Module 4

Motivational Strategies for Starting the Physical Activity Behaviour Change Process¹

This module focuses on specific strategies for improving motivation for physical activity participation. Most patients will not be sufficiently active although they may see value in physical activity. For these patients, the first step is to develop discrepancy; that is to show mismatch between the importance of physical activity and their contrasting sedentary behaviour.

Decisional Balance Activity

An excellent starting point for discussions on physical activity is with the use of a Decisional Balance.

How Decisional Balance Works

• Decisional Balance is a simple activity that involves having the patient you are working with make a list of pros and cons for becoming more physically active and a similar list for remaining sedentary. Decisional Balance provides the patient an opportunity to think through ambivalence concerning physical activity.

• Not only does this technique help develop discrepancy and inspire change talk (statements that indicate desire, confidence, or plans to make positive changes in physical activity), Decisional Balance may help patients become more aware of personal reasons for becoming more physically active. This activity works best if the patient actually writes out all the pros and cons rather than simply verbalizing them.

An example of a list of pros and cons from a decisional balance activity is found below:

Pros for being physically active Lose weight Better heart health Better blood pressure	Pros for being sedentary More time for other things
Cons for being physically active Too time consuming Get sweaty	Cons for being sedentary Increase risk of heart attack Don’t live as long

Probing for more points

When the patient has completed a Decisional Balance, probe to see if there are additional points that have not been considered – for example, you might notice that a patient’s pros for physical activity list has only general health benefits listed. You may ask if there are other relevant social or mental health benefits of physical activity. Often people don’t initially think about benefits beyond health and weight control. However, when they start encouraged to think from new perspective, they may find that there are lots of reasons to be physically active.

Where to go from here

Once the patient has made a full list of pros and cons, you can start discussing some of the individual points or summarize themes that have emerged.

Remember, the idea is to develop discrepancy and inspire change talk. Don’t expect a complete transformation to start an exercise program at this point. The idea is to begin the behaviour change process by getting patients thinking about (and becoming committed to) adding more physical activity to their routines.

 

The following is an example of a dialogue between a sedentary patient and a nurse following completion of a Decisional Balance:

Nurse: Looking at this, it sure looks like you have a lot of reasons for being physically active.
Patient: Yeah, there are lots of health problems in my family.
Nurse: Oh, is there heart disease in your family then? I notice you mention that in several places here.
Patient: Both my parents died of heart disease and my brother recently went on meds for his high blood pressure. I am pretty worried about it actually.
Nurse: If I am hearing you right, it sounds like you feel you are vulnerable too?
Patient: Well, yeah, heart problems have been pretty close to home.
Nurse: I notice that “heart disease” and related points are listed in “pros for physical activity” and “cons for being sedentary.” It seems you have a sense that physical activity may reduce your risk?
Patient: Of course! Exercising is really the only way I know to strengthen the heart. Of course, getting motivated to actually stick to it is what I need!

Here we can see that Decisional Balance brought an ambivalent patient to begin to develop discrepancy (his sedentary behaviour does not match his feelings that physical activity can reduce risk of heart disease). This is the first step in eliciting change talk and promoting change in physical activity habits.

 

Asking Evocative Questions to Elicit Change Talk

Remember that when you start hearing change talk, the patient is moving towards making a commitment to increasing physical activity. The following are examples of questions that you may use to elicit further change talk:

Disadvantages of status quo

• What worries you about your current situation?
• What are some negatives associated with being sedentary?
• What will happen if you don’t change?

Advantages of change

• What would be good things about becoming active?
• What are the main reasons for making a change?

Optimism about change

• What do think would work for you if you decided to change?
• What strengths do you have that will help you succeed?

Intention to change

• What are you thinking about in terms of being active at this point?
• What would you be willing to try?

Look forward

• What will happen if you don’t start becoming more physically active?
• If you succeeded at being active, how would your life be different?

Look backward

• Have you ever been physically active, what was it like?
• What were things like before you had these health problems (assuming the patient links health problems to poor health behaviours)?

Importance and Confidence Scales

Effective tools to use for helping facilitate change talk and taking steps in readiness for physical activity are confidence and importance scales. It is recommended that you have a paper version of these scales available as a visual aid for the patient.

Importance Scale

This scale helps develop discussion and discrepancy about the importance of physical activity for the patient. An example of a way to use the importance scale is the following:

On a scale of 1 to 10 (show the visual aid), how important is it for you to become more physically active?

 

1	2	3	4	5	6	7	8	9	10
Not at all important				Somewhat important				Very Important

 

If the answer is 8 to 10, then ask why it is so important. This question allows patients to argue for why it is important to become more active, increasing the likelihood that they will make a commitment to increase physical activity.

If the answer is less than 8 but greater than 1, you can still elicit reasons for why physical activity is of some importance, prompting the patient to make arguments for physical activity. For example, if the patient answers 5, then probe “why did you answer 5 and not a 3 or 4?” The patient will be consequently prompted to explore benefits of physical activity, which will help develop discrepancy and potentially lead to change talk.

If the patient answers with a 1, then you can use this opportunity to open a discussion of the underlying issues. It is possible that the patient has a serious health issue or disability that prohibits physical activity. This type of patient is likely to be very resistant to becoming physically active.

Try to resist the temptation to start “educating” the person on the benefits of physical activity as this will likely lead to more resistance. Fortunately, very few patients will have such an extreme response as most people see some value in physical activity.

Confidence Scale

The confidence scale can be used as a tool with patients who see some importance to being physically active and have shown signs of being ready to start thinking of ways to become more active.  An example of a way to use the confidence scale is as follows:

On a scale of 1 to 10 (show visual aid), how confident are you that you could start a regular physical activity program.

 

1	2	3	4	5	6	7	8	9	10
Not at all confident				Somewhat confident				Very confident

 

If the answer is 10, and the importance scale was fairly high as well, you can ask if the patient has any specific motivational strategies or plans to help with adding physical activity to the daily routine. The next module will focus on specific strategies for maintaining regular physical activity.

If the answer is less than 10, then further probing will help identify obstacles to physical activity and start to elicit strategies for increasing motivation and overcoming barriers. For example, if the patient answers 6, you could ask “why a 6 and not an 8 or 9?” This question will open a discussion about barriers to physical activity for the patient. A follow-up question could be “what would it take to move your answer from a 6 to a 7 or 8?” This question helps the patient think specifically about strategies that would be relevant to overcoming specific barriers and motivational challenges.

Be careful at this stage not to add too much unsolicited “advice .” If you begin to sense resistance, you should remember to “roll with it.” Try and get the patient to come up with specific strategies, or at least promote autonomy by providing choices and asking for input.

 

Sample Dialog using the Confidence Scale with a Patient who indicated High Importance for Physical Activity

Nurse: So it seems you find physical activity to be important, which is great. How confident are you that, on a scale of 1 to 10, you could stick to a regular exercise program?
Patient: Oh yeah, that would probably be lower, maybe a 6.
Nurse: Okay, now 6 isn’t that bad, but tell me why you didn’t say 8 or 9?
Patient: Well, I have a really hard time staying motivated. I find exercising to be so boring! Every time I start it isn’t long and I start to lose interest.
Nurse: Staying motivated is really hard for a lot of people, so I can certainly appreciate that. Let’s look at this a different way, what do you think it would take to move your answer from a 6 to a 7 or 8? I mean, what would it take to increase your motivation, to make exercise less boring?
Patient: Hmmm, well, maybe if I had a friend to go to the gym with it would really help keep me motivated. Or if I could do exercise outside of the gym that might work too.
Nurse: Those are great ideas, and actually pretty common things I have heard. Would it be reasonable to be able to actually put either of these into practice?

 

Comparing Motivational and Non-motivational Approaches

Watch the videos below to see the difference between a non-motivational counselling approach (first video) and an approach that uses Motivational Interviewing (second video). Video credit: University of Florida, Department of Psychiatry.

Non-Motivational Counselling Demonstration

Effective Motivational Interviewing Demonstration

Key Points:

• Decisional balance is an activity that involves making a list of pros and cons for becoming more physically active versus remaining sedentary.

• Evocative questions for eliciting change talk is a strategy that involves asking questions that will likely result in change talk.

• Confidence and importance scales are tools that help elicit change talk, prompt discussion about physical activity, and provide a starting point for beginning to formulate strategies for initiating physical activity participation.

From this module you will have learned specific strategies for improving motivation for physical activity participation. The next module will focus on strategies for the adoption and maintenance of regular physical activity.

Please click on the following link to start the quiz.

Start Module 4 Quiz

References

1. Wagner CC, Motivational Interviewing Network of Trainers (MINT), Miller WR, Rollnick S. Motivational interviewing: Background information. Retrieved September 3, 2015 from: http://www.motivationalinterview.net/clinical/overview.html.