Health beliefs and physical activity behavior in adults with multiple sclerosis

Disability and Health Journal 5 (2012) 261e268 www.disabilityandhealthjnl.com

Research Paper

Health beliefs and physical activity behavior in adults with multiple sclerosis Susan L. Kasser, Ph.D.a,*, and Maria Kosma, Ph.D.b a

Department of Rehabilitation and Movement Science, 106 Carrigan Drive, University of Vermont, Burlington, VT 05405, USA b Department of Kinesiology, Louisiana State University, Baton Rouge, LA, USA

Abstract Background: Understanding how health beliefs intersect with physical activity in people with multiple sclerosis (MS) is an important step in developing effective activity promotion programs. Objective: The purpose of the study was to employ the Health Belief Model (HBM) to assess the health beliefs of adults with MS and examine the relationship between health beliefs and physical activity behavior. Method: Participants with MS (N 5 384) completed a web-based survey assessing the following HBM constructs: perceived susceptibility and seriousness of negative health outcomes, perceived benefits and barriers to physical activity, cues to action, and self-efficacy. Self-reported physical activity was also surveyed. Results: Participant perceptions of susceptibility to negative health outcomes were focused more on physical conditioning and functioning rather than on general health conditions. The most important HBM predictors of physical activity were self-efficacy and perceived benefits of exercise. Even when controlling for the significant effects of disability level on physical activity, self-efficacy and perceived benefits remained robust exercise predictors. Conclusion: Individuals with MS believe they can benefit from physical activity and remain healthy even in the context of their disease. They also acknowledge the fact that their disability levels limit their exercise capabilities. Given that self-efficacy and perceived benefits of activity are important determinants of physical activity, health promotion efforts should be directed at these modifiable factors. Ó 2012 Elsevier Inc. All rights reserved. Keywords: Multiple sclerosis; Health beliefs; Physical activity; Exercise benefits; Self-efficacy

Health beliefs and physical activity behavior in adults with multiple sclerosis The benefits of regular exercise in promoting general health and facilitating psychological well-being are well known. Recent evidence suggests, however, that individuals with multiple sclerosis (MS) engage in less physical activity and at lower intensity levels than adults without the disease.1,2 Physical inactivity is particularly problematic for this group as they, like the general population, are at risk for cardiovascular diseases and other chronic health Disclosure of financial interests and potential conflicts of interest: The authors do not have any relevant financial disclosures or conflicts of interest pertaining to this research and manuscript. We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated The authors do not have any relevant financial disclosures or conflicts of interest pertaining to this research and manuscript. * Corresponding author. Tel.: þ1 802 656 7742; fax: þ1 802 656 6586. E-mail address: [email protected] (S.L. Kasser). 1936-6574/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2012.07.001

conditions associated with deconditioning.3 Evidence suggests that activity curtailment in adults with MS is also associated with poorer health-related quality of life.4,5 Despite the acknowledged benefits of physical activity for this group,6e12 deeper insight into the determinants that facilitate exercise adoption and support adherence to activity is needed. While research has revealed restricted activity levels with declining function,1,13e15 a range of cognitivebehavioral determinants have also been identified as important correlates of physical activity in this population. Such determinants include self-efficacy,4,5,16e18 outcome expectations,18,19 and perceived barriers and benefits.20,21 Specifically, people with MS perceive exercise beneficial for maintaining function and independence, facilitating social acceptance and companionship, and enhancing a sense of accomplishment and coping.16,19 Conversely, fatigue, lack of motivation or energy, physical exertion, and health concerns are the most frequently cited reasons people with MS report for not exercising.1,5,20,21

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Although decisions to become regularly active are likely multifactorial, conceptually grounded research on how various cognitive-behavioral determinants intersect to influence the health decision-making of people with MS is warranted. The Health Belief Model (HBM)22 offers an important theoretical framework for understanding physical activity determinants in this group. The main tenet of the HBM is that people’s personal beliefs around possible illness or disease and the desire to prevent these negative health conditions underlie their motivation to take action.23 According to this theory, a person’s readiness to take on some health-promoting behavior, such as exercise, depends on a) a perception of vulnerability to existing or future health issues related to inactivity, b) a belief about the seriousness of possible consequences arising from these health conditions, c) a belief that participation will effectively prevent the threat of the negative health outcomes, and d) a belief that the anticipated benefits of the activity will outweigh the costs of action. More recently, self-efficacy to successfully perform the behavior has been added to the model.24 The HBM framework has also been expanded to include cues to action (events, people, or things that increase awareness and trigger behavior) and examination of the influence of demographic and sociopsychological variables on health-related behavior have been recommended. Included within this array of variables influencing activity compliance may be one’s definition of health. Walker et al25 found that, among other factors, one’s definition of health contributed significantly to exercise behavior. For individuals with MS, this may have important implications as the existence of a chronic condition (i.e., MS) may take precedence over, and even decrease, any thoughts about other health conditions associated with inactivity. In other words, individuals with MS may or may not perceive themselves to be healthy outside of the disease. Several studies have employed the HBM as a conceptual platform for evaluating health behavior decision-making in those with MS. Turner et al26 found that HBM perceptions related to benefit best predicted adherence to disease modifying therapies in veterans with MS. Likewise, Stuifbergen and colleagues27 reported the efficacy of a wellness intervention based, in part, on the HBM for improving self-efficacy and health-promoting behaviors in women with MS. Although this research provided initial understanding on how select HBM constructs (i.e., barriers and self-efficacy) support health behavior in those with MS, the utility of the framework in understanding decisions regarding physical activity as a preventive health strategy remains unclear. Therefore, the purpose of the study was to explore the health beliefs of adults with MS in terms of chronic conditions associated with inactivity and examine the predictive value of health beliefs to physical activity behavior in this population. Understanding how health beliefs intersect with physical activity is necessary in identifying modifiable factors related to inactivity and for developing effective activity promotion programs for individuals with MS.

Participants Participants in the study included 348 individuals with MS from the northeast region of the Unites States. Participants with MS were included if they had doctor-diagnosed MS, were 18 years of age or older, and had not experienced an exacerbation of symptoms preventing physical activity participation in the two weeks prior to completion of the study. Eligibility was assessed via self-reported answers to eligibility questions. To assure requisite cognitive ability, three fact-based questions (i.e., a simple addition problem, the current year, and correct day of the week after the one identified) were also included. If any of the items were marked incorrectly, the participant was deemed ineligible to take the survey and not allowed to continue. In this study, 539 out of 5759 individuals with MS (6% response rate) responded to our request to visit the web-based survey. Of these 539 potential participants, 359 completed the survey (66.6% participation rate), 45 started but did not complete the survey, and 135 were deemed ineligible and were informed they could not continue. Approval for the study was obtained from the Institutional Review Boards of both authors’ respective institutions and consent was implied if participants completed the surveys.

Data collection Participants with MS were recruited through electronic mailings sent out by the Greater New England Chapter of the National Multiple Sclerosis Society. An email briefly describing the study and providing a link to the webbased survey was sent to all those individuals with MS listed in the database of the organization. The email also informed participants that all information provided by the web survey would be anonymous and in no way linked to their personal email. A follow-up email and link was sent two weeks later to these same individuals.

Measures Demographic information Age, sex, marital status, level of education, and ethnicity were obtained from single-item questions at the start of the survey. In addition, disease information such as type of MS, years post diagnosis, and disability level (mild, moderate, severe) were similarly obtained. Health belief scales and exercise The Health Belief Scales for exercise originally developed and validated by Hayslip and colleagues28 were used for the study. The instrument included five scales related to perceived susceptibility to serious health problems, perceived seriousness of health problems, benefits of exercise, barriers to exercise, and cues to action.

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Perceived susceptibility to serious health problems The susceptibility scale consists of 15 items measuring perceptions of susceptibility to diseases or negatively perceived health problems related to inactivity. Such health problems included diabetes, obesity, heart attack, stiffness and high blood pressure. Participants rated the perceived risk to develop these health problems on a 5-point scale ranging from 1 (somewhat low risk) to 5 (extremely high risk).

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exercise, perceived benefits to exercise, and cues to action were 0.90, 0.80, 0.89, and 0.87, respectively.28 In the present study, the internal consistency of the HBM scales, assessed using Cronbach’s alpha,29 ranged from 0.62 to 0.94 respectively, as seen in Table 1. These values are consistent with that reported by Hayslip and others28 and better than the reliability data of health belief constructs and exercise in other patient populations.30 Self-efficacy

Seriousness of health problems The seriousness scale contains 6 statements related to the seriousness that the unhealthy consequences of inactivity would pose for the individual. Respondents rated the perceived impact of inactivity on their life, financial consequences, and the others around them. Response values range from 1 (strongly disagree) to 5 (strongly agree). Benefits of exercise The benefits of exercise scale included 13 potentially positive outcomes associated with physical activity including feeling better psychologically, getting stronger, lower blood pressure, and reduced risk of heart disease. Individuals rated the degree of agreement concerning each benefit on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Barriers to exercise Seventeen potential barriers to physical activity are identified including not having enough time, lack of motivation, and cost. Participants rated the degree of agreement concerning these major reasons for not exercising on a 5point scale with 1 equal to strongly disagree and 5 indicating strongly agree. Cues to action For this scale, twelve possible factors are provided that might lead to an increased awareness of the need to be physically active. These factors included doctor’s recommendation, advice from family or friends, advertisements in the media, and difficulty in doing daily chores. Individuals rated the degree to which each factor cued action on a scale from 1 to 5 with 1 indicating strongly disagree and 5 indicating strongly agree. Previously reported reliability measures for perceived susceptibility to health conditions, perceived barriers to

Self-efficacy was measured with a 14-item scale that asked participants to rate how confident they were to participate in regular physical activity under various circumstances such as when on vacation, when tired, or when busy.31 Each item was rated on a scale from 0 percent to 100 percent with 0 indicating no confidence and 100 indicating absolute confidence. Physical activity Physical activity was assessed using the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD).32 The PASIPD is a seven-day recall physical activity questionnaire for individuals with physical disabilities. It asks participants to record the number of days per week and hours per day for participation in leisure time, household, and occupational physical activities over the past week. MET hrs/day are then calculated on the activity report of participants with a possible total score of 199.5 MET-hrs/day. The 13-items scale has been found to be a valid measure of physical activity for those with physical disabilities.33

Analyses The Statistical Package for the Social Sciences (SPSS version 14) was used to analyze the study’s data. Descriptive statistics and Pearson correlation analyses were performed to report the characteristics of the participants and determine the relations of the continuous variables. Two independent samples t-tests were also conducted to identify if there were differences in physical activity levels based on sex and disability level (mild vs. moderate). A stepwise multiple regression analysis was conducted to examine the most important predictors of physical

Table 1 Internal consistency and descriptive statistics of the scales for HBM and exercise (N 5 348) Scale Alpha values Mean (SD)

Study range

Possible range

Perceived susceptibility to chronic conditions Perceived seriousness of chronic conditions Perceived barriers to exercise Perceived benefits of exercise Cues to action Self-efficacy to exercise Physical activity

15e75 11e30 17e67 30e65 12e51 0e100 0.17e78.72

15e75 6e30 17e85 13e65 12e60 0e100 0e199.5

0.93 0.62 0.82 0.86 0.80 0.94 NA

45.55 21.13 42.97 52.25 31.17 61.60 22.38

(10.62) (3.21) (9.39) (6.19) (6.88) (20.904) (15.47)

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activity based solely on the constructs of the HBM. A second stepwise multiple regression within blocks analysis was then performed to analyze the most important predictors of physical activity based on both the constructs of the HBM in addition to socio-demographic variables (i.e., sex and disability level). In this analysis, the sociodemographic variables were entered first followed by the HBM constructs in order to determine the most important HBM predictors of exercise after controlling for the potential effects of sex and disability level. The probability to (variable) enter criterion was 0.05 and the probability to (variable) removal criterion was 0.10.34

Results For the regression analyses, 11 univariate and multivariate outliers were identified and excluded from the analyses. The ‘‘Mahalanobis distance through regression’’ technique was used to identify the multivariate outliers and z scores in excess of 63.29 was used as the criterion for identifying univariate outliers.34 Given that there were only ten individuals who reported their disability level to be severe, these cases were also excluded from the analyses.34 As such, a total of 348 participants were included in analysis of scale reliabilities and assessing determinants of physical activity. Participant characteristics

Table 2 Sample demographics Variable Age Years post diagnosis

Sex Male Female Disability levela Mild Moderate Marital status Married Single Divorced/separated Living together Widowed Education !College >College Ethnicity/race African American White/European American Hispanic/Latino American Middle Eastern/Middle Eastern American Other MS type Relapse-remitting Primary progressive Secondary progressive a

Table 2 highlights demographic and disability-related information of the study participants. Of the 348 participants, 291 were female and 57 were male, with a mean age of 50.32 (SD 5 11.01) years. Participants reported that they had been diagnosed with MS on average for 11.82 (SD 5 10.35) years and that the majority (75%) of them had relapse-remitting MS. Health beliefs of participants In general, participants ranged widely in their health beliefs (Table 1). Their perceptions of susceptibility to negative health outcomes associated with inactivity were leaned more toward specific outcomes regarding physical conditioning rather than general health conditions. Participants, on average, believed they were at a high risk of experiencing stiffness, a lack of strength and becoming overweight from not exercising, while only at moderate risk for experiencing a stroke or heart disease and at low risk of developing diabetes. They also believed that these unhealthy consequences of inactivity would be serious and have major consequences in their lives. More than 49% of participants reported getting stronger as a major benefit of exercise while 46% rated improved health and 45% rated feeling better psychologically as important benefits of physical activity. Conversely, socializing, mental alertness, heart disease, and high blood pressure were not rated as major benefits of exercise by

N 5 348 Mean 50.32 11.82

SD 11.01 10.35

n

%

57 291

16.4 83.6

216 122

62.1 35.1

229 48 47 17 7

65.8 13.8 13.5 4.9 2.0

114 234

32.8 67.2

7 330 4 1 6

2.0 94.8 1.1 0.3 1.7

261 25 62

75 7.2 17.8

Does not include 10 cases severe disability.

many of the study participants. Results further revealed that 65% of participants noted being too tired, 38% identified limiting health reasons, and 46% reported a lack of motivation as major barriers to physical activity. Issues related to disapproval of others, transportation, and lack of facilities were not noted as major barriers by participants. For this sample, the strongest cues to action included a doctor’s recommendation and the availability of an exercise program, while the weakest cues were related to advertisements in the media. Participants in the study were more than somewhat confident that they could overcome barriers to exercising (M 5 61% out of 100%), yet this self-efficacy for exercise varied considerably across the group (SD 5 20.90). Relationship across health belief constructs and physical activity The low correlations between components of the HBM model support that the model indeed measures independent constructs (Table 3). There was, however, a moderate association between perceived susceptibility and perceived seriousness, which, in fact, makes sense given these two variables together conceptually relate to the construct of perceived threat. There was an inverse relationship between

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Table 3 Correlations among HBM components and physical activity Variable 1 2

3

4

5

6

1. 2. 3. 4. 5. 6. 7.

0.124* 0.288** 0.253** 0.286**

0.615** 0.324** 0.245**

0.251** 0.344**

0.096

Susceptibility Seriousness Benefits Barriers Self-efficacy Cues to action Physical activity

0.503** 0.437** 0.042 0.022 0.211** 0.155**

0.384** 0.092 0.033 0.276** 0.143**

*p ! 0.05, **p ! 0.01.

barriers to exercise and self-efficacy. As self-efficacy increased, participants perceived fewer barriers to exercise. The strongest significant relationship was found between physical activity and self-efficacy. Those participants who possessed higher confidence in overcoming barriers to exercise had higher levels of physical activity. Physical activity levels In general, participants varied greatly in their level of physical activity (0.17e78.72 MET-hrs/day). Two independent samples t-tests were performed to observe any differences in physical activity levels based on sex and disability level (mild vs. moderate). Based on the results for sex, women were more active than men (Mean 5 23.53 MET-hrs/day vs. 16.51 METhrs/day, respectively) (t(346) 5 3.17, p ! 0.001). As for disability level, people with mild disability were more active than people with moderate disability levels (Mean 5 27.14 MET-hrs/day vs. 15.02 MET-hrs/day, respectively) (t(336) 5 7.45, p ! 0.001). Physical activity determinants Based on the first stepwise multiple regression analysis, the most important HBM predictors of physical activity were self-efficacy (Fchange (1, 346) 5 46.39, p ! 0.001; R2change 5 11.8%; b 5 0.34) and perceived benefits of exercise (Fchange (1, 345) 5 18.70, p ! 0.001; R2change 5 4.5%; b 5 0.22). Self-efficacy remained the strongest predictor of exercise behavior (b 5 0.29) even when benefits entered the prediction equation. The total variance explained by the two variables was 16.4%. In the second stepwise multiple regression within blocks analysis, the socio-demographic predictors were entered in block 1 and the HBM predictors were entered in block 2. The most important predictors of physical activity were disability level, self-efficacy, and perceived benefits. Disability level remained the strongest exercise predictor following the inclusion of self-efficacy and perceived benefits in the second block. In Table 4, the statistics related to this regression analysis are reported (e.g., standardized coefficients and unique variance explained). The total variance explained by the predictors was 24.8%.

Discussion Understanding the motivational foundation to be physically active in adults with MS is a necessary first step in increasing activity levels and facilitating improved health and quality of life in these individuals. In this study, specific health beliefs of participants with MS confirmed the importance of exercising for functional benefit and for improvement in disease-related impairments (i.e., strength gains).16,19 There was, however, seemingly less concern for, and perceived threat of, other chronic conditions associated with inactivity (i.e., heart disease and diabetes). The major barriers of fatigue and lack of motivation to exercise identified by participants in the study were commensurate with those found in other MS research.5,20 In fact, perceived control over MS-related fatigue has been found to notably influence exercise choices in those with the disease.35 As research has also indicated that exercise can be beneficial for managing MS-related fatigue,36 the development of knowledge and skills to reduce this and other barriers is critical to health promotion programs for individuals with MS.5,21,27 The study further confirmed previous research highlighting the influence of disability level on physical activity for people with MS,1,3,13e15 as individuals with greater levels of disability were less active compared to those with more mild functional impairment. Similar to past research,37 individuals in this study who were more active also had higher self-efficacy to be physically active and perceived greater benefits from activity participation. Self-efficacy and perceived benefits remained robust even after controlling for the effects of disability level. While the study further Table 4 HBM and socio-demographic predictors of physical activity F (df) p R2change Block 1 Disability level

14.3%

Block 2 Disability level Efficacy Benefits

10.5%

R2total

24.8%

55.86 (1336)

13.97 (1334)

b

!0.001 !0.001

0.38

!0.001 !0.001 !0.001 !0.001

0.31 0.24 0.18

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supported the importance of self-efficacy and perceived benefit on physical activity, the fact that this finding was independent of participants’ perceived susceptibility to other general health conditions or chronic disease is of importance. If individuals with MS, although functionally capable, are not physically active and do not perceive themselves to be at risk of diseases related to inactivity, they may develop a reduced tolerance to activity, become more sedentary, and further compromise their health as they age with the disease. While the present study acknowledges exercise benefits similar to those found in other MS research, the heavier emphasis on functional and conditioning specific benefits may have been due to both scale construction as well as sample demographics. For instance, the benefits scale involved multiple items associated with symptoms and functioning and only two items related to more general chronic health conditions. Additionally, the sample involved individuals who were relatively young (mean age of 50). Although speculative, it might be that these participants felt less vulnerable to or concerned with various health conditions associated with advanced age. The notion of age influencing perceptions of susceptibility to health difficulties has been seen in other research on health beliefs.28 Although there was a difference in physical activity between participants with mild and moderate disability, participants in the present study were comparably active to participants with other types of disabilities. Washburn and colleagues32 found, in their sample of participants with physical and sensory disabilities, that the MET-hrs/day ranged from 0.0 to 67.9 with an average MET-hrs/day of 20.2. In the present study, more than 75% of the participants had values greater than 32 MET-hrs/day. While these values denote lowered activity by some, it does suggest that these individuals with MS had an active lifestyle, although not necessarily involving vigorous activity. Similar to other physical activity research in MS, participants in this study accrued increased MET values with light to moderate exercise.3,14 In regard to sex, women with MS in this study were more active than the men with MS. However, the skewed distribution of men and women in the sample may have accounted for the significant gender difference found. As well, this uneven distribution may have also affected the accuracy of regression results in terms of gender being an important determinant of physical activity. It is unclear why, in the present study, cues to action were not strongly related to or predictive of activity behavior. While Hayslip et al,28 found cues to action associated with fitness-related activity participation, they acknowledged that the scale was heavily biased in favor of external cues (i.e., advise from others and advertisements) rather than internal cues (i.e., shortness of breath or difficulty climbing stairs). Although speculative, it may have been that, for this study sample, these external cues were not as relevant or meaningful and, therefore, limited in precipitating an awareness of the need to exercise. This may explain the negative relation

between cues to action and self-efficacy. In other words, although certain cues to action may not be applicable to the participants, individuals can still have high selfefficacy toward exercise participation. It may also be the case that, while a particular cue was rated high as having the potential to elicit action, specific barriers still existed thus rendering the cue ineffective. For instance, participants reported that one of the strongest cues to action would be the availability of an exercise program. However, it is difficult to ascertain whether or not such programs existed. Additionally, difficulty climbing stairs may or may not serve as a cue if stair climbing is avoided as a compensatory strategy for possessing lower extremity weakness. Therefore, the positive relationship between cues to action and exercise barriers may be explained by the possibility that individuals may interpret certain cues as important to exercise participation but still perceive high levels of particular exercise barriers. Nonetheless, research has shown that, as individuals age, they become less susceptible to, and not as strongly motivated by, cues to action.28 It is clear that more research is needed to explore which cues are most relevant to elicit physical activity in those with MS, especially given the greater focus on functional benefits and symptom management and the primary identification with MS-related health needs rather than those of the general population.

Study limitations Although the study offered insight into the health beliefs of people with MS and the association of health beliefs and physical activity in this group, findings should be considered in light of several limitations. The study sample included individuals with MS who were ambulatory, had mild to moderate disability, and may have been more active and thus willing to participate. Differences in age, disability status, and activity levels may not necessarily be representative of the general MS population. In addition, the study involved more women than men, and although typical of the MS population,38 may have contributed to the limited predictive value of gender to physical activity in this study sample. In this study, levels of physical activity were obtained though self-report of participants and may have been subject to social desirability bias and overestimation. Although the MET values obtained in the present study seemed realistic given the overall level of functioning of participants and comparability to other disability research, future research should include more objective measures of physical activity. Disability level was also self-reported by the participants themselves rather than through a formal evaluation by medical personnel or a standardized disability rating system (i.e., EDSS). Future research exploring determinants of physical activity could more objectively categorize participant level of disability or functioning and explore if determinants of physical activity differ across disability levels.

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The study found that specific health beliefs related to self-efficacy, perceived benefits, and disability level associated with physical activity. However, decisions to engage in physical activity are likely multidimensional. Research that includes other cognitive-behavioral determinants (e.g., outcome expectations) as well as considers level of physiological conditioning and co-morbidities may offer a deeper understanding of why people with MS choose to exercise.18,39 The results do, however, provide important directions for health promotion efforts aimed at increasing physical activity in those with MS. Future research could deepen the associative results of this study by evaluating the effectiveness of interventions aimed at developing knowledge regarding chronic conditions associated with inactivity and aging with the disease, reducing MSrelated barriers, and enhancing self-efficacy to exercise in order to promote physical activity and health in this population.

Conclusion Until now, little was known about the health beliefs of individuals with MS and how these perceptions underscored the physical activity decisions of those with the disease. In examining the health beliefs of people with MS, it appears that maintaining function and being conditioned may be more important motivators for physical activity than preventing chronic disease. There is preliminary evidence to suggest that individuals with MS may perceive themselves to be healthy, even within the context of their MS, and may perceive themselves not to be at any more risk of chronic disease than the general population. It is therefore prudent to design interventions aimed at educating individuals with MS about the benefits of being physically active, including future susceptibility to other chronic diseases associated with a sedentary lifestyle, and increasing self-efficacy as both have the potential to increase physical activity, improve health, and delay disability associated with declining function and advancing age. References 1. Beckerman H, de Groot V, Scholten MA, Kempen JC, Lankhorst GJ. Physcial activity behavior of people with multiple sclerosis: understanding how they can be more physically active. Phys Ther. 2010;90: 1001e1013. 2. Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult Scler. 2005;11(4):5459e5463. 3. Slawta JN, Wilcox AR, McCubbin JA, Nalle DJ, Fox SD, Anderson G. Health behaviors, body composition, and coronary heart disease risk in women with multiple sclerosis. Arch Phys Med Rehabil. 2003;84: 1823e1830. 4. Motl RW, McAuley E, Snook EM, Gliottoni RC. Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain self-efficacy and social support. Psych Health Med. 2009;14:111e124.

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