Submitted:
26 April 2024
Posted:
30 April 2024
You are already at the latest version
Abstract
Background: Low-level physical activity (PA) among Chronic Low Back Pain (cLBP) is associated with various biopsychosocial factors. This research aimed to study the predictors of PA behavior among cLBP patients. Methods: In the present study 300 eligible patients with cLBP who referred to comprehensive health service centers in the Shahid Beheshti University of Medical Sciences (SBUMS) in Tehran, Iran were random selected.To diagnose the predictors of PA behavior, all the Theory of Reasoned Action (TRA) constructs were examined as risk factors to see if they influence on the probability of PA behavior occurrence and were interpreted through odds ratio (OR). SPSS version 19 was used to analyze the data. Results: Totally 280 cLBP patients with mean age of 57.07 ±13.09 years old participated in the study. This study showed that motivation to comply significant predictor the cLBP patients for subjective norm OR (%95CI): 2.095(0.116-2.792), p-value<0.001), intention was significant predictor for perform the PA behavior OR (%95CI): 1.431(0.138-1.538), p-value <0.001), behavior beliefs could predictor for attitude OR (%95CI): 1.276(0.106-1.355), p-value= 0.002). attitude, normative beliefs, subjective norm ,and evaluation outcome behavior could predictors the cLBP patients for intention to perform the PA behavior OR (%95CI): 1.188(0.032-1.312), p-value<0.001)., OR (%95CI): 1.158(0.076-2.208), p-value=0.003) ., OR (%95CI): 1.104(0.076-1.128), p-value<0.001) ., OR (%95CI): 0.814(0.301-1.440), p-value=0.007). Conclusions: This study showed that the cLBP patients who were normative beliefs and evaluation regarding PA behavior could effect on the intention to engage in greater PA than those via other constructs (attitude and subjective norm). This study showed that the cLBP patients who were normative beliefs and evaluation regarding PA behavior could effect on the intention to engage in greater PA than those via other constructs (attitude and subjective norm). This study showed that the cLBP patients who were normative beliefs and evaluation regarding PA behavior could effect on the intention to engage in greater PA than those via other constructs (attitude and subjective norm).
Keywords:
reasoned action
; behavior
; models
; self-care
Introduction
A lot of the population suffers from chronic low back pain (cLBP). cLBP is a high-cost and prevalent disease such that could want to physical disabilities, social and mental health engagement[1], cLBP is determined through a complicated interaction among pain, behavior and biopsychosocial factors[2].
Although, there are several treatment procedures to improve cLBP, cLBP control and management programs to be more effective than others support to change behavior[2]. Physical Activity (PA) is observed as an effective intervention in the management of cLBP patients[3]. Although PA education have been shown to benefit cLBP patients[4].
Background
The theory of reasoned action (TRA) is one of the theories that claims that people consider the consequences of their actions before making decisions to engage or disengage in any given behavior[5]. Individuals who have positive beliefs and positive outcome evaluations about PA behavior are more likely to engage in healthier behavior[6].However this theory check that healthy behaviors will be predicted by the subjective norm[7].evidence showed that patients’ perceptions of the social cognition and social environment effected on PA[8].
Social cognitive concept (SCT) proposed that patients’ behavior occurred even as each individual-level cognitive factors interacted with the environmental factors[9]. In this regard, our study was conducted with the aim of determining predictors of physical activity behavior among cLBP patients With reference to the comprehensive health service centers of Shahid Beheshti University of Medical Sciences (SBUMS), Tehran, Iran.
Materials and Methods
Participants
This study was conducted among patients referred to five comprehensive health service centers. Health networks and centers of North, East, Shemiranat, Pardis and Pakdasht area of Tehran and were affiliated to SBUMS, from 13 January - 27 August 2019). This article is part of postdoctoral research. After describing the aims and methods, all patients were satisfied to be studied and knowingly and voluntarily signed the written consent forms. This study was approved by the research ethics committee of (without university name) on January 2019 with ID: IR. MODARES.REC.1398.163 and Trial Identification Number in Clinical Trials Registry was TCTR20190728001.
300 eligible cLBP patients referred to comprehensive health service centers in SBUMS Tehran, Iran from 13 January to 27 August 2019 were random selected A total of 280 cLBP patients with an average age of 57.07 ± 13.09 years participated in this study. Figure 1 shows the procedure of patients sampling. according to Inclusion & Excluding criteria [10] to identification Predictors of PA behavior (Figure 2), All theory of reasoned action (TRA) constructs were examined for risk factors to see if they influence the probability of PA behavior. SPSS version 19 was used for data analysis. The odds ratio was used to determine whether particular exposures like TRA constructs could be risk factors for occurrence of the outcome like PA[11]. Based on the existed reference the sample size based on estimate five people per item[12]. So for one 60 sample size item questionnaire were calculated 60 times 5= 300.
Study Design
In this cross-sectional study, questionnaire TRA regarding PA behaviors and demographic questionnaire, were used. TRA constructs questionnaire consist of 8 subscales according to TRA constructs (Figure 2). The PA behavior questionnaire was discerned using a 14-item questionnaire.
Qualitative and quantitative approaches were applied by 15 patients with cLBP to assess facial validity of TRA constructs questionnaire. To confirm the content validity of the questionnaire, the expert panel including 12 experts in different fields of health education, health psychologist, psychometric, physical medicine, and pain experts checked all the survey items by which The CVI value of ≥0.79 was observed acceptable for each item. The reliability of the questionnaire was determined with the help of Cranach’s alpha coefficient that was in acceptable range of 0.70 to 0.88 in 8 subscales according to TRA constructs. Cranach’s alpha was obtained as 0. 78. The study was questionnaire questions with 7-point scale except behavioral intention structure that was questions with 4-point scale.
Data Collection and Analysis
To determine the relationship between different TRA constructs with each other and with PA behavior, R Spearman was apply because K-S test displayed the data were non parametric. To predict the factors influencing PA behaviors logistic regression analysis was applied. Lower odds of PA (P<0.05) was statistically significant.
Results
Totally 300 patients with cLBP recruited of which 280 persons who were visited by the physician and they had inclusion criteria of the study. The means age of the patients was 57.7 years (SD=13.09) and most of them were between 40 and 49 years old. (39.6%). Overall, 31.4% of the patients with cLBP (N=88) were housewives. Table 1 show all socio demographic data as well as the Mean (SD) of all studied variables based on TRA.
Logistic correlation test was used to examine the relationship between TRA constructs and PA behavior .Table 2 shows these correlations. As this table shows, there were a direct a significant correlation between behavior beliefs and attitude with intention. So that the patients who normative beliefs were more likely to the predictor for subjective norms significantly (p-value < 0.001).
This study stated that motivation to comply in cLBP patients for norm subjective OR (95% CI): 2.095 (0.116-2.792), p-value<0.001, a significant predictor of intention to perform the behavior was PA (Table 3). (95% CI). 1.431 (1.538-0.138), p-value <0.001), behavioral beliefs can be predictive for attitude OR (%95CI): 1.276 (1.355-0.106), p-value = 0.002). Attitude, normative beliefs, subjective norm, and evaluation outcome behavior can predict cLBP patients for intention to perform PA behavior (OR (95CI): 1.188 (0.032-1.312), p-value<0.001). : 1.158 (0.076-2.208), p-value=0.003., OR (%95CI): 1.104(0.076-1.128), p-value<0.001., OR (%95CI): 0.814(0.301), p-value 0.007).
Discussion
Only some results of this study are in the line of results protected from previous study[13]. As well as the role of subjective norm and attitude were determined as influencing factors for PA behavior via Intention. The findings of the present study are fully in line with the theoretical assumptions of the theory of reasoned action[14].On the other hand, Attitude means a general feeling of liking or disliking towards any given PA behavior[11].
In Carvalho’s study, people who did not have a good attitude toward physical activity prevented their physical activity[12]. Moreover, in accordance with the present study, numerous studies have revealed that subjective norm has been as the best predictor variable for actual PA[14,15]. Therefore, strategies for raising subjective norm, such as strengthening subjective norm through Role Playing and focus groups discussion could lead to better and more effective health promotion programs Iranian cLBP patients and should be considered in future intervention[16]. Motivation to comply was as the predictor variable for subjective norm.
These programs could propose that highly individuals has normative beliefs and evaluation outcome behavior Make more effort to overcome and master PA behaviors through intention and persist longer in the face of obstacles that stand in the way of such intention to engage in PA behavior. Sweeney in their study showed that normative beliefs are predictors of persistence of physical activity[17]. Thus, studies have shown that positive social life is a good predictor of PA[17].
This study was verified that the patients’ behavior beliefs could be a predictor of patients’ towards PA via Attitude likes Kirks study[18]. Ajzen noted that behavior beliefs Increase the chance of PA involvement[19]. These results are confirmed by a large number of previous researches and show that the people who have the most beliefs of the patients about PA and they’re self- evaluation regarding the outcome of PA to the performance of PA are more likely to do this behavior[20,21].
Outcome evaluation emphasizes that; encouraging patients with cLBP to do preventive behaviors of Back pain is chronic, so better to highlight the benefits and positive outcomes of doing preventive PA behaviors to improve chronic low back pain. Previous evidence verified that preventive behaviors of chronic low back pain behavior could influence CLBP improvement [22].
Conclusions
This study showed that all patients had positive beliefs and evaluated the consequences of PA behavior, respectively via attitude and subjective norms were more like to perform this behavior. Therefore, Cognitive, behavioral, and psychological factors can contribute to the experience of pain among patients with cLBP [23]. There is a need for cognitive-behavioral educational intervention based on the theory of reasoned action on changing the preventive behaviors and beliefs of chronic back pain. But behavioral intentions are interpreted as a key predictor of action in many health behaviors theories[24]. Consistent this study prediction, the Carroll study showed a significant and positive correlated between the health behavioral intentions of cLBP patients with low back pain prevention behaviors[24].
Relevance for Clinical Practice
After obtaining the predictive constructs of the present study, an intervention program will be conducted in four training sessions at one-week intervals by two trained physical education and professional health instructors. The educational program will be designed and used completely based on the basic constructs of the theory of reasoned action
Limitations
First, the data used were collected through self-report that might interfere this study results. The cLBP patients were randomly selected from one university. However a number of key factors like large sample size were considered to ensure the representation of the population under study.
Funding
This research received grant funding from Iran National Science Foundation (INSF) (INSF, Health and Environment Committee Grant Code no. insf-97021581-2019-06-20), and the Tarbiat Modares University.
Author contribution
M H D conducted whole study and had full access to all data for analysis. AH, supervised study and also contributed to the drafting of the article. FP verified the data analysis. All authors confirmed the final version of the manuscript.
Acknowledgement
The authors would like to thank all patients who participated in the study and also thank research deputy of Iran National Science Foundation (INSF) and Tarbiat Modares University for its financial support for this study.
key points
The (Theory of Reasoned Action )TRA constructs questionnaire could be a validated and reliable instrument to determine the factors that influence Physical Activity Behavior among 280 cLBP patients who Referring to Comprehensive Health Service Centers in the Shahid Beheshti University of Medical Sciences in Tehran, Iran. it is also suggested that the TRA constructs questionnaire should be justified to other languages and cultures so that it could be applied in other countries. Given that our study has found effective factors for physical activity in patients with low back pain, it is possible to focus on these factors for more effective training to make training more effective and cost-effective. Appropriate interventions based on these predictors should be designed to motivate patients with low back pain to engage in physical activity. The use of TRA constructs is more efficient than models. However, to do more research to ensure that these results are recommended.
Finance/Disclosure
None declared.
Conflict of interest
The authors acclaimed that they have no rivaling interests.
References
- Brooks, J.M.; Iwanaga, K.; Chiu, C.-Y.; Cotton, B.P.; Deiches, J.; Morrison, B.; Moser, E.; Chan, F. Relationships between self-determination theory and theory of planned behavior applied to physical activity and exercise behavior in chronic pain. Psychol. Heal. Med. 2017, 22, 814–822. [Google Scholar] [CrossRef]
- Gardner, T.; Refshauge, K.; McAuley, J.; Hübscher, M.; Goodall, S.; Smith, L. Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomised controlled trial. Br. J. Sports Med. 2019, 53, 1424–1431. [Google Scholar] [CrossRef] [PubMed]
- Gao, C.; Chen, G.; Yang, H.; Hua, Z.; Xu, P.; Wong, M.; He, C. Relative effectiveness of different forms of exercises for treatment of chronic low back pain: protocol for a systematic review incorporating Bayesian network meta-analysis. BMJ Open 2019, 9, e025971. [Google Scholar] [CrossRef] [PubMed]
- Sequin, E.; Joseph, J.; Cowen, V.S. A Review of the Addition of Cognitive Behavioral Therapy to Physical Rehabilitation for Chronic Nonspecific Low Back Pain. JBJS J. Orthop. Physician Assist. 2019, 7, e1. [Google Scholar] [CrossRef]
- Abraham C, Sheeran P. Implications of goal theories for the theories of reasoned action and planned behavior. Planned Behavior: Routledge; 2017. p. 101-22.
- Montano, D.E.; Kasprzyk, D. Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. Health behavior: Theory, research and practice. 2015, 70, 231. [Google Scholar]
- Kautonen, T.; Van Gelderen, M.; Fink, M. Robustness of the Theory of Planned Behavior in Predicting Entrepreneurial Intentions and Actions. Entrep. Theory Pract. 2015, 39, 655–674. [Google Scholar] [CrossRef]
- Bosch, S.J.; Lorusso, L.N. Promoting patient and family engagement through healthcare facility design: A systematic literature review. J. Environ. Psychol. 2019, 62, 74–83. [Google Scholar] [CrossRef]
- A Hivner, E.; Hoke, A.M.; Francis, E.B.; Lehman, E.B.; Hwang, G.W.; Kraschnewski, J.L. Training teachers to implement physical activity: Applying social cognitive theory. Heal. Educ. J. 2019, 78, 464–475. [Google Scholar] [CrossRef]
- hammad Hossein Delshad AH, Fatemeh Pourhaji. Effectiveness of a theory-based Educational intervention on the promotion of Physical Activity-related behavior among Chronic Low Back Pain of the Patients: a Health Center-based randomized controlled trial (RAT-BAC). Scientiarum, Health Sciences. 2023;Inpress.
- Ajzen, I. The theory of planned behaviour: Reactions and reflections. Psychol. Health 2011, 26, 1113–1127. [Google Scholar] [CrossRef] [PubMed]
- Carvalho, F.A.; Maher, C.G.; Franco, M.R.; Morelhão, P.K.; Oliveira, C.B.; Silva, F.G.; Pinto, R.Z. Fear of Movement Is Not Associated With Objective and Subjective Physical Activity Levels in Chronic Nonspecific Low Back Pain. Arch. Phys. Med. Rehabilitation 2017, 98, 96–104. [Google Scholar] [CrossRef]
- McEachan, R.R.C.; Conner, M.; Taylor, N.J.; Lawton, R.J. Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis. Heal. Psychol. Rev. 2011, 5, 97–144. [Google Scholar] [CrossRef]
- Úbeda-Colomer, J.; Ginis, K.A.M.; Monforte, J.; Pérez-Samaniego, V.; Devís-Devís, J. Predicting physical activity in university students with disabilities: The role of social ecological barriers in the theory of planned behaviour. Disabil. Heal. J. 2019, 12, 574–580. [Google Scholar] [CrossRef]
- Kim, J.; Eys, M.; Robertson-Wilson, J.; Dunn, E.; Rellinger, K. Subjective norms matter for physical activity intentions more than previously thought: Reconsidering measurement and analytical approaches. Psychol. Sport Exerc. 2019, 43, 359–367. [Google Scholar] [CrossRef]
- Wyer Jr, RS. Cognitive organization and change: An information-processing approach: Psychology Press; 2019.
- Garn AC, Moore EW, Centeio EE, Kulik N, Somers C, McCaughtry N. Reciprocal effects model of Children’s physical activity, physical self-concept, and enjoyment. Psychology of Sport and Exercise. 2019:101568.
- Kirk, T.N.; Haegele, J.A. Theory of Planned Behavior in Research Examining Physical Activity Factors Among Individuals With Disabilities: A Review. Adapt. Phys. Act. Q. 2019, 36, 164–182. [Google Scholar] [CrossRef]
- Ajzen, I. The theory of planned behavior. Organizational behavior and human decision processes. 1991;50(2):179-211.
- Benyamini, Y.; Leventhal, H. 24 Beliefs and Perceptions of Health and Illness. Cambridge Handbook of Psychology, Health and Medicine. 2019:106.
- Lang, C.; Brand, S.; Colledge, F.; Ludyga, S.; Pühse, U.; Gerber, M. Adolescents’ personal beliefs about sufficient physical activity are more closely related to sleep and psychological functioning than self-reported physical activity: A prospective study. J. Sport Heal. Sci. 2019, 8, 280–288. [Google Scholar] [CrossRef]
- Hein V, Koka A, Tilga H, Kalajas H, Raudsepp L. HOW OBJECTIVELY MEASURED PHYSICAL ACTIVITY IS RELATED TO PSYCHOLOGICAL CONSTRUCTS: A PILOT STUDY AMONG ESTONIAN STUDENTS. LASE JOURNAL OF SPORT SCIENCE is a Scientific Journal published two times per year in Sport Science LASE Journal for sport scientists and sport experts/specialists.28.
- Gromisch ES, Kerns RD, Czlapinski R, Beenken B, Otis J, Lo AC, et al. Cognitive behavioral therapy for the management of multiple sclerosis–related pain: a randomized clinical trial. International Journal of MS Care. 2019.
- Carroll, L.; Whyte, A. Predicting chronic back pain sufferers’ intention to exercise. Br. J. Ther. Rehabilitation 2003, 10, 53–58. [Google Scholar] [CrossRef]
Figure 1.
Flow diagram of participation sampling among the Patients Referring to Comprehensive Health Service Centers of Tehran, Iran.
Figure 1.
Flow diagram of participation sampling among the Patients Referring to Comprehensive Health Service Centers of Tehran, Iran.
Figure 2.
Schematic representation of the theory of reasoned action (Ajen, 2015). The TRA framework is based on the theory of reasoned action (TRA), which has been shown to be a predictor of health behavior.
Figure 2.
Schematic representation of the theory of reasoned action (Ajen, 2015). The TRA framework is based on the theory of reasoned action (TRA), which has been shown to be a predictor of health behavior.
Table 1.
Socio-demographic characteristics of the studied the Patients.
| Studied variables and Constructs | Sufficient | N (%) | Mean (SD) |
|---|---|---|---|
| Age | 30-39 40-49 50-59 60-69 70-79 |
20(7.2) 111(39.6) 92(32.8) 39(13.9) 18(6.5) |
57.07 ±13.09 |
| Years of education | 12years 14 years 16years(Bachelor) 18 years(Master) |
34(12.4) 76(27.1) 80(28.6) 90(32.1) |
12.08±10.87 |
| Marital status | Single Married Widow Divorced |
53(18.9) 178(63.6) 24(8.6) 25(8.9) |
- |
| Occupation | Housewife‘ Manager Employed Non-employed Farmer Worker Retired |
88(31.4) 12(4.3) 57(20.4) 43(15.4) 14(5) 34(12.1) 32(11.4) |
- |
| Intention | 4.80±1.18 | ||
| Attitude | 40.62±10.22 | ||
| Behavior beliefs | 6.38±2.42 | ||
| Evaluation outcome behavior | 7.26±2.46 | ||
| Normative beliefs | 6.39±2.87 | ||
| Motivation to comply | 8.34±12.84 | ||
| Subjective norms | 48.02±8.12 | ||
Mean (SD): Mean (Standard Deviation).
Table 2.
Correlation matrix of the constructs of Theory of Reasoned Action in Physical Activity in the Patients Referring.
Table 2.
Correlation matrix of the constructs of Theory of Reasoned Action in Physical Activity in the Patients Referring.
| Variables | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
| 1.Intention | 1 | ||||||
| 2.Attitude | R=0.728** | 1 | |||||
| 3.Behavior beliefs | 0.413* | R=0.696** | 1 | ||||
| 4.Evaluation outcome behavior | 0.486** | 0.635** | R=0.057 | 1 | |||
| 5.Subjective norms | 0.718** | 0.024** | 0.013** | R=0.112* | 1 | ||
| 6.Normative beliefs | 0.566** | 0.021 | 0.082 | 0.053 | R=0.514** | 1 | |
| 7.Motivation to comply | 0.212* | 0.011 | 0.133* | 0.062 | 0.714** | R=0.554 | 7 |
Spearman’s** correlation is significant at the 0.01 level (two-sided). * Correlation is meaningful at the 0.05 level (2-sided).
Table 3.
Predictors of Physical Activity behavior based on Theory of Reasoned Action through logistic regression analysis.
Table 3.
Predictors of Physical Activity behavior based on Theory of Reasoned Action through logistic regression analysis.
| Independent | Variables | B | S.E | P | OR(%95CI) |
|---|---|---|---|---|---|
| Variable | predictors | ||||
| Intention | behavior | 0.358 | 0. 044 | <0.001 | 1.431(0.138-1.538) |
| Attitude | Intention | 0.173 | 0.072 | <0.001 | 1.188(0.032-1.312) |
| Behavior beliefs | Attitude | 0.244 | 0.058 | 0.002 | 1.276(0.106-1.355) |
| Motivation to comply | Subjective norms | 0.74 | 0.044 | <0.001 | 2.095(0.116-2.792) |
| Normative beliefs | Intention | 0.099 | 0.078 | 0.003 | 1.158(0.076-2.208) |
| Evaluation outcome behavior | Intention | -0.206 | 0.076 | 0.007 | 0.814(0.301-1.440) |
| Subjective norms | Intention | 0.146 | 0.046 | <0.001 | 1.104(0.076-1.128) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
