Effects of the stages of change model-based education and motivational interview on exercise behavior in diabetic women

Effects of the stages of change model-based education and motivational interview on exercise... Abstract In this study, we examined the effects of exercise education and a motivational interview program, based on the stages of change model (SCM), on stage of change, using cognitive and behavioral methods, perceived benefits and barriers and self-confidence in Turkish women with diabetes. This intervention study was carried out in 2015 on 55 women selected from a family health centers’ population. An exercise guide was prepared based on the SCM for the intervention group. The intervention group was followed seven times at 1-month intervals via home visits, and exercise education and the motivational interview program were conducted to identify changes in behavior. The control group received no intervention. Data were collected from both groups using a personal description form, Exercise Stages of Change Scale, Exercise Processes of Change Scale, Exercise Decisional Balance Scale, and Exercise Self-Efficacy Scale. After the exercise program, each group was re-subjected to the same scales. We used a chi-square test and independent and paired sample t-tests to analyze the data. The stages of change, using cognitive and behavioral methods, perceived benefits and self-confidence for exercise in the intervention group significantly improved compared with that in the control group (p < .05). In the intervention group, 81.5% of the participants started exercising. The exercise education and motivational interview program based on SCM positively affected stages of change, using cognitive and behavioral methods, perceived benefits, perceived barriers, and self-confidence for exercise behavior in women with diabetes. We conclude that the education and motivational interview program based on SCM are effective in promoting exercise habit. Implications Practice: Public health practitioners should consider incorporating education and motivational interview programs for exercise into routine practice. Policy: Policymakers should implement policies to support the more widespread use of education and motivational interview programs. Research: Research has demonstrated the benefits of education and motivational interview programs in improving exercise in women with diabetes. INTRODUCTION Diabetes mellitus (DM) is a complex chronic illness that, beyond requiring glycemic control, demands ongoing medical care, including multi-factored risk reduction strategies [1]. The International Diabetes Federation (IDF) has estimated that the number of diabetics globally could increase from 422 million in 2014 to 592 million in 2035. The global prevalence of diabetes in adults over the age of 18 years is 8.5% [2, 3]. The World Health Organization (WHO) announced in its 2016 Global report on diabetes that the increase in diabetes is connected with rising obesity rates; moreover, the disease has instigated the death of 1.5 million people. The report also highlighted diabetes’ direct relationship with heart attacks, paralysis, blindness, kidney failure, and lower extremity amputations [3]. The incidence of DM has been rapidly increasing in Turkey [4]. The Diabetic Epidemiology Study, conducted between 1988 and 2011, revealed a 90% growth in the incidence of diabetes. The prevalence of diabetes among Turkish adults is 14.8% [4], and according to the IDF report, Turkey is the country with the highest prevalence of diabetes in the European Region [2]. It has been reported that the risk of diabetes can be reduced or delayed by 44–58% through simple, healthy lifestyle changes [4]. The key to prevent diabetes is the development of a lifestyle that incorporates healthy eating and regular physical activity [2–4]. Physical inactivity represents the primary cause of obesity, diabetes, and hypertension [5]. Previous research indicates that globally, 6% of deaths, 30% of ischemic heart disease, 21–25% of breast and colon cancer, and 27% of diabetes are caused by inactivity [3]. Exercise is crucial to preventing or controlling the health complications associated with diabetes, including insulin resistance and gestational diabetes. It is essential that exercise programs be custom-made to meet the needs of the individual. They should also be planned and carried out regularly for a sufficient period of time and at adequate intervals [1, 4]. It is recommended that individuals with diabetes exercise for 150 min per week, or for 30 min three times a week, at a medium level of exertion [2]. Exercising at appropriate intervals for a sufficient period of time increases cardiovascular capacity and keeps obesity under control. It also lowers HgA1c values and increases insulin sensitivity [1–4]. Exercise is critical to control diabetes due to its role in improving glycemic regulation; preventing hyperglycemia, hypertension, and dyslipidemia; and reducing anxiety [2, 4]. Despite the potential health benefits, individuals with diabetes in many countries exercise little [1, 2, 4]. The majority of the Turkish population with diabetes are not active enough [4]. Moreover, in the region where the research was conducted, a study conducted with women aged upwards of 20 found that the prevalence of metabolic syndrome and diabetes was high. At the same time, the women’s physical activity levels were considered low [6]. Therefore, women with diabetes need encouragement and should be made aware of the effects of exercise. Research should focus on ways to enhance exercise behavior in women with diabetes. Health care professionals have a major responsibility to ensure that exercise becomes a central component of a healthy lifestyle. They have a duty to help reduce individuals’ risky behaviors and to instead encourage healthy behaviors, with the aim of improving the general health of society [7]. They should commit themselves to enabling individuals to become aware of their own resources and to find a form of exercise that is personally suitable [7, 8]. Health care professionals are interested in finding an effective way to encourage diabetics to adopt exercise behavior [8]. Research studies indicate that exercise intervention and motivational interviews using the stages of change model (SCM) increase exercise behavior among inactive individuals with diabetes [8, 9]. Developed by Prochaska and Diclemente in 1982, the SCM states that behavioral change consists of five stages: precontemplation, contemplation, preparation, action, and maintenance [10]. Precontemplation is the stage in which healthy behavior is not performed or thought about. In this stage, individuals are barely aware of their problems or totally unaware and unwilling to solve them. In the contemplation stage, healthy behavior is not performed but planned to be performed in 6 months. This stage is where both the problem and change are evaluated with their advantages and disadvantages. Preparation is the stage in which the healthy behavior is planned to be performed in 3 months. Action is the first 6-month stage in which the healthy behavior is performed. Maintenance is a stage in which the healthy behavior is performed for more than 6 months [10, 11]. Determining the stage of change assesses perception of behavior and, therefore, may help to improve the effectiveness of intervention when the proposed intervention is tailored to suit the current stage rather than generic messaging. For a successful behavioral change, the individual’s stage should be determined and training and counseling provided, according to the present stage [10, 11]. Some intermediate concepts (e.g., process of change, self-confidence, and decisional balance) are often used in conjunction with the SCM. Process of change (method of change) identifies which processes or methods are used by the individual during the behavior change to change the unhealthy behavior. These methods involve two levels: cognitive and behavioral methods [10]. Cognitive methods contribute to overcoming the indecision about change and noticing the importance of change. Behavioral methods are operative strategies which help in behavior change. Studies have claimed that individuals in stages of change utilize both cognitive and behavior methods in behavior change [12, 13]. In the early stages of change, cognitive methods come into prominence, while behavioral methods stand out in the later stages [12, 14]. Self-confidence refers to a person’s belief in their ability to adopt an exercise routine consistently, even in difficult circumstances [10]. Studies conducted to find out the relationship between self-confidence and exercise have reported that during the stages of change, the level of self-confidence rises, and high self-confidence scores are effective in starting and maintaining the healthy behavior [12, 13]. In behavior change, self-confidence is expected to have a positive effect on the progress among the stages and be at different levels in every stage [14]. Decisional balance measures a person’s evaluation of the perceived benefits and perceived barriers relating to behavior change. Perceived benefits and barriers related to exercise are the positive and negative cognitive factors which could encourage or discourage exercise. Efforts to promote healthy behaviors need to identify barriers people face and continue to develop interventions that help eliminate these barriers [12, 13]. The effectiveness of the SCM in planning effective interviewing toward the promotion of exercise behavior has been investigated [9, 13]. Studies have shown that interviews, based on the SCM, that have been adjusted to the stage of change are faster and more effective than general interviews [13, 15]. The SCM is unique because it emphasizes the stages of change over specified time periods, while other models focus only on the behavior [13]. We used the SCM in this study to identify the educational needs of the women, according to the stages they are in, and to prepare them to progress to the next stage. We examined the effects of exercise education and a motivational interview program, based on the SCM, on stage of change, using cognitive and behavioral methods, perceived benefits and barriers and self-confidence in Turkish women with diabetes. The present study focused on examining the stages experienced by women with diabetes, conducted SCM-based motivational interviews to encourage exercise behavior, provided a model-based exercise guide and evaluated the efficacy of resultant behavioral change. The results of this study will expand available knowledge about the effects of SCM-based interventions and form the basis of and provide guidance for future research. The main aim of this study was to identify the impacts of exercise education and motivational interviews, based on the SCM, on exercise behavior in women with diabetes. METHODS Study design and sample selection We used a nonrandomized control group intervention study design. The study sample was drawn from a population of 252 women with diabetes recorded in three different family health centers in Ankara, Turkey. To achieve a power of 90% with a margin of error of 0.05, the target sample size was determined to be 50 (25 per group) individuals using sample size software and power analysis. To account for potential participant drop-out during follow-up, a total of 56 (28 per group) individuals were included in the study sample. In the fifth month of the study, one woman in the intervention group dropped out of the study due to pregnancy; thus, 55 women completed the study. Preliminary interviews were conducted to assess whether the women who came to the family health center for any reason met the criteria for inclusion in the study. Women with diabetes who met the criteria were invited to participate and were informed of the study’s structure and their desired involvement. The inclusion criteria were: being literate, 18–49 years old, diagnosed with diabetes, noninsulin dependent and, not having any health problems preventing exercise. In total, 56 women volunteered to participate in the study and made up the sample group. After joining the study, these women were placed into intervention and control groups based on stages of change. Instruments A personal description form This form includes sociodemographic properties (age, education, marital status, and employment status), diabetes history (smoking, regular use of antidiabetic drugs and receiving education about diabetes) and the average duration of daily exercise. Exercise Stages of Change Scale (ESCS) This scale was developed by Prochaska and Diclemente in 1982 to evaluate the behavior of smoking cessation. It was adapted by Marcus et al. [14] to evaluate exercising behavior, and the test reliability was reported to be 0.78. Test–retest reliability coefficients of stages of change for exercise were 0.53 in a study by Donovan et al. [16]. Gümüş and Kitiş [17] found the test reliability to be 0.79. The ESCS is composed of one question. The scale describes five stages of change an individual goes through in adopting exercising behavior: precontemplation, contemplation, preparation, action, and maintenance [14]. Exercise Processes of Change Scale (EPCS) This scale was developed by Marcus et al. [18], and the test reliability was reported to be 0.83. It was adapted to Turkish culture by Gümüş and Kitiş, and the test reliability was found to be 0.97 [17]. The EPCS consists of two basic methods (cognitive and behavioral). The EPCS is a five-point Likert scale and is composed of 40 questions. The lowest and the highest scores for both cognitive and behavioral methods are 20 and 100, respectively. High scores indicate an increased chance of a successful change [18]. Exercise Decisional Balance Scale (EDBS) This scale was developed by Marcus et al. [14], and the test reliability was found to be 0.95 for its perceived benefits subscale and 0.79 for its perceived barriers subscale. It was adapted to Turkish culture by Gümüş and Kitiş, and its test reliability was found to be 0.90 [17]. The scale describes positive and negative aspects of behavioral change through two subdimensions [18]. Perceived benefits measure positive thoughts about exercise. Perceived barriers measure negative thoughts about exercise. The scale is a five-point Likert scale comprising 16 items. The lowest and the highest scores for perceived benefits are 10 and 50, respectively. The lowest and the highest scores for perceived barriers are 6 and 30, respectively. High scores show an individual’s awareness regarding the benefits and risks of exercise behavior and an increased chance of decisional balance regarding the change [18]. Exercise Self-Efficacy Scale (ESES) The ESES was developed by Marcus et al. [19], and the test reliability was reported to be 0.76. Test–retest reliability for the self-efficacy scale over a 2-week period was 0.90. The scale was adapted for Turkish culture by Gümüş and Kitiş, and the adaptation’s reliability was found to be 0.85 [17]. The ESES is a five-point Likert scale and is composed of five questions. The lowest and the highest possible scores are 5 and 25, respectively. High scores indicate that an individual is confident and has a high chance of success for change [19]. Exercise guide The guide was prepared for the participants in light of the relevant literature, and it was based on the SCM, stage of change in exercise behavior and principles of motivational interviews [2, 4, 5, 20]. The guide offered strategies to individuals experiencing the five different stages of exercise behavior. Intervention group interviews Interviews and exercise education were carried out by only one researcher. The first interview of the intervention and control groups was conducted at the family health center. Participants were informed about the aim, confidentiality, duration, methodology, and requirements of the study and researcher’s expectations. After giving their informed consent, participants were given data collection forms. Filling out the forms took only 30 min. Subsequent interviews were conducted in the participants’ homes. Inclusive of the first and final interviews, a total of seven interviews within intervals of 30 ± 3 days were conducted with the intervention group. Stages of change were identified in each visit (approximately 2 min), and education and a motivational interview were provided, according to the participant’s current stage with the exercise guide based on the SCM. Exercise education and motivational interview sessions lasted for 45–60 min. Time and dates of the interviews were determined with the participants. Each data collection form was reconducted at the last visit. Training and interviews were conducted through computer and exercise guides. Training was not provided at the first or final interview. Exercise training based on SCM was given to the intervention group for which the stage of change was identified. When requested by a participant, simple, clear, brief training was provided, including lecturing, question-and-answer (Q&A) sessions, visual techniques, and case examples. Exercise education and motivational interviews were provided for the participants in accordance with their stage of change as follows. Precontemplation stage Following the general information which aims at raising awareness on exercise and diabetes (i.e., the definition, symptoms, signs and treatment of diabetes, importance of exercise in diabetes management, and types of moderate and vigorous exercise) a contradiction was tried to be created about exercise behavior of person. To do so, participants were asked about how they want to see themselves and where they want to be in the future. It is accepted that participants who prioritize health, peace, happiness, success, and a positive sense of self-started to have contradictions. At this stage, it is common that those who are not aware of the advantages of exercise on health or who do not intend to change their behavior or who avoid exercise due to previous negative experiences. Contemplation stage Interviews were carried out to form a social support team (consisting of mother, father, brothers or sisters, children, spouse, neighbors, etc.) who could motivate the participants of this stage to do exercise. Features of people to be included in the team were discussed in terms of the needs of the participant (e.g., listening to the participant, having time and conditions to exercise together, giving reminders to exercise, accompanying them in exercise, etc.). In addition, it was emphasized that the participant at this stage should use provided social supports in their exercise program. Playfields in the neighborhood, public spot ads, and related campaigns, as well as free exercise facilities (trekking and jogging paths, bicycle trails), were also discussed. Preparation stage Interviews for guiding the preparation of an exercise plan were done with the participants in the preparation stage to determine the duration and type of exercise, define necessary environmental arrangements and affirm their commitment to the program. Within that period, we tried to emphasize the benefits of exercise and support participant’s determination. The individual’s potential barriers and knowing how to overcome them are also important issues. Nurses should bring solution suggestions and teach how to use social support systems. Individuals at the preparation and following stages were provided with towels, water bowls, and pedometers. The researcher guided participants in proper footwear selection and foot care. Action stage As the novelty wears off, participants’ determination may wane, causing them to return to old behaviors. We discussed focusing on successful experiences with participants to keep them motivated. We suggested ways to make exercise lively and engaging, including exercising to different music; cycling, instead of trekking; exercising with supporters, instead of alone; choosing from random favorite exercises collected in a box. Suggestions were provided on preventing negativity that can occur during exercise (wearing comfortable and suitable clothes for exercise, applying sun protection cream, using sun protective clothing, avoiding going out in direct sunlight, coordinating exercise and meal times, etc.). Moreover, they were advised on drinking plenty of water before and after exercise, preferring indoor exercise in too hot, too cold or moist days, and stopping exercise and getting medical help in cases of dizziness, shortness of breath, and pain in the chest. Maintenance stage Supporting the achievement is the main aim of the training in individuals at maintenance stage. It is known that even those who maintain an exercise routine may turn back to unhealthy behavior. Thus, the participants were encouraged not to give up in case of unexpected situations, and the importance of making a plan for those situations in advance was mentioned. They were supported in finding solutions for the situations by identifying frequently experienced situations (e.g., going on holiday, ineffective time management, having visitors, etc.). Suggestions were agreed on, such as asking for help from the support team, remembering the reasons to start exercise, changing the environment that prevents them from exercising, doing short exercises instead of long exercises and changing the time of exercise. At the end of each interview, the process was summarized with the participant, and the next meeting was planned. Participants who progressed onto the upper stage were rewarded both verbally and with certificates of achievement throughout the interviews. Each scale was reconducted at the last interview, and participants were informed that the study was complete. Control group interviews Parallel to the first interview of intervention group, first interview of the control group was conducted at the family health center. Participants were informed about the aim, confidentiality, duration, methodology, and acquirements of the study and researcher’s expectations. Participants’ questions were answered, and their informed consent was obtained. Then, they were given data collection forms. Without giving training in exercise, they were informed that the following meeting would take place around 6 months later and the interview was ended. Parallel to the last interview of the intervention group, the last interview of the control group was carried out by visiting them in their houses. The last interview was held with the aim of collecting the final data from the control group. Each scale was reassessment at the last interview, and participants were informed that the study was completed. Given that it would have been unethical not to provide education, training was offered to women in the control group. To facilitate participants’ transportation from different family health centers, a group training center was established at a meeting hall belonging to a centrally located municipality. The women were called and invited to the meeting 3 or 4 days before the group interview. A second meeting was also held for those unable to attend. This ensured that all participants in the control group were able to receive education from the researcher overseeing the intervention group (Fig. 1). The content of the training was the same regardless of the group, comprising the benefits of exercise, preparing to exercise, awareness of environmental resources, and suggestions to enable a more straightforward alteration in behavior. Data analysis For data analysis, we used the Statistical Package Program for Social Sciences, and p values <.05 were considered significant. Our data showed normal distribution. Besides descriptive statistics, we performed an independent samples t-test to analyze the differences between the intervention and control groups in the cognitive methods, behavioral methods, perceived benefits, perceived barriers, and self-confidence scores. In addition, we conducted a paired samples t-test to determine differences among the first and last interview scores of the intervention and control groups. RESULTS Fifty-five women completed the study. One participant assigned to the intervention group was unable to complete the exercise program and was therefore excluded from the final analysis. Approximately half of the intervention group (48.2%) consisted of women aged 40–49 years. Of the 27 women in this group, 48.1% had graduated from either primary or secondary school. Most were married and working as housewives. Most (85.2%) of the women in this group were using anti-diabetic medication, and 25.9% had received education about diabetes. Half of the control group (50%) consisted of women aged 40–49 years. Of the 28 women in this group, 39.3% had graduated from either primary or secondary school. Again, most were married and were housewives. Most (78.6%) of the women in this group were using anti-diabetic medication, and 21.4% had received education about diabetes. There was no significant difference in age, education, marital status, employment status, smoking, regular use of antidiabetic drugs and receiving education about diabetes between the groups (p > .05; Table 1). Table 1 Participants’ descriptive characteristics Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 ap: Pearson chi-squared test. View Large Table 1 Participants’ descriptive characteristics Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 ap: Pearson chi-squared test. View Large In the intervention group, five women experiencing the maintenance stage at the first interview (18.5%) remained at the same stage and 22 women (81.5%) exhibited a progression in their stage of change. In the control group, a woman experiencing contemplation at the first interview (3.6%) had regressed to precontemplation by the last interview, 25 women (89.3%) remained at the same stage and two women going through the preparation stage at the first interview (7.1%) displayed a progression to the action stage. The stages of change in exercise behavior in the first interview did not significantly differ between the intervention and the control groups (p > .05). The stages of change in exercise behavior in the last interview significantly differed between the intervention and the control groups (p < 0.05, Table 2). Table 2 The stages of change in exercise behavior at the first and the last interviews. Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 View Large Table 2 The stages of change in exercise behavior at the first and the last interviews. Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 View Large We found that the mean duration of exercise (min/day) of women with diabetes in the intervention group also increased, and there was a significant difference between their first and last interviews (p < .05). Similarly, the EPCS, perceived benefits subdimension of EDBS, and ESES scores in the intervention group increased, and there was a significant difference between their first and last interview test scores (p < .05). In addition, the perceived barriers subdimension of EDBS scores in the intervention group decreased, and there was a significant difference between their first and last interviews (p < .05, Table 3). Table 3 The mean first and last interview test scores of the different scales in the intervention group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 3 The mean first and last interview test scores of the different scales in the intervention group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large The mean duration of exercise (min/day) of women with diabetes in the control group also increased, but there was no significant difference between their first and last interviews (p > .05). Likewise, no significant difference was found between the first and last interview test scores in the control group for the EPCS, EDBS and ESES scales (p > .05, Table 4). Table 4 The mean first and last interview test scores for the different scales in the control group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 4 The mean first and last interview test scores for the different scales in the control group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large When the last interview mean duration of exercise (min/day) and test scores for EPCS, EDBS, and ESES scales in the intervention and the control groups were reviewed, we observed higher scores in the intervention group; the difference between the two groups is statistically significant (p < .05, Table 5). Table 5 The mean last interview test scores for the different scales in the intervention and control groups. Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 5 The mean last interview test scores for the different scales in the intervention and control groups. Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large DISCUSSION There are considerable effects of exercise education and an SCM-based motivational interview program on individuals with diabetes [9–11]; these aids can improve stages of change in exercise behavior, using cognitive and behavioral methods, perceived benefits of exercise, and self-confidence. In our study, stages of change in exercise behavior in the intervention group, unlike the control group, improved significantly after the education and motivational interview program. The women in the intervention group experiencing initial stages of change at the first interview advanced towards action and maintenance stages by the last interview. Tosun and Zincir [11], in their study on the effects of motivational interviews on weight loss, physical activity, and glycemic control in patients with type 2 diabetes, revealed that patients observed similar progress. Our results are consistent with the literature in that training and counseling were effective in progression across the stages of change for exercise behavior [21–23]. This result matches those of previous studies, which have reported that education and a motivational interview program, based on the SCM, can increase the amount of exercise [13, 21, 22, 24, 25]. One of the important parts of the stage of change is that the risk of relapse is acknowledged [18]. While there were no relapses in our intervention group, relapses occurred in the control group. Returning to a previous stage was seen in a participant in the contemplation stage. It is thought that perceived barriers play an important role in the occurrence of relapse. Training and counseling about strategies to cope with barriers prevent the persistence of relapses and help individuals to return to healthy behavior. Goals of nursing care during relapses should be to teach individuals coping strategies, to discuss reasons for relapses, to strengthen individuals, and to support healthy behavior. Exercise education and motivational interview program based on SCM, improve cognitive and behavioral methods [9, 10, 13]. In this study, the completion of exercise education and the motivational interview program was associated with developing cognitive and behavioral methods for exercise. Exercise education and a motivational interview program resulted in improvements in many of the psychosocial parameters measured in this study, including cognitive methods of change (caring about consequences to others, increasing healthy opportunities, increasing knowledge, using public supports, creating a new self-image) and behavioral methods of change (rewarding oneself, committing oneself, reminding, substituting alternatives, and enlisting social support). This finding is in agreement with those of Zare et al. [13], who concluded that exercise education and motivational interviews had a significant and positive effect on the methods of change. Present study findings are also in agreement with those of another study where there was a positive effect on the methods of change for the intervention group following an exercise program based on SCM [9]. Given these results, encouragement and support by family and friends is important. Interventions for health behaviors (e.g., exercise club activities) are important when women intend to exercise even though exercise activation is irregular, unlike in the stage of contemplation. This result also suggests the importance of sub-factors for the process of change, such as provision of information and books that explain advantages and types of exercise, rewards, and praise. In this study, perceived benefits of exercise increased after exercise education and motivational interviews. Other studies have shown that an exercise program based on SCM can increase the perceived benefits significantly [24, 26, 27]. Consistent with the literature, our study shows that education and a motivational interview program were effective in progression across perceived benefits of exercise [7, 10]. We found that some of the perceived benefits that women cited in motivational interviews included success, better sleep at night, fitness, a feeling of freshness, stress relief, increased energy, and less pain in the lower feet, neck, and back. This finding highlights the need for continuous education until individuals fully comprehend the benefits of exercise. In this study, perceived barriers of exercise decreased after exercise education and the motivational interview program. Other studies have shown that an exercise program based on SCM can decrease the perceived barriers significantly [24, 26, 27]. In the present study, some of the perceived barriers that women cited in motivational interviews included not having free time to exercise, warm weather, long working hours, and being away from sport facilities. Similar factors have been identified by other studies [28, 29]. Education and motivational interview programs that enable women to overcome obstacles should be conducted, and measures to reduce perceived barriers should be presented to improve the stage for exercise at this point. Some solutions to reduce barriers should be considered. Strategies proposed for women in this study to reduce exercise barriers included increasing access to exercise facilities, setting up a swimming pool and hiking group, making exercise opportunities available in the office and holding fitness classes at work. Other solutions may include communication with relevant agencies, such as the municipalities and the Ministry of Youth and Sports, to install sport equipment in all the parks and increase public access to sporting facilities. Finally, self-confidence can be increased through education and a motivational interview program [8, 12]. We found that self-confidence for exercise behavior in the intervention group, unlike the control group, improved significantly after the education and motivational interview program. This result matches those of previous studies, which have reported that education and a motivational interview program based on the SCM can increase exercise. In addition, self-confidence can indirectly boost exercise by reducing perceived barriers [24]. Therefore, in educational interventions, particular attention must be paid to strengthening this cognitive factor [30]. Limitations Limitations of our research include a short observation period, nonrandom assignment and comparing a control group with an intervention. CONCLUSIONS The results of this study show that exercise education and a motivational interview program can improve stages of change in exercise behavior, using cognitive and behavioral methods, perceived benefits of exercise, and self-confidence. Although this study was conducted with women with diabetes, results suggest that a similar intervention may benefit adults who are at the risk for other chronic conditions. Fig 1. View largeDownload slide Schematic representation of the research plan. Fig 1. View largeDownload slide Schematic representation of the research plan. Acknowledgments This study was funded by The Scientific and Technological Research Council of Turkey (grant number 115S956). Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no conflict of interest. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Institutional Review Board of Gazi University (77082166-604.01.02-12526). Written informed consent was taken from all the participants. The findings reported have not been previously published, and the manuscript is not being simultaneously submitted elsewhere. Informed Consent: Informed consent was obtained from all individual participants included in the study. References 1. Polat MG . The physical activity / exercise in type II diabetes . Turkiye Klinikleri J Physiother Rehabil-Special Topics . 2016 ; 2 ( 1 ): 57 – 62 . 2. International Diabetes Federation (IDF), Guideline Development Group . Global guideline for type 2 diabetes . 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Effects of the stages of change model-based education and motivational interview on exercise behavior in diabetic women

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Abstract

Abstract In this study, we examined the effects of exercise education and a motivational interview program, based on the stages of change model (SCM), on stage of change, using cognitive and behavioral methods, perceived benefits and barriers and self-confidence in Turkish women with diabetes. This intervention study was carried out in 2015 on 55 women selected from a family health centers’ population. An exercise guide was prepared based on the SCM for the intervention group. The intervention group was followed seven times at 1-month intervals via home visits, and exercise education and the motivational interview program were conducted to identify changes in behavior. The control group received no intervention. Data were collected from both groups using a personal description form, Exercise Stages of Change Scale, Exercise Processes of Change Scale, Exercise Decisional Balance Scale, and Exercise Self-Efficacy Scale. After the exercise program, each group was re-subjected to the same scales. We used a chi-square test and independent and paired sample t-tests to analyze the data. The stages of change, using cognitive and behavioral methods, perceived benefits and self-confidence for exercise in the intervention group significantly improved compared with that in the control group (p < .05). In the intervention group, 81.5% of the participants started exercising. The exercise education and motivational interview program based on SCM positively affected stages of change, using cognitive and behavioral methods, perceived benefits, perceived barriers, and self-confidence for exercise behavior in women with diabetes. We conclude that the education and motivational interview program based on SCM are effective in promoting exercise habit. Implications Practice: Public health practitioners should consider incorporating education and motivational interview programs for exercise into routine practice. Policy: Policymakers should implement policies to support the more widespread use of education and motivational interview programs. Research: Research has demonstrated the benefits of education and motivational interview programs in improving exercise in women with diabetes. INTRODUCTION Diabetes mellitus (DM) is a complex chronic illness that, beyond requiring glycemic control, demands ongoing medical care, including multi-factored risk reduction strategies [1]. The International Diabetes Federation (IDF) has estimated that the number of diabetics globally could increase from 422 million in 2014 to 592 million in 2035. The global prevalence of diabetes in adults over the age of 18 years is 8.5% [2, 3]. The World Health Organization (WHO) announced in its 2016 Global report on diabetes that the increase in diabetes is connected with rising obesity rates; moreover, the disease has instigated the death of 1.5 million people. The report also highlighted diabetes’ direct relationship with heart attacks, paralysis, blindness, kidney failure, and lower extremity amputations [3]. The incidence of DM has been rapidly increasing in Turkey [4]. The Diabetic Epidemiology Study, conducted between 1988 and 2011, revealed a 90% growth in the incidence of diabetes. The prevalence of diabetes among Turkish adults is 14.8% [4], and according to the IDF report, Turkey is the country with the highest prevalence of diabetes in the European Region [2]. It has been reported that the risk of diabetes can be reduced or delayed by 44–58% through simple, healthy lifestyle changes [4]. The key to prevent diabetes is the development of a lifestyle that incorporates healthy eating and regular physical activity [2–4]. Physical inactivity represents the primary cause of obesity, diabetes, and hypertension [5]. Previous research indicates that globally, 6% of deaths, 30% of ischemic heart disease, 21–25% of breast and colon cancer, and 27% of diabetes are caused by inactivity [3]. Exercise is crucial to preventing or controlling the health complications associated with diabetes, including insulin resistance and gestational diabetes. It is essential that exercise programs be custom-made to meet the needs of the individual. They should also be planned and carried out regularly for a sufficient period of time and at adequate intervals [1, 4]. It is recommended that individuals with diabetes exercise for 150 min per week, or for 30 min three times a week, at a medium level of exertion [2]. Exercising at appropriate intervals for a sufficient period of time increases cardiovascular capacity and keeps obesity under control. It also lowers HgA1c values and increases insulin sensitivity [1–4]. Exercise is critical to control diabetes due to its role in improving glycemic regulation; preventing hyperglycemia, hypertension, and dyslipidemia; and reducing anxiety [2, 4]. Despite the potential health benefits, individuals with diabetes in many countries exercise little [1, 2, 4]. The majority of the Turkish population with diabetes are not active enough [4]. Moreover, in the region where the research was conducted, a study conducted with women aged upwards of 20 found that the prevalence of metabolic syndrome and diabetes was high. At the same time, the women’s physical activity levels were considered low [6]. Therefore, women with diabetes need encouragement and should be made aware of the effects of exercise. Research should focus on ways to enhance exercise behavior in women with diabetes. Health care professionals have a major responsibility to ensure that exercise becomes a central component of a healthy lifestyle. They have a duty to help reduce individuals’ risky behaviors and to instead encourage healthy behaviors, with the aim of improving the general health of society [7]. They should commit themselves to enabling individuals to become aware of their own resources and to find a form of exercise that is personally suitable [7, 8]. Health care professionals are interested in finding an effective way to encourage diabetics to adopt exercise behavior [8]. Research studies indicate that exercise intervention and motivational interviews using the stages of change model (SCM) increase exercise behavior among inactive individuals with diabetes [8, 9]. Developed by Prochaska and Diclemente in 1982, the SCM states that behavioral change consists of five stages: precontemplation, contemplation, preparation, action, and maintenance [10]. Precontemplation is the stage in which healthy behavior is not performed or thought about. In this stage, individuals are barely aware of their problems or totally unaware and unwilling to solve them. In the contemplation stage, healthy behavior is not performed but planned to be performed in 6 months. This stage is where both the problem and change are evaluated with their advantages and disadvantages. Preparation is the stage in which the healthy behavior is planned to be performed in 3 months. Action is the first 6-month stage in which the healthy behavior is performed. Maintenance is a stage in which the healthy behavior is performed for more than 6 months [10, 11]. Determining the stage of change assesses perception of behavior and, therefore, may help to improve the effectiveness of intervention when the proposed intervention is tailored to suit the current stage rather than generic messaging. For a successful behavioral change, the individual’s stage should be determined and training and counseling provided, according to the present stage [10, 11]. Some intermediate concepts (e.g., process of change, self-confidence, and decisional balance) are often used in conjunction with the SCM. Process of change (method of change) identifies which processes or methods are used by the individual during the behavior change to change the unhealthy behavior. These methods involve two levels: cognitive and behavioral methods [10]. Cognitive methods contribute to overcoming the indecision about change and noticing the importance of change. Behavioral methods are operative strategies which help in behavior change. Studies have claimed that individuals in stages of change utilize both cognitive and behavior methods in behavior change [12, 13]. In the early stages of change, cognitive methods come into prominence, while behavioral methods stand out in the later stages [12, 14]. Self-confidence refers to a person’s belief in their ability to adopt an exercise routine consistently, even in difficult circumstances [10]. Studies conducted to find out the relationship between self-confidence and exercise have reported that during the stages of change, the level of self-confidence rises, and high self-confidence scores are effective in starting and maintaining the healthy behavior [12, 13]. In behavior change, self-confidence is expected to have a positive effect on the progress among the stages and be at different levels in every stage [14]. Decisional balance measures a person’s evaluation of the perceived benefits and perceived barriers relating to behavior change. Perceived benefits and barriers related to exercise are the positive and negative cognitive factors which could encourage or discourage exercise. Efforts to promote healthy behaviors need to identify barriers people face and continue to develop interventions that help eliminate these barriers [12, 13]. The effectiveness of the SCM in planning effective interviewing toward the promotion of exercise behavior has been investigated [9, 13]. Studies have shown that interviews, based on the SCM, that have been adjusted to the stage of change are faster and more effective than general interviews [13, 15]. The SCM is unique because it emphasizes the stages of change over specified time periods, while other models focus only on the behavior [13]. We used the SCM in this study to identify the educational needs of the women, according to the stages they are in, and to prepare them to progress to the next stage. We examined the effects of exercise education and a motivational interview program, based on the SCM, on stage of change, using cognitive and behavioral methods, perceived benefits and barriers and self-confidence in Turkish women with diabetes. The present study focused on examining the stages experienced by women with diabetes, conducted SCM-based motivational interviews to encourage exercise behavior, provided a model-based exercise guide and evaluated the efficacy of resultant behavioral change. The results of this study will expand available knowledge about the effects of SCM-based interventions and form the basis of and provide guidance for future research. The main aim of this study was to identify the impacts of exercise education and motivational interviews, based on the SCM, on exercise behavior in women with diabetes. METHODS Study design and sample selection We used a nonrandomized control group intervention study design. The study sample was drawn from a population of 252 women with diabetes recorded in three different family health centers in Ankara, Turkey. To achieve a power of 90% with a margin of error of 0.05, the target sample size was determined to be 50 (25 per group) individuals using sample size software and power analysis. To account for potential participant drop-out during follow-up, a total of 56 (28 per group) individuals were included in the study sample. In the fifth month of the study, one woman in the intervention group dropped out of the study due to pregnancy; thus, 55 women completed the study. Preliminary interviews were conducted to assess whether the women who came to the family health center for any reason met the criteria for inclusion in the study. Women with diabetes who met the criteria were invited to participate and were informed of the study’s structure and their desired involvement. The inclusion criteria were: being literate, 18–49 years old, diagnosed with diabetes, noninsulin dependent and, not having any health problems preventing exercise. In total, 56 women volunteered to participate in the study and made up the sample group. After joining the study, these women were placed into intervention and control groups based on stages of change. Instruments A personal description form This form includes sociodemographic properties (age, education, marital status, and employment status), diabetes history (smoking, regular use of antidiabetic drugs and receiving education about diabetes) and the average duration of daily exercise. Exercise Stages of Change Scale (ESCS) This scale was developed by Prochaska and Diclemente in 1982 to evaluate the behavior of smoking cessation. It was adapted by Marcus et al. [14] to evaluate exercising behavior, and the test reliability was reported to be 0.78. Test–retest reliability coefficients of stages of change for exercise were 0.53 in a study by Donovan et al. [16]. Gümüş and Kitiş [17] found the test reliability to be 0.79. The ESCS is composed of one question. The scale describes five stages of change an individual goes through in adopting exercising behavior: precontemplation, contemplation, preparation, action, and maintenance [14]. Exercise Processes of Change Scale (EPCS) This scale was developed by Marcus et al. [18], and the test reliability was reported to be 0.83. It was adapted to Turkish culture by Gümüş and Kitiş, and the test reliability was found to be 0.97 [17]. The EPCS consists of two basic methods (cognitive and behavioral). The EPCS is a five-point Likert scale and is composed of 40 questions. The lowest and the highest scores for both cognitive and behavioral methods are 20 and 100, respectively. High scores indicate an increased chance of a successful change [18]. Exercise Decisional Balance Scale (EDBS) This scale was developed by Marcus et al. [14], and the test reliability was found to be 0.95 for its perceived benefits subscale and 0.79 for its perceived barriers subscale. It was adapted to Turkish culture by Gümüş and Kitiş, and its test reliability was found to be 0.90 [17]. The scale describes positive and negative aspects of behavioral change through two subdimensions [18]. Perceived benefits measure positive thoughts about exercise. Perceived barriers measure negative thoughts about exercise. The scale is a five-point Likert scale comprising 16 items. The lowest and the highest scores for perceived benefits are 10 and 50, respectively. The lowest and the highest scores for perceived barriers are 6 and 30, respectively. High scores show an individual’s awareness regarding the benefits and risks of exercise behavior and an increased chance of decisional balance regarding the change [18]. Exercise Self-Efficacy Scale (ESES) The ESES was developed by Marcus et al. [19], and the test reliability was reported to be 0.76. Test–retest reliability for the self-efficacy scale over a 2-week period was 0.90. The scale was adapted for Turkish culture by Gümüş and Kitiş, and the adaptation’s reliability was found to be 0.85 [17]. The ESES is a five-point Likert scale and is composed of five questions. The lowest and the highest possible scores are 5 and 25, respectively. High scores indicate that an individual is confident and has a high chance of success for change [19]. Exercise guide The guide was prepared for the participants in light of the relevant literature, and it was based on the SCM, stage of change in exercise behavior and principles of motivational interviews [2, 4, 5, 20]. The guide offered strategies to individuals experiencing the five different stages of exercise behavior. Intervention group interviews Interviews and exercise education were carried out by only one researcher. The first interview of the intervention and control groups was conducted at the family health center. Participants were informed about the aim, confidentiality, duration, methodology, and requirements of the study and researcher’s expectations. After giving their informed consent, participants were given data collection forms. Filling out the forms took only 30 min. Subsequent interviews were conducted in the participants’ homes. Inclusive of the first and final interviews, a total of seven interviews within intervals of 30 ± 3 days were conducted with the intervention group. Stages of change were identified in each visit (approximately 2 min), and education and a motivational interview were provided, according to the participant’s current stage with the exercise guide based on the SCM. Exercise education and motivational interview sessions lasted for 45–60 min. Time and dates of the interviews were determined with the participants. Each data collection form was reconducted at the last visit. Training and interviews were conducted through computer and exercise guides. Training was not provided at the first or final interview. Exercise training based on SCM was given to the intervention group for which the stage of change was identified. When requested by a participant, simple, clear, brief training was provided, including lecturing, question-and-answer (Q&A) sessions, visual techniques, and case examples. Exercise education and motivational interviews were provided for the participants in accordance with their stage of change as follows. Precontemplation stage Following the general information which aims at raising awareness on exercise and diabetes (i.e., the definition, symptoms, signs and treatment of diabetes, importance of exercise in diabetes management, and types of moderate and vigorous exercise) a contradiction was tried to be created about exercise behavior of person. To do so, participants were asked about how they want to see themselves and where they want to be in the future. It is accepted that participants who prioritize health, peace, happiness, success, and a positive sense of self-started to have contradictions. At this stage, it is common that those who are not aware of the advantages of exercise on health or who do not intend to change their behavior or who avoid exercise due to previous negative experiences. Contemplation stage Interviews were carried out to form a social support team (consisting of mother, father, brothers or sisters, children, spouse, neighbors, etc.) who could motivate the participants of this stage to do exercise. Features of people to be included in the team were discussed in terms of the needs of the participant (e.g., listening to the participant, having time and conditions to exercise together, giving reminders to exercise, accompanying them in exercise, etc.). In addition, it was emphasized that the participant at this stage should use provided social supports in their exercise program. Playfields in the neighborhood, public spot ads, and related campaigns, as well as free exercise facilities (trekking and jogging paths, bicycle trails), were also discussed. Preparation stage Interviews for guiding the preparation of an exercise plan were done with the participants in the preparation stage to determine the duration and type of exercise, define necessary environmental arrangements and affirm their commitment to the program. Within that period, we tried to emphasize the benefits of exercise and support participant’s determination. The individual’s potential barriers and knowing how to overcome them are also important issues. Nurses should bring solution suggestions and teach how to use social support systems. Individuals at the preparation and following stages were provided with towels, water bowls, and pedometers. The researcher guided participants in proper footwear selection and foot care. Action stage As the novelty wears off, participants’ determination may wane, causing them to return to old behaviors. We discussed focusing on successful experiences with participants to keep them motivated. We suggested ways to make exercise lively and engaging, including exercising to different music; cycling, instead of trekking; exercising with supporters, instead of alone; choosing from random favorite exercises collected in a box. Suggestions were provided on preventing negativity that can occur during exercise (wearing comfortable and suitable clothes for exercise, applying sun protection cream, using sun protective clothing, avoiding going out in direct sunlight, coordinating exercise and meal times, etc.). Moreover, they were advised on drinking plenty of water before and after exercise, preferring indoor exercise in too hot, too cold or moist days, and stopping exercise and getting medical help in cases of dizziness, shortness of breath, and pain in the chest. Maintenance stage Supporting the achievement is the main aim of the training in individuals at maintenance stage. It is known that even those who maintain an exercise routine may turn back to unhealthy behavior. Thus, the participants were encouraged not to give up in case of unexpected situations, and the importance of making a plan for those situations in advance was mentioned. They were supported in finding solutions for the situations by identifying frequently experienced situations (e.g., going on holiday, ineffective time management, having visitors, etc.). Suggestions were agreed on, such as asking for help from the support team, remembering the reasons to start exercise, changing the environment that prevents them from exercising, doing short exercises instead of long exercises and changing the time of exercise. At the end of each interview, the process was summarized with the participant, and the next meeting was planned. Participants who progressed onto the upper stage were rewarded both verbally and with certificates of achievement throughout the interviews. Each scale was reconducted at the last interview, and participants were informed that the study was complete. Control group interviews Parallel to the first interview of intervention group, first interview of the control group was conducted at the family health center. Participants were informed about the aim, confidentiality, duration, methodology, and acquirements of the study and researcher’s expectations. Participants’ questions were answered, and their informed consent was obtained. Then, they were given data collection forms. Without giving training in exercise, they were informed that the following meeting would take place around 6 months later and the interview was ended. Parallel to the last interview of the intervention group, the last interview of the control group was carried out by visiting them in their houses. The last interview was held with the aim of collecting the final data from the control group. Each scale was reassessment at the last interview, and participants were informed that the study was completed. Given that it would have been unethical not to provide education, training was offered to women in the control group. To facilitate participants’ transportation from different family health centers, a group training center was established at a meeting hall belonging to a centrally located municipality. The women were called and invited to the meeting 3 or 4 days before the group interview. A second meeting was also held for those unable to attend. This ensured that all participants in the control group were able to receive education from the researcher overseeing the intervention group (Fig. 1). The content of the training was the same regardless of the group, comprising the benefits of exercise, preparing to exercise, awareness of environmental resources, and suggestions to enable a more straightforward alteration in behavior. Data analysis For data analysis, we used the Statistical Package Program for Social Sciences, and p values <.05 were considered significant. Our data showed normal distribution. Besides descriptive statistics, we performed an independent samples t-test to analyze the differences between the intervention and control groups in the cognitive methods, behavioral methods, perceived benefits, perceived barriers, and self-confidence scores. In addition, we conducted a paired samples t-test to determine differences among the first and last interview scores of the intervention and control groups. RESULTS Fifty-five women completed the study. One participant assigned to the intervention group was unable to complete the exercise program and was therefore excluded from the final analysis. Approximately half of the intervention group (48.2%) consisted of women aged 40–49 years. Of the 27 women in this group, 48.1% had graduated from either primary or secondary school. Most were married and working as housewives. Most (85.2%) of the women in this group were using anti-diabetic medication, and 25.9% had received education about diabetes. Half of the control group (50%) consisted of women aged 40–49 years. Of the 28 women in this group, 39.3% had graduated from either primary or secondary school. Again, most were married and were housewives. Most (78.6%) of the women in this group were using anti-diabetic medication, and 21.4% had received education about diabetes. There was no significant difference in age, education, marital status, employment status, smoking, regular use of antidiabetic drugs and receiving education about diabetes between the groups (p > .05; Table 1). Table 1 Participants’ descriptive characteristics Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 ap: Pearson chi-squared test. View Large Table 1 Participants’ descriptive characteristics Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 Variables Intervention group (n = 27) Control group (n = 28) χ2 / pa n % n % Age (year)  25–39 14 51.8 14 49.0 χ2 = 0.678  40–49 13 48.2 14 50.0 p = .527 Education  Primary and secondary school 13 48.1 11 39.3  High school 9 33.4 10 35.7 χ2 = 0.765  University 5 18.5 7 25.0 p = .535 Marital status  Married 20 74.1 23 82.1 χ2 = 0.469  Single 7 25.9 5 17.9 p = .525 Employment status  Working 5 18.5 6 7.1 χ2 = 0.787  Housewife 22 81.5 22 92.9 p = .730 Smoking  Yes 6 22.2 8 28.6 χ2 = 0.293  No 21 77.8 20 71.4 p = .589 Regular use of anti-diabetic drugs  Yes 23 85.2 22 78.6 χ2 = 0.404  No 4 14.8 6 21.4 p = .525 Receiving education about diabetes  Yes 7 25.9 6 21.4 χ2 = 0.154  No 20 74.1 22 78.6 p = .695 Total 27 100.0 28 100.0 ap: Pearson chi-squared test. View Large In the intervention group, five women experiencing the maintenance stage at the first interview (18.5%) remained at the same stage and 22 women (81.5%) exhibited a progression in their stage of change. In the control group, a woman experiencing contemplation at the first interview (3.6%) had regressed to precontemplation by the last interview, 25 women (89.3%) remained at the same stage and two women going through the preparation stage at the first interview (7.1%) displayed a progression to the action stage. The stages of change in exercise behavior in the first interview did not significantly differ between the intervention and the control groups (p > .05). The stages of change in exercise behavior in the last interview significantly differed between the intervention and the control groups (p < 0.05, Table 2). Table 2 The stages of change in exercise behavior at the first and the last interviews. Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 View Large Table 2 The stages of change in exercise behavior at the first and the last interviews. Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 Stages of change Intervention group (n = 27) Control group (n = 28) P (Between the groups at the first interview) P (Between the groups at the last interview) First interview Last interview First interview Last interview n % n % n % n % Precontemplation 6 22.25 5 17.9 6 21.3 Contemplation 5 18.5 6 21.3 5 17.9 Preparation 6 22.25 7 25.0 5 17.9 Action 5 18.5 17 63.0 5 17.9 7 25.0 p = .072 p = .018 Maintenance 5 18.5 10 37.0 5 17.9 5 17.9 Total 27 100.0 27 100.0 28 100.0 28 100.0 View Large We found that the mean duration of exercise (min/day) of women with diabetes in the intervention group also increased, and there was a significant difference between their first and last interviews (p < .05). Similarly, the EPCS, perceived benefits subdimension of EDBS, and ESES scores in the intervention group increased, and there was a significant difference between their first and last interview test scores (p < .05). In addition, the perceived barriers subdimension of EDBS scores in the intervention group decreased, and there was a significant difference between their first and last interviews (p < .05, Table 3). Table 3 The mean first and last interview test scores of the different scales in the intervention group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 3 The mean first and last interview test scores of the different scales in the intervention group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 16.8 ± 24.1 0–60 40.9 ± 15.1 30–60 9.064 .000 EPCS  Cognitive methods 61.1 ± 15.8 32–91 76.5 ± 12.3 52–96 3.551 .000  Behavioral methods 61.3 ± 21.3 25–95 78.4 ± 9.9 62–95 2.242 .000 EDBS  Perceived benefits 31.7 ± 11.7 12–50 43.4 ± 3.7 36–55 6.037 .000  Perceived barriers 16.4 ± 6.9 7–27 9.5 ± 3.4 6–11 5.515 .000 ESES  Self-confidence 14.5 ± 6.2 6–25 22.0 ± 2.1 17–25 6.810 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large The mean duration of exercise (min/day) of women with diabetes in the control group also increased, but there was no significant difference between their first and last interviews (p > .05). Likewise, no significant difference was found between the first and last interview test scores in the control group for the EPCS, EDBS and ESES scales (p > .05, Table 4). Table 4 The mean first and last interview test scores for the different scales in the control group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 4 The mean first and last interview test scores for the different scales in the control group Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 Scales First interview Last interview t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 17.8 ± 25.4 0–60 19.6 ± 24.8 0–60 0.644 .525 EPCS  Cognitive methods 69.6 ± 14.2 28–92 65.9 ± 18.3 33–82 0.460 .647  Behavioral methods 68.0 ± 18.6 26–90 63.0 ± 19.7 30–89 0.870 .390 EDBS  Perceived benefits 31.6 ± 9.0 15–48 27.7 ± 9.9 14–45 1.102 .280  Perceived barriers 14.1 ± 6.5 6–26 17.8 ± 7.0 8–27 2.547 .170 ESES  Self-confidence 14.9 ± 5.7 5–24 13.2 ± 5.9 5–22 1.923 .065 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large When the last interview mean duration of exercise (min/day) and test scores for EPCS, EDBS, and ESES scales in the intervention and the control groups were reviewed, we observed higher scores in the intervention group; the difference between the two groups is statistically significant (p < .05, Table 5). Table 5 The mean last interview test scores for the different scales in the intervention and control groups. Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large Table 5 The mean last interview test scores for the different scales in the intervention and control groups. Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 Scales Intervention group Control group t-Test p Value Mean ± SD Min–max Mean ± SD Min–max Duration of exercise 40.90 ± 15.13 30–60 19.6 ± 24.8 0–60 3.817 .000 EPCS Cognitive methods 76.5 ± 12.3 52–96 65.9 ± 18.3 33–82 7.562 .010 Behavioral methods 78.4 ± 9.9 62–95 63.0 ± 19.7 30–89 5.345 .024 EDBS Perceived benefits 43.4 ± 3.7 36–55 27.7 ± 9.9 14–45 5.340 .000 Perceived barriers 9.5 ± 3.4 6–11 17.8 ± 7.0 8–27 5.577 .000 ESES Self-confidence 22 ± 2.1 7–25 13.2 ± 5.9 5–22 7.323 .000 EDBS Exercise Decisional Balance Scale; EPCS Exercise Processes of Change Scale; ESES Exercise Self-Efficacy Scale; SD standard deviation. View Large DISCUSSION There are considerable effects of exercise education and an SCM-based motivational interview program on individuals with diabetes [9–11]; these aids can improve stages of change in exercise behavior, using cognitive and behavioral methods, perceived benefits of exercise, and self-confidence. In our study, stages of change in exercise behavior in the intervention group, unlike the control group, improved significantly after the education and motivational interview program. The women in the intervention group experiencing initial stages of change at the first interview advanced towards action and maintenance stages by the last interview. Tosun and Zincir [11], in their study on the effects of motivational interviews on weight loss, physical activity, and glycemic control in patients with type 2 diabetes, revealed that patients observed similar progress. Our results are consistent with the literature in that training and counseling were effective in progression across the stages of change for exercise behavior [21–23]. This result matches those of previous studies, which have reported that education and a motivational interview program, based on the SCM, can increase the amount of exercise [13, 21, 22, 24, 25]. One of the important parts of the stage of change is that the risk of relapse is acknowledged [18]. While there were no relapses in our intervention group, relapses occurred in the control group. Returning to a previous stage was seen in a participant in the contemplation stage. It is thought that perceived barriers play an important role in the occurrence of relapse. Training and counseling about strategies to cope with barriers prevent the persistence of relapses and help individuals to return to healthy behavior. Goals of nursing care during relapses should be to teach individuals coping strategies, to discuss reasons for relapses, to strengthen individuals, and to support healthy behavior. Exercise education and motivational interview program based on SCM, improve cognitive and behavioral methods [9, 10, 13]. In this study, the completion of exercise education and the motivational interview program was associated with developing cognitive and behavioral methods for exercise. Exercise education and a motivational interview program resulted in improvements in many of the psychosocial parameters measured in this study, including cognitive methods of change (caring about consequences to others, increasing healthy opportunities, increasing knowledge, using public supports, creating a new self-image) and behavioral methods of change (rewarding oneself, committing oneself, reminding, substituting alternatives, and enlisting social support). This finding is in agreement with those of Zare et al. [13], who concluded that exercise education and motivational interviews had a significant and positive effect on the methods of change. Present study findings are also in agreement with those of another study where there was a positive effect on the methods of change for the intervention group following an exercise program based on SCM [9]. Given these results, encouragement and support by family and friends is important. Interventions for health behaviors (e.g., exercise club activities) are important when women intend to exercise even though exercise activation is irregular, unlike in the stage of contemplation. This result also suggests the importance of sub-factors for the process of change, such as provision of information and books that explain advantages and types of exercise, rewards, and praise. In this study, perceived benefits of exercise increased after exercise education and motivational interviews. Other studies have shown that an exercise program based on SCM can increase the perceived benefits significantly [24, 26, 27]. Consistent with the literature, our study shows that education and a motivational interview program were effective in progression across perceived benefits of exercise [7, 10]. We found that some of the perceived benefits that women cited in motivational interviews included success, better sleep at night, fitness, a feeling of freshness, stress relief, increased energy, and less pain in the lower feet, neck, and back. This finding highlights the need for continuous education until individuals fully comprehend the benefits of exercise. In this study, perceived barriers of exercise decreased after exercise education and the motivational interview program. Other studies have shown that an exercise program based on SCM can decrease the perceived barriers significantly [24, 26, 27]. In the present study, some of the perceived barriers that women cited in motivational interviews included not having free time to exercise, warm weather, long working hours, and being away from sport facilities. Similar factors have been identified by other studies [28, 29]. Education and motivational interview programs that enable women to overcome obstacles should be conducted, and measures to reduce perceived barriers should be presented to improve the stage for exercise at this point. Some solutions to reduce barriers should be considered. Strategies proposed for women in this study to reduce exercise barriers included increasing access to exercise facilities, setting up a swimming pool and hiking group, making exercise opportunities available in the office and holding fitness classes at work. Other solutions may include communication with relevant agencies, such as the municipalities and the Ministry of Youth and Sports, to install sport equipment in all the parks and increase public access to sporting facilities. Finally, self-confidence can be increased through education and a motivational interview program [8, 12]. We found that self-confidence for exercise behavior in the intervention group, unlike the control group, improved significantly after the education and motivational interview program. This result matches those of previous studies, which have reported that education and a motivational interview program based on the SCM can increase exercise. In addition, self-confidence can indirectly boost exercise by reducing perceived barriers [24]. Therefore, in educational interventions, particular attention must be paid to strengthening this cognitive factor [30]. Limitations Limitations of our research include a short observation period, nonrandom assignment and comparing a control group with an intervention. CONCLUSIONS The results of this study show that exercise education and a motivational interview program can improve stages of change in exercise behavior, using cognitive and behavioral methods, perceived benefits of exercise, and self-confidence. Although this study was conducted with women with diabetes, results suggest that a similar intervention may benefit adults who are at the risk for other chronic conditions. Fig 1. View largeDownload slide Schematic representation of the research plan. Fig 1. View largeDownload slide Schematic representation of the research plan. Acknowledgments This study was funded by The Scientific and Technological Research Council of Turkey (grant number 115S956). Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no conflict of interest. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Institutional Review Board of Gazi University (77082166-604.01.02-12526). Written informed consent was taken from all the participants. The findings reported have not been previously published, and the manuscript is not being simultaneously submitted elsewhere. Informed Consent: Informed consent was obtained from all individual participants included in the study. References 1. Polat MG . The physical activity / exercise in type II diabetes . Turkiye Klinikleri J Physiother Rehabil-Special Topics . 2016 ; 2 ( 1 ): 57 – 62 . 2. International Diabetes Federation (IDF), Guideline Development Group . Global guideline for type 2 diabetes . 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Translational Behavioral MedicineOxford University Press

Published: May 8, 2018

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