Physical Activity Counseling

Lack of regular physical activity poses a health risk, but for many people, becoming more active is a difficult goal to achieve. Physical activity counseling offers a method of helping individuals increase their physical activity levels. It adopts a person-centered approach to help individuals find ways that physical activity can be included in everyday life. Counselors must develop appropriate counseling skills as well as knowledge about physical activity. Such counseling can take place in a variety of settings, including health services, workplaces, and schools.

Physical Inactivity as a Public Health Concern

Physical inactivity is a public health problem worldwide. Major health improvements could be achieved if the majority of most Western populations achieved the minimum recommendations of 30 minutes of moderate activity, such as walking, on most days of the week. Strategies to promote increases in physical activity at a population level are wide ranging and include government policy, environmental changes such as increasing the number of bike paths, promotional activities led by organizations such as schools and workplaces, activities that focus on groups such as exercise classes, and individual approaches such as mailing people information or meeting with them on an individual basis to counsel about how they might achieve more physical activity in their lives.

Historically, individual approaches to increasing physical activity levels focused on sport and structured exercises that were “prescribed” to clients. Exercise prescriptions were formulated for various groups of the population such as older adults, people with type 2 diabetes, and pregnant women. However, reviews of interventions aimed at promoting physical activity have shown that a person-centered approach is likely to be more effective than a “one size fits all” prescription. In the early days of the use of the person-centered approach, a term such as exercise consultation or exercise counseling may have been used. Exercise was usually defined as a structured activity, such as attending a gym or an exercise class, with an aim of increasing fitness levels. The current preferred term is physical activity counseling/consultation because of the shift toward everyday activities such as walking or gardening, being considered important.

Approaches to Physical Activity Counseling

Most approaches to physical activity counseling assume that individuals move through stages of decision making and behavior change. At one end of the spectrum, there are people who are regularly active and need encouragement to stay active; at the other end of the spectrum, there are people who have not considered being more active and who need information about the benefits an active life might bring to them. In the middle of the spectrum are individuals who are thinking about change or who may have tried to change, but have not succeeded. Sometimes moving through stages happens spontaneously or through self-help procedures. However, health professionals, such as exercise psychologists, can assist people to move through stages.

Specific guidelines about using a person-centered approach to increasing activity levels have been published. These guidelines are based on the available knowledge of what assists people in making exercise behavior change and suggest the following steps:

Step 1: Determine physical activity history. Discuss the reasons that the client has for wanting to increase activity. Take note of when the client was last active, the kinds of activities he or she might like now, and a measure of recent physical activity (e.g., a 7-day recall of activity).
Step 2: Discuss decision balance. Ask the client to consider what the pros and cons of increasing activity are for him or her. If there are more cons than pros, ask the client to consider how to minimize some of the cons.
Step 3: Ensure social support. Determine with the client what kind of support he or she might need and who can provide it.
Step 4: Negotiate goals. Help the client set realistic and time-phased goals for gradually increasing activity up to a level they have determined (e.g., “In 4 weeks’ time I would like to be walking for 30 minutes more on at least 3 days of the week”). Write these goals down.
Step 5: Discuss relapse prevention. If there is time or if the counseling session is with someone who is already active, then discussion on how to prevent relapse from regular activity should take place. Identifying situations in which relapses back to more sedentary living are seen to be likely, such as holidays, changing jobs, or increased family responsibilities, is a first step in preventing relapse. The client must also consider how to avoid the relapse or minimize the effect of these risky situations.
Step 6: Provide information on local opportunities. All information on relevant local activities, such as walking paths, swimming pools, and classes, should be on hand to supplement discussion as required.

The counseling will take 45 to 60 minutes if all six steps are dealt with in one session. Some approaches are very intensive, requiring clients to meet weekly or monthly, while other approaches have been successful with as little as two counseling sessions backed up with supporting phone calls.

Another approach to physical activity counseling comes from a general health behavior change style known as motivational interviewing. Motivational interviewing is a person-centered style that can be applied to any health-enhancing behavior, such as trying to stop smoking, change diet, or increase physical activity. The focus of this style is to help clients think about the ambivalence they have concerning changing the behavior in question. For example, in considering the adoption of physical activity, a sedentary person may express the views that “being more active will be good for helping me lose weight,” but also believe that “physical activity is time consuming and hard work.” Counseling in the style of motivational interviewing requires the client to focus on three key issues:

Importance: Why should I change? Is it worthwhile?
Confidence: Can I change? How will I cope if . . . ?
Readiness: Should I do it now? What about other issues?

Skills Required

The person doing the counseling must have excellent communication and reflective listening skills, and empathy for the people who are seeking help. Specific training in general counseling skills is a prerequisite for a physical activity counselor. Counselors must also be knowledgeable about physical activity for general and clinical populations, including any contraindications for particular groups. Finally, counselors must understand the various theories of behavior change and the various factors that will influence whether or not a person will succeed in becoming more active.

Settings for Using Physical Activity Counseling

The primary care setting offers an opportunity to counsel people who are not achieving the minimum levels of physical activity and help them become more active.

Many clinical conditions can be improved, in terms of increased quality of life and reductions of mortality or morbidity related to the condition, by patients’ increasing their level of physical activity. Thus, outpatient and follow-up clinics for a range of conditions could provide a physical activity counseling opportunity. The strongest evidence of the benefits of increasing physical activity levels is for cardiovascular disease, type 2 diabetes, depression, certain cancers, and osteoporosis. However, there are very few clinical conditions in which increasing physical activity would not be beneficial. Other locations that provide physical activity counseling opportunities include workplaces, private and public fitness and health facilities, neighborhood walking groups, slimming classes, schools, colleges, and adult education centers.

Future Needs

There is a need to increase the evidence base on the effectiveness of physical activity counseling approaches for different segments of the population. In addition, more detailed knowledge is needed about which elements of the counseling process are linked to behavior change. Finally, the optimal duration and the frequency of counseling sessions required for long-term behavior change are not yet known.

References:

Dunn, A. L., Marcus, B. H., Kampert, J. B., Garcia, M. E., Kohl, H. W., & Blair, S. N. (1999). Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness—A randomized trial. Journal of the American Medical Association, 281(4), 327-334.
Kahn, E. B., Ramsey, L. T., Brownson, R. C., Heath, G. W., Howze, E. H., Powell, K. E., et al. (2002). The effectiveness of interventions to increase physical activity—A systematic review. American Journal of Preventive Medicine, 22(4), 73-108.
Kirk, A. F., Mutrie, N., Maclntyre, P. D., & Fisher, M. B. (2004). Promoting and maintaining physical activity in people with type 2 diabetes. American Journal of Preventive Medicine, 27(4), 289-296.
Loughlan, C., & Mutrie, N. (1995). Conducting an exercise consultation: Guidelines for health professionals. Journal of the Institute of Health Education, 33(3), 78-82.
Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change: A guide for practitioners. Edinburgh: Churchill Livingstone.
U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.
World Health Organization. (2004). Global strategy on diet, physical activity, and health. Geneva: Author.