Mediators of change in physical activity following an intervention in primary care: PACE

Self-Efficacy is Associated with Health Behaviors Related to Obesity and Cardiovascular Risk among Hispanic/Latinx and Somali Immigrants to the United States

BACKGROUND

Self-efficacy theory proposes that confidence to engage in a health behavior is associated with engaging in that specific behavior. Most research examining self-efficacy has been conducted with white young adult populations. This secondary analysis examined the association of self-efficacy (i.e., confidence) for healthy eating and physical activity in two immigrant communities.

METHODS

At enrollment into the Healthy Immigrant Community study, a clinical weight management and cardiovascular risk reduction intervention set in southeastern [state], 475 participants completed assessments about their confidence for healthy eating and physical activity. Measurements also included self-reports of dietary quality and intake, physical activity, quality of life, and biometric assessments. Study materials were available in English, Spanish, and Somali. Results In total, 450 adults (Hispanic/Latinx = 267; Somali = 183) completed measures at baseline and were included for analysis. Their average age was 45 years (range 18-87) and 59% were female. Confidence for healthy eating was significantly associated with self-report of eating healthy snacks ( p  = < 0.0001) and less consumption of high-calorie drinks ( p  = 0.02) and regular soda ( p  = < 0.0001). Confidence to be physically active was significantly associated with more self-reported physical activity ( p  = < 0.01). Conclusions Confidence to eat healthy and be physically active appears to be associated with having a healthier diet and higher levels of physical activity. Given the large sample size and strength of the associations, it also appears that the theoretical model of self-efficacy can be effectively measured and applied within these immigrant populations. Self-efficacy theory may be useful in understanding potential mediating mechanisms when designing future interventions with immigrant communities.

CLINICALTRIALS

gov registration: NCT05136339; April 23, 2022.

Negative mood is associated with sociobehavioral factors contributing to cardiovascular risk in an immigrant population

BACKGROUND

After settling in the United States (US), immigrants often accumulate obesity and cardiovascular risk factors. As mood is often associated with health behaviors in the US population, mood may be an important mediating factor in immigrant populations.

METHODS

The Healthy Immigrant Community (HIC) study, set in southeast Minnesota, enrolled 475 adult participants in a weight loss intervention designed to reduce cardiovascular risk. Baseline questionnaires assessed mood, nutrition, physical activity, self-efficacy for healthy eating and physical activity, social support, and cohesion. A single-item mood rating of poor or fair was considered "negative", while ratings of good, very good, or excellent were considered "positive".

RESULTS

Hispanic/Latino (n = 268) and Somali (n = 181) adults enrolled in HIC completed baseline measures and were included in this analysis. Participants endorsing negative mood compared to positive mood had lower healthy eating scores (p = 0.02), lower physical activity levels (p = 0.03), lower confidence in eating a healthy diet (p = 0.001), and felt less of a sense of belonging to their community (p = 0.01). Those endorsing negative mood reported receiving less social support to eat healthy (p =  < 0.001) and be physically active (p = 0.01). They also accessed community resources for healthy eating (p = 0.001) and physical activity (p =  < 0.01) less frequently than participants endorsing positive mood.

CONCLUSIONS

On self-report, negative mood was associated with less healthy nutrition, lower confidence in eating healthy, sedentary lifestyle, and perceived lack of belonging to the community. Integrating mood management and self-efficacy strategies may enhance the effectiveness of lifestyle interventions to reduce obesity and cardiovascular risk among immigrants who report negative mood.

TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT05136339; April 23, 2022.

Negative Mood is Associated with Sociobehavioral Factors Contributing to Cardiovascular Risk in an Immigrant Population

Background

Immigrants to the United States, on average, accumulate cardiovascular risk after resettlement, including obesity. There is a need to co-create interventions to address these disparities, and mood may be an important mediating factor.

Methods

The Healthy Immigrant Community (HIC) study, set in southeast Minnesota, enrolled 475 adult participants in a weight loss intervention to reduce cardiovascular risk. Baseline questionnaires assessed mood, nutrition, physical activity, self-efficacy for healthy eating and physical activity, social support, and cohesion. A single-item mood rating of poor or fair was considered "negative", while ratings of good, very good, or excellent were considered "positive".

Results

A total of 449 HIC participants (268 Hispanic/Latino and 181 Somali) with complete baseline measures and were included in this analysis. Participants endorsing negative mood compared to those endorsing positive mood had lower scores for healthy eating (p = 0.02) and physical activity levels (p = 0.03), lower confidence in eating a healthy diet (p = 0.001), and felt less of a sense of belonging to their community (p = 0.01). Those endorsing negative mood also reported receiving less social support from their family and friends to eat healthy (p = < 0.001) and be physically active (p = 0.01), and less often accessed community resources for healthy eating (p = 0.001) and physical activity (p = < 0.01) compared to participants reporting positive mood.

Conclusions

Negative mood was associated with less healthy nutrition, lower confidence in eating healthy, sedentary lifestyle, and perceived lack of belonging to the community. Integrating mood management and self-efficacy strategies may enhance the effectiveness of lifestyle interventions among immigrants who report negative mood.

ClinicalTrialsgov registration

NCT05136339; April 23, 2022.

Healthy immigrant community study protocol: A randomized controlled trial of a social network intervention for cardiovascular risk reduction among Hispanic and Somali adults

BACKGROUND

Immigrants to the United States face structural barriers that contribute to rising cardiovascular risk factors and obesity after immigration. This manuscript describes the development of the Healthy Immigrant Community protocol and baseline measures for a stepped wedge cluster randomized trial to test the effectiveness of a social network intervention for cardiovascular risk reduction among two immigrant populations.

METHODS

We developed a social network-informed, community-based, participatory research-derived health promotion intervention with Hispanic and Somali immigrant communities in Minnesota consisting of mentoring, educational and motivational sessions, group activities, and a community toolkit for healthy weight loss delivered by culturally concordant health promoters (HPs) to their social networks. Using a stepped wedge cluster randomized design, social network-based groups were randomly assigned to receive the intervention either immediately or after a delay of one year. Outcomes, measured at baseline, 6 months, 12 months, and 24 months, were derived from the American Heart Association's "Life's Simple 7": BMI and waist circumference, blood pressure, fasting blood glucose, total cholesterol, physical activity level, and dietary quality.

RESULTS

A total of 51 HPs were enrolled and randomized (29 Hispanic; 22 Somali). There were 475 participants enrolled in the study, representing a mean social network group size of 8 (range, 5-12). The mean BMI of the sample (32.2) was in the "obese" range.

CONCLUSION

Processes and products from this Healthy Immigrant Community protocol are relevant to other communities seeking to reduce cardiovascular risk factors and negative health behaviors among immigrant populations by leveraging the influence of their social networks.

Implementation and evaluation of Exercise is Medicine in primary care clinics within a large academic health system

OBJECTIVE

Exercise is Medicine (EIM) is a global initiative encouraging healthcare providers to routinely assess and promote physical activity (PA) among patients. The objective of this study was to evaluate the feasibility, adoption, implementation and effectiveness of EIM from patient, clinician and healthcare staff perspectives using a combination of electronic health record (EHR), survey and interview data.

DESIGN

This study used a combination of the Practical Robust Implementation and Sustainability Model (PRISM) and the Learning Evaluation model to implement EIM. Data captured from the EHR, including Physical Activity Vital Sign (PAVS) scores, and data collected from qualitative surveys and interviews were used to evaluate the programme's Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM, which is embedded within PRISM) from provider, staff and patient perspectives.

SETTING

Five primary care clinics within a large academic health system.

PARTICIPANTS

A total of 24 443 patients from all participating clinics had at least one PAVS score during the study period. A total of 17 clinicians completed surveys, and 4 clinicians, 8 medical assistants and 9 patients completed interviews.

RESULTS

Implementation fidelity metrics varied widely between components and across clinics but were generally consistent over time, indicating a high degree of programme maintenance. Fidelity was highest during the first 6 months of the COVID-19 pandemic when most visits were virtual. Mean PAVS scores increased from 57.7 (95% CI: 56 to 59.4) to 95.2 (95% CI: 91.6 to 98.8) min per week at 6 months for patients not meeting PA guidelines at baseline and decreased from 253.84 (95% CI: 252 to 255.7) to 208.3 (95% CI: 204.2 to 212.4) min per week at 6 months for patients meeting PA guidelines at baseline. After EIM implementation, clinician-estimated time spent discussing PA with patients increased for 35% of providers and stayed the same for 53%.

CONCLUSION

Overall, this study established EIM's feasibility, adoption, implementation and maintenance in routine primary care practice within a large academic health system. From a population health perspective, EIM is a model to emulate to help primary care providers efficiently address healthy lifestyle behaviours in routine primary care visits.

Effect of nutrition education intervention to improve dietary diversity practice and nutritional status of the older people: A cluster randomized controlled trial

The growing aging population raises nutrition and health concerns, with malnutrition in the elderly linked to negative health outcomes. Our objective was to implement theory-based nutritional education interventions to improve the nutritional status of the elderly through diversified dietary practices. A cluster randomized controlled trial was conducted from December 1, 2021, to May 30, 2021, among 782 older persons randomly selected from two urban and 12 semi-urban areas in southwest Ethiopia. We used Social cognitive theory (SCT) in guiding the nutritional education intervention. Data were collected using an interviewer-administered questionnaire. The Mini Nutritional Assessment (MNA) tool was used to assess nutritional status, and a qualitative 24-h eating recall was used to evaluate dietary diversity. Difference-in-difference and generalized estimating equation models were used to assess the intervention effect. In total, 720 participants (361 in the intervention group and 359 in the control group) were included for analysis. The mean dietary diversity score differed significantly between the intervention group and the control group (p < .001). According to the multivariable generalized estimating equations model, the intervention group was 7.7 times (AOR = 7.746, 95% CI: 5.012, 11.973) more likely to consume a diverse diet than the control group. The nutrition status of the elderly in the intervention group improved significantly at the end of the intervention (p < .001). SCT-based nutritional education interventions can effectively improve healthy eating and nutritional status. For older adults, with its convenient approach and low cost, SCT should be considered an effective and efficient nutritional education approach for behavior change.

Self-Compassion and Physical Activity: The Underpinning Role of Psychological Distress and Barrier Self-Efficacy

Unlike other personality traits or dispositions, self-compassion can be nurtured and is likely a driving source for physical activity. Emerging research has started to examine self-compassion in physical activity contexts; however, most existing studies were underpowered and overlooked the psycho-behavioural factors underlying the link between self-compassion and physical activity. In a sample of 569 UK adults (mean age = 41.92 years, SD = 13.70; 47.8% female), we examined the hypothesis that self-compassion's positive influence on physical activity operates through reduced psychological distress and subsequently increased barrier self-efficacy. Results supported the prediction, with the positive influences of self-compassion being more prominent in more vigorous physical activity. The findings suggest that self-compassion is a good source of emotional resources (i.e., attenuated psychological distress) and confidence to overcome challenges and obstacles (i.e., increased barrier self-efficacy) in the context of physical activity. Future interventions and programs could consider incorporating self-compassion for physical activity adoption and maintenance.

Increasing the Effectiveness of a Physical Activity Smartphone Intervention With Positive Suggestions: Randomized Controlled Trial

Background

eHealth interventions have the potential to increase the physical activity of users. However, their effectiveness varies, and they often have only short-term effects. A possible way of enhancing their effectiveness is to increase the positive outcome expectations of users by giving them positive suggestions regarding the effectiveness of the intervention. It has been shown that when individuals have positive expectations regarding various types of interventions, they tend to benefit from these interventions more.

Objective

The main objective of this web-based study is to investigate whether positive suggestions can change the expectations of participants regarding the effectiveness of a smartphone physical activity intervention and subsequently enhance the number of steps the participants take during the intervention. In addition, we study whether suggestions affect perceived app effectiveness, engagement with the app, self-reported vitality, and fatigue of the participants.

Methods

This study involved a 21-day fully automated physical activity intervention aimed at helping participants to walk more steps. The intervention was delivered via a smartphone-based app that delivered specific tasks to participants (eg, setting activity goals or looking for social support) and recorded their daily step count. Participants were randomized to either a positive suggestions group (69/133, 51.9%) or a control group (64/133, 48.1%). Positive suggestions emphasizing the effectiveness of the intervention were implemented in a web-based flyer sent to the participants before the intervention. Suggestions were repeated on days 8 and 15 of the intervention via the app.

Results

Participants significantly increased their daily step count from baseline compared with 21 days of the intervention (t₁₀₇=−8.62; P<.001) regardless of the suggestions. Participants in the positive suggestions group had more positive expectations regarding the app (B=−1.61, SE 0.47; P<.001) and higher expected engagement with the app (B=3.80, SE 0.63; P<.001) than the participants in the control group. No effects of suggestions on the step count (B=−22.05, SE 334.90; P=.95), perceived effectiveness of the app (B=0.78, SE 0.69; P=.26), engagement with the app (B=0.78, SE 0.75; P=.29), and vitality (B=0.01, SE 0.11; P=.95) were found. Positive suggestions decreased the fatigue of the participants during the 3 weeks of the intervention (B=0.11, SE 0.02; P<.001).

Conclusions

Although the suggestions did not affect the number of daily steps, they increased the positive expectations of the participants and decreased their fatigue. These results indicate that adding positive suggestions to eHealth physical activity interventions might be a promising way of influencing subjective but not objective outcomes of interventions. Future research should focus on finding ways of strengthening the suggestions, as they have the potential to boost the effectiveness of eHealth interventions.

Trial Registration

Open Science Framework 10.17605/OSF.IO/CWJES; https://osf.io/cwjes

Use of a Smartphone App Versus Motivational Interviewing to Increase Walking Distance and Weight Loss in Overweight/Obese Adults With Peripheral Artery Disease: Pilot Randomized Trial

BACKGROUND

Walking therapy improves functional outcomes in patients with peripheral artery disease (PAD). Less is known about the additive benefit of a dietary intervention.

OBJECTIVE

Our objectives were to develop a smartphone app and, as a pilot, explore its potential efficacy as compared to motivational interviewing (MI) to increase walking distance and promote weight loss in overweight/obese adults with PAD.

METHODS

We conducted a 3-month, 2-arm randomized pilot study at the University of Kansas. Inclusion criteria were BMI >27 kg/m2 and symptomatic PAD, defined by an ankle-brachial index <0.9. Patients were randomized into 2 groups: MI, delivered through in-person and telephone counseling, and app, a mobile smartphone app. Both interventions encouraged walking for exercise and healthy dietary habits (increasing fruits and vegetables and whole grains while reducing fat and sugary drinks). We assessed medical history at baseline. At baseline and 3 months, participants completed an assessment of 6-minute walking distance, weight, quality of life, exercise behaviors, and dietary habits. The primary outcome was 3-month change in walking distance. Secondary outcomes were changes in weight, quality of life, exercise behaviors, and dietary habits. We used a Wilcoxon rank-sum test to analyze the primary and secondary outcomes at 3 months within the MI and app groups and to compare the changes between the groups with adjustment for baseline.

RESULTS

We randomized 29 participants with a mean age of 66.03 (SD 8.12) years; 25 participants completed the trial. At baseline, mean walking distance among completers was 260.40 (SD 94.32) meters and 326.15 (SD 69.28) meters for MI and app participants, respectively. At 3 months, the mean walking distance was 298.67 (SD 101.20) meters and 331.19 (SD 58.63) meters for MI and app participants, respectively (group difference P=.03, adjusting for baseline). Increase in walking distance at 3 months was 40.5 meters (95% CI 6.77 to 61.34; P=.02) in MI group. At baseline, mean body weight was 253.10 (SD 59.45) lbs and 225.13 (SD 58.93) lbs for MI and app participants, respectively. At 3 months, mean body weight was 242.14 (SD 58.54) lbs and 223.44 (SD 59.54) lbs for MI and app, respectively (group difference P=.006, adjusting for baseline). Pre-post study decrease in weight was 10.1 lbs (95% CI -17.9 to -3.0) and 2.3 lbs (95% CI -3.4 to -0.7) in MI and app group, respectively. Comparing baseline to 3 months, there were no statistically significant differences in quality of life, exercise behaviors, or dietary habits.

CONCLUSIONS

Our study demonstrates that MI can promote walking and weight loss in overweight/obese adults with PAD. The smartphone app showed a small weight loss but no statistically significant increase in walking distance. As this was a pilot study, future large-scale studies are needed to replicate the efficacy of MI to promote weight loss in overweight or obese adults with PAD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03694652; https://clinicaltrials.gov/ct2/show/NCT03694652.

Predictors of physical activity behavior change based on the current stage of change-an analysis of young people from Hawai'i

This study investigated the corresponding change between psycho-social predictors and physical activity (PA) behavior and if these relationships were dependent on the stages of change from the Transtheoretical Model in Minority American adolescents. We conducted a longitudinal field study with N = 357 students aged 13-18 years (M = 14.24 years, SD = 0.88); predominantly Filipino (61.2%) using a test-retest design assessing psycho-social PA predictors (enjoyment, self-efficacy, family support, friends' support, knowledge, stage of change) and moderate-to-vigorous physical activity (MVPA) at two time points over six months. Hierarchical regression results indicated that a positive change of enjoyment, knowledge about PA and family support predicted a change of MVPA, independently of stage. The time-varying covariation showed the importance of the current stage of change for enjoyment, self-efficacy and support of friends for a change of MVPA. Overall, our findings suggest that an individual's current stage of change should be considered to determine individually appropriate starting points and goals for designing interventions to promote PA among Minority American adolescents.

Behavior-Specific Cognitions Moderate Rural Women's Responsiveness to Web-Based Interventions for Weight Loss

OBJECTIVE

To examine whether baseline behavior-specific cognitions moderated the effects of 2 Web-based interventions with enhanced features on weight loss success in rural women.

DESIGN

Secondary analysis of behavior-specific cognition data from a community-based, randomized controlled trial, as potential moderators of weight loss over 30 months.

PARTICIPANTS

Women, overweight or obese, from rural communities, aged 40-69 years (n = 200).

INTERVENTIONS

Theory-based Web interventions, with enhanced features of either peer-led Web discussion or professional e-mail counseling.

MAIN OUTCOME MEASURES

Benefits and barriers to healthy eating and activity; self-efficacy and interpersonal support for healthy eating and activity using validated surveys; and weight.

ANALYSIS

Longitudinal multilevel models.

RESULTS

Women in the professional e-mail counseling group were more likely to lose weight if they perceived fewer barriers to and higher self-efficacy for healthy eating and activity. Greater weight loss in the peer-led discussion group was observed for women with lower self-efficacy and higher perceptions of barriers. Interpersonal support did not moderate the effects of the interventions.

CONCLUSIONS AND IMPLICATIONS

Although women in 2 different Web-enhanced interventions achieved similar weight loss, their baseline perceptions of behavior-specific cognitions moderated their relationship with the type of intervention and weight loss success. These findings, although exploratory, may assist in matching women to Web interventions that would best maximize weight loss success. Further research is needed.

Effects of Active Video Games on Children's Psychosocial Beliefs and School Day Energy Expenditure

Purpose: Examine the effects of active video games (AVGs) on children's school-day energy expenditure (EE) and physical activity (PA)-related self-efficacy, social support, and outcome expectancy over 9 months. Method: Participants were 81 fourth grade students ( X ¯ age = 9.23 years, SD = 0.62; 39 girls) from two urban Minnesota elementary schools. A once-weekly 50 min AVG intervention was implemented in the intervention school for 9 months in 2014-2015 while the control school continued regular recess. Children's school-day EE (daily caloric expenditure) and mean daily metabolic equivalent (MET) values were estimated via accelerometry whereas self-efficacy, social support, and outcome expectancy were assessed with psychometrically-validated questionnaires. All measures were completed at baseline and at the 4th and 9th months. Results: We observed significant interaction effects for daily caloric expenditure, F(1, 58) = 15.8, p < 0.01, mean daily MET values, F(1, 58) = 11.3, p < 0.01, and outcome expectancy, F(1, 58) = 4.5, p < 0.05. Specifically, intervention children had greater increases in daily caloric expenditure (91 kilocalorie/day post-intervention group difference), with control children decreasing daily caloric expenditure over time. We observed identical trends for mean daily MET values (0.35 METs/day post-intervention group difference). Interestingly, we observed outcome expectancy to increase in the control children, but decrease among intervention children, at post-intervention (1.35 group difference). Finally, we observed a marginally significant interaction effect for social support, F(1, 58) = 3.104, p = 0.08, with an increase and decrease seen in the intervention and control children, respectively. We observed no interaction or main effects for self-efficacy. Discussion: Observations suggested an AVG intervention contributed to longitudinal increases in school-day EE and social support compared to the control condition. Future research should examine how self-efficacy and outcome expectancy might be promoted during school-based AVG interventions.

The role of perceived benefits and barriers in colorectal cancer screening in intervention trials among African Americans

The Health Belief Model (HBM) is widely used in health behavior interventions. The lack of diverse samples in the development of this theory warrants additional study on how it performs among minorities. While studies have utilized HBM to address colorectal cancer (CRC) screening, limited information exists confirming how these constructs influence screening. Data from three CRC screening trials were used to examine how perceived benefits/barriers perform among African Americans (AA) and whether they serve as mechanisms of the intervention effects on screening. The data were collected in AA churches (Study 1: N = 103; Study 2: N = 285; Study 3: N = 374) where lay members conducted CRC education to increase screening. Participants perceived benefits from colonoscopy (M = 2.4/3, SD = 0.87) and perceived few barriers (M = 0.63/8, SD = 1.1). Benefits were perceived for the fecal occult blood test (M = 11.4/15, SD = 2.1), and few barriers were reported (M = 11.7/30, SD = 3.4). Benefits more consistently predicted pre-intervention screening relative to barriers. For Study 3, individuals with fewer barriers reported a greater increase in colonoscopy screening at 12-months versus those with higher barriers (OR = 0.595, 95% CI = 0.368-0.964), P = 0.035). Benefits/barriers did not mediate the relationship. Potential measurement limitations, particularly for barriers, were uncovered and further research on how to assess factors preventing AA from screening is needed.

Relationship Between Negative Mood and Health Behaviors in an Immigrant and Refugee Population

Immigrants experience an escalation of negative health behaviors after arrival to the United States. Negative mood is associated with poorer health behaviors in the general population; however, this relationship is understudied in immigrant populations. Adolescent (n = 81) and adult (n = 70) participants completed a health behavior survey for immigrant families using a community-based participatory research approach. Data was collected for mood, nutrition, and physical activity. Adolescents with positive mood drank less regular soda, and demonstrated more minutes, higher levels, and greater social support for physical activity (all ps < .05). Adults with positive mood reported more snacking on fruits/vegetables, greater self-efficacy for physical activity, and better physical well-being (all ps < .05). Negative mood was associated with low physical activity level and poor nutritional habits in adolescent and adult immigrants. Designing community-based programs offering strategies for mood management and healthy lifestyle change may be efficacious for immigrant populations.

Item response modeling: a psychometric assessment of the children's fruit, vegetable, water, and physical activity self-efficacy scales among Chinese children

Background

This study aimed to evaluate the psychometric properties of four self-efficacy scales (i.e., self-efficacy for fruit (FSE), vegetable (VSE), and water (WSE) intakes, and physical activity (PASE)) and to investigate their differences in item functioning across sex, age, and body weight status groups using item response modeling (IRM) and differential item functioning (DIF).

Methods

Four self-efficacy scales were administrated to 763 Hong Kong Chinese children (55.2% boys) aged 8-13 years. Classical test theory (CTT) was used to examine the reliability and factorial validity of scales. IRM was conducted and DIF analyses were performed to assess the characteristics of item parameter estimates on the basis of children’s sex, age and body weight status.

Results

All self-efficacy scales demonstrated adequate to excellent internal consistency reliability (Cronbach’s α: 0.79-0.91). One FSE misfit item and one PASE misfit item were detected. Small DIF were found for all the scale items across children’s age groups. Items with medium to large DIF were detected in different sex and body weight status groups, which will require modification. A Wright map revealed that items covered the range of the distribution of participants’ self-efficacy for each scale except VSE.

Conclusions

Several self-efficacy scales’ items functioned differently by children’s sex and body weight status. Additional research is required to modify the four self-efficacy scales to minimize these moderating influences for application.

Physical Activity and Cognitive Function in Older Adults: The Mediating Effect of Depressive Symptoms

Depressive symptoms and social networks may influence the relationship between physical activity and cognition. Using structural equation modeling, depressive symptoms and social networks were examined as mediators between physical activity and cognition in community-dwelling older adults (N = 122), with a range of cognitive abilities (e.g., normal, mild cognitive impairment). The model included age, physical activity, sedentary behavior, sleeping, social networks, depressive symptoms, and cognitive function. A path was observed between physical activity, depressive symptoms, and cognition; specifically, those who were more physically active experienced less depression and better cognitive functioning. No relationship between social networks and cognition was found. This model fits the data well (goodness-of-fit index = .93, adjusted goodness-of-fit index = .90, root mean square error of approximation = .06). Results suggest that physical activity may mitigate depressive symptoms, with beneficial effects on cognitive functioning in both those with and without mild cognitive impairment. Suggestions for managing depression and improving cognitive functioning are provided.

Validating Stages of Change for Obesogenic Behaviors Across Filipino and Other Asian-American and Pacific Islander Adolescents

Filipino adolescents are underrepresented in obesity research, although Filipinos are the second largest Asian-American and Pacific Islander (AAPI) subpopulation in the USA. An understanding of how well the theories of behavior change apply to Filipino and other AAPI adolescents is critical to addressing obesogenic behaviors in these groups. This study aimed to validate the transtheoretical model of behavior change (TTM) for physical activity (PA) and fruit and vegetable intake (FV) among a majority Filipino adolescent population. Adolescents in grades 9-11 (N = 159, 82.4% female) completed measures of PA and FV behaviors and PA and FV stages of change. One-way ANOVAs and Tukey's HSD post hoc tests were computed to assess the validity of the PA and FV stages of change with the respective behaviors. There was a significant effect for fruit (action > contemplation, preparation) and vegetable (maintenance, action > contemplation) intakes across the FV stages of change. There was a significant effect of strenuous PA (precontemplation/contemplation, preparation < action < maintenance) and moderate PA (precontemplation/contemplation < action, maintenance) across the PA stages of change. Some variability in associations emerged when the sample was stratified by gender. This study provides validity evidence for the TTM stages of change for FV and PA among Filipino and other AAPI adolescents. This validation, in turn, extends the generalizability of the stages of change construct to include this ethnic group and replicates other adolescent studies.

Randomized Trial of a Lifestyle Physical Activity Intervention for Breast Cancer Survivors: Effects on Transtheoretical Model Variables

This study examined whether a physical activity intervention affects transtheoretical model (TTM) variables that facilitate exercise adoption in breast cancer survivors. Sixty sedentary breast cancer survivors were randomized to a 6-month lifestyle physical activity intervention or standard care. TTM variables that have been shown to facilitate exercise adoption and progress through the stages of change, including self-efficacy, decisional balance, and processes of change, were measured at baseline, 3 months, and 6 months. Differences in TTM variables between groups were tested using repeated measures analysis of variance. The intervention group had significantly higher self-efficacy ( F = 9.55, p = .003) and perceived significantly fewer cons of exercise ( F = 5.416, p = .025) at 3 and 6 months compared with the standard care group. Self-liberation, counterconditioning, and reinforcement management processes of change increased significantly from baseline to 6 months in the intervention group, and self-efficacy and reinforcement management were significantly associated with improvement in stage of change. The stage-based physical activity intervention increased use of select processes of change, improved self-efficacy, decreased perceptions of the cons of exercise, and helped participants advance in stage of change. These results point to the importance of using a theory-based approach in interventions to increase physical activity in cancer survivors.

Process of Behavioral Change as it Relates to Intentional Physical Activity

During the past 100 years, America has changed from an agrarian society, where the intent of physical activity was to produce needed materials, to a postindustrial society, where 60% of American adults are not regularly physically active and 25% are not active at all (Centers for Disease Control and Prevention, 1999). With sedentary lifestyle and its attendant consequences on the rise, the occupational health nurse can increase individuals' knowledge, facilitate their decision making, and motivate them to try new behaviors and change existing behaviors. The occupational health nurse can use a model to organize individual workers' information and clarify strategies to promote behavior change. The goal is to decrease the morbidity and mortality associated with sedentary lifestyles of American workers by using the model when individuals present to the occupational health service. Individuals benefit from health care professionals who understand personal risks and communicate strategies to address barriers and concerns when they consider behavior changes such as increasing physical activity.

Predictive Ability of Pender’s Health Promotion Model for Physical Activity and Exercise in People With Spinal Cord Injuries

The main objective of this study was to validate Pender’s Health Promotion Model (HPM) as a motivational model for exercise/physical activity self-management for people with spinal cord injuries (SCIs). Quantitative descriptive research design using hierarchical regression analysis (HRA) was used. A total of 126 individuals with SCI were recruited through the National Spinal Cord Injury Association, other SCI support groups, and professors in rehabilitation counseling across the United States. Outcome measures used were the International Physical Activity Questionnaire and the Physical Activity Stages of Change Instrument. The HRA results indicated that preinjury physical activity/exercise level, severity of SCI, and commitment to a plan for exercise and physical activity were predictive of postinjury exercise and physical activity level. In addition, friend/family support, perceived self-efficacy, and perceived benefits were the strongest predictors of commitment to a plan of action for exercise and physical activity. The research findings support the applicability of Pender’s HPM as a motivational model for exercise/physical activity for people with SCI. The information can be used to design health promotion behavioral interventions for people with SCI living in the community.

Mediator Analysis of Moms on the Move

This study examined whether improvements in physical activity discovered in a test of Moms on the Move were mediated by the behavioral constructs from which the intervention was derived. Identifying mediator variables is vital for intervention planning. The intervention was derived from the Transtheoretical Model (TTM) of behavior change and promoted moderately intense activities like walking. Sedentary mothers with children enrolled in the Women, Infants, and Children program (N = 44) were randomly assigned to the experimental intervention or attention control. Large effect sizes were reported for improvements in physical activity and changes in TTM constructs. This study examined whether the physical activity improvements were mediated by the behavioral constructs. Statistical analyses used bivariate correlation coefficients and two-stage multiple linear regression. These exploratory findings did not support the hypothesis that increased physical activity, which was associated with the experimental intervention, was mediated by the TTM constructs.

Self-Efficacy Intervention Effect on Physical Activity in Older Adults

This study determined the effectiveness of a self-efficacy intervention designed to improve selfefficacy and physical activity in older adults postcardiac event. An experimental three-group design tested the intervention, with treatment groups receiving 1 of 2 supportive telephone protocols (theory-based self-efficacy coaching or attention control). Outcome variables included selfefficacy expectations for physical activity (PA), self-reported PA, and PA performance (distance walked in 6 minutes). The self-efficacy intervention was effective in demonstrating greater PA performance when compared to the attention control intervention, and PA self-efficacy was significantly correlated with both measures of PA. There were significant main effects of time for PA self-efficacy and distance walked, and a significant interaction effect on the distance walked because of time and treatment condition. Although the self-efficacy intervention did not show a direct effect on level of PA self-efficacy as hypothesized, there was an indirect interaction effect on distance walked and physical activity confidence.

Behavior-Specific Influences for Physical Activity Among African American Women

The purpose of this study was to describe physical activity (PA) behaviors and physical functioning of prehypertensive and Stage I hypertensive African American Women (AAW) and to examine the relationships between PA behavior, physical functioning, personal factors, and behavior-specific influences. Pender's Health Promotion Model was the conceptual framework for the study. A cross-sectional design and convenience sample were used. The PA domain where the greatest amount of time was spent was in work-related activity, followed by household, leisure time, and transportation activity. Personal factors most strongly correlated to lower PA were greater body mass index and waist circumference. AAW perceived moderate barriers to PA and minimal family and friend social support for PA. Future interventions need to focus on removing barriers to and improving social support for PA among AAW.

Healthy immigrant families: Participatory development and baseline characteristics of a community-based physical activity and nutrition intervention

BACKGROUND

US immigrants often have escalating cardiovascular risk. Barriers to optimal physical activity and diet have a significant role in this risk accumulation.

METHODS

We developed a physical activity and nutrition intervention with immigrant and refugee families through a community-based participatory research approach. Work groups of community members and health scientists developed an intervention manual with 12 content modules that were based on social-learning theory. Family health promoters from the participating communities (Hispanic, Somali, Sudanese) were trained to deliver the intervention through 12 home visits during the first 6 months and up to 12 phone calls during the second 6 months. The intervention was tested through a randomized community-based trial with a delayed-intervention control group, with measurements at baseline, 6, 12, and 24 months. Primary measurements included accelerometer-based assessment of physical activity and 24-hour dietary recall. Secondary measures included biometrics and theory-based instruments.

RESULTS

One hundred fifty-one individuals (81 adolescents, 70 adults; 44 families) were randomized. At baseline, mean (SD) time spent in moderate-to-vigorous physical activity was 64.7 (30.2) minutes/day for adolescents and 43.1 (35.4) minutes/day for adults. Moderate dietary quality was observed in both age groups. Biometric measures showed that 45.7% of adolescents and 80.0% of adults were overweight or obese. Moderate levels of self-efficacy and social support were reported for physical activity and nutrition.

DISCUSSION

Processes and products from this program are relevant to other communities aiming to reduce cardiovascular risk and negative health behaviors among immigrants and refugees.

TRIAL REGISTRATION

This trial was registered at Clinicaltrials.gov (NCT01952808).

Self-regulation of exercise behavior in the TIGER study

OBJECTIVE

This study aimed to test experiential and behavioral processes of change as mediators of the prediction of exercise behavior by two self-regulation traits, self-efficacy and self-motivation, while controlling for exercise enjoyment.

METHODS

Structural equation modeling was applied to questionnaire responses obtained from a diverse sample of participants. Objective measures defined adherence (928 of 1,279 participants attended 80 % or more of sessions) and compliance (867 of 1,145 participants exercised 30 min or more each session at their prescribed heart rate).

RESULTS

Prediction of attendance by self-efficacy (inversely) and self-motivation was direct and also indirect, mediated through positive relations with the typical use of behavioral change processes. Enjoyment and self-efficacy (inversely) predicted compliance with the exercise prescription.

CONCLUSIONS

The results support the usefulness of self-regulatory behavioral processes of the transtheoretical model for predicting exercise adherence, but not compliance, extending the supportive evidence for self-regulation beyond self-reports of physical activity used in prior observational studies.

Upgrading physical activity counselling in primary care in the Netherlands

The systematic development of a counselling protocol in primary care combined with a monitoring and feedback tool to support chronically ill patients to achieve a more active lifestyle. An iterative user-centred design method was used to develop a counselling protocol: the Self-management Support Programme (SSP). The needs and preferences of future users of this protocol were identified by analysing the literature, through qualitative research, and by consulting an expert panel. The counselling protocol is based on the Five A's model. Practice nurses apply motivational interviewing, risk communication and goal setting to support self-management of patients in planning how to achieve a more active lifestyle. The protocol consists of a limited number of behaviour change consultations intertwined with interaction with and responses from the It's LiFe! monitoring and feedback tool. This tool provides feedback on patients' physical activity levels via an app on their smartphone. A summary of these levels is automatically sent to the general practice so that practice nurses can respond to this information. A SSP to stimulate physical activity was defined based on user requirements of care providers and patients, followed by a review by a panel of experts. By following this user-centred approach, the organization of care was carefully taken into account, which has led to a practical and affordable protocol for physical activity counselling combined with mobile technology.

Physical activity perceptions and beliefs following total hip and knee arthroplasty: a qualitative study

BACKGROUND

Despite improvements in pain and physical capacity experienced by patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA), recent studies suggest that levels of physical activity may not change. This study aimed to qualitatively explore people's beliefs and perspectives about physical activity at 6 months following THA or TKA for the treatment of osteoarthritis (OA).

METHODS

Semi-structured interviews were conducted with 10 participants (age range 51-78 years) at 6 months post-arthroplasty surgery. Participants were recruited from a concurrent larger quantitative study examining quantitative physical activity levels via accelerometers. Interviews were transcribed, coded and analysed using a thematic approach.

RESULTS

Participants described greater capacity to be physically active post-surgery despite no increase in objective measures. Three themes emerged from the interviews relating to the participants perspective of physical activity after surgery: (1) physical activity is for enjoying living; (2) new limitations on physical activity: age and comorbidities; and (3) personal beliefs about physical activity: it is enough to know you can.

CONCLUSION

Individual beliefs and perceptions are important in understanding factors influencing physical activity following THA and TKA. Health practitioners should examine this when developing management plans aimed at optimizing physical activity.

Clinical management of alcohol use disorders in the neurology clinic

Alcohol misuse adversely affects health outcomes, but alcohol misuse and alcohol use disorders (AUDs) are often ignored by healthcare providers in primary and specialty ambulatory care clinics. Data show that early identification and brief intervention for alcohol misuse in these settings can effectively reduce alcohol consumption and its medical sequelae. The aim of this chapter is to review the epidemiology of problematic alcohol use in ambulatory care settings, the diagnostic criteria for AUDs, the approach called SBIRT (screening, brief intervention and referral to treatment) as a model program to target alcohol misuse in everyday clinical practice, when and how to refer patients to resources beyond the clinic for their alcohol use problems, and the medical illnesses associated with AUDs.

A monitoring and feedback tool embedded in a counselling protocol to increase physical activity of patients with COPD or type 2 diabetes in primary care: study protocol of a three-arm cluster randomised controlled trial

Background

Physical activity is important for a healthy lifestyle. Although physical activity can delay complications and decrease the burden of the disease, the level of activity of patients with chronic obstructive pulmonary disease (COPD) or type 2 Diabetes Mellitus (DM2) is often far from optimal. To stimulate physical activity, a monitoring and feedback tool, consisting of an accelerometer linked to a smart phone and webserver (It’s LiFe! tool), and a counselling protocol for practice nurses in primary care was developed (the Self-management Support Program). The main objective of this study is to measure the longitudinal effects of this counselling protocol and the added value of using the tool.

Methods/Design

This three-armed cluster randomised controlled trial with 120 participants with COPD and 120 participants with DM2 (aged 40–70), compares the counselling protocol with and without the use of the tool (group 1 and 2) with usual care (group 3). Recruitment takes place at GP practices in the southern regions of the Netherlands. Randomisation takes place at the practice level. The intended sample (three arms of 8 practices) powers the study to detect a 10-minute difference of moderate and intense physical activity per day between groups 1 and 3. Participants in the intervention groups have to visit the practice nurse 3–4 times for physical activity counselling, in a 4-6-month period. Specific activity goals tailored to the individual patient's preferences and needs will be set. In addition, participants in group 1 will be instructed to use the tool in daily life. The primary outcome, physical activity, will be measured in all groups with a physical activity monitor (PAM). Secondary outcomes are quality of life, general - and exercise - self-efficacy, and health status. Follow-up will take place after 6 and 9 months. Separately, a process evaluation will be conducted to explore reasons for trial non-participation, and the intervention’s acceptability for participating patients and nurses.

Discussion

Results of this study will give insight into the effects of the It’s LiFe! monitoring and feedback tool combined with care from a practice nurse for people with COPD or DM2 on physical activity.

Trial registration

ClinicalTrials.gov: NCT01867970

A pilot study of a tool to stimulate physical activity in patients with COPD or type 2 diabetes in primary care

We tested the performance, acceptance and user satisfaction of a tool to stimulate physical activity. The tool consisted of an accelerometer, a smartphone app and a server/web application. Patients received feedback concerning their physical activity relative to a goal, which was set in dialogue with their practice nurse. Nurses could monitor their patients' physical activity via a website. Twenty patients with COPD or type 2 diabetes used the tool for three months, combined with behaviour change counselling. Physical activity data were collected at the server and a log file was used to record technical problems. We interviewed patients and nurses after every consultation. At baseline, and after the intervention, patients completed questionnaires. Participants were positive about the tool, although motivation dropped when technical problems occurred caused by log-in and connectivity errors. On average, physical activity increased from 29 (SD 21) min per day in the first two weeks to 39 (SD 24) min per day in the last two weeks (P = 0.02), and quality of life scores increased from 0.76 (SD 0.21) to 0.84 (SD 0.17) (P = 0.04). Provided that no connectivity problems occur, the tool is a feasible intervention when embedded in primary care, and has a positive effect on physical activity levels.

Engineering online and in-person social networks to sustain physical activity: application of a conceptual model

BACKGROUND

High rates of physical inactivity compromise the health status of populations globally. Social networks have been shown to influence physical activity (PA), but little is known about how best to engineer social networks to sustain PA. To improve procedures for building networks that shape PA as a normative behavior, there is a need for more specific hypotheses about how social variables influence PA. There is also a need to integrate concepts from network science with ecological concepts that often guide the design of in-person and electronically-mediated interventions. Therefore, this paper: (1) proposes a conceptual model that integrates principles from network science and ecology across in-person and electronically-mediated intervention modes; and (2) illustrates the application of this model to the design and evaluation of a social network intervention for PA.

METHODS/DESIGN

A conceptual model for engineering social networks was developed based on a scoping literature review of modifiable social influences on PA. The model guided the design of a cluster randomized controlled trial in which 308 sedentary adults were randomly assigned to three groups: WalkLink+: prompted and provided feedback on participants' online and in-person social-network interactions to expand networks for PA, plus provided evidence-based online walking program and weekly walking tips; WalkLink: evidence-based online walking program and weekly tips only; Minimal Treatment Control: weekly tips only. The effects of these treatment conditions were assessed at baseline, post-program, and 6-month follow-up. The primary outcome was accelerometer-measured PA. Secondary outcomes included objectively-measured aerobic fitness, body mass index, waist circumference, blood pressure, and neighborhood walkability; and self-reported measures of the physical environment, social network environment, and social network interactions. The differential effects of the three treatment conditions on primary and secondary outcomes will be analyzed using general linear modeling (GLM), or generalized linear modeling if the assumptions for GLM cannot be met.

DISCUSSION

Results will contribute to greater understanding of how to conceptualize and implement social networks to support long-term PA. Establishing social networks for PA across multiple life settings could contribute to cultural norms that sustain active living.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01142804.

How does physician BMI impact patient trust and perceived stigma?

OBJECTIVE

The objective is to evaluate whether physician body mass index (BMI) impacts their patients' trust or perceptions of weight-related stigma.

METHODS

We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates.

RESULTS

Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI=8.6; overweight=8.3; obese=8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p=0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23-41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7-20).

CONCLUSION

Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.

Effect of baseline self-efficacy on physical activity and psychological stress after a one-week pedometer intervention

Physical activity and psychological stress were hypothesized to improve more in participants with high self-efficacy than in those with low and medium self-efficacy after a one-week intervention. 39 female university students participated. The intervention had two steps: a lecture on self-monitoring and goal setting (160 min.) and a one-week pedometer intervention. Analyses were conducted on tertile groups according to self-efficacy at baseline. Pedometer step counts were higher in the high self-efficacy group than in the low self-efficacy group after intervention. Helplessness decreased time dependently after intervention only in the high-self-efficacy group. Because physical activity improved more in the high self-efficacy group after a one-week intervention, one hypothesis was supported.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

BACKGROUND

To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).

METHODS

A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.

RESULTS

52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.

CONCLUSION

Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

Background

People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.

Methods

Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.

The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.

Results

52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.

Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.

Conclusion

Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.

Impact of physician BMI on obesity care and beliefs

Using a national cross-sectional survey of 500 primary care physicians conducted between 9 February and 1 March 2011, the objective of this study was to assess the impact of physician BMI on obesity care, physician self-efficacy, perceptions of role-modeling weight-related health behaviors, and perceptions of patient trust in weight loss advice. We found that physicians with normal BMI were more likely to engage their obese patients in weight loss discussions as compared to overweight/obese physicians (30% vs. 18%, P = 0.010). Physicians with normal BMI had greater confidence in their ability to provide diet (53% vs. 37%, P = 0.002) and exercise counseling (56% vs. 38%, P = 0.001) to their obese patients. A higher percentage of normal BMI physicians believed that overweight/obese patients would be less likely to trust weight loss advice from overweight/obese doctors (80% vs. 69%, P = 0.02). Physicians in the normal BMI category were more likely to believe that physicians should model healthy weight-related behaviors-maintaining a healthy weight (72% vs. 56%, P = 0.002) and exercising regularly (73% vs. 57%, P = 0.001). The probability of a physician recording an obesity diagnosis (93% vs. 7%, P < 0.001) or initiating a weight loss conversation (89% vs. 11%, P ≤ 0.001) with their obese patients was higher when the physicians' perception of the patients' body weight met or exceeded their own personal body weight. These results suggest that more normal weight physicians provided recommended obesity care to their patients and felt confident doing so.

Impact of patient-doctor race concordance on rates of weight-related counseling in visits by black and white obese individuals

The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005-2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient-physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.

The influence of cognitive-perceptual variables on patterns of change over time in rural midlife and older women's healthy eating

Although studies demonstrate that dietary interventions for healthy adults can result in beneficial dietary changes, few studies examine when and how people change in response to these interventions, particularly in rural populations. The purpose of this study was to examine patterns of change over time in healthy eating behaviors in midlife and older women in response to a one-year health-promoting intervention, and to examine what predictors (perceived benefits, barriers, self-efficacy, and family support for healthy eating) influence the changes during the intervention and follow-up. Data for this secondary analysis were from the Wellness for Women community-based trial. Women (N = 225) between the ages of 50-69 in rural Nebraska, U.S.A., were recruited. A repeated-measures experimental design was used with randomization of two rural counties to intervention (tailored newsletter) or comparison (standard newsletter) groups. Eating behavior was measured by the Healthy Eating Index. The predictor variables were assessed using standard measures. Data analysis was done using latent growth curve modeling. The tailored newsletter group was successful in improving their healthy eating behavior compared to the standard newsletter group during the one-year intervention, at the end of the intervention, and during the follow-up phase. Family support at the end of the intervention was positively associated with healthy eating at the end of the intervention. Perceived barriers had the strongest impact on healthy eating behavior at all time points. Compared to participants in the standard newsletter group, those in the tailored newsletter group perceived more family support and fewer barriers for healthy eating at the end of the intervention (mediation effects). Based on these findings, both family support and perceived barriers should be central components of interventions focused on healthy eating behavior in rural midlife and older women.

Predicting changes in lifestyle and clinical outcomes in preventing diabetes: the Greater Green Triangle Diabetes Prevention Project

OBJECTIVES

To analyse how psychosocial determinants of lifestyle changes targeted in the Greater Green Triangle Diabetes Prevention Project conducted in Southeast Australia in 2004-2006 predict changes in dietary behaviour and clinical risk factors.

METHODS

A longitudinal pre-test and post-test study design was used. The group program was completed by 237 people at high risk of type 2 diabetes. Associations between changes in the variables were examined by structural equation modelling using a path model in which changes in psychological determinants for lifestyle predicted changes in dietary behaviours (fat and fibre intake), which subsequently predicted changes in waist circumference and other clinical outcomes. Standardised regression weights are presented, with β=±0.1 and β=±0.3 representing small and medium associations, respectively.

RESULTS

Improvements in coping self-efficacy and planning predicted improvements in fat (β=-0.15, p<0.05 and β=-0.32, p<0.001, respectively) and fibre intake (β=0.15, p<0.05 and β=0.23, p<0.001, respectively) which in turn predicted improvements in waist circumference (β=0.18, p<0.01 and β=-0.16, p<0.05, respectively). Improvements in waist circumference predicted improvements in diastolic blood pressure (β=0.13, p<0.05), HDL (β=-0.16, p<0.05), triglycerides (β=0.17, p<0.01), and fasting glucose (β=0.15, p<0.05).

CONCLUSIONS

Psychological changes predicted behaviour changes, resulting in 12-month biophysical changes. The findings support the theoretical basis of the interventions.

Testing hypothesized psychosocial mediators: lessons learned in the MassBUILT study

Only a few of the interventions that target blue-collar workers have conducted formal analysis to evaluate the specific attributes of their intervention that are associated with success or failure. This study examined the role of dual hazard and decisional balance in the MassBUILT smoking cessation intervention. The authors conducted sets of multivariable linear and logistic regressions that examined if (a) the intervention was associated with changes in the psychosocial variables and (b) increase in psychosocial variables was associated with increase in smoking cessation. As hypothesized by the theoretical basis of the study, higher scores on both of the psychosocial variables were significantly associated with smoking cessation. However, the intervention did not change decisional balance and decreased dual hazard. The variables examined were important but were not mediators of the MassBUILT intervention and this could have contributed to the significant relapse in smoking among study participants.

Adherence to an exercise prescription scheme: The role of expectations, self-efficacy, stage of change and psychological well-being

OBJECTIVES

Poor rates of adherence to exercise prescription schemes present a potential barrier to the goal of increasing physical activity in patient samples. This study investigated the role of participant expectations, self-efficacy, stage of change and psychological well-being in adherence to a 12-week course of gym based exercise. It also aimed to assess the impact of failure to adhere on self-efficacy and psychological well-being.

METHOD

The 119 participants, referred by their medical practitioner for a course of exercise, completed questionnaires at the start of the course and 77 went on to complete second questionnaires. Objective measures included a range of physiological measures based on gym assessments.

RESULTS

Participants typically had high expectations of the scheme. Those who completed the course had more modest expectations of change and came closer to achieving these expected changes than those who dropped out. Initial stage of change and self-efficacy did not discriminate between the two groups. While self-efficacy improved over the scheme for completers, it tended to deteriorate for drop-outs. GHQ scores also failed to improve over time for drop-outs.

CONCLUSION

Overly optimistic expectations of inexperienced exercisers may lead to disappointment and attrition. Interventions to ensure realistic expectations might increase success and prevent potential negative effects of failure.

Psychosocial mediators of physical activity and fitness changes in the activity counseling trial

BACKGROUND

Improved understanding of the mediators of physical activity (PA) interventions could lead to improvements in theory and programs.

PURPOSE

To examine the 24-month mediating effects of psychosocial variables on PA and cardiorespiratory fitness (CRF) outcomes in 878 initially sedentary adults aged 35-75 participating in the Activity Counseling Trial.

METHODS

Participants were assigned to one of three intervention arms: physician advice, assistance, or counseling. MacKinnon's product of coefficients was used to test for longitudinal and contemporaneous mediation.

RESULTS

Changes in behavioral processes of change from baseline to 24 months significantly mediated the relationship between the active intervention arms and improvements in PA and CRF from baseline to 24 months in both men and women. None of the other psychosocial variables tested met criteria for mediation.

CONCLUSIONS

Results indicate that behavioral interventions should incorporate methods to encourage participants to use these behavioral strategies as they attempt to become more active.

Using constructs of the transtheoretical model to predict classes of change in regular physical activity: a multi-ethnic longitudinal cohort study

Explaining variation in meeting recommended levels of physical activity across time is important for the design of effective public health interventions. To model longitudinal change in constructs of the Transtheoretical Model and test their hypothesized relations with change in meeting the Healthy People 2010 guidelines for regular participation in moderate or vigorous physical activity, a cohort (N = 497) from a random, multi-ethnic sample of 700 adults living in Hawaii was assessed at 6-month intervals three or more times for 2 years. Latent class growth modeling was used to classify people according to their initial levels and trajectories of change in the transtheoretical variables and separately according to whether they met the physical activity guideline each time. Relations of the variables and their change with classes of meeting the guideline were then tested using multinomial logistic regression. Despite declines or no change in mean scores for all transtheoretical variables except self-efficacy, participants who maintained or attained the physical activity guideline were more likely to retain higher scores across the 2 years of observation. The usefulness of transtheoretical constructs for predicting maintenance of, or increases in, public health levels of physical activity was generally supported. These longitudinal results support earlier cross-sectional findings which indicate that, contrary to theory, people appear to use both experiential and behavioral processes while they attempt to increase or maintain their physical activity.

Validity of processes of change in physical activity among college students in the TIGER study

OBJECTIVE

To test the factorial validity and measurement equivalence/invariance of scales used to measure processes of change derived from the Transtheoretical Model (TTM) applied to physical activity.

METHODS

Confirmatory factor analysis of questionnaire responses obtained from a diverse sample (N = 1,429) of students enrolled in the Training Interventions and Genetics of Exercise Response (TIGER) Study at the University of Houston during academic years 2004-2005 through 2007-2008. Cohorts of students (N = 1,163) completed the scales at the beginning and end of each Fall semester, permitting longitudinal analysis.

RESULTS

Theoretically and statistically sound models were developed that support the factorial validity of nine of the ten hypothesized 1st-order factors. A structure of nine correlated 1st order factors or a hierarchical structure of those factors subordinate to two correlated 2nd-order factors were each defensible. Multi-group invariance of each model was confirmed across race/ethnicity groups (African American, Hispanic, non-Hispanic White), gender, age, BMI levels, employment status, physical activity level, and study adherence. Longitudinal invariance across the semester was also confirmed.

CONCLUSION

The scores from the scales provide valid assessments that can be used in observational studies of naturally occurring change or in interventions designed to test the usefulness of TTM processes as mediators of change in physical activity among college students. Item content and factor structure require further evaluation in other samples in order to advance TTM theory applied to physical activity.