|Year : 2022 | Volume
| Issue : 3 | Page : 93-100
A theory-based educational intervention to promote behavior change and physical activity participation in middle-aged women: A randomized controlled trial
Hamid Joveini1, Zeinab Malaijerdi1, Nader Sharifi2, Rohollah Borghabani3, Masoumeh Hashemian1
1 Department of Health Education and Promotion, School of Health, Sabzevar University of Medical Sciences, Sabzevar, Iran
2 Department of Public Health, Khomein University of Medical Sciences, Khomein, Iran
3 Department of Disease Management, Sabzevar University of Medical Sciences, Sabzevar, Iran
|Date of Submission||22-Feb-2022|
|Date of Decision||21-Jul-2022|
|Date of Acceptance||26-Jul-2022|
|Date of Web Publication||9-Aug-2022|
Department of Health Education and Promotion, School of Health, Sabzevar University of Medical Sciences, Sabzevar
Source of Support: None, Conflict of Interest: None
Introduction: Promoting physical activity (PA) behavior by education can help people to create and maintain an active lifestyle until old age. This study aimed to design and evaluate a theory-based educational intervention to promote behavior change and PA in middle-aged women. Methods: This randomized controlled trial was conducted on 73 middle-aged women in Jovein, Iran, from January to November 2018. A researcher-made questionnaire based on the volition phase constructs of the Health Action Process Approach (HAPA) model was used. Randomly, one health base and one health house were assigned to the intervention group and one health base and one health house were assigned to the control group, and the participants were randomly selected from these centers. Both the groups completed the questionnaires before, immediately after, and 3 months after the educational intervention. The educational intervention was held in three 60-min sessions among three groups of approximately 17 participants. PA maintenance was measured 6 months after the intervention. Results: Immediately and 3 months after the intervention, the mean scores of all the volition phase constructs significantly increased in the intervention group compared to the control group (P < 0.05). Three and 6 months after the intervention, the number of people who had at least 150 min of moderate PA per week was significantly higher in the intervention group compared to the control group (P < 0.05). Conclusion: The educational intervention based on the volition phase constructs of the HAPA increased PA intention and facilitated the transition from an inactive lifestyle to an active lifestyle among middle-aged women.
Keywords: Aging, health promotion, sedentary behavior
|How to cite this article:|
Joveini H, Malaijerdi Z, Sharifi N, Borghabani R, Hashemian M. A theory-based educational intervention to promote behavior change and physical activity participation in middle-aged women: A randomized controlled trial. Asian J Soc Health Behav 2022;5:93-100
|How to cite this URL:|
Joveini H, Malaijerdi Z, Sharifi N, Borghabani R, Hashemian M. A theory-based educational intervention to promote behavior change and physical activity participation in middle-aged women: A randomized controlled trial. Asian J Soc Health Behav [serial online] 2022 [cited 2022 Sep 29];5:93-100. Available from: http://www.healthandbehavior.com/text.asp?2022/5/3/93/353636
| Introduction|| |
Physical inactivity has become a public health problem in developed and developing countries.,,, Some factors, including the use of a variety of home-grown appliances, use of cars for commuting, working with machines, apartment life, and emerging different entertainments (television, computer, and online games), have led to a reduction and, in some cases, complete elimination of muscular work and physical activity (PA). PA in everyday life encompasses a variety of activities, such as walking, swimming, and cycling. PA and exercise are often mistakenly used, but there are differences between them. Exercise is, in fact, a subset of PA, both of which are useful for health and disease prevention.,
The regular PA standard according to the World Health Organization (WHO) recommendations for adults (aged 18–64) are the moderate PA of at least 5 days a week for 30 min (overall 150 min a week), or intense PA of at least 3 days a week for 25 min (total 75 min a week), or an equivalent combination of two modes. Lack of PA has been proclaimed a concern by the WHO, and in the global action plan on PA (2018–2030), a series of specific policy measures have been proposed to achieve higher levels of PA.
With age and reaching middle age, the body's functional capacity decreases which is associated with lifestyle changes, such as decreased PA, poor diet, smoking, and alcohol consumption, which early intervention can reduce functional capacity and early disability in middle-aged people.
Sedentary lifestyle is one of the problems of urbanization and industrial development, which contributes to the emergence of diseases, disabilities, and deaths., Lack of PA is one of the top ten causes of death and disability worldwide. Out of the total deaths occurring every year in the world, at least 3.2 million are associated with low PA.,
According to a report from the WHO in 2018, worldwide, 23% of adults and 81% of adolescents have not currently met the WHO global recommendations on PA for health. The highest rates of adult inactivity are in the Eastern Mediterranean, North America, Europe, and the Western Pacific. As countries develop economically, levels of inactivity increase. In some countries, levels of inactivity are as high as 70%, due to changing patterns of transportation and increased use of technology and urbanization. Patterns of PA vary across age groups, so that the amount of exercise reduces with age, and women tend to have less PA than men. These patterns indicate that middle-aged women are the main target group for PA that should to be addressed. Promoting PA in middle-aged women can help create and sustain an active lifestyle until the elderly. In addition, the risk of women's health problems increases with age, which can be minimized by performing Pas.,
According to scientific documents, education is one of the essential tools and methods for promoting individuals' PA., Health education enables individuals to have more control over their health and on factors affecting their health. On the other hand, behavioral change theories increase the effectiveness of health education interventions and involve the individual in health education interventions. Therefore, today, it is necessary to use behavioral change theories and patterns for health education and health promotion experts.
The volition phase constructs of the Health Action Process Approach (HAPA) model were selected as a theoretical framework. The HAPA is a cognitive-social and psychological model in the field of health education, which is helpful in better understanding the factors affecting the creation of healthy behaviors. In this model, the process of behavior change occurs within two phases, including motivation and volition. The motivation phase includes risk perception, outcome expectancies, action self-efficacy, and behavioral intention.,,
When the behavioral intention is formed, the individual enters into the volition phase. The volition phase constructs include action planning, coping planning, and maintenance self-efficacy.,,
Thus, the present study aims to design and evaluate a theory-based educational intervention to promote behavior change and PA in middle-aged women.
| Methods|| |
Study design and participants
The present research is a randomized controlled trial study. The study population consisted of middle-aged women living in Jovein city in northeastern Iran from January to November 2018. The inclusion criteria consisted of age range of 30–59 years, lack of physical and movement limitation, lack of enough PA (obtaining a score equal to or <7.20 based on the Baecke habitual PA questionnaire), having the intention to do PA at the optimal level according to the WHO recommendation (at least 150 min of moderate PA per week), and having informed consent about voluntary participation in the study. The exclusion criterion was being absent in more than two sessions of educations.
Sample size estimation
A total of 148 individuals (74 for each groups) were considered for the sample size according to the study by Pazoki. (d = 0.15, power 80%, Type I error (α) 5%, and 95% confidence level).
Sampling was done in several stages. First, one urban center and one rural center were randomly selected from the city health centers. In the next stage, two health bases were selected randomly from the urban center and two health houses from the rural center. Then, one health base and one health house were randomly placed in the intervention group and another health base and health house in the control group. The list of middle-aged women who had health records in the selected centers was extracted, and participants were contacted and invited through phone calls. The Baecke habitual PA questionnaire was administered to 208 female volunteers who met the inclusion criteria. After analyzing the data, 163 participants with low PA (with a score equal to or <7.20, according to Baecke habitual PA questionnaire) were identified.
Finally, 78 women were in the intervention group and 78 women were in the control group. The second stage of the study (based on the volition phase of the HAPA) continued in two groups on women who had reached the intention of PA. In this stage, the researcher-made questionnaire, developed based on the motivation phase constructs of HAPA, was administered to the participants to measure their intention for performing PA. This questionnaire included two questions about the intention to plan and initiate PA in the next month. The minimum and maximum achievable scores were zero and eight, respectively. After analyzing the data, 73 participants of the first stage (49 in the intervention group and 24 in the control group) who intended to start PA (with a score of more than 4) were identified and included in the study [Figure 1].
To prevent the transmission of information and educational materials, the intervention and control groups were selected from two separate health base and health house. Therefore, random division was not done to select intervention and control groups.
The educational intervention was administered to the intervention group based on the pretest results of volition phase constructs of the HAPA model and according to the health education and sport science experts' opinions. The educational intervention was held in three 60-min sessions among three groups of approximately 17 participants. The first session was held with the purpose of planning for doing PA. Group discussion and brainstorming were held regarding the choice of PAs and favorite sports and in accordance with their conditions (where, how, and under what conditions it will be conducted). Women's questions and concerns were answered in this regard. The second session was held with the aim of planning to deal with the potential barriers to PA. In the case of barriers, different problems and situations that could be encountered for the participants were discussed, and attempts were made to resolve all possible problems through group discussion and question and answer methods. The third session aimed at enhancing the self-efficacy of individuals to overcome the possible obstacles to continue the PA and to return to PA after a period of interruption or failure.
Educational strategies included lectures, question and answer, group discussion, and brainstorming. Educational materials and supplies, both printed and nonprinted, were posters, pamphlets, booklets, CDs, educational videos of PA at home, and pedometer software for installing on Android phones, laptops, and mobile phones for sending reminder SMS. In the end, the participants were asked to have a moderate PA of at least 5 times per week for at least 30 min (equivalent to at least 150 min/week). The researcher-made questionnaire was filled out by both intervention and control groups at baseline and immediately after and 3 months after the intervention. In order to identify the individuals who have changed their PA behavior, 3 months after the intervention, the question “Do you have PA?” was asked. Those who responded “Yes” were then asked about the type, frequency, and amount of PA. Through these questions, the researchers could identify women who had at least 150 min of moderate PA per week. Six months after the intervention, PA behavior was monitored in the intervention and control groups by making phone calls, and those who continued their PA were identified.
The demographic characteristics were measured using five questions.
Baecke habitual physical activity
The Persian version of the Baecke habitual PA questionnaire was used to determine the type, amount, and intensity of PA per week. This questionnaire has been developed by Baecke et al. to evaluate the status and level of PA over the past 12 months. The questionnaire, briefly, consists of 16 questions organized in three dimensions, including PA at work (questions 1–8), sport during leisure time (questions 9–12), and PA during leisure time excluding sport (questions 12–16). The items were scored on a 5-point Likert scale ranging from “never” to “always” or “very often. Higher scores indicated performing higher levels of PA. The total score is a sum of scores obtained by three dimensions. The range of possible attainable score varied from 3 (inactive) up to 15 (very active).,, The validity and reliability of the Persian version of this questionnaire have been confirmed by Sadeghisani et al. According to the purpose of this study and other similar studies, people with a score equal to or <7.40 were considered inactive due to low PA levels.,
Volition phase of the HAPA
The volition phase of the HAPA was assessed using a researcher-made questionnaire. The first draft of the questionnaire was designed based on the literature review and opinions of health education experts. Then, the following steps were taken to determine the validity and reliability of the tool. The face validity of the questionnaire was measured by administrating the draft to 20 middle-aged women. Then, items were investigated about the difficulty in understanding words and phrases, the degree of fit and the proper relationship between the expressions and dimensions of the questionnaire, ambiguity in the expressions, or lack of meaning in words. Women's opinions were applied in the questionnaire with minor changes. The content validity ratio (CVR) and content validity index (CVI) were measured quantitatively by ten health education experts. Items with CVR of more than 0.62 and CVI of more than 0.79 were considered satisfactory., To determine the reliability of the questionnaire, Cronbach's alpha coefficient was calculated. The Cronbach's alpha value of all constructs was above 0.7, including action planning (0.93), coping planning (0.92), maintenance self-efficacy (0.86), recovery self-efficacy (0.72), and behavioral intention (0.91); thus, their reliability was confirmed. The final questionnaire included 25 questions, including action planning (3 questions), coping planning (9 questions), maintenance self-efficacy (8 questions), recovery self-efficacy (3 questions), and behavioral intention (2 questions). Items were scored on a 4-point Likert scale from “completely correct” to “completely incorrect.” Moreover, according to the questions which were positive or negative, they scored 0–3 points. The behavioral intention construct was scored on a 5-point Likert scale, including never (0), unlikely (1), have no idea (2), most likely (3), and definitely (4).
This study was approved by the Ethics Committee of Sabzevar University of Medical Sciences (IR.MEDSAB: REC.1396.120). This study was registered at the Iranian Registry of clinical trials (IRCT20180626040243N1).
The data were entered into SPSS 17.0. (SPSS Inc., Chicago, IL, USA) and the normality of data distribution was evaluated by Kolmogorov–Smirnov test and parametric tests were used for data with normal distribution and nonparametric tests for data with normal distribution. The data were analyzed using descriptive statistics (frequency, percentage, mean, and standard deviation [SD]) and analytical statistics (Chi-square, Fischer's exact test, independent t-test, Mann–Whitney U, ANOVA, and Friedman test). P < 0.05 was regarded as statistically significant.
| Results|| |
The mean (SD) age of the participants in the intervention and control group was 37.34 (5.43) and 36.7 (7.58) years, respectively. The mean (SD) body mass index (BMI) of the participants in the intervention and control group was 25.9 (3.48) and 27.46 (5.6), respectively. There was no significant difference between the two groups in terms of demographic variables at baseline. Details of demographic variables are listed in [Table 1].
|Table 1: The baseline demographic characteristics of the participants (n=73)|
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The results of the ANOVA test showed that there was no statistically significant relationship between age, occupation, educational level, and BMI of the participants with any of the constructs of the HAPA model (P < 0.05) [Table 2].
|Table 2: The mean and standard deviation of volition phase constructs at baseline according to the demographic variables (n=73)|
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The results of the Mann–Whitney U-test showed that there was a significant difference between the control and intervention groups in the mean score of maintenance self-efficacy and recovery self-efficacy (P < 0.05). There was a significant difference in the mean score of the four constructs between the two groups immediately after and 3 months after the educational intervention (P < 0.05) [Table 3].
|Table 3: The mean and standard deviation of the volition phase constructs before, immediately after, and three months after the educational intervention (n=73)|
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Three and 6 months after the intervention, the number of people who had at least 150 min of moderate PA per week was significantly higher in the intervention group compared to the control group (P < 0.05). Twenty-five participants in the intervention group reached the maintenance of behavior [Table 4].
|Table 4: Physical activity status before, 3 months, and 6 months after the educational intervention (n=73)|
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| Discussion|| |
Middle-aged women are the primary target group for PA that should be paid attention. The promotion of PA in middle-aged women can help create and sustain an active lifestyle until the aging period and reduce the health problems among them., The findings revealed that the groups were in the same condition in terms of demographic characteristics at baseline, and the effects of these variables on the intervention results were controlled. According to the findings of this study, there was no significant relationship between age, occupation, educational level, and BMI of the participants with the mean score of the HAPA constructs. However, 30–40-year-old women obtained the highest mean score of the HAPA constructs compared to other age groups, which is consistent with many other studies. It indicates that the amount of PA reduces with age, which can be due to reduced mobility and increased prevalence of health problems.,, The retired participants compared to the homemakers and employees, and the homemakers compared to the employees obtained more scores regarding the studied constructs. Findings from other studies reveal that employed people have less PA than unemployed people, which can be due to the lack of time for PA in this group.,,
Results have indicated that by increasing the educational level, the mean score of HAPA constructs increases, which is consistent with other studies.,,, By increasing the level of education, the individuals' awareness of the benefits of regular PA increases. Obesity occurs when there is an imbalance between energy intake and its consumption, and lack of PA is an important etiology for obesity. Considering the above findings, it is suggested that health policymakers integrate PA promotion programs into the regular health program for middle-aged women.
In the present study, immediately after and 3 months after the intervention, the mean score of the studied constructs significantly increased in the intervention group. However, these differences were not significant in the control group (except for the recovery self-efficacy).
Based on the findings of various studies, planning of when, where, how, and in what circumstances PA should be done (action planning) is a significant and positive predictor of PA participation.,, Therefore, by increasing action planning, the likelihood of regular PA increases. Therefore, when implementing educational interventions to promote PA in middle-aged women, it is suggested to use a variety of educational methods and strategies to promote action planning. Based on the findings of other studies, planning to cope with obstacles to do PA is also a significant and positive predictor of doing PA., Therefore, it is suggested to discuss possible obstacles and try to find a solution to all possible problems. Barriers may include lack of time, inability to pay sport club fees, lack of access to sports facilities, and loss of favorite TV shows when going to the club or walking.
Findings from other studies have indicated that maintenance self-efficacy and recovery self-efficacy are significant and positive predictors of performing PA.,, Therefore, it is suggested to use different methods and strategies for promoting maintenance self-efficacy and recovery self-efficacy among inactive people. Three months after the intervention, the number of people who had at least 150 min of moderate PA per week significantly increased in the intervention group compared to the control group. Furthermore, 6 months after the intervention, the number of women who could maintain a behavior change was significantly higher in the intervention group compared to the control group. Other studies have indicated that HAPA constructs can predict PA in different target groups.,,
Regarding limitation, the use of a self-report questionnaire as an information-gathering tool may have increased the probability of unreal responses among participants, especially questions related to the maintenance of behavior. To compensate, the briefing sessions were implemented, and appropriate steps were taken to maximize anonymity and gain the trust of the participants.
| Conclusion|| |
The educational intervention based on the volition phase constructs of the HAPA had all the aspects required to convert the intention of PA into the actual behavior and to create a lasting change in middle-aged women. Given that middle-aged women are at risk of inactivity and sedentary due to reduced mobility and increased health problems caused by age, it is suggested to design the HAPA-based educational interventions to enhance PA among them and integrate the interventions into their routine health care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]