COMPLEXITY OF PHYSICAL ACTIVITY BEHAVIOR
Most Americans are aware of the numerous physical and psychological benefits associated with physical activity, yet more than half of U.S. adults do not participate in enough physical activity to realize these health benefits (4). In addition, for those who do decide to become active, 50% will drop out within six months (5). As physical activity is such a complex behavior and technology makes physical activity almost completely unnecessary, many individuals find it difficult to adopt a physically active lifestyle, and even harder to maintain a regular physical activity program. Thus, it is important for health and fitness professionals to be aware of appropriate behavior change strategies to effectively guide their patients and clients to adopt and maintain the active lifestyle necessary to attain the physiological and psychological health benefits associated with physical activity.
To fully understand how to get individuals to initiate and maintain regular physical activity, it is first important to understand the complexity of physical activity behavior. It is not quite as simple as lacing up athletic shoes. Individuals must be motivated, make a commitment to being active, and understand the basic principles of an exercise program (e.g., overload, specificity, progression, etc.), as well as what to expect in each stage of physical activity program adoption (e.g., initial, improvement, and maintenance conditioning stages). Simply providing individuals with an exercise prescription outlining the recommended frequency, intensity, and duration is insufficient. Individuals need to develop an understanding of how to use behavior change strategies to successfully adhere to a regular physical activity program. This understanding may be best developed through incorporating health behavior change theories in the design and implementation of physical activity programs.
APPLYING BEHAVIOR CHANGE THEORY: STRATEGIES FOR BECOMING AND STAYING ACTIVE
A theory is defined as a set of concepts, definitions, and propositions that represents a systematic way of understanding and explaining events or situations by illustrating the relationships between variables. Although theories are often used to guide physical activity research, they also are an important, and often neglected, element of programs or interventions where behavior change is an outcome goal (6). It is important that practitioners develop a sound understanding of theories and their application to physical activity behavior change to develop programs that incorporate effective strategies and maximize the maintenance of long-term behavior change (see Figure 1). In this article, we outline some of the key health behavior change theories and suggest strategies that can be applied to maximize the effectiveness of physical activity programs for changing individuals' behaviors.
Social Cognitive Theory
Social Cognitive Theory (SCT) specifies a core set of psychosocial determinants for effectively understanding a broad range of health behaviors, including physical activity (2). Self-efficacy is the core element of SCT and is thought to influence behavior both directly and indirectly through the other model constructs (2). Table 1 includes examples of strategies to influence each of the model components discussed later.
Self-efficacy is a situation-specific self-confidence in one's ability to accomplish a task (3). Self-efficacy is one of the most consistent determinants of physical activity behavior and adherence to exercise programs (10). There are four sources of efficacy information: mastery experiences, social modeling, social persuasion, and the interpretation of physiological and emotional responses (3). Mastery experiences reflect previous successes that bolster one's confidence in his or her ability to succeed again. Social modeling involves watching similar others (i.e., same sex, race, age, fitness level, etc.) successfully complete a task. Social persuasion includes motivation and support from others (i.e., "You are doing great! Keep going!") during or after successful completion of an exercise session. The appropriate interpretation of physiological responses involves identifying somatic states that are indicative of improving physical capabilities. Incorporating each of these sources of efficacy information (see Table 1) when an individual begins or is struggling to maintain a regular physical activity program can contribute to increases in adherence and participation in physical activity. In addition, self-efficacy has been shown to influence other elements of SCT such that individuals with higher levels of self-efficacy have more positive expectations about what the behavior will bring about, set higher goals for themselves, and are more likely to believe that they are capable of overcoming difficulties and barriers with effort and coping skills (2).
An outcome expectation is a belief that a given behavior will produce a specific outcome (2). Individuals with high outcome expectations tend to be more active. However, unrealistic outcome expectations can lead to attrition as individuals become discouraged that their targets are out of reach. Thus, establishing realistic outcome expectations for your clients is important as it increases the likelihood they will be achieved, thereby maintaining individual motivation.
Goals serve as powerful motivators and are important for focusing and directing activity, prompting increased effort, and promoting development of new creative strategies. Setting goals can be one of the most effective behavioral change tools, but individuals must set appropriate goals that adhere to the SMART principles (i.e., Specific, Measureable, Action-oriented, Realistic, and Timely) to enhance their effectiveness and allow individuals to evaluate their progress (8). Goals should be set at an appropriately challenging level so that they require effort but are still attainable. Individuals also should focus on process goals or those focused on aspects of the physical activity program that are directly under their control (i.e., frequency of participation, intensity, etc.). In addition, goals should be set within a specific time frame (i.e., short- or long-term) that can serve as a checkpoint to evaluate progress and set new goals. Long-term goals (e.g., next 6 months or year) help individuals keep the big picture in mind, whereas short-term goals focus on the near future (e.g., current day, week, or month) and are critical for maintaining high levels of motivation and bolstering self-efficacy.
Perceived barriers. All prospective exercisers encounter barriers to physical activity, but barriers vary from individual to individual. Barriers can be categorized as personal (e.g., outcome expectations, time commitments); social (e.g., social support, social norms); environmental (i.e., neighborhood safety, access to physical activity-friendly areas); and exercise history/exertion barriers (i.e., past performance, exercise program characteristics). Higher levels of perceived barriers are associated with lower levels of physical activity participation (11). Individuals need to establish creative strategies for effectively overcoming barriers to prevent them from interfering with their participation in physical activity. One approach is to have clients list their barriers to physical activity and then jointly discuss solutions for overcoming these barriers. A list of common barriers and their potential solutions is shown in Table 2.
Social support. Social support is the physical and emotional comfort provided by others. Individuals who have support from others in their lives for their physical activity behavior are more likely to participate in and adhere to a regular program (11). Having a buddy to exercise with or check in on one's progress can reinforce an individual's commitment to behavior change. Thus, it is important to encourage clients trying to initiate and maintain a physically active lifestyle to surround themselves with supportive others who can provide the necessary positive feedback, encouragement, and support, and do not attempt to derail their efforts. Practitioners can facilitate this further by encouraging clients to participate in group exercise classes or offering sessions for pairs or groups. The more people one has on his or her team, the better.
Theory of Planned Behavior
The Theory of Planned Behavior (1) suggests that the best predictor of physical activity behavior is a person's intent to be active. Intention is viewed as a function of attitudes, subjective norms, and perceived behavioral control. Table 3 includes examples of strategies for influencing each of these constructs.
Physical activity is an intentional behavior, and individuals with strong intentions are generally more likely to engage in the behavior (1). Clients with strong intentions are more likely to invest more effort into planning and maintaining an exercise routine.
Attitudes reflect the degree to which a behavior is positively or negatively valued (1). Individuals who have more positive attitudes toward physical activity are more likely to engage in physical activity. Therefore, shaping clients' attitudes to view physical activity in a more positive light may contribute to greater participation and adherence.
One way to enhance positive attitudes toward physical activity is to positively alter decisional balance. Decisional balance is the comparison of potential benefits and costs of engaging in physical activity. Individuals who believe that the benefits of engaging in physical activity outweigh the costs are more likely to become and stay active. In most cases, participants who reflect on these factors with an honest and accurate perspective are able to see that the costs (e.g., taking time away from watching a favorite television show) are minimal compared with the benefits (e.g., helping me to effectively manage my diabetes). This is likely to serve as a source of motivation to initiate and maintain participation in physical activity.
Subjective norms are beliefs about how others will view participation in physical activity (1). They are influenced by others' important beliefs and by the importance one places on what other people think. An individual holds a positive subjective norm if he or she believes significant others think exercise is important, and the individual wants to meet the significant others' expectations. Positive subjective norms may stimulate exercise behavior as individuals feel compelled to adhere to these norms (1).
Perceived behavioral control
Perceived behavioral control is a subjective judgment of the perceived ease or difficulty of engaging in a behavior (1). Although there may be times when an individual's control is limited, for the most part, each individual bears the personal responsibility to make the lifestyle changes necessary to enhance physical and mental health. Perceived control is considered an important predictor of health behavior because individuals will expend more effort to perform a behavior when they believe that they are capable of changing that behavior (1).
For long-term behavior change to be successful, individuals must be committed to the changes and use self-management strategies to maintain control of their exercise behavior (7). Examples of self-management strategies include goal setting, behavioral cues to action, self-monitoring, and self-reinforcement (see Table 4).
Behavioral cues to action
Behavioral cues act as prompts to the initiation of the desired behavior (7). They are simple, yet powerful, because individuals associate them with exercise. For example, seeing the running shoes that were laid out last night will prompt an individual to go for a run or walk in the morning.
Behavioral contracts also can serve as cues to action. Contracts are written signed agreements that specify exercise goals and include realistic objectives, a time frame for achieving goals, plans for overcoming barriers, and rewards or consequences for meeting or failing to meet goals (see Figure 2). Contracts should be signed by a witness to make them official documents. The mere act of entering into a signed agreement with another person can encourage physical activity behavior by enhancing individual commitment and accountability. Posting behavioral contracts in a prominent place also can serve as a constant reminder of an individual's decision to lead a healthier lifestyle.
After an individual has established his or her behavior change goals, self-monitoring should be used to evaluate progress. If an individual's behavior is congruent with his or her goals, it can reinforce physical activity behavior and enhance self-efficacy for continued adherence to these goals (7). On the other hand, if an individual has fallen short of the established goals, it can serve as a motivator to increase efforts to change behavior or, alternatively, to reevaluate and adjust goals to make them more manageable. Thus, self-monitoring can provide the necessary feedback to reinforce positive achievements, stimulate effort in the face of failure, and modify goals as needed to maximize success (7).
Reinforcement and rewards can provide motivation for exercise participation. Intrinsic motivation comes from rewards inherent in the task (e.g., enjoyment) and is not a result of external factors. Intrinsic motivators are critical for long-term exercise adherence, but extrinsic or tangible rewards (e.g., new workout outfit) also may be useful for positive reinforcement in the early stages of behavior change (7). Reinforcements and rewards should be aligned with health goals and awarded when goals have been successfully achieved. Nonmaterial forms of reinforcement, such as progress charts, also can be useful. This may lead to a greater personal investment of effort in maintaining the positive behavior. Ultimately, as individuals continue to be active and the activity becomes intrinsically satisfying, extrinsic rewards can be phased out.
Maintaining an active lifestyle is a continuous process. Even individuals in maintenance stages must continue to work to prevent relapsing into previous habits of inactivity. There are two main components to the relapse prevention process: 1) preventing initial lapses (i.e., missing a workout) and 2) preventing any lapses from escalating into total relapse (9).
The key to minimizing missed workouts will be to identify and avoid high-risk situations. A high-risk situation is any situation that makes an individual vulnerable to having a lapse in his or her normal physical activity regimen. High-risk situations vary from individual to individual but may include travel, working late, and seasonal changes. Once identified, high-risk situations can be avoided by using previously discussed behavioral change strategies. For example, if working late interferes with one's normal exercise routine, workouts can be completed in the morning on days when it is likely the individual will end up staying late at the office. Assisting clients to identify high-risk situations and develop effective plans of action will reduce lapses and facilitate maintenance of behavior change during the long-term.
It is important for individuals to realize that it is perfectly acceptable to miss a workout occasionally, and one lapse does not necessitate abandoning the exercise program entirely. Lapses should be viewed as mistakes, rather than failures, and mistakes should be considered learning opportunities. During the critical period after a missed workout, it will be important for an individual to remember his or her reason for exercising, to focus on past successes (i.e., all the exercise sessions already attended), and if necessary, to create a contract to continue the exercise program. High levels of self-efficacy for overcoming barriers to physical activity are essential for relapse prevention and can aid individuals in maintaining an active healthy lifestyle.
Physical activity is a complex behavior, and changing such complex behaviors is a gradual and continuous process. Although most individuals have good intentions to begin exercising on a regular basis, many are unsuccessful because they fail to effectively self-regulate their behavior. Whether an individual is just thinking about initiating an exercise program or has been engaging in physical activity for years, the potential for barriers to interfere with their ability to maintain an active lifestyle always exists.
Knowledgeable and effective physical activity practitioners are already using behavior change strategies to enhance their clients' motivation and adherence to exercise programs. As we continue to battle inactivity in the United States, it will be critical for exercise leaders to be creative and develop innovative ideas, strategies, and programs grounded in theory for promoting successful physical activity behavior change. Our nation did not become sedentary overnight and, unfortunately, will not become active overnight. Therefore, it is important that practitioners try to maximize the impact of our physical activity behavior change programs by empowering individuals and providing them with the most effective behavior change strategies. The health benefits of physical activity for individuals and society will never be realized without successfully changing long-term physical activity behavior.
CONDENSED VERSION AND BOTTOM LINE
Although engaging in regular physical activity is a challenging task, many behavior change theories and strategies can be effectively applied to help individuals maintain active lifestyles. If exercise practitioners are aware of these theories and strategies and include them as an integral part of their work, they are likely to increase the potential of their clients' reaching and surpassing their exercise goals.