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Physical Activity: The Science of Health Promotion Through Tailored Messages (CE)
Sedentary behavior warrants greater attention from rehabilitation nurses because physical fitness plays a role in the success of an individualized rehabilitation program. With one of every two adults being inactive, rates of sedentary lifestyle and obesity are increasing in the United States and are responsible for a large portion of our healthcare costs. Conversely, engaging in regular physical activity reduces the risks of obesity, premature death, myocardial infarction, diabetes, hypertension, colon cancer, depression, and anxiety. Because physical activity improves overall function, it is a component of many rehabilitation programs. Tailored health messages can be highly effective in helping people change unhealthy behaviors by providing information and behavior change strategies that are customized for the unique needs, interests, and concerns of different people. The rehabilitation nurse can help the client manage long-term health problems and maximize well-being by tailoring messages geared toward increasing physical activity levels. Although the exact mechanism responsible for the tailoring effect is not known, it is generally thought that the personally relevant information communicated in the message is more likely to improve motivation and health behavior change. The goal of a tailored message is to produce an individualized communication so that the participant can say, “This applies to me.” This article examines tailored message approaches geared toward engaging people in intentional physical activity.
With one of every two adults being inactive, rates of obesity and sedentary lifestyle are increasing in the United States and are responsible for a large portion of our healthcare costs. In the United States, these two conditions play such an important role in disease burden that Healthy People 2010 lists physical inactivity and obesity as the top two health indicators, followed by tobacco use (U.S. Department of Health and Human Services, 2002). Engaging in regular physical activity reduces the risks of obesity, premature death, myocardial infarction, diabetes, hypertension, colon cancer, depression, and anxiety (Centers for Disease Control and Prevention [CDC], 1999). In fact, obesity in the U.S. population has doubled in the last decade, and the trend is continuing. Because of this increase, obesity can be considered the defining disease of our generation.
Obesity, defined as more than 25% body fat for men or 32% for women, affected only 11.6% of the U.S. population in 1990, compared to 22.1% in 2002. This is a 10.5% increase over 12 years, and the upward trend is continuing (CDC, 2003b). CDC director Julie L. Gerberding testified before Congress on February 17, 2003, that the spread of obesity and its related consequences can no longer be permitted; the cost to our nation cannot be ignored (CDC, 2003a). Central to reducing this trend in obesity is increasing physical activity. The rehabilitation nurse may be in a position to initiate and maintain client participation in recommended physical activity, which can reduce weight-related problems and improve the physical stamina needed for activities that are an important part of daily living and the rehabilitation process.
An increase in physical activity is an important part of a weight management program, and the President’s Council on Physical Activity and Sports notes that a sedentary lifestyle contributes to 300,000 preventable deaths a year in the United States. Physical activity trends are discouraging. Data from CDC suggest that despite the proven benefits of physical activity, more than 50% of American adults do not engage in enough physical activity to reap the benefits, and 25% of adults are not at all active in their leisure time (CDC, 2006). Rehabilitation nurses have a unique challenge when dealing with obese and sedentary clients, such as the obese client who just had hip replacement surgery and is unable to ambulate because of muscle deterioration.
This article examines the intervention of tailored messages geared toward engaging individuals in increasing intentional physical activity. When an increase in physical activity is mentioned, most people envision exercise as a “planned, structured, repetitive, and purposive bodily movement done to improve or maintain one or more components of physical fitness” (Caspersen, Powell, & Christenson, 1985, p. 128). For some people, these beliefs inhibit structured exercise; however, exercise is only one component of physical activity. Increasing physical activity can be done not only through formal exercise but through daily activities such as performing yard work or housework or taking the stairs instead of the elevator. These examples entail consciously increasing the physical activity level in daily activities. One way to improve the level of physical activity is by helping people change their perceptions of negative aspects that keep them from engaging in physical activity, defined as “any bodily movements produced by skeletal muscles that result in energy expenditure” (Caspersen et al., 1985, p. 126).
The technique of tailoring involves increasing the relevance of a message by customizing it to the recipient’s interests, concerns, and needs for information (Kreuter, Farrell, Olevitch, & Brennan, 2000). In the current literature, the terms tailored interventions and tailored messages are used interchangeably, and the current literature does not provide a consistent definition of a tailored message. A broad definition offered by Pasick (1997) is that tailored materials “best fit the relevant needs and characteristics of a specific target population” (cited in Glanz, 2002, p. 553). However, in the article “Tailoring: What’s in a Name?” Kreuter and Skinner (2000) suggested that the definition of tailoring be “any combination of information or change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assessment” (Kreuter & Skinner, 2000, p. 1, italics in original).A distinction must be made between tailoring for a population and tailoring for an individual. Tailoring a message for an individual should be based on an assessment, which results in a message that provides an individual-focused approach to behavior change. This is very important to the rehabilitation nurse because all rehabilitation programs should be tailored to the individual client. As clinicians, we have the opportunity to influence our clients through our communication by providing personally relevant education and direction and by giving strategies for engaging in physical activities and acknowledging possible obstacles to doing so.
Traditional health education materials have been generic, and the overall intent was to provide as much information as possible without considering the specific needs of the prospective recipients. Although the exact mechanism responsible for the tailoring effect is not known, it is generally thought that including personally relevant information in the message is more likely to improve motivation and health behavior change (Kreuter, Strecher, & Glassman, 1999).
Standardizing terminology in order to evaluate communication-based tailored messages is essential. The authors of the book Tailoring Health Messages described a range of health communications, looking at the level of assessment and the nature of the content (Kreuter et al., 2000). These authors postulated five levels of communication: generic, targeted, personalized, tailored, and interpersonal (Kreuter & Skinner, 2000). Throughout the literature the different levels of communication have been called tailored interventions; this article will refer to them as tailored messages. The following describes the meaning of these five levels of communication, each of which has been or can be used in rehabilitation nursing.
Generic communication attempts to be an all-encompassing message that can inform almost all people; this method does not recognize that individuals have different needs for information. Targeted health material implies the development of an intervention that would be geared toward a particular subset of a population. This approach assumes homogeneity among the recipients and does not address variations in individuals. Personalization is attaching the recipient’s name to draw attention to an otherwise generic message (Kreuter et al., 2000). The tailored health promotion materials are a combination of information and behavior change strategies geared toward an individual. The highest level of tailored communication appears to be interpersonal communication, which consists of a one-to-one interaction from a health professional. This article focuses on health promotion messages that are individually tailored to increase physical activity.
Variables of Tailoring a Message
Mass-produced materials on health education can provide information about the general risks of no physical activity but may not effectively communicate ways of overcoming perceived negative aspects that inhibit increasing physical activity levels. However, the tailored message tends to be more personally relevant and thus to attract more attention (Kreuter et al., 2000). The goal of a tailored message is to produce an individualized communication so that the participant can say, “This applies to me.” For example, a Pentecostal woman may know of the need to be physically active, but she perceives that the skirt she wears impedes jogging; therefore, a tailored message could suggest brisk walking as an alternative. Likewise, tailored messages have the ability to take into account a host of other individual factors that affect how people perceive and respond to risks. However, the people who receive the tailored information need more than just accurate, personal risk estimates; they must know how they, as individuals, can reduce their risks. Furthermore, it cannot be assumed that health is of equal concern for people of every race, age, gender, or ethnicity. Finally, it must be understood that the presentation and expression of the risk estimates may influence the recipient’s interpretations. Tailoring involves making a message more relevant to a recipient by using information known about the individual. By recognizing obstacles and suggesting strategies that will connect the client with the idea of increasing physical activity levels through the tailored message, the rehabilitation nurse can enhance client motivation and adherence to the suggested regime.
This literature review examines current research involving tailored messages regarding physical activity and is not intended as a comprehensive review of tailored messages. Rather, our interest was in identifying the more recent literature on the topic and examining the lessons learned and the research needed to advance the science of communication about physical activity (Table 1). The method used for this review included searching Medline and the Cumulative Index to Nursing and Allied Health Literature for the key terms tailored messages, tailored interventions, tailoring, physical activity, and exercise. The search resulted in six appropriate citations as of March 25, 2006. Citations were considered appropriate if they focused primarily on a form of tailored communication as a behavioral intervention (preference for messages) and if physical activity was the variable being explored. The results were limited to English- language journals and research that was no more than 10 years old. The reference lists of the literature were searched and used for other potential sources. In their article on how to write an evidence-based clinical review article, Siwek, Gourlay, Slawson, and Shaughnessy (2002) developed evidence-based criteria and defined randomized controlled studies as the highest level of evidence. Therefore, studies examined for this review were chosen because they were randomized controlled studies.
To date, tailored messages concerned with physical activity programs have relied on the transtheoretical model (TTM) of stages of change (Prochaska, DiClemente, & Norcross, 1992) as the theoretical basis for placing participants in a classification system in which individuals are assessed for their readiness for behavioral change. TTM posits that readiness for change occurs on a continuum and that there are five stages of change: precontemplation (person has no intention to change behavior), contemplation (person is aware that a problem exists but has not taken steps for correction), preparation (person intends to take action in the next month), action (person is currently attempting to modify the behavior), and maintenance (person is working to prevent relapse of behavior change). This model assumes that people progress in a series of stages in their readiness for change. Movement along the continuum is nonlinear, often moving back and forth before the final stage of maintenance is reached. In order to appropriately design and implement a tailored intervention, researchers believe it is important to know what stage of change the person is in (Prochaska, Redding, & Evers, 2000). In an editorial critiquing TTM, Bandura noted that “individualized interventions, tailored to personal attributes and rate of progress, are more effective than uniform ones” (Bandura, 1997, p. 9).
Tailored messages about physical activity derived from the TTM that match treatment to a single change or combined stages of change have been shown to be more effective than no treatment or standard care among working adults and healthy adult primary care patients (Bull, Jamrozik, & Blanksby, 1999; Fahrenwald, Atwood, Noble-Walker, Johnson, & Berg, 2004; Marcus et al., 1998). Randomized controlled studies in this review have illustrated the efficacy of tailored messages. However, some studies examined here refute the idea of tailoring messages for increasing physical activity because these studies suggest only that equivocal evidence exists to support tailoring as an effective approach to promoting physical activity (Bull, Jamrozik, et al.; Bull, Kreuter, & Scharff, 1999; Marshall, Leslie, Bauman, Marcus, & Owen, 2003). These studies did not reveal the power analysis, and therefore it is unknown whether the sample size was adequate, which could be the reason for the equivocal results.
Assessing why some studies had positive results for tailoring and others showed negligible results is difficult because these studies did not give adequate examples of their tailored messages (with the exception of Fahrenwald et al., 2004, who referred the reader to the published study elsewhere that gave the examples). Because the published literature lacks details on the content, structure, description, and examples of the actual tailored messages used to promote physical activity, evaluating or directly comparing the studies is difficult.
By standardizing how a tailored message is constructed with its theoretical underpinnings and mode of delivery, one can tease out and compare the variables that affect the success of this intervention. As indicated by this review, the tailored message was delivered in various ways, such as print-based materials (Bull, Jamrozik, et al., 1999; Bull, Kreuter, et al., 1999; Marcus et al., 1998; Marshall, Bauman, et al., 2003), Web-based materials (Marshall, Leslie, et al., 2003), personalization of standard material (Marcus et al., 1998; Marshall, Leslie, et al., 2003), and interpersonal (Bull, Jamrozik, et al., 1999; Fahrenwald et al., 2004). Currently, no direct comparison of the delivery modes has been reported, and therefore the effect of the delivery mode has not been well established. Delivery mode of the tailored messages is an area that warrants further research.
TTM is not a parsimonious theory but a strong theoretical framework that can be used to examine behavioral change. The model integrates important constructs from other behavioral theories and is best known for its description of behavior change occurring in separate stages. However, staging an individual uses only one construct from the theory. Other constructs are decisional balance, processes of change, and self-efficacy. TTM also encompasses concepts from decision making (Janis & Mann, 1977) and social cognitive (Bandura, 1989) theories. However, in the current literature TTM often is used for staging in conjunction with other theoretical constructs such as perceived benefits and barriers from the health belief model and self-efficacy from the social cognitive theory. This list of theories used in conjunction with TTM is not exhaustive but merely an attempt to acknowledge that researchers have not adhered to the true theoretical nature of TTM. TTM is an integrative and comprehensive framework, and it can be used efficiently and effectively by itself for tailoring an intervention (Fahrenwald et al., 2004; Marcus et al., 1998).
The studies that were examined staged the participants using TTM in order to create the message. Some of these studies claimed to blend theories but provided little description of how this was done (Bock, Marcus, Pinto, & Forsyth, 2001; Bull, Jamrozik, et al., 1999). Nonetheless, TTM continues to be the theoretical framework of choice even though it is not used in its entirety. Programs targeting the individual’s stage of motivational readiness have been shown to increase the overall physical activity (Marshall, Bauman, et al., 2003). However, other constructs within the theory of behavioral change can be addressed by TTM.
Prochaska and Velicer (1997) maintain that pros and cons (the decisional balance construct in TTM) are an excellent indicator of an individual’s progress from precontemplation to contemplation, preparation, and action stages. In these studies the TTM construct of decisional balance generally was called the individual’s perceived benefits and barriers (Bull, Jamrozik, et al., 1999; Bull, Kreuter, et al., 1999; Fahrenwald et al., 2004; Marcus et al., 1998), that is, the language and concepts from the health belief model, not TTM. With this inconsistent use of theoretical concepts, the measurement of the pros and cons could have been inadequate and not a true reflection of the individual’s decisional process. This could have an effect on the tailored message that was developed. Future research must examine theoretical constructs that inform the intervention because the way these constructs are measured affects the way the tailored messages are written.
A theoretical model synthesizing TTM and Maslow’s hierarchy of needs has been proposed for tailoring advice (Yap & Davis, 2007). This model is intuitively appealing. Because theory is developed slowly over time as evidence becomes available to provide support, it is a bit premature to call this an effective approach for tailoring a message toward behavior change. This is not to say that the model and its concepts are devoid of merit; rather, behavior change and compliance concerns are complex, and all rehabilitation clients must be individually evaluated and treated, hence the importance of tailoring.
U.S. society is highly technological, making it increasingly convenient for people to remain sedentary and discouraging physical activity in both subtle and obvious ways. The lack of physical activity is of grave concern to rehabilitation nurses because many clients may be debilitated by a sedentary lifestyle as well as their illness or injury. Increasing intentional physical activity is a key to a successful rehabilitation program because physical fitness is a physiological state composed of cardiorespiratory endurance, muscle strength endurance, flexibility, and body fat composition. Consequently, by increasing physical activity the rehabilitation nurse would be moving the client toward better overall health.
The tailored message is an evidence-based means of increasing physical activity in sedentary people. When a population is homogenous, the difference between the tailored and standard messages is small (Bull, Kreuter, et al., 1999). When there is variability in the population, tailored messages should be quite effective, although a tailored message can be of value for a unique homogenous subset of the general population (Fahrenwald et al., 2004).
Tailoring assessments should “go beyond a basic theoretical construct to a deeper understanding of an individual’s living patterns [and this] should lead to more effective tailored messages” (Bull, Kreuter, et al., 1999, p. 190). Future research should carefully examine the variables within the population. The identification of social, psychological, and environmental variables is important for creating tailored material; tailoring to the values and norms of the individual will improve the rate of participation and change (Fahrenwald et al., 2004; Marshall, Leslie, et al., 2003).
Bock et al. (2001) found that with a tailored message, individuals met and sometimes exceeded exercise participation goals. However, when the intervention ceased, there was no long-term maintenance, suggesting that a lifestyle change requires not only an individualized message but also a sustained mode of delivery. The delivery would carry on past the maintenance stage, anywhere from 6 months to 5 years, presumably with less intensity (Prochaska & Velicer, 1997).
Because pertinent studies indicate that content should be geared toward a particular stage of change, staging the client appropriately before implementation is instrumental in determining the content of a tailored message. Furthermore, as the client’s stage changes, the message changes and is tailored to the appropriate stage. The effectiveness of an intervention can be measured by the client’s progression between the stages (Bock et al., 2001; Fahrenwald et al., 2004).
When the client has been staged, the rehabilitation nurse can decrease sedentary behavior by engaging and motivating the client through individualized tailored messages. Because personalized information often stimulates interest, motivation can be elevated, which leads to better compliance with the prescribed regimen. For example, if a client is enrolled in a rehabilitation program two times a week, tailored messages can be used on the days the client is not seen.
Health promotion during rehabilitation is an art and a science directed at improving lifestyles that foster optimal health. Sedentary lifestyle is a major public health problem and should be a focus of health promotion in rehabilitation programs. The rehabilitation nurse is a key person to help the client manage long-term health problems and maximize potential well-being through physical activity. If the clients of the rehabilitation program are more physically fit, the program is more successful. Tailored messages are one way to promote physical fitness and compliance with the rehabilitation program. It can be inferred that tailoring works because tailored education materials have shown promising effects in helping individuals change behaviors related to improving their health (Kreuter et al., 2000).
The word tailored is used throughout the literature with different connotations, and one must be careful when comparing studies because of those differences. Tailoring ranges from targeting a stage (Marshall, Bauman, et al., 2003) to interpersonal communication (Fahrenwald et al., 2004). There may be little difference between high-quality standardized print material and tailored print material for targeting the general population. The American Heart Association brochure (which is a high-quality standard pamphlet) appeared to have as much of an impact as a tailored pamphlet in the general population (Bull, Jamrozik, et al., 1999; Bull, Kreuter, et al., 1999). This implies that tailoring must go to a deeper level of understanding of the individual who is targeted to receive the message; race, gender, socioeconomic status, religion, age, and cultural values all play a role in how the message must be tailored to have an impact beyond that of standard printed material. Recommendations were made for future research that focuses on identifying which physical, social, psychological, or environmental variables should be addressed to improve outcomes beyond the effects of well-designed generic materials (Bull, Jamrozik, et al.; Bull, Kreuter, et al.).
Tailoring messages is a unique way of communicating with patients, and it is important to understand what variables are necessary for tailoring a rehabilitation program toward behavior change and compliance. Further research is needed to help develop the tailored messages that would be used to increase physical activity in any rehabilitation program. This article focused on increasing intentional physical activity; however, rehabilitation programs can benefit from tailoring messages to promote any behavior change. For example, an obese and sedentary person who recently had hip replacement and needs to increase range of motion will need unique information to promote behavior change toward increasing his or her current level of physical activity. This information would include reminders and prompts for implementing strategies to increase physical activity that complements rehabilitation efforts in his or her daily routine. In addition, clients who are now living in a damaged body need to be aware of obstacles that could be encountered, such as depression, fear of falling, or pain. Being made aware and empowered with appropriate personal information allows prevention of further impairment and a reduction of disability as well as restoration of function and roles to help clients make informed decisions. Rehabilitation nurses are in the ideal position to use tailored health messages geared toward intentional physical activity. This approach to health promotion must be assessment based before being individual focused, resulting in a customized end product.
About the Authors
Tracey L. Yap, BSN RN, is a doctoral candidate at the University of Cincinnati College of Nursing, Cincinnati. Address correspondence to her at firstname.lastname@example.org.
L. Sue Davis, PhD RN, is a professor and the director of occupational health nursing program at the University of Cincinnati College of Nursing, Cincinnati.
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