Health Promotion

Health  promotion  has  been  defined  in  a  number of  different  ways  and  used  in  reference  to  a  constellation  of  behaviors,  such  as  eating,  exercise, and  stress  management.  For  the  purposes  of  this entry, we consider health promotion to be defined as  strategies  that  (1)  facilitate  awareness  of  the benefits  of,  and  opportunities  for,  physical  activity;  (2)  enhance  exercise  motivation  and  skills; and (3) intervene to make environments supportive  for  active  living.  Within  this  definition  is  the explicit acknowledgment that both individual and environmental-level  factors  are  related  to  health promotion. In this entry, we focus on health promotion  strategies  to  increase  exercise  or  physical activity that focus on individuals, groups, and specific settings.

Individual-Level Interventions

Strategies  that  are  based  on  underlying  theories appear to be more effective than strategies that are not. Social cognitive theories that include outcome expectations, control beliefs, and social influences are the typical underlying theories for individual level  physical  activity  promotion  interventions. Using these models, participants develop goals and plans to achieve these goals. This personal action planning  is  essential  to  many  of  the  individual level interventions.

Personal Action Planning

Personal action planning can be useful in health promotion  interventions  targeting  physical  activity. Action plans allow the participants to focus on personally relevant motives as to why they should increase physical activity. For example, one person may  list  that  engaging  in  an  exercise  routine  will maintain or improve health while another may list the desire to stay young with one’s children. These personally  relevant  motives  are  directly  related to  the  outcome  expectations  a  person  may  have relative to a given behavior. Personal action plans also  allow  for  the  behavior  changes  to  be  goal directed,  meaning  a  person  may  cite  specific  and measurable  goals  and  activities  to  increase  their physical  activity.  To  overcome  barriers  that  may decrease  a  person’s  self-efficacy,  or  the  belief  in ability or competence to perform a certain action, a person may brainstorm ways to overcome obstacles that may impede personal goals. For example, if one cites not enjoying exercise because it is boring, that person may want to try different activities at the local YMCA until finding something stimulating. A personal action plan process works well to assist participants in resolving these issues. It is also a key tool in a goal setting and feedback loop that  can  be  initiated  between  a  participant  and  a health professional.

health-promotion-sports-psychologyThere are a number of effective individual-level interventions that vary in the way they are delivered. It is clear that one-on-one counseling can be an  effective  method  to  increase  physical  activity and  that  the  more  frequent  and  longer  duration of  the  intervention,  the  more  likely  it  is  to  lead to  behavior  changes.  One-on-one  counseling  has been done successfully using face-to-face methods, telephone  methods—both  live  and  automated— and,  more  recently  through  computer  interactive sessions and mobile phones.

The  ALIVE!  study  provides  a  good  example of  an  individual-level  intervention  that  includes action  planning.  The  study  used  a  computerized program to motivate participants to increase their physical  activity  as  well  as  a  number  of  other behaviors. The intervention included assessing participants’  health  behaviors  and  then  encouraging them to set a goal in the area of greatest behavioral need  (the  behavior  that  they  were  currently  not doing). Over the next three months, the program facilitated a series of small goals to provide participants with an opportunity to be successful before progressing to more challenging goals. During the program,  participants  received  feedback  on  their accomplishments.  The  results  of  ALIVE!  showed that  people  who  participated  in  the  intervention increased their physical activity more than those in a control group.

Group-Based Interventions

Group-based  interventions  are  those  that  use  a group-dynamics  approach  to  promote  physical activity.  It  is  important  to  distinguish  between individual-level interventions that are delivered to an  aggregate  of  people—like  a  group-education class—and   a   group-based   intervention   that includes  strategies  that  consider  the  positive  and negative forces that reside within groups and target those forces to enact behavior change.

For group-based interventions, one of the driving  concepts  is  that  group  cohesion  is  key  in  the process of behavior change and that three general areas  of  influence  can  be  used  to  facilitate  group cohesion.  First,  the  group  environment,  which includes  the  sense  of  distinctiveness  participants hold  within  the  group  and  the  size  of  the  group, is thought to influence group cohesion and adherence. It appears as though the ideal exercise class size  is  5  to  17  members,  and  the  most  common method used to generate a sense of distinctiveness is to create a group name. Some use games to create member proximity to remove barriers that are typical when people exercise together. Second, the structure  of  a  group,  including  norms,  roles,  and even location of members within group meetings, facilitate  group  cohesion.  Group  norms  are  often developed  through  the  public  sharing  of  individual  behavior  and  goals.  Roles  can  be  developed formally  to  aid  in  participants  feeling  a  stronger responsibility  toward  the  group  (e.g.,  attendance tracker,  warm-up  leader)  and  participants  can  be encouraged  to  exercise  in  the  same  space  at  each group meeting to give a sense of belonging and fit within  the  group.  Third,  specific  group  processes that  included  communication,  cooperation,  and competition  in  the  pursuit  of  a  common  group goal  can  enhance  group  cohesion.  The  common goal can be an aggregate of the individual goals of people within the group so that they feel accountable to the group. A group goal is critical and perhaps the most important aspect of group dynamics strategies to promote physical activity.

When  a  physical  activity  promotion  strategy includes  components  that  focus  on  group  environment,  structure,  and  process,  it  will  typically lead  to  large  changes  in  behavior.  In  fact,  when compared  to  individual  interventions  (with  or without social support) group-based interventions lead  to  significantly  larger  changes.  Interestingly, unlike  individual-level  interventions,  group-based interventions  seem  to  be  effective  regardless  of the  intensity  and  duration  of  the  intervention program.  Early  research  that  focused  on  group based approaches typically used interventions that included three to five sessions per week over a 3 to 6-month period. These interventions were successful in improving adherence, outcome expectations, and  control  beliefs  as  well  as  increasing  exercise participation.  These  types  of  interventions  also demonstrated  improved  maintenance  of  exercise after the sessions were completed.

At  the  other  end  of  the  spectrum,  studies  like Move  More  tested  the  degree  to  which  group based  interventions  could  increase  and  maintain physical  activity  with  just  two,  2-hour  sessions spaced a month apart with the focus of the second session  on  increasing  exercise  once  the  program was  completed.  Move  More  targeted  insufficiently  active  adult  patients,  and  the  participants were  randomly  assigned  to  either  a  group-based intervention,  which  used  group  dynamic  strategies,  or  an  enhanced-standard  care  group,  which used  social  cognitive  theory  and  a  self-directed approach  (action  planning  workbook,  information  on  resources  in  the  community,  a  follow-up telephone call). The results showed that although both interventions succeeded in increasing physical activity  over  the  first  3  months,  the  participants in  the  group-dynamics  approach  were  able  to sustain and further increase their physical activity 6 months after the intervention ended while those in the enhanced-standard care group did not.

Site-Specific Interventions

The next sections discuss health promotion efforts across  a  number  of  different  sites.  In  each  case, individual-level  strategies,  group-based  strategies,  or  both  could  be  applied.  As  you  will  note in  the  examples  below,  site-specific  interventions also regularly use social (e.g., policy changes) and physical (e.g., development of walking paths) environmental strategies to support physical activity.

School-Based Interventions

Children  spend  much  of  their  time  in  school, and  school  provides  a  great  place  to  offer  health promotion  activities.  As  children  get  older,  their time doing physical activity significantly declines. In  the  Healthy  Youth  Places  Project,  an  intervention  rooted  in  social  cognitive  theory,  researchers wanted to increase the availability and acceptability of physical activity for middle-school students. The underlying proposition of the Healthy Youth Places  Project  was  that  engaging  student,  staff, and faculty leaders within the intervention would enhance the likelihood that intervention strategies

would  be  effective.  Change  teams  made  up  of these  key  stakeholders  received  training  on  effective  strategies  to  promote  physical  activity  and implemented  a  number  of  different  environmental  strategies  to  improve  student  perceptions  of connection,  autonomy,  skill  building  and  healthy norms  related  to  physical  activity.  The  results  of the  Healthy  Youth  Places  project  demonstrated that  students  in  the  schools  with  change  teams increased  their  physical  activity  over  3  years  significantly more than those students in the control group.

Worksite Interventions

Like  schools  for  children,  worksites  are  the location  that  adults  spend  most  of  their  waking  hours.  Worksite  wellness  has  a  long  history because  of  the  role  of  health  in  worker  productivity  and  satisfaction.  Worksites  also  provide  a wide variety of avenues for intervention strategies (e.g.,  interpersonal  relationships,  group  settings, organizational  structure  and  policy).  The  Active for Life work-based physical activity intervention provides a good example of a typical approach for this setting. The intervention included changes to the  physical  environment  in  the  form  of  posters and  onsite  health  fairs  and  individually  targeted materials  in  the  form  of  regular  newsletters,  goal setting,  self-monitoring,  and  incentives.  It  also included  a  group-based  approach  that  was  facilitated  by  site  captains  and  included  interoffice friendly competitions. The program reached about a third of the employees and lasted for 10 weeks. By  the  end  of  the  intervention,  the  proportion  of employees  who  were  meeting  the  recommended guidelines  for  physical  activity  increased  from  34%  to  48%.  However,  6  months  following  the intervention  most  of  the  employees  had  returned to a less active level. This lack of maintenance of physical  activity  change  is  common  across  health promotion strategies and provides an area in need of considerable research focus.

Health Care–Based Interventions

Medical  clinics  have  the  potential  for  broad reach into the U.S. population. Furthermore, clinicians are considered credible and objective sources of  health  information  for  patients.  A  number  of researchers  have  attempted  to  take  advantage  of the  credibility  of  physicians  to  promote  physical activity.  Unfortunately,  it  appears  as  though  a simple  prescription  for  physical  activity  is  insufficient  to  initiate  physical  activity  change.  Some researchers have attempted to increase the amount of  time  that  physicians  spend  counseling  patients on physical activity and have also used techniques such  as  motivational  interviewing.  While  there has  been  some  success  with  these  approaches  in efficacy  trials,  there  is  limited  evidence  that  physicians  have  the  time  necessary  to  even  insert  a 2to 3-minute counseling session for each patient that presents with a low level of physical activity. Where  the  most  promise  appears  to  be  in  regard to  clinic-based  physical  activity  promotion  is  at the  intersection  of  health  information  technology  and  community  resources.  With  the  growing prevalence  of  the  electronic  health  record  and the push to include exercise as a vital sign, clinics have moved to the forefront as a location to identify  people  who  could  benefit  from  more  physical  activity.  Still  other  researchers  have  shown that when physicians refer patients to a proactive community physical activity organization like the YMCA,  the  results  are  typically  quite  good  in terms of increased physical activity.

Faith-Based Interventions

The rationale for intervening in faith-based institutions is not very different than some of the other place-based  or  settings-based  interventions  mentioned above. A large proportion of the American population  attends  a  weekly  faith-based  service, and  these  services  provide  a  great  opportunity  to promote  physical  activity.  Just  as  with  worksites, there  are  a  number  of  different  levels  of  potential  intervention  in  a  faith-based  organization— sermons,  socials,  and  service  opportunities.  Guide to Health provides a strong example of an effective intervention that was evaluated across 14 churches in  southwest  Virginia.  The  intervention  prompted congregates to create weekly step-count goals, and when step counts were met, the future goals changed by an additional 500 steps. If a congregant failed to meet a weekly goal, helpful self-regulation strategies were used to help that person meet personal goals. The intervention was successful in initiating physical activity among congregation members.

References:

  1. Dzewaltowski, D. A., Estabrooks, P. A., Welk, G., Hill, J., Milliken, G., Karteroliotis, K., et al. (2009). Healthy youth places: A randomized controlled trial to determine the effectiveness of facilitating adult and youth leaders to promote physical activity and fruit and vegetable consumption in middle schools. Health Education & Behavior, 36(3), 583–600.
  2. Estabrooks, P. A., & Glasgow, R. E. (2006). Translating effective clinic-based physical activity interventions into practice. American Journal of Preventive Medicine, 31(Suppl. 4), S45–S56.
  3. Green, B. B., Cheadle, A., Pellegrini, A. S., & Harris, J. R. (2007). Active for life: A work-based physical activity program. Preventing Chronic Disease, 4(3), A63.
  4. O’Donnell, M. P. (2009). Definition of health promotion 2.0: Embracing passion, enhancing motivation, recognizing dynamic balance, and creating opportunities. American Journal of Health Promotion, 24(1), iv.
  5. Winett, R. A., Anderson, E. S., Wojcik, J. R., Winett, S. G., & Bowden, T. (2007). Guide to health: Nutrition and physical activity outcomes of a group randomized trial of an Internet-based intervention in churches. Annals of Behavioral Medicine, 33(3), 251–261.

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