PA

Ch.12.pptx

Chapter 12 Behavioral Theories and Strategies for Promoting Exercise

Behavioral Theories and Strategies for Promoting Exercise

Research has identified consistent correlates to engaging in regular physical activity (PA).

Numerous demographic factors (e.g., age, gender, socioeconomic status, education, ethnicity) are consistently related to the likelihood that an individual will exercise on a regular basis.

These factors are not amenable to intervention, although they do suggest who might benefit most from the exercise intervention.

Exercise Prescription

Given the flexibility in the Frequency, Intensity, Time, and Type (FITT) principle of Ex Rx for the targeted population, it is important to first understand what impact variations in the Ex Rx might have on adoption or maintenance of a habitually active lifestyle.

Exercise Prescription: Frequency/Time

Ex Rx recommendations allow for flexibility in the different combinations of frequency and/or time/duration to achieve them.

Reviews of randomized trials showed that there is no difference in exercise adherence when different combinations of frequency and time are used to achieve the same total volume of PA.

These results should be viewed with caution, however, because the included studies were randomized trials that assigned participants to different combinations.

Allowing individuals to self-select frequency and time may influence adherence to exercise interventions.

Exercise Prescription: Intensity

Although previous studies on the effects of exercise intensity on adherence suggests that individuals are more likely to adhere to lower intensity programs, a more recent review suggests that the inverse relationship between intensity and adherence is not particularly strong and may be moderated by prior exercise behavior.

There is evidence that individuals with more exercise experience fare better with higher intensity programs (65%–75% heart rate reserve [HRR]), whereas those adopting exercise for the first time may be better suited to, and self-select, moderate intensity programs (45%–55% HRR).

Exercise Prescription: Type

Although it is recommended that individuals participate in a variety of exercise types (i.e., aerobic, resistance, neuromotor, and flexibility), there have been few systematic tests of the effects of different exercise modalities on adoption and maintenance.

Most has focused on aerobic exercise, especially walking

Little is known about the characteristics of those that adopt and maintain resistance training and flexibility exercise programs.

Exercise Prescription: Type (cont.)

In the area of health behavior, type also focuses on program/delivery type. Compared to supervised exercise programs, home-based programs that include remotely delivered support have shown comparable or greater adherence.

Telephone interventions have been effective in increasing PA in many populations

Technology delivered interventions hold promise for promotion PA

Commercially available apps generally lack behavior change strategies

Theoretical Foundations for Understanding Exercise Behavior

Social Cognitive Theory

Transtheoretical Model

Health Belief Model

Self-determination Theory

Theory of Planned Behavior

Social Ecological Models

Social Cognitive Theory and Self-Efficacy

Social cognitive theory (SCT) is a comprehensive theoretical framework that has been extensively employed in understanding, describing, and changing exercise behavior.

SCT is based on the principle of reciprocal determinism; that is, the individual (e.g., emotion, personality, cognition, biology), behavior (i.e., past and current achievement), and environment (i.e., physical, social, and cultural) all interact to influence future behavior.

Social Cognitive Theory and Self-Efficacy (cont.)

Central to SCT is the concept of self-efficacy, which refers to one’s beliefs in her or his capability to successfully complete a course of action such as exercise.

Task self-efficacy refers to an individual’s belief that she or he can actually do the behavior in question, whereas barriers self-efficacy refers to whether an individual believes she or he can regularly exercise in the face of common barriers such as lack of time, poor weather, and feeling tired.

Social Cognitive Theory and Self-Efficacy (cont.)

The higher the sense of efficacy, the greater the effort, persistence, and resilience an individual will exhibit, especially when faced with barriers or challenges.

Self efficacy is one of the most consistently found correlates of PA in adults and youth.

Social Cognitive Theory and Self-Efficacy (cont.)

Outcome expectations and expectancies, key concepts of SCT, are anticipatory results of a behavior and the value places on these results.

If specific outcomes are valued, then behavior change is more likely to occur.

For example, if an overweight adults who wants to lose weight and believes that walking will help is more likely to start and maintain a walking program.

Social Cognitive Theory and Self-Efficacy (cont.)

Self-regulation or self-control is another important concept in SCT. This refers to a person’s ability to:

Set goals

Monitor progress toward those goals

Problem solve when faced with barriers

Engage in self-reward

Transtheoretical Model

The Transtheoretical Model (TTM) was developed as a framework for understanding behavior change and is one of the most popular approach for promoting exercise behavior.

The popularity of the use of stages of change from the TTM stems from the intuitive appeal that individuals are at different stages of readiness to make behavioral changes and thus require tailored interventions.

Transtheoretical Model (cont.)

The stages of change

Precontemplation (no intention to be regularly active in the next 6 months)

Contemplation (intending to be regularly active in the next 6 months)

Preparation (intending to be regularly active in the next 30 days)

Action (regularly active for <6 months)

Maintenance (regularly active for >6 months)

Transtheoretical Model (cont.)

Associated with the five stages of change are the constructs of processes of change, decisional balance, and self-efficacy.

The 10 processes of change illustrate the strategies used by individuals in attempting to advance through the five stages of change.

The 10 processes can be divided into two second order factors:

experiential (i.e., consciousness raising, dramatic relief, self-reevaluation, social reevaluation, and social liberation); recommended in earlier pre-action stages of change.

behavioral (i.e., self-liberation, counterconditioning, stimulus control, contingency management, and helping relationship); recommended in later stages of change.

Health Belief Model

Theorizes that one’s beliefs about whether they are susceptible to disease and their perceptions of the benefits of trying to avoid it influence their readiness to act

The theory is grounded in the notion that individuals are ready to act if they:

Believe they are susceptible to the condition (i.e., perceived susceptibility)

Believe the condition has serious consequences (i.e., perceived severity)

Believe that taking action reduces their susceptibility to the condition or its severity (i.e., perceived benefits)

Health Belief Model (cont.)

The theory is grounded in the notion that individuals are ready to act if they:

Believe that costs of taking action (i.e., perceived barriers) are outweighed by the benefits

Are confident in their ability to successfully perform an action (i.e., self-efficacy)

Are exposed to factors that prompt action (e.g., seeing their weight on the scale or a reminder from one’s physician to exercise) (i.e., cues to action

Self-Determination Theory

The underlying assumption of the self-determination theory (SDT) is that individuals have three primary psychosocial needs that they are trying to satisfy:

Self-determination or autonomy

Demonstration of competence or mastery

Relatedness or ability to experience meaningful social interactions with others

Self-Determination Theory (cont.)

The theory proposes that motivation exists on a continuum from amotivation to intrinsic motivation, with amotivation having the lowest levels of self-determination and intrinsic motivation having the highest degree of self-determination.

Individuals with amotivation have no desire to engage in exercise.

Individuals high in intrinsic motivation are interested in engaging in physical activity for the satisfaction, challenge, or pleasure that comes from it.

Between amotivation and intrinsic motivation is extrinsic motivation, that is, when individuals engage in a physical activity for reasons that are external to the individual.

Self-Determination Theory (cont.)

The SDT suggests that the use of rewards to get individuals to start exercising may have limited effectiveness because they promote extrinsic motivation.

Programs should be designed to enhance autonomy by promoting choice and incorporating simple, easy exercises initially to enhance feelings of competence and enjoyment.

Theory of Planned Behavior

According to the theory of planned behavior (TPB), intention to perform a behavior is the primary determinant of actual behavior.

Intentions reflect an individual’s probability that she or he will exercise but do not always translate directly into behavior because of issues related to behavioral control.

Social Ecological

Social ecological models are important because they consider the impact of and connections between individuals and their environments.

The explicit recognition of relations between an individual and their physical environment is a defining feature of ecological models.

Behavior results from influences at multiple levels, including intrapersonal factors, interpersonal/cultural factors, organizational factors, physical environments, and policies

Table 12.2 Levels of Social Ecological Model and Potential PA Intervention Strategies

Social Ecological Level	Components	Potential Change Strategies
Intrapersonal Factors	Knowledge, attitudes, beliefs, perceived barriers, motivation, enjoyment Skills and self-efficacy Demographics (age, sex, education, and socioeconomic and employment status	Focus on changing individual’s knowledge, skills and attitude Use theories and approaches such as SCT, TTM, TPB, and SDT Use demographic information to identify subgroups at risk or subgroups that require different approaches to intervention

Table 12.2, cont.

Social Ecological Level	Components	Potential Change Strategies
Intrapersonal Factors/social environment	Family, spouse, or partner Peers Coworkers Access to social support Influence of health professionals Community norms Cultural background	Use community education, support groups, and peer programs Social marketing campaigns may promote positive community attitudes and awareness toward participation in PA Consistent, accurate, and encouraging messages to promote PA

Table 12.2, cont.

Social Ecological Level	Components	Potential Change Strategies
Organizational Factors	Schools, workplaces. Faith-based settings, and community organizations	Create opportunities for organizations, at both the individual and group level, to adopt or increase PA

Decreasing Barriers to Physical Activity

Individuals face a number of personal, social, and environmental-related barriers in both the adoption and maintenance of PA

Table 12.2, cont.

Social Ecological Level	Components	Potential Change Strategies
Physical Environment	Natural factors such as weather or geography Availability and access to exercise facilities Aesthetics or perceived qualities of facilities or the natural environment Safety such as crime rates and traffic Community design Public transportation options	Create walking trails or parks Enhance existing environments (e.g., park/neighborhood cleanups) Help individuals become more aware of opportunities for PA in their communities (e.g., parks, trails, community centers)

Table 12.2 cont.

Social Ecological Level	Components	Potential Change Strategies
Policy	Urban planning policies Education policies such as physical education classes Health policies Environmental policies Workplace and other organizational policies	Align PA participation with priorities such as reducing reliance on fossil fuels and the reduction of greenhouse gas emissions Emphasize importance of regular physical education Require workplaces to provide support for PA

Table 12.3 cont.

Cognitive and Behavioral Strategies for Increasing Physical Activity Behavior

Cognitive strategies focus on changing the way individuals think, reason, and imagine themselves in regard to exercise behavior

Behavioral strategies refer to individual actions and reactions to environmental stimuli. Because actions and reactions are thought to be learned, the behavioral approach posits that these actions and reactions can be unlearned or modified

Cognitive and behavioral strategies include enhancing self-efficacy, goal setting, reinforcement, social support, self-monitoring, problem solving, and relapse prevention

Enhancing Self-Efficacy

Self-efficacy is a central component of most of the theories previously discussed (i.e., SCT, TTM, HBM, and TPB).

Strategies to increase self-efficacy include

Mastery experiences (experiencing success)

Vicarious experiences (seeing others who are similar to them having positive experiences and successful application of strategies)

Verbal persuasion (encouragement from others)

Physiological feedback (enjoyment, positive mood states)

Goal Setting

Goal setting is a powerful tool for behavior change that cuts across numerous theories but must be done as part of an ongoing process to be effective.

Set both short- and long-term goals. Individuals often focus on long-term goals; however when attempting a new behavior, setting achievable short-term goals is important for increasing self-efficacy.

Goal Setting

The SMARTS principle can be used to guide effective goal setting

Specific: Goals should be precise

Measureable: Goals should be quantifiable

Action-oriented: Goals should indicate what needs to be done

Realistic: Goals should be achievable

Timely: Goals should have a specific and realistic time frame

Self-determined: Goals should be developed primarily by the patient/client

Reinforcement

Individuals should be encouraged to reward themselves for meeting behavioral goals

Extrinsic rewards include tangible, physical rewards (e.g., new pair of shoes) and social reinforcement (e.g., praise).

Intrinsic rewards come from within, such as a feeling of accomplishment. Individuals are more likely to adhere to exercise over the long term if they are doing the activity for intrinsic reasons such as for fun, enjoyment, and challenge.

Reinforcement (cont.)

It may be difficult to give intrinsic reinforcers to participants, but it may be possible to develop an environment that can promote intrinsic motivation.

These environments focus on the autonomy of the participant and have been shown to lead to higher levels of PA.

Environments promoting intrinsic motivation focus on (a) providing positive feedback to help the participant increase feelings of competence; (b) acknowledging participant difficulties within the program; and (c) enhancing sense of choice and self-initiation of activities to build feelings of autonomy.

Social Support

Social support is a powerful motivator to exercise for many individuals and important in SCT, TTM, TPB, and social ecological models; and can come from an instructor, family members, workout partners, coworkers, or neighbors, as well as exercise and other health professionals.

Social Support (cont.)

Social support can be provided to clients/patients in various ways including:

guidance (i.e., advice, information)

reliable alliance (i.e., assurance that others can be counted on in times of stress)

reassurance of worth (i.e., recognition of one’s competence that individuals in the exercise group or personal trainer believe in their abilities)

attachment (i.e., emotional closeness with the personal trainer or at least one other individual in the exercise group)

social integration (i.e., a sense of belonging and feeling comfortable in group exercise situations)

opportunity for nurturance (i.e., providing assistance to others in the exercise group).

Social Support (cont.)

Providing social support in the form of guidance is most common when working with clients/patients.

Individuals beginning an exercise program may have feelings of incompetence.

Increasing their confidence through mastery experiences, social modeling, and providing praise are practical ways to increase acknowledgement of one’s competence.

Social Support (cont.)

Implementing ways to increase an individual’s attachment and feelings of being part of a group is also important.

A method to make exercisers feel comfortable is to establish buddy groups.

In group settings, exercisers can benefit from watching others complete their exercise routines and from instructors and fellow exercisers giving input on proper technique and execution.

Creating supportive exercise groups within communities has been linked with greater levels of exercise behavior.

Self-monitoring

Self-monitoring involves observing and recording behavior and is important in exercise behavior change.

Self-monitoring can take many forms such as:

Paper-and-pencil log

Heart rate monitor

Pedometer or wearable technology

Problem Solving

Problem solving assists individuals in identifying strategies to eliminate barriers and includes four main steps:

Identify the barrier

Brainstorm ways to overcome the barrier

Select a strategy that is likely to be successfu;

Analyze how well the plan worked and revise as necessary

Relapse Prevention

Active individual may encounter situations that make sticking to their exercise program difficult or nearly impossible. Relapse prevention can be implemented across all approaches once individuals adopt and try to maintain exercise.

Relapse prevention strategies include:

Being aware of and anticipating high-risk situations (e.g., travel, vacation, holiday, illness, family obligations, inclement weather)

Having a plan to ensure that a lapse does not become a relapse

Theoretical Strategies and Approaches to Increase Exercise Adoption and Adherence

Brief Counseling and Motivational Interviewing

Stage of Change Tailored Counseling

Group Leader Interactions

Brief Counseling and Motivational Interviewing

A promising area for increasing exercise adoption is through the use of brief counseling, often conducted by health care professionals.

Motivational interviewing (MI) is a person-centered method of communication where the professional and the client/patient work collaboratively for change.

A major focus of MI is to help the ambivalent individual realize the different intrinsic motivators that can lead to positive change.

Brief Counseling and Motivational Interviewing, cont.

During the initial phase of MI, the primary goal is to help resolve ambivalence and increase motivation for change.

“Change talk” refers to an individual’s mention or discussion of a desire or reason to change, making it more likely that change will occur.

Table 12.7, cont.

Stage of Change Tailored Counseling

The TTM is predicated on the notion of stages of change, but the key to progressing through the model is the appropriate use of stage-specific strategies and the processes of change to help individuals advance that result in “tailoring” interventions.

Box 12.2 Example Strategies to Facilitate Stage Transitions

Provide information about the benefits of regular PA

Discuss how some of the barriers they perceive may be misconceived such as: “It can be done in shorter and accumulated bouts if they don’t have the time”

Have them visualize what they would feel like if they were physically active with an emphasis on short-term, easily achievable benefits of activity such as sleeping better, reducing stress, and having more energy

Explore how their inactivity impacts individuals other than themselves such as their spouse and children

PRECONTEMPLATION ➔ CONTEMPLATION

Explore potential solutions to their PA barriers

Assess level of self-efficacy and begin techniques to build efficacy

Emphasize the importance of even small steps in progressing toward being regularly active

Encourage viewing oneself as a healthy, physically active person

CONTEMPLATION ➔ PREPARATION

Box 12.2 Example Strategies to Facilitate Stage Transitions (cont.)

Help develop an appropriate plan of activity to meet their PA goals and use a goal setting worksheet or contract to make it a formal commitment

Use reinforcement to reward steps toward being active

Teach self-monitoring techniques such as tracking time and distance

Continue discussion of how to overcome any obstacles they feel are in their way of being active

Encourage them to help create an environment that helps remind them to be active

Encourage ways to substitute sedentary behavior with activity

PREPARATION ➔ ACTION

Box 12.2 Example Strategies to Facilitate Stage Transitions (cont.)

ACTION ➔ MAINTENANCE

Provide positive and contingent feedback on goal progress

Explore different types of activities they can do to avoid burnout

Encourage them to work with and even help others become more active

Discuss relapse prevention strategies

Discuss potential rewards that can be used to maintain motivation

Group Leader Interactions

Exercising in a group where the instructor purposefully creates group dynamics and goals has consistently been shown to be superior to exercising in a usual class (where each individual functions autonomously) or exercising at home with or without contact

Participants who have an exercise leader that has a socially supportive leadership style report greater self-efficacy, more energy, more enjoyment, stronger intentions to exercise, less fatigue, and less concern about embarrassment.

Group Leader Interactions (cont.)

Five principles have been successfully used to improve cohesion and lower dropout rates among exercise groups:

Distinctiveness - creating a group identity (e.g., group name)

Positions - giving members of the class responsibilities and roles for the group

Group norms - adopt common goals for the group to achieve

Sacrifice - individuals in the group may have to give up something for the greater good of the group

Interaction and communication - the belief that the more social interactions that are made possible for the group, the greater the cohesion

Special Populations

An important area of exercise promotion is the proper tailoring of interventions to promote exercise behavior across diverse populations that present unique challenges.

Proper tailoring requires an understanding of potential unique beliefs, values, environments, and obstacles within a population or individual.

Cultural Diversity

In order to provide culturally competent care, it is necessary to be exposed to and understand cultural beliefs, values, and practices of the desired population.

This includes but is not limited to housing, neighborhood characteristics, religion, access to resources, crime, race, ethnicity, age, ability level, and social class

Perhaps, the most important characteristic of exercise interventions that target different racial/ethnic groups is being culturally sensitive and tailored.

Older Adults

Older adults may lack knowledge about the benefits of PA or how to set up a safe and effective exercise program so health/fitness and clinical exercise professionals need to provide some initial education.

Although typically viewed as beneficial, social support is not necessarily positive, especially in older adults.

Family and friends may exert negative influences by telling them to “take it easy” and “let me do it.”

The implicit message is that they are too old or frail to be physically active.

Older Adults (cont.)

Many of the typical barriers to physical activity are similar among younger and older adults such as lack of time and motivation; however, there are several barriers that may take on special significance among older adults.

These barriers include lack of social support and increased social isolation.

Quite possibly, the largest barrier to exercise participation in older adults is the fear that exercise will cause injury, pain, and discomfort or exacerbate existing conditions.

Youth

When working with children (see Chapter 8), it is important to recognize that they are likely engaging in an exercise program because their parents wish them to, implying an extrinsic motivation, and typically require tangible forms of social support (e.g., transportation, payment of fees).

To help them maintain exercise behavior over their lifetime, children need help shifting toward a sense of autonomy and to feel a sense of self-efficacy and behavioral control.

It is imperative to work toward establishing a sense of autonomy and intrinsic motivation through the creation of a supportive environment.

Individuals with Obesity

Individuals with obesity may face unique weight-related barriers to exercise (e.g., feeling uncomfortable while exercising, being uncomfortable with their appearance).

Individuals with obesity may have had negative mastery experiences with exercise in the past and will need to enhance their self-efficacy so that they will believe they can successfully exercise.

They may also be quite deconditioned and perceive even moderate intensity exercise as challenging, so keeping activities fun and at a low enough intensity that they feel positive may be particularly important.

Individuals with Obesity (cont.)

Individuals with obesity may need help setting realistic weight loss goals and identifying appropriate levels of physical activity to help them reach those goals.

Individuals with Chronic Diseases and Health Conditions

A concern when working with individuals with chronic diseases and health conditions is their ability to do the exercise both from a task self-efficacy perspective as well as in the face of the barriers presented by their condition.

Special consideration should be given to ensure activities are chosen to prevent, treat, or control the disease or health condition.

Being aware of the unique barriers and fears of individuals with chronic diseases and health conditions can help assure the chosen physical activities are appropriate.