Exercise: adherence (FS-09)

Exercise adherence: integrating theory, evidence and behaviour change techniques

Jean Hay-Smith (New Zealand), Sarah Dean (United Kingdom), Helena Frawley (Australia), Doreen McClurg (United Kingdom), Chantale Dumoulin (Canada)

Focused symposium

Sunday 3 May 2015, 08:30-10:00, Hall 404

Exercise adherence: integrating theory, evidence and behaviour change techniques

Hay-Smith J. 1, Dean S. 2, Frawley H. 3, McClurg D. 4, Dumoulin C. 5

1University of Otago, Wellington, Dept Medicine, Wellington, New Zealand, 2University of Exeter, University of Exeter Medical School, Exeter, United Kingdom, 3La Trobe University, Department of Physiotherapy, Melbourne, Australia, 4Glasgow Caledonian University, Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow, United Kingdom, 5University of Montreal, École de réadaptation, Faculté de médecine, Montreal, Canada

Learning objectives

  1. Explain why longer-term exercise adherence is problematic, and how theory informs our understanding of adherence;
  2. Appreciate that theory application is informed by context specific research; and
  3. Name, define and discuss the application of at least one behaviour change technique that might be relevant in their practice setting.


Physiotherapeutic rehabilitation of acute and chronic conditions commonly includes exercise, and exercise is strongly recommended for general health and fitness.1 Accumulating and maintaining exercise benefit requires medium to longer-term adherence, which is commonly poor .2 Successful treatment adherence usually requires behaviour change, which is often complex and influenced by many factors, with over 200 variables shown to correlate with exercise adherence alone.3,4 Using examples drawn frompelvic floor muscle training (PFMT) research we demonstrate the contributions of health behaviour theory, evidence synthesis and implementation science in understanding the general and context specific problems of exercise adherence.We suggest how the judicious application of behaviour change techniques might address some common problems.

It is strongly recommended that interventions to change health behaviours, including those that promote treatment adherence, are based on a theoretical model which provides an explanation of that behaviour.5,6 We briefly introduce and critique the use of six models applied in PFMT research 7-12 (and commonly used in other exercise research) and a seventh (the Information-Motivation-Behavioural Skills model)13 which is being used as the theoretical basis of the intervention in the Optimising Pelvic floor exercises to Achieve Long-term benefits (OPAL) trial (www.opaltrial.co.uk).

Behavioural determinants are factors that positively or negatively influence the behaviour and these determinants may interact.9 Many factors may predict facilitate or impedes a patient´s ability to adhere to an exercise regimen; for example, the amount of exercise supervision, symptom severity, exercise self-efficacy, level of

information provided, etc. We summarise the determinants of adherence reported in primary or secondary analyses of randomised trials of PFMT interventions (commenting on features shared with the wider exercise adherence literature as well as context specific determinants), and examine what can be learned from trials investigating specific adherence strategies.14-17

Physiotherapists and patients may see adherence, and the relative importance of the various determinants, differently. For example, even if patients experience similar amounts of symptom bother their ability to engage in exercise might be influenced by their assessment of other competing priorities in their lives, exercise self-efficacy, their relationship with health-care provider and other variables. Further,

for any determinant, what might be regarded as a facilitator by a physiotherapist might not be so regarded by a patient. Drawing on a synthesis of qualitative studies of PFMT experiences (Hay-Smith et al, manuscript in preparation) we show how some determinants of exercise may be particular to the exercise type and environment. We suggest that qualitative studies have potential to elucidate context specific factors that have yet to be directly investigated in other types of research.

Even when physiotherapists can identify, based on theory and evidence, potential determinants of PFMT adherence the challenge is then to decide how to address these in the practice setting. One approach to operationalizing the theory and evidence is to select and use appropriate behaviour change techniques. We introduce the 93 item behaviour change technique taxonomy proposed by Michie and colleagues (2013).18 Drawing on the intervention development for the OPAL trial, we select and illustrate the application of a few behaviour change techniques from the taxonomy (because they ´map´ well to the theory and evidence reviewed above, and are feasible for physiotherapists and patients to implement) in more detail using a clinical vignette.

Further, it is well known that evidence can take a long time to be implemented in practice19 and treatment effects demonstrated in research can be 'lost in translation' to the clinical environment. The developing field of implementation science looks at effective ways of implementing procedures and practices to contribute to better health care19. We give an example of a translational research project designed to help health professionals adopt more effective and context specific ways of teaching a PFMT intervention that encourages patient adherence, and we explore the barriers and facilitators of change in professional practice.20

Implications / Conclusions

With few trials investigating interventions to increase adherence to PFMT and few secondary analysis of adherence determinants we nevertheless found utility in health behaviour theory and reports of patient and therapist experiences. We suggest a number of potential modifiers of exercise adherence that could be directly addressed through judicious use of appropriate behaviour change techniques in the clinical setting.
Note: references 1 to 20 available on request from the authors.


Adherence; Behaviour change; Exercise

Funding acknowledgements

Jean: none.
Sarah: Sarah Dean's time is supported by the National Institute for Health Research
(NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health in England.
Doreen: none.
Chantale: none.
Helena: none.

Relevance to WCPT and expected audience

Accumulating and maintaining exercise benefit requires adherence, which is usually poor in the longer-term. Adopting and maintaining an exercise programme requires behaviour change. Using the example of pelvic floor muscle training, we suggest that physiotherapists might support their patients to improved long-term exercise adherence through the judicious use of behaviour change techniques, and how the choice of these is supported by understanding relevant health behaviour theories and evidence specific to the condition and context.

Target audience

Physiotherapists prescribing exercise in rehabilitation of chronic conditions; particularly physiotherapists working in the field of continence, pelvic floor dysfunction and women's health.