Promoting Adherence to Physical Activity Advice

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Introduction

Physical Activity (PA) can be described as any body movements produced by skeletal muscles that requires energy expenditure[1]. Based on this definition, the level of PA ranges from sedentary to vigorous. However, public health guidelines refer to “Physical Activity” as health-enhancing physical activity[2]. Since sedentary activity has shown to adversely affect cardiometabolic markers in healthy adults[3], we can use the term “Physical Activity” to describe any non-sedentary activities that may include active recreational, occupational, and household activities as well as structured exercise regime.

There is vast evidence on the benefits of regular physical activity. Among others, it is effective in preventing cardiovascular, cerebrovascular, and cancer diseases; and in improving overall physical and mental health status[4]. There are many studies that examine the effectiveness of various clinical and community interventions to increase physical activity levels of general and specific population. However, other studies show that about 50% of adult population who start a physical activity program will drop out within a few months[5]. This article will cover the general principles, charasteristics, examples, and evidences of interventions that promote adherence to physical activity in general population. 

Risk Factors for Non-adherence to Physical Activity[6]

The following table lists the factors that may lead to lower adherence to physical activity level as recommended by public health guidelines:

Factors associated with non-adherence to physical activity Notes
Demographic Factors older age correlates of inactivity among older adults include poor health status, poor perception of overall health, depressive symptoms, mobility limitations, pain and fear of pain, lower self-efficacy, lower social support, maladaptive beliefs, and lack of encouragement from physicians.
female gender women tend to adopt moderate PA rather than vigorous. Other correlates of less PA among women include social environment that is not as supportive as men's and multiple roles that women play (i.e. family and work).
non-white ethnicity lower participation of PA among non-white people may partly be an effect of differences in socioeconomic background. However, barriers and facilitators of PA among non-white ethnicity have not been well-examined.
low socioeconomic background several likelys reason for less participation in PA are financial constraint, lack of facilities in their communities, lack of social support, and lack of work flexibility.
Health Related Factors chronic illnesses -
poor general health and physical function -
obesity -
Cognitive and Psychological Factors Greater perceived barriers to physical activity the most commonly reported barrier is lack of time. Other barriers include lack of facilities, fatigue, poor health, and self-consciousness about appearance.
Lack of enjoyment of physical activity Enjoyment is consistenly associated with greater PA level.
Low expectations of benefits from physical activity -
Poor psychological health -
Low self-efficacy for physical activity self-efficacy is someone's confidence in their ability to be physically active in a regular basis. Self-efficacy is needed in maintaining PA adherence in the long-term and it can be the target of intervention.
Low self-motivation for physical activity -
Lack of readiness to change physical activity behaviors -
Poor fitness level -
Behavioural Factors Prior physical activity -
Smoking -
Type A behavior Type A behaviour is associated with competitiveness, striving for achievement, and aggresiveness. Type A behaviour is associated with higher level of PA but lower adherence to supervised PA program.
Social Factors Lack of cohesion in exercise group The influence of cohesion in exercise group on PA level is not as strong as that of physician's and social support.
Lack of physician influence/advice for physical activity Physician's support has shown a consistent influence towards PA level.
Lack of social support for physical activity Social support has shown a consistent influence towards PA level.
Program-related Factors High physical activity intensity Adherence may be lower for high-intensity PA as compared to lower-intensity PA program.
Long physical activity duration Some evidence shows that completing several short PA programs lead to higher adherence than one long PA program, while maintaining the same health benefit.
Environmental Factors Lack of access to facilities/parks/trails Inconvenient access to facilities may lead to lower adherence to PA.
Lack of neighborhood safety Neighborhood safety is particularly important among women, older adults, and individuals with lower education level.

General Principles of Effective Physical Activity Promotion Interventions

Based on the risk factors described above and the available evidence, the following general principles of an effective intervention were generated[6]. A program aimed to promote adherence to physical activity should

  1. Incorporate multiple components of intervention (which will be discussed below)
  2. Include cognitive-behavioural strategies to address psychological issues of non-adherence
  3. Provide sufficient intensity by at least providing guidance on how to start PA program and an ongoing/ follow-up support
  4. Be a tailored approch to suit individual cases[7]
  5. Use a lifestyle approach to PA, which is associated with greater adherence[8] while maintaining the same health benefit[9]. Lifestyle PA includes leisure, occupational, and household physical activities

Intervention Components and the Evidence

A systematic review by Kahn et al (2002)[7] categorized individual interventions based on their approach: informational, social-behavioural, and environmental or policy. Listed below are examples of interventions of each approach that have shown effectiveness in promoting adherence to PA. 

Interventions Description Evidence
Informational Approach
Health Education Providing participants with necessary information such as the benefits of exercise, appropriate exercise techniques, and physiological changes related to exercise. Health Education alone is not sufficient to promote long term adherence. However, it is a foundational component of a combined intervention.[6]
Point-of-decision prompts/signs to encourage stair use Posting signs about the benefit of taking the stairs in multistorey buildings to encourage stair use instead of an elevator/escalator. This intervention is likely to be effective across diverse population provided that a good care is taken to deliver the message if targeting a specific population (i.e. obese population tends to take the stairs if the message about potential weight loss is included).[7]
Community-wide PA campaigns A combined intervention that includes informational approach through mass media and social approach through self-help groups, risk factors screening, counseling, and/or health education in various community settings. Since many studies examined this type of intervention as a combined package, it was hard to distinguish which intervention component that contributes the most to the increase of PA level. This combined intervention is likely to be effective across diverse population[7].
Behavioural Approach
Health risk appraisal This intervention provides information of participant's current health, risk factor, and/or fitness level. As a part of multicomponent intervention, health risk appraisal can help increase participant's intrinsic motivation and it can be used to monitor changes over time[6].
Goal-setting With the help of healthcare/exercise professional, participant must set their own goals that are realistic, specific, and time-bound. In line with the guideline from American Heart Foundation on the prevention of heart diseases and the US Association of Diabetes Educators[10].
Self-monitoring Participant is asked to keep a physical activity 'diary'. In line with the guideline from American Heart Foundation on the prevention of heart diseases and the US Association of Diabetes Educators[10]. Participants (fit adults and sedentary adults) who received self-monitoring as the only intervention showed significant exercise frequency over 18 weeks period. However, this intervention had little effect on participants who already exercise regularly[11]
Reinforcement and incentives As compared to self-monitoring, this intervention encourages participants to report their PA to another person that may give them incentives for completed goals. This intervention is usually combined with self-monitoring and/or goal setting. Participants (fit adults and sedentary adults) who received reinforcement and incentives as the only intervention showed significant exercise frequency over 18 weeks period. However, this intervention had little effect on participants who already exercises regularly[11]
Problem solving Participant is encouraged to identify potential barriers to their PA plans. Then, they create, implement, and evaluate the solutions to those barriers. The evidence for problem solving is not available as a standalone intervention but as a part of counseling program or cognitive-behavioural therapy[12][13].
Relapse prevention Participants is asked to identify future situations that may lead to lapses in PA adherence. Then, they create and implement prevention strategies. In line with the guideline from the US Association of Diabetes Educators[10].
Stimulus control Teaching participants how to structure their daily environment in such a way that encourages PA. The evidence for stimulus control is not available as a standalone intervention but as a part of counseling program or cognitive-behavioural therapy
Cognitive restructuring Teaching participants to recognize and replace maladaptive thoughts with positive ones that can encourage PA. An example of maladaptive thought: a belief that PA must be vigorous and painful to give any health benefit. The evidence for cognitive restructuring is not available as a standalone intervention but as a part of counseling program or cognitive-behavioural therapy
Motivational Interviewing Increasing participant's intrinsic motivation by negotiating behaviour changes. The distinguishing characteristic of motivational interviewing is that it is guiding instead of directing. In line with the guideline from American Heart Foundation on the prevention of heart diseases[10].
Social Approach
Enhancing social support Social support includes group activity programs, family/friends involvement, and interaction with personal trainers/healthcare professionals. Various research have shown that social support (i.e. from community, friends, and family) is effective in increasing PA levels and improving health status in older adults, women, and socio-economically disadvantaged people[14][7].
Modeling Sharing success stories with participants. The evidence for modeling is not available as a standalone intervention but as a part of counseling program or cognitive-behavioural therapy
Environment and Policy
Enhancing access to leisure physical activity facilities Providing an easy access to facilities that promote PA e.g. parks, bicycle trails, footpath, fitness centres. and activity clubs. Other environmental characteristics such as neighbourhood safety, lighting, weather, and pollution can also affect PA participation. Many studies reported that enhanced access to PA facilities combined with other interventions (informational, behavioural, and social approaches) can effectively increase PA level of people across diverse backgrounds. However, it is hard to distinguish the contribution of this particular intervention due to the multicomponent nature of the examined interventions[7].

Resources

The Motivate2Move website, created by Wales Deanery, has a useful section on sedentary behaviour.

The Move More plan is a value-based, whole systems approach aiming to create a culture of physical activity resulting in Sheffield becoming the most active city in the UK by 2020. This is a comprehensive docuement which includes suggestions to promote adherence to PA advice.

References

  1. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.  Public Health Reports 1985;100(2):126-131.
  2. Centers for Disease Control and Prevention. Physical Activity: Glossary of Terms. https://www.cdc.gov/physicalactivity/basics/glossary/index.htm. (accessed 27 April 2018)
  3. Healy GN, Matthews CE, Dunstan DW, Winkler EA, & Owen N. Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003–06. European Heart Journal 201132(5), 590-597.
  4. Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the evidence. CMAJ: Canadian Medical Association Journal 2006;174(6):801-809. doi:10.1503/cmaj.051351.
  5. Dishman RK. Overview. In: Dishman RK, ed. Exercise adherence: It’s impact on public health. Champaign, IL: Human Kinetics; 1988.
  6. 6.0 6.1 6.2 6.3 Allen K, Morey MC. Physical activity and adherence. In Improving patient treatment adherence. 2010 (pp. 9-38). Springer, New York, NY.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, Stone EJ, Rajab MW, Corso P. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med. 2002 May;22(4 Suppl):73-107.
  8. Dunn AL, Andersen, RE, & Jakicic JM. Lifestyle physical activity interventions: History, short-and long-term effects, and recommendations. American journal of preventive medicine 199815(4), 398-412.
  9. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl III HW, & Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. Jama 1999281(4), 327-334.
  10. 10.0 10.1 10.2 10.3 Greaves CJ, Sheppard KE, Abraham C, Hardeman W, Roden M, Evans PH, & Schwarz P. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC public health 201111(1), 119.
  11. 11.0 11.1 Noland, MP. The effects of self-monitoring and reinforcement on exercise adherence. Research Quarterly for Exercise and Sport 198960(3), 216-224.
  12. Simons-Morton DG, Blair SN, King AC, Morgan TM, Applegate WB, O'Toole M, ... & Shih JH. Effects of physical activity counseling in primary care: The Activity Counseling Trial: A randomized controlled trial. JAMA: Journal of the American Medical Association 2001; 286(6):677-87.
  13. Rejeski WJ, Brawley LR, Ambrosius WT, Brubaker PH, Focht BC, Foy CG, & Fox LD. Older adults with chronic disease: benefits of group-mediated counseling in the promotion of physically active lifestyles. Health Psychology 2003, 22(4), 414.
  14. What Works for Health: Policies and Programs to Improve Wisconsin's Health. Community-based social support for physical activity. http://whatworksforhealth.wisc.edu/program.php?t1=21&t2=12&t3=78&id=406 (accessed 08 May 2018)