Transcript Taking exercise psychology into public health research and practice

AASP 2012
Exercise psychology keynote address
Taking exercise psychology
into public health research and
practice
Ken Fox PhD FFPH
Emeritus Professor,
Centre for Exercise, Nutrition and Health Sciences
University of Bristol
Post Graduate
Centre for Exercise, Nutrition and Health
Sciences,
University of Bristol 1999-present
MSc in Nutrition, Physical
Activity and Public Health
Research into biomedical,
psycho-social,and
socio-environmental
aspects of activity
and nutrition
The mediating role of the self
Well-being
Self
Exercise
The development and preliminary validation of the Physical Self-Perception Profile,
Journal of Sport and Exercise Psychology, 1989
The Physical Self: From Motivation to Well-Being. Human Kinetics, Champaign,IL ,
1997
Presentation outline
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Public health and its development
Exercise psychology in public health
Working in the world of public health
Working in the commercial sector
Opportunities for exercise psychology
Public health and its development
Earliest public health epidemiology
Problem:
Cholera spreading in London (1853-4)
Thought to spread through ‘bad’ air or miasma
But Dr John Snow suspected something different
Death Rates From Cholera
1853-54
Water
Company
Southwark
& Vauxhall
Lambeth
Rest of
London
Number of
Houses
Deaths From
Cholera
Deaths per
10,000 Houses
40,046
1263
315
26,107
98
37
256,423
1422
59
Simple and cheap
solution?:
Remove the handle from
the Broad Street pump.
This ended the epidemic
Original Broad Street with pump
Not much to do with psychology?
UK Public Health Association:
Definition of public health
• an approach that focuses on the health and well being
of a society and the most effective means of
protecting and improving it
• encompasses the science, art and politics of
preventing illness and disease and promoting health
and well being
• addresses the root causes of illness and disease,
including the interacting social, environmental,
biological and psychological dimensions, as well as
the provision of effective health services
Kmietowicz, Z. BMJ 2003;327:68
Reducing health inequalities:
Implications for studies and policy
1. Must focus on the health needy sector of the
population
2. Convenience sampling is out of the question
3. Have to show that you have recruited the
difficult to reach sector to your intervention
4. If not you are at risk of increasing
inequalities!
Foresight report into obesity (2008)
Modern diseases have multiple
causes that need multiple solutions
Societal influences
Individual
psychology
Food Production
Individual
activity
Food
Consumption
Biology
Activity
environment
Societal influences
Individual
psychology
Food Production
Individual
activity
Food
Consumption
Biology
Activity
environment
Biological and cultural
mismatches to the westernised
environment
FOOD
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Strong signals to eat
Weak signals to stop
Increased availability
Eating is rewarding
No viable alternatives
Eating well is high
status
ACTIVITY
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Weak activity signal
Strong signals to stop
Reduced availability
Inactivity is rewarding
Inactivity is a viable
alternative
• Inactivity is high status
Hippocrates (400 BC)
“Eating alone will not keep a man well:
he must also exercise. For food and exercise
while possessing opposite qualities, yet work
together to produce health.
It is necessary….. to proportion exercise to
the bulk of food, to the constitution of the
patient and the age of the individual”
First clinical episodes* of
CHD in male central London
bus drivers and conductors
aged 35-64, 1949-1950
No. of
cases
Age standardised
Rate per 1000 p.a.
Drivers
80
2.7
Conductors
31
1.9
*Angina, MI, CHD mortality
Professor Jerry Morris et al.,
Lancet 1953
59 years ago!
A Tribute to Professor Jeremy Morris (1912-2010):
The Man Who Invented the Field of
Physical Activity Epidemiology
Steven N. Blair, George Davey Smith, I-Min Lee,
Kenneth Fox, Melvyn Hillsdon, Robert McKeown,
William L. Haskell
American Journal of Epidemiology (2011)
"We in the West are the first generation in human history in which
the mass of the population has to deliberately exercise to be healthy.
How can society's collective adaptations match?" (Jerry Morris, 2009)
Health behavior is simply a case of
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Being informed ?
Making intelligent choices ?
Having positive attitudes ?
Making health a priority ?
A nudge in the right direction? (Thaler and Sunstein, 2008)
Nuffield intervention ladder of policy
approaches to behavior change
Eliminate choice
Restrict choice
Guide choice by disincentives
Guide choice by incentives
Guide choice by changing default policy
Enable choice
Provide information
Do nothing
Legislation
Brockman, R., Fox, K.R. (2011). Activity promotion by stealth not health ?
The potential health benefits of a workplace transport plan. Public Health.. 125, 210-216
A Taxonomy of Behaviour Change Techniques use in Interventions
Abrahams & Michie, Health Psychology, 2008
The behaviour change wheel: A new method for characterising and designing
behaviour change interventions
Michie, van Stralen, West . Implementation Science, 6, 2011.
The need for a stronger focus on behavior
change strategies is finally being recognised
• National Prevention Research Initiative (4 phases)
• Lifelong Health and Well-Being Initiative
• NIHR Public Health section
Show us you that you can produce long term change in
health behavior in a way that might be replicated in the
community
Exercise psychology and physical
activity for health
Popular theoretical frameworks featured
in exercise psychology
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Attribution theory
Theory of planned behavior
Self-efficacy theory
Self-perception models
Achievement goals theory
Goal setting theories
Health belief model
Transtheoretical model
Health action process approach
(Biddle 1994, 2007. 2011)
Systematic reviews of reviews of intervention components associated with
increased effectiveness in dietary and physical activity interventions
Greaves, Sheppard, Abraham, Hardeman, Roden, Evans, Schwartz, IMAGE Study
Group, BMC Public Health (2011)
Evidence to support the following strategies:
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Providing instruction
Establishing self-monitoring
Relapse prevention techniques
Goal setting
Individual tailoring (for PA)
Time management techniques
Encouraging self talk
Use of pedometers
Motivational interviewing
Challenges in the application of theory to
activity interventions
• For public health application we need to be theory
users
• We need strategies that change constructs that
clearly emerge from theories
• Testing theory means seeking evidence of which
constructs mediate change in behavior
• Often need a menu of ‘best bet’ strategies that derive
from several theories
• Measurement opportunities are very limited in
public health settings.
Importance of measurement of
processes and product
Motivational
theory
Self-perception theory
Target
construct
Physical self-perceptions
Intervention
strategy
Confidence building
through incremental success
Effect on
behavior
Adherence to
exercise program
Deep-seated drivers of human behavior
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Unconditional love and regard
Competence
Autonomy and control
Significance and importance
Affiliation, relatedness and belonging
(Rogers, 1951; Epstein, 1973; Campbell, 1984; Baumeister,
1993; Cloninger, 1994; Deci & Ryan, 1995;)
Self-determination theory (SDT)
Deci & Ryan, 2001
The self as the agency of change
Perceived autonomy drives long term
behaviors
The self drives attempts to satisfy needs
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Need to feel autonomous and in control
Need to feel competence and confidence
Need to feel relatedness and belonging
Key SDT strategies
• Language changes from instruction and prescription to
facilitation
• Increase participant competence and confidence through
incremental mastery goals
• Engage participants in choice decisions and encourage
ownership “you made it happen”
• Build behaviors into a new identity
• Maximise the social benefits including belonging, support,
and contribution
• SDT fits well with motivational interviewing, some aspects
of CBT, self theories, achievement goals theory (task v
ego)
Motives evidence
• Mental benefits
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Improved mood
Improved subjective well-being
Reduced anxiety and tension
Improved physical self-perceptions
Social affiliation and interaction
Physical activity and psychological well-being
Biddle, Fox, Boutcher (2000) Routledge
Intrinsic-extrinsic continuum
Intrinsic
(emersion?)
Pleasure
Extrinsic
(coersion?)
(persuasion?)
Competence
Weight loss
Payment
Mastery
Autonomy
Fitness
Body image
Mood
Friendship
Competition
Status
Prize
Other theories worth considering or revisiting?
“Should I go or should I stay” The Clash theory
Personal investment theory (Rusbult and Farrell, 1983)
Commitment theory (Scanlan 1993)
Moreira, H, Fox, K.R., & Sparkes, A.C. (2002). Job motivation profiles of physical
educators. British Educational Research Journal, 28, 845-861
Habit theory (Verplanken, 1993, 2008)
Social learning theory (Bandura)
confidence building
modelling as a means of inspiring others
Exercise psychology
Key questions:1. How do we increase exercise and sport
participation among the population?
2. How does exercise and sport influence
mental health and well-being?
Mental health
and well-being
Participation
and
performance
Mental health
PHYSICAL
DISEASE RISK
Prevention
MENTAL
ILLNESS
Treatment/therapy
COGNITIVE
FUNCTION
MENTAL
WELL-BEING
Public health relevance
• Prevalence of suffering
– % of population
• Burden of suffering
– Mortality and morbidity
– Human costs – QoL and well-being of sufferers and carers
– Economic costs – health and social care, productivity
• Potential for reduction of suffering
– Feasibility
– Cost-effectiveness
Physical activity and risk of dementia
Abbott (2004) Male
Andel (2008)
Carlson (2008) Male
Fabrigoule (1995)
Hebert (2000) Male
Hebert (2000) Female
Larson (2006)
Laurin (2001) Male
Laurin (2001) Female
Podewilis (2005)
Ravaglia (2008)
Rovio (2005)
Simons (2006) Male
Simons (2006) Female
Wang (2002)
Yoshitake (1995)
Combined
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risk ratio
1
1.5
Physical activity is associated with lower risk of premature cognitive decline,
dementia and Alzheimer’s disease: Systematic review and meta-regression analysis.
Kenneth R Fox, Neha Khandpur, Rod Taylor , Mark Davis
Exercise training increases size of
hippocampus and improves memory
Erikson et al. (2011) Proc Nat Acad Sci, USA
• 120 older adults without dementia assigned to
intervention and control
• Moderate intensity aerobic exercise 3 days per
week for 12 months
• Size of hippocampus (anterior) increased 2% in
exercise group and decreased 1.4% in stretching
control
• Change was related to change in aerobic fitness
Exploring the effects of exercise and brain
stimulation on brain plasticity
(Funded by Wellcome Trust and NIHR)
NIHR Biomedical Research Unit
University of Oxford
Heidi Johansen-Berg, Claire Mackay,
Helen Dawes, Ken Fox et al. (2012-17)
Objectives
1. Improve sensitivity of fMRI measures
2. Identify key changes in brain structure and function
3. Assess effects of frequency, intensity, duration, setting, and
concomitant conditions of exercise?
Breaking the decline spiral in older age
Today’s best buy in public health?
Sedentary and low activity habits
Decline in physical and cognitive function
Increasing isolation and loss of independence
Accelerated biological ageing / subclinical disease
Chronic disease development and huge care costs
Premature death
Cost and
suffering
Working in the world of public health
research and practice:
A few lessons learned
1. Developing partnerships and networks to
create sequences of research
Research councils require:
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Multidisciplinarity
Service providers, agencies and user involvement
That your work has IMPACT
Older people and active living
Research partners:
Geographers
Planners
Economists
Sociologists
Local authorities
Primary care trusts
Older adults
Socio-ecological models
Research with older adults……..
• 2003-5 Better Ageing - EU funded intervention
• 2006-9 Project OPAL – NPRI funded descriptive study
using objective measures
• 2009-10 AVONet – LLHW funded collaborative
network
• 2010-11 OPAL-PLUS – 3 yrs on – Dunhill Medical
Trust
• 2012-14 Project ACE
• 2012- Projects ENABLE, HABIT and PALS?
Avon Network for the Promotion of Active Ageing
in the Community (AVONet) 2009-10
Lifelong Health and Well-Being Collaborative Network
3 universities, local councils, service providers, older people
themselves
Aim:
Identify ‘best bet’ solutions to physical activity promotion for older
adults
Network activities over 12 months
• Reviews of formal and grey literature
• Three day-long workshops
– Structured exercise/physical activity interventions for
older people living in the community
– Lifestyle and environmental interventions targeting older
people living in the community
– Best bet strategies for physical activity promotion in
older adults in the Avon region
• Guidance report for commissioners of services and
activity coordinators
• Two grant proposals for interventions
Lesson learned
Managing networks
Helping all parties feel valued
Getting buy-in
Servicing the needs of all parties
Communicating objectives
Regular updates
Celebrating outcomes
Lessons learned
• Logical sequences of research increase credibility
• Establishing strong and stable core teams is effective
• Successful partnerships:
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Increase credibility for further grants
Improve intervention design
Provide strategies for recruiting health needy populations
Provide networks for recruitment of participants
Ground interventions in the reality of local challenges and
the needs of the population
Working in the world of public health
research and practice:
2. Recognising different priorities and
questions in public health
Moving from efficacy to
public health effectiveness
• Does physical activity work? - efficacy trial?
• Does it work for those who need it most?–
feasibility and recruitment studies?
• Does it work in the delivery system? - pragmatic
trial?
• Is it actually being delivered adequately?
• Is the effect worth the public investment – cost
effectiveness, cost comparison?
EFFICACY and PROOF of CONCEPT
Physical
activity
Health outcomes
INTERVENTION
PACKAGE:
Application of regime to
increase activity
Psychosocial
states and
conditions
Physical
activity
INTERVENTION
PACKAGE:
Behavior change strategies
Theoretical framework and
evidence base
Health
outcomes
Recruiting
the target
population
Psychosocial
states and
conditions
Activity and
eating behaviors
INTERVENTION PACKAGE:
Recruitment strategies
Behavior change strategies
Theoretical framework and
evidence base
Health outcomes
PUBLIC HEALTH SERVICE
INTERVENTIONS
A Pragmatic Randomised Controlled Trial
to Evaluate Physical Activity as a Treatment
for Depression
Chalder, M., Wiles, N.J., Campbell, J., Hollinghurst, S.P., Haase,
A.M., Taylor, A.H., Fox, K.R., Costelloe, C., Searle, A., Baxter, H.,
Winder, R., Wright, C., Turner, K.M., Calnan, M., Lawlor, D.A.,
Peters, T.J., Sharp, D.J., Montgomery, A.A., Lewis, G. (2012).
Facilitated physical activity as a treatment for depressed adults:
randomised controlled trial. British Medical Journal. 344:e2758 doi:
10.1136/bmj.e2758
Primary Care, Social Medicine, Exercise, Nutrition and Health Sciences,
University of Bristol and Exeter
Intervention components
• Delivered by a visiting primary care physical activity
facilitator (PAF) trained in counselling and motivational
interviewing techniques
• 4 face to face sessions and up to 10 phone sessions
• Based on self-determination theory and targets
– Confidence building (incremental goal setting)
– Autonomy and independence (driven by the patient)
– Activity preference/choice rather than prescription
– Support (the PAF and significant others)
Haase, A.M., Taylor, A.H., Fox, K.R., Thorp, H., Lewis, G. Rationale and development of the physical
activity counselling intervention for a pragmatic Trial of Exercise and Depression in the UK
(TREAD-UK). Mental Health and Physical Activity. November 2010 issue.
Recruiting
the target
population
Psychosocial
states and
conditions
Did we recruit the right people?
Did we retain them?
Which bits worked for participants?
What did the professionals feel?
Was the intervention delivered?
Which bits actually made a difference?
How does this affect future trials?
Physical
activity
INTERVENTION PACKAGE:
Recruitment strategies
Behavior change strategies
Training strategies
Theoretical framework and
evidence base
Health outcomes
PUBLIC HEALTH SERVICE
INTERVENTIONS
Results and outcomes
• No evidence of impact on symptoms of
depression (BDI)
• Heavy media coverage stating that “exercise
is no good for depression”
• Evidence of small increases in physical
activity in intervention group sustained at
12 months
• Currently looking at mediators of activity
Lessons learned
• Be really careful when presenting results to the
media
• There is plenty to learn from RCTs even if the
results aren’t what you want
• Exercise psychology needs to produce construct
measures that are brief, understandable, and
have diagnostic properties
Working in the world of public
health research and practice
3. Importance of feasibility and
recruitment strategies research
Feasibility studies: Research questions
• Intervention refinement using professionals and
potential users – what is acceptable
• What is the recruitment rate using different
strategies?
• What is the burden of the measurement load
• What are attendance and completion rates?
• What are participants reactions to intervention
elements
• Estimates of outcome variances, basic costs
Project ACE:
Active, Connected, and Engaged (LLHW)
24 month feasibility study
• Neighbourhood based to encourage getting out
and about
• Paid neighbourhood champions (ACE
coordinators)
• Unpaid volunteers (ACE activators) (n=20)
• ACE participants (n=100)
All three roles to be evaluated in terms of activity
and well-being effects
Current feasibility or recruitment studies
• TEAMPLAY - parenting program for increasing activity in 7-8
year olds
• ACTION330 - teaching assistant led after school program to
increase activity in 11-12 year olds
• FIT and FAB – recruiting hard to reach into activity interventions
Lessons learned
• Smaller projects needing less funding
• A great starting place for early career researchers
who want to get an idea going
• Starting place for building a program of research
• Now seen as necessary before RCTs are funded
• Qualitative and quantitative methods needed
• Results are publishable and valuable
Working with commercial organisations
to increase physical activity for health
and weight management
Partnership with a commercial weight loss company
(SlimmingWorld) to promote physical activity
Benefits:
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Genuine desire to upgrade emphasis on physical activity
Access to large numbers (500,000) on a weekly basis of a
healthy needy population who are
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overweight/obese,
low SES
low activity levels
Experienced marketing machine
Know their population, how to get their attention, and
how to talk to them
Challenge
• Facilitate more positive attitudes towards
physical activity and its benefits
• Provide a system that will facilitate
sustainable increases in physical activity
• Deliver it through 1 x 90 minute class/wk
by non specialists and with support from
booklet, recognition system, web-based
support, magazine articles
Theoretical framework
• Self-perceptions, self-esteem and identity
• Positive health motives
– Improved mood and well-being
– Free time and relaxation
– Improved physical self-perceptions
– Social affiliation and interaction
• Modelling by similar models
• Evidence-based behaviour change strategies
Commitment to physical activity
Exercise
Education
Expectations
Expertise
Experience
Efficacy
Behavioural
commitment
Strategies
Support systems
Psychological
commitment
Exercise
adherence
Intrinsic
commitment
Personal identification
Intrinsic rewards
Mental well-being
Fox, K.R. (1992). A clinical approach to exercise in the markedly obese. In
T.A. Wadden & T.B. Van Itallie (Eds.). Treating the severely obese patient (pp
354-381). New York: Guilford Press
Meet five Slimming World
members who have lost weight
and learned to love exercise.
‘We’re
exercise
converts
Here they share the Body Magic
moves that work for them
Together
we’ve lost
more than
16st
Beth Fraser, 65, is retired and has lost 6st at
Christine Warren’s Slimming World group in
Alexandria, Scotland How did you discover
your healthy heart class?
Six years ago, I had a heart attack caused by the
high blood pressure I’ve had since I was 21. I
heard about the healthy heart class through the
cardiac rehabilitation programme at my local
hospital and it seemed like the ideal way to keep
fit.
What do you like about it?
It’s a fun, circuit-based routine which we take at
our own pace. After warming up, we split up into
small groups and work our way around each
‘station’ doing a variety of aerobic and strength
exercises, from hand weights and stretching to
stepping and shuttle walks – or, as in my case
now, runs! I’m even going to do a couple of charity
runs this year and
I never thought I’d say that!
Is Body Magic being delivered well?
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Surveys of consultants (2003, 2008)
Over 90% believed in the importance of exercise
30% highly committed, 30% not treating it as a priority
Commitment associated with confidence to deliver
activity, their own activity levels, and feeling they don’t
set a good example
• Company is currently upgrading their training provision
and quality assurance procedures
Lessons learned
Academic/commercial partnerships can bring
– Access to a large health needy population
– Good resources for communication and marketing
– Input of scientific evidence and theory into
practical strategies that match the population’s
needs, language, and level of understanding
Summary of 10 opportunities for
exercise psychology in public health
1. Carry on with what you are doing to develop and refine
theories.
2. But think carefully about instrument development and
versions that are public health friendly
3. Get involved in multidisciplinary teams to secure funding
for larger interventions and RCTs
4. Take responsibility for intervention design, mediating
factors, process, intervention fidelity research
5. Take the lead on chasing research funds that address the
role of activity in mental illness and mental well-being as
they increase in status
6. Start with feasibility and developmental studies and
document user and professional input and reactions
7. Become expert in overcoming recruitment challenges
8. Be skilled in qualitative work to understanding
participant and professional needs and perceptions.
9. Study break points in the delivery system and find out
how to rectify
10. Need for off the shelf packages, training programmes,
manuals for recruitment strategies, weight loss, drug
companies.
Many thanks for listening
Any easy questions?
[email protected]