Physical activity promotion in social work.

Williams, D.J. ; Strean, William B.

Although most social work clinicians probably know the health benefits of physical activity, many may not know how it may be used clinically within the practice context or how to promote it as a therapeutic adjunct. Others may not be fully aware of the tremendous potential psychotherapeutic benefits that may be obtained through physical activity. Perhaps it may be easy for clinicians to say, in effect, "Of course physical activity is good for you so 'just do it.'" Unfortunately, deference to this popular sneaker company slogan does little to bring about positive change in clients' fitness and health and, consequently, their desired physical and psychological effects. Social workers need to get active in promoting physical activity, and in doing so, they need to collaborate with other fields directly involved in addressing the physical inactivity problem, including physical activity sciences, health psychology, public health, and medicine.

The scholarly literature illustrating positive physical and psychological benefits of regular physical activity is growing. Despite this burgeoning knowledge, most people do not maintain a sufficiently active lifestyle (Pratt, Macera, & Blanton, 1999; U.S. Department of Health and Human Services, 1996). Physical inactivity among a large portion of the U.S. population is responsible for rapid increases in medical care costs that will become increasingly more difficult to sustain. Indeed, research has shown that by increasing participation in regular moderate activity levels among the 88 million inactive Americans ages 15 and older, annual medical costs may be reduced by as much as $76.6 billion (Pratt, Macera, &Wang, 2000). Currently, however, physical inactivity has become a widespread but silent social and public health problem.

Meta-analytic reviews demonstrate that regular physical activity is inversely associated with depression (Craft & Landers, 1998; North, McCullagh, & Tran, 1990; Wang & Brown, 2004) and stress reactivity and anxiety (Landers, 1997; Landers & Petruzzello, 1994). On the other hand, being physically active is positively associated with cognitive functioning (Etnier et al., 1997). Regular physical activity enhances well-being and vigor and produces beneficial emotional effects across all ages and for both genders. Therefore, it can be an appropriate adjunct to mental health therapy (Fontaine, 2000; International Society of Sport Psychology, 1992).

Behavioral medicine researchers are acutely aware of the difficulties in getting people to adopt a physically active lifestyle. Seeking to remedy the problem has led to the proposal of several ecological models that incorporate both internal and external factors that may affect a client's participation (Spence & Lee, 2003). For example, a recent article in the Journal of the American Medical Association suggested that multiple community organizations, agencies, and programs should work together to provide support for client physical activity (Estabrooks, Glasgow, & Dzewaltowski, 2003). This suggestion has important implications for social workers who perhaps are not yet significant players in physical activity promotion efforts. Practitioners, therefore, need to be knowledgeable about the conditions under which increased physical activity may be particularly helpful for clients, and they need the resources to promote physical activity among all of their clients. In addition, wherever possible, social workers must align with other professions and organizations to encourage physical activity, fitness, and health if they are to fully promote the total well-being of their clients.

PRIMARY CONSIDERATIONS: CLIENT AND CONTEXT

Buckworth and Dishman (2002) cautioned that "one size does not fit all" when attempting to adopt regular exercise behavior. The unique personal characteristics of the client, along with the client's physical and psychosocial contexts, must be carefully considered (Buckworth & Dishman; Estabrooks et al., 2003). Existing client motivation for physical activity, previous activity experiences (associated with positive or negative affective states), potential constraints to activity participation, cultural differences, and the particular clinical condition of the individual should be thought out by the social worker before any attempt at encouraging a change in the individual's behavior. Indeed, effective physical activity promotion appears to be dependent on these broader conditions, and of course, it is always prudent for clients to consult their physicians before beginning a structured exercise program.

Micro-Level Considerations

Practitioners can quickly and easily determine their clients' motivation to exercise through questions adapted from the Transtheoretical Model ([TTM]; Prochaska & DiClemente, 1982). The model identifies stages of exercise readiness (Lee, Nigg, DiClemente, & Courneya, 2001). According to proponents of TTM, behavioral change (including exercise adoption) occurs through sequential stages from precontemplation, contemplation, and preparation to action and maintenance. Consistent with TTM, clients in the precontemplation and contemplation stages of exercise readiness are likely to benefit from interventions that are education-oriented, such as weighing the pros and cons of engaging in physical activity and addressing constraints to participation. For example, a client in precontemplation or contemplation may be critical of her or his body image; this self-conception functions as a constraint to physical activity. In such a case, encouraging this client to engage in strength training at a gym may not be wise. Activity choices such as gardening or walking with a friend may be more appropriate. TTM includes several processes that are designed to move clients strategically through the behavioral change experience, and interventions to increase physical activity may be designed according to these processes. (For a more detailed description of TTM and its efficacy in exercise behaviors, see Lee et al., 2001; Marcus, Eaton, Rossi, & Harlow, 1994; and Marcus & Simkin, 1993).

Another popular approach to behavioral change, Self-Determination Theory ([SDT]; Deci & Ryan, 1985; Ryan & Deci, 2000), posits that behavioral change is likely to be sustained when people feel competent at succeeding in the new behavior, when they are given sufficient autonomy regarding its application, and when they feel the new behavior is personally meaningful to them. From an SDT framework, practitioners seek to improve the motivational climate for behavioral change of their clients. They do so by seeking ways to increase clients' feelings of competence, autonomy, and meaningfulness in implementing the new behavior (Ryan & Deci). Like TTM, this theory also requires the practitioner to understand client goals, values, lifestyle, and environmental conditions. An awareness of these components by social workers may be helpful in promoting a variety of desirable behaviors, including physical activity.

Constraints to activity participation at the micro level that may need to be negotiated include lack of motivation, financial issues that limit resources available for activities, lack of support, a clinical disorder (severe depression, anxiety, agoraphobia, for example), and lack of time--consistently the most frequent reason given for nonparticipation. Social workers can find creative solutions and help overcome many of these barriers. First, they should remember that even small increases in activity level can produce significant health and mental health benefits. For example, a short walk can generate stress reduction effects within five minutes and last for up to two hours (Landers & Petruzzello, 1994).

Meso-Level Considerations

Physical activity promotion can occur at the meso level of practice, including within families and small groups. Fisher and Ransom (1995) reported that parents' perceptions of family patterns of functioning are related to family members' health and health promotion. A more recent study suggested that different families may have different mechanisms of influence on physical activity habits (Soubhi, Potvin, & Paradis, 2004). Valach and colleagues (1996) alerted us to the social nature of health behaviors within the family and the need to consider them as family health promotion projects. This is an important area for future research. For now, social workers can look for opportunities to encourage family members to engage in fun activities that promote active living and social cohesion.

Social support for physical activity participation also may come from individuals outside the family. Neighbors, coworkers, and other community members may be encouraged to participate together in specific activities that are mutually desirable, such as sports, walking or running clubs, or longer-term community fitness challenges sponsored by national organizations and public figures. Common constraints to activity participation at the meso level may include financial limitations and thus a limited number of possible activities, differences between individuals on what activities are perceived to be enjoyable, and finding time when everyone is able to participate together. Again, there may be times when social workers can be active in helping clients negotiate such barriers, which may lead to both physical health and social benefits.

Macro-Level Considerations

People need opportunities and resources to adopt and maintain a physically active lifestyle. It is important, therefore, that a wide range of cultural, community, and environmental factors are considered in physical activity promotion. Community programs that are widely available and accessible can help, along with use of parks and recreation areas that attract and encourage active living. Successfully promoting active living in ways that are consistent with specific cultural norms is ethically sound, but needs to be explored further (see Pittman, 2003). As an example, Guerin and colleagues (2003) reported on several initiatives within a local Somali community to increase opportunities for women to participate in physical activity. These initiatives included exercise classes in a community center, trial memberships at a local women-only fitness center, and walking and sports groups. As advocates of cultural awareness, social justice, and political activism, social workers could potentially make significant contributions to effective physical activity promotion by encouraging dialogue and collaboration among various organizations on important macro-level factors. The potential contribution of the social work profession in this regard should not be underestimated.

THE STRENGTHS APPROACH

Social workers may work from the familiar strengths approach (see Aspinwall & Staudinger, 2003) to promote active living. In promoting physical activity among clients, we encourage social workers to consider available strengths and resources that are potentially available at all levels: micro, meso, and macro. Elsewhere we have reported that assumptions underlying strengths-based approaches can be adapted specifically to encourage physical activity participation, potentially leading to the realization of health benefits (Williams & Strean, 2005). Put simply, people have personal strengths and resources available to them to solve the problem of insufficient physical activity. The role of the clinician is to amplify positive change. In reality, small changes are all that are needed at the start, and there is no single, "correct" way to structure physical activity. Virtually no one is sedentary 100 percent of the time, and almost everyone has had positive experiences with physical activity at some time in his or her life (Williams & Strean). Social workers who believe physical activity may be beneficial in helping to address specific clinical conditions, such as alleviating anxiety, stress, or depression or improving a sense of overall well-being, may help a client explore specific times when the client is, or has been, physically active. Considering the various strengths and resources that are available, the clinician may then seek to reproduce and strengthen such positive behaviors.

Social workers also may work from the strengths approach to encourage community organizations to work together and provide additional opportunities for individuals to be physically active. Questions that might be explored among community leaders include "What resources are currently available to create opportunities for greater numbers of people to increase their activity levels?" "How can agencies better collaborate to produce new or improved avenues for physical activity and positive health behaviors?" and "Given that a common goal or value across organizations is to improve the personal and collective quality of life of all people, how can we better support each other, as agencies or organizations, in bringing about such improvements?"

CONCLUSION

Because of the many potential physical, psychological, and social benefits of physical activity, clinical social workers may consider physical activity promotion in ways that support and help clients fulfill specific treatment goals. In so doing, it is participation in activity that should be encouraged and reinforced by clinicians. Some clients may tend to judge themselves by popular, but largely irrelevant and counterproductive criteria--such as amount of weight loss, changes in clothing size, or various fitness comparisons with others. The social worker should remind clients that substantial physical and psychological benefits from physical activity are often quite subtle and may occur without significant changes in appearance, size, or bodyweight.

Although clients may participate in a variety of different activities, it is often helpful for each client to have what we refer to as an "exercise staple"-one primary activity that is particularly enjoyable and that he or she will engage in regularly. For some, particularly those in early TTM stages of exercise adoption, 15 minutes of gardening or daily walking may be a staple. For those further along in their adoption of a physical activity journey, potential staples may include biking, swimming, hiking, jogging, aerobics, weightlifting--whatever activity the client is most motivated to do regularly and consistently.

Finally, some key questions to ask clients as follow-up to activity promotion include:

* "Have you been participating in (specific physical activity)?"

* "Has (the activity) helped you to ... (link to specific treatment goal), feel less depressed, feel better about yourself, experience less stress, spend enjoyable time with your kids, meet a new friend?"

* "Do you want to keep participating in (specific activity) or add a different activity?"

The recommendations proposed here are meant as suggestions, and clinical social workers are encouraged, after considering important personal and contextual implications, to work with other relevant professionals in being creative with clients when promoting physical activity. Social workers should be aware of the unique activity needs of their clients, focus on activity participation rather than fitness levels, promote feelings of self-esteem and competence, and emphasize self-management of healthy living (see Corbin, 2002). Social workers, as generalists, are in a unique position to promote enjoyable physical activity. Social workers know how to help clients negotiate barriers and use personal strengths. They tend to be aware of community resources that can assist clients, and they advocate for positive change within society. These existing skills can be used in various ways to potentially help individuals become more physically active. We have offered a number of possible theoretical suggestions herein, including TTM, SDT, and a strengths approach, any one (or more) of which could be used by social workers to help their clients, depending on clinician orientation and specific client needs. Indeed, we believe that it is time for social work to become a more active participant in physical activity promotion.

REFERENCES

Aspinwall, L. G., & Staudinger, U. M. (2003). A psychology of human strengths: Fundamental questions and future directions for a positive psychology. Washington, DC: American Psychological Association.

Buckworth, J., & Dishman, R. K. (2002). Exercise psychology. Champaign, IL: Human Kinetics.

Corbin, C. B. (2002). Physical activity for everyone: What every physical educator should know about promoting lifelong physical activity. Journal of Teaching in Physical Education, 21, 128-144.

Craft, L. L., & Landers, D. M. (1998).The effect of exercise on clinical depression resulting from mental illness: A meta-analysis. Journal of Sport & Exercise Psychology, 20, 339-357.

Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum.

Estabrooks, P. A., Glasgow, R. E., & Dzewaltowski, D. A. (2003). Physical activity promotion through primary care. JAMA, 289, 2913-2916.

Etnier, J. L., Salazar, W., Landers, D. M., Petruzzello, S. J., Han, M., & Nowell, P. (1997).The influence of physical fitness and exercise upon cognitive functioning: A meta-analysis. Journal of Sport and & Exercise Psychology, 19, 249-277.

Fisher, L., & Ransom, D. C. (1995). An empirically derived typology of families: I. Relationships with adult health. Family Process, 34, 161-182.

Fontaine, K. R. (2000). Physical activity improves mental health. The Physician and Sportsmedicine, 28(10), 83-84. Retrieved May 22, 2004, from http:// www.physsportsmed.com/issues/2000/10_00/ fontaine.htm

Guerin, P. B., Diiriye, R. O., Corrigan, C., & Guerin, B. (2003). Physical activity programs for refugee Somali women: Working out in a new century. Women & Health, 38(1), 83-99.

International Society of Sport Psychology. (1992). Physical activity and psychological benefits. The Physician and Sportsmedicine, 20, 179-184.

Landers, D. M. (1997).The influence of exercise on mental health. President's Council on Physical Fitness and Sports Research Digest, 2(12), 1-8.

Landers, D. M., & Petruzzello, S.J. (1994).The effectiveness of exercise and physical activity in reducing anxiety and reactivity to psychosocial stressors. In H. A. Quinney, L. Gauvin, & A.E.T. Wall (Eds.), Toward active living: Proceedings of the International Conference on Physical Activity, Fitness, and Health (pp. 77-82). Champaign, IL: Human Kinetics.

Lee, R. E., Nigg, C. R., DiClemente, C. C., & Courneya, K. S. (2001).Validating motivational readiness for exercise behavior with adolescents. Research Quarterly for Exercise and Sport, 72, 401-410.

Marcus, B. H., Eaton, C.A., Rossi, J. S., & Harlow, L. L. (1994). Self-efficacy, decision-making, and the stages of change: An integrative model of physical exercise. Journal of Applied Social Psychology, 24, 489-508.

Marcus, B. H., & Simkin, L. R. (1993). The stages of exercise behavior. Journal of Sports Medicine and Physical Fitness, 33, 83-88.

North, T. C., McCullagh, P., & Tran, Z. V. (1990). Effect of exercise on depression. Exercise and Sport Sciences Reviews, 18, 379-415.

Pittman, B. D. (2003). The Afrocentric paradigm in health-related physical activity. Journal of Black Studies, 33, 623-636.

Pratt, M., Macera, C. A., & Blanton, C. (1999). Levels of physical activity and inactivity in children and adults in the United States: Current evidence and research issues. Medicine and Science in Sport and Exercise, 31(Suppl. 11), S526-S533.

Pratt, M., Macera, C. A., & Wang, G. (2000). Higher direct medical costs associated with physical inactivity. The Physician and Sportsmedicine, 28(10), 63-70. Retrieved May 22, 2004, from http://www. physsportsmed.com/issues/2000/10_00/pratt.htm

Prochaska, J. O., & DiClemente, C. C. (1982).Trans-theoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276-288.

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-78.

Soubhi, H., Potvin, L., & Paradis, G. (2004). Family process and parent's leisure time physical activity. American Journal of Health Behavior, 28, 218-230.

Spence, J. C., & Lee, R. E. (2003).Toward a comprehensive model of physical activity. Psychology of Sport and Exercise, 4, 7-24.

U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the surgeon general. Washington, DC: Author.

Valach, L., Young, R. A., & Lynam, M. (1996). Family health promotion projects: An action-theoretical perspective. Journal of Health Psychology, 1, 49-63.

Wang, G., & Brown, D. R. (2004). Impact of physical activity on medical expenditures among adults downhearted and blue. American Journal of Health Behavior, 28, 208-217.

Williams, D. J., & Strean, W. B. (2005). Little pain, much gain: Solution-focused counseling on physical activity. Canadian Family Physician, 51, 677-678.

D. J. Williams, PhD, LCSW, is a postdoctoral fellow, and William B. Strean, PhD, is associate professor, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Alberta, Canada. Address correspondence to Dr. Williams, E-424 Van Vliet Centre, University of Alberta, Edmonton, Alberta T6G 2H9, Canada; e-mail: dj.williams@ ualberta.ca.