‘The positive feel’: Unpacking the role of positive thinking in people with multiple sclerosis’s thinking aloud about staying physically active

Introduction

Regular physical activity (PA) is connected with improved physical health, emotional well-being, social connection and improved quality of life in the general population (Bize et al., 2007). The benefits of PA are particularly important for people with chronic illnesses, but further research is required into how psychological processes around motivation and ‘positive thinking’ feature in the PA of people with chronic illnesses (see Beckerman et al., 2010; Hale et al., 2012).

Multiple sclerosis (MS) is a chronic illness that has a particularly complicated relationship between fatigue and perceived ability to exercise (Smith et al., 2009, 2011, 2014; Stroud and Minahan, 2009). People with MS typically experience symptoms such as co-ordination and balance loss, sensory numbing and fatigue (Bear et al., 2007), all of which can make PA more challenging. Despite these challenges, engaging in regular PA has been shown to reduce the physical impact of MS in just 3 months (Hale et al., 2013; Learmonth et al., 2013). In the longer term, Stroud and Minahan (2009) found people with MS who engaged in regular PA reported less fatigue, fewer symptoms of depression and a greater quality of life.

Although regular PA has many benefits, people with MS tend to be less active than the general population (Motl et al., 2005). It is therefore critical to understand what motivates people with MS to engage in regular PA and to keep doing so over the long-term. Dlugonski et al. (2012) found that women with MS were motivated to do PA for enjoyment, to feel good, gain a sense of accomplishment and to maintain physical capabilities. Women and men with MS may also be motivated to exercise as a means of cultivating optimism and hope (Kasser, 2009).

It is also essential to understand factors affecting PA motivation. Using a qualitative research approach, Smith et al. (2011) explored how exercise motivation was impacted by perceived control over MS fatigue. The core contributors to this perceived control are believing that (1) exercise can improve health, (2) exercise can help achieve goals and (3) fatigue is controllable. An important avenue for further exploration is how positive thinking features in those beliefs, or in an absence of those beliefs, to impact PA motivation. Based on a review of qualitative research, Hale et al. (2012) concluded that long-term engagement in PA is more likely when individuals with MS have choice over their PA, control over the type and amount of PA, and support in their decisions. A corollary of this theory is that an individual’s stage of change is an important reflection of their readiness to exercise when they have MS, as per the transtheoretical model (Prochaska, 1979). Chiu et al. (2012) found that people with MS in the action stage of change for PA have higher self-efficacy and outcome expectancy than those in a contemplative or pre-contemplative stage, but the role of positive thinking was not examined in their study. Hence, there is a need to explore whether positive thinking also distinguishes people in the stages of change and whether positive thinking could promote a more active stage of change for PA.

Thought processes, such as positive thinking, may benefit PA motivation for people with MS. Kosma et al. (2012) argued that PA interventions should first emphasise cognitive processes of change such as positive thoughts about PA, followed by behavioural strategies such as goal setting. Self-efficacy and stages of change were two of best predictors of initial PA levels over a year in a sample of people with chronic illnesses of whom 53.8 per cent had MS. However, perceived benefits, as well as cognitive and behavioural processes of change (e.g. self-reevaluation and reinforcement) were among the best predictors of PA change over the long-term. These findings point to thoughts as effective tools in garnering the motivation necessary to commit to behavioural change and highlight the need to explore kinds of thoughts that might motivate people in MS community to be more physically active. In addition, Morrison and Stuifbergen (2014) found social and physical outcome expectations explained 11.5 per cent of the variance in PA participation among individuals with long-standing MS (>15 years). However, physical, social or self-evaluative outcome expectations did not explain differences in physical capability. Morrison and Stuifbergen (2014) concluded that social and physical outcome expectations that are positive in nature may serve to enhance PA motivation in people with long-standing MS. Alongside these quantitative studies, more in-depth research exploring the perspectives of people with MS is needed, particularly whether they believe such positive thinking strategies could increase PA motivation.

Overall, thought-based practices may provide a positive addition to current strategies that aim to help people with MS increase their PA motivation. To explore this possibility, there is an unaddressed need to investigate thoughts that affect PA motivation among people with MS. One way to achieve this is by using cognitive interviewing techniques, some of which include completion of standardised questionnaires in the context of a qualitative interview (Adamson et al., 2004; Anderson-Lister and Treharne, 2014). This multi-method approach has been regarded as extremely valuable for gathering qualitative data in health research because it can provide triggers to explore complex issues (Adamson et al., 2004). One form of cognitive interviewing is called the concurrent think-aloud method. In this procedure, participants are asked to verbalise their thought processes as they read questionnaire items or respond to interview questions. In doing so, substantial insight can be gained regarding participants’ perspectives (Lundgrén-Laine and Salanterä, 2010). The think-aloud method has previously been applied to explore perceptions of people undergoing physiotherapy for various reasons (Van Oort et al., 2011), as well as people’s perceptions about health behaviours (Al-Janabi et al., 2013; Anderson-Lister and Treharne, 2014; Kaklamanou et al., 2013), walking (Darker and French, 2009) and attempting to increase PA levels (French et al., 2007). The think-aloud method has previously been used in studies of people with MS but only to assess the content validity of new questionnaires (Wicks et al., 2012) and not to provide in-depth exploration of their experiences and beliefs.

The aim of this study was to explore thoughts around motivation to be physically active among individuals with MS. A think-aloud method was used to gain an understanding of participants’ perspectives by providing a range of prompts, and we took an in-depth qualitative approach to the think-aloud data (Koro-Ljungberg et al., 2013; McGavock and Treharne, 2011). The main research question in this study was the following: How do people with MS describe their thought processes related to PA and their motivations to be physically active?

Methods

Results

Discussion

This study explored thoughts related to PA motivation in people with MS, using a think-aloud method. Four major themes were identified using inductive thematic analysis: thoughts about purpose, self-efficacy and the past, as well as reinforcement through positive thinking.

Thoughts about purpose (theme 1), or reasons for doing PA, were connected with increased PA motivation in the participants. When thinking about PA as a way to manage MS, be independent or meet commitments to others, participants were highly motivated to engage in PA. These findings fit with previous research by Smith et al. (2011), who found perceived control over MS fatigue involved beliefs that exercise could improve health and help achieve goals. Similarly, participants in this study expressed high PA motivation when they thought PA would allow them to maintain or improve their physical capabilities and help them achieve physical goals. This suggests similar cognitive processes may govern both perceived control of fatigue and enhanced PA motivation. Additionally, such processes seem to apply to both exercise and to PA more broadly. Theme 1 is also consistent with the findings of Dlugonski et al. (2012), who found one reason women with MS were motivated to do PA was to maintain physical capabilities. This study indicates that this reason for doing PA also applies to men with MS, furthering previous findings that men with MS use goal readjustment to overcome the impact of fatigue on PA levels (Smith et al., 2014). Based on theme 1, we conclude that having a clear reason to engage in PA, and thinking about that reason, may be important for enhancing PA motivation in the MS community. The purpose should be relevant and meaningful to each individual; however, key targets for intervention may centre around maintaining physical capabilities, being independent and meeting commitments to others.

Thoughts about self-efficacy (theme 2) were also important for PA motivation. Participants who believed they were capable of PA expressed strong motivation to pursue their PA goals, regardless of their actual physical abilities. This is consistent with the findings of Chiu et al. (2012), who found MS individuals in the action stage of change for PA had higher action self-efficacy than those in the contemplative stage. Moreover, one participant in the contemplative stage predicted that developing self-efficacy would help him move to a more active stage, suggesting that thoughts around self-efficacy may enhance PA motivation for people with MS. Two participants in this study referred to using self-talk, a positive thinking strategy, as a way to develop self-efficacy and help achieve their PA goals. This is consistent with research showing motivational self-talk can improve confidence during athletic activities (Goudas et al., 2006) and the proposal that positively interpreted self-talk may benefit motivation for athletes and exercisers (Hardy and Oliver, 2014). Theme 2 is also consistent with the findings of Kosma et al. (2012), who showed self-efficacy and stages of change best predicted initial PA levels; however, cognitive processes of change were among the best predictors of long-term PA engagement. Taken together with theme 2, this suggests that use of positive thinking strategies, such as self-talk, may be effective in enhancing and sustaining PA motivation for people with MS over the long-term. Although self-efficacy was important in PA motivation, participants stressed it was insufficient to change the reality of their MS symptoms. This suggests PA self-efficacy needs to be realistic and sensitive to current MS symptoms in order to be effective.

Thoughts about the past (theme 3) could enhance or diminish PA motivation, depending on the individual and the focus of the memory. One participant in this study recalls past success in PA to bolster her motivation and push herself in the moment. For another, this was not an effective strategy because it emphasised things she could no longer do. One possible reason for this is that, in the first case, the memory may help to bolster self-efficacy for present activity. In the second case, awareness on lost capabilities may diminish self-efficacy and thereby PA motivation. Based on theme 3, we conclude that thoughts about the past may enhance PA motivation for certain individuals who have a history of past success in PA. Emphasis must be given to re-experiencing those past successes rather than making comparisons with the present and drawing awareness to loss of physical capabilities. From an intervention standpoint, fostering thoughts about the past may not be appropriate for all individuals with MS.

Reinforcement through positive thinking (theme 4) demonstrated that positive thinking enhanced future PA motivation. Participants expressed that PA fuelled positive thoughts and feelings, which reinforced PA behaviour, creating a positive spiral that enhanced PA motivation. This finding is particularly interesting because it suggests PA behaviour precedes positive thinking. However, this may reflect that participants were not consciously aware of positive thoughts that preceded activity or that they were unable to recall them. The one participant who was not regularly physically active (Richard) predicted that choosing to think positively would help him move into the preparation stage of change for PA. These findings suggest positive thinking may be particularly effective in promoting PA motivation for those not yet in the action or maintenance stages of change. Once in the action stage, positive thinking may take on a reinforcing role, to help sustain PA motivation over the long-term. This fits with research by Kosma et al. (2012) who found that cognitive processes of change were among the best predictors of long-term PA change. Theme 4 also provides an extension to the findings of Chiu et al. (2012), suggesting that positive thinking may be another factor distinguishing MS individuals in the action versus contemplation stages of change for PA. Furthermore, theme 4 supports the conclusion by Morrison and Stuifbergen (2014) that positive social or physical outcome explanations may enhance PA motivation in people with long-standing MS. Based on theme 4, we conclude that positive thinking may be a useful addition to current interventions aiming to increase PA motivation and behaviour in people with MS and to help sustain this motivation over the long-term.

This study provided an in-depth exploration of participants’ experiences, revealing themes relevant to enhancing their PA motivation. One limitation of this approach was that, in focusing on depth, we used a relatively small sample size, placing constraints on the external generalisability of our findings. The central focus on the questionnaire items in the think-aloud method offers less flexibility than unstructured interviews or focus groups but is suitable for generating qualitative data (Anderson-Lister and Treharne, 2014; Koro-Ljungberg et al., 2013; McGavock and Treharne, 2011) and we applied a semi-structured version of thinking aloud that involved additional planned and spontaneous probes (Adamson et al., 2004). Some of these probes may not have been asked as openly as would have been desirable but they served to allow participants to elaborate on unexpected issues around PA and thought processes.

Future research should include quantitative measures to test whether the themes formulated apply to the wider MS community. The present findings map directly onto items 18 and 33 in a previously established taxonomy of behaviour change interventions (Michie et al., 2011). Thus, future research could also design and test the feasibility of a pilot PA intervention that incorporates positive thinking practices. Specifically, such an intervention could focus on developing purpose for PA behaviour and building self-efficacy through positive thinking strategies such as self-talk. In addition, it could involve strategic use of positive thinking to motivate inactive members of the MS community to move into a more active stage of change or to reinforce PA behaviour for people who are already physically active.

Many strategies exist to help increase PA for people with MS. The present findings support the potential of thought-based strategies to increase PA motivation. Thus, we conclude that positive thinking and related thought-based strategies may serve as useful tools to enhance motivation for PA in the MS community.