issue 1 - 2017

ISSN 2522-1310

ISSUE 1 - 2017

EUROPEACTIVE The House of Sport Avenue des Arts 43 – 7ème étage 1040 Brussels, Belgium Tel.: +3226499044 www.europeactive.eu

Issue 1 - 2017

Contents FOREWORD by Rita Santos Rocha & Alfonso Jimenez ................................................ 4 European Journal for Exercise Professionals – SCOPE AND EDITORIAL BOARD .... 6 1 - EXPERT OPINION: The need for Research and Evaluation skills for Exercise Professionals, a high-value challenge to be addressed [Alfonso Jimenez & Simona Pajaujiene] ........................................................................................................................ 9 Introduction ................................................................................................................ 10 Physical activity vs inactivity ..................................................................................... 11 Current physical activity policy and challenges for the health and fitness sector ...... 12 Conclusions ................................................................................................................ 15 References .............................................................................................................. 16 2 - EXPERT OPINION: Exercise counselling by general practitioners. Exercise prescription by exercise specialists [César Chaves Oliveira & Rui Garganta] .............. 18 Promoting Exercise .................................................................................................... 19 Are general practitioners promoting more exercise? .................................................. 20 Are we more active? ................................................................................................... 20 Barriers to exercise prescription by general practitioners .......................................... 21 Why “exercise is NOT medicine” .............................................................................. 24 Conclusion .................................................................................................................. 26 References .............................................................................................................. 27 3 - REVIEW PAPER: Fitness professionals’ pedagogical intervention [Susana Franco & Vera Simões] .............................................................................................................. 29 Background ................................................................................................................. 30 Discussion................................................................................................................... 30 Implications for practice ............................................................................................. 35 References .............................................................................................................. 36 4 - ORIGINAL RESEARCH: The transtheoretical model of behaviour change and strategies for fitness professionals to increase exercise behaviour [Jan Middelkamp] .. 39

ISSN: 2522-1310 ©Copyright EuropeActive 2017

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Issue 1 - 2017

Introduction ................................................................................................................ 40 Transtheoretical Model of Behaviour Change........................................................ 40 Integrative Model ................................................................................................... 44 Practical applications .................................................................................................. 45 Conclusion .................................................................................................................. 47 References .............................................................................................................. 48 5 - ORIGINAL RESEARCH: Health Promotion in Commercial Fitness Gyms. An analysis of organizational culture as an organization-specific premise for decisionmaking. [Thomas Rieger & Michael Pfleger] ................................................................ 50 Introduction ................................................................................................................ 51 State of Research .................................................................................................... 52 Aspects of Organizational Theory .......................................................................... 53 The Organizational Culture as a part of the Social System .................................... 54 The Implementation of a Health Promotion Orientation ........................................ 58 Derivation of Research Questions .......................................................................... 59 Methodological approach ........................................................................................... 59 Qualitative Evaluation ............................................................................................ 60 Document Analysis ................................................................................................ 61 Results ........................................................................................................................ 61 Self-Conception of Commercial Fitness Gyms ...................................................... 61 Organizational Culture and Health Promotion ....................................................... 65 Conclusion .................................................................................................................. 68 References .............................................................................................................. 69 6 - ORIGINAL RESEARCH: How exercising women feel about their bodies and behave in fitness club environment? [Simona Pajaujiene] ............................................. 71 Introduction ................................................................................................................ 72 Methods ...................................................................................................................... 74 Participants ............................................................................................................. 74 Instrument ............................................................................................................... 74 Results ........................................................................................................................ 74 Discussion................................................................................................................... 79 Conclusions ................................................................................................................ 82 Practical applications .................................................................................................. 82


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Issue 1 - 2017

References .............................................................................................................. 83 7 - ORIGINAL RESEARCH: Step-Exercise as a mean of bone health improvement [Rita Santos Rocha] ........................................................................................................ 84 Introduction ................................................................................................................ 85 Exercise and bone health ........................................................................................ 85 Exercise and ground reaction forces ....................................................................... 87 Step-Exercise and osteogenic potential .................................................................. 88 Purposes .................................................................................................................. 89 Methods ...................................................................................................................... 90 Results ........................................................................................................................ 91 Discussion................................................................................................................... 94 Implications for practice ............................................................................................. 96 Conclusion .................................................................................................................. 97 References .............................................................................................................. 97 8 - PRACTICE UPDATE: How can we motivate the "unsocial" children in Fitness classes? [Eljona Spaho] ................................................................................................ 100 Introduction .............................................................................................................. 101 How can we motivate the "unsocial" children/members in fitness classes? ............ 101 How can we motivate the children/student/member?............................................... 102 What should we do as teachers/instructors to motivate the children/members? ...... 105 How can we involve the parents? ............................................................................. 106 How can we adopt our teaching method? ................................................................. 107 Discussion................................................................................................................. 110 Overall Conclusion ................................................................................................... 111 References ............................................................................................................ 111 European Journal for Exercise Professionals – INSTRUCTIONS FOR AUTHORS AND SUBMISSION PROCESS .................................................................................. 112 OTHER PUBLICATIONS BY EUROPEACTIVE ..................................................... 115


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Issue 1 - 2017

FOREWORD by Rita Santos Rocha & Alfonso Jimenez

It is our pleasure to welcome you to the First Issue of the European Journal for Exercise Professionals. This new publication by EuropeActive is focused on providing up-to-date information to all exercise professionals, from research to practice and from practice to research on all topics of interest for the fitness industry, active leisure, health promotion, and sports fields. Current literature supports the recommendation to initiate or continue an active and healthy lifestyle in our perinatal lives and across the lifespan. There are plenty of evidence-based studies that support the benefits of physical activity and exercise on the promotion of health and well-being outcomes. Those include, as examples, the reduction of several disease risks, prevention of hypertension, diabetes, or musculoskeletal disorders, improvement of weight control, mental health, and physical fitness, as well as the improvement of several disease treatments. Moreover, epidemiologic studies prove the positive effect of physical fitness in terms of a reduced risk of mortality, and improved quality of life. Exercise professionals are key players in promoting the above benefits, and are the main actors in planning and delivering exercise programmes, and in assuring positive fitness outcomes. Exercise professionals are required to develop and maintain a commitment to the lifelong learning process in relation to their role, the professional context in which they operate (including market evolution and development) and any technical and scientific updates focusing on their particular field of expertise and experience. Our aim, each year, is to gather relevant materials for exercise professionals, and their multidisciplinary teams, that will support these requirements and bridge the gap between science and practice.


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Issue 1 - 2017 This first issue includes a selection of content, from “expert opinion”, “original articles”, “review articles”, and ”practice updates” coming from authors across Europe (Germany, The Netherlands, Denmark, Lithuania, United Kingdom, Spain, and Portugal). A wide range of content - research and higher education, marketing and management, vocational education and practice based - will be included in future editions, and as editors we aim to further involve exercise professionals, employers, suppliers, students, and researchers in contributing to these editions. We are pleased to recommend this first issue to all exercise professionals, and to anyone else who is interested in the fitness industry, and in getting MORE PEOPLE, MORE ACTIVE, MORE OFTEN.


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Issue 1 - 2017

European Journal for Exercise Professionals – SCOPE AND EDITORIAL BOARD

The European Journal for Exercise Professionals is an on-going peer-reviewed online journal which publishes articles on important trends and developments in the fitness industry and related fields.

Journal scope: The European Journal for Exercise Professionals is an official publication of EuropeActive, available free to all EREPS members. It aims to provide up-to-date information to all exercise professionals, from research to practice and from practice to research on all topics of interest for the active leisure and sports fields. Topics include exercise prescription & assessment, personal training, group exercise, outdoor exercise, sports, health & nutrition, lifestyle, injuries prevention, professional development, special populations (special phases of life, clinical conditions and disabled people), fitness trends, exercise and health costs, worksite health & exercise promotion, physiology and biomechanics of exercise, pedagogy and psychology of sports and exercise, club management, sport law, among others. Its mission is to promote and distribute accurate, unbiased, and authoritative information on health and fitness. The European Journal for Exercise Professionals includes components of research and higher education, marketing and management, vocational education and

practice

based

on

EuropeActive’s

Fitness

Standards

and

European

Qualifications Framework, as well as continuing education opportunities.

Target audience: Mainly practitioner-focused, the European Journal for Exercise Professionals will

be

written

for


exercise

specialists,

personal

trainers,

exercise

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Issue 1 - 2017 leaders/instructors, academics and researchers working in the Health & Fitness field, in-training professionals, graduate students in the field of Health & Fitness, programme managers, club managers, rehabilitation specialists, exercise-test technologists, and other professionals related to the Health & Fitness industry. Publisher: EuropeActive House of Sport, Avenue des Arts 43 - 7 ème étage 1040 Bruxelles, Belgium ISSN 2522-1310 Key title: European journal for exercise professionals Abbreviated key title: Eur. j. exerc. prof. URL: http://www.ereps.eu/ejep/ejep Editors-in-Chief: 

Prof. Rita Santos-Rocha, PhD, ESDRM-IPSantarém / EuropeActive (Portugal)



Prof. Alfonso Jimenez, Coventry University (United Kingdom / Spain)

Editorial Board: 

Dr. Simona Pajaujiene, PhD, Lithuanian Sports University / Active Training / EuropeActive (Lithuania)



Dr. Alexis Batrakoulis, MSc, GRAFTS / EuropeActive (Greece)



Dr. László Zopcsak, PhD, International Wellness Institute (Hungary)



Dr. Lou Atkinson, PhD, Aston University (United Kingdom)



Dr. Cedric X. Bryant, PhD, FACSM, American Council on Exercise (United States)



Prof. Gary Liguori, PhD, University of Rhode Island (United States)



Prof. Thomas Rieger, BiTS University (Germany)



Dr. Jan Middlekamp, HDD Group / BlackBoxFitness (The Netherlands)



Dr. Julian Berriman, MA, Professional Standards Committee, EuropeActive (United Kingdom)


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Issue 1 - 2017 External Reviewers: 

Dr. Silvano Zanuso, PhD, University of Padova / Technogym Research Department (Italy)



Dr. Anna Szumilewicz, PhD, Gdansk Sports University (Poland)



Prof. Susana Franco, PhD, ESDRM-IPSantarém (Portugal)



Dr. Antonino Bianco, PhD, University of Palermo (Italy)



Dr. Fernando Naclerio, University of Greenwich (United Kingdom)



Prof. João Brito, ESDRM-IPSantarém (Portugal)



Dr. Adrian Casas, University of La Plata (Argentina)



Dr. Steven Mann, ukactive Research Institute (United Kingdom)


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Issue 1 - 2017

1 - EXPERT OPINION: The need for Research and Evaluation skills for Exercise Professionals, a high-value challenge to be addressed [Alfonso Jimenez & Simona Pajaujiene]

Alfonso Jimenez1 , Simona Pajaujiene2 1

Centre for Applied Biological & Exercise Sciences, Coventry University, UK.

E-mail: [email protected] 2

Lithuanian Sports University, Lithuania. ActiveTraining – Training provider,

Lithuania. EuropeActive – Professional Standards Committee. E-mail: [email protected]

1

Alfonso Jimenez, 1970, Madrid, Spain. A truly international scholar, fully involved in the health and fitness industry since the late 80s, Alfonso has worked as fitness and group exercise instructor, personal trainer, programme director, club manager and senior executive before moving into academia. Former Chairman of the Standards Council at EuropeActive and Honorary Member, he is Professor of Exercise Science & Health and Executive Director of the Centre for Applied Biological and Exercise Sciences at Coventry University; Chair of the Research & Dissemination Commission at the Healthy & Active Living Foundation in Spain. Co-Director of the Healthy & Active Living National Observatory at Universidad Rey Juan Carlos de Madrid (Spain); Scientific Advisory Board member at ukactive Research Institute; Formal member of the “Active Leisure Alliance Task Group” as expert from Academia; and Visiting Professor at ISEAL, Victoria University (Melbourne, Australia), the University of Greenwich (London, UK) and EUSES, University of Girona (Spain). Research interests: active living, exercise prescription, clinical exercise and worksite health promotion. Qualifications: BSc in Sport & Exercise Sciences (1993); PhD in Exercise Physiology (2003), postdoctoral training in Physical Activity & Health Promotion (2007), CSCS, NSCA-CPT. More info: CoventryU ResearchGate LinkedIn 2 Simona Pajaujien, 1970, Kaunas, Lithuania. She has been involved in fitness training, exercise for health and fitness education for over 25 years and currently works as trainer, group fitness instructor, educator, speaker, author and technical expert. She is a lecturer and coordinator for several study programmes at the Lithuanian Sports University since 2004. Research interest: Health Education; Body Image in Sport and Leisure Physical Activity; Weight Control and Exercising Behaviour. She is a program director and founder of accredited vocational training school - ActiveTraining. Member of Professional Standards Committee – EuropeActive. Qualifications: BSc in Sport Sciences (1995); MSc in Public Health – Health and Fitness (2004); PhD in Social Science – Sports Science and Education (2012). More info: ResearchGate LinkedIn ISSN: 2522-1310 ©Copyright EuropeActive 2017

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Issue 1 - 2017

“High-quality research and robust evidence are the cornerstones of effective policy, and while we know that physical activity is one of the most powerful medicines available to society, and we’ve proven that adding just small amounts of activity improves the health and wellbeing of almost everyone – all the resources and time spent investigating activity amounts to very little unless we know how to support more people, to be more active, more often. We have to support the academic community and physical activity providers to put research at the heart of practice.” (Prof. Greg Whyte, ukactive Blueprint for an Active Britain, 2015) [1]

Abstract: Despite the known benefits of physical activity, there is a worldwide trend towards less total daily physical activity, and as a consequence, physical inactivity has become a leading risk factor for chronic health disorders. The health and fitness sector is expanding very fast, although its overall impact is only addressing the needs of about 11% of the European population. Exercise professionals should play a more proactive role model supporting thousands of inactive potential clients. Providing solid evidence-based information about the benefits of active living could act as a valuable driver for positive behavioral change. The education and professional development of exercise professionals are missing a solid training in basic research and evaluation skills. These new skills, integrated into the formal training and practice of exercise professionals, will allow the whole Physical Activity sector, and specially the health and fitness industry, to develop new knowledge, transform current professional practice, inform public policy and expand the innovation capacity of our field.

Key-words: health and fitness sector, physical activity, research, evidence-based, competency, exercise professionals

Introduction A sedentary lifestyle is a risk factor for the development of many chronic illnesses, and a main cause of premature death. Furthermore, living an active life brings other social and psychological benefits. At the same time, poor nutrition makes an important contribution to the burden of disease. A diet high in saturated fat and energy-dense foods, and low in fruit and vegetables – along with a sedentary lifestyle and smoking – is the major cause of cardiovascular diseases (CVD), cancer and obesity. There is significant evidence to show that physical inactivity and over-nutrition are associated

with

a

substantial

economic

burden

in

industrialized

countries.

Implementation of specific strategies to modify inactive behavior is critical, but could be associated with considerable costs if they are not properly evidenced and


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Issue 1 - 2017 structured. To address large and meaningful public health benefits in improving the health of adults, the cost-effectiveness of those intervention strategies will be of major importance in addition to their health/clinical effectiveness. The current level of evidence is not sufficient [2], and few studies published relate to the potential positive impact that the health and fitness industry could bring. From the UN High-level Meeting on NCDs Prevention and Control Political Declaration (NYC, Sep’11) [3], to the top evidences published at Lancet Series on Physical Activity (2012, 2016) [4,5], there is a clear message that Physical Activity and Exercise can play a major role in the Public Health agenda, and significant funding and resources are being put in place to identify cost-effective active living models of implementation and delivery.

Physical activity vs inactivity Physical activity is one of the most basic human functions. It is an important foundation of health throughout life. Its known health benefits include a reduced risk of cardiovascular disease, hypertension, diabetes and certain forms of cancer; it also has an important role in the management of certain chronic conditions. In addition, it has positive effects on mental health by reducing stress reactions, anxiety and depression and by possibly delaying the effects of Alzheimer’s disease and other forms of dementia. Furthermore, physical activity is a key determinant of energy expenditure and is therefore fundamental to achieving energy balance and weight

control. Throughout

childhood

and

adolescence, physical

activity is

necessary for the development of basic motor skills, as well as musculoskeletal development. Furthermore, physical activity is also embedded in the United Nations Convention on the Rights of the Child. In adults, physical activity maintains muscle strength and increases cardiorespiratory fitness and bone health. Among older people,

physical

activity

helps

to

maintain

health,

agility

and

functional

independence and to enhance social participation and quality of life. It may also help to prevent falls and assists in chronic disease rehabilitation, becoming a critical component of a healthy life. Despite the known benefits of physical activity, there is a worldwide trend towards


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Issue 1 - 2017 less total daily physical activity. Globally, one-third of adults do not achieve the recommended levels of physical activity. In Europe, estimates indicate that more than one-third of adults are insufficiently active [6]. While there are some continuing challenges in terms of the validity and comparability of data on levels of physical activity across Europe, recent figures from member States of the European Union (EU) indicate that six in every 10 people above 15 years of age never or seldom exercise or play a sport and more than half never or seldom engage in other kinds of physical activity, such as cycling, dancing or gardening. At the same time, a high proportion of adults in Europe spends more than four hours a day sitting, which could be a contributing factor to sedentary lifestyles. As a consequence, physical inactivity has become a leading risk factor for chronic health disorders: 1 million deaths (about 10% of the total) and 8.3 million disability-adjusted life years lost per year in the WHO European Region are attributable to physical inactivity. It is estimated to cause 5% of the burden of coronary heart disease, 7% of type 2 diabetes, 9% of breast cancer and 10% of colon cancer [7]. Rising rates of overweight and obesity have also been reported in many countries in the Region during the past few decades. The statistics are disturbing: in 46 countries (accounting for 87% of the Region), more than 50% of adults are overweight or obese; in several of those countries the rate is close to 70% of the adult population. Overweight and obesity are also highly prevalent among children and adolescents, particularly in Southern European countries. Physical inactivity has been identified as contributing to the energy imbalance that leads to weight gain. Collectively, physical inactivity has not only substantial consequences for direct health-care costs but also causes high indirect costs due to increased periods of sick leave, work disabilities and premature deaths. For a population of 10 million people, where half the population is insufficiently active, the overall cost is estimated to be €910 million per year [8].

Current physical activity policy and challenges for the health and fitness sector The recently launched Physical Activity Strategy for the WHO European


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Issue 1 - 2017 Region 2016–2025 [9] is building on the commitments of Health 2020 – the WHO European policy framework for health and well-being – and aligns with existing WHO frameworks and strategies, such as the Global action plan for the prevention and control of non-communicable diseases 2013–2020, the Action Plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012–2016, the Global Strategy on Diet, Physical Activity and Health and the WHO Global Recommendations on Physical Activity for Health. The leadership for promoting health-enhancing physical activity is set out for the national ministries of health with a formal encouragement to establish coordination mechanisms between the areas of health, sports, education, transport, urban planning, environment and social affairs sectors. The EU-WHO Strategy identifies five priority areas, with Evaluation and Research as the fifth one (1 – Providing leadership and coordination for the promotion of physical activity; 2 – Supporting the development of children and adolescents; 3 – Promoting physical activity for all adults as part of daily life, including during transport, leisure time, at the workplace and through the health-care system; 4 – Promoting physical activity among older people; 5 – Supporting action through monitoring, surveillance, the provision of tools, enabling platforms, evaluation and research) [9]. With the main goal of supporting the strategy and related actions (through monitoring, surveillance, and provision of tools, enabling platforms, evaluation and research), the priority considers that strengthen the evidence base for physical activity promotion is a key issue to address. The European health and fitness sector is rapidly developing. It currently serves over 50 million consumers, generates 26.8 billion Euro in revenues, employs 400,000 people, and consists of 48,000 facilities [10]. The collaboration between healthcare systems and the health and fitness sector is very important, yet the interaction between both in Europe is not always sufficient [11, 12]. Getting and staying fit is the result of the integration of both physical activity and exercise in your lifestyle and the application of solid evidence-based interventions


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Issue 1 - 2017 will guarantee effective positive results achieved safely and progressively. Science and applied research are progressing faster than ever, and we, exercise professionals, should be able to build the bridge between theory and practice. Exercise professionals should be upskilled based on the current evidences allowing the public to achieve their exercise goals easier, faster and safer. The health and fitness industry, and very specially EuropeActive, have been actively involved (since 2007) in projects and activities in partnership with Governments across Europe to promote an active and healthy behaviour, and significant funding support has been received from the European Commission in that regard [13]. In fact, the health and fitness sector, represented by EuropeActive, recognizes its responsibility to work with partners at all levels across the European Union to create a healthier society, where living an active lifestyle is the social norm, rather than an exception, and where daily physical activity and exercise is seen as part of the routine part of the prevention and management of disease. Its mission is to get more people | more active | more often [14]. But despite the obvious capacity of the fitness sector across Europe, its willingness to contribute to increased levels of physical activity, and its track record of positive performance, the sector is rarely recognized in national governments’ physical activity promotion programmes and campaigns. The underlying reasons for the interaction between the healthcare system and health and fitness industry in Europe are not always sufficient identified [11, 12]. And what we consider are the reasons for this? Firstly, exercise professionals have not historically been considered as an extension of the health care team [12]. Unfortunately, representatives of healthcare systems tend to view the health and fitness sector to be founded on principles that differ from medical system and lacking the “credibility” and “authenticity” to partner on NCDs prevention [14]. The main problem is that the health and fitness sector in some cases is seen as a private multibillion industry, feeding modern consumerism and making business by manipulating clients’ concerns similarly as hamburger restaurant chains [15]. Secondly, the healthcare system is not prepared to apply exercise prescription as a


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Issue 1 - 2017 first-line therapy because of the lack of the specific HEPA related education in the training of general practitioners [16]. Exercise professionals are the main source to convey exercise-related information for

the general

public. They provide information

and

implement

exercise

counselling, exercise prescription, client’s fitness assessment and guidance. Unfortunately, there is a lack of review studies on the analysis of their education and professional competencies [17], it is unclear how they obtain evidence–based information and other issues associated with their education and lifelong learning [17, 18]. However, it is revealed that exercise professionals with higher level of education (e.g., graduate degrees) are more likely to use scholarly sources of evidence compared to those with lower levels of education who are more likely to rely on mass media, including the internet [19, 20]. Therefore, given exercise professional's role in advising the general public, their accessibility, and the emerging evidence-based guidelines on the best practices related to the use of exercise and nutrition interventions, further research is needed to ensure that exercise professionals, working with the public, integrate new research knowledge into their fitness assessment and exercise guidance [17]. One critical element in this regard is the fact that the Health and Fitness Industry is not investing resources to provide solid evidences supporting its capacity to deliver meaningful and sustainable public health outcomes.

Conclusions As health and fitness sector expands very fast, exercise professionals should play a proactive role model for thousands of clients. The education and professional development of exercise professionals are missing a solid training in basic research and evaluation skills (from critical analysis to data collection, pre- and post- intervention assessments, data analysis and reporting). These new skills integrated into the formal training and practice of exercise professionals will allow the whole Physical Activity sector, and specially the health and fitness industry, to develop new knowledge, transform current professional practice, inform public policy and expand the innovation capacity of our field.


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Issue 1 - 2017

Public health commissioners should not only insist on evidence-based practice, but should insist that ongoing data capture is a feature of all commissioned interventions. Accordingly, we (practitioners, operators and training providers) must become adept at embedding data capture and analysis into all relevant activity. Representative bodies must lobby government, health agencies and research councils to provide greater funding for effectiveness research [21]. The value of Research and Evaluation for the health and fitness industry will be immense on delivering solutions and innovative ways of tackling inactivity at population level, and its broad implementation will become a long lasting legacy for a different, positive and more active future. Due to the aforementioned challenges in public health, the healthcare and the health and fitness sector should review and reformulate their current strategies. This will be critically important in the light of the implementation of the EU-WHO Physical Activity Strategy for the European Region 2016-2025. Moreover, it will be relevant for the recognition of the value of the health and fitness sector as an effective partner on the public health agenda worldwide. References 1. 2. 3. 4. 5. 6. 7. 8. 9.

ukactive (2015). ukactive’s Blueprint for an Active Britain, Research and Evaluation, 30-34. http://www.ukactive.com/downloads/managed/ukactives_Blueprint_for_an_Active_Britain__online.pdf Muller-Riemenschneider, F., Reinhold, T., Willich, S. N. (2009). Cost-effectiveness of interventions promoting physical activity. British Journal of Sports Medicine, 43, 70–76. http://www.ncdalliance.org/sites/default/files/rfiles/Key%20Points%20of%20Political%20Declarati on.pdf The Lancet Series on Physical Activity (2012). Physical Activity 2012. http://www.thelancet.com/series/physical-activity The Lancet Series on Physical Activity (2016). Physical Activity 2016: Progress and Challenges. http://www.thelancet.com/series/physical-activity-2016 Hallal, P.C., Andersen, L.B., Bull, F.C., Guthold, R., Haskell, W., Ekelund, U. (2012). Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet, 380(9838), 247–257. Lee, I.M., Shiroma, E.J., Lobelo, F., Puska, P., Blair, S.N., Katzmarzyk, P.T. (2012). Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet, 380(9838), 219–229. Word Health Organization (2007). Steps to health: a European framework to promote physical activity for health. Copenhagen: WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0020/101684/E90191.pdf World Health Organization (2015). Physical activity strategy for the WHO European Region 2016– 2025. Copenhagen: WHO Regional Office for Europe. http://www.euro.who.int/__data/assets/pdf_file/0010/282961/65wd09e_PhysicalActivityStrategy _150474.pdf?ua=1


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Issue 1 - 2017 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Deloitte & EuropeActive (2016). European Health & Fitness Market Report 2016. Cologne, Germany. Available: http://www.europeactive.eu/blog/europeactive-and-deloitte-publisheuropean-health-fitness-market-report-2016 Sagner, M., Katz, D., Egger, G., Lianov, L., Schulz, K.H., Braman, M., et al. (2014). Lifestyle medicine potential for reversing a world of chronic disease epidemic: from cell to community. Int J Clin Pract, 68(11), 1289-92. Muth, N.D., Vargo, K., Bryant, C.X. (2015). The role of the fitness professional in the clinical setting. Curr Sports Med Rep, 14(4), 301-12. EHFA (2011). Becoming the Hub. The Health and Fitness Sector and the Future of Health Enhancing Physical Activity. Final Report, http://www.ehfa-programmes.eu/sites/ehfaprogrammes.eu/files/documents/hub/HUB_THE%20FINAL%20REPORT.pdf Matheson, G.O., Klügl, M., Engebretsen, L., Bendiksen, F., Blair, S.N., Börjesson, M., et al. (2013). Prevention and management of non-communicable disease: the IOC consensus statement, Lausanne. British Journal of Sports Medicine, 47(16), 1003-11. Andreasson, J., Johansson, T. (2014). ‘Doing for group exercise what McDonald's did for hamburgers’: Les Mills, and the fitness professional as global traveler. Sport Educ Soc, 21(2), 148-65. Joy, E., Blair, S.N., McBride, P., Sallis, R. (2013). Physical activity counselling in sports medicine: a call to action. British Journal of Sports Medicine, 47(1), 49-53. Stacey, D., Hopkins, M., Adamo, K.B., Shorr, R., Prud’home, D. (2010). Knowledge translation to fitness trainers: A systematic review. Implementation Science, 5:28. Waryasz, G.R., Daniels, A.H., Gil, J.A., Siric, V., Eberson, C.P. (2016). Personal trainer demographics, current practice trends and common trainee injuries. Orthopedic Reviews, 8:6600. Hare, S.W., Price, J.H., Flynn, M.G., King, K.A. (2000). Attitudes and perceptions of fitness professionals regarding obesity. J Community Health, 25, 5-21. Forsyth, G., Handcock, P., Rose, E., Jenkins, C. (2005). Fitness instructors: How does their knowledge on weight loss measure up? Health Education Journal, 64(2), 154-167. Beedie, C., Mann, S., Jimenez, A., et al. (2016). Death by effectiveness: exercise as medicine caught in the efficacy trap! British Journal of Sports Medicine, 50(6), 323-4.


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Issue 1 - 2017

2

-

EXPERT

OPINION:

Exercise

counselling

by

general

practitioners. Exercise prescription by exercise specialists [César Chaves Oliveira & Rui Garganta]

César Chaves Oliveira3, Rui Garganta4 3

Instituto Politécnico de Viana do Castelo, Escola Superior de Desporto e Lazer,

Portugal. E-mail: [email protected] 4

Faculdade de Desporto, Universidade do Porto, Portugal.

E-mail: [email protected]

Abstract: In 2007, the American College of Sports Medicine (ACSM), with endorsement from the American Medical Association and the Office of the Surgeon General, launched a global initiative termed “Exercise is Medicine”, to mobilize physicians, healthcare professionals and providers, and educators to promote exercise in their practice or activities to prevent, reduce, manage, or treat diseases that impact health and the quality of life in humans. Since then, physicians are increasingly advising their patients to exercise, although the number of them that comply with this practice is still generally low. Far more important, data shows that people are less active than before. Here we discuss the main barriers physicians face to exercise promotion and highlight the main features of successful interventions, with an emphasis on the role of exercise specialists. Finally, we argue that exercise prescription should only be performed by exercise specialists, as only they possess the required deep knowledge of the exercise techniques, methods, and types most suited for each individual and only they have the time and commitment to support, supervise and motivate patients before, during and after any kind of physical activity or exercise programme that is implemented.

Key-words: exercise prescription, personal trainer, medicine, exercise is medicine. 3

César Chaves Oliveira has a PhD in Physical Activity and Health and is currently an assistant teacher at Sports and Leisure School, of Polytechnic Institute of Viana do Castelo, Portugal. He has worked in the exercise training and fitness industries for almost 2 decades, addressing both special and healthy populations. He is a scientific writer, consultant and lecturer in exercise, health and nutrition subjects. 4 Rui Garganta has a PhD in Sports Sciences and is currently a full professor at Oporto Sports Faculty, University of Porto, Portugal. He has worked in the exercise training and fitness industries for almost 3 decades, addressing both special and healthy populations. He is a scientific writer, consultant and lecturer in exercise, health and nutrition subjects. ISSN: 2522-1310 ©Copyright EuropeActive 2017

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Issue 1 - 2017

Promoting Exercise The protective effects of physical activity and exercise on various chronic diseases are overwhelmingly well studied and supported in the literature and are comparable to drug interventions on mortality outcomes [1, 2]. Whether through physical activity or by exhibiting a higher fitness level or reducing the amount of time one spends sitting, non-sedentary people can significantly reduce their mortality risks [3]. Nevertheless, a recent European Report found that the amount of people that never exercises or play sports raised from the previously 39% in 2009 to 42% four years later [4]. In the United States, only 21% of the total population met the full guidelines for both aerobic and muscle-strengthening activity and critically only 3% met the muscle-strengthening activity guidelines [5]. Furthermore, it may be that for several health diseases, the recommended minimum amount of physical activity does not convey special protection. In particular, it was found that individuals with a total activity level of 600 metabolic equivalents (MET [6]) minutes/week (the minimum recommended level, corresponding to 150 minutes/week at a moderate intensity or 75 minutes/week at a vigorous intensity) had only a 2% lower risk of diabetes compared with those reporting no physical activity. However, an increase from 600 to 3600 MET minutes/week reduced the risk by an additional 19%. This means that for significant reductions in the risk of some conditions (this study addressed breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events), people may actually need to perform several times the recommended minimum of physical activity [7]. Hence, getting people to be more active seems to be a vital public health matter. The role and relevance of medical professionals are evident and pivotal, as they can reach almost all of the total population of a country and within a relatively short period of time [8]. As such, in 2007, the American College of Sports Medicine (ACSM), with endorsement from the American Medical Association and the Office of the Surgeon General, launched a global initiative (termed “Exercise is Medicine - EIM”) to mobilize physicians, healthcare professionals and providers, and educators to promote exercise in their practice or activities to prevent, reduce, manage, or treat diseases that impact health and the quality of life in humans [9, 10]. According to the programme, the EIM initiative is achieved by: 1 - Assessing physical activity levels of each patient at


19

Issue 1 - 2017 every clinic visit; 2 - Providing patients with an exercise “prescription” that can be tailored to their specific disease conditions; and 3 - Referring patients to a trusted network of local evidence-based physical activity programs led by qualified professionals [11]. In summary, the EIM clinically links all the community in order to develop and support a physically active lifestyle of all patients involved in this initiative. So is EIM initiative being successful?

Are general practitioners promoting more exercise? The first thing one must consider is if general practitioners are actually prescribing more physical activity to their patients nowadays. By analysing data from the National Center for Health Statistics, of the Centers for Disease Control and Prevention, we can observe that in 2010, about one in three adults who had seen a physician or other health professional in the past year had been advised to begin or continue to do exercise or physical activity. From the same database we also find that the percentage of adults who have been advised to exercise increased from 22.6% in 2000 to 32.4% in 2010 [12]. In the UK, it was found that 46% of patients have reported receiving advice about physical activity and exercise from their general practitioner [13]. This data seems to confirm that physicians are increasingly advising their patients to exercise. Nevertheless, these numbers are still far from optimal and are generally considered to be low [13].

Are we more active? Although physicians are increasingly recommending physical activity and exercise for their patients, data from the total population evidences that people are not getting more active. In fact, trends from 2010 to 2015 reveal that the inactivity rate changed from 26.8% in 2010 to 27.7% in 2015, which translates to a total of 81,6 million inactive Americans in the past year [14]. In Europe the trend for physical inactivity is similar, as previously pointed [4]. Not surprisingly, studies confirm that the effectiveness of physical activity counselling in improving patient’s physical activity levels is mixed [15]. Simply advising people to take more exercise seems to be an ineffective means to get them more active, but even adopting a more personalized approach may not render the intended effects. To highlight this, we recall the results of a study that compared the effects of direct advice or brief


20

Issue 1 - 2017 negotiation groups to a control group and found no differences in weekly energy expenditure among them, after the intervention [16]. In fact, exercise advice has shown multiple times its efficacy (results in a controlled environment) but not its effectiveness [17].

Barriers to exercise prescription by general practitioners Physicians meet various barriers to physical activity promotion and these barriers are at least partially responsible for the mixed results on the physical activity advice effectiveness. These include the perception

that

their patients are

uninterested in increasing their physical activity levels and are unlikely to change their behaviour [18], and the fact that when they do devote time to counselling, they do not usually receive positive feedback from patients becoming more physically active [19]. This is not without reasoning, especially when we look at the best case scenario adopted in a study conducted in Spain [20], where fifty-six Spanish family physicians were randomized to either the intervention or standard care arm of the trial. The physicians recruited 4.317 physically inactive patients (2.248 for intervention and 2.069 for control protocols) from a systematic sample after assessing their physical activity in routine practice. Intervention physicians provided advice to all patients and a physical activity prescription to the subgroup attending an additional appointment (30%). The main outcome measure was the change in physical activity measured by blinded nurses using the 7-Day Physical Activity Recall [21]. Secondary outcomes included cardiorespiratory fitness and health-related quality of life. The results are surprising. At 6 months, intervention patients increased physical activity more than controls (18 min/wk) but the proportion of the population achieving minimal physical activity recommendations was only 3.9% higher in the intervention group. Moreover, no differences were found in secondary outcomes, despite all patients from the intervention group being advised to exercise and 30% of them being given a physical activity prescription [20]. Nevertheless, there are other barriers to exercise promotion, like physician’s own physical activity habits, as less active physicians are less likely to engage in such practices with their patients [22]. However, we consider the following two, to be some of the most important barriers to exercise promotion: the first one is the physician’s lack of knowledge of physical activity and exercise: more than one-half


21

Issue 1 - 2017 of the physicians trained in the US in 2013 received no formal education in physical activity and most courses focused on exercise physiology and used a clinical approach, rendering physicians ill-prepared to assist their patients in a manner consistent with several national programmes, like Healthy People 2020, the National Physical Activity Plan, or the EIM initiative [23]. In a study conducted on UK medical students, on their final year, it was found that: physical inactivity was incorrectly perceived to be the least important risk factor for global mortality; that only 36% of students reported they were aware of the current UK physical activity guidelines, while (by comparison) 94% knew UK alcohol guidelines; and that only 9% were able to adequately define ‘moderate/vigorous exercise intensity’, key aspects of the UK Chief Medical Office physical activity guidelines (a number of responses could be considered dangerous to patient’s health) [24]. Despite these findings, 52% of the students stated they felt adequately trained to give physical activity advice to the general public. The other notable barrier to physical activity promotion is physicians’ lack of time [18]: a study designed to compare determinants

of

consultation

length

in

six

European

countries

(Belgium,

Switzerland, Germany, Spain, Netherlands, United Kingdom), found that the average length of a consultation in general practice was just under 11 minutes, ranging from 7.6 minutes in Germany to 15.6 in Switzerland (20). Since even ‘brief counselling’ in successful physical activity promotion interventions requires at least 3 to 5 minutes [25], we argue if physicians should devote almost 50% of their consultation time to accurately evaluate their patient’s fitness levels and to prescribe exercise according to his condition/illness, while concomitantly neglecting medical related issues. Fortunately, physicians do not need to perform extensive counselling to be able to assist their patients with increasing their physical activity, as they could use their limited time and resources by referring them to external sources for more comprehensive community-based support. Exercise referral schemes consist of an assessment involving a primary care or allied health professional to determine that someone is inactive, a referral to a physical activity specialist or service, an assessment to determine what programme of physical activity to recommend and participation in that programme [26]. These type of schemes show promise in


22

Issue 1 - 2017 conveying better health outcomes than a far simpler exercise advice procedure [26, 27]. Along with exercise adherence, which is defined as successful if participants complete a prescribed exercise routine for at least two-thirds of the time [28], exercise maintenance is a key feature for a lifelong healthy physical activity status. One of the most cited barriers to exercise maintenance after study completion was the lack of professional support beyond the end of the programme, as found in a review of 33 UK-relevant studies [26]. Participants who dropped out of exercise post-completion of referral cited the removal of the exercise professional as the primary motivating factor [29]. In a recent study, the researchers explored the experiences of weight management clients in their meetings with registered dietitians, personal trainers, and health behaviour counsellors in order to explain how these services are perceived and received by participants. It was found that the personal trainers received the highest percentage of positive codes (92.1%) and that the participants tended to highlight the interpersonal experiences and knowledge acquired and the specific exercise techniques or personalized programs that were available [30]. Research also suggests that one-on-one personal training is an effective method for changing attitudes and thereby increasing the amount of physical activity. In one study, it was found that weekly sessions with a personal trainer significantly increased clients’ ability to move upward through the stages of change in regard to physical activity. Overall, 60 percent of study participants moved up one stage, while 13 percent moved up two stages, demonstrating evidence of health-behaviour change over a 10-week period [31]. Others demonstrated more favourable outcomes on cognitive processes of change, decisional balance, and scheduling self-efficacy of female college students receiving personal trainer services [32] or higher values for the perception of autonomy support, relatedness and competence in the same context of personal training [33]. This kind of supervision does not necessarily need to take place at a traditional gym facility. In fact, researchers at Adelphi University compared in-home and at-thegym personal training and found that both were effective in terms of weight loss, cardiovascular function, adherence and motivation, with little differences between the two [34]. Although not rich, some research points to less loss to follow-up and more adherence to exercise with a personal trainer versus unsupervised exercise or a group exercise modality as BodyPump™ (loss to follow-up and number of


23

Issue 1 - 2017 sessions completed were 17% and 32.2 with a personal trainer, 40% and 26.9 with unsupervised training and 32% and 21.1 with BodyPump™) [35]. Once being supervised, patients are expected not only to exhibit lesser drop-out rates but also a significant improvement on specific and relevant health indicators. It has been shown that members whose training was directed by well-qualified personal trainers administering evidence-based training regimens achieved significantly greater improvements in lean body mass and other dimensions of fitness than members who direct their own training [36]. Other studies achieved similar results [37, 38]. This highlights not only the importance of interdisciplinary approaches to achieving a favourable outcome, but also the specific and unique contribution of exercise specialists and specifically personal trainers to the promotion and maintenance of an active lifestyle.

Why “exercise is NOT medicine” Many people are advocates of the EIM philosophy. We can easily understand why this happens, as exercise undoubtedly has the ability to boost the health of the populations. But “exercise” and “medicine” are actually two very distinct concepts that should never be confused: we define “medicine” as “the science or practice of the diagnosis, treatment, and prevention of disease” [39], while the definition of “exercise” is much more comprehensive and reflects its reach - that is obviously not constrained to health promotion or management - “something performed or practiced in order to develop, improve, or display a specific capability or skill”; “Activity requiring physical effort, carried out to sustain or improve health and fitness” [39]. As Andy Smith brilliantly puts it, “Exercise is Recreation not Medicine” [40]. In his article, he further highlights the realms of “exercise is recreation” by stating its features: (1) a focus on the experience of the user, (2) the promotion of well-being, (3) the importance of community, (4) embracing inclusivity, (5) sport, (6) aesthetics, and (7) leisure time [40]. As we can easily find, most of these characteristics are unique to “exercise” and not to “medicine”. Even if we compare both terms from a medical point of view, we can see many differences between


24

Issue 1 - 2017 them (table 1).

Table 1 - Comparison of Medicine vs Exercise

MEDICINE

EXERCISE

When to use

In the need to prevent, manage or treat a diagnosed disease

To improve health, to have fun, to master a skill, to improve body composition, and many others

Target

Someone's disease

The person

Contraindications

Several: See Drug Label

Not applicable

How to use

According to drug label

Endless possibilities

Dosage


Endless possibilities

Duration of treatment


Not applicable

Action in case of overdose


Rest

Interaction with other drugs/forms of exercise

From non-significant to lifethreatening

From non-significant to beneficial

If we further indulge ourselves in this kind of comparisons, we can continue to find significant differences between two of the most well-known forms of administration of medicine and exercise (table 2). Nevertheless, there are two major similarities between “medicine” and “exercise”: 1) a bad prescription can strongly affect the beneficial outcomes expected from both sciences and 2) the best practice is made by those who are trained and have studied and worked in the related area of expertise.


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Issue 1 - 2017 Table 2 - Comparison of Aspirin vs Walking/running

ASPIRIN [41]

WALKING/RUNNING

Minimum dose to promote an effect

50 mg

Variable: depends on subject characteristics5

Contraindications

Allergy; Reye’s Syndrome

None6

Warnings Precautions

Drug/exercise interaction

Adverse reaction

Alcohol, Coagulation Abnormalities, GI side effects, Peptic Ulcer Disease Renal Failure, Hepatic Insufficiency, Sodium Restricted Diets ACE inhibitors, Acetazolamide, Anticoagulant Therapy, Anticonvulsants, Beta Blockers, Diuretics, Methotrexate, Nonsteroidal Anti-inflammatory Drugs, Oral Hypoglycemics, Uricosuric Agents Dysrhythmias, dyspepsia, coagulopathy, acute anaphylaxis, rhabdomyolysis, pulmonary edema, and many others

None None, except those regarding injury prevention and outdoor conditions (e.g. traffic conditions)

Interaction with other forms of exercise is generally favourable

Rare, occasional delay onset muscle soreness

Conclusion In conclusion, we believe that the EIM mantra is reductionist to exercise as exercise is much more than medicine [42-44]. Exercise presents both treatment AND preventative benefits, but also many other unique facets that medicine can never aspire to convey. One in particular is critical for a successful exercise promotion intervention: enjoyment. Instead of exercise being prescribed like a drug [45], we feel that the medical staff should only refer their patient’s to community-based exercise facilities and/or to exercise professionals as only they possess the required deep knowledge on the exercise techniques, methods, and types most suited for each individual and only they have the time and commitment to support, supervise and motivate patients before, during and after any kind of physical activity or exercise programme that is implemented. An interdisciplinary approach is needed to augment population’s physical activity levels but the specificity of each intervention is key. For the results

5

Some subjects can (and do) achieve some kind of “effect” with lower doses than ACSM suggested guidelines. Conversely, others need higher doses to provoke any measurable effect. 6 The risks of walking or running under a determined medical condition are still lesser than the benefits of walking or running under those conditions, hence there are no contraindications for these modes of exercise. ISSN: 2522-1310 ©Copyright EuropeActive 2017

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Issue 1 - 2017 we are all aiming for, we believe that general practitioners should only prescribe medicine and exercise should only be prescribed by exercise specialists. References 1. Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347. 2. Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3:1-72. 3. Bouchard C, Blair SN, Katzmarzyk PT. Less Sitting, More Physical Activity, or Higher Fitness? Mayo Clinic proceedings. 2015;90(11):1533-40. 4. Commission E. Special Eurobarometer 412 “Sport and physical activity”. 2014. 5. Blackwell D, Lucas J, Clarke T. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. 2014. 6. Autier P, Pizot C. Meaningless METS: studying the link between physical activity and health. BMJ. 2016;354. 7. Kyu HH, Bachman VF, Alexander LT, Mumford JE, Afshin A, Estep K, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ. 2016;354. 8. McPhail S, Schippers M. An evolving perspective on physical activity counselling by medical professionals. BMC Family Practice. 2012;13(1):1-8. 9. Tipton CM. The history of "Exercise Is Medicine" in ancient civilizations. Advances in physiology education. 2014;38(2):109-17. 10. Berryman JW. Exercise is medicine: a historical perspective. Curr Sports Med Rep. 2010;9(4):195201. 11. Medicine ACoS. What is the EIM solution? http://www.exerciseismedicine.org/support_page.php/theeim-solution5/2016 [cited 2016 15th of August]. 12. Barnes P, Schoenborn C. Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. Hyattsville, MD: National Center for Health Statistics, 2012. 13. Health. Do. High quality care for all: NHS next stage review final report. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf: 2008. 14. Council PA. 2016 Participation Report. http://www.physicalactivitycouncil.com/PDFs/current.pdf: 2016. 15. Eden KB, Orleans CT, Mulrow CD, Pender NJ, Teutsch SM. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(3):208-15. 16. Hillsdon M, Thorogood M, White I, Foster C. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. International Journal of Epidemiology. 2002;31(4):808-15. 17. Beedie C, Mann S, Jimenez A, Kennedy L, Lane AM, Domone S, et al. Death by effectiveness: exercise as medicine caught in the efficacy trap! Br J Sports Med. 2016;50(6):323-4. 18. Cornuz J, Ghali WA, Di Carlantonio D, Pecoud A, Paccaud F. Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits. Fam Pract. 2000;17(6):535-40. 19. Flocke SA, Crabtree BF, Stange KC. Clinician reflections on promotion of healthy behaviors in primary care practice. Health policy (Amsterdam, Netherlands). 2007;84(2-3):277-83. 20. Grandes G, Sanchez A, Sanchez-Pinilla R, et al. Effectiveness of physical activity advice and prescription by physicians in routine primary care: A cluster randomized trial. Archives of Internal Medicine. 2009;169(7):694-701. 21. Sallis JF, Haskell WL, Wood PD, Fortmann SP, Rogers T, Blair SN, et al. Physical activity assessment methodology in the Five-City Project. Am J Epidemiol. 1985;121(1):91-106. 22. Fie S, Norman IJ, While AE. The relationship between physicians’ and nurses’ personal physical activity habits and their health-promotion practice: A systematic review. Health Education Journal. 2013;72(1):102-19. 23. Cardinal BJ, Park EA, Kim M, Cardinal MK. If Exercise is Medicine, Where is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content. J Phys Act Health.


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Issue 1 - 2017 2015;12(9):1336-43. 24. Dunlop M, Murray AD. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum. Br J Sports Med. 2013;47(11):718-20. 25. Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. The Journal of family practice. 2000;49(2):158-68. 26. Morgan F, Battersby A, Weightman AL, Searchfield L, Turley R, Morgan H, et al. Adherence to exercise referral schemes by participants – what do providers and commissioners need to know? A systematic review of barriers and facilitators. BMC Public Health. 2016;16(1):1-11. 27. Mann S, Jimenez A, Domone S, Beedie C. Comparative effects of three 48-week community-based physical activity and exercise interventions on aerobic capacity, total cholesterol and mean arterial blood pressure. BMJ Open Sport & Exercise Medicine. 2016;2(1). 28. King AC, Kiernan M, Oman RF, Kraemer HC, Hull M, Ahn D. Can we identify who will adhere to longterm physical activity? Signal detection methodology as a potential aid to clinical decision making. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 1997;16(4):380-9. 29. Cock D. Development of REFERQUAL; an Instrument for Evaluating Service Quality in GP Exercise Referral Schemes. University of Central Lancashire: University of Central Lancashire; 2006. 30. Zizzi S, Kadushin P, Michel J, Abildso C. Client Experiences With Dietary, Exercise, and Behavioral Services in a Community-Based Weight Management Program. Health promotion practice. 2016;17(1):98-106. 31. McClaran SR. The Effectiveness of Personal Training on Changing Attitudes Towards Physical Activity. Journal of sports science & medicine. 2003;2(1):10-4. 32. Fischer DV, Bryant J. Effect of certified personal trainer services on stage of exercise behavior and exercise mediators in female college students. Journal of American college health : J of ACH. 2008;56(4):369-76. 33. Klain IP, de Matos DG, Leitão JC, Cid L, Moutão J. Self-Determination and Physical Exercise Adherence in the Contexts of Fitness Academies and Personal Training. Journal of Human Kinetics. 2015;46:241-9. 34. Sykes D, Probst L, Otto RM, Wygand JW. The Effects of In‐Home versus facility Personal Training: 2009: Board #79 May 31 2:00 PM −3:30 PM. Medicine & Science in Sports & Exercise. 2007;39(5):S349-S50. 35. Rustaden AM, Haakstad LA, Paulsen G, Bo K. Bodypump And Resistance Training With And Without A Personal Trainer - A Randomized Controlled Trial: 2125 Board #277 June 2, 3: 30 PM - 5: 00 PM. Med Sci Sports Exerc. 2016;48(5 Suppl 1):599. 36. Storer TW, Dolezal BA, Berenc MN, Timmins JE, Cooper CB. Effect of supervised, periodized exercise training vs. self-directed training on lean body mass and other fitness variables in health club members. J Strength Cond Res. 2014;28(7):1995-2006. 37. Maloof RM, Zabik RM, Dawson ML. THE EFFECT OF USE OF A PERSONAL TRAINER ON IMPROVEMENT OF HEALTH RELATED FITNESS FOR ADULTS. Medicine & Science in Sports & Exercise. 2001;33(5):S74. 38. Ratamess NA, Faigenbaum AD, Hoffman JR, Kang J. Self-Selected Resistance Training Intensity in Healthy Women: The Influence of a Personal Trainer. The Journal of Strength & Conditioning Research. 2008;22(1):103-11. 39. Dictionaries O. Language matters http://www.oxforddictionaries.com/definition/english/exercise2016 [cited 2016 10th of September]. 40. Smith A. Exercise is recreation not medicine. Journal of Sport and Health Science. 2016;5(2):129-34. 41. FDA. Aspirin. Comprehensive Prescribing Information http://www.fda.gov/ohrms/dockets/ac/03/briefing/4012B1_03_Appd%201Professional%20Labeling.pdf: FDA; 2016 [cited 2016 10th of September]. 42. Swisher AK. Yes, “Exercise is Medicine”….but It Is So Much More! Cardiopulmonary Physical Therapy Journal. 2010;21(4):4-. 43. Nesti MS. Exercise for health: Serious fun for the whole person? Journal of Sport and Health Science. 2016;5(2):135-8. 44. Sjøgaard G, Christensen JR, Justesen JB, Murray M, Dalager T, Fredslund GH, et al. Exercise is more than medicine: The working age population's well-being and productivity. Journal of Sport and Health Science. 2016;5(2):159-65. 45. Nunan D. Doctors should be able to prescribe exercise like a drug. BMJ. 2016;353.


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Issue 1 - 2017

3

-

REVIEW

PAPER:

Fitness

professionals’

pedagogical

intervention [Susana Franco & Vera Simões]

Susana Franco7, Vera Simões8 7

ESDRM-IPSantarém - Sport Sciences School of Rio Maior, Polytechnic Institute of

Santarém, Portugal. E-mail: [email protected] 8

ESDRM-IPSantarém - Sport Sciences School of Rio Maior, Polytechnic Institute of

Santarém, Portugal. E-mail: [email protected]

Abstract: It is recognised the importance of fitness professionals’ intervention for fitness centres’ quality and participants’ satisfaction and retention. The objective of this article is to present several studies that show some particular aspects of pedagogical intervention which must be taken into account for participants’ satisfaction and retention, namely encouragement, instruction and pay attention to participants. Some implications for the practice of fitness professionals’ pedagogical intervention are presented.

Key-words: Pedagogical intervention; Fitness professionals; Quality; Satisfaction

7

PhD Methodological Foundations of Research on Physical Activity and Sport; Master Degree in Exercise and Health; Bachelor in Sport Sciences – Physical Education and Sport. Associate Professor at ESDRM-IPSantarém, Portugal. Subjects teaching: Fitness; Fitness Assessment and Exercise Prescription; Sport and Fitness Pedagogy; Fitness Internship, Thesis. Fitness Instructor in several Health Clubs. Conferences’ speaker in several events related with Fitness. Participation in several workshops, Conventions, Congress related with Fitness. Research and publication areas: Fitness and Sport Pedagogy. Participation in several European I&D Projects: Sport Physical Education and Coaching in Health (SPEACH), Fitness e-Learning Team Training (FELT2), e-Learning Fitness (e-LF), Physical Activity and Lifestyle Counselling (PALC), European Accreditation – Fitness (EA-Fitness), ECVET-Fitness, Aligning a European Higher Education Structure in Sport Science (AEHESIS). 8 PhD in Sport Sciences; Master Degree in Sport and Exercise Psychology; Post-Graduations in Fitness – Personal Training and in Groups Fitness Instructor; Bachelor in Sport – Fitness. Assistant Professor at ESDRM-IPSantarém, Portugal. Subjects teaching: Fitness; Fitness Assessment and Exercise Prescription; Sport and Fitness Pedagogy; Exercise for Special Populations; Sport Systematic; Fitness Internship, Thesis. Teacher and coordinator of extracurricular subject, Fitness, in an elementary private school in Lisbon. Fitness Instructor in several Health Clubs. Conferences’ speaker in several events related with Fitness. Participation in several workshops, Conventions, Congress related with Fitness. Research and publication areas: Fitness and Sport Pedagogy. Participation in several European I&D Projects: Fitness e-Learning Team Training (FELT2), e-Learning Fitness (e-LF), Physical Activity and Lifestyle Counselling (PALC). ISSN: 2522-1310 ©Copyright EuropeActive 2017

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Issue 1 - 2017

Background Although known the innumerable benefits of exercise [1,2], according to Sport and Physical Activity Eurobarometer [3], there is still a large number (42%) of European Union citizens that never exercised or played sport. One of the concerns of fitness centres managers is to present a quality service, which, according to several authors, may provide clients’ satisfaction and consequently clients’ retention [4-12]. Several authors refer the importance of human resources, particularly fitness professionals, in a quality service of fitness centres and participants’ satisfaction and retention [12-22]. The adherence to physical activity in unsupervised program setting is very low [23], which reinforce the importance of the intervention of fitness professionals. Fitness professionals can be one of the participant's drop out motives from fitness centres [24], or can be a motive to choose a fitness centre [25].

Discussion Considering the importance of fitness professionals’ quality for participants’ satisfaction and retention, Campos, Simões and Franco [26] develop a study to identify the quality indicators of group fitness instructors. After interviewed 100 fitness stakeholders (gym owners/general managers, technical directors, trainers, instructor and fitness participants) and have done a content analysis, they found 4 dimensions of group fitness instructors’ quality: professional, relational, technical and pedagogical. The quality indicators of each dimension can be observed in table 3. Table 3 - Quality indicators of each dimension of group fitness instructors’ quality [26] Dimensions

Indicators

Professional

Assiduity, Dedication, Ethics, Experience, Image, Punctuality

Relational Technical

Good mood, Communication, Cordiality, Availability, Empathy, Honesty, Humility, Sympathy Fitness level, Knowledge, Musical skills, Technical performance, Technical

Pedagogical


education, Innovation, Planning Adaptability, Dynamism, Instruction, Motivate

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Issue 1 - 2017

The most cited quality indicators, in Campos et al. study [26], were empathy (from relational dimension), motivate and instruction (from pedagogical dimension). This study,

like

others

studies

[6,12,27-30],

reveal

the

importance

of

fitness

professionals’ pedagogical intervention in fitness centres’ quality and participants’ satisfaction and retention. In fact, there is a positive relation between the participants’ satisfaction and the fitness professionals’ pedagogical behaviour [31]. Franco et al. [31] studied this relation, in group fitness classes, and found a significant positive relation between participants’

satisfaction

and

behaviours:

encouragement,

the

following

instruction

fitness

instructors’

(information,

pedagogical

correction,

positive

evaluation, negative evaluation and questioning) and monitoring (observe and pay attention to what participants do and say). Therefore, behaviours for encouraging, instruct and for pay attention to participants can contribute to increasing participants’ satisfaction. Authors also found a significant negative relation between participants’ satisfaction and the behaviour independent exercise of fitness instructors, which means that if during a group fitness classes the fitness instructor performs the exercise with participants but don’t pay attention to them, participants will be less satisfied. According to the multidimensional model of sports leadership from Chelladurai [32], the satisfaction level of participants results from the level of congruence between required, actual and preferred behaviour. This model also shows that situational characteristics (e.g., group dimension, activity, objectives, tasks, etc.) and member characteristics (e.g., age, gender, participant experience, personality, etc.) are related to required and preferred behaviour. Based on this model, Franco, Cordeiro and Cabeceiras [33] study participants’ preferences about group fitness instructors characteristics in different activities, namely: resistance training, hip hop, aquafitness and fitness-combat. They found some similarities in the participants’ preferences about group fitness instructors’ characteristics in different fitness activities, such as being dynamic and motivator, that are two of the most preferred characteristics by participants about group fitness instructors. However, authors


31

Issue 1 - 2017 found significant differences between groups in 8 of the 23 characteristics. Authors also study participants’ preferences of different group ages, about fitness instructors’ characteristics, and they verify similarities in different group ages about the most preferred characteristics in group fitness instructors, namely being dynamic, motivator and imaginative. Nonetheless, they found significant differences between groups in 14 of the 23 characteristics. Considering these results, it’s important that fitness professionals adapt their intervention to participants’ characteristics, such as participants’ age, and to situational characteristics, such as the activity. Considering the importance, for participants’ satisfaction, of congruence between required, actual and preferred behaviour about fitness professionals, it’s important to know what participants prefer for fitness professionals act according to their preferences.

Participants’

preferences

about

fitness

instructors’

pedagogical

behaviour were studied, in different group fitness activities, namely resistance training [31], indoor cycling [34] and Zumba® [35]. Results are summarized in table 4. Table 4 - Participants’ preferences about fitness instructors’ pedagogical behaviour, in resistance training [31], indoor cycling [34] and Zumba® [35]: most preferred and less preferred behaviours. Most preferred behaviours

Less preferred behaviours Conversations with others (clients or staff out of the class; E, WE), Attention to interventions of others (clients or staff out Encouragement (E, WE), Demonstration of the class; E, WE), Negative affectivity with information, Information (E, WE), Resistance (E, WE), Other behaviours (e.g., drink Participative exercise (with clients as a training water or clean the face with a towel participant), Correction (E, WE), Positive without pay attention to participants), evaluation (E), Questioning (E) Independent exercise (do exercise without pay attention to participants), Demonstration without information Encouragement (E, WE), Questioning Negative affectivity (E, WE), Conversations Indoor (WE), Participative exercise, Positive with others (E, WE), Attention to cycling evaluation (E), Positive affectivity (E, WE), interventions of others (E, WE), Correction (WE), Information (E) Independent exercise, Other behaviours Conversations with others (E, WE), Attention to interventions of others (E, Demonstration with information, Zumba® WE), Independent exercise, Negative Information (E, WE), Encouragement (E) affectivity (E, WE), Other behaviours, Demonstration without information E: fitness instructor behaviour doing exercise simultaneously; WE: fitness instructor behaviour without doing exercise simultaneously.


32

Issue 1 - 2017 There are some common participants’ preferred fitness professionals’ behaviours in different activities, such as encourage participants and give information to explain exercise while performing the exercise with participants (table 4). However, there is some behaviours specificity that participants prefer in each group fitness activity. For example, considering that indoor cycling requires fewer changes in the exercises and consequently less instruction than the others activities, so, probably for “breaking the ice” during practice, participants like that the instructor interacts with them to create a good climate. In activities that require more technical skills, like resistance training or Zumba®, participants prefer that, besides just show (demonstrate) the model, also explain, with verbal and/or non-verbal instruction, how to perform the exercises. Franco et al. [35] also found significant differences between participants’ preference about the following instructional behaviour, which means that participants don’t want just a model to see during “the Zumba ® party”, but also an explanation of the exercises: give information explaining the exercise, verbally or non-verbally, while doing exercise; give information explaining the exercise, verbally or non-verbally; show the model, before participants perform the exercise, and give information explaining the exercise, verbally or non-verbally; just show the model before participants perform the exercise (significantly less preferred, compared with others). There are also some common less participants’ preferred fitness professionals’ behaviours in different activities, which are related to bad mood or don’t pay attention to participants, namely: negative affectivity creating a bad class climate; conversations with people outside of the class (other clients or staff); pay attention to interventions of people out of the class (other clients or staff); other behaviours, such as fix the clothes, drink water, clean the sweat; do exercise without pay attention to participants. Considering that for a participant have a higher level of satisfaction the perception and the preferences should be congruent [32], some studies were done to check this congruence in fitness. Franco and Simões [36] compared participants’ perception

and

preferences,

about

pedagogical

feedback

of

Body

Pump ®

instructors, and found significant differences in 19 of the 24 types of feedback.


33

Issue 1 - 2017 These results probably mean that participants are not satisfied with feedback of Body Pump® instructors, which may be due to, in closed pre-choreographed program, the obligation to follow the choreography, and perform pedagogical functions for that, may limit the availability of fitness professional to observe and correct participants. In another study [31] group fitness instructors’ observed behaviour, participants’ perception and preferences, about pedagogical intervention, were related. Although there was no congruence between the observed behaviour of the instructors and the preference of the participants in various categories (26 of 33), there was always congruence between perception and preference, which, perhaps, may contribute to the participants satisfaction with the instructor, considering that satisfaction results from the level perception. But when

authors

of congruence between preference and

relate observed

behaviour with participants’

perception they only found 15 significant positive relations in the 33 tested behaviours. Participants’ perception is influenced by their preference and affective reactions, so the participants’ perception may not reflect reality [37]. Sometimes it is not just the participants who have no sense of reality, but also fitness professionals. A study [38] that relates self-perception with the observed behaviour of group fitness instructors, verified that fitness instructors had no idea about one-third of the behaviours they performed. Considering these results, it is important that fitness professionals do a self-analysis of their own intervention to have a better sense of the reality [38]. A systematic process of supervision and self-analysis, through observation, using for example videos, observation systems or checklists, should be done to collect information about fitness professionals’ intervention, and give feedback for they improve their professional performance. There are some observation systems about fitness professional intervention, validated for fitness context, namely about general pedagogic intervention [31,39], pedagogic feedback [40], class climate [41],

instruction

[42],

non-verbal

kinetic

communication

[43],

non-verbal

proxemics communication [44].


34

Issue 1 - 2017

There are also instruments to know participants opinion about fitness professionals’ intervention, validated for this context, namely about fitness professional quality [45], general pedagogic intervention [31,46] and pedagogic feedback [47].

Implications for practice For participants’ retention and satisfaction, fitness professionals should focus their pedagogical intervention especially in [31,34,35]: 

Encouragement for practice;



Instruction situations: demonstrating and explaining verbally and nonverbally the exercises, question participants about their physical state and exercises’ understanding, correct participants’ performance and praise them;



Pay attention to participants, observing and hear them.

Fitness professionals should adapt their intervention to participants’ characteristics (e.g.,

age,

gender,

participant

experience,

personality)

and

to

situational

characteristics (e.g., group dimension, activity, objectives, tasks). For a continuous professional development fitness professionals should often do: 

Continuous education [48];



Systematic self-analysis [49,50];



Be supervised by other professionals or coordinators [49,50];

For systematic self-analysis and supervision, observation systems, specific for fitness context

[31,39-44], can

be used

for this process. Surveys about

participants’ opinion [31,45-47] should sometimes be applied, to know their opinion and adapt the intervention to preferences of class in general and to each individual in specific, which can contribute to participants’ satisfaction and retention. A triangulation of these different perspectives (observed behaviour, participants’ perception and preferences, instructors’ self-perception) can be used for a better comprehension of the fitness professionals’ intervention, adjusting and improving it [31,38,51].


35

Issue 1 - 2017 References 1. Physical Activity Guidelines Advisory Committe. Physical Activity Guidelines Advisory Committee Report 2008. Washington, DC: U.S. Department of Health and Human Services; 2008. 2. World Health Organization. Global Recommendation on Physical Activity for Health. Geneve: World Health Organization; 2010. 3. TNS Opinion & Social. Special Eurobarometer 412 / Wave EB80.2 "Sport and Physical Activity". Brussels: TNS Opinion & Social; 2014. 4. Chang K. Understanding Service Quality in Health/Fitness Clubs from a Systems Perspective 1999 [6/1999]. Available from: www.dure.net/~kma/kjm/thesis/1c/KJM1c_4.pdf. 5. Makover B. Examining the Employee-Customer Chain in the Fitness Industry [Doctor Thesis]. Florida: The Florida State University - College of Education; 2003. 6. Papadimitriou DA, Karteroliotis K. The Service Quality Expectations in Private Sport and Fitness Centers: A Reexamination of the Factor Structure. Sport Marketing Quarterly. 2000;9(3):157-64. 7. Theodorakis N, Alexandris K, Rodriguez P, Sarmento PJ. Measuring Customer Satisfaction in the Context of Health Clubs in Portugal. International Sports Journal. 2004;8(1):44-53. 8. Fernández JG, Carrión GC, Ruíz DM. La Satisfacción de Clientes y su Relación con la Percepción de Calidad en Centro de Fitness: Utilización de la Escala CALIDFIT. Revista de Psicología del Deporte. 2012;21(2):309-19. 9. Gonçalves C, Meireles P, Carvalho MJ. Consumer Behaviour in Fitness Club: Study of the Weekly Frequency of Use, Expectations, Satisfaction and Retention. The Open Sports Sciences Journal. 2016;9(Suppl-1, M8):62-70. 10. Pedragosa V, Correia A. Expectations, Satisfaction and Loyalty in Health and Fitness Clubs. International Journal of Sport Management and Marketing. 2009;5(4):450-64. 11. Theodorakis N, Howat G, Ko YJ, Avourdiadou S. A Comparison of Service Evaluation Models in the Context of Sport and Fitness Centres in Greece. Managing Leisure. 2014;19(1):18-35. 12. Avourdiadou S, Theodorakis N. The Development of Loyalty Among Novice and Experienced Customers of Sport and Fitness Centres. Sport Management Review. 2014;17(4):419-31. 13. Gonçalves C, Buchman C, Carvalho MJ. Perceção da Qualidade do Serviço e Satisfação dos Sócios de Fitness: Contribuições para o Papel do Gestor. Revista Intercontinental de Gestão Desportiva. 2013;3(S2):47-58. 14. Albayrak T, Caber M. Symmetric and Asymmetric Influences of Service Attributes: The Case of Fitness Clubs Managing Leisure. 2014;19(5):307-20. 15. Liu Y-D, Hsu H-H. Identifying the Factor Structure of Costumer Satisfaction with Public Leisure Services. International Journal of Leisure and Tourism Marketing. 2010;1(3):288-303. 16. Pedragosa V, Biscaia R, Correia A. The Role of Emotions on Consumers' Satisfaction Within the Fitness Context. Motriz. 2015;21(2):116-24. 17. Argan M, Argan MT, Köse H, Soner A. The Relationship Between Fitness-Related Quality Satisfaction and Intention. International Refereed Academic Journal of Sports, Health and Medical Sciences. 2015;5(16):1-19. 18. Bodet G. Investigating Customer Satisfaction in a Health Club Context by an Application of the Tetraclasse Model. European Sport Management Quarterly. 2006;6(2):149-65. 19. Alexandris K, Palialia E. Measuring Customer Satisfaction in Fitness Centres in Greece: An Exploratory Study. Managing Leisure. 1999;4(4):218-28. 20. Lagrosen S, Lagrosen Y. Exploring Service Quality in the Health and Fitness Industry. Managing Service Quality. 2007;17(1):41-53. 21. Yildiz SM. An Importance-Performance Analysis of Fitness Center Service Quality: Empirical Results from Fitness Centers inTurkey. African Journal of Business Management. 2011;5(16):7031-41. 22. Tsitskari E, Antoniadis C, Costa G. Investigating the Relationship Among Service Quality, Customer Satisfaction and Psychological Commitment in Cyprian Fitness Centres. Journal of Physical Education and Sport. 2014;14(4):514-20. 23. Sperandei S, Vieira MC, Reis AC. Adherence to Physical Activity in an Unsupervised Setting: Explanatory Variables for High Attrition Rates Among Fitness Center Members. Journal of Science and Medicine in Sport. 2016;19:916-20. 24. Franco S, Pereira L, Simões V, editors. Dropout Motives in Exercise. 13th Annual Congress of the European College of Sport Science; 2008; Estoril, Portugal. 25. Szumilewicz A. Multiple Influences Affecting the Women's Choice of a Fitness Club. Baltic Journal of Health and Physical Activity. 2011;3(1):55-64. 26. Campos F, Simões V, Franco S. Characterization and Comparison of the Quality Indicators of the Group Exercise Fitness Instructor, Considering the Intervenient, Gender and Age. International Journal of Sport, Exercise and Training Science. 2016;2(2):50-9. 27. Wininger SR. Instructors' and Classroom Characteristics Associated with Exercise Enjoyment by Females. Perceptual and Motor Skills. 2002;94:395-8.


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Issue 1 - 2017 28. Cloes M, Laraki N, Zatta S, Piéron M, editors. Identification des Critères Associés à la Qualité des Instructeurs d'Aérobic. Comparaison des Avis des Clients et des Intervenants. Colloque L'Intervention dans le Domaine des Activités Physiques et Sportives: Compétence(s) en Mutation?; 2001; Grenoble. 29. Loughead TM, Carron AV. The Mediating Role of Cohesion in the Leader Behavior - Satisfaction Relationship. Psychology of Sport and Exercise. 2004;5:355-71. 30. Collishaw MA, Dyer L, Boies K. The Authenticity of Positive Emotional Displays: Client Responses to Leisure Service Employees. Journal of Leisure Research. 2008;40(1):23-46. 31. Franco S, Rodrigues J, Castañer M. Case Study 6.3: The Behaviour of Fitness Instructors and the Preferences and Satisfaction Levels of Users. In: Camerino O, Castañer M, Anguera MT, editors. Mixed Methods Research in the Movement Sciences. Oxon: Routledge; 2012. p. 202-14. 32. Chelladurai P. Leadership in Sport: A Review. International Journal of Sport Psychology. 1990;21:328-54. 33. Franco S, Cordeiro V, Cabeceiras M, editors. Perception and Preferences of Participants about Fitness Instructors' Profile - Comparison between Age Groups and Different Activities. 9th Annual Congress of the European College of Sport Science; 2004; Clermont-Ferrand, France: European College of Sport Science. 34. Mercê C, Franco S, Alves S, Campos F, Simões V. Preferências dos Praticantes de Indoor-Cycling, relativamente ao Comportamento Pedagógico do Instrutor. Revista da UIIPS. 2014;2(1):59. 35. Franco S, Mercê C, Simões V. Preferência dos Praticantes Acerca do Comportamento Pedagógico dos Instrutores de Zumba. Journal of Sport Pedagogy and Research. 2015;1(6):30-5. 36. Franco S, Simões V, editors. Participants' Perception and Preference about Body Pump® Instructors' Pedagogical Feedback. 11th Annual Congress of the European College of Sport Science; 2006; Lausanne - Switzerland. 37. Chelladurai P, Riemer HA. Measurement of Leadership in Sport. In: Duda JL, editor. Advances in Sport and Exercise Psychology. Morgantown, WV: Fitness Information Technology; 1998. p. 227-53. 38. Franco S, Simões V, Castañer M, Rodrigues J, Anguera MT. La Conducta de los Instructores de Fitness: Triangulación entre la Percepción de los Practicantes, Auto-percepción de los Instructores Y Conducta Observada. Revista de Psicología del Deporte. 2013;22(2):321-9. 39. Franco S, Rodrigues J, Castañer M. Comportamento Pedagógico dos Instrutores de Aulas de Grupo de Fitness de Localizada. Fitness & Performance Journal. 2008;7(4):251-63. 40. Simões V. Análise do Feedback Pedagógico em Instrutores Estagiários e Experientes na Atividade de Localizada. Comportamentos de Feedback Observados, Auto-perceção dos Instrutores e Preferências dos Praticantes [Tese de Doutoramento]. Vila Real: Universidade de Trás-os-Montes e Alto Douro; 2013. 41. Dias I. Desenvolvimento e Validação do Sistema de Observação do Clima de Aula, em Aulas de Grupo de Fitness [Dissertação de Mestrado]. Rio Maior: Escola Superior de Desporto de Rio Maior; 2015. 42. Luís T. Desenvolvimento, Validação e Aplicação Piloto do Sistema de Obsrvação da Instrução do Instrutor de Fitness em Aulas de Grupo de Pilates (SOIIF-Pilates) [Dissertação de Mestrado]. Rio Maior: Escola Superior de Desporto de Rio Maior; 2017. 43. Alves S, Rodrigues J, Balcells MC, Foguet OC, Sequeira P, Carvalhinho L, et al. Validação e Desenvolvimento de um Sistema de Observação da Comunicação Cinésica do Instrutor de Fitness. Motricidade. 2014;10(1):77-87. 44. Alves S, Rodrigues J, Balcells MC, Foguet OC, Sequeira P, Carvalhinho L, et al. Sistema de Observação da Comunicação Proxémica do Instrutor de Fitness (SOPROX-Fitness): Desenvolvimento, Validação e Estudo Piloto. Revista Iberoamericana de Psicología del Ejercicio y el Deporte. 2013;8(2):281-99. 45. Campos F, Simões V, Franco S. A Qualidade em Atividades de Grupo de Fitness: Construção e Validação do Questionário "Qualidade do Instrutor de Fitness - Atividades de Grupo" (QIF-AG). Revista Psicologia. 2016;30(1):37-48. 46. Franco S, Simões V, Alves S, Moutão J, Cid L, Rodrigues J, editors. Development of the Questionnaire Instructors’ Pedagogical Behavior in Group Fitness Classes. XII ENSSEE Forum; 2013; Groningen, Holand. 47. Simões V, Rodrigues J, Alves S, Franco S. Validação do Questionário de Feedback de Instrutores de Fitness em Aulas de Grupo. Revista da UIIPS. 2013;1(1):227. 48. Batrakoulis A, Rieger T. European Barometer on the Top Future Trends in Education, Training and Certification of the Exercise Professionals. Journal for Physical Education and Sport Science. 2014;1(1):10-26. 49. Franco S, Simões V. Lazer e Qualidade de Vida: Formação de Técnicos de Fitness. In: Resende R, Albuquerque A, Gomes AR, editors. Formação e Saberes em Desporto e Educação Física. Lisboa: Visão e Contextos; 2015. p. 477-508. 50. Simões V, Santos-Rocha R. Communication: Giving and Gaining Feedback. In: Santos-Rocha R,


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Issue 1 - 2017 Rieger T, Jiménez A, editors. EuropeActive’s Essentials of Fitness Instructiors. Champaing, IL: Human Kinetics; 2015. p. 9-13. 51. Simões V, Santos-Rocha R. Body Awareness and Exercise Technique. In: Rieger T, Naclerio F, Jiménez A, Moody J, editors. EuropeActive's Foundations for Exercise Professionals. Champaign, Il: Human Kinetics; 2015. p. 191-8.


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Issue 1 - 2017

4 - ORIGINAL RESEARCH: The transtheoretical model of behaviour change and strategies for fitness professionals to increase exercise behaviour [Jan Middelkamp]

Jan Middelkamp9 9

Behavioural Science Institute, Radboud University, Montessorilaan 3,

Postbox 9104, 6500 HE, Nijmegen, the Netherlands. E-mail: [email protected]

Abstract: The transtheoretical model of behaviour change (TTM) is often used to understand changes in health-related behaviour, like exercise. This model also provides a practical framework for tailor-made interventions, using four core constructs. The purpose of this paper is to apply this integrative model towards exercise and provide strategies to be used by fitness professionals to increase exercise behaviour of their clients or members, ultimately to maximise their health and fitness levels.

Key-words: Stages of change, adherence, health

9

Jan Middelkamp is a PhD researcher at the Radboud University in The Netherlands with a special interest in exercise behaviour change. He lectures in motivation, health behaviour change, personal training and member retention. Jan is a board member of EuropeActive, Development Director at HDD Group and CEO of BlackBoxPublishers. More info: www.janmiddelkamp.com.


39

Issue 1 - 2017

Introduction It is well documented that physical activity (PA) and exercise are beneficial for health. This holds for individuals as well as for the population in general [1,2]. This article focuses on exercise only, defined as planned, structured, repetitive bodily movements with the intention to improve or maintain (physical) fitness or health [3]. In the health and fitness sector, clients or members predominantly exercise for health benefits [4]. Several studies demonstrate that exercise behaviour, meaning the adoption of new behaviour and the maintenance of existing behaviour (adherence), is problematic [5]. According to the International, Health, Racquet and Sportsclub Association [6], approximately 151 million individuals exercise in fitness facilities worldwide. In regards to exercising in a fitness setting, three kinds of behaviour are relevant. First, an individual has to enter the facility, denoted as attendance behaviour. Second, the individual has to attend the programme, labelled as programme attendance. Third, the person needs to exercise according to certain standards or minimums in terms of frequency, duration and intensity, in short exercise behaviour. Research on attendance and exercise behaviour in health and fitness shows strong indications that the frequencies are low. Middelkamp et al. [7] reported low amounts of exercise sessions, analysing a database of 259,000 exmembers with an average of 1.1 sessions per month over 24-months, including a mix of individual and group exercise behaviour. Health effects based on these frequencies will be marginal at best. In regards to types of exercises, a Dutch study [8] reports that most males (60%) and females (45%) combine individual and group exercises, but 31% of the females only participate in group exercise programmes. The study also reports that most individuals participate in two or more types of programmes; about 50% participate in at least one group exercise programme and 23% participate only in group exercise classes with an instructor. A core task of fitness professionals is to support and increase all three kinds of behaviour, to ultimately maximise the effects of exercise towards the health and fitness levels of clients and members. Transtheoretical Model of Behaviour Change To systematically study and understand exercise behaviour, but also to provide practical strategies, several social-cognitive models have been put forward. The


40

Issue 1 - 2017 transtheoretical model (TTM) is frequently used to study different kinds of health behaviours,

including

smoking,

physical

activity

and

exercise.

In

different

populations and settings, the existence of significant relationships between the TTM and exercise behaviour have been demonstrated [9-11]. To increase exercise behaviour, an in-depth understanding of the development of this specific behaviour and its change over time is needed, which makes the TTM useful as a theoretical model. The TTM model was originally developed by observing smokers that wanted to change their behaviour without professional intervention, the so-called selfchangers. The model describes four key variables: stages of change; decisional balance; self-efficacy and processes of change. The stages of change contain five main stages to cease an unhealthy or adopt a healthy behaviour (like exercise), or six stages if the termination/relapse stage is also included [12]. The stages are presented in table 5.

Table 5 - Stages of change. Stage 1

Name Precontemplation

2

Contemplation

3

Preparation

4

Action

5

Maintenance

6

Relapse

Description People who aren’t currently not thinking of changing their behaviour. In short: I WON’T and I CAN’T stage. People who aren’t currently changing their behaviour, but do intent to change in the next six months. In short: I MIGHT stage. People who are preparing to change their behaviour within the next 30 days. In short: I WILL stage. People who made a change in their behaviour, but have changed recently (up to six months but no longer). In short: I AM stage. People who have changed for some time, at least six months. The behaviour has become a reasonably stable characteristic. In short: I HAVE stage. On the one hand, people can maintain their behaviour, on the other hand, they can relapse into the previous behaviour and return to the earlier stages.

The decisional balance is the second construct of the TTM, and contains two main scales of Pros and Cons for changing behaviour. There are four dimensions for Pros: useful benefits for the self; useful benefits for others; self-approval; approval of others. There are also four dimensions for Cons: useful losses for the self; useful losses for others; self-disapproval; disapproval of others. The Pros and Cons are important

for

influencing

persons

in

an

early

stage

(pre-contemplation

–

preparation) to the action stage. The third construct is self-efficacy [13]. In short, self-efficacy is a person’s belief in


41

Issue 1 - 2017 capabilities to overcome personal, social and environmental barriers to exercise. Self-efficacy is commonly split and measured in two aspects and scales: Barrier self-efficacy is the confidence to overcome barriers to exercise; Temptation is characterised as the negative impulses to revert back to previous behaviours. According to self-efficacy theory, two important factors can influence the confidence to adopt and maintain exercise behaviour. The first is efficacy expectations, that is one’s

belief

about

their

own

competence.

The

second

factor

is

outcome

expectations, one’s belief in regards to the perceived result or outcomes of exercise behaviour.

According

to

self-efficacy

theory,

human

behaviour

is

strongly

influenced by self-regulation [14]. The self-regulative mechanisms operate through three subfunctions; Self-monitoring of one’s behaviour on determinants and consequences; Judgement of one’s behaviour in relation to personal standards and circumstances; Affective self-reaction. To increase self-efficacy, exercisers should be first supported in selecting the right exercises to increase efficacy expectations. Second, they need guidance in managing outcome expectations, for example by setting and tracking relevant goals. The fourth construct measures ten processes of change, which can be divided into five cognitive processes and five behavioural processes. The five cognitive processes are: consciousness raising (e.g., looking for information); dramatic relief (e.g., emotional aspects of change); environmental reevaluation (e.g., assessment of how inactivity affects society); self-reevaluation (e.g., assessment of personal values) and social liberation (e.g., awareness, availability and acceptance of active lifestyles in society). The five behavioural processes are: counter conditioning (e.g., substituting physical activity for sedentary leisure choices); helping relationship (e.g., using social support during change); reinforcement management (e.g., selfreward for change); self-liberation (e.g., commitment and self-efficacy beliefs about change); stimulus control (e.g., managing situations that prompt inactivity or activity) [15,16]. Spencer et al. [11] reviewed 150 studies using the TTM. A total of 31 stagematched intervention studies were reviewed and 25 studies were shown to be successful in motivating participants towards higher stages and increased amounts


42

Issue 1 - 2017 of exercise. Towards the health and fitness sector, Middelkamp et al. [17] executed a systematic review on exercise behaviour in fitness clubs. A small amount of studies used constructs of the TTM. For example, Nigg et al. [18] tested the decisional balance sheet (DBS). The experimental group received a phone call and were asked to think systematically and record the expected gains and losses of exercising in a fitness centre. Members reported twice as many Pros as Cons. Pros were: good equipment/facilities and social interaction. Cons were: crowded conditions and lack of equipment. Attendance declined from the 4th week baseline to the 8th week in control and placebo group, but less change in the experimental group. DBS was effective to keep attendance up [19]. Annesi [19] tested the effect of a multiple component behaviour change treatment package (for 36 weeks), partly based on the constructs of self-efficacy and processes of change. The package included strategies like relapse prevention, self-reinforcement, and contracting. All studies (US, Great Britain and Italy) showed a significantly higher attendance (13-30%) and less drop-out (30-39%) for the treatment group [19]. This coach-approach system was also tested in Annesi [20,21], Annesi and Unruh [22], and Annesi et al. [23], and proved again that adherence was positively influenced by the intervention. Cox et al. [24] compared home versus fitness centre based exercise for 18 months, using the stages of change constructs. The centre based group had higher adherence than the home based group (97, 94, 81% versus 87, 76, 61%) at respectively 6, 12 and 18 months. The levels of drop-out range from 3 to 39%. Levesque et al. [25] studied how learned resourcefulness is related to spontaneous process of change in 6 months, at adult members (n=104) in the preparation stage of the TTM. Learned resourcefulness are regulatory skills that enable a person to self-control his/her behaviour. Persons with stronger selfregulatory capacity use more processes of change over time. They try harder in attempting to maintain exercise involvement. Middelkamp et al. (2016) tested two self-regulation interventions to increase self-efficacy and group exercise behaviour. In total 122 participants (Mage 42.02 yr.; SD 12.29; 67% females) were recruited and randomly assigned to one control and two experimental groups. The control group was limited to participate in one virtual group exercise programme only (group 1). The first experimental group was able to self-set their activities and participate in multiple group exercise programmes (group 2). The second


43

Issue 1 - 2017 experimental group received an additional monthly coaching protocol to manage self-set goals (group 3). An ANOVA indicated that mean sessions between group 1 and 3, and 2 and 3 differed significantly (p