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Unit III: Chapters 8-11 & 17-19 1

Promoting Physical Activity

Individual Level Intervention StrategiesGroup Level Intervention StrategiesCommunity Level Intervention Strategies


Individual Intervention Strategies


Types of Interventions

Behavior modificationReinforcementGoal settingContractsClient profiling (e.g. barriers to exercise)Self-monitoring(e.g. logs, fitness testing)


Types of Interventions

Health EducationBenefits of exercise

Health risk appraisalConfronting the client about their risk

Exercise prescriptionDuration, intensity, frequencyProgression

Physical Education Programs


Individual InterventionsWhat chance will one adhere to exercise in the absence of an interventionBenefits of an intervention program was:

Identical for both genders, across ages, and race.Greater for healthy clients then non-healthy

Small to moderate effect size for people who were high risk for CV disease

Found to increase adherence rates by as much as 38%


Which type of intervention is the most important?

Behavior modification had a very largeeffect size on increasing physical activity where as all others approaches were small.


How should the intervention be delivered?

Mediated Interventions were more effective then face-to-faceInterventions delivered in groups were better then those delivered individuallyLarger in non-supervised than supervisedInterventions delivered in community settings had greatest impact then schools, home, work site and health care settings.


Delivery (continued!)

Interactive software over the computer has been shown be an effective intervention.

Webcam’sUse the web & internet


Exercise Prescription Intervention

Interventions that targeted a more active leisure time lifestyle was greater then specific strength and/or aerobic exercise programming.Low-intensity PA was greater then high intensity PA. Shorter exercise bouts were greater than longer.

“It would seem that people are more likely to be physically activity if the behavior (exercise) is not perceived to be overly stressful and integrated into their lifestyle”


Behavior Modification Interventions

Based upon:Bandura’s Model of Self-efficacyTranstheortical or Stage Model


Self-Efficacy

Belief and expectations about how capable one is to perform PA or exercise to achieve an outcome( e.g. low weight, fitness).Major determinate of adherence in all the models


Self-EfficacySpecific to a type of exercise

High self-efficacy for following an aerobic routines increases the likelihood someone will enroll in an aerobic class but may not generalize to beginning a weight training class.High self-efficacy for low to moderate exercise dance but not high intensity, high impact aerobic dance

Self–Efficacy Sources

ExerciseExercise


Stage TheoryStage model reflects behavior change in exercise adherenceAssumes individuals in same stage are similar with respect to characteristics, such as level of PA.Therefore, there are specific behavior modification interventions that are appropriate at each stage.


Stage Model

1. Pre-contemplation2. Contemplation3. Preparation4. Action5. Maintenance


Precontemplation Stage

Individual are inactive and have no intention to start exercising. They are not seriously thinking about changing their level of PA within the next six months.


Behavior Interventions at Precontemplation Stage

Goal: To begin thinking about changing

Strategies:Provide them health information of benefitsReduce the actual and perceived costs & barriers

Intention to exercise is lowWillingness is lowSelf-efficacy is lowPerceived & actual access to facilities

Strengthen actual and perceived benefits of PA


Pre-contemplation Stage

Health pamphletsMedia advertisingAwareness of risksBenefits of exercisingHealth clinics & workshopsWellness seminars (topics such as weight loss and physical activity)


Contemplation Stage

Individuals are also inactive, but they intend to start regular exercise within the next six months.


Behavior Intervention at Contemplation State

Goal: To adopt regular exercise

StrategiesMarketing and media campaigns with accurate informationActivities to increase self-efficacy

Modeling, demonstrating, verbal persuasionEvaluate pros and cons of exercise


Decision Balance SheetPositive Negative


Preparation Stage

Individuals are active below the criterion level (CDC or ASCM) but intend to become more active in near future (1 month)Starters or irregular exercisers


Intervention for Preparation Stage

Goals: To adopt regular exercise at criterion levels

StrategiesAssessment of physical and psychosocial traitsGoal SettingEvaluate one’s environment and social supportEvaluate one’s barriers to modifying behavior


Preparation StrategiesSelf-Monitoring activities

Weekly workout progress logComputer programs that record your workouts

Self-monitoring exerciser checklist of type, mode, intensity of exercise, time, distance, heart rate, number of steps, kcal, etc.

Cue controlsStarter Program


Cue Controls

Have a set time for PASeparate PA from other activitiesPA is pleasant surroundingsSeek to spend time with friendsExercise postersModeling effect from spouse


Starter Program3-5 METS (low in intensity)Establish a exercise habit3 days a week!Just do it! 6-8 weeks!Short in duration

Aerobic 10 -15 minutesWeight 7-10 stations; 8-15 reps.

Gradually work on duration not intensity.Client choiceKeep a logBefore and after (Show benefit in weight, inches, etc.)


Action Stage

Individual engaged in regular exercise at the criterion level for less than six months.This is the least stable stage are are at great risk of relapse.


Assessment Physiological

Medical HistoryExercise restrictionsResting HR/BPBMI (obesity)Body Fat %Functional capacityDietary information

PsychosocialExercise HistorySelf-efficacyBarriers to exerciseExercise thoughtsStage of changeMeasures of stress, depression, & anxietyGoals


Psychosocial ThemeDetermine one’s risk for non-adherence:

Based on assessmentsExercise thoughts, level of self-efficacy, etc.

OccupationLevel of activity at work, time demands, and flexible schedule

StressLevel of job stress and style of coping with stress.

Social SupportLevel of support from others, spouse, etc.

Attendence RateFrequency in attending PA faculty or class.

GoalsVague in nature or specific


Interventions at Action StageGoal: To establish exercise as a habit

Strategies:Rewards and punishment

Contingency contracts

Slippage controlBoredom, lack of time, laziness, vacations, and illness

Proper exercise prescription


Contracts

I will:______I will enlist the help of:____My responsibilities are:______My helper’s responsibilities are:____My reward:____My punishment:____


Effective Rewards What kinds of things do you like to have?What are your major interests? Hobbies?Who do you like to be with?What do you do for fun?What do you do to relax?What makes you feel good?What would you hate to lose?


Slippage ControlTime management trainingStress management trainingBarriers to exercise

Tape the TV showBackup Plan (type & place)

Swimming pool not open I will walk on treadmillSnowing can’t walk, put on a aerobic tape


Maintenance Stage

Individuals who have been exercising regularly for more than six months.Risk of relapse is low.


Intervention at Maintenance Stage

Re-evaluate goals at regular intervals every 6-8 weeks.ACSM Exercise prescription GuidelinesVariety of exercise routines


Group level Strategies


Group Level Interventions

50% of people who come to private fitness clubs, community centers, universities, and etc., drop out in 3-6 months.Goal is to keeping them together and get them to interact toward a common goal!!---Become physically involved and fit


Dyersville Experience

450 participants lost a combined 7,500 pounds

Each week, entire team stepped onto a giant truck scale to monitor their progress

Example of Group level intervention that worked but WHY!!


Keys to Group CohesionEach PA groups must be made distinctive(foster feelings of distinctiveness)

Group name, group T-shirtHave the individuals be given the right to choose

Intensity, duration, and goals of programHave each experienced group member spend time helping new members

New members will learn individual sacrifice, techniques necessary for participation in the class, and gain skills


Keys to CohesionThe group should have a common goal

Lose weight, finish grandma’sIndividual accountability

Self-responsibility to do your partYou need to communicate

Positive, specific, sincere, frequent early, and focus on effort


Group-based InterventionsEnvironmental Strategies

Have group nameT-shirts, head bands, or shoelacesMake up posters/slogans for class

Group Structure StrategiesAbility group the members based on fitness levelProvide exercises for low, medium, & high impact exercisesEstablish a group goal


Group-based InterventionsGroup processes strategies

Set daily workout goalsNew group members should be assigned to another member who does exercises in the group on regular basisStress the effort not the outcome of exercises

Interaction StrategiesWork in small groups (3-5 sub groups max)Use more partner activitiesGet to know each other


Long-term consequencesGroup based interventions are effective in the short term but what happens when the class or program ends?

Do the clients stop exercising or regain the weight?Do the clients PA behavior regress?

Group-mediated programs maintain a higher rate of PA after the program then traditional exercise programs.


Community Intervention Strategies

Considered to be the most important!!


Community Level Interventions

Interventions that assist entire communities

Cross country trailsWalking & Biking TrailsOpen GymUniversity, School, & Community Projects


Key Factor in Community Intervention

Must be a shared common value to people in the community and by all institutions (government, private business, mass media, schools, university, etc)

Interventions must associate with their way of life in the regionIntervention must provide the people with some distinctiveness


Community PA Delivery Sites

SchoolsWork siteHealth Care Facilities


School Sites

Offered through Physical EducationSchool today offer few PE classesDuration of PE classes are usually short

School-based interventions have shownImprove knowledge and attitudes toward PADoes increase PA during PE classes but typically, are unsuccessful in increasing out-of-school PA

School based (CATCH) interventions has shown out-of-school PA increases.


Work Sites

Industry assumes that there is a link between worker productivity and fitness

To date work site PA interventions have had little impact.


Health Care SitesTouches both healthy and CV diseased populationMost primary prevention programs have had short term positive effects but no long term changes

PACE used DR’s as an intervention to promote PA supports the above results

Programs for CV diseased clients also indicated the above findings.


Let’s take a look at PACE

Example of Community Intervention Program at a Health Care Site


Project PACEhttp://www.paceproject.org


Project PACE

Physician-based Assessment and Counseling for Exercise

1990


Helping your patients improve their physical activity and nutrition behaviors is an important part of good primary medical care.


Project PACE is a practical system of matching physician counseling with patient readiness for physical activity.


Project PACE was developed in 1990 with support from the Centers for Disease Control and Prevention and San Diego State University.


Counseling patients about the value of physical activity and nutrition is one of many areas primary care physicians can positively impact the lifestyle choices of their patients.


Physicians counsel less often about physical activity than about other important health behaviors.


Barriers preventing physicians from counseling include:

Lack of knowledgeLack of third party reimbursementInadequate training & skills in health promotion & counselingLack of timeNeed standardized counseling protocols


PACE teaches physicians to spend precious counseling time targeting change.


PACE teaches physicians to use the most effective behavior-changing skills.


PACE focuses on moderate-intensity activities that are safe, effective, and familiar to most patients. They may be recommended without a sophisticated evaluation or complicated exercise prescription.


Why are physicians effective clinical coaches?

80% of Americans indicate that their primary source of health information is their personal physician. Americans average 2.7 visits per person per year. 60% of these visits are to a primary care physician.Physicians are in a unique position to improve their patients’ physical activity levels and have access to their medical records and health history.


Why are physicians effective clinical coaches?

Patient surveys show that patients want information about physical activity and that they feel their personal physician is a reliable source of information.


PACE MaterialsPhysician’s Manual: reference on the benefits of physical activity, risk assessment guide to PACE counseling and answering patients’ questions.Physical Activity Assessment Form: A questionnaire that determines the patient’s level of physical activity and their readiness to increase or maintain activity.


Physical Activity Levels Identified in the Self-Assessment Phase

Precontemplator (1) - People not willing to consider making a change. Contemplator (2 - 4) - People thinking about making a health behavior change, but don’t have the skills, knowledge, or incentive to do so.Active (5 - 11) - People in this stage are doing something!


How does the PACE scale work?

Patients select one statement that best describes their activity pattern.The number determines the physician’s counseling protocol.

1 Pre-contemplators 10%2 - 5 Contemplators 50%6 - 11 Actives 40%


How PACE worksThe entire PACE process requires only 2-5 minutes of interaction between physician and patient.Before seeing the physician, the patient completes the PACEassessment form.


How PACE Works

Based on the patient’s PACE score, the office staff gives him/her three PACE counseling protocols, which the patient completes in 2 -3 minutes before seeing the physician.The protocols are printed so that the patient can take home a copy and the physician has one for the medical record.


How PACE WorksThe outcome is strengthened by brief, inexpensive follow-up procedures such as a phone call from the office staff and/or a postcard.Follow-up prompts the patients to continue their activity program. Accountability.


Benefits of PACESimple and inexpensivePAR-Q identifies those at risk of a cardiovascular event.Roadblocks of exercise - Stages of Change theoryGuidelines for “moderate activity”developed by ACSM


Benefits of PACEScore relates directly to the counseling protocol to be used.Encourages follow-up assessmentLevels of both under-exercisers and over-exercisers are usedHelps to retain patients and build a good rapport


Summary and Key Findings

Conclusions: Physician-based counseling produced a moderate physical activity among previously sedentary patients.Conclusions: Physicians found PACE improved their confidence to counsel patients about physical activity in 1 - 5 minutes.


Community Wide Interventions

Legislative, Policy, and Community wide changes in PA

Naval Community ProjectStanford Five-City Project

Most power long lasting impact on individuals level of PA


Mass Media Interventions

Telephone based intervention in weight lossMailing interventionBoth intervention techniques were very positive.


CDC StrategiesPublic Policy

Increase budget toward recreationZoning & codes

EnvironmentRequire sidewalks Bike lanesOpen gyms, community centers

Physical EducationHave it in the school!Emphasis on fitnessIncrease frequency and duration

Health EducationBenefits of exercise

ExtracurricularIncrease access

Health ServicesHospitals need be involved!Doctors, nurses, PT’s & AT’s need to involved

Community ProgramsInvolve all institutionBe a common goal of community

Increase Parental InvolvementIncrease the Density of Personal Training


CDC Strategies

To change the physical activity patterns of a population, one should not rely on just one to see long term effects. Change occurs when a community implements all the strategies.


SummaryInterventions based on model of PA involvement are the best strategy.Behavioral modification interventions are the best.Stage theory and Bandura’s Self-efficacy models are key models today.Groups interventions relate highly to social cohesion.Community interventions are the most important.Health-care programs outweigh worksite or school site programs

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