ACSM’s Guidelines for Exercise Testing and Prescription

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Prev\tChronic\tDis\t[Internet].\t2014;11:130389.\t[cited\t2015\tJan\t6].\tAvailable\tfrom: http:\/\/www.cdc.gov\/pcd\/issues\/2014\/pdf\/13_0389.pdf.\tdoi:10.5888\/pcd11.130389. 309.\tWeaver\tFM,\tFollett\tK,\tStern\tM,\tet\tal.\tBilateral\tdeep\tbrain\tstimulation\tvs\tbest\tmedical\ttherapy\tfor patients\twith\tadvanced\tParkinson\tdisease:\ta\trandomized\tcontrolled\ttrial.\tJAMA.\t2009;301(1):63\u201373. 310.\tWee\tS,\tPitetti\tKH,\tGoulopoulou\tS,\tCollier\tSR,\tGuerra\tM,\tBaynard\tT.\tImpact\tof\tobesity\tand\tDown syndrome\ton\tpeak\theart\trate\tand\taerobic\tcapacity\tin\tyouth\tand\tadults.\tRes\tDev\tDisabil.\t2014;36C:198\u2013 206. 311.\tWerner\tWG,\tDiFrancisco-Donoghue\tJ,\tLamberg\tEM.\tCardiovascular\tresponse\tto\ttreadmill\ttesting\tin Parkinson\tdisease.\tJ\tNeurol\tPhys\tTher.\t2006;30(2):68\u201373. 312.\tWhite\tLJ,\tMcCoy\tSC,\tCastellano\tV,\tet\tal.\tResistance\ttraining\timproves\tstrength\tand\tfunctional capacity\tin\tpersons\twith\tmultiple\tsclerosis.\tMult\tScler.\t2004;10(6):668\u201374. 313.\tWiart\tL,\tDarrah\tJ,\tKembhavi\tG.\tStretching\twith\tchildren\twith\tcerebral\tpalsy:\twhat\tdo\twe\tknow\tand where\tare\twe\tgoing?\tPediatr\tPhys\tTher.\t2008;20(2):173\u20138. 314.\tWolfe\tF,\tBr\u00e4hler\tE,\tHinz\tA,\tH\u00e4user\tW.\tFibromyalgia\tprevalence,\tsomatic\tsymptom\treporting,\tand\tthe dimensionality\tof\tpolysypmtomatic\tdistress:\tresults\tfrom\ta\tsurvey\tof\tthe\tgeneral\tpopulation.\tArthritis Care\tRes.\t2013;65(5):777\u201385. 315.\tWolfe\tF,\tSmythe\tHA,\tYunus\tMB,\tet\tal.\tThe\tAmerican\tCollege\tof\tRheumatology\t1990\tcriteria\tfor\tthe classification\tof\tfibromyalgia:\treport\tof\tthe\tmulticenter\tcriteria\tcommittee.\tArthritis\tRheum. 1990;33(2):160\u201372. 316.\tYarasheski\tKE,\tRoubennoff\tR.\tExercise\ttreatment\tfor\tHIV-associated\tmetabolic\tand\tanthropomorphic complications.\tExerc\tSport\tSci\tRev.\t2001;29(4):170\u20134. 317.\tZiemssen\tT,\tReichmann\tH.\tCardiovascular\tautonomic\tdysfunction\tin\tParkinson\u2019s\tdisease.\tJ\tNeurol\tSci.","2010;289:74\u201380. 318.\tZigmond\tMJ,\tSmeyne\tR.\tExercise:\tis\tit\ta\tneuroprotective\tand\tif\tso,\thow\tdoes\tit\twork?\tParkinsonism Relat\tDisord.\t2014;20(Suppl\t1):S123\u20137.","Behavioral\tTheories\tand 12 Strategies\tfor\tPromoting Exercise INTRODUCTION The\tpurpose\tof\tthis\tchapter\tis\tto\tprovide\texercise\tand\thealth\tcare\tprofessionals\ta basic\tunderstanding\tof\thow\tto\tassist\tindividuals\tto\tadopt\tand\tadhere\tto\tthe exercise\tprescription\t(Ex\tRx)\trecommendations\tthat\tare\tmade\tthroughout\tthe Guidelines.\tChapter\t1\tof\tthe\tGuidelines\tfocuses\ton\tthe\tpublic\thealth recommendations\tfor\ta\tphysically\tactive\tlifestyle,\tyet\tmost\tof\tthe\tpublic\tremains unaware\tof\tthese\trecommendations\t(11).\tFurthermore,\tmost\tadults\tin\tthe\tUnited States\tdo\tnot\tengage\tin\tthe\trecommended\tamounts\tof\tphysical\tactivity\t(PA)\t(99). Simply\tproviding\tknowledge\tand\tpromoting\tawareness\tof\tEx\tRx recommendations\tmay\tbe\tinsufficient\tto\tproduce\tbehavior\tchange\t(48); therefore,\ta\tbetter\tunderstanding\tof\tbehavioral\tstrategies\tthat\tcan\tbe\tused\tto promote\ta\tphysically\tactive\tlifestyle\tis\twarranted. Research\thas\tidentified\tconsistent\tcorrelates\tto\tengaging\tin\tregular\texercise. Numerous\tdemographic\tfactors\t(e.g.,\tage,\tgender,\tsocioeconomic\tstatus, education,\tethnicity)\tare\tconsistently\trelated\tto\tthe\tlikelihood\tthat\tan\tindividual will\texercise\ton\ta\tregular\tbasis\t(10,57).\tAlthough\tthese\tfactors\tare\tnot\tamenable to\tintervention,\tthey\tdo\tsuggest\twho\tmight\tbenefit\tmost\tfrom\texercise intervention.\tThis\tchapter\tfocuses\ton\t(a)\tthe\trole\tthat\tmodifiable\tfactors\thave\ton the\tEx\tRx,\t(b)\tbehavioral\ttheories\tand\tmodels\tthat\thave\tbeen\tapplied\tto\tenhance exercise\tadoption\tand\tmaintenance,\t(c)\tbehavioral\tstrategies\tand\tapproaches\tthat can\tbe\tused\tto\tincrease\tPA\tbehaviors,\tand\t(d)\tunique\tconsiderations\tfor\tspecial populations.","EXERCISE\tPRESCRIPTION Given\tthe\tflexibility\tin\tthe\tFrequency,\tIntensity,\tTime,\tand\tType\t(FITT) principle\tof\tEx\tRx\tfor\tthe\ttargeted\tpopulation,\tit\tis\timportant\tto\tfirst\tunderstand what\timpact\tvariations\tin\tthe\tEx\tRx\tmight\thave\ton\tadoption\tor\tmaintenance\tof\ta habitually\tactive\tlifestyle. Frequency\/Time Ex\tRx\trecommendations\tallow\tfor\tflexibility\tin\tthe\tdifferent\tcombinations\tof frequency\tand\ttime\tto\tachieve\tthem.\tA\tcommonly\theld\tbelief\twas\tthat\tflexibility in\tterms\tof\tthe\ttime\/duration\tand\texercise\tvolume\trecommended\twould\tallow individuals\tto\tovercome\tthe\tmost\tfrequently\treported\tbarrier\tto\tregular\texercise, that\tis,\tlack\tof\ttime\t(71).\tHowever,\tthe\tlack\tof\tany\treal\tchange\tin\tPA\tlevels\tin\tthe United\tStates\tfrom\t1998\tto\t2008\tsuggests\totherwise\t(17).\tReviews\tof randomized\ttrials\thave\tnot\tidentified\tdifferences\tin\texercise\tadherence\twhen different\tcombinations\tof\tfrequency\tand\ttime\tare\tused\tto\tachieve\tthe\tsame\ttotal volume\tof\tPA\t(53,79).\tThese\tresults\tshould\tbe\tviewed\twith\tcaution,\thowever, because\tthe\tincluded\tstudies\twere\trandomized\ttrials\tthat\tassigned\tparticipants\tto different\tcombinations.\tAllowing\tindividuals\tto\tself-select\tfrequency\tand\ttime may\tpositively\tinfluence\tadherence\tto\texercise\tinterventions. Intensity Although\tprevious\tstudies\tof\tthe\teffects\tof\texercise\tintensity\ton\tadherence suggest\tthat\tindividuals\tare\tmore\tlikely\tto\tadhere\tto\tlower\tintensity\texercise programs\t(33,72),\ta\tmore\trecent\treview\tsuggests\tthat\tthis\tinverse\trelationship\tis not\tparticularly\tstrong\tand\tmay\tbe\tmoderated\tby\tprior\texercise\tbehavior\t(79). There\tis\tevidence\tthat\tindividuals\twith\tmore\texercise\texperience\tfare\tbetter\twith higher\tintensity\tprograms\t(65%\u201375%\theart\trate\treserve\t[HRR]),\twhereas\tthose adopting\texercise\tfor\tthe\tfirst\ttime\tmay\tbe\tbetter\tsuited\tto,\tand\tself-select, moderate\tintensity\tprograms\t(45%\u201355%\tHRR)\t(3). Type Although\tit\tis\trecommended\tthat\tindividuals\tparticipate\tin\ta\tvariety\tof\texercise types\t(i.e.,\taerobic,\tresistance,\tneuromotor,\tand\tflexibility)\t(42),\tthere\thave\tbeen","few\tsystematic\ttests\tof\tthe\teffects\tof\tdifferent\texercise\tmodalities\ton\tadoption and\tmaintenance.\tMost\tof\tthe\tresearch\tthat\thas\texamined\tadherence\thas investigated\taerobic\tactivity,\toften\twith\ta\tfocus\ton\twalking,\tyet\tthere\tis\tno compelling\tevidence\tthat\texercise\tmode\tis\trelated\tto\tadherence\t(79).\tTo\tdate, little\tis\tknown\tabout\tthe\tcharacteristics\tof\tthose\twho\tadopt\tand\tmaintain resistance\ttraining\tand\tflexibility-exercise\tprograms. In\tthe\tFITT\tprinciple\tof\tEx\tRx,\t\u201cType\u201d\tuniversally\trefers\tto\tthe\tmode\tor\tkind of\texercise.\tHowever,\tin\tthe\tarea\tof\thealth\tbehavior,\tType\thas\tan\tadditional context,\tfocusing\tmore\ton\tprogram\/delivery\ttype\t(i.e.,\thome-based,\tsupervised). Although\tthe\ttraditional\tapproach\tin\tEx\tRx\tis\tto\tprovide\tstructured,\tsupervised exercise\tprograms,\tstudies\thave\tshown\tcomparable\tor\tgreater\tadherence\tto home-based\tprograms\tthat\tinclude\tthe\tprovision\tof\tremotely\tdelivered\tsupport (24,43).\tInterventions\tdelivered\tentirely\tor\tpredominantly\tvia\ttelephone\thave been\tshown\tto\tbe\teffective\tin\tincreasing\tPA\tin\ta\trange\tof\tpopulations\t(44),\tand technology-delivered\tinterventions\talso\thold\tpromise\tfor\tpromoting\tPA\twith greater\treach\tand\tlower\tcost\t(56).\tAlthough\tthere\tare\tan\tabundance\tof commercially\tavailable\tapps\tthat\trelate\tto\tPA\tand\tfitness,\tthey\tgenerally\tlack\tthe inclusion\tof\tevidence-based\tbehavior\tchange\tstrategies,\tprinciples,\tand\ttheories (62,86). THEORETICAL\tFOUNDATIONS\tFOR\tUNDERSTANDING EXERCISE\tBEHAVIOR Theories\tand\tmodels\tprovide\tframeworks\tfor\tunderstanding\texercise participation\tand\tthe\tfactors\tthat\tmay\tfacilitate\tor\timpede\tbeing\tphysically active.\tUsing\tappropriate\ttheories\tcan\tguide\texercise\tand\thealth\tprofessionals\tin determining\tappropriate\tstrategies\tto\tassist\tindividuals\tto\tadopt\tand\tmaintain regular\tPA.\tThe\tmost\twidely\tused\ttheories\tand\tmodels\tin\tthe\tPA\tliterature\tare described\tas\tfollows.\tThe\tpurpose\tof\tthis\tsection\tis\tto\tprovide\ta\tbasic understanding\tof\tthe\ttheories\tand\tmodels.\tA\tlater\tsection\tdescribes\tthe application\tof\tstrategies\tthat\tresult\tfrom\tthese\ttheories\tand\tmodels. Social\tCognitive\tTheory Social\tcognitive\ttheory\t(SCT)\tis\ta\tcomprehensive\ttheoretical\tframework\tthat\thas","been\textensively\temployed\tin\tunderstanding,\tdescribing,\tand\tchanging\texercise behavior.\tThe\ttheory\tand\tstrategies\tderived\tfrom\tSCT\thave\tbeen\tsuccessfully applied\tin\texercise\tinterventions\tacross\tdiverse\tpopulations\t(6,60,61).\tSCT\tis based\ton\tthe\tprinciple\tof\treciprocal\tdeterminism;\tthat\tis,\tthe\tindividual\t(e.g., emotion,\tpersonality,\tcognition,\tbiology),\tbehavior\t(e.g.,\tpast\tand\tcurrent achievement),\tand\tenvironment\t(i.e.,\tphysical,\tsocial,\tand\tcultural)\tall\tinteract\tto influence\tbehavior\t(8).\tIt\tis\timportant\tto\trecognize\tthat\tthese\tare\tdynamic\tfactors that\tinfluence\teach\tother\tdifferently\tover\ttime.\tFor\texample,\tan\tindividual\twho begins\tan\texercise\tprogram\tmay\tfeel\ta\tsense\tof\taccomplishment,\tencouraging even\tmore\texercise,\twhich\tleads\tto\tmaking\tthe\tenvironment\tmore\tconducive\tto subsequent\texercise\t(e.g.,\tbuying\thome\texercise\tequipment).\tConversely, another\tindividual\tmay\tstart\tan\texercise\tprogram,\twork\ttoo\thard\tand\tfeel fatigued,\tlose\tmotivation,\tand\tmove\tthe\texercise\tequipment\tto\tthe\tbasement\tto make\tthe\tenvironment\tless\tconducive\tto\texercising.\tSCT\tposits\tthat\tindividuals learn\tfrom\texternal\treinforcements\tand\tpunishments,\tby\tobserving\tothers,\tand through\tcognitive\tprocesses\t(9). Central\tto\tSCT\tis\tthe\tconcept\tof\tself-efficacy,\twhich\trefers\tto\tone\u2019s\tbeliefs\tin his\tor\ther\tcapability\tto\tsuccessfully\tcomplete\ta\tcourse\tof\taction\tsuch\tas\texercise (8).\tThere\tare\ttwo\tsalient\ttypes\tof\tself-efficacy\twhen\tconsidering\texercise behavior.\tTask\tself-efficacy\trefers\tto\tan\tindividual\u2019s\tbelief\the\tor\tshe\tcan\tactually do\tthe\tbehavior\tin\tquestion,\twhereas\tbarriers\tself-efficacy\trefers\tto\twhether\tan individual\tbelieves\the\tor\tshe\tcan\tregularly\texercise\tin\tthe\tface\tof\tcommon barriers\tsuch\tas\tlack\tof\ttime\tand\tpoor\tweather.\tThe\thigher\tthe\tsense\tof\tefficacy, the\tgreater\tthe\teffort,\tpersistence,\tand\tresilience\tan\tindividual\twill\texhibit, particularly\twhen\tfaced\twith\tbarriers\tor\tchallenges.\tSelf-efficacy\tis\tone\tof\tthe most\tconsistently\tfound\tcorrelates\tof\tPA\tin\tadults\tand\tyouth\t(10).\tFor\texample, an\tolder\tadult\twho\tdoes\tnot\tbelieve\the\tor\tshe\tcan\t\u201clift\tweights\u201d\twould\tnot\teven consider\tenrolling\tin\ta\tprogram\tthat\tincluded\tresistance\ttraining.\tThis\tindividual would\thave\tto\twork\ton\tincreasing\this\tor\ther\tconfidence\tin\this\tor\ther\tcapability to\tperform\tresistance\ttraining.\tStrategies\tfor\tenhancing\tself-efficacy\tare described\tlater\tin\tthis\tchapter. Outcome\texpectations\tand\texpectancies,\tkey\tconcepts\tof\tSCT,\tare\tanticipatory results\tof\ta\tbehavior\tand\tthe\tvalue\tplaced\ton\tthese\tresults\t(105).\tIf\tspecific outcomes\tare\tseen\tas\tlikely\tto\toccur\tand\tare\tvalued,\tthen\tbehavior\tchange\tis","more\tlikely\tto\toccur\t(105).\tFor\texample,\tan\toverweight\tadult\twho\twants\tto\tlose weight\tand\tbelieves\tthat\twalking\twill\thelp\tis\tmore\tlikely\tto\tstart\tand\tmaintain such\ta\tprogram.\tConversely,\ta\twoman\twho\tbelieves\tthat\tresistance\ttraining\twill lead\tto\tlooking\t\u201cmuscular\u201d\tor\t\u201cmasculine\u201d\twill\tbe\tunlikely\tto\tstart\ta\tresistance training\tprogram\tif\tthese\ttraits\tare\tperceived\tas\tundesirable. Another\timportant\tconcept\tin\tSCT\tis\tself-regulation\tor\tself-control.\tSelf- regulation\/self-control\tis\ta\tperson\u2019s\tability\tto\tset\tgoals,\tmonitor\tprogress\ttoward those\tgoals\t(or\tself-monitor),\tproblem\tsolve\twhen\tfaced\twith\tbarriers,\tand engage\tin\tself-reward.\tA\tmeta-analysis\tfound\tthat\texercise\tinterventions\twere most\teffective\twhen\tself-monitoring\twas\tcombined\twith\tat\tleast\tone\tother technique\twithin\tthe\tself-regulation\/self-control\tconstruct\t(61). Transtheoretical\tModel The\ttranstheoretical\tmodel\t(TTM)\twas\tdeveloped\tas\ta\tframework\tfor understanding\tbehavior\tchange\tand\tis\tone\tof\tthe\tmost\tpopular\tapproaches\tfor promoting\texercise\tbehavior\t(67,73,74).\tThe\tpopularity\tof\tthe\tTTM\tstems\tfrom the\tintuitive\tappeal\tthat\tindividuals\tare\tat\tdifferent\tstages\tof\treadiness\tto\tmake behavioral\tchanges\tand\tthus\trequire\ttailored\tinterventions.\tThe\tTTM\tincludes five\tstages\tof\tchange:\tprecontemplation\t(i.e.,\tno\tintention\tto\tbe\tregularly\tactive in\tthe\tnext\t6\tmo),\tcontemplation\t(i.e.,\tintending\tto\tbe\tregularly\tactive\tin\tthe\tnext 6\tmo),\tpreparation\t(i.e.,\tintending\tto\tbe\tregularly\tactive\tin\tthe\tnext\t30\td),\taction (i.e.,\tregularly\tactive\tfor\t<6\tmo),\tand\tmaintenance\t(i.e.,\tregularly\tactive\tfor\t\u22656 mo).\tAs\tindividuals\tattempt\tto\tchange\ttheir\tbehavior,\tthey\tmay\tmove\tlinearly through\tthese\tstages,\tbut\trepeated\trelapse\tand\tsuccessful\tchange\tafter\tseveral unsuccessful\tattempts\tmay\talso\toccur. Associated\twith\tthe\tfive\tstages\tof\tchange\tare\tthe\tconstructs\tof\tprocesses\tof change,\tdecisional\tbalance,\tand\tself-efficacy.\tThe\t10\tprocesses\tof\tchange illustrate\tthe\tstrategies\tused\tby\tindividuals\tin\tattempting\tto\tadvance\tthrough\tthe five\tstages\tof\tchange.\tEmphasizing\texperiential\tor\tcognitive\tprocesses\tof\tchange (e.g.,\tunderstanding\tthe\trisks\tof\tinactivity)\tis\trecommended\tin\tearlier,\tpre-action stages\tof\tchange,\twhereas\tpromoting\tbehavioral\tprocesses\tof\tchange\t(e.g., rewarding\toneself)\tis\tmost\thelpful\tin\tlater\tstages\tof\tchange.\tDecisional\tbalance involves\tweighing\tthe\tpros\tand\tcons\tof\tchanging\texercise\tbehavior.\tDuring\tpre- action\tstages\tof\tchange,\tthe\tcons\ttypically\toutweigh\tthe\tpros,\twhereas\tduring","action\tand\tmaintenance,\tthe\tpros\ttypically\toutweigh\tthe\tcons\t(74).\tSelf-efficacy is\tlowest\tin\tthe\tearliest\tstages\tof\tchange\tand\thighest\tin\tthe\tlatest\tstages\tof change.\tThere\tare\tspecific\tprocesses\tof\tchange\tand\tpattern\tin\tdecisional\tbalance and\tself-efficacy\tthat\thave\tbeen\tshown\tto\tbe\tmost\tuseful\tto\tfacilitate\tprogression through\teach\tof\tthe\tstages\tof\tchange\tfor\texercise\t(29,67)\t(Figure\t12.1). The\tTTM\thighlights\tdifferent\tapproaches\tto\texercise\tadoption\tand","maintenance\tthat\tneed\tto\tbe\ttaken\twith\tdifferent\tindividuals\tbased\ton\tstage\tof change\tor\treadiness\tfor\tbehavior\tchange.\tStage-based\tinterventions,\tacross various\tgroups\tand\tpopulations,\thave\tbeen\teffective\tin\thelping\tindividuals\tmake progress\ttoward\tbecoming\tregularly\tactive\t(67,93).\tStrategies\tto\tfacilitate transitioning\tthrough\tthe\tstages\tof\tchange\tare\tpresented\tlater\tin\tthis\tchapter. Health\tBelief\tModel The\thealth\tbelief\tmodel\t(HBM)\ttheorizes\tthat\tan\tindividual\u2019s\tbeliefs\tabout whether\tor\tnot\the\tor\tshe\tis\tsusceptible\tto\tdisease,\tand\this\tor\ther\tperceptions\tof the\tbenefits\tof\ttrying\tto\tavoid\tit,\tinfluence\this\tor\ther\treadiness\tto\tact\t(82). The\ttheory\tis\tgrounded\tin\tthe\tnotion\tthat\tindividuals\tare\tready\tto\tact\tif\tthey: \t\tBelieve\tthey\tare\tsusceptible\tto\tthe\tcondition\t(i.e.,\tperceived\tsusceptibility). \t\tBelieve\tthe\tcondition\thas\tserious\tconsequences\t(i.e.,\tperceived\tseverity). \t\tBelieve\ttaking\taction\treduces\ttheir\tsusceptibility\tto\tthe\tcondition\tor\tits severity\t(i.e.,\tperceived\tbenefits). \t\tBelieve\tcosts\tof\ttaking\taction\t(i.e.,\tperceived\tbarriers)\tare\toutweighed\tby\tthe benefits. \t\tAre\tconfident\tin\ttheir\tability\tto\tsuccessfully\tperform\tan\taction\t(i.e.,\tself- efficacy). \t\tAre\texposed\tto\tfactors\tthat\tprompt\taction\t(e.g.,\tseeing\ttheir\tweight\ton\tthe scale,\ta\treminder\tfrom\tone\u2019s\tphysician\tto\texercise)\t(i.e.,\tcues\tto\taction). Together,\tthe\tsix\tconstructs\tof\tthe\tHBM\tsuggest\tstrategies\tfor\tmotivating individuals\tto\tchange\ttheir\texercise\tbehavior\tbecause\tof\thealth\tissues\t(Table 12.1).\tFor\texample,\tan\tindividual\twould\tneed\tto\tfeel\tthat\the\tor\tshe\tis\tat\trisk\tfor having\ta\theart\tattack\t(perceived\tsusceptibility),\tfeel\tthat\ta\theart\tattack\twould negatively\timpact\this\tor\ther\tlife\t(perceived\tseverity),\tbelieve\tthat\tstarting\tan exercise\tprogram\twould\treduce\this\tor\ther\trisk\t(perceived\tbenefits),\tfeel\tthat\tthe amount\tof\treduction\tin\trisk\tis\tworth\tthe\ttime\tand\tenergy\the\tor\tshe\twould\thave\tto commit\tto\texercise\t(perceived\tbenefits\toutweigh\tperceived\tbarriers),\tand\tbelieve he\tor\tshe\tcould\texercise\ton\ta\tregular\tbasis\t(self-efficacy).\tHowever,\tthose\tfactors alone\tare\tnot\tenough\tfor\tan\tindividual\tto\tstart\texercising;\the\tor\tshe\talso\tneeds some\ttype\tof\tprompt\t(e.g.,\ta\tfriend\/relative\thaving\ta\theart\tattack)\tto\tactually begin\tto\texercise\t(cue\tto\taction).\tTherefore,\tthere\tis\ta\tneed\tto\tprime\tindividuals","to\tbe\tready\tto\tchange\tand\talso\thelp\tdevise\tways\tto\tprompt\tthem\tinto\ttaking action. Given\tits\tobvious\tfocus\ton\thealth\tissues\tfor\tunderstanding\tmotivation,\tthe HBM\tmay\tbe\tmost\tsuitable\tfor\tunderstanding\tand\tintervening\twith\tpopulations that\tare\tmotivated\tto\tbe\tphysically\tactive\tprimarily\tfor\thealth\t(39).\tThus,\tthe HBM\thas\tbeen\tapplied\tto\tcardiac\trehabilitation\tand\tdiabetes\tmellitus\t(DM) prevention\tand\tmanagement\t(64,92). Self-Determination\tTheory A\ttheory\tthat\thas\trecently\treceived\tan\tincreasing\tamount\tof\tattention\trelated\tto exercise\tis\tself-determination\ttheory\t(SDT)\t(25,40,96).\tThe\tunderlying assumption\tof\tSDT\tis\tindividuals\thave\tthree\tprimary\tpsychosocial\tneeds\tthat they\tare\ttrying\tto\tsatisfy:\t(a)\tself-determination\tor\tautonomy,\t(b)\tdemonstration of\tcompetence\tor\tmastery,\tand\t(c)\trelatedness\tor\tthe\tability\tto\texperience","meaningful\tsocial\tinteractions\twith\tothers.\tThe\ttheory\tproposes\tthat\tmotivation exists\ton\ta\tcontinuum\tfrom\tamotivation\tto\tintrinsic\tmotivation.\tIndividuals\twith amotivation\thave\tthe\tlowest\tlevels\tof\tself-determination\tand\thave\tno\tdesire\tto engage\tin\texercise.\tIndividuals\twith\tintrinsic\tmotivation\thave\tthe\thighest\tdegree of\tself-determination\tand\tare\tinterested\tin\tengaging\tin\texercise\tsimply\tfor\tthe satisfaction,\tchallenge,\tor\tpleasure\tit\tbrings.\tBetween\tamotivation\tand\tintrinsic motivation\tlies\textrinsic\tmotivation;\tthat\tis,\twhen\tindividuals\tengage\tin\texercise for\treasons\tthat\tare\texternal\tto\tthe\tindividual,\tsuch\tas\tbeing\tphysically\tactive\tto make\toneself\tmore\tattractive\tto\tothers\t(40,96). SDT\tsuggests\tthat\tthe\tuse\tof\trewards\tto\tget\tindividuals\tto\tstart\texercising\tmay have\tlimited\teffectiveness\tbecause\tthey\tpromote\textrinsic\tmotivation.\tRather, programs\tshould\tbe\tdesigned\tto\tenhance\tautonomy\tby\tpromoting\tchoice\tand incorporating\tsimple,\teasy\texercises\tinitially\tto\tenhance\tfeelings\tof\tcompetence and\tenjoyment.\tInterventions\tthat\ttarget\tstrategies\tto\tincrease\tautonomy\thave been\teffective\tat\tenhancing\tPA\tlevels\t(19,89,90). Theory\tof\tPlanned\tBehavior According\tto\tthe\ttheory\tof\tplanned\tbehavior\t(TPB),\tintention\tto\tperform\ta behavior\tis\tthe\tprimary\tdeterminant\tof\tactual\tbehavior\t(1).\tIntentions\treflect\tan individual\u2019s\tperceived\tprobability\tor\tlikelihood\tthat\the\tor\tshe\twill\texercise\tbut do\tnot\talways\ttranslate\tdirectly\tinto\tbehavior\tbecause\tof\tissues\trelated\tto behavioral\tcontrol\t(22).\tIntentions\tare\tdetermined\tby\tan\tindividual\u2019s\tattitudes, subjective\tnorms,\tand\tperceived\tbehavioral\tcontrol.\tAttitudes\tare\tinfluenced\tby behavioral\tbeliefs\tthat\texercise\twill\tlead\tto\tcertain\toutcomes\t(positive\tor negative)\tcombined\twith\tthe\tevaluation\tof\tthose\toutcomes.\tSubjective\tnorms\tare the\tsocial\tcomponent\tand\tare\tinfluenced\tby\tindividual\u2019s\tbeliefs\tthat\tothers\twant him\tor\ther\tto\tbe\tphysically\tactive\t(normative\tbeliefs)\tcombined\twith\this\tor\ther motivation\tto\tcomply\twith\tthe\tdesires\tof\tsignificant\tothers.\tFinally,\tperceived behavioral\tcontrol\tis\tinfluenced\tby\tthe\tindividual\u2019s\tbelief\tabout\thow\teasy\tor difficult\tperformance\tof\tthe\tbehavior\tis\tlikely\tto\tbe\t(control\tbeliefs)\tcombined with\tthe\tperceived\tpower\tof\tthe\tbarrier\tor\tfacilitator.\tThus,\tan\tindividual\tintends to\tbe\tphysically\tactive\tif\the\tor\tshe\tbelieves\texercise\twould\tlead\tto\tdesire outcomes,\tis\tvalued\tby\tsomeone\twhose\topinion\tthey\tvalue,\tand\tis\twithin\this\tor her\tcontrol\t(Figure\t12.2).","Although\tintentions\tare\tthe\tprimary\tpredictor\tof\tbehavior,\tthere\tis\talso\ta hypothesized\tdirect\tlink\t(dashed\tline\tin\tFigure\t12.2)\tbetween\tperceived behavioral\tcontrol\tand\tbehavior.\tAn\tindividual\u2019s\tsubjective\tnorms\tmay\tlead\thim or\ther\ttoward\thealthier\tbehavior,\tand\the\tor\tshe\tmay\talso\thave\ta\tpositive\tattitude, but\tpowerful\tbarriers\toutside\tof\tthe\tperson\u2019s\tcontrol\tmay\tact\tdirectly\tto\tlimit exercise\tparticipation.\tFor\texample,\tif\tan\tindividual\tperceives\tlow\tcontrol\tover his\tor\ther\tability\tto\tengage\tin\texercise\twhen\tthe\tweather\tis\tpoor,\the\tor\tshe\tis likely\tto\tskip\tan\texercise\tsession\tif\tit\tis\training. In\tcross-sectional\tand\tprospective\tstudies,\tthe\tTPB\tconsistently\texplains exercise\tintentions\tand\tbehavior\t(14,32);\thowever,\tthere\tis\tless\tevidence\tthat interventions\tbased\ton\tthe\tTPB\tare\teffective\tat\tincreasing\tPA\tlevels\t(49,101). This\tmodel\thas\tbeen\tapplied\tmost\tfrequently\tto\tclinical\tpopulations,\tincluding patients\twith\tcancer\t(102),\tcardiac\trehabilitation\tparticipants\t(13),\tand\tpregnant women\t(31). Social\tEcological\tModels","Social\tecological\tmodels\tare\timportant\tbecause\tthey\tconsider\tthe\timpact\tof\tand connections\tbetween\tindividuals\tand\ttheir\tenvironments.\tThe\texplicit recognition\tof\trelations\tbetween\tindividuals\tand\ttheir\tphysical\tenvironments\tis\ta defining\tfeature\tof\tecological\tmodels\t(84,85).\tEcological\tmodels\tposit\tthat behavior\tresults\tfrom\tinfluences\tat\tmultiple\tlevels,\tincluding\tintrapersonal factors\t(e.g.,\tbiological,\tpsychological),\tinterpersonal\/cultural\tfactors\t(e.g., family,\tfriends,\tculture),\torganizational\tfactors\t(e.g.,\tschools,\tworksites, churches),\tphysical\tenvironments\t(e.g.,\tbuilt,\tnatural),\tand\tpolicies\t(e.g.,\tlaws, regulations,\tcodes)\t(Table\t12.2).\tImportantly,\tenvironmental\tfactors\tinfluence behavior\tnot\tonly\tdirectly\tbut\talso\tindirectly\tthrough\tan\tindividual\u2019s\tperceptions. A\tkey\tbelief\tis\tthat\tinterventions\tare\tmost\tlikely\tto\tbe\teffective\twhen\tthey\ttarget multiple\tlevels\t(84,85).\tFor\texample,\tadding\ta\twalking\tpath\tin\ta\tpark\tis\tmost likely\tto\tbe\teffective\tin\tincreasing\tPA\twhen\tthere\tis\ta\tcampaign\tto\tpromote awareness\tof\tthe\tpath\tperhaps\tcombined\twith\tan\tintervention\tthat\ttargets individual\tbeliefs\tand\tmotivations\tabout\twalking.\tAlthough\tresearch\texamining the\timpact\tof\tinterventions\tbased\ton\tecological\tmodels\tis\tlimited,\tresults\tappear promising\t(85).","DECREASING\tBARRIERS\tTO\tPHYSICAL\tACTIVITY Individuals\tface\ta\tnumber\tof\tpersonal,\tsocial,\tand\tenvironmental-related\tbarriers (e.g.,\tlack\tof\ttime;\tinconvenience;\tlack\tof\tself-motivation;\tfinding\tPA\tboring\tor not\tenjoyable;\tand\tlacking\tself-management\tskills,\tself-efficacy,\tsocial\tsupport, or\tplaces\tto\tbe\tactive)\tin\tboth\tthe\tadoption\tand\tmaintenance\tof\tPA\t(16,66).\tTable","12.3\toutlines\tcommon\tchallenges\tthat\tindividuals\tface\tin\tthe\tadoption\tand maintenance\tof\texercise\tthat\tcan\tbe\tbetter\tunderstood\tand\taddressed\tthrough\tthe application\tof\tdifferent\tbehavioral\ttheories.","COGNITIVE\tAND\tBEHAVIORAL\tSTRATEGIES\tFOR INCREASING\tPHYSICAL\tACTIVITY\tBEHAVIOR Cognitive\tstrategies\tare\tan\tessential\tcomponent\tof\tinterventions\tfocused\ton exercise\tbehavior\tchange\t(6)\tand\tare\tespecially\teffective\tat\tincreasing\tPA\tlevels (28).\tThese\tstrategies\tfocus\ton\tchanging\tthe\tway\tindividuals\tthink,\treason,\tand imagine\tabout\tthemselves\tin\tregard\tto\texercise\tbehavior.\tBehavioral\tstrategies are\talso\tan\timportant\tcomponent\tof\texercise\tinterventions\tand\trefer\tto\tindividual actions\tand\treactions\tto\tvarious\tenvironmental\tstimuli.\tBecause\tactions\tand reactions\tare\tthought\tto\tbe\tlearned,\tthe\tbehavioral\tapproach\tto\tchange\tposits\tthat these\tactions\tand\treactions\tcan\talso\tbe\tunlearned\tor\tmodified.\tEvidenced-based cognitive\tand\tbehavioral\tstrategies\tthat\tcan\tbe\tused\tto\tincrease\tPA\tbehavior\tare presented\tin\tTable\t12.4\tand\tdiscussed\tin\tthe\tfollowing\tsections.","Enhancing\tSelf-Efficacy Self-efficacy,\tthe\tconfidence\tin\tone\u2019s\tability\tto\tcarry\tout\tactions\tnecessary\tto perform\tcertain\tbehaviors\t(8),\tis\ta\tcentral\tcomponent\tof\tmost\tof\tthe\ttheories previously\tdiscussed\t(i.e.,\tSCT,\tTTM,\tHBM,\tand\tTPB).\tIncreased\tself-efficacy is\trelated\tto\tPA\tbehavior\tchange\t(6).\tIndividuals\tdraw\ton\tvarious\tsources\tof efficacy\tinformation\tto\tincrease\texercise\tbehavior,\tincluding\tmastery experiences\t(e.g.,\texperiencing\tsuccess),\twhich\tare\tthe\tmost\tpowerful\tsource, vicarious\texperience\t(e.g.,\tobserving\tothers\twho\tare\tsimilar\tto\tthem\thaving positive\texperiences),\tverbal\tpersuasion\t(e.g.,\tencouragement\tfrom\tothers),\tand physiological\tfeedback\t(e.g.,\tenjoyment,\tpositive\tmood\tstates)\t(6).\tTable\t12.5 describes\tthe\tsources\tof\tefficacy\tand\toutlines\tstrategies\tthat\tcan\tbe\tused\tto enhance\tan\tindividual\u2019s\tsense\tof\tself-efficacy\tfor\texercise.","Goal\tSetting Goal\tsetting\tis\ta\tpowerful\ttool\tfor\tbehavior\tchange\tthat\tleads\tto\tpositive\tchanges in\texercise\tbehavior\t(6).\tThe\texercise\tprofessional\tcan\twork\twith\tthe patients\/clients\tto\thelp\tdevelop,\timplement,\tmeasure,\tand\trevise\tgoals\ton\ta consistent\tbasis\tto\tprovide\tdirection\tto\ttheir\tefforts;\tenhance\tpersistence;\tand learn\tnew\tstrategies.\tThe\tSMARTS\tprinciple\tcan\tbe\tused\tto\tguide\teffective\tgoal setting: \t\tSpecific:\tGoals\tshould\tbe\tprecise. \t\tMeasurable:\tGoals\tshould\tbe\tquantifiable. \t\tAction-oriented:\tGoals\tshould\tindicate\twhat\tneeds\tto\tbe\tdone. \t\tRealistic:\tGoals\tshould\tbe\tachievable. \t\tTimely:\tGoals\tshould\thave\ta\tspecific\tand\trealistic\ttime\tframe. \t\tSelf-determined:\tGoals\tshould\tbe\tdeveloped\tprimarily\tby\tthe\tclient\/patient. It\tis\timportant\tfor\tindividuals\tto\tset\tboth\tshort-\tand\tlong-term\tgoals\tthat\tallow for\tmeasurement\tand\tassessment\ton\ta\tregular\tbasis.\tIndividuals\toften\tfocus\ton long-term\tgoals;\thowever,\twhen\tattempting\tto\tinitiate\ta\tnew\tbehavior,\tsetting","short-term\tachievable\tgoals\t(i.e.,\tdaily\tor\tweekly)\tis\timportant\tfor\tincreasing self-efficacy\t(97).\tThe\texercise\tprofessional\tshould\tregularly\tmonitor\tprogress, provide\tfeedback,\tand\tdiscuss\tsuccesses\tand\tstruggles\twith\tthe\tindividual. Setting\tproper\tgoals\tis\tan\timportant\tpart\tof\tnumerous\tPA\tstudies;\thowever, because\tgoal\tsetting\tis\tincorporated\tinto\tmany\ttheories\tand\tinterventions,\tthere is\tlimited\tevidence\ton\tits\tsole\tcontribution\tto\tchanging\texercise\tbehavior (55,87,88). Reinforcement The\tuse\tof\tpositive\treinforcement\t(i.e.,\trewards)\tis\temphasized\tin\tSCT,\tSDT,\tand TTM.\tIndividuals\tshould\tbe\tencouraged\tto\treward\tthemselves\tfor\tmeeting behavioral\tgoals.\tExtrinsic\trewards\tinclude\ttangible,\tphysical\trewards\tsuch\tas money,\ta\tnew\tpair\tof\tshoes,\tor\ta\tnew\tbook\tand\tare\toften\tused\tto\tinitiate\tbehavior change\t(68).\tSocial\treinforcement\tsuch\tas\tpraise\tfrom\tan\texercise\tprofessional or\tfamily\tmember\tis\talso\tan\textrinsic\treinforcer.\tIntrinsic\trewards\tare\tintangible rewards\tthat\tcome\tfrom\twithin,\tsuch\tas\ta\tfeeling\tof\taccomplishment,\tconfidence, or\tenjoyment.\tIndividuals\tare\tmore\tlikely\tto\tadhere\tto\tregular\texercise\tover\tthe long\tterm\tif\tthey\tare\tdoing\tthe\tactivity\tfor\tintrinsic\treasons\t(83).\tIt\tmay\tbe difficult\tto\tgive\tintrinsic\treinforcers\tto\tparticipants,\tbut\tit\tmay\tbe\tpossible\tto develop\tan\tenvironment\tthat\tcan\tpromote\tintrinsic\tmotivation.\tThese environments\tfocus\ton\tthe\tautonomy\tof\tthe\tparticipant\tand\thave\tbeen\tshown\tto lead\tto\thigher\tlevels\tof\tPA\t(19).\tEnvironments\tpromoting\tintrinsic\tmotivation focus\ton\t(a)\tproviding\tpositive\tfeedback\tto\thelp\tthe\tparticipant\tincrease\tfeelings of\tcompetence,\t(b)\tacknowledging\tparticipant\tdifficulties\twithin\tthe\tprogram, and\t(c)\tenhancing\tsense\tof\tchoice\tand\tself-initiation\tof\tactivities\tto\tbuild feelings\tof\tautonomy. Social\tSupport Social\tsupport\tis\ta\tpowerful\tmotivator\tto\texercise\tfor\tmany\tindividuals\tand important\tin\tSCT,\tTTM,\tTPB,\tand\tsocial\tecological\tmodels\tand\tcan\tcome\tfrom an\tinstructor,\tfamily\tmembers,\tworkout\tpartners,\tcoworkers,\tneighbors,\tas\twell as\texercise\tand\tother\thealth\tprofessionals.\tSocial\tsupport\tcan\tbe\tprovided\tto clients\/patients\tin\tvarious\tways\tincluding\t(a)\tguidance\t(i.e.,\tadvice\tand information),\t(b)\treliable\talliance\t(i.e.,\tassurance\tthat\tothers\tcan\tbe\tcounted\ton\tin","times\tof\tstress),\t(c)\treassurance\tof\tworth\t(i.e.,\trecognition\tof\tone\u2019s\tcompetence that\tindividuals\tin\tthe\texercise\tgroup\tor\tpersonal\ttrainer\tbelieve\tin\this\tor\ther abilities),\t(d)\tattachment\t(i.e.,\temotional\tcloseness\twith\tthe\tpersonal\ttrainer\tor\tat least\tone\tother\tindividual\tin\tthe\texercise\tgroup),\t(e)\tsocial\tintegration\t(i.e.,\ta sense\tof\tbelonging\tand\tfeeling\tcomfortable\tin\tgroup\texercise\tsituations),\tand\t(f) opportunity\tfor\tnurturance\t(i.e.,\tproviding\tassistance\tto\tothers\tin\tthe\texercise group)\t(103). Providing\tsocial\tsupport\tin\tthe\tform\tof\tguidance\tis\tmost\tcommon\twhen working\twith\tclients\/patients.\tIndividuals\tbeginning\tan\texercise\tprogram\tneed\tto feel\tsupported\tin\ttimes\tof\tstress\tor\ttimes\twhen\tcontinuing\tto\texercise\tis\tdifficult (36,38).\tMoreover,\tindividuals\tbeginning\tan\texercise\tprogram\tmay\thave\tfeelings of\tincompetence.\tIncreasing\tone\u2019s\tconfidence\tthrough\tmastery\texperiences, social\tmodeling,\tand\tproviding\tpraise\tare\tpractical\tways\tto\tincrease acknowledgment\tof\tone\u2019s\tcompetence\t(8). Implementing\tways\tto\tincrease\tan\tindividual\u2019s\tattachment\tand\tfeelings\tof being\tpart\tof\ta\tgroup\tis\talso\timportant.\tThe\texerciser\tneeds\tto\tfeel\tcomfortable. A\tmethod\tto\tmake\texercisers\tfeel\tcomfortable\tis\tto\testablish\tbuddy\tgroups.\tIn group\tsettings,\texercisers\tcan\tbenefit\tfrom\twatching\tothers\tcomplete\ttheir exercise\troutines\tand\tfrom\tinstructors\tand\tfellow\texercisers\tgiving\tinput\ton proper\ttechnique\tand\texecution.\tCreating\tsupportive\texercise\tgroups\twithin communities\thas\tbeen\tlinked\twith\tgreater\tlevels\tof\texercise\tbehavior\t(48). Self-Monitoring Self-monitoring,\tan\timportant\tcomponent\tof\tSCT\tand\tTTM,\tinvolves\tobserving and\trecording\tbehavior\tand\thas\tbeen\tshown\tto\tbe\timportant\tin\texercise\tbehavior change\t(6,61).\tSelf-monitoring\tof\texercise\tcan\tbe\tin\tthe\tform\tof\ta\tpaper-and- pencil\tlog,\ta\theart\trate\tmonitor,\tpedometer,\tor\t\u201cwearable\u201d\ttechnology\tsuch\tas\ta smart\twatch.\tTechnology\tdevices\tcan\tprovide\tthe\tindividual\twith\tdetailed feedback\tthat\tincludes\tminutes\tof\texercise,\texercise\tintensity,\tdistance\ttravelled, or\tstep\tcounts.\tVisual\tdocumentation\t(e.g.,\tworkout\tlog)\tcan\tbe\tuseful\tfor tracking\tprogress\ttoward\tgoals,\tidentifying\tbarriers\tto\tchanging\tbehavior,\tand\tas a\treminder\tto\texercise. Problem\tSolving","Individuals\tencounter\ta\tnumber\tof\tbarriers\tthat\tmay\timpede\tefforts\tof\tbecoming physically\tactive\t(see\tTable\t12.3).\tProblem\tsolving\tcan\tassist\tindividuals\tin identifying\tstrategies\tto\treduce\tor\teliminate\tbarriers\tand\tincludes\tfour\tmain steps:\t(a)\tidentify\tthe\tbarrier,\t(b)\tbrainstorm\tways\tto\tovercome\tthe\tbarrier,\t(c) select\ta\tstrategy\tgenerated\tin\tbrainstorming\tviewed\tas\tmost\tlikely\tto\tbe successful,\tand\t(d)\tanalyze\thow\twell\tthe\tplan\tworked\tand\trevise\tas\tnecessary (12).\tSolutions\tto\tbarriers\tshould\tideally\tbe\tgenerated\tby\tthe\tindividual\tand\tnot by\tthe\texercise\tprofessional.\tFor\texample,\tif\tlack\tof\ttime\tis\ta\tbarrier\tto\tengaging in\texercise,\tthe\tindividual,\tin\tconjunction\twith\tthe\texercise\tprofessional,\tcan identify\tpossible\tsolutions\tfor\tovercoming\tthis\tbarrier\t(e.g.,\tschedule\texercise \u201cappointments,\u201d\tincorporate\tPA\tinto\texisting\tactivities). Relapse\tPrevention Regularly\tactive\tindividuals\twill\toccasionally\tencounter\tsituations\tthat\tmake sticking\twith\ttheir\texercise\tprogram\tdifficult\tor\tnearly\timpossible.\tTherefore,\tan important\tpart\tof\tmany\ttheories\tand\tapproaches\tis\tthe\tdevelopment\tof\tstrategies to\thelp\tindividuals\tovercome\tsetbacks\tand\tmaintain\ttheir\tPA\tlevels\t(94). Although\tit\tis\tnot\tunusual\tto\thave\ta\tlapse\tfrom\tan\texercise\tprogram\t(i.e., missing\ta\tfew\texercise\tsessions),\tpreparing\tfor\tsituations\twhich\tmay\tresult\tin\ta return\tto\ta\tsedentary\tlifestyle,\tor\trelapse,\tis\tmost\tcritical.\tRelapse\tprevention strategies\tinclude\tbeing\taware\tof\tand\tanticipating\thigh-risk\tsituations\t(e.g., travel,\tvacation,\tholidays,\tillness,\tcompeting\tfamily\tobligations,\tand\tpoor weather)\tand\thaving\ta\tplan\tto\tensure\tthat\ta\tlapse\tdoes\tnot\tbecome\ta\trelapse\t(94). At\ttimes,\tmissing\tplanned\texercise\tis\tunavoidable,\tyet\tgood\tlapse\tand\trelapse strategies\tcan\thelp\tan\tindividual\tto\tstay\ton\ttrack\tor\tto\tget\tback\ton\ttrack\tonce\tthe situation\thas\tpassed.\tFinally,\tindividuals\tshould\tavoid\t\u201call-or-nothing\u201d\tthinking and\tnot\tget\tdiscouraged\twhen\tthey\tmiss\ta\tsession\tof\tplanned\texercise. THEORETICAL\tSTRATEGIES\tAND\tAPPROACHES\tTO INCREASE\tEXERCISE\tADOPTION\tAND\tADHERENCE Brief\tCounseling\tand\tMotivational\tInterviewing A\tpromising\tarea\tfor\tincreasing\texercise\tadoption\tis\tthrough\tthe\tuse\tof\tbrief counseling,\toften\tconducted\tby\thealth\tcare\tprofessionals\t(4).\tThese\tbrief","counseling\tapproaches\tcan\tbe\tbased\ton\tany\tof\tthe\ttheories\tpreviously\tdiscussed; however,\tit\tis\timperative\tthat\tthey\tbe\tmore\tthorough\tthan\tsimply\tasking\tabout PA\tlevels\tand\tadvising\tthe\tpatient\tto\tincrease\this\tor\ther\texercise\tbehavior.\tBox 12.1\tprovides\texamples\tof\testablished\tstrategies\tand\ttechniques\tthat\tcan\tbe incorporated\tinto\tcounseling\tsessions.\tNumerous\tmedical\tassociations\tand Healthy\tPeople\t2020\thave\tadopted\tthe\tposition\tthat\tprimary\tcare\tproviders should\tmake\tPA\tcounseling\ta\tpart\tof\tevery\troutine\tpatient\tvisit\t(47),\tyet\tthe\tU.S. Preventive\tServices\tTask\tForce\tconcluded\tthat\tthe\thealth\tbenefit\tof\tbehavioral counseling\tin\tthe\tprimary\tcare\tsetting\tto\tpromote\tPA\tis\tsmall\t(65,95). Box\t12.1 Client-Centered\tPhysical\tActivity\tCounseling\t(Five\tA\u2019s Model) Assess\tphysical\tactivity\tbehavior,\tbeliefs,\tknowledge,\tand\treadiness\tto change. Advise\tclient\ton\tthe\tbenefits\tof\tphysical\tactivity\tand\tthe\thealth\trisks\tof inactivity. Agree\tcollaboratively\ton\tphysical\tactivity\tgoals\tbased\ton\tclient\u2019s\tinterests, confidence,\tability,\tand\treadiness\tto\tchange. Assist\tclient\tto\tidentify\tand\tovercome\tbarriers\tusing\tproblem-solving techniques\tand\tsocial\tand\tenvironmental\tsupport\tand\tresources. Arrange\ta\tspecific\tplan\tfor\tfollow-up\tfeedback,\tassessment,\tand\tsupport. Motivational\tinterviewing\thas\tevolved\tover\tthe\tpast\ttwo\tdecades\tand\tcan\tnow be\tsuccessfully\tapplied\tto\tmany\thealth\tbehaviors,\tincluding\tPA\t(59,69)\tand weight\tloss\t(5).\tMotivational\tinterviewing\tis\ta\tperson-centered\tmethod\tof communication\twhere\tthe\tprofessional\tand\tthe\tclient\/patient\twork collaboratively\tfor\tchange.\tThe\tprofessional\u2019s\tapproach\tshould\tbe nonjudgmental,\tempathic,\tand\tencouraging.\tA\tmajor\tfocus\tof\tmotivational interviewing\tis\tto\thelp\tthe\tambivalent\tindividual\trealize\tthe\tdifferent\tintrinsic motivators\tthat\tcan\tlead\tto\tpositive\tchange.\tThe\tapproach\trespects\tclient\/patient autonomy\tand\tviews\tthe\tclient\tas\tfully\tresponsible\tfor\tchange.\tTable\t12.6 highlights\tsome\tof\tthe\tdifferences\tbetween\ttraditional\tcounseling\tand\ta motivational\tinterviewing\tapproach.\tMotivational\tinterviewing\tcan\tbe\tadapted and\tused\tin\tcombination\twith\tmost\texisting\ttheories\tto\thelp\tmotivate\tchange\tand","confidence\tamong\tindividuals\twho\tare\tseeking\tto\tadopt\tor\tmaintain\tan\texercise program.\tBecause\tof\ttheoretical\tsimilarities\tbetween\tmotivational\tinterviewing and\tSDT\t(e.g.,\tintrinsic\tmotivation,\tautonomy),\tthere\tis\ta\tgrowing\tinterest\tto combine\tthese\tin\tintervention\tdevelopment\t(78). Principles\tof\tmotivational\tinterviewing\tcan\tbe\tapplied\tin\thealth\tcare\tand public\thealth\tsettings,\twhere\ttime\tpressures\tare\toften\tgreat\t(81).\tIn\tthese settings,\tthe\tprimary\tgoal\tis\tto\thelp\tresolve\tambivalence\tand\tincrease\tmotivation for\tchange,\twhich\tis\talso\tthe\tinitial\tphase\tof\tmotivational\tinterviewing,\twhen \u201cchange\ttalk\u201d\tcan\toccur.\tChange\ttalk\trefers\tto\tan\tindividual\u2019s\tmention\tor discussion\tof\ta\tdesire\tor\treason\tto\tchange,\tmaking\tit\tmore\tlikely\tthe\tchange\twill occur\t(Table\t12.7)\t(63).\tSeveral\tconcrete\tand\tpractical\tmethods\thave\tbeen\tused in\tPA\tinterventions\t(see\t[77])\tand\tmay\tbe\teasily\tincorporated\tinto\tthese\tbrief contact\tperiods.","Stage\tof\tChange\tTailored\tCounseling The\tTTM\tis\tpredicated\ton\tthe\tnotion\tof\tstages\tof\tchange\tand\tthat\tprogression through\tthe\tstages\tcan\tbe\tfacilitated\tby\tthe\tuse\tof\tstage-specific\tstrategies\tand processes\tof\tchange\tthat\tresult\tin\t\u201ctailoring\u201d\tinterventions.\tBox\t12.2\tprovides examples\tof\thow\tone\tmight\tuse\tspecific\tstrategies\twithin\teach\tstage\tto\ttailor\tthe intervention\tto\tan\tindividual\tto\thelp\tthem\tprogress\tto\tthe\tnext\tstage.\tIntervention","studies\thave\tconsistently\tfound\tstage-tailored\tinterventions\tthat\tinclude\tall\tof\tthe components\tof\tthe\tTTM\tare\tappropriate\tfor\tmany\tdifferent\tpopulations\tand\tare effective\tat\tenhancing\tPA\tlevels\t(46,93). Box\t12.2 Example\tStrategies\tto\tFacilitate\tStage\tTransitions Precontemplation\t \tContemplation \t\tProvide\tinformation\tabout\tthe\tbenefits\tof\tregular\tphysical\tactivity. \t\tDiscuss\thow\tsome\tof\tthe\tbarriers\tthey\tperceive\tmay\tbe\tmisconceived\tsuch as\t\u201cIt\tcan\tbe\tdone\tin\tshorter\tand\taccumulated\tbouts\tif\tthey\tdon\u2019t\thave\tthe time.\u201d \t\tHave\tthem\tvisualize\twhat\tthey\twould\tfeel\tlike\tif\tthey\twere\tphysically active\twith\tan\temphasis\ton\tshort-term,\teasily\tachievable\tbenefits\tof\tactivity such\tas\tsleeping\tbetter,\treducing\tstress,\tand\thaving\tmore\tenergy. \t\tExplore\thow\ttheir\tinactivity\timpacts\tindividuals\tother\tthan\tthemselves\tsuch as\ttheir\tspouse\tand\tchildren. Contemplation\t \tPreparation \t\tExplore\tpotential\tsolutions\tto\ttheir\tphysical\tactivity\tbarriers. \t\tAssess\tlevel\tof\tself-efficacy\tand\tbegin\ttechniques\tto\tbuild\tefficacy. \t\tEmphasize\tthe\timportance\tof\teven\tsmall\tsteps\tin\tprogressing\ttoward\tbeing regularly\tactive. \t\tEncourage\tviewing\toneself\tas\ta\thealthy,\tphysically\tactive\tperson. Preparation\t \tAction \t\tHelp\tdevelop\tan\tappropriate\tplan\tof\tactivity\tto\tmeet\ttheir\tphysical\tactivity goals\tand\tuse\ta\tgoal\tsetting\tworksheet\tor\tcontract\tto\tmake\tit\ta\tformal commitment. \t\tUse\treinforcement\tto\treward\tsteps\ttoward\tbeing\tactive. \t\tTeach\tself-monitoring\ttechniques\tsuch\tas\ttracking\ttime\tand\tdistance. \t\tContinue\tdiscussion\tof\thow\tto\tovercome\tany\tobstacles\tthey\tfeel\tare\tin\ttheir way\tof\tbeing\tactive. \t\tEncourage\tthem\tto\thelp\tcreate\tan\tenvironment\tthat\thelps\tremind\tthem\tto\tbe active. \t\tEncourage\tways\tto\tsubstitute\tsedentary\tbehavior\twith\tactivity.","Action\t \tMaintenance \t\tProvide\tpositive\tand\tcontingent\tfeedback\ton\tgoal\tprogress. \t\tExplore\tdifferent\ttypes\tof\tactivities\tthey\tcan\tdo\tto\tavoid\tburnout. \t\tEncourage\tthem\tto\twork\twith\tand\teven\thelp\tothers\tbecome\tmore\tactive. \t\tDiscuss\trelapse\tprevention\tstrategies. \t\tDiscuss\tpotential\trewards\tthat\tcan\tbe\tused\tto\tmaintain\tmotivation. Group\tLeader\tInteractions Separate\tfrom\tattempts\tto\timplement\tindividual\tbehavior\tchange\tis\tthe\tconcept of\tgroup\tinterventions\tto\timprove\texercise\tadoption\tand\tadherence.\tAdherence, social\tinteraction,\tquality\tof\tlife,\tphysiological\teffectiveness,\tand\tfunctional effectiveness\thave\tall\tbeen\tstudied\tin\tgroup\tsettings\tand\talso\tcompared\tto\thome- based\tprograms,\thome-based\tprograms\tinvolving\tsome\tcontact\tby\thealth\tcare professionals,\tand\tusual\texercise\tclasses.\tExercising\tin\ta\tgroup,\twhere\tthe instructor\tpurposefully\tcreates\tgroup\tdynamics\tand\tgoals,\thas\tconsistently\tbeen shown\tsuperior\tto\texercising\tin\ta\tusual\texercise\tclass\t(where\teach\tindividual functions\tautonomously)\tor\texercising\tat\thome\twith\tor\twithout\tcontact.\tThese outcomes\thighlight\tthe\tvalue\tof\tgroup-based\tPA\tinterventions\t(15). Exercise\tleaders\thave\tan\tinfluence\ton\tPA\tparticipation\tand\tthe\tpsychological benefits\tthat\toccur\tas\ta\tresult\tof\tPA\t(36).\tThe\texercise\tleader\tand\tgroup\tplay significant\troles\tin\tSCT\tand\tSDT.\tAn\texercise\tleader\twith\ta\tsocially\tsupportive leadership\tstyle\tis\tone\tthat\tprovides\tencouragement,\tverbal\treinforcement, praise,\tand\tinterest\tin\tthe\tparticipant\t(38).\tParticipants\twho\thave\tan\texercise leader\twho\thas\ta\tsocially\tsupportive\tleadership\tstyle\treport\tgreater\tself-efficacy, more\tenergy,\tmore\tenjoyment,\tstronger\tintentions\tto\texercise,\tless\tfatigue,\tand less\tconcern\tabout\tembarrassment\t(41).\tIn\taddition\tto\tthe\texercise\tleader, aspects\tof\tthe\texercise\tgroup\tmay\talso\tinfluence\tPA\tparticipation.\tOne\tsuch aspect\tis\tthat\tof\tgroup\tcohesion,\tthat\tis,\ta\tdynamic\tprocess\treflected\tin\tthe tendency\tof\ta\tgroup\tto\tstick\ttogether\tand\tremain\tunited\tin\tthe\tpursuit\tof\tits instrumental\tobjectives\tand\/or\tsatisfaction\tof\tmember\taffective\tneeds.\tFive principles\thave\tbeen\tsuccessfully\tused\tto\timprove\tcohesion\tand\tlower\tdropout rates\tamong\texercise\tgroups\t(18,37): \t\tDistinctiveness\t\u2014\tcreating\ta\tgroup\tidentity\t(e.g.,\tgroup\tname)","Positions\t\u2014\tgiving\tmembers\tof\tthe\tclass\tresponsibilities\tand\troles\tfor\tthe group \t\tGroup\tnorms\t\u2014\tadopt\tcommon\tgoals\tfor\tthe\tgroup\tto\tachieve \t\tSacrifice\t\u2014\tindividuals\tin\tthe\tgroup\tgiving\tup\tsomething\tfor\tthe\tgreater\tgood of\tthe\tgroup \t\tInteraction\tand\tcommunication\t\u2014\tthe\tbelief\tthat\tthe\tmore\tsocial\tinteractions that\tare\tmade\tpossible\tfor\tthe\tgroup,\tthe\tgreater\tthe\tcohesion SPECIAL\tPOPULATIONS An\timportant\tarea\tof\texercise\tpromotion\tis\tthe\tproper\ttailoring\tof\tinterventions to\tpromote\texercise\tbehavior\tacross\tdiverse\tpopulations\tthat\tpresent\tunique challenges.\tProper\ttailoring\trequires\tan\tunderstanding\tof\tpotential\tunique beliefs,\tvalues,\tenvironments,\tand\tobstacles\twithin\ta\tpopulation\tor\tindividual. Although\tevery\tindividual\tis\tclearly\tunique,\tthe\tfollowing\tsections\tdiscuss behavioral\tconsiderations\tof\tsome\tof\tthe\tmore\tcommon\tspecial\tgroups\twith whom\texercise\tprofessionals\tmay\twork. Cultural\tDiversity In\torder\tto\tprovide\tculturally\tcompetent\tcare\tto\texercisers,\tit\tis\tnecessary\tto\tbe exposed\tto\tand\tunderstand\tthe\tcultural\tbeliefs,\tvalues,\tand\tpractices\tof\tthe desired\tpopulation.\tThis\tincludes\tbut\tis\tnot\tlimited\tto\thousing,\tneighborhood characteristics,\treligion,\taccess\tto\tresources,\tcrime,\trace,\tethnicity,\tage,\tability level,\tand\tsocial\tclass.\tFor\texample,\tthe\thigher\tlevels\tof\tphysical\tinactivity among\tAfrican\tAmericans\tcompared\tto\tother\tracial\/ethnic\tgroups\tmay\tbe\tcaused not\tonly\tby\tenvironmental\tconstraints\tbut\talso\tby\tcultural\tbeliefs\t(70).\tAfrican American\twomen\thave\tcited\tlack\tof\tPA\texposure\tand\tthus\tlack\tof\trole\tmodels, family\tresponsibilities\t(i.e.,\tneed\tto\tbe\tthe\tcaregiver),\tissues\trelated\tto\tbody\tsize (i.e.,\tlarger\tbody\tsizes\tand\tcurves\ttend\tto\tbe\tappreciated,\tand\tthus,\tlower perceived\tneed\tfor\tPA),\tand\thairstyles\tas\tbarriers\tto\tPA\t(45).\tIncluding\tstrategies that\taddress\tthese\tbarriers\tmay\tbe\tessential\tin\tinterventions\tfocusing\ton\tthis population. Perhaps\tthe\tmost\timportant\tcharacteristic\tof\texercise\tinterventions\tthat\ttarget different\tracial\/ethnic\tgroups\tis\tbeing\tculturally\tsensitive\tand\ttailored.\tCulturally sensitive\tinterventions\tshould\tinclude\tsurface\tstructure\tand\tdeep\tstructure\t(76).","Surface\tstructure\tinvolves\tmatching\tintervention\tmaterials\tand\tmessages\tto observable,\t\u201csuperficial\u201d\tcharacteristics\tof\tthe\ttarget\tpopulation.\tThe\tpeople, places,\tlanguage,\tmusic,\tfood,\tlocations,\tand\tclothing\tthat\tare\tfamiliar\tto\tand preferred\tby\tthe\tpopulation\tshould\tbe\tused.\tFor\texample,\tan\tintervention targeting\tAfrican\tAmericans\tshould\tinclude\tpictures\tof\tAfrican\tAmericans\tin program\tmaterials.\tDeep\tstructure\tinvolves\tincorporating\tthe\tcultural,\tsocial, historical,\tenvironmental,\tand\tpsychological\tforces\tthat\tinfluence\tPA\tin\tthe targeted\tpopulation.\tFor\texample,\tin\tLatino\tcultures,\tthe\tfamily\tunit\tis\tvery important.\tThus,\trecommendations\tfor\tincreasing\tPA\tmight\tincorporate\tmethods to\tget\tall\tfamily\tmembers\texercising\ttogether\t(e.g.,\ttaking\twalks\twith\tthe\twhole family).\tIncluding\tboth\tdimensions\twithin\tinterventions\tcan\tincrease\tthe receptivity\tand\tacceptance\tof\tthe\tmessages\t(surface\tstructure)\tand\tsaliency\t(deep structure)\t(76). Older\tAdults There\tare\tseveral\tchallenges\twhen\tworking\twith\tpromoting\tthe\tadoption\tand adherence\tof\texercise\tamong\tolder\tadults\t(see\tChapter\t7)\t(2,23).\tOlder\tadults may\tlack\tknowledge\tabout\tthe\tbenefits\tof\tPA\tor\thow\tto\tset\tup\ta\tsafe\tand effective\texercise\tprogram;\ttherefore,\tthe\texercise\tprofessionals\tneed\tto\tprovide some\tinitial\teducation\t(106).\tAlthough\ttypically\tviewed\tas\tbeneficial,\tsocial support\tis\tnot\tnecessarily\tpositive,\tespecially\tin\tolder\tadults\t(20).\tFamily\tand friends\tmay\texert\tnegative\tinfluences\tby\ttelling\tthem\tto\t\u201ctake\tit\teasy\u201d\tand\t\u201clet me\tdo\tit.\u201d\tThe\timplicit\tmessage\tis\tthat\tthey\tare\ttoo\told\tor\tfrail\tto\tbe\tphysically active\t(20). Although\tolder\tadults\texperience\tmany\tof\tthe\tcommonly\treported\tbarriers\tto PA\t(e.g.,\tlack\tof\ttime,\tmotivation)\t(23,66),\tthere\tare\tseveral\tbarriers\tthat\tmay take\ton\tspecial\tsignificance,\tincluding\tlack\tof\tor\tindifferent\tsocial\tsupport; increased\tsocial\tisolation;\tfear\tof\tfalling\/safety;\tand\tphysical\tailments\tsuch\tas injury,\tchronic\tillness,\tand\tpoor\thealth\t(51,66).\tQuite\tpossibly,\tthe\tlargest\tbarrier to\texercise\tparticipation\tin\tolder\tadults\tis\tthe\tfear\tthat\texercise\twill\tcause\tinjury, pain,\tand\tdiscomfort\tor\texacerbate\texisting\tconditions\t(66).\tIn\taddition,\tolder women\tin\tparticular\tmay\thave\thad\tlittle\tearly-life\texposure\tto\tPA\tdue\tto\tsocial norms\tthat\twere\tless\taccepting\tof\tthis\tbehavior\tin\twomen.\tThese\tunique\tbarriers can\tbe\tsignificant\tand\trequire\tcareful\tconsideration\twhen\tpromoting\tPA\tand","developing\tinterventions\tfor\tthis\tpopulation. Youth When\tworking\twith\tchildren\t(see\tChapter\t7),\tit\tis\timportant\tto\trecognize\tthey are\tlikely\tengaging\tin\tan\texercise\tprogram\tbecause\ttheir\tparents\twish\tthem\tto, implying\tan\textrinsic\tmotivation,\tand\ttypically\trequire\ttangible\tforms\tof\tsocial support\t(e.g.,\ttransportation,\tpayment\tof\tfees)\t(66).\tHowever,\tto\thelp\tchildren maintain\texercise\tbehavior\tover\ttheir\tlifetime,\tthey\tneed\thelp\tshifting\ttoward\ta sense\tof\tautonomy\t(98)\tand\tto\tfeel\ta\tsense\tof\tself-efficacy\tand\tbehavioral control.\tEstablishing\ta\tsense\tof\tautonomy\tand\tintrinsic\tmotivation\tthrough\tthe creation\tof\ta\tsupportive\tenvironment,\tas\tdiscussed\tpreviously,\tshould\tbe\ta\thigh priority\twhen\tfostering\tPA\tamong\tchildren\tand\tyouth\t(19). Schools\tare\tan\tappealing\tsetting\tfor\timplementing\tPA\tinterventions,\tas\tthey reach\ta\tmajority\tof\tyouth.\tSimple\tmodifications\tto\tphysical\teducation\tclasses (54,91),\tsmall\tchanges\tduring\trecess\t(80),\tand\tpromoting\tstructured\tPA\twithin the\tclassroom\tcan\tincrease\tPA\t(50).\tAlthough\tthere\tis\tsome\tconcern\tthat\tschool- based\tPA\tprograms\twill\tinterfere\twith\tacademic\ttime\tand\tthus\treduce\tacademic performance,\tthe\tdata\tdo\tnot\tsupport\tthis\tnotion.\tWith\tfew\texceptions,\tphysical education,\trecess,\tand\tclassroom-based\tPA\tinterventions\tconsistently\tshow\ta positive\tor\tno\tassociation\twith\tacademic\tachievement,\tacademic\tbehavior,\tand cognitive\tskills\tand\tattitudes\t(75). Individuals\twith\tObesity PA\tdecreases\tacross\tbody\tmass\tindex\tcategories,\twith\tindividuals\twho\tare\tobese being\tthe\tleast\tactive\tgroup\t(100).\tAlthough\tconcerns\tabout\texcess\tweight\tis\tthe primary\treason\twhy\tmany\tindividuals\twith\tobesity\tadopt\tan\texercise\tprogram (30),\tthey\tmay\tface\tadditional,\tunique,\tweight-related\tbarriers\tto\tengaging\tin\tPA such\tas\tfeeling\tphysically\tuncomfortable\twhile\texercising,\tbeing\tuncomfortable with\ttheir\tappearance,\tand\tnot\twanting\tto\texercise\tin\tfront\tof\tothers\t(52). Individuals\twith\tobesity\tmay\thave\thad\tnegative\tmastery\texperiences\twith exercise\tin\tthe\tpast\tand\twill\tneed\tto\tenhance\ttheir\tself-efficacy\tso\tthey\tbelieve that\tthey\tcan\tsuccessfully\texercise\t(7,21).\tFurthermore,\tthey\tmay\tbe\tquite deconditioned\tand\tperceive\teven\tmoderate\tintensity\texercise\tas\tchallenging,\tso keeping\tactivities\tfun\tand\tat\ta\tlight\tintensity\tmay\tbe\tparticularly\timportant\tto","promote\tpositive\tperceptions\tof\tPA\t(34).\tAlthough\tgoals\tshould\tremain\tself- determined,\tindividuals\twith\tobesity\tmay\tneed\thelp\tsetting\trealistic\tweight\tloss goals\tand\tidentifying\tappropriate\tlevels\tof\tPA\tto\thelp\tthem\treach\tthose\tgoals (26). Individuals\twith\tChronic\tDiseases\tand\tHealth\tConditions PA\timproves\tsymptoms\tassociated\twith\ta\tnumber\tof\tchronic\tdiseases\tand\thealth conditions.\tA\tconcern\twhen\tworking\twith\tindividuals\twith\tchronic\tdiseases\tand health\tconditions\tis\ttheir\tability\tto\tdo\tthe\texercise\tboth\tfrom\ta\ttask\tself-efficacy perspective\tas\twell\tas\tin\tthe\tface\tof\tthe\tbarriers\tspecifically\trelated\tto\ttheir condition\t(66).\tFor\texample,\tindividuals\twith\tarthritis\treport\tpain,\tfatigue,\tand mobility\tlimitations\tas\tbarriers\tto\tPA\tparticipation\t(27,104).\tThose\twith neurological\tconditions\t(i.e.,\tmuscular\tdystrophy,\tmultiple\tsclerosis,\tmotor neuron\tdisease,\tand\tParkinson\tdisease)\tcite\tfatigue,\tfear\tof\tfalling\tor\tlosing balance,\tand\tsafety\tdue\tto\tthe\tprogression\tof\tdisease\tas\tbarriers\t(35).\tSpecial consideration\tshould\tbe\tgiven\tto\tensure\tactivities\tare\tchosen\tto\tprevent,\ttreat,\tor control\tthe\tdisease\tor\thealth\tcondition.\tFurthermore,\tbeing\taware\tof\tthe\tunique barriers\tand\tfears\tof\tindividuals\twith\tchronic\tdiseases\tand\thealth\tconditions\tcan help\tassure\tthe\tphysical\tactivities\tchosen\tare\tappropriate. 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