Web-based intervention on the promotion of physical activity among Iranian youth using the transtheoretical model
Asiyeh Pirzadeh1, Fereshteh Zamani1, Mehri Khoshali2, Roya Kelishadi2
1 Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
2 Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||17-Feb-2020|
|Date of Acceptance||05-Mar-2020|
|Date of Web Publication||28-May-2020|
Dr. Roya Kelishadi
Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
BACKGROUND: Sedentary habits may increase the noncommunicable disease risk factors, and few teens get enough physical activity. Therefore, the current study aimed to examine the effects of a web-based intervention on the promotion of physical activity among adolescents using the transtheoretical model (TTM).
METHODS AND MATERIALS: A quasi-experimental study was conducted on 278 high school students who were randomly allocated into one of the three groups: two web-based intervention groups. The intervention groups 1 and 2 received education through web (www.salamat.family), but the second group received educational strategies based on TTM. Five questionnaires were applied two times before the intervention and 6 months after the intervention. And, in the control group, the data were collected using stage of exercise behavior change questionnaire and the International Physical Activity Questionnaire. Student's t-test and two-way analysis of variance, and McNemar's test were applied to compare before and after the intervention. P < 0.05 was considered statistically significant.
RESULTS: The mean differences for TTM constructs related to exercise behaviors (processes of change, self-efficacy, and decisional balance) in intervention groups 1 and 2 were very higher than the control group. Participants in intervention groups 1 and 2 who had low or moderate physical activity before the intervention were placed in high physical activity after it.
CONCLUSION: According to the obtained results, education on PA based on website effective, but if we use education based on TTM, it will be more useful on the behavior.
Keywords: Behavior change strategies, intervention, physical activity, web
|How to cite this article:|
Pirzadeh A, Zamani F, Khoshali M, Kelishadi R. Web-based intervention on the promotion of physical activity among Iranian youth using the transtheoretical model. J Edu Health Promot 2020;9:118
|How to cite this URL:|
Pirzadeh A, Zamani F, Khoshali M, Kelishadi R. Web-based intervention on the promotion of physical activity among Iranian youth using the transtheoretical model. J Edu Health Promot [serial online] 2020 [cited 2021 Jun 14];9:118. Available from: https://www.jehp.net/text.asp?2020/9/1/118/285152
| Introduction|| |
Nowadays, with the urbanization expansion, the industrialization of societies and lifestyle changes lead to increasing levels of insufficient physical activity and therefore contribute to the increase in the prevalence of obesity and noncommunicable diseases (NCDs).
Physical activity is one of the health-promoting behaviors, and sedentary habits can increase the NCD risk factors including elevated blood pressure, insulin resistance, and dyslipidemia.,
In Iran, the escalating trend of excess weight among children and adolescents and its strong association with lifestyle habits, most notably inadequate physical activity are well documented. The national prevalence of overweight and obesity in Iranian children and adolescents is reported 5.0%–13.5% and 3.2%–11.9%, respectively.
Adolescents must do at least 60 min physical activity daily. However, according to reports, few teens reach this level of participation in physical activity. The results from studies conducted on Iranian adolescents reported a decrease in regular physical activity, most notably in girls.,
Different methods have been used to increase the amount of physical activity. Web-based physical activity programs are considered as a promising method for adolescents and young people. Interventions on using the web to increase physical activity have highlighted the effectiveness of such interventions. A study conducted on the use of web-based interventions to increase walking in low-mobility individuals demonstrated beneficial effects. Another study using web-based interventions in adolescent girls showed an increase in physical activity, such as walking, exercise, and exercise among participants.,
Websites that provide “tailored” messages and individually adapted feedback about physical activity are more interacting and have higher effectiveness.,
Users search and receive tailored education are more interesting and using information against people who get regular information because it is personally relevant. Computer-based education can engage a large number of people in the training without expensive waste.
Therefore, we decided to apply one of the most widely used health education models in the field of physical activity that offers training based on how people are placed in different stages of behavior change with various processes. Various studies conducted on the basis of the transtheoretical model (TTM) on physical activity have shown the effectiveness of the mentioned model on behavior change.,,,,,
Studies applying the TTM as the theoretical framework for hanging behavior have been criticized in that interventions have focused only on stages of change, while they neglected other components including decisional balance, processes of change, and self-efficacy.
Only few studies have applied TTM and education based on web for school students, and most of them have used traditional education and lectures. Therefore, the aim of the current study was to examine the effects of web-based intervention on the promotion of physical activity among adolescents by applying TTM.
| Methods and Materials|| |
Study design and participants
This quasi-experimental study was conducted in 2018 at Isfahan University of Medical Sciences, Iran. The study participants were 278 high school students, who were randomly assigned to one of the three groups: intervention group 1 (n = 94), intervention group 2 (n = 97), and control (n = 87).
Intervention group 1 received education through web (www.salamat.family), in this web for participants in every stage, health educators had placed tailored education as shown in [Table 1].
|Table 1: Stages of change and tailored education in every stage of precontemplation, contemplation, preparation, action, and maintenance|
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For participants in precontemplation and contemplation, we used pyramid physical activity with four levels, and described appropriate physical activity in every level using pictures.
Participants in preparation stage received 24-h table of activities and goal setting, as well as commitment to physical activity.
In the action and maintenance stage, we placed types of physical activity, i.e., warm-up exercises, endurance sports, flexibility exercises, balance exercises, strengthening exercises, and isometric exercises with pictures. Moreover, we uploaded the printable pamphlet containing all of contents to the website. Considering the importance of walking, the correct walking method with pictures and how to measure the maximum heart rate and tensile strength before and after running were placed on the website.
For relaxation education, three relaxation techniques such as deep breathing, muscle relaxation, and visualization meditation were uploaded on the website.
Temptation control is a technique for avoiding negative stimuli, and exposing positive stimuli as well as sending daily exercise reminder SMS from project team to participants and planning for mass sports and family and friends sports.
The intervention group 2 received education by the same website, but they had access to untailored education, i.e., only public information about physical activity. In this group, we presented the amount and types of physical activity for children and adolescents, physical activity pyramid, good sleep pattern, strategies for increasing physical activity in children and adolescents, some important points of physical activity on academic achievement and two clips related to aerobic raining and exercise at home.
The control group did not receive the abovementioned education during intervention times, but after the intervention period, both the intervention groups became familiar with the web site in one session.
The following questionnaires were applied two times, before the intervention and 6 months after intervention in the intervention and control groups.
First Q.: Stage of exercise behavior change questionnaire. It is a 5-item questionnaire developed by Marcus et al. Students were asked to select which items best described their level of PA. Finally, according to their selection, they would be placed in 5 stages (precontemplation, contemplation, preparation, action, and maintenance). The validity and reliability of the questionnaire have been confirmed in Iran. After placing people in different stages, they receive education based on change processes, decision-making, and self-efficacy, that are very effective in changing their individual behavior.
Second Q.: Processes of change questionnaire includes 40 items about cognitive and behavioral strategies and uses a five-point scale (never, rarely, sometimes, often, and always).
Third Q.: Decision-making balance questionnaire has 43 items asked by four-scaled criteria. His scale ranged from “I quite disagree” to “I totally agree.” This questionnaire show pros (perceived benefit) and cons (perceived barrier) about PA in participants.
Fourth Q.: Exercise self-efficacy sale and it consists of 16 items with 4 scales (ranging from “not quite sure” to “I”m quite sure”).
Fifth Q.: International Physical Activity Questionnaire short form. Each person selects items that show level of PA in a week (severe, moderate, and walking).
Continuous variables were expressed as means ± standard error (SE), and categorical data were presented as number (percentage). The normality of data was assessed graphically and Kolmogorov–Smirnov. Comparisons between means of TTM constructs in participants who moved in a progressive pattern from precontemplation, contemplation or preparation at baseline to action or maintenance after intervention (group 1) and people who remained in precontemplation, contemplation, or preparation before and after intervention were performed using independent Student's t-test. The Pearson correlation coefficients were used to determine associations between scores of TTM constructs. Two-way analysis of variance (ANOVA) was used to examine the interaction effect of interventional groups and TTM stages on TTM constructs. The multivariate ANOVA (MANOVA) was performed to assess interaction effect of interventional groups and TTM stages on each three TTM constructs. McNemar's test was applied to compare the physical activity status before and after the intervention. P < 0.05 was considered statistically significant, as shown in [Flow Diagram 1].
Data were collected anonymously, and confidentiality of the students' information was secured. Participants were informed that they could withdrawal from the study any time. Written informed consent was obtained from parents who agreed to participate before pretest and data collection.
| Results|| |
[Figure 1] shows comparison of participants' self-reported stage of change before and after intervention. After intervention, the majority of participants were in groups of action or maintenance. The scores of TTM constructs at baseline are shown in [Table 2]. The correlation coefficients between the scores of TTM constructs are shown in [Table 3]. All coefficients were significant and scores of self-efficacy and processes of changes showed the highest correlation.
|Figure 1: Comparison of participants' self-reported stage of change at before and after intervention|
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|Table 3: Correlation between transtheoretical model constructs scores at baseline|
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[Table 4] shows mean ± SE for difference of scores before and after intervention for processes of changes, self-efficacy, and decisional balance in exercise behavior for participants who moved in a progressive pattern from precontemplation, contemplation, or preparation at baseline to action or maintenance after intervention (group 1) and people who remained in precontemplation, contemplation or preparation before and after the intervention (group 2). Mean differences for decisional balance, and self-efficacy in intervention group 1 were higher than those group intervention 2. These differences were significant for decisional balance in both intervention groups 1 and 2. The mean differences for TTM constructs related to exercise behaviors (processes of change, self-efficacy, and decisional balance) in intervention groups 1 and 2 were significantly higher than those in controls. The results of two-way ANOVA showed that interaction effect between these two factors was not significant for each three TTM constructs P > 0.05. Furthermore, it indicated the significant main effect of the interventional group on each three TTM constructs with F (2230) = 31.51, F (2229) = 52.31, and F (2235) =11.79 for self-efficacy, processes of change, and decisional balance, respectively; the P values were statistically significant for each three (P < 0.001). The main effect for stage group was significant for processes of change and decisional balance with F (1229) = 6.50; P = 0.011 and F (1235) = 15.29; P < 0.001, respectively. The Tukey post hoc multiple comparisons of means for decisional balance changes and self-efficacy changes revealed significant differences in mean between intervention groups 1 and 2 and the control group, but not between intervention group 1 and intervention group 2. Moreover, there were statistically significant differences in mean between the intervention group 1 and intervention group 2, as well as intervention groups 1 and 2 and the control group. The interaction between interventional group and stage group on TTM constructs was not significant based on MANOVA test (Wilk's λ = 0.994, F (6448) =0.23, P = 0.966). However, the main effects of interventional group and stage groups on TTM constructs were significant with Wilk's λ = 0.633, P < 0.001 and 0.938; P = 0.002, respectively. [Table 4] shows the distribution frequency (%) physical activity before and after intervention. Based on McNemar's test, distribution frequency of physical activity before and after intervention was significantly different (P < 0.05), participants in intervention groups 1 and 2 who had low or moderate physical activity before intervention, were placed in high physical activity after it [Table 5].
|Table 4: Comparison of mean differences between before and after in groups of stage change and interventional|
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|Table 5: Distribution frequency (%) physical activity before and after intervention|
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| Discussion|| |
The primary aim of the current study was to determine the effectiveness of a web-based intervention on the promotion of physical activity in Iranian youth by applying TTM.
Regarding the postintervention, participants showed significant progress during stages of change and changes were greater in the group who was trained by TTM. A large number of people after intervention were placed in three stages (preparation, action, and maintenance). Changes in the process of moving towards higher change stages have been seen in other studies that have been carried out using the TTM.,
The percentage of students with low, moderate, and severe levels of physical activity in the two intervention groups has increased significantly after the intervention. This indicates the impact of Web education on the physical activity of adolescents. With respect to the intervention group findings, similar increases in total physical activity have been found in previous web-based studies., For example, in the study of Asghari et al., all the three severe, moderate, and low physical activity categories have increased in the intervention group at the time of intervention. Furthermore, Hargreaves et al.'s study showed improvements in step counts and physical and psychological health after 12 weeks in intervention groups by a web-based intervention to encourage walking.
In education based on model, in the intervention group that received tailored education, there were significant changes in the two decision-making balance and self-efficacy structures, while in those who received only general education, only the decision-making structures focusing on increasing pros and reduction of cons have changed significantly.
Decision-making balance is an important aspect, and the balance between the pros and cons could make the individuals to have physical activities. The reason for changing this structure in the group that received the general education was that it provided some of the lessons on the advantages of physical activity and the disadvantages of not do it. Regarding the role of decision-making balance in the adoption of physical activity behavior in other studies,, it is also recommended that special attention be paid to this structure in related education.
In our study, to improve self-efficacy, we used goal-setting strategies and planning for doing exercise, breaking PA in smaller steps and using verbal and nonverbal enhancement to achieve the goals. These strategies may have resulted in successfully increasing self-efficacy in students. This is in agreement with other studies.,,,
The present study has the unique combination of intervention methods including TTM which was linked to the web site and tailored messages.
The intervention group received a web-based intervention equipped with tailored message for people in every stage that is similar to Kim and Kang study that applied interactive features, personalized goal setting, activity planning, and personalized information.
| Conclusion|| |
According to the obtained results, education on PA based on website can be effective, but if we use education based on the TTM by applying some constructs such as self-efficacy, it will be more useful on the behavior. The limitations of this study included the fact that it was not possible to control all factors affecting the PA among students, especially economic, cultural, and familial factors. We also needed more time to measure the sustainability of physical activity. Therefore, the evaluation of PA level after 6 months may have undermined the intervention effects in terms of changes in PA behavior over the 6-month period.
The authors would like to thank the students who participated in this study.
Financial support and sponsorship
The study was approved by Isfahan University of Medical Sciences, IRAN (The Research and Ethics code: 194234).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kelishadi R, Heshmat R, Motlagh ME, Majdzadeh R, Keramatian K, Qorbani M, et al
. Methodology and Early Findings of the Third Survey of CASPIAN Study: A National School-based Surveillance of Students' High Risk Behaviors. Int J Prev Med 2012;3:394-401.
Kokkinos P, Myers J. Exercise and physical activity: Clinical outcomes and applications. Circulation 2010;122:1637-48.
Pereira S, Pereira D. Metabolic syndrome and physical activity. Acta Med Port 2011;24:785-90.
Agha-Alinejad H, Farzad B, Salari M, Kamjoo S, Harbaugh BL, Peeri M. Prevalence of overweight and obesity among Iranian preschoolers: Interrelationship with physical fitness. J Res Med Sci 2015;20:334-41.
] [Full text]
Jafari-Adli S, Jouyandeh Z, Qorbani M, Soroush A, Larijani B, Hasani-Ranjbar S. Prevalence of obesity and overweight in adults and children in Iran; a systematic review. J Diabetes Metab Disord 2014;13:121.
Mark AE, Janssen I. Influence of movement intensity and physical activity on adiposity in youth. J Phys Act Health 2011;8:164-73.
Collings PJ, Wijndaele K, Corder K, Westgate K, Ridgway CL, Dunn V, et al
. Levels and patterns of objectively-measured physical activity volume and intensity distribution in UK adolescents: The ROOTS study. Int J Behav Nutr Phys Act 2014;11:23.
Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, et al
. Global physical activity levels: Surveillance progress, pitfalls, and prospects. Lancet 2012;380:247-57.
Friederichs SA, Bolman C, Oenema A, Verboon P, Lechner L. Exploring the working mechanisms of a web-based physical activity intervention, based on self-determination theory and motivational interviewing. Internet Interv 2016;3:8-17.
Vandelanotte C, Short C, Plotnikoff RC, Hooker C, Canoy D, Rebar A, et al
. TaylorActive—Examining the effectiveness of web-based personally-tailored videos to increase physical activity: A randomised controlled trial protocol. BMC Public Health 2015;15:1020.
Hurling R, Catt M, Boni MD, Fairley BW, Hurst T, Murray P, et al
. Using internet and mobile phone technology to deliver an automated physical activity program: Randomized controlled trial. J Med Internet Res 2007;9:e7.
Davies CA, Spence JC, Vandelanotte C, Caperchione CM, Mummery WK. Meta-analysis of internet-delivered interventions to increase physical activity levels. Int J Behav Nutr Phys Act 2012;9:52.
Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12:e4.
Vandelanotte C, De Bourdeaudhuij I, Sallis JF, Spittaels H, Brug J. Efficacy of sequential or simultaneous interactive computer-tailored interventions for increasing physical activity and decreasing fat intake. Ann Behav Med 2005;29:138-46.
Krebs P, Prochaska JO, Rossi JS. Defining what works in tailoring: A meta-analysis of computer tailored interventions for health behaviour change. Prev Med 2011;51:214-21.
Taymoori P, Niknami S, Berry T, Lubans D, Ghofranipour F, Kazemnejad A. A school-based randomized controlled trial to improve physical activity among Iranian high school girls. Int J Behav Nutr Phys Act 2008;5:18.
Han H, Pettee Gabriel K, Kohl HW 3rd
. Application of the transtheoretical model to sedentary behaviors and its association with physical activity status. PLoS One 2017;12:e0176330.
Shaver ER, McGlumphy KC, Gill AK, Hasson RE. Application of the transtheoretical model to physical activity and exercise behaviors in African-American adolescents. Am J Health Behav 2019;43:119-32.
Ham OK, Sung KM, Lee BG, Choi HW, Im EO. Transtheoretical model based exercise counseling combined with music skipping rope exercise on childhood obesity. Asian Nurs Res (Korean Soc Nurs Sci) 2016;10:116-22.
Romain AJ, Bortolon C, Gourlan M, Carayol M, Decker E, Lareyre O, et al
. Matched or nonmatched interventions based on the transtheoretical model to promote physical activity. A meta-analysis of randomized controlled trials. J Sport Health Sci 2018;7:50-7.
Pirzadeh A, Mostafavi F, Ghofranipour F, Feizi A. Applying transtheoretical model to promote physical activities among women. Iran J Psychiatry Behav Sci 2015;9:e1580.
Hutchison AJ, Breckon JD, Johnston LH. Physical activity behavior change interventions based on the transtheoretical model: A systematic review. Health Educ Behav 2009;36:829-45.
Marcus BH, Rakowski W, Rossi JS. Assessing motivational readiness and decision making for exercise. Health Psychol 1992;11:257-61.
Roozbahani N, Ghofranipour F, Ardabili EH, Hajizadeh E. Factors influencing physical activity among postpartum Iranian women. Health Edu J 2014;73:466-76.
Biddle SJ, Nigg CR. Theories of exercise behavior. Int J Sport Psychol. 2000;312:290-304.
Sechrist KR, Walker SN, Pender NJ. Development and psychometric evaluation of the exercise benefits/barriers scale. Res Nurs Health 1987;10:357-65.
Nigg CR. The transtheoretical model: Research review of exercise behavior and older adults. Promoting Exercise and Behavior Change in Older Adults: Interventions with the Transtheoretical Model. New York: Springer; 2002. p. 147-80.
International Physical Activity Questionnaire Research Committee. Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ) – Short and Long Form Scoring; 2005. Available from: https://sites.google.com/site/theipaq/scoring-protocol.
[Last accessed on 2018 May 25].
Zare F, Aghamolaei T, Zare M, Ghanbarnejad A. The Effect of Educational Intervention Based on the Transtheoretical Model on Stages of Change of Physical Activity in a Sample of Employees in Iran. Health Scope 2016;5:e24345.
Vandelanotte C, Spathonis KM, Eakin EG, Owen N. Website-delivered physical activity interventions a review of the literature. Am J Prev Med 2007;33:54-64.
Kim CJ, Kang DH. Utility of a Web-based intervention for individuals with type 2 diabetes: The impact on physical activity levels and glycemic control. Comput Inform Nurs 2006;24:337-45.
Asghari A, Aghdasi MT, Ahmadi M. Effects of Web-Based Physical Activity Interventions on Physical Activity and Well-being in Adolescents with Insufficient Physical Activity. Health Psychol 2018;6:53-68.
Hargreaves EA, Mutrie N, Fleming JD. A Web-Based Intervention to Encourage Walking (StepWise): Pilot Randomized Controlled Trial. JMIR Res Protoc 2016;5:e14.
Pate RR, Saunders RP, O'Neill JR, Dowda M. Overcoming barriers to physical activity: Helping youth be more active. ACSM's Health Fit J 2011;15:7-12.
Kelishadi R, Ghatrehsamani S, Hosseini M, Mirmoghtadaee P, Mansouri S, Poursafa P. Barriers to Physical Activity in a Population-based Sample of Children and Adolescents in Isfahan, Iran. Int J Prev Med 2010;1:131-7.
Bergh IH, Bjelland M, Grydeland M, Lien N, Andersen LF, Klepp KI, et al
. Mid-way and post-intervention effects on potential determinants of physical activity and sedentary behavior, results of the HEIA study-A multi-component school-based randomized trial. Int J Behav Nutr Phys Act 2012;9:63.
Plotnikoff RC, Costigan SA, Karunamuni N, Lubans DR. Social cognitive theories used to explain physical activity behavior in adolescents: A systematic review and meta-analysis. Prev Med 2013;56:245-53.
Ardestani M, Niknami S, Hidarnia A, Hajizadeh E. Predictors of Physical Activity among Adolescent Girl Students Based on the Social Cognitive Theory. J Res Health Sci 2015;15:223-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]