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1.  Better exercise adherence after treatment for cancer (BEAT Cancer) study: Rationale, design, and methods 
Contemporary Clinical Trials  2011;33(1):124-137.
Most breast cancer survivors do not engage in regular physical activity. Our physical activity behavior change intervention for breast cancer survivors significantly improved physical activity and health outcomes post-intervention during a pilot, feasibility study. Testing in additional sites with a larger sample and longer follow-up is warranted to confirm program effectiveness short and longer term. Importantly, the pilot intervention resulted in changes in physical activity and social cognitive theory constructs, enhancing our potential for testing mechanisms mediating physical activity behavior change. Here, we report the rationale, design, and methods for a two-site, randomized controlled trial comparing the effects of the BEAT Cancer physical activity behavior change intervention to usual care on short and longer term physical activity adherence among breast cancer survivors. Secondary aims include examining social cognitive theory mechanisms of physical activity behavior change and health benefits of the intervention. Study recruitment goal is 256 breast cancer survivors with a history of ductal carcinoma in situ or Stage I, II, or IIIA disease who have completed primary cancer treatment. Outcome measures are obtained at baseline, 3 months (i.e., immediately post-intervention), 6 months, and 12 months and include physical activity, psychosocial factors, fatigue, sleep quality, lower extremity joint dysfunction, cardiorespiratory fitness, muscle strength, and waist-to-hip ratio. Confirming behavior change effectiveness, health effects, and underlying mechanisms of physical activity behavior change interventions will facilitate translation to community settings for improving the health and well-being of breast cancer survivors.
doi:10.1016/j.cct.2011.09.004
PMCID: PMC3253876  PMID: 21983625
oncology; exercise; survivorship; predictors; adherence
2.  Moms in motion: a group-mediated cognitive-behavioral physical activity intervention 
Background
When examining the prevalence of physical inactivity by gender and age, women over the age of 25 are at an increased risk for sedentary behavior. Childbearing and motherhood have been explored as one possible explanation for this increased risk. Post natal exercise studies to date demonstrate promising physical and psychological outcomes, however few physical activity interventions have been theory-driven and tailored to post natal exercise initiates. The purpose of this study was to compare the effects of a group-mediated cognitive behavioral intervention based upon social-cognitive theory and group dynamics (GMCB) to a standard care postnatal exercise program (SE).
Method
A randomized, two-arm intervention design was used. Fifty-seven post natal women were randomized to one of two conditions: (1) a standard exercise treatment (SE) and (2) a standard exercise treatment plus group-mediated cognitive behavioral intervention (GMCB). Participants in both conditions participated in a four-week intensive phase where participants received standard exercise training. In addition, GMCB participants received self-regulatory behavioral skills training via six group-mediated counseling sessions. Following the intensive phase, participants engaged in a four-week home-based phase of self-structured exercise. Measures of physical activity, barrier efficacy, and proximal outcome expectations were administered and data were analyzed using ANCOVA procedures.
Results and discussion
ANCOVA of change scores for frequency, minutes, and volume of physical activity revealed significant treatment effects over the intensive and home-based phases (p's < 0.01). In addition, ANCOVA of change in mean barrier efficacy and proximal outcome expectations at the conclusion of the intensive phase demonstrated that GMCB participants increased their initial level of barrier efficacy and outcome expectations while SE participants decreased (p < 0.05).
Conclusion
While both exercise programs resulted in improvements to exercise participation, the GMCB intervention produced greater improvement in overall physical activity, barrier efficacy and proximal outcome expectations.
doi:10.1186/1479-5868-3-23
PMCID: PMC1564034  PMID: 16925809
3.  A cluster-randomised, controlled trial to assess the impact of a workplace osteoporosis prevention intervention on the dietary and physical activity behaviours of working women: study protocol 
BMC Public Health  2013;13:405.
Background
Osteoporosis is a debilitating disease and its risk can be reduced through adequate calcium consumption and physical activity. This protocol paper describes a workplace-based intervention targeting behaviour change in premenopausal women working in sedentary occupations.
Method/Design
A cluster-randomised design was used, comparing the efficacy of a tailored intervention to standard care. Workplaces were the clusters and units of randomisation and intervention. Sample size calculations incorporated the cluster design. Final number of clusters was determined to be 16, based on a cluster size of 20 and calcium intake parameters (effect size 250 mg, ICC 0.5 and standard deviation 290 mg) as it required the highest number of clusters.
Sixteen workplaces were recruited from a pool of 97 workplaces and randomly assigned to intervention and control arms (eight in each). Women meeting specified inclusion criteria were then recruited to participate. Workplaces in the intervention arm received three participatory workshops and organisation wide educational activities. Workplaces in the control/standard care arm received print resources. Intervention workshops were guided by self-efficacy theory and included participatory activities such as goal setting, problem solving, local food sampling, exercise trials, group discussion and behaviour feedback.
Outcomes measures were calcium intake (milligrams/day) and physical activity level (duration: minutes/week), measured at baseline, four weeks and six months post intervention.
Discussion
This study addresses the current lack of evidence for behaviour change interventions focussing on osteoporosis prevention. It addresses missed opportunities of using workplaces as a platform to target high-risk individuals with sedentary occupations. The intervention was designed to modify behaviour levels to bring about risk reduction. It is the first to address dietary and physical activity components each with unique intervention strategies in the context of osteoporosis prevention. The intervention used locally relevant behavioural strategies previously shown to support good outcomes in other countries. The combination of these elements have not been incorporated in similar studies in the past, supporting the study hypothesis that the intervention will be more efficacious than standard practice in osteoporosis prevention through improvements in calcium intake and physical activity.
doi:10.1186/1471-2458-13-405
PMCID: PMC3654951  PMID: 23627684
Osteoporosis prevention; Cluster randomised trial; Premenopausal women; Workplace; Calcium intake; Physical activity
4.  Testing a workplace physical activity intervention: a cluster randomized controlled trial 
Background
Increased physical activity levels benefit both an individuals' health and productivity at work. The purpose of the current study was to explore the impact and cost-effectiveness of a workplace physical activity intervention designed to increase physical activity levels.
Methods
A total of 1260 participants from 44 UK worksites (based within 5 organizations) were recruited to a cluster randomized controlled trial with worksites randomly allocated to an intervention or control condition. Measurement of physical activity and other variables occurred at baseline, and at 0 months, 3 months and 9 months post-intervention. Health outcomes were measured during a 30 minute health check conducted in worksites at baseline and 9 months post intervention. The intervention consisted of a 3 month tool-kit of activities targeting components of the Theory of Planned Behavior, delivered in-house by nominated facilitators. Self-reported physical activity (measured using the IPAQ short-form) and health outcomes were assessed.
Results and discussion
Multilevel modelling found no significant effect of the intervention on MET minutes of activity (from the IPAQ) at any of the follow-up time points controlling for baseline activity. However, the intervention did significantly reduce systolic blood pressure (B = -1.79 mm/Hg) and resting heart rate (B = -2.08 beats) and significantly increased body mass index (B = .18 units) compared to control. The intervention was found not to be cost-effective, however the substantial variability round this estimate suggested that further research is warranted.
Conclusions
The current study found mixed support for this worksite physical activity intervention. The paper discusses some of the tensions involved in conducting rigorous evaluations of large-scale randomized controlled trials in real-world settings.
Trial registration
Current controlled trials ISRCTN08807396
doi:10.1186/1479-5868-8-29
PMCID: PMC3094266  PMID: 21481265
5.  A randomised controlled trial among cleaners-Effects on strength, balance and kinesiophobia 
BMC Public Health  2011;11:776.
Background
Cleaners constitute a job group with poor health and low socioeconomic resources. Therefore, there is a great need for scientifically documented health promoting initiatives for cleaners. However, both workplace initiatives and high quality intervention studies are lacking. The aim of this study was to evaluate the effects of a 3-month workplace trial with interventions to improve physical or cognitive behavioural resources among cleaners.
Methods
A cluster randomised controlled trial was conducted among 294 female cleaners from 9 workplaces. The participants were allocated to three groups: Physical coordination training (PCT, n = 95), Cognitive behavioural theory-based training (CBTr, n = 99) and Reference group (REF, n = 100). Interventions were conducted during work hours for an average of 1 hour/week. Muscle strength was measured by maximal voluntary contractions in trunk/extension, and shoulder abduction/elevation. Postural balance was measured on a force platform. Kinesiophobia was measured with Tampa Scale for Kinesiophobia. Test and questionnaires were completed at baseline and at 3-month follow-up and analyses followed the intention-to-treat (ITT) principle with last observation carried forward in case of missing data at follow-up. Reports and analyses are given on true observations as well.
Results
ITT-analyses revealed that PCT improved strength of the trunk (p < .05) and postural balance (p < .05) compared to CBTr and REF. Based on true observations the strength and balance improvements corresponded to ~20% and ~16%, respectively. ITT-analyses showed that CBTr reduced kinesiophobia compared to PCT and REF (p < .05). Based on true observations, the improvement corresponded to a ~16% improvement.
Conclusion
This workplace-based intervention study including PCT and CBTr among cleaners improved strength and postural balance from PCT, and kinesiophobia from CBTr. The improved strength, postural balance and kinesiophobia may improve the cleaners' tolerance for high physical work demands. Future studies should investigate the potential in the combination of PCT and CBTr in a workplace intervention.
Trial registration
Current controlled trials ISRCTN96241850
doi:10.1186/1471-2458-11-776
PMCID: PMC3201927  PMID: 21985226
6.  Healthy for Life: A Randomized Trial Examining Physical Activity Outcomes and Psychosocial Mediators 
Background
Researchers theorize that interventions increase physical activity by influencing key theory-based mediators (e.g., behavioral processes). However, few studies have been adequately powered to examine the importance of mediators.
Purpose
This study examined both physical activity behavior and psychosocial mediators in a randomized trial specifically powered to detect mediation.
Methods
Healthy, sedentary adults (n=448; 70% Caucasian, 87% women, mean age was 43) were randomly assigned to either a six-month print-based theory tailored physical activity intervention (n=224) or a six-month health/wellness contact control arm (n=224).
Results
The print intervention arm exhibited greater increases in physical activity than the control arm at six and 12 months (p<.05). Additionally, behavioral processes were found to be an important mediator of physical activity behavior.
Conclusions
It is important for researchers and practitioners to focus on increasing behavioral strategies for physical activity adoption. Future studies should examine other potential mediators of physical activity.
doi:10.1007/s12160-012-9439-5
PMCID: PMC3597765  PMID: 23229158
Exercise; Physical Activity; Mediators; Intervention Studies
7.  The Role of Theory in Increasing Adherence to Prescribed Practice 
Physiotherapy Canada  2009;61(2):68-77.
ABSTRACT
Purpose: The purpose of this article is to apply theoretical frameworks to adherence behaviour and to guide the development of an intervention to increase adherence to prescribed home programmes.
Summary of Key Points: Delivering an effective intervention requires establishing one that is evidence based and of adequate dosage. Two-thirds of patients who receive home exercise prescriptions do not adhere to their home programme, which may contribute to their physiotherapy's being ineffective. The mediating concepts of self-efficacy (SE) and outcome expectations (OE) are common to the five relevant theories used to explain adherence to exercise: the health belief model, protection motivation theory, theory of reasoned action, theory of planned behaviour, and social cognitive theory.
Conclusion/Recommendations: Few intervention studies with any theoretical underpinning have examined adherence to exercise. Even fewer have been designed to affect and measure change in the theoretical mediators of SE and OE in patient populations. Physiotherapists must consider increasing adherence as a component of effective physiotherapy. Ongoing research is needed to increase our understanding of adherence to prescribed home programmes and to design interventions to affect theoretical mediators for increasing adherence.
doi:10.3138/physio.61.2.68
PMCID: PMC2792241  PMID: 20190989
adherence; learning; motor; practice; theory; fidélité; apprentissage; moteur; pratique; théorie
8.  Role of Suppressor Variables in Primary Prevention Obesity Research: Examples from Two Predictive Models 
ISRN Obesity  2014;2014:567523.
Pediatric obesity is a pertinent public health challenge. Child physical activity and screen time behaviors enacted within the context of the family and home environment are important determinants of pediatric obesity. The purpose of this study was to operationalize five, maternal-facilitated, social cognitive theory constructs for predicting physical activity and screen time behaviors in children. A secondary purpose was to elucidate the function of suppressor variables in the design and implementation of family- and home-based interventions seeking to prevent pediatric obesity. Instrumentation included face and content validity of the measurement tool by a panel of experts, test-retest reliability of the theoretical constructs, and predictive validity of the constructs through structural equation modeling. Physical activity and screen time were modeled separately according to the five selected social cognitive theory constructs. Data were collected from 224 mothers with children between four and six years of age. Specification indices indicated satisfactory fit for the final physical activity and screen time models. Through a series of four procedures, the structural models identified emotional coping and expectations as suppressor variables for self-efficacy. Suppressor variables can complement program design recommendations by providing a suggested ordering to construct integration within an intervention.
doi:10.1155/2014/567523
PMCID: PMC3929355  PMID: 24634793
9.  Impact of a physical activity intervention program on cognitive predictors of behaviour among adults at risk of Type 2 diabetes (ProActive randomised controlled trial) 
Background
In the ProActive Trial an intensive theory-based intervention program was no more effective than theory-based brief advice in increasing objectively measured physical activity among adults at risk of Type 2 diabetes. We aimed to illuminate these findings by assessing whether the intervention program changed cognitions about increasing activity, defined by the Theory of Planned Behaviour, in ways consistent with the theory.
Methods
N = 365 sedentary participants aged 30–50 years with a parental history of Type 2 diabetes were randomised to brief advice alone or to brief advice plus the intervention program delivered face-to-face or by telephone. Questionnaires at baseline, 6 and 12 months assessed cognitions about becoming more physically active. Analysis of covariance was used to test intervention impact. Bootstrapping was used to test multiple mediation of intervention impact.
Results
At 6 months, combined intervention groups (face-to-face and telephone) reported that they found increasing activity more enjoyable (affective attitude, d = .25), and they perceived more instrumental benefits (e.g., improving health) (d = .23) and more control (d = .32) over increasing activity than participants receiving brief advice alone. Stronger intentions (d = .50) in the intervention groups than the brief advice group at 6 months were partially explained by affective attitude and perceived control. At 12 months, intervention groups perceived more positive instrumental (d = .21) and affective benefits (d = .29) than brief advice participants. The intervention did not change perceived social pressure to increase activity.
Conclusion
Lack of effect of the intervention program on physical activity over and above brief advice was consistent with limited and mostly small short-term effects on cognitions. Targeting affective benefits (e.g., enjoyment, social interaction) and addressing barriers to physical activity may strengthen intentions, but stronger intentions did not result in more behaviour change. More powerful interventions which induce large changes in TPB cognitions may be needed. Other interventions deserving further evaluation include theory-based brief advice, intensive measurement of physical and psychological factors, and monitoring of physical activity. Future research should consider a wider range of mediators of physical activity change, assess participants' use of self-regulatory strategies taught in the intervention, and conduct experimental studies or statistical modelling prior to trial evaluation. ISRCTN61323766.
doi:10.1186/1479-5868-6-16
PMCID: PMC2669044  PMID: 19292926
10.  Healthy Eating Strategies in the Workplace 
Purpose
There is a clear link between dietary behavior and a range of chronic diseases, and overweight and obesity constitute an indirect risk in relation to these diseases. The worksite is a central venue for influencing dietary behavior. The purpose of this paper is to provide an overview of workplace influences on worker dietary patterns.
Design/methodology/approach
The paper reviews the evidence of the effectiveness of dietary health promotion, and provides a brief overview of appropriate theoretical frameworks to guide intervention design and evaluation. The findings are illustrated through research examples.
Findings
Through case studies and published research, it is found that workplace dietary interventions are generally effective, especially fruit and vegetable interventions. There is less consistent evidence on the long term effectiveness of workplace weight management interventions, underscoring the need for further research in this area. This paper also reports evidence that changes in the work environment, including through health and safety programs, may contribute to enhancing the effectiveness of workplace health promotion, including dietary interventions. Organizational factors such as work schedule may also influence dietary patterns. The social ecological model, the social contextual model and political process approach are presented as exemplar conceptual models that may be useful when designing or assessing the effects of workplace health promotion.
Originality/value
Using the worksite as setting for influencing health by influencing dietary patterns holds considerable promise and may be instrumental in reducing workers’ risk of chronic diseases.
doi:10.1108/17538351011078929
PMCID: PMC3737584  PMID: 23935706
Workplace; nutrition; obesity; health promotion; occupational safety and health
11.  The influence of self-efficacy and outcome expectations on the relationship between perceived environment and physical activity in the workplace 
Background
Recent research and commentary contends that ecological approaches may be particularly useful for understanding and promoting physical activity participation in various settings including the workplace. Yet within the physical activity domain there is a lack of understanding of how ecological environment factors influence behaviour. Thus, the purpose of this study was to examine the relationships between perceived environment, social-cognitive variables, and physical activity behaviour.
Methods
Participants (N = 897) were employees from three large worksites who completed self-report inventories containing measures of self-efficacy, outcome expectations, perceptions of the workplace environment (PWES), and physical activity behaviour during both leisure-time and incorporated throughout the workday.
Results
Results of both bivariate and multiple regression analyses indicated the global PWES scores had a limited association with leisure-time physical activity (R2adj =.01). Sequential regression analyses supported a weak association between physical activity incorporated in the workplace and PWES (R2adj = .04) and the partial mediation of self-efficacy on the relationship between PWES and workplace physical activity (variance accounted for reduced to R2adj = .02 when self-efficacy was controlled).
Conclusion
Overall, the results of the present investigation indicate that self-efficacy acted as a partial mediator of the relationship between perceived environment and workplace physical activity participation. Implications of the findings for physical activity promotion using ecological-based approaches, and future directions for research from this perspective in worksite settings are discussed.
doi:10.1186/1479-5868-1-7
PMCID: PMC416569  PMID: 15169560
12.  Iterative development of Stand Up Australia: a multi-component intervention to reduce workplace sitting 
Background
Sitting, particularly in prolonged, unbroken bouts, is widespread within the office workplace, yet few interventions have addressed this newly-identified health risk behaviour. This paper describes the iterative development process and resulting intervention procedures for the Stand Up Australia research program focusing on a multi-component workplace intervention to reduce sitting time.
Methods
The development of Stand Up Australia followed three phases. 1) Conceptualisation: Stand Up Australia was based on social cognitive theory and social ecological model components. These were operationalised via a taxonomy of intervention strategies and designed to target multiple levels of influence including: organisational structures (e.g. via management consultation), the physical work environment (via provision of height-adjustable workstations), and individual employees (e.g. via face-to-face coaching). 2) Formative research: Intervention components were separately tested for their feasibility and acceptability. 3) Pilot studies: Stand Up Comcare tested the integrated intervention elements in a controlled pilot study examining efficacy, feasibility and acceptability. Stand Up UQ examined the additional value of the organisational- and individual-level components over height-adjustable workstations only in a three-arm controlled trial. In both pilot studies, office workers’ sitting time was measured objectively using activPAL3 devices and the intervention was refined based on qualitative feedback from managers and employees.
Results
Results and feedback from participants and managers involved in the intervention development phases suggest high efficacy, acceptance, and feasibility of all intervention components. The final version of the Stand Up Australia intervention includes strategies at the organisational (senior management consultation, representatives consultation workshop, team champions, staff information and brainstorming session with information booklet, and supportive emails from managers to staff), environmental (height-adjustable workstations), and individual level (face-to-face coaching session and telephone support). Stand Up Australia is currently being evaluated in the context of a cluster-randomised controlled trial at the Department of Human Services (DHS) in Melbourne, Australia.
Conclusions
Stand Up Australia is an evidence-guided and systematically developed workplace intervention targeting reductions in office workers’ sitting time.
doi:10.1186/1479-5868-11-21
PMCID: PMC3936706  PMID: 24559162
Intervention development; Sedentary behaviour; Sitting time; Sit-stand; Physical activity; Postural transitions; Workplace; Workplace intervention; Office workers; Height-adjustable workstations
13.  Mediators of physical activity change in a behavioral modification program for type 2 diabetes patients 
Background
Many studies have reported significant behavioral impact of physical activity interventions. However, few have examined changes in potential mediators of change preceding behavioral changes, resulting in a lack of information concerning how the intervention worked. Our purpose was to examine mediation effects of changes in psychosocial variables on changes in physical activity in type 2 diabetes patients.
Methods
Ninety-two patients (62 ± 9 years, 30, 0 ± 2.5 kg/m2, 69% males) participated in a randomized controlled trial. The 24-week intervention was based on social-cognitive constructs and consisted of a face-to-face session, telephone follow-ups, and the use of a pedometer. Social-cognitive variables and physical activity (device-based and self-reported) were collected at baseline, after the 24-week intervention and at one year post-baseline. PA was measured by pedometer, accelerometer and questionnaire.
Results
Post-intervention physical activity changes were mediated by coping with relapse, changes in social norm, and social modeling from family members (p ≤ 0.05). One-year physical activity changes were mediated by coping with relapse, changes in social support from family and self-efficacy towards physical activity barriers (p ≤ 0.05)
Conclusions
For patients with type 2 diabetes, initiatives to increase their physical activity could usefully focus on strategies for resuming regular patterns of activity, on engaging family social support and on building confidence about dealing with actual and perceived barriers to activity.
Trial Registration
NCT00903500, ClinicalTrials.gov.
doi:10.1186/1479-5868-8-105
PMCID: PMC3191467  PMID: 21958233
14.  A description of the social–ecological framework used in the trial of activity for adolescent girls (TAAG) 
Health education research  2006;22(2):155-165.
Social–ecological (SE) models are becoming more widely used in health behavior research. Applying SE models to the design of interventions is challenging because models must be tailor-made for each behavior and population, other theories need to be integrated into multilevel frameworks, and empirical research to guide model development is limited. The purpose of the present paper is to describe a SE framework that guided the intervention and measurement plans for a specific study. The trial of activity for adolescent girls (TAAG) is a multi-center study of interventions to reduce the decline of physical activity in adolescent girls. The TAAG framework incorporates operant learning theory, social cognitive theory, organizational change theory and the diffusion of innovation model in a multi-level model. The explicit and practical model developed for TAAG has already benefited the study and may have elements that can generalize to other health promotion studies.
doi:10.1093/her/cyl059
PMCID: PMC2764407  PMID: 16855014
15.  Influence of individual and social contextual factors on changes in leisure-time physical activity in working-class populations: results of the Healthy Directions–Small Businesses Study 
Cancer causes & control : CCC  2012;23(9):1475-1487.
Background
As part of the Harvard Cancer Prevention Program Project, we sought to address disparities reflected in social class and race/ethnicity by developing and testing a behavioral intervention model that targeted fruit and vegetable consumption, red meat consumption, multivitamin intake, and physical activity in working-class, multiethnic populations.
Methods
This paper examined the associations between change in leisure-time physical activity and individual and social contextual factors in participants employed in small businesses (n = 850) at both baseline and at 18-month final.
Results
In bivariate analyses, age, language acculturation, social ties, and workplace social capital were significantly associated with physical activity at final. In multivariable analyses, being younger and having high language acculturation were significantly associated with greater leisuretime physical activity at final; high workplace social capital was significantly associated with a decline in physical activity at final.
Conclusion
These findings have implications for understanding factors that are integral to promoting change in physical activity among working-class, multiethnic populations.
doi:10.1007/s10552-012-0021-z
PMCID: PMC3652385  PMID: 22806257
Health disparities; Multivitamin; Nutrition; Physical activity; Race/ethnicity; Social context
16.  Interventions to Increase Walking Behavior 
Medicine and science in sports and exercise  2008;40(7 Suppl):S567-S573.
Walking is the most prevalent and preferred method of physical activity for both work and leisure purposes, thus making it a prime target for physical activity promotion interventions. We identified 14 randomized controlled trials, which tested interventions specifically targeting and assessing walking behavior. Results show that among self-selected samples intensive interventions can increase walking behavior relative to controls. Brief telephone prompts appear to be as effective as more substantial telephone counseling. Although more research is needed, individual studies support prescriptions to walk 5–7 d/wk versus 3–5 d/wk and at a moderate (versus vigorous) intensity pace, with no differences in total walking minutes when single or multiple daily walking bouts are prescribed. Mediated interventions delivering physical activity promotion materials through non-face-to-face channels may be ideal for delivering walking promotion interventions and have shown efficacy in promoting overall physical activity, especially when theory-based and individually tailored. Mass media campaigns targeting broader audiences, including those who may not intend to increase their physical activity, have been successful at increasing knowledge and awareness about physical activity, but are often too diffuse to successfully impact individual behavior change. Incorporating individually tailored programs into broader mass media campaigns may be an important next step, and the Internet could be a useful vehicle.
doi:10.1249/MSS.0b013e31817c7006
PMCID: PMC2694671  PMID: 18562974
Walking; Physical Activity; Exercise; Mediated Interventions; Behavior Change
17.  MEDIATORS OF PHYSICAL ACTIVITY BEHAVIOR CHANGE 
Using a multivariate extension of the Baron and Kenny (1986) mediation framework, we examined the simultaneous effect of psychosocial variables hypothesized to mediate the relationship between a motivationally-tailored physical activity intervention, and 6-month physical activity behavior in 239 healthy, under-active adults (mean age=47.5; 82% women). Participants were randomly assigned to 1) Print-based feedback; 2) Telephone-based feedback; or 3) Contact Control. All mediation criteria were satisfied for both intervention arms. In terms of effect size, a moderate indirect effect of Print (0.39, 95% CI=0.21, 0.57) was due to increases in behavioral processes (0.54, 95% CI= 0.29, 0.80) being attenuated by decreases due to cognitive processes (-0.17, 95%CI= -0.31,-.03). A moderate indirect effect was observed for Telephone (0.47, 95% CI=0.28, 0.66), with increases due to behavioral processes (0.61, 95% CI=0.34, 0.87) attenuated by decreases due to cognitive processes (0.15, 95% CI=-0.27, -0.02); self-efficacy and decisional balance mediational paths did not attain statistical significance. These findings highlight the importance of studies that deconstruct the theoretical components of interventions to determine which combination produces the greatest behavior changes at the lowest cost.
doi:10.1037/0278-6133.27.4.409
PMCID: PMC2692944  PMID: 18642998
Mediators; Physical Activity; Intervention studies; Randomized controlled trial; Multivariate analysis
18.  A Pilot Study of Increasing Nonpurposeful Movement Breaks at Work as a Means of Reducing Prolonged Sitting 
There is a plethora of workplace physical activity interventions designed to increase purposeful movement, yet few are designed to alleviate prolonged occupational sitting time. A pilot study was conducted to test the feasibility of a workplace e-health intervention based on a passive approach to increase nonpurposeful movement as a means of reducing sitting time. The study was trialled in a professional workplace with forty-six participants (33 females and 13 males) for a period of twenty-six weeks. Participants in the first thirteen weeks received a passive prompt every 45 minutes on their computer screen reminding them to stand and engage in nonpurposeful activity throughout their workday. After thirteen weeks, the prompt was disabled, and participants were then free to voluntary engage the software. Results demonstrated that when employees were exposed to a passive prompt, as opposed to an active prompt, they were five times more likely to fully adhere to completing a movement break every hour of the workday. Based on this pilot study, we suggest that the notion that people are willing to participate in a coercive workplace e-health intervention is promising, and there is a need for further investigation.
doi:10.1155/2013/128376
PMCID: PMC3649663  PMID: 23690798
19.  Does an ‘Activity-Permissive’ Workplace Change Office Workers’ Sitting and Activity Time? 
PLoS ONE  2013;8(10):e76723.
Introduction
To describe changes in workplace physical activity, and health-, and work-related outcomes, in workers who transitioned from a conventional to an ‘activity-permissive’ workplace.
Methods
A natural pre-post experiment conducted in Vancouver, Canada in 2011. A convenience sample of office-based workers (n=24, 75% women, mean [SD] age = 34.5 [8.1] years) were examined four months following relocation from a conventional workplace (pre) to a newly-constructed, purpose-built, movement-oriented physical environment (post). Workplace activity- (activPAL3-derived stepping, standing, and sitting time), health- (body composition and fasting cardio-metabolic blood profile), and work- (performance; job satisfaction) related outcomes were measured pre- and post-move and compared using paired t-tests.
Results
Pre-move, on average (mean [SD]) the majority of the day was spent sitting (364 [43.0] mins/8-hr workday), followed by standing (78.2 [32.1] mins/8-hr workday) and stepping (37.7 [15.6] mins/8-hr workday). The transition to the ‘activity-permissive’ workplace resulted in a significant increase in standing time (+18.5, 95% CI: 1.8, 35.2 mins/8-hr workday), likely driven by reduced sitting time (-19.7, 95% CI: -42.1, 2.8 mins/8-hr workday) rather than increased stepping time (+1.2, 95% CI: -6.2, 8.5 mins/8-hr workday). There were no statistically significant differences observed in health- or work-related outcomes.
Discussion
This novel, opportunistic study demonstrated that the broader workplace physical environment can beneficially impact on standing time in office workers. The long-term health and work-related benefits, and the influence of individual, organizational, and social factors on this change, requires further evaluation.
doi:10.1371/journal.pone.0076723
PMCID: PMC3788722  PMID: 24098555
20.  Reduced Barriers Mediated Physical Activity Maintenance Among Breast Cancer Survivors 
To better understand mechanisms of physical activity (PA) behavior change in breast cancer survivors, we examined mediation of a successful PA behavior change intervention by social cognitive theory (SCT) constructs. Our exploratory study randomized 41 breast cancer survivors to receive the 3-month intervention (INT) or usual care (UC). We used the Freedman and Schatzkin approach to examine mediation of intervention effect on PA 3 months postintervention by changes in SCT constructs from baseline to immediately postintervention. Compared with UC, the INT group reported lower barriers interference (mean difference = −7.8, 95% CI [−15.1, −0.4], d = −0.67, p = .04) and greater PA enjoyment (mean difference = 0.7, 95% CI [0, 1.5], d = 0.61, p = .06). Barriers interference mediated 39% (p = .004) of the intervention effect on PA 3 months postintervention. PA enjoyment was not a significant mediator. Reducing barriers to PA partially explained our intervention effect.
PMCID: PMC3145412  PMID: 21558582
oncology; exercise; social cognitive theory; predictor; breast cancer; survivorship
21.  A theory-based exercise intervention in patients with heart failure: A protocol for randomized, controlled trial 
Background:
Regular exercise has been associated with improved quality of life (QoL) in patients with heart failure (HF). However, less is known on the theoretical framework, depicting how educational intervention on psychological, social, and cognitive variables affects physical activity (PA). The purpose of this study is to assess the effectiveness of a social cognitive theory-based (SCT-based) exercise intervention in patients with HF.
Materials and Methods:
This is a randomized controlled trial, with measurements at baseline, immediately following the intervention, and at 1, 3, and 6 months follow-up. Sixty patients who are referred to the cardiac rehabilitation (CR) unit and meet the inclusion criteria will be randomly allocated to either an intervention group or a usual-care control group. Data will be collected using various methods (i.e., questionnaires, physical tests, paraclinical tests, patients’ interviews, and focus groups). The patients in the intervention group will receive eight face-to-face counseling sessions, two focus groups, and six educational sessions over a 2-month period. The intervention will include watching videos, using book and pamphlets, and sending short massage services to the participants. The primary outcome measures are PA and QoL. The secondary outcome measures will be the components of SCT, heart rate and blood pressure at rest, body mass index, left ventricular ejection fraction, exercise capacity, and maximum heart rate.
Conclusion:
The findings of this trial may assist with the development of a theoretical model for exercise intervention in CR. The intervention seems to be promising and has the potential to bridge the gap of the usually limited and incoherent provision of educational care in the CR setting.
PMCID: PMC3872604  PMID: 24379841
Cardiac rehabilitation; exercise; heart failure; quality of life; randomized controlled trial; social cognitive theory
22.  Office-Based Physical Activity and Nutrition Intervention: Barriers, Enablers, and Preferred Strategies for Workplace Obesity Prevention, Perth, Western Australia, 2012 
Introduction
Workplace health promotion programs to prevent overweight and obesity in office-based employees should be evidence-based and comprehensive and should consider behavioral, social, organizational, and environmental factors. The objective of this study was to identify barriers to and enablers of physical activity and nutrition as well as intervention strategies for health promotion in office-based workplaces in the Perth, Western Australia, metropolitan area in 2012.
Methods
We conducted an online survey of 111 employees from 55 organizations. The online survey investigated demographics, individual and workplace characteristics, barriers and enablers, intervention-strategy preferences, and physical activity and nutrition behaviors. We used χ2 and Mann–Whitney U statistics to test for differences between age and sex groups for barriers and enablers, intervention-strategy preferences, and physical activity and nutrition behaviors. Stepwise multiple regression analysis determined factors that affect physical activity and nutrition behaviors.
Results
We identified several factors that affected physical activity and nutrition behaviors, including the most common barriers (“too tired” and “access to unhealthy food”) and enablers (“enjoy physical activity” and “nutrition knowledge”). Intervention-strategy preferences demonstrated employee support for health promotion in the workplace.
Conclusion
The findings provide useful insights into employees’ preferences for interventions; they can be used to develop comprehensive programs for evidence-based workplace health promotion that consider environmental and policy influences as well as the individual.
doi:10.5888/pcd10.130029
PMCID: PMC3775360  PMID: 24028834
23.  Evidence, Theory and Context: Using intervention mapping to develop a worksite physical activity intervention 
BMC Public Health  2008;8:326.
Background
The workplace is an ideal setting for health promotion. Helping employees to be more physically active can not only improve their physical and mental health, but can also have economic benefits such as reduced sickness absence. The current paper describes the development of a three month theory-based intervention that aims to increase levels of moderate intensity physical activity amongst employees in sedentary occupations.
Methods
The intervention was developed using an intervention mapping protocol. The intervention was also informed by previous literature, qualitative focus groups, an expert steering group, and feedback from key contacts within a range of organisations.
Results
The intervention was designed to target awareness (e.g. provision of information), motivation (e.g. goal setting, social support) and environment (e.g. management support) and to address behavioural (e.g. increasing moderate physical activity in work) and interpersonal outcomes (e.g. encourage colleagues to be more physically active). The intervention can be implemented by local facilitators without the requirement for a large investment of resources. A facilitator manual was developed which listed step by step instructions on how to implement each component along with a suggested timetable.
Conclusion
Although time consuming, intervention mapping was found to be a useful tool for developing a theory based intervention. The length of this process has implications for the way in which funding bodies allow for the development of interventions as part of their funding policy. The intervention will be evaluated in a cluster randomised trial involving 1350 employees from 5 different organisations, results available September 2009.
doi:10.1186/1471-2458-8-326
PMCID: PMC2567979  PMID: 18808709
24.  Effectiveness of Community-based Intervention to Promote Iran's Food-based Dietary Guidelines 
Background:
Dietary Guidelines are considered as a useful tool for the promotion of healthy dietary behaviors. In Iran, despite the development of the latest National Food-Based Dietary Guidelines, in 2006, it has not been introduced at the community level yet. The present study aims to evaluate the effectiveness of an intervention program to promote Iran's Food-Based Dietary Guidelines (IFBDGs) in urban adult women.
Methods:
A sample of 435 healthy women, aged 26 to 54 years, was randomly assigned to the intervention or control groups. The intervention group was designed based on the Health Belief Model (HBM). Each subject in the intervention group received three sessions of group education on IFBDGs and the food guide pyramid and participated in a healthy cooking class. Dietary intake, cognitive outcomes related to the constructs of the HBM, physical activity, and the BMI were measured in both groups before, immediately, and one month after the intervention. The outcome measures were compared with the analysis of covariance (ANCOVA), by adjusting for baseline values.
Results:
The intervention group had a significantly lower total daily energy intake than the control group after the intervention (P=.000). The adjusted differences in the changes of body mass index from the baseline were significant in both post intervention measurements in the intervention group compared to the controls.
Conclusions:
The intervention designed based on the Health Belief Model was effective in improving the adherence to FBDGs and could serve as a basic model for the promotion of healthy nutrition behavior among women in the primary health care setting.
PMCID: PMC3354394  PMID: 22624081
Community-based trial; food-based dietary guidelines; health belief model; Iran; urban women
25.  Physical Functioning: Effect of Behavioral Intervention for Symptoms Among Individuals With Cancer 
Nursing research  2006;55(3):161-171.
Background
Individuals with cancer receiving chemotherapy suffer deterioration in physical functioning due to symptoms arising from the cancer disease process and its treatment.
Objectives
To determine if age, chronic health conditions (comorbidity), stage of cancer, depressive symptomatology, symptom limitations, sex, and site of cancer moderate the effects of cognitive behavioral intervention on physical function and to determine if symptom limitations mediate the effect of the intervention on physical functioning.
Methods
Two hundred thirty-seven individuals with solid tumor cancer (118 experimental and 119 control group) participated in this 10-contact, 18-week randomized control trial. Cognitive behavioral theory guided the nurse-delivered problem-solving experimental intervention. The control group received conventional care. Interviews occurred at baseline and 10, 20, and 32 weeks.
Results
Women with breast cancer had significantly better physical functioning than women with lung cancer. Chronic health conditions, symptom limitation, and depressive symptomatology at baseline were found to moderate the effect of intervention on physical function. Symptom limitation, however, was not found to mediate the effect of intervention on physical functioning.
Discussion
The intervention was shown to affect physical function trajectories differently for individuals with different personal and health characteristics. Because poor physical functioning is strongly associated with mortality and poor quality of life, this information may be used by health professionals to target interventions to those who might be most responsive.
PMCID: PMC2012950  PMID: 16708040
depressive symptomatology; physical functioning; solid tumor cancer; symptoms

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