Behavioral Approaches to Physical Activity Promotion

8/15/2019 Behavioral Approaches to Physical Activity Promotion

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Behavioral Approaches toPhysical Activity Promotion

Gregory W. Heath, DHSc, MPH

he clinical exercise physiologist can use a numberof behavioral strategies in assessing and counselingindividual patients or clients about their physical activit y

behavior change. The behav ioral s trategies discussed in

this chapter are intended to be used in the context of sup-

portive social and physical envi ronments. A nonsupport-

ive environment is considered a barrier to regular physical

activity par ticipation; consequently, if this barr ier is not

altered, change is unlikely to occur. Thus, one of the cli ni-

cian’s goals is to identify environmental barriers with theclient, include steps on how to overcome these barriers,

and build supportive social and physical environments as

part of the counseling strategy. Although no guarantees

can be made, the literature suggests that if clinicians take

a behavior-based approach to physical activity counsel ing,

within the context of a supportive environment, they may

indeed experience greater success in getting t heir clients

moving. Therefore, this chapter also presents informa-

tion about the role of social and contextual settings in

promoting health- and fitness-related levels of physical

activity. The most important task of the clinical exercise

physiologist is to g uide a client into a lifelong pattern of

regular, safe, and effective physical activit y.

BENEFITS OF PHYSICAL ACTIVITY

he exercise physiologis, who undersands he physio-logical basis for acivi y as well as he impac of pahology

on human performance, is well posiioned for such coun-seling. However, o be an effecive counselor, he clin icalexercise physiologis also needs o undersand human

behavior in he conex of he indiv idual clien’s socia land physical milieu. his chaper seeks o underscoresome of he imporan heories and models of behaviorha have been shown o be imporan adjuncs for cli ni-cians seeking o help people make posiive changes inheir physical aciviy behavior.

The historical literature has established evidence thatpersons who engage in regular physical activity have anincreased physical working capacity (59); decreased

body fat (51); increased lean body tissue (51); increased bone density (52); and lower rates of coronary heartdisease (CHD) (39), diabetes mellitus, hypertension(55), and cancer (27). Increased physical activity is alsoassociated with greater longevity (40). Regular physicalactivity and exercise can also assist persons in improv-ing mood and motivational climate (38), enhancingtheir quality of life, improving their capacity for workand recreation, and altering their rate of decline infunctional status (50). A recent internat ional review ofthe health benefits of physical activity reinforces thesefindings (28).

When one is promoing planned exercise and physicalaciviy, one mus pay aenion o specifical ly designedoucomes. Noably, one needs o accoun for he healhand finess oucomes of a well-designed exercise prescrip-ion. Finally, a number of physiological, anaomical, and

behavioral characerisics should also be considered o


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ensure a safe, effecive, and enjoyable exercise experiencefor he paricipan.

Health Benefits

Physical activ ity has been defined as any bodily move-men produced by skeleal muscles ha resuls in caloricexpendiure (13). Because caloric expendiure usesenergy and because energy use enhances weigh loss or

weigh mainena nce, caloric expend iure is imporan inhe prevenion and managemen of obesiy, CHD, anddiabees mellius. Healhy People 2020 Physical AciviyObjecive PA-2.1 (58) highlighs he need for every adultto engage in moderate aerobic physical activity for at least150 min per week or 75 min of vigorous aerobic physicalactivity per week or an equivalent combination. Currenresearch suggess ha engaging regularly in moderaeaerobic physical aciv iy for a leas 150 min per week or

75 min of vigorous physical aciviy per week will helpensure ha he calories expended confer specific healh

benefis. For example, dai ly physical aciv iy equ ivaleno a susained walk for 30 min per day for 7 d would resulin an energy expendiure of abou 1,050 kcal per week.Epidemiologic sudies sugges ha a weekly expendi-ure of 1,000 kcal could have significan individual andpublic healh benefis for CHD prevenion, especiallyamong hose who are iniially inacive. More recenly, he

American College of Spors Medicine and he AmericanHear A ssociaion concluded ha he scienific evidenceclearly demonsraes ha regular, moderae-inensiyphysical aciviy provides subsanial healh benefis

(18). In addiion, following an exensive review of hephysiological, epidemiological, and clinical evidence, heScienific Commiee for he Naional Physical AciviyGuidelines formulaed his guideline:

Every U.S. adult should accumulate a minimum of 150min or more of moderate-intensity aerobic physicalactivity or 75 min of vigorous aerobic physical activity

per week (18).

his guideline emphasizes he benefis of moderaeand vigorous aerobic physical aciviy ha can be accu-mulaed in bous of 10 min of exercise or more. Iner-mien aciviy has been shown o confer subsanial

benefis. herefore, he recommended minues of aciviy

can be accumulaed in shorer bous of 10 min spacedhroughou he day. Alhough he accumulaion of 150min of moderae-inensiy or 75 min of vigorous-inensiyaerobic physical aciviy per week has been shown oconfer imporan healh benefis, hese guidelines areno inended o represen he opimal amoun of physicalaciviy for healh bu insead a minimum sandard or

base on which o build o obai n more speci fic oucomesrelaed o physical aciviy and exercise. Specifically,seleced finess-relaed oucomes may be a desired resulfor he physical aciviy paricipan, who may seek headdiional benefis of improved cardiorespiraory finess,muscle endurance, muscle srengh, f lexibiliy, and body

composiion. Indeed, Healhy People 2020 acually ookhese guidelines even furher by proposing addiionalobjecives. Objec ive PA-2.2 is o increase he propor ionof aduls who engage in aerobic physical aciv iy of a leasmoderae inensiy for more han 300 min/week, or morehan 150 min/week of vigorous inensiy, or an equiva lencombinaion; objecive PA-2.3 i s o increase he propor-ion of aduls who perform muscle-srenghening acivi-ies on 2 or more days of he week (58).

Fitness BenefitsRegular vigorous physical aciviy helps achieve andmainain higher levels of cardiorespiraory finess hanmoderae physical aciviy. here are five componens ofhealh-relaed finess: cardiorespiraory finess, musclesrengh, muscle endurance, flexibiliy, and enhanced

body composiion (see “Examples of Healh and FinessBenefis of Physical Aciv iy”).

Cardiorespiratory fitness or aerobic capaciy referso he body’s abiliy o perform high-inensiy aciv iy fora prolonged period of ime wihou undue physical sress

Examples of Health and Fitness Benefits of Physical Activity

Health benefits Fitness benefits Reduction in premature mortality Cardiorespiratory fitness

Reduction in cardiovascular disease risk Muscle strength and endurance

Reduction in colon cancer Enhanced body composition

Reduction in type 2 diabetes mellitus Flexibility

Improved mental health


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or faigue. Having h igher levels of cardiorespiraory fi-ness enables people o carry ou heir daily occupaionalasks and leisure pursuis more easily and wih greaerefficiency. Vigorous physical aciviies such as he fol-lowing help o achieve and mainain cardiorespiraory

finess and can also conribue subsanially o caloricexpendiure:

Very brisk wa lking

Jogging, ru nning

Lap swimming

Cycling

Fas dancing

Skaing

Rope jumping

Soccer

Baskeball

Volleyball

hese aciviies may also provide addiional proec-ion agains CHD over moderae forms of physical aciv-iy. People can achieve higher levels of cardiorespiraoryfiness by increasing he frequency, duraion, or inensiyof an aciv iy beyond he minimum recommendaion of20 min per occasion, on hree occasions per week, a morehan 45% of aerobic capaciy (3).

Muscular strength and endurance are he abiliyof skeleal muscles o perform work ha is hard or pro-longed or boh (3). Regular use of skeleal muscles helpso improve and mainain srengh and endurance, which

grealy affecs he abiliy o perform he asks of dailyliving wihou undue physical sress and faigue. Exam-ples of asks of daily living include home mainenanceand household aciviies such as sweeping, gardening,and raking. Engaging in regular physical aciviy suchas weigh raining or he regular lifing and carryingof heavy objecs appears o mainain essenial musclesrengh and endurance for he efficien and effecivecompleion of mos aciviies of dai ly living hroughouhe life cycle (3). he prevalence of such physical aciviy

behavior is si ll quie low, w ih recen prevalence esi-maes indicaing ha only 19.6% of he adul populaionengages in srengh rai ning a leas w ice per week (56).

Musculoskeletal flexibility refers o he range ofmoion in a join or sequence of joins. Join movemenhroughou he fu ll range of moion helps o improve andmainain flexibiliy (3). hose wih greaer oal bodyflexibiliy may have a lower risk of back injury (10). Olderaduls wih beer join flexibiliy may be able o drivean auomobile more safely (3, 61). Engaging regularly insreching exercises and a variey of physical aciviies

ha require one o soop, bend, crouch, and reach mayhelp o mainain a level of flexibiliy ha is compaible

wih quali y aciviies of daily living (3).Excess body weight occurs when oo few calories

are expended and oo many consumed for individual

meabolic requiremens (41). he mainenance of anaccepable raio of fa o lean body weigh is anoherdesired componen of healh-relaed finess. he resulsof weigh loss programs focused on dieary resricionsalone have no been encouraging. Physical aciv iy burnscalories, increases he proporion of lean o fa bodymass, and raises he meabolic rae (62). herefore, acombinaion of caloric conrol and increased physicalaciviy is i mporan for aaining a healhy body weigh.he 2010 Unied Saes Dieary Guidelines (57) havehighlighed he imporance of increasing he duraionof moderae-inensiy physical aciviy o 60 o 90 minper day as he necessary dose o preven weigh gain and

regain, respecively.

PARTICIPATION IN REGULARPHYSICAL ACTIVITY

In designing any exercise prescripion, he professionalneeds o consider various physiological, behavioral,psychosocial, and environmenal (physical and social)

var iables ha are relaed o par ic ipa ion in physicalaciviy (47). wo commonly idenified deerminansof physical aciviy paricipaion are self-efficacy andsocial support.

Self-efficacy, a consruc from social cogniive heory,is mos characerized by he person’s confidence oexercise under a number of circumsances and appearso be posiively associaed wih greaer paricipaion inphysical aciviy. Social suppor from fami ly and friendshas consisenly been shown o be associaed wih greaerlevels of physical aciviy paricipaion. Incorporaingsome mechanism of social suppor wihin he exerciseprescripion appears o be an imporan sraegy forenhancing compliance wih a physical aciv iy plan (23).Common barriers o paricipaion in physical aciviy areime consrains and injury. he professional can akehese barriers ino accoun by encouraging paricipans

o include physical aciviy as par of heir li fesyle, husno only engaging in planned exercise bu also incorpora-ing ransporaion, occupaional , and household physicalaciviy ino heir daily rouine.

Paricipans can also be counseled o help preveninjury. People are more likely o adhere o a program oflow- o moderae-inensiy physical aciviies han onecomprising high-inensiy aciviies during he early


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phases of an exercise program. Moreover, moderae aciv-iy is less l ikely o cause injury or undue discomfor (43).

A number of physical and social environmental fac-tors can also affec physical aciviy behavior (48). Familyand friends can be role models, can provide encourage-

men, or can be companions during physical aciviy. hephysical environmen ofen presens imporan barr ierso paricipaion in physical aciviy, including a lack of

bicyc le ra ils and walking pah s away from vehicularraffic, inclemen weaher, and unsafe neighborhoods(49). Sedenary behaviors such as excessive elevision

view ing or compuer use may also deer persons from being physica lly ac ive (49).

Risk Assessment

An exercise prescrip ion may be fulfi lled in a leas hreedifferen ways: (1) on a program-based level ha con-

siss primarily of supervised exercise raining (24); (2)hrough exercise counseling and exercise prescripionfollowed by a self-moniored exercise program (26); and(3) hrough communiy-based exercise programmingha is self-direced and self-moniored (63).

Wihin supervised exercise programs a nd programsoffering exercise counseling and prescripion, parici-pans should complee a brief medical hisory and riskfacor quesionnaire and a preprogram evaluaion (3).More informaion on he medical hisory and risk facorquesionnaire and preprogram evaluaion is presenedin chaper 4.

When one is developing a communiy-based, sel f-

direced program, medical clearance is lef o he judg-men of he individual paricipan. An acive physicalaciviy promoion campaign in he communiy seekso educae he populaion regarding precauions andrecommendaions for moderae and vigorous physicalaciviy (14). hese messages should provide i nformaionha paricipans mus know before beginning a regularprogram of moderae o vigorous physical aciv iy. hisinformaion should encompass he following:

1. Awareness of preex ising medica l problems (e.g.,CHD, arhriis, oseoporosis, or diabees mellius)

2. Consulaion before saring a program, w ih a phy-

sician or oher appropriae healh professional, if anyof he previously menioned problems are suspeced

3. Appropriae mode of ac iviy and ips on differenypes of aciviies

4. Principles of raining inensiy and general guide-lines as o raing of perceived exerion and ra ininghear rae

5. Progression of aciviy and principles of saringslowly and gradually increasing aciviy ime andinensiy

6. Principles of monioring sympoms of excessivefaigue

7. Maki ng exercise fun and enjoyable

Theories and Models ofPhysical Activity Promotion

Hisorically, he mos common approach o exerciseprescripion aken by healh professionals has been direcinformaion. In he pas, he counseling sequence ofenconsised of he following:

1. Exercise assessmen, usually cardiorespiraory fi-ness measures

2. Formulaion of he exercise prescripion3. Counseling he paien regarding

• mode (usually large-muscle aciviy),

• frequency (hree o five sessions per week),

• duraion (20-30 mi n per session), and

• inensiy (assigned arge hear rae based onhe exercise assessmen) (25)

4. Review of he exercise prescripion by he healhprofessional and paricipan

5. Follow-up

• Visis (reassessmens and revising of heexercise prescripion)

• Phone conac

Mos of he research evaluaing his radiionalapproach o exercise prescripion has no been oofavorable in erms of is resuls wih respec o long-ermcompliance and benefis (42). ha is, mos people who

begin an exercise program drop ou during he firs 6 mo. Why has he radiional i nformaion-sharing approach been used? Because i’s easies for he clinic ian, requ iresless ime, and is prescripive. However, i is no ineracive

wih he clien . More recenly, conempora ry heoriesand models of human behavior have been examined anddeveloped for use in exercise counseling and inerven-

ions (1, 2, 4-6, 32, 33, 44, 45). hese heories, referredo as cogniive–behavioral echniques, represen hemos salien heories and models ha have been usedo promoe he iniiaion of and adherence o physicalaciviy. hese approaches vary in heir applicabiliy ophysical aciviy promoion. Some models and heories

were desi gned pri mari ly as gu ides o unders and ing


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behavior, no as guides for designi ng i nervenion pro-ocols. Ohers were specifical ly consruced wih a viewoward developing cogniive–behavioral echniques forphysical aciviy behavior iniiaion and mainenance.

Consequenly, he clinical exercise physiologis may findha he majoriy of he heories summarized in able2.1 will assis in undersanding physical aciviy behav-ior change. Neverheless, oher heories have evolved

Table 2.1 Summary of Theories and Models Used in Physical Activity Promotion

Theory or model Level Key concepts

Health belief model (45) Individual Perceived susceptibility

Perceived severity

Perceived benefits

Perceived barriers

Cues to action

Self-efficacy

Relapse prevention (32, 33) Individual Skills training

Cognitive reframing

Lifestyle rebalancing

Theory of planned behavior (1, 2) Individual Attitude toward behavior

Outcome expectations

Value of outcome expectations

Subjective norm

Beliefs of others

Motive to comply with others

Perceived behavioral control

Social cognitive theory (4, 6) Interpersonal Reciprocal determinism

Behavioral capability

Self-efficacy

Outcome expectations

Observational learning

Reinforcement

Social support (5) Interpersonal Instrumental support

Informational support

Emotional support

Appraisal support

Ecological perspective (29) Environmental Multiple levels of influence:

• Intrapersonal

• Interpersonal

• Institutional

• Community

• Public policy

Transtheoretical model (11, 30, 31, 44) Individual PrecontemplationContemplation

Preparation

Action

Maintenance

Adapted from K. Glanz and B.K. Rimer, 1995, Theory-at-a-glance: A guide for health promotion practice. (U.S. Department of Healthand Human Services).


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sufficienly o provide specific inervenion echniqueso assis in behavior change.

he Paien-Cenered Assessmen & Counseling forExercise & Nur iion (PACE and PACE+) maeria ls weredeveloped for use by he primary care provider in he

clinical seing argeing apparenly clinically healhyaduls (30). he maerials have been evaluaed for bohaccepabiliy and effeciveness in a number of differenclinical seings (11, 30, 31). Sample maerials aken fromPACE have been included in pracical applicaion 2.1.hese maerials are i nended o provide a quick look ahe seps in assessing and counseling an individual forphysical aciviy. he maerials incorporae many ofhe principles from a number of heoreical consrucsreviewed in able 2.1. For furher explanaion of PACEmaerials, visi he PACE websie a www.paceprojec.org.

Wankel and colleagues (60) demonsraed he effecive-ness of cogniive–behavioral echniques for enhancing

physical aciviy promoion effors in showing ha heuse of increased social suppor and decisional sraegiesimproved adherence o exercise classes among parici-pans. Marin and colleagues (34) demonsraed hrougha series of sudies he posiive effecs of personalizedpraise and feedback and he use of flexible goal seingamong paricipans on exercise class adherence. Parici-pans in he enhanced i nervenion group demonsraedan 80% aendance rae during he inervenion compared

wih he conrol group’s 50% aendance rae (34).McAuley and coworkers (35) successful ly emphasized

sraegies o increase self-efficacy and hereby increasephysical aciviy levels among adul paricipans in a

communiy-based physical aciviy promoion program.hese successful sraegies included social modelingand social persuasion o i mprove compliance and exer-cise adherence. Promoing physical aciviy hrough

home-based sraegies holds much promise and mighprove o be cos-effecive (54). hrough ailored mailand elephone inervenions, significan levels of socialsuppor and reinforcemen have been shown o enhanceparicipans’ self-efficacy i n complying wih exercise pre-

scripion, hus significanly i mproving levels of physicalaciviy (15).

Final ly, i has been demonsraed ha lifestyle-basedphysical activity promoion increases he levels ofmoderae physical aciv iy among aduls. Lifesyle-basedphysical aciviy focuses on home- or communiy-basedparicipaion in many forms of aciviy ha include muchof a person’s daily rouine (e.g., ranspor, home repairand mainenance, yard mainenance) (16). his approachevolved from he idea ha physical aciv iy healh benefismay accrue from an accumulaion of physical aciviyminues over he course of he day (59). Because lackof ime is a common barrier o regular physical aciv-

iy, some researchers recommend promoing lifesylechanges whereby people can enjoy physical aciviyhroughou he day as par of heir l ifesyle. aking hesairs a work, aking a walk during lunch, and walkingor biking for ransporaion are all effecive forms oflifesyle physical aciviy. Assessing he common barriers(able 2.2) o physical aciviy among paricipans can behelpful for developing individual awareness and argeingsraegies o overcome he barriers.

Ecological Perspective

A cr iicism of mos heories and models of behavior

change is ha hey emphasize individual behavior changeand pay lile aenion o socioculura l and physical envi-ronmenal inf luences on behavior (7). Recenly, inereshas developed in ecological approaches o increasing

Table 2.2 Barriers to Being Active Quiz: What Keeps You From Being More Active?

Insruc ions: Lised here are reasons ha people give o indicae why hey do no ge as much physical aciviy as heyshould. Please read each saemen and circle he number ha represens how likely you are o say i.

How likely are you to say?Verylikely

Somewhatlikely

Somewhatunlikely

Veryunlikely

1. My day is so busy now that I just don’t think I can make the timeto include physical activity in my regular schedule.

3 2 1 0

2. None of my family members or friends like to do anything active,so I don’t have a chance to exercise.

3 2 1 0

3. I’m just too tired after work to get any exercise. 3 2 1 0

4. I’ve been thinking about getting more exercise, but I just can’tseem to get started.

3 2 1 0

5. I’m getting older so exercise can be risky. 3 2 1 0


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How likely are you to say?Verylikely

Somewhatlikely

Somewhatunlikely

Veryunlikely

6. I don’t get enough exercise because I have never learned the skillsfor any sport.

3 2 1 0

7. I don’t have access to jogging trails, swimming pools, bike paths,and so forth. 3 2 1 0

8. Physical activity takes too much time away from othercommitments—time, work, family, and so on.

3 2 1 0

9. I’m embarrassed about how I will look when I exercise with others. 3 2 1 0

10. I don’t get enough sleep as it is. I just couldn’t get up early or stayup late to get some exercise.

3 2 1 0

11. It’s easier for me to find excuses not to exercise than to go out todo something.

3 2 1 0

12. I know of too many people who have hurt themselves by overdoingit with exercise.

3 2 1 0

13. I really can’t see learning a new sport at my age. 3 2 1 0

14. It ’s just too expensive. You have to take a class or join a club or buythe right equipment.

3 2 1 0

15. My free times during the day are too short to include exercise. 3 2 1 0

16. My usual social activities with family or friends do not includephysical activity.

3 2 1 0

17. I’m too tired during the week and I need the weekend to catch upon my rest.

3 2 1 0

18. I want to get more exercise, but I just can’t seem to make myselfstick to anything.

3 2 1 0

19. I’m afraid I might injure myself or have a heart attack. 3 2 1 0

20. I’m not good enough at any physical activity to make it fun. 3 2 1 0

21. If we had exercise facilities and showers at work, then I would bemore likely to exercise. 3 2 1 0

Follow hese insrucions o score yourself:

• Ener he numbers you circled in he spaces provided, puing he number for saemen 1 in space 1, for sae-men 2 in space 2, and so on.

• Add he hree scores on each row. Your barriers o physical aciv iy fall ino one or more of seven caegories: lackof ime, social influences, lack of energy, lack of willpower, fear of injury, lack of skill, and lack of resources. Ascore of 5 or above in any caegory shows ha he barrier is an imporan one for you o overcome.

1 = 8 = 15 = Row sum = Lack of time

2 = 9 = 16 = Row sum = Social influence

3 = 10 = 17 = Row sum = Lack of energy4 = 11 = 18 = Row sum = Lack of willpower

5 = 12 = 19 = Row sum = Fear of injury

6 = 13 = 20 = Row sum = Lack of skill

7 = 14 = 21 = Row sum = Lack of resources

From Centers for Disease Control and Prevention. Available: www.cdc.gov


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paricipaion in physical aciviy (46). hese approachesplace he creaion of supporive environmens on par

wih he developmen of personal skil ls and he reoriena-ion of healh services. Creaion of supporive physicalenvironmens is as imporan as inrapersonal facors

when behavior change is he defined oucome. Sokols(53) il lusraed his concep of a healh-promoing envi-ronmen by describing how physical aciviy could bepromoed hrough he esablishmen of environmenalsuppors such as bike pahs, parks, and incenives oencourage walking or bicycling o work. An u nderlyingheme of ecological perspecives is ha he mos effec iveinervenions occur on muliple levels. Inervenions hasimulaneously influence muliple levels and mulipleseings (e.g., schools, worksies) may be expeced o lead

o greaer and longer-lasing changes and ma inenanceof exisi ng healh-promoing habis.

In addiion, i nvesigaors have recenly demonsraedha behavioral inervenions primarily work by means ofmediaing variables of inrapersonal and environmenalfacors (46). Mediaing variables are hose ha faciliaeand shape behaviorswe all have a se of inrapersonal

facors (e.g., personaliy ype, moivaion, geneic pre-disposiions) and environmenal facors (e.g., social

neworks like family, culural influences, and he builand physical environmens). However, few researchershave aemped o delineae he role of hese mediaingfacors in faciliaing healh behavior change. Sall is andcolleagues (46) recenly discussed how difficul i is oassess he effeciveness of environmenal and policyinervenions because of he relaively few evaluaionsudies available. However, based on he experienceof he New Souh Wales (Ausralia) Physical Aciviyask Force, a model has been proposed o help wihundersanding he seps necessary o implemen heseinervenions (37). Figure 2.1 presens an adapaion ofhis model as prepared by Salli s and colleagues (46) and

oulines he necessary ineracion beween advocacy,coordinaion, or planning, agencies, policies, and envi-ronmens o make such inervenions a rea liy. Anoherpragmaic model ha appears o have relevance for hepromoion of physical aciviy has been proposed byMcLeroy and colleagues (36). his model specifies fivelevels of deerminans for healh behavior:

Practical Application 2.1

THE PACE+ MODEL

Telling patients what to do doesn’t work, especially over the long term. An effective behavioral model helps tofacilitate long-term changes by telling them how to change. PACE (Patient-Centered Assessment & Counseling forExercise & Nutrition) is a comprehensive approach to physical activity and nutrition counseling that uses materialsdeveloped by a team of researchers at San Diego State University. The curriculum draws heavily on the “stages ofchange” model, which suggests that individuals change their habits in stages. Taking into account each person’sreadiness to make changes, PACE provides tailored recommendations for patients in each stage. PACE offersthree different counseling protocols. Empirically derived behavioral strategies are applied in each protocol. Thedevelopment of the PACE model began in 1990, with funding originally from the Centers for Disease Controland Prevention, the Association of Teachers of Preventive Medicine, and San Diego State University. The originalPACE materials, first released in 1994, dealt only with physical activity. The program was originally developedto overcome barriers to physician counseling for physical activity—especially lack of time for counseling, lack ofstandardized counseling protocols, and lack of training in behavioral counseling. Counseling was designed tobe delivered in 2 to 5 min during a general patient checkup.

The PACE+ materials were thoroughly tested and found to be acceptable and usable by health care providers

and patients across the United States. Physicians also found PACE to be practical, improving their confidence incounseling patients about physical activity (12). In a controlled efficacy study of 212 sedentary adults, patientswho received PACE counseling increased their minutes of weekly walking by 38.1 compared with 7.5 among thecontrol group. Additionally, 52% of the patients who received PACE counseling adopted some physical activitycompared with 12% of the control group (12).

Since these earlier studies, the current PACE+ materials have been revised to include the recommendationsfrom the Surgeon General’s report Physical Activity and Health (59), as well as the Physical Activity Guidelines(42). The current materials also address nutrition behaviors such as decreasing dietary fat consumption; increasingfruit, vegetable, and fiber consumption; and balancing caloric intake and expenditure for weight control (12).


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1. Inrapersonal facors, including psychological and biological variables, as well as developmenal hisory

2. Inerpersonal processes and primary social groups,including family, friends, and coworkers

3. Insiuional facors, including organizaions such

as companies, schools, healh agencies, or healhcare faciliies

4. Communiy facors, which include relaionshipsamong organizaions, insiuions, and social ne-

works in a defined area

5. Public policy, which consiss of laws and policies ahe local, sae, naional, and supranaional levels

Important in implementing this concept of behav-ioral determinants is real izing the key role of behavioralsettings, which are the physical and social situations in

which behavior occ urs. Simply stated, human behaviorsuch as physical activity is shaped by its surroundingsif

you’re in a support ive socia l environment with accessto space and facilities, you are more likely to be active.

It is important to acknowledge the determinant roleof selected behavioral settings: Some are designed toencourage healthy behavior (e.g., sport fields, gymna-siums, health clubs, and bicycle paths), whereas othersencourage unhealthy (or less healthy) behaviors (e.g., fast

food restaurants, vending machines with high-fat andhigh-sugar foods, movie theaters). We need to under-stand the environment in which our client lives. Thesestructures (e.g., fields, gymnasiums, community centers)are part of each of our liv ing environments; people whodisregard them are less l ikely to be act ive. For physicalactivity providers, a potentially important adjunct inassessing and prescribing physical activity interventionsfor participants is understanding the physical and socialcontexts in which their patients live. This informationcan be obtained from various sources and can be at thelevel of the individual or at the more general commu-nity level. When individual physical activity behavior

information is coupled with sociodemographic, physi-cal, and social context information, physical activity

Coalition or intersectoral groupPublic healthMedicalSportFitness industryResearchEducationParks and recreation

Local government

Safety• Crime reduction• Bike lane design• Sidewalk repair

Support forpersonaltransportation(walking, biking)

Supportiveenvironments• Settings• Facilities• Programs

Parks and recreation departmentsWorkplacesSchoolsSports organizationsChurches

Community organizationsUrban planningGovernments for funding

Criminal justiceCommunity groupsTransportation departmentLocal government

Transportation department (roads)Urban planning or developersPublic transitGovernments for funding

ArchitectsGovernments for building codes

Transportation departmentsEmployersHealth insuranceGovernments

Health or medicalEducation

MediaFitness industrySports organizations

Advocacy, coordination, orplanning

Agencies Policies Environments

Availability oraccess to facilities,programs

Support for incidentalactivity indoors

Incentives forphysical activity

Education

Behavior changeprograms

Physical

activity

Figure 2.1 Conceptualization of the development of policy and environmental interventions to promote physical activity.

Reprined from American Journal of Preventive Medicine , Vol. 15, J .F. Sal lis e a l., “Environmenal and policy inervenions o promoephysical acivi y,” pgs. 379-397, Copyrigh 1998, wih permission from Elsevier.


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interventions can be further tailored to maximize theparticipant’s physical activity behavior change andmaintenance plan. Exercise physiologists cannot alterthe cl ient’s physical environment; however, they should

be able to address environmental barriers and provide

insights into how to overcome these barriers. I n the longrun, we all should be a part of changing our environmentsfor the better.

An example of such ailoring for physica l ac iviypromoion ha alers physical aciviy behaviors is he

work of Linenger and colleagues (29), an effor o increasephysical aciviy levels among naval personnel hrougha mulifacorial environmenal and policy approacho physical aciv iy promoion. hese invesigaorscompared an “enhanced base” o a “conrol base.” heenhancemens involved increasing he number of bikerails on base, acquir ing new exercise equipmen for helocal gy m, opening a women’s finess cener, insiui ng

aciviy clubs, and providing released ime for physicalaciviy and exercise (29). he changes were posiivefor hose living on he enhanced baseha is, heyincreased heir physical aciviy levels.

Another example, this time emphasizing an incentive- based approach to promoting physical activ ity, is the work of Epstein and Wing (17). A lthough this work was underta ken quite some time ago, the lessons are very relevant in today’s inactive culture. In this study,contracts and the use of a lottery (a popular enterprisetoday!) were used to boost exercise attendance withthe consequence of increasing participants’ overallphysical activity levels. Compared with results for a

“usual care” comparison group, adherence and activ itylevels were significantly improved and sustained (37).However, caution in using an incentive-based approach

has been urged by some researchers who believe thatover the long term, participants never internalize thehealth behaviormeaning that they are likely to stray

back to sedentar y habits once the incentive is removedor loses its appeal. Nevertheless, incentives have been

proven to be effective in the short term. Additionalcommunity-based environmental efforts to influencephysical activ ity behavior have included the use of signsin public settings to increase use of stairs a nd walkways(8, 9). These latter studies are examples of single inter-

vention efforts that can be carr ied out in concert withsystematic exercise prescription efforts among indi-

viduals. Thus, the increase in stair usage as a result of apromotional campaign ca n help individuals meet theirprescribed energy expenditure requirements. Table 2.3outlines some of the common barriers to people becom-ing more physically active. Also listed are some sug-gested solutions, although these can var y from client to

client.Useful resources for he clinical exercise physiologis

are he very recen evidence-based recommendaionsfor physical aciviy promoion in communiies (www.hecommuniyguide.org/pa/defaul.hm). he evidence

base for hese recommenda ions provides insighs i nohow exercise praciioners can inegrae heir clinicaleffors o assess and counsel paiens ino supporive andreinforcing environmens. he recommendaions aresummari zed wih respec o informaional, behavioral–social, and environmenal approaches o promoingphysical aciviy (able 2.4) (20, 22). A more recenreview furher esablishes hese physical aciviy iner-

venion domains and expa nds he number of ev idence- ba se d ap proa ch es o promo ing ph ys ic al ac iv i y(21).

Table 2.3 Tips on Overcoming Potential Barriers to Regular Physical Activity

Barriers Suggestions for overcoming physical activity barriers

Lack oftime

Identify available time slots. Monitor your daily activities for 1 wk. Identify at least three 30 min timeslots you could use for physical activity.

Add physical activity to your daily routine. For example, walk or ride your bike to work or shopping,organize school activities around physical activity, walk the dog, exercise while you watch TV, parkfarther from your destination.

Make time for physical activity. For example, walk, jog, or swim during your lunch hour, or take fitnessbreaks instead of coffee breaks.

Select activities that require minimal time, such as walking, jogging, or stair climbing.

Socialinfluence

Explain your interest in physical activity to friends and family. Ask them to support your efforts.

Invite friends and family members to exercise with you. Plan social activities that involve exercise.

Develop new friendships with physically active people. Join a group, such as the YMCA or a hikingclub.


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Barriers Suggestions for overcoming physical activity barriers

Lack ofenergy

Schedule physical activity for times in the day or week when you feel energetic.

Convince yourself that if you give it a chance, physical activity will increase your energy level; then try it.

Lack of

motivation

Plan ahead. Make physical activity a regular part of your daily or weekly schedule and write it on your

calendar.Invite a friend to exercise with you on a regular basis. Then both of you write it on your calendars.

Join an exercise group or class.

Fear ofinjury

Learn how to warm up and cool down to prevent injury.

Learn how to exercise appropriately considering your age, fitness level, skill level, and health status.

Choose activities that involve minimum risk.

Lack ofskill

Select activities that require no new skills, such as walking, climbing stairs, or jogging.

Exercise with friends who are at the same skill level as you are.

Find a friend who is willing to teach you some new skills.

Take a class to develop new skills.

Lack ofresources

Select activities that require minimal facilities or equipment, such as walking, jogging, jumping rope, orcalisthenics.

Identify inexpensive, convenient resources available in your community (community educationprograms, park and recreation programs, worksite programs, and so on).

Weatherconditions

Develop a set of regular activities that are always available regardless of weather (e.g., indoor cycling,aerobic dance, indoor swimming, calisthenics, stair climbing, rope skipping, mall walking, dancing,gymnasium games).

Look at outdoor activities that depend on weather conditions (e.g., cross-country skiing, outdoorswimming, outdoor tennis) as bonuses—extra activities possible when weather and circumstancespermit.

Travel Put a jump rope in your suitcase and jump rope.

Walk the halls and climb the stairs in hotels.

Stay in places with swimming pools or exercise facilities.

Join the YMCA or YWCA (ask about reciprocal membership agreement).

Visit the local shopping mall and walk for 30 min or more.Take a portable audio player and listen to your favorite upbeat music as you exercise.

Familyobligations

Trade babysitting time with a friend, neighbor, or family member who also has small children.

Exercise with the kids—go for a walk together, play tag or other running games, or get aerobic danceor exercise music for kids (several are on the market) and exercise together. You can spend timetogether and still get your exercise.

Hire a babysitter and look at the cost as a worthwhile investment in your physical and mental health.

Jump rope, do calisthenics, ride a stationary bicycle, or use other home gymnasium equipment whilethe kids are busy playing or sleeping.

Try to exercise when the kids are not around (e.g., during school hours or their nap time).

Encourage exercise facilities to provide child care services.

Retirementyears

Look at your retirement as an opportunity to become more active instead of less. Spend more timegardening, walking the dog, and playing with your grandchildren. Children with short legs and

grandparents with slower gaits are often great walking partners.Learn a new skill that you’ve always been interested in, such as ballroom dancing, square dancing, orswimming.

Now that you have the time, make regular physical activity a part of every day. Go for a walk everymorning or every evening before dinner. Treat yourself to an exercise bicycle and ride every day whilereading a favorite book or magazine.

Content in the “Personal Barriers” taken from Promoting physical activity: A guide for community action, 1999 (USDHHS).


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CONCLUSION Wihin he pas decade, physical aciviy has emerged asa key facor in he prevenion and managemen of chroniccondiions. Alhough he role of exercise in healh pro-moion has been appreciaed and applied for decades,recen findings regarding he mode, frequency, duraion,and inensiy of physical aciviy have modif ied exerciseprescripion pracices. Included in hese modificaionshas been he delineaion beween healh and finessoucomes relaive o he physical aciviy prescripion.Mos imporanly, new approaches o physical aciviyprescripion and promoion ha emphasize a behavioralapproach wih documened improvemens in compli-ance have now become available o healh professionals.Behavioral science has conribued grealy o he under-sanding of healh behaviors such as physical aciviy.Behavioral heories and models of healh behavior have

been reexamined in ligh of physical aciviy and exercise.

Alhough more resea rch is needed o furher developsuccessful, well-defined applicaions ha are easily adap-able for inervenion purposes, behavioral principles andguidelines have evolved ha are designed o help hehealh professional undersand healh behavior changeand guide people ino lifelong paerns of increased physi-cal aciviy and improved exercise compliance.

New froniers in he applicaion of exercise prescrip-ion o specific populaions, as well as effors o definehe specific dose (frequency, inensiy, duraion) ofphysical aciviy for specif ic healh and finess oucomes,are now being explored. As his informaion becomesavailable, i mus be inroduced o he paricipan via hemos effecive behavioral paradigms, such as he modelsdiscussed in h is chaper. Moreover, posiive changes inhe paricipan’s physical and social envi ronmens musoccur o enhance compliance wih exercise prescripions.In urn, increased levels of physical aciviy among allpeople will improve healh and funcion.

Table 2.4 Summary of Recommended Physical Activity Interventions—Guide toCommunity Preventive Services

Intervention Recommendation

INFORMATIONAL APPROACHES TO INCREASING PHYSICAL ACTIVITY

Community-wide campaigns Recommended (strong evidence)

Point-of-decision prompts Recommended (sufficient evidence)

Mass media campaigns Insufficient evidence

BEHAVIORAL AND SOCIAL APPROACHES TO INCREASING PHYSICAL ACTIVITY

Individually adapted health behavior change Recommended (strong evidence)

Health education with TV and video turnoff Insufficient evidence

College-age physical and health education Insufficient evidence

Family-based social support Insufficient evidence

School-based physical education Recommended (strong evidence)

Community social support Recommended (strong evidence)

ENVIRONMENTAL AND POLICY APPROACHES TO INCREASING PHYSICAL ACTIVITY

Creation of or enhanced access to places for physical activity Recommended (strong evidence)

Community-scale urban design and land use Recommended (sufficient evidence)

Street-scale urban design and land use Recommended (sufficient evidence)

Transport policy and practices Insufficient evidence

Reprinted from Guide to Community Preventive Services. Available: www.thecommunityguide.org/pa/pa.pdf


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Key Terms

cardiorespiratory fitness (p. 20)

environmental factors (p. 22)

excess body weight (p. 21)

lifestyle-based physical activity(p. 24)

muscular strength and

endurance (p. 21)

musculoskeletal flexibility (p. 21)

physical activity (p. 20)

self-efficacy (p. 21)

social support (p. 21)

CASE STUDY

MEDICAL HISTORY Mrs. KY is a 45 yr old Caucasian female, married w ih wo eenage sons. She is employed as a senior manager aa large bank and repors ex periencing an “above average” level of ension and sress. She presens a he referralof her primary care physician, who has observed ha he clien has elevaed blood pressure and choleserollevels ha may be atribued o her sressful and highly sedenary job. In addiion, he clien admis ha she

would like o lose 30 o 40 lb (14 o 18 kg) and improve her finess so ha she can ride her bike wih her husbandon a communiy rai l rail recenly insa lled by her neighborhood.

DIAGNOSISMrs. KY is a sedenary bu oherw ise healhy middle-aged female wih significan risk facors for cardiovasculardisease including obesiy, dyslipidemia, and psychosocial sress. A he reques of her physician she seeks osar exercising as par of a disease prevenion program.

EXERCISE TEST RESULTSTe clien is 5 fee 6 in. all (168 cm) and weighs 196 lb (89 kg), wih a body mass index of 31.7. She has aresing hear rae of 85 beas · min–1 and a resing blood pressure of 136/89 mmHg. Her oal choleserol is198 mg · dl–1 unreaed, and her high-densiy lipoproeins are 34 mg · dl–1. Her graded readmill sress esrevealed ha she has a V

. O

2max of 20.5 ml · kg–1 · min–1 , which is normal for an unfi woman of her age range.

Her elecrocardiogram was also unremarkable a res, as well as dur ing and following her es. In addiion, sherepored smoking from ages 17 o 40. She also complains of occasional join siffness in her hands and an kles.Te clien describes herself as nonahleic and admis o never paricipaing in an organized spor or exerciseseting. She is aware of he benefis of exercise bu did no feel an i ncenive o begin a formal program unilher docor’s recommendaion. Te clien jokes ha alhough her workday is highly organized and sr ucured,he res of her life is chaoic and ha i is due only o he suppor of her husband and kids ha any hing gesdone a home. She lamens ha her eaing habis are arocious and ha she is so i red when she ges home from

work ha she has only enough energy o ma ke din ner before crashing i n fron of he elevision. She presenso you o sar a workou program ha w ill help achieve her goals.

EXERCISE PRESCRIPTIONTe exercise plan including he radiional componensfrequency, inensiy, duraion, and modaliy(discussed in dea il in laer chapers)may be ailored o address speci fic risk facors. Te subjec’s medical

hisory, however, clearly indicaes ha hi s person had no prioriized exercise paricipaion unil she receivedher docor’s recommendaion. Moreover, she presens wih numerous poenial barriers o engaging in aphysically acive lifesyle, as well as behaviors ha conribue o her overweigh saus. Te clinician should assishe paricipan in esablishing awareness and developing sraegies o address hose barriers. Furhermore, heclinician should consider ailoring sraegies for moivaing he par icipan oward he adopion of a healhy,physically acive lifesyle.

(continued)


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DISCUSSION QUESTIONS

1. Applying he ransheoreica l model, a wha sage of exercise adopion is h is clien?

2. Based on your response o quesion 1, wha ypes of inervenions are mos appropriae for his sageof change and why?

3. If you used he healh belief model, wha facors would you emphasize o achieve opimal exerciseadherence?

4. How would Bandura’s social cog niive heory be relevan o fosering exercise adherence for his cl ien?

Case Study (continued)

Behavioral Approaches to Physical Activity Promotion

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