Evidence-Based Strategies for Increasing Participation
In Physical Activity in Community Recreation, Fitness and Sport

 

 

March 27, 2000

By: Peggy Edwards

 

 



 


 

© Queen's Printer for Ontario, 2000

Contents

1. Introduction

1.1 Background
1.2 Purpose of This Paper
1.3 Community Recreation, Fitness and Sport Settings

2. Theories Most Commonly Applied to Physical Activity

2.1 Stages of Change Model
2.2 Self-Efficacy Theory
2.3 The Decisional Balance Model
2.4 Social Support Theory
2.5 Putting It All Together

3. Implementation Strategies

3.1 Understand Your Audience
3.2 Build Supportive Environments
3.3 Use Multi-Level Community-Based Approaches as Well as Individualized Ones
3.4 Work With Partners

4. Maximizing Participation

4.1 Program Considerations
4.2 Considerations for Resource Development

Conclusion

References

Additional References (reviewed but not cited)


1. Introduction

Back to Top

1.1 Background

Only 38% of the Ontario population are physically active enough to benefit their health, and over seven million Ontarians face increased health risks as a result of sedentary lifestyles. The Ontario government has made a commitment to improve the level of physical activity in the province, particularly by inactive individuals. The goal is to increase the percentage of Ontarians who are active enough to benefit their health from 38% (current rate) to 41% in the year 2001.

Physical activity need not be strenuous to achieve health benefits. Sixty minutes of daily light activity or 30 minutes of moderate intensity activity (not necessarily all at once) four days a week is sufficient for most adults to achieve health benefits (Canada’s Physical Activity Guide, 1999). While children and youth generally require more physical activity for optimal growth and development, helping inactive children get involved in any regular activity will benefit their health, development and prospects for being active as adults. Thus, a small change in physical activity levels throughout the population will have a dramatic effect on the health and well-being of Ontarians.

The Community Sport, Fitness and Recreation Initiative is one of the key strategies for increasing participation levels in community and home settings. The initiative is a joint activity of the Sport and Recreation Branch of the Ministry of Citizenship, Culture and Recreation and the Health Promotion Branch of the Ministry of Health, in collaboration with Parks and Recreation Ontario and many other partners.

One of the objectives of the Community Sport, Fitness and Recreation Initiative is to develop useful tools, programs and training that are based on solid evidence and applicable health promotion and behaviour change theories. These will assist leaders (front-line, supervisors and policy-makers) in community sport, fitness and recreation systems in their efforts to help inactive Ontarians become and stay active, on a regular basis.

Back to Top

1.2 Purpose of This Paper

The main purpose of this paper is to provide evidence-based guidance for leaders and people who are developing resources and training programs for leaders in community recreation, fitness and sport. In order to do this, the paper covers three key areas.

1. Theories Most Commonly Applied to Physical Activity

The paper begins by examining the application of several theoretical models to help us understand and increase participation in physical activity among inactive Ontarians, particularly those who are considering a change. These include the Stages of Change Model, Self-Efficacy Theory, the Decisional-Balance Model and Social Support Theory. Applying these theories to the practical development of programs, policies and products will help leaders and resource developers attain greater success in promoting active living among all Ontarians.

2. Implementation Strategies

This section discusses three key implementation strategies: understanding your audience, building supportive environments and the use of multi-level, community approaches.

3. Maximizing Participation

This section discusses ideas that can help maximize participation in programs and the use of resources.

Back to Top

1.3 Community, Recreation, Fitness and Sport Settings

The community sport, fitness and recreation sectors are ideally positioned to enable inactive Ontarians to become and stay active. These systems provide information and support through awareness and education campaigns, programs, classes, personal counselling, environmental polices (such as supplying bike paths), indoor and outdoor facilities, leadership, trained experts and coaches, events, and other opportunities to be active.

New and revised ways of working can build on well-established, effective resources in these sectors. Almost two million Ontarians are registered members of provincial sport organizations. Ontario residents annually spend over $3 billion on goods and services related to physical activity. Over 660,000 adult volunteers contribute an estimated $2.3 billion in time and an additional $292 million in out-of-pocket expenses.

According to the 1995 Physical Activity Monitor, 58% of males and 52% of females in Canada used public facilities at some point in the last year (may not be consistent use) for physical activity. Twenty-nine per cent of males and 24% of females used private facilities. However, the home remains the most popular place to be active: 79% of males and 85% of females select this location for physical activity. Therefore, efforts to reach inactive Ontarians need to extend beyond traditional facilities and engage people where they most want to be active.

Back to Top

Theories Most Commonly Applied to Physical Activity

This section describes four theories of behaviour change that have been shown to be particularly useful in designing interventions that encourage and enable people to be physically active. It also suggests some practical implications of these theories for leaders.

2.1 Stages of Change Model

The Stages of Change or Transtheoretical Model proposes that individuals move through five stages in the process of behaviour change (Prochaska and Diclemente 1992). The questions in each description allow the leader to assess the stage of change a particular person is in (Mummery and Spence, 1999).

1. Precontemplation: The individual has no intention of changing his or her behaviour in the foreseeable future ("never"). Ask: "Have you thought about participating in regular physical activity in the last six months?" Answer: "No".

2. Contemplation: The individual is seriously thinking about changing his or her behaviour but has not yet made a commitment to take action ("someday"). Ask: "Have you thought about participating in regular physical activity in the last six months?"Answer: "Yes".

3. Preparation: The individual is intending to take action within the next six months and may have already taken action which he or she was unable to sustain ("soon"). Ask: "Do you intend to participate in regular physical activity in the next six months?" Answer: "Yes".

4. Action: The individual modifies his or her behaviour ("now"). Ask: "Do you currently participate in regular physical activity?" Answer: "Yes".

5. Maintenance: The individual works to prevent relapse and maintain the behaviour change ("forever"). Ask: "Have you participated in regular physical activity in the past six months?" Answer: "Yes".

Prochaska and Diclemente suggest that behaviour change is a cyclical process. Thus, people move back and forth between the stages, experiencing one or more periods of relapse to earlier stages. In successful behaviour change, individuals relapse but continue to spiral upward over time until they reach the maintenance stage.

Enhancing Progress Through the Five Stages

Certain processes facilitate progress through the various stages of change (Prochaska and Velicer, 1997). Here are some examples:

Consciousness raising involves increased awareness about the issue. Interventions that raise consciousness are most important in the early stages and include education, feedback, interpretation, information and media campaigns.

Social liberation or societal support for a specific behaviour is required throughout all stages. Advocacy and appropriate policies can increase opportunities, especially for people who are disadvantaged.

Dramatic relief or emotional arousal appeals most to contemplators. Role playing, testimonials and media campaigns are examples of techniques that can move people emotionally.

Stimulus control removes cues for unhealthy habits and prompts healthier alternatives. Avoidance, self-help groups and re-engineering are strategies that affect stimulus control. Planning parking lots with a 5-minute walk to the office and putting art displays and good lighting in stairwells are examples of re-engineering that can encourage increased physical activity.

Numerous evaluations in community and worksite settings have shown the usefulness of tailoring interventions to the stage of change that individuals and groups of people are in (Schooler, 1995, Marcus et al, 1992, Marcus et al, 1994).

Implications to Leaders

• Design proactive awareness, marketing and educational information to appeal to the stage of change inactive people are in. For example, preparers are interested in easy options and program lists that will help them move to action; people in relapse need messages that encourage them to start again.

• Divide target audiences into the various stages of change and design interventions that best suit each stage.

In a recent article, Prochaska and Velicer (1997) suggest that to progress from precontemplation to contemplation, the pros (or perceived benefits) of changing must increase. To move from contemplation to action the cons of changing must decrease dramatically in relation to the pros. They also found that it is more effective to use different change processes at different times. In the early stages, people apply cognitive (learning), affective (emotional) and evaluative processes. In later stages, people rely more on commitments, conditioning, environmental controls and social support for progressing toward and staying in maintenance.

• Track the movement of individuals and groups from stage to stage. Program success is determined by the number of people who move to a higher stage of change, not by the number who achieve ultimate behaviour change.

• Use tools to support the various stages of change. For example, promising outcomes have been shown with computer-based individualized, interactive counselling combined with proactive recruitment strategies for people in the early stages of change (Prochaska and Velicer 1997). Awareness materials may be particularly important at the precontemplation and contemplation stages (e.g., posters, payroll stuffers, calendars, community presentations). Educational materials designed for those in the preparation stage might include self-care publications, activity guides and telephone or internet support. The action stage may require formal and self-directed programs, audio tapes and multimedia programs. Maintenance is supported by target newsletters, tele-support, booster classes, payroll stuffers, etc.

• Work with clients and groups to overcome stage-specific barriers to participation.

Stage-Specific Barriers

Research suggests that there are stage-specific barriers to physical activity (CFLRI, 1997b). Here are the major, moderate and minor barriers identified by Canadians in the contemplation and preparation stages.

Major Moderate Minor

Back to Top

2.2 Self-Efficacy Theory

Self-efficacy is the degree to which individuals believe that they can successfully engage in a new behaviour or perform a specific task (Bandura, 1977). This perceived confidence to act is a strong predictor of participation in physical activity among adults (Marcus et al, 1994, McAuley et al, 1994) and children. It remains an important determinant of physical activity, even in the presence of other factors that are known to influence participation, such as gender and activity history (Marcus et al, 1996).

People in the start-up stage of physical activity or those that have dropped out may be particularly receptive to intervention strategies and messages that promote self-efficacy and skill development (Oman and King, 1998).

When it comes to overall recommended activity patterns, three-quarters (75%) of Ontarians are very or moderately confident that they can accumulate an hour of activity a day, or at least 30 minutes of moderate-intensity activity every other day (more so for the first pattern). More men are very confident they can accumulate one hour of light physical activity daily than women and/or that they can do 30 minutes of moderate activity every other day. Younger people (age 18 to 44) are more likely to believe they can accomplish the 30 minutes every other day than people in the older groups (age 45+) (Craig et al, 1999).

Among older adults, 29% say they are "very" or "moderately" confident that they can accumulate 60 minutes of light activity each day; 31% are very or moderately confident that they can be moderately active every other day. Many factors contribute to low feelings of confidence and self-worth in older adults including health problems, social isolation, ageist attitudes, forced retirement and lack of family support for being active (O’Brien-Cousins, 1996)

Unfortunately, the perception remains in general society that vigorous physical activity, particularly in some sports programs, is intended more for boys than girls. This stereotyping of certain activities as more "male" or "female" plays a significant part in the disparities in both the participation rates and the activity choices of boys and girls (CFLRI, 1996b). It may also play a part in girls’ and young women’s lower levels of self-efficacy in physical activity. A recent study found that a much higher percentage of 11-year-old boys (41%) than girls (19%) believe they are among the best in their sports ability (King and Coles, 1992).

Enhancing Self-Efficacy

Perceived self-efficacy can be modified in a number of ways:

Modelling or observation. Watching others perform new behaviours and overcome barriers, either directly or via mass media, builds confidence to attempt new behaviours and teaches people how to perform certain actions (Schooler, 1995).
Tracking progress. Providing people with detailed information and feedback on goal setting and self-monitoring can increase self-efficacy (Dzewaltowski, 1994).
Performance accomplishments. Providing adequate training and reinforcement of basic, activity-specific skills allows people to successfully perform an activity, which in turn, builds their confidence (Bandura, 1977).
Constructive feedback. Providing constructive feedback, opportunities for guided practice and positive reinforcement supports peoples’ efforts to learn and perform skills and behaviours on their own, with decreasing reliance on the leader over time (Bandura, 1977). Praise and encouragement from significant others may be especially important for children—not for winning, but for practicing hard to improve, and for successful performances of individual and team skills.
Adequate, safe equipment. Making sure that people have the right clothes and equipment to succeed is important, especially for those who may fear injury as a result of participation.

Implications for Leaders

• Help people identify the overall pattern of participation they are most able to adhere to, and then strive to achieve and maintain that pattern over time (CFLRI, 1997d).
• Frame messages and interventions about activity patterns differently for different age groups, e.g., people in midlife and older are more likely to feel confident they can accumulate 60 minutes of light activity a day than do moderate-level activity for 30 minutes every second day (CFLRI, 1997a).
• Identify the specific skills people need to make a change in their physical activity levels, then teach those skills (e.g., how to start a walking or jogging program, how to take golf or tennis lessons, techniques for warming up, how to exercise while sitting in a chair).
• Work with other professionals (e.g., physical therapists, exercise physiologists) to design appropriate, high-quality instruction programs for specific groups.
• Make self-instruction materials (e.g., videos or kits) available.
• Distribute community resource lists so people can find skill-development courses.
• Reach out. Provide instruction in small community settings and homes, not just at central facilities.
• Sponsor demonstrations and events where people can see a variety of activities and try them out with guided instruction from experts and coaches.
• Reward effort, praise success and provide constructive feedback. Stress the value of progressing in small steps.
• Encourage people to do more of the activities they already feel confident they can do (e.g., walking, gardening, cycling, social dancing).
• Provide goal-setting and self-monitoring tools and help people use them.

Back to Top

2.3 The Decisional Balance Model

Decisional balance involves a comparison of the perceived benefits and costs of participation in physical activity (Marcus et al, 1992). Individuals who see more benefits or value the benefits of activity above the costs are more likely to participate.

Enhancing Positive Decisions

The use of a decisional balance sheet, in which an individual writes down the anticipated benefits and costs of participation can promote increased awareness of the pros and cons (Wankell, 1984). Leaders can then discuss the results and ways to avoid or cope with the negative consequences.

The vast majority of Canadians (85%) value physical activity: 42% rate it very important to them personally and another 41% rate it as quite important. Thirty-three percent of adults believe physical activity is very important to their family life (especially women); 25% believe it is very important to their social life and 18% believe it is very important to feeling part of the community. Valuing the contribution of physical activity to family, social and community life increases markedly with age (Craig et al, 1999).

Almost three quarters of Canadians agree very strongly with the preventive role of physical activity in reducing the risk of heart disease. A majority also agree that physical activity produces benefits such as a healthy weight, stress management, increased energy, relaxation and improved functional ability. At the same time, many Canadians believe that participation leads to injuries (56%), ongoing pain and stiffness (42%) and to being too muscular (27%) (Craig et al, 1999).

Seventy-seven per cent of older adults say that physical activity is moderately or strongly important to them personally and 80% strongly agree that physical activity is important to their health (CFLRI 1998b). While these percentages seem high, they are lower than younger age groups. This may reflect shifting values with age. Since many older Ontarians have chronic health problems, they may come to value physical activity less and treatment activities more.

Older adults are the most likely of any age group to believe that physical activity leads to pain (55%) and to being too muscular (39%). They are far less likely than younger adults to strongly agree that physical activity prevents heart disease, helps people feel energized, helps maintain a healthy weight, helps people relax and cope with stress, maintains the ability to do everyday tasks, and prevents other diseases such as adult-onset diabetes and osteoporosis (CFLRI, 1998c).

The exercise content may be less important than a positive exercise experience in motivating some older adults to maintain exercise. Barriers that are especially influential for this age group include transportation problems, medical concerns (including fear of injury), physician advice to exercise, attitudinal barriers (including perceived lack of ability) and erroneous beliefs about physical activity. Older women cite enjoyment, mental health improvement and physical enhancement as top benefits of physical activity, and inconvenient locations, safety, social embarrassment, and perceived unpleasantness of physical exertion as major barriers to physical activity.

For people with disabilities and functional limitations (the inability to carry out normal daily tasks and roles), physical effort greater than that to which an individual is accustomed can lead to small increases in stamina, strength and flexibility. These changes, in turn, can lead to large improvements in quality of life. For example, simple daily stretching exercises increase joint lubrication. This makes movement less painful for persons with arthritis and helps prevent the worsening of degenerative joint disease (Heath and Fentem, 1997) (CFLRI, 1998a).

Beyond physical improvements, physical activity offers challenge and rewards that build self-confidence, self-control, self-esteem and social skills. This is important at all ages, but especially for children and young people with physical and/or mental disabilities.

A significant amount of research has been done on how children view the benefits of sport. In a recent international study 81% of Canadian boys and 83% of girls age 11 said that having fun was the most important reason for doing a sporting activity (King and Coles, 1992).

 

Implications for Leaders

• Reinforce positive attitudes toward physical activity that people already have and address the concerns of people who hold negative beliefs. For example, inform older people that research on arthritis suggests that safe, appropriate exercise helps reduce joint pain and stiffness and that not exercising aggravates it (O’Brien Cousins, 1998).

• Use a decisional balance sheet to help guide discussions and the pros and cons of being active.

• Make fun and friendships the obvious benefits of programs, especially for children and youth.

• Provide information on the benefits of physical activity in a variety of formats. Emphasize both the short- and long-term benefits. Debunk myths, fallacies and misconceptions.

• Link your messages and programs to prevailing attitudes and values of specific groups. For example, if your target audience values the family benefits of physical activity, stress these benefits in your messages and structure programs so that they reinforce this benefit.

• If you are unsure of a specific group’s beliefs and values, ask them!

• Reiterate that it is never too late to experience the benefits of physical activity and that becoming active is safe for most people.

• Show people how to be active safely. This may be particularly important for young people who are the most likely to believe that participation leads to injuries and are also the most likely to engage in high-risk and vigorous activities (Craig et al, 1999).

 Back to Top

2.4 Social Support Theory

A number of studies document the value of social support in implementing and maintaining behaviour change (Schooler, 1995). Socially supportive relationships provide some form of assistance, such as tangible aid, timely and appropriate information, feedback, advice or genuine expressions of openness, trust and caring. Unsupportive relationships are characterized by distrust, ridicule, criticism, domination and harassment (Heaney and Israel, 1997).

Social support is most successfully shared among people who have common life experiences, have coped with similar stressors and who tend to have similar attributes, such as beliefs and educational levels. Who provides support is often more important than what help is given. For example, parents are the most important supporters of children, whereas in adolescence, peers become equally or more important. At the same time, participating in active leisure activities has been shown to help people develop friendships and provide effective relief for people dealing with excess stressors (Coleman et al, 1991).

Children and youth are less likely than adults to participate in physical activity on their own; only two in ten children are active without partners (CFLRI, 1996c). Younger children (up to age 12) site family members as their most common activity partners, and active parents have more active preschoolers, preadolescents and adolescents. However, a change occurs in the teen years when classmates and friends become the partners of choice (Klesges et al., 1990). And while children are more likely to participate in physical recreation and sport activities when their best friends are also involved, role models for youth may come more from peers and the media (Hansell & Mechanic, 1990). Excessive peer influence, however, is associated with among other things, inadequate exercise (Conger, 1991).

Adults aged 65-plus are the most likely of all age groups to participate in physical activity alone (45%). Among those who participate with others, older women are more likely to be active with friends. Older men are more likely to be active with family members. Many older adults (especially women) who are always active alone, only participate in the home setting. They are also the most likely to be inactive (CFLRI, 1996a).

Enhancing Social Support

Interventions that target existing social networks or help create new ones can positively influence the adoption of physical activity (CFLRI, 1996d).

• An intervention conducted by Foster and colleagues in 1985 with adolescents demonstrated the usefulness of peer support in promoting exercise. That program included counselling and social support from slightly older, well-liked peers. At the end of the 12-week program, fewer participants were inactive and overweight than a control group at another school.

• Peer support works for other age groups as well. An intervention reported by Haber and colleagues in 1993 showed that older men and women who had peer and physician support were more likely to adopt an exercise routine.

• Providing participants with relationship-building skills can help them obtain the social support they need to stay physically active. Team-building programs have also been shown to enhance attendance and reduce drop-out rates in exercise classes.

• Studies have shown that the activity behaviours of adolescents tends to correlate with that of their parents. In the reverse, children can influence the activity behaviours of parents and siblings. Spouses can also have a strong influence by providing (or withdrawing) social support for physical activity.

• Involving parents enhances the effectiveness of behaviour change interventions targeting children and youth. Family-based interventions have also been effective with adults.

Implications For Leaders

Leaders can promote social support and supportive networks for physical activity behaviour:

• Introduce people to each other, use people’s names and encourage the development of friendships.
• Provide help with relationship-building skills.
• Include activities that can be easily incorporated into family interactions, such as activities that can be enjoyed by children and adults together.
• Encourage people to find support for their decision to be physically active from coworkers, friends, partners, etc.
• Set up teams, buddy systems or adopt-an-exercise-partner activities. Hold team events and playful competitions between groups.
• Involve parents, spouses and significant others when possible and appropriate.
• Set up telephone hot lines and help lines with people similar to the target audience.
• Form and support local walking and sports clubs.
• Conduct family and peer-oriented events, programs and classes.
• Group people who have similar concerns, abilities and risk factors for chronic diseases.
• Coordinate self-help and support groups and interactive computer technologies, such as list serves and chat groups.
• Identify natural leaders and role models in specific groups and groom them as "champions" of physical activity.
• Provide network members who take on specialized roles with appropriate rewards and recognition.
• Lessen the frequency and intensity of negative social interactions (e.g., help a disruptive child gain confidence and learn to be a team player).

Back to Top

2.5 Putting It All Together

Most experts suggest using an integration of the various theoretical approaches for promoting physical activity (Epstein, 1998). Because of the complexity of behaviour change in both individual and group settings, no one theory has all the answers or solutions. At the same time, it is clear that all of the four theories discussed here overlap in real life situations. Decision-making and self-efficacy tend to change and progress with successive levels of behavioural change. And the power of social support is that it can help move people through the various stages or derail them. Therefore, leaders need a tool bag of proven strategies and interventions based on all of these theories combined.

 

Essentials For Behaviour Change Among Inactive Populations

Leading behavioral scientists suggest the following are essential for behaviour change among inactive populations (Fishbein et al, 1992).

1. They must believe that the advantages (i.e., the benefits, positive anticipated outcomes or expectations) of performing the behaviour outweigh the disadvantages (i.e, the costs, negative anticipated outcomes or expectations).

2. Their emotional reaction to performing the behaviour must be more positive than negative.

3. Performing the behaviour must be consistent with their self-image; performance does not violate personal standards or values that might activate negative self-sanctions (i.e., guilt, self-reprimand).

* 4. They must have revealed a strong commitment to perform the behaviour, or have formed a strong positive intention to do it.

* 5. They must possess or demonstrate the skills necessary to perform the behaviour.

6. Their self-efficacy to perform the desired behaviour must be high; they must believe they are capable of performing the behaviour under a number of different circumstances.

7. They must perceive more social pressure to perform the behaviour than not to perform it.

* 8. The environment must be free of constraints that would make it impossible or difficult for the behaviour to occur; the environment should provide opportunities to perform the desired behaviour.

* Participants in a consensus workshop viewed three of these factors—numbers 4, 5 and 8—as necessary and sufficient for a behaviour to occur. The remaining five variables were viewed as important influences on the strength and direction of a person’s intention to perform any specified behaviour (Fishbein 1995).

 

Implications For Leaders

Recipe for an Effective, Tailored Intervention

Ingredients

• Awareness
• Knowledge
• Motivation
• Readiness to change
• A strong personal commitment or intention to perform the desired behaviour
• The skills needed to establish and maintain the desired change
• Strong self-efficacy specific to the desired behaviour
• Opportunities to practice skills and new behaviours in a safe environment
• Strong social support
• A supportive environment free of any constraints to change.

Source: Promoting Physical Activity: A Guide for Community Action
(U.S. Department of Health and Human Services, 1999)

Interventions with Children and Youth

There is a lack of relevant, up-to-date evaluations of behavioural theory-based interventions in physical activity, sport and recreation programs and services for children and youth. However, successful interventions (mostly aimed at youth-at-risk and their families) suggest the following guidelines:

Interventions With Older Adults

A review of the literature on interventions to promote physical activity among older adults (age 50 plus) highlighted the following key elements of successful interventions (King, Rejeski and Buchner, 1998).

• Relatively few printed materials and programs aimed at older adults explicitly include the types of individual and social strategies that have been shown to be effective in promoting behaviour change. One exception in the U.S. is a recent effort to disseminate information and build skills (through printed materials and training seminars) on strength-training developed at Tufts University.

• The vast majority of studies have not looked at differences by gender and among important subgroups of older adults, including low income and minority groups, the oldest old (80 plus) and older adults with significant chronic conditions or disabilities. The exceptions to the last point include two well-designed trials focussed on exercise interventions for arthritis sufferers and cardiac populations.

• Programs using a supervised home-based format or a combination of group- and home-based formats report comparable or better adherence than structured class formats.

• Ongoing telephone supervision of a physical activity program is an effective alternative to face-to-face, on-site instruction. Most programs use a 20 to 40 minute initial face-to-face instruction session in combination with 12 to 15 telephone contacts of about 10 minutes over the course of a year. After that, calls promoting maintenance can be spaced at greater intervals. One study showed that this approach may be particularly effective with less-educated older adults with low fitness levels (i.e., the inactive contemplators).

These findings suggest several implications for leaders:

• Know your audience. Assess needs, preferences, attitudes, beliefs and stage of change for specific sub-populations of older adults before implementing programs or designing resources.

• Implement or expand home-based programs, including telephone-supervised programs for inactive adults in the community.

• As inactive older adults begin to exercise at home, consider networking services and partner programming to increase adherence. Encourage isolated seniors to join group programs such as mall walking, water aerobics and social dancing.

 

Implications of Studies of Interventions With Under-Serviced Populations

Low-income, racial and ethnic minorities, and populations with disabilities are more likely to be sedentary than the general population. Increasing physical activity levels among these groups hold particular promise for improving quality of life. This is an important challenge for recreation, sport and fitness leaders, as well as for public health practitioners and educators.

A thorough investigation of interventions for these population groups (Taylor, Baranowski and Rohm Young, 1998) identified only 14 well-constructed studies. While stressing the need for further theory-based research with these groups, the authors stressed two key factors that were associated with successful interventions:

Meaningful participation of the community. This means that the program’s priorities, content and implementation are developed by a coalition of interested community organizations and individuals, particularly those in the targeted group.

Thorough assessment of needs, attitudes and unique barriers prior to implementation of the intervention. This assessment can be conducted through surveys, focus groups, town-hall meetings and individual interviews. As a result, barriers such as transportation, cost, motivation or child-care issues can be minimized or prevented.

It is beyond the scope of this paper to examine the specific literature for each of these groups. These should be subjects for future research. Many of the guidelines suggested in this paper apply to these population groups. At the same time, community recreation, sport and fitness must make a special effort to understand these groups and involve them in program, policy and resource development.

We also need to recognize and respect the diversity within each of these groups (for example the diverse characteristics of Aboriginal communities and groups). Identifying subgroups in the community that are homogeneous in terms of readiness for change and related beliefs and practices is helpful (Baranowski, Anderson and Carmack, 1998).

Back to Top

3. Implementation Strategies

Effective interventions are based on evidence related to behaviour change theories. But they also depend on effective implementation. This section discusses three key implementation strategies: understanding your audience, building a supportive environment and the use of multi-level community-based approaches as well as individualized ones.

 Back to Top

3.1 Understand Your Audience

Understanding your audience is a basic tenet of effective marketing and successful intervention planning. Messages, products and services that are sensitive and appropriate to specific target groups are more informative, persuasive and effective (Lefebvre and Flora, 1988).

Segment Your Audience

Segmenting your target audience increases the likelihood that the audience you want to reach (i.e., the inactive) are most likely to hear and respond. Without segmentation and directly listening to your audience, leaders run the risk of

• offering programs that only benefit and appeal to those who are already active
• offering "one size fits all" programs that are rarely effective or justifiable (Sutton et al, 1995).

A number of variables are used to segment groups and develop audience profiles, including:

1. demographics (e.g., gender, age, ethnicity, income, education, etc.)
2. geography (region or area they live in
3. physical characteristics (e.g., physical condition, risk factors for disease, physical challenges)
4. behavioural characteristics (e.g., what they enjoy doing, media habits, places they frequent, etc.)
5. psychographic characteristics (e.g., descriptions of beliefs, opinions, preferences, feelings of self-efficacy, readiness to change, perceived barriers to participation, etc.).

Contemplators and People in the Preparation Stage

The Stages of Change Model (see page 4) suggests that individuals move through five stages of change when adopting or reinstituting a new behaviour. In attempting to encourage inactive Ontarians to become active, community sport, recreation and fitness leaders are most likely to be dealing with people in the contemplation and preparation stages (stages 2 and 3). A sizable portion of the population is also in relapse (CFLRI, 1996). In an Alberta study, the majority of people in relapse were contemplating a return to regular physical activity (Mummery and Spence, 1998).

People in the contemplation stage are thinking about becoming active in the next six months, but are not yet committed to taking action.

• They may still feel ambivalent about getting active.
• They may be stuck in the decisional balance dilemma. The perceived barriers may still outweigh the perceived benefits, or perhaps the reasons not to change still outweigh the reasons to change.
• A certain barrier, such as finding the time to exercise, may still seem too difficult to overcome.

People in the preparation stage are ready to begin participating or may currently be active, but not regularly.

• They may make short-termed attempts or exercise sporadically (e.g., they joined an aerobics class but attend only occasionally or drop out after three weeks).
• They know what they need to do and may have an action plan, yet they may still be uncertain about the outcomes of that plan.
• They may show small signs of progress, e.g., they have experienced mixed or inconsistent results after starting a home exercise program.

A fairly extensive focus group study (U.S. Centre for Disease Control and Prevention, Nutrition and Physical Activity Communication Team, 1995) with American adults aged 29 to 54 who were either in the contemplation or preparation stages of healthy eating and regular physical activity revealed five overarching themes:

• Family is a priority and setting a good example for children and grandchildren is a key motivator.
• Life is busy and stressful (lack of time is a key barrier).
• Children’s ages, more than the ages of participants themselves, influence behaviour and lifestyle choices.
• Being "healthy" was associated with spiritual, mental and emotional well-being, not just physical health.
• Health is valued for enabling one to meet daily responsibilities and enjoy life’s pleasures.

Key findings related to physical activity included the following:

• Connotations of "physical activity" and "exercise" differed substantially. Exercise (e.g., jogging, weight lifting, step aerobics) was considered an unpleasant, scheduled, repetitive chore. Physical activity was seen as a range of enjoyable activities (e.g., walking, dancing, yard work). Health benefits, however, were more clearly associated with exercise.
• Participants questioned whether moderate activity would sufficiently raise one’s heart rate to result in health benefits.
• Women particularly valued the social benefits of physical activity. Some expressed a concern about the safety of walking or running alone. They frequently mentioned feeling guilty about taking time away from their families to participate in physical activity.
• Participants felt barraged with and wary of ever-changing health-related information, particularly when messages were contradictory. They disliked messages that tell people what to do in a commanding tone.

Another focus group conducted with inactive adults in Saskatoon (Anderson/Fast and Associates, 1999) found the following :

• Men (especially younger men) are more likely than women to associate physical activity with sports and structured activities. As they become older they find it increasingly difficult to find activities they are interested in that match their skill levels.
• Women between the ages of 20 to 39 typically experience a major life transition (see next section) when they begin new jobs and new families. This means they have less time to participate in physical activity and often, they do not view participation as a priority compared to family responsibilities. Other barriers for women were financial cost, not having someone to participate with, and a lack of self-confidence.
• Both men and women wanted specific information on program availability directed separately to women and men.

Developmental Stages and Life Transitions

Numerous researchers have emphasized the life span or life stages approach to understanding leisure behaviour. According to this approach, people seek both stability and change, structure and variety, and familiarity and novelty in their leisure pursuits throughout the various stages of the lifecycle (Iso-Ahola, Jackson and Dunn, 1994).

Levinson’s model (1978) is often used to describe the "four seasons" of life: childhood and adolescence (up to 23 years of age), early adulthood (24 to 43), middle adulthood (44 to 63) and late adulthood (64 and older). More recently, researchers and advocates for healthy child development have identified four key transitions for children and youth: transition to the first year of life, transition to school, transition to adolescence, and transition to adulthood. (Ontario Premier’s Council on Health, Well-Being and Social Justice, 1994.)

Understanding the developmental tasks at each transition can help leaders design activities that facilitate optimal development. For example, exposing preschoolers to active play with other children can assist in the healthy development of needed physical, social and emotional control skills and capacities.

It also helps to understand that each life stage usually begins with a transitional period of turbulence, when people question their existing lifestyles and experience. Transition periods are often accompanied by major life changes such as entering school, leaving school for work, getting married, becoming parents, menopause, becoming ill and retirement (Mergenhagen, 1995). These transition periods may be ideal times to invite people to include active pursuits in their leisure time as a positive way of addressing the stresses of change.

A large Alberta survey (Iso-Ahola, Jackson and Dunn, 1994) looked at the starting, ceasing and replacement rates for a number of leisure activities. The number of people "starting" new activities was highest in the first season of the life span, declined markedly in early- and middle adulthood, then levelled off in older adulthood. The number of people "ceasing" activities declined across the life span. In the first life stage, both boys and girls were highly likely to "replace" dropped activities with new ones. In the second stage, women’s replacement rates were positive, while men’s were negative. In the third stage, the replacement rate was negative for both males and females, but especially for men. In the fourth, men’s rates rebounded to the positive side, while females’ rates continued to decline.

In terms of active leisure:

• Exercise-oriented activities were the most frequently started type of activity in all four life stages and ranked third in replacement rates. However, participation in exercise-oriented activities declined from 54% in the first stage to 33% in the fourth stage.
• Outdoor recreation activities were more frequently started by people in the second and third stages, especially by men on the third stage. They ranked fourth in replacement rates.
• The proportion of people taking up team sports decreased with age (17% in the first stage and 4% in the last stage).
• Participation in hobbies and home-based recreation activities increased dramatically with each life stage and had the lowest cessation rates.

Implications For Leaders

• The tendency to maintain stability through familiar leisure activities increases with each life stage. This points to the need to teach basic activity skills and familiarize children and young adults with "lifetime" activities such as individual sports (e.g., tennis) and outdoor activities (e.g., cross-country skiing). For most people, it is easier to continue or return to activities they are familiar with and feel confident that they can do.
One exception to this appears to be men’s enthusiasm for taking up outdoor activities in the third stage of life. Thus, men who are winding down in their careers may be particularly open to learning new activities such as windsurfing, skiing and curling.

• The decrease in participation in team sports and increase in participation in home-based activities with each successive life stage suggests the need to provide advice and offer skill-building programs to middle-aged and older adults in activities such as home exercise, individual sports and gardening.

• While the replacement rate for men rebounded in the fourth stage, for women it declined linearly over the life span groups. This may reflect the fact that for women, family and work demands do not change much from one stage to another and may even increase over the life span (for example most women in midlife and later life switch from caring for children to caring for parents or an ailing spouse). It may also reflect women’s high burden of chronic health problems such as arthritis and osteoporosis as they age. Whatever the reason, special efforts to re-introduce active leisure choices may be required for women.

Back to Top 

3.2 Build Supportive Environments

Physical and social environments can encourage or discourage physical activity. Some of the most effective interventions include efforts in re-engineering the physical environment, and implementing policies that remove social and personal barriers to participation.

Physical and Socioeconomic Environments

When Canadians were asked about publically provided resources they needed to be active (Craig et al, 1999), the top three were: access to safe streets and safe public places (seen as particularly important in Ontario), access to affordable facilities and programs, and access to paths, trails and green spaces.

According to the 1997 Physical Activity Monitor (Craig et al, 1999), two-thirds of Canadian children and youth do not meet the current activity guideline for optimal growth and development. The 1995 Physical Activity Monitor reported that girls were less physically active (77%) than boys (57%).

Affordability may be especially critical for children, youth and young families. Children from economically disadvantaged families have much lower participation rates (Offord and Jones, 1983; Offord et al., 1992). Certain factors, such as strengths in families and communities, access to good parks, and living in a civic neighbourhood can mute the effects of low income; however, they cannot eliminate them (Offord et al., 1998)). According to the Canadian Council on Social Development, 1997), nearly half of families with incomes below $20,000 a year cite high costs as a reason for not participating, as compared with one-third of families with an income of $60,000 or more. They also cited lack of safe places (30%) and insufficient programs (24%) more often than their wealthier counterparts.

Two-thirds of children from the most well-off families participate in team sports compared to less than half of low-income children (Torrance, 1998). This may be due to the cost of equipment and instruction classes. Transportation, in part because of its cost, can also be a hindrance to participation.

Racial discrimination for Aboriginal and other minority children and youth can be a barrier to their participation and many believe that most programs are designed for the needs and values of the middle class (Interprovincial Sport and Recreation Council, 1998).

According to the 1995 Physical Activity Monitor, 76% of older adults are inactive. People over 65 are also the most likely to experience chronic disease and disability.

Despite the fact that one in five older Canadians—especially women who are alone— live in low-income situations, they are the least likely of all age groups to rate affordable facilities, services and programs, and access to paths, trails and green spaces as "highly important" supports for participation. This may reflect the tendency of the majority of older adults to prefer activity at home instead of in community classes and facilities, and the reduced fees or free services offered to older adults in most communities (CFLRI Progress in Prevention, 1996c).

Ways to Build Supportive Environments

James Sallis and colleagues (1998) and William Russell (1999) found that physical activity is enhanced by:

• access to park and recreation land for safe unstructured activities such as walking and cycling
• providing safe, well-maintained walking and cycling paths for commuting
• creating aesthetically pleasing parks and tree-lined paths
• providing more play spaces for children near their homes
• encouraging children to go outside more
• providing more convenient exercise facilities near people’s homes
• providing appropriately designed and staffed programs: barriers to health club use included the perception that staff were too young and too thin, and therefore, the facility was only for very fit people
• returning monetary deposits to people who attend a program regularly
• using point of decision prompts to increase the attractiveness of the active alternative (for example, posting signs promoting the use of the stairs at the choice point between the stairs and the elevator in workplace settings immediately doubled the use of the stairs) (Russell et al., 1999)
• designing neighbourhoods with shops, schools and people within walking distance
• providing mass transit within walking distance.

Policy Support

Research (Schooler, 1995) has shown that other public policies which increase participation in physical activity include:

• increasing the safety and convenience of facilities such as skating rinks, public swimming pools, public tracks and par courses (especially for young people)
• providing police protection where necessary to ensure that people can be active in safe outdoor environments, and changing liability legislation to increase safety
• altering zoning to encourage the use of stairs, and walking and cycling as modes of commuting
• offering tax breaks for companies that provide incentives (such as time or facilities) for exercise, and lockers and showers for employees who actively commute.

Offord and Jones (1983) and others have shown that providing free activities led by qualified coaches and instructors in low-income areas enhances the participation and performances of the children and youth who live there, and helps to reduce crime in the area.

Reciprocal agreements regarding free school use of community facilities during the day and free community use of school facilities after school hours is an important example of a partnership policy that can enhance opportunities for physical activity.

Back to Top 

3.3 Use A Multi-Level, Community-Based Approach as Well as Individualized Ones

Ultimately, behaviour change happens at the individual level. But more often than not, the largest effects are shown with delivery to groups in community settings (Dishman and Buckworth 1996).

Community-based interventions need to take into account the infrastructure and social structures around individuals that greatly affect both collective and individual change.

Health promotion research supports five levels of social structure. Change interventions are more successful when each level is supportive of the change (Gottlieb and Mcleroy, 1994).

1. Individual level: the person undergoing the change process.
2. Network level: informal groups and individuals who influence the individual (e.g., friends, peer groups, family members, leaders at work and community champions).
3. Organizational level: organizations, institutions and associations such as schools, workplaces, hospitals, places of worship and provincial organizations.
4. Community level: entities that cross organizational lines such as coalitions, interagency task forces, school districts, the combined business community and locally-elected officials.
5. Societal level: entities that affect society at large, such as public opinion, the media, political parties and legislative bodies.

Evidence suggests that the most effective and comprehensive interventions occur when individual and environmental strategies are directed at several levels of the societal structure simultaneously (Gottlieb and Mcleroy, 1994). For example, a comprehensive effort to move an inactive population to the action and maintenance stages would:

• enhance individual readiness for change and foster self-efficacy
• create or enhance social support in informal networks
• address organizational structures, policies and values by encouraging workplaces, schools and places of worship to encourage and provide increased opportunities for physical activity
• address the policies and influence of community level entities, form coalitions for physical activity, approach business coalitions, etc
• address societal level influence by getting increased media coverage or advocating legal or monetary incentives for physical activity.

Back to Top

3.4 Work With Partners

Partnerships are formed when groups or sectors work with others to accomplish greater things together than any individual group could have done alone. Partnerships provide synergy, increase access to knowledge and resources (financial and human), reduce duplication, reach more people and help achieve a bigger impact (U.S. Department of Human Services, 1999). There are many potential partners for promoting physical activity, both within and outside the recreation, sport and fitness sectors. These include, among others, schools and the education sector, health, transportation, crime prevention, voluntary and business sectors, the media, faith communities, libraries, public housing and healthy cities coalitions.

Partnerships between schools and communities are particularly important for introducing children to physical activity and providing them with opportunities to master skills and to learn to value active living. The Healthy Active Schools initiative suggests that connections between schools and key community groups and services are essential for promoting health and physical activity (CAHPERD, 1999).

Back to Top

4. Maximizing Participation

The use of well-planned and executed interventions and implementation strategies have the potential to improve physical activity participation rates by 20 to 35% (Dishman and Buckworth, 1996). At the same time, the quality of programs and of leadership development can greatly influence participation.

Back to Top

4.1 Program Considerations

Here are some recent findings related to program considerations.
In The Art of Health Promotion, Chapman (1998) suggests the need to:

• position your program to the best advantage to your target audience ("this program is valuable to you because....")
• use surveys, focus groups and interventions to form clusters of people by interests and readiness to change
• improve program design: remove barriers, increase access
• stress enjoyment and fun
• enhance supervisor and management support through informal and formal involvement, reporting and evaluation
• use proactive recruitment strategies (e.g., by telephone or Internet).

Dunn and colleagues (1997) carried out a review of lifestyle versus structured physical activity interventions. Participants in the Structured Group were offered individualized, supervised sessions five days a week and encouraged to be more self-directed over time. Participants in the Lifestyle Group were asked to strive for 30 minutes or more of moderate-level activity most days of the week. They were advised how to do this at small group meetings held once a week for the first 16 weeks and once every two weeks thereafter (there was no structured exercise at the meetings). The stages of change model was used to suggest strategies for achieving the goal.

After six months, 78% of the Lifestyle Group and 85% of the Structured Group were meeting or exceeding the goal. For the Lifestyle Group, the most important strategies were substituting active alternatives for sedentary habits, enlisting support, rewarding themselves and making a commitment through goal setting.

Thus, success can be achieved with large population groups through interventions other than face-to-face, structured programs. This approach may be best suited to people who have difficulty finding the time for structured exercise, those who prefer to exercise at home and those who lack access to a facility or program, because of location or finances.

In a review of program characteristics in fitness classes, Barry Franklin, (1988) identified the negative and positive variables that most influence exercise adherence.

Negative variables

Positive variables

(leading to poor adherence)
(leading to good adherence)
inadequate leadership
enthusiastic, encouraging leader
inconvenient times
regular, convenient times
musculoskeletal problems
free of injury
exercise boredom
fun, variety, enjoyment
individual commitment
group camaraderie
lack of awareness of progress
progress monitoring and recording
spouse and peer disapproval

spouse and peer approval

 

Back to Top

4.2 Considerations For Resource Development

While it is outside the realm of this paper to review the literature related to effective resource development, the author’s experience suggests that effective resources and training courses for leaders are:

• expressed in clear language (written or verbal)
• combine a variety of techniques (visual, oral and hands-on) and approaches (individual study, group work, partnered observation, etc.)
• clearly describe the theory and evidence behind successful interventions, while stressing the practical application of the findings
• build team spirit and peer support for innovation
• build supervisor and management support for new approaches.

Based on this paper, helpful resources could include:

• a handbook and training on behaviour change theories and the implications to practice
• tools to assess readiness (stages) for change, self-efficacy, decisional balance and social support
• tools to assist with implementing the processes of change, e,g., goal setting sheets, sample contracts, a tool to help participants list and discuss the pros and cons of being active
• instruction and practice in segmenting target groups and developing audience profiles
• instruction and practice in clear language
• instruction and practice in community and media advocacy for environmental change
• instruction and practice in building social support, peer-assisted learning and nurturing community champions for active recreation, sport and fitness
• how-to manuals for implementing innovative, multi-level, community-based interventions for various audiences
• instruction and practice for evaluating programs based on stages of change• lists of and access to samples of evidence-based resources and program descriptions that have already been developed
• Internet-based ongoing education and information
• the creation of a network of leaders who are implementing innovative and evidence-based approaches to increasing participation (especially among the inactive) in recreation, sport and fitness
• instruction and practice in building and sustaining partnerships and coalitions for physical activity.

Back to Top

Conclusion

Most current programs in recreation, sport and fitness are directed at those who are already active. It is therefore essential to reach out to the inactive who represent the majority of Ontarians. Research evidence suggests that successful efforts to stimulate and sustain behaviour change make use of the following strategies:

• They meet the needs of individuals at each of five stages of change (described in this paper) and involve the target audience.
• They employ proactive recruitment and stage-matched interventions
• They use multiple channels and levels to reach people.
• They enhance self-efficacy.
• They help "tip" an individual’s decision-making balance scale in favour of being active.
• They provide social support for participation.
• They remove barriers and provide a supportive environment for participation.
• They stress fun and enjoyment.
• They stress small, every day active living choices.

By understanding our clients and building on the evidence for successful interventions presented in this paper, recreation, fitness and sport leaders can help more Ontarians become and stay active.

Back to Top

References

Altman, D. G., Feighery, E., Robinson, T.N., et al. (1998). "Psychosocial Factors Associated With Youth Involvement in Community Activities Promoting Heart Health." Health Education & Behaviour.

Anderson/Fast and Associates. (1999). Saskatoon Leisure Services Physically Inactive Adults Focus Group Results. A report prepared for Saskatoon Leisure Services.

Bandura, A. (1977). Self-Efficacy: The Exercise of Control. W.H. Freeman and Company.

Baranowski, T., Anderson, C. and Carmack, C. (1998). "Mediating Variable Framework in Physical Activity Interventions." American Journal of Preventive Medicine, 15(4): 266-297.

Brawley, L. (1993). "Social-Psychological Aspects of Fitness Promotion." In Exercise Psychology: The Influence of Physical Exercise on Psychological Processes, P. Seraganian (Ed). New York: John Willy & Sons, 254-298.

CAHPERD (1999). "Special Issue: Healthy, Active Schools", CAHPERD Journal, 65(1).

Canadian Council on Social Development (CCSD) (1997)."Community Resources" The Progress of Canada’s Children ‘97. Ottawa: CCSD.

Canadian Fitness and Lifestyle Research Institute (CFLRI) (1996). "Stages of Change in Physical Activity." Progress in Prevention, No. 5.

CFLRI (1996a). "Leisure Pursuits of Canadians." Progress in Prevention, No 7.

CFLRI (1996b). "Physical Activity in Children." Progress in Prevention, No 8.

CFLRI (1996c). "Partners for Physical Activity." Progress in Prevention, No 11.

CFLRI (1996d). "Increasing Social Support for Physical Activity." The Research File, No. 96-01.

CFLRI (1997a). "Self-Efficacy." Progress in Prevention, No 24.

CFLRI. (1997b). Physical Activity Monitor, 1995.

CFLRI (1998a). "Physical Activity and Disabilities." The Research File, No. 98-12.

CFLRI (1998b). "Valuing Physical Activity". Progress in Prevention, No 25.

CFLRI (1998c). "Negative Beliefs." Progress in Prevention, No 27.

CFLRI (1998d). "Meeting Guidelines." Progress in Prevention, No 31.

CFLRI (1999-2). "Interventions for Older Adults." The Research File, No. 99-03.

Chapman, L. (1998) "Maximizing Program Participation." The Art of Health Promotion, 2(2), May-June.

Coleman, D. and Iso-Ahola, S. (1993). "Leisure and Health: The Role of Social Support and Self-Determination." Journal of Leisure Research, 25(2): 111-128.

Conger, J.J. (1991). Adolescence and Youth: Psychological Development in a Changing World, 4th Edition. New York: Harper Collins.

Craig, C.L., Russell, S.J., Cameron, C. and Beaulieu, A. (1999). Foundation for Joint Action: Reducing Physical Inactivity (1997 Physical Activity Monitor). Ottawa: Canadian Fitness and Lifestyle Research Institute.

Dishman, R.K. and Buckworth, J. (1996). "Increasing Physical Activity: A Quantitative Synthesis." Medicine and Science in Sports and Exercise, March: 706-719.

Dunn, A.L., Anderson, R.E. and Jakicic, J. (1998). "Lifestyle Physical Activity Interventions: History, Short- and Long-Term Effects and Recommendations." American Journal of Preventive Medicine, 15(4): 398-412.

Dzewaltowski, D.A. (1994). "Physical Activity Determinants: A Social Cognitive Approach." Medicine Science and Sports Exercise, 26: 1395-99.

Epstein, L. (1998). "Integrating Theoretical Approaches to Promote Physical Activity." American Journal of Preventive Medicine, 15(4): 257-265.

Fishbein, M., Bandura, A., Triandis, H.C., et al. (1992). Factors Influencing Behaviour and Behaviour Change: Final Report—Theorist’s Workshop. Rockville, MD: National Institute of Mental Health.

Fishbein, M. (1995). "Developing Effective Behaviour Change Interventions: Some Lessons Learned from Behavioural Research." In Reviewing the Behavioural Science Knowledge Base in Technology Transfer. T. E. Becker, S. L. David and G. Soucy (Eds). Rockville, MD: National Institute of Mental Health, 246-261.

Franklin, B. (1988). "Program Factors That Influence Exercise Adherence: Practical Adherence Skills For the Clinical Staff" in Exercise Adherence: Its Impact on Public Health, R. Dishman (Ed). Champaign, Illinois: Human Kinetics Books.

Gottlieb, N.H. and McLeroy, K.R. (1994). "Social Health" in Health Promotion in the Workplace (2nd Edition), M.P O’Donnell and J.S. Harris (Eds). Albany, New York: Delmar Publishers.

Hansell, S. and Mechanic, D. (1990). "Parent and Peer Effects on Adolescent Health Behaviour." In K. Hurrelman & F.Losel (Eds). Health Hazards in Adolescence. New York: Walter de Gruyter, 43-66.

Heaney, C.A. and Israel, B.A. (1997). "Social Networks and Social Support." In Health Behaviour and Health Education: Theory, Research and Practice (2nd edition), K. Glanz, F. Lewis and B. Rimer (Eds). San Francisco: Jossey-Bass Publishers, 179-205.

Heath, G.W. and Fentem, P.H. (1997). "Physical Activity Among Persons With Disabilities—A Public Health Perspective." Exercise and Sport Science Reviews, 25: 195-234.

Herrick, A.B., Stone, W.J. and Mettler, M.M. (1997). "Stages of Change, Decisional Balance and Self-Efficacy Across Four Health Behaviours in a Worksite Environment." American Journal of Health Promotion, 12(1): 49-56.

Hotz, S.B. (1996 update). Understanding and Using the Stages of Change. A booklet prepared for The Program Training and Consultation Centre, Ontario Tobacco Strategy.

Hyndman, B. Libstug, A., Giesbrecht, N., Hershfield, L. and Rootman, I. (1993). The Use of Social Science Theory to Develop Health Promotion Programs. Toronto: Centre for Health Promotion, University of Toronto.

Interprovincial Sport and Recreation Council (1998). Physical Activity and Recreation: Providing Opportunities for Children and Youth Living in Poverty. Ottawa: Health Canada.

Iso-Ahola, S.E., Jackson, E. and Dunn, E. (1994). "Starting, Ceasing and Replacing Leisure Activities Over the Life-Span." Journal of Leisure Research, 26(3).

King, A and Coles, B. (1992). The Health of Canada’s Youth. Ottawa: Health Canada.

King, A.C., Rejeski, W.J. and Buchner, D.J. (1998). "Physical Activity Interventions Targeting Older Adults: A Critical Review and Recommendations." American Journal of Preventive Medicine, 15(4): 316-333.

Klesges, R.C., Bek, L.H., Haddock, C.L., et al. (1990). "Effects of Obesity, Social Interactions and Physical Environment on Physical Activity in Preschoolers." Health Psychology 9(4): 435- 49.

Lefebvre, R. And Flora, J. (1988). "Social Marketing and Public Health Interventions." Health Education Quarterly, 15: 299-315.

Levinson, D.J. (1978). The Season’s of a Man’s Life. New York: Alfred A. Knopf.

Marcus, B.H., Banspach, S.W. Lefebvre, R.C. et al. (1992). "Using the Stages of Change Model to Increase the Adoption of Physical Activity Among Community Participants." American Journal of Health Promotion, 6(6): 424-429.

Marcus, B.H., Pinto, B.M., Simkin, L.R., et al. (1994). "Application of Theoretical Models to Exercise Behaviour Among Employed Women." American Journal of Health Promotion, 9(1): 49-54.

Marcus, B.H., King, T.K., Clark, M.C., et al. (1996). "Theories and Techniques for Promoting Physical Activity Behaviours." Sports Medicine, 22(5): 321-331.

McAuley, E., Courneya, K.S., Rudolph, D.L., et al (1994). "Enhancing Exercise Adherence in Middle-Aged Males and Females." Preventive Medicine 23: 498-506.

Mergenhagen, P. (1995). Targeting Transitions: Marketing to Consumers During Life Changes. Ithaca, NY: American Demographics Books.

Mummery, W.K., Spence, J. (1998). "Stages of Physical Activity in the Alberta Population". Canadian Journal of Public Health, 89(6): 421-423.

National Institute of Nutrition (1995). "Nutritional Issues for Low Income Children." RAPPORT 10(4): 2.

O’Brien Cousins, S. (1998). "Promoting Active Living and Healthy Eating Among Older Canadians." Determinants of Health: Adults and Seniors. National Forum on Health. Sainte-Foy: Éditions MultiMondes.

Offord, D.R. and Jones, M.B. (1983). "Skill Development: A Community Intervention Program for the Prevention of Antisocial Behaviour" in Childhood Psychopathology and Development, S.B. Guze, J.F. Earls and J.E. Bennett (Eds). New York: Ravens Press.

Offord, D.R., Hanna, E.M., Hoult, L.A., (1992). Recreation and the Development of Children and Youth: A Discussion Paper. Prepared for the Ministry of Tourism and Recreation, Ontario.

Offord, D.R., Lipman, E., Duku, E.K., (1998). "Which Children Don’t Participate in Sports, the Arts and Community Programs?" Paper prepared for Investing in Children: A National Research Conference, 1998.

Oman, R.F. and King, A.C. (1998). "Predicting the Adoption and Maintenance of Exercise Participation Using Self-Efficacy and Previous Exercise Participation Rates." American Journal of Health Promotion, 12(3): 154-161.

Ontario Premier’s Council on Health, Well-Being and Social Justice (1994). Yours, Mine and Ours: Ontario’s Children and Youth, Phase 1. Toronto: Queen’s Printer for Ontario.

Prochaska, J.O., Diclemente, C.C. and Norcross, J.C. (1992). "In Search of How People Change": Applications to Addictive Behaviours." American Psychologist 47(9): 1102-14.

Prochaska, J.O. and Velicer, W.F. (1997). "The Transtheoretical Model of Health Behaviour Change." American Journal of Health Promotion, 12(1): 38-48.

Russell, W.D., Dzewaltowski, D.A., and Ryan, G. (1999). "The Effectiveness of a Point-of -Decision Prompt in Deterring Sedentary Behaviour." American Journal of Health Promotion 13(5): 257-9.

Sallis, J., Bauman, A. and Pratt, M. (1998). "Environmental and Policy Interventions to Promote Physical Activity." American Journal of Preventive Medicine, 15(4): 379-389.

Schooler, C. Physical Activity Interventions: Evidence and Implications (1995). Ottawa: Canadian Fitness and Lifestyle Research Institute. Prepared for Ontario Ministry of Citizenship, Culture and Recreation and Ontario Ministry of Health.

Taylor, W.C., Baranowski, T. and Rohm Young, D. (1998). "Physical Activity Interventions in Low-Income, Ethnic Minority and Populations With Disability." American Journal of Preventive Medicine, 15(4): 334-343.

Torrance, G. (1998). "Physical Activity and Socioeconomic Status among Children and Youth, Aged 10 to 20". Unpublished paper prepared for Health Canada, cited in Interprovincial Sport and Recreation Council, Physical Activity and Recreation: Providing Opportunities for Children and Youth Living in Poverty.

U.S. Centre for Disease Control and Prevention, Nutrition and Physical Activity Communication Team (1995). Healthy Eating and Physical Activity: Focus Group Research With Contemplators and Preparers, Atlanta, Georgia.

U.S. Department of Human Services, Centers for Disease Control (1999). Promoting Physical Activity: A Guide For Community Action. Windsor, ON: Human Kinetics.

Wankell, L. M. (1984). "Decision-Making and Social Support Strategies for Increasing Exercise Involvement." Journal Cardiac Rehabilitation, 4: 124-135.

Back to Top

Additional References (reviewed but not cited)

Jaffee, L., Mahle Lutter, J., Rex, J. et al. (1999). "Incentives and Barriers to Physical Activity for Working Women." American Journal of Health Promotion, 13(4): 215-218.

Keast, M., Sehmrau, U., McCue, W., Pike, J., Dupas,J., Hreljac, S., and Clayton, C. (1996). Report of the Recreation and Sport System Working Group. Internal paper Ministry of Citizenship, Culture and Recreation and Ministry of Health, Ontario.

Russell, S.J. and Craig, C.L. Behaviour Change: Theories, Models and Implications for Policy and Practice (1995). Ottawa: Canadian Fitness and Lifestyle Research Institute. Prepared for Ontario Ministry of Citizenship, Culture and Recreation and Ontario Ministry of Health.

Stephens et al. (1985). "A descriptive epidemiology of leisure-time physical activity." Public Health Reports, 100(2): 147-158.

Stone, E.J., McKenzie, T.L. Welk, G.J. and Booth, M.L. (1998). "Effects of Physical Activity Interventions in Youth: Review and Synthesis." American Journal of Preventive Medicine, 15(4): 298-315.

University of Toronto, Canadian Association for Health, Physical Education, Recreation and Dance, the Canadian Association for School Health and Health Canada (1999). Partners for Health - Schools, Communities and Young People Working Together.

U.S. Centre for Disease Control (1997). Summary Recommendation Notes from a Conference on Physical Activity Interventions (faxed copy).

U.S. Department of Health and Human Services (1996). Physical Activity and Health: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

U.S. Department of Health and Human Services (1997). "Guidelines for School and Community Programs to Promote Lifelong Physical Activity Among Young People." Morbidity and Mortality Weekly Report. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC).

Back to Top

LIN logo

Appropriate Use of Documents: Documents may be downloaded or printed (single copy only). You are free to edit the documents you download and use them for your own projects, but you should show your appreciation by providing credit to the originator of the document. You must not sell the document or make a profit from reproducing it. You must not copy, extract, summarize or distribute downloaded documents outside of your own organization in a manner which competes with or substitutes for the distribution of the database by LIN.