The vast majority of the study participants (74% of men and 76% of women) perceived a need to increase their PAL. This reflects the high value placed on physical activity among the type 2 diabetes at-risk population, as indicated also by previous studies [12
]. Considering the importance of increased physical activity in diabetes prevention, and the high prevalence of inactivity among the study population, the finding is promising, bearing in mind also that expression of a perceived need to change is a key component of a client’s “change talk”, predicting a commitment to change health behaviour [27
]. Through professional advice [52
] and effective counselling techniques e.g. [53
] those perceiving the need to increase PAL could be encouraged to make a genuine commitment to changing their behaviour.
The present study showed that people at the contemplation stage of change, who perceived their PAL as sufficient, and who were classified as physically inactive, were more likely than others to perceive a need to increase their PAL. In addition, women who gave lower ratings to their personal physical fitness were more likely than others to perceive this need. A previous study [22
] found general health and well-being, physical fitness, and weight control to be the most important determinants of a perceived need to exercise. Along similar lines, the present paper indicated a significant association between increased waist circumference and a perceived need to increase PAL in both sexes. By contrast, other type 2 diabetes risk factors did not contribute to this perception. These findings indicate the groups which are least likely to increase their PAL, and which should therefore be given particular attention within health care, in terms of endeavours towards diabetes prevention. Increased PAL would be of great benefit to individuals with a family history of diabetes, elevated blood pressure, or dyslipidaemia [8
], yet the benefit does not appear to be recognised by these people. Waist circumference is an objective measure which is highly tangible for the individual, and which inevitably reflects the person’s current PAL in a manner readily apparent to that individual.
Our results suggest that among the high-risk population the need to increase PAL is strongly determined by the individual’s subjective perceptions. This finding is in line with the principles of the motivational interviewing approach to counselling, which emphasise the importance of listening to and reflecting individuals’ perceptions if one is to evoke the motivation to change. However, clients’ perceptions may easily be overlooked in a busy primary health care practice, especially if health professionals view the client as reluctant to change [54
]. We would argue that if the perceptions of clients are neglected in health counselling, an important opportunity to support the client’s motivation for behaviour change will remain unutilised.
Our results support previous findings on PAL awareness indicating that overestimation of one’s PAL may be an obstacle to behaviour change [37
]. In demonstrating a lack of any intention to change, the overestimators differed only slightly from realistic active persons, but there was a large difference between the overestimators and the realistic inactive persons. If the overestimators could be led to view their PAL realistically, they could be expected to see more clearly the need for change. Such efforts could also help to prevent incorrect tailoring in physical activity counselling [55
As far as we know, no other studies have so far simultaneously assessed such a variety of determinants of the perceived need to increase PAL. One could expect that factors associated with a failure to perceive a need for increased PAL would be in line with determinants of the pre-contemplation stage of change. However, we found no evidence to support this presumption [37
]. It appears that the pre-contemplation stage can best be regarded as a complex entity with its own set of determinants. It seems to be the case that some individuals at the precontemplation stage simply do not perceive the need to change their behaviours [57
]. However, others perceive the need to increase their PAL in principle, yet – for whatever reason – do not consider changing their behaviour.
A previous study by Payne et al. [22
] conducted among the general population (n
286) found that 94% of the participants perceived the need to exercise (note that the authors did not assess the need to increase exercise
, merely the need to exercise
in general). It is true that the authors did not find a significant association between the perceived need and the intention or behaviour; yet the concept of perceived need requires further examination. Payne et al. assessed short-range intention only (the intention to exercise next week, and actual exercise behaviour a week later). Here it is worth bearing in mind that e.g. in the Diabetes Prevention Programme (DPP) [12
], those who were at the contemplation stage at the baseline actually continued to increase their PAL until the 3-year (final) follow-up assessments; by contrast, other groups decreased their PAL. In fact, even six months can be regarded as a short period for changing physical activity behaviour [58
]. The causal relationships between the perceived need to change, intentions, and behaviour should be assessed in future studies.
The study has some limitations. The study population is considered to represent the Finnish high-risk population [61
]. Nevertheless, as opportunistic screening was used in the programme, there is a possibility of selection bias. The study participants were aware of their risk due to health examinations, and this aspect limits comparisons with the unaware high-risk population outside the programme. Furthermore, the assessment of the perceived need to change health behaviours was based on an evaluation form developed for the FIN-D2D intervention. The nurses were instructed to record not their own, but merely the participant’s perception; however, it is possible that a persuasive style on the part of the nurse could have influenced the responses (though attempts were made to avoid such a bias through careful instruction of the nurses). Furthermore, the self-reporting method of measuring physical activity limits the assessment of PAL and PAL awareness, due to issues of recall and response bias (e.g. social desirability, inaccurate memory) and the inability of the respondent to estimate the frequency, intensity, and duration of physical activity [62
]. It was due to these considerations that we did not assess lifestyle physical activity, which is often sporadic, and even more difficult to recall and report than planned, discretionary, leisure-time exercise [63
]. Here it should be noted that with regard to cost, staff training, participant burden, and time, self-reporting was the only feasible method for measuring PAL in such a large implementation programme [64
]. It should also be noted that the cut-off point for physically active and inactive participants was not determined according to the CDC/ACSM physical activity recommendations [65
], due to the limitations of the questionnaire. However, it has been suggested [7
] that the amount of physical activity needed to prevent diabetes should in fact be set at lower than the recommendations for the general adult population given by CDC/ASCM.