs condescending. Why should you be amazed that Candy wants to do something with her life?
Speaking of, letâs not be so quick to share memes and posts that are based on the idea that disabled people are a burden. Sure, invite your autistic classmate to the dance. But that gesture at inclusion backfires if youâre applauded for your self-sacrifice. This is about forming connections that work for everyone.[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]You share your apartment with three other guys. Imran is having a hard time getting to Ultimate Frisbee, and he tells you how much heâs missing it. On top of his usual workload, heâs rehearsing for a performance and is involved in the care of his sick father, so he doesnât even have much time to hang out.[/vc_column_text][vc_tta_accordion shape=”square” c_icon=”chevron” active_section=”” collapsible_all=”true”][vc_tta_section title=”A. Post a calendar inside the bathroom door with Ultimate Frisbee!!! highlighted on the relevant days. Ask Imran to take you along, and liaise about the logistics. ” tab_id=”1489681884513-1ed5a39e-e8f4″][vc_column_text]
YAAASSS
The calendar presents a plan and serves as a cue to action (reminder)âtwo effective strategies for making this happen. Joining Imran for Ultimate Frisbee is reinforcing and rewarding for both of you, while adding accountabilityâyouâll nudge each other to get there. Just make sure the calendar doesnât become so familiar that you guys start tuning it out. Switch up your reminders every so often.
Point to note: Planning is key to establishing new habits. In a 2006 study of people with cardiac issues, participants who wrote down their workout plan (and anticipated how they would handle any obstacles) were far more likely to be physically active over the next two months than those who did not make a plan (British Journal of Health Psychology).
For more on buddy workouts and why they help, see Q1.[/vc_column_text][/vc_tta_section][vc_tta_section title=”B. On Frisbee day, use your free hour to tackle the household chores that generally fall to Imran. Let him know that on your way to the lab, which passes the pharmacy, you can pick up his dadâs medication.” tab_id=”1489681884690-3403e1d7-78df”][vc_column_text]
YAAASSS
Providing invisible support is an act of true friendship. You understand the barriers Imran faces and youâre helping reduce them, without drawing attention to yourself, without expecting to be repaid in some way, and without insisting that he use the time to play Frisbee. Itâs great if he does, but sometimes that might not be an option.[/vc_column_text][/vc_tta_section][vc_tta_section title=”C. Understand how pressured Imranâs life is currently. Let him know itâs OK to wait until he has time for this.” tab_id=”1489681884870-26c9750f-3db2″][vc_column_text]NOT REALLY BUT
Sympathy is a good thing. Acknowledging reality is too. That said, Imran has told you heâs missing Frisbee. Getting back into the game would give him a break from the pressure, help him reconnect with friends, and keep his spirits up. You canât impose a solution, of course, but you can probably make it easier.
Lack of time is a problem for many of us, which is why those small goals are so helpful (see Q1). If you canât run for your usual 40 minutes, run for 15âthat will still help you feel good, as well as sustaining the habit. Or go lower. âIf all you can fit in is an extra five minutes a day, make that your plan and go from there,â says Dr. Michelle Segar, author of No Sweat: How the Simple Science of Motivation Can Bring You a Lifetime of Fitness (Amacom, 2015).
Student perspective
âRunning is like therapy to me. I am able to clear my mind of negative thoughts and I also feel better when I done. I breathe more smoothly and am more relaxed.â
âFourth-year undergraduate, Illinois State University[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]You have a family history of chronic illness. You worry that your sedentary lifestyle is setting you up for pain and disability down the road, but you have trouble sustaining your motivation to be active. What do you say to yourself?[/vc_column_text][vc_tta_accordion shape=”square” c_icon=”chevron” active_section=”” collapsible_all=”true”][vc_tta_section title=”A. Itâs difficult with my relatives as role models. But nothing is impossible with willpower. I just have to want this enough.” tab_id=”1489682036323-127b4184-0976″][vc_column_text]
NOOOOO
This isnât an effective motivational strategy. Judging and shaming your family, and implicitly yourself, is unlikely to work long term (see Q1 and Q2).
Your belief in willpower may let you down too. In experiments, willpower seems to be a finite, inconsistent resource. In other words, when weâre physically or mentally fatigued, weâre less likely to make it to the pool than we are to pick up a pizza. Even social interaction can drain our willpower, according to a 2005 study in the Journal of Personality and Social Psychology. (That said, this can go both ways. Being in a good mood gives us a willpower boost, and our own attitudes and beliefs can affect willpower too, according to the American Psychological Association.) Bottom line: Donât count on willpower always being there for you.
Instead, two key approaches can help you make changes that stick:
- Set up your home and schedule in ways that make physical activity more convenient
- Think differently about physical activity: See Q2 and answer B (next slide).
Student perspective
âWhen Iâm not in the mood to get active, I motivate myself by listening to workout music.
I steadily start to get pumped up.â
âThird-year undergraduate, Michigan Technology University[/vc_column_text][/vc_tta_section][vc_tta_section title=”B. Letâs say I go for a short run or climbed a hill right now. How would that make me feel?” tab_id=”1489682036553-211e8350-4c2f”][vc_column_text]YAAASSS
Immediate benefits are far more motivating than the distant prospect of better health, according to behavioral scientists.
Identify the immediate perks of taking that run or climbing the hill. These likely include a better mood, increased energy, a brainpower boost, stress relief, sharper focus, and feeling good about yourself. High-energy music helps bring about a rapid attitude adjustment (try the latest trap beat).
Not feeling it? Put on workout gear anyway. âSometimes I actively think about how much I donât want to go for a run while I put my body mindlessly through the actions of starting anyway,â says a second-year undergraduate at Colorado College. âI let my mind think itâs talked me out of it, but I keep putting on my shoes and shorts. I might even still be thinking about excuses when I take my first few steps into a warm-up jog, but by then itâs too late and Iâve already started.â
Other mind tricks can help make this not just about fitness (see Q2). Take a walk through the woods, ending up somewhere pretty where you can sit and read. Ride to the beach to watch the sunset. Get a friend to join you in a kayak. Put on some music and dance.
Student perspective
âIâll remember the time I was in a dull meeting and had to run outside to grab something, then how much more alert I felt afterward.â
âThird-year undergraduate, Rochester Institute of Technology, New York[/vc_column_text][/vc_tta_section][vc_tta_section title=”C. Iâll go by the health center tomorrow and pick up some leaflets on heart disease and diabetes.” tab_id=”1489682036774-28bfe165-8589″][vc_column_text]NOT REALLY BUT
Itâs always good to be informed. Health info can help us think about how susceptible we are to a disease and how that disease might affect us. That said, health information alone rarely enables us to change our habits.
Instead, think about specific barriers to getting active. Whatâs stopping you? Maybe itâs something practical (the logistics of getting to the basketball court). Maybe itâs psychological (working out feels like a chore). Maybe itâs financial (the cost of a personal trainer).
Now think about ways you can minimize those barriers. The basketball court is not your only option; whatâs nearby? Have you noticed that when you do get active it actually feels pretty good (for real)? Do you have access to a free training session on campusâand what app or video series could substitute for a personal trainer?
Student perspective
âI was pre-diabetic before I started to be physically active. I am now 100 pounds lighter. My mental clarity is way better than it was before. I never thought I would ever hear myself say that.â
âSecond-year undergraduate, Park University (online)
App and tracker comparisons (Wellocracy)[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]Your on-trend friend Issa wants to work out with you. Sheâs into Barryâs Bootcamp and SoulCycle, but right now those are beyond her budget. Instead, sheâs sitting around watching reality shows (she enjoys those too). Whatâs a good strategy here?[/vc_column_text][vc_tta_accordion shape=”square” c_icon=”chevron” active_section=”” collapsible_all=”true”][vc_tta_section title=”A.Celeb trainer Sergeant Squat is coming to campus for a free YOLO Boot Camp and will be giving away workout DVDs. Bam. Youâve got this.” tab_id=”1489682194984-f1b88209-448b”][vc_column_text]
YAAASSS
Issa is hooked in to popular culture and likes to be ahead of the crowd. When influential people spearhead activities and campaigns, thereâs a social ripple effect. Here, Sergeant Squat is poised to turn Issa (and you) on to a new fitness approach. Maybe you and she will transmit it to others.
In addition, youâre making a specific plan and working out togetherâtwo keys to success (see Q4 and Q1). Just make sure that if the new workout feels good, you plan how to keep at it. And if itâs not for you, look around for alternatives.[/vc_column_text][/vc_tta_section][vc_tta_section title=”B. Join Issa for two reality shows a week. Turn them into buddy workouts. Bonus: Reality shows make more sense when viewed upside down through your legs in Downward Dog.” tab_id=”1489682195250-f672248a-be7b”][vc_column_text]YAAASSS
Buddy workouts are gang (see Q1).
To keep things fresh, use the Deck of Cards approach. Take turns to draw a card from a deck. Each suit represents a different move. For example: hearts = squats, spades = burpees, diamonds = planks, clubs = lunges. The number on the card is your number of reps. You can change up the moves with each show or round, of course.
Student perspective
âItâs a lot easier to get off the couch if you know your friends are waiting for you.â
âThird-year undergraduate, University of Dallas, Texas[/vc_column_text][/vc_tta_section][vc_tta_section title=”C. Agree together that you only get to watch The Handmaidâs Tale or Twin Peaks when youâre on a StairMasterÂŪ, stationary bike, or elliptical.” tab_id=”1489682195500-668b943c-b2f1″][vc_column_text]YAAASSS
Rewards can be strategic and effective. You can switch them up. Maybe your workout time is when you listen to a killer audio book. Maybe you get a smoothie afterward, give each other a pedi, or download a new app or podcast.
Another approach to rewards: the commitment contract. âFor example, you give money to a friend. If you hit your exercise target, you get the money back, but if you donât, your friend gets to keep it,â says Dr. Fred Zimmerman, a professor in the Department of Health Policy and Management at the University of California, Los Angeles, who researches exercise behavior. âOr the money would be donated to the opposite political party than which you agree or a group youâre not too fond of. This way, missing your goal is painful.â
To sign up for a commitment contract, see Stickk.com. To earn money rewards for workouts, check out the app Pactâbut remember that if youâre the one missing your workouts, your cash rewards others.
Student perspective
âThe hardest thing to do for me is to work out in the morning. So I would make a rule that if I donât get out of bed to work out, then I only get to drink water the entire day. Yes, no coffee. Â :(â
âSecond-year undergraduate, college withheld
Pact cash rewards (or penalties)
+Â iOS
+Â Android[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row]
The lowdown on health apps and trackers: Wellocracy/Partners HealthCare
Customized student lifestyle change: Pro-Change Behavior Systems
Make a commitment contract: Stickk.com
No Sweat: How the Simple Science of Motivation Can Bring You a Lifetime of Fitness: Michelle Segar
(American Management Association, 2015)
8 ways to get fit and be social: American Council on Exercise
Chris Stuck-Girard, MPH, JD, contributed to this article.
Deb Burgard, PhD, psychologist, California.
Sara Stahlman, MA, marketing and communication coordinator, Campus Health Services, University of North Carolina at Chapel Hill.
Edward Phillips, MD, founder and director, Institute of Lifestyle Medicine, Harvard Medical School, Massachusetts.
Michelle Segar, PhD, MPH, author; No Sweat: How the Simple Science of Motivation Can Bring You a Lifetime of Fitness (Amacom, 2015).
Xiaomeng Xu, PhD, professor of psychology, Idaho State University.
Fred Zimmerman, PhD, professor, Department of Health Policy and Management, University of California, Los Angeles.
American Psychological Association. (2017). What you need to know about willpower. Retrieved from https://www.apa.org/helpcenter/willpower.aspx
Irwin, B. C., Scorniaenchi, J., Kerr, N. L., Eisenmann, J., et al. (2012). Aerobic exercise is promoted when individual performance affects the group: A test of the Kohler motivation gain effect. Annals of Behavioral Medicine, 44(2), 151â159.
Kawn, B. M., Stevens, C. J., & Bryan, A. D. (2016). What to expect when you’re exercising: An experimental test of the anticipated affect-exercise relationship. Health Psychology.
National Research Council. (2011). Explaining divergent levels of longevity in high-income countries. [Report]. Retrieved from https://www.nap.edu/read/13089/chapter/8
Pro-Change Behavior Systems: LiveWell. [Website]. Retrieved from https://www.prochange.com/college-health
Rackow, P., Scholz, U., & Hornung, R. (2015). Received social support and exercising: An intervention study to test the enabling hypothesis. British Journal of Health Psychology, 20(4), 763â776.
Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide to health promotion practice [pdf]. US Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Retrieved from https://sbccimplementationkits.org/demandrmnch/ikitresources/theory-at-a-glance-a-guide-for-health-promotion-practice-second-edition/
Sniehotta, F. F., Scholz, U., & Schwarzer, R. (2006). Action plans and coping plans for physical exercise: A longitudinal intervention study in cardiac rehabilitation. British Journal of Health Psychology, 11(1), 23â37.
Student Health 101 surveys, April 2015 and December 2014.
Vohs, K., Baumeister, R. F., & Ciarocca, N. J. (2005). Self-regulation and self-presentation: regulatory resource depletion impairs impression management and effortful self-presentation depletes regulatory resources. Journal of Personality and Social Psychology, 88(4), 632â657.
Wellocracy. (n.d.). Activity apps. Partners HealthCare. Retrieved from https://www.wellocracy.com/mobile-activity-apps
World Health Organization. (2017). Physical activity and adults. Retrieved from https://www.who.int/dietphysicalactivity/factsheet_adults/en/
World Health Organization. (2017). What is moderate-intensity and vigorous-intensity physical activity? Retrieved from https://www.who.int/dietphysicalactivity/physical_activity_intensity/en/
World Health Organization & World Bank. (2011). World report on disability. [Report]. Retrieved from https://www.who.int/disabilities/world_report/2011/report.pdf