Exercise stereotypes as psychological barriers in vulnerable populations
An emerging body of literature has focused on the specific influence of exercise stereotypes on different populations, such as the elderly or individuals with chronic diseases. Exercise stereotypes can be defined as shared beliefs about the characteristics of a group in the specific context of regular PA and exercise. Particular measures have been generated to investigate exercise stereotypes in these populations. For example, the “Aging Stereotypes and Exercise Scale” was developed and validated to assess different aspects of aging stereotypes in the exercise sphere, such as (a) stereotypes regarding exercise benefits, (b) stereotypes about exercise risks, and (c) stereotypes related to self-efficacy (Chalabaev et al., 2013b). This line of research indicates that endorsement of negative aging exercise stereotypes is related to lower levels of PA among the elderly (Emile et al., 2014; Sánchez Palacios et al., 2009).
Another stereotypes scale is the “Cancer Exercise Stereotypes Scale” (CESS) (Falzon et al., 2014), which evaluates stereotypes related to exercise in cancer patients: (a) stereotypes related to the lack of interest in exercise, (b) stereotypes regarding exercise self-efficacy, (c) stereotypes about the side effects of treatment, (d) stereotypes related to the risks of exercise and, (e) stereotypes associated with the benefits of exercise. In both scales, some subscales refer to negative exercise stereotypes, and others refer to positive exercise stereotypes thus emphasising the presence of both negative and positive exercise stereotypes in vulnerable populations. Through these approaches to exercise stereotypes, researchers suggested that these stereotypes influence health behaviours and more specifically, PA participation through different mechanisms. In the following sections we look at the multiple mechanisms at play in the relationship between stereotypes and health behaviours, including PA.
The stereotype embodiment theory
In psychology, internalisation is defined as the unconscious internalisation of aspects of the world (especially aspects of persons) within the self in such a way that the internalised representation takes over the psychological functions of the external objects (Lawrence & Valsiner, 1993). The study of stereotype internalisation has focused mainly on largely “discriminating” factors, such as gender (e.g., Bonnot & Croizet, 2007; Chalabaev, Sarrazin, & Fontayne, 2009; Granié, 2009; Weisgram & Bigler, 2006), age (e.g., Emile et al., 2014; Hale, 1998; Levy, 2009) or level of education (e.g., Grusec & Goodnow, 1994) for example. Stereotype internalisation is considered to effect individuals’ behaviours due to their internalisation throughout socialisation.
According to the Stereotype Embodiment Theory (SET: Levy, 2009), age stereotypes are internalised into self-perceptions of aging and aging experiences are interpreted via this process (Levy & Leifheit-Limson, 2009). The SET (Levy, 2009) focuses on age stereotypes and advances the idea that the stereotype internalisation process is made-up of three steps: (a) ages stereotypes are internalised at a young age, (b) at some point, these age stereotypes become “self-stereotypes” about oneself as an aging individual, (c) these self-stereotypes are then consciously and unconsciously activated to exert their effect on individual health. Underlying these three steps of the SET are four components: the stereotypes, (a) become internalised across the lifespan, (b) can operate unconsciously, (c) gain salience from self-relevance, and (d) utilise multiple pathways (Levy, 2009).
In a similar way that age-stereotypes gain salience from self-relevance, it is plausible that stereotypes related to different pathological conditions gain salience in the same manner with an important difference that the aging process is inevitable. Furthermore, stereotypes exert their influence on individual health through different mechanisms. Levy (2009) hypothesised that stereotypes exert their influence according to psychological, behavioural and physiological mechanisms. The psychological mechanism is thought to operate via self-fulfilling expectations with higher, positive self-perceptions of aging at baseline being associated with better functional health and greater longevity (Levy, Slade, & Kasl, 2002; Levy & Banaji, 2002). The behavioural mechanism would operate via health practices. Healthy behaviours are considered as futile when they are seen as inevitable consequences of growing old (Levy & Myers, 2004) and hinder self-efficacy (Levy, Ashman, & Dror, 2000). When older adults have higher positive self-perceptions of aging they are more likely to engage in healthy behaviours (Levy & Myers, 2004). The physiological mechanism would implicate the autonomic nervous system. Using cardiovascular reactivity as a measure of the autonomic nervous system’s response to stress, Levy, Hausdorff, Henecke, and Wei (2000) observed elevated cardiovascular responses to stress when negative age stereotypes were subliminally primed. Repetitive strain on cardiovascular response can lead to detrimental effects on cardiovascular health, with a further study showing that the presence of negative age stereotypes in younger life doubling the risk of having an adverse cardiovascular event after the age of sixty (Levy & Leifheit-Limson, 2009).
Stereotype internalisation and physical activity
In the physical activity domain, most stereotype internalisation studies have focused on women and older adults. Indeed, research has shown that the internalisation of sex-stereotypes would prompt women to feel less competent, attribute less importance to sports practices and take part in sports activities to a lesser extent than men (e.g., Biddle, Atkin, Cavill, & Foster, 2011; Fredricks & Eccles, 2005). These negative perceptions impact PA participation among the targeted groups (i.e., girls). Therefore, taking into consideration the psychosocial determinants of PA participation are essential.
PA is one of the most important health behaviours associated with prevention of frailty and disease management. Thus, research has focused on the role of stereotype internalisation on PA participation in vulnerable populations. Sanchez Palacios et al. (2009) suggested that PA participation would be negatively impacted by negative age stereotypes whereas positive views of aging contributed to higher levels of PA (Wurm, Tomasik, & Tesch-Romer, 2010). Further studies have looked more specifically at the influence of exercise stereotypes, with both negative and positive exercise stereotypes being endorsed or adhered to among vulnerable populations, including older adults (Emile et al., 2014) and cancer patients (Falzon et al., 2014). An active mechanism in the relation between exercise stereotypes and PA level in older adults was internalisation as indexed by physical self-worth (Emile et al., 2014).
In a subsequent study these authors (Emile et al., 2015) showed that self-perceptions of aging as the active construct in internalisation may not be the only mechanism through which exercise stereotype endorsement impacts health behaviours.
The ego depletion account and stereotypes
In a longitudinal study including 192 older adults who regularly participated in organised PA, Emile et al. (2015) showed that age stereotypes endorsement across waves predicted subjective vitality, after controlling for self-perceptions of aging and relevant covariates. These results suggest that stereotypes might be related to health-behaviours in active older adults through an ego depletion mechanism.
Ego depletion is a self-regulatory mechanism based on the idea that engaging in acts of self-control, referring to the mental effort individuals use to regulate their own behaviour (Muraven & Baumeister, 2000), draws from a limited ‘reservoir’ which, when depleted, results in reduced capacity for further self-regulation (Muraven, Tice, & Baumeister, 2000). Thus monitoring your impressions, controlling your emotions, eating and drinking in moderation, and engaging in regular exercise are all actions requiring self-control (e.g., Vohs, Baumeister, & Ciarocco, 2005). Ego depletion specifically refers to the exertion of self-control on one task that drains self-control strength and impairs performance on subsequent tasks that require this same resource, according to the strength model of self-control (Muraven, Tice, & Baumeister, 2000).
Inzlicht, McKay, and Aronson (2006) suggested that stigmatised individuals use and deplete self-control to manage their devalued social identity, reducing their self-regulatory resources. Thus, stigma could weaken the fundamental ability to control and regulate one’s actions and behaviours. Suppressing stereotypes may require an effortful act of self-regulation as stereotypes can be activated automatically upon contact with a person in the target category (e.g., Devine, 1989) Thus, Gailliot, Plant, Butz, and Baumeister (2016) suggested that self-regulation plays a role in stereotype suppression with stereotype suppression resulting in poorer subsequent self-control performance. They do however, come to an encouraging conclusion that “increasing self-control strength through self-regulatory exercise can reduce the intrapsychic cost of suppressing stereotypes” (Gailliot, Plant, Butz, & Baumeister, 2007).
In their meta-analysis, Hagger, Wood, Stiff, and Chatzisarantis (2010) looked at possible alternative explanations to the self-regulatory failure that leads to ego depletion and are either consistent with, compete with, or complement the predictions of the strength model of self-control. Skill, affect, self-efficacy, motivation and fatigue were considered as plausible alternative explanations of ego depletion. As a consistent detriment in self-control task performance was observed independently of the level of difficulty of the task in ego depletion experiments; skill was rejected as a possible explanation (Muraven, Tice, & Baumeister, 1998).
Regulating affect requires an individual to overcome the intuitive tendency to display emotions in response to environmental stimuli; therefore, the active regulation of emotion or mood has been shown to deplete self-control resources (Bruyneel & Dewitte, 2012; Bruyneel, Dewitte, Franses, & Dekimpe, 2009; Muraven et al., 1998). Negative affect was shown to be significantly related to ego depletion, regardless of whether the task required affect regulation (Tice & Bratslavsky, 2000). Ego depletion is thus suggested to be a result of coping with negative affect and presents an alternative explanation.
Self-efficacy, as measured through task goal perception (i.e., attractive or important) and the belief in one’s ability to achieve the goal supposing the required effort is exerted, was thought to be reduced when in a state of depletion (e.g., Baumeister, Gailliot, DeWall, & Oaten, 2006). However, due to self-efficacy not necessarily being transferable across task domains, no relationship between self-efficacy and ego depletion was observed (e.g., Baumeister et al., 2006; Finkel et al., 2006). Motivation, and more specifically decreased motivation, could provide an alternative explanation for ego depletion. Muraven and Baumeister (2000) suggested that the effects of self-control resource availability and motivation on task performance might be interactive. Performing difficult and effortful tasks would lead to a state of mental fatigue and reduce the perceived importance of subsequent task goals relative to the expected effort required, resulting in decreased motivation to perform subsequent tasks that are perceived to be difficult, effortful and fatiguing. Nevertheless, this “motivation-only” explanation is not incompatible with the strength model of self-control and provides an alternative explanation through its close association with fatigue. Indeed, incentives such as rewards may moderate the effects of self-control resource depletion on task performance (Muraven & Slessareva, 2016), but this can only be temporary as fatigue is inevitable (Baumeister, Vohs, & Tice, 2007).
With regard to fatigue, Cameron (1973) suggested that subjective fatigue is experienced when mental resources are taxed. In ego depletion experiments, people engaging in depleting tasks showed increased subjective fatigue (e.g., Friese, Hofmann, & Wänke, 2008; Hagger, Wood, Stiff, & Chatzisarantis, 2010). Furthermore, in cognitively demanding tasks the fatigue induced lead to elevated physiological responses of general fatigue and reduced performance on subsequent tasks (e.g., Segerstrom & Nes, 2016; Wright et al., 2007). Fatigue can thus be considered as an indicator of ego depletion, but also as a mediator of the effects of self-regulatory resource depletion on subsequent task performance (Muraven et al., 2000). In this thesis, we will focus specifically on the fatigue explanation for ego depletion as the population of people living with HIV report fatigue as the most prevalent symptom. Beyond internalisation mechanisms stereotypes can be activated by the context and be a threat.
The stereotype threat theory
Activating a stereotype is typically thought to lead to people behaving in a stereotype-consistent way. “Stereotype activation was defined as the increased accessibility of the constellation of attributes that are believed to characterise members of a given social category” (Wheeler & Petty, 2001). Activated stereotypes could concern one’s own group memberships and are referred to as self-stereotypes, or stereotypes could concern groups to which one does not belong, referred to as other-stereotypes. The impact of self-stereotypes has been explained mainly through the stereotype threat mechanism and will be the focus of this section.
Table of contents :
Chapter 1 – The multidimensional aspects of fatigue in PLHIV
I. FATIGUE AMONG PLHIV
I. 1. BIOLOGICAL FACTORS OF FATIGUE IN PLHIV
I. 2. PSYCHOLOGICAL FACTORS OF FATIGUE IN PLHIV
I. 3. SOCIOLOGICAL FACTORS OF FATIGUE IN PLHIV
I. 4. MODELS OF FATIGUE IN CHRONIC DISEASES
II. PERFORMANCE FATIGABILITY
II. 1. PERIPHERAL FACTORS OF PERFORMANCE FATIGABILITY
II. 2. CENTRAL FACTORS OF PERFORMANCE FATIGABILITY
Chapter 2 – Physical activity in PLHIV
I. DEFINITIONS OF PHYSICAL ACTIVITY, EXERCISE AND RECOMMENDATIONS
II. PA BENEFITS AND HEALTH-RELATED EFFECTS
II. 1. PHYSIOLOGICAL BENEFITS OF PA IN PLHIV
II. 2. PSYCHOLOGICAL BENEFITS OF PA IN PLHIV
III. UNMET PHYSICAL ACTIVITY RECOMMENDATIONS IN PLHIV
IV. BARRIERS TO PHYSICAL ACTIVITY IN PLHIV
IV. 1. FATIGUE AS A PREVALENT SYMPTOM OF HIV AND A BARRIER TO PA
IV. 2. PSYCHOLOGICAL BARRIERS TO PA
Chapter 3 – Stereotypes and PA in vulnerable populations
I. DEFINITION OF STEREOTYPES
II. HIV STIGMA AND STEREOTYPES
III. STEREOTYPES RELATED TO PHYSICAL ACTIVITY AND EXERCISE
III. 1. THE NONEXERCISER STEREOTOYPE
III. 2. EXERCISER STEREOTYPES AS PSYCHOLOGICAL BARRIERS IN VULNERABLE POPULATIONS
IV. STEREOTYPE INTERNALISATION
IV. 1. THE STEREOTYPE EMBODIMENT THEORY
IV. 2. STEREOTYPE INTERNALISATION AND PHYSICAL ACTIVITY
V. THE EGO DEPLETION ACCOUNT AND STEREOTYPES
VI. THE STEREOTYPE THREAT THEORY
VI. 1. STEREOTYPE THREAT
VI. 2. STEREOTYPE THREAT IN THE PA DOMAIN
VII. OTHER STEREOTYPE EFFECTS
VIII. STEREOTYPE LIFT
Study 1 Perceived barriers to and facilitators of physical activity in people living with HIV: A qualitative study in a French sample
Summary of Study 1
Study 2 Exercise stereotypes and health-related outcomes in French people living with HIV:
Development and validation of the HIV Exercise Stereotype Scale (HIVESS)
Summary of Study 2
Study 3 Exercise stereotypes and fatigue in people living with HIV: does self-efficacy play a mediating or moderating role?
Summary of Study 3
Study 4 Characterising perceived fatigue and objective neuromuscular fatigability in active and less active people living with HIV
Summary of Study 4
Study 5 Does self-efficacy modulate the effect of stereotype threat on performance
on a fatiguing task in less active people living with HIV?
Summary of Study 5
Study 6 Performance on a fatiguing task among exercisers and nonexercisers: effects of the nonexerciser stereotype
Summary of Study 6