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Evidence-based
Approaches to Practice

Edited by
Lindsey Dugdill,
Diane Crone
& Rebecca Murphy

®WI LEY- BLACKWELL

 r-
l"h UOSPITA,

Physical Activity and Health Promotion:

Evidence-based Approaches to Practice

Edited by

Lindsey Dugdill
Diane Crone
and
Rebecca Murphy

LIBRARY RAMPTON HOSPITAL

fiWI LEY- BLACKWELL
A John Wiley & Sons, Ltd., Publication

R79287
This edition first published 2009
© 2009 Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Physical activity and health promotion: evidence-based approaches to practice/edited
by Lindsey Dugdill, Diane Crone, Rebecca Murphy,
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-6925-7 (pbk. : alk. paper)
I. Exercise. 2. Health promotion. 3. Evidence-based medicine. I. Dugdill, Lindsey.
II. Crone, Diane. III. Murphy, Rebecca.
[DNLM: 1. Exercise. 2. Evidence-Based Medicine. 3. Health Behavior.
4. Health Promotion. QT 255 P57215 2008]

RA781.P5615 2008
613.7—dc22
2008030013

A catalogue record for this book is available from the British Library.

Set in 10/12.5 pt Palatino by Newgen Imaging Systems Pvt. Ltd, Chennai, India
Printed in Singapore by C.O.S Printers Pte Ltd

1 2009
 Contents

Contributors ix
Foreword xii
Dedication xiv
Acknowledgements xv

Part I Concepts for the development of physical activity practice 1

1 Physical activity, health and health promotion 3

Rebecca Murphy, Lindsey Dugdill and Diane Crone

Introduction 3
Learning outcomes 4
Defining exercise and physical activity 4
Understanding the political climate 4
Physical activity prevalence and trends 5
Health and health promotion 6
Determinants of health 7
Health and health promotion - a historical perspective 8
The role of physical activity in promoting health 9
Recommendations for physical activity 10
Health promotion approaches to improving health and
physical activity 12
Summary 16
References 16

2 Influencing health behaviour: applying theory to practice 21

Lynne Halley Johnston, Jeff David Breckon and Andrew John Hutchison

Introduction 21
Learning outcomes 21
Models of behaviour change 21
Social cognition models 22
Self-determination theory 22
Stage models 23
iv Contents

The Transtheoretical Model: the dominant theoretical framework

for physical activity behaviour change ' 23
Applying the TTM 24
Criticisms of the TTM 24
A systematic review of TTM-based physical activity interventions 27
TTM or the stages of change 28
The relationship between the processes and stages of physical
activity behaviour change 29
Does a poorly applied theoretical framework influence the
efficacy of interventions? 29
Implications for practitioners: TTM 30
Treatment fidelity and the Behaviour Change Consortium (BCC)
framework 31
Physical activity counselling interventions and treatment fidelity 32
A review of physical activity counselling interventions 32
Applying treatment fidelity measures to physical activity
interventions 34
Applying treatment fidelity measures to training and delivery 35
Applying treatment fidelity measures to ensure receipt
and enactment 36
Implications for practitioners: treatment fidelity 36
Conclusion 37

References 38

3 Promoting physical activity through policy change:

art, science or politics? 43
Nick Cavill

Introduction 43
Learning outcomes 43
UK health policy on physical activity 45
Physical activity policy: everything or nothing? 46
Key issues for physical activity policy 48
The conflation of environment and policy in physical activity
literature 4g

The paucity of policy evaluations in the literature 50

Evidence-based policy or policy-based evidence? 56
Conclusions 57
References 5g

4 Developing the evidence base for physical activity interventions 60

Lindsey Dugdill, Gareth Stratton and Paula Watson

Introduction gp
Learning outcomes 53

Models of evaluation: methodological considerations 61

Evaluating interventions g2
 Contents v

An example of an evaluation framework: RE-AIM 62

Stages of evaluation 63
Stage one - planning 63
Stage two - measurement 64
Stage three - data analysis 74
Stage four - dissemination 75
Case study: Getting Our Active Lifestyles Started! (GOALS) - Phase 1 75
Conclusion: implications for practice 78
Acknowledgements 81
References 81

Part II Interventions in physical activity practice 85

5 Physical activity promotion in primary health care 87

Chris Gidlow and Rebecca Murphy

Introduction 87
Learning outcomes 87
Why use the primary care setting? 88
Exercise referral programmes (ERPs) 89
Determining the effectiveness of ERPs as a public
health intervention 90
Experimental evaluations 91
Non-experimental quantitative evaluations 93
Limitations of RCT/quantitative data - challenging the quality
of delivery 94
Qualitative evaluations 95
Health professional perspectives and partnership working 96
Case study: The ProActive exercise referral programme 97
Summary and implications for practice 100
References 102

6 Physical activity interventions in the community 110

Diane Crone and Colin Baker

Introduction 110
Learning outcomes 110
Physical activity interventions in the community: an historical
perspective in the UK 110
County Sports Partnerships: organisation and purpose 117
The Single Delivery System 118
Case study: Active Gloucestershire - an effective partnership to
increase community participation? 123
Conclusion 126
Summary and conclusion 126
References 127
vi Contents

7 Developing physically active workplaces 130

Lindsey Dugdill and Margaret Coffey

Introduction 130
Learning outcomes 131
The nature of contemporary workplaces in the UK 131
Health and ill health at work 134
A 'settings-based' approach to health at work 136
Evidence of effectiveness of workplace physical activity
interventions 138
Case study: An evaluation of the Liverpool Corporate Cup
(Evans, 2002) 141
Conclusion: implications for practice 143
References 144

8 Young people and physical activity 150

Gareth Stratton and Paula Watson

Introduction 150
Learning outcomes 150
Benefits of physical activity for young people 151
Recommended levels of physical activity for young people 152
Sedentary behaviour 153
How active are children and adolescents in the UK? 154
Fitness and fatness 156
Promoting physical activity to young people 156
Evaluating interventions 163
Case studies 164
Case study 1: Changing the environment to promote physical
activity - the sporting playgrounds project 164
Case study 2: A social-cognitive approach to promote physical
activity (through the family) - The Getting Our Active Lifestyles
Started! (GOALS) Project 166
Conclusion and implications for practice 168
Acknowledgements 169
References 169

9 Populations: older people and physical activity 174

Afroditi Stathi

Introduction 174
Learning outcomes 175
Physical activity and health: the evidence in older people 175
Prevalence of physical activity in older adults 178
Effectiveness of interventions targeting older adults 179
Theoretical frameworks 180
 Contents vii

Translating evidence to guidelines and practice 182

Implications for public health policy 184
New directions in physical activity and ageing research 185
Case study: The Better Ageing Project 187
Conclusion and implications for practice 189
References 189

10 Physical activity and mental health 198

Diane Crone, Linda Heaney and Christopher Stephen Owens

Introduction 198
Learning outcomes 198
Types of mental health problems 199
Overview of mental health services in England 200
The place of physical activity in mental health policy and services 201
Physical activity and mental health - the evidence 205
Holistic benefits of physical activity 208
Practical guidelines to date 208
Case study: Research in mental health services 209
Summary and implications for practice 211
References 212

11 International developments in physical activity promotion 218

Jim McKenna

Introduction 218
Learning outcomes 218
Physical activity levels 219
New recommendations: fitness and/or physical activity? 220
Physical activity, weight control and diabetes 222
Non-medical outcomes resulting from physical activity 223
Physical activity promotion for children and adolescents 226
Physical activity promotion in health care systems 229
Workplace physical activity promotion 232
Cost-effectiveness of physical activity 234
Conclusion: implications for practice 236
References 236

12 The way forward for physical activity and health promotion:

designing interventions for the future 245
Andy Smith with a case study from Sara Moore

Introduction 245
Reaching consensus? 246
Reaching creditability 246
Reaching further 247
viii Contents

Case study: HMPS Exercise Referral Programme 247

(By Sara Moore: National Programme Lead for Public
Health and Physical Activity and Offender Health in the
Department of Health) 247
Reaching to intervene with interventions 251
A contemporary model of interventions 251
Reaching into the future 254
Conclusion 257
References 257

Index 259
Contributors

Colin Baker, BA (Hons), MSc, Dip FTST

Colin is a PhD research student at the Faculty of Sport, Health and
Social Care at the University of Gloucestershire. His main research
interests are in evaluating methods of delivery for community sport
and physical activity initiatives and the role played by professionals in
exercise provision.

Jeff David Breckon, BSc (Hons), MSc, PGCert HE, PhD, C Psychol
Jeff is senior lecturer in exercise psychology at Sheffield Hallam
University. He is a member of BASES, the BPS and the Motivational
Interviewing Network of Trainers. He has published internationally
in physical activity counselling and has over 14 years experience of
physical activity referral schemes across the UK.

Nick Cavill, BA (Hons), MPH

Nick is an independent health promotion consultant, a research associ¬
ate of the University of Oxford BHF Health Promotion Research Group,
an associate of the BHF National Centre for Physical Activity and Health
at Loughborough University and honorary senior research fellow,
University of Salford. He specialises in the development of policy and
programmes on physical activity and sport and sustainable transport.

Margaret Coffey, BA (Hons), PhD

Margaret is a senior lecturer in Health at Liverpool Hope University.
She is a member of the Institute of Health Promotion & Education and
the UK Public Health Association. Her main research interests are on
the impact of the work environment on stress, health and well-being.

Diane Crone, BSc (Hons), PhD

Diane is reader in exercise science at the Faculty of Sport, Health
and Social Care at the University of Gloucestershire and is a BASES
accredited exercise scientist (support and research). Her main research
interests and activities are in the evaluation of exercise referral schemes
and the holistic role of physical activity for people with mental health
problems.
x Contributors

Lindsey Dugdill, BA (Hons), MA, MPhil, PhD

Lindsey is reader in exercise and health at the University of Salford.
She worked (1993-2000) as research advisor on the Health Education
Authority's Health at Work in the NHS programme and has been a
consultant for the World Health Organization publishing work on
health evaluation. Her current research focuses on physical activity
promotion in all community settings.

Chris Gidlow, BSc (Hons), MSc, PhD

Chris is a researcher within the Centre for Sport and Exercise Research
at Staffordshire University. His main research interests and activities are
in exercise referral, children's physical activity, and more recently, the
relationship between physical activity and the environment.

Linda Heaney, MBBS, LLM, MRCPsych

Linda Heaney is a consultant psychiatrist working in a Support and
Recovery Team in Bristol. She is keen to promote physical activity as
part of a holistic approach in working towards recovery in mental
health problems.

Andrew John Hutchison, BSc (Hons), MSc

Andrew is a doctoral student at Sheffield Hallam University. His
research interests are centred around physical activity behaviour
change. His PhD is using a grounded theory methodology to investigate
how people make long-term behavioural changes to their physical
activity habits.

Lynne Halley Johnston, BA (Hons), MSc, PhD, CPsychol

Lynne is a chartered psychologist (BPS), an Accredited Sport and
Exercise Psychologist (BASES), and a recognised trainer in Motivational
Interviewing (MINT). She has supervised several PhD students and
published internationally on physical activity promotion. Formerly a
reader in exercise psychology, at Sheffield Hallam University, she is
currently completing her second doctorate in Clinical Psychology at
Newcastle University.

Jim McKenna, BHum (Hons), MPhil, PhD

Jim is professor of physical activity and health at Leeds Metropolitan
University and is head of the Active Lifestyles research centre. He pub¬
lishes extensively and was a scientific contributor to the Chief Medical
Officer's Report (2004). He researches workplace and community inter¬
ventions, currently focusing on ageing and health literacy.

Sara Moore
Sara Moore is the programme lead for Public Health and Physical
Activity, Offender Health, Department of Health. This work involves
her in policy development as well as operational implementation. Sara
is a Fellow of the Royal Institute of Public Health.
 Contributors xi

Rebecca Murphy, BSc (Hons), PGCert, LTHE, PhD

Rebecca is lecturer in exercise and health at Liverpool John Moores
University, on the BSc Physical Activity, Exercise and Health degree
programme. Rebecca's doctoral work investigated the effectiveness
of an exercise referral programme using key stakeholder perspectives
(participants, exercise professionals and health professionals).

Christopher Stephen Owens, BSc (Hons), PGCert, MSc (Res)

Christopher is a PhD student in the Faculty of Sport, Health and Social
Care at the University of Gloucestershire. His main research interests
are around sport and physical activity participation in adolescents and
the place and promotion of well-being for service users within mental
health services.

Andy Smith, BA (Hons), PhD, FBASES

Andy is the director of Institutional Advancement at York St John
University. He is a professor of exercise and sports science and was
made an Honorary Fellow of BASES for his 'exceptional contribution'.
Andy has written extensively on physical activity. His current interests
are rehabilitation from neurosurgery and futurology.

Afroditi Stathi, BSc (Hons), MSc, PhD

Afroditi is a lecturer in exercise psychology in the School for Health
at the University of Bath. Her research focuses on two inter-related
themes: the relationship between physical activity and well-being,
particularly in older adults, and the effectiveness of physical activity
interventions.

Gareth Stratton, BHum (Hons), PGCE, MPhil, PhD

Gareth is professor in paediatric exercise science at Liverpool John
Moores University. He chairs the Research into Exercise, Activity and
Children's Health (REACH) Group and the National Institute for
Health and Clinical Excellence group, currently writing national
guidelines for physical activity in young people. His current reseach
involves evaluating physical activity interventions in children and
adolescents.

Paula Watson, BSc (Hons), MSc

Paula is principal researcher on the GOALS project at Liverpool John
Moores University, working with agencies across the North-West of
England to develop and evaluate a family-centred lifestyle interven¬
tion for obese children. Paula's research interests lie in the psychoso¬
cial process of adopting and adhering to a physically active lifestyle,
particularly in the role played by the family in children's experiences
of activity.
Foreword

This book must be placed in the context of contemporary lifestyles, the

widely varying physical activities of people and the morbidities asso¬
ciated with long-term sedentary behaviour. Among the disorders due
to an imbalance between daily energy intake and energy expenditure
are the cardiovascular diseases, metabolic syndrome, overweight and
obesity, mental health problems and certain forms of cancer - the list is
long and the evidence for a link is well established. Yet denial is a com¬
monplace reaction of individuals in the community at large, solutions
are offered but the problems persist or are getting worse. The increased
prevalence of obesity across developed countries, and through the
lifespan from childhood, is on a scale that causes bewilderment with
regard to how easily humans can activate a virtual self-destruct but¬
ton. Defective genes, conspicuous consumption, fast-food facilities, and
sloth have all been in the firing line but the causes and remedies are
complex. We need to have a better understanding of these causal phe¬
nomena if this adverse trend is to be halted and reversed. The content of
this book should go some way towards developing this understanding
from individual to societal levels and to providing frameworks within
which solutions may be implemented and evaluated.
It is clear that physical activity and exercise programmes have a
role to play alongside nutrition and habitual activity patterns in both
disease prevention and health promotion. The gains are manifold,
ranging from benefits of self-satisfaction and personal worth to the
workplace benefits of enhanced mobility, fitness status and improved
weight control. Yet for those who might gain most health-wise from
activity programmes, compliance is a persistent and obdurate chal¬
lenge. It is a truism that humans are reluctant to change, particularly
from a passive lifestyle that encourages indulgence. In this text various
theories of behaviour change are considered and placed in the context
of. exercise as a public health intervention.
The editors have done a remarkable job in pulling together the
expert contributions from different authors in order to draw out the
many contemporary issues associated with promoting healthy lifestyles.
 Foreword xiii

They accommodate a range of perspectives including medical and

non-medical models of health and place a number of current policies
and initiatives in context. The interdisciplinary nature of the text
enhances its readability, with explanations of the social and political
milieu for different schemes. The material is supported by a comprehen¬
sive evidence base and augmented by illustrations where appropriate.
The book should be a valuable learning resource for a range of
health professionals and students with an interest in physical activity
and exercise. The former includes personnel employed in various guises
as health promotion specialists. The latter includes those working
towards academic qualifications in health studies, exercise and health,
sport and exercise sciences, physiotherapy and related disciplines. It
should be an essential reference for those engaged in health-related
projects and for healthcare professionals and their peers in community
schemes. All of these readers should benefit from the information pro¬
vided in this text as well as gain inspiration from the enthusiasm and
commitment of the contributors to this book. It is a landmark volume
which is authoritative and informative.

Thomas Reilly, BA, Dip PE, M Sc, PhD, DSc,

DHC, F Erg S, FI Biol, FRSM

Director, Research Institute for Sport and Exercise Sciences,

Liverpool John Moores University
Dedication

To our parents with dearest love and thanks to Tom Reilly, a much
valued friend, colleague and mentor
Acknowledgements

The editors would like to thank everyone who has supported the
production of this book. Firstly, the contributors - for their wide-ranging
expertise, enthusiasm and engagement with the material for this book.
It would not have been possible without their dedication to the task and
for that we are very grateful.
Secondly, the publishing team at Wiley-Blackwell, including Amy
Brown, who have made the process both enjoyable and enlightening.
To colleagues and in particular, Linzi Mackie at University of Salford,
for technical support.
To our families who have, as always, supported us throughout the
process of writing this book. It is their love and support that makes all
things possible.
Finally, very sincere thanks to all the practitioners, professionals, gen¬
eral public and students whom we have worked with. The contribution
of each individual has helped to shape our interest and understanding of
physical activity and its promotion in the community.
I
Part I Concepts for the
development of physical
activity practice

Part I consists of four chapters: Chapter 1 provides an introduction

to physical activity promotion by presenting definitions, explanations
and health promotion approaches to improving health. Chapter 2
presents a critical appraisal of health behaviour theory and provides
a contemporary perspective for practice. In Chapter 3 the importance
of policy and the political context of physical activity promotion is
analysed. Chapter 4 concludes the section with an explanation of the
process of evaluation to guide the reader through key principles of
intervention evaluation.
 1 Physical activity, health and
health promotion
Rebecca Murphy, Lindsey Dugdill and Diane Crone

Introduction

Physical activity research has clearly established the link between

inactivity and poor health status in populations (United States
Department of Health and Human Services, 1996; Department of
Health, 2004 a,b,c; Department of Health, 2005). In addition, it is
widely accepted that population physical activity levels in the UK are
lower than that recommended for ensuring optimal health. Physical
inactivity is becoming an issue of extreme public health impor¬
tance to all health professionals and agencies within the UK, across
Europe and in other Western industrialised countries. A range of
global and international health policies outline the significance
to public health of promoting healthy lifestyles in the twenty first
century (Department of Health, 2004a, 2008; World Health Organi¬
sation [WHO], 2004; Wanless, 2004; Hillsdon et al., 2004). In the
UK, physical activity is cited as a key intervention to tackle many
health problems (Department of Health 2004a). The Department of
Health has a joint public service agreement with the Treasury, the
Department for Education and Skills and the Department for
Culture Media and Sport (DCMS, 2002) to halt the year-on-year rise
in obesity among children under 11 by 2010, in the context of a broad¬
er strategy to tackle obesity in the population as a whole (Dugdill
and Stratton, 2007; Department of Health, 2008). In addition, the
importance of physical activity as a risk factor for coronary heart
disease is increasingly being recognised throughout Europe (Health
Enhancing Physical Activity Guidelines [HEPA], 2000) and beyond
(WHO, 2004).
Physical activity is a key component to maintaining a healthy
lifestyle for all individuals. To assist in contextualising the significance
of physical activity promotion to public health, this chapter outlines
and considers definitions of health and health promotion, health trends,
and current recommendations for physical activity within health
promotion.
4 Concepts for the development of physical activity practice

Learning outcomes

The aims of this chapter are to:

1. define concepts of physical activity, exercise, health and health promotion

2. introduce relevant policy drivers
3. describe current trends in physical activity participation
4. introduce concepts and determinants of health and health promotion
5. explain the public health importance of physical activity promotion
6. outline approaches to physical activity promotion in the UK

Defining exercise and physical activity

Physical activity is defined as any bodily movement produced by

skeletal muscles that results in energy expenditure (Caspersen et al., 1985).
It has dimensions of Volume (how much), duration (how long), frequency
(how often), intensity (how hard) and mode (what type)' (Cale and
Harris, 2005, p. 7). It is, therefore, a multi-faceted, complex and broad¬
ranging behaviour that may encompass activities of daily living (house¬
work, gardening, stair climbing), occupation-related activity completed as
part of one's job (walking, hauling, lifting and packing), transportation
physical activity [walking, biking or wheeling (for wheelchair users), to
and from places)] also known as active travel or transport, leisure time
activity (exercise, sports recreation or hobbies), or engagement in specific
prescribed interventions (Dugdill and Stratton, 2007). Exercise is consid¬
ered a subset of physical activity which includes planned, structured, and
repetitive bodily movement which is undertaken to improve or maintain
one or more components of physical fitness (Casperson et al., 1985).

Understanding the political climate

In recent years, the Chief Medical Officer has collated and summarised
the scientific evidence on the contribution of active living to promot¬
ing health and well-being across the lifespan (Department of Health,
2004b). Evidence suggests that increasing physical activity participation
could significantly contribute to the prevention and management of
over 20 diseases and conditions. In addition it is estimated that the cost
of inactivity in England could be £8.2 billon annually (DCMS, 2002).
In recent years various targets for increasing participation levels in
sport and physical activity have been proposed. These include a tar¬
get to increase participation levels to 70% of individuals undertaking
30 minutes of physical activity 5 days a week by 2020 (DCMS, 2002),
and a less ambitious target of an increase in participation to 50% by 2020
 Physical activity, health and health promotion 5

(Wanless, 2004) (see also Chapters 3 and 6). Physical activity promotion
was a key target of the Public Health White Paper Choosing Health:
Making Healthier Choices Easier (Department of Health, 2004a).
Furthermore, Choosing Activity: A Physical Activity Action Plan
(Department of Health, 2005) outlined the action that needs to be tak¬
en in order to promote physical activity in the UK, and documents
Government priorities for physical activity promotion in the form of
cross-departmental Public Service Agreement Targets, which are:

' To halt the year-on-year increase in obesity among children un¬

der 11 by 2010, in the context of a broader strategy to tackle obesity
in the population as a whole.

By 2008, increase the uptake of cultural and sporting opportuni¬

ties by adults and young people aged 16 and above from priority
groups by increasing the number of people who participate in
active sports, at least 12 times a year by 3% and increasing the
number who engage in at least 30 minutes of moderate intensity
level sport, at least 3 times a week by 3%.

Enhance the take-up of sporting opportunities by 5-16 year olds

so that the percentage of school children in England who spend a
minimum of two hours each week on high quality PE and school
sport, within and beyond the curriculum, increases from 25% in
2002 to 75% by 2006 and 85% by 2008 in England, and at least 75%
in each school sport partnership by 2008'.
(Department of Health, 2005, p. 7)

Physical activity prevalence and trends

Worldwide, 60% of the population are insufficiently active to benefit

their health (WHO, 2004) and physical activity levels in the UK are
exceptionally low (Department of Health, 2004b); e.g. only 21% of the
adult population are regularly participating in sport or recreational
activity (defined as taking part, on at least 3 days a week, in moderate
intensity sport and active recreation, for at least 30 minutes continu¬
ously in any one session) (Sport England, 2006). Variation in participa¬
tion exists according to demographic variables. More males (37%) than
females (25%), residing within the UK, attain current recommended
activity guidelines (Department of Health, 2004c), participation
declines with age for both men and women and, compared with the
general population, men from certain ethnic groups (Indian, Pakistani,
Bangladeshi and Chinese) are less likely to meet physical activity recom¬
mendations (Department of Health, 2004c). According to the National
Travel Survey (Department for Transport, 2001) between 1975-1976 and
6 Concepts for the development of physical activity practice

1999-2001 average miles travelled by foot and bicycle had decreased

by approximately 26%. In contrast, participation levels in selected lei¬
sure time physical activity such as walking, swimming and keep-fit/
yoga were reported to have increased or at least remained the
same between 1987 and 1996 (Department for Transport, 2001). In
conclusion, therefore, over the past 20-30 years it seems that there has
been a significant decrease in physical activity as part of daily routines
and a small increase in activity during leisure time.

Health and health promotion

Health is a multidisciplinary concept, which encompasses states of

both positive and negative well-being. Definitions of health arise from
different perspectives, and as such, broad variations exist (Lucas and
Lloyd, 2005). Historically, definitions have evolved with social change:

'The rising expectations of the past 150 years have led to a shift
away from viewing health in terms of survival, through a phase of
defining it in terms of freedom from disease, onward to an empha¬
sis on an individuals ability to perform daily activities, and more
recently to an emphasis on positive themes of happiness, social and
emotional well-being, and quality of life'. (Lindau et al., 2003, p. 3)

In 1948 the World Health Organisation defined health as 'a complete state
of physical, mental and social well-being, and not merely the absence
of disease or infirmity' (cited in Nutbeam, 1998, p. 351). This definition
encapsulates health as both a positive and holistic concept emphasising
physical, mental and social elements. In contrast, biomedical models of
health propose a negative definition, through which health is defined as
freedom from disease, dysfunction or injury (Naidoo and Wills, 2000). In
historical terms biomedical definitions of health were commonly adopted
during the nineteenth and twentieth centuries, during which time the
predominant focus of public health was to control disease and infec¬
tion. Despite more recent acceptance of the holistic concept of health,
arguably, the biomedical perspective remains the favoured definition
adopted by health care professionals in the UK (Ewles and Simnett, 1999).
In addition to biomedical and holistic approaches to defining health,
Keleher and Murphy (2004) also outline sociological, socio-ecological,
lay and health promotion approaches to understanding health.
The complexity of the concept of health is further evident when
considering the various dimensions of health. Viewed from a holistic
perspective, health can be experienced from a range of inter-related
and interdependent dimensions, including physical, mental, emo¬
tional, social and spiritual (Ewles and Simnett, 1999), as such complex
 Physical activity, health and health promotion 7

states of health can co-exist. Physical and mental health, arguably

the most commonly described dimensions of health, are concerned
with the mechanistic function of the body and the ability to think clear¬
ly and coherently, respectively. Emotional and social health are closely
related to mental health and refer to the ability to recognise emotions
and the ability to make and maintain relationships. Spiritual health
is concerned with feeling at peace with oneself and the quality of
'innermost' feelings.

Determinants of health

Health is shaped by multiple factors including personal lifestyle and

the social, cultural and physical environment within which a person
exists. The multi-layered model of factors determining health status
(Dahlgren and Whitehead, 1991) represents the inter-related nature of
the determinants of health (Figure 1.1). At the centre of the model are
non-modifiable (fixed determinants) factors such as age, gender and
genetics. Extending from the centre of the model are layers of influence
that are potentially modifiable (variable determinants) by manipula¬
tion of either the environment or individual behaviour. The inner most
layer represents individual lifestyle factors such as physical activity or
dietary behaviour. Elements of the social environment include fam¬
ily structure and social networks and the final outer layer represents
physical environmental conditions that have been linked to health.

The main determinants of health

Figure 1.1 The social determinants of health as illustrated by Dahlgren and

Whitehead (1991a,b). Reproduced with permission.
8 Concepts for the development of physical activity practice

which include the provision of public services such as education,

housing and healthcare. This model recognises the importance of the
broader social, cultural and environmental determinants of health, and
their inter-relationship with lifestyle choices of individuals.

Health and health promotion - an historical perspective

Expressed in terms of measurable biological outcomes, i.e. morbidity

(disease) or mortality (death) rates, significant improvements in pop¬
ulation health and well-being have been experienced. Such improve¬
ments have been attributed to rising standards of living (Department
of Health, 2004a), advances in science, medicine and technology, and
suppression of the incidences of infectious diseases, in developed
countries (Naidoo and Wills, 2000). Over the last 50 years, global life
expectancy at birth has increased by approximately 20 years, from
46.5 years in 1950 to 65.2 years in 2002 (WHO, 2003). In the UK, in 2004,
female life expectancy was 81.1 years, for males 76.7 years (ONS, 2006).
Increased life expectancy is not, however, synonymous with healthy
life expectancy. Primarily as a consequence of non-communicable dis¬
eases individuals experience a significant number of unhealthy years at
the end of life. Healthy life expectancy in the UK is currently 69.9 years
and 67.1 years for females and males, respectively (ONS, 2006). In both
developed and developing countries, non-communicable diseases
represent 60% of the global disease burden (WHO, 2006). For example,
circulatory diseases and cancer are the two most common causes of
death and disability in the UK. Furthermore, coronary heart disease,
diabetes and stroke are the most common illness to impair quality of
life (ONS, 2006). In developed countries, therefore, a large proportion
of illness and deaths can be attributed to a small number of lifestyle-
behavioural risk factors, unhealthy diet, tobacco usage, physical
inactivity and alcohol abuse (Wanless, 2004).
Health promotion has emerged as an increasingly important
academic and professional multi-discipline (Ewles and Simnett,
1999). Measures designed to enhance health include health education
(lifestyle and preventative) approaches alongside environmental
(policy and fiscal) measures (Tones, 2001). The foundations of health
promotion have emerged from the specialist areas of public health
and health education (Edmonson and Kelleher, 2000). Public health is
defined as The science and art of preventing disease, prolonging life and
promotinghealth through the organised efforts of society' (Nutbeam, 1998,
p. 352). In the nineteenth century, public health action was primarily con¬
cerned with the improvement of living conditions and infectious disease
control with a focus upon better housing, education and sanitation.
In contrast health education, when introduced in the 1960s, was
 Physical activity, health and health promotion 9

primarily concerned with individual responsibility for health and

illness and arose as a result of increasing lifestyle related diseases and
the subsequent requirement to convey information regarding personal
health behaviours (Egger et al., 1999).
Health promotion emerged in an attempt to overcome the limited
focus of both public health and health education on individual health
behaviour, and recognised the importance of addressing environmental
as well as individual (behavioural) determinants of health (Tones and
Green, 2004). A wide range of actions constitutes the multi-disciplinary
nature of health promotion practice (Rootman et al., 2001); and since its
inception, broad ranges of health promotion definitions have emerged
(Rootman et al., 2001). Explanations of health promotion action are un¬
derpinned by the different meanings attached to the concept of health,
including considerations of the determinants of health (Naidoo and
Wills, 2000). For example, WHO define health promotion as 'the process
of enabling people to increase control over, and to improve, their health'
(Ottawa Charter, 1986, p. 2).
Health promotion therefore includes the strengthening of individ¬
ual capabilities to influence economic, societal and political actions
in order to impact on public health (Naidoo and Wills, 2000). This is
reflected in the Ottawa Charter (1986), a seminal document in the
emergence and development of health promotion, which outlined
five inter-related action areas for health promotion interventions,
including: (1) building healthy public policy, (2) creating supportive
environments, (3) strengthening community action, (4) developing
personal skills and (5) reorienting health services.
The principles of, and strategies for health promotion can be applied
to a variety of population groups (e.g. older people), risk factors
(e.g. hyperlipidaemia), diseases (e.g. coronary heart disease) and
settings (e.g. inner city areas) (O'Byrne, 2000). Over the past 10 years
physical activity has become increasingly recognised as an activity
that has positive health benefits in both treatment and prevention of
ill health. As a consequence, physical activity exists within the context
of health promotion and it is not unusual, for example for a primary
care trust (PCT) to have a lead health professional, who has a remit for
the strategic promotion of physical activity.

The role of physical activity in promoting health

The benefits of physical activity in health promotion and disease

prevention are widely established and extensively documented (United
States Department of Health and Human Services, 1996; Department of
Health, 2004 a,b). Increasing levels of chronic, lifestyle-related diseases
are causing concern for healthcare and other professionals in the UK
10 Concepts for the development of physical activity practice

(National Institute of Health and Clinical Excellence [NICE], 2006).

Furthermore, physical activity has a known positive relationship with
these chronic conditions for prevention, treatment or in the management
of diseases (Biddle et ah, 2000; Department of Health, 2004a). There is
considerable evidence to indicate that individuals who are more physi¬
cally active suffer from reduced morbidity and mortality from a wide
range of diseases. Adults who are physically active have a 20-30%
reduced risk of premature death and up to 50% less chance of devel¬
oping major chronic diseases (Department of Health, 2004a). The ben¬
efits of physical activity are also experienced across the life course. In
children, engagement in physical activity results in amelioration of risk
factors for disease (Department of Health, 2004a); and in adults, it pro¬
vides protection against the diseases themselves. For both adults and
children, participation in physical activity can result in improvements
in musculoskeletal health and can have a significant impact upon
mental well-being. Evidence (Department of Health, 2004a) outlines the
beneficial effect of exercise in relation to approximately 20 specific dis¬
eases. In particular, physical activity has a key role to play in the preven¬
tion of coronary heart disease, type II diabetes, and various cancers, for
example colon cancer. Furthermore, there is evidence of a dose-response
relationship for such diseases (Department of Health, 2004a).

Recommendations for physical activity

Public health recommendations for health-related physical activity, in

adults, is 30 minutes of at least moderate intensity physical activity a
day, on 5 or more days per week (Department of Health, 2004a,b). This
advice is outlined for general health benefits across a wide range of
diseases (Department of Health, 2004a,b), and may be achieved through
structured bouts of exercise, or alternatively through physical activity
that is integrated into daily life. In addition, 30 minutes may be achieved
in one complete session or alternatively through several shorter bouts
of 10 minutes or more (Murphy et ah, 2000). The aforementioned guide¬
lines supplement the more vigorous exercise training-physical fitness
(Haskell, 1994) guidelines of continuous aerobic activity, on 3-5 days
per week at a vigorous intensity for 15-60 minutes per session
(American College of Sports Medicine [ACSM], 1990).
ACSM (2007) have recently reviewed their guidelines for physi¬
cal activity and public health and they currently recommend that
healthy adults (under age 65) should participate in moderately intense
cardio (aerobic) activity for at least 30 minutes a day, 5 days a week,
or do vigorously intense cardio activity for 20 minutes a day, 3 days a
week. In addition 8-10 strength training exercises should be performed,
with 8-12 repetitions of each exercise, twice a week. The 30-minute
 Physical activity, health and health promotion 11

recommendation is for the average healthy adult to maintain health

and reduce the risk for chronic disease; however, in order to lose weight
or maintain weight loss, 60-90 minutes of physical activity may be
necessary. ACSM explicitly state that 'The new recommendation empha¬
sizes the important fact that physical activity above the recommended
minimum amount provides even greater health benefits. The point of
maximum benefit for most health benefits has not been established but
likely varies with genetic endowment, age, sex, health status, body com¬
position and other factors. Exceeding the minimum recommendation
further reduces the risk of inactivity-related chronic disease' (2007).
ACSM (2007) physical activity guidelines for adults aged over 65
(or adults aged 50-64 with chronic conditions, such as arthritis) state
that they should participate in moderately intense aerobic activity for
at least 30 minutes a day, 5 days a week or do vigorously intense aerobic
activity for 20 minutes a day, 3 days a week. In addition 8-10 strength
training exercises should be performed, with 10-15 repetitions of each
exercise, twice or thrice a week. Adults at risk of falling are recommended
to perform balance exercises and develop a physical activity plan with
the advice of a health professional. Strength training is recognised as
being 'important for all adults, but especially so for older adults, as it
prevents loss of muscle mass and bone, and is beneficial for functional
health' (ACSM, 2007).
The decision to recommend moderate as opposed to vigorous
intensity physical activity at a population level is twofold. Firstly,
unacquainted vigorous physical activity is potentially hazardous for
previously sedentary individuals, and secondly, from a behavioural
perspective, it may be difficult to encourage a previously sedentary
individual to engage in vigorous physical activity (Hardman and
Stensel, 2003).
Although these broad recommendations are helpful, the recom¬
mended frequency, intensity and duration can be varied according
to specifically desired health outcomes. Adult recommendations for
health enhancing physical activities are appropriate for elderly indi¬
viduals, with additional activities encouraged to promote strength,
co-ordination and balance. Children are recommended to accumulate
60-90 minutes of daily moderate to vigorous physical activity and,
in addition, participate in activities, twice weekly, that improve and
maintain muscular strength, flexibility and bone health (Anderson
et al., 2006). However, despite this there is limited evidence regarding
the dose-response relationship and specific health outcomes (Hardman
and Stensel, 2003). For example, it is widely accepted that the aforemen¬
tioned health-enhancing guidelines are insufficient in the prevention
of weight gain or maintenance, and therefore, for obesity prevention it
is recommended that adults participate in 45-60 minutes of at least
moderate physical activity each day (Saris et al, 2003).
12 Concepts for the development of physical activity practice

Health promotion approaches to improving health and physical activity

■>

In acknowledgment of the clearly established link between inactivity

and poor health status in populations, physical activity promotion
has been the target of health promotion interventions, strategies and
actions. In order to effectively promote physical activity, it is necessary
to have an appreciation of the factors that influence participation. Physi¬
cal activity behaviour has been linked to an extensive range of correlates
(Sallis and Owen, 1999; Sallis et al., 2000). A review conducted by Sallis
and Owen (1999) summarised approximately 300 studies of physical
activity determinants, within which the following categories of deter¬
minants were proposed demographic and biological factors (e.g. age,
education, gender, marital status, income); psychological, cognitive and
emotional factors (e.g. attitudes, intention to exercise, self-efficacy, per¬
ceived health or fitness); behavioural attributes and skills (e.g. activity
history during adulthood, type A behaviour pattern); social and cultural
factors (e.g. group cohesion, physician influence, social support); physi¬
cal environment factors (e.g. access to facilities) and physical activity
characteristics (intensity, perceived effort). Correlates can, therefore,
exist at the level of the individual or the environment (social or
physical). Correlates associated with physical activity have been identi¬
fied within all categories, the most consistent of which include enjoy¬
ment of exercise, self-efficacy, social support and perceived access to
facilities. However, most research on the correlates of physical activity
has focused upon individual level psychological and social variables
(Gorely, 2005).
Knowledge of physical activity correlates is important since
methods of physical activity promotion must be linked to explanations
and understandings of factors that influence exercise behaviour. In this
sense, unmodifiable correlates can be used to identify target popula¬
tions who are least likely to engage in physical activity. Similarly, modi¬
fiable correlates can be used to identify specific strategies and actions
that are used to intervene with such populations. Correlates can vary in
strength in different population sub-groups and for different modes of
physical activity, and therefore different intervention strategies must be
used for different populations.
A broad range of approaches have been utilised to increase activity
amongst different populations and in different settings. These
include informational, behavioural/social and environmental/policy
approaches (Kahn et al., 2002). Interventions to promote physical
activity have been variously described, in health promotion terms, such
approaches can be broadly categorised as individualist or structuralist
in nature (MacDonald and Bunton, 1992). The approach utilised will
be dependent upon assumptions regarding the factors that influence
physical activity behaviour (i.e. individual or environmental).
 Physical activity, health and health promotion 13

Individual approaches to physical activity promotion emphasise

the importance of cognitive antecedents of behaviour change, and
consequently focus upon understanding and modifying the psychol¬
ogy of the individual. Intervention strategies that are synonymous
with such an approach focus upon individual behaviour change.
Interventions are delivered in a structured format and typically
involve face-to-face training or counselling by a health or fitness
professional. Techniques to change behaviour may involve fitness
testing, health risk assessments, health education and cognitive
behavioural-change techniques such as self-monitoring, goal setting
or decisional balance. Cognitive behavioural interventions are derived
from theories that reflect psychology and social psychology. The most
dominant theories that have been applied to the promotion of physi¬
cal activity include Social Cognitive Theory (Bandura, 1986); Theory
of Reasoned Action/Planned Behaviour (Fishbein and Azjen, 1975;
Azjen, 1991); the Transtheoretical Model (Prochaska and DiClemente,
1983) and the Health Belief Model (Rosenstock, 1966). The aforemen¬
tioned theories focus upon understanding cognitions as mediators of
behaviour and behaviour change. Social Cognitive Theory and the
Transtheoretical Model demonstrate the importance of self-efficacy
to predicting behaviour change. The Theory of Reasoned Action
proposes that exercise behaviour is predicted by intention to engage in
such behaviour which is in turn is influenced by attitudes and social
norms. The key components of such models are located at the level
of the individual. This approach consequently leads to an individual
approach to health promotion (Becker, 1992).
It has been suggested that behaviour change needs to take place at
a societal level, as well as an individual level, and long-term patterns
of healthy behaviour established if real health gains are to be experi¬
enced at a population level. Radical changes to the environment, both
cultural and structural, may be required if significant shifts in popula¬
tion physical activity levels are to be achieved (Sallis and Owen, 1999).
Socio-ecological models of health purport that health behaviours and
health outcomes represent the result of the reciprocal relationship
between individuals and their environments (Cohen et al, 2000; McLaren
and Hawe, 2005). The general argument therefore is that environments
restrict behaviour by promoting and demanding certain actions and
discouraging or prohibiting other actions (Sallis et al, 1998). Such mod¬
els are holistic and multi-level, that endeavour to understand behaviour
at a variety of levels. Five levels of behavioural determinants are
specified; these include intrapersonal factors, interpersonal processes,
institutional factors, community factors, and public policy (McLeroy
et al, 1988). In contrast to the individually orientated, structured
approach of social cognitive models, ecological models of behaviour
change endorse the use of environmental or policy approaches to
14 Concepts for the development of physical activity practice

behaviour change (see also Chapter 2). Indeed, environmental

approaches to public health promotion have proven successful in leg¬
islation for seat belt use and, more recently, tobacco control. However,
such approaches have rarely been applied in chronic disease control
and, in particular, the promotion of physical activity (Sallis et ah, 1998).
Sallis and Owen (1999) have previously discussed the importance
of the concept of socio-ecological models in understanding and pro¬
moting physical activity behaviour. Environmental interventions to
promote physical activity must consider the influence of natural and
constructed environments upon behavioural choice. In addition, policy
interventions to promote physical activity may be related to incentives
for activity (such as subsidised health club membership for employees)
or resources and infrastructure for physical activity (such as provision
of greater funding for walking and biking routes). Ecological models
provide a general framework for explaining behaviour, and therefore
this approach embraces models and theories that have focused upon
individual level correlates of behaviour. Such models have moved the
agenda for physical activity promotion away from a focus on individual
behaviour change alone (which has had limited success) to a broader
focus on the environmental structures and policies to promote physi¬
cal activity. Socio-ecological approaches focus on the importance of
the inter-connections between individuals, their environment and the
subsequent impact on behaviour.
Physical activity promotion requires understanding of the scien¬
tific theory of exercise and health promotion from a multi-disciplinary
(i.e. psychological, behavioural, social and physiological) perspec¬
tive. Traditionally, health and physical activity research and practice
have focused upon the natural science paradigm (e.g. physiological
change of individuals) rather than social science paradigm (e.g. psycho¬
social factors such as social support) (Crone et ah, 2004). This is reflected
in the predominance of individualistic approaches to physical activity
promotion that advocate the philosophy of individual responsibility
for, and personal control over, health (King, 1991).
Despite the advantages of such approaches, (e.g. they provide a
convenient method of physical activity promotion with a range of
strategies available to health and exercise professionals), there is
increasing recognition of the limitations, and large resource implica¬
tions, of using such interventions alone in order to improve population
physical activity levels. Individual approaches have been further
criticised from a behavioural change perspective. Despite recognition
of the value of regular physical activity amongst population groups,
there is evidence to suggest that such positive beliefs do not trans¬
late into actual behaviour (Kearney et ah, 1999). In response, multi¬
level (or socio-ecological) approaches, for example King (1991) and
Figure 1.2, are increasingly being recognised as more appropriate in
 Physical activity, health and health promotion 15

Level ol Channel Target group Strategy

intervention (delivery mode)

Personal Face-to-face: Patients, Information on health risk

physician’s office; clients and benefits, counsellor
health clinic; health support, personal monitoring
spas and clubs and feedback, problem
solving (relapse prevention)

Mediated: telephone, As above As above

mail etc.
Interpersonal Classes, telephone/ Patients, Information; peer, family and
mail, health spas and healthy counsellor support; group
clubs, peer-led groups individuals, affiliation; personal or public
families, peers monitoring and feedback;
group problem solving.

Organisational/ Schools, worksites, Students Curricula, point-of-choice

environmental neighbourhoods, populations, education and prompts,
community facilities employees, organisational support,
(walk/bike paths), local public feedback, incentives
churches, community residents,
organisations, sites for social norms
activities of daily living
(public stairs, shopping
malls, car parks)

Institutional/ Policies, laws, Broad Standardisation of

legislative regulation spectrum of exercise-related curricula,
the community insurance incentives for
or population regular exercisers, flexible
work time to permit exercise,
monetary incentives for the
development of exercise
facilities

Figure 1.2 King’s socio-ecological model showing levels of intervention (taken from King,

1991, p. 247).

understanding behaviour change. Figure 1.2 considers four levels of

intervention that may be considered when designing and implement¬
ing a physical activity programme ranging from those that focus at the
level of the individual to those that focus at an environmental and
legislative level. Action at all levels within the model is more likely to
result in population-level behavioural change.
To date, research concerning the effectiveness of health promotion
programmes has focused predominantly upon individual approaches
(Hillsdon et ah, 2004) (see also Chapter 4). However, despite the pop¬
ularity of individual approaches, in both research and applied terms,
they appear to have been unsuccessful in halting trends towards
16 Concepts for the development of physical activity practice

sedentary behaviour in the UK. The reasons for this are unclear;
however, this may be as much to with the nature and transferability
of research evidence as it is to do with the limitations of individual
behaviour change techniques. For example, research evidence has test¬
ed the predictable power of cognitive variables upon physical activity
behaviour; however, despite a strong relationship in terms of efficacy,
there are problems when translating into practice (i.e. effectiveness).
In future, the evaluation of physical activity will require an eclectic,
portfolio approach to outcome measurement where wider aspects of
health benefit, e.g. mental health, are recorded. The challenge for both
researchers and practitioners is to measure real world physical activity
behaviour and then appropriately translate research evidence into
practice (Blarney and Mutrie, 2004).

Summary

Physical activity promotion has been identified as a public health

priority for the twenty-first century (Department of Health, 2004a; WHO,
2004). Traditionally, biomedical models have predominated medical
research, education and discourse in the UK (Suls and Rothman, 2004).
This book aims to critically discuss physical activity promotion within a
health promotion framework, in particular focusing on a socio-ecological
approach. Because physical activity is a behavioural intervention or
lifestyle choice, promoting it is a complex activity that requires input
of many professional groups to achieve success (Hopman-Rock, 2000;
McKenna and Riddoch, 2003; James and Johnston, 2004; Smith, 2004).
Currently, there is a need to develop both theoretical and practitioner
perspectives in order to improve the design, development, implementa¬
tion and evaluation of physical activity interventions that are effective
in sustaining behaviour change (McKay et al., 2003) within a variety
of population groups. The following chapters will address many
contemporary issues relevant to this debate.

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 2 Influencing health behaviour:
applying theory to practice
Lynne Halley Johnston, Jeff David Breckon and Andrew John Hutchison

Introduction

For more than a decade researchers in exercise psychology have

recognised that much of the work in behaviour change lacked a sound
conceptual or theoretical basis (e.g. Sonstroem, 1988; Rejeski, 1992).
In 2001, Biddle and Mutrie (2001) reported that theoretical foundations
had emerged within exercise psychology borrowing from well-known
educational, motivational and social psychology theories. By providing
insights into how people change, these health behaviour models have
suggested more effective methods for achieving behaviour change than
a traditional reliance on subjective interventions. Despite the obvious
benefits of these models, there are a number of considerations that need
to be addressed when applying theory to practice.

Learning outcomes
The aims of this chapter are to:

1. provide an outline of the dominant health behaviour change models in the

context of exercise and physical activity
2. present contemporary research evidence to highlight and critique the
application of the dominant model (i.e. the transtheoretical model, TTM) and its
role in the development of physical activity behaviour change interventions
3. emphasise the need for researchers and practitioners to apply more stringent
measures in order to protect the validity of applications of theory to practice
4. critically discuss and summarise the implications for practice and research

Models of behaviour change

There are a plethora of models and theories available to guide both

researchers and practitioners towards the development and imple¬
mentation of physical activity and other health behaviour change
22 Concepts for the development of physical activity practice

interventions. These models attempt to explain the mechanisms behind

how and why people change. As might be expected, there is no single
theory or model that explains how best to assist individuals in adopt¬
ing habitual physical activity behaviours (Marcus and Forsyth, 2003).
As a result the physical activity behaviour change research literature
incorporates a range of different models and theories to assist with the
development of interventions.

Social cognition models

Health behaviour change models have been classified within catego¬

ries determined by their social, cognitive or environmental foundations
(Foster et al., 2005). Among these categories are social cognition models,
which include Social Cognitive Theory (SCT; Bandura, 1986), the Health
Belief Model (HBM; Becker and Maiman, 1975), Theory of Reasoned
Action (TRA; Fishbein and Ajzen, 1975) and Theory of Planned
Behaviour (TPB; Ajzen, 1985). Social cognition is concerned with how
individuals make sense of social situations (Connor and Norman, 2005)
and models are designed to better understand the correlates and deter¬
minants of health behaviours. Fiske and Taylor (1991) explain that these
approaches focus on individual cognitions or thoughts as processes that
intervene between observable stimuli and responses in real-world situ¬
ations. However, it has been suggested that health behaviour change
research has focussed too much on social cognition models and their
practical utility has been questioned (e.g. Jeffery, 2005). This may sug¬
gest a reason for the shift toward other theories and more applied 'stage'
models. For a more detailed explanation of social cognitive models,
see Connor and Norman (2005).

Self-determination theory

An alternative approach to the prediction of health behaviour that

is receiving increasing attention is Self-Determination Theory (SDT;
Deci and Ryan, 1985; Ryan and Deci, 2000). SDT has been described as
a theory of personality development and self-motivated behaviour
change (Markland et al., 2005). SDT posits that people have an innate
organizational tendency toward growth, integration of the self, and
the resolution of psychological inconsistency (Ryan and Deci, 2000).
The theory (as illustrated in Figure 2.1) suggests that individuals pur¬
sue self-determined (intrinsically motivated) goals to satisfy their basic
psychological needs to independently solve problems, interact socially
and master tasks (Hagger and Chatzisarantis, 2007). While there is
 Influencing health behaviour: applying theory to practice 23

External Introjected Identified Integrated Intrinsic

regulation regulation regulation regulation regulation

-►
Increasing self-determination

Figure 2.1 The continuum of autonomy: self-determination theory (adapted from Ryan and
Deci, 2002, p. 16).

support for SDT as a tool for understanding motivation for physical

activity behaviour change (e.g. Ntoumanis, 2001; Standage et al, 2003),
its applied implications are yet to be fully explored. Therefore, future
research needs to consider exploring the efficacy of physical activity
interventions developed using the principles of SDT. For a more detailed
overview of SDT, see Ryan and Deci (2002; see Figure 2.1).

Stage models

Another set of models frequently cited in health behaviour change

research are stage-based approaches. These focus on the idea that behav¬
iour change occurs through a series of qualitatively different stages.
The most dominant of these is the Transtheoretical Model (TTM:
Prochaska, 1979; Prochaska and DiClemente, 1983), an integrative
model of behaviour change (Velicer et al., 1998) originally developed
by Prochaska (1979) in response to the increasing theoretical diver¬
sity within psychotherapy. Since its conception, the model has been
applied to a variety of behaviour change contexts such as HIV pre¬
vention (Prochaska et al., 1994), substance abuse (Brown et al, 2000),
diet (Steptoe et al, 1996) and physical activity (Kim et al., 2004) [for a
detailed overview of the TTM, see Prochaska et al. (1992) and Velicer
et al. (1998)]. Other stage-based approaches include the precaution adop¬
tion process (Weinstein, 1988) and the health action process approach
(Schwarzer and Fuchs, 1995).

The Transtheoretical Model: the dominant theoretical framework for

physical activity behaviour change

Within physical activity, meta-analytical and systematic review-based

research evidence (Marshall and Biddle, 2001; Marcus and Forsyth,
2003) and governmental reports on physical activity and behaviour
change (United States Department of Health and Human Services
[USDHHS], 1996; Foster et al, 2005) suggest that the TTM is the most
 24 Concepts for the development of physical activity practice

commonly adopted theoretical framework. The TTM is a multi-dimen¬

sional theoretical model commonly adopted by researchers to explain
how people change various problem behaviours. The model is made
up of four dimensions, which all contribute to explain not only the
processes involved in behaviour change but when they are used and
how they affect different types of outcomes. The four dimensions of the
TTM are: the stages of change, the processes of change, self-efficacy/
temptation and decisional balance. See Table 2.1 for an overview of
each dimension. For a more detailed description of all the dimensions
of TTM and their relationship to physical activity, see Biddle and Mutrie
(2008).

Applying the TTM

If used appropriately, the four dimensions of the TTM potentially pro¬

vide a valuable tool for the development of effective health behaviour
change interventions. For example, the TTM construes change as a pro¬
cess that involves progress through a series of five stages. In order to
explain how this change occurs the model describes 10 cognitive and
behavioural processes that people use to progress through the stages.
To accurately monitor a person's progress through the stages of change
the model also incorporates decisional balance and self-efficacy dimen¬
sions which have been shown to change in a predictable pattern across
the stages of change.
Using all dimensions of the model, Prochaska and Norcross (2001)
explain that both the therapy relationship and treatment interven¬
tion can be tailored to meet an individual's specific needs based on
their stage of change. For example, if a person is classified as a pre-
contemplator, research has highlighted that processes such as
consciousness raising and dramatic relief' need to be emphasised in
order to encourage stage progression (Prochaska and Velicer, 1997).
Therefore, an appropriate intervention strategy might be to provide
information about the risks associated with an individual's current
health behaviour in order to increase their awareness (consciousness
raising) and arouse negative emotions (dramatic relief) towards their
current behaviour. In order to monitor any resultant changes and adapt
the intervention accordingly, ongoing assessments of decisional balance
and/or self efficacy might also be conducted (Figure 2.3).

Criticisms of the TTM

Despite the model's popularity, previous reviews have questioned the

effectiveness of TTM based health promotion and physical activity
 Influencing health behaviour: applying theory to practice 25

Table 2.1 The four dimensions of the transtheoretical model of behaviour change
(adapted from Prochaska et al., 1992; Velicer et al., 1998; Prochaska and Norcross, 2001
and Hutchison et a!., 2008).

Dimension Description Role in TTM-based

physical activity
interventions

Stages of change ■ The stages of change represent Commonly referred to

ordered categories along a continuum in the physical activity
of motivational readiness. The five literature
stages are:
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
(See Figure 2.2 for a overview of the
stages and how movement through them
occurs.)
Processes of ■ The processes of change explain how Despite being the
change individuals move through the stages of original dimension
change of the TTM, the
■ They are 10 strategies that describe processes of change
the techniques that individuals use are not acknowledged
to modify their thoughts feelings and as frequently as the
behaviour stages of change
■ Five of the processes are labelled
as experiential and five are labelled
behavioural
■ Experiential processes have been
shown to be used primarily during the
earlier stages of and behavioural
during later stage transitions

Self-efficacy/ ■ Self-efficacy represents the situation Rarely linked to TTM

temptation specific self-confidence that people in the physical activity
have that they can cope with behaviour literature
change without relapsing
■ It is an intermediate/outcome measure
that is hypothesised to vary depending
on stage of change
(See Figure 2.3 for a overview of how
self-efficacy and temptation relate to the
stages of change.)

Decisional balance ■ The decisional balance construct refers Often not

to the relative weighting of the pros and acknowledged as a
cons of change dimension of TTM in
■ It is an intermediate/outcome measure the physical activity
that is hypothesised to vary across the literature
stages of change and with the type of
behaviour being considered
26 Concepts for the development of physical activity practice

Preparation

Contemplation Action

Enter Pre-contemplation Maintenance j_^ Exit

— — — — — Relapse

Figure 2.2 Movement through the stages of change (taken from Scales and Miller, 2003, p. 168).

Figure 2.3 The relationship between the stages of change and both self-efficacy and temptation
(taken from Velicer et al. 1998, p. 221).

interventions (e.g. Bunton et al., 2000; Adams and White, 2003; Bridle
et al., 2005). For example, Adams and White (2003) produced evidence
to suggest that TTM-based physical activity promotion interventions
are reasonably effective in promoting physical activity adoption but
have little influence on long-term maintenance of increased activity
levels.
A number of arguments have been presented to explain the lack of
support for TTM-based interventions. Firstly, it has been suggested
that physical activity behaviour is more complex than single behav¬
iours such as smoking and that individuals could be in a number of
different stages of change depending on the type of activity being con¬
sidered (Adams and White, 2005). Secondly, the importance of accu¬
rately determining current stage of change is necessary and yet many
intervention studies lack validated algorithms to assess this (Bunton
et al., 2000). Thirdly, exercise behaviour may be influenced by a num¬
ber of factors not considered by the TTM. For example, Adams and
 Influencing health behaviour: applying theory to practice 27

White (2005) argue that the TTM focuses on personal motivation for
behaviour change and does not take into account external and social
factors such as age, gender and socio-economic position (e.g. Gidlow
et al., 2006, 2007; James et al., 2008). Finally, it has been suggested that
many of the previously reviewed interventions may not have been
complex enough to do justice to the multidimensional nature of the
TTM (Adams and White, 2005). Bridle et al. (2005) explained that many
of the studies reported in their review of TTM-based health behaviour
interventions were tailored only to stage of change and neglected the
other ciimensions of the model. Therefore, some TTM-based interven¬
tions may be conceptually flawed because they fail to fully represent
the model.
While Adams and White (2005) questioned whether the physical
activity interventions in their review were complex enough to do justice
to the TTM, a limitation with their 2003 review is that they failed to
conduct any assessment of the quality of each intervention and more
importantly, the extent to which each intervention was based accurately
on the TTM. A systematic review should identify the effectiveness of
interventions based on a particular theoretical model, and within
such a review, it is crucial to examine how accurately the intervention
represents the theoretical model in question. Bridle et al.'s (2005)
review of health behaviour change interventions based on the TTM
did suggest that some of the components of the TTM may have been
neglected, resulting in partial rather than full intervention tailoring.
However, their review failed to present details regarding how many
interventions neglected dimensions of the model and the impact that
this might have on their efficacy. Therefore, the next section of this chap¬
ter reports on a systematic review, designed to assess the effectiveness
and design of TTM-based physical activity interventions (Hutchison
et al., 2008).

A systematic review of TTM-based physical activity interventions

The aims of the review were: to critically examine how the TTM is being
applied to develop physical activity behaviour change interventions
and to determine whether these TTM-based interventions are effective
in promoting physical activity behaviour change. The review identi¬
fied 24 physical activity behaviour change interventions based on the
studies inclusion criteria (see Hutchison et al., 2008, for study design
characteristics). Regarding the first aim, results revealed that only seven
of the interventions (29%) were developed using all four dimensions
of TTM (see Table 2.2 for full details). Therefore, very few studies are
reporting to have applied all facets of the model and subsequently have
28 Concepts for the development of physical activity practice

Table 2.2 TTM dimensions used in the development of physical

activity interventions (Hutchison et at., 2008). v

Characteristic No. of studies (%)

TTM dimensions
Stages of change 24 (100)
Processes of change 17 (70.8)
Decisional balance 15 (62.5)
Self-efficacy 8 (33)
Number of TTM dimensions Included
1 2 (8.3)
2 112 (45.8)
3 42 (16.7)
4 7(29)

not acknowledged its multidimensional nature. As a result, it could be

argued that only seven of the reviewed interventions can accurately
claim to be based on the TTM.
In addition to the fact that researchers are clearly neglecting a number
of the dimensions of the TTM, the review also identified some addi¬
tional pitfalls associated with misrepresenting the model when apply¬
ing it to the development of physical activity interventions.

TTM or the stages of change

Consistent with Bridle et al.'s (2005) findings, the stages of change was
the dominant dimension of the model, as it was cited in the develop¬
ment of all the reviewed interventions. When describing the TTM,
Velicer et al. (1998) clearly explain that the stages of change is just one
of four key dimensions of the model. Despite this the TTM is often
referred to as the 'stages of change model' (Bunton et al, 2000; Adams
and White, 2005) irrespective of the fact that the processes of change
(cited in 71% of the reviewed interventions) was the original dimen¬
sion. Bridle et al. (2005) explain that the stages of change construct
is a variable, not a theory, and state that it is unclear why research¬
ers would assume that a variable could facilitate consistent interven¬
tion effects. As a result. Bridle et al. suggested that many TTM-based
interventions may be conceptually flawed because they are variable
rather than theory driven. Therefore, it is crucial for researchers and
practitioners to recognise that the stages of change are just one of the
dimensions of the TTM.
 Influencing health behaviour: applying theory to practice 29

The relationship between the processes and stages of physical activity

behaviour change

Given that 71% of the reviewed interventions were developed with

reference to both the stages and processes of change dimensions of
TTM, it is important for researchers to demonstrate a good under¬
standing of how these two variables interact with one another. There
is evidence to suggest that the relationship between the stages and
processes of change differs depending on the behaviour change
context that they are applied to (Marcus et al., 1992; Velicer et al.,
1998). Originally, the TTM was refined and tested based on a num¬
ber of studies which investigated behaviour change within smok¬
ing cessation (e.g. DiClemente and Prochaska, 1982; Prochaska and
DiClemente, 1983).
For physical activity adoption and maintenance, Marcus et al. (1992)
found that the use of behavioural processes has been shown not to
decline as individuals progress from action through to maintenance (as
for smoking cessation) and the use of experiential processes peaks in
the action stage for physical activity adoption compared to the prepa¬
ration stage for smoking cessation. Therefore, any interventions based
on these findings are likely to differ with regards to the timing of spe¬
cific process related strategies. The results revealed that some of the
interventions were developed with reference to the findings observed
within smoking cessation and others were developed based on Marcus
et al.'s (1992) physical-activity-based findings. Therefore, while all these
interventions claim to be developed using the TTM, some of them have
clearly failed to recognise the observed differences between physical
activity behaviour change and smoking cessation with regards to stage
and process interactions. As a result, the model is often applied without
proper consideration regarding its application to physical activity.

Does a poorly applied theoretical framework influence the efficacy of

interventions?

So far this chapter has presented research evidence which suggests

that, in order to protect the validity of physical activity and other health
behaviour change interventions, it is a crucial for those developing the
interventions to demonstrate a good understanding of the theoretical
models they choose to use. However, when this is not achieved and
interventions fail to accurately represent the theoretical model in ques¬
tion, are they any less effective? While the findings of the review seem
to reflect favourably on interventions that are accurately based on all
four facets of the TTM (i.e. of the seven studies that demonstrated a
complete understanding of the TTM six reported significant findings).
30 Concepts for the development of physical activity practice

a number of interventions that failed to consider every dimension of the

TTM also reported significant findings. "
Specifically, 17 of the interventions were not tailored to all four dimen¬
sions of the TTM, and of those, 12 (71%) reported significant short-term
results in favour of the intervention group. One intervention (Hilton
et al., 1999; Steptoe et al., 1999, 2001), which was tailored to only one
dimension of the TTM (the stages of change), was shown to be effective
in both the short and long term. Therefore, the extent to which inter¬
ventions are accurately based on the TTM does not seem to be the only
factor influencing their efficacy. As a result it is important for those
developing interventions to consider the impact of other factors relat¬
ing to the design and delivery of the intervention.
In order to explore the role of one such factor and provide a com¬
prehensive picture of intervention integrity, the reviewed interventions
were categorised into brief, medium or intensive. Results revealed that
TTM based physical activity behaviour change interventions vary in
their intensity from very brief interventions, involving only one deliv¬
ery of intervention material, to intensive interventions which last for
up to 6 months and involve multiple modes of delivery. Both intensive
and medium intensity interventions were effective in the short term in
86% and 89% of studies respectively compared to 57% of brief inter¬
vention studies. Of the two interventions that reported significant long¬
term findings one was categorised as medium intensity and the other
intensive. Therefore, consistent with findings presented by Marcus
et al. (2006), the intensity of physical activity interventions does seem to
influence their effectiveness. Thus, the application of theory to practice
is not simply a case of accurately applying the principles of a theoreti¬
cal model such as TTM because the role of other design related factors
and their relationship with the theoretical model in question must be
considered. For example, the TTM posits that behaviour change is a
process that involves progression through a series of stages. Therefore,
TTM-based interventions should arguably involve multiple patient
contacts and follow ups in order to adapt the intervention to the changes
that individuals are going through.

Implications for practitioners: TTM

While the TTM continues to provide a popular framework for the devel¬
opment of physical activity interventions, numerous inconsistencies
regarding the development and implementation of interventions based
on the model have been observed. As a result, it is difficult to deter¬
mine whether findings are simply due to factors relating to intervention
implementation or to a poorly conceptualised intervention. In order to
draw more concrete conclusions about the efficacy of TTM and other
 Influencing health behaviour: applying theory to practice 31

theoretical model-based approaches, it is crucial for those developing

interventions to fully articulate the nature of the interventions within
the study protocol. To achieve this, future studies need to apply treat¬
ment fidelity measures to encourage researchers to fully describe the
exact nature of their interventions. Applying such measures to accu¬
rately describe the nature of interventions is a crucial part of applying
theory to practice.

Treatment fidelity and the Behaviour Change Consortium (BCC)

framework

This chapter has highlighted the increase in research into physical

activity behaviour change; there are, however, concerns over the lack of
detail of physical activity interventions. For example, there is little dis-
cemable reporting of the content and type of intervention, the theoreti¬
cal underpinning, or competence of the physical activity professional
(or researcher) in delivering the intervention. Treatment fidelity refers
to the methodological strategies used to monitor and enhance the reli¬
ability and validity of behavioural interventions (Bellg et al., 2004). The
following section will consider treatment fidelity measures and provide
recommendations for practitioners and researchers.
In comparison to physical activity interventions, 'health' behaviour
change research has for some time embedded fidelity tests into inter¬
ventions and research (Hahn et al., 2002; Dusenbury et al., 2003; Fiander
et al., 2003) in order to preserve the internal validity and enhance the
external validity of studies (Bellg et al., 2004). In order to address the
issue of treatment fidelity for behaviour change settings, a consortium
of health behaviour change studies was gathered in the US under the
auspice of the National Institute of Health Behavior Change Consortium
(BCC). The BCC group recommended five areas for implementing fidel¬
ity treatment measures in behavioural trials. The five components are
summarised as a need to encourage fidelity at the design, training,
delivery, receipt and enactment stages.
It is important to examine the potential efficacy of health behaviour
change fidelity measures in order to ensure reliable, valid and robust
interventions based on sound theoretical and scientific principles.
Intervention fidelity testing is therefore a key methodological require¬
ment for research into physical activity behaviour change. It provides
a systematic process for the intervention design and when applied
correctly, should ensure consistent and reliable results (Resnick et al.,
2005). Treatment fidelity therefore plays a central role in ensuring that an
intervention has been accurately evaluated. A recent synopsis of research
projects into behaviour change fidelity has suggested that treatment
fidelity requirements are only met if: (a) the treatment provided was given
32 Concepts for the development of physical activity practice

consistently to all participants randomised to treatment, (b) there was no

evidence of non-treatment-related effects, and (c) the intervention was
true to the goals and theory underpinning the research (Bellg et ah, 2004).
For a more in-depth description of each fidelity goal, description and
strategy the reader is referred to the BCC guidelines (Bellg et ah, 2004).

Physical activity counselling interventions and treatment fidelity

Within physical activity behaviour change settings, counselling based

interventions are becoming increasingly popular in a variety of pri¬
mary, secondary and community health care settings (Kennedy and
Meeuwisse, 2003; Kirk et ah, 2003; McKenna and Vernon, 2004; Melanson
et ah, 2004) to the point that physical activity counselling is becoming
part of normal healthcare in the prevention, treatment and management
of chronic diseases (Foster et ah, 2005). In the UK, the first guidelines
for conducting an exercise (or physical activity) consultation were pro¬
duced in 1995 by Loughlan and Mutrie. While these early guidelines
filled a void, subsequent interventions applying these principles have
compromised and confused the original guidelines (Kirk et ah, 2001,
2003; Hughes et ah, 2002).
Accurate descriptions of physical activity interventions are often
lacking with little or no detail as to the fidelity, and therefore qual¬
ity, of the intervention. Moreover, there is often no standardised mea¬
surement of physical activity outcome, physical activity counselling
content, technique or patient readiness and receptiveness to the inter¬
vention (Kennedy and Meeuwisse, 2003). Table 2.3 represents an appli¬
cation of the five treatment fidelity components to the physical activity
counselling setting along with the strategies for achieving each criterion
(adapted from Breckon et ah, 2008).
In order to highlight the extent to which treatment fidelity measures
are being adopted within physical activity counselling, the next section
of this chapter reports on a systematic review of physical activity coun¬
selling interventions in clinical and community settings.

A review of physical activity counselling interventions

The review (Breckon et ah, 2008) identified 26 articles that examined

the efficacy of physical activity/exercise counselling or consultations.
Although the search criteria were for studies between 1995 and 2006,
only one of the included studies was published before 2000 (Harland
et ah, 1999) and 15 of the 26 studies (63%) were published after 2003,
highlighting the increasing popularity of counselling-based physical
 Influencing health behaviour: applying theory to practice 33

Table 2.3 Treatment fidelity components and physical activity counselling applications.

Component Definition and description Application to an physical

of treatment activity counselling
fidelity intervention

Design Treatment fidelity applied at the Intervention consistent with

design stage to ensure that the behaviour change theory such as
intervention can adequately test TTM, self-determination or social
the proposed hypotheses. This in learning theory. Clear physical
relation to underlying theory and activity counselling protocol
clinical processes developed
Training To ensure that those delivering A combination of supervised role-
the intervention have been playing, clinical supervision and
satisfactorily trained, assessment reviews of audiotapes applied as
is carried out of their skills and an adjunct to a training manual
competencies in relation to the
study
Delivery Treatment fidelity processes Physical activity counselling
are applied to monitor that the interventions audio taped and
intervention is delivered in line with reviewed using a behavioural
the proposed design checklist based on the study
protocol. Correction of observed
intervention deviations
Receipt The focus is toward the recipient Evaluation of the effects of the
of the intervention. The fidelity physical activity counselling
facet here aims to ensure that intervention using post-session
the intervention or treatment questionnaires or interviews
received is understood by the (cognitive) and checklist of
individual and that they can apply participant strategies employed
the intervention at a cognitive and (behavioural)
behavioural level
Enactment An analysis is taken of the Completion of intervention
application of the treatment by the strategy goals specific to
individual. This monitoring ensures the study outcomes. Clients
that behavioural and cognitive encouraged to record accurately
strategies are applied in real-life completed and missed sessions
settings and to report occurrences of
relapse

activity interventions. The results revealed that very few physical

activity counselling interventions address treatment fidelity issues. At
best, the physical activity counselling interventions reviewed indicated
a theoretical underpinning but did not fully articulate the application
of theory to practice by specifically detailing how components of the
theoretical model (e.g. TTM) had been applied.
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 — Ei ijäksi! Haluathan nähdä minua taas. Ole iloinen mieleltäsi ja
sano: Me tapaamme taas!

— Me tapaamme taas!

— No niin! — Ja tavatessamme taas, käymme yhdessä lasten

kanssa metsien helmaan!

— Sokrates ei ollutkaan se, joksi häntä luulin…

— Mene, tahdon nukkua!

Ja hän meni, mutta kohtasi ovessa Platonin ja Kritonin.

— Hetki lähestyy, ystävät! sanoi Sokrates väsyneesti, silmät

palavina.

— Onko sinussa rauha, mestari?

— Totta sanoakseni, olen sangen rauhallinen; iloinen en tahdo

väittää olevani, mutta omatuntoni ei minua ahdista.

— Milloin, Sokrates, milloin… on se tapahtuva?

— Tarkoitat, milloin… se on tapahtuva, se viimeinen? Platon,

parkani, rakkaani… kiire on… olen äsken nauttinut uneksimisesta…
olen käynyt joen yli, toiselle puolelle; olen silmänräpäyksen nähnyt
katoomattoman kauneuden ikikuvia, joiden hämäriä varjoja vain ovat
nämä näkyvät… olen nähnyt tulevaisuutta, ihmissuvun kohtaloita;
olen puhunut mahtavien kanssa, korkeitten, puhtaitten; opin
tuntemaan sen viisaan järjestyksen, joka vallitsee suurta näennäistä
epäjärjestystä; minä vapisin kaikkeuden tutkimatonta salaisuutta,
josta aavistusta tunsin; ja käsitin tietämättömyyteni koko laajuuden.
Platon, sinä olet sen kirjoittava. Sinä olet opettava ihmislapsia
kohtuullisesti halveksien katselemaan asioita, hartaina nostamaan
katseensa ylös näkymättömiin, kunnioittamaan kauneutta,
harjoittamaan hyveitä ja toivomaan pelastusta työn teosta,
velvollisuuksista ja kieltäytymisien kautta!

Hän kävi vuoteelle ja laskeusi makuulle. Platon seurasi:

— Oletko sairas, mestari?

— En, olen ollut, mutta nyt parannun.

— Oletko jo…

— Olen jo tyhjentänyt maljan!

— Viisain lähtee luotamme!

— Ei ole kukaan kuolevainen viisas! Mutta minä ylistän jumalia,

jotka ovat antaneet minulle hävyn ja oikeuden tunnetta.

Sitten syntyi huoneessa äänettömyys.

— Sokrates on kuollut!

Flaccus ja Maro.

Sokratesin kuoltua oli Athenan suuruus mennyttä. Sparta oli sitten

aikansa vallassa, ja sen jälkeen seurasi Theben vuoro. Theben
jälkeen makedonialaiset syöksyivät maahan, ja nämä vallitsivat
vuoteen 196, jolloin roomalaiset valtasivat sekä Makedonian että
Kreikan, Korintti hävitettiin perin pohjin, mutta Athena, joka Sullan
aikana menetti linnoituksensa, säästyi kuitenkin suurten muistojensa
takia. Nyt Caesarin aikana oli yleistä muotia se että nuoriso
lähetettiin Athenaan opiskelemaan grammatikaa, retorikaa ja
filosofiaa. Mitään uskontoakaan ei ollut, sillä kukaan ei uskonut
valtion jumaliin, vaikka uhrijuhlia vietettiin vanhasta tottumuksesta.
Athena oli vainajana, kuten koko vanha maailma, Egypti, Syria,
Vähä-Asia. Roomassa elettiin Kreikan muinaisuudella, ja kun miehistä
suurin, Cicero, käsitteli filosofista ainetta, alotti hän aina puhumalla
mitä vanhat kreikkalaiset siitä asiasta arvelivat ja siten hän lopettikin,
sillä mitään omaa mielipidettä esimerkiksi jumalain luonteesta ei
hänellä ollut.

Eräänä varhaisena kevätpäivänä Julius Caesarin viimeisinä aikoina

istui kaksi ylioppilasta lehtimajassa Lykabettosin alapuolella,
vastapäätä Kynosargesin kimnaasia. Pöydällä oli heillä viiniä, mutta
eivät he olleet kovin persoja keltaiselle Chios-viinilleen. He istuivat
ääneti, velttoina aivan kuin odotellen. Mutta kaikki heidän
ympärillään näytti myöskin olevan saman tylsyyden vallassa.
Ravintolan isäntä nukkui istuillaan, vastapäisen kimnaasin oppilaat
seisoa vetelehtivät porttikäytävässä, vaeltajat maantiellä kulkea
tassuttelivat äänettöminä eteenpäin tervehtimättä; talonpoika
pellolla istui aurallaan ja pyyhkeili hikeä otsaltaan. Ylioppilaista
vanhempi hypisteli lasiaan ja avasi vihdoin suunsa:

— Sano jotakin!

— Minulla ei ole mitään sanomista, sillä en tiedä mitään.

— Oletko jo täysin oppinut?

— Olen.
 — Minä tulin Roomasta eilen suuret toivot mielessäni että saan
oppia uutta ja kuulla kuulumattomia asioita, mutta saan kuulla vain
äänettömyyttä.

— Rakas Maro, minä olen makaillut täällä vuosikausia ja olenpa

kuullutkin, mutta en mitään uutta. Olen kuullut, että Thales on
väittänyt jumalia ei koskaan olleen, vaan että kaikkeus on syntynyt
jostain kosteasta. Edelleen tunnen Anaximenesin opin että kaikki on
ilmasta kotoisin, Ferekydesin eetteristä perussyynä, Heraklitin
tulesta. Anaximander on opettanut minulle että maailman kaikkeus
on syntynyt jostain alkuaineesta. Lenkippos ja Demokritos antoivat
minulle opetusta tyhjästä maailmanavaruudesta, jossa on
alkuruumiita eli atoomeja. Anaxagoras on minulle uskotellut että
atoomeilla, hiukkasilla on järki. Xenofanes tahtoi saada minut
vakuutetuksi että jumala ja maailma on sama. Empedokles, koko
sakista viisain, joutui epätoivoon ymmärryksen puutteellisuuden
takia ja heittäytyi epätoivossaan pää edellä Etnan tulta suitsuavaan
vuoreen.

— Uskotko sitä?

— En! Se on kyllä valetta niikuin kaikki muukin. — Sitten opin

Platolta koko joukon hyviä asioita, jotka sitten Aristoteles kumosi.
Seurauksena oli, että pysähdyin viisaista viisaimman Sokratesin
pariin, joka avomielisesti selitti, kuten tiedät, ettei hän mitään
tiennyt.

— Sehän oli sofistin oppi: ettei sitä voi mitään tietää, tuskin
sitäkään.

— Olet oikeassa, sentakia oli hyvä Sokratesimme sofisti

tahtomattaan! Mutta onpa yksi, yksi ainoa, joka… niin, tarkoitan
Pytagorasta. Hänhän on julistellut sinne tänne, itään ja länteen,
mutta olenpa hänen filosofiastaan löytänyt ankkurin, jonka olen
laskenut pohjaan. Kyllähän minä tuulessa keikkuilen, mutta en
ajelehdi enää sinne tänne.

— Kerrohan!

— Niin se kuuluu näin: Tee sitä, mitä pidät jalona, vaikkapa

maanpakolaisuuden uhallakin; joukko on jalouden tuomariksi
kelvoton. Sentakia vähäksy sen kiitosta ja halveksi sen moitetta.
Hoitele uskonveljiäsi, mutta pidä muita ihmisiä kaikkea arvoa vailla
olevana laumana. Ole alituisella sotakannalla papujen kanssa (hän
tarkoittaa demokrateja)! "Odi profanum vulgus et arceo!"

— Sinun pitäisi asua kotona Roomassa, Flaccus, missä…

— Niin, miten siellä Roomassa nyt on laita?

— Caesar on Caesar, on valloittanut maailman ja hänen

persoonaansa on yhdistettynä kaikki korkeimmat virat, vieläpä
papillisetkin. Tätä vastaan ei minulla ole mitään, mutta väittävät
hänen pyytävän jumalaistuttamista.

— Miksi ei? Kaikki jumalat ovat olleet sankareita ennen, eikä

monetkaan jumalat ole olleet niin suuria kuin Caesar. Romulushan ei
ollut mikään erinomainen poika, vaikka hän sattui joutumaan
ensimäiseksi ja jonkun kaiketi täytyy ensimäinen olla. Mutta sittenkin
on hän nyt jumala, temppelit ja uhrit on hänelle.

— Se on kyllä valetta, kuten kaikki muukin.

— Arvattavasti.
 — Niin, olenpa kuullut toisenkin tarun Rooman perustamisesta
Aeneasin pojan Ascaniusin toimesta, hänen, joka pakeni Trojasta, ja
sille tarinalle olen päättänyt rakentaa suuren runoelmani…

— Onko se Aeneis, josta kerrotaan?

— On, se se on!

— Onko se runoileminen vaikeata?

— Ei, sitä vain seurataan hyviä esikuvia. Tähän asti on Teokril ollut
esikuvanani, mutta nyt turvaudun itse isä Homerosiin.

— Herkules vieköön! — No täällä voit olla rauhassa, niin kauvan

nimittäin kuin Mecaenas lähettää sinulle säännöllisesti kolikoita!

— Sen hän tekee mutta kuinka sinä tulet toimeen?

— Vanha isäni, vapautettu orja, hänhän se ahertelee valtion

rahastossa, minne hän koettaa hankkia minulle paikan
tulevaisuudessa.

— Eikö sinulla ole mitään harrastuksia, mitään intohimoja, mitään

kunnianpyyntiä?

— Ei, mitäpä minä sellaisella! Nihil admirari. Se on tunnussanani.

Kun on kerran jumalia, jotka vallitsevat ihmisten ja kansojen
kohtalot, niin miksipä ryhtyisin minä peukaloimaan asioita ja
ränsistyttämään itseäni turhassa taistelussa. Ajattelehan vain
Demosthenesta, joka kolme vuosikymmentä puhui makedonialaisia
vastaan, varoittaen kansalaisiaan, jotka eivät tahtoneet häntä kuulla.
Jumalat kävivät makedonialaisten puolelle ja tuomitsivat Hellasin
turmioon. Demosthenes joutui vankilaan — lystillistä kyllä syytettynä
samojen makedonialaisten lahjomaksi. Se oli valetta luonnollisesti!
Tämän patriootin, joka uhrautui isänmaan pelastamiseksi, joka luuli
puhuvansa jumalain puolesta, täytyi nauttia myrkkyä ja hän kaatui
taistellen jumalia vastaan! Vestigia terrent!

Tämän keskustelun aikana oli päivä laskenut, ja nyt hämärissä

saatiin nähdä tulia sytytettävän Aeginalla, Salamissa, Phalerosin
kupeella, Piraeuissa ja lopulta Akropolisilla. Kaupungista kuuluva
äänten sorina lisääntyi, ja nousi yhtäjaksoiseksi äärettömäksi
riemukirkunaksi. Väkeä näkyi tulevan tiellä kuljettaen mukanaan
naisia, lapsia, toiset kävellen, toiset ajaen ja ratsastaen.

Kunnon Agathon, ravintolan isäntä, oli herännyt ja käynyt

maantielle saamaan selvää hälinän aiheesta.

Molemmat ylioppilaat olivat nousseet viinikellarin katolle

tähystelemään, mutta aavistellen heidän kaltaisiaan muukalaisia
vaaran uhkaavan ja yltyväin huutojen pelottamina, he laskeusivat
alas ja kätkeytyivät puserrushuoneeseen.

Vihdoin kuului Agathonin ääni:

— Caesar on murhattu! Surma roomalaisille! Hellas vapaaksi!

Se oli uutinen.

Viinisaksan puutarha tuli täyteen väkeä, viini virtaili ja

riemuhuutojen seassa kajahteli ivasanoja sivu kulkeville roomalaisille,
joita pakeni kaupungista pohjoista kohti Makedonian rajalle pyrkien.

Maro ja Flaccus saivat olla ankarassa pinteessä, piilossa kun olivat

viinipuristimen ammeessa, josta tirkistellen he saivat tietää koko
uutisen sivuhaaroineen päivineen.
 Cassius ja Brutus murhanneet Caesarin Capitoliumissa.

— Brutus? kuiskasi Maro: sitten ovat kai Caesarien päivät menneet

samalla tavalla kuin vanha Brutus lopetti kuninkaitten!

— Ja Brutus pakomatkalla Hellasiin yllyttämään helleenit

roomalaisia vastaan.

— Eläköön Brutus! huudettiin puutarhassa.

— Sittenpä saamme mekin elää, hoksasi nokkela Flaccus. Caesar

on kuollut, ylistäkäämme Brutusta, toistaiseksi.

*****

Monta vuotta oli kulunut, kun entinen atheenalainen ylioppilas,

Quintus Horatius Flaccus käyskenteli Sabinilaisvuoristossa olevan
huvilansa puutarhassa. Tämän huvilan hän oli saanut ystävältään
Macaenasilta, joka aivan vieressä itse Tiburissa istuskeli komeassa
maalaistalossa.

Horatius oli nyt sangen kuuluisa runoilija, mutta kuitenkin sama

kuin athenalainen ylioppilas. Kohtalo tai jumalat olivat leikitelleet
hänen elämällään, mutta runoilijapa oli pitänyt sitä taivahaisten
hauskana juhlana, johon hän oli satiirilla vastannut.

Caesarin murhan jälestä oli nimittäin Brutus paennut Kreikkaan ja

siellä saanut niin hyvän vastaanoton, että athenalaiset olivat
pystyttäneet hänen kuvapatsaansa ja pestanneet joukkoja hänelle
Antoniusta ja niitä toisia vastaan, joiden joukossa oli sairas
Octavianus (vastainen Augustus). Horatius tungettiin sotilaaksi ja
hän johtikin todella legioonaa Philippin taistelussa, jossa Brutus
kaatui. Runoilija, joka ei ollut sotilas, pakeni ylivoimaa ja saapui
Roomaan, jossa hän amnestian, sovitusjulistuksen jälkeen pääsi
kirjuriksi kaupungin laitokseen. Samaan aikaan hän oli alkanut
runoilla, Mecaenas hänet keksi, ja hän sai palkkiokseen maatalon.
Augustus keisari ihaili häntä ja tarjosi hänelle sihteerin paikan, mutta
Horatius kieltäytyi, osaksi sen tähden, ettei hän koskaan voinut tätä
imperatoria pitää muuna kuin vallan kaappaajana, osaksi sen tähden
että hän ennen kaikkea rakasti vapautta ja riippumattomuutta.

Nyt hän käyskenteli puutarhassaan, jonka hedelmäpuut hän itse

oli ymppäillyt. Hän poimiskeli ruusuja ja hyasintteja, sillä hän odotteli
kävijää, rakasta vierasta, vanhaa Athenan aikuista ylioppilastoveria,
Publius Virgilius Maroa, joka oli yhtä mainittava maineeltaan kuin
Horatius, vaikka ei ollutkaan "julaissut" käsin kirjoitettuna
Aeneistaan.

Viiniköynnösmajassa oli pöytä katettuna; vanhaa massialaista ja

falernilaista oli jo jäissä. Ostereita ja ankeriasta oli siinä; vohla ja
muutama viiriäinen olivat varrasta odottamassa paistinhuoneessa;
puutarhan hedelmiä oli poimittuna; kahta henkilöä varten katetulta
pöydältä puuttui vain kukkia.

Vähäinen kirjoitustaitoinen orja juoksenteli puutarhaveräjän ja

kyyhkyislakan väliä tähystämässä odotettua vierasta.

Runoilija seisoi juuri käsiään pesemässä vesiammeen ääressä

lopetettuaan kukkien poimintansa, kun joku häntä taputti olalle:

— Virgilius! Mitä tietä olet tullut?

— Mäkien yli Tiburista, Mecaenasin luota.

 — Tervetuloa, tulitpa mitä tietä tahansa, vaeltaja, istu, raukea,
puoliympyrääni kotiviljeltyjen olivien varjoon, sillä aikaa paistinvarras
sirisee ja hakkuuraudat käyvät! Tässä näet turpeeni, joka on
edustavinaan maailmaa…

Ensi tervehdyksistä ja kysymyksistä oli päästy, ja ystävät olivat

asettuneet pöydän ääreen. Isäntä oli kyllä epikurolainen, eli
nautinnon ihailija, mutta voidakseen nauttia, täytyy pysyä
kohtuudessa, ja ateria oli roomalaistavan mukaan arvosteltuna varsin
kodikas, itsessään yksinkertainen, mutta loistokas.

Sitten tuli maljain vuoro, ja viini herätti muistot, huolimatta siitä

että sen unhotusta suovan ominaisuuden väitetään sammuttavan
niitä.

— No, sinähän olit sodassa, sinä poika? alotti Virgilius.

— Niin, ja häpeällisesti pötkin pakoon, kuten tiedät.

— Olen kyllä lukenut sellaista jossain runossasi, mutta totta se ei

liene, vaan olet itseäsi panetellut.

— Olenko? Ehkä! Ainahan sitä lörpöttelee runoillessaan.

— Sinä runoilija, muistatko että Athenassa kysyit minulta, oliko se

vaikeata? Miten sitten johduit kirjoittelemaan?

— Tarvitsin rahoja!

— Nyt taas panettelet itseäsi. Jos kaikki rahaa tarvitsevat kärkkyjät

osaisivat kirjoitella, niin olisipa maailma täynnä runoilijoita.
 — Ehkäpä ei siis ollutkaan asian laita niin! Mutta puhuppa nyt
itsestäsi! Aeneisistäsi!

Virgilius synkistyi:

— Siitä en halua puhua.

— Onko se valmis?

— Liiankin valmis! Se on mennyttä, lopussa!

— Lopussa?

— Niin! Lukeissani sen, älysin epäonnistuneeni! — Missä siinä ei

ollut Homerusta, siinä se ei ollut mistään kotoisin! Se oli rangaistus
siitä, että tahdoin loistaa isää kirkkaammin…

— Oletko hävittänyt sen?

— En vielä, mutta se on sinetöitynä, määrätty hävitettäväksi

kuoltuani.

— Nyt sinä panettelet itseäsi, et ole vuosien masentama, Maro, et

ehkä työnkään, vaan jonkun muun.

— Niin, jonkun muun. Se mikä tuleva on, se minut saa

levottomaksi.

Horatius heilautti maljaansa ja lausuili:

Rikollista on etsiä rajaa, mi elon etehen taivaan laittama on,

Leuconoé, Kaldean viisailta kohtaloos älä etsi, saavuttaaksesi
vanhaa näin.
 Täys vain maljas kun on,
sanat ne syntyä voi!
Kadehtien elo pakenee.
Nauttios nyt, huomenta epäile!

— En voi, keskeytti Virgilius, en voi mitään upottaa maljaan,

nähdessäni isänmaani menehtyvän.

Onko Rooma koskaan ollut niin mahtava kuin nyt? Eikö meidän
maamme ole koko tiedossa oleva maailma, Egypti, Syria, Kreikka,
Italia, Espanja, Germania, Gallia, Britannia? Onko muuta saatavissa,
ellen mainitse Intiaa ja Persiaa? Ja kuitenkin elämme rauhan aikaa;
Janustemppeli on kiinni, maassa ilo vallitsee, taiteet kukoistavat eikä
kauppa ole koskaan ollut niin verratonta kuin nyt.

— Niin, rauhaa sodan edellä! Sillä kaikki nämä kukistetut kansat

ovat heränneet ja viskelevät silmäyksiään Roomaa kohti, eivät välitä
Kreikasta, niinkuin ennen, sillä Kreikka on erämaa ja käy suureen
rauhaan. Tiedätkö, että Suua ja Mithridates ovat samonneet poikki
Hellasin murhaten, ryöväten, niin että kaikki tiede ja taide on
paennut Egyptin Aleksandriaan tai kasvavaan Bysanziin? Tiedätkö,
että tuntematonta heimoa, idästäpäin kotoisin olevat merirosvot ovat
hiljattain ryövänneet jokaisen Hellasin temppelin, niin että tuskin
siellä enää voidaan jumalanpalvelusta pitää? Orakelit ovat käyneet
mykiksi, runoilijat vaienneet kuin laululinnut ukkossäällä,
murhenäytelmiä, niitä suurien teoksia, ei enää esitetä, vaan käydään
katselemassa ilveilyjä ja gladiatorien näytäntöjä. Raunioina on
Hellas, ja Rooma on pian oleva samoin.

— Aika on paha, sen tunnustan, mutta joka aika on ollut

rappeutunutta ja samalla uutta aikakautta valmistavaa. Syksyn korea
lehtipuku maatuu seuraavan kevään kukkaiskylvön pientareeksi,
luonto, elämä, historia uusiintuu aina kuolemassa. Siksi on kuolema
minusta vain uudistusta, vaihdosta, ja tavatessani ruumissaaton,
päättelen aina itsekseni: Voi, kuinka eläminen on hupaista!

— Rakas Flaccus, sinä elät unelmissasi kulta-aikaa, kun taas me

toiset laahustamme vain tätä rauta-aikaa. Muistatko, kuinka
Hesiodus valittelee hänkin jo?

— En, sen olen unohtanut, mutta sinun mieliksesi tahdon

kuunnella.

— Rautakansaa on tämä nykyinen, eikä se koskaan lepää työn

taakkaa kantaessaan, ei päivin, ei öin! Syntistä kansaa se on, ja
jumalat lähettävät sille vaivalloisia murheita, mutta kun he iloakin
lähettävät, tuottaa sekin sille onnettomuutta. Kerran on Zeus
juurineen sen hävittävä, tämän monikielisen kansan, kun sen lapset
syntyvät kulmat harmaina. Lapsemmehan syntyvät jo vanhuksina,
hampaattomina, ryppyisinä ja kaljupäisinä. Ei välitä isä lapsestaan, ei
lapsi isästään, ei vieras isännästään, ei palvelija palvelijasta, ei veli
veljestään. Milloin lapset häpäisevät ijäkkäitä vanhempiaan,
solvaavat heitä, puhuvat tylyjä sanoja, nämä nuoret lurjukset, jotka
eivät jumalaisesta kostosta mitään tiedä ja jotka eivät ikinä palkitse
harmaantuneita vanhempiaan lapsuusaikaisesta hoidosta. Nyrkki on
oikeutena, ja toinen kaupunki toista hävittää. Ei rehellisyys ja
uskollisuus valoja kohtaan saa koskaan palkkaansa, yhtä vähän kuin
hyvyys tai oikeuskaan. Voi ei, joka syntiä tekee ja lakia rikkoo, häntä
kunnioitetaan. Lurjukset pettävät jaloja ihmisiä ja epäröimättä
vannovat väärin, kateus vainoo ihmisiä, näitä kovaonnisia, ääneltään
ilettäviä, kasvoiltaan kauheita, jotka riemuitsevat siitä pahasta ja
vahingosta, jota voivat matkaan saattaa.
 — Niin, sillä tavalla sanoi Hesiodus tuhat vuotta sitten, ja voinhan
tunnustaa, että sen kaltaista se on, mutta mitäpä sille voi?

— Niin, sellaista se on! Cicero murhattiin, ja minua himottaisi

seurata Caton esimerkkiä, hänen joka kuoloon kulki syntiä
välttääkseen. Minä painun, Flaccus, alaspäin valheeseen ja
teeskentelyyn, mutta minä en tahdo painua, tahdon kohota… Olen
ylistänyt Augustusta ja hänen poikaansa Marcellusta, mutta en luota
heihin enää, sillä he eivät ole tulevaisuus. Siksi on Aeneis poltettava!

— Sinä saat minut levottomaksi. Maro! — Mutta mihin luotat?

— Luotan sibyllaan, joka on ennustanut, että rauta-aika on

loppuva ja kulta-aika jälleen palaava…

— Tuota olet laulanut neljännessä luvussa muistaakseni… Onko

sinussa kuumetta.

— On luullakseni… Muistatko, et, isämme muistavat, kun

Kapitolium paloi ja sibylla-kirjat mukana. Mutta nyt on tullut uusia
kirjoja Aleksandriasta, ja niistä on luettu, että uusi ajanlasku on pian
alkava; että Rooma on hukkuva, mutta että se rakennetaan
uudelleen, ja että kulta-aika…

Tässä taukosi ennustaja.

— Anteeksi, Flaccus, mutta olen sairas ja ratsastan kotiin,

ennenkuin Campagnanin usvat nousevat.

— Eheu Jugaces Posthume, Posthume! Labuntur anni! Minä käyn

kanssasi, ystäväni, aasini selässä, sillä sinä olet sairas! Mutta:
 Jos tahto luja, oikea sydän on,
ei älyttömäin kiihko, mi pahaan vie,
ei tyrannien uhkakatse
saa miestä horjumaan tai pelkoon!
———
Ja vaikka maailma kumoon kaatuis,
pelotta seisois hän raunioissa!

Muutamaa päivää myöhemmin Virgilius oli vainajana Neapelissa.

Hänen testamenttinsa avattiin, ja siinä todellakin havaittiin olevan
pyyntö, että hänen Aeneisinsa poltettaisiin. Mutta hänen pyyntöänsä
ei täytetty.

Jälkimaailma on eri tavalla arvostellut tätä kuolevan viimeistä

tahtoa vastaan tehtyä rikosta; toiset arvelevat että se oli vahingoksi,
toiset että se oli eduksi.

Kristinuskon tullessa Virgilius laskettiin profeettoihin; Aeneis

otettiin talteen sibylla-kirjana ja liitettiin Liturgiaan; runoilijan
haudalle tehtiin pyhiinvaelluksia, ja sittemmin hänet Dante kohotti
pyhimystäkin korkeammalle.

Leontopolis.

Muuan karavaani oli leiriytynyt vanhan egyptiläisen Heliopolisin

itäpuolella olevalle kunnaalle. Siinä oli paljon väkeä, mutta kaikki
heprealaisia, ja he olivat kameleilla ja aaseilla vaeltaneet Palestinasta
läpi erämaan, saman erämaan, jonka halki Israelin lapset olivat
samoilleet enemmän kuin tuhat vuotta sitten.
 Illan hämärissä, puolikuun himmeässä valossa näkyi leiritulia
sadottain, ja niiden ääressä istui vaimoja pikku lapsineen, miesten
kantaessa vettä. Ei ollut kai milloinkaan erämaassa nähty niin paljon
pikku lapsia; ja kun heitä nyt oli laiteltava yöasuun, kajahteli leirissä
lasten kirkuna. Se oli kuin suurena lapsikamarina. Mutta kun
pesemisistä oli päästy, ja pienokaiset soviteltu äitien rinnoille, vaikeni
kirkuna toinen toisensa jälkeen, ja maa kävi aivan äänettömäksi.

Erään sykomorin varjossa istui vaimo ja imetti lastansa, vieressä

seisoi heprealainen mies ja laitteli rehua aasilleen. Päästyään tästä
toimesta, läksi hän kunnaan laelle ja tähysteli pohjoiseen.

Muukalainen, puvusta päättäen roomalainen, kulki ohi, tarkasti

vaimoa lapsineen kuin lukua laskeakseen.

Heprealainen kävi levottomaksi, mutta salatakseen mieltään ryhtyi

hän puheisiin roomalaisen kanssa.

— Sanohan, vaeltaja, onko tuo auringon kaupunki, tuo tuolla

lännessä?

— Sinä näet sen! vastasi roomalainen.

— Tämä siis on Beth Semes?

— Heliopolis, josta kreikkalaiset ja roomalaiset ovat viisautensa

ammentaneet; itse Platon on ollut täällä…

— Näkyykö Leontopoliskin tänne?

— Näethän temppelin harjat kahden peninkulman päässä

pohjoisessa.
 — Tämä siis on Gosenin maa, jossa Abraham isämme on käynyt ja
jonka Jakob sai osakseen, sanoi heprealainen kääntyen vaimonsa
puoleen, joka vastasi vain päätään nyökäyttäen.

Sitten roomalaiselle:

— Israel vaelsi Egyptistä Kananin maalle, mutta Babylonian

vankeuden jälkeen palasi osa jälleen tänne ja asettui asumaan.
Tämän tiedät.

— Sen tiedän osapuilleen, ja nyt ovat israelilaiset lisääntyneet

monituhantiseksi sielujoukoksi, sitä paitsi ovat he rakentaneet oman
temppelinsä, juuri tuon, jonka kaukana näet. Oletko sen tiennyt?

— Olen tiennyt sen osapuilleen. Mutta tämä on siis Rooman

maata?

— Se on!

— Kaikki on nyt Rooman: Syria, Kanan, Kreikan maa, Egypti…

— Germania, Gallia, Britannia; maailma on Rooman Cumeusin

sibyllan ennustuksen mukaan.

— No niin! Mutta maailman on vapahtava Israel Jumalan oman

lupauksen mukaan isällemme Abrahamille.

— Sen tarinan olen myöskin kuullut, mutta tätä nykyä on Roomalla

lupaus. — Tuletko Jerusalemista?

— Tulen halki erämaan, kuten toiset, ja mukanani on vaimo ja

lapsi.

— Lapsi niin! Miksi laahaatte mukananne niin paljon lapsia?

 Heprealainen kävi äänettömäksi; mutta kun hän arveli roomalaisen
tietävän syyn, ja tämä muuten näytti hyväntahtoiselta mieheltä,
päätti hän sanoa totuuden.

— Niin, hän sanoi, Herodes tetrarka sai kuulla Itämaitten viisailta

miehiltä ennustuksen, että juutalaiskuningas oli syntynyt
Betlehemissä Judanmaalla. Pelastuakseen tästä luulovaarasta,
murhautti Herodes kaikki poikalapset, jotka olivat niillä tienoilla
syntyneet lähiaikoina. Aivan samoin kuin farao juuri täällä surmautti
esikoisemme, jolloin Mooses kuitenkin pelastui vapauttaakseen
kansamme Egyptin orjuudesta.

— Kuuleppas, tuo kuningas? Kuka sen pitäisi oleman?

— Se on Messias, se luvattu.

— Luuletko, että se on syntynyt?

— En voi tietää sitä!

— Minä tiedän, että hän on syntynyt, sanoi roomalainen, hän joka

on vallitseva maailman ja laskeva kaikki kansat valtikkansa alaiseksi.

— Kukahan se olisi?

— Keisari, Augustus.

— Onko hän Abrahamin siementä tai Davidin huoneesta? Ei hän

ole. Ja onko hän tullut rauhaa tuomaan, kuten Jesajas on
ennustanut: "Hänen herrautensa on suuri oleva eikä rauhalla loppua
oleva"? Keisarihan ei suinkaan ole rauhan mies.
 — Hyvästi, Israelin lapsi; nyt olet Rooman alamainen; tyydy vain
Roomasta tulevaan vapautukseen; muusta me emme mitään tiedä.

Roomalainen läksi. Heprealainen lähestyi vaimoa:

— Maria! hän sanoi.

— Josef! toinen vastasi. Kulje hiljaa! Lapsi nukkuu!

Karitsa.

Herodes Antipas, tetrarka, oli tullut Jerusalemiin, koska

levottomuuden enteitä oli kansan keskuudessa. Nyt hän oli
majoittunut Pilatus maaherran luokse, ja oli viipyvä siellä pääsiäisen
yli järjestääkseen kaupungin asioita. Koska hän edellisenä iltana oli
ollut sirkuksessa katselemassa gladiatorinäytäntöä sekä sen jälkeistä
irstailua, nukkui hän aamulla pitkään, niin kauan, että hänen
isäntänsä odotellessaan kohtaavansa hänet oli käynyt talon katolle
kävelemään.

Siinä nyt oli se pyhä kaupunki, siinä Moria vuori ja temppeli, Zion
ja Davidin huone. Luoteessa ja lännessä kurottautui Saronin laakso
Välimerta kohti, joka selkeässä ilmassa sinisenä viiruna näkyi viiden
peninkulman päässä. Idässä kohoutui Öljymäki puu- ja
viinitarhoineen, kasvaen oliveja, viikunoita ja terebintejä; alapuolella
lirisi Kidronin puro, jonka rannat nyt olivat kevätpuvussaan, täynnä
kukkivia ruusukerroksia, tamariskejä ja raitoja.

Maaherran mieli ei ollut levollinen, ja hän pysähtyi usein

kaidepuun luo katsoakseen alas temppelin esikartanolle, jossa väkeä
liikkui tavattoman vilkkaasti, kerääntyen ryhmiin, jotka hajaantuivat
heti jälleen kasaantuakseen vieläkin suuremmiksi.

Vihdoinkin ilmestyi tetrarka unen pöpperössä ja silmät veristävinä.

Hän tervehti lyhyesti ja istuutui heti aivan kuin vastaanottoa varten.
Mutta hänen oli vaikeata päästä puheeseen, leuka riippui
avuttomana, eikä hän tiennyt miten alottaa, sillä hän oli unohtanut
asian yöllisessä irstailussa.

Pilatus ehätti hänen avukseen:

— Puhu, Herodes; sydämmesi on täynnä ja mielesi levoton.

— Mitä sanoikaan veljeni?

— Me puhuimme eilen siitä eriskummallisesta miehestä, joka

kiihottaa kansaa.

— Aivan! — Minähän mestautin sen Johanneksen, hänkö se

kummittelee?

— Ei, toinen se on nyt!

— Onko niitä kaksi?

— On, tämä on toinen.

— Mutta heidän historiansa on sama; ennustus, joka lausuttiin

ennen heidän syntymistään, ja tarina yliluonnollisesta syntymästä,
aivan kuin mytologian Perseus ja historian filosofi Platon. Onko
tapahtunut henkilöitten vaihdos?

— Ei, ei suinkaan.
 — Mikä hänen nimensä on? Josua, Jesse…

— Hänen nimensä on Jesus, ja lienee viettänyt lapsuutensa

Egyptin
Heliopolisissa ja Leontopolisissa…

— Hän on loihtija tai poppamies, eikö hän voi tulla minua

huvittamaan?

— Häntä on vaikea tavata, sillä milloin näyttäytyy hän siellä,

milloin täällä. Mutta tiedustakaamme ylimmäiseltä papilta, olen
kutsunut häntä ja hän odottaa tuolla alhaalla.

— Mikä meteli käy temppelin esikartanolla?

— Keisarin kuva aiotaan asettaa temppelin pyhiin huoneisiin.

— Aivan! Armollinen keisarimme Tiberius elää kuin mielipuoli

Caprilla, saa selkäänsä veljensä pojalta Caligulalta, jos häntä voipi
veljen pojaksi sanoa, kun pojat ovat naimisissa äitiensä kanssa, ja
nyt hänestä on tuleva jumala. Haha!

— Antiokus Epiphanes ripustutti Zeusin juutalaisten kaikkein

pyhimpään, se oli kuitenkin jumala; mutta jos he ripustavat sinne
Tiberiusin, sen naudan, niin on kapina edessämme.

— Mitäpä sille voi? — Kutsu pappi tänne.

Pilatus läksi alas tuomaan Kaiphasta, ylimmäistä pappia.

Herodes sulki silmänsä ja solmi kätensä rinnalleen. Kaikkia, mikä

koski virkaa, piti hän huvitustensa häiritsemisenä, ja yleensä hän piti
asiain lyhyestä menosta.
 Pilatuksen palatessa Kaiphasin kanssa tetrarka heräsi
torkuksistaan, eikä tiennyt missä oli tai mistä oli kysymys.

Pilatus astui esille ja herätti esimiehensä tietoisuuteen sekä sai

hänet tarkkaamaan nykyhetkeä.

— Temppelissä metelöidään! oli hänen ensimäinen huomionsa,

sillä se häiritsi hänen untaan. — Vai niin, siinähän on pappi. Mikä
melu on tuolla alhaalla?

— Galilealainen siellä on ryhtynyt väkivaltaan ja ajanut vaihtajat

ulos temppelistä.

Herodes kävi uteliaaksi.

— Katsokaamme häntä!

— Hän on jo poissa.

— Sanohan meille, ylimmäinen pappi, miten on tämän miehen

laita, onko hän Messias?

— Kuinka voisin sellaista uskoa? Erään kirvesmiehen poika rukka,

joka on päästään vialla.

— Onko hän profeetta?

— Hän kiihottaa kansaa, hän rikkoo lakia, on ylensyömäri ja viinin

juomari, ja hän pilkkaa jumalaa; niin, hän sanoo olevansa jumala,
korkeimman poika.

— Onko teillä todistajia?

— On, mutta he puhuvat ristiin.

 — Hankkikaa parempia todistajia, yhteen puhuvia todistajia. —
Mutta nyt, pappi, puhumme toisesta asiasta. Tiedät, että keisari
senaatin päätöksellä on julistettu jumalaksi ja että hänen kuvansa on
ripustettava temppeliin. Mitä arvelette?

— Me elämme keisarimme armoilla, mutta jos se häväistys

tapahtuu, niin käymme kaikki kuolemaan, kuten makkabealaiset
tekivät.

— No käykää siis kuolemaan!

Kaiphas ajatteli hetkisen, ennenkuin vastasi:

— Tahdon kutsua kokoon korkean raadin ja ilmoittaa keisarin

tahdon.

— Tee se, ja ennen pääsiäisjuhlaa tulee sinun saattaa tämä

Galilean mies eteeni, sillä tahdon nähdä hänet.

— Kyllä.

— Mene rauhassa!

Kaiphas poistui.

— Se on kovaa kansaa tämä Israel, sanoi Pilatus jotakin

sanoakseen.

— Minäkin polveudun Israelista, vastasi Herodes jotenkin jyrkästi,

sillä olen edomealainen, Esaun heimoa, ja äitini oli samaritar, sitä
halveksittua kansaa.

Pilatus huomasi iskeneensä harhaan, ja siksi löi hän

virkasauvallaan kolme kertaa lattiaan. Suuri luukku avautui, ja ylös
hinattiin pöytä, joka oli täynnä kaikkia herkkuja, mitä vain
roomalainen silloin saattoi toivoa.

Herodesin katse kirkastui.

*****

Pappien esikartanolla seisoivat Kaiphas ja Annas keskustellen.

— Kun emme voi päästä häväistyksestä, sanoi Kaiphas, ja keisarin

kuva on ripustettava kaikkein pyhimpään, kun kansa on menehtyvä
kapinassa, on meille parempi, että saatamme Herralle uhrimme ja
että joku kuolee kansan edestä.

— Oikein puhut, erinomainen sovitusuhri on meille välttämätön, ja

kun pääsiäinen on tulossa, niin uhratkaamme galilealainen.

— No niin! Mutta uhrin tulee olla puhdas, onko galilealainen

puhdas?

— Puhdas kuin karitsa.

— Ottakoon hän siis Israelin synnit kannettavikseen, jotta hänen

verensä meidät vapahtaa. Ken saattaa hänet meidän käsiimme?

Muuan hänen opetuslapsistaan, joka on tuolla ulkona.

Johannes, myöhemmin evankelistaksi sanottu, tuotiin sisälle, ja

Kaiphas alotti kuulustelun:

— Mitä todistat opettajastasi? Onko hän noussut Mooseksen lakia

vastaan?

— Hän on täyttänyt lain.

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