Exercise Adherence among Adults with MR – Pre and Post assessment tools

Heller, T., PhD
Rimmer, J., PhD
Project title: 
Rehabilitation Research and Training Center on Aging with Developmental Disabilities
Project Number: 
Tool type: 
Needs Assessment
Tool class: 
Nonengineering tool
Disability targeted: 
Developmental Disabilities
Study target: 
Adults with mild to moderate mental retardation (MR).
Study purpose or goal: 
To test the efficacy of a physical exercise program for adults with MR and test the applicability of the transtheoretical model and social cognitive theory for predicting long-term adherence to enhanced levels of physical activity in this population.
Who administers this tool?: 
The psychosocial section can be completed with the parents. The physiological sections must be completed by a health professional.
Ease of use: 
Skills needed: 
The physiological sections must be completed by a health professional.
Equipment required: 
Sensitive issues: 
Yes: issues of diet, health, and wellness may be considered sensitive. Confidentiality is addressed through a consent form.
Are any approvals required?: 
Before any participant begins the exercise training, they complete a medical history questionnaire and a Clearance Form, developed by the American College of Sports Medicine.
How is it administered?: 
The psychosocial section can be completed by participants with a parent or assistant. This is done in a question/scale format. The physiological section must be completed by a health professional.
What is the scope or what areas does it cover?: 
The assessment collects information regarding the participants overall health and wellness; fatigue; pain; life satisfaction issues including work, homelife, and activities (adapted from an existing scale by Hawkins, Eklund, and Martz, 1997) ; community integration, social participation; choice making; support; and exercise. Confidentiality is addressed through a consent form. Issues of diet, health, and wellness may be considered sensitive.
Development background: 
Literature and database reviews included the National Medical Expenditure Survey, and literature review in fields of MR, cardiovascular health and training, exercise training, and health promotion.
Development methodology: 
The methodology and questions were selected following two major perspectives concerning how persons change health practices guide the present study: 1) the transtheoretical model of behavior change (Prochaska & DiClemente, 1983) and Bandura's social cognitive theory of social learning theory (Bandura, 1977; 1989). The transtheoretical model states that persons change their health behaviors by proceeding through a process of stages: precontemplation (no thought of changing), contemplation (aware of need to change), preparation (takes small steps), action (modifies behavior), and behavior maintenance (incorporates change into routine). The model allows us to understand when particular shifts in attitudes, intentions, and behaviors occur. Two studies have reported that pre-treatment stages of change according to this model are associated with movement to active participation in exercise activities (Barke & Nicholas, 1990; Marcus, Rakowski, & Rossi, 1992). This model includes the concept of decisional balance, which refers to one's evaluation of the personal gains and losses with changing behavior. Marcus and colleagues found that individuals are more likely to exercise if the perceived gains outweighed the perceived losses. However, no study has examined the applicability of this model to persons with MR. Bandura's social cognitive theory posits that behavior change is a function of setting goals based on outcome expectations associated with the behavior change, the tasks required to achieve those goals, and self-efficacy expectations for achieving the goals (Bandura, 1977; 1989). Thus, individuals are more likely to change their exercise behaviors if they believe that: a) their current lifestyles pose threats to personally valued goals; b) exercise behaviors will help reduce the threat (outcome expectations); and c) they are personally capable of adopting the new behaviors (self-efficacy expectations). This theory has been applied widely to the study of health behaviors. Self-efficacy has been shown to be a major predictor of adherence to preventive health programs (O'Leary, 1985), and to exercise involvement (McAuley, Lox, & Duncan, 1993). Bandura also emphasizes the informative and motivational role of reinforcement and observational learning through modeling the behavior of others. Hence, environmental cues, including support from others, play an important role. Berkman (1995) notes that interventions aimed at restructuring naturally occurring networks will be more effective than those that rely on short-term constructed support groups. A few exploratory studies suggest that social support is essential in promoting positive health behaviors for adults with MR (Fox, et al., 1985; Fujiura et al., 1997). The present study is designed to investigate the applicability of both the transtheoretical model in delineating stages of behavioral change and the social cognitive model in explaining the factors predicting long-term adherence to an exercise program among adults with a life-long cognitive disability, such as adults with MR.
Outside consultation: 
Consultations were made with the National Center on Physical Activity and Disability (NCPAD) and the Royal Centre on Health Promotion for Adults with Disabilities in the UK.
Consumer input: 
Input from consumers and physicians was included in the development.
Has sensitivity and specificity been tested?: 
These instruments have been found to be reliable and should be useful to others interested in studying exercise adherence in this population.
Can this tool be used for other purposes/populations?: 
Sample type: 
Adults with Down syndrome
Data analysis: 
Is complete
Researchers developed and pilot-tested a health behavior education curriculum, Exercise and Nutrition Health Education Curriculum for Adults with Developmental Disabilities (Heller, Marks, & Ailey, 2001) that is based on their social-cognitive model of health behavior change. The Exercise and Nutrition Health Education Curriculum is being used by Special Olympics to develop their health education program. The project has developed new instruments to assess social-cognitive aspects of exercise adherence for adults with cognitive impairments. These instruments have been found to be reliable and should be useful to others interested in studying exercise adherence in this population. There are no other instruments available to assess these constructs. In pre-post-test analyses of the 34 with Down syndrome in the intervention and 18 with Down syndrome in the control group, we found participants in the intervention had significantly improved cardiovascular function, strength, and endurance as compared to participants in the control group. Participants in the intervention groups also lost more weight and were more likely to decrease their level of triglycerides and reported less pain in daily activities. In regard to psychosocial measure the participants in the intervention groups reported increases in confidence to perform exercise, positive attitude to exercise, and life satisfaction, and less barriers to exercise.
Impact of these findings on the field: 
These data suggest that adults with Down syndrome can understand health behavior education and benefit from an exercise and health education program.
Peer review status: 
The survey and resulting data have been published under peer review. Heller, T., Hsieh, K., Rimmer, J. (2002) Barriers and supports for exercise participation among adults with Down Syndrome. _Journal of Gerontological Social Work, 38_(1/2), 161-178.Marks, B. A., Heller, T. (2003) Bridging the equity gap: Health promotion for adults with intellectual and developmental disabilities. _The Nursing Clinics of North America, 38_, 205-228.
Who uses the collected data?: 
Health professionals, independent living counselors.
Is this tool available free of charge?: 
Tool file: 
Tool contact: 
Alan Factor, Associate Director
800/996-8845 (V), 312/413-1510 (V), 312/413-0453 (TTY).
Alan Factor