THE ROLE OF SELF MOTIVATION

EXERCISE ADHERENCE
West
A Thesis
Presented
The Faculty
n Washington
to
of
University
Partial Fulfillment
of the uirements for the Degree
Master of Science
by
John W. Clark
May 1986
THE RI)LE OF SELF MOTMTION
IN EXERCISE ADHERENCE
John Clark
Accepterl in Partial Completion
Of the Rerluirements for the Degree
l aster of Science
Arlvisory Conttn1gl..
-W;,On4M
Robert M. Thorndike
By
I.I .
Graduate
. Kleinknecht, Chairman
ABSTMCT
Physical fi.tness testirlg, exercise reports, and psychological measures
were used to assess thr: role of self-motivation as measured by the
Self-Motivation Inventr>ry (SMI) (Dishman,
Ickes, & Morgan, 1980) in
exercise adherence. Pirrticipants were healthy men and women who worked
at an industrial plant where the employer was sponsoring a health and
exercise program; 334 persons began the study and analyses were
carried out on this grorrp and smaller subgroupings of it dependi-ng on
identifying informatiorr avaj-labIe and on participation in the various
phases of the study. Data were collected on four occasions during the
exercise program which continued approximately one year. Some of the
subgroupings for analyr;is had a very sma11 number of subjects with a
full set of data due to the voluntary participation and identification
at each of the four da1:a collection sessions. Because of the sma1l
number of subjects in riome of the subgroupings, the results of this
study and inferences dr:awn from the results must be treated wi-th
caution. Stepwise mult:ip1e regression analyses revealed that the SMI
coupled with percent body fat and weight did not account for a significant
portion of the variance in exercise adherence as had been reported by
Dishman and GeLtman
(1!f80),
though evidence supporting some psycho-
biologic mix of factors; was found. The presence of irnmediate rewards
from exercise seemed to play a more important role in exercise adherence
than did self-moEivation. Compilation of reasons cited for starting, not
starting, conti-nuing, ernd dropping out of exercise and cluster analysis
of reasons cited for sl:arting and not. starting exercise indicated that
those persons who starl:ed and continued exercise were 1i.ke1y to cite
immediate physical and psychological rewards from exercise while those
who did not start or who dropped out were likely to report difficulty
with scheduling 4nd le:ation of classes and not being motivated enough
to exercise. t-tests at the .05 alpha level revealed that SMI scores
of starters were signiEicantly higher than those of nonstarters, but
that there was no significant difference between SMI scores of those
who dropped out and those who adhered to an exercise program. SMI was
supported as a measure of self-motivation, but it does not appear to be
a pure measure of the ger.etaLj-zed, nonspecific tendency to persevere
defined by Dishman and Gettman
(1980). A significant negative correlation
between a measure of anxiety, the State-Trait Anxiety Inventory
(STAI-T)
(spielberger, Gorsuch, & Luschene, L97O) and SMI
(r=-.37, n=334) linking
higher levels of anxiety to lower SMI scores suggests that as different
specific situations elicit different levels of anxiety in participants
the SMI administered in the context of the specific situations will tend
to vary. Self-motivation as measured by the SMI seems to be one factor
in exercise adherence, but the results of this study suggest that the
SMI score is at least partially siEuation specific and that the degree
of irnurediate reward th.e individual
perceives as resulting from exercise
is probably more impoltant in exercise adherence than self-motivati-on'
Introduction
Regular, vigorousr physical exercise can have positive
effects in
several areas of life. The body functions better with improved
metaboli-sm, a lower percentage of fat, and a more efficient use of oxygen.
A general feeling of u'el1-being with increased effectiveness in work,
sleep, and social behavior is associ.ated with exercise (Folkins
& Si_me,
1981; Morris & Ilusman, 1978).
people
who exercise regularly show a
decreased tendency tovard heart disease, hypertension, and obesity
(Morris,
Everitt, Pollard, chave, & semmence, 19g1;
paffenbarger,
wing, &
Hyde, L978). Fina11y, those who exercise display less anxiety, less
tension, less depressi.on, less fati.gue, and more vigor
-than
those who do
noL (Folkins
& Sime, 19811 Blumenthal, wi11iams, Need.els, & wallace, L9B2;
Kaplan, Mendelson, & Dubroff, 1983; Fetsch & Spri_nkle, 1983).
The issue of pote:rtia1 benefits of any activity is moot for those who
do not
ParticiPate
or Eor whom the participation
level is not particularly
high. In reviewing strrdies of regular exercise Dishman (1982)
and Martin
& Dubbert (i982)
noted that among those who began an exercj_se program,
dropout rates between ll0 and 70 percent were conslstent.ly reported. The
most dropouts occurred during the first three months and after L2 to 24
months the number of p<:rsons adhering to an exercise program was stable.
The factors involrred in exercise adherence and the relationships
between them hold the keys to predicting who will have trouble maintainlng
an exercise program. Such prediction might then enable us to tailor an
exercise
Program
to ir.dividual needs and increase the adherence rate.
A number of factcrs related to exercise ad.herence have been
identified and are divided into three groups: parti-cipant factors
(physiological
and psychological),
social factors (famj-ly,
friends,
employers, etc.), and exercise program factors (location,
schedule,
leadership, and content). No one factor or one of the three groups of
factors explains exercise adherence by itself; adherence results from an
i-nteraction of factors.
Self-notivation (a psychological factor) and how the other factors in
exercise adherence rel,rte to it are the central interests of this study.
The self Motivation rn'rentory, (sMr), (Dishman,
rckes, & Morgan, 19g0) is
a paper and pencil tesE designed to measure a personrs level of
self-motivation. Presr:ntly, the sMr is the best single psychological
predictor
of exereise irdherence (Dishman,
rckes, & Morgan, 1990).
Therefore, the
Purpose
of this study is to learn more about what the SMI
is measuring, how that measure relates to the construct of
self-motivation, and h<lw the SMI score and self-motivation relate to
exercise adherence
"
llreatment Compliance
A field of study
trrara1le1
to exercise adherence
j-s
medical treatment
compliance. The two he.ve similarities in their concern for health, in
faetors contributing tc adherence/compliance, in dropout rates, and in
Patterns
of dropout. Since the lj.terature on medical compliance has a
longer history and more breadth than that on exerci-se adherence it is
useful in the study oE exercise adherence.
In medici-ne, treirtment compliance means following the clinical
prescriptj-on
in such r:hj-ngs as taking medications, following hygienic
routines, and making .Lifestyle changes (sackett,
Lg76). synonyms are
adherencer prsverence,
and persistence. Antonyms are dropout, relapse,
and recidivism.
The word compliarrce carries negative connotations for some by
implying blind obedierrce to professional
dicta. This lmplication is
unfortunate because ir. current usage it is felt that the best c1j-nica1
prescription
i-s formulated by the patient and physician
together (Sackett,
L976). However, both the history of use of the term compliance and
possible confusion of alternaEive words seem to d.ictate conti-nued. use of
the term compliance.
Patients tend not to eomply with health related regimens and. thj-s
noncompli-ance greatly conplicates treatment planning. rt is not
sufficient to determi-ne what patients need to do; the helping professional
must also get them to do it. until more is known about achieviag
treatment compliance we will continue to have useful treatments that
significant numbers of people cannot or will not fol1ow.
Treatment compliarrce behavior does not consistently follow any one
pattern, but there are conmonalities that offer starting points for
research and discussioll. Pati.ents have shown difficulty in mai-ntaining
compliance and simila:: patterns of dropout in such programs as following a
physiciants prescript:Lon for medication and hygiene; abstaining from
alcohol, tobacco, and other addictive substances; continuing in
psychotherapy; dietinl; to lose weight; and exercising regularly (Dishman
& Gettman, 1980; Sutton, 1979; Hunt, Barnett, & Branch, L97L; Baekeland &
Lundwall, L975).
In addition to tlte rather gross simi-laritj"es in dropout rates and
patterns, Haynes (197(t)
has identified some major correlates of
noncompliance that ap1rly to the variety of health settings that share
dropout
Patterns
mentj.oned above. These correlates of noncoupliance
include: (a) psychi.at:ric illness,
(b)
a regimen that is complex, that
requires a great deal of behavioral change, that is of long duration, or
all of these,
(c)
treat,ment occurring in clinics that are inefficient,
inconvenient, or both,
(d)
inadequate supervision of the treatment program
by the therapist, dissatisfaction with the therapist by the patient, or
both, and
(e)
a patier,t with inappropriate health beliefs, previous or
present noncompliance with other regimens, family instability, or all of
these.
Patient Factors
The main interest in this paper is with psychological factors and how
they relate to other factors in compliance. These psychologi-cal factors
are included in the patient factors that Haynes calls health beliefs.
Health beliefs and their relation to other compliance factors have been
described by several rnodels including the Health Belief Mode1, Social
Learning Theory, the tftility Model of Preventive Behavior, and the Relapse
Mode1.
Health Belief Model: The healrh belief model, (HBM), (Rosensrock,
L974), was created in a preventive health setting to explain the liklihood
that a person would comply with a reco
'nended
course of action. rts
components are:
1. the perceived seriousness of the consequences
of not taking preventive or curative action,
2. the perceived susceptibility of the person to
the negaEive outcome,
3. the perceived barriers and benefits to taking
the pres,:ribed action,
4. the perc,rived efficacy of the prescribed
action.
A general relation bettoeen beliefs and preventive health actions has been
shown to exist in clin:Lcal situations (Aho,
1977). And, as simple as the
Health Belief Model is, it provides a useful framework for study and
therapy.
Clinical applicat:Lon of rhe health betief model has led to a
broadening of the orig:Lnal proposal. Jenkins (1979)
assembled a set of
specific questions based on the health belief model that clarified the
patientst beliefs, per(:eptions, motives, needs, learned habits, and social
and physical environment,s for health behavior in order to prescribe a
course of treatment tltat l^rould be cornplied with. Jenkinst
compilation of
specific components irr each personfs
compliance structure underscores the
assuuption that there can be uo
ttstandard
regimen,, because there is no
"standard
patientfr (Fink,
1976).
Even when broadened to include as much personal context as possible,
attitudes and beliefs measured before treatment begins have not been
particularly predictive of long term compliance. Health beli.efs do become
better predictors
of compliance when measured as treatment progresses
(Luborsky,
et al., 1980). Furthermore, those who do comply with treatment
develop more positive health beliefs as they continue in treatment (Bruhn,
i983). Understanding ,cf
compliance behavior must include this shaping of
attitudes and beliefs 5y experience.
social learning theory: social learning theory incorporates the
interplay between indi'ridual experience and behavior by viewing humans as
learning, choosingr prr)blem-solving organisms. central concepts are
perceptions of threat, rewardr possible solutions, and ability to carry
out various actions.
Specific social learning theory concepts such as locus of control,
behavioral capability, expectations, self control, and self efficacy have
been used effectively l:o explain and to iuprove treatment compli.ance
(Bruhn,
i983). For exemple, it has been found that locus of control
(the
degree to which indivicluals believe they control their envi-ronment)
explains successes and failures in rigid versus flexible weight-loss
programs (Kincey,
1983). Compliance with a self-care regi-men in
adorescent diabetics uras improved by using self-monitori.ngr goal
setting, and behaviore.l contracting (schafer,
Glasgow, & Mccaul, l9g2).
Ilowever, Kaplan 6 cowles (1978)
have warned that some common
misapplications of social learning theory concepts can confound
conclusions about compliance, citing two examples. The first example was
in trying to apply a generalized measure of locus of control to a specific
situation. Individuals who generally have an internal locus of control
(feeling
thaE they control their environment) may display a very external
locus of control (feeling
that their behavior is controlled by forces
outside themselves) in a specLaLized sett.ing such as medical treatment.
The same warning probably has some validity for other general
psyehological measures being applied in specifj.c situations. The second
misapplication of social learning theory described by Kaplan & cowles
involved trying to explain behavior through beliefs without consi-deri.ng
the values that the inCividual placed on the possible outcomes.
Utility nodel of preventive behavior: The utility model of
preventive behavior
(C,rhen,
i984) focuses directly on the value
participants put on varlous possible out.comes. Thj-s model is based
directly on a model us,rd in Economics to describe how individuals behave
with respect to risk. In the economic model the term
"uti1ity"
is defined
as a very broad measurr: of value which includes all forms of reward in
taking a given action be they monetary, personal, or soci-al.
The Utility model retains the rnajor elements of the health belief
model such as perceptir>ns of personal risk and costs and benefits of
preventive acEion, but goes further to assert that the primary motivating
factor in taking prev,rntive
action is the anxiety associated
with
threat of harm rather than the harm itself. An action that makes
individual feel better i.mmediately is most likely to be followed.
rn the case of a long-term or a preventive
regimen the vitar factor
is the personal
style of the patient i-n d.ealing with risk. Each person
has a 1evel of aversic)n to risk and of willingness to pay now to avoid
future risk- A persorLfs risk-taking
style determines whether a given
behavior has a positive,
negative, or neutral utility at a specific tine.
The broad scope of the teru utility is a reminder that even in health
related behaviors, health is only one of the possible
values that goes
into determining utility level.
. Relapse model: A single lapse can lead a person to drop out of a'
Program.
The lapse may be overeating while on a weight loss diet, missi-ng
a therapy session, or Eailing to take medication. Marlatt and Gordon
(1980)
have suggested E.hat a personts ability to recover from such a lapse
and to continue with tl:e prescribed
regimen is influenced by the personrs
cognitive skills in coPing with the relapse. rf the person sees the
relapse as proof that he cannot succeed and that he is weak, then
conti-nuing the prescribed
regimen is un1ike1y. Marlatr and Gordon (19g0)
have suggested that tr:rining in how to deal with relapse can have
significant effects on the overall adherence rate. Indeed, this model has
been applled successful.ly both in stopping an unrrTanted behavior (smoking)
(Condiotte
& Lichtensterin, 198l), and in encouraging a positive behavior
(running) (fing
& Frede,riksen, 1984).
the
Ehe
Treatment Factors
The nature of ther treatment itself plays a significant role in the
degree of compliance. If the treatment is painful or has other unpleasant
side effects, the char,ce of noncompliance i-s increased. The behavj.or of
clinic staff members, the scheduling of appointments, and the location of
the treatment site all also play roles in eompliance.
The quality of the relationship between the physician and the patient
has been consistently given a central role in compliance (Ilaynes,
et a1.,
lg76). Sometimes other factors thaE favor noncompliance cannot be hetped
and the relationship between the patient and physician must be the one
that makes compliance possible. As stated previously, the prescription
most 1ikely to be complied with is one jointly
determined by patient and
physician. The physicianrs knowledge of disease and treatment must be
joined
with hoI^I the patient is being affected or threatened by an ailment
and how that patient deals cogni.tively with health. If the formulation of
the treatment plan considers the beliefs, habits, capabilities, and
expectations of the patient as well as the content and rationale for the
treatment, chances of achieving compliance are enhanced.
Social/environmental f actors
If the pati-ent
I
s Eamily supports maintaining the treatment program
the chance of success is great.ly increased. A number of studies showing
the importance of the Eauily i.n adherence to medi-cal treatment have been
reviewed by Haynes
(1976).
Support of some significant other
10
person
is recognized
as a vital component
of compliance (Bruhn,
19g3)
the negative side, fainily instability has already been mentioned as a
factor in noncomplian,:e (Haynes
,
tg76).
No matter what trre rerationship
with the physician
or the personrs
beliefs, he lives mosl: of the time with his family, friends,
and ferlow
workers. The role of other people
significant
to the patient
in
compliance
suggests ttLat considering
only the patient
in formulating
the
prescription
may be ol'erlooking
some seri-ous problems
and opportunities.
Exercise Adherence
The degree of adherence to programs
of regular physical
exerci.se,
like medical adherence,
is 1ow. Typicarly,
after six months of a program
about 507" of the partir:ipants
have dropped out (Dlshman,
r9g2). Factors
involved
j-n
exercise arlherence can be grouped
into participant
factors,
soeial/environmental
f.rcEors, and program
factors. The focus of this
study i-s on the psycho:-ogicar
components
of the participant
factors
and how these psycholoS;ical
factors relate to other factors in exercise
adherence.
Participant Factors
Attitudes: Perhaps the most obvious psychological
measure of whether
a
Person
would exercise or not would be attitude toward exercise. However
this has not been found to be the case. Even very sedentary people have
On
11
been shown to have posri-tive
attitudes toward. exercise (Dishman
& Gettman,
1980) .
Sedentary people who value exercise have attitud.es that are in
conflict with their actions. Festinger (L957)
described such a conflict
as cognitive dissonance. He suggested that when people find themselves in
a state of dissonance they are uncomfortable and will try to change
something to achieve consistency. If consistency is not gained through
acti.on, then the person is likely to redefine his situation so that
beliefs and actions are consistent. Efforts to achieve this consistency
often involve distorticns of reality that Freud described as defense
mechanisms. In the case of exercise, the person can achieve consistency
either by exercising o.r by having a reason that is acceptable to him not
to exercise. Acceptab Le reasons can include anything that makes the
person feel consistent (be
the reasons rational or not), such as having a
physical ailuent that
Precludes
exercise, not needing to be in better
physical condition, thr: exercise site being inconvenient, or not having
Eime to exercise.
How a sedentary
l)erson
is resolving the dissonance would seem to be
vital in understanding his compliance/adherence patterns. While cognitive
dissonance theory and ::esearch seem potentially fruitful in compliance and
adherence, studies spe<:ifica11y using this approach r,rere not found.
Motivation: A corrmon reason cited by participants for dropping out
of an exercise progran has been
"1ack
of motivation" (oldridge,
et al.,
1978). Exactly what w:rs meant by
ttlaek
of motivation" was not explained
by O1dridge.
L2
MotivaEion has beren defined by Lefton (1982)
as
"...
any internal
condition within an or:ganism that appears (by
inference) to produce
goal-directed
behaviot'" (p.
137). It may be caused by some imbalance that
pushes the organism tcr act
(drive
theory) or by some expectance of a
desirable outcome that pu1ls the organism to act (expectancy
theory). It
seems likely that the people in Oldridge's study meant that they did not
vrant to do the activity badly enough to overcome obstacles to contlnuing.
tr{hat it was inside the participants that either made the activity itself
not positive enough to draw them past the barriers or so unpleasant that
their desire for good health was not strong enough to push them past the
barriers is, of course, not known, but it can be inferred through
observable behavior, self-statement, and physical capabilities.
Significant and consistent differences in how people perceive and
interpret the same experience do exist. It has been shown that
differences in response to stressful situations can be accounted for by
cogni"tive methods people use to deal with them
(Koriat,
et al., 1972) .
The i-nterpretat.ions anil strategies that the partici_pants employ are
available for study through self-report and changeable through relearning
(Meichenbaum,
I975). Ihis makes eognitive activity a potentially powerful
tool for understanding, predicting, and changing behavior.
A paper and penciL test designed to measure onets tendency to
persevere is called t.h,l Self-Motivation Inventory (SMI) (Dishman, Ickes, &
Morgan, 1980). The SMt consists of statements that the subject rates I to
5 on a scale of
trextrernely
uncharacteristic of mett to
ttextremely
characteristic of me", profiling her or his cognitive interpretations and
strategies relative to perseverence. The SMI has been demonstrated to be
13
the best single psychological predictor of exercise adherence. Dishman
and Gettman (1980)
halre called the tendency to persevere that is measured.
by the SMI self-motiv:rtion and have defined it as follows:
'...
a generalized, nonspecific tendency to
persist in t:he absence of exErinsic reinforcement
and is thus largely independent of situational
influence... ismost likely a socially learned
characterist:ic dependent upon the capacity for
self-reinforcement it may incorporate the
ability to c.e1ay gratification ... is apparently
independent of concepts such as approval
motivation, achievemenE motivation, locus of
control, or attributions for success or failure
... may invc,lve cognitive ski11s similar to
i-magery or fantasy about goal attainment,
self-talk strategies, or possibly eongruence
between self-perception and behaviorrr (p.
297).
Intrinsically motivated behaviors have been described by Edward Decl-
(L975)
as ones that the person undertakes to feel competent and in
control. Deci related internal and external motivators by suggesting that
some goals are self-generated, but externally measured. For example,
adherence and effort put i-nto a physical task have been shor^m to increase
when people achieve their own exercise goals (Martin
& Dubbert, L982;
Bandura & Cervone, 1983).
Some reference points for deciding whether to persevere or not may be
i"nherent in the environment. For example, in a competitive sports setting
participants have reported an increase in intrinsic and a decrease in
extrinsic motivation levels after winning, (Weinberg,
1979)
"
It is as i.f
the person likes the game better for itself when he has evidence, through
winning, that he is good at it. This fits with Decirs concept of an
intrinsically motivating aetivity.
(Since
half of the particlpants lose
in most games, this finding brings up important questions for educators
l/1
trying to build positive lifelong habits of exercise in their students).
Physiology: It nray be that people
because of how exercisre feels to them.
factors was pointed ugr when Dishman and
successful in predicti.ng the variance in
by utilizing the percnt body fat, body
participant.
continue to exercise or quit
The significance of physical
Gettman (1980)
were most
adherence in an exercise program
weight, and SMI score of each
Affective and physiological changes occurring during and after
exercise may provi.de a means by which exercise can provide imrnediate
reward or aversion to participants. Because vigorous exercise raises body
temperature, atranquilizing effect uay occur,
(de
Vries, 1981). Vigorous
physical activity is consistently associated with a decrease in state
anxiety
(the
level of anxiety a person experiences at a given moment)
(Morgan,
1979). Muscular exercise increases blood levels of hormones
(Hartley,
L975). And, <lfmost recent interest, sustained aerobic exercise
results in increased levels of a morphine-like substance, beta-endorphi-n,
in the blood of exercisers
(Grossman
& Sutton, 1985). This last
observation has lead to front. page explanations of a
ttrunnerts
hightt.
However, there are other plausible explanations of affecti-ve changes
associated with exercise that do not involve endorphins
(Morgan,
1985).
The runner's high does exist and beta-endorphin levels in the blood are
elevated after exercise, but how, or if, the two relaLe and what this
might have to do with exercise adherence is not yet clear.
The role of beta-endorphin in response to exercise is becomi-ng
clearer, but is not a simple case of a euphoria similar to one due to
t5
drugs. colt, wardlaw, and Frantz (1981)
have pointed out thar though
beta-endorphins administered centrally have been shornm to produce profound
behavioral and analgesic effects, intravenous doses 1,000 to 10,000 times
as strong as levels measured in the blood after exercise have fai-led to
produce the same results, (Berger,
et al, 1980; Gerner, et a1., 19g0).
Moore (1982)
reminds us that beta-endorphins are produced both by the
brain and the pituitary gland with those of the latter origin, outside the
blood-brain barrier, being the ones that have been detected after
exercise. I^Ihat is occurring in the brain
j-s
not known. on the other
hand, beta-endorphin is i-mplicated in less profound changes in pain
sensitivity and mood that rnay play a role in the good feelings reported
after exercise (Janal,
Colt, Clark, & Glusman, 1984).
The existence of rhysiological and related psychological responses Lo
exercise may relate to the observation that people who could gain the most
from regular exercise ilre the least 1ikely to adhere. High weight and
Percentage
of body fat are predictors of nonadherence, (Dishman
& Gettman,
1980). Pati"ents recovrlring from heart attacks who di-splay the most damage
to heart functioning hrrve been shovm to be least 1ike1y to adhere to a
therapeutic exercise pr:ogram (Blumenthal,
wi11ians, wallace, wi11iams, &
Needels
'
L982). If ext:rcise is painful or frightening, noncompliance can
be expected.
How exercise feels; to the participant blurs the line between
participant and prograrl factors, because it depends so much on what
exercise is done and al: whaL intensity. For example, in one adherence
study it was noted that: the observed pattern of adherence may have been
due to the exercise st;lrting too s1owly for the more fit participants
16
causing them to get bored and drop out (Gale,
Eckhoff, Moge1, & Rodnick,
1985). The wide varie:ty of individual abilities and preferences makes
this a likely source cf variance in adherence.
Social/environmental f actors
Being supported by others for exercising, both at home and in the
exercise settingr has been related to adherence (Martin
& Dubbert, 1982
;
King & Frederiksen, L984; Fetsch & Sprinkle, 1983). This facror in
adherence introduces the beliefs, capabilities, and actions of people
other than the participant. For example, the amount of support wives gave
husbands for preventive and Eherapeutic exercise for heart disease has
been explained by the health beliefs of the wives (Aho,
1977). While
identification with a group that is exercising can have posi-tive results
(King
& Frederiksen, 1984) problems in adherence can occur when the person
leaves the goup either due to termination of a program, moving, or
diverging physical capabilities. Other social and
environmental factors that have correlated with dropping
program include smoking, inactive lei-sure-time pursuits,
work (Oldridge,
1979).
out
and
of an exercise
bluecollar
Exercise program factors
Fina1ly, the exer,:ise program itself has been studied as a factor in
compliance. Given all of the factors outside the control of the program
leaders, it makes sens: to have the exercise program be as positive as
possible. This includ,rs where, how, and when the participants exercise.
L7
Inconvenience
of the exercise program
location,
inappropriate
intensity
of
the exercise,
and unfriendly
or unsupportive
manner
of the program
personnel
have been cited as reasons
for dropping
out (Martin
& Dubbert,
1982; Andrew
&
parker,
1g7g).
Finding
the time and. discipline
to exerci,se
is challenge
enough without
it being difficult
simply to get
to the exercise
site. As previously
rrentioned,
the exercise
intensity
must match the
needs of the participzrnt;
too 1itt1e phsyical
challenge
leads to boredom
and too much to unnecrssary
discomfort
and possibly
injury.
Summary
There are a numbe:r
good
for people
if the.r
difficult
to adhere ro
reasons
to beli.eve
that regular
exercise
is
it. Unfortunately,
many people
find it
exerci_se program.
of
do
an
Exerci"se
adherencrr
and medical treatment
compliance
are quite
si'milar,
both relying
trpon the patients
or participants
to follow
the
prescribed
program'
Fcr thi-s reason the riterature
on medical
treatment
compliance
has been reviewed
here i.n an effort
to broaden
the background
for considering
factors
in exerci.se
adherence.
compliance
models
i-ncluding
the Health Belief Model,
social Learning
Theory,
the utility
Model of Preventive
Behavior,
and the Relapse Moder were reviewed.
The Health Belief lfodel (Rosenstock,
lg74) provides
a basic framework
for viewing
treatment
er:mpliance,
taking into account
the patientrs
perception
of the risk, the efficacy
of the preventive
action, and the
barriers
to taking preventive
acti.on. Several other models of medical
18
comPliance showing dil:ferent ways to explain compliance refine and. expand
on the Health Belief lvtodel. Social Learning Theory uses such concepts as
behavioral capability, expectaEions, locus of control, and self-efficacy;
the Utility Model of I'reventive Behavior uses an economic theoretical
basis to describe the utility
(inmediate
value in a broad sense) that the
person puts on each pcssible behavior; and the Relapse Model considers
lapses i-n adherence tc be inevitable and considers how the patienE deals
with the lapse in maintaining the regimen. These models complement each
other and, taken together, provide a broad framework for better
understanding and study of treatment compliance and exercise adherence.
In the field of exercise the most successful prediction of adherence
to a program has come through a mix of physiological and psychological
factors; one proposed mix being percent body fat, body weight, and score
on the Self-Motivation Inventory. As the most successful psychological
measure in predicting and describing exercise adherence SMI and how it
interacts with other factors in adherence and compliance comprise the major
focus of this study.
Objectives of the Study
In the Spring of 1984 the Center for Fitness Evaluation at Western
Washington UnirTersity contracted with the Atlantic Richfield Cherry Point
Refinery in Ferndale, rrlasington to provide a comprehensive employee
fitness program. The program was agreed to include
(a)
a complete
physical assessment of each participant, (b)
individual consultat.ions on
coronary heart disease risk profi-les, personalized exercise prescriptions,
and dietary counseling,
(c)
supervised exercise sessions at WLIU, and
(d)
19
monthly educational
sesr;ions on a variety of health related topics
'
The
physical assessments
be;gan in May 1984 and were coBpleted by october 1984'
Exercise clases began i:n August 1984. The present study was
ProPosed
to
the wVlU Center for Fitness Evaluation and ARCO management
in June of 1984
to examine exercise
participation
and adherence in the coupany sponsored
exercise
program. The psychological
data were collected for this study in
J-ate September
Lg84, February 1985, and July 1985'
Specifically,
the present study was
Proposed
to examine the role of
self-motivation
in exercise adherence
in a group of healthy, working
adults.
It was hYPothesized
that:
1. The Self-,Motivation
Inventory
(s!II) score coupled with percent
body fat and total
weight would account
for a significant
proportion oj: the variance in adherence'
2. The consl:ruct
of Self-Motivation'
defined by Dishman and
Gettman'
(19130), would be supported
as a major factor in
exercise adh,rrence.
3. The Self-Motivation
lnventory,
(SMI)
'
score would be
supported
as a measure
of Self-Itotivation'
20
Method
Subj ects
Thesubjectswere334maleandfemaleemployeesatanindustrial
plant in Whatcom CounEy, Washi-ngton.
(Gender breakdown
varies by data set
and will be detailed later.)
They were asked to take part in this study as
aPartofageneralhealthandexerciseProgrambeingprovidedbytheir
employer.
Materials
Exercise
l"leasures
Exercise
Repqlq-i#.1,
(EXl)
'
The first self-report
of exercise
(EXl)
was made at the Februa::y
1985 psychological
testing and covered the
period
from November
l, 1984, to February
15' 1985'
If the respondent
had
exercisedatleastthreetiuesperweekforadurationofatleast15
minutesateachsessio,nduringtheprevioustwoweeksheorshechecked
that time
period on the exercise
rePort form
(Appendix II' forrn 5)
'
Exercise Report /12,
(EXz). The second exercise
report
(EX2) was made
attheJunelgS5psychologiealtestingandcoveredtheperiodfrom
SeptemberI,1984,toMay15,1985'(AppendixIII'ExerciseReport)'The
secondexerciserePort:wasinthesameformasthefirstexercisereport
and used the same crit:eria
for reporting
a week of exercise
'
2I
Exercise Report #3,
(EX3) . To use self-reports
made as closely to
Ehe reporting
period as possible, Exercise
from the information collected in the first
It covers the same 36 week period as EX2'
exercise rePort, EX3, ccmbines information
September
1, 1984, to October L5,
November 1, L984, to FebruarY 15
'
March l, 1985, to MaY 15, f9B5
Report /13
(Ex3) was calculated
and second exercise rePorts.
The calculated comPosite
EXI and EX2 as follows:
1984
(EX2),
198s
(Exl),
(Ex2).
Psvcholoeical
Measures
Self l"lotivation
Inventory
(SMI)
,
(Dishman, Ickes, & Morgan, 1980)
'
The SMI
(Appendix I, fcrm 1) consists of 40 statements
which are marked on
a fi-ve part Likert scal.e from
"highly
characteristic
of me" to
"highly
uncharacteristic
of me." Those who score high on the inventory are assumed
to have a higher level of self-motivation
than those who score low' Iligh
internal consistency
for the 40-item scale measured by Cronbachrs alpha
coefficient
has been rtlported
(
= .91) and repeated measurements
over a
period of I to 5 monthr; indicated stability
of the scale
(r's ranging from
.86 to .92)
(Dishman & rckes, 1981)'
Questionnai-re,
STAI-T),
(Spielberger, Gorsuch' & Lushene'
1970)' The
STAI-T(AppendixI,forn2A;AppendixII'form28;AppendixIII'form28)
is a self-report
measure of general trait anxiety'
The scale consists
of
20 items which the subject marks as "almost
alwaysr'
(4),
"often"
(3)
'
,,sometimes,,
(2), or "almost
never"
(1). A higher individual
scale score
State-Trait
AnxieEy Inventory, Trait,
(Self-Evaluation
22
indicates higher trait anxiety'
Reasons for Starting a Structured
Exercise Program
(START)
'
The
Reasons for starting a Structured
Exercise Program forrn
(Appendix
t form 3) was
constructed
by the auth.or and consists of a list of 17 possible reasons
for starting
an exercise Program.
Subjects who have started an exercise
program check as many sitatements
as apply to thern
(0
to 17)
'
Reasons for Not St:arting a Structured
Exercise Program
(NST)
'
The
Reasons for Not Startitrg a Structured
Exercise Program form
(Appendix
Irforrn4)wasconstrur:tedbytheauthorandconsistsofalistof
19 possible reasons
fo:: not starting
an exercise Program'
subjects who
have not st,arted 3I1 eXr3rcise
program check as many of the statements
as
apply to them
(0 to 19).
ReasonsforContinuingaStructuredExerciseProgram.TheReasons
for Continuing
a Structured
Exercise Program form
(Appendix II' forrn 5 and
AppendixIII,form5)r,lasconstructedbyEheauthorandconsistsofalist
of16possiblereasonsforcontinuinganexerciseprogram.Subjectswho
arecontinuingtoexelcisecheckasmanyoftheStatementsasapplyto
then
(0
to 16).
Reasonsfgl--pas-c('ntinuingaStructuredExercise?rogram'TheReasons
for Discontinui-ng
a sl:ructured
Exercise Programform
(APpendix II' form 6
and Appendix
1II, forrn 6) was constructed
by the author and consists
of a
list of 17 possible rrrasons
for discontinuing
an exercise
program'
Subjects
who had repo:rted sEarting
an exercise
program or starting
and
continuinganexercis.:programandhavestoppedexercisingcheckaSmany
of the statements
as apply to them
(0 to 17)
'
23
Phvsioloeical Measures
Bodv Weieht
(WGT). BodY weight
scale to the nearest 50 grams.
was measured on a Toledo beam balance
Height
(HGT). Ilei13ht was measured with a stadiometer to the nearest
.5 cm.
Maximal Aerobic Po.rer,
(V02). Maximal Aerobic Power is the maximal
rare at which oxygen can be consumed,
in ml./min.lkg.
(Ruppel, 1982)
'
The
Bruce
protocol (Bruce & Ilornsten, 1969) was perforured by all participants
using a
Quinton
motor driven treadmill
for the assessment of maximal
oxygenconsuuption.Workwasinitiatedatstagelandeontinueduntil
subjectscouldnolongerparticj"pate.opencircuitspirometrymethods
were utilized for the collection of metabolic data. Respiratory
gases
were conEinuously
measu.red and recorded by the automatic Beckman Metabolic
Measurement Cart . AnaT.yzers \^7ere frequently calibrated with standard
gas
mixtures.
In vigorous activities of prolonged duration the aerobic system
supplies most of the erLergy used by the body making aerobic
Power
a major
factor
(Center for Fitrress Evaluation,
WWU' f984a)
'
Bodv composition.
Total body volume was determined by hydrostatic
weighing
(Katch, Michar:l, and llorvath'
1967) and residual
volume was
measured out of water l>y an oxygen diluEion technique in the bent forurard
seated
posiEion
(Wilmo:re,1969). Body fat was calculated
from body
density using the siri formula
(1956) and lean body weight was determined
by difference.
a. Percent
Percent bodY fat is the
Percentage
24
of total body weight th:rt is fat.
obesity
(CFE, 1984b).
b. Lean body weight,
(LBW).
couponents other than firt such as
It is the most direct measure for
Lean body weight
muscle, bone, and
is the weight bodY
water,
(CFE, 1984b)
Flexibility. star:ic flexibility of the lower back, hips, and
shoulder was assessed irrdirectly through linear measurements of the
range of motion
(Johnsorr, L977).
a.Trunkflexion,(FLEXI).Trunkflexionrefersto
to sit and reach forwarimeasured
in inches. The degree
depends on the length of the trunk extensor muscles of
also the hamstring muscles
(CFE, 1984c)
'
b. Trunk extension,
(FLEX2). The trunk extension
measure of the range of the lower back in inches. Poor
this region can be an indication of potential lower back
of
the
the ability
trunk flexion
lower back and
test is a
flexibility in
problems
(CFE,
r984c).
c. shoulder Extension,
(FLEX3). The shoulder extension test
measures the range of flexion at the shoulder
joint in inches,
(CFE,
1984c).
Blood pressure. Systolic and diastoli-c blood pressure was determined
at rest bY auscultatiorr.
ExpiratoryVolumesiandBreathingCapacity.ForcedvitalcapaciEywas
performed for the purpose of assessing forced expiratory volume as
described by Ruppel
(11)82). To deleruine maximal breathing capacity,
subjects exhaled forcefrrlly and rapidly as possible into a turbine driven
penumoscan for 12 secolrds.
This value was reported as a minute capacity
by multiplying the numller of liters in 12 seconds by five'
25
a. Forced viral capacity,
(FVC). Forced vital capacity is the
maxi-mum amount of air that can be inspired and expired in one breath
(Ruppel, Lg82). Low va.Lues may indicate obstructed airways, clogged
bronchioles, or latent Lung disease
(CFE, 1984d)
'
b. Forced
g*pi13tr)ry
Volume,
(FEV). Forced expiratory volume i-s
the amount of air that c,rn be expelled in one second
(Ruppel
,
L9B2). Low
values indicate high airway resistance' or trapping of air in the 1ungs,
and may also be indicative of obstructive lung disease
(Cff, 1984d).
c. Maxj.mum Breathing capacr!yr__(49t-).-
Maximum breathing capacity
is the maximum volume of air that can be breathed in 60 seconds
(RupPel'
lg82). It is used to determine level of functioning of lungs and
respiratory muscles. Low values are generally indicative of weak
respiratory muscles or high airflow resistance caused by blocked airways
(cFE, 1984).
Serum Lipids: Total Cholesterof
(TCttOL)
,
ttigh D"ns rotein
(IIDL), Low Density Lipcprotein
(LDL), and Triglycerides
(TRI).
Blood samples for total. cholesterol,
IIDL-C, and triglycerides
were drar'rn
after a 12 hour fast from an antecuboidal vein' Total cholesterol conEent
was determined by the nrethod of Atlain, Poon, chan, Richmond, and Fu
(1g74). Iligh density f-ipoprotein
was measured by precipitating
all other
cholesterol
fractions with phosphotungstate-magnesium
(Lipid Research
clinics Program, Lg75) leaving a supernatant
which was measured
for
cholesterol
content. ltriglyceride
levels \rere quantitatively assayed by
an enzymatic hydranalyr;is
technique described by Beckuan Instruments
(1983). Low density l:Lpoprotein
(LDL-C) was calculated according to the
method of Eriedewald, -evy'
and Fredrickson
(L972)
'
26
Aooaratus for Phvsiological Measurement
The Center for Fitness Evaluation utilized the following aPparatus:
1. a motor driven treadmill to provide controlled exercise,
2. a face mask to collect expired air samples,
3. a Beckman metabolic cart expired air ana1-yzet to determine oxygen
and carbon dioxide concentrations of expired air'
4. a Pneumoscan turbine spirometer to determine pulmonary
ventilatlon.
5. a Toledo beam balance scale to measure body weight to the nearest
50 graus,
6. a stadiometer to measure height to the nearest 0.5 centimeters,
7. a seat suspenc.ed from a calibrated Chatillion scale to measure
body weight submerged in water to determine body volume for computing
percent bodY fat,
8. a background
j.nformation-
form on which the subjects are asked to
supply demographi<: and health related data,
(ApPendix IV)
'
g.
a yardstick t<l measure movement in flexibility tests'
27
Procedure
The present study rr7as an adjunct to a year-long employee health and
fitness
program. Two t Lmelines will be presented to clarify what happened
when in this study. First, the components and scheduling of the entire
health and fitness program
(including this study) rsi11 be outlined' Then'
a second timeline expan,ding on the components of the present study will be
provided.
Timeline for the health and fitness
program'
i. winter 1984. The Director of the center for Eitness Evaluation
proposed an employee fitness program to management
at the Atlantic
Richfield Companyts Cherry Point Refinery at Ferndale, Washington.'
2. Spring 1984. During the spring of 1984 ARCO contracted
wiEh the
wl{u center for Fitness Evaluation to
Provide
a comprehensive
fitness
evaluation
program incl.uding:
(a) complete
physical assessments
of
individuals,
(b) indivj.dual
consultations
on assessment
results' diet' and
exercise
prescriptions
(c) supervised
exercise sessj-ons at wl,tru' and
(d)
educational
sessions olrer the course of a year'
3. May 1984. I:r.dividual fitness evaluations
(PHYS) began and
continued
throughout
the sunmer and into the fall, the last evaluations
being completed in oct,rber. Shortly after the physical evaluation
each
person received
a personalized exercise
plan which he or she could start
immediately
or include in ongoing exercise
'
4. June 1984. The present study
l^7as
Proposed
to ARCO management
by
28
way of the director to Ehe Center for Fitness Evaluation of study
adherence in the ARCO E:nployee Fitness Program'
5. August 1984. Exercise elasses for ARCO employees began at WWU.
6. September 1984. The content and timeline of this study was
agreed upon with the Enployee Relations Director at ARCO in early
September 1984. The first set of psychological
questionnaires was
administered by ARCO Employee Relations Office personnel in late September
1984.
7. February 1985. The second psychological testing, abbreviated as
PSY2, was conducted at the ARCO Cherry Point Refinery'
g.
May 1985. Th.e exercise classes at WWU concluded and
Post-program
fitness evaluations beg,an and continued
j-nto
the fa1l.
g.
June 1985. lihe final psychological testi-ng, abbreviated as PSY3,
was conducted at the AII'CO Cherry Point Refi-nery'
Tineline for the present study.
1. In September r.984 the first psychological Eesting
(PSYI) was
conducted as follows:
a.SubjectswererecruitedforthePreSentstudyatregular
department meetinl;s during work hours'
b. Those who chol;e to participate were asked to complete a set
of questionnaires. The set of questionnaires was constructed to
a11ow al1 employe(3s to partieipate by completing only those forms
that applied to t,:em. The packet of psychological
questionnaires
29
used for the first testing
(Appendix I) included:
(1) a cover letter from the plant manager explaining the
Purpose
of the study and the voluntary
nature of participation,
(2) a
Proposed
timeline
for the study'
(3) the Self-I4,otivation
Inventory
(SMI) to be cornpleted
by
all
ParticiPants
in the studY,
(4)theSTAI.T,labelledtheSelf-EvaluationQuestionnaire
(STAI), to be completed
by all partieipants
in the study'
(5) the Reascrns for Recently Starting a Structured
ExercisePro6;ramform(STRT),tobecompletedbyindividuals
currently
acl:ive in a structured
exercise
program'
(6) the Reasons for Not Starting a Structured
Exercise
Program forrr
(NST), to be completed
by individuals
not currently
active in a l;tructured
exercise
program' and
(7) an AdjecEive
Checklist to be completed
by all
individuals
completing
the packet of questionnaires'
(The Adjective
checklist
r.7as part of another study of the ARC0 Exercise Project
and was included in this packet as a courtesy to that investigator) '
c. The completed
packets were mailed to Lhe investigaEor
at
wwu.
d. Participants
were asked to provide their social security
numbersonEhepa'cketofquestionnairestoallowmatchingofdata
with subsequent
claEa.
e. Participatin5;
in the study rnras voluntary
in two ways"
First,
potential subjects
had the option
not to complete
the
questionnaire.Secondly,theycouldcomplet,ethequestionnaires'
but not provide Bhei'r social security
number
'
30
2. In February 1985 the second
psychological testing
(PSY2) was
conducted.
a. The testing procedure was identical to that used in
SepEember.
b. The test packet
(Appendix II) included the following
questionnaires:
(l) the STAI-T, in which the subjects were asked to indicate
how they had felt in the last two months
(STAIA)
'
(2)
the Reasons for continuing a structured Exercise
Program and exercise report for the period from November 1, 1984,
to February 15, 1985
(CoNT) Eo be completed by those individuals
currently
participating in a structured exercise
program, and
(3) the Reasc,ns for Discontinuing a Structured Exercise
program
form(.QUIT) to be completed by those who received a
physiological- assessment at wl{u and started a structured
exercise
Program,
but discontinued it
'
3. the third set of psychological test sessions
(PSY3) took
place at the ARCO Cherr:y Point Refinery in June of 1985'
a. This set of trlsting sessions
was conducted by the
investigator
in a]r effort to receive as many packets of questionnaires
with idenEifying
r3ocial security numbers as possible'
b.Thetestpacket(AppendixIII)includedthefollowing:
(1)anexercisereportform(Ex2)coveri.ngtheperiodfrom
September
1, 1984, to MaY 15, 1985'
(2)theSTAI-T,inwhichthesubjectswereaskedtoindicate
how they had felt in the last two months
(STAIB)
'
(3)theReasonsforContinuingaStructuredExercise
Program form
in a struc
completing
th
(4) The Reas
Program form
recei-ved a
Ph
structured e
(5) an Adject
(again this
c. The comPleted
from the
jobsite
31
CONTA) To
exercise
be completed bY
program at the
individuals ParticiPating
time theY were
f orm,
s for Discontinuing
a Structured
Exercise
QUITA),
to be completed
by individuals
who had
iological assessment
at wi'ru and started a
rcise
program, but had discontinued
it' and
ve Checklist to be completed
by all participants
stionnaire
was not part of the present study)
'
orms from this testi-ng were collected
and taken
the lnvestigator.