CASE STUDY 1

Active plus: Systematic Development, Implementation, and Evaluation of a Physical Activity Interventionfor the Over-Fifties

Maartje M van Stralen,1,2 Catherine Bolman,1 Aart N. Mudde,1Denise Peels,1Hein de Vries,3and Lilian Lechner1

1Open University of the Netherlands, Department of Psychology, PO Box 2960, 6401 DL, Heerlen, the Netherlands.

2VU University, Faculty of Earth and Life Sciences, Department of Health Sciences and the EMGO Institute for Health and Care Research, De Boelelaan 1085, 1081 HV Amsterdam

3Maastricht University, Department of Health Promotion, PO Box 616, 6200 MD, Maastricht, The Netherlands

LEARNING OBJECTIVES

  • Specify how to addresspersonal determinants of behavior change.
  • Specify how to select theoretical methods and practical applications.
  • Develop a computer tailored program to promote behavior change.
  • Describe how to evaluate effectiveness, acceptability, and usability of the program and to translate these findings into an adapted and improved program.
  • Conceptualize how to assess conditions for implementation on a broad scale.

INTRODUCTION

Regular physical activity reduces the risk of health problems such as cardiovascular disease, obesity, and type 2 diabetes (Department of Health, 2004; Haskell et al., 2007; Kesaniemi et al., 2001; Nelson et al., 2007; Rankinen & Bouchard, 2002; The Swedish National Institute of Public Health, 2007; World Health Organization, 2003), health problems which become more prevalent and have greaterimpact aspeople age (Department of Health, 2004). Because of the aging population in the Netherlands, promoting physical activity among people over 50 years of age is of major relevance. It has long been recognized that usinga systematic approach to the development of a health promotion intervention leads to more effective interventions(Bartholomew, Parcel, Kok, Gottlieb, & Fernández, 2011; Green & Kreuter, 2005). Therefore, we systematically developed, implemented, and evaluatedthe Active plus program,atheory- and evidence-based computer-tailored physical activity intervention for the over-fifties. For this purpose, we used the six steps of the Intervention Mapping (IM) protocol. In this case study, we first describe the systematic development of the Active plus program followed by the results of the efficacy evaluation,which was conducted from 2005–2009. Lastly, we briefly describe the follow-up project (from 2009–2014)consisting of an improvement and evaluation of the adapted (web-based) Active plus intervention based on the evaluation results of the original projectand assessing the conditions for implementation of the project (see Project Follow-Up)

PERSPECTIVES

In this chapter we demonstrate how tailored physical activity promotion programs can be developed, implemented, evaluated, and improved in a systematic way, including an environmental-based intervention, following the IM protocol. The Active plus program is unique in that it addresses environmental barriers and facilitators to being physically active in addition to personal factors. In this chapter we extensively describe the combination of studies used to assess the broad range of personal and environmental determinants of physical activity behavior change in the over-fifties and how we used several theories to select methods to target these determinants. Further, we provide an insight into the goals, applications, and materials used, participant recruitment, implementation, and evaluation of the interventions. In addition, we describe how IM was used to adapt the evidence based program in an improved program and a different (web-based) delivery mode. Lastly, in this chapter we describe how to assess conditions for broad scale implementation of the interventions.

USING INTERVENTION MAPPING TO PLAN ACTIVE PLUS

In this first section, we describe the systematic application of IM to develop, implement, and evaluate the original Active plus program.

IM STEP 1: LOGIC MODEL OF THE PROBLEM

In the first step of IM we established a planning group, described the context for the intervention, conducted the needs assessment to create a logic model of the problem (see Figure 1), and set program goals. We useda combination of methods for the needs assessment including a literature search, focus-group interviews with the target group (adults aged 50 and over) and additional interviews with staffat Municipal Health Organizations and the health promotion departments of local authorities(van Stralen et al., 2008). By incorporating the target group and potential program implementersin the needs assessment, we could take into account their wishes and preferencesfor the intervention.

Our search of the literature led to the identification of lack of sufficient physical activity as a risk behavior and older adults as the target population in preventing chronic illnesses (Department of Health, 2004; Haskell et al., 2007; Kesaniemi et al., 2001; Nelson et al., 2007; Rankinen & Bouchard, 2002; The Swedish National Institute of Public Health, 2007; World Health Organization, 2003). Furthermore, insufficientphysical activity is particularly important for older adults as it might influence their mobility (Bean et al., 2003), independence (Spirduso & Cronin, 2001), muscle strength (Latham, Anderson, Bennett, & Stretton, 2003), mental and emotional wellbeing (Penninx et al., 2002), and their risk of falling(Gillespie et al., 2003). The review of the literature also suggested that physical activity interventions in older adults should be directed towards several phases of changing physical activity, including raising awareness of being insufficiently physically active, promotion of initiating or increasing physical activity, and the promotion of maintaining physical activity. In addition, research on ecological aspects showed the importance ofincluding environmental facilitating and hindering factors in the determinant analysis and intervention development.

Figure 1: Logic model of the problem

We conducted six focus-group interviews according to predefined protocols with a total of 47 adults aged 50 and over to ascertain the needs of the target group with regard to physical activity promotion, activities in which they participated, their reason for being (and not being) physically active, barriersand facilitators of their physical activity, and strategies that could increase awareness, initiation, and maintenance of physical activity (Morgan & Krueger, 1998). These interviews gained further in-depth knowledge of the needs of older adults with regard to physical activity, physical activity promotion, and physical activity interventions in addition to the findings fromthe literature.

From the needs assessment three desired program goals emerged. The program goals were based on the findings of the systematic literature review (see step 2), the focusgroups and the physical activity recommendations set by the American College of Sports Medicine and the American Heart Association, promoting 30–60 minutes of moderate-intensity aerobic activity per day in older adults (Nelson et al., 2007). Specifically, older adults who do not reach the international physical activity guideline of at least 30 minutes per day on at least five days of the week should become aware of their insufficient physical activity level, they should initiate a new physical activity level,and they should maintain this new level. Second, older adults who do reach the physical activity guideline of at least 30 minutes per day, but are physically active for less than 60 minutes per day, should maintain their physical activity level and if possible increase their physical activity level to at least 60 minutes per day. Third, older adults who are physically active for more than 60 minutes per day at a moderate intensity should maintain this sufficient level of physical activity.

IM STEP 2: PROGRAM OUTCOMES AND OBJECTIVES –

LOGIC MODEL OF CHANGE

In the second step of the IM protocol, we specified expected behavioraloutcomes,related performance objectives and selected important and changeable determinants. We also assessed how best to address environmental barriers and facilitators to being physically active.

Our first task in this step was to translate the previously mentioned risk behavior, i.e., lack of physical activity, into a health-promoting behavior. Based on a literature search and focus-group interviews with the target group and potential implementers, we identified two ways of increasing physical activity. First, recreational physical activity was to be encouraged, such as playing sports, walking, and cycling. Second, increasing the amount of physical activity in people’s daily routines should be promoted, for instance by promoting walking and cycling for transport and promoting physical activity at work (e.g., by taking the stairs instead of the elevator, going for a walk during lunch breaks, or walking over to speak to colleagues instead of using email) and at home (e.g., while doing gardening, chores, and household activities) (see BehavioralOutcome box of Figure 2).

As a second task in step 2 we further specified the two behaviors into performance objectives, which are the exact behavioral outcomes of the program expected from the target group. We specified the performance objectives via a combination of methods. These were a review of the literature(van Stralen, De Vries, Mudde, Bolman, & Lechner, 2009a), a Delphi study among 118 international experts in the field of health promotion and/or in the field ofphysical activity determinants(van Stralen, Lechner, Mudde, de Vries, & Bolman, 2010), and a review of theoretical models, such as the I-Change model (De Vries, Mesters, van-de-Steeg, & Honing, 2005; De Vries, Mesters, Van 't Riet, Willems, & Reubsaet, 2006; De Vries et al., 2003), the Health Action Process Approach (De Vries et al., 2005; De Vries et al., 2006; De Vries et al., 2003; Schwarzer, 2001, 2008; Schwarzer & Renner, 2000), theories of self-regulation (Baumeister & Vohs, 2004; Boekaerts, Pintrich, & Zeidner, 2001; Zimmerman, 2000), and the Precaution Adoption Process Model (Weinstein & Sandman, 1992). We specified eight performance objectives for each behavioral outcome. Table 1 shows, as an illustration, the performance objectives for the first program outcome,i.e.,enhancement of recreational physical activity.

Table 1. Performance objectives for awareness, initiation, and maintenance of recreational physical activity among older adults.

Raise awareness
P.O.1.Older adults monitor their recreational physical activity level
Initiate recreational physical activity
P.O.2.Older adults indicate reasons to be physically active as recreation
P.O.3.Older adults identify solutions to take away the barriers to being physically active for recreation
P.O.4.Older adults decide to become more recreationally physically active
P.O.5.Older adults make specific plans to become more recreationally physically active
P.O.6.Older adults increasetheir recreational physical activityto 30–60 minutes
Maintain recreational physical activity
P.O.7.Older adults make specific plans to cope with difficult situations occurring while being recreationally physically active
P.O.8.Older adults maintain their recreational physical activity by enhancing their routine and preventing relapses

As a third task in step 2, we conducted a structured analysis to assess the most relevant and changeable determinants of our behavioral outcomes. This analysis was based ona review of the scientific literature on the determinants of initiation and maintenance of physical activity(van Stralen et al., 2009a), and a Delphi study among international experts in the fields of physical activity determinants and/orhealth promotion theories(van Stralen, Lechner, et al., 2010). Furthermore, in focus-groups interviews with older adults we explored the determinants of awareness-raising and physical activity initiation and maintenance, as well as intervention strategies to stimulate these determinants(van Stralen et al., 2008). We selected the most relevant and changeable determinants of the performance objectives. They are shown in the farleft hand box of Figure 2.

Figure 2: Logic model of change

Finally, we developed a matrix that linked the performance objectives and their hypothesized determinants, resulting in specific change objectives. Selected examples of the rows in one matrix of change objectives are shown in Table 2.

Table 2. Sample change objectives (combination of performance objectives and determinants) for promoting recreational physical activity

Performance objectives / Determinants
Awareness / Attitude / Self-efficacy
1. Older adults monitor their recreational physical activity level / Older adults describe the purpose of monitoring and reporting their own recreational physical activity / Older adults express confidence about being able to monitor and report their own recreational physical activity
2. Older adults indicate reasons to be physically active as recreation / Older adults list the personally relevant benefits of being sufficiently physically active / Older adults express a positive attitude about being sufficiently physically active
3. Older adults identify solutions to take away the barriers to being physically active for recreation / Older adults describe the situations and barriers that prevent them from being sufficiently physically active / Older adults express confidence about being able to take away and to cope with their barriers

Researchers have acknowledged the importance of anecological approach to health promotion intervention thataddresses social and physical environmental conditions that influence physical activity in addition to psychological motivational determinants of the at-risk group. The availability and accessibility of physical activity opportunities in the environment is associated with physical activity behavior in older adults (Li et al., 2005; Morris, McAuley, & Motl, 2008). In our needs assessment we determined that both for recreational and active transport our risk group had good potential access. For example, the Netherlands has an extensive network of walking and cycling routes. On the other hand, individuals aged 50 and over often had perceptions of lower access or lack of awareness of local opportunities. This determinant of lack of awareness of these specific environmental conditions is a personal determinant that is directly related to potential optimal use of positive environmental characteristics. Humpel and colleagues found that improved perceptions of the physical activity opportunities in the neighborhood were associated with increased walking levels (Humpel, Marshall, Leslie, Bauman, & Owen, 2004). Also, Sallis et al. found that the physical activity behavior of adults aged 50 or over was more affected as compared to younger adults by their perceived environmental characteristics(Sallis, King, Sirard, & Albright, 2007). Consequently, we planned intervention elements aimed at developing realistic perceptions of what is feasible with respect to physical activity in the environments of over-fifties. We developed two interventions:the basic intervention focused on the psychosocial determinants of physical activity awareness, initiation and maintenance, while the second intervention (the intervention plus) additionally addressed several perceptions of environmental characteristics and increasing the participants’ social network.

IM STEP 3: PROGRAM DESIGN

In the third step of IM, we selected theoretical change methods and practical applications that had previously been found or were likely to promote the identified change objectives(Bartholomew et al., 2011). A theoretical change method is a general technique or process that is derived from theory and that can be applied to influence behavioral determinants. For example, modelling is a method derived from the Social Cognitive Theory (Bandura, 1986) that can be applied to influence the older adults’ self-efficacy and perceptions of social influence (Bartholomew et al., 2011). A practical application is a specific application of a theoretical change method appropriate for the target population and the intervention setting (Bartholomew et al., 2011). For example, in the Active plus program, a practical application used for the method of modelling was to include several role model stories, including pictures of active similar others (of the same age and gender) together with a quote about their motivation for being active, situations which they found hindered being active, and how they coped with them, or plans to become more active or stay active. When translating the theoretical change methods into practical applications, it is important to meet the theoretical conditions or parameters that apply to the method used (Kok, Schaalma, Ruiter, van Empelen, & Brug, 2004). For example, Social Cognitive Theory (Bandura, 1986) states that modelling is only effective when the presentation of the method meets certain conditions, such as participant identification with the model,recognizable reinforcement of the model,and the model’s demonstration of adequate skills.

We searched for theoretical change methods, their parameters or conditions for effective use, and practical applicationsfrom the literature (Bartholomew et al., 2011), existing intervention programs such as the Vitalum intervention (van Keulen et al., 2008), and focus-group interviews with the target group. A review of theoretical models resulted in models that fitted the problem area of physical activity change such as theTranstheoretical model (Prochaska & DiClemente, 1983),the precaution adoption process model (Weinstein & Sandman, 1992),the I-Change model (De Vries et al., 2005; De Vries et al., 2006; De Vries et al., 2003), the Health Action Process Approach (De Vries et al., 2005; De Vries et al., 2006; De Vries et al., 2003; Schwarzer, 2001, 2008; Schwarzer & Renner, 2000), and theories of self-regulation (Baumeister & Vohs, 2004; Boekaerts et al., 2001; Zimmerman, 2000). The Transtheoretical model (stages of change model)(Prochaska & DiClemente, 1983) assumes that behavioral change is a five-stage process, including precontemplation, contemplation, preparation for action, action, and maintenance. At the precontemplation stage, an individual has no plans of changing behavior whereas during contemplation, the individual begins thinking about changing behavior. At the preparation stage, the individual plans to change behavior, and during the action stage the individual initiates the new behavior. If the individual acts on the behavior for over six months, the individual enters the maintenance stage. The Transtheoretical model guided the content of our intervention by directing the determinants that were targeted per participant based on the stage of change in which they were.For example, in intervention materials for precontemplators, participants received messages addressing changes objectives regarding perceived pros of being sufficiently physically active, and contemplators received messages addressing change objectives regarding perceived pros, cons, and self-efficacy (see step 4 and Figure 3). In addition, the precaution adoption process model (Weinstein & Sandman, 1992) is another stages theory that assumes that behavior change consists of seven distinct stages between unawareness of the issue and maintenance of the action. This theory guided our intervention with its focus on the awareness of the problem/risk behavior. Our intervention explicitly focused on making individuals aware of their (in)sufficient physical activity before stimulating initiation and maintenance of their behavior, following the stages of the precaution adoption process model.