Predicting exercise stage transitions over two consecutive 6-month periods: a test of the theory of planned behaviour in a population-based sample

As Much As I Can - Utilizing Immersive Theatre to Reduce HIV-Related Stigma and Discrimination Toward Black Sexual Minority Men

BACKGROUND

Despite advances in biomedical HIV prevention modalities such as pre-exposure prophylaxis to prevent the transmission of HIV, racial/ethnic and sexual/gender minority populations are disproportionately impacted by HIV epidemic. Alarming rates of HIV have persisted among Black gay and bisexual men, particularly in Southern states.

METHODS

Utilizing data from the ViiV ACCELERATE! initiative, we explored the impact of As Much As I Can, an immersive theatre production, on HIV-related stigma behaviors. A self-administered post-performance survey was conducted with a cohort (n = 322) of randomly selected audience members.

RESULTS

Overall, the results showed participants had a highly favorable experience, rating the performance with a mean score of 9.77/10. Respondents indicated they intended to change behaviors to promote HIV prevention education and to reduce stigma and discrimination including: (1) Say something if I hear stigmatizing language against people living with HIV (75.4%), (2) Say something if I hear anti-gay language (69.7%) and (3) Tell others about HIV prevention options (e.g., PrEP, PEP, condoms (64.1%). The findings show there is an association between HIV-related behavior intention and linkage to HIV care. Respondents who reported they were more likely to say something about HIV stigma were almost three times (O.R. 2.77; 95% C.I. 0.98-7.8) more likely to indicate they would follow up with a healthcare professional.

CONCLUSIONS

This study suggests that immersive theatre is an effective method for communicating HIV prevention education and reducing HIV-related structural stigma and discrimination that increases HIV vulnerability for Black sexual minority men.

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Development of a tool for quantifying need-supportive coaching in technology-mediated exercise classes

Technology-mediated interventions to promote physical activity are growing in popularity and appear to be effective for supporting continued adherence for some people. Some of this efficacy may be related to the cultivation of motivation that is self-determined (i.e., autonomous), which is posited to arise from the satisfaction of three basic psychological needs: competence, relatedness, and autonomy. We developed an observational coding tool for quantifying the frequency of needs-supportive and needs-indifferent coaching during technology-mediated exercise classes. The Peloton Instructor Needs-Supportive Coaching (PINC) tool shows evidence of reliability (average kappa = .91). We also demonstrated the utility of the PINC for characterizing needs-supportive coaching profiles across 4 different types of classes (Beginner, Power Zone, Groove, and High-Intensity Interval Training) and the construct validity of the PINC with respect to examining the relationship of needs-supportive coaching to intrinsic motivation. The PINC offers a useful tool with which future studies could evaluate whether and how instructor coaching impacts self-determined motivation to exercise within a technology-mediated context.

Integrating the Extended Theory of Planned Behavior With the Stages of Change to Predict Exercise Among Chinese People With Type 2 Diabetes

Background: There have been very limited prospective studies examining social-cognitive models within stages of behavior change in the exercise domain. Purpose: We examined the utility of the theory of planned behavior (TPB), incorporating self-identity and descriptive norm constructs, to predict exercise behavior across the stages of change, in individuals with type 2 diabetes. Methods: Data were obtained from a longitudinal study. Multi-group structural equation modeling was used to estimate the association between extended TPB constructs and exercise within different stages groups. Results: 647 individuals completed a self-report questionnaire at baseline and at 3 months follow-up. The extended TPB model explained 8-15% variance of exercise behavior and 42-81% variance of exercise intention within three stages groups in the cross-sectional design. The extended TPB model explained 4%-13% variance of exercise behavior and 42-66% variance of exercise intention in the longitudinal design. Intention was significantly related to exercise behavior in the pre-action and action stages. Self-identity, perceived behavioral control and descriptive norms were stronger predictors of intention in different stages. Conclusion: Discontinuity patterns in the extended theory of planned behavior for the different stages groups were found. Intention was a significant predictor of exercise in the pre-action and action stages at 3 months.

Redesigning walking brochures using behaviour change theory: implications for walking intentions in natural environments

Natural environments can be used to promote health through facilitating recreational walking. However, efforts to encourage this often neglect messages identified in psychological research that are effective at influencing intentions to walk. This is despite the National Institute for Health and Care Excellence stating that promotional efforts should utilize theoretical frameworks of behaviour change and be targeted towards less active adults. As an illustrative example, this experiment compared a prototypical recreational walking brochure with an "enhanced" version including such persuasive messages on people's intentions to walk for recreation in natural environments. The enhanced brochure heightened intentions for inexperienced recreational walkers through our hypothesized mechanisms, but appeared to dissuade already-experienced walkers. Optimal messaging strategies in recreational walking brochures require tailoring to more and less active readerships. Guidelines are provided for authors of recreational walking brochures, though the principles and techniques could easily be extended to other means of outdoor walking promotion.

A Standard Form of Cardiac Rehabilitation Can Improve Self-Reported Positive Behavior Changes in the Short- to Medium-Term

PURPOSE

Little is known about the impact of standard cardiac rehabilitation (CR), consisting of health education and exercise, on self-reported behavior change among people who have completed rehabilitation. This qualitative study aimed to explore the lived experiences of participants' behaviors toward exercise and diet in the short- to medium-term after CR program completion.

METHODS

Using a phenomenological framework, we interviewed participants who had completed a 4-wk CR program and then 6 mo later. The program included education and exercise in a private outpatient facility. A thematic analysis was conducted to explore changes in self-reported behavior. These themes were triangulated with Bandura's self-efficacy scales and Stages of Readiness for Change questionnaires to identify any convergence of themes.

RESULTS

A total of 21 participants were recruited to the study. One main theme and 4 subthemes emerged from analysis of the data. Most participants reported that they had either maintained or initiated positive lifestyle changes in both exercise and diet in the short- and medium-term. Fear of having another myocardial infarction, seeing the benefits of adhering with recommendations, and family involvements were motivating factors along with the involvement of the multidisciplinary staff in the program. The themes converged with the results from the questionnaires.

CONCLUSIONS

A standard form of CR can result in positive self-reported behavior change in the short- to medium-term. Further trials are needed to determine whether a standard form of rehabilitation is sufficient to change health behaviors at sufficient levels to result in long-term health benefits.

Views on Public Transport and How Personal Experiences Can Contribute to a More Positive Attitude and Behavioural Change

To reduce car usage, several strategies are needed, one of which focuses on social psychological factors. The aim of this study was to predict and explain bus usage using the theory of planned behaviour and the transtheoretical model of change in a sample of 983 residents. The study also evaluated the effect of providing a group of regular car users (n = 34) with a free travel pass, to be used on busses and trains in the region. A regression analysis showed that the theory of planned behaviour (TPB) explained 26% of the variance in intention to use the bus, increasing to 59% when past behaviour was added. The use of the free travel pass resulted in a more positive attitude towards bus usage, with a large number having either changed or having started to change their behaviour. When the same people were contacted three months later, 50% still used public transport. The conclusion is that negative attitudes and travel habits can be altered by experience. Although, a reduction of car use can only be achieved if several measures are implemented that make car driving less attractive and sustainable modes of transport more attractive.

Evaluation of a School-Based Intervention Programme to Promote Physical Activity: An Application of the Theory of Planned Behavior

The Theory of Planned Behavior provides a useful framework to study attitudes toward participation in physical activity. The objective of the study was to test the effectiveness of an intervention in manipulating the variables of the Theory of Planned Behavior and exercise habits with 366 high school students ( M = 14.2 yr., SD = .7; 201 boys and 165 girls). The students were divided into intervention and control groups. A questionnaire to measure components of the theory, and the Baecke Questionnaire of Habitual Activity measuring exercise habits, were administered. The intervention lasted 12 wk. and included posters and lectures promoting participation in physical activity. Analyses showed the intervention was effective in improving attitudes towards physical activity, perceived behavioral control, intention, and self-reported actual behavior, but it was ineffective for improving attitude strength, subjective norms, and role identity. The results provide useful information for physical education teachers interested in promoting students' positive attitudes towards physical activity.

The Efficacy of Stage-Matched and Standard Public Health Materials for Promoting Physical Activity in the Workplace: The Physical Activity Workplace Study (PAWS)

Purpose.

To compare the effects of stage-matched and standard print materials for physical activity (PA) change.

Design.

Participants were randomized into (1) a stage-matched intervention group (n = 165), (2) a standard intervention group (n = 176), or (3) a no-contact control group (n = 166). The stage-matched and standard intervention groups both received materials at baseline, 3 months, and 6 months. Assessments of all three groups were conducted at baseline, 6, and 12 months.

Setting.

Canadian worksites.

Subjects.

Employees (N = 507).

Interventions.

Five motivationally targeted booklets were developed for the stage-matched group. The standard group received Canada's Physical Activity Guide and handbook.

Measures.

The main dependent variable was PA, expressed as metabolic equivalent (MET) minutes and measured using the Godin Leisure-Time Exercise Questionnaire. Demographic characteristics and stages of change for PA were also assessed.

Results.

At 12 months mean weekly MET minutes for combined moderate and vigorous activity increased from baseline by 223, 67, and 78 for the stage-matched, standard, and control groups, respectively; however, differences were not significant (p > .05). Women in the stage-matched group over the 12-month period significantly increased their activity by 327 weekly MET minutes whereas the standard and control groups declined their activity (F = 3.01, p < .05).

Conclusion.

PA stage-matched materials delivered in the workplace are efficacious for women but not men. Future interventions should explore the use of these intervention materials in conjunction with multilevel strategies, and particular attention should be paid to possible gender differences.

Determinants of Forward Stage Transition from Precontemplation and Contemplation for Fruit Consumption

Purpose.

To examine associations between decisional balance, self-efficacy, fruit intake, and stage of change transition from precontemplation and contemplation with cross-sectional and longitudinal methods.

Design.

A longitudinal cohort study with the use of electronic questionnaires was conducted. Three measurements were analyzed cross-sectionally, and the two intervals between the measurements were analyzed longitudinally.

Setting.

A random sample of 1500 individuals from an existing Dutch Internet panel resulted in a cohort of 735 individuals. Of the cohort, 648 (response rate 88%), 592 (response rate 81%), and 570 (response rate 78%) respondents completed questionnaires at the start of the present study (T1), 53 days after T1 (T2), and 106 days after T1 (T3), respectively.

Subjects.

Mean age was 37.5 years, 51% were women, and 57% ate less than the recommended intake of 250 g of fruit per day.

Measures.

Questionnaires included items measuring stage of change, factors favoring (pros) or working against (cons) behavior change, and self-efficacy. A food frequency questionnaire was used to assess fruit intake.

Results.

Logistic regression analyses showed that pros, fruit intake, and self-efficacy predicted forward stage transition from precontemplation. Self-efficacy predicted forward stage transition from contemplation. Cons did not predict stage transitions. Results from longitudinal analyses were similar to cross-sectional results, except for self-efficacy: no differences between early stages in self-efficacy were found, whereas self-efficacy predicted these early stage transitions.

Conclusions.

Within the limitations posed by the sampling frame, results provided support for the Transtheoretical Model, although determinants might not always be stage specific.

University Students Intend to Eat Better but Lack Coping Self-Efficacy and Knowledge of Dietary Recommendations

OBJECTIVE

To assess university students' knowledge, intentions, and coping self-efficacy related to dietary recommendations.

DESIGN

The study used a cross-sectional online survey.

SETTING

Large university campus.

PARTICIPANTS

Students (n = 6,638; 22% response).

VARIABLES MEASURED

Self-efficacy and intentions were measured using 11-point scales. Students' perceived dietary recommendations were evaluated as correct or incorrect.

ANALYSIS

Categorical variables were analyzed using chi-square and continuous variables by t tests or ANOVAs. Significance was set at P ≤ .05 and multiple comparisons at P ≤ .01.

RESULTS

Respondents believed that they need fewer vegetables and fruit and more milk or alternatives servings/d than recommended; eg, males aged ≥ 19 years perceived milk or alternatives recommendations to be 4.3 ± 2.1 servings/d, significantly more than the 2 servings/d recommended (P < .001). Students in health sciences or with a food or nutrition course were significantly more likely to claim that they met recommendations (eg, 56% with vs 47% without a food or nutrition course for vegetables and fruit; P < .001); however, they were no more likely to identify them correctly. Males aged < 19 years had higher coping self-efficacy than females aged < 19 years to consume vegetables (68.3 ± 24.2 vs 64.0 ± 24.7; P < .01) and avoid high-calorie foods and beverages (HCFB) (56.2 ± 27.2 vs 49.0 ± 25.2; P < .01) when under stress; however, they had significantly lower intentions to consume vegetables (72.1 ± 24.5 vs 80.9 ± 20.3; P < .01) and avoid HCFB (60.5 ± 30.3 vs 77.7 ± 22.8; P < .01).

CONCLUSIONS AND IMPLICATIONS

Students do not have adequate knowledge of age- and sex-specific food guide recommendations. Simpler food guide recommendations or age- and sex-targeted campaigns may enhance knowledge. Students intend to consume more vegetables and less HCFB; however, they have low coping self-efficacy, all of which could be targeted in nutrition interventions.

Predictors of physical activity change among adults using observational designs

BACKGROUND

Regular physical activity (PA) is foundational to human health, yet most people are inactive. A sound understanding of the determinants of PA may be instructive for building interventions and/or identifying critical target groups to promote PA. Most research on PA correlates has been biased by cross-sectional or passive prospective designs that fail to examine within-person analysis of PA change.

OBJECTIVE

The purpose of this review was to collect and appraise the available literature on the predictors of PA change conceived broadly in terms of increases/decreases from baseline assessment as well as specifically in terms of adoption and maintenance.

METHODS

Eligible studies were from English, peer-reviewed published articles that examined predictors of natural change of PA over 3 months + using observational (non-experimental) data in adult samples. Searches were performed from June 2012 to January 2014 in eight databases.

RESULTS

Sixty-seven independent data-sets, from 12 countries, primarily of medium quality/risk of bias, were identified with 26 correlates spanning demographic, behavioral, intra-individual, inter-individual, and environmental categories. Only intention and the onset of motherhood could reliably predict overall PA change. Among datasets configured to predict PA adoption, affective judgments and behavioral processes of change were the only reliable predictors, although both only have a small number of available studies. There were no reliable predictors of maintenance when compared to PA relapse.

CONCLUSION

The results underscore the importance of individual-level motivation and behavioral regulation in PA change, but also denote critical social variables. These findings, however, are constrained by PA measurement bias and limited studies that employed time-varying covariation between predictor variables and PA.

Prediction of attendance at fitness center: a comparison between the theory of planned behavior, the social cognitive theory, and the physical activity maintenance theory

In the processes of physical activity (PA) maintenance specific predictors are effective, which differ from other stages of PA development. Recently, Physical Activity Maintenance Theory (PAMT) was specifically developed for prediction of PA maintenance. The aim of the present study was to evaluate the predictability of the future behavior by the PAMT and compare it with the Theory of Planned Behavior (TPB) and Social Cognitive Theory (SCT). Participation rate in a fitness center was observed for 101 college students (53 female) aged between 19 and 32 years (M = 23.6; SD = 2.9) over 20 weeks using a magnetic card. In order to predict the pattern of participation TPB, SCT and PAMT were used. A latent class zero-inflated Poisson growth curve analysis identified two participation patterns: regular attenders and intermittent exercisers. SCT showed the highest predictive power followed by PAMT and TPB. Impeding aspects as life stress and barriers were the strongest predictors suggesting that overcoming barriers might be an important aspect for working out on a regular basis. Self-efficacy, perceived behavioral control, and social support could also significantly differentiate between the participation patterns.

Using the intervention mapping protocol to develop a maintenance programme for the SLIMMER diabetes prevention intervention

Background

Although lifestyle interventions have shown to be effective in reducing the risk for type 2 diabetes mellitus, maintenance of achieved results is difficult, as participants often experience relapse after the intervention has ended. This paper describes the systematic development of a maintenance programme for the extensive SLIMMER intervention, an existing diabetes prevention intervention for high-risk individuals, implemented in a real-life setting in the Netherlands.

Methods

The maintenance programme was developed using the Intervention Mapping protocol. Programme development was informed by a literature study supplemented by various focus group discussions and feedback from implementers of the extensive SLIMMER intervention.

Results

The maintenance programme was designed to sustain a healthy diet and physical activity pattern by targeting knowledge, attitudes, subjective norms and perceived behavioural control of the SLIMMER participants. Practical applications were clustered into nine programme components, including sports clinics at local sports clubs, a concluding meeting with the physiotherapist and dietician, and a return session with the physiotherapist, dietician and physical activity group. Manuals were developed for the implementers and included a detailed time table and step-by-step instructions on how to implement the maintenance programme.

Conclusions

The Intervention Mapping protocol provided a useful framework to systematically plan a maintenance programme for the extensive SLIMMER intervention. The study showed that planning a maintenance programme can build on existing implementation structures of the extensive programme. Future research is needed to determine to what extent the maintenance programme contributes to sustained effects in participants of lifestyle interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1108) contains supplementary material, which is available to authorized users.

Predictors of leisure time physical activity among people with spinal cord injury

BACKGROUND

Most studies of physical activity predictors in people with disability have lacked a guiding theoretical framework. Identifying theory-based predictors is important for developing activity-enhancing strategies.

PURPOSE

To use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to identify predictors of leisure time physical activity among people with spinal cord injury (SCI).

METHODS

Six hundred ninety-five persons with SCI (M age=47; 76% male) completed measures of Body Functions and Structures, Activities and Participation, Personal Factors, and Environmental Factors at baseline and 6-months. Activity was measured at 6 and 18 months. Logistic and linear regression models were computed to prospectively examine predictors of activity status and activity minutes per day.

RESULTS

Models explained 19%-25% of variance in leisure time physical activity. Activities and Participation and Personal Factors were the strongest, most consistent predictors.

CONCLUSIONS

The ICF framework shows promise for identifying and conceptualizing predictors of leisure time physical activity in persons with disability.

Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials

BACKGROUND

Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care.

METHODS / DESIGN

One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed.

DISCUSSION

Results of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings.

TRIAL REGISTRATION

NCT01130740 (VA); NCT 01435109 (NIH).

Physical activity after surgery for severe obesity: the role of exercise cognitions

Background

Physical activity after bariatric surgery is associated with sustained weight loss and improved quality of life. Some bariatric patients engage insufficiently in physical activity. This may be due to exercise cognitions, i.e., specific beliefs about benefits of and barriers to physical exercise. The aim of this study was to examine whether and to what extent both physical activity and exercise cognitions changed at 1 and 2 years post-surgery and whether exercise cognitions predict physical activity.

Methods

Forty-two bariatric patients (38 women, 4 men; mean age 38 ± 8 years, mean body mass index prior to surgery 47 ± 6 kg/m²) filled out self-report instruments to examine physical activity and exercise cognitions pre- and post-surgery.

Results

A large increase in physical activity and favorable changes in exercise cognitions were observed after surgery, viz. a decrease of fear of injury and embarrassment and an increase of the perception of exercise benefits and confidence in exercising. Perceiving less exercise benefits and having less confidence in exercising before surgery predicted less physical activity 2 years after surgery. High fear of injury 1 year after surgery predicted less physical activity 2 years after surgery.

Conclusions

After bariatric surgery, favorable changes in physical activity and beliefs about the benefits and barriers of exercising are observed. Our results suggest that targeting exercise cognitions before and after surgery might be relevant to improve physical activity.

Self-determination and exercise stages of change: results from the Diabetes Aerobic and Resistance Exercise trial

Little longitudinal research exists on the relationship between exercise self-determination and stage of change. This study investigated how self-determined motivation changes in patients with type 2 diabetes (N = 175) as they moved through the stages of change over a six-month exercise trial. Hierarchical linear modelling revealed that patients who progressed through the stages of exercise change had an overall increase in self-determined motivation, while non-progressors experienced a reduction in self-determined motivation from three to six months. These results indicate that individuals engaging in regular exercise at six months maintain initial increases in self-determined motivation. Findings are discussed in light of self-determination theory.

Efficacy of a workplace-based weight loss program for overweight male shift workers: the Workplace POWER (Preventing Obesity Without Eating like a Rabbit) randomized controlled trial

OBJECTIVE

To evaluate the feasibility and efficacy of a workplace-based weight loss program (Workplace POWER-WP) for male shift workers.

METHOD

A prospective, two-armed randomized controlled trial of 110 overweight/obese (BMI 25-40) (mean [SD] age = 44.4 [8.6] years; BMI = 30.5 [3.6]) male employees at Tomago Aluminium aged 18-65. In October (2009) men were randomized to either (i) WP program (n=65) or (ii) a 14-week wait-list control group (n=45). The 3-month program involved one information session, program booklets, group-based financial incentives and an online component. Men were assessed at baseline and at 14-week follow-up for weight (primary outcome), waist circumference, BMI, blood pressure, resting heart rate, self-reported physical activity and dietary variables, and physical activity and dietary cognitions.

RESULTS

Intention-to-treat analysis using linear mixed models revealed significant between group differences for weight loss after 14 weeks (P < .001, Cohen's d = 0.34). Significant intervention effects were also found for waist circumference (P < .001, d = 0.63), BMI (P < .001, d = 0.41), systolic blood pressure (P = .02, d = 0.48), resting heart rate (P < .001, d = 0.81), physical activity (P = .03, d = 0.77), sweetened beverages (P < .02, d = 0.5-0.6) and physical activity-related cognitions (P < .02, d=0.6).

CONCLUSION

The WP program was feasible and efficacious and resulted in significant weight loss and improved health-related outcomes and behaviours in overweight male shift workers.

The SHED-IT community trial study protocol: a randomised controlled trial of weight loss programs for overweight and obese men

BACKGROUND

Obesity is a major cause of preventable death in Australia with prevalence increasing at an alarming rate. Of particular concern is that approximately 68% of men are overweight/obese, yet are notoriously difficult to engage in weight loss programs, despite being more susceptible than women to adverse weight-related outcomes. There is a need to develop and evaluate obesity treatment programs that target and appeal to men. The primary aim of this study is to evaluate the efficacy of two relatively low intensity weight loss programs developed specifically for men.

METHODS AND DESIGN

The study design is an assessor blinded, parallel-group randomised controlled trial that recruited 159 overweight and obese men in Newcastle, Australia. Inclusion criteria included: BMI 25-40 (kg/m2); no participation in other weight loss programs during the study; pass a health-screening questionnaire and pre-exercise risk assessment; available for assessment sessions; access to a computer with e-mail and Internet facilities; and own a mobile phone. Men were recruited to the SHED-IT (Self-Help, Exercise and Diet using Internet Technology) study via the media and emails sent to male dominated workplaces. Men were stratified by BMI category (overweight, obese class I, obese class II) and randomised to one of three groups: (1) SHED-IT Resources - provision of materials (DVD, handbooks, pedometer, tape measure) with embedded behaviour change strategies to support weight loss; (2) SHED-IT Online - same materials as SHED-IT Resources plus access to and instruction on how to use the study website; (3) Wait-list Control. The intervention programs are three months long with outcome measures taken by assessors blinded to group allocation at baseline, and 3- and 6-months post baseline. Outcome measures include: weight (primary outcome), % body fat, waist circumference, blood pressure, resting heart rate, objectively measured physical activity, self-reported dietary intake, sedentary behaviour, physical activity and dietary cognitions, sleepiness, quality of life, and perceived sexual health. Generalised linear mixed models will be used to assess all outcomes for the impact of group (Resources, Online, and Control), time (treated as categorical with levels baseline, 3-months and 6-months) and the group-by-time interaction. These three terms will form the base model. 'Intention-to-treat' analysis will include all randomised participants.

DISCUSSION

Our study will compare evidence-based and theoretically driven, low cost and easily disseminated strategies specifically targeting weight loss in men. The SHED-IT community trial will provide evidence to inform development and dissemination of sustainable strategies to reduce obesity in men.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12610000699066).

The SHED-IT community trial study protocol: a randomised controlled trial of weight loss programs for overweight and obese men

BACKGROUND

Obesity is a major cause of preventable death in Australia with prevalence increasing at an alarming rate. Of particular concern is that approximately 68% of men are overweight/obese, yet are notoriously difficult to engage in weight loss programs, despite being more susceptible than women to adverse weight-related outcomes. There is a need to develop and evaluate obesity treatment programs that target and appeal to men. The primary aim of this study is to evaluate the efficacy of two relatively low intensity weight loss programs developed specifically for men.

METHODS AND DESIGN

The study design is an assessor blinded, parallel-group randomised controlled trial that recruited 159 overweight and obese men in Newcastle, Australia. Inclusion criteria included: BMI 25-40 (kg/m2); no participation in other weight loss programs during the study; pass a health-screening questionnaire and pre-exercise risk assessment; available for assessment sessions; access to a computer with e-mail and Internet facilities; and own a mobile phone. Men were recruited to the SHED-IT (Self-Help, Exercise and Diet using Internet Technology) study via the media and emails sent to male dominated workplaces. Men were stratified by BMI category (overweight, obese class I, obese class II) and randomised to one of three groups: (1) SHED-IT Resources - provision of materials (DVD, handbooks, pedometer, tape measure) with embedded behaviour change strategies to support weight loss; (2) SHED-IT Online - same materials as SHED-IT Resources plus access to and instruction on how to use the study website; (3) Wait-list Control. The intervention programs are three months long with outcome measures taken by assessors blinded to group allocation at baseline, and 3- and 6-months post baseline. Outcome measures include: weight (primary outcome), % body fat, waist circumference, blood pressure, resting heart rate, objectively measured physical activity, self-reported dietary intake, sedentary behaviour, physical activity and dietary cognitions, sleepiness, quality of life, and perceived sexual health. Generalised linear mixed models will be used to assess all outcomes for the impact of group (Resources, Online, and Control), time (treated as categorical with levels baseline, 3-months and 6-months) and the group-by-time interaction. These three terms will form the base model. 'Intention-to-treat' analysis will include all randomised participants.

DISCUSSION

Our study will compare evidence-based and theoretically driven, low cost and easily disseminated strategies specifically targeting weight loss in men. The SHED-IT community trial will provide evidence to inform development and dissemination of sustainable strategies to reduce obesity in men.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12610000699066).

A test of cognitive mediation in a 12-month physical activity workplace intervention: does it explain behaviour change in women?

BACKGROUND

Attempts to demonstrate the efficacy of interventions aimed at increasing physical activity (PA) have been mixed. Further, studies are seldom designed in a manner that facilitates the understanding of how or why a treatment is effective or ineffective and PA intervention designs should be guided by a heavier reliance upon behavioral theory. The use of a mediating variable framework offers a systematic methodological approach to testing the role of theory, and could also identify the effectiveness of specific intervention components. The primary purpose of this paper was to test the mediating role that cognitive constructs may have played in regards to the positive effect that a workplace behavioral intervention had on leisure-time PA for women. A subsidiary purpose was to examine the cross-sectional relationships of these cognitive constructs with PA behavior.

METHODS

The Physical Activity Workplace Study was a randomized controlled trial which compared the effects of stage-matched and standard print materials upon self-reported leisure-time PA, within a workplace sample at 6 and 12-months. In this secondary analysis we examined the mediation effects of 14 psychosocial constructs across 3 major social-cognitive theories which were operationalized for the intervention materials and measured at baseline, 6 and 12-months. We examined change in PA and change in the psychological constructs employing a mediation strategy proposed by Baron and Kenny for: (1) the first 6-months (i.e., initial change), (2) the second 6-months (i.e., delayed change), and (3) the entire 12-months (overall change) of the study on 323 women (n = 213 control/standard materials group; n = 110 stage-matched materials group).

RESULTS

Of the 14 constructs and 42 tests (including initial, delayed and overall change) two positive results were identified (i.e., overall change in pros, initial change in experiential powerful intervention approaches processes), with very small effect sizes. However, these mediating results were eliminated after adjusting for the multiple statistical tests.

CONCLUSIONS

The intervention did not change these mediators in any substantive way, and show a similar pattern to prior research where interventions generally do not result in a change in mediation of behavior change. It is important to report mediation results in randomized controlled trials whether the findings are null or positive. Future studies may wish to focus on more detailed dose-response issues between mediators and behavior, the inclusion of moderators that could affect individual change, or different mediator constructs at higher levels of measurement specificity. Continued work on innovative and more powerful PA intervention approaches are needed.

A test of cognitive mediation in a 12-month physical activity workplace intervention: does it explain behaviour change in women?

BACKGROUND

Attempts to demonstrate the efficacy of interventions aimed at increasing physical activity (PA) have been mixed. Further, studies are seldom designed in a manner that facilitates the understanding of how or why a treatment is effective or ineffective and PA intervention designs should be guided by a heavier reliance upon behavioral theory. The use of a mediating variable framework offers a systematic methodological approach to testing the role of theory, and could also identify the effectiveness of specific intervention components. The primary purpose of this paper was to test the mediating role that cognitive constructs may have played in regards to the positive effect that a workplace behavioral intervention had on leisure-time PA for women. A subsidiary purpose was to examine the cross-sectional relationships of these cognitive constructs with PA behavior.

METHODS

The Physical Activity Workplace Study was a randomized controlled trial which compared the effects of stage-matched and standard print materials upon self-reported leisure-time PA, within a workplace sample at 6 and 12-months. In this secondary analysis we examined the mediation effects of 14 psychosocial constructs across 3 major social-cognitive theories which were operationalized for the intervention materials and measured at baseline, 6 and 12-months. We examined change in PA and change in the psychological constructs employing a mediation strategy proposed by Baron and Kenny for: (1) the first 6-months (i.e., initial change), (2) the second 6-months (i.e., delayed change), and (3) the entire 12-months (overall change) of the study on 323 women (n = 213 control/standard materials group; n = 110 stage-matched materials group).

RESULTS

Of the 14 constructs and 42 tests (including initial, delayed and overall change) two positive results were identified (i.e., overall change in pros, initial change in experiential powerful intervention approaches processes), with very small effect sizes. However, these mediating results were eliminated after adjusting for the multiple statistical tests.

CONCLUSIONS

The intervention did not change these mediators in any substantive way, and show a similar pattern to prior research where interventions generally do not result in a change in mediation of behavior change. It is important to report mediation results in randomized controlled trials whether the findings are null or positive. Future studies may wish to focus on more detailed dose-response issues between mediators and behavior, the inclusion of moderators that could affect individual change, or different mediator constructs at higher levels of measurement specificity. Continued work on innovative and more powerful PA intervention approaches are needed.

Protection motivation theory and physical activity: a longitudinal test among a representative population sample of Canadian adults

The purpose of this study was to examine the Protection Motivation Theory (PMT) to predict physical activity (PA) behaviour in a large, population-based sample of adults. One thousand six hundred and two randomly selected individuals completed two telephone interviews over two consecutive six-month periods assessing PMT constructs. PMT explained 35 per cent and 20 per cent of the variance in intention and behaviour respectively. Coping cognitions as moderators of threat explained 1 per cent of the variance in intention and behaviour. Age and gender as moderators of threat did not provide additional variance in the models. We conclude that salient PMT predictors (e.g. self-efficacy) may guide the development of effective PA interventions in the general population.

Alberta Diabetes and Physical Activity Trial (ADAPT): a randomized theory-based efficacy trial for adults with type 2 diabetes--rationale, design, recruitment, evaluation, and dissemination

BACKGROUND

The primary aim of this study was to compare the efficacy of three physical activity (PA) behavioural intervention strategies in a sample of adults with type 2 diabetes.

METHOD/DESIGN

Participants (N = 287) were randomly assigned to one of three groups consisting of the following intervention strategies: (1) standard printed PA educational materials provided by the Canadian Diabetes Association [i.e., Group 1/control group)]; (2) standard printed PA educational materials as in Group 1, pedometers, a log book and printed PA information matched to individuals' PA stage of readiness provided every 3 months (i.e., Group 2); and (3) PA telephone counseling protocol matched to PA stage of readiness and tailored to personal characteristics, in addition to the materials provided in Groups 1 and 2 (i.e., Group 3). PA behaviour measured by the Godin Leisure Time Exercise Questionnaire and related social-cognitive measures were assessed at baseline, 3, 6, 9, 12 and 18-months (i.e., 6-month follow-up). Clinical (biomarkers) and health-related quality of life assessments were conducted at baseline, 12-months, and 18-months. Linear Mixed Model (LMM) analyses will be used to examine time-dependent changes from baseline across study time points for Groups 2 and 3 relative to Group 1.

DISCUSSION

ADAPT will determine whether tailored but low-cost interventions can lead to sustainable increases in PA behaviours. The results may have implications for practitioners in designing and implementing theory-based physical activity promotion programs for this population.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT00221234.

Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-century health priorities and be aligned with global and regional public health strategies. A proposed focus on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and disability. The 21st-century physical therapist needs to be able to practice such competencies within the context of a culturally diverse society to effect positive health behavior change. The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions. Physical therapists need to impact health globally through public and social health policy as well as one-on-one care. This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical therapists to health and well-being and reduced health risk is consistent with minimizing the substantial social and economic burdens of lifestyle conditions globally.

Prediction of stage transitions in fruit and vegetable intake

Stage theories propose that individuals pass through different stages on their way toward behavior change. The present study examines stage-specific prediction patterns of social-cognitive variables (risk perception, outcome expectancies, perceived self-efficacy, action planning and social support) regarding transitions between the three stages of the Health Action Process Approach (HAPA; preintention, intention and action stage). In an online study (n = 494) on fruit and vegetable intake, social-cognitive variables and stages were assessed at baseline and stage transitions 4 weeks later. Transitions between the preintention, intention and action stage were predicted by social-cognitive variables using binary and multinomial logistic regression analyses. Stage-specific prediction patterns emerged for stage progression and stage regression. Outcome expectancies predicted progression from the preintention stage, whereas social support predicted progression to the action stage. Low levels of planning were associated with relapse to the preintention and the intention stage. Self-efficacy emerged as a universal predictor of stage transitions. Findings support not only the usefulness of the stage construct for describing health behavior change but also the validity of the HAPA variables as predictors of stage transitions. Stage-matched interventions targeting the variables identified as stage-specific predictors might support stage progression toward the goal behavior.

A prospective evaluation of the Transtheoretical Model of Change applied to exercise in young people

OBJECTIVES

To investigate the utility of the Transtheoretical Model of Change in predicting exercise in young people.

DESIGN

A prospective study: assessments were done at baseline and follow-up 6 months later.

METHOD

Using stratified random sampling 1055 Chinese high school pupils living in Hong Kong, 533 of who were followed up at 6 months, completed measures of stage of change (SCQ), self-efficacy (SEQ), perceptions of the pros and cons of exercising (DBQ) and processes of change (PCQ). Data were analysed using one-way ANOVA, repeated measures ANOVA and independent sample t tests.

RESULTS

The utility of the TTM to predict exercise in this population is not strong; increases in self-efficacy and decisional balance discriminated between those remaining active at baseline and follow-up, but not in changing from an inactive (e.g., Precontemplation or Contemplation) to an active state (e.g., Maintenance) as one would anticipate given the staging algorithm of the TTM.

CONCLUSION

The TTM is a modest predictor of future stage of change for exercise in young Chinese people. Where there is evidence that TTM variables may shape movement over time, self-efficacy, pros and behavioural processes of change appear to be the strongest predictors.

Social-cognitive theories for predicting physical activity behaviours of employed women with and without young children

Chronic disease interventions for women have been understudied in the workplace domain. Understanding the role of cognitions in individual behaviour can help motivate change and suggest directions for achieving improvements in health. The purpose of this study was to identify psychosocial constructs and social-cognitive theories [e.g. Transtheoretical model (TTM), Theory of Planned Behaviour (TPB), Protection Motivation Theory (PMT) and Social Cognitive Theory (SCT)] that are most salient for explaining physical activity behaviour among employed women (n = 1183). Demographic information, and social-cognitive measures related to physical activity, intention and behaviours (e.g. stage of change, energy expenditure) were assessed. A series of multiple regression analyses predicting intention, energy expenditure and stage of change were conducted separately for: (1) women with young children (n = 302), and (2) women without young children (n = 881) for each of the respective social-cognitive theories. Although taken as a whole the results were relatively similar between the two sub-groups of women for each of the socio-cognitive theories examined in this study, differences were observed in the relative contributions of the theoretical constructs between the two sub-groups. Results also indicate that self-efficacy and intention were the strongest predictors of behaviour among both women with and without young children. The explained variances (R(2)) for the theories examined in this study for different sub-groups ranged from 16 to 60%, generally reflecting what has been reported in other studies within the physical activity domain. The results of this study could be useful in guiding future research and in designing physical activity intervention programs for these specific population groups. Integrating approaches of individual lifestyle change while addressing issues related to creating supportive environments for women in various life stages is a suggested strategy for future work in this area.

Getting beyond outcomes: a realist approach to help understand the impact of a nutritional intervention during smoking cessation

OBJECTIVES

This paper discusses the benefits that a 'realist' approach can bring to an outcome study using the example of a nutritional intervention offered as an adjunct to the existing smoking cessation programmes to limit post-cessation weight gain.

SUBJECTS AND SETTING

Participants of a smoking cessation programme in areas of deprivation in the north, south and west of Glasgow.

RESULTS

A realist approach enabled the development of a framework able to investigate both implementation and outcomes of the intervention. Drawing on theoretical and experiential knowledge, context-mechanism-outcome hypotheses were developed for further testing at later stages of evaluation. This will focus the further stages of evaluation on testing these specific hypotheses using outcome data collected at the end of the intervention.

CONCLUSION

Adopting such an evaluation approach enables integration of process and outcome data that will refine our understanding of contexts and mechanisms, which are associated with these behavioural changes. It can aid further policy decisions by identifying the type of participant and circumstances that are associated with positive outcomes and those subgroups of participants that can be targeted more effectively using other approaches.

The effects of subjective norms on behaviour in the theory of planned behaviour: a meta-analysis

A meta-analysis investigated the effects of perceived injunctive (IN) and descriptive (DN) norms on behaviour (BEH) within the theory of planned behaviour (TPB) in a sample of 196 studies. Two related correlation matrices (pairwise and listwise) were synthesized from the data and used to model the TPB relations with path analyses. Convergent evidence indicated that the relation between DN and BEH was stronger than the relation between IN and BEH. Evidence also suggested a significant direct relation between DN and BEH in the context of TPB. A suppressor effect of IN on DN in its relation with BEH was also noted. Moderator analyses indicated that the DN-BEH relation was stronger when there was more time between measures of cognition and behaviour, when behaviours were not socially approved, more socially motive and more pleasant; results were mixed in the case of the IN-BEH relation. Results imply that IN and DN are conceptually different constructs.

Predicting and explaining transtheoretical model stage transitions in relation to condom-carrying behaviour

OBJECTIVES

The stages of change component of the transtheoretical model have been applied to safe sex behaviours in cross-sectional analyses, but have not yet been subject to prospective analysis. It was predicted that: (a) cross-sectional analyses would demonstrate good discrimination between the stages of change; (b) prospective analyses would allow for the identification of predictors of stage transitions; and (c) implementation intentions would explain progression from the preparation stage.

DESIGN

This study employed an experimental longitudinal design. Participants were randomly assigned to the experimental (implementation intention) or control conditions and completed questionnaires at baseline and at 2-month follow-up.

METHODS

Five hundred and twenty-five adolescents who were broadly representative of the UK population completed questionnaires at baseline and follow-up (N=393) measuring: demographic variables; stage of change; theory of planned behaviour constructs; anticipated regret; and moral norm in relation to condom-carrying behaviour. The experimental condition completed a self-generated implementation intention to carry condoms at the end of the baseline questionnaire.

RESULTS

Discriminant function analyses indicated that the stages of change could be accurately discriminated from one another cross-sectionally and that, longitudinally, the measured variables were able to predict transitions between most stages. Implementation intentions caused people to progress from the preparation stage.

CONCLUSIONS

Transitions between most stages were reliably predicted, thereby providing potential targets for intervention. The brief implementation intention intervention was effective and could easily be utilized and expanded to encompass a broader range of sexual health behaviours.

Adolescent sexual risk: factors predicting condom use across the stages of change

This study examined factors associated with high-risk adolescents' movement toward or away from adopting consistent condom use behavior using the Transtheoretical Model Stages of Change. Participants drawn from the inactive comparison condition of a randomized HIV prevention trial (Project SHIELD) responded to items assessing pros and cons of condom use, peer norms, condom communication, and perceived invulnerability to HIV. Participants were categorized based on their condom use behavior using the Transtheoretical Model. Multiple logistic regressions found that progression to consistent condom use was predicted by continuing to perceive more advantages to condom use, reporting greater condom use communication with partners, and less perceived invulnerability to HIV. Movement away from adopting consistent condom use was predicted by a decrease in perceived advantages to condom use, increased perceived condom disadvantages, and fewer condom discussions. Future interventions may be tailored to enhance these factors that were found to change over time.

Toward a Theory of Change Readiness

This research article describes and constructs a model of performance readiness. The goal of this article is to illustrate how one might meet the challenges of change effectively. The author explores the factors and principles driving the positive transformational change of a high-performing soccer team. Framed by theories of cognitive appraisal, stress, and coping, the study reveals critical variables to the change readiness process to be appraisal, focus, and perceived control. By inquiring deeply into individual appraisals of a change, it may be possible to facilitate a focal shift from “resistance” to “resolution” and from a desire for “power over” a change to a recognition of one's “power to” change effectively.

Neighbourhood perceptions of physical activity: a qualitative study

Background

Effective promotion of physical activity in low income communities is essential given the high prevalence of inactivity in this sector.

Methods

This study explored determinants of engaging in physical activity in two Irish city based neighbourhoods using a series of six focus groups and twenty five interviews with adult residents. Data were analysed using constant comparison methods with a grounded theory approach.

Results

Study findings centred on the concept of 'community contentment'. Physical activity was related to the degree of contentment/comfort within the 'self' and how the 'self' interacts within the neighbourhood. Contemporary focus on outer bodily appearance and pressure to comply with societal expectations influenced participants' sense of confidence and competence. Social interaction, involvement, and provision of adequate social supports were viewed as positive and motivating. However normative expectations appeared to affect participants' ability to engage in physical activity, which may reflect the 'close knit' culture of the study neighbourhoods. Access to suitable local facilities and amenities such as structured and pleasant walking routes was regarded as essential. Indeed participants considered walking to be their preferred form of physical activity which may relate to the minimal skill requirement, ease of access and low financial costs incurred.

Conclusion

In the context of physical activity, health promoters need to be conscious of the difficulties that individuals feel in relation to bodily appearance and the pressure to comply with societal standards. This may be particularly relevant in low income settings where insufficient allocation of resources and social supports means that individuals have less opportunity to attend to physical activity than individuals living in higher income settings.

Who will be active? Predicting exercise stage transitions after hospitalization for coronary artery diseaseThis paper is one of a selection of papers published in this Special Issue, entitled Young Investigators' Forum

We describe transitions between exercise stages of change in people with coronary artery disease (CAD) over a 6-month period following a CAD-related hospitalization and evaluate constructs from Protection Motivation Theory, Theory of Planned Behavior, Social Cognitive Theory, the Ecological Model, and participation in cardiac rehabilitation as correlates of stage transition. Seven hundred eighty-two adults hospitalized with CAD were recruited and administered a baseline survey including assessments of theory-based constructs and exercise stage of change. Mailed surveys were used to gather information concerning exercise stage of change and participation in cardiac rehabilitation 6 months later. Progression from pre-action stages between baseline and 6 month follow-up was associated with greater perceived efficacy of exercise to reduce risk of future disease, fewer barriers to exercise, more access to home exercise equipment, and participation in cardiac rehabilitation. Regression from already active stages between baseline and 6 month follow-up was associated with increased perceived susceptibility to a future CAD-related event, fewer intentions to exercise, lower self-efficacy, and more barriers to exercise.

Readiness to exercise: a comparison of 3 instruments and an interview

Exercise stage of change (ESOC), or readiness to exercise, has been measured using at least 13 instruments and 4 interviews, yet no comparison studies are available to determine optimal measures for use by health care providers. This pilot study compares ESOC classification between 3 instruments (scale-ladder, scale-true/false, and scale-5 choice); explores the feasibility of using a face-to-face structured interview; compares classification between instruments and interview; and examines the influence of sex, age, and education level on stage classification. Thirty healthy adults completed ESOC instruments in random order and then the interview. Scale-ladder and scale-true/false instruments exhibited almost perfect agreement (weighted kappa, 0.897). All instruments exhibited substantial agreement with interview (weighted kappa, 0.620-0.790). Stage classification did not differ significantly by sex, age, or education level. The authors recommend word clarification revision of the scale-5 choice instrument and further testing of the interview.