The Health Care Manager Volume 33, Number 1, pp. 82–90 Copyright # 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Determinants and Benefits of Physical Activity Maintenance in Hospital Employees Me ´lanie Lavoie-Tremblay, N.PhD, RN; Charles Sounan, PhD; Kara Martin, MA; Julie G. Trudel, PhD; Genevieve L. Lavigne, PhD; Steven A. Grover, MD; Ilka Lowensteyn, PhD This study investigated whether the positive behavioral and anthropometric outcomes of a pedometerbased physical activity 8-week challenge were maintained 6 months after the end of the program. It further investigated the motivational profile of those who maintained their physical activity levels in the months following the end of the program and of those who did not. Hospital employees from a university-affiliated multisite health care center in Canada participated using a questionnaire. Of the 235 participants who completed the 8-week challenge, 157 questionnaires were returned 6 months later. Paired-samples t tests were conducted between the baseline and follow-up scores as well as between the postprogram and follow-up scores to detect significant differences between the measurement points.This study shows that the pedometer-based physical activity helped hospital employees maintain a high level of physical activity as well as maintain a healthy body mass index after 6 months. The results demonstrated that during maintenance the high physical activity group obtained higher scores for identified regulation and intrinsic regulation compared with the other groups. The results of the study revealed that identified and intrinsic regulations are important contributors to maintaining physical activity among hospital employees. Key words: hospital staff, maintenance, motivational profile, pedometer-based intervention, physical activity
HE HEALTH BENEFITS of exercise at both the individual and societal level are well recognized.1 Specifically, exercising on a regular basis reduces the risk of chronic diseases, improves psychological health,
T
Author Affiliations: Ingram School of Nursing, McGill University (Drs Lavoie-Tremblay and Lavigne), McGill University Health Centre (Dr Sounan and Ms Martin), University Health Network (Dr Trudel); and McGill Cardiovascular Health Improvement Program (Drs Grover and Lowensteyn), Canada.
increases workplace productivity, and decreases absenteeism.1 However, the physical and psychological benefits associated with physical activity only persist with constant and regular physical activity. Unfortunately, the long-term maintenance of physical activity is difficult because many individuals who begin a physical activity program quit or relapse.2 Long-term maintenance is defined as regular physical activity at least 3 months following the intervention.3
The authors thank the Canadian Institute of Health Research CIHR and Fonds de la Recherche en sante´ au Que´bec FRSQ for providing financial support for this study.
STUDIES ON PHYSICAL ACTIVITY MAINTENANCE
The authors report no conflicts of interest.
The literature review prepared by Marcus et al4 on the maintenance of physical activity revealed that few studies looked at it beyond 6 months of adoption of the behavior. Also, the majority of participants were healthy adults or patients with chronic diseases (cardiac problems and hypertension). Even today, patients with
Correspondence: Me´lanie Lavoie-Tremblay, N.PhD, RN, FRSQ, Junior 2 Career Award, Associate Professor, Ingram School of Nursing, McGill University and Nurse Scientist McGill University Health Centre, 3506 University St, Montreal, Quebec, Canada H3A 2A7 ([email protected]). DOI: 10.1097/HCM.0b013e3182a9d682
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Physical Activity Maintenance in Hospital Employees chronic diseases are primarily chosen to be part of physical activity maintenance studies. For example, in a recent study, Eakin et al5 used a 12-month telephone-delivered intervention to promote maintenance of physical activity. The results showed that the telephone intervention promoted maintenance of physical activity for diabetic patients and those suffering from hypertension 6 months after the intervention. Very few studies have explored the maintenance of physical activity in the workplace. In 1 study,6 a cognitive-behavioral approach aided sedentary employees to maintain their improved level of physical activity. In another study, Murphy et al7 used a motivational approach as the intervention and reassessed physical activity levels and health outcomes after 6 months in sedentary civil servants. The motivational intervention seems beneficial for maintaining improvements in physical activity and blood pressure. One main limitation to research regarding physical activity maintenance has been that few studies have included workplace employees, especially hospital employees. This group is often confronted with difficult working conditions, and the maintenance of physical activity will help them cope better and improve their overall health. As a result, healthy hospital employees may contribute to increased productivity by reducing absenteeism and sick leave.8 Determinants of physical activity maintenance There is a need to better understand the reasons why physical activity maintenance is hard to achieve. By identifying the determinants associated with physical activity maintenance, our ability to comprehend behaviors needed to maintain good health can be enhanced. In turn, strategies could be put in place to help individuals maintain their level of physical activity.9 According to Nigg et al,2 physical activity maintenance determinants encompass 2 categories of variables: individual psychosocial variables (goal setting, motivation, and self-efficacy) and contextual variables, which include environmental and life stress factors. Other researchers10,11 have cited social, environmental, cultural, and psychological factors
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as contributing factors to the maintenance of physical activity. Of all the determinants mentioned, motivation is often cited as a determining factor in the uptake and maintenance of physical activity. More specifically, motivation theories, such as the Self-regulation Theory (self-determination), are often used to understand the psychological mechanisms underlying the uptake and maintenance of physical activity. Self-determination Theory12-15 consists of various degrees of motivation along a continuum representing varying degrees of autonomy from amotivation through external, introjected, identified, and intrinsic motivation.16 According to some researchers,17-23 individuals who are more self-determined motivators exhibit more regular physical activity. Benefits of physical activity maintenance among hospital employees A pedometer-based 8-week intervention (Wellness Challenge) was set up at a university health center in Montreal, Canada. Many benefits were associated with the intervention.24 In fact, it demonstrated some level of improvement in 4 categories of health outcomes, namely, behavioral, biomedical, anthropometric, and psychological outcomes. However, the Wellness Challenge was also aimed at maintaining those changes. To our knowledge, no study has examined whether such benefits were maintained for at least 6 months among hospital employees. This would give insight as to whether such an intervention can have long-term benefits. The objectives of the present study were 2-fold. The first was to determine if the positive behavioral and anthropometric outcomes of a pedometerbased physical activity challenge were maintained 6 months after the end of the program. The second was to present the motivational profile of those who maintained their physical activity levels in the months following the end of the program and of those who did not. METHODS Study design The study design was a pretest and posttest design followed by a maintenance measurement point 6 months after the posttest (follow-up).
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Participants Participants were recruited in a universityaffiliated multisite health care center in Canada, which includes 6 sites and 10 000 employees. The research team set up information tables with posters to attract employees entering the workplace. Employees interested in participating gave their contact information to the project coordinator, who then sent them an e-mail message to make an appointment for a prescreening evaluation. Inclusion criteria included being a hospital employee and successfully completing the Physical Activity Readiness Questionnaire. Individuals who answered yes to any question on the Physical Activity Readiness Questionnaire were further screened by a health professional. Intervention The ‘‘Wellness Challenge’’ intervention comprised a 1-hour on-site lunch lecture, 30-minute one-on-one pretest and posttest evaluations during work hours (including cardiovascular, diabetes, insomnia, stress, and fatigue risk assessments and interpretation by a health professional from McGill Cardiovascular Health Improvement Program), and the 8-week pedometer activity challenge (September 19, 2011, to November 13, 2011). The lunch-hour lecture provided information on physical activity and nutrition as well as instructions on proper pedometer use. The activity challenge involved tracking physical activity on a Web site, www.myhealth checkup.ca. Pedometer step counts or the step equivalents of other physical activities were recorded daily. A goal of 10 000 steps was used to motivate participants, and a goal of being the first site to cross Canada virtually as a group was used to motivate the teams. The Web site allowed participants to see their progress as individuals, as a site, and as an entire group. All eligible participants received a pedometer at the lecture and a code to access the program Web site. The organization offered a variety of options to help participants remain active following the Pedometer Program: (1) participants were encouraged to continue wearing their pedometers in order to maintain their physical activity behavior, and the Web site remained available; (2) weekly lunch-hour lifestyle management
educational sessions (over 6 weeks) were presented by the wellness facilitator; (3) weekly pilates sessions were offered over 6 weeks; and (4) the research coordinator remained available as an exercise and behavior change consultant for participants who requested further assistance. A new stair climbing challenge was introduced to employees who could safely engage in higherintensity exercise. Participants were asked to choose stairs over elevators/escalators as much as possible. Procedure Data were collected at baseline, 8 weeks after the start of the intervention, and at the 6-month follow-up (maintenance) using self-administered questionnaires (returned by mail). Questionnaires contained 2 categories of outcome: behavioral and anthropometric. Measures Maintenance. Participants were asked if they had maintained their levels of physical activity in the 6 months following the end of the program. This question was presented as a yes/no question. International Physical Activity Questionnaire (IPAQ). Participants completed the short selfadministered format of the IPAQ for young and middle-aged adults25 at 3 measurement points. This measure is composed of 4 questions assessing participants’ physical activity levels in the past 7 days. Continuous variables are created for each level of physical activity by weighting participants’ reported minutes per week within each activity category by a Metabolic Equivalent of Task (MET) energy expenditure estimate assigned to each category of activity (see Craig et al25 for detailed description of the origin of the MET levels). For instance, for vigorous activity, the energy expenditure estimate is 8.0 METs, and the formula is 8.0 minutes of vigorous activity / day days per week. A total MET variable is created by adding the walking, moderate activity, and vigorous activity scores. The reliability and validity of the IPAQ have been well documented.25 Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2). Participants completed the BREQ.26 This 19-item scale is a measure of
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Physical Activity Maintenance in Hospital Employees behavioral regulation based on the widely validated Self-determination Theory.12,27 It is composed of 5 subscales ranging from the most self-determined form of regulation (intrinsic regulation) to the least self-determined form of regulation (amotivation). Specifically, the intrinsic regulation dimension is composed of 4 items ( = .91), the identified regulation subscale is composed of 4 items ( = .72), the introjected regulation dimension is composed of 3 items ( = .73), the external regulation dimension is composed of 3 items ( = .81), and finally, the amotivation dimension is composed of 3 items ( = .84). Anthropometric. Trained staff measured the weight and height for each participant at both baseline and at the end of the program. Participants self-reported their weight at the maintenance measurement point. Motivators, facilitators, and barriers. Participants were asked how important was a list of 8 motivators, 8 facilitators, and 4 barriers for the maintenance of their physical activity following the program. Participants reported on a 5-point scale ranging from 1 (not important at all) to 5 (very important). Statistical analyses Paired-samples t tests were conducted between the baseline and follow-up scores as well as between the postprogram and follow-up scores to detect significant differences between the measurement points. Furthermore, univariate analyses of variance were conducted on the BREQ exercise regulation scores to detect significant differences between maintenance of physical activity groups. All analyses were conducted with SPSS 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Ethics Participants gave written consent to participate. The study was approved by the health care organization’s research ethics committee (reference no. 10-066-PSY). RESULTS Of the 380 candidates who were interested and were invited to the prescreening evaluation,
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310 subjects (81.6%) were eligible and agreed to participate in the study (9.7% males, and 90.3% females). These subjects were 22 to 70 years of age (mean, 47.11 [SD, 9.19] years). Postprogram, 95 participants were lost (71% response rate), which resulted in a sample of 235 (7.7% males and 92.3% females), ranging in age from 24 to 70 (mean, 47.59 [SD, 9.10] years). Finally, 6 months after the end of the program, 157 questionnaires were returned to the research team (66.81% response rate). This final sample of participants (8.3% males and 91.7% females) was aged between 24 and 70 years (mean, 48.66 [SD, 8.95] years). Analyses were conducted to identify sociodemographic differences between those who completed baseline and postprogram measurements and those who completed only baseline measurements. A greater proportion of men failed to complete both measurements (38.7% of men and 20.2% of women completed only baseline measurements). No significant differences were found between the 2 groups on their physical activity levels at baseline. Analyses were conducted to identify sociodemographicdifferences between those who completed postprogram and maintenance measurements and those who completed only postprogram measurements. One significant difference was found: those who completed both the postprogram and the maintenance measurements were older (average, 47.68 [SD, 8.95] years) than those who only completed the postprogram measurements (average, 45.40 [SD, 9.68] years; t284 = 4.29, P = .039). Furthermore, the only significant difference between those who completed both measurements and those who completed only the postprogram measurements was the vigorous activity measure (t199 = 5.43, P = .021) and total MET score (t181 = 5.09, P = .025) at postprogram. Participants who completed only the postprogram measurements had lower vigorous activity scores (average, 508.34 [SD, 1136.12]) and total MET scores (average, 2383.87 [SD, 2127.16]) than did those who completed both measurements (vigorous activity: average, 1136.12 [SD, 2163.38]; MET scores: average, 3380.65 [SD, 3146.40]). No significant differences were found between the 2 groups on their physical activity levels at baseline.
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Table 1. Motivators to Maintaining Physical Activity Following the End of the Pedometer Program Motivators Losing weight Increasing physical activity Reducing blood pressure Reducing stress Improving sleep Reducing fatigue Family members Colleagues at work
n
Average
SD
Min/Max
158 158 158 157 158 156 157 156
3.95 4.24 3.21 3.89 3.77 3.83 2.44 2.17
1.18 0.83 1.58 1.19 1.37 1.18 1.31 1.27
1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum.
Determinants of physical activity maintenance Motivators, facilitators, and barriers associated with maintenance A total of 75.8% (n = 119) of participants said that they had maintained their level of physical activity at the 6-month follow-up. Tables 1 to 3 show the descriptive statistics regarding each motivator, facilitator, and barrier. Benefits of physical activity maintenance Behavioral Participants’ total MET scores did change significantly between both baseline and 6-month follow-up (Table 4) and postprogram and 6-month follow-up (Table 5). These significant differences suggest that the total level of physical activity was not only maintained but kept increasing following the end of the program. Univariate analysis of variance was conducted
on the 3 MET scores at postprogram (vigorous activity, moderate activity, walking) as well as on the total MET score postprogram in order to detect significant differences between those who completed both the postprogram and the maintenance questionnaire and those who completed only the postprogram questionnaire. Significant differences were found on the vigorous activity score (F1,199 = 5.434, P = .021) and the total MET score (F1,181 = 5.093, P = .025). In both cases, those who completed the maintenance questionnaire had higher scores than did those who did not complete the maintenance questionnaire. No differences were found for the moderate activity and walking variables. For the vigorous physical activity MET scores, a significant difference was observed only between baseline and follow-up (Table 4). For the moderate activity MET scores, the differences between the 3 measurement points were found to be only marginally significant (Tables 4 and 5). Finally, for the walking MET
Table 2. Facilitators to Maintaining Physical Activity Following the End of the Pedometer Program Facilitators Tracking physical activity with a pedometer Continuing to use the MUHC Wellness Challenge Web site Participating in the 7-summits stairs challenge Attending the knowledge transfer sessions Colleagues support Coordinator on site for support Joining a gym Home workouts
n
Average
SD
Min/Max
158 158 148 152 150 143 156 156
3.42 2.91 2.66 2.73 2.67 3.08 2.43 3.26
1.38 1.43 1.54 1.38 1.41 1.43 1.51 1.33
1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum; MUHC, McGill University Health Centre.
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Physical Activity Maintenance in Hospital Employees
Table 3. Barriers to Maintaining Physical Activity Following the End of the Pedometer Program
Lack of motivation Lack of time Not having a personalized exercise program No access to facilities
n
Average
SD
Min/Max
154 158 156 154
3.16 3.56 2.60 2.45
1.28 1.23 1.35 1.50
1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum.
scores, a significant difference was observed between baseline and follow-up (Table 4). No significant differences were found regarding the amounts of time spent sitting each weekday. Anthropometric A significant decrease in participants’ weight was observed between baseline and follow-up (Table 4) as well as between postprogram and follow-up (Table 5). Participants’ body mass index (BMI) decreased from 26.42 (SD, 4.67) kg/m2 at baseline to 26.17 (SD, 4.54) kg/m2 at follow-up (t155 = 2.748, P = .007). Similarly, the difference in BMI was also significant between postprogram and follow-up (Tables 4 and 5). Exercise regulation profile as an individual psychosocial determinant In order to distinguish the individuals who maintained their physical activity levels from those who did not in terms of their exercise regulation, 4 groups were created based on the IPAQ classification. Specifically, those who were classified as having high levels of physical activity at the end of the program as well as 6 months
later formed the maintenance of high physical activity group (26.0%, n = 33). Those who were classified as having moderate levels of physical activity at the end of the program as well as 6 months later formed the maintenance of moderate physical activity group (29.1%, n = 37). Those who went from a lower category of physical activity level to a higher category 6 months after the end of the program formed the increase of physical activity group (29.1%, n = 37). Finally, those who went from a higher category of physical activity to a lower category 6 months after the end of the program formed the decrease of physical activity group (15.7%, n = 20). The groups were not found to differ on sociodemographic variables such as age. The results from univariate analysis of variance (Table 6) showed a marginally significant difference on the identified regulation dimension (F3,123 = 2.62, P = .054) as well as a significant difference between the groups on the intrinsic regulation dimension (F3,123 = 3.66, P = .014). Subsequent post hoc analyses showed that the maintenance of high physical activity group had higher scores of identified regulation and intrinsic regulation than did the
Table 4. Clinical Measurements and Questionnaire Variables at Baseline and Follow-up
Weight, kg BMI, kg/m2 Vigorous activity MET Moderate activity MET Walking MET Total MET score Sitting, min/weekday
n
Baseline Average (SD)
155 155 152 149 142 134 148
71.35 (14.22) 26.42 (4.67) 794.21 (1299.97) 642.42 (1647.68) 1409.96 (1763.84) 2699.03 (2606.76) 427.79 (234.47)
Follow-up Average (SD) 70.25 26.17 1378.95 1271.17 2040.49 4946.40 413.89
(13.88) (4.54) (2548.23) (4188.11) (3401.73) (7171.36) (369.03)
P .001 .007 .004 .081 .038 .001 .673
Abbreviations: BMI, body mass index; MET, metabolic equivalent of task.
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Table 5. Clinical Measurements and Questionnaire Variables at Postprogram and Follow-up
Weight, kg BMI, kg/m2 Vigorous activity MET Moderate activity MET Walking MET Total MET score Sitting, min/weekday
n
Postprogram Average (SD)
Follow-up Average (SD)
P
138 138 135 130 126 116 132
71.03 (14.19) 26.47 (4.73) 1052.92 (2009.26) 624.95 (1104.11) 1654.92 (1912.37) 3289.90 (3076.07) 355.86 (193.21)
70.11 (13.84) 26.29 (4.59) 1331.85 (2634.87) 1260.03 (4409.00) 1877.46 (3298.64) 4550.55 (7291.60) 415.04 (383.18)
.001 .041 .279 .060 .478 .049 .098
Abbreviations: BMI, body mass index; MET, metabolic equivalent of task.
maintenance of moderate physical activity group as well as the increase of physical activity group. No differences were detected on the other dimensions of exercise regulation.
DISCUSSION The results indicated that there are 3 important motivators for hospital employees to maintain their physical activity levels 6 months after intervention: increasing their physical activity, losing weight, and reducing stress. In other studies, the exercise maintainers have cited losing weight, improved appearance, and stress reduction as perceived benefits.28 In this study, monitoring physical activity levels with a pedometer, doing workouts at home, and having a coordinator on site for support were the 3 most important facilitators cited by the hospital employees. The pedometer was also used among weight maintainers to record their daily steps.29 Other research has also established that social support is important for exercise maintainers.28
The present study shows that social support (from the coordinator) is beneficial for those who want to remain active. Finally, in this study, lack of time was judged to be the most important barrier to maintaining physical activity levels after intervention. This barrier is often cited by other researchers.28,30 In addition, the results demonstrated that the maintenance of high physical activity group obtained higher scores of identified regulation and intrinsic regulation compared with the other groups. This result is consistent with what was obtained by Wilson et al31 in another population. In this study, the hospital employees utilized more self-determined motives (identified and intrinsic motivation) than controlled ones for physical activity maintenance. This result aligns with research that shows that selfregulation (self-management) is effective for behavior change for a variety of health behaviors including physical activity initiation and maintenance.32,33 In summary, physical activity maintenance strategies should target individuals as well as their environment.
Table 6. Exercise Regulation Profiles of the 4 Physical Activity Groups Maintenance High Maintenance Moderate Increase in PA Decrease in PA PA Levels Average PA Levels Average Levels Average Levels Average (SD) (n = 37) (SD) (n = 33) (SD) (n = 37) (SD) (n = 20) Amotivation External regulation Introjected regulation Identified regulation Intrinsic regulation
0.28 0.53 1.86 3.36 3.23
(0.88) (0.89) (1.23) (0.78) (0.97)
0.11 0.45 1.56 2.92 2.46
(0.26) (0.60) (0.98) (0.60) (1.03)
0.25 0.50 1.64 3.00 2.68
(0.54) (0.89) (1.00) (0.73) (1.05)
0.20 0.34 1.25 3.01 2.88
(0.50) (0.46) (0.89) (0.73) (1.04)
Abbreviation: PA, physical activity.
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Physical Activity Maintenance in Hospital Employees With regard to the maintenance of the Wellness Challenge benefits, this study shows that the intervention helped hospital employees maintain a high level of physical activity as well as maintain a healthy BMI. Limitations This study does not include a control group. Future quasi-experimental research in the health care sector is needed to establish the determinants for the maintenance of physical activity among hospital employees.
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CONCLUSIONS The results of the current study revealed that identified and intrinsic regulations are important contributors to maintaining physical activity among hospital employees. This finding points to the importance of evaluating identified and intrinsic regulation within a physical activity intervention. Programs should also be put in place to increase self-determined motivation so that individuals maintain their level of physical activity over a long period.
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Determinants and Benefits of Physical Activity Maintenance in Hospital Employees Me ´lanie Lavoie-Tremblay, N.PhD, RN; Charles Sounan, PhD; Kara Martin, MA; Julie G. Trudel, PhD; Genevieve L. Lavigne, PhD; Steven A. Grover, MD; Ilka Lowensteyn, PhD This study investigated whether the positive behavioral and anthropometric outcomes of a pedometerbased physical activity 8-week challenge were maintained 6 months after the end of the program. It further investigated the motivational profile of those who maintained their physical activity levels in the months following the end of the program and of those who did not. Hospital employees from a university-affiliated multisite health care center in Canada participated using a questionnaire. Of the 235 participants who completed the 8-week challenge, 157 questionnaires were returned 6 months later. Paired-samples t tests were conducted between the baseline and follow-up scores as well as between the postprogram and follow-up scores to detect significant differences between the measurement points.This study shows that the pedometer-based physical activity helped hospital employees maintain a high level of physical activity as well as maintain a healthy body mass index after 6 months. The results demonstrated that during maintenance the high physical activity group obtained higher scores for identified regulation and intrinsic regulation compared with the other groups. The results of the study revealed that identified and intrinsic regulations are important contributors to maintaining physical activity among hospital employees. Key words: hospital staff, maintenance, motivational profile, pedometer-based intervention, physical activity
HE HEALTH BENEFITS of exercise at both the individual and societal level are well recognized.1 Specifically, exercising on a regular basis reduces the risk of chronic diseases, improves psychological health,
T
Author Affiliations: Ingram School of Nursing, McGill University (Drs Lavoie-Tremblay and Lavigne), McGill University Health Centre (Dr Sounan and Ms Martin), University Health Network (Dr Trudel); and McGill Cardiovascular Health Improvement Program (Drs Grover and Lowensteyn), Canada.
increases workplace productivity, and decreases absenteeism.1 However, the physical and psychological benefits associated with physical activity only persist with constant and regular physical activity. Unfortunately, the long-term maintenance of physical activity is difficult because many individuals who begin a physical activity program quit or relapse.2 Long-term maintenance is defined as regular physical activity at least 3 months following the intervention.3
The authors thank the Canadian Institute of Health Research CIHR and Fonds de la Recherche en sante´ au Que´bec FRSQ for providing financial support for this study.
STUDIES ON PHYSICAL ACTIVITY MAINTENANCE
The authors report no conflicts of interest.
The literature review prepared by Marcus et al4 on the maintenance of physical activity revealed that few studies looked at it beyond 6 months of adoption of the behavior. Also, the majority of participants were healthy adults or patients with chronic diseases (cardiac problems and hypertension). Even today, patients with
Correspondence: Me´lanie Lavoie-Tremblay, N.PhD, RN, FRSQ, Junior 2 Career Award, Associate Professor, Ingram School of Nursing, McGill University and Nurse Scientist McGill University Health Centre, 3506 University St, Montreal, Quebec, Canada H3A 2A7 ([email protected]). DOI: 10.1097/HCM.0b013e3182a9d682
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Physical Activity Maintenance in Hospital Employees chronic diseases are primarily chosen to be part of physical activity maintenance studies. For example, in a recent study, Eakin et al5 used a 12-month telephone-delivered intervention to promote maintenance of physical activity. The results showed that the telephone intervention promoted maintenance of physical activity for diabetic patients and those suffering from hypertension 6 months after the intervention. Very few studies have explored the maintenance of physical activity in the workplace. In 1 study,6 a cognitive-behavioral approach aided sedentary employees to maintain their improved level of physical activity. In another study, Murphy et al7 used a motivational approach as the intervention and reassessed physical activity levels and health outcomes after 6 months in sedentary civil servants. The motivational intervention seems beneficial for maintaining improvements in physical activity and blood pressure. One main limitation to research regarding physical activity maintenance has been that few studies have included workplace employees, especially hospital employees. This group is often confronted with difficult working conditions, and the maintenance of physical activity will help them cope better and improve their overall health. As a result, healthy hospital employees may contribute to increased productivity by reducing absenteeism and sick leave.8 Determinants of physical activity maintenance There is a need to better understand the reasons why physical activity maintenance is hard to achieve. By identifying the determinants associated with physical activity maintenance, our ability to comprehend behaviors needed to maintain good health can be enhanced. In turn, strategies could be put in place to help individuals maintain their level of physical activity.9 According to Nigg et al,2 physical activity maintenance determinants encompass 2 categories of variables: individual psychosocial variables (goal setting, motivation, and self-efficacy) and contextual variables, which include environmental and life stress factors. Other researchers10,11 have cited social, environmental, cultural, and psychological factors
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as contributing factors to the maintenance of physical activity. Of all the determinants mentioned, motivation is often cited as a determining factor in the uptake and maintenance of physical activity. More specifically, motivation theories, such as the Self-regulation Theory (self-determination), are often used to understand the psychological mechanisms underlying the uptake and maintenance of physical activity. Self-determination Theory12-15 consists of various degrees of motivation along a continuum representing varying degrees of autonomy from amotivation through external, introjected, identified, and intrinsic motivation.16 According to some researchers,17-23 individuals who are more self-determined motivators exhibit more regular physical activity. Benefits of physical activity maintenance among hospital employees A pedometer-based 8-week intervention (Wellness Challenge) was set up at a university health center in Montreal, Canada. Many benefits were associated with the intervention.24 In fact, it demonstrated some level of improvement in 4 categories of health outcomes, namely, behavioral, biomedical, anthropometric, and psychological outcomes. However, the Wellness Challenge was also aimed at maintaining those changes. To our knowledge, no study has examined whether such benefits were maintained for at least 6 months among hospital employees. This would give insight as to whether such an intervention can have long-term benefits. The objectives of the present study were 2-fold. The first was to determine if the positive behavioral and anthropometric outcomes of a pedometerbased physical activity challenge were maintained 6 months after the end of the program. The second was to present the motivational profile of those who maintained their physical activity levels in the months following the end of the program and of those who did not. METHODS Study design The study design was a pretest and posttest design followed by a maintenance measurement point 6 months after the posttest (follow-up).
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Participants Participants were recruited in a universityaffiliated multisite health care center in Canada, which includes 6 sites and 10 000 employees. The research team set up information tables with posters to attract employees entering the workplace. Employees interested in participating gave their contact information to the project coordinator, who then sent them an e-mail message to make an appointment for a prescreening evaluation. Inclusion criteria included being a hospital employee and successfully completing the Physical Activity Readiness Questionnaire. Individuals who answered yes to any question on the Physical Activity Readiness Questionnaire were further screened by a health professional. Intervention The ‘‘Wellness Challenge’’ intervention comprised a 1-hour on-site lunch lecture, 30-minute one-on-one pretest and posttest evaluations during work hours (including cardiovascular, diabetes, insomnia, stress, and fatigue risk assessments and interpretation by a health professional from McGill Cardiovascular Health Improvement Program), and the 8-week pedometer activity challenge (September 19, 2011, to November 13, 2011). The lunch-hour lecture provided information on physical activity and nutrition as well as instructions on proper pedometer use. The activity challenge involved tracking physical activity on a Web site, www.myhealth checkup.ca. Pedometer step counts or the step equivalents of other physical activities were recorded daily. A goal of 10 000 steps was used to motivate participants, and a goal of being the first site to cross Canada virtually as a group was used to motivate the teams. The Web site allowed participants to see their progress as individuals, as a site, and as an entire group. All eligible participants received a pedometer at the lecture and a code to access the program Web site. The organization offered a variety of options to help participants remain active following the Pedometer Program: (1) participants were encouraged to continue wearing their pedometers in order to maintain their physical activity behavior, and the Web site remained available; (2) weekly lunch-hour lifestyle management
educational sessions (over 6 weeks) were presented by the wellness facilitator; (3) weekly pilates sessions were offered over 6 weeks; and (4) the research coordinator remained available as an exercise and behavior change consultant for participants who requested further assistance. A new stair climbing challenge was introduced to employees who could safely engage in higherintensity exercise. Participants were asked to choose stairs over elevators/escalators as much as possible. Procedure Data were collected at baseline, 8 weeks after the start of the intervention, and at the 6-month follow-up (maintenance) using self-administered questionnaires (returned by mail). Questionnaires contained 2 categories of outcome: behavioral and anthropometric. Measures Maintenance. Participants were asked if they had maintained their levels of physical activity in the 6 months following the end of the program. This question was presented as a yes/no question. International Physical Activity Questionnaire (IPAQ). Participants completed the short selfadministered format of the IPAQ for young and middle-aged adults25 at 3 measurement points. This measure is composed of 4 questions assessing participants’ physical activity levels in the past 7 days. Continuous variables are created for each level of physical activity by weighting participants’ reported minutes per week within each activity category by a Metabolic Equivalent of Task (MET) energy expenditure estimate assigned to each category of activity (see Craig et al25 for detailed description of the origin of the MET levels). For instance, for vigorous activity, the energy expenditure estimate is 8.0 METs, and the formula is 8.0 minutes of vigorous activity / day days per week. A total MET variable is created by adding the walking, moderate activity, and vigorous activity scores. The reliability and validity of the IPAQ have been well documented.25 Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2). Participants completed the BREQ.26 This 19-item scale is a measure of
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Physical Activity Maintenance in Hospital Employees behavioral regulation based on the widely validated Self-determination Theory.12,27 It is composed of 5 subscales ranging from the most self-determined form of regulation (intrinsic regulation) to the least self-determined form of regulation (amotivation). Specifically, the intrinsic regulation dimension is composed of 4 items ( = .91), the identified regulation subscale is composed of 4 items ( = .72), the introjected regulation dimension is composed of 3 items ( = .73), the external regulation dimension is composed of 3 items ( = .81), and finally, the amotivation dimension is composed of 3 items ( = .84). Anthropometric. Trained staff measured the weight and height for each participant at both baseline and at the end of the program. Participants self-reported their weight at the maintenance measurement point. Motivators, facilitators, and barriers. Participants were asked how important was a list of 8 motivators, 8 facilitators, and 4 barriers for the maintenance of their physical activity following the program. Participants reported on a 5-point scale ranging from 1 (not important at all) to 5 (very important). Statistical analyses Paired-samples t tests were conducted between the baseline and follow-up scores as well as between the postprogram and follow-up scores to detect significant differences between the measurement points. Furthermore, univariate analyses of variance were conducted on the BREQ exercise regulation scores to detect significant differences between maintenance of physical activity groups. All analyses were conducted with SPSS 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Ethics Participants gave written consent to participate. The study was approved by the health care organization’s research ethics committee (reference no. 10-066-PSY). RESULTS Of the 380 candidates who were interested and were invited to the prescreening evaluation,
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310 subjects (81.6%) were eligible and agreed to participate in the study (9.7% males, and 90.3% females). These subjects were 22 to 70 years of age (mean, 47.11 [SD, 9.19] years). Postprogram, 95 participants were lost (71% response rate), which resulted in a sample of 235 (7.7% males and 92.3% females), ranging in age from 24 to 70 (mean, 47.59 [SD, 9.10] years). Finally, 6 months after the end of the program, 157 questionnaires were returned to the research team (66.81% response rate). This final sample of participants (8.3% males and 91.7% females) was aged between 24 and 70 years (mean, 48.66 [SD, 8.95] years). Analyses were conducted to identify sociodemographic differences between those who completed baseline and postprogram measurements and those who completed only baseline measurements. A greater proportion of men failed to complete both measurements (38.7% of men and 20.2% of women completed only baseline measurements). No significant differences were found between the 2 groups on their physical activity levels at baseline. Analyses were conducted to identify sociodemographicdifferences between those who completed postprogram and maintenance measurements and those who completed only postprogram measurements. One significant difference was found: those who completed both the postprogram and the maintenance measurements were older (average, 47.68 [SD, 8.95] years) than those who only completed the postprogram measurements (average, 45.40 [SD, 9.68] years; t284 = 4.29, P = .039). Furthermore, the only significant difference between those who completed both measurements and those who completed only the postprogram measurements was the vigorous activity measure (t199 = 5.43, P = .021) and total MET score (t181 = 5.09, P = .025) at postprogram. Participants who completed only the postprogram measurements had lower vigorous activity scores (average, 508.34 [SD, 1136.12]) and total MET scores (average, 2383.87 [SD, 2127.16]) than did those who completed both measurements (vigorous activity: average, 1136.12 [SD, 2163.38]; MET scores: average, 3380.65 [SD, 3146.40]). No significant differences were found between the 2 groups on their physical activity levels at baseline.
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Table 1. Motivators to Maintaining Physical Activity Following the End of the Pedometer Program Motivators Losing weight Increasing physical activity Reducing blood pressure Reducing stress Improving sleep Reducing fatigue Family members Colleagues at work
n
Average
SD
Min/Max
158 158 158 157 158 156 157 156
3.95 4.24 3.21 3.89 3.77 3.83 2.44 2.17
1.18 0.83 1.58 1.19 1.37 1.18 1.31 1.27
1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum.
Determinants of physical activity maintenance Motivators, facilitators, and barriers associated with maintenance A total of 75.8% (n = 119) of participants said that they had maintained their level of physical activity at the 6-month follow-up. Tables 1 to 3 show the descriptive statistics regarding each motivator, facilitator, and barrier. Benefits of physical activity maintenance Behavioral Participants’ total MET scores did change significantly between both baseline and 6-month follow-up (Table 4) and postprogram and 6-month follow-up (Table 5). These significant differences suggest that the total level of physical activity was not only maintained but kept increasing following the end of the program. Univariate analysis of variance was conducted
on the 3 MET scores at postprogram (vigorous activity, moderate activity, walking) as well as on the total MET score postprogram in order to detect significant differences between those who completed both the postprogram and the maintenance questionnaire and those who completed only the postprogram questionnaire. Significant differences were found on the vigorous activity score (F1,199 = 5.434, P = .021) and the total MET score (F1,181 = 5.093, P = .025). In both cases, those who completed the maintenance questionnaire had higher scores than did those who did not complete the maintenance questionnaire. No differences were found for the moderate activity and walking variables. For the vigorous physical activity MET scores, a significant difference was observed only between baseline and follow-up (Table 4). For the moderate activity MET scores, the differences between the 3 measurement points were found to be only marginally significant (Tables 4 and 5). Finally, for the walking MET
Table 2. Facilitators to Maintaining Physical Activity Following the End of the Pedometer Program Facilitators Tracking physical activity with a pedometer Continuing to use the MUHC Wellness Challenge Web site Participating in the 7-summits stairs challenge Attending the knowledge transfer sessions Colleagues support Coordinator on site for support Joining a gym Home workouts
n
Average
SD
Min/Max
158 158 148 152 150 143 156 156
3.42 2.91 2.66 2.73 2.67 3.08 2.43 3.26
1.38 1.43 1.54 1.38 1.41 1.43 1.51 1.33
1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum; MUHC, McGill University Health Centre.
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Physical Activity Maintenance in Hospital Employees
Table 3. Barriers to Maintaining Physical Activity Following the End of the Pedometer Program
Lack of motivation Lack of time Not having a personalized exercise program No access to facilities
n
Average
SD
Min/Max
154 158 156 154
3.16 3.56 2.60 2.45
1.28 1.23 1.35 1.50
1/5 1/5 1/5 1/5
Abbreviations: Max, maximum; min, minimum.
scores, a significant difference was observed between baseline and follow-up (Table 4). No significant differences were found regarding the amounts of time spent sitting each weekday. Anthropometric A significant decrease in participants’ weight was observed between baseline and follow-up (Table 4) as well as between postprogram and follow-up (Table 5). Participants’ body mass index (BMI) decreased from 26.42 (SD, 4.67) kg/m2 at baseline to 26.17 (SD, 4.54) kg/m2 at follow-up (t155 = 2.748, P = .007). Similarly, the difference in BMI was also significant between postprogram and follow-up (Tables 4 and 5). Exercise regulation profile as an individual psychosocial determinant In order to distinguish the individuals who maintained their physical activity levels from those who did not in terms of their exercise regulation, 4 groups were created based on the IPAQ classification. Specifically, those who were classified as having high levels of physical activity at the end of the program as well as 6 months
later formed the maintenance of high physical activity group (26.0%, n = 33). Those who were classified as having moderate levels of physical activity at the end of the program as well as 6 months later formed the maintenance of moderate physical activity group (29.1%, n = 37). Those who went from a lower category of physical activity level to a higher category 6 months after the end of the program formed the increase of physical activity group (29.1%, n = 37). Finally, those who went from a higher category of physical activity to a lower category 6 months after the end of the program formed the decrease of physical activity group (15.7%, n = 20). The groups were not found to differ on sociodemographic variables such as age. The results from univariate analysis of variance (Table 6) showed a marginally significant difference on the identified regulation dimension (F3,123 = 2.62, P = .054) as well as a significant difference between the groups on the intrinsic regulation dimension (F3,123 = 3.66, P = .014). Subsequent post hoc analyses showed that the maintenance of high physical activity group had higher scores of identified regulation and intrinsic regulation than did the
Table 4. Clinical Measurements and Questionnaire Variables at Baseline and Follow-up
Weight, kg BMI, kg/m2 Vigorous activity MET Moderate activity MET Walking MET Total MET score Sitting, min/weekday
n
Baseline Average (SD)
155 155 152 149 142 134 148
71.35 (14.22) 26.42 (4.67) 794.21 (1299.97) 642.42 (1647.68) 1409.96 (1763.84) 2699.03 (2606.76) 427.79 (234.47)
Follow-up Average (SD) 70.25 26.17 1378.95 1271.17 2040.49 4946.40 413.89
(13.88) (4.54) (2548.23) (4188.11) (3401.73) (7171.36) (369.03)
P .001 .007 .004 .081 .038 .001 .673
Abbreviations: BMI, body mass index; MET, metabolic equivalent of task.
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Table 5. Clinical Measurements and Questionnaire Variables at Postprogram and Follow-up
Weight, kg BMI, kg/m2 Vigorous activity MET Moderate activity MET Walking MET Total MET score Sitting, min/weekday
n
Postprogram Average (SD)
Follow-up Average (SD)
P
138 138 135 130 126 116 132
71.03 (14.19) 26.47 (4.73) 1052.92 (2009.26) 624.95 (1104.11) 1654.92 (1912.37) 3289.90 (3076.07) 355.86 (193.21)
70.11 (13.84) 26.29 (4.59) 1331.85 (2634.87) 1260.03 (4409.00) 1877.46 (3298.64) 4550.55 (7291.60) 415.04 (383.18)
.001 .041 .279 .060 .478 .049 .098
Abbreviations: BMI, body mass index; MET, metabolic equivalent of task.
maintenance of moderate physical activity group as well as the increase of physical activity group. No differences were detected on the other dimensions of exercise regulation.
DISCUSSION The results indicated that there are 3 important motivators for hospital employees to maintain their physical activity levels 6 months after intervention: increasing their physical activity, losing weight, and reducing stress. In other studies, the exercise maintainers have cited losing weight, improved appearance, and stress reduction as perceived benefits.28 In this study, monitoring physical activity levels with a pedometer, doing workouts at home, and having a coordinator on site for support were the 3 most important facilitators cited by the hospital employees. The pedometer was also used among weight maintainers to record their daily steps.29 Other research has also established that social support is important for exercise maintainers.28
The present study shows that social support (from the coordinator) is beneficial for those who want to remain active. Finally, in this study, lack of time was judged to be the most important barrier to maintaining physical activity levels after intervention. This barrier is often cited by other researchers.28,30 In addition, the results demonstrated that the maintenance of high physical activity group obtained higher scores of identified regulation and intrinsic regulation compared with the other groups. This result is consistent with what was obtained by Wilson et al31 in another population. In this study, the hospital employees utilized more self-determined motives (identified and intrinsic motivation) than controlled ones for physical activity maintenance. This result aligns with research that shows that selfregulation (self-management) is effective for behavior change for a variety of health behaviors including physical activity initiation and maintenance.32,33 In summary, physical activity maintenance strategies should target individuals as well as their environment.
Table 6. Exercise Regulation Profiles of the 4 Physical Activity Groups Maintenance High Maintenance Moderate Increase in PA Decrease in PA PA Levels Average PA Levels Average Levels Average Levels Average (SD) (n = 37) (SD) (n = 33) (SD) (n = 37) (SD) (n = 20) Amotivation External regulation Introjected regulation Identified regulation Intrinsic regulation
0.28 0.53 1.86 3.36 3.23
(0.88) (0.89) (1.23) (0.78) (0.97)
0.11 0.45 1.56 2.92 2.46
(0.26) (0.60) (0.98) (0.60) (1.03)
0.25 0.50 1.64 3.00 2.68
(0.54) (0.89) (1.00) (0.73) (1.05)
0.20 0.34 1.25 3.01 2.88
(0.50) (0.46) (0.89) (0.73) (1.04)
Abbreviation: PA, physical activity.
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Physical Activity Maintenance in Hospital Employees With regard to the maintenance of the Wellness Challenge benefits, this study shows that the intervention helped hospital employees maintain a high level of physical activity as well as maintain a healthy BMI. Limitations This study does not include a control group. Future quasi-experimental research in the health care sector is needed to establish the determinants for the maintenance of physical activity among hospital employees.
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CONCLUSIONS The results of the current study revealed that identified and intrinsic regulations are important contributors to maintaining physical activity among hospital employees. This finding points to the importance of evaluating identified and intrinsic regulation within a physical activity intervention. Programs should also be put in place to increase self-determined motivation so that individuals maintain their level of physical activity over a long period.
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