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1.  Personal, social and environmental determinants of educational inequalities in walking: a multilevel study 
Objective
To investigate the contribution of personal, social and environmental factors to mediating socioeconomic (educational) inequalities in women's leisure‐time walking and walking for transport.
Methods
A community sample of 1282 women provided survey data on walking for leisure and transport; educational level; enjoyment of, and self‐efficacy for, walking; physical activity barriers and intentions; social support for physical activity; sporting/recreational club membership; dog ownership; and perceived environmental aesthetics and safety. These data were linked with objective environmental data on the density of public open space and walking tracks in the women's local neighbourhood, coastal proximity and street connectivity.
Results
Multilevel modelling showed that different personal, social and environmental factors were associated with walking for leisure and walking for transport. Variables from all three domains explained (mediated) educational inequalities in leisure‐time walking, including neighbourhood walking tracks; coastal proximity; friends' social support; dog ownership; self‐efficacy, enjoyment and intentions. On the other hand, few of the variables examined explained educational variations in walking for transport, exceptions being neighbourhood, coastal proximity, street connectivity and social support from family.
Conclusions
Public health initiatives aimed at promoting, and reducing educational inequalities in, leisure‐time walking should incorporate a focus on environmental strategies, such as advocating for neighbourhood walking tracks, as well as personal and social factors. Further investigation is required to better understand the pathways by which education might influence walking for transport.
doi:10.1136/jech.2006.048520
PMCID: PMC2465645  PMID: 17234868
2.  Socioeconomic differences in lack of recreational walking among older adults: the role of neighbourhood and individual factors 
Background
People with a low socioeconomic status (SES) are more likely to be physically inactive than their higher status counterparts, however, the mechanisms underlying this socioeconomic gradient in physical inactivity remain largely unknown. Our aims were (1) to investigate socioeconomic differences in recreational walking among older adults and (2) to examine to what extent neighbourhood perceptions and individual cognitions regarding regular physical activity can explain these differences.
Methods
Data were obtained by a large-scale postal survey among a stratified sample of older adults (age 55–75 years) (N = 1994), residing in 147 neighbourhoods of Eindhoven and surrounding areas, in the Netherlands. Multilevel logistic regression analyses assessed associations between SES (i.e. education and income), perceptions of the social and physical neighbourhood environment, measures of individual cognitions derived from the Theory of Planned Behaviour (e.g. attitude, perceived behaviour control), and recreational walking for ≥10 minutes/week (no vs. yes).
Results
Participants in the lowest educational group (OR 1.67 (95% CI, 1.18–2.35)) and lowest income group (OR 1.40 (95% CI, 0.98–2.01)) were more likely to report no recreational walking than their higher status counterparts. The association between SES and recreational walking attenuated when neighbourhood aesthetics was included in the model, and largely reduced when individual cognitions were added to the model (with largest effects of attitude, and intention regarding regular physical activity). The assiation between poor neighbourhood aesthetics and no recreational walking attenuated to (borderline) insignificance when individual cognitions were taken into account.
Conclusion
Both neighbourhood aesthetics and individual cognitions regarding physical activity contributed to the explanation of socioeconomic differences in no recreational walking. Neighbourhood aesthetics may explain the association between SES and recreational walking largely via individual cognitions towards physical activity. Intervention and policy strategies to reduce socioeconomic differences in lack of recreational walking among older adults would be most effective if they intervene on both neighbourhood perceptions as well as individual cognitions.
doi:10.1186/1479-5868-6-1
PMCID: PMC2631001  PMID: 19123927
3.  Environmental perceptions as mediators of the relationship between the objective built environment and walking among socio-economically disadvantaged women 
Background
Women living in socio-economically disadvantaged neighbourhoods are at increased risk for physical inactivity and associated health outcomes and are difficult to reach through personally tailored interventions. Targeting the built environment may be an effective strategy in this population subgroup. The aim of this study was to examine the mediating role of environmental perceptions in the relationship between the objective environment and walking for transportation/recreation among women from socio-economically disadvantaged neighbourhoods.
Methods
Baseline data of the Resilience for Eating and Activity Despite Inequality (READI) study were used. In total, 4139 women (18–46 years) completed a postal survey assessing physical environmental perceptions (aesthetics, neighbourhood physical activity environment, personal safety, neighbourhood social cohesion), physical activity, and socio-demographics. Objectively-assessed data on street connectivity and density of destinations were collected using a Geographic Information System database and based on the objective z-scores, an objective destinations/connectivity score was calculated. This index was positively scored, with higher scores representing a more favourable environment. Two-level mixed models regression analyses were conducted and the MacKinnon product-of-coefficients test was used to examine the mediating effects.
Results
The destinations/connectivity score was positively associated with transport-related walking. The perceived physical activity environment mediated 6.1% of this positive association. The destinations/connectivity score was negatively associated with leisure-time walking. Negative perceptions of aesthetics, personal safety and social cohesion of the neighbourhood jointly mediated 24.1% of this negative association.
Conclusion
For women living in socio-economically disadvantaged neighbourhoods, environmental perceptions were important mediators of the relationship between the objective built environment and walking. To increase both transport-related and leisure-time walking, it is necessary to improve both objective walkability-related characteristics (street connectivity and proximity of destinations), and perceptions of personal safety, favourable aesthetics and neighbourhood social cohesion.
doi:10.1186/1479-5868-10-108
PMCID: PMC3848750  PMID: 24050686
Physical activity; Adults; GIS; Physical environment
4.  Gender-Specific Associations between Perceived Neighbourhood Walkability and Meeting Walking Recommendations When Walking for Transport and Recreation for Czech Inhabitants over 50 Years of Age 
Few studies have investigated the different effects that the built environment may have on the physical activity behaviours of men and women. Therefore, the aim of this study was to estimate the gender differences in meeting walking recommendations in relation to perceived neighbourhood walkability attributes within the active transportation and leisure-time domains for Czech inhabitants over 50 years of age. The sample included 1,417 men and 1,422 women who were randomly selected. The Abbreviated Neighbourhood Environment Walkability Scale (ANEWS) was used to obtain information about the perceived environment. The self-administered long version of the IPAQ was used to assess physical activity levels. When walking for transport, men living in neighbourhoods with high street connectivity (OR = 1.47, CI = 1.04–2.9) and higher traffic and crime safety (OR = 1.28, CI = 1.02–1.6) and women living in neighbourhoods with high proximity (OR = 1.36, CI = 1.04–1.77) and high neighbourhood aesthetics (OR = 1.36, CI = 1.04–1.76) were more likely to meet recommended levels of walking. No environmental attributes were found to significantly influence the accomplishment of walking recommendations by men or women when walking for leisure. The study results indicate the gender-specific associations between transportation-related walking and the environment factors. The consideration of those factors in the design of gender-specific walking interventions for Czech inhabitants may help the interventions to be more effective in promotion of physical activity.
doi:10.3390/ijerph110100527
PMCID: PMC3924458  PMID: 24380981
ANEWS; IPAQ; walking recommendations; neighbourhood environment
5.  Theory of planned behaviour variables and objective walking behaviour do not show seasonal variation in a randomised controlled trial 
BMC Public Health  2014;14:120.
Background
Longitudinal studies have shown that objectively measured walking behaviour is subject to seasonal variation, with people walking more in summer compared to winter. Seasonality therefore may have the potential to bias the results of randomised controlled trials if there are not adequate statistical or design controls. Despite this there are no studies that assess the impact of seasonality on walking behaviour in a randomised controlled trial, to quantify the extent of such bias. Further there have been no studies assessing how season impacts on the psychological predictors of walking behaviour to date. The aim of the present study was to assess seasonal differences in a) objective walking behaviour and b) Theory of Planned Behaviour (TPB) variables during a randomised controlled trial of an intervention to promote walking.
Methods
315 patients were recruited to a two-arm cluster randomised controlled trial of an intervention to promote walking in primary care. A series of repeated measures ANCOVAs were conducted to examine the effect of season on pedometer measures of walking behaviour and TPB measures, assessed immediately post-intervention and six months later. Hierarchical regression analyses were conducted to assess whether season moderated the prediction of intention and behaviour by TPB measures.
Results
There were no significant differences in time spent walking in spring/summer compared to autumn/winter. There was no significant seasonal variation in most TPB variables, although the belief that there will be good weather was significantly higher in spring/summer (F = 19.46, p < .001). Season did not significantly predict intention or objective walking behaviour, or moderate the effects of TPB variables on intention or behaviour.
Conclusion
Seasonality does not influence objectively measured walking behaviour or psychological variables during a randomised controlled trial. Consequently physical activity behaviour outcomes in trials will not be biased by the season in which they are measured. Previous studies may have overestimated the extent of seasonality effects by selecting the most extreme summer and winter months to assess PA. In addition, participants recruited to behaviour change interventions might have higher levels of motivation to change and are less affected by seasonal barriers.
Trial registration
Current Controlled Trials ISRCTN95932902
doi:10.1186/1471-2458-14-120
PMCID: PMC3924404  PMID: 24499405
Season; Walking; Randomised controlled trial; Theory of planned behaviour; Behaviour change
6.  The impact of the natural environment on the promotion of active living: An integrative systematic review 
BMC Public Health  2014;14(1):873.
Background
An understanding of how the living environment influences physical activity (PA) is of great importance for health promotion. Researchers have reported increased PA when there is a greater availability of nature within people’s living environment. However, little has been said about underlying motivational processes. The aim of this study was to review the existing literature on the relationship between the natural environment (NE) and PA, integrating it into a conceptual model that depicts the motivational process underlying this relationship.
Methods
Through a systematic literature search in line with PRISMA guidelines, peer-reviewed articles were sought using PubMed (search updated to October 2013) and scrutiny of reference lists. In addition, we contacted experts within our network. We reviewed papers in which the research question(s) concerned: 1) Effects of PA in NE on individuals’ feelings and beliefs; 2) Relationships between PA and availability of NEs; and 3) Motivational processes underlying visits to NEs in association with PA. Analysis and integration of the 90 selected studies were performed using the theory of planned behaviour (TPB).
Results
People’s experiences in using the NE can enhance attitudes toward PA and perceived behavioural control via positive psychological states and stress-relieving effects, which lead to firmer intentions to engage in PA. Individual and environmental barriers, as expressions of social support and actual behavioural control, impact the process via subjective norm and perceived behavioural control. Instrumental beliefs such as a desire to enjoy nature and the expected health benefits also influence the process via attitudes. Different patterns have been identified for neighbourhood-based PA and outdoor recreations that take place in a NE.
Conclusions
The availability of a NE and attractive views of nature within an individual’s living environment are important contributors to PA, yet attention should focus on personal characteristics and environmental barriers. Policy and infrastructural interventions should aim to guarantee access and maintenance of the NE, as well as information and programming of social activities. Social campaigns via media and health institutions should highlight how nature can be a source of motivation for maintaining a PA routine, reducing stress and achieving aesthetic and health goals.
doi:10.1186/1471-2458-14-873
PMCID: PMC4246567  PMID: 25150711
Natural environment; Health promotion; Physical activity; Attitude; Motivation; Exercise
7.  Inequitable walking conditions among older people: examining the interrelationship of neighbourhood socio-economic status and urban form using a comparative case study 
BMC Public Health  2010;10:677.
Background
Supportive neighbourhood walking conditions are particularly important for older people as they age and who, as a group, prefer walking as a form of physical activity. Urban form and socio-economic status (SES) can influence neighbourhood walking behaviour. The objectives of this study were: a) to examine how urban form and neighbourhood SES inter-relate to affect the experiences of older people who walk in their neighbourhoods; b) to examine differences among neighbourhood stakeholder key informant perspectives on socio-political processes that shape the walkability of neighbourhood environments.
Methods
An embedded comparative case study examined differences among four Ottawa neighbourhoods that were purposefully selected to provide contrasts on urban form (inner-urban versus suburban) and SES (higher versus lower). Qualitative data collected from 75 older walkers and 19 neighbourhood key informants, as well as quantitative indicators were compared on the two axes of urban form and SES among the four neighbourhoods.
Results and discussion
Examining the inter-relationship of neighbourhood SES and urban form characteristics on older people's walking experiences indicated that urban form differences were accentuated positively in higher SES neighbourhoods and negatively in lower SES neighbourhoods. Older people in lower SES neighbourhoods were more affected by traffic hazards and more reliant on public transit compared to their higher SES counterparts. In higher SES neighbourhoods the disadvantages of traffic in the inner-urban neighbourhood and lack of commercial destinations in the suburban neighbourhood were partially offset by other factors including neighbourhood aesthetics. Key informant descriptions of the socio-political process highlighted how lower SES neighbourhoods may face greater challenges in creating walkable places. These differences pertained to the size of neighbourhood associations, relationships with political representatives, accessing information and salient neighbourhood association issues. Findings provide evidence of inequitable walking environments.
Conclusion
Future research on walking must consider urban form-SES inter-relationships and further examine the equitable distribution of walking conditions as well as the socio-political processes driving these conditions. There is a need for municipal governments to monitor differences in walking conditions among higher and lower SES neighbourhoods, to be receptive to the needs of lower SES neighbourhood and to ensure that policy decisions are taken to address inequitable walking conditions.
doi:10.1186/1471-2458-10-677
PMCID: PMC2992515  PMID: 21054879
8.  Gender differences in perceived environmental correlates of physical activity 
Background
Limited research has been conducted on gender differences in perceived environmental correlates of physical activity (PA). The purpose of this study was to explore the potential role of gender in the link between perceived environment and PA.
Methods
Using a telephone-administered survey, data was collected on leisure time physical activity (LTPA), perceptions of the neighbourhood environment, and self-efficacy in a representative sample of 1209 adults from the province of Alberta, Canada. LTPA was regressed on ten measures of perceived neighbourhood environment and self-efficacy in a series of logistic regressions.
Results
Women were more likely than men to perceive their neighbourhood as unsafe to go for walks at night (χ2 = 67.46, p < 0.001) and to report seeing people being active in their neighbourhood (χ2 = 6.73, p < 0.01). Conversely, women were less likely to perceive easy access to places for PA (χ2 = 11.50, p < 0.01) and availability of places to buy things within easy walking distance from home (χ2 = 4.30, p < 0.05). Adjusting for age, education, income, and place of residence, access to places for PA (OR = 2.49) and interesting things to look at in the neighbourhood (OR = 1.94), were associated with higher levels of LTPA in men. Access to places for PA (OR = 2.63) and reporting seeing people being active (OR = 1.50) were associated with increased LTPA among women. After controlling for sociodemographic variables and self-efficacy, the presence of shops and places to buy things within easy walking distance from home (OR = 1.73), interesting things to look at in the neighbourhood (OR = 1.65), and access to places for PA (OR = 1.82) were associated with higher levels of LTPA in men. Among women, no significant relationships were observed between perceived environment and LTPA after adjusting for self-efficacy.
Conclusion
The results provide additional support for the use of models in which gender is treated as a potential moderator of the link between the perceived environment and PA. Further, the results suggest the possibility of differential interventions to increase PA based on factors associated with gender.
doi:10.1186/1479-5868-2-12
PMCID: PMC1253529  PMID: 16159404
9.  Access to commercial destinations within the neighbourhood and walking among Australian older adults 
Background
Physical activity, particularly walking, is greatly beneficial to health; yet a sizeable proportion of older adults are insufficiently active. The importance of built environment attributes for walking is known, but few studies of older adults have examined neighbourhood destinations and none have investigated access to specific, objectively-measured commercial destinations and walking.
Methods
We undertook a secondary analysis of data from the Western Australian state government’s health surveillance survey for those aged 65–84 years and living in the Perth metropolitan region from 2003–2009 (n = 2,918). Individual-level road network service areas were generated at 400 m and 800 m distances, and the presence or absence of six commercial destination types within the neighbourhood service areas identified (food retail, general retail, medical care services, financial services, general services, and social infrastructure). Adjusted logistic regression models examined access to and mix of commercial destination types within neighbourhoods for associations with self-reported walking behaviour.
Results
On average, the sample was aged 72.9 years (SD = 5.4), and was predominantly female (55.9%) and married (62.0%). Overall, 66.2% reported some weekly walking and 30.8% reported sufficient walking (≥150 min/week). Older adults with access to general services within 400 m (OR = 1.33, 95% CI = 1.07-1.66) and 800 m (OR = 1.20, 95% CI = 1.02-1.42), and social infrastructure within 800 m (OR = 1.19, 95% CI = 1.01-1.40) were more likely to engage in some weekly walking. Access to medical care services within 400 m (OR = 0.77, 95% CI = 0.63-0.93) and 800 m (OR = 0.83, 95% CI = 0.70-0.99) reduced the odds of sufficient walking. Access to food retail, general retail, financial services, and the mix of commercial destination types within the neighbourhood were all unrelated to walking.
Conclusions
The types of neighbourhood commercial destinations that encourage older adults to walk appear to differ slightly from those reported for adult samples. Destinations that facilitate more social interaction, for example eating at a restaurant or church involvement, or provide opportunities for some incidental social contact, for example visiting the pharmacy or hairdresser, were the strongest predictors for walking among seniors in this study. This underscores the importance of planning neighbourhoods with proximate access to social infrastructure, and highlights the need to create residential environments that support activity across the life course.
doi:10.1186/1479-5868-9-133
PMCID: PMC3538606  PMID: 23164357
Physical activity; Walking; Built environment; Neighbourhood; Destinations; Objective measurement; Older adults; Seniors
10.  Applying psychological theories to evidence-based clinical practice: Identifying factors predictive of managing upper respiratory tract infections without antibiotics 
Background
Psychological models can be used to understand and predict behaviour in a wide range of settings. However, they have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. The aim of this study was to explore the usefulness of a range of psychological theories to predict health professional behaviour relating to management of upper respiratory tract infections (URTIs) without antibiotics.
Methods
Psychological measures were collected by postal questionnaire survey from a random sample of general practitioners (GPs) in Scotland. The outcome measures were clinical behaviour (using antibiotic prescription rates as a proxy indicator), behavioural simulation (scenario-based decisions to managing URTI with or without antibiotics) and behavioural intention (general intention to managing URTI without antibiotics). Explanatory variables were the constructs within the following theories: Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model (SM), and knowledge (a non-theoretical construct). For each outcome measure, multiple regression analysis was used to examine the predictive value of each theoretical model individually. Following this 'theory level' analysis, a 'cross theory' analysis was conducted to investigate the combined predictive value of all significant individual constructs across theories.
Results
All theories were tested, but only significant results are presented. When predicting behaviour, at the theory level, OLT explained 6% of the variance and, in a cross theory analysis, OLT 'evidence of habitual behaviour' also explained 6%. When predicting behavioural simulation, at the theory level, the proportion of variance explained was: TPB, 31%; SCT, 26%; II, 6%; OLT, 24%. GPs who reported having already decided to change their management to try to avoid the use of antibiotics made significantly fewer scenario-based decisions to prescribe. In the cross theory analysis, perceived behavioural control (TPB), evidence of habitual behaviour (OLT), CS-SRM cause (chance/bad luck), and intention entered the equation, together explaining 36% of the variance. When predicting intention, at the theory level, the proportion of variance explained was: TPB, 30%; SCT, 29%; CS-SRM 27%; OLT, 43%. GPs who reported that they had already decided to change their management to try to avoid the use of antibiotics had a significantly higher intention to manage URTIs without prescribing antibiotics. In the cross theory analysis, OLT evidence of habitual behaviour, TPB attitudes, risk perception, CS-SRM control by doctor, TPB perceived behavioural control and CS-SRM control by treatment entered the equation, together explaining 49% of the variance in intention.
Conclusion
The study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.
doi:10.1186/1748-5908-2-26
PMCID: PMC2042498  PMID: 17683558
11.  Which factors explain variation in intention to disclose a diagnosis of dementia? A theory-based survey of mental health professionals 
Background
For people with dementia, patient-centred care should involve timely explanation of the diagnosis and its implications. However, this is not routine. Theoretical models of behaviour change offer a generalisable framework for understanding professional practice and identifying modifiable factors to target with an intervention. Theoretical models and empirical work indicate that behavioural intention represents a modifiable predictor of actual professional behaviour. We identified factors that predict the intentions of members of older people's mental health teams (MHTs) to perform key behaviours involved in the disclosure of dementia.
Design
Postal questionnaire survey.
Participants
Professionals from MHTs in the English National Health Service.
Methods
We selected three behaviours: Determining what patients already know or suspect about their diagnosis; using explicit terminology when talking to patients; and exploring what the diagnosis means to patients. The questionnaire was based upon the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), and exploratory team variables.
Main outcomes
Behavioural intentions.
Results
Out of 1,269 professionals working in 85 MHTs, 399 (31.4%) returned completed questionnaires. Overall, the TPB best explained behavioural intention. For determining what patients already know, the TPB variables of subjective norm, perceived behavioural control and attitude explained 29.4% of the variance in intention. For the use of explicit terminology, the same variables explained 53.7% of intention. For exploring what the diagnosis means to patients, subjective norm and perceived behavioural control explained 48.6% of intention.
Conclusion
These psychological models can explain up to half of the variation in intention to perform key disclosure behaviours. This provides an empirically-supported, theoretical basis for the design of interventions to improve disclosure practice by targeting relevant predictive factors.
Trial Registration
ISRCTN15871014.
doi:10.1186/1748-5908-2-31
PMCID: PMC2042985  PMID: 17894893
12.  Preparatory behaviours and condom use during receptive and insertive anal sex among male-to-female transgenders (Waria) in Jakarta, Indonesia 
Introduction
The male-to-female transgender (waria) is part of a key population at higher risk for HIV. This study aims to test whether psychosocial determinants as defined by the theory of planned behaviour (TPB) can explain behaviours related to condom use among waria. Three preparatory behaviours (getting, carrying, and offering a condom) and two condom use behaviours (during receptive and insertive anal sex) were assessed.
Methods
The study involved 209 waria, recruited from five districts in Jakarta and interviewed by using structured questionnaires. Specific measures were developed to study attitudes, subjective norms and perceived behavioural control (PBC) in order to predict intentions and behaviours.
Results
The explained variance between intentions with regard to three preparatory behaviours and two condom uses ranged between 30 and 57%, and the variance between the actual preparatory behaviours of three preparatory and two condom uses ranged between 21 and 42%. In our study, as with several previous studies of the TPB on HIV protection behaviours, the TPB variables differed in their predictive power. With regard to intention, attitude and PBC were consistently significant predictors; attitude was the strongest predictor of intention for all three preparatory behaviours, and PBC was the strongest predictor of intention for condom use, both during receptive and insertive anal sex. TPB variables were also significantly related to the second parameter of future behaviour: actual (past) behaviour. TPB variables were differentially related to the five behaviours. Attitude was predictive in three behaviours, PBC in three behaviours and subjective norms in two behaviours.
Conclusions
Our results have implications for the development of interventions to target preparatory behaviours and condom use behaviours. Five behaviours and three psychological factors as defined in the TPB are to be targeted.
doi:10.7448/IAS.17.1.19343
PMCID: PMC4273177  PMID: 25529498
transgender; theory of planned behaviour; preparatory behaviours; condom use; HIV/AIDS; Indonesia
13.  Evidence base for an intervention to maximise uptake of glaucoma testing: a theory-based cross-sectional survey 
BMJ Open  2012;2(2):e000710.
Objective
To identify factors associated with intention to attend a hypothetical eye health test and provide an evidence base for developing an intervention to maximise attendance, for use in studies evaluating glaucoma screening programmes.
Design
Theory-based cross-sectional survey, based on an extended Theory of Planned Behaviour (TPB) and the Common Sense Self-Regulation Model, conducted in June 2010.
Participants
General population including oversampling from low socioeconomic areas.
Setting
Aberdeenshire and the London Boroughs of Lewisham and Southwark, UK.
Results
From 867 questionnaires posted, 327 completed questionnaires were returned (38%). In hierarchical regression analysis, the three theoretical predictors in the TPB (Attitude, Subjective norm and Perceived Behavioural Control) accounted for two-thirds of the variance in intention scores (adjusted R2=0.65). All three predictors contributed significantly to prediction. Adding ‘Anticipated regret’ as a factor in the TPB model resulted in a significant increase in prediction (adjusted R2=0.74). In the Common Sense Self-Regulation Model, only illness representations about the personal consequences of glaucoma (How much do you think glaucoma would affect your life?) and illness concern (How concerned are you about getting glaucoma?) significantly predicted. The final model explained 75% of the variance in intention scores, with ethnicity significantly contributing to prediction.
Conclusions
In this population-based sample (including over-representation of lower socioeconomic groupings), the main predictors of intention to attend a hypothetical eye health test were Attitude, Perceived control over attendance, Anticipated regret if did not attend and black ethnicity. This evidence informs the design of a behavioural intervention with intervention components targeting low intentions and predicted to influence health-related behaviours.
Article summary
Article focus
The current UK practice of opportunistic case finding during routine sight tests misses a majority of those with glaucoma. Early detection and treatment of glaucoma reduces the risk of blindness.
The feasibility and cost-effectiveness of screening programmes is largely determined by uptake by the target population.
This study identified empirical evidence, based on models of behaviour change, to inform the design of an intervention to maximise uptake.
Key messages
Intention to attend an eye health check to detect glaucoma is associated with positive Attitude, Perceived control over screening attendance, Anticipated regret if test is not attended, perceived consequences of glaucoma and black ethnicity. These factors can be targeted in an intervention to maximise uptake.
Strengths and limitations of this study
This study is the largest of its kind and uses a robust methodology based on plausible models of change to identify potential barriers to attendance for eye care.
The response rate was 38%, which is higher than generally achieved in similar population-based surveys.
There was evidence to suggest that this sample was representative of the target population (general population with over-representation of black ethnicity or of low socioeconomic status).
doi:10.1136/bmjopen-2011-000710
PMCID: PMC3293143  PMID: 22382121
14.  The associations between objectively-determined and self-reported urban form characteristics and neighborhood-based walking in adults 
Background
Self-reported and objectively-determined neighborhood built characteristics are associated with physical activity, yet little is known about their combined influence on walking. This study: 1) compared self-reported measures of the neighborhood built environment between objectively-determined low, medium, and high walkable neighborhoods; 2) estimated the relative associations between self-reported and objectively-determined neighborhood characteristics and walking and; 3) examined the extent to which the objectively-determined built environment moderates the association between self-reported measures of the neighborhood built environment and walking.
Methods
A random cross-section of 1875 Canadian adults completed a telephone-interview and postal questionnaire capturing neighborhood walkability, neighborhood-based walking, socio-demographic characteristics, walking attitudes, and residential self-selection. Walkability of each respondent’s neighborhood was objectively-determined (low [LW], medium [MW], and high walkable [HW]). Covariate-adjusted regression models estimated the associations between weekly participation and duration in transportation and recreational walking and self-reported and objectively-determined walkability.
Results
Compared with objectively-determined LW neighborhoods, respondents in HW neighborhoods positively perceived access to services, street connectivity, pedestrian infrastructure, and utilitarian and recreation destination mix, but negatively perceived motor vehicle traffic and crime related safety. Compared with residents of objectively-determined LW neighborhoods, residents of HW neighborhoods were more likely (p < .05) to participate in (odds ratio [OR] = 3.06), and spend more time, per week (193 min/wk) transportation walking. Perceived access to services, street connectivity, motor vehicle safety, and mix of recreational destinations were also significantly associated with transportation walking. With regard to interactions, HW x utilitarian destination mix was positively associated with participation, HW x physical barriers and MW x pedestrian infrastructure were positively associated with minutes, and HW x safety from crime was negatively associated with minutes, of transportation walking. Neither neighborhood type nor its interactions with perceived measures of walkability were associated with recreational walking, although perceived aesthetics was associated with participation (OR = 1.18, p < .05).
Conclusions
Objectively-determined and self-reported built characteristics are associated with neighborhood-based transportation walking. The objectively-determined built environment might moderate associations between perceptions of walkability and neighborhood-based transportation walking. Interventions that target perceptions in addition to modifications to the neighborhood built environment could result in increases in physical activity among adults.
doi:10.1186/1479-5868-11-71
PMCID: PMC4049386  PMID: 24893719
15.  Development and validation of a generic questionnaire for the implementation of complex medical interventions 
GMS German Medical Science  2014;12:Doc08.
Introduction: The implementation of complex medical interventions in daily practice is often fraught with difficulties. According to the iterative phase model proposed by the British Medical Research Council (MRC), the development, implementation and evaluation of complex interventions should be theory-driven. A conceptual model that seems to be a promising framework is the Theory of planned behaviour (TPB). In our study we aimed to develop and validate a generic and multifaceted questionnaire based on the TPB to detect physicians’ willingness to implement complex medical interventions and the factors influencing this willingness.
Methods: The questionnaire was developed according to the literature and was informed by previous qualitative research of our department. It was validated on the example of an electronic library of decision aids, arriba-lib. The sample consisted of 181 General Practitioners (GPs) who received a training regarding arriba-lib and subsequently filled in the questionnaire, assessing the TPB variables attitude, subjective norm, perceived behaviour control and intention. Follow-up assessments were conducted after two (assessing retest reliability) and eight weeks (assessing target behaviour). We performed a confirmatory factor analysis investigating the factorial structure of our questionnaire according to the TPB. Beside the calculation of the questionnaire’s psychometric properties we conducted a structural equation model and an ordinal regression to predict actual behaviour regarding the installation and application of arriba-lib.
Results: The postulated three factorial model (attitude, subjective norm, perceived behaviour control) of our questionnaire based on the TPB was rejected. A two factorial model with a combined factor subjective norm/perceived behaviour control was accepted. The explained variance in the ordinal regression was low (Nagelkerke’s R2=.12). Neither attitude nor intention were able to predict the use or non-use of arriba-lib (attitude: p=.68, intention: p=.44). For the combined factor subjective norm/perceived behaviour control a significant, but small effect (p=.03) was shown.
Conclusions: The TPB is not an adequate theoretical framework to guide the development of a generic questionnaire in the context of the implementation of complex interventions. To enable the successful implementation of complex medical interventions evaluators have to go through the whole development and evaluation process according to the MRC-model, without short cuts. Further, it has to be discussed if a generic instrument can be valid and useful. Regarding the TPB a publication bias regarding the theory’s applicability might have to be considered.
doi:10.3205/000193
PMCID: PMC3972438  PMID: 24696674
implementation; questionnaires; primary health care; theory of planned behaviour
16.  Correlates of physical activity in a population-based sample of kidney cancer survivors: an application of the theory of planned behavior 
Background
Over half of kidney cancer survivors (KCS) are completely inactive and only a quarter are meeting physical activity (PA) guidelines. This highlights the need to identify and understand the determinants of PA in this understudied population. The purpose of this study is to determine the social cognitive correlates of PA intention and behavior in KCS using the Theory of Planned Behavior (TPB).
Methods
All 1,985 KCS diagnosed between 1996 and 2010 in Alberta, Canada were mailed a self-report survey that consisted of the Godin Leisure Time Exercise Questionnaire and standard TPB items for intention, planning, perceived behavioral control (PBC), affective and instrumental attitudes, and descriptive and injunctive norms. Standard demographic and medical variables were also collected.
Results
Completed surveys were received from 703 of 1,654 (43%) eligible KCS. The TPB was tested using structural equation modelling and demonstrated an adequate-to-good fit to the data [χ² = 256.88, p < .001; TLI = 0.97; CFI = 0.98; RMSEA = 0.06, 90% CI = 0.05-0.06].
There were significant pathways to PA from PBC (ß = 0.18, p = 0.02), planning (ß = 0.22, p < 0.01), and intention (ß = 0.31, p < 0.01); and to planning from intention (ß = 0.81, p < 0.01). In addition, there were significant model pathways to intention from instrumental attitude (ß = 0.28, p = 0.03), descriptive norm (ß = 0.09, p = 0.01), and PBC (ß = 0.52, p < 0.01). Overall, the TPB accounted for 69%, 63%, and 42% of the variance in intention, planning and PA, respectively.
Conclusion
The TPB appears to be a useful model for explaining PA in KCS. All TPB constructs except injunctive norm and affective attitude were useful for explaining intention with PBC emerging as the largest correlate. Developing PA interventions based on the TPB may be effective in promoting PA in KCS and may lead to important improvements in health.
doi:10.1186/1479-5868-9-96
PMCID: PMC3489870  PMID: 22866956
Exercise; Motivation; Social cognitive models; Correlates
17.  How important is the land use mix measure in understanding walking behaviour? Results from the RESIDE study 
Background
Understanding the relationship between urban design and physical activity is a high priority. Different representations of land use diversity may impact the association between neighbourhood design and specific walking behaviours. This study examined different entropy based computations of land use mix (LUM) used in the development of walkability indices (WIs) and their association with walking behaviour.
Methods
Participants in the RESIDential Environments project (RESIDE) self-reported mins/week of recreational, transport and total walking using the Neighbourhood Physical Activity Questionnaire (n = 1798). Land use categories were incrementally added to test five different LUM models to identify the strongest associations with recreational, transport and total walking. Logistic regression was used to analyse associations between WIs and walking behaviour using three cut points: any (> 0 mins), ≥ 60 mins and ≥ 150 mins walking/week.
Results
Participants in high (vs. low) walkable neighbourhoods reported up to almost twice the amount of walking, irrespective of the LUM measure used. However, different computations of LUM were found to be relevant for different types and amounts of walking (i.e., > 0, ≥ 60 or ≥ 150 mins/week). Transport walking (≥ 60 mins/week) had the strongest and most significant association (OR = 2.24; 95% CI:1.58-3.18) with the WI when the LUM included 'residential', 'retail', 'office', 'health, welfare and community', and 'entertainment, culture and recreation'. However, any (> 0 mins/week) recreational walking was more strongly associated with the WI (OR = 1.36; 95% CI:1.04-1.78) when land use categories included 'public open space', 'sporting infrastructure' and 'primary and rural' land uses. The observed associations were generally stronger for ≥ 60 mins/week compared with > 0 mins/week of transport walking and total walking but this relationship was not seen for recreational walking.
Conclusions
Varying the combination of land uses in the LUM calculation of WIs affects the strength of relationships with different types (and amounts) of walking. Future research should examine the relationship between walkability and specific types and different amounts of walking. Our results provide an important first step towards developing a context-specific WI that is associated with recreational walking. Inherent problems with administrative data and the use of entropy formulas for the calculation of LUM highlight the need to explore alternative or complimentary measures of the environment.
doi:10.1186/1479-5868-8-55
PMCID: PMC3142478  PMID: 21631958
Physical activity; Environment; Neighborhood, Walkability; Land use; Land use mix; Walking; Transport; Recreation; Entropy models; Methodology; Planning
18.  Psychosocial determinants of fruit and vegetable intake in adult population: a systematic review 
Background
Accumulating evidence suggests that fruit and vegetable intake (FVI) plays a protective role against major diseases. Despite this protective role and the obesity pandemic context, populations in Western countries usually eat far less than five servings of fruits and vegetables per day. In order to increase the efficiency of interventions, they should be tailored to the most important determinants or mediators of FVI. The objective was to systematically review social cognitive theory-based studies of FVI and to identify its main psychosocial determinants.
Methods
Published papers were systematically sought using Current Contents (2007-2009) and Medline, Embase, PsycINFO, Proquest and Thesis, as well as Cinhal (1980-2009). Additional studies were identified by a manual search in the bibliographies. Search terms included fruit, vegetable, behaviour, intention, as well as names of specific theories. Only studies predicting FVI or intention to eat fruits and vegetables in the general population and using a social cognitive theory were included. Independent extraction of information was carried out by two persons using predefined data fields, including study quality criteria.
Results
A total of 23 studies were identified and included, 15 studying only the determinants of FVI, seven studying the determinants of FVI and intention and one studying only the determinants of intention. All pooled analyses were based on random-effects models. The random-effect R2 observed for the prediction of FVI was 0.23 and it was 0.34 for the prediction of intention. Multicomponent theoretical frameworks and the theory of planned behaviour (TPB) were most often used. A number of methodological moderators influenced the efficacy of prediction of FVI. The most consistent variables predicting behaviour were habit, motivation and goals, beliefs about capabilities, knowledge and taste; those explaining intention were beliefs about capabilities, beliefs about consequences and perceived social influences.
Conclusions
Our results suggest that the TPB and social cognitive theory (SCT) are the preferable social cognitive theories to predict behaviour and TPB to explain intention. Efficacy of prediction was nonetheless negatively affected by methodological factors such as the study design and the quality of psychosocial and behavioural measures.
doi:10.1186/1479-5868-7-12
PMCID: PMC2831029  PMID: 20181070
19.  Predicting active school travel: The role of planned behavior and habit strength 
Background
Despite strong support for predictive validity of the theory of planned behavior (TPB) substantial variance in both intention and behavior is unaccounted for by the model’s predictors. The present study tested the extent to which habit strength augments the predictive validity of the TPB in relation to a currently under-researched behavior that has important health implications, namely children’s active school travel.
Method
Participants (N = 126 children aged 8–9 years; 59 % males) were sampled from five elementary schools in the west of Scotland and completed questionnaire measures of all TPB constructs in relation to walking to school and both walking and car/bus use habit. Over the subsequent week, commuting steps on school journeys were measured objectively using an accelerometer. Hierarchical multiple regressions were used to test the predictive utility of the TPB and habit strength in relation to both intention and subsequent behavior.
Results
The TPB accounted for 41 % and 10 % of the variance in intention and objectively measured behavior, respectively. Together, walking habit and car/bus habit significantly increased the proportion of explained variance in both intention and behavior by 6 %. Perceived behavioral control and both walking and car/bus habit independently predicted intention. Intention and car/bus habit independently predicted behavior.
Conclusions
The TPB significantly predicts children’s active school travel. However, habit strength augments the predictive validity of the model. The results indicate that school travel is controlled by both intentional and habitual processes. In practice, interventions could usefully decrease the habitual use of motorized transport for travel to school and increase children’s intention to walk (via increases in perceived behavioral control and walking habit, and decreases in car/bus habit). Further research is needed to identify effective strategies for changing these antecedents of children’s active school travel.
doi:10.1186/1479-5868-9-65
PMCID: PMC3419676  PMID: 22647194
Theory of planned behavior; Habit; Active school travel; Walking; Children
20.  Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001459.
Using data from the Indian Migration Study, Christopher Millett and colleagues examine the associations between active travel to work and overweight, hypertension, and diabetes.
Please see later in the article for the Editors' Summary
Background
Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes.
Methods and Findings
Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58–0.88) or bicycling to work (ARR 0.66; 95% CI 0.55–0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36–0.71) or diabetes (ARR 0.65; 95% CI 0.44–0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found.
Conclusions
Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs) and obesity (excessive body fat) are major threats to global health. Every year, more than 36 million people (including 29 million in LMICs) die from NCDs—nearly two-thirds of the world's annual deaths. Cardiovascular diseases (conditions that affect the heart and the circulation), diabetes, cancer, and respiratory diseases are responsible for most NCD-related deaths. Obesity is a risk factor for all these NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. In 2008, 35% of adults were overweight and 11% were obese. One reason for the growing burden of both obesity and NCDs is increasing physical inactivity. Regular physical activity helps to maintain a healthy body weight and to prevent or delay the onset of NCDs. For an adult, 30 minutes of moderate physical activity—walking briskly or cycling, for example—five times a week is sufficient to promote and maintain health. But the daily lives of people in both developed and developing countries are becoming increasingly sedentary and, nowadays, at least 60% of the world's population does not do even this modest amount of exercise.
Why Was This Study Done?
Strategies to increase physical activity levels often promote active travel (walking, cycling, and using public transport). The positive impact of active travel on physical activity levels and cardiovascular health is well established in high-income countries, but little is known about the patterns of active travel or the health benefits associated with active travel in poorer countries. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers examine the mode and duration of travel to work in rural and urban India and associations between active travel and overweight/obesity, hypertension (high blood pressure, a risk factor for cardiovascular disease), and diabetes. In India, a lower middle-income country, the prevalence of overweight and NCDs is projected to increase rapidly over the next two decades. Moreover, rapid unplanned urbanization and a large increase in registered motor vehicles has resulted in inadequate development of the public transport infrastructure and hazardous conditions for walking and cycling in most Indian towns and cities.
What Did the Researchers Do and Find?
For their study, researchers analyzed physical activity and health data collected from participants in the Indian Migration Study, which examined the association between migration from rural to urban areas and obesity and diabetes risk. People living in rural areas were more likely to cycle to work than people living in towns and cities (68.3% versus 15.9%). Among people who travelled to work by private transport, public transport, walking, and cycling, the prevalence of overweight or obesity was 50.0%, 37.6%, 24.9%, and 24.2%, respectively. Similar patterns were seen for the prevalence of hypertension and diabetes. After adjustment for factors that affect the risk of obesity, hypertension, and diabetes (for example, daily fat intake and leisure time physical activity), people walking or cycling to work were less likely to be overweight or obese than those travelling by public transport, and those cycling to walk were less likely to have hypertension or diabetes. Finally, people with long cycle rides to work had a lower risk of being overweight or having hypertension or diabetes than people with short cycle rides.
What Do These Findings Mean?
These findings suggest that, as in high-income settings, walking and cycling to work are associated with a reduced risk of cardiovascular disease in India. Because this was a cross-sectional study, these findings do not prove that active travel reduces the risk of cardiovascular disease—people who cycle to work may share other unknown characteristics that are actually responsible for their reduced risk of cardiovascular disease. Moreover, this study did not consider non-cardiovascular outcomes associated with active travel that might affect health such as increased exposure to air pollution. Nevertheless, these findings suggest that programs designed to maintain healthy weight and prevent NCDs in India should endeavor to increase active travel in urban areas and to halt declines in rural areas by, for example, increasing investment in public transport and improving the safety and convenience of walking and cycling routes in urban areas.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001459.
This study is further discussed in a PLOS Medicine Perspective by Kavi Bhalla
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, on overweight and obesity and on non-communicable diseases around the world; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health, about obesity, and about non-communicable diseases (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce NCD-related illnesses and death through implementation of the 20082013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); Face to face with chronic diseases is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association provides information on many important risk factors for non-communicable diseases and provides tips for becoming more active
Information about the Indian Migration Study is available
doi:10.1371/journal.pmed.1001459
PMCID: PMC3679004  PMID: 23776412
21.  Applying the theory of planned behaviour to explain HIV testing in antenatal settings in Addis Ababa - a cohort study 
Background
To facilitate access to the prevention of mother-to-child HIV transmission (PMTCT) services, HIV counselling and testing are offered routinely in antenatal care settings. Focusing a cohort of pregnant women attending public and private antenatal care facilities, this study applied an extended version of the Theory of Planned Behaviour (TPB) to explain intended- and actual HIV testing.
Methods
A sequential exploratory mixed methods study was conducted in Addis Ababa in 2009. The study involved first time antenatal attendees from public- and private health care facilities. Three Focus Group Discussions were conducted to inform the TPB questionnaire. A total of 3033 women completed the baseline TPB interviews, including attitudes, subjective norms, perceived behavioural control and intention with respect to HIV testing, whereas 2928 completed actual HIV testing at follow up. Data were analysed using descriptive statistics, Chi-square tests, Fisher's Exact tests, Internal consistency reliability, Pearson's correlation, Linear regression, Logistic regression and using Epidemiological indices. P-values < 0.05 was considered significant and 95% Confidence Interval (CI) was used for the odds ratio.
Results
The TPB explained 9.2% and 16.4% of the variance in intention among public- and private health facility attendees. Intention and perceived barriers explained 2.4% and external variables explained 7% of the total variance in HIV testing. Positive and negative predictive values of intention were 96% and 6% respectively. Across both groups, subjective norm explained a substantial amount of variance in intention, followed by attitudes. Women intended to test for HIV if they perceived social support and anticipated positive consequences following test performance. Type of counselling did not modify the link between intended and actual HIV testing.
Conclusion
The TPB explained substantial amount of variance in intention to test but was less sufficient in explaining actual HIV testing. This low explanatory power of TPB was mainly due to the large proportion of low intenders that ended up being tested contrary to their intention before entering the antenatal clinic. PMTCT programs should strengthen women's intention through social approval and information that testing will provide positive consequences for them. However, women's rights to opt-out should be emphasized in any attempt to improve the PMTCT programs.
doi:10.1186/1472-6963-11-196
PMCID: PMC3169463  PMID: 21851613
22.  Environmental perceptions and objective walking trail audits inform a community-based participatory research walking intervention 
Background
Given the documented physical activity disparities that exist among low-income minority communities and the increased focused on socio-ecological approaches to address physical inactivity, efforts aimed at understanding the built environment to support physical activity are needed. This community-based participatory research (CBPR) project investigates walking trails perceptions in a high minority southern community and objectively examines walking trails. The primary aim is to explore if perceived and objective audit variables predict meeting recommendations for walking and physical activity, MET/minutes/week of physical activity, and frequency of trail use.
Methods
A proportional sampling plan was used to survey community residents in this cross-sectional study. Previously validated instruments were pilot tested and appropriately adapted and included the short version of the validated International Physical Activity Questionnaire, trail use, and perceptions of walking trails. Walking trails were assessed using the valid and reliable Path Environmental Audit Tool which assesses four content areas including: design features, amenities, maintenance, and pedestrian safety from traffic. Analyses included Chi-square, one-way ANOVA's, multiple linear regression, and multiple logistic models.
Results
Numerous (n = 21) high quality walking trails were available. Across trails, there were very few indicators of incivilities and safety features rated relatively high. Among the 372 respondents, trail use significantly predicted meeting recommendations for walking and physical activity, and MET/minutes/week. While controlling for other variables, significant predictors of trail use included proximity to trails, as well as perceptions of walking trail safety, trail amenities, and neighborhood pedestrian safety. Furthermore, while controlling for education, gender, and income; for every one time per week increase in using walking trails, the odds for meeting walking recommendations increased 1.27 times, and the odds for meeting PA recommendation increased 3.54 times. Perceived and objective audit variables did not predict meeting physical activity recommendations.
Conclusions
To improve physical activity levels, intervention efforts are needed to maximize the use of existing trails, as well as improve residents' perceptions related to incivilities, safety, conditions of trail, and amenities of the walking trails. This study provides important insights for informing development of the CBPR walking intervention and informing local recreational and environmental policies in this southern community.
doi:10.1186/1479-5868-9-6
PMCID: PMC3283478  PMID: 22289653
23.  Perceived community environment and physical activity involvement in a northern-rural Aboriginal community 
Background
Type 2 diabetes disproportionately affects Aboriginal peoples in Canada. Ample evidence shows that regular physical activity (PA) plays an important role in the prevention and treatment of type 2 diabetes. Evidence is beginning to emerge linking PA to the physical environment but little is known about the relationship between remote rural environments and PA involvement in Aboriginal peoples. This study's purpose was to investigate the relationship between perceptions of the environment and PA and walking patterns in Aboriginal adults in order to inform the planning and implementation of community-relevant PA interventions.
Methods
Two hundred and sixty three residents (133 women, mean age = 35.6 years, SD = 12.3 and 130 men, mean age = 37.2 years, SD = 13.1) from Moose Factory, Ontario were asked about environmental factors related to walking and PA involvement. Survey items were drawn from standardized, validated questionnaires. Descriptive statistics (means, standard deviations, percentages) were calculated. A series of hierarchical multiple regressions were performed to determine associations between walking and overall PA with perceived environmental variables.
Results
Hierarchical multiple regression to predict walking revealed significant associations between walking and perceived safety and aesthetics. Owning home exercise equipment predicted strenuous PA. Different aspects of the physical environment appear to influence different types of physical activities. The significant amount of variance in behaviour accounted for by perceived environmental variables (5.3% walking) included safety, aesthetics, convenience, owning home exercise equipment and comfortable shoes for walking.
Conclusion
Results suggest that a supportive physical environment is important for PA involvement and that walking and activities of different intensity appear to be mediated by different perceived environmental variables. Implications for PA promotion in rural environments where Aboriginal people face many unique environmental features (e.g., bears, mosquitoes, extreme cold) are discussed.
doi:10.1186/1479-5868-4-63
PMCID: PMC2217526  PMID: 18053217
24.  The CHOICE Study: A “taste-test” of utilitarian vs. leisure walking among older adults 
Health Psychology  2011;31(1):126-129.
BACKGROUND
Utilitarian walking (e.g., walking for transport) and leisure walking (e.g., walking for health/recreation) are encouraged to promote health, yet few studies have explored specific preferences for these two forms of physical activity or factors that impact such preferences.
OBJECTIVE
A quasi-experimental crossover design was used to evaluate how training underactive midlife and older adults in each type of walking impacted total steps taken and how it was linked to their subsequent choice of walking types.
METHODS
Participants (N=16) were midlife and older adults (M age=64±8 yrs) who were mostly women (81%) and white (75%). To control for order effects, participants were randomized to instruction in either utilitarian or leisure walking for 2 weeks and then the other type for 2 weeks. Participants then entered a 2-week “free choice” phase in which they chose any mixture of the walking types. Outcome variables included walking via OMRON pedometer and the ratio of utilitarian vs. leisure walking during the free-choice phase. Participants completed surveys about their neighborhood (NEWS) and daily travel to multiple locations.
RESULTS
Instruction in leisure -only, utilitarian-only, and a freely chosen mixture of the two each resulted in significant increases in steps taken relative to baseline (ps<0.05). Having to go to multiple locations daily and traveling greater distances to locations were associated with engagement in more utilitarian walking. In contrast, good walking paths, neighborhood aesthetics, easy access to exercise facilities, and perceiving easier access to neighborhood services were associated with more leisure walking.
DISCUSSION
Results from this pilot study suggest that midlife and older adults may most easily meet guidelines through either leisure only or a mixture of leisure and utilitarian walking, and tailored suggestions based on the person’s neighborhood may be useful.
doi:10.1037/a0025567
PMCID: PMC3254726  PMID: 21928901
Physical Activity; Preferences; Perceived Built Environment; Walking Intervention; Utilitarian Physical Activity
25.  Factors influencing the surgery intentions and choices of women with early breast cancer: the predictive utility of an extended theory of planned behaviour 
Background
Women diagnosed with early breast cancer (stage I or II) can be offered the choice between mastectomy or breast conservation surgery with radiotherapy due to equivalence in survival rates. A wide variation in the surgical management of breast cancer and a lack of theoretically guided research on this issue highlight the need for further research into the factors influencing women’s choices. An extended Theory of Planned Behaviour (TPB) could provide a basis to understand and predict women’s surgery choices. The aims of this study were to understand and predict the surgery intentions and choices of women newly diagnosed with early breast cancer, examining the predictive utility of an extended TPB.
Methods
Sixty-two women recruited from three UK breast clinics participated in the study; 48 women, newly diagnosed with early breast cancer, completed online questionnaires both before their surgery and after accessing an online decision support intervention (BresDex). Questionnaires assessed views about breast cancer and the available treatment options using items designed to measure constructs of an extended TPB (i.e., attitudes, subjective norms, perceived behavioural control, and anticipated regret), and women’s intentions to choose mastectomy or BCS. Objective data were collected on women’s choice of surgery via the clinical breast teams. Multiple and logistic regression analyses examined predictors of surgery intentions and subsequent choice of surgery.
Results
The extended TPB accounted for 69.9% of the variance in intentions (p <.001); attitudes and subjective norms were significant predictors. Including additional variables revealed anticipated regret to be a more important predictor than subjective norms. Surgery intentions significantly predicted surgery choices (p <.01).
Conclusions
These findings demonstrate the utility of an extended TPB in predicting and understanding women’s surgery intentions and choices for early breast cancer. Understanding these factors should help to identify key components of interventions to support women while considering their surgery options.
doi:10.1186/1472-6947-13-92
PMCID: PMC3849725  PMID: 23962230
Breast cancer; Mastectomy; Breast conserving surgery; Decision making; Theory of planned behaviour

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