Promoting Active Living in Young People Through Behaviour Change
Original Editors - Arden Metford, Rónán Mac Cann, Lee Krol, Lee Pettett, Sameena Anjum, Brian McGowan, and Iarla Byrne
The physical and mental health behaviour of today’s adolescent generation are determinants of growth and development, now and throughout their lifespan  . The technological advances of modern society have contributed to sedentary lifestyles, causing young people to have an increased body weight and body mass index (BMI) than one generation earlier. The gradual increase of habitual sedentary behaviour and physical inactivity seen in adolescents is a major contributor to chronic health conditions and is strongly correlated with the diagnosis of these diseases . This trend is at risk for continuing with the present day's young generation, as research suggests that the levels of physical activity decreases between the ages of 11-15 . Globally, physical inactivity is the fourth leading risk factor for mortality, causing 3.2- 5 million deaths annually   . While many of these chronic diseases are identified in adulthood, research suggests that the development of these conditions originate in childhood and adolescence  . Furthermore, young people may have a less impressionable attitude towards their body image than adults, which may provide less resistance to behavioural change interventions  . Therefore, the learning of healthy behavioural habits must be accomplished during adolescent years, which will assist in carrying forward this healthy active behaviour into adulthood. Behaviours of active living established in early years can provide the greatest impact on maintaining these positive habits across one’s lifespan and influence mortality and longevity  .
Physiotherapists have the knowledge and skills to design, plan and implement interventions aimed at increasing levels of physical activity in young people. Although research in the area of increasing physical activity is well established, interventions aimed at maintaining an active lifestyle is an emerging area. Physiotherapists are in a good position to facilitate and guide active living behaviours in young people so that this behaviour is maintained into adulthood.Behavioural change frameworks can be utilised for the larger young population, delivered in different community settings. Particular emphasis will be placed on the Transtheoretical Model (TTM)  of behaviour change, which categorises individuals into various stages, depending on their physical activity levels. A modified questionnaire has been developed within this resource to assist practitioners in identifying which stage of the TTM the young population is in. This categorisation is based upon the amounts of vigorous, moderate or walking activities performed within the last week. The physiotherapists can use this knowledge to identify and build upon the individuals’ or groups’ strengths to encourage them to maintain active living behaviour into adulthood. By focusing on individual factors and activities that individuals enjoy, the aim is to encourage adolescents to stay in the maintenance phase of the TTM of behaviour change, rather than regressing to other stages, thus maintaining an active, healthy lifestyle .
- 1 Introduction
- 2 What is Active Living?
- 3 Physical Activity Guidelines
- 4 Benefits of Physical Activity in Young People
- 5 Epidemiology, Physical Activity and Physical Inactivity
- 6 Justification for the Emerging Role Within Physiotherapy
- 7 Economic Implications of Physical Inactivity
- 8 Barriers to Physical Activity
- 9 Facilitators to Physical Activity
- 10 Ethical Considerations When Working With Young People
- 11 Current Government Strategies
- 12 Health-Related Behaviour Change
- 13 Models of Behaviour Change
- 14 Proposed Questionnaire for Measuring Physical Activity
- 15 Modified IPAQ-SF Scoring System into the Transtheoretical Model
- 16 Behavioural Change Progression
- 17 Strategies/Interventions to Promote Active Living
- 18 Adapting Motivational Interviewing into Groups
- 19 Empowering Young People to Maintain Active Living
- 20 Resources
- 21 References
What is Active Living?
Active living is defined as a way of life that integrates physical and recreational activity into your everyday routine to encourage a healthier lifestyle . These active routines include:
- Being active in outdoor parks, fitness centres
- Biking to work
- Walking to school
- Playing a recreational sport or game
- Activities of daily living
- Planned exercise sessions
Physical activity (PA) is defined as any movement carried out by a skeletal muscle that requires energy and ranges from low, moderate to vigorous PA with varying amounts of energy expenditure. While sedentary behaviour is defined as an individual who engages in prolonged sitting or lying positions without much movement . Common sedentary behaviours includes TV viewing, video game playing, computer use (collectively termed “screen time”), driving automobiles and reading .
Physical Activity Guidelines
The World Health Organization’s physical activity guidelines to improve cardiovascular fitness, muscular and bone health as well as metabolic health bio-markers for young people as shown in the figure below 
Physical activity for young people in the context of family, school and community activities includes :
- Transportation – walking, bicycling, skateboarding etc
- Recreation and leisure activities
- Physical education and planned exercise
Benefits of Physical Activity in Young People
Epidemiology, Physical Activity and Physical Inactivity
- Research suggests that on average 39% of adults in the UK are not physically active . Physical inactivity causes 3.2-5 million global deaths annually and is the 4th leading risk factor for global mortality .
- Nearly half of the young population in the UK are sedentary apart from school activities . Common sedentary activities include: screen-based sedentary behaviour, social sedentary behaviour, TV-viewing, homework and academics and lastly motorized transport .
- It is predicted that the 4.1 million children and young people who are obese and overweight globally are likely to remain obese and overweight into adulthood leading to greater risk of developing non-communal diseases such as diabetes and cardiovascular conditions at a younger age 
- It is estimated that 13% of the young people aged between 11-15 yrs in England are not meeting the physical activity recommendations .
- Increased sedentary behaviour has been shown to greatly affect the health outcomes such as increased risk of obesity rates, lowered cardiorespiratory fitness and lowered insulin sensitivity in young people aged between 11-18 years old . However, alarmingly physical activity levels tend to drop off from ages 11-15 in most european countries 
Justification for the Emerging Role Within Physiotherapy
Physiotherapy is delivered in a variety of settings. Traditionally physiotherapists predominantly see the most of their clientele within a clinical setting on an individual basis . Good strategies and policy have been established in order to promote more active lifestyles within these settings. ‘Making Every Contact Count’ is a strategy introduced to help all organisations responsible for the health, well-being and care of the public to implement and deliver healthy messages systematically and encourage healthy lifestyles 
If this strategy is actually carried out it has the opportunity to impact many people, with physiotherapy outpatient contacts alone numbering 3 million across the UK . This serves patients that attend clinics well as an active lifestyle is promoted to them. The issue is that this only targets the population that attend the clinic which is reactive rather than a pro-active/preventative. A large proportion of the population who lead sedentary lifestyles but have no current health issues or have not attended a health professional’s appointment are missed. There is also little known on the extent to which physiotherapists embed physical activity promotion in their routine care and sparse evidence that it is comprehensively promoted in healthcare settings .
In order to increase physical activity worldwide it has been identified that a systems approach is required that focuses on populations and the complex interactions among the correlates of physical inactivity, rather than solely a behavioural science approach focusing on individuals . Healthcare is part of this system and within healthcare there is a need for organisational, environmental and individual approaches promoting active living. Several government, national health service and organisation strategies and policies have been developed which highlight the importance of community-based health care and the need to proactively seek to change the future of the nations health. In 2015 an agreement was signed by all allied health professionals to their professions to the forefront of public health workforce  and ensure that they are working to improve the four domains of public health (Health Promotion, Wider Determinants, Public Health Care and Health Improvements). Some of the key contributions were: community development programmes, supported self-management, prevention, health improvement campaigns and promoting healthy environments. Recently the Chartered Society of Physiotherapists has released in corporate strategy for 2017-2020 which states that physiotherapists should "empower individuals and communities to maximise independence and live long and live well". With the approach of going out to communities physiotherapists can guide and facilitate young people in communities to take control of their lives to reduce the risk of developing conditions later in life and therefore improving the quality of life for all individuals.
As experts in movement and exercise, and with a thorough knowledge of functional anatomy and pathology and its effects on all systems, physiotherapists have specific competence and expertise and are ideally suited to promote, guide, prescribe and manage active living. Additional to the promotion in their current settings waiting for the patients to come in order to reach a larger population, physiotherapists need to immerse themselves more widely in the community to tackle sedentary lifestyles proactively and prevent their associated co-morbidities. Physical education programmes at schools have been identified as an important tool to increase the awareness of health-enhancing physical activity . Evidence suggests the quality of such programmes is of importance for their outcome . With extensive knowledge of promoting, guiding, prescribing and managing physical activity for young people with different needs, physiotherapists are excellent partners to develop, implement and follow-up high-quality physical education programmes in schools and community centres. This movement, additional to the individual patients seen will allow for a wider population to be targeted, which is paramount given the statistics relating to sedentary behaviour.
Economic Implications of Physical Inactivity
Establishing routine physical activity as an adolescent is associated with an increased probability to continue this behaviour into adulthood and a reduced risk of disease . However, with nearly half of young people aged 10-24 not achieving the recommended physical activity guidelines , the healthcare costs to communities and the NHS are under strain. In Scotland, physical inactivity causes 2500 deaths per year and costs the NHS £91 million per year . In the UK, the levels of physical inactivity in young people will result in predicted diseases, decreased quality of life and reduced lifespan. The economic costs of these anticipated morbidities are estimated in Figure 5.
If the total number of young people meeting physical activity guidelines could increase by only 1%, the UK could save £0.8 billion. Figure 6 displays the viable economic savings associated with young people’s increase in physical activity.
Barriers to Physical Activity
There are several barriers to physical activity and active living that are perceived by young people and parents, which varies from personal preferences, access to facilities and opportunities as shown below :
- Preferences and priorities:
- Sports or exercise is not enjoyable
- Negative body-image and physique
- Weak motor coordination and not suited for sports
- Potential shame/embarrassment of letting teams and oneself down
- Preference for other sedentary activities instead
- Family life and parental support
- Parents’ lack of current participation in or enthusiasm for sports, exercise or other types of PA
- Restricted access to opportunities
- The cost in taking part in sports and activities
- Complexity and burden of organizing safe facilities
- Availability of local facilities
- Safety concerns
- Transportation advantages of cars for enabling quick and safe travelling
Facilitators to Physical Activity
- Valued aspects of physical activity
- Having fun and enjoying oneself
- Belonging to a sports team or group
- Afterschool program leisure activities
- Opportunities for spending time with family
- Keeping fit and health
- Mental health and well-being
- Choice of sporting opportunity
- Greater access to opportunities and facilities
- Afterschool programs to facilitate a greater level of physical activity with friends and serve as a basis of social interaction
- Proper bicycle paths and sidewalks in neighbourhoods
- Leisure Centres
Ethical Considerations When Working With Young People
Government legislation and policies for working with young people
- Getting it Right for Every Child
- The Ready to Act Plan
- Children and Young People (Scotland) Act 2014
Other considerations for working with young people
- Safeguarding Young People
- Informed Consent
Knowledge and understanding of relevant legal frameworks, including local policies are essential for Physiotherapists who work with young people to ensure they work effectively and deliver services appropriately .
Getting it Right for Every Child
Central to the Children and Young People (Scotland) Act 2014 , is the ‘Getting It Right for Every Child (GIRFEC)’ policy . This policy states that all adults working with children and young people should ensure their actions support the best interest of children and young people through promoting, supporting and safeguarding well-being and reporting on well-being outcomes .
- GIRFEC is a key part of the Scottish Government’s commitment to addressing inequalities and improving outcomes for children and the young through early intervention and prevention 
- GIRFEC is underpinned by the recognised need for shared principles and values and a common language among practitioners who provide services for young people and families 
- GIRFEC is intended to be used by health practitioners to gather information about a young person's well-being to identify concerns and determine what support and action may be needed 
The GIRFEC approach:
- Integrated Working: focuses on children, young people, parents and services they need working together in a coordinated way to meet the specific needs and to improve overall well-being.
- Child Focused: ensures the child or young person (and their family) are at the centre of decision-making and have appropriate support available to them.
- Well-being of Children: focuses on a child or young person’s overall well-being.
- Early Interventions: focuses on tackling the needs of a child and young person early, aiming to ensure the needs are identified as early as possible to avoid larger concerns and problems to develop.
The well-being of children and young people is at the heart of GIRFEC . The approach uses eight areas of well-being, called SHANARRI indicators, which represent the basic requirements for all children and young people to grow and develop to reach their full potential. The eight SHANARRI indicators of the GIRFEC well-being wheel are illustrated in below .
The Ready to Act Plan
The Ready to Act Plan  delivers one of the actions from the AHP National Delivery Plan, where allied health professionals (AHPs) act as Agents of Change in Health and Social Care . The Ready to Act Plan  will contribute to the development of the Active and Independent Living Improvement Programme . The plan sets out five key ambitions for AHP services based on the outcomes young people, their parents, carers, families and stakeholders reported that mattered to their lives. The key ambitions are illustrated in the table below:
The Ready to Act Plan  is the first children and young people’s services plan in Scotland to focus on the support provided by AHPs. The plan sets the direction of travel for the design and delivery of AHP services to meet the well-being needs of young people. It is underpinned by the Children and Young People (Scotland) Act 2014 , the principles of Getting it Right for Every Child (GIRFEC)  and the United Nations Convention on the Rights of the Child .
Children and Young People (Scotland) Act 2014
The Children and Young People (Scotland) Act 2014  establishes a legal framework within which services create new and dynamic partnerships to support young people, their parents, carers and families to achieve meaningful well-being outcomes  . These outcomes include what has come to be known as the SHANARRI indicators of well-being. AHPs, including physiotherapists, play a key role in young people achieving well-being outcomes through developing their resilience and creating protective environments to enable participation and self-reliance .
Safeguarding Young People
Safeguarding is a term which is broader than ‘child protection’ and relates to the action taken to promote the welfare of young people and protect them from harm . Safeguarding is everyone’s responsibility.
- Protecting children and young people from maltreatment
- Preventing impairment of children’s and young people’s health and development
- Ensuring that children and young people grow up in circumstances consistent with the provision of safe and effective care and
- Taking action to enable all children and young people to have the best outcomes
In order to safeguard and promote the welfare of children in Scotland, Physiotherapists should act in accordance with the following legislation and guidance:
- Children (Scotland) Act 1995 
- Protection from Abuse (Scotland) Act 2001 
- Protection of Children and Prevention of Sexual Offences (Scotland) Act 2005 
- Protection of Vulnerable Groups (Scotland) Act 2007 
- Children and Young People (Scotland) 2014 
The National Society for the Prevention of Cruelty to Children (NCPPC)  offer links to the following documents for advice and guidance for health practitioners with concerns for children and young people:
- What to do if you’re worried a child is being abused: advice for practitioners 
- Safeguarding children and young people from sexual exploitation 
- Safeguarding children in whom illness is fabricated or induced 
The position on consent in relation to young people is complex . It is important for physiotherapists working with young people to be familiar with literature, statutes, case law, professional guidance and department of health guidance on the ethical and legal aspects of young people’s consent . The issue regarding capacity is of particular importance when dealing with young people . The law recognises broadly three stages of childhood with respect to consent:
- Children and young people who lack capacity: If the child or young person does not have the capacity to give their own consent e.g. they are too young or do not understand fully what is involved, then a parent/ person with parental responsibility, or the Court, may give consent on the child’s behalf 
- Children and young people with capacity: A young person under 16 who has the capacity to make their own decisions may be referred to as ‘Gillick competent’ after the legal case that established children can make their own decisions in certain circumstances .
- Children and young people over the age of 16: All 16-17 year olds with capacity are permitted by law to give their own consent to health interventions . Those young people who are 16 or over on the date they attend for treatment do not need parental consent for Physiotherapy . You should not share confidential information about 16-17 year olds with their parents, or others, unless you have specific permission to do so and/or you are legally obliged to.
According to Scottish law, children over the age of 12 are usually considered to be sufficiently mature to form a view and can have the legal capacity to consent to health interventions, where in the opinion of a qualified health practitioner, the child is capable of understanding the nature and possible consequences of the intervention .
This is a matter of clinical judgement and will depend on several things, including :
- The age of the patient
- The maturity of the patient
- The complexity of the proposed intervention
- The likely outcome of the intervention
- The risks associated with the intervention
If the young person is not capable of understanding the nature of the healthcare intervention and its consequences, it is then advised to contact the child’s parent or guardian for consent to proceed with the intervention . Although a young person is deemed capable of giving consent independently, it is still highly encouraged to seek consent from both the young person and their parents or guardians  
Confidentiality is of fundamental importance to young people as outlined in the United Nations Convention on the Rights of the Child . Young people have the same rights to confidentiality as adults, however the duty to safeguard young people should come first   . When obtaining consent, confidentiality needs to be explained to young people in terms that they understand and that they are aware of events in which the physiotherapist may be required to act on concerning information and pass it on to relevant organisations . In addition, parents of young people may request access to the young person’s responses after undertaking a health intervention, questionnaire or survey. There are strong ethical reasons why parents should not have access to what their child says on a questionnaire, as young children may be harmed, embarrassed or punished based on the responses they have given . Rather than giving parents access to responses, it may be beneficial to offer parents to view the questionnaire prior to it being completed  or to encourage parents to initiate discussions about the questionnaire with their children in a home setting .
Current Government Strategies
The Scottish Government was one of the first countries in the world to release a national physical activity strategy, by providing a broad framework and implementation plan, called 'Lets Make Scotland More Active' in 2003 .
The five-year review of the 20-year strategy acknowledged there has been progress made increasing the levels of physical activity. It has been followed up recently after the 2014 commonwealth games with the strategy 'A More Active Scotland' . This is an adaptation of 'The Toronto Charter for Physical Activity' (2010) which is a global call for increased physical activity levels and the need for health professionals to promote this change in behaviour .
When specifically looking at young people, the strategies aim is to create a long lasting change in physical activity levels through:
Communities services and facilities:
- More children will have opportunities for active and outdoor play
- More children will routinely take part in play, sport, or other forms of active recreation
- More children will have opportunities for active and outdoor play
- Urban and rural environments will be designed to increase physical activity
- 20 mph zones will be widely introduced in residential and shopping areas
- Education staff have the appropriate knowledge and skills to promote increased physical activity
- All places of learning can demonstrate the use of their estate and green space for physical activity
- All places of learning can demonstrate that pupils, students and staff have increased levels of physical activity
- More children and students use active travel to get to their places of learning
This aimed to be achieved through legacies with over 50 being launched since their inception. Legacies are part of the implementation plan and examples include: a national week encouraging increased female participation in sport, as they have been found to be less active than males. The statistics show young peoples physical activity have slightly increased both including and excluding the increased physical activity in schools. It is still unclear however what impact this has on long-term active living and whether this increase in PA is carrying on into adulthood.
Health-Related Behaviour Change
Behaviour change involves influencing health-related knowledge, attitudes and behaviours and should be targeted at an individual, household, population or community . With an ever-changing health system, it is widely believed that by addressing problem behaviours early this can have an impact on the development of co-morbidities and mortality in later life which influences quality of life . In addition, these healthy changes reduce the risk of preventable diseases which place a huge economic burden on our health-system . The behavioural science/medicine literature has been growing exponentially in recent years with the National Institute for Health and Clinical Excellence and many academic researchers producing evidence-based behavioural health treatments and guidance for health professionals . In their latest corporate strategy (2017-2020)  for physiotherapy, the CSP have acknowledged the role physiotherapists will play in empowering individuals in communities to take control of their own lives to stay healthy for longer. This will involve physiotherapists using expert knowledge in human movement and health promotion to implement effective health-related behavioural change strategies in a preventative way among different populations. One of the fundamental problems with behaviour change and health promotion however is indeed its application into practice .
Based on the science of behaviour a large amount of literature has been published examining the effectiveness of several behaviour change models. These models have been developed to conceptualise the overwhelming amount and complexity of behavioural change theory and to help our understanding of the dynamic interrelationships that are necessary for sustained active living. With the use of these model’s health professionals can systematically implement change. They are broken down into the following: Social-Cognitive theory, Belief /Attitude theories (Theory of Planned Behaviour), Competence-based theories (Self-Efficacy Theory), Control-based theories (Self-Determination Theory), Stage-based theories (Transtheoretical Model) and other hybrid models . Although there is a vast array of theory to choose from, the stage-based model (Transtheoretical model-TTM) is arguably the most commonly used in behaviour change. The following section will focus on the TTM and how this framework can be used in the process of behaviour change.
Models of Behaviour Change
The Transtheoretical Model (TTM), first proposed by Prochaska and DiClemente (1983) , is a process-oriented framework for understanding and implementing effective health behaviour change . This model brings together many psychotherapy theories in one concise framework to establish a person/groups ‘readiness to change’ (Biopsychosocial) . As Marcus and Forsyth (2003)  wrote, quite often “physical readiness is not likely to be the main barrier to activity; rather it is the psychological readiness to change”. Due to the heterogeneity of humans, many people have different readiness to change and therefore require interventions that reflect the natural cycles of health-related behaviour change. The fundamental purpose of the TTM is to systematically affect lifelong active living and it describes when and how people change .
- Stages of Change (SOC)
- Independent variables (Processes of Change).
- Dependent variables (Decisional Balance; Self-Efficacy)
The Processes of change are concerned with ‘how’ individuals change.  There are ten processes of change (Table 2) and the choice of the most appropriate strategy is based on the stage of change that the individuals are in. Once a SOC has been established physiotherapists can use the processes of change to design appropriate interventions/strategies for effective behaviour change. At a higher order structure these processes are sub-divided into experiential (cognitive-affective) and behavioural processes . In their study Romain and colleagues (2018)  propose that public health interventions should use a combination of experiential and behavioural processes of change to achieve moderate physical activity levels and sustained active living among individuals. The first five processes are experiential and are concerned with thinking about an activity/new behaviour whereas the last five are behavioural processes which involve action .
Decisional balance, first proposed by Janis and Mann (1977) , is one of the core constructs for progression through the TTM. It is concerned with the pros (perceived advantages) and cons (perceived disadvantages) of changing behaviour  .Several studies have shown a strong relationship between decisional balance and an individual’s readiness to increase physical activity . As individuals move through the SOC from precontemplation to maintenance the balance shifts in favour of the pros of changing behaviour. Interestingly in the contemplation stage the pros and cons are of equal weight which may leave individuals ambivalent to change. It can be argued that an emphasis should be placed on education and motivational interviewing at these stages to increase adherence and decrease opposition .
Self-efficacy, first proposed by Bandura and colleagues (1977) , can be defined as “an individuals belief in his or her ability to perform a specific action required to attain a desired outcome”  p. 176. Self-efficacy is part of social-cognitive theory and a key construct of the TTM. Young people with high PA self-efficacy typically participate in activity for longer periods of time and therefore it is vitally important for sustained active living. With a higher self-efficacy, individuals try harder to achieve their goals, can conquer barriers and set-backs and will look to maintain their healthy behaviours throughout life . This personal component can be improved throughout health-behaviour change as individuals progress through the SOC. In the early SOC the self-efficacy to participate in physical activity is outweighed by the temptations to stay physically inactive. Individuals are said to lack the confidence in themselves to change their behaviours. Work is required through education and support /guidance to increase this self-esteem. In the later stages of health-behaviour change realistic goal setting the creation of social support systems become more important as individuals look to maintain this new active lifestyle. The probability of relapse in this population is quite high due to other social factors that may come into play at this age. Studies have shown decreases of 7% in PA in young people (11-18year olds) each year  with an estimated 60-70% decline globally as they transition into adulthood. Self-efficacy and social support have been widely acknowledged as key determinants of PA  and it is hypothesized that these components work interchangeably during adolescence  to prevent relapse. If an adolescent’s self-efficacy is low, social support systems may compensate . At this age peer support becomes more important as adolescents move away from the comforts of parental support and begin to independently make decisions .
Proposed Questionnaire for Measuring Physical Activity
The following questionnaire is a modified version of the International Physical Activity Questionnaire short form (IPAQ-SF) , comprising of seven questions. The aim of this questionnaire is to assist in identifying which stage of the Transtheoretical model the adolescent participants are in. After the total minutes of vigorous, moderate or walking activities performed over the participant's last seven days have been calculated, the physiotherapist can utilise the marking scheme provided in table 3 to establish which stage of the Transtheoretical model the participant is in. Although this modified IPAQ-SF is answered on an individual basis, this questionnaire may be administered in group community settings, resulting in small groups of participants allocated into their individual stages of behaviour change.
A critical evaluation of the literature has shown a lack of consensus in the evidence for this assessment in adults. A large-scale study investigating the reliability and validity in 12 countries found the questionnaire to be an acceptable instrument with equal effectiveness compared to other questionnaires . In contrast, a systematic review found the IPAQ-SF typically overestimated physical activity and concluded it to be a weak measure . The evidence is more robust with adolescents, as a significant correlation was found between the questionnaire and moderate vigorous physical activity recorded on an accelerometer . Another study investigating it's use in adolescents found the IPAQ-SF to be valid and reliable measure of physical activity .
Modification of the IPAQ-SF  was performed by QMU students in April 2018. Alterations included asking the participant to record the total "minutes per day" of activities performed and excluding "hours per day". This was done on the basis that UK physical activity guidelines are calculated in minutes, not hours , therefore simplifying the marking process for the physiotherapist, especially when fast calculation of multiple questionnaires are required. Additionally, questions 2.1, 2.2, 4.1 and 4.2 were added to facilitate a simple "yes" or "no" criteria for the scoring into the "maintenance" or "action" stages in the transtheoretical model.
Modified IPAQ-SF Scoring System into the Transtheoretical Model
The following table depicts the marking criteria for the identification of behavioural change stages in the transtheoretical model.
Instructions on determining the stage of behaviour change:
- Calculate total number of minutes exercised in the last 7 days for vigorous, moderate and walking intensities.
- Using the table above, classify the participant into the corresponding Transtheoretical Stage of Change using the total number of minutes exercised in accordance to level of intensity.
- Please note that the participant may be placed into the “maintenance” or “action” phase if they answered yes to corresponding questions 2.1-2.2 or 4.1-4.2.
Behavioural Change Progression
Once the physiotherapist has established at which stage the young person is at they then have to find ways to facilitate their progression through the stages to achieve the ultimate goal of sustained active living. The following figure and table give examples of strategies/interventions and open questions that can be used at each stage of the TTM to help progress onto the next stage. In the table there is a particular focus on the open questions that can be used by physiotherapists to get young people thinking about their behaviours and how they could change. Some of the most important strategies/interventions will then be discussed in greater detail.
Strategies/Interventions to Promote Active Living
Motivational interviewing (MI) is a technique for helping people to change their desired behaviour. MI can be defined as a collaborative conversation style for strengthening a person’s own motivation and commitment to change . MI is a useful technique often selected to progress individuals through the stages of TTM-SOC mentioned previously which can help to promote behaviour change and results in progression towards active living . In addition, the earlier stages of change (precontemplation and contemplation) often are linked with ambivalence, which is defined as having mixed thoughts. MI is especially useful in the earlier stages of change as it promotes the exploration and resolution of ambivalence to change by highlighting and increasing an individual’s perceived discrepancy between current behaviour, personal goals and values . Motivational interviewing can be used as a tool to enhance intrinsic motivation, which begins to initiate and maintain behaviour change efforts. Physiotherapists can use MI to facilitate behaviour change processes by being empathetic, supportive and administer counselling strategies that facilitates an increase in self-efficacy and in turn result in improved feelings of accomplishment that are needed to get to and stay in the action and maintenance stages of change . Miller and Rollnick (2001) have described four principles and five counselling strategies that are key to the MI approach as shown below.
The Four Principles of Motivational Interviewing
- Develop Discrepancy:
- To highlight discrepancies in one’s own perceived behaviour by the individual examining the advantages and disadvantages of not changing current behaviours.
- As the individual becomes more aware of the discrepancies, the individual then begins to generate rationales or arguments for needing to make a change. Physiotherapist can guide this through use of the five counselling strategies.
- Roll with Resistance:
- When resistance is detected, instead of ignoring or fighting it, the physiotherapist uses the individual’s resistance by employing one or more MI strategies such as simply reflecting on the individual’s concern or reframing the issue so that the individual does not feel defeated, anxious, angry about sharing his/her concerns.
- Express Empathy:
- One of the most valuable skills in MI for the physiotherapist is reflective listening. It is important for the physiotherapist to actively listen to the individual without being judgemental, critical or blaming to better understand the individual’s situation and perspective.
- Physiotherapists must understand that an individual who is in an earlier stage of change may not be ready to give up their current behaviours just yet.
- The initial focus is on building a rapport and supporting the individual rather than on directly promoting change.
- Support Self-efficacy:
- Physiotherapists help support and build an individual’s confidence in having the ability to change in a variety of ways.
- Self-efficacy is enhanced by a positive individual-physiotherapist relationship in which the individual feels understood and supported.
- Other approaches are presenting the client with the examples of positive changes she/he made in the past and highlighting client’s courage in considering choices and taking responsibility.
The Five Counselling Strategies for Motivational Interviewing
Miller and Rollnick (2001)  identify five specific counselling strategies that help to facilitate the four principles of MI. These techniques are summarized by the acronym: OARS
- Open questions: open questions as opposed to closed ones promote discussion and exploration. Examples of such open questions are included in this Wiki to help physiotherapists to choose what to ask at each SOC. These questions will help people to reflect and move past their ambivalence to change.
- Affirmations: convey respect and appreciation as well as highlight individual’s success.
- Reflections: selectively used to convey an understanding of the individual’s perspective and reinforce motivation and can be several types including simple, amplified, double sided and reframes.
- Summaries: providing a summary on the current topics discussed, highlights to the client the current stages of change.
A fifth strategy is to elicit change talk (i.e. talk favoring new behaviour) rather than sustain talk (i.e. talk about continuing problem behaviours), and this can be utilized to begin a positive shift in the person’s ambivalence to change. The aim is to try help evoke more change talk and increase an individual’s own motivation and planning skills to implement health-related behaviour change . There are four processes that help elicit a positive change outcome by using ‘Change Talk’ , as listed below:
- Desire to Change: Individuals must have the willingness to change before the process can even begin.
- Ability to Change: By reflecting on current skills and values that can help highlight the individual’s ability
- Reasons to Change: Allows the individual to reflect on their current behaviour and how it influences them
- Commitment to Change: Through increase intrinsic motivation and self-efficacy support through MI process an individual can make the decision to stay committed to the change and result in positive outcome.
There are several styles of MI which include directing, guiding and following (Table 5). During the MI process therapists will typically jump between these styles. It is important to note that the common mistakes of preaching, lecturing or giving unsolicited advice can cause opposition despite the therapist's best intentions for their person and therefore these should be avoided. The underlying spirit of MI is one of compassion, collaboration, acceptance and evocation
In summary, the task of the physiotherapist is to help the individual resolve their ambivalence to change by “tipping the balance of the saddle” in the favor of change and reinforcing the individual’s responses that indicate desire, ability, need and reasons for change . As Blaise Pascal wrote “‘People are generally better persuaded by the reasons they have themselves discovered than by those which have come into the minds of others” p.1. Once this is established, the physiotherapist than shifts to further support the individual in their commitment to change by helping the individual set goals and develop a specific health-behaviour change plan.The following video is an example of how a physiotherapist can perform MI with individuals. The same approach can be used with a small group of young people to initiate a change in behaviour
Adapting Motivational Interviewing into Groups
Traditionally, MI has been utilized for behaviour change on an individual basis. However as the role of physiotherapists and other allied health care professionals are extending into the community to implement proactive care, MI has been more recently adapted to be used for groups. Velasquez et al. (2009)  suggests that to efficiently utilize MI into group settings special considerations need to be explored. Dividing groups into the different stages of behaviour change is essential. Hence, by using the modified version of the IPAQ and clinical reasoning skills, individuals can be placed into separate groups corresponding to what stage of change the individual is currently in.
In order to effectively carry out MI in a group format, all individuals in the group are encouraged to share views and experiences as a means of providing learning opportunities for the group and setting ground rules for the group discussion. If however, individuals at any point feel that their views/experiences are feeding back as judgemental/critical rather than empathetic –a resistance to share may develop. As previously mentioned, one of the principles of MI is to ‘Roll with Resistance’ and can be adapted to the group settings by the physiotherapists creating an atmosphere for mutual respect, collaboration, models of positive ways of providing feedback and gently redirect less helpful comments and responses . In addition, it is very important to elicit reasons for changes for each individual in the group to emphasize the heterogeneity in the group . Lastly, the knowledge and skill set of physiotherapists is shared, however the willingness to change is the responsibility of the individuals in the group . This process will be performed with the use of open questions which require the group to think about their lives and behaviours. Physiotherapists and their delivery of MI may be hugely effective in maximizing behavioral change for young people and their families. A study by Grays and steele (2014) found MI to be an effective intervention for promoting health-related behaviour change in the paediatric population and is most influential when done with both parent and child. Furthermore, physiotherapists skilled in MI and trained in its education may teach it to other health care workers, P.E teachers, coaches and other partners to aid them in helping young people to have more active lifestyles.
Empowering Young People to Maintain Active Living
Long-term adherence to health-related behaviour change is relatively poor which provides a challenge for interventions to achieve sustained active living . Although a positive adherence is seen initially several authors have described a gradual decline in the maintenance of this adherence as individuals progress through the SOC . Once adolescents have reached the action and maintenance SOC the question remains as to how we ensure that these new behaviours are sustained into adulthood? Physiotherapists can facilitate the process of health-behaviour change  and the empowerment of communities by providing individuals or groups with the skills and knowledge to take control of their lives and ultimately rely less on health professionals . In the 2020 workforce vision for Scotland  it has been stated that NHS Scotland will strive to have an “integrated health and social care system that will focus on prevention, anticipation and supported self-management” . With this proactive/preventative community-based approach to healthy living it is believed that the risk of developing non-communicable diseases could be prevented before adolescent’s progress into adulthood. It is therefore imperative to maintain this change with effective self-management. There are a number of strategies/interventions that can be used to initiate self-management for sustained active living in young people which include the following: self-reinforcement, relapse prevention, problem-solving skills training and the creation of good peer support systems.
Self-reinforcement involves both the intrinsic (e.g. feelings of enjoyment or achievement) and extrinsic (e.g. money) rewards of changing behaviour . This positive reinforcement concept can act as a highly effective motivator for young people to stay active as they are perceived to gain something from persistence and lose something for relapsing. Realistic goal setting is often used as a method of self-reinforcement to give people a sense of achievement once the goals have been reached. Another method that can be used is self-reflection/evaluation whereby individuals critically assess how far they have come since they started their change.
Relapse prevention involves providing individuals/groups with the necessary skills to avoid “high risk” situations that have a high probability of relapse . The idea is that by providing guidance on coping strategies for lapses it is possible to revert the situation quickly before individuals relapse to old problem behaviours.
The attitudes and skills to overcome barriers to change should be thought in problem-solving sessions at all stages of behaviour change . Middleton and colleagues proposed the following five skills as important to problem-solving:
- Development of positive thoughts regarding the problem behaviour and the ability to manage it.
- Recognition of problem and its characteristics/attributes.
- Generation of alternatives (e.g. brainstorming sessions)
- Decisional balance (Pros and Cons of changing behaviour)
- Implementation of solution
A strong relationship exists between physical activity adherence and social support. It has been shown that the risk of non-adherence is twice as high in those with no social support . A solution to this problem is the use of group-based interventions to create peer support systems. A large amount of research has shown the effectiveness of group-based interventions . It has been suggested by Middleton and colleagues (2013) that recruiting friends and family to help in health behaviour change can be beneficial for adherence. In addition, these authors proposed the idea of performing lifestyle changes in group situations to increase peer support. In her study Lindqvist (2017) examined the role physiotherapists can play in health promotion in a community setting (i.e. school) using social-cognitive theory, empowerment interventions and communication technology. In these interventions, created by the children, participants agreed to send reminders and messages of encouragement to their peers regarding physical activity and set goals. It was found that encouragement from peers was beneficial for PA adherence and that activities should be cater for all likes and dislikes.
The following is a list of organisations and resources that will give the physiotherapist additional information and ideas for design, plan and implementation of behavioural change interventions for increased active living:
- Sport England have chosen 12 grassroots pilot projects to help build healthier more active communities across England. Over a period of four years £100m of national lottery funding will be invested in these pilot projects to create innovative solutions to make physical activity more accessible to people in these communities. The aim is to address inequalities and break down barriers that stop people getting active and encourage wider, collaborative partnerships which look at how all parts of a community can better work together and help the inactive. These partnerships will encompass organisations such as voluntary groups, social enterprises, faith organisations and parenting groups. The improvements will include transport links, street lighting, increased quality of parks and open spaces and guidance on how sport and activity is promoted by health professionals.
Key elements of Sport England’s work with young people are focused on easing transitions so that short-term lapses in participation do not become longer-term loss of habit. “Back to...” programmes have been successful increasing interest in particular sports such as netball and hockey. The focus is not just on better sign-posting through transitions but rather on changing behaviour with better opportunities that respond to the motivations of individuals as opposed to just lowering the practical barriers. If inactive youths begin to associate ‘sport’ with things they really want to do, such as meeting their friends, relaxing and de-stressing from everyday life, they are much more likely to participate.
Sport England are also using their funding to encourage sport deliverers to think differently, to make sport more accessible and participation less formal. An example of this is the investment of £500k in an innovative programme designed to get new people into sport using the National Trust brand and the idyllic settings of their properties.
One of the key features of the strategy is making sure children as young as 5 are able to enjoy physical activity and making sure experiences are enjoyable and fun. Sport England have invested a £40 million ‘Families Fund’ in projects that offer opportunities for families with children to do sport and physical activity together. Investments will also be made into free teacher training programmes, improving physical education experiences, support for satellite clubs and recognising the importance of transitions between primary and post-primary schools.
- Change4Life - Public Health England and the NHS’s ‘Change4Life’ campaign develops and implements programmes and initiatives designed to increase physical activity in youths. Change4Life uses high profile campaigns and partnerships with local authorities, schools and the commercial sector to encourage youths to achieve their guideline of 60 active minutes. There are also now Change4Life Sports Clubs in over 6,500 primary schools and all 3000 Secondary Schools. Change4Life also have a number of resources and tips available on their website for leading a more active life.
- The National Institute for Health and Clinical Excellence Centre (NICE) consistently promote the benefits of healthy lifestyles across the curriculum at primary, secondary and higher education levels, and the benefits of group activities along with promoting campaigns for cycling and walking to school.
- Centres for Disease Control and Prevention have developed an easy-to-read leaflet that can be given to parents to encourage and develop ideas on how to get their child to lead a more active lifestyle outside of school.
- Parkrun is a locally-led and voluntarily-run weekly free 5km timed runs in parks throughout the country. They are open to people to all ages and standards.
- Sport Scotland – Active Schools aims to provide more and higher quality opportunities to take part in sport and physical activity before school, during lunchtime and after school, and to develop effective pathways between schools and sports clubs in the local community.
- Alliance for a Healthier Generation is a US organisation which has developed a ‘Healthy Out-of-School Time’ initiative to give out-of-school time providers a science-based framework designed to help create environments where youth are encouraged to eat healthier and move more. An assessment tool is provided to track what you are already doing to support health and wellness and highlight opportunities and strategies for growth and improvement.
Given that many young people constantly use mobile phones on a daily basis, mobile phones can be a viable tool to promote an active lifestyle and deliver positive health interventions . Mobile Apps can be selected according to individual needs of the participant and can be a fun, interactive, cost-effective and social platform to encourage a more active lifestyle . Apps can enable users to set targets, enhance self‐monitoring, and increase awareness .
There are vast amounts of different mobile apps available that focus on healthy living and physical activity, however the below list is a small selection of free apps that may be helpful to promote an active lifestyle:
- Active 10 Walker: An NHS approved app for people looking for easy ways to add activity to their day and improve their health by getting into the habit of walking briskly for 10 minutes every day. IOS download Android download
- Couch to 5k: An NHS approved app designed to get people off the couch and running 5km in 9 weeks. IOS download Android download
- Dungeon Runner Fitness Quest: The user progresses through the game by fighting enemies with punches, opening secret passages with squats and avoiding traps with ski-jumps. This app incorporates motion-tracked exercises through the gram to encourage physical activity. IOS download
- Rise & Recharge: Developed to help reduce sitting time and encourage regular movement. IOS download Android download
- Geocaching ®: Geocaching is a real-world, outdoor treasure hunting game using GPS-enabled devices. Participants navigate to a specific set of GPS coordinates and then attempt to find a container hidden at that location. IOS download Android download
- Zombies, Run! 5 K Training: A training program, with a series of missions , whereby the user runs and listens to various audio narrations to collect virtual supplies and gets fit to escape the zombies. IOS download Android download
- Charity Miles: Earn money for charities every time you run, walk, or bicycle. Corporate sponsors agree to donate a few pennies for every mile you complete. IOS download Android download
- Fitnett: An abundance of five to seven-minute targeted workouts. The app also incorporates the phone’s camera to measure how closely the participant follows the moves on the screen. IOS download
- Pokémon Go: Encourages people to get off the couch and become more active by exploring the outside world. Participants complete a variety of objectives with the opportunity to earn rewards and discover various Pokémon. IOS download Android download
- Ingress: Transforms the real world into a landscape for a global game of mystery, intrigue, and competition. The app encourages users to get off the couch and become active by trying to complete objectives and take over hack points. IOS download Android download
- Sworkit: A number of built-in exercise regimens, including yoga, that simply gets people moving all the way up to 60 minute work-outs. The work outs can be personalised with over 160 exercises. IOS download Android download
- Strava: Tracks running and riding with GPS, offers options to join challenges, share photos from activities and follow friends activities. IOS download Android download
The increase of habitual sedentary behaviour and physical inactivity within the young population is a major contributor to the development of chronic health conditions and increased mortality rates in later life. Promoting an active lifestyle in the young population could reduce these risks and assist in carrying healthy behaviours into adulthood. Physiotherapists are ideally placed to play a crucial proactive role in promoting and facilitating an active lifestyle in the young population.
As the roles and responsibilities of physiotherapists are emerging there has been a shift away from the traditional clinical setting to a more community-based approach. In this setting physiotherapists can act as facilitators for the adoption of active living in a wider population, thus making a larger positive impact in the young population. Administering tools, such as the modified IPAQ-SF, in a community setting enable physiotherapists to identify which stage of the TTM of behaviour change young people are in. This is crucial, as physiotherapists can utilise their skills and knowledge, such as motivational interviewing and signposting, to promote and encourage an active lifestyle to young people in the early stages of the TTM. Additionally, for young people identified in the maintenance stage of the TTM, physiotherapists can utilise individualised strategies to enable young people to stay in this stage, rather than regressing. As behaviours of active living established in young years can greatly impact on maintaining positive habits across a person’s lifespan, It is of the utmost importance to enable young people to stay in the maintenance stage, thus potentially decreasing the future risks of chronic health and early mortality rates. As role models of healthy living physiotherapists will play a role in positively influencing decisions that impact on the health and well-being of communities. As the saying goes "prevention is better than cure" and physiotherapists have a role and responsibility to do more to prevent people having to present at emergency and out-patient settings due to non-communicable diseases.
"Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it" Plato
If you wish to further develop your knowledge of active living and behaviour change for young people, please utilise the links below...
- Active Living Research
- The Association of Paediatric Chartered Physiotherapists
- Consent and Physiotherapy Practice
- Behaviour Change:General Approaches (NICE 2007)
- Training professionals in motivational interviewing (The Health Foundation 2011)
- Energising Lives: A guide to promoting physical activity in primary care (NHS Scotland 2008)
- Young people: Practical strategies for promoting physical activity
- Healthy Futures: Physical activity and active living
- Allied Health Professions into Action: Using allied health professionals to transform health, care and well-being
- Promoting physical activity for children and young people (NICE 2015)
- Motivation and Confidence: What does it take to change behaviour?
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