EXCUSERCISE: DIFFERENTIATING THE RELAPSE STAGE OF EXERCISE BEHAVIOR CHANGE IN TERMS OF PERCEIVED BAR

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EXCUSERCISE DIFFERENTIATING THE RELAPSE STAGE OF
EXERCISE BEHAVIOR CHANGE IN TERMS OF PERCEIVED
BARRIERS, SELF-EFFICACY, AND MOTIVES VIA AN
INTERNET BASED DATA COLLECTION

• Temple University
• College of Education
• Department of Kinesiology
• Exercise and Sport Psychology
• Bruce S. Cohen
• August 5, 2003

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Need for the Study

• 50 dropout rate after 6 months (Dishman, 1988)
• Only 20 of U.S. population active (DHHS, 1996)
• Good at adopting. Bad at adhering.

• Psychosocial determinants
• Identify Relapser characteristics
• Develop intervention strategies based on stage of
  change

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Regular Exercise

• Any planned or physical activity (e.g., brisk
  walking, group exercise class, jogging,
  bicycling, swimming, rowing, etc.) performed to
  increase physical fitness. Such activity should
  be performed 3-5 times per week for 20-60 minutes
  per session. Exercise does not have to painful
  to be effective but should be at a level that
  increases breathing rate and causes one to break
  a sweat (ACSM, 1990).

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Relapse

• I was exercising regularly at times over the past
  12 months. I am not currently exercising
  regularly. I intend to resume exercising
  regularly in the future.
• (derivative of Canadian Study on Physical
  Activity, 1998)

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Transtheoretical Model (TTM) / a.k.a. Stages of
Behavior Change

• Based on Prochaska, Norcross DiClemente (1982,
  1994).
• Original 6 stages gt smoking cessation
• Spiral pathway allots for slips, lapses
• Relapse to early stages Pre Cont
• 3 mediating factors self-efficacy, decisional
  balance, and processes of change.
• Exercise work based on Marcus (1992)
• 5 stage gt drop termination
• Precontemplation, Contemplation, Preparation,
  Action, Maintenance
• Relapse ignored

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Statement of the Problem

• The purpose of this study was to define the
  exercise relapse stage of behavior change in
  terms of excuses or perceived barriers,
  self-efficacy, decisional balance, and motives in
  the adult population.

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Self-Efficacy

• Confidence to continue to exercise in the face of
  challenging or tempting situations.
• Based on Banduras Social Cognitive Theory (1977,
  1990).

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Motives

• Motivations or reasons to participate in regular
  exercise.
• Deci Ryans Self-Determination Theory (1985,
  1990) incorporates intrinsic/extrinsic
  motivation.
• Ingledew, Markland Medley (1998). Use of EMI-2
  and TTM.
• Extrinsic (bodily) motives gt early stages
• Intrinsic (e.g., enjoyment) gt later stages

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Perceived Barriers/Excuses

• Origin in Health Belief Model (Rosenstock, 1974).
  Perceived susceptibility to illness or barrier
  outweighed by benefits.
• Similar found also in Godins exercise
  interventions (1994), Ajzens Theory of Planned
  Behavior (1988), Banduras Self-Efficacy (1977,
  1990), and Janis Manns Decisional Balance
  Pros vs. Cons (1977).
• Utilized in TTM/Stages of Change (Prochaska,
  1984 Marcus,1992).

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Hypotheses

• In comparison to people in other stages of
  behavior change, exercise Relapsers have
• 1. different determinants.
• 2. differing motives for participation.
• 3. differing levels of self-efficacy.
• 4. differing excuses or barriers.

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Research Design

• Cross-sectional descriptive data collected via
  electronic survey on internet

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Overview of Procedures

• Data collection via Internet
• Classified stages of change
• Define length and frequency of Relapse among
  Relapsers
• Compared Relapsers with other stages in terms of
  exercise determinants

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E-Based Data Collection

• E-mail survey benefits
• Quicker return rates
• Higher quality data (fewer missed items)
• Saved considerable time, effort and finances.
• Mehta (1995), Stanton (1998), Schmidt (1999)

• E-dissertations
• Zizzi Perna (2002)
• E-contact equal to or superior to traditional
  contact methods.
• Price (2001)
• Allaboutdepression.com
• Educational website

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Participants Recruitment Procedures

• Sample of convenience
• Adults with access to internet
• Domain search Excusercise
• Key word search exercise adherence
• E-mail press release to
• Professional organizations
• Former present clients
• Family friends
• Listservs

• Consent form preceded survey access
• Confidential no identification
• No minors
• No compensation other than companion education
  site, future group results posting to web site.
• 24/7 access

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Web Site Access

• Domain Registration
• Excusercise.org
• Pick Internet Provider
• Originally FeaturePrice
• Now IXWebhosting
• Web Site Educational Component Design
• Microsoft Front Page
• Data Manipulation
• SPSS

• Original survey host Survey Assistant Software
• Free
• no technical support
• Subsequent survey host Keysurvey.com
• cost
• technical support

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Measures

• Exercise Decisional Balance (EDB), Marcus, 1992.
• Self-Efficacy Exercise Behavior Scale (SEEBS),
  Marcus, 1992.
• Motives checklist based on Exercise Motivations
  Inventory-2 (EMI-2), Markland, Ingledew, Hardy,
  1993, 1997). Likert scale added.
• Barriers checklist similar to Canadian Fitness
  Lifestyle Research Institute (CFLRI), 1995 study.
  Likert scale and item added.

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Data Analyses

• Demographics
• Age, gender, marital status, children, education,
  geographic location
• Descriptive Statistics
• Length of lapse (mean, SD in of weeks)
• Frequency of lapse (mean, SD in of
  starts/restarts/year)

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Data Analyses

• Primary Data Analysis
• MANOVA
• 6 (stages) x 4 (Exercise Determinants Pro-EDB,
  Con-EDB, Self-Efficacy, Barriers)
• Global scores for Barriers and Self-Efficacy
• Motives 6 x 14 run separately no subscales
• Dunnet Post-Hoc Test
• Compared Relapsers to other stages
• Minimize pair-wise comparisons not relevant to
  hypotheses

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Data Analyses

• Additional Analysis
• MANOVA
• 6 (stages) x 4 (Exercise Determinants Pro-EDB,
  Con-EDB, Self-Efficacy, Barriers)
• Tukey HSD Post-Hoc Comparisons
• Compared differences between stages on all
  determinants which were significant on univariate
  tests

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Sample Demographics (N 931)

• Geographic Area
• 96 North America
• 39 states
• MA 25
• PA 17.6
• NJ 11.4
• Age
• Between 18-115 years
• Mean age 37.4 (SD 12.87)

• Race
• Caucasian 88.2
• Gender
• Women 62.4
• Marital
• Married 53.0
• No Children 59.7
• Education
• College Grad 84.4

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Percentages of Respondents by Stage of Exercise
Change
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Relapse Characteristics

• 92 Relapsers
• Average Lapse 4.03 months (SD 3.24)
• Frequency of Relapse 2.17 times/year (SD
  1.36)

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Hypothesis 1 Results

• Exercise Determinants
• Relapsers had
• gtPros than Pre
• ltPros than Main
• ltCons than Con, Prep
• ltBarriers than Con
• gtBarriers than Main
• gtSelf-Efficacy than Pre
• ltSelf-Eff than Act, Main

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Hypothesis 1 - Summary of Exercise Determinants
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Second Hypothesis Results-Mean Motive frequency
ratings for Relapsers

• Top 6 Motives for Relapser
• Lowest Motives for Relapsers
• Challenge
• Health Pressures
• Competition
• Social Recognition
• Affiliation

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Second Hypothesis Results

• Motives
• In general Relapsers
• Affect (Intrinsic) vs. Health Clustering
• Frequently differ from Maintainers
  Precontemplators
• Similar to those in Preparation and Action
• Differ from Preparation on Enjoyment, Challenge,
  Strength Endurance
• Specifically Relapsers
• Have no sig. differences from those in Action
• Differ from Maintainers on multiple intrinsic
  motives (stress, revital, affiliate, compete,
  health, nimble, strength endurance)

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Second Hypothesis Significant Motives Compared
to Relapsers
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Third Hypothesis-Mean Self-Efficacy ratings for
Relapsers

• Top 3 Self-Efficacy subscale scores for Relapsers
• Lowest 3 Self-Efficacy subscale scores for
  Relapsers
• Alone
• Weather
• Excuses

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Third Hypothesis Results

• Self-Efficacy
• In general Relapsers
• gt Self- Efficacy than Pre
• lt Self-Efficacy than Act, Main
• Specifically Relapsers
• Have no sig. difference from those in Prep
• lt Action on 5 Self-Efficacy subscales.
• lt Maintainers on all 6 Self-Efficacy subscales

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Fourth Hypothesis Results Mean barrier
frequency ratings for Relapsers

• Top 5 Barriers for Relapsers (top 4 mood/affect
  related)
• Note. Likert scale
• 1 Never, 3 Sometimes,
  5 Always
• Note.
• N 931, significance level p lt .05.

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Fourth Hypothesis Results

• Barriers/Excuses
• In general Relapsers
• lt barriers than Cont
• gt barriers than Main
• Specifically Relapsers
• Top 4 of 5 Barriers are affect related
• Did not sig. report any barriers less frequently
  than Preparation or Action.
• Did report lack of time, lack of energy and lack
  of motivation more frequently than Action and
  Maintenance (which also reported uncomfortable,
  partner, insufficient programs, support, and
  sad/blue)

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Fourth Hypothesis - Significant Barriers Compared
to Relapsers
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Additional Analyses

• All Stage Comparisons
• Self-Efficacy
• Increases with advancing stage
• Relapsers most similar to Action
• Decisional Balance Pros
• Increases with advancing stage
• Relapsers most similar to those in Prep and
  Action
• Decisional Balance Cons
• Increase in Con, then decrease to Main
• Relapsers most similar to Action
• Barriers
• Increase in Con, then decrease to Main
• Relapsers between Prep and Action (closer to
  Action)

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Respondent Characteristics Discussion

• Internet survey respondents.
• Sample of convienence effect
• Mean age Excusercise ( Relapse stage)
  participant was 37.4 years.
• 62.6 were women
• 36.6 college undergraduate, 30.9 post graduate
  masters level, and 17 post graduate doctoral
  level.
• Schmidt (1997) average web survey responders
• males in their late teens or early thirties
• above average socio-economic status and education
  level.

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Relapser Characteristics Discussion

• Relapse duration frequency
• 4 months long, 2 x year
• Exercise benefits dissappear in 2-8 months
• Relapse prevalence
• Active definition dependent
• Excusercise (2003) 10 (67 Active),
  Canadian (1995) 16 (76 Active)
• AUS/USA (Marcus Owen, 1992) 35 Active
• Meta-Analysis (Marshall Biddle, 2001) 47
  Active
• U.S. Surgeon General (1996) 20 Active

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First Hypothesis DiscussionExercise Determinants

• Relapse as a stage 10 of a highly active
  sample
• Self-Efficacy most powerful determinant of stage
• Regression
• Velicer (1998), Marcus (1992) Relapse-less
  non-exercise studies
• 15 regress to Pre majority to Con Prep
• Excusercise Rel most like Prep Action
• Early stages cognitive processes
• Later stages behavioral processess

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Second Hypothesis Discussion

• Motives
• Relapsers similar to Prep Act
• Relapsers differ greatly from Main Intrinsic
• Quantity of reasons/motives
• Ingledew (1998)
• Deci Ryan Self-Determination
• Extrinsic (bodily) early stages of change
• Intrinsic (enjoyment)
• later stages of change (Marcus, 1992, Velicer,
  1998)
• Long term adherence (Wankel, 1985, Dishman, 1988)
• Fun Factor (Fine Sachs) kids friends, fun,
  skill challenge

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Third Hypothesis Discussion

• Self-Efficacy
• Increase Self-Efficacy with advancing stage
  (similar to Marcus (1992)
• Relapsers similar to those in Preparation
• Largest change bewteen Relapse Main
• Negative affect, excuses, resistance from others
• Biddle (2001) smallest from Pre to Cont
• Velicer (1998) Temptation Self-efficacy cross
  between Preparation and Action

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Third Hypothesis Discussion

• Exercise Decisional Balance
• Pros increase, Cons decrease with advancing stage
• Similar to Velicer (1998) Marcus (1992)
• Most similar to Action stage
• Decisional balance sheet Janis Mann (1977)

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Fourth Hypothesis Discussion

• Barriers
• Strength of barrier, Likert scale (never,
  sometimes, always), not just checklist
• Relapsers 4 affect injury
• Similar to Canadian (1995) time, energy, motive
• Added feeling sad/blue
• Barriers decrease with advancing stage
• Relapse between Prep Action (closer)

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Hypothesis Discussion Summary

• Better stage identification including Relapse to
  tailor appropriate inverventions
• Treat like Prep/Act not Pre/Cont
• More behavioral than cognitive
• Increase self-efficacy to become Main
• Increase Intrinsic motivation enjoyment
• Reduce length of relapse
• Affect and Injury Relapse prevention strategies

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Implications for Researchers

• Web Site Process
• Time Consuming Web Editors Survey Tools
• Test run in various Web Browsers
• Data Transfer
• Disappearing Web Hosts

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Implications for Practitioners

• Relapsers, unlike previous notions are not like
  Pre Con, more like Prep Act hence the need
  for more behavioral strategies
• Intrinsic motivation
• SMART goal setting
• Planned lapses
• Barrrier busting strategies
• Larger support system
• Change environmental factors
• Multiple modes of exercise.
• Visit Excusercise.org for more strategies

• Interventions designed to increase Self-Efficacy
  Relapse Prevention
• To improve self-efficacy provide a mastery
  experience, vicarious experience, verbal
  persuasion, and physiological arousal.
• Relapse Prevention Therapy coping skills
  training, cognitive therapy, and lifestyle
  modifications.

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Conclusions Hypothesis 1

• Generally, Relapsers differ significantly from
  other stages of change in terms of Decisional
  Balance, Self-Efficacy, Motives, and Barriers.
• Specifically, a relapse lasts for four months and
  occurs twice per year.
• Ten percent of Excusercise respondents were found
  to be in this stage of change.

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Conclusions Hypothesis 2

• Relapsers do have differing motives for exercise
  participation compared to people at other stages.
  
• Generally, Relapsers were similar to participants
  in Preparation and Action in terms of
  motivations.
• Most specifically, a significant difference among
  Relapsers and those in Maintenance was noted.
  Maintainers reported many more motives in
  quantity as well as quality, especially intrinsic
  motives such as enjoyment.

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Conclusions Hypothesis 3

• Relapsers do have differing levels of
  self-efficacy compared to people at other stages.
  
• Generally, self-efficacy scores and decisional
  balance pros increased with advancing stage of
  change.
• Specifically, Relapsers self-efficacy scores were
  closest to those individuals in the Preparation
  stage, while furthest from those in the
  Maintenance stage particularly in reference to
  negative affect, excuses, and resistance from
  others.

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Conclusions Hypothesis 4

• Relapsers do have differing excuses or barriers
  compared to people at other stages of changes.
• Generally, barrier frequency scores decrease
  with advancing stage of Preparation and Action
  (closer to Action).
• Specifically, Relapsers report lack of time, lack
  of motivation and lack of energy as their top
  three excuses for lack of participation in
  exercise. Relapsers report significantly more
  barriers particularly of the personal affect
  type than do Maintainers.

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Future Recommendations

• Processes of change, the five experiential and
  five behavioral.
• The more (motives) the maintainer.
• Does weather or climate improve adherence, reduce
  relapse length and frequency?

• Time of year, or season Winter, Spring, Summer,
  or Fall.
• Socio-cultural patterns schooling, vacationing.
• Life stages (college, first job, just married,
  first child, divorce, death of spouse).