Effect of physical activity counseling on physical activity of older people in Finland (ISRCTN )

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1 Health Promotion International Advance Access published September 11, 2011 Health Promotion International doi: /heapro/dar057 # The Author (2011). Published by Oxford University Press. All rights reserved. For Permissions, please journals.permissions@oup.com Effect of physical activity counseling on physical activity of older people in Finland (ISRCTN ) MINNA RASINAHO 1*, MIRJA HIRVENSALO 1, TIMO TÖRMÄKANGAS 2, RAIJA LEINONEN 3, TARU LINTUNEN 1 and TAINA RANTANEN 2 1 Department of Sport Sciences, University of Jyväskylä, Jyväskylä, Finland 2 Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland 3 Gerocenter, Jyväskylä, Finland *Corresponding author. minna.rasinaho@jyu.fi SUMMARY The aim of this study was to describe the underlying theory and the implementation of a 2-year individualized physical activity counseling intervention and to evaluate whether benefits persisted 1.5 years after the intervention. The sample included 632 sedentary 75- to 81-year-old participants. Data were collected in The participants were randomly assigned to an intervention group and a control group. The intervention consisted of an individualized face-to-face meeting followed by telephone contacts every 4 months for 2 years, with the aim to increase participation in specific physical activities as well as to increase habitual physical activity. At the 2-year follow-up, the prevalence of physical activities in the intervention group vs. control group was as follows: supervised calisthenics Key words: health-related behaviors; healthy aging; intervention studies training 20 vs. 16%, walking for fitness 69 vs. 62%, weight training 13 vs. 8% and water aerobics 19 vs. 7%. For water aerobics and walking for fitness, the treatment effect was significant [water aerobics odds ratio (OR) 2.49, 95% confidence interval (CI) , walking for fitness OR 1.58, 95% CI ]. As to the other activities, the effect did not reach statistical significance. At the 1.5-year post-intervention, the follow-up results indicated that the intervention effect was still evident. The subgroup analyses suggested that physical activity counseling may be most efficacious among people with intact mobility, while those having manifest mobility limitations may not benefit from it. Older people who have manifest mobility limitations may need more face-to-face counseling. INTRODUCTION Developing effective interventions to increase physical activity and prevent disability of older adults is a public health priority (Ferrucci et al., 2004). People who are not yet disabled but are at risk of becoming disabled are probably the group that benefits more than others from exercise prescriptions tailored for their needs and abilities (King et al., 1998; Heath and Stuart, 2002; Guralnik et al., 2003). Primary care-based physical activity counseling with continued telephone support has shown to increase the physical activity level among older people in randomized control trials (RCTs) (Hillsdon et al., 2005; Kerse et al., 2005; Pinto et al., 2005). There is also evidence showing that professional guidance combined with an individualized physical activity plan is an efficacious approach (Hillsdon et al., 2005). The theoretical basis that most RCTs on physical activity interventions studies have used is the social cognitive theory (Bandura, 1986, 1997), the transtheoretical model (Prochaska and DiClemente, 1982) and mixed multiple theoretical approaches. According to the social Page 1 of 12

2 Page 2 of 12 M. Rasinaho et al. cognitive theory, the perceived confidence in being able to perform a specific task and the anticipated consequences of doing this task influence behavior. In the transtheoretical model, the central organizing construct is the stages of change, where the change is a process which progresses through a series of stages: pre-contemplation, contemplation, preparation, action and maintenance. Studies using combined theoretical approaches when planning physical activity interventions have had significant effects (King, 2001; Brawley et al., 2003; Marcus et al., 2006). Health promotion trials are often divided as efficacy or effectiveness interventions. Efficacy interventions test the impact of an intervention under controlled circumstances. Effectiveness trials, such as this study, test the impact of an intervention under near-normal circumstances. The benefit is that the results can be better generalized to other times, places or populations (Green, 2005). Physical activity promotion has mainly been studied under conditions that are typical for efficacy studies, i.e. the circumstances for the interventions are optimal, the exercise classes are provided by the research team and the staff is well trained and highly motivated. Adopting such interventions as part of services provided by municipalities or civil society faces many challenges. First of all, when the funding runs out, the program may stop. Developing and testing interventions that are carried out as part of the routine activities of the host organization may be a powerful way to help build physical activity and exercise services which will continue also after the intervention. We performed an RCT on the effects of an individualized physical activity counseling intervention on physical activity and exercise participation of older, initially inactive people. The study project Screening and Counseling for Physical Activity and Mobility in Older People (SCAMOB) was designed to develop a customer-oriented physical activity counseling program suitable for the context of primary care (Leinonen et al., 2007). Collaborating in the study were the municipal health-care center, the municipal leisure services of the City of Jyväskylä and University of Jyväskylä. It was hypothesized that physical activity counseling would increase physical activity, which in turn would decrease mobility difficulties and the need for home care. The results showed that physical activity counseling decreased mobility limitations (Mänty et al., 2009) and home care (von Bonsdorff et al., 2009). The aim of this paper is to describe the intervention methods and to examine the effects of the intervention on habitual physical activity and on participation in specific physical activities. METHODS Study design and participants Screening and Counseling for Physical Activity and Mobility (SCAMOB) was a 2-year, singleblinded, RCT on the effectiveness of individualized physical activity counseling on the physical activity and mobility of older sedentary people. The design and methodology of the SCAMOB project have been reported in detail elsewhere (Leinonen et al., 2007) and are summarized here. This study was approved by the Ethical Committee of the Central Finland Health Care District. All the participants gave their written informed consent prior to the study. The ISRCTN trial registration number is The flow chart of the study is presented in Figure 1. In this paper, we report the results from the physical activity outcomes. Community-living men and women aged years were recruited by mail from the central area of the City of Jyväskylä in Finland (n ¼ 1310). At baseline, a four-phase screening process was conducted, consisting of a telephone interview, an at-home face-to-face interview, and a nurse s examination and functional tests in the study centre, supplemented with a physician s examination if needed. The inclusion criteria for participation in the study were set as follows: (i) ability to walk 0.5 km without assistance, (ii) physical activity status at moderate or sedentary (at most 3 h of walking or habitual physical activity per week), (iii) no memory impairment (MMSE 22) (Folstein et al., 1975), (iv) no medical contraindications for physical activity and (v) informed consent to participate. The purpose of the screening criteria was to identify those people for the RCT who would most likely benefit from the physical activity counseling intervention, i.e. they are not yet disabled but are at risk of becoming disabled. In the screening process, only 9% of the sample was excluded, the rest was considered to benefit from a physical activity intervention (Figure 1).

3 Effect of physical activity counseling Page 3 of 12 Fig. 1: Study flow chart in After the baseline interviews and study center examinations, the study population (n ¼ 632) was randomized into an intervention group (n ¼ 318) and a control group (n ¼ 314). Randomization was followed by a 24-month intervention period during which 16 participants

4 Page 4 of 12 M. Rasinaho et al. died (intervention group n ¼ 8 and control group n ¼ 8) and 9 withdrew from the study (intervention group n ¼ 5 and control group n ¼ 4). The completion of the assessments at the end of the intervention was high: 295 (93%) of the intervention group and 283 (90%) of the control group. The interviews and physical assessments were performed by interviewers and nurses blinded to the group assignment. After the 2-year intervention, the physical activity level and the mobility limitations were assessed at the 1.5-year post-intervention follow-up. Thus, the total follow-up time was 42 months. The control group did not receive any treatment. SCAMOB intervention The SCAMOB trial tested the efficacy of physiotherapist-delivered physical activity counseling on initiating specific physical exercise and habitual physical activity. The physical activity intervention started with a face-to-face counseling session lasting about an hour and continued by the same physiotherapist with regular telephone contacts at least three times a year throughout the 2-year intervention. The mean duration of the phone calls was 13 min. Before the initial face-to-face counseling session, the physiotherapist familiarized herself with the background information gathered earlier. The topics covered during the session included the present level of physical activity, the participant s interest in beginning or maintaining physical activity or exercise, willingness to be active in everyday chores, exercising on his/her own or in participating in supervised exercise classes. The main aim of this session was that the participant and the physiotherapist devised a personalized physical activity plan together and signed it. The theoretical framework of the intervention was based on social cognitive theory (Bandura, 1986; 1997) and transtheoretical model (Prochaska and DiClemente, 1982). The counseling method was based on the motivational interviewing technique (Miller and Rollnick, 1991). The aim was to arouse interest in changing physical activity behavior by making the participants aware of the inconsistency between their current and desired levels of physical activity. The components and methods of the physical activity counseling intervention are presented in the Appendix. Transtheoretical model The transtheoretical model is construed of stages of change involving a gradual progress in physical activity behavior in time. For this study, we assigned the participants into three groups representing the theoretical stages: precontemplation, contemplation and preparation. The group assignment was based on two motivational readiness questions: (i) would you like to increase your physical activity? and (ii) would it be possible to increase your physical activity? If the participant had not even thought of being physically active or it was difficult to increase activity, e.g. lack of a walking partner, the counselor tried to motivate him/her by explaining the benefits of being active and by considering together with the participant who would be a suitable walking partner. If the participant was occasionally active, the counselor tried to strengthen the activity. As to the participants who were already somewhat active and who could benefit from more versatile activity, the counselor tried to encourage them to find more interesting physical activity modes, such as weight training or water gymnastic. Social cognitive theory Important elements of the intervention used in this study were the promotion of self-efficacy and self-regulatory skills and discussions on social and environmental factors. The physiotherapist suggested easy and achievable methods to increase physical activity that would in turn affirm the participant s self-efficacy to realize the plans made. The physiotherapist helped the participant utilize problem-solving approaches to overcome the barriers to behavior change and develop a written plan for more physically active behavior. In addition, possible support of the relatives and friends was discussed. The barriers were discussed, and concrete and practical ways were sought to overcome them. For example, if a participant wanted to attend a water aerobics class, he/she was shown the exact walking route or bus-line to the swimming hall. Locationwise the program delivery was expanded beyond specific physical exercise settings to include a more general lifestyle environment, with a consequent increase in both program accessibility and flexibility. The physiotherapist gave examples in the participant s own immediate surroundings, on what could be done, including daily routines (e.g. taking the

5 stairs), transportation (e.g. walking to the grocery store) and household chores. If these activities were already on a satisfactory level, the participant was encouraged to do home exercises, walk for fitness and engage in supervised exercise groups organized by the city. If the participant wanted, the physiotherapist demonstrated an individualized home-based gymnastics program and gave written instructions to perform it. The purpose was to offer versatile possibilities for older people to seek out those activities and programs that might potentially meet their individual needs and preferences. Because the suggested group activities were regularly provided by the city, this was believed to ensure continuity even after the intervention. Motivational interviewing technique (Miller and Rollnick, 1991) The motivational interviewing technique is based on the assumption that all behavior is motivated. The key element of this is to encourage the personal intention to change. The approach takes into account the fact that people might have ambiguous feelings when they decide to make changes. They perceive it both advantageous and disadvantageous to change or continue physical activity. The counselor s purpose was to listen, reinforce and give clues to the sought-after behavior. Behavior change was supported in follow-up contacts by telephone: the physiotherapist assessed the participant s personal situation, reviewed the progress, supported behavior change and updated the goals and plans. In addition, to motivate the intervention group even more, two lectures on physical activity were offered to the group members, and a written (illustrated) home-based exercise program was mailed to them as part of the intervention. Measurements Background characteristics Demographic information and self-reported chronic conditions lasting over 3 months were collected in face-to-face interviews at participants homes and for confirmation again in the study center visits. Depression was measured with Center for Epidemiologic Studies Depression Scale (Radloff, 1977) (CES-D) and cognitive impairment was assessed with the MMSE (Folstein et al., 1975). Effect of physical activity counseling Page 5 of 12 Outcomes This study reports the prevalence of specific physical activities and habitual physical activity which was hypothesized to increase after physical activity counseling. Habitual physical activity in this study refers to overall daily activity including, for example, domestic chores and specific physical exercises. Physical exercise refers to specific activities such as walking for exercise to maintain health (Caspersen et al., 1985). Physical exercise was studied by asking the participants to name the activities in which they participate in order to maintain their health and physical fitness. Exercise participation was asked separately for walking, supervised calisthenics training, weight training, swimming, cycling and other possible exercise forms. We measured the frequency of exercise activities with the following alternatives: (i) almost daily, (ii) two to three times a week, (iii) weekly, (iv) two to three times a month, (v) once a month or more rarely and (vi) non-participation. For statistical analyses concerning logistic regression analysis and based on the proportions of the participants exercise involvement, we reclassified the responses into two groups, active and inactive, by two options: those who reported walking for exercise two or more times a week or once a week in other exercise forms were categorized as active; the others were categorized as inactive. To capture the participants physical activity levels in more detail, we evaluated the intensity and frequency of all the activity forms that the participants were doing as habitual physical activity. It was assessed with a previously validated seven-point scale with the following response categories (Grimby, 1986) (1) mainly resting, (2) most activities performed sitting down, (3) light physical activity 1 2 h/week, (4) moderate physical activity or housework 3 h/ week, (5) moderate physical activity or housework at least 4 h/week, (6) strenuous physical exercise several times a week or (7) competitive sports several times a week. The participants who reported doing strenuous physical exercise or competitive sports several times a week (two highest categories) were excluded from the study before randomization because they were presumed not to benefit from physical activity counseling. For logistic regression, we reclassified the responses into two groups: those who reported at least moderate physical activity or housework 4 h/

6 Page 6 of 12 M. Rasinaho et al. week were categorized as active; the others were categorized as inactive. The assessment of habitual physical activity showed a good reliability in 2-week interval (Kendall s tau-b ¼ 0.874). The question probing perceived mobility limitations was formulated as follows: Do you have difficulty in walking 0.5 km?, and five response categories were given: (1) able to manage without difficulty, (2) able to manage with some difficulty, (3) able to manage with a great deal of difficulty, (4) able to manage only with help from another person and (5) unable to manage even with help. At the 2-year follow-up, the participants were asked if they had a great deal of difficulty, need for help from another person, or inability, and the responses were classified accordingly. The participants were then categorized as having (1) manifest mobility limitations, (2) pre-clinical mobility limitations and (3) no mobility limitations. At the 1.5-year postintervention follow-up, the participants were classified in the same way: manifest mobility limitations, pre-clinical mobility limitations and no mobility limitations. The participants reports of their perceived degree of difficulty have been found to be reliable and valid measures in capturing mobility disability among older people (Gurlanik et al., 1996; Mänty et al., 2007). Statistical methods We report secondary analyses of an RCT. The primary outcome was mobility limitation, and power calculations were based on anticipated changes in mobility. Based on our pilot sample, we estimated that 60% of the target population were experiencing, or at increased risk for, mobility limitation. The significance level was set at 5% and power at 80%. A within-person correlation of 0.4 was assumed. To allow for 10% attrition, the total sample size needed was 630. The comparisons of discrete baseline characteristics were performed using x 2 tests, and the comparisons of continuous variables were done using independent samples t-test. All significances were two-tailed and set at p, 0.05 level. These analyses were performed in SPSS version All the randomized subjects who were alive and interviewed at baseline, at 24 months and at 42 months were used to compute intentionto-treat analyses of unadjusted group differences. The percentages of the new initiators were used to summarize the data. Due to the longitudinal nature of the data, a generalized estimated equation (GEE) approach was used to estimate the parameters and test the differences between the groups, while allowing for withinperson correlation. The main hypothesis being tested was that physical activity counseling affects the numbers of new exercisers. The GEE analyses were performed using SAS version 9.1. RESULTS Ninety-one percent of the follow-up sample completed the interview at every semi-annual follow-up point during the counseling intervention. During the intervention, 16 participants died and 38 withdrew from the study (Figure 1). No adverse events could be found among the participants in the adverse outcomes studied (Table 1). At baseline, 30% of the intervention group and 28% of the control group reported some form of injury in the previous year. At the 2-year follow-up, the numbers had stayed similar with no statistical differences between the groups. This suggests that the intervention did not cause adverse events. The baseline characteristics of the intervention group and the control group were comparable (Table 2). The mean age was 77.6 years, 75% were females and they had an average of three chronic conditions. At baseline, the percentage of the participants who participated in supervised callisthenic training, walking for Table 1: Adverse events according to randomized groups Intervention group (n ¼ 318) (%) Wound/bruise Vertebral injury/ fracture Joint injury Muscle injury Unconsciousness Hernia Concussion Heart attack Heart symptoms Musculoskeletal problems Rheumatoid arthritis got worse Arterial hypertension Other Control group (n ¼ 314) (%)

7 Table 2: Baseline characteristics of the intervention group and the control group Intervention group (n ¼ 318) Control group (n ¼ 314) Age Married (%) Years of education Female (%) Number of chronic conditions CES-D score MMSE score Mobility limitation (ability to walk 0.5 km) (%) No mobility limitation Pre-clinical mobility limitation Manifest mobility limitation Habitual physical activity (%) Mainly resting 0 0 Most activities performed sitting down Light physical activity h/week Moderate physical activity h Moderate physical activity h Specific physical activities Supervised callisthenic training Walking for exercise Weight training 9 6 Water aerobics 8 9 exercise, weight training and water aerobics in the intervention group did not differ significantly from that of the control group. At the 2-year follow-up, some differences were found; 13% in the intervention group vs. 8% in the control group ( p ¼ 0.043) in weight training, 20 vs. 16% in supervised calisthenics training, 69 vs. 63% in walking for fitness and 19 vs. 7% (p, 0.001) in water aerobics (Figure 2). At baseline, 24% of the participants in the intervention group and 26% in the control group reported a moderate habitual physical exercise level (moderate physical activity or housework at least 4 h/week); the rest were more sedentary. The corresponding percentages after the 2-year follow-up were 42 and 39% ( p ¼ 0.020). The 2-year follow-up results indicated that participation in water aerobics was twice as common in the intervention group [odds ratio (OR) 2.49, 95% confidence interval (CI) ] as in the control group. Walking for exercise slightly decreased, more in the control group than in the intervention group (OR 1.58, 95% Effect of physical activity counseling Page 7 of 12 CI ), and so did habitual physical activity and weight training, but they did not reach statistical significance at the 2-year follow-up (Table 3). The ancillary analyses showed that the intervention effect was most evident among the participants with no mobility limitations or with pre-clinical mobility limitations, while no significant effects were observed among those with manifest mobility limitations. Especially those participants in the intervention group who had no mobility limitations did weight training more often (OR 7.41, 95% CI ). Those who had preclinical mobility limitations did walking for fitness (OR 2.13, 95% CI ) more often than their counterparts in the control group. The 1.5-year post-intervention follow-up results showed that the percentage of the participants, who took part in different exercises and activities, decreased from the 2-year follow-up results but remained at least at the baseline level. However, weight training was still as common as in the 2-year follow-up; 13% of the participants in the control group reported weight training both at the 2-year follow-up and at the 1.5-year post-intervention (Figure 2). The 1.5-year post-intervention follow-up results indicated that significant effects had disappeared in water aerobics and walking for exercise, but were evident in weight training (OR 2.33, 95% CI ) and in habitual physical activity (OR 1.58, 95% CI ). DISCUSSION The 2-year telephone-assisted randomized, controlled intervention study showed that counseling was effective in initiating new physical exercise among 75- to 81-year-old participants and that the positive results were still evident at the post-intervention follow-up. Positive physical activity results have also been observed in earlier physical activity counseling interventions among older adults (Stewart et al., 2001; The Writing Group for the Activity Counseling Trial Research Group, 2001; Hillsdon et al., 2005; Kerse et al., 2005; Pinto et al., 2005; de Jong et al., 2006; Espeland et al., 2007; Chodzko- Zajko et al., 2009). The uniqueness of this study was that it examined the effectiveness of a counseling intervention that was carried out as part of the normal activities of the surrounding city organization.

8 Page 8 of 12 M. Rasinaho et al. Fig. 2: Proportion of the participants in specific physical exercises and habitual physical activity according to randomized groups at the 2-year intervention (24 months) and the 1.5-year post-intervention follow-up (42 months). The intervention consisted of a motivational face-to-face physical activity counseling session by a physiotherapist and follow-up telephone calls every 4 months by the same physiotherapist over the 2-year intervention. The counseling method was motivational interviewing, which can be seen as a cognitive-behavioral strategy. The participants considered advantages of, and possible barriers to, participating in physical activity and made their decision with the physiotherapist. Also, King et al. (King et al., 1998) pointed out in their review of physical activity counseling studies that it was effective interventions that employed behavioral or cognitivebehavioral strategies delivered by telephone. This study also showed that in order to assist in the initiation of physical exercises, it was essential that the intervention was tailored to the individuals needs and preferences, and that a variety of physical activity options were made available. The counselor had to have knowledge about physical activity, exercise, functional performance of older adults and to be familiar with the existing services. The City of Jyväskylä organizes multiple training groups for older adults with different chronic conditions, targeting at aerobic, strength and balance training. The groups are available for, for example, gym

9 Effect of physical activity counseling Page 9 of 12 Table 3: Effects in the GEE model on physical activity (group time, OR, 95% CI) in the intervention group and the control group for all participants and subgroups according to baseline mobility limitations after the 2-year intervention (24 months) and the 1.5-year post-intervention follow-up (42 months) 24 months (group time) 42 months (group time) OR 95% CI OR 95% CI All participants Habitual physical activity Walking for exercise Weight training Water aerobics No mobility limitation Habitual physical activity Walking for exercise Weight training Water aerobics Pre-clinical mobility limitation Habitual physical activity Walking for exercise Weight training Water aerobics Manifest mobility limitation Habitual physical activity Walking for exercise Weight training Water aerobics Bold numbers are statistically significant effects. training or swimming hall activities. We wanted to promote the use of these existing communitybased resources. When initiating a new exercise form, the critical point for older people may also be transportation. In our counseling sessions, transportation was discussed in detail, e.g. how to go to the swimming hall or the strength training gym. The benefits of weight training were also discussed on the basis of scientific knowledge and public programs (Rantanen et al., 1999; Government Resolution on Policies to Develop Health-Enhancing Physical Activity in Finland, 2002; Latham et al., 2004). A few population-based surveys suggest that middle-aged and older adults may actually prefer physical activities undertaken outside of a formal class or group setting(king, 2001). Our idea was to promote physical activity that is naturally incorporated in a person s daily life, such as climbing stairs or walking. Habitual physical exercise increased, in both groups, suggesting homecentered physical activity. In this study, it was interesting to see that walking could not be increased by counseling. In the intervention group, however, walking for exercise decreased somewhat less than in the control group. The reason why the overall number of walkers decreased is not clear. Themainreasonmayhavebeenthehighnumber of regular walkers at baseline (over 70%). Another reason may have been the long winter in Finland. Icy and dark roads may have deferred such study participants from walking who were afraid of falling on slippery roads. Organized walking groups or walking partners may be an important support for those persons and for those who emphasize the social aspects. Mobility limitations seem to be an important factor that needs to be considered in effective counseling programs. Our results suggest that people with pre-clinical or manifest mobility limitations need even more support for initiating new forms of exercise. While more older adults with no mobility limitations in the intervention group initiated weight training and water aerobics than in the control group, the participants in the intervention group with mobility limitations did not initiate these physical exercises more often than their controls. However, the CIs were wide: there were new participants who took these exercises. When an older person already has mobility limitations, the impact of multiple impairments on exercise potential may be difficult for the counselor to estimate, especially on the telephone. To ensure an

10 Page 10 of 12 appropriate exercise prescription, we recommend a complete evaluation of chronic conditions and functional assessments (Hirvensalo et al., 2007; Nelson et al., 2007). The older adults with mobility limitations in this study may have benefited from the physiotherapist s home visit. Further studies are warranted in this area. Most of the earlier studies have examined the efficacy of participation in physical exercise classes organized by study projects. The existing resources are scarcely used. However, the California Active Aging Project (Hooker, 2002; Hooker et al., 2005) implemented a choice-based, telephone-assisted promotion strategy efficaciously in practice. The physical activity level of the study participants increased significantly. The design of the California study was not, however, an RCT. The strength of our study is that it was an RCT targeted at a large population-based group of older people. In addition, there were only few drop-outs. The minimal subject loss may be due to the counseling method that did not oblige participation in any physical activities. The study had inclusive eligibility criteria, particularly with respect to health. The intervention did not cause any specific adverse events, either. A limitation of this intervention study could be due to the physical activity-related interviews or information flow from the intervention group to the control group. Possible unintended activation may have caused some underestimation in the results. We also used self-rating questions, which are usually considered less objective measures than, for example, direct observations and may also be subject to an interviewer effect. In the current RCT, we promoted the use of existing exercise services for older people because the services were available for the participants also after the end of the project. The approach is an example of sustainable means for promoting physical activity in sedentary older people who have no mobility limitations yet. Aging adults who are least likely to participate in physical activity studies constitute a major challenge: they may be the ones most in need of increased activity. An effective counseling approach included practical implementation. FUNDING M. Rasinaho et al. Finnish Ministry of Education, Juho Vainio Foundation. REFERENCES Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs, NJ. Bandura, A. (1997). Self-efficacy: The Exercise of Control. Freeman, New York. Brawley, L. R., Rejeski, W. J. and King, A. C. (2003). Promoting physical activity for older adults the challenges for changing behavior. American Journal of Preventive Medicine, 25(3 Suppl 2), Caspersen, C. J., Powell, K. E. and Christenson, G. M. 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12 Page 12 of 12 Continued M. Rasinaho et al. Theories Mediators of behavior change Intervention objective Counseling component and methods Transtheoretical model (2) Incentives (3) Self-regulatory skills Addressing motivational and inhibiting factors for physical activity Goal setting by identifying realistic outcomes that can be achieved with physical activity Achieving planned short-term goals to experience success To concretize the benefits of physical activity Choose activities that are possible and enjoyable Make the feedback noticeable Develop means to overcome and avoid barriers Get feedback on progress and give reward to oneself Have an active image of oneself Have a realistic view on occasional relapses Social variables (1) Observational learning Interact with other physically active people (2) Support of physical activity Have people with whom to share the activities Receive support from counselor and physician Environment variables (1) Access to facilities Become familiar with local facilities and walking trails (2) Access to resources that promote physical activity Stay informed about local services Listening Reinforcement Giving clues Telephone contacts Face-to-face session Individualized home-exercise program Telephone contacts Face-to-face session Physician informed about the counseling Utilization of the individual and environmental background information Face-to-face session, telephone contacts Physical activity schedule of the City of Jyväskylä (3) Access to programs Become familiar with local programs Two voluntary lectures on physical activity and disability prevention Personal variable (stages of change) Pre-contemplation Contemplation Preparation Assess the readiness to change or increase physical activity level Provide pertinent information and skills Preliminary information gathered from research data Home exercise program