Exercise Intervention Case Study Subject: Nathalia Campos Mary Rose Walker EXSS 422 Chris Covino 12-20-07 Ashley Hogan Nathalia is a middle-class 21 year old Brazilian woman. She has completed the majority of her undergraduate education in Brazil, but is taking time off because she has moved to Ithaca with her husband. Her husband, Marcel, enjoys soccer and plays with a University team once a week. Nathalia participated in sports in high school but since moving to the United States in July, she has been sedentary. A busy schedule, unfamiliarity with the area, and lack of social support act as barriers to starting an exercise regimen. Regional demographics play a role in our case studies‟ lack of activity. Coming from a tropical, warm climate like Brazil Nathalia is not too excited by the cold Ithaca weather. She states she wants to avoid the cold as much as possible. Ithaca‟s dark, gloomy weather also tends to generate a lethargic mood in people. These might be reasons of why the northeast is the second highest in physical inactivity in minority groups (Crespo, 2000). Nathalia definitely believes she has many barriers to exercise. She is busy all day with various activities and enjoys seeing her husband when he returns home in the evenings. She also is not used to inclement weather and will be avoiding the impending cold. We believe a large part of the reason she has not begun exercising is that while she enjoys keeping busy, she focuses on school and work related activities as opposed to physical ones. She does not recognize the benefits of fitting exercise into her schedule or prioritizing it and feels that she is already a motivated person. What Nathalia may need is a reminder of the social and health benefits that physical activity will bring to her life, as well as the potential health risks that staying sedentary may entail. Her cultural background could also play into the issue: perhaps the ideal body type is different, or there is simply less emphasis on physical appearance. Studies have also found that physical inactivity is more prevalent among Hispanics compared with whites (Weinberg and Gould, 2003, p. 400). Nathalia‟s Hispanic background plays a role in her adherence to an exercise program. Americans have an image of the ideal body type which often encourages a healthy lifestyle. Other cultures, like those in some Hispanic countries, may not have the same beliefs. Marquez and McAuley (2006) focused directly on the exercise habits of Latinos, stating they are the highest among all ethnic groups to be inactive during leisure time. Compared to other cultures, Latinos feel they have little “leisure time”—a statement reflected in Nathalia‟s description of her busy schedule and barriers to exercise. Because of this, it is expected they have lower levels of self-efficacy to exercise. (Marquez & McAuley, 2006). There is little research or comparison between individual minorities and the beliefs that, as a group, they hold about physical activity. However, Nathalia does fit into the profile of a female member of a minority group., and studies have shown “among women, physical inactivity is more prevalent than among men, as it is among black and Hispanics compared to whites” (Crespo, 2000; Weinberg and Gould, 2003, p. 400). The Health belief model best describes Nathalia‟s exercise behavior. This theory says that “the likelihood of an individual‟s engaging in preventive health behavior depends on the person‟s perception of the severity of the potential illness as well as his appraisal of the costs and benefits of taking action” (Weinberg and Gould, 2003, p. 404). As a young and seemingly healthy woman, it is likely Nathalia does not recognize any looming medical issues and so is not in the process of taking steps towards adopting the target health behavior of exercising to prevent any possible health defects. In addition, the transtheoretical model helps characterize Nathalia‟s intention to exercise (Weinberg and Gould, 2003, p. 406). She has regularly exercised in the past, but is currently in transition from the contemplation stage (she intends to exercise in the next 6 months) and the preparation stage (she has attended an occasional yoga class). These lifetime shifts in Nathalia‟s levels of physical activity show cyclic movement—not linear. The Transtheoretical model argues that different people require unique exercise interventions depending on the stages they are in, suggesting a tailor-made intervention addressing Nathalia‟s barriers and elaborating on the health benefits of exercise would be the best method for the situation. Once the proper motivation is established, it is important to track the stages of change Nathalia is undergoing. Using the transtheoretical model, we can encourage her to progress through contemplation, preparation, action, to maintenance. Change is not a fast process and within each step, a different approach of intervention must be taken. We placed Nathalia started in the contemplation stage as she was seriously intending to exercise within the next six months. After an intervention about time management, she moved to the preparation stage by walking a few times a week and preparing to exercise more often. At preparation, research has shown people put more weight in the „pros‟ of exercising than the cons. We used the health belief model to help move Nathalia into the preparation stage by explaining the „pros‟ of exercise and increasing her perceived self- efficacy (Weinberg & Gould , 2003, p. 64-72). The health belief model was first introduced in the 1950‟s by social psychologists. It was first used as a scare tactic to encourage the population to take preventative measures against the flu virus, but is applicable to exercise adherence. Nathalia expressed that although she knows exercise is “good”, she does not truly understand the physical, mental, and emotional benefits of it. By explaining the severity of consequences of inactivity to Nathalia and her perceived susceptibility to it, she will hopefully begin to engage in a healthy behavior of exercise. The model also includes the benefits of taking action as an additional motivator for her. Another end product of the health belief model is a feeling of self-efficacy because Nathalia will be actively in control of the prevention of the negative consequences we described to her (Weinberg & Gould, 2003, p. 138-144). The intervention that we planned was based around the health belief model. This model is based on two elements with the first being the value someone places on a health goal, for example in our case the desire for our subject to avoid illness in the future. The second part the belief one has in the efficacy of a specific personal health goal action to achieve this health goal (Landry & Solmon, 2002). We felt that the health belief model was the best strategy to base our intervention on because Nathalia has no competitive motivation for being involved in physical activity (such as playing on a sports team) and she is not aware of either the physical benefits of exercise or the risks from lack of exercise. Our goal for intervention was based around educating our subject on the two aforementioned factors. We began by going through the risks of not exercising on a regular basis such as higher risk of developing cardiovascular disease and/or osteoporosis—especially pertinent to Nathalia because women are at a higher risk for the condition. Personalized it to her specific situation, we detailed the benefits of exercise. We showed Nathalia how exercise could help increase her focus and energy throughout her workday, improve her mood and the quality of her sleep cycles, and overall provide general health improvements. We also discussed the definition of „exercise‟ as part of our education plan, explaining that she didn‟t have to run six miles everyday it could be much more simple and easy then that such as taking walks. Staying within the parameters of the assignment, we did not formulate a regime for her: instead, we referred her to resources that she could use to plan her exercise program. The social cognitive theory, which stresses the use of goals to achieve a desired behavior, was the basis of the next part of the intervention. Studies of adult goal setting have shown promise in changing physical activity behavior (Shilts, Horowitz, &Townsend, 2004). To implement this, we educated her about goal setting and encouraged her to set up goals for herself that were attainable, realistic, and appropriate for her situation. Specifically, we asked Nathalia to focus on process goals such as just going to the gym or for a walk 3 days a week. We reviewed the strategy of “flagging the mine field”, so she could pinpoint what issues could be potential „deal breakers‟ in obtaining these goals. Finally, we stressed the importance of her finding social support—for example going for walks with a partner or exercising with her husband. Additionally, we said we would communicate with her on a weekly basis and add our own type of social support. This social support aspect has been identified as key to achieving success in a physical activity program. In a metastudy done by Shilts, Horowitz, & Townsend (2004), the more social support for a person received for their exercise program, the more successful the program was. Nathalia‟s survey results suggest that before beginning her six week exercise regimen, she has felt substantial amounts of stress but also feels confident in her ability to cope with it and keep her life under control. She showed a strong positive attitude towards herself and her accomplishments. In addition, while she expressed some anxiety over her physique, it was moderate at best. Nathalia does not seem to suffer from low self-esteem and was comfortable stating that she thought, “I always think that I could look better, but I rarely think I look bad.” Nathalia initially cited lack of time as a substantial barrier to her adopting an exercise regimen. In our intervention, we encouraged Nathalia to create a schedule that helped her allot time to exercise during her busy week. Due to financial concerns, she was unable to join a gym or participate in weekly classes, but we felt she came up with an excellent alternative. Because she is new to the area, Nathalia wanted to become more familiar with her surroundings and the town of Ithaca. She felt that taking long walks would not only give her the exercise she needed for the day but also help her in getting to know the area. In the week following the intervention, she was successful in fitting in longer duration walks several times a week. The second week, however, Nathalia unexpectedly got a full-time job as a preschool teacher. She reported that the lifestyle switch was exhausting and she was unable to find time to fit in a work out. We met with Nathalia again at the end of the second week and spoke with her about the physiological benefits of exercise. We explained that maintaining an active lifestyle would actually boost her energy level and help her adjust to her new schedule. She listened to our advice and while she was not able to keep up the same routine, she did make an effort to establish and sustain her developing good habits in the ensuing weeks. A final meeting after the 6-week period had ended revealed that Nathalia had noticed significant changes in her energy level and sleep patterns since adopting a minimal exercise routine. She expressed interest in continuing what she had begun and even increasing her workouts once she “had more time on her hands.” Ideally, Nathalia would have picked up and continued an exercise schedule molded around her busy life. The program we encouraged her to create would have included 3-5 days of roughly 30 minutes each week. Her first week shows a clear effort, especially towards the end of the week where she took two longer-duration walks. Once she started her new job she became distracted and immediately disregarded her routine. Our second meeting was intended to be a check-in for her, helping to track any immediate health benefits. However, because she seemed to have lost focus on her goals, we again discussed the health benefits of exercise with Nathalia, hoping to rejuvenate her motivation and get her back on track. Nathalia‟s stress level seemed to have risen substantially since our last meeting and she reported feeling overwhelmed and overworked. “I barely have time to breathe,” she stated, “let alone fit a walk into my day.” In response to this, we suggested Nathalia sit down and block out times she could walk (as that was her preferred activity) during the day, such as her lunch break or before work. While we did not supervise the actually planning, we assured her that any exercise was better than none. She responded well to this and even spontaneously found a yoga class that she felt would relax her when she came home from work. In the weeks following this second meeting, Nathalia began taking short walks on her lunch break and attending the yoga class on Wednesday afternoons. As stated above, she developed a routine and noticed immediate health benefits, including, “more patience with the kids and the energy to keep up with them.” We felt our intervention was a success. Not only did Nathalia begin and continue her exercise regime but she seemed to be doing it for her own benefit, not for ours. Perhaps she took our counseling to heart and was faithful to her program for future health benefits, or perhaps it was the immediate and noticeable consequences of her actions that drove her to persist, but either way she was enthusiastic about continuing the program past the six weeks. She even announced that she planned on keeping the exercise log as it helped keep her on track and made her feel confident about being able to fit the walks into her schedule. The effectiveness of our intervention was due to several factors. The first was the social support we provided in the form of several meetings and progress check-ups. During these meetings we worked to solve any issues she was having in adhering to her exercise program. Nathalia‟s primary barrier, time, continued to be a major problem. We worked with her to break down her schedule and helped her see that it was possible to fit short bouts of exercise in during her lunch break or before work. To reinforce elements from our first meeting, we continued to instill the benefits of exercise and related it to her situation, i.e. we addressed her excuse of lack of energy by telling her that exercise can increase energy levels. This working with her and continue education specific to her was what seemed to work. The second and most important factor was of course Nathalia herself. She was very receptive, did an excellent job of working with us, and listened to what we had to say and offer. She was also very open and gave us excellent feedback about what was causing problems with her exercise regime. This was critical because it made it so we could work with her, altering our strategy as these issues came up. Without the cooperation of Nathalia, this intervention could not have been as successful. Our initial plan was not perfect, but it was designed to be flexible. If we had simple handed Nathalia an exercise program without proper follow ups, we feel that our intervention would have failed. Instead, we set it up to ensure we could get over potential barriers as they came along. Nathalia‟s excellent attitude along with our ability to adapt the intervention repeatedly to issues that she presented us with led to our success with this intervention. We definitely enjoyed working with Nathalia and feel that we used a good strategy for our intervention. References: Crespo, C. J. (2000). Encouraging physical activity in minorities. The Physician and Sportsmedicine. 28; 10: 36. Landry, J. B., & Solmon, M. A. (2002). Self-determination theory as an organizing framework to investigate women‟s‟ physical activity behavior. http://www.humankinetics.com. 54: 332-354. Marquez, D. X., McAuley, E. (2006). Social cognitive correlates of leisure time physical activity among Latinos. Journal of Behavior Medicine. 29; 3:281-289. Shilts, M. K., Horowitz, M., & Townsend, M. S. (2004). Goal setting as a strategy for dietary and physical activity behavior change: A review of literature." American Journal of Health Promotion. 12: 81-93. Weinberg, R, & Gould, D (2003). Foundations of Sport and Exercise Psychology. Miami: Human Kinetics Publishers.
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