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AASP Newsletter - September 2016

Applying the Transtheoretical Model in Health and Exercise Psychology: Maintaining Physical Activity

Melissa Madeson, PhD, Hardin Simmons University, CC-AASP, RYT 200

Most individuals are well aware of the benefits of physical activity and the detrimental health risks associated with inactivity. Regular physical activity is associated with the benefits of weight control, disease prevention, healthy aging, improved self-esteem and decreased anxiety, depression, and stress (O’Donovan et al., 2010). Yet only 52% of U.S. adults meet the minimum guidelines of 150 minutes of moderate activity per week (CDC, 2013). Every year, thousands of individuals begin physical activity programs, join health clubs, and start weight loss or fitness challenges only to drop out within weeks or months. A review of controlled physical activity interventions between 2000 and 2009 found that 80% of the trials were successful at increasing activity among participants (Fjeldsoe et al., 2011). However, research on long-term maintenance is lacking, and most studies do not follow participants for more than six months.

Within the field of exercise psychology, the Transtheoretical model (TTM) is one method that has been used to describe the stages of change indicating an individual’s readiness to exercise. The first five stages of change are identified as precontemplation (denial of problem), contemplation (thinking about change), preparation (making plans to change), action (initiating activity), and maintenance (remaining active for six months) (Sarkin, Johnson, Prochaska, & Prochaska, 2001). Critical to this model are the three core constructs of decision balance (i.e., pros versus cons), self-efficacy (i.e., level of confidence to be successfully active) and processes of change (i.e., frequency of using cognitive/behavioral activities to facilitate progress) (Marcus et al., 1992).

This model can help exercise psychologists and practitioners keep individuals active and move to the stage of maintenance rather than “relapse” as the majority of people do within months. Practical aspects of the TTM include the decision balance scale (weighing pros and cons), assessing self-efficacy, and cognitive/behavioral processes. In TTM-driven research examining the difference between non-exercisers, maintainers, and relapsers, factors relating the decision balance scale predict exercise maintenance at 12 and 24 months (Lipschitz, et al., 2015). Utilizing a decision balance activity may be key to helping maintain active behaviors.

Employing a decision balance scale can be done with an individual at any stage of change for implementing an activity program. In practical terms, it asks the individual to critically evaluate every pro and con involved in a specific physical activity program. An example of this would be a client “Anna” who has a goal to lose weight and “get fit”. Anna has been sporadic with exercise and has a gym membership she uses for a few weeks and then stops. Her “pros” for establishing a regular activity schedule (i.e., going to the gym five times a week) include: health benefits, potential weight loss, increased energy, stress reduction, husband would like her to go, she has knowledge and experience lifting weights/working out, and increased fitness to keep up with her 18-month old son. Her “cons” include: time constraints, lack of motivation and energy, missing out on time with son (as a stay at home mom), and the feeling that she is neglecting other obligations. Research on cognitive dissonance as it relates to the TTM states that people attempt to resolve the discrepancy between perceiving exercise as important but failing to keep it consistent by telling themselves that the pros of activity are not as important as the cons (Festinger, 1957). Further, it has been found that cons might be a stronger predictor of successful exercise interventions because they tend to be more immediate than pros (Lipschitz, et al., 2015). With this tendency in mind, Anna should take two additional actions after completing a decision balance scale. First, Anna should find “pros” that provide immediate reinforcement, which is more powerful than delayed results. Giving herself a small reward of some type after each workout the first week, and then tapering off to rewards after completing each successful week (with the goal of five workouts a week). Rewards might include allowing herself 30 minutes to read a favorite book or watch TV while her son naps, buying herself a small (non-food) reward, lunch with a friend, etc. Anna should also get initial measurements beyond weight and BMI so that progress can be tracked through multiple methods. These assessments might include physical assessments like blood pressure, cholesterol, body fat percentage, strength, and flexibility assessments as well as rating levels of stress, anxiety, depression, and quality of life. When individuals can see progress, it provides reinforcement and motivation to continue. One of the most common reasons for discontinuing an exercise program is lack of results (Middlekamp & Steenbergen, 2015). This outcome might be attributed to selecting unattainable goals to begin with. Or, it might be that goals are too limited in nature (e.g., only looking at body weight). Even without losing weight, evidence that one feels better, has gotten stronger, or has decreased blood pressure readings, can provide enough motivation to continue.

Finally, since “cons” can be such a strong predictor of exercise success or failure, Anna should examine her list and come up with a game plan for overcoming obstacles. This task is where exercise psychology can tap into the use of strategies such as time management, establishing routines, and motivational strategies including self-talk, statements of positive affirmation, and visualization. If Anna can create a schedule and set routine where she attends the gym at the same time every day, she will begin to feel comfortable leaving her son with the day care providers and potentially meet people who work out at the same time and have similar interests. This outcome will provide further motivation to continue the routine. Anna also needs to become aware of her self-talk and develop a positive dialogue to get her to the gym and keep her engaged once she’s there. Motivational quotes and positive affirmations can be taped to commonly viewed areas such as in her car, on her son’s bed, and in the bathroom. While two of Anna’s “cons” was time away from her son and feeling guilty about other obligations, she needs to constantly remind herself that she will be more productive and have more energy with her son once she completes the workout.

The TTM is a model of behavior change that has been adopted and researched within the field of exercise psychology. It provides guidance for how one might adopt the scientist-practitioner approach and apply its premises to exercise settings. Anna is one example of how this might work, but the challenge is bringing it to personal cases, individual clients, students, health clubs, and fitness facilities.

References
Centers for Disease Control and Prevention (CDC). (2013). Adult participation in aerobic and muscle-strengthening physical activities- United States, 2011. MMWR 62(17), 326-330.

Festinger, L. A. (1957). A theory of cognitive dissonance. Evanston, IL: Row, Peterson.  

Fjeldsoe, B. Neuhaus, M., Winkler, E., & Eakin, E. (2011). Systematic review of maintenance of behavior change following physical activity and dietary interventions. Health Psychology, 30(1), 99-109.

Lipschitz, J. M., Yusufov, M., Paiva, A., Redding, C. A., Rossi, J. S., Johnson, S., Blissmer, B., Gokbayrak, S. N., Velicer, W. F. & Prochaska, J. O. (2015). Transtheoretical principles and processes for adopting physical activity: A longitudinal 24-month comparison of maintainers, relapsers, and nonchangers. Journal of Sport & Exercise Psychology, 37, 592-606.

Marcus, B. H., Rakowski, W., & Rossi, J. S. (1992). Assessing motivational readiness and decision making for exercise. Health Psychology, 11, 257-261.

Middlekamp, J. & Steenbergen, B. (2015). The Transtheorectical Model and exercise behavior of members in fitness clubs. Journal of Fitness Research, 4(2), 43-54.

O’Donovan, G., Blazevich, A. J., Boreham, C., Cooper, A. R., Crank, H., Ekelunch, U., & Stamatakis, E. (2010). The ABC of physical activity for health: A consensus statement from the British Association of Sport and Exercise Sciences. Journal of Sports Sciences, 28, 573-591.

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.

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