Maintaining physical activity: lessons for educators.

Abstract: Despite the known risks of physical inactivity, a large proportion of the population lives a sedentary lifestyle. The purpose of this study was to understand how individuals maintain physical activity. Using a grounded theory approach, in-depth interviews were conducted with 15 individuals who had trained for at least one marathon. Findings demonstrated three major themes reflecting the elements participants perceived as important to maintaining physical activity. Themes included: a) a supportive environment, b) goal setting, and c) a focus on mental health. This study provides a basis for a potential future grounded theory aimed at the maintenance of physical activity.

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In 2000, in the United States, poor diet and physical activity accounted for an estimated 17% of total deaths (United States Department of Health and Human Services [USDHHS], 2004). The Centers for Disease Control and Prevention (CDC) has stated that a direct relationship exists between physical inactivity and coronary heart disease (USDHHS, 1996). Despite the known risks of physical inactivity, a large proportion of the population lives a sedentary lifestyle (USDHHS, 2004).

Because of the relationship between physical inactivity and various chronic diseases, several objectives of Healthy People 2010 were developed to increase physical activity (USDHHS, 2004). Numerous barriers to maintaining physical activity have been reported by the general public including time, seasonal and geographic influences, safety, increase in technology, structural factors, fatigue, lack of commitment, and access to facilities (Kohl & Hobbs, 1998; Guggenbuhl, 2004; Conn, Tripp-Reimer, & Maas, 2003; Marcus, Rakowski, & Rossi, 1992). Approximately 50% of individuals who initiate an exercise program will drop out during the first three to six months (Marcus, Rossi, Selby, Niaura, & Abrams, 1992). A consistent theme in current literature, however, is that an exercise program will be effective to alleviate serious medical problems only if it is regularly followed and that casual adherence does not seem sufficient to effect beneficial change in health (Litt, Kleppinger, & Judge, 2002). "It is important, therefore, to determine what factors are most predictive of adherence to exercise, particularly in the long term, if exercise regimens are to have their optimal effects" (Litt et al., p. 84).

Development of theory-based frameworks for health education programs is included as a competency for Certified Health Education Specialists. Numerous health education models/theories have been applied to physical activity, including the Transtheoretical Model of Behavior Change, the Theory of Planned Behavior, and Social Cognitive Theory (Janz, Champion, & Strecher, 2002, Maibach & Cotton, 1995; Montano & Kasprzyk, 2002; Prochaska, Redding, & Evers, 2002). Few of these models, however, have been applied to the maintenance of physical activity, and therefore, health educators attempting to apply these models/theories to initiation of physical activity most likely will struggle to keep program participants engaged over time. The basis of the Transtheoretical Model of Behavior Change is that individuals engaging in a new behavior move through a series of stages (Marcus, Rossi, et al., 1992; Marcus, Rakowski, et al., 1992). These stages include precontemplation, contemplation, preparation, action, and maintenance (Prochaska et al., 2002). Several studies have shown that people use certain processes when transitioning from the action stage to maintenance which include counter conditioning, helping relationships, and stimulus control (Prochaska). There is little literature to suggest, however, if these processes are still effective in maintenance of behavior change longer than six months.

Social Cognitive Theory also has been applied to physical activity. "Social Cognitive Theory (SCT) describes human behavior as being reciprocally determined by internal personal factors and the environment in which a person lives" (Maibach & Cotton, 1995, p. 43). Self-efficacy, which is included in Social Cognitive Theory, as well as several other models, refers to personal beliefs about how capable one is of performing a behavior that produces favorable outcomes (Bandura, 1997). Litt, Kleppinger, and Judge (2002) applied components of Social Learning Theory to initiation and maintenance of exercise behavior in older women. Results demonstrated that self-efficacy was a stronger determinant at 12 months than at initiation of physical activity. Rimal (2001) also studied longitudinal influences on exercise behavior and found that self-efficacy was a strong predictor of maintenance.

The Theory of Planned Behavior includes constructs that are concerned with an individual's motivational factors as determinants of the likelihood of performing a specific behavior (Montano & Kasprzyk, 2002). Stiggelbout, Hopman-Rock, Lechner, and van Mechelen (2005) applied an adapted planned behavior model that included Social Learning Theory and the Theory of Planned Behavior to predict exercise maintenance among older adults. Results demonstrated that to promote maintenance of exercise participation for older adults, programs must address preventing lapses, coping with lapses, and improving attitudes towards exercise participation in planning efforts (Stiggelbout et al., 2005).

Few studies have examined predictors of maintenance of physical activity beyond the six month time period. The purpose of this study was to examine the important elements in the maintenance of physical activity. For the purposes of this study, the definition of maintenance was based on the CDC's (2005) recommendation of 30 minutes or more of physical activity that increases heart and breathing rates for three to five days per week for at least a year prior to the study.

METHOD

The design for this study was qualitative using elements of a grounded theory approach. According to Jackson and Philips (2003), "qualitative research methods provide the best approach for collecting the lived experiences of participants in their own words" (p. 179). In this study, incorporating the language of study participants who have maintained physical activity allows readers to understand the experiences of those who have sustained physical activity. This understanding leads to findings that could realistically be applied to programs concerned with the maintenance of physical activity.

Grounded theory in qualitative research is a powerful tool used to identify theory that emerges from the researcher's observation and interviews in the real world rather than in a laboratory or other controlled environment (Patton, 2002). The intent of a grounded theory is to generate or discover a theory that relates to a particular situation (Creswell, 1998). Because one study of 15 participants may not lend itself to such a theory, this study was designed to provide a basis for future studies aimed at developing a theory for maintenance of physical activity.

INSTRUMENT

In-depth interviews with questions derived from two pilot studies were conducted. The first pilot study identified major considerations with regard to initiating and maintaining physical activity. Questions were drafted and tested with a second pilot study to determine if they would bring the rich description needed to describe participants' experiences consistent with grounded theory development. Questions were revised based on these pilots and continued to be revised throughout the study. Data collection and analysis were not linear, but rather continuous and flexible. Consistent with a grounded theory approach, the primary researcher began with a set of interview questions, conducted and analyzed a set of five interviews, formed a tentative interpretation, and then compared this interpretation with related literature (Strauss & Corbin, 1998). Specific areas that needed more exploration or confirmation were addressed in the next set of interviews (Strauss & Corbin).

PARTICIPANTS

The study sample included 15 individuals who had initiated training for at least one marathon. While it may appear that individuals who train for a marathon are not "average," they share with non-exercisers common barriers that must be overcome to maintain motivation and self-efficacy (Marcus et al., 1992; Masters & Ogles, 1995). Marathon runners also present a convenient group for exploring factors related to maintenance of physical activity and have obvious experience with goal setting, self-efficacy, motivation, and maintenance of physical activity.

Upon receiving human subjects' approval, a purposive, snowball sampling method was used to identify participants who belonged to running groups in two states. Participants were obtained from email contact through various websites. Once interviewed, participants were asked to identify additional runners who would qualify for the study. While this sampling method reduced generalizability of findings, it helped identify individuals who provided information that developed and conceptually linked emerging categories (Krefting, 1999).

Three participants who were part of the second pilot study were included in round one of interviewing because of the relevant descriptions their interviews provided. Ten participants were female. Participants' ages ranged from 24 to 52 years, with a mean age of 37.4 years. Fourteen participants were either married, dating, living with a significant other, or engaged. Seven participants had children living at home. Thirteen participants worked outside the home while two were stay-at-home mothers. All participants considered themselves average people with jobs, families, and other time commitments. In this way, the sample is reflective of past research with regard to barriers people report as hindering them from regular physical activity (Marcus et al., 1992; Masters & Ogles, 1995).

DATA ANALYSIS

Typically, in qualitative research, terms such as validity and reliability are not used. Rather, the term "trustworthiness" is used to establish confidence the researcher has in the truth of the findings (Krefting, 1999). The following steps were taken to increase trustworthiness. All interviews were audio recorded and transcribed verbatim. Open coding began by marking with italics passages relevant to elements participants perceived as important to maintenance of physical activity. To establish credibility (parallel to internal validity), member checking was used. Marked transcripts were sent via email to participants for review. Participants then were asked to expand, delete, or add any information they felt was important.

To further increase credibility, peer review was used. The primary researcher derived tentative thematic categories from italicized passages and assigned a symbol for coding purposes. Tentative categories, their symbols, and transcripts then were sent to three peer reviewers who were trained in the process of coding interview data (i.e., successful completion of a doctoral level interview methods course). Peer reviewers coded the transcripts using the tentative categories as a guide. If the peer reviewers felt that additional categories were warranted, they were free to identify them within the transcript.

To increase consistency (parallel to reliability), the primary researcher recoded transcripts using the tentative categories. The researcher's recoded transcripts were then compared to coded transcripts from the peer reviewers. Passages were determined to fit into a category if three of the four reviewers coded them as such.

Three rounds of interviews with five interviews in each round were conducted. Because of the nature of grounded theory and the revision of questions based on tentative analysis of the interview, interview questions were revised after each round of interviews based on deeper exploration of the established categories determined by peer review and code-recode. Deeper exploration also was determined based on a review of relevant studies regarding physical activity. Once thematic categories were determined in round one and used to revise interview questions in round two, axial coding began in which the researcher began to derive sub-categories from categories. Through this process, themes were established which are described in Table 1.

Confirmability (parallel to objectivity) was established through the use of researcher reflexivity. Being a former marathon runner, the primary researcher was considered an insider (i.e., someone having shared the phenomenon of the sample). To avoid bias, the researcher reflected upon her role through use of extensive journaling to capture ideas and explore relationships among categories emerging from the data. She then compared data in her journal with actual transcript data to confirm that determined categories were based on participant experiences and not her own. Through this constant comparison, coding was verified and saturated while themes emerged (Jack, DiCenso, & Lohfeld, 2005). Researcher reflections are included in the findings section to assist in describing this sequence of events.

The search for disconfirming evidence was a final measure used to increase confirmability. Transcripts were read again in search of evidence that either confirmed or disconfirmed established themes (Creswell & Miller, 2000). While one or two instances occurred in which a particular experience did not fit into an established theme, confirming evidence was the norm. Resulting themes were used to provide an understanding of maintenance of physical activity incorporating the language of study participants. Results of this study then were sent via email to study participants for their review and approval. In this way, findings were credible, dependable, and represented the language of study participants.

RESULTS

Interview data revealed three major themes, or elements, perceived as important to maintenance of physical activity. These themes were: a) a supportive environment, b) goal setting, and c) a focus on mental health.

A SUPPORTIVE ENVIRONMENT

Initially, accountability and obligation started to emerge in this area when coding transcripts during round one based on the role running partners and coaches played in participants' experiences. Participants revealed, however, the significant role non-runners played in maintenance of such an endeavor as training for a marathon. As questions were revised for round two, distinctions emerged between accountability and support and a need for socialization. A sense of belonging and camaraderie emerged as contributors to "relationship building" as a motivation for continuing to run. All the various sectors of individuals present in these runners' lives contributed to a supportive environment.

"I suppose it was a peer group thing," said Adam, a 31-year-old engineer who was training for his first marathon, "We did our long runs together and tailored our noon time, lunch time runs." Thirty-four-year-old Beth, a married mother of two, agreed. "Doing it with a friend, we bounced the positive energy off each other. If one was having a bad day, we'd say, 'Oh, we can do this.' That helps a lot."

To 32-year-old Bridget, with a family and career, relationship building was the incentive to her maintenance of a running routine.

   [What I remember most about my early
   running days] was just developing a really
   good friendship with my training partner. I
   didn't expect that at all. I thought it was going
   to be work. But, with her, we kept a really
   good pace and we chatted the whole time. And
   she was very encouraging. She would always
   say 'Of course you can do it.' The social part
   of it ... really helps me keep going. I would
   say some of my closest friends are my running
   friends.

Nearly half of participants joined an established running program to meet others who were runners. Socialization and relationship building was the attraction to belonging to such a group. Fifty-two-year-old Jan discussed such a group.

   As far as staying with it, I think the team
   aspect and the friendships that you build
   and the camaraderie on Saturday morning is
   something you can't get anywhere else. People
   will go through [a training] program ... [and]
   when it's finished you realize that you're going
   to lose constant contact with a group of people
   that have become in some ways closer to you
   than your own family. When you're out there
   for 18 weeks running next to someone you
   talk about things that you might not talk
   about with people that you're living with ...
   that's a lot of what brings me back.

Male participants also discussed socialization and friendships as they pertained to group runs. Gary, a 43-year-old husband and father, said, "It's a different relationship with those people because ... it's two hours, three hours ... those long runs are long, and we ran them where we could talk. And I can still remember specific conversations. I mean those [were my] guy friends but they weren't my best friends. But, some of the stuff we got into was some of my best friend talk."

The support of family and friends who were non-runners was just as vital to the success of some participants as having running friends. Jennifer, a 33-year-old, stay-at-home-mother with two children, described support she received from family that was vital to her ability to maintain her training program.

   My husband doesn't understand. He doesn't
   quite get it but he's very supportive ... he'll do
   anything to help me to be able to run on the
   weekends. I'll say [to him] gosh, the bathroom
   needs to be cleaned ... thanks for not saying
   anything. Thanks for not complaining about
   it. And he's like, "I know you're busy taking
   care of the kids and you have to work out ...
   I know you'll do it, you'll get to it." And then
   sometimes he'll surprise me and do it.

The desire to be role models for their children was a significant motivator for some participants. Creating an environment of being physically active, for example, was important in Jerry's household.

   I think I want to help [my son] be the best
   that he can be ... to see that all these things
   he's doing right now ... there's no rule that
   after high school's over you've got to quit being
   physically active. I want him to feel good about
   physical activity [and know] that he can be in
   shape for his whole life and I think that will
   help him have a better quality of life.

GOAL SETTING

Setting a goal to increase motivation seemed obvious and the feeling of accomplishment at completion of this goal is a feeling marathoners know well. The participants' ability to recognize increased confidence in other areas of their lives appeared to be a separate category and one which seemed would evolve under a "self-efficacy" theme. While increased self-efficacy could arguably be a theme, as interviewing continued, increased confidence become more closely related with accomplishment of goals. As a result, increased confidence became a sub-category of goal setting. Jerry was a 42-year-old husband and father.

   I like to have a long-term goal to work towards,
   whatever it is. It helps me feel like there is
   a purpose to what I'm doing. Even though
   I can't sit back and [say] I've contributed to
   mankind in some way ... it does give me a
   reason, because everyday you've got to get out
   there and put in the miles. It's real easy to say
   I don't want to [run] today because my toe
   hurts or whatever and having that sort of
   underlying [goal] helps you to keep focus.

Gary emphasized, however, that the goal should not be weight loss. "I think we, as a group, tend to get too focused on weight ... I think if it's completing an event as opposed to just losing weight, that worked for me." Joe, a 24-year-old college student, training for his first marathon, agreed. "If you focus on losing weight, then you're going to give up anyway instead of sticking with it. So, you have to have alternate goals ..."

Accomplishment of goals also become more directly related to making running a priority and part of a healthy lifestyle. As running became a habit for participants, they adopted an identity of someone who was physically active. This identity then reflected back on their refinement of goals. Todd, a 30-year-old engineer, discussed his family history as it related to his desire to be physically active.

   I was probably a sophomore in college [when]
   my dad first had the symptoms of a rapid
   and irregular heartbeat. He ended up in the
   hospital for probably about two or three weeks
   and basically he's been struggling ... ever since.
   But, seeing what he had to go through ...
   kind of shocked me into thinking am I doing
   everything right in my life? Am I taking all
   the proper steps to at least have things in my
   favor?

Sandy, a 53-year-old wife and mother, agreed. "I need to exercise. I want to be physically active when I'm 70 years old. I see people who are decrepit and old and can't move around and I don't want to be in that category. I want to be able to do things with my grandchildren. I mean, just look around, too many people just let themselves go and I don't want to do that."

MENTAL HEALTH

Mental health had different meanings to different participants. Running alone meant spiritual time and problem solving for some. Socialization became an avenue for stress relief and problem solving for others. For many participants, feeling strong and healthy contributed to better moods and lack of running was quickly noticed by family and friends. A focus on these aspects was key to motivation with participants regardless of their personal meaning of mental health. Therefore, mental health became a broad theme that encompassed all of these motivators.

Kay, a 52-year-old wife, mother of two, and career woman began her story with the time her first husband divorced her. She had two small children, was jobless, and was without reliable transportation.

   I think I was kind of high strung; a single
   mother of a six and eight [year old] with
   a limited income. So many major things
   happened to me in one year that shouldn't
   happen to people all at once. Newly divorced,
   I bought this little bitty house, a new car, then
   a full-time job all at the same time. I found
   running shortly afterwards. I think I was a
   better parent because I ran. My kids are 20
   months apart and my daughter had a terrible
   time being an adolescent. We got through a lot
   of things because I didn't just freak out and
   beat on them. I ran all that stress out. I've
   become a much more calm person. I think I
   was saved somehow by running.

Jan said, "That's my alone time and my way of getting my day in perspective. It's amazing what it will do for your head. You can solve all of your problems in an hour ... I found myself solving other people's problems because I'd gone through all of mine."

Male participants also discussed using running as time to improve mental health. "That's where I have my best thoughts, when I'm running." Gary said. "I can work things out in my head better. I think your mind goes over a lot of different things and that goes back to what I enjoy about running. It can be a work problem, it can be trouble you're having with your wife, it can be goals and dreams."

Beth, a 34-year-old stay-at-home mother of two young children, discussed her depression following the birth of her second child. A recommendation from her doctor guided her in the direction of physical activity. Beth said, "I just felt like I needed something more. I stay at home and I think I was looking for something to get me out of the house for myself. I started exercising everyday, just [running] a mile or two on the treadmill. I needed some type of goal ..." After completing her first marathon, Beth described the change in her self-perspective.

   I have self-confidence ... feeling like I'm worth
   something. I feel so much better about myself
   and I really want to do another [marathon]
   because I felt it was really worth the training.
   For a mom who stays at home, it's my outlet,
   my motivation, and it's really just helped me
   with my self-confidence.

Health professionals, as well as society, tend to focus on physical aspects of physical activity. Similar to studies regarding initiation of physical activity, an emphasis on mental health, such as enhanced confidence, feeling good about oneself, and stress relief, sustained participants' motivation (Marcus, Rakowski, et al., 1992).

DISCUSSION

For health education efforts to be effective in meeting the goals of Healthy People 2010, health educators must find ways to engage participants for extended periods of time. Health educators must not limit themselves to promoting programs that increase initiation of physical activity, but rather should place more emphasis on maintenance. At initiation of behavior change, practitioners might employ methods such as teaching participants how to develop a supportive environment, to focus on mental health, and to set achievable goals, that may contribute to maintenance of these behaviors over the long haul.

While training for a marathon may not be considered "average," study participants were all individuals with families and careers and numerous time commitments. What better people to learn from than those who have accomplished what we are studying? Participants' messages were about surrounding themselves with motivation (i.e., people who were passionate about physical activity). Thus, an important lesson for practitioners is to address the importance of establishing a supportive environment to keep participants engaged. Health educators can facilitate this process by being a resource for local gyms or running groups, enlisting the help of family, co-workers, and friends, and helping participants strengthen their support systems.

Other implications for health education include incorporating both short- and long-term goal-setting into programs aimed at maintaining physical activity from the beginning of the program. This study corroborates research recommendations that practitioners assist participants in setting realistic, achievable goals to increase motivation and self-efficacy (Maibach & Cotton, 1995). Furthermore, continuing to refine and re-evaluate goals once achieved kept these participants motivated over a sustained period of time. Focusing on the mental benefits of physical activity rather than just the physical aspects is also an important element for practice.

Several models and theories have been tested and proven successful in behavior change programs. However, these prior models focus primarily on the initiation of change. Looking at new ways of combining constructs of existing models/theories to describe the process of physical activity maintenance would aid health educators in assisting clients in developing a lifestyle of physical activity and contribute to the use of theory in the field. Consider, for example, if educators included the following constructs of several models/theories:

* Creating a supportive environment by enlisting support from exercise partners, spouses and significant others, and exercise groups/classes/clubs/gyms (i.e., Social Cognitive Theory); and gaining the approval and support of significant others and surrounding oneself with others who exercise to capitalize on the subjective norm (i.e., Theory of Planned Behavior).

* Setting goals with concrete, achievable objectives that are celebrated along the way. Focusing on the short-term goal increases motivation and commitment. Emphasizing accomplishment of goals increases self-efficacy. Improved self-efficacy increases perceived control over one's environment and circumstances (i.e., Theory of Planned Behavior).

* Helping participants focus on more than just the physical benefits of physical activity by incorporating improved mental health as motivators, which will then influence positive attitudes towards physical activity (i.e., Theory of Planned Behavior, Transtheoretical Model).

As mentioned, one study does not typically lend itself to a true grounded theory, especially with 15 participants. Therefore, further studies are warranted with other forms of physical activity and with non-marathoners and broader samples. Further analysis is needed to differentiate between those participants who are no longer maintaining physical activity after completion of a marathon and those who are. Finally, additional studies should attempt to combine and/or test elements of existing models and theories with regard to maintenance of physical activity. Combining constructs of models, such as the Theory of Planned Behavior and Social Cognitive Theory, could help develop specific processes used to maintain physical activity, which then could contribute to the Transtheoretical Model's maintenance stage of behavior change. In this way, health educators can contribute to development of theory-based frameworks that could guide planning efforts and ensure successful health education programs.

Based on findings from this study, goal setting increased commitment to physical activity as well as a sense of accomplishment and confidence. A supportive environment such as running groups and enlisting the help of family and friends provided motivation to keep participants engaged. Participants who maintained physical activity focused on mental benefits as opposed to only physical benefits. Health educators could incorporate any and all of these elements into programs designed to maintain healthy behaviors. The study also provides a basis for future studies aimed at developing a theory of maintenance of physical activity.

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RESPONSIBILITIES AND COMPETENCIES IN HEALTH EDUCATION

Responsibility II--Planning Effective Health Education Programs

Competency B: Develop a logical scope and sequence plan for a health education program

Sub-Competency:

1. Develop a theory-based framework for health education programs

Kerry Whipple, PhD, CHES, is an Assistant Professor of Health Education in the Department of Health and Applied Human Sciences at the University of North Carolina Wilmington. Joyce Fetro, PhD, CHES, FASHA, is a Professor of Health Education in the Department of Health Education and Recreation at Southern Illinois University Carbondale. Kathleen Welshimer, PhD, MSPH, is an Associate Professor of Health Education in the Department of Health Education and Recreation at Southern Illinois University Carbondale. Judy Drolet, PhD, CHES, FASHA, is a Professor of Health Education in the Department of Health Education and Recreation at Southern Illinois University Carbondale. Please address all correspondence to Kerry Whipple, PhD, CHES Department of Health and Applied Human Sciences, University of North Carolina Wilmington, 601 S. College Road, Wilmington, NC 28412; PHONE: [phone]; FAX [phone]; EMAIL: [e-mail].

Table 1. Explanation and Categorization of Themes

                                                  Final themes with
                                                  subcategories derived
Tentative category                                by agreement between
derived by primary                                three of four peer
researcher               Explanations             reviewers

Support/influence        Significant others       Supportive
from significant         included training        environment:
others                   partners/coaches,        Significant others
                         understanding/           Accountability
                         supportive family
                         Social time

Mental health            Mental health defined    Focus on mental
                         as stress relief,        health: Stress relief
                         problem solving, mood    Mood enhancement
                         enhancement, taking      Problem solving
                         time for oneself,        Increased self-esteem
                         spirituality

Health as a priority     Priority defined as      Lack of agreement
                         weight control,          from peer reviewers;
                         better sleep, more       removed as theme
                         energy

Goal setting             Goal setting             Goal setting:
                         increased motivation     Increased motivation
                         Achieving goals led      Refining of goals
                         to refinement of         Competition
                         goals and increased      Sense of
                         confidence               accomplishment
                         Competition served
                         as motivator

Sense of identity        Identity defined as      Lack of agreement
                         personal empowerment     from peer reviewers;
                         and finding a niche'     removed as theme
                         Filling a void
                         Role modeling for
                         family