CPD Motivation1 Postural Stability Instructor Update: Motivation Welcome to London Thursday 12 th...

CPD Motivation 1

Postural Stability Instructor Update:

Motivation

Welcome to LondonThursday 12th October

CPD Motivation 2

Programme for the day

1. PSI experiences in motivation in falls prevention, drop out, barriers and motivation

2. Understanding behaviour change, listening and talking about physical activity

Lunch break

3. Strategies to increase adherence - induction, goal setting and support

4. Increasing participation through choices, planning for next steps and evaluation

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Aims of the Day

• to review instructors’ experience of motivating participants and the barriers they face in adopting and maintaining exercise behaviour

• to introduce instructors to the theoretical principles of motivation and adherence to exercise

• to introduce instructors to the specific motivational issues related to exercise and falls programmes

• to introduce exercise instructors to strategies designed to support exercise participation

• to enable instructors to practise listening and talking about overcoming barriers to exercise

and ………?

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Session 1

PSI experiences of motivation in falls prevention

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From referral to regular physical activity/exercise

• The process• Assessed at risk/or a faller• Advice/referral (from ?)• Preparation and exploration• Early Adoption• Action• Maintenance• Sustained participation in physical activity

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Introductory task

Identify two practical examples of barriers or drop out you have

encountered in your practice and be prepared to

share with the group

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PSI investigation

From the results of the PSI review, identify the top four

barriers, motivators and

reasons for drop out cited

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Barriers to physical activity

• Intrinsic barriers - are those that relate to the individual’s beliefs, motives and experiences concerning physical activity. These are most likely to be addressed by those who provide counselling, advice, motivation - for example, a peer mentor, health visitor or GP

• Extrinsic barriers - are those that relate to the broader physical activity environment, the attitudes of others and the types of opportunities that are available. These barriers are more likely to be influenced by other people and those responsible for policy and strategic developments.

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Previous experiences

• Limited opportunities and experiences in school (How long ago ?)

• Physical activity not associated with fitness and health

• Armed forces

• Limited experiences of sport

• All aspects of life were more physically demanding

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Older people’s sources of beliefs

• The media (radio, TV, magazines, newspapers)

• Workplace, H.P leaflets • ‘Common sense’• Personal experiences (and experiences of

others)• Medical and health professionals

authoritative(Finch, 1997)

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Beliefs about activity

• It’s good for you.• It’s common sense.• General health benefits• Specific health benefits e.g. weight control,

mental well-being, specific conditions• Maintenance of function• Onset of ageing as a signal(Finch, 1997)

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Moderation “at our age”

• “You can overdo it.”

• Gentler activities are more suitable.

• It depends on the individual.

• Might make something worse

• Fears over breathlessness and increased heart rate.

(Finch, 1997)

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Beliefs – exceptions to the positive view

• The health ‘lottery’

• A fashion for exercise nowadays

• “You need to be fit to do physical activity.”

• Too late to start

• Dangers when you stop

• “It can become an obsession.” (Finch, 1997)

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Overcoming barriers

• The association between physical activity and exercise and sport

• Frequency

• Intensity

• Old age is a time to slow down.

• Reassurance and education (Finch, 1997)

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Beliefs about activity – the underlying motivators

• To maintain suppleness and agility, and control weight

• ‘Feeling better’• Enjoyment• Prevent future illness• Manage existing health problems• To keep going, be independent (live longer

rare)• Adventure/challenge, new learning (Finch, 1997)

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Overcoming concerns about being active

• “I don’t think I should start at my age.”

• “I’m worried I might hurt something.”

• “I have to take it easy at my age.”

• “My aches and pains will get worse.”

• “Can I do exercise with my blood pressure ?”

advice/views of a GP powerful.

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‘Triggers’ and life events

• Wanting to play with grandchildren• Physiological signs of ageing• Retirement, children leaving home• Onset of ailment or illness• Moving home• Bereavement • Maintaining independence • Acute/crisis event a fall or MI (Finch, 1997)

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Extrinsic barriers

• Skills and attitudes of others, e.g. exercise instructors, GPs, leisure/recreation managers, family and friends

• Appropriate programming

• Accessible opportunities (transport)

• Safe activity environments (parks, well-lit streets, traffic)

• Positive images of older people

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Barriers to physical activity including programming

Intrinsic Programming Extrinsic

Poor self image, self efficacy

No history of positive

experience of exercise

Fear of over-exertion

Inconvenient time

Location and transport

Boredom

Exercising alone

Poor instruction

Too easy, too hard

Lack of family/partner

support

Social support

Weather/season

Medical problems

(Jones & Rose 2005)

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Understanding older people’s views of falls prevention advice:

focus group and interview study

Lucy Yardley & Chris Todd

with Margaret Donovan-Hall and Kate Francis (HT Aged 2005)

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Aims

• to explore older people’s views of different types of falls prevention advice

• to identify features of communications about balance training and falls prevention that may result in negative experiences

• to discover how messages may be improved

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Method

• Nine focus groups with 45 people (35 women and 10 men) aged 66 to 90

• Interviews with 21 participants (14 men and six women) aged 61 to 94

• Recruited from sheltered accommodation, church groups, senior citizen clubs, leisure centres, university staff newsletter, opportunity sampling

• Explored past experiences, presented and discussed different types of advice about balance training/falls prevention

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Findings

Perceptions of available falls prevention advice

• Reported none received! (though actually some mention of receiving information)

• Perceived falls prevention in terms of hazard reduction (rather than balance improvement), often through restriction of personal (physical) activity

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Perceptions of falls prevention messages presented

Discussion of falling prevention is beneficial

‘I think it would be helpful if someone knows what you should do and what you shouldn’t do’

‘I think it would give me more confidence of building up your balance if I read this [leaflet about improving balance] now. I think it would give me more confidence when I’m out.’

(Members of focus group of women aged 78 to 95 living in sheltered accommodation)

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Perceptions of falls prevention messages presented (cont).

It’s good advice BUT- they wouldn’t necessarily act on (all of) it‘It’s all good. I mean its good advice, yes,

excellent, I agree. I doesn’t mean to say I do it all but I agree.’

- it may not fit with their circumstances, lifestyle, prioritised goals

‘ No, no, no, no, no, no ... Nobody would go around with padding.’

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Perceptions of falls prevention messages presented (cont).

It’s good advice - for ‘them’- only seen as relevant to ‘elderly’‘Because we’re that much fitter -- we don’t really take too

much notice of it, only for other people, for other disabled or elderly people that we have to watch … we always watch older people anyway’.

(male participant aged 79 in sheltered accommodation)- rejected by fit, younger people, seen as humiliating‘I wouldn’t go for that [advice] because it didn’t apply to me

in any shape or form. Is there a bit of pride, is there a bit of “Well, you know, I’m not there yet”?’

(Denial ?)

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Perceptions of falls prevention messages presented cont.

Falls prevention advice unnecessary, upsetting‘It can make you feel – somebody producing the

leaflets here – that these people here are senile and they just don’t have any common sense and they need to be told everything.’

‘The last thing you want as you get older is to be told that you’ve got to be conscious every time you go out and might fall, you don’t want that, otherwise your life’s gone.’

(female participant, 78, who had recently fallen)

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Participants’ suggestions for future advice

• Incorporate falls prevention activities into lifestyle and general exercise programmes, and promote these activities as enjoyable, interesting, sociable

• Offer suggestions in constructive manner recognising individual’s knowledge and choice regarding their own lifestyle, and giving explanations for suggestions

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Evidence about falls - 1

• Exercise - Perceived positive factors and benefits• Noticeable benefit/improvement (restoring/maintaining

fitness and functioning, better health –blood pressure, dizziness, diabetes)

• Feel and look good (less stiff, less pain, more mobile, strong, energetic, better balance, mood, weight loss)

• Able to do more things (walk, do without stick, climb stairs, travel, go out alone, go shopping, ADLs)

• Maintaining and increasing independence• Social contact (bond formed through prolonged contact

with group)• Confidence/pride in achievement (general increase in

self-confidence, approval of family/friends/doctor)• Enjoy the activity (get out of house, use equipment)

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Evidence about falls - 2

• Exercise - Negative factors• Health problems (actual and perceived

interference)• No observed positive effects when tried

programme (didn’t work !)• Not liking social contacts in classes (peers or

leader!)• Unpleasant experiences (fatigue, pain etc.) or

not enjoyable• Low motivation or perceived relevance• Other priorities (caring for dependents, holidays,

other appointments, housework, bingo)

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Evidence about falls - 3• What are the key motivations for older

people to take up strength and balance training exercises?

• thinking you are the kind of person who should do these activities (self-efficacy)

• thinking other people think you should do these exercises

• believing that these activities would be enjoyable• concern about the risk of a future fall• (NOT having recent falls, or risk factors for falls)

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Session 2

Understanding change, listening and talking

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Advising older people to become active

• Use of a health educator and an extended consultation time

• Assessment of problem areas• Recognition of readiness to change• Goals agreed by both the older person and the

professional• Identification and recognition of social and

environmental barriers • Tailored action plan (specifies activity)• A choice and range of accessible local activities

including lifestyle activities• Supplementary educational materials• Systematic follow-up and support over a period of time

Promoting physical activity with older people. Recommendations for practice (BHF 2003)

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Pre-exercise assessment

• Health

• Function

• Readiness to exercise(Later Life Training Manaul)

How do we assess readiness to exercise among participants ?

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Lifetime model of physical activity

Staying

active

“Not doing Starting

A lot or

sedentary” out

Stopping Restarting

Time

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Generic models of behaviour change

• Theory of Reasoned Action – intention determined by attitude towards behaviour and social influences (Fishbean & Azjen 1975)

• Theory of Planned Behaviour + perceived behavioural control (confidence and opportunity) (Azjen 1985)

• Social Cognitive Theory - Self Efficacy and knowledge of health risks (Bandura 1986)

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Models of behaviour changeSummary - Change is more likely when

• Perceived benefits of physical activity outweigh the costs• Becoming more active will lead to social approval, not

disapproval• Being more active will lead to self-satisfaction and is

consistent with highly valued, broader life goals• Desirable outcomes are within one’s personal control,

achievable through one’s own actions• There are few obstacles/barriers to achieving desirable

outcomes• Opportunities and access to physical activity are high

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the decisional balance between benefits and cost – starting a

walking regime

Get out of the house and get some fresh air.

(Might) loose some weight

Meet some new people

Will help with my blood pressure

Difficult to get into the mood

Shopping will take longer

I’ve got a stiff knee

There are other things I want to do

Janis and Mann 1977

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Transtheoretical model of change (Marcus & Forsyth 2003)

Stage number Stage name Description

1 Pre-contemplation No intention of changing behaviour

2 Contemplation Thinking of changing behaviour

3 Preparation Preparing/planning to change behaviour

4 Action Adopted the intended behaviour, but for less than 6 months

5 Maintenance Adopted the intended behaviour for longer than 6 months

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Relapse

Relapse

(commonly described as dropping out) is identified as being very relevant (it

happens to most people !)

it is not a stage as such, but may appear between the stages.

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Transtheoretical/Stages of Change

1. Inactive and not thinking about becoming active

1. Inactive and thinking about becoming more active

2. Doing some physical activity3. Doing enough physical activity4. Making physical activity a habit

Marcus B (2003)-

• Increasing knowledge about physical activity and health

• Awareness of risks• Consequences to others e.g.

family• Understanding of benefits• Looking at previous experiences

of activity• Exploration of barriers (real or

excuses)• First steps to confidence (you

could)

Pre-contemplation

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3. Doing some physical activity4. Doing enough physical activity5. Making physical activity a habit

Marcus B (2003)

• Exploring past successes• Exploring self projection (what

would it look like ?)• Personalise benefits• What changes would you

expect ?• Explore lifestyle and time use• Explore types of activities that

might be manageable • Explore practical strategies

(setting a date/time - specific goals

• First steps to confidence and self efficacy (you could)

• Peer or buddy support

Contemplation

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3. Doing some physical activity

4. Doing enough physical activity5. Making physical activity a habit

Marcus B (2003)

• Exploring benefits from current activity patterns

• Exploring current problems e.g. what gets in the way ?

• Exploring preferences, choices• Setting incremental targets (5

minutes more ?)• Prompts to increasing

frequency (lifestyle activity)• Peer or buddy support

Preparation

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3. Doing some physical activity

4. Doing enough physical activity

5. Making physical activity a habit

Marcus B (2003)

• Maintenance and working towards (goal setting)

• How much is enough frequency, time, intensity, components e.g. strength and flexibility

• Mode, e.g. brisk walking or strolling with the dog

• Continuing to explore problems e.g. Anticipating relapse events loss of buddy, illness (ability to re-start)

• Exploring benefits (rewards) from current activity patterns (real or perceived, physical, psychological

Action

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3. Doing some physical activity4. Doing enough physical activity

5. Making physical activity a habit (six months)

Marcus B (2003)

• Maintenance and working towards (review of goal setting)

• Choices and variation (new horizons)

• Refresh and review e.g. support structures

• Anticipating relapse events loss of buddy, illness (ability to re-start)

• Re-enforcement through physical appraisal, e.g. weight loss, improved VO2 max

• How much is enough ?Maintenance

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Lapse or Relapse model

• What are the situations that might result in drop out ?

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• What are the situations that might result in drop out ?

• It poured with rain all day• Injury/illness• I didn’t want to go• Increased work/caring• Loss of buddy, partner• Moving houseMonitoring to anticipate – relapse is normal

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What’s the difference ?

• Lapse is missing a session or two

• Relapse returning to sedentary behaviour

What’s your role once relapse occurs ?

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Key questions to ask (exploring thoughts)

• Importance question - I wonder how important being active is for you ?

• General questions - What kinds of physical activity do you do at the moment ?

• Benefits question - Imagine if you did more, what benefits would you expect to see ?

• Barriers question - What things prevent you from being more active ?

• Concerns question - What things worry you about being more active ?

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Listening and talking about physical activity

Our response

1. Respond to barriers

2. Investigate neutral responses

3. Build upon positive answers (reinforce through goal setting)

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Neutral responses

• Well I don’t know but ……

• Imagine if…

• What could you see yourself doing ?

• How could we get there ?

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Motivation

Helping people make decisions…..

Helping people to motivate themselves

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So far !

• PSI perceptions of motivation, barriers• Evidence around physical activity and

older people• Evidence relating to falls advice and

exercise• Theory of helping people change

behaviour• Listening and talking about physical

activity

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Session 3

Strategies to increase adherence• Induction strategies

• Goal setting

• Support strategies

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Getting started

Once they have made a decision to come

The induction process

What are the most common questions and concerns that appear at this stage ?

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Common barriers

• Fear of falling or fear of the unknown

• Over-exertion

• Harming oneself

• Make a condition worse

• Others ?

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The induction session

What’s the model of best practice ?

What are the key elements you need to cover

(outlined in LLT manual)

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Goal setting – 6 steps

1. Expectations (during individual screening or initial assessment ?)

2. Set own goals SMART - long term and short term (Early goals must be achieved so behavioural goals not outcomes (self-efficacy)

3. Monitor and provide feedback4. Reward and incentives5. Problem solving to overcome obstacles6. Promote long term adherence

(Jones and Rose 2005)

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Goal setting

• Behavioural • Outcome goals

What short term goals can we set that lead to early success and

achievement ?

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Goal setting

• Behavioural (short term)

• To attend the next three classes

• To keep Tuesdays clear

• Outcome goals (long term)

• To increase strength• To improve balance• To improve

independence

Establish patterns of behaviour and success that will lead to longer term goals

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A different “spin” on fitness• Strength to lift household

objects, open a jar and get in and out of the bath

• Flexibility to wash hair, tie shoes• Balance and agility to climb

stairs• Co-ordination and dexterity to

open a door with a key• Speed to cross the road whilst

the lights are green• Endurance to walk to the shops,

play with the grandchildren

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Getting our message across

Strong arms give

better hugs

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Getting our message across

“She deserves to dance with Grandpa”

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Otago Exercise Programme - Schedule

• X 4 home visits in first 2 months

• Booster visit at 6 months

• 1 hour first visit, 30 mins.v subsequent visits

• Telephone call x 1 p/m between visits

• Exercises (warm up, strength, balance, flexibility, cool down)

• Walking

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Otago Exercise Programme - Schedule

Month 1 2 3 4 5 6 ……

12

Week 1 2 4 8

Home Exercise Visits

Telephone follow up

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Support strategies

• All literature provides strong evidence that they are effective (NICE, HDA, CDC, Campbell, FAME)

• Communication strategies

• Technologies

• Activities

Which are the “three best buys ?”

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Kirklees PAMs

• Local exercise referral programme for “at risk” and CHD rehab

• Volunteer buddies attached to programme• Trained in understanding physical activity and

health, understanding barriers and motivation• Integral to programme e.g. “Meet and greet”, 1

to 1 support• NB Not instructors• 96% + within programme beyond 12 months

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Session 4

Increasing participation through choices

• Home based exercise

• Active Lifestyles approaches

• Summary and evaluation

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Increasing participation through choices

Evidence supports effectiveness of outcomes

• Home based exercise

• Active Lifestyles approaches e.g. the promotion of walking

• Exit routes

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Home based exercise and walking

• From home or at home ?

• Evidence is equivocal

• Ease of access

• 20 minutes max ?

• Strategies to improve ?

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Independent choices

What strategies have you employed that have lead to success in

• Home based exercise programme

• Walking

• Access and exit to other programmes

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Implications for practice

Learning Actions

1 1

2 2

3 3

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Aims of the Day - reflection

• to review instructors’ experience of motivating participants and the barriers they face in adopting and maintaining exercise behaviour

• to introduce instructors to the theoretical principles of motivation and adherence to exercise

• to introduce instructors to the specific motivational issues related to exercise and falls programmes

• to introduce exercise instructors to strategies designed to support exercise participation

• to enable instructors to practise listening and talking about overcoming barriers to exercise

and ………?

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Evaluation

Other information (certificates)

Safe journey home

[email protected]

www.laterlifetraining.co.uk

mailto:[email protected]

http://www.laterlifetraining.co.uk/

CPD Motivation1 Postural Stability Instructor Update: Motivation Welcome to London Thursday 12 th...

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