COMPARING EXERCISE MOTIVATIONS FOR EACH STAGE OF CHANGE AMONG PEOPLE WITH A PHYSICAL DISABILITY: A PILOT STUDY

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1 COMPARING EXERCISE MOTIVATIONS FOR EACH STAGE OF CHANGE AMONG PEOPLE WITH A PHYSICAL DISABILITY: A PILOT STUDY JEREME D. WILROY University of Alabama ADAM P. KNOWLDEN University of Alabama DAVID A. BIRCH University of Alabama Abstract Background: In 2011, over 19.9 million individuals in the United States identified as living with an ambulatory disability, which increases risk for chronic diseases. The purpose of the study was to compare motivations for exercise and physical activity stages of readiness among people with physical disabilities. The primary hypothesis was that there were significant differences in exercise motivations among individuals in various stages of readiness for physical activity. Methods: Respondents (n = 141) included clients of two medical supply companies contacted via and advertisements on the companies Facebook page and website. The instrument used in this study included items from the Exercise Motivations Inventory-2 and the Physical Activity Stages of Change Questionnaire, and demographic items that addressed gender and ethnicity/race. The dependent variables included the five stages of readiness (precontemplation, contemplation, preparation, action, maintenance). The independent variables included 14 constructs hypothesized to influence exercise motivations. Data were collected online, over a four-week period. Results: Analysis found that enjoyment (p =.012) and revitalization (p =.041) were significant overall and post hoc found significant difference based on whether individuals were in the precontemplation or maintenance stages of readiness for physical activity. Conclusions: The exercise motivations of enjoyment and revitalization were higher for those in the maintenance stage compared to those in the precontemplation stage. These results suggest interventions with people in the precontemplation stage should focus on improving the perceived enjoyment of physical activity as well as the positive side effects of physical activity, such as increased feelings of well-being for this population. Recommendations for intervention design and implementation are provided. Keywords: exercise motivations; disability; physical activity Introduction It is estimated that over 19.9 million people who are noninstitutionalized live with an ambulatory disability, defined as a person having serious difficulty walking or climbing stairs (Erickson, Lee, & von Schrader, 2013). People with physical disabilities are at a greater risk of lowered physical functioning, which is the body s ability to perform natural activities, such as regulating blood glucose, oxygenation of the body, stroke volume of the heart, and work capacity of the muscles (Buchholz, Ginis, Bray, Craven, Hicks, & Hayes, 2009; Hicks, Martin, Ditor, Latimer, Craven, & Bugaresti, 2003). Regular participation in physical activity can prevent secondary conditions, reduce depression, decrease risk of cardiac disease and obesity (Warms et al., 2004), type 2 diabetes (Buchholz et al., 2009), and glucose tolerance (Raymond, Harmer, Temesi, & van Kemenade, 2010).The World Health Organization (WHO, 2014) defines physical activity as any bodily movement produced by skeletal muscles that requires energy expenditure, and states that there is significant health benefits for participating in regular moderate intensity physical activity, such as walking, cycling, and playing sports. Individuals with physical disabilities who do not participate in physical activity have been shown to have a decrease in physical functioning which leads to further inactivity, with spinal cord injury being at the lowest level of the activity spectrum (Warms, Belza, Whitney, Mitchell, & Stiens, 2004). Studies have shown that individuals with a physical disability who are less active have lower peak oxygen uptake than those who are active, and that endurance exercise training can significantly increase peak oxygen uptake (Washburn & Figoni, 1999). Physical activity has been associated with increased strength and endurance (Warms et al., 2004; Jacobs, Nash, & Rusinowski, 2001) and increased pulmonary function (Crane et al., 1994) among people with physical disabilities. Understanding why some people choose to exercise and others do not may have practical value because of the physical and psychological benefits of exercise (Duda, 1989; Malone, Barfield, Brasher, 2012; Willis & Campbell, 1992). Exercise is an aspect of physical activity, defined by Physi- Vol. 30, No PALAESTRA 43

2 cal Activity Guidelines for Americans (PAG, 2008), that is planned, structured, and repetitive physical activity for the purpose of conditioning any part of the body to improve health, maintain fitness, or increasing physical performance. Motivations to exercise have been linked to goals and objectives of theoretical models (Ingledew & Markland, 2008; Markland & Hardy, 1993). Participation motive, or motivation, is important when it comes to increasing physical activity, and recent research has aided understanding of physical activity motivation (Dacey, Baltzell, & Zaichkowsky, 2008). It has been proposed that including an exercise motivation that has shown to increase physical activity in theory or research will possibly lead to other exercise motivations to develop as a person moves from non-exerciser to exerciser (Ingledew & Markland, 2008). Stages of change, a component of the transtheoretical model, has been used to more distinctly identify a person s readiness for a specific behavior by distinguishing between five stages (Prochaska, & DiClemente, 1992). Identifying these stages help to provide the participant with tailored information to move from one stage to the next. Motivations for exercise and stages of change for exercise have been studied together in the general population (Ingledew, Markland, & Medley, 1998). This study is lacking among people with physical disabilities and could possibly help to inform programs how to increase physical activity among this population. The purpose of the study was to compare motivations for exercise and the following five physical activity stages of readiness among people with physical disabilities: (a) not thinking about exercise, (b) contemplating exercise, (c) preparing to exercise, (d) exercising, and finally (e) maintaining exercise for at least six months. The hypothesis was that people who are in the action or maintenance stages for exercise would score higher on each of the motivations for exercise than those in the precontemplation, contemplation, and preparation stages of change for physical activity. This study hopes to identify any possible variation in exercise motivations between these stages. Methods Participants Two medical supply companies located in the Southeastern region of the United States were contacted and asked about their willingness to recruit clients for the questionnaire. The companies agreed to post an advertisement with a link to the questionnaire on their website and Facebook pages and to the link to their clients. The companies both post new products and specials, as well as education materials and service and outreach projects to their websites and Facebook pages. The Facebook pages are also an opportunity for the clients to communicate with each other and the company. Participation motive, or motivation, is important when it comes to increasing physical activity. (Photo courtesy of 2014 Get Out Enjoy Life Campaign) 44 PALAESTRA 2016 Vol. 30, No. 1

3 Table 1 Exercise Motivation and Stages of Change ANOVA Stages (Means (SD)) Motivation Pre-contemplation Contemplation Preparation Action Maintenance Exact Sig. Stress 13.84(6.44) 14.93(5.63) 15.00(6.58) 16.92(5.09) 16.48(5.34).428 Management* Enjoyment* 10.85(6.61) 14.39(5.90) 15.89(5.38) 17.38(6.64) 17.02(6.21).012** Revitalization* 9.85(5.13) 12.70(3.45) 12.60(3.76) 13.69(3.44) 13.59(4.01).041** Challenge* 15.07(5.69) 14.64(5.30) 14.85(5.02) 16.85(4.26) 16.86(5.28).246 Social 11.33(6.34) 9.17(4.75) 10.20(5.79) 12.00(4.32) 11.83(5.53).130 Recognition* Affiliation* 8.77(4.66) 9.12(4.02) 10.10(4.60) 11.31(4.15) 10.20(4.48).411 Competition* 9.92(6.17) 9.62(4.46) 12.16(6.73) 14.53(7.14) 13.89(7.61).010 Health Pressures 7.17(3.16) 8.04(3.22) 6.75(2.67) 7.69(1.60) 7.82(2.17).437 Ill Health 12.77(4.64) 14.79(2.91) 13.95(2.52) 16.85(1.52) 14.91(3.11).012 Avoidance* Positive Health* 12.00(5.10) 15.42(2.44) 14.80(2.80) 16.69(1.70) 16.22(2.25).000 Weight 18.67(6.67) 19.66(4.46) 20.25(3.68) 19.38(4.93) 17.48(4.77).135 Management* Appearance* 13.54(7.11) 16.28(5.29) 16.42(4.97) 17.69(3.52) 16.17(5.39).376 Strength 16.75(6.94) 22.02(2.68) 21.05(2.72) 22.77(1.64) 21.23(2.88).000 Endurance* Nimbleness* 12.08(5.32) 15.00(2.74) 13.25(3.65) 16.23(1.88) 15.15(2.81).003 Note. * Cronbach s α > 0.7; ** p > 0.05 and did not violate homogeneity of variance of p >.05 or meet Welch test of p <.05; SD standard deviation Measures The survey used for this study to measure exercise motivations and stages of change for physical activity was based on the Exercise Motivation Inventory (EMI-2) and the Physical Activity Stages of Change-Questionnaire (RM1-FM) (Markland, & Ingledew, 1997; Marcus, & Forsyth, 2003). The EMI-2 evolved from the original Exercise Motivation Inventory, developed by Markland and Hardy (1993), that explores the role of participation motives in exercise adherence by assessing their influence on participation, choice of activities, affective responses to exercising, and the reciprocal influence of exercise on participation motives. Exercise motivations were measured by the EMI-2, a 51-item scale comprising of 14 subscales, stress management, revitalization, enjoyment, challenge, social recognition, affiliation, competition, health pressures, ill-health avoidance, positive health, weight management, appearance, strength and endurance, and nimbleness, which are grouped into five motives: psychological, interpersonal, health, body-related, and fitness motives (Markland & Ingledew, 1997). The EMI-2 is differentiated from the original instrument by the addition of subscales of participation motives by further expanding the fitness-related and health-related reasons for exercise, and rephrased the question stem ( Personally, I exercise ) to include (or might exercise), in order to make the questionnaire applicable to non-exercisers. The EMI-2 has five motives connected to the fourteen subscales. Each of the subscales are connected to three or four of the items in the instrument, which are scored using a Likert scale ranging from 0, Not at all true of me to 5, Very true of me. The possible range of scores for the each subscale was 0 to 20 for those with four items and 0 to 15 for those with three items. The higher the score indicates higher levels of motivation to exercise for that particular subscale. For more information about the motives, subscales, and items, see Table 1. Confirmatory factor analytic procedures have been used to test factorial validity and invariance of the factor structures across gender, and the EMI-2 has been found to discriminate between people at different stages in that stage of change for exercise (Markland & Ingledew, 1997; Medley, 1998). Psychological Motives The stress management sub-scale was comprised of four items, and samples included, To give me space to think, and Because it helps to reduce tension. The possible range of scores for the stress management construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for stress management. The revitalization subscale was comprised of three items, and such as, Because it makes me feel good, and Because I find exercise invigorating. The possible range of scores for the revitalization construct was 0 to 15, with higher scores indicating higher levels of motivation to exercise for revitalization. The enjoyment sub-scale was comprised of four items, and samples included, Because I enjoy the feeling of exerting myself, and Because I find exercising satisfying in and of itself. The possible range of scores for the enjoyment construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for enjoyment. The challenge sub-scale was comprised of four items, and samples included, To give me Vol. 30, No PALAESTRA 45

4 goals to work towards, and To give me personal challenges to face. The possible range of scores for the challenge construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for challenge. Interpersonal Motives The social recognition sub-scale was comprised of four items, and samples included, To show my worth to others and To compare my abilities with other peoples. The possible range of scores for the social recognition construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for social recognition. The affiliation sub-scale was comprised of four items, and samples included, To spend time with friends and To enjoy the social aspects of exercising. The possible range of scores for the affiliation construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for affiliation. The competition sub-scale was comprised of four items, and samples included, Because I like trying to win in physical activities and Because I enjoy competing. The possible range of scores for the competition construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for competition. Health Motives The health pressures sub-scale was comprised of three items, and samples included, Because my doctor advised me to exercise and To help prevent an illness that runs in my family. The possible range of scores for the health pressures construct was 0 to 15, with higher scores indicating higher levels of motivation to exercise for health pressures. The ill-health avoidance sub-scale was comprised of three items, and samples included, To avoid ill health and To prevent health problems. The possible range of scores for the ill-health avoidance construct was 0 to 15, with higher scores indicating higher levels of motivation to exercise for ill-health avoidance. The positive health sub-scale was comprised of three items, and samples included, To have a healthy body and Because I want to maintain good health. The possible range of scores for the positive health construct was 0 to 15, with higher scores indicating higher levels of motivation to exercise for positive health. Body-Related Motives The weight management sub-scale was comprised of four items, and samples included, To stay slim and To lose weight. The possible range of scores for the weight management construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for weight management. The appearance sub-scale was comprised of four items, and samples included, To help me look younger and To have a good body. The possible range of scores for the appearance construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for appearance. Fitness Motives The strength and endurance sub-scale was comprised of four items, and samples included, To build up my strength and To increase my endurance. The possible range of scores for the strength and endurance construct was 0 to 20, with higher scores indicating higher levels of motivation to exercise for strength and endurance. The nimbleness subscale was comprised of three items, and samples included, To stay/become more agile and To maintain flexibility. The possible range of scores for the nimbleness construct was 0 to 15, with higher scores indicating higher levels of motivation to exercise for nimbleness. For the Physical Activity Stages of Change-Questionnaire (RM1-FM), there were four statements concerning an individual s physical activity level with a dichotomous response option, with yes being one and no being zero. The first two statements were about current physical activity habits and included I am currently physically active and I intend to become more physically active in the next six months. The third and fourth statements concerned being regularly physically active and included I currently engage in regular physical activity and I have been regularly physically active for the past six months. A scoring system was then used to classify respondents into one of the five stages of change: precontemplation, contemplation, preparation, action, and maintenance. Individuals reporting no to statements one and two were classified as being in the precontemplation stage, those reporting no to statement one and yes to statement two were classified as being in the contemplation stage, those reporting yes to statement one and no to statement three were classified as being in the preparation stage, those reporting yes to statement one, yes to statement three, and no to statement four were classified as being in the action stage, those reporting yes to statement one, three, and four were classified as being in the maintenance stage. The RM 1-FM has been used in many studies looking at physical activity stages of readiness since being developed and tested by B. H. Marcus and colleagues (Marcus, Rossi, Selby, Niaura, & Abrams, 1992). Procedures An electronic version of the questionnaire was delivered using Qualtrics software. An was sent to each company that included instructions on what to forward to their clients. The companies were instructed to copy the specified information and paste it into an to send to their clients. Also included in the were instructions for posting a link to their website and Facebook page. Seven days later, a reminder was sent to the clients. Fourteen days after the first about the questionnaire was sent out, a second reminder was ed out to the clients. There were 131 responses for the first week, three responses for week two, and eight responses for week three. The most responses were from the Facebook pages at 83% of total response. Response rate was unable to be determined as there was no way to know how many clients received the or viewed the Facebook posting. The participants that were willing to fill out the questionnaire followed the specified link and completed it on Qualtrics. There was no identifiable information required on the questionnaire and the participants were able to stop taking it at any time. Average time to complete the questionnaire was 12 minutes. 46 PALAESTRA 2016 Vol. 30, No. 1

5 The strength and endurance sub-scale was comprised of four items, and samples included, To build up my strength and To increase my endurance. (Photo courtesy of 2014 Get Out Enjoy Life Campaign) The questionnaire remained open for a total of three weeks. After three weeks the postings on the companies websites were removed and the online questionnaire closed. Any questionnaires with identifiable information were deleted. Access to the questionnaire was permitted only to the Principal Investigator. Data Analysis The results of the study have been analyzed using SPSS v.22. An analysis of variance (ANOVA) was used to test for differences in mean scores between stages of change for each motivation, and the post-hoc analysis Bonferroni was used to identify any group differences, a priori at p < Cohen s d is used to measure effect size, with low effect size interpreted as 0.2 or lower, moderate at , and a large effect size at 0.8 or higher (Cohen, 1977). The two instruments have not been reportedly used with people with disabilities; therefore, Cronbach s alpha was computed to analyze reliability for each subscale. The hypotheses were set a priori at p < Results The majority of the respondents were female (n=75; 53%), non-hispanic (n=134; 95%), and White (n=127; 92%). The age of the respondents ranged from (M=43.91; SD = 13.07). The majority of participants had incurred the disability later in life (n= 116; 89%) while few were disabled at birth. Type of disability was spinal cord injury (n=90; 64%), spinal bifida (n=13; 10%), multiple sclerosis (n=11; 8%), cerebral palsy (n=4; 3%), amputee (n=3; 2%), and other (n=18; 13%). For the stages of change, most of the respondents were in the contemplation stage (n=49; 35%), followed by maintenance (n=46; 33%), preparation (n=20; 14%), pre-contemplation (n=13; 9%), and action (n=13; 9%). Among the exercise motivations, ANOVA found enjoyment (p =.012) and revitalization (p =.041) to be significantly different among the stages of change. Post hoc analysis found significant differences between the pre-contemplation stage (M = 10.85; SD = 6.61) and maintenance stage (M = 17.02; SD = 6.21) for enjoyment (p =.016; cohen s d =.96). Posthoc analysis also found significant differences between the pre-contemplation stage (M = 9.85; SD = 5.13) and maintenance stage (M = 13.59; SD = 3.95) for revitalization (p =.025; cohen s d =.82) (Table 2). While not statistically significant, there were sequential increments of improvements of scores between stages for the other motivations. Discussion This study tested the hypothesis that people with physical disabilities who are in the action or maintenance stages for physical activity will score higher on each of the motivations for exercise than those in other stages. Though not all statistically significant, the mean scores for most of the motivations were higher for those in the action or maintenance stage over those in the pre-contemplation stage. The results showed that only two of the mean scores for motivations were significantly different based on stage of change: enjoyment and revitalization. Enjoyment and revitalization have the highest correlation of the other subscales in the instrument (Markland & Ingledew, 1997). These two constructs have also been emphasized as important motives for people who begin exercising (Ingledew & Markland, 2008). Placing people into a stage of change helps health educators tailor interventions for the individual. The goal of the study was to identify key motivations for people with physical disabilities among the different stages to aid in the development of personalized physical activity interventions. People at different stages of change typically have different motivations (Dacey, 2009). For example, having stronger intrinsic and self-determined extrinsic motivations are generally characteristic of regular exercisers when compared to non-exercisers (Dacey, 2009). Enjoyment has been shown to be higher for people that are in the later stages of change in the elderly population (Dacey, 2009), and a key motivation for those who regularly exercise (Markland & Hardy, 1993). Revitalization has been measured in physical activity Vol. 30, No PALAESTRA 47

6 interventions as an exercise-induced feeling, and has been shown to be important to increase in interventions trying to increase physical activity (Papandonatos et al., 2012). Dacey (2009) offered five strategies to encourage exercise including creating a vision, discussing what matters, providing autonomy and supportive environments, promoting enjoyment, and encouraging mindfulness. These strategies have the potential to empower the individual and to include into their identity that of an exerciser, or one who exercises, which will encourage their behavior to come from their values, their beliefs, and their life experiences. One strategy for an intervention would be including an activity such as Exerimaging, which is practicing mental imagery, to enable the person to build self-efficacy through visualization (Kimiecik, 2002). Other strategies include focus groups before the intervention that help participants establish goals for both exercising and for their life in general, providing options for the participants to encourage autonomy, having them to rate which activities throughout that they enjoy most, and creating a more holistic approach to exercise that includes addressing the mental aspect and stress management (Dacey, 2009). These strategies are practical suggestions for the processes of change, such as self-reevaluation, self-liberation, social liberation, and consciousness-raising, developed by Prochaska and DiClemente (1986). In considering the findings of this study, some limitations should be noted. One limitation of the study was the low sample size lending to low statistical power. There were 141 respondents, but when they were broken down into five categories representing the stages of change, which decreased the sample size for analysis. There were sequential increases among the stages for other motivations. Perhaps these motivations would have shown significant results if the sample size was larger. The questionnaire was originally developed for people without physical disabilities, and may not have been a reliable measure for people with physical disabilities. Future studies should assess processes of change for physical activity among individuals with physical disabilities. This will help in the understanding of moving people from one stage to the next. Additionally, research that focuses on people with physical disabilities that are in the early stages of change for physical activity would be beneficial to aiding in the development of interventions in this area. References Buchholz, A. C., Ginis, K. A. M., Bray, S. R., Craven, B. C., Hicks, A. L., & Hayes, K. C. (2009). Greater daily leisure time physical activity is associated with lower chronic disease risk in adults with spinal cord injury. 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(2010). Glucose tolerance and physical activity level in people with spinal cord injury. Spinal Cord, 48(8), Warms, C. A., Belza, L. B., Whitney, J. D., Mitchell, P. H., & Stiens, S. A. (2004). Lifestyle physical activity for individuals with spinal cord injury: A pilot study. American Journal of Health Promotion, 18, 288. Washburn, R. A., & Figoni, S. F. (1999). High density lipoprotein cholesterol in individuals with spinal cord injury: The potential role of physical activity. Spinal Cord, 37, Willis, J. D., & Campbell, L. F. (1992). Exercise psychology. Champaign IL: Human Kinetics. Jereme D. Wilroy, is a doctoral student and graduate assistant in the Department of Heath Science at The University of Alabama. Adam P. Knowlden, is a professor of Health Science at The University of Alabama. Dr. Knowlden specializes in behavioral epidemiology and program evaluation. David A. Birch, is a professor and chair of the Department of Health Science at The University of Alabama. 48 PALAESTRA 2016 Vol. 30, No. 1

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