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Journal of Nursing & Care
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The Effect of a TTM-Based Intervention on the Level of Physical Activity in ICU Nurses

Saghar Fatemi*

Health and Environment Research Center, Guilan University of Medical Science and Health Services, Guilan, Iran

*Corresponding Author:
Saghar Fatemi
Health and Environment Research Center
Guilan University of Medical Science and Health Services
Guilan, Iran
Tel: 981333238053
E-mail: saghar_10@hotmail.com

Received date: April 14, 2017; Accepted date: April 29, 2017; Published date: May 9, 2017

Citation: Fatemi S (2017) The Effect of a TTM-Based Intervention on the Level of Physical Activity in ICU Nurses. J Nurs Care 6:397. doi:10.4172/2167-1168.1000397

Copyright: © 2017 Fatemi S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

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Abstract

Background: Theory-oriented interventions play a key role in promoting people’s quality of life and preventing the risks of immobility. Given this key role and also the critical nature of nurses’ professional duties, the present study was conducted to determine the effect of a TTM (trans theoretical model)-based intervention on the level of physical activity in ICU nurses working at hospitals affiliated to Gilan University of Medical Sciences. Methods: Based on the study objectives, this randomized controlled trial first selected 82 nurses through the census method in order to determine their Stage of Change (SOC) and then assigned 68 nurses who were in the first three stages into a case group and a negative control group. Valid and reliable data collection tools were used, including a demographic questionnaire and the TTM constructs (SOC, GPAQ, SE, DB and POC). The path analysis of the data was performed inLisrel-8.80 and the inter-correlation matrix between the models constructs them and with the level of physical activity was determined in order to design and implement the intervention. A two-stage assessment was performed, once immediately after the intervention and again six months later. The data obtained were analyzed using appropriate statistical tests and Pearson’s correlation coefficient. Results: A total of 97.6% of the participants were female, 59.8% were married, 92.7% had bachelor’s degrees and 82.9% were in the first three stages of the TTM. Immediately after the intervention, 55.9% of the participants were in the preparation stage, 44.1% were in the pre-contemplation stage and 76.5% were in the contemplation stage. Before the intervention, however, only 26.5% of the participants were in preparation and 44.1% were in precontemplation. There was a statistically significant difference (P=0.0001) between the negative control and the case groups immediately and six months after the intervention. Conclusion: Performing the TTM-based intervention appears to have led to the subjects’ placement in higher levels in the five SOC.

Keywords

TTM; Physical activity; Nurses

Background

One of the most important problems of the modern world is the reduced level of physical activity. The modern sedentary lifestyle is the cause of many diseases and may be a warning sign for health service planners [1]. The negative outcomes of immobility and the consequent diseases have led to 1,240,000 deaths and 1,243,000 years of life lost in 2000 in the Eastern Mediterranean alone [2].

A national study conducted in Iran reported the prevalence of immobility as 76.3% in urban and 58.8% in rural areas in women and men aged 15-64 and reported the overall prevalence in the same age group as 67.5% [3].

Promoting lifestyles may necessitate people’s increased awareness about the risks and consequences of immobility, but awareness is not enough. Since traditional health training interventions are not very efficient, new theory-based interventions should be implemented within clear frameworks [4].

In addition to implementing health interventions for promoting quality of life, it is also essential to emphasize the implementation of training programs based on theory-oriented approaches and behavioral change models [5,6] The need to use the constructs of the Stage Of Change (SOC) was first introduced by Prochaska [1]. Based on the Trans Theoretical Model or TTM, people are at different stages of motivation and preparation for performing behaviors and can take advantage of training interventions no matter their stage of preparation.

The main constructs of the model include the SOC (precontemplation, contemplation, preparation, action and maintenance), the Process of Change or POC (cognitive and behavioral processes), Decisional Balance or DB and Self-Efficacy or SE [7]. To date, the TTM has been used to change certain behaviors in different groups of people, including quitting smoking, family-centered empowerment and promoting physical activity [1,4].

The physical activity level of nurses all over the world, especially ICU nurses who are mostly female, is very limited [8-10]. Since nurses are a role-model for patients as trainers of health behaviors, they should adhere to a lifestyle of adequate physical activity. The nurses’ performance of physical activity is a behavior that significantly affects the outcomes of the instructions they provide to their patients about performing physical activities as part of their therapeutic programs. The regular practice of physical activity not only keeps nurses healthy, but also promotes their communication with the patients and improves the quality of the health services they provide by improving their mental health [11]. This study was conducted to determine the effect of a TTM-based intervention on the level of physical activity in ICU nurses working at teaching hospitals affiliated to Guilan University of Medical Sciences.

Methods

This randomized, controlled, experimental trial was performed to examine the effect of a TTM-based intervention on the level of physical activity in ICU nurses working at teaching hospitals affiliated to Guilan University of Medical Sciences in 2014. The study population consisted of 82 ICU nurses with bachelor’s degrees and higher. The study subjects were selected through the census method and according to the inclusion criteria: willingness to participate in the study, having no orthopedic diseases and at least one year of work experience at the ICU. The study sample size was determined through the following steps:

The first step of the study was descriptive and cross-sectional and evaluated 82 ICU nurses in terms of their SOC, namely precontemplation, contemplation, preparation, action and maintenance.

In the second step, nurses who were in the stages of precontemplation, contemplation and preparation were randomly divided into a case and a control group (n=34 per group).

Data Collection Tools

Valid and reliable tools were used in this study, including

A) A demographic questionnaire consisting of items on age, gender, height, weight, marital status, level of education and type of housing;

B) The Stages of Exercise behavior Change Questionnaire (SECQS): In this questionnaire, the stages of change were examined on the basis of physical activity within five statements, “I do not plan on exercising regularly in the next six months/I plan on exercising regularly during the next six months/I plan on exercising regularly during the next 30 days/I have been exercising regularly for less than six months/I have been exercising regularly for more than six months”, which were given in response to the question of “Do you exercise regularly?” The participants were placed at one of the stages (i.e., pre-contemplation, contemplation, preparation, action and maintenance) based on their answers to the question [4,12-14]. The retest coefficient of this instrument was calculated as 0.92 in this study.

C) The Global Physical Activity Questionnaire (GPAQ): The GPAQ was introduced by the WHO to measure the amount of exercise performed based on the Metabolic Equivalent of Task (MET) scale using the following equation:

Weekly exercise score = (Frequency of light exercise per week × 0) + (Frequency of moderate exercise per week × 4) + (Frequency of intense exercise per week × 8)

The retest coefficient for this tool was calculated as 0.80 in this study. The questionnaire consists of 16 items on physical activity in the workplace, at leisure time, at home, during the commute and while sitting. The cut-off point for the tool was determined as1600 MET. The subject’s level of physical activity per week is extracted and reported in MET min/week based on the questionnaire’s scoring guideline for selfreports.

Necessary instructions about light, moderate and intense activity were given to the participants prior to completing the GPAQ [8,12,13,15-17].

D) The Process of Change Questionnaire (PCQ): The PCQ consists of 30 items and is scored based on a five-point Likert scale (1 point for choosing the ‘Never True’ option to 5 points for the ‘Always True’ option). Items 1 to 15 determine cognitive strategies and items 16-30 determine behavioral strategies. The Cronbach’s alpha reliability of the questionnaire was calculated as 0.91. In the 15 cognitive items, items 1-3 are concerned with consciousness raising, items 4-6 with dramatic relief, items 7-9 with environmental revaluation, items 10-12 with selfrevaluation and items 13-15 with social liberation. In the 15 behavioral items, items 16-18 are concerned with counter conditioning, items 19-21 with helping relationships, items 22-24 with reinforcement management, items 25-27 with self-liberation and items 28-30 with stimulus control. In this part, the participants choose an option that best describes their experience over the past month and the responses are scored based on the five-point Likert scale previously discussed [13].

E) The Self-Efficacy Scale (SE): The SE was introduced by Nigg and Riebe in 2002 [14]. The Cronbach’s alpha reliability of the questionnaire was calculated as 0.89.

F) The Decisional Balance Questionnaire (DBQ): Assuming that the respondents are in the stage of deciding about performing exercises or increasing its frequency/intensity, the weight or importance of their opinion is calculated based on their choice of one of the five given options (which are scored based on a five-point Likert scale from 1 point for ‘Not Important’ to 5 points for ‘Extremely Important’)for each item in the questionnaire (which consists of five items on the facilitators and five items on the barriers to the discussed behavior). The Cronbach’s alpha reliability of the questionnaire was calculated as 0.93 for the facilitators and as 0.75 for the barriers.

Validity and reliability assessment of the data collection tools

The validity of the data collection tools used in this study was determined through the content validity method and their reliability was calculated using Cronbach’s alpha and test-retest coefficients.

Data Collection

In the first phase of the study, which was descriptive and analytical, valid and reliable data collection tools designed based on the TTM constructs were distributed among 82 nurses. Participants’ SOC, POC, SE, DB and MET data were collected and analyzed in SPSS-16. The TTM constructs were evaluated and the data were analyzed through a path analysis, and a training content appropriate for the intervention was developed with an emphasis on the strongest predictors of the behavior in question. After classifying and summarizing the data and the SOC, 68 eligible participants who were at stages of precontemplation, contemplation and preparation were selected for the second phase of the study and were then divided into a case and control group of 34 each.

TTM-based intervention sessions were designed for the case group in the form of lectures and practical training along with the distribution of CDs based on the SOC and according to the path analysis results obtained and were held after arrangements were made with the training supervisors. The first phase of the intervention assessment was performed immediately after the intervention and the second phase was performed six months later based on the model constructs and in line with the objectives of the study. The final analysis and conclusion followed [4,18].

Data Analysis

The data were analyzed in accordance with variable type (i.e., qualitative or quantitative) using descriptive inferential statistics suitable for the data. Participants’ age, work experience and DB, SE, POC and MET values were taken as continuous quantitative variables, their gender, marital status and type of housing as nominal qualitative variables and their level of education and SOC as ordinal qualitative variables. Descriptive inferential statistics were used to analyze and calculate the constructs’ mean values and determine the matrix of correlation between the constructs themselves and with physical activity behavior. The level of physical activity, the frequency of the SOC and the scores of SE, DB and POC were analyzed using descriptive statistics (absolute and relative frequency and mean and standard deviation). The strongest constructs predicting the MET were determined using the statistic and modification indices contained in Lisrel 8.80. The strongest constructs predicting participants’ level of physical activity were thus determined alongside their level of physical activity. In the controlled trial part of the study, intergroup differences were determined in terms of changes in the dependent variables from the beginning of the intervention to the end; the changes were measured immediately after the intervention and then six months later using the independent t test and the ANOVA. The repeated measures ANOVA and Friedman’s test were used to examine changes in the case group at each phase of the study.

Results

A total of 97.6% of the participants were female, 59.8% were married, 92.7% had bachelor’s degrees, 7.3% had master’s degrees and 68.3% lived in apartments. The two groups were not significantly different in terms of their demographic variables. The mean and variance of the level of physical activity was 3592.20 ± 4926.780 in the participants and the distribution of the MET, SOC, POC, SE and DB variables was normal (P<0.05). According to the results, there was a significant relationship between the case (0.0001) and control (0.002) groups before, immediately after and six months after the intervention and also between the case and control groups immediately and six months after the intervention in terms of the SOC in exercise behavior. There was also a significant relationship between the case group and control groups (0.0001) before, immediately after and six months after the intervention and also between the case and control groups six months after the intervention in terms of the MET. The POC in exercise varied significantly (0.0001) in the case group before, immediately after and six months after the intervention, and the case and control groups differed significantly in terms of the POC in exercise before, immediately after and six months after the intervention. There was a significant relationship between SE and physical activity in the case group (0.0001) before, immediately after and six months after the intervention, and there was also a significant difference between the case and control groups in terms of the relationship between SE and physical activity before, immediately after and six months after the intervention. There was a significant relationship between the perceived benefits of physical activity in the case group (0.02) before, immediately after and six months after the intervention and there was a significant difference between the case and control groups in terms of the relationship between the perceived benefits of physical activity before, immediately after and six months after the intervention.

Discussion and Conclusion

Using the TTM for the prediction of the SOC in regular physical activity and the evaluation of its constructs before, immediately after and six months after the intervention is essential for describing physical activity with the aim of maintaining public health and promoting quality of life; it is worth noting that most highly-efficient training programs are based on theory-oriented approaches [5,6]. The results of the present study confirm this fact with the significant relationship obtained between the case (0.0001) and control (0.002) groups before, immediately after and six months after the intervention and also between the case and control groups immediately after and six months after the intervention in terms of the SOC in exercise behavior. This finding is consistent with the results obtained by Farmanbar on the effect of a TTM-based intervention on the SOC in exercise behavior in students of Gilan University of Medical Sciences [4] and the study by Johnson et al. on the effectiveness of a TTM-based intervention for weight control in Boston, US, and the resultant ascending trend from the stage of pre-contemplation to the action stage before and six months after the intervention and also the maintenance of behavior within 12 and 24 months [19]. Participants’ improvement from the stage of pre-contemplation to the stage of preparation in the present study therefore appears to be a reasonable change rooted in the TTM-based intervention performed.

The mean and variance of the MET was 2096.35 ± 2447.92 in the case group immediately after the intervention, which follows an upward trend compared to the level of physical activity in this group before the intervention (852.76 ± 1090.95) and also compared to the cut-off point presented in the instrument (1600). The results obtained by Ghahremani et al. on the implementation of training interventions for the promotion of the MET in old men [20] and those obtained by Shirazi et al. [21] and Farmanbar indicating a significant increase in the level of physical activity and participants’ progression in the SOC of physical activity after a SOC-based intervention [22] confirm the present findings.

The distribution of the participants across the five stages (precontemplation, contemplation, preparation, action and maintenance) also showed a significant change. Six months after the intervention, 91.2% of the participants were at the stage of action, 5.9% at the stage of maintenance and only 2.9% at the stage of preparation. The study conducted by Farmanbar also achieved similar results [22]. Lee conducted a study on Korean women and reported a significant change (P=0.000) from the stage of pre-contemplation to the stage of maintenance [23].

The mean and variance of the MET was 3172.58±2813.06 in the case group, which follows an upward trend compared to the mean and standard deviation of the level of physical activity before the intervention (852.76 ± 1090.95) and also compared to the mean and variance of the MET immediately after the intervention (2096.35 ± 2447.92), there by suggesting the effectiveness of the TTM-based intervention. In a similar study on a TTM-based intervention conducted in the US, Melissa et al. obtained similar results and revealed an increase in physical activity levels with this intervention [24].

In the case group, participants’ distribution in terms of the SOC in exercise behavior before the intervention was such that44.1% were at the stage of pre-contemplation, 29.4% at contemplation and 26.5% at preparation; immediately after the intervention, 2.9% were at the stage of pre-contemplation, 20.6% at contemplation and 55.9% at preparation, while 17.6% were at the stage of action and 2.9% at the stage of maintenance. Six months after the intervention, the distribution of participants across the SOC changed in such a way that 91.2% were at the stage of action, 5.9% at maintenance and only 2.9% at preparation (P=0.0001). In the control group, participants’ distribution in terms of the SOC was such that 23.5% were at the stage of pre-contemplation, 61.8% at contemplation and 14.5% at the stage of preparation and these figures changed to 8.8%, 82.4% and 5.9% immediately after the intervention; moreover, 2.9% of the participants were at the stage of action at this point in the study. Six months after the intervention, participants’ distribution had changed to 76.5% being at the contemplation stage, 14.7% at preparation and 5.9% at action (P=0.002). Based on the statistical tests performed immediately and six months after the intervention, a significant difference existed between the case and control groups (P=0.0001). In their study on the effectiveness of a TTM-based intervention in weight control in a case and control group within six, 12 and 24 months, Johnson et al. reported the SOC as 43%, 37.7% and 44.9% in the case group and as 34.6%, 35.9% and 38.1% in the control group from the action stage to the maintenance stage, suggesting a significant difference (P=0.05) [17]. According to the present researcher, the significant difference between the case and control groups on the three occasions arises from the implementation of an effective TTM-based intervention for ICU nurses.

The mean and variance of the MET was 852.76 ± 1090.95 in the case group and 634.94 ± 492.28 in the control group before the intervention, 2096.35 ± 2447.92 and 914.12 ± 1091.87 immediately after the intervention and 3172.58 ± 2813.06 and 1196.47 ± 1441.29 six months after the intervention. The two groups were significantly different in terms of these mean values before, immediately after and six months after the intervention (P=0.0001). Meanwhile, there was a significant difference between the case and control groups in terms of the MET six months after the intervention (P=0.02). In another study, Hazavei et al. observed a significant difference between their case and control groups in terms of the MET after the intervention [25]. The study by Opdenacker et al., however, showed inconsistent findings, which appears reasonable given that their training intervention was briefly provided in only one session and with some reminder notes [26] According to the present researcher, this study’s development of a training program based on the TTM, its multiplicity of training sessions and the use of a combination of lectures, practical exercises, films and instructional pamphlet for training have contributed to the positive results obtained. Similarly, Heesch found that the exercises performed and the scores obtained correlated in the TTM-based intervention performed for physical activity and lifestyle improvement [27].

In the present study, the mean score of the POC followed an upward trend in the case group before, immediately after and six months after the intervention and showed a significant difference with the control group (P=0.0001), as the trend of change was not significant in the control group. No significant differences were observed between the case and control groups before the intervention in terms of the mean score of the POC (cognitive-behavioral) in physical activity, while the two groups were significantly different in this regard immediately and six months after the intervention (p=0.0001). The upward trend of the mean score of the POC (cognitive-behavioral) in physical activity in the case group suggests the effectiveness of the training intervention performed on the participants, which is also consistent with the results obtained by Farmanbar and Dishman et al. on the role of the POC (cognitive-behavioral) in the maintenance and promotion of health in the society through physical activities (22 and28). The promotion and maintenance of physical activities therefore require a progression from cognitive POC to behavioral POC. According to the present researcher, people need regular programs of learning experience, self-reevaluation, environmental reevaluation and counter conditioning accessible through TTM-based interventions in order to promote their POC in physical activity.

The mean score of SE showed a significant difference before, immediately after and six months after the intervention in the case group (P=0.0001); however, no significant differences were observed in the control group. A significant difference was also observed between the case and control groups in terms of the mean score of SE before, immediately after and six months after the intervention (P=0.0001). These results are consistent with the results obtained by Farmanbar [22]. Moori et al. also reported a relationship between SE and people’s placement in higher levels of the SOC constructs in young and middleaged Japanese men [28]. In a similar study, Melissa emphasized the relationship between SE as an important factor for the maintenance of physical activity based on the changes in the mean score of SE (0.20) in the participants remaining at the maintenance stage of weight stabilization behavior and the mean score of SE (0.33) in the participants whose weight stabilization behavior had not yet reached the stage of maintenance even 12 months after the intervention [24]. According the present researcher, the SE construct is an important factor that connects consciousness to action and that can be considered a variable affecting health behaviors. Vahedian et al. also introduced SE as the most important factor involved in promoting the level of physical activity [29].

The mean score of DB showed a significant difference in the case group before, immediately after and six months after the intervention (P=0.02); however, no significant differences of this sort were observed in the control group. A significant difference was observed between the case and control groups in terms of the mean score of DB before (P=0.007) and immediately and six months after the intervention (P=0.0001). The TTM-based intervention therefore appears to have helped increase the mean score of DB. Dishman et al. also emphasized the effect of TTM-based interventions on the maintenance and promotion of physical activities and argued that this model is effective on the POC and DB as well [30] Vahedian et al. also showed a significant relationship (P=0.011) between the SOC, the level of physical activity, SE and DB [29].

Final Conclusion

TTM-based interventions help place people in higher levels of the five SOC.

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