«Authors Anita Wester, PhD, Psychologist, National Agency for Education, Stockholm, Sweden Lina Wahlgren, MSc, Swedish School of Sport and Health ...»
4. Becoming physically active
Anita Wester, PhD, Psychologist, National Agency for Education, Stockholm, Sweden
Lina Wahlgren, MSc, Swedish School of Sport and Health Sciences, Stockholm, and Department
of Health Sciences, Örebro University, Örebro, Sweden
Ingemar Wedman, PhD, Professor, Swedish School of Sport and Health Sciences, Stockholm,
Växjö University, Växjö, and University of Gävle, Gävle, Sweden*
Regular physical activity increasing health and well-being for the individual and saving society considerable cost are known facts today. It is estimated that the cost resulting from insufficient physical activity amounts to approximately SEK 6 billion per year (1). Efforts are being pursued in society as a whole and in schools to increase the level of physical activity (2).
Many are aware of the benefit of physical activity and recommend regular physical activity, but are nonetheless passive in their daily lives. The research that concerns going from being physically passive to being active show that this process is more difficult than what can initially be believed. Behavioural change is a difficult process to grasp in many regards (3–6).
With the recommendations for physical activity that exist today (a minimum of 30 minutes a day) (7), a majority of the adult population is inactive (8). Inactivity results in a lack of energy and excess weight. Daily life also places increasingly fewer demands on natural physical activity. We can change tyres on the car at a garage. We can take the lift instead of stairs, etc. The excess weight sneaks in and, consequently, the weight gain is not as striking – circumstances “cushion” a loss of energy and weight gain.
Physical activity in a time perspective In a study from Västerbotten, a health follow-up has long taken place among persons who turn 40, 50 and 60 years old. The study is being carried out by the Västerbotten County Council and comprises diverse data, including a few questions regarding physical activity.
As a part of the study, a follow-up was carried out of approximately 16,000 people after ten years (9, 10). See table 1.
4. becoming physically active Table 1. Responses to the question of how often the person had exercised after first having changed into training clothes. The same question was answered by 16,000 people with ten years in between.
First year Never Now and 1 time/week 2–3 times/ More than Total Tenth year then week 3 times/week Never 4 022 933 503 354 112 6 004 Now and then 1 679 1 336 685 522
The questions asked in this context pertain to exercise where one changes into training clothes. It then turns out that virtually everyone is classed as physically inactive, and approximately 4,000 have never changed into training clothes, not even over a period of ten years.
Thoughts about changing lifestyles Riksbankens Jubileumsfond (Jubilee Fund of the Swedish Central Bank) carried out a conference 25 years ago with the title “Changing lifestyles”, which also became the title of a book published after the conference (11). At this conference, a number of researchers participated with various areas of interest, including antidotal smoking treatments, physical activity, diabetes follow-up, etc. The common message from these scientists was that it is difficult to change behaviour, regardless of which behaviour is in question.
Behavioural change models in the area of physical activity A number of models have been used and are currently used to try to understand, explain and change behaviour in various health-related areas (12). In the area of physical activity, the following theories and models have been used or are used in research on behavioural change: Classic learning theories, Health belief model, Transtheoretical model, Relapse prevention, Social cognitive theory, Theory of planned behaviour, Social support and Ecological perspective (7, 13). One example where various models are combined is the Groningen Active Living Model (GALM), which focuses on the elderly (14). The most common today are the Transtheoretical model and Social cognitive theory. It appears as if theory-based behavioural interventions increase physical activity. For example, improvements in physical activity can be seen in the state of ill-health, such as cardiovascular disease, when behavioural change programmes have been used in treatment. Furthermore, interventions that include lifestyle changes, or changes in multiple areas such as physical activity and diet, appear to increase physical activity (15).
70 physical activity in the prevention and treatment of disease Transtheoretical model One of the most popular and most used models to describe and change behaviour is the transtheoretical model. The transtheoretical model was developed, and refined, by the U.S.
researchers Prochaska, DiClemente and Norcros at the beginning of the 1980s. Work on the model began with an analysis of theories that have been used for behavioural change in psychotherapy. The objective of the analysis was to harmonize the various theories with each other into a model. The transtheoretical model can therefore definitely be said to be transtheoretical, since it harmonizes behavioural change principles and approaches for change from a number of different intervention theories (5, 16).
After the work on harmonizing the various theories, it was investigated how often various approaches were used by people in for instance antidotal smoking treatments.
Then it turned out that people use different approaches at different points in time in their efforts to stop smoking. Consequently, behavioural change is considered to occur by moving through different stages (5, 16).
Hence, the transtheoretical model had its origins in smoke cessation, but has also been used in other health-related areas, such as alcohol abuse, obesity and physical inactivity (5, 16). Although the transtheoretical model id not directly developed for the area of physical activity, its use appears to be promising in the area (17). The model’s use also appears to be promising in work on physical activity in rehabilitation (18). A popular science and practically applicable example of the transtheoretical model tied to the area of physical activity is J. Faskunger’s book Motivation för motion [Motivation for exercise] (6).
The transtheoretical model comprises several different components. One of the components is called the stages of change and contains various stages based on people’s inclination for change, in other words where a person is in the behavioural change process. Another component is called the processes of change1 and includes various approaches through which people move between various stages of change. The third component focuses on why people change and consists of activity-specific self-efficacy and motivation balance (5, 16). In working with behavioural change, it is important to use all of the components of the model to achieve a successful result, meaning to change a behaviour (17).
Stages of change According to the transtheoretical model, behavioural change is seen as a process over time and there are six stages of change: Precontemplation, contemplation, preparation, action, maintenance and termination(5, 6, 16).
People who are not regularly physically active nor are interested in or intend to change their inactive behaviour are in the precontemplation stage. One reason they are in the precontemplation stage may be too little knowledge or information about the risks of being physically inactive. Another reason may be that they have tried to change their behaviour a number of times, but have failed and thereby lost faith in their ability to change. Regardless of reason, people in the precontemplation (or denial) stage avoid reading about, talking about and thinking about their risky inactive behaviour. They deny that physical inactivity is a problem for them (5, 6, 16).
People who are not regularly physically active, but who intend to change their inactive behaviour in the next six months are in the contemplation stage. They understand that physical inactivity is a problem for them and honestly contemplate how to go about becoming physically active. However, some people do not make it any farther, but rather get stuck at the contemplation stage for a prolonged period. They become “chronic contemplators”. People at this stage are not ready for traditional activity-oriented interventions where the participant is expected to become active immediately (5, 6, 16).
People who are not regularly physically active, but have plans of becoming physically active in the near future, most often within one month, are in the preparation stage.
Usually, people in the preparation stage have tried some form of physical activity in the past year and also have a concrete plan for implementation. For people in the preparation stage, activity-oriented interventions are suitable since they are ready to become physically active (5, 6, 16).
People who are regularly physically active and have been so for six months are in the action stage. Changes in the action stage are more visible to the surroundings than in the other stages of change. It is therefore easy to believe that people in the action stage have achieved a change in behaviour, but the action stage should only be considered a part of the behavioural change process. Regular physically active behaviour requires time to be established (5, 6, 16).
People who are regularly physically active and have been so for more than six months are in the maintenance stage. As in the other stages, there are also challenges in the maintenance stage. People in the maintenance stage should focus on the work of consolidating and strengthening the gains of being physically active, based on lessons from the other stages of change. They should also work on preventing relapse (5, 6, 16). People who have fully assumed a behaviour are in the termination stage. The have full faith in their 72 physical activity in the prevention and treatment of disease behaviour and that they will not return to their previous behaviour, regardless of the situation. Behaviour takes place out of habit and automatically (5, 6, 16). One example is that one puts on the seat belt without thinking about it when getting into the car (19). The termination stage has been debated. It may be so that the termination stage is too strict and the realistic goal for areas such as physical activity is to be in a lifelong maintenance stage (5, 16, 20). The termination stage could possibly be associated with the areas of everyday exercise, such as always spontaneously choosing to take the stairs instead of the lift.
The behavioural change process should not be seen as a linear process, but rather as spiral shaped. The shift between the stages can take place both forwards and backwards.
Relapses should be viewed as a natural part of the process. It is therefore important to work with relapse prevention so that the relapses do not become more than sidesteps. People often need to go through both success and setbacks to succeed in making a change (5, 16).
In working with behavioural change, it is important to know the stage of change that people are in so that the efforts agree with people’s receptivity. If efforts and stages of change do not agree, the number who drop out may increase. In the area of physical activity, it can be easy to think about activity-oriented interventions as an opportunity for behavioural change. However, succeeding with activity-oriented interventions presuppose that people are in the preparatory stage or further. However, this does not appear to be the case. A majority appear instead to be in the earlier stages of change of the precontemplative and contemplative stages (5, 16, 21).
To obtain information about which stage of change people are in, the following statements, presented in table 2, can be used (5).
Table 2. Statements that can be used to gather information about which stage of change a person is in.
preparatory stage. If the answer is no to the first statement and yes to the second, the person is in the action stage. Lastly, if the answer is yes to the first statement, the person is in the maintenance stage (5). A yes to the first statement could also mean that the person is in the termination stage.
Processes of change Activities or processes that people use in the respective stages of change to move to another stage can provide guidelines for interventions, in other words they can be a good guide for the person changing behaviour. There are ten processes that have proven to have the strongest empirical support. The following five approaches can be viewed as experiential or contemplative: consciousness raising, dramatic relief, environmental re-evaluation, self re-evaluation and social liberation, and the following five can be viewed as behaviourally or activity oriented: counter-conditioning, helping relationships, reinforcement management, self-liberation and stimulus control (5, 6, 16).
Consciousness raising involves seek new knowledge and information about physical activity.
Dramatic relief involves negative feelings associated with physical inactivity, such as breathlessness and excess weight. The negative feelings can decrease and can even become positive when the physical activity increases in scope.
Environmental re-evaluation involves re-evaluating how physical activity and physical inactivity affect one’s surroundings. This can include the person’s assessment of how a physically inactive lifestyle affects family and friends.
Self re-evaluation involves intellectually and emotionally re-evaluating the value of physical activity to one personally; for example, physical activity makes me stronger and more energetic.
Social liberation includes becoming aware, accepting and finding possible alternatives for physical activity in society, including everyday exercise.
Counter-conditioning involves handling situations that entail everyday physical inactivity. One example is taking the stairs instead of the lift.
Helping relationships involve getting help from others to be able to increase the physically active behaviour.
Reinforcement management involves changing physically inactive behaviour by rewarding physically active behaviour.