Exercise behaviour and stages of change2 Opinions
In the United Kingdom around 70% of the adult population fail to meet the guideline amounts for physical activity (Adams & White, 2005). The current recommendations, as set out by the UK Physical Activity Guide 2010, and based upon research such as Turner-Warwick et al. (1991) are that adults should participate in a minimum of thirty minutes of moderate intensity exercise, five or more days per week. Due to lifestyle changes over the past twenty five years which have seen fewer people walking and cycling, and a decrease within the proportion of people employed within manual labour, promotion of increased levels of physical activity through interventions such as those based on Prochaska and Di Clemente’s (1982) Transtheoretical Model (TTM) of behavioural change have become increasingly necessary in order to increase physical activity participation levels.
The stages of change an individual progresses through with regards to exercise behaviour can be explained using the TTM, and an individual would be considered within the Pre-contemplation stage when they have no desire to take up exercise, and are uninformed of the benefits (Prochaska & Velicer, 1997). Contemplation would encompass the time period where an individual is thinking about taking up exercise, and plans to reach the recommended guideline amounts within the next six months. The Preparation stage would include individuals that have researched possible exercise options, who may have discussed the benefits of exercise with a doctor, developed a plan of action, and who intend to begin exercising to the required guidelines within the next month. It is thought that at this stage individuals are more receptive to interventions and promotion of exercise programmes and so this may be the optimum time to introduce such (Prochaska & Velicer, 1997). The Action stage of the model, when related to sport and exercise, would involve the suggested level of activity having been taken up within the past six months. The Maintenance phase involves individuals working to prevent relapse, and is a stage in which behaviour can develop to be more automatic, rather than consciously decided. The ultimate goal within health related behaviour is termination of the cycle, which would involve complete dedication, with no temptation of relapse involved. This, however, is unlikely to be achieved, and so ongoing maintenance is suggested as a more realistic goal.
Within the stages of change model differences may be seen between stages in terms of the frequency of exercise carried out. Increased levels of exercise are noted within action and maintenance stages, as compared with pre-contemplation, contemplation, and preparation stages (De Bourdeaudhuij et al., 2005). Not only is more exercise and sport undertaken in the action and maintenance stages, but levels of physical activity associated with lifestyle (for example, taking the stairs, or getting off the bus a stop earlier and walking the rest of the way) are also increased, as seen within adolescent (De Bourdeaudhuij et al., 2005) and overweight adult (Sarkin et al., 2001) populations. This suggests that those in the first stages of the cycle are at great risk of developing lifestyle diseases such as Cardiovascular Disease and diabetes, and must thus be targeted for interventions; possibly using a stage based approach to initially increase levels of daily activity, followed by the introduction of structured exercise later in the cycle. Would this then be true for other populations such as the elderly, and those individuals with physical disabilities? Or would a structured programme be easier to achieve, with a visit to a gym for example, rather than trying to incorporate exercise into the daily routine, which may impractical?
Because different processes of change operate at different stages of change, interventions must be tailored taking this into account. It fits that individuals within the preparation stage have re-evaluated their behaviours and made the decision to change, and are thus more receptive to interventions, and more willing to ensure they are effective. However, an intervention may be able to be introduced in stages, with information and advice provided to the client in the pre-contemplation stage, in order to educate to the benefits of exercise, and what options are available, and prompt the individual to gradually increase levels of physical activity and progress through to preparation within a shorter time period than would be observed if no intervention was made until the individual had themselves reached the preparation stage. Once the preparation stage has been reached, a structured programme of planned exercise may be introduced and thus increase the chance of programme adherence.
The power of three
Alongside this, motivation research suggests that if three options are presented to an individual with regards to behaviour change, then greater commitment is likely to be observed (Prochaska & Velicer, 1997). It would be interesting to see if this theory applies to exercise prescription, and if offering three alternative exercise programmes which all subscribed to the recommended weekly guidelines, has bearing upon the level of exercise adherence as compared with being offered one set programme, or five programme options. It may be argued that by offering a choice of three programmes, the client is offered a sense of ownership which in turn increases the likelihood of continued commitment, rather than being confused by too many options as may occur when more than three programmes are presented.
Adam and White (2005) suggest that stage based activity promotion interventions do not always work, and that exercise behaviour is too complex to be simplified to five stages of change. Few methods of allocating individuals to stages have been validated, and so accuracy of choosing which style of intervention should be applied is questionable. De Bourdeauhuij et al. (2005) allocates adolescents into each of the stages of change, although data is based upon self report measures, and used an algorithm which had been validated on adults previously, suggesting that results may not be valid and reliable for the adolescent population studied within the paper. Where the TTM looks mostly at motivation as the operant factor, it does not consider other influencing factors such as socio-economic position, which may also have bearing upon exercise behaviour change.
Stage based activity promotion programmes can be seen to be effective in the short term, but there is little longitudinal evidence to support the effectiveness of the model over time. Stage based interventions have also yet to discriminate between exercise typography, specific frequency, and duration that may be coexistent within each stage of change. So whilst the TTM may appear to be effective when applied to exercise behaviour change, for continued exercise adherence a modified model may be required whereby other external factors are accounted for, and validity and reliability of single stage interventions, as well as a full five stage intervention offered. Where Prochaska and DiClemente (1982) may have been correct in explaining change as a process rather than an event, it seems the complexity of the process may have been somewhat overlooked.
Adams, J., & White, M. (2005). Why don’t stage-based activity promotion interventions work? Health Education Research, 20(2), 237-243.
De Bourdeauhuij, I.D., Philippaerts, R., Crombez, G., Matton, L., Wijndaele, K., Balduck, A., & Lefevre, J. (2005). Stages of change for physical activity in a community sample of adolescents. Health Education Research, 20(3), 357-366.
Prochaska, J., & DiClemente, C. (1982). Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276-288.
Prochaska, J., & Velicer, W. (1997). The Transtheoretical Model of Health Behaviour Change. American Journal of Health Promotion, 12(1), 38-48.
Sarkin, J.A., Johnson, S.S., Prochaska, J.O., & Prochaska, J.M. (2001). Applying the Transtheoretical Model to regular Moderate Exercise in an Overweight Population: Validation of a Stages of Change Measure. Preventative Medicine, 33, 462-469.
Turner-Warwick, M., Pentecost, B., Jones, J., Bannister, R., Chambers, T., Clayton, R., Dodds, W., Fentem, P., Marrian, V., Milledge, J., Newsholme, E., Read, A., Thompson, R., Tunstall Pedoe, D., & Pyke, D. (1991). Medical aspects of exercise, summary of a report of the Royal College of Physicians. Journal of the Royal College of Physicians of London, 25, 193-196.
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About Niyc Pidgeon
Positive Psychologist with a specialism in physical activity. Speaker. Writer. Coach. PT. Young Business Person Of The Year 2015. Founder of optimallyou and Newcastle parkrun