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WALKING l

INITIATING WALKING As A REGULAR PHYSICAL ACTIVITY FOR SEDENTARY
ADULTS: A PROTOCOL AND TOOLS FOR PRIMARY CARE PROVIDERS
By

Robert John Ziola

A Scholarly Project
Submitted to
Michigan State University
In partial fulfillment of the requirements

For the degree of

Master of Science in Nursing

1999

WALKING 2

Abstract

INITIATING WALKING AS A REGULAR PHYSICAL ACTIVITY FOR SEDENTARY
ADULTS: A PROTOCOL AND TOOLS FOR PRIMARY CARE PROVIDERS

By
Robert John Ziola

Despite the known benefits of regular physical activity and the risks associated with sedentary
lifestyles, more than 60 percent of American adults do not engage in the suggested amounts of regular
physical activity necessary to prevent chronic health problems and improve health. Compounding this
image of the sedentary American is data indicating that only 30 percent of primary care providers
counsel their inactive clients.

Primary care providers, including the Advanced Practice Nurse (APN), can positively impact
the health of individuals, families and communities by integrating walking information and routine
physical activity assessments into their practices. This project 1) examined research, theories,
interventions, and strategies in the literature related to regular physical activity; 2) developed a
walking protocol and assessment tool for primary care providers to use with low-risk sedentary adults
20-50 years of age; 3) developed a brochure to stimulate interest in, and information about, walking
for those interested in increasing their physical activity; and 4) developed tools for the client to use to

increase the chances of increasing physical activity through regular walking.

WALKING 3

I would like to dedicate this project to
my loving wife Mary, my dear 4 year-old son Anthony, and
my dear six month-old daughter Elizabeth.
They supported me in the completion of this project and in meeting the many demands

of graduate school.

WALKING 4

ACKNOWLEDGEMENTS

Many thanks to my committee members - George Allen (chair),
Linda Spence, and Sue Wheeler. Their assistance, direction, and support

aided‘me in the completion of this project.

Thanks also to Michigan State University College of Nursing
faculty and staff - Sandy Altenritter, Sharon Graver, Millie Omar, and Brigid Warren —
and clinical preceptors Linda Speegle MD and Maureen Street MI).
They provided valuable time, assistance,

learning experiences, and a nurturing environment in which to work.

WALKING 5

Table of Contents
Introduction ................................................................................................ 9
Statement of the Problem ................................................................................ 10
Purpose of this Scholarly Project ........................................................................ 11
Literature Review ................................ I .......................................................... 13
Definition of Physical Activity ................................................................. 13
Cardiorespiratory Recommendations ......................................................... 13
Activity for Health ...................................................................... 14
Dose of Activity ............................................................... 14
Activity for Fitness ..................................................................... 15
Health Activity Equivalents ........................................................... 15
Maintaining Benefits of Physical Activity .......................................... 16
Determinants of Physical Activity ............................................................ 17
Benefits of Physical Activity .................................................................. l7
Barriers to Physical Activity ................................................................... l9
Risks Associated with Physical Activity ...................................................... 20
Theoretical Foundation .................................................................................. 21
Operant Conditioning .......................................................................... 21
Social Learning Theory ........................................................................ 22
The Transtheoretical Model ................................................................... 23

The Health Belief Model ..................................................................... 24

WALKING 6

Conceptual Definitions of the Health Belief Model ................................................. 24
Individual Perceptions ......................................................................... 24
Modifying Factors ............................................................................. 24
Likelihood of Action .......................................................................... 24
Self-efficacy ......................................................... j ........................... 27

Application of the Health Belief Model to Sedentary Adults ....................................... 27

Conclusions .............................................................................................. 30

Implications forthe Advanced Practice Nurse ........................... 32
Education ...................................................................................... 32
Research ........................................................................................ 33
Practice ......................................................................................... 34

Client ................................................................................. 34

Family ................................................................................. 35

Community ........................................................................... 36
Clinical Application of the Walking Protocol ...................................................... 36
Appendix A ............................................................................................. 43
Appendix B ............................................................................................. 45
Appendix C ............................................................................................ 49
Appendix D ............................................................................................ 51
Appendix E ............................................................................................. 54
Appendix F ............................................................................................. 56

Appendix G ............................................................................................ 58

WALKING 7

References ............................................................................................. 6O

WALKING 8
List of Figures
Figure 1. The Rosenstock Health Belief Model ................................................... 25

Figure 2. The Adapted Health Belief Model ...................................................... 28

WALKING 9
Introduction

There is ample evidence in the literature demonstrating the physiological and psychological
benefits of regular physical activity (Blair et al, 1996; Berlin & Colditz, 1990; Butler et al, 1998;
Kushi et al, 1997; McAuley et al, 1997; Paffenbarger et al, 1993; Steinberg et al, 1997). According to
the Surgeon General’s Report on Physical Activity and Health (USDHHS, 1996), regular physical
activity is associated with lower mortality rates for younger and older adults, decreased risks of colon
cancer, Type 2 diabetes, and cardiovascular disease mortality. Regular physical activity is also linked
to maintaining healthy bones, muscles and joints, controlling weight, building lean muscle, reducing
fat, preventing or delaying high blood pressure, improving functioning in persons compromised by
poor health, improving mood, and, for some, relieving symptoms of depression and anxiety and
enhancing well-being.

Healthy People 2000 (U SDHHS, 1990), a national consortium of over 300 local, state and
national organizations whose goal is to achieve improved health for all Americans, has recognized the
importance of regular physical activity and has included it in their goals. Many of the objectives
specifically address increasing regular physical activity among adolescents, adults, and high risk
populations in an effort to decrease the number of people who engage’in no leisure-time activity and
the health risks associated with inactivity.

There is an international consensus regarding the significance of physical activity for
preventing and controlling coronary heart disease (CI-ID) and other preventable chronic and emotional
conditions (Bouchard, Shephard & Stephens, 1994). Lost productivity, health expenses, absenteeism,

job-related strain, and anxiety due to the lack of physical activity are concerns for many employers.

WALKING 10

There is also growing recognition of the need to increase regular physical activity among Americans
in hopes of reducing costs associated with cardiovascular disease, diabetes, hypertension, obesity,
colon cancer, and arthritis (Hatziandreu, Koplan, Weinstein, Caspersen & Warner, 1988; USDHHS,
1990). For example, it is estimated that two to four million Americans have congestive heart failure
(CHF), a disease of high mortality which is correlated with increasing age. CHF accounts for over
500,000 hospital admissions per year (Ghali, 1992). As the “baby boomers” age and the geriatric
population increases, there is a concern that CHF will increase the cost to the healthcare system and
account for increased morbidity and hospitalizations.
The Problem

Despite what is known about the benefits of regular physical activity and the risks associated
with sedentary lifestyles, more than 60 percent of American adults do not engage in the suggested
amounts of regular activity (Caspersen et al, 1994). Approximately 15 percent of US. adults
participate in regular vigorous physical activity. Less than 10 percent of US. adults exercise three or
more times a week at an intensity that will improve cardiorespiratory fitness (U SDI-IHS, 1990).
Approximately 25 percent of US. adults are not active at all (USDHHS, 1996). In a national cross-
sectional study of over 16,000 women and over 10,000 men, Jones et al (1998) found that only one
third of US. adults engaged in moderate activities that met the recommendations of the 1993 Centers
For Disease Control and Prevention (CDC), the American College Of Sports Medicine (ACSM), or
the 1996 SGR on Physical Activity and Health guidelines.

A similar trend is seen among adolescents and young adults. Among high school students,
daily enrollment in physical education classes dropped from 42 percent to 25 percent between 1991

and 1995. Almost 50 percent of those 12-21 are not vigorously active on a regular basis; and physical

WALKING 11
activity of any kind drops dramatically as age or grade in school increases (U SDI-IHS, 1996).
DeMarco & Sidney (1989) found that, given a choice, children often elect not to take physical
education classes, and those who do engage in physical education classes fail to show any fitness gains
due to lack of duration and intensity. This findings is disturbing when evidence suggests that
participation in physical activity early in life may be linked to physical activity later in life (Barnelow-
Bergkvist et al, 1996; Telama et al, 1996).
11mm;

The purposes of this scholarly project are: 1) to examine the research, theories, interventions,
and strategies 'in the literature that relate to regular physical activities; 2) to provide an informational
brochure that identifies strategies that have been shown to be effective for adults and encourages the
client to consult with his/her primary care provider; 3) to develop an assessment tool for primary care
providers that will provide information about the client who is interested in walking; and 4) to develop
a protocol that promotes walking as a means of regular physical activity for low-risk sedentary adults
20-50 years of age and that increases the likelihood of successful goal Obtainment.

Following available theoretical and research-based knowledge, and educational brochure and
aids for clients and a protocol and assessment tool for providers were developed to support physical
activity among sedentary adults 20 to 50 years of age who are contemplating or preparing to increase
their physical activity by walking. This client age range was chosen due to l) the sudden drop in
physical activity that is seen after high school and which is maintained through middle adulthood, and
2) the relatively stable musculoskeletal and socioeconomic health of adults in this age range. The

target population excludes those with acute myocardial infarction or respiratory difficulty or clients

WALKING 12
with class III or IV CHF. The exclusion of these groups is based on the risks associated with such
groups and the inability to safely monitor changes in such groups in a primary care setting.

This project was undertaken because of the many positive aspects of walking as a regular
physical activity. In addition to its positive impact on health, walking is a convenient form of exercise
(Pate et al, 1997 ; USDHHS, 1996). As a health activity, walking is associated with relatively low
risks (Panush, 1994; Swan & Seedhom, 1993; Thompson et al, 1982). There are higher compliance
rates with moderate physical activities such as walking (Duncan et al, 1991; King et al, 1991;
USDHHS, 1996). And there is a need to provide simple, useful and specific strategies to support
regular physical activity.

Primary care providers are not meeting all of the health needs of their sedentary clients.
According to The Report of the US. Preventive Services Task Force (USDHHS, 1998), only about 30
percent of primary care clinicians provide counseling to their inactive clients. In a midcourse review
of their goals, Healthy People 2000 (U SDI-Il-IS, 1995) found that internists inquired about the exercise
habits of 40 percent of their clients and formulated exercise plans for 25 percent; nurse practitioners
(NP’s) routinely inquired about the exercise habits of 30 percent of their clients and formulated
exercise plans for 14 percent; lower percentages were found among family practitioners, pediatricians,
and obstetricians and gynecologists. Though exercise is an essential part of diabetes management,
Krug et a1 (1991) found that only 25 percent of Type 2 diabetics reported receiving specific guidelines
for exercise.

This lack of activity assessment and specific exercise planning and support is important for the
Advanced Practice Nurse (APN) and the client. The APN’S focus has long included education and

practice in health promotion and disease prevention based on education, theory, research, and

WALKING 13
evidence with demonstrated outcomes (American Nurses Association, 1994). For the APN, a
protocol and an assessment tool that is based on sound theory and research and that employs simple
successful strategies for supporting regular physical activity such as walking may increase the number
of clients reached, the success of those reached, and the health of the client, the family and the
community in which they reside. For the client, educational materials and tools that increase
information about regular physical activity, that are easy to understand and use, that address a wide
spectrum of client profiles with unique qualities, circumstances, strengths, and resources, and that
provide support and direction increase the chances for client compliance and success (King, 1992).
Such educational materials and tools support client self-care and self-efficacy.
REVIEW OF LITERATURE

Physigl Activity

Physical activity is broadly defined in the literature and can cover a broad range of activities
from washing a car, gardening, raking leaves, and walking to basketball, running, and football. This
broad use of the term physical activity complicates comparing research frndings and necessitates a
more precise definition. In 1985, Caspersen et al. defined physical activity as any skeletal activity that
results in energy expenditure. Within Caspersen’s definition, any activity — aerobic or resistance
training — that involves skeletal muscles and burns calories is physical activity. This definition,
though more restricted, does not address the intent of many research studies on physical activity.

The CDC, the ACSM, and the SGR (U SDHHS, 1996) developed evidence-based parameters
for the concept of physical activity. Regarded as authorities in physical health and activity, they have
provided recommendations, based on the evidence thus far, on the amount and the intensity of '

physical activity necessary to obtain cardiorespiratory benefits. In 1993, the CDC and the ACSM

WALKING 14
recommended that every US. adult should accumulate 30 or more minutes of “moderate-intensity
activity on most, preferably all, days of the wee ” (Pate et al, 1995). Moderate-intensity activity is
defined as an activity that is performed at an intensity of 3 to 6 metabolic equivalents (METs). This
would include such activities as aerobic dance, brisk walking or gardening. In 1996, however, the
SGR redefined beneficial physical activity. Instead of a variety of “target heart rates” for 20-30
minutes 3-7 days per week, the SGR now maintains that minimum cardiorespiratory changes can be
achieved in sessions as small as 10 continuous minutes, three times per day. The amount of physical
activity required for Cardiorespiratory benefit is a function of duration, intensity and fiequency of
activity. Based on its findings, the SGR developed two categories of physical activity. The new
categories are named “activity for heal ” and “activity for fitness.”

“Activity for health” is defined as 30 minutes of physical activity of moderate intensity (or less
than 60 percent of maximum heart rate for age) 5-7 days per week with the stipulation that only
sessions of 10 or more continuous minutes are counted. Maximum heart rate for age equals 220 beats
per minute minus age. Moderate physical activity is equivalent to an activity of sufficient duration to
expend 150 calories per day or 1000 calories per week, and the activities may vary per day or week. It
requires “sustained, rhythmic muscular movements, is at least equivalent to walking,” and is
performed at less than 60 percent of maximum heart rate for age (U SDI-IHS, 1996). However,
because the amount of physical activity required for cardiorespiratory benefit is a function of duration,
intensity and frequency, the same benefit can be obtained in longer sessions of moderately intense
activities such as brisk walking as in shorter sessions of more intense activities such as running. Thus,

examples of moderate amounts of physical activity would include stair walking for 15 minutes,

WALKING 15
shoveling snow for 15 minutes, walking two miles in 30 minutes, wheeling selfin wheelchair for 30 -
40 minutes, and washing or waxing a car for 45 - 60 minutes (SGR, 1996).

Another way to understand the relationship between physical activity duration and intensity is
this: the greater the intensity of the sustained effort of activity, the less time is necessary to receive
cardiorespiratory benefit. Likewise, the less vigorous the sustained activity, the more time is needed
to obtain cardiorespiratory benefit. Appendix C reflects the variation in activities which meet the
definition of activity for health. I have named them health activity equivalents (HAE’s) or activity
substitutes to reflect the relationships between various daily activities and those activities that meet the
minimum requirements to obtain cardiorespiratory benefit. This range of physical activity allows the
primary care provider to better individualize recommendations for clients and draws upon a broader
range of activities that can be performed at home, at work, or within a structured environment.

“Activity for fitness” is defined as 20 minutes or more of vigorous activity (e. g. running,
swimming, or greater than 60% maximum heart rate for age) 3-5 days per week. Activity for fitness
requires rhythmic repetitive activities that use large muscle groups at 60% or more of maximum heart
rate for age (USDHHS, 1996). As was the case with activity for health, because the amount of
physical activity required for cardiOrespiratory benefit is a function of duration, intensity and
frequency, the same benefit can be obtained in longer sessions of less vigorous activities as in shorter
sessions of more vigorous activities.

In addition to cardiorespiratory activity guidelines, the SGR (U SDHHS, 1996) recommends
muscle strength development two or more times per week to decrease the risk of falls. This may have
the greatest impact on the elderly who, with increased musculoskeletal conditioning, may improve

their ability to live independently.

WALKING l6

Regardless of how physical activity is measured, it is clear that the benefits that accompany
physical activity are sustained only if the individual maintains appropriate physical activity over the
long term (Pafffenbarger et al, 1984; SGR, 1996). Many of the beneficial effects of physical activity
diminish within 2 weeks if the activity is substantially reduced, and effects disappear within 2—8

,months if physical activity is not resumed.

Except for detening osteOporosis in premenopausal and postmenopausal women and reducing
the risk of hip fractures postmenopausal women, physical activity cannot be performed occasionally to
obtain physiological benefits (Magnus et al, 197 9). In a population-base case-control study of over
1500 postmenopausal women with hip fracture, Jaglal et al (1993) showed independent protective
effects of past physical activity and moderate levels of recent physical activity on the risk of hip
fi'acture. Dalsky et a] (1988) found that weight-bearing exercise deterred lumbar spine bone loss in
postmenopausal women. Unlike the relationship of physical activity to osteoporosis and risk of hip
fractures, an individual cannot expect protection from CHD for having exercised regularly in the past
(Paffenbarger et al, 1984). It does, however, appear that beginning moderately vigorous physical
activity in adulthood may reduce the risk of CHD for those who have been physically inactive for
many years (Paffebarger et al, 1993).

Unfortunately, many studies have shown that up to 50 percent of the individuals who begin an
exercise program stop within the first six months (Blair 1988; Kriska et 31.1986; Leith, 1992). Similar
adherence results have been found with children (Epstein et al., 1984). The SGR (U SDI-IHS, 1996)
found that though many people embarked on vigorous exercise programs, most did not maintain their
participation. Though regular vigorous physical activity is likely to be most beneficial, moderate

physical activity has higher compliance rates, is more adaptable to various lifestyles, and is maintained

WALKING 17
better over time (Blair et al 1989; Duncan et al, 1991; King et al, 1991; USDHHS, 1998). These
studies suggest that efforts to increase regular physical activity focus on moderate physical activities
such as walking.

Determinants

A number of variables have been positively linked to physical activity. Dishman (1994) found
that physical activity habits are positively correlated with higher education, increased income, male
gender, and non-Hispanic white race. Physical activity in childhood correlates with future activity
(Bamekow-Bergkvist, 1996; Telarna, 1996). Perceived benefits (Muto et al, 1996), perceived
enjoyment (SGR, 1996) and social influences (i.e. Support from family and friends) specific to
exercise are positively correlated with physical activity participation (Bungurn & Vincent, 1997;
Dishman, 1994; Oka et al, 1995; SGR, 1996). Perceived convenience of the activity setting and its
proximity to the home or workplace have also been shown to be positively correlated with physical
activity adherence (Andrew et al, 1981; Tsai et al, 1987). There is also growing evidence to suggest
that those who are physically active prefer to engage in activities outside of formal programs (King et
al, 1990; Shephard, 1988).
m

The physiological effects of physical activity include its ability to decrease fat mass, increase
high-density lipoprotein cholesterol, and decrease triglycerides and total cholesterol (Paffenbarger et
al, 1993; Schuler et al, 1992). These positive physiological effects of regular physical activity are
involved in the prevention and/or control of cancers, hypertension, cardiovascular disease, CHF, and

Type 2 diabetes.

WALKING 18

Physically active people are less likely to die from CHD. In a meta-analysis of primary
prevention of CHD, Berlin & Colditz (1990) found that the relative risk of death from CHD was 1.9
times greater for sedentary people as compared to the physically active. In a prospective cohort study
over 7 years among 40,417 postmenopausal women, Kushi et al. (1997) found an inverse relationship
between physical activity and all-cause mortality. After excluding such confounding variables such as .
cancer and heart disease, women who reported regular physical activity were at significantly reduced
risk of death compared with women who did not (relative risk 0.77; 95% confidence interval [CI]
0.66-0.90). In a prospective study of men 40-59 over 15 years, Wannamethee et al. (1998) found that
maintaining or initiating light or moderate physical activity reduced mortality and heart attacks in
older men with or without diagnosed cardiovascular disease. Relative risks for the groups who
reported light or moderate activity were 0.61(95% CI 0.48-0.86) and 0.50 (95% CI 0.31-0.79),
respectively.

Evidence suggests that physically fit adults live 2 to 3 years longer and have a better quality of
life than sedentary individuals (Blair et al, 1996; Butler et al, 1998). In addition, in a 9-year
longitudinal study of elderly runners and non-exercisers, Fries et al. (1994) found that musculoskeletal
pain and stiffness were 25 percent lower in the exercisers than in the non-exercisers. Fries et al. also
reported that no total joint replacements were performed on the group that exercised and over the
course of the study, the initial disability at age 68 (.026 for nmners vs. .077 for non-exercisers; p
<.001) widened to .06 for runners and .23 for non-exercisers (p<.001).

In a review of 21 studies that examined the relationship of physical activity to breast cancer,
Friedenreich et al (1998) found that 15 of 21 studies suggested that physical activity reduces the risk of

breast cancer, four studies found no assOciation between physical activity and risk of breast cancer,

WALKING 19
and two studies found an increased risk of breast cancer associated with physical activity. Overall, the
evidence appeared to support an inverse relationship between risk of breast cancer and physical
activity.

Many studies have linked physical activity to psychological changes or perceptions. These
non-physiological elements have included enhanced mood and creative thinking (Steinberg et al.
1997), self-esteem (McAuley et al., 1997; Muto et al, 1996), and self-efficacy (Fontaine & Shaw,
1995; McAuley, 1995 & 1993; Sallis et al, 1992; SGR, 1996). Other qualities associated with
increased physical activity include perceived romantic appeal, self-worth, and athletic competency
(Douthitt, 1994), physical appearance and attraction (Douthitt, 1994: McAuley et al, 1993), and
decreased anxiety (McAuley et al, 1995).

m

The most common obstacles for participation in physical activity include perceived lack of
time (Hurrell, RM, 1997 ; Marcus, 1992) and lack of convenience (Andrew et al, 1981). Other
common obstacles for engaging in physical activity identified in the literature include lack of support
from family and fiiends and confidence in one’s ability to engage in regular physical activity (Pate et
al, 1997; SGR, 1996), confidence in the value of physical activity (Andrew et al, 1981; Dishman,
1991), perceived barriers (Muto et al, 1996), and increased age (Dishman, 1994).

Complementing these reports are findings that physical inactivig is greatest among women,
Blacks, Hispanics, older adults, and the less affluent (SGR, 1996; Jones et al, 1998). Physical
inactivity is a significant risk factor for the disabled or physically impaired (SGR, 1996). Such are the
risks associated with these groups that Healthy 2000 (U SDHHS, 1990) has targeted specific goals and

resources to reduce their risks.

WALKING 20

Sallis and Owen (1997 ) believe that modern society has created an environment that
encourages sedentary lifestyles. They suggest that modern transportation, passive entertainment such
as television, movies, and computer games, and labor saving technology at home and at work promote
inactivity. This perspective may be useful in understanding an individual’s barriers and lack of
motivation for change.
Ris_ks

There may be risks associated with physical activity, including musculoskeletal injury,
osteoarthritis, myocardial infarct, changes in menstrual function, fractures, and, rarely, sudden death.
The risk of sudden death is increased during vigorous physical activity (Thompson et al, 1982).
However it is the sedentary individual who initiates vigorous activity that is at greater risk of sudden
death (Siscovick et al, 1984; Kohl et al, 1992). Most of the remaining risks are preventable and are
often the result of sudden significant increases in physical activity, excessive levels of physical
activity, and/or improper technique (U SDI-IHS, 1998). Comfortable moderate physical activity that
puts joints through normal range of motion does not - in the absence of joint abnormality - inevitably
lead to injury (Panush, 1994). Graduated physical activity that allows cartilage to adapt is less likely to

induce osteoarthritis (Swan & Seedhorn, 1993).

WALKING 21
THEORETICAL FOUNDATION

Several theories are popular in the literature and have been used as the basis for strategies and
interventions to initiate and maintain regular physical activity. The most common of these are based
on Operant conditioning (Nemeroff & Karoly, 1991), social learning theory (Bandura, 1977), the
Transtheoretical Model (Prochaska, 1983), and the Health Belief Model (Rosenstock, 1974).

Operant conditioning is based on the theory that behaviors are learned through a process of
positive and/or negative reinforcements and self—management techniques (Skinner, 1953). That is, the
presentation of a positive reinforcement or the removal of a negative reinforcement increases the
likelihood of a behavior. Initially, reinforcements must be timely, frequent, and of significance to the
individual. This feedback is particularly important with physical activity or exercise in which the
immediate consequences can be negative (e. g. feeling hot, sweaty, and/or fatigued) while the rewards
of physical activity or exercise may be delayed (e. g. weight loss, improved blood pressure, improved
mood).

Strategies such as written contracts which specify the contingencies surrounding the behavior,
and stimulus control methods which employ cues like visual or spoken reminders for initiating
physical activity, have been used to increase exercise adherence (Brownell et al, 1980; Epstein &
Wing, 1980; Neale et al, 1990). Logs used to self-monitor the behavior facilitate shaping (the gradual
acquisition of goals over time), identify the risk of relapse, and prevent over-exercising (Juneau et al,
1987). Even the statement of the intent to change exercise behaviors has been shown to increase
physical activity (Huddy et al, 1995). However, for long-term maintenance of a behavior it is
important that control shift to self-regulation and that exuinsic reinforcers Change to more intrinsic

reinforcers such as self-efficacy, sense of well-being or improved mood (Marcus, et al, 1996).

WALKING 22
Social learning theory is based on the belief that behavior, the environment, and personal
factors interact to determine behavior (Bandura, 1977). This theory also stresses the importance of 1)
an individual’s sense of self-efficacy and ability to control behavior, 2) the belief that behavior is
motivated by some meaningful reinforcement, and 3) that changes in the individual and/or the
environment can produce the potential for behavioral change. Attainment of goals by vicarious
experience, small goal attainment, or support from others leads to a sense of self-efficacy, which can
then act as motivation for behavior change.

Strategies based on social learning theory have successfully used various techniques to
produce behavior change. Wankel (1984) found that decisional balance sheets - a comparison of the
perceived costs and benefits of exercise participation - increased physical activity involvement among
participants in a university fitness program, a commercial fitness center, and a community-based
fitness class. Wankel also found that social support, such as an activity “buddy,” attendance charts,
and family support, was also linked to increased physical activity participation in an exercise class.
Relapse prevention training - cognitively and behaviorally learning to prevent and/or cope with
relapses back to undesirable behaviors — was successfully used by employees within a large national
corporation to increase physical activity (King et al, 1988). Marcus & Stanton (1994) attributed
relapse prevention training and reinforcement to increased short-term attendance among overweight
female university employees. Stimulus control strategies i.e., manipulation of events or the
environment which act as cues for physical activity, were employed by Brownell et al. (1980) to
increase stair climbing behavior and by Keefe & Blumenthal ( 1980) to increase walking and jogging

adherence in overweight males.

WALKING 23

The Transtheoretical Model (TTM) or stages of change model, suggests that an individual’s
current behaviors and readiness to maintain or change their behavior’influence the likelihood of
change (Prochaska et al, 1997). The five stages of the TTM are: 1) precontemplation - there is no
intention to take action in the next 6 months; 2) contemplation — one intends to take action in the next
6 months; 3) preparation - one intends to take action in the next 30 days and has taken some steps in
that direction; 4) action - one has changed one’s overt behavior in the last 6 months; and 5)
maintenance - one has changed one’s overt behavior for more than 6 months. The TTM suggests that
cognitive processes such as consciousness raising, dramatic relief, and self-evaluation are used more
in early stages and that behavioral processes such as stimulus control, counter-conditioning, and
helping relationships are used more often in later stages to change behaviors. Movement through
these stages is not always linear but may be cyclical or the individual may make several attempts at
behavior change before their goals are accomplished. Interventions based on the TTM match
treatments with an individual’s stage of readiness. For example, treatment of an individual in the
precontemplation stage of exercise would focus on cognitive processes, whereas treatment of
individuals in the action stage would focus on such behavior processes as reinforcement, stimulus
control, and helping relationships.

Studies have shown that the TTM works well with smoking cessation programs with adults
(Prochaska et al, 1993), and sexual behavior change (Grimley et al, 1993; Grimley et al, 1995). The
TTM’s usefulness in maintaining physical activity is promising but less abundantly documented
Using construct interventions specifically related to stage-matched participants, Marcus et al (1992)
were able to increase adoption of physical activity among 610 community volunteers. In a study using

the TTM with interventions on 349 cardiac rehabilitation participants, Hellman (1997 ) also found an

WALKING 24
increase in exercise behaviors and movement through the stages. The TTM provides a model that uses
the concepts of other models (e.g., cognition, behavior, and self-efficacy) but is more dynamic,
provides choices, and is adaptable to the variety of client profiles and needs.

The Health Belief Model is a theory based on value expectancy (Rosenstock, 1974), that is,
the individual 1) identifies a perceived susceptibility to and/or severity of illness, 2) uses modifying
factors such as knowledge, education, symptoms, experience, and socioeconomic factors, to 3)
determine the perceived threat of disease or illness, and then 4) weighs the perceived benefits and
barriers to behavior change. This process impacts the likelihood of behavior change (Strecher &
Rosenstock, 1997 ). Although the HBM was originally used to explain preventive health behaviors
such as immunizations, it has also been used to explain other preventive behaviors. In a 15 year
prospective study of 1032 men and 1394 women, Ferrini et al.( 1994) found that individuals who
agreed with the belief that diet and exercise were important health factors and who were willing to
spend money on their health were more likely to make positive changes in their diet and activity
behaviors.

Because this project focuses on individuals who are ready to increase physical activity, the
Health Belief Model (Figure 1) was chosen as the basis for developing the tools and protocol of this
project.

Conceptual Definitions of the Health Belief Model

As may be seen in Figure 1, the HBM has three major constructs: “individual perceptions”
“modifying factors” and “likelihood of action.” Individual perceptions include perceived
susceptibility/severity of disease. Modifying factors include demographic and socio-psychological

variables and perceived threat Likelihood of action includes perceived benefits minus perceived

WALKING 25

Figure 1. THE ROSENSTOCK HEALTH BELIEF MODEL COMPONENTS AND LINKAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual Perceptions Modifying Factors Likelihood of Action
Age, sex, ethnicity Perceived benefits
Personality —p minus perceived
/ Socio-economics barriers to behavior
Knowledge change
Perceived Perceived . .
Susceptibility/severity of ’ threatof L‘kehhmd °f
. . change
disease disease
Cues to action
Education
Symptoms,
illness
0 Media
information

 

 

 

 

 

 

 

 

In: Glanz, K, Lewis, F.M., & Rimer, B.K (Eds). 1997. Health Behavior a_nd Health Education.
2'“1 Edition. San Francisco: J ossey-Bass Publishers

WALKING 26
barriers to behavior change and likelihood of behavior change. The interactions of these constructs
determines the readiness of an individual to take action and the probability of behavior change.

Perceived susceptibility is the individual’s subjective perception of his/her risk or vulnerability
of contracting an illness or disease. This perception may or may not be correct.

Perceived severity is the individual’s subjective interpretation of the seriousness of an illness
or disease, if the individual is susceptible. Like perceived susceptibility, it may or may not be
accurate. The individual’s perceived susceptibility and perceived severity of illness or
disease would reflect an individual’s perceived threat of an illness. Because of their strong cognitive
component, perceived susceptibility and severity are dependent, in part, on knowledge (Rosenstock,
1974).

Demographic and socio-psychological variables, such as age, gender, ethnicity, personality,
income, and knowledge, may indirectly influence behavior change. For example, lack of education or
lack of access to useful information may influence one’s ability to accurately gage one’s susceptibility,
severity, or threat of illness or the benefits or baniers to behavior change.

Cues to action are those triggers that prompt an individual to consider or to begin to initiate
behavior change. Cues include educational and/or media information and signs and symptoms of
illness. They may also include the death of a friend or advice from a friend.

Perceived benefits refers to the individual’s belief that a behavior such as increasing physical
activity will reduce the severity or susceptibility of disease or illness or will provide other perceived
personal benefits. For example, engaging in a regular physical activity like walking may not only

prevent hypertension but may have the added benefit of increasing one’s sense of well-being.

WALKING 27

Perceived barriers are those perceived impediments to undertaking an activity or activities that
would reduce the risk or severity of a perceived illness or health condition. Such perceived barriers
would include lack of time, lack of convenience and lack of self-efficacy.

Self-efficacy is the belief that one can actually perform the behavior necessary to produce the
desired outcome or goal. It is not identified in the model but plays an important role-in determining
outcomes (Bandura, 1977).

Aggie—anon of th_e IBM to Sedenm Adults

Application of the HBM to sedentary adults who are ready to in increase their physical activity
by walking does not focus on the motivation of, or many of the modifying factors of the individual.
Instead, it focuses on providing cues to action in the form of educational information, which is
accurate, easily understood, safe, evidence-based, and specific to increasing physical activity by
walking (Figure 2).

Given the readiness of the population identified to initiate increased physical activity by
walking, perceived susceptibility/severity of disease would be limited to briefly informing the.
individual about some of the health risks and health benefits of physical activity such as decreasing the
risk of heart disease, controlling and/or reducing weight, reducing or preventing hypertension, and
relieving symptoms of anxiety and depression.

Given the interest in walking and the relatively low-risk status of the target population, it is
assumed that the perceived threat of disease is present to the individual. Since the threat is determined
by the interaction of other variables in the model, any new information provided by individual

perceptions or modifying factors will influence or confirm perceived threat of disease.

WALKING 28

figs 2. ADAPTED HEALTH BELIEF MODEL

 

 

 

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Information Perceived Benefits
- for all ages - increased lifespan
— convenience - decreased risk of CHD
- prior experience - improved quality of life
- support system - improved mood
- realistic goals - fewer medical costs
- weight loss
- lowered cholesterol
- increased self-confidence
Perceived Barriers
- lack of time
- lack of convenience
- lack of support
- lack of confidence

 

' i

Perceived Susceptibility/Severity + Perceived Threat ' Likelihood of Change

- risk of CHD self-assessment

- anxiety and/or depression
self-assessment

- high blood pressure self-assessment

- body weight self-assessment

A

 

- perceived benefits minus
perceived barriers
- readiness
- self-efficacy
Cues to Action
- personal triggers/cues

- educational or media information
- primary care provider intervention(s)

 

Figure 2. Health Belief Model adapted to the client who wishes to begin walking as a regular activity.

August, 1999; Robert J. Ziola.

 

WALKING 29

Within the context of modifying factors, information is provided to increase knowledge and
assist individuals in meeting their goals. Knowledge gained fi'om prior experience and success at an
activity, convenience such as proximity to home or work, and support from family and friends may
reinforce or support their decision to begin physical activity. To reduce the risks associated with
increasing physical activity, directions about consulting with a health care provider about the plan to
increase physical activity will be included in the model.

Perceived benefits focus on findings in the literature regarding the benefits of increased
physical activity, including possibly increasing one’s life span and quality of life, decreased medical
costs and musculoskeletal pain, weight loss, improved mood and cholesterol levels, decreasing the
risk of CHD, and improved self-confidence.

Perceived barriers include those barriers found in the literature and strategies used to reduce or
overcome barriers. Such strategies would include writing specific goals, telling family, fiiends or
coworkers of those goals, finding a partner with whom to exercise, setting a date to begin, using the
stairs at work, providing an activity schedule to increase walking, and substituting comparable
activities when the planned activity is not feasible. The Walking Questionnaire (Appendix B) will be
used to assess baniers and, with both client’s and provider’s involvement, will be used to identify
strategies to overcome those barriers.

By clarifying misconceptions, providing accurate information, strategies to overcome barriers,
support, and useful tools for the client, the likelihood of behavior change (i.e., walking for exercise)
will be increased. Use of the HBM in conjunction with a protocol, tools for supporting change, and

successful strategies for increasing physical activity can provide the client with more resources to

WALKING 30
increase walking and provide the primary care provider with more tools to provide primary care
services.

Conclusions

Physical activity is a modifiable factor that can impact an individual’s relative risk for many
chronic diseases. Lack of regular physical activity contributes to many preventable diseases. Many
factors, including past history of physical activity, perceptions, self-confidence, resources, fears and
risk status come into play in determining the degree of physical activity maintained. Maximizing the
effectiveness of interventions to maintain or increase physical activity necessitates an understanding of
the findings in the literature, the recommendations of experts in the field, and the theories and
interventions which have shown promise. It is likely that multiple levels of intervention derived from
various theoretical frameworks need be employed to succeed at enhancing individual and public levels
of physical activity (Marcus et al, 1992; Prochaska et al, 1997).

V The SGR (U SDHHS, 1996) states that individuals of all ages can benefit from physical
activity and recommends that sedentary individuals increase physical activity in daily habits (e.g., mall
walking, gardening, washing the car by hand, begin physical activity of short duration and moderate
intensity, and gradually increase the duration and/or the intensity until a goal is reached thereby
increasing the likelihood of success and helping to avoid musculoskeletal injuries. Men over 40,
women over 50, individuals with chronic illnesses, and those at high risk (e. g., cardiovascular disease)
should consult with a health care provider before initiating new physical activity regimes.

The Report of the US. Preventive Task Force (U SDHHS, 1998) recommends short-term
goals for the sedentary that are a small increase over current levels. Over several months these

individuals can progress to a level of physical activity that provides cardiorespiratory benefits.

WALKING 31
Sporadic, vigorous physical activity is discouraged in the sedentary in favor of consistent moderate
physical activity.

For better health the ACSM (1998) and the USDHHS (1996), suggest that physical activity be
performed regularly, that is, a rrrinirnum of 30 minutes of physical activity of moderate intensity (e. g.
brisk walking) on most if not all days of the week For greater benefit, physical activity of vigorous
intensity, increased frequency or longer duration is recommended

The literature suggests that many Americans need to increase their physical activity to reduce
the risk of chronic health problems. Activities selected should be enjoyable, convenient, affordable,
and appropriate for the individual’s readiness, circumstances, current activity level, and risk factors.
Strategies for increasing physical activity include realistic goal-setting, written contracts, logs, visual
or auditory cues, telling others about goals for physical activity, using rewards, and eliciting the

support fiom others (e. g., family and friends).

WALKING 32
IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE

The literature thus suggests that to provide a service that increases the likelihood of physical
activity by walking, primary care providers like the APN must have sufficient knowledge and skills
(Jones & McGlynn, 1990). Understanding the client’s perceptions, experiences, abilities, sense of
self-efficacy, resources, and readiness is necessary to provide successful walking interventions.
Knowledge Of cunent health recommendations and standard practices, and the theories, evidence, and
interventions associated with behavior change is necessary to provide this service, as is the ability to
assess the client’s health, risks, endurance, aerobic capacity, and strength. The timing of various
interventions and emphasizing the immediate symptom relief benefits of exercise such as decreased
anxiety, improved mood, enhanced self-esteem, and enhanced self-efficacy are necessary to increase
physical activities within this client population.

Nursing Educalig

Nursing education will benefit from this project because the content herein includes an
updated synopsis of those theories, evidence and interventions that have provided positive outcomes
in health promotion and disease prevention. This project reinforces the dynamic nature of the
behavioral change process and methods to enhance health care practice and quality associated with
achieving increased physical activity among primary care clients. This paper provides a review of the
current scope of the problem associated with physical inactivity, the risks associated with physical
activity, the determinants linked to physical activity, and the benefits of, and the barriers to physical
activity. This project gives the APN the newest recommendations provided by the CDC and the

ACSM to achieve cardiorespiratory benefits (e. g. “dosing” of physical activity), and explains the

WALKING 33
application of the HBM and interventions used to. increase physical activity in a common primary care
population.

Nursing Research

This paper provides the basis for research that explores theoretical models, tools, protocols,
concepts, and interventions for increasing physical activity through walking. The efficacy of the
protocol and tools herein could be evaluated through a small pilot study. This could be accomplished
by application of the protocol and tools to the target population in the primary care setting by this
author. The author’s clients could provide feedback regarding the protocol, tools, and interventions
that could then be used to improve the protocol and tools. Effectiveness of the protocol and tools
could be evaluated by comparing such outcomes as increased physical activity from baseline and/or
maintenance of increased physical activity greater than six months with the same outcomes of the
target population among other providers in the practice setting and/or other practice settings.

If the findings prove significant, another pilot study could be developed from this paper that
examines an experimental group which receives the intervention described herein versus a control
group which receives routine care. The results of such research could provide valuable data that
would be useful in developing or refining interventions that support physical activity for this group or
others. Further research, which uses a prospective approach, may provide data relating to long term
outcomes using this protocol and tools.

In addition to research aimed at increasing physical activity, research is needed on factors and
interventions that maintain physical activity such as walking. These factors may include enjoyability,

control, decision-making processes, support and reinforcement, the effects of mass media campaigns,

WALKING 34
and school or community programs for promoting physical activity in specific segrrrents of the
population.

Nursing Practice

Perhaps the greatest impact of this paper may be in nursing practice. Many experts agree that
physical inactivity contributes to high mortality rates and increased risk of disease. And walking is
recognized for its convenience as a form of exercise (Pate et al, 1997 ; SGR, 1996), the low risks
associated with it (Panusch, 1994; Swan & Seedhom, 1993; Thompson et a], 1982), and the higher
compliance rates associated with such moderate physical activities (Duncan et al, 1991; King et al,
1991; SGR, 1996). This paper provides the APN with an overview of the literature associated with
walking and physical activity, the recommendations Of experts in the area of walking and physical
activity, and, based on the literature, a protocol and tools to increase the chances of client success with
this population.

Because APNs work not only with clients, but also with families and communities, good
practice entails involvement of the practitioner at multiple levels. At the client level, the literature
shows that the APN should stay abreast of developments within the area of physical activity (i.e.,
promotion and maintenance), provide a thorough assessment and history, and provide support and
long-term follow-up care for maintaining increased physical activity. If a client agrees to increase
his/her physical activity, the APN should provide a rationale for treatment, involve the client in goal-
setting and treatment plan, and provide detailed, concrete information in small amounts. Interventions
should be designed to decrease forgetfulness, overcome baniers, and consider the client’s unique
qualities, circumstances, strengths, resources, and stages of readiness. By providing a quality service,

involving the client in his/her care, and actively listening to the client, the APN can better establish a

WALKING 35
trusting relationship that is essential to client compliance. At this level, the APN serves in the role of
assessor, clinician, educator, planner, coordinator, counselor, and change agent.

At the family level, the APN can involve the family in supporting clients in meeting goals to
increase physical activity. This involvement may later lead to other family members’ interest and
participation in increasing physical activity. At the family level, the APN acts as educator, consultant
and client advocate.

At the community level, the APN can take on the broader roles of advocate and role model.
The APN should support programs and policies that promote lifelong physical activities. These
programs may be in the form of fun walks/runs and physical education, or church, workplace, and
community center programs that promote lifelong activities such as gardening, walking or swimming.

The APN should also support efforts to create environmental inducements to physical activity that are
safe, attractive, and accessible such as parks and trails for walking and bicycling, or open schools for
community recreation, support neighborhood watch groups, as well as efforts to increase sidewalks
with curbcuts.

The community involvement of the APN transcends the overt relationship seen between the
APN and his or her individual clients. The community involvement also involves the APN’s support
of policies that positively impact the health of the community. In the context of this paper, such
policies would include healthcare insurance coverage for exercise counseling and rehabilitation,
childcare arrangements to encourage participation of single women with children in physical activities,
and federal and state assistance to disseminate information and provide services to the members of the

community and under-served areas.

WALKING 36

The implications for the APN - education, research, and practice — ultimately revolve around
the acquisition of knowledge, research to confirm and improve practice, and application of that
knowledge and those research findings to provide a quality service to the client. If this project is
successful, its overall effect on the client, family, and/or community may be to decrease healthcare
costs, by decreasing the demand for illness services, and improve quality of life.
Clinical Application of the Walking Protocol

A cover letter (Appendix A) provides information about the target population - 20-50 years of
age - and the settings in which it would be used — primary care. It would also include an assessment
tool (Appendix B) to be used by the provider to assist in determining client past and present physical
activities, the Health Activities Equivalents —a table of activities which can be substituted for walking
and meet the minimum requirements to provide cardiorespiratory benefits (Appendix C), a log for the
client to record activities (Appendix D), a sample contract (Appendix E), a walking protocol diagram
(Appendix F), and an educational brochure (Appendix G) for the client which will provide
information on walking.

w ASSESSING CLIENT INTEREST

At annual physical or annual review of client status, the client would be asked if he/she is
interested in increasing physical activity by walking. This could be accomplished in one or more of
several ways. First, the question “Are you interested in increasing your physical activity by walking?”
may be placed on a questionnaire or nredical review form to be answered by the client in the waiting
room. This question would be accompanied by the question “Would you like your primary care
provider to talk with you about starting a walking program ?’ ’ This approach provides early

determination of readiness for and interest in walking. This approach also allows the client the

WALKIN G 37
fieedom to accept or decline the intervention. If the client responds ‘yes” to the second question,
he/she will be instructed to ask the receptionist for the “Walking Questionnaire” and to begin
answering the questions.

Second, the educational brochure that accompanies this tool or some other form of notice
(e.g., a written announcement) may be placed in the waiting room with instructions to inquire with the
receptionist about completing the Walking Questionnaire. This approach has several benefits. First, it
potentially reaches clients at an earlier point in their interest in and/or readiness for starting walking.
Second, it also determines readiness for and interest in walking, and is non-coercive.

Third, the client may be asked by ancillary personnel (e. g., receptionists or staff who seat the
client), using the questions above, about their interest in walking. If the client’s response is “yes” to
the second question, the staff will provide the client with the Walking Questionnaire. This approach
may also potentially reach more clients earlier in their readiness for and/or interest in walking.
However, unlike the other methods described above, the client may perceive this approach as coercive
and/or awkward.

Fourth, the provider or the client may identify the need for increased physical activity. If the
client is agreeable to walking as a physical activity, the provider can use the walking questionnaire to
guide the interview or have the client complete the questions.

§T_'E_l_’_2_: ASSESSING CLIENT RISK STATUS

The APN will review the Walking Questionnaire with the client and assess the ability of the
client to increase physical activity by walking. This procedure requires that the provider make a
clinical decision about the appropriateness of walking for the client. This decision would include the

physical ability of the individual to walk, the client’s current and past physical activity, the presence of

WALKING 38
any health problems that place the client at risk if walking is initiated (e. g. acute myocardial infarction
or respiratory difficulty, or Class III or IV CHF), and an assessment of the client’s resources,
environment, knowledge about walking, and perceived benefits and barriers to walking on a regular
basis. The assessment tool provided (Appendix B) will assist the provider in asking those questions
that will provide information about the individual’s risk status.

If the provider determines that the individual is not physically suited to engage in walking to
increase physical activity, less demanding activities should be considered or current activities may be
increased until walking is appropriate: The literature indicates that this approach toward increasing
physical activity increases the likelihood of success and helps avoid injuries and the risk of myocardial
infarction.

@133 SET REALISTIC GOALS

Once it is determined that the client is an appropriate candidate for walking, a realistic goal
and timetable must be agreed upon by the provider and client. It is at this stage that the provider uses
information gathered during the subjective and objective evaluation of the client to provide feedback
about the client’s health status, educate her/him regarding the benefits of walking and increased
physical activity, clarify misconceptions, reinforce past and present positive health activities, and
support the client’s decision.

$1113.: DETERMINE THE PLAN

It is important that the client agree to and/or suggest the date to start, the amount of walking,
the frequency of walking, and the conditions under which it will occur. It may be useful for the
provider to suggest a written contract (Appendix E) to formalize the goals. Later, this contract may be

used to measure success and evaluate effectiveness of the plan.

WALKING 39

Standard formulas for beginning and increasing walking have been developed and are used
routinely once an individual is found to be an appropriate candidate for walking. The Surgeon General
(U SDHHS, 1996) has stated that cardiorespiratory benefit is achieved when an activity of “moderate”
intensity is performed for at least 30 minutes, in which only sessions of 10 or more continuous
minutes are counted, at less than 60% maximum heart rate for age, expends approximately 150
calories per day, is equivalent to walking and uses sustained, rhythmic muscular movements, 5-7 days
per week. For an individual with no major health problems, maximum heart rate (mhr) is generally
deterrrrined by the following formula: 220 beats per minute (bpm) minus age in years. Thus, for a
healthy 40 year old, walking that elicits a heart rate of approximately108 beats per minute [(220-40) -
.6) and meets the duration, intensity and frequency requirements set forth by the Surgeon General
(1996) provides cardiorespiratory benefit.

Establishing rewards may increase client adherence to the planned walking activity. Rewards
for achieving daily goals such as soaking in a bathtub instead of taking a shower and/or going to a
movie for achieving weekly goals provide pleasurable incentives for meeting goals while also
fulfilling the need for cleanliness and rest. It is important, however, that the rewards identified be
administered in a timely fashion and that the client find the rewards of significant value to provide
motivation for the new walking behavior.

It is at this stage that the provider also assists the client in identifying resources and baniers to
achieving the identified goal. The assessment tool (Walking Questionnaire, Appendix B) asks the
client those questions that elicit the client’s motivation for pursuing walking, prior and current
physical activity, health risks and medication use, perceived and actual benefits and barriers to

increase physical activity, and actual and perceived resources for increased physical activity at home,

WALKING 40
work and in the community. By using this tool, the provider will better understand the client’s
motivation, perceptions and resources for walking. The information provided by the questionnaire
can be completed by the client prior to being seen by the provider or the provider can use the tool
during an encounter to elicit the information.

m OVERCOMIN G BARRIERS AND PREVENTING RELAPSE

To increase adherence and prevent relapse, the provider needs to provide anticipatory
guidance. Anticipatory guidance for a client might include discussion of strategies to overcorrre
baniers such as blocking time into a client’s schedule to walk, setting realistic goals, using visual cues,
walking with a partner, having the client tell others about their goals, using the HAE’s when walking
is not a viable option (e.g., safety, weather), and/Or using rewards to reinforce the walking activities
that are achieved.

A log sheet (Appendix D) is provided to the client that, if used correctly, visually provides
immediate information on walking activities and HAE’s over a time period. The log sheet can be
used to measure success, identify change, reinforce physical activity behavior, and/or aid in identifying
patterns that support or inhibit regular physical activity.

It is extremely important that the APN emphasize that a minimum of 10 continuous minutes
of walking totaling 30 rrrinutes per day (or the HAE’s) is necessary 5-7 days per week to obtain
cardiorespiratory benefit. These amounts have been found to be the minimum necessary to obtain a
risk reduction in chronic and preventive diseases. For the client who meets the criteria for inclusion
and has been recently physically active, this goal of 30 rrrinutes per day 5-7 days per week may be
achieved within a few weeks or months. For the client who meets the criteria for inclusion but who

has not been physically active, smaller goals such as five nrinutes per day three days per week may be

WALKING 41
more realistic for the client - with the ultimate goal being 30 minutes/day, 5-7 days per week (30-5-7).
Finally, the provider should make it clear that he/she will be a source of support and advice to the
client. Support is identified as one of the main reasons for increasing physical activity. Step 6 has
been developed to increase the likelihood of client success.

S_TEL6: FOLLOW-UP

A telephone call or other form of communication by ancillary staff or provider is suggested
after two weeks, or as agreed upon by the client and APN. This contact provides support that may not
be available to the client fiom family, friends, coworkers, or siblings and allows for early evaluation of
the plan. Any contacts with the client and any recommendations or changes in plan must be
documented in the client’s record to maintain continuity and patient safety.

If the client is successfirl at achieving initial goals, the APN should provide support:
congratulate, identify success, and discuss baniers or anticipated problems. A follow-up call or
contact by ancillary staff or provider should be scheduled for 12 weeks after start of walking program.

Ongoing contact by the health care team provides the opportunity both to support the client and to
evaluate the plan.

If the client is unable to achieve initial goals, follow-up contact by the provider is
recommended to reassess the client and the appropriateness of plan and to make recommendations. If
new goals and/or a date for a new start are detemrined, a follow-up contact by ancillary staff should be
agreed to by provider and client. If the client is still unable to meet new goals by agreed upon date,

follow-up by provider is recommended to reassess the goals, the plan and the client’s circumstances.

WALKING 42

SEE EVALUATION

Evaluation of walking program effectiveness is an ongoing process that consists of both
subjective and objective components. According to the literature (Shepard, 1988; Sallis et al, 1992)
and the HBM (Rosenstock, 1974), the client’s subjective evaluation of progress or benefits from
walking is instrumental in increasing the likelihood of behavior change such as walking. Because of
the impact of such client perceptions on the likelihood of behavior change, it is extremely important
that the APN continuously assess the client’s views, clarify misconceptions, use objective measures to
identify behavior change, and provide support.

The objective component of the evaluation of the client’s walking program is detemrined by
whether the agreed upon goals are met and changes in walking behaviors, or number of HAE’s, above
baseline. These objective data provide useful information in determining goal achievement,

identifying barriers to walking, and/or determining new goals.

WALKING 43

Appendix A

WALKING 44
ROBERT J. ZIOLA
2714 ELMWOOD
ANN ARBOR, MI. 48104
SEPTEMBER, 1999
Dear Primary Care Provider,

Enclosed are materials designed to assist you in providing information and tools to your
sedentary but otherwise healthy clients, aged 20-50, who desire to begin walking as a form of regular
physical activity. The recommendations presented are based on guidelines by the 1996 US. Surgeon
General’s Report on Physical Fitness and Health and are meant to provide the minimum activities
required to receive cardiorespiratory benefit and to aid in disease prevention.

Included in these materials is an assessment tool to guide you in assessing client past and
present physical activities, and an educational brochure for your clients who are ready and able to
begin a walking program. The educational brochure contains information on walking, strategies to
support walking, the Health Activities Equivalents table which presents substitutes for walking that
meet the minimum requirements for cardiorespiratory benefits, and a sample recording form which.
can be copied and used by your clients for tracking their activities.

I hope you find the enclosed materials useful in your practice. Please contact me if you have

any questions or if I can be of any help.

Sincerely,

Robert J. Ziola MSN

WALKING 45

Appendix B

WALKING 46

WALIGN G QUESTIONNAIRE
Directions: To design a fitness program that best fits your needs, please complete the following
questions.
1. Why do you want to begin walking?
2. Do you have any medical conditions that keep you from exercising? _ yes _ no

\I

00

If yes, please specify:

 

. Do you have any of the following health problems?

_ Asthma _ High Blood Pressure (Hypertension)
_ Obesity _ Heart Problems

What prescription or over-the-counter medications, supplements or herbs — if any - do you

use?

Do you have any environmental allergies (for example, to pollen, dander, dust, etc.)? If yes,
please list.

 

What kind of physical activity have you done regularly in the past (e. g. in school, in the military,

for recreation)?

a. Please check the items that apply:
_ walking _ running _ biking __ swirrrrning _ tennis
_ baseball _ aerobics _ dancing _ basketball _ football
_ soccer _ gardening _ rowing __ treadmill _ squash
_ weight lifting _ Stairmaster _ racquetball _ volleyball
_ other (Please describe: I

. How long and what intensity (ex. light, moderate or vigorous) did you do the activities that you

checked above?
a. Ifyou stopped an activity above, why?

What kind of physical activity do you regularly (3-7days/week) do now?
a. Please check the items that apply:

__ walking _ running _ biking _ swirrrrning _ tennis
_ baseball _ aerobics _ dancing _ basketball _ football
_ soccer _ Stairmaster _ gardening _ treadmill
_ weightlifting _house cleaning _ hiking _ rowing
_ seasonal (ex. shoveling snow, raking leaves, using a pushmower)
_ wheelchair ergometry _ other:

 

WALKING 47

b. Of those activities that you do now,
How long have you done them? Indicate number of _ weeks, _ months, or _ years.
How many days per week do you do them? _ days
How many minutes per week do you do spend doing them? _ rrrinutes per week

9. In general, at what intensity do you do these activities now?
_ light (little or no effort needed - comfortable)
_ moderate (breath heavily)
_ vigorous (out of breath or fatigued by the end of the activity)

10. What do you enjoy about the activities that you do?
_ Feel better
_ Stay fit
_ Relieve stress
_ Socialize
_ Change of scenery
_ other (please specify: )

11. Do you currently walk? _ yes
_ no

a. If yes, how many days per week ?_
How many minutes per week ?_
And at what intensity? _ light _ moderate _ vigorous
b. Do you usually spend at least 10 continuous nrinutes walking? _ yes _ no

c. DO any of your immediate family, fi'iends or coworkers walk? _ yes _ no
If yes, please list.

Directions: Below are statements that relate to attitudes about walking. Please indicate as many as
apply to you.

_ I don’t usually have enough time _ I’m too overweight

_ It’s Often not convenient _ I don’t have anyone to walk with
_ It’s often too cold outside _ I don’t like working up a sweat
_ It’s often too hot outside _ I have bad knees

_ It’s not safe outside _ I have asthma

_ I’m too depressed _ It’s boring

_ I’m not motivated _ I travel a lot

_ I’m too old _ other (please specify):

 

WALKING 48

Directions: Please check the statements about walking that are applicable to you. Please indicate as
many as apply to you.

__ I want to lose weight
_ I want to prevent health problem
_ I want to look better
__ I want to feel better
_ I want to sleep better
_ I want to improve my health
_ I want to control my diabetes
_ I want to control my high blood pressure
_ I want to have more energy
_ I want to walk with others
_ I like to walk alone
_ Walking is inexpensive
_ Walking helps relieve stress
_ Walking is dangerous in my neighborhood
__ There are areas to walk near my m: or 31911; which include:
_ malls
_ gyms
_ trails
_ parks
_ sidewalks
_ parking lots
_ other (please specify):

 

12. How fit do you feel?
_ very fit
_ moderately fit
_ poor

13.What, if any, are the main. barriers to walking for you?

WALKING 49

Appendix C

Health Activity Equivalents

Table 1
Examples of Moderate Physical Activity

WALIGNG 50

 

Washing and waxing a car for 45-60 rrrinutes
Washing windows or floors for 45-60 rrrinutes
Playing Volleyball for 45 minutes

Playing touch football for 30-45 minutes
Gardening for 30-45 rrrinutes

Wheeling self in wheelchair for 30—40 minutes
Walking 1 3A miles in 35 minutes (20 min/mile)
Basketball (shooting baskets) for 30 minutes
Bicycling 5 miles in 30 rrrinutes = 10 mph
Dancing fast (social) for 30 rrrinutes

Pushing a stroller 1 1/2 mile in 30 minutes
Raking leaves for 30 minutes

Walking 2 miles in 30 rrrinutes

Water aerobics for 30 minutes

Swimming laps for 20 rrrinutes

Wheelchair basketball for 20 rrrinutes
Basketball (playing a game) for 15-20 rrrinutes
Bicycling 4 miles in 15 rrrinutes = 16 mph
Jumping rOpe for 15 minutes

Running 1 1/2 miles in 15 minutes (10 min/mile)
Shoveling snow for 15 rrrinutes

Stairvvalking for 15 rrrinutes

 

Less Vigorous Activity Requires More Time To Gain Benefit

A

 

V

More Vigorous Activity Requires Less Time To Gain Benefit

 

 

Note. Adapted from the US. Surgeon General’s Report 1996. August, 1999;

Robert J. Ziola.

WALKING 51

Appendix D

WALKING 52

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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WALKING 53

 

 

 

 

 

 

 

 

 

 

 

 

 

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WALKING 54

Appendix E

WALKING 55

Sample Contract

The purpose of this contract is to assist you in meeting your goals to increase your physical
activity. Contracts have been used successfully by many people and are meant to remind you of the
corrrrnitrnent you have to yourself. Below is a sample contact that can assist you in reaching your
goals. Keep it where you want. Some people put it on their refrigerator - others place it in a less
public place.

I, . . agree to start walking (goal)

I will begin walking on Jdav of week) . _(date)

I will accomplish this by walking (distance) . times per .
To support me in reaching my goals I will:

1.

 

2.

 

 

 

 

 

 

8.

 

 

When I reach my Jweele/monthlyL goals, I will reward myself by

 

IfI am having difficulty attaining my goals, I will

 

 

Signature and date

 

WALKING 56

Appendix F

WALKING 57

Figure 3. WALKING PROTOCOL DIAGRAM

 

 

 

ASSESS CLIENT FOR INTEREST

l

ASSESS CLIENT RISK

/\

 

 

 

 

 

 

 

 

 

 

ELIGIBLE FOR PROTOCOL I INELIGIBLE FOR PROTOCOL

 

 

 

 

 

 

SET REALISTIC GOALS

l

DETERMINE THE
PLAN

1

FOLLOW UP

 

 

 

 

 

 

 

 

 

WALKING 58

Appendix G

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WALKING 60
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