Learning to guide behavior change : physical therapists’ promotion of health-enhancing physical activity in people with rheumatoid arthritis

Background and Aim: Physical activity is important for management of rheumatoid arthritis (RA). In the Physical Activity in RA (PARA) 2010 study physical therapists (PTs) delivered a one-year health-enhancing physical activity (HEPA) intervention in people with RA. The PTs’ guided behavior change by structured use of behavior change techniques (BCTs) and adapted a biopsychosocial approach during biweekly support group sessions. Since this may not be mainstream practice for PTs it is important to increase the knowledge of what happens when PTs deliver such interventions. The main aim of this thesis was to explore PTs’ experiences and behavior delivering a HEPA intervention in people with RA. A secondary aim was to investigate the measurement properties of a scale to assess a mediating variable, exercise selfefficacy, for physical activity in RA. Participants and Methods: The PTs received a tailored education and training for a total of six days based on Social Cognitive Theory (SCT) principles, including exercises, positive reinforcement and modeling, targeting increased knowledge, skills and self-efficacy to guide behavior change. Twelve PTs enrolled in the PARA 2010 intervention participated in Study I, 10 of them in Study II and 11 in Study III. All were registered PTs and all but two had worked in rheumatology. In Study IV 244 intervention participants with RA from the PARA 2010 study were included in validity tests and 84 of them in test-retest measurements. Study I employed an exploratory qualitative design with semi-structured interviews investigating PTs’ experiences delivering the intervention. Study II was a longitudinal case study with questionnaires and logbooks measuring knowledge on physical activity and BCTs, fear-avoidance beliefs and self-efficacy to guide behavior change before and throughout the HEPA intervention. Study III was an explorative study where the PTs were video-recorded during the intervention to explore strategies in their guiding of HEPA behavior. Study IV was a methodological study investigating the reliability and validity of the Swedish Exercise self-efficacy scale (ESES-S). Results: The results from Study I-III were aggregated into a main theme; the PTs’ progression ‘From clinical expert to guide’, and four categories; 1) ‘Education, training and support’ where PTs expressed e.g. benefits of feedback on performance and the need for clear tasks and role, 2) ‘Challenges in the new role’ including e.g. insecurities on when to lead or to follow the group, initial stress and intervention participants not performing physical activity, 3) ‘Behaviors in the new role’ e.g. the majority of PTs did not totally adhere to the intervention protocol, and PTs altering between information giving and strategies facilitating group interaction to handle challenges, and 4) ‘Growing into the new role’ e.g. the PTs’ progression to guide through increased selfefficacy, relinquishing steering and control over the group and growing in confidence to promote HEPA behaviors. Study IV indicated partial support for construct validity, moderate test-retest reliability and respectable internal consistency of the ESES-S. Conclusions: The results indicate that PTs adaptation to a new role to guide behavior change takes time and effort and include challenges and growth, and may be assisted by education and training. The ESES-S has sufficient test-retest reliability, but further investigation on construct validity in an RA population is recommended.