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Although research has examined the determinants of physical activity, this research has focused primarily on men and few efforts have been made to explain the interrelationships between commonly used predictors of physical activity. Descriptive data and regression analyses were conducted with 193 female students, faculty, staff and community members of a southwestern Virginia university town. Variables that were entered into the regression included age, body mass index, exercise knowledge, self-esteem, depression level,self-efficacy, stage of change, exercise goals, outcome expectations and outcome values. Because of the high correlations between some of these variables, a principal components factor analysis was conducted. The factor analysis indicated significant overlap between items on the stage of change and knowledge measures with self-efficacy. Some knowledge items were dropped to create a more succinct measure and self-efficacy and stage of change were combined into one measure. Results indicated that the variables listed above significantly predicted physical activity level as measured by kilocalories expended per day on the Aerobic Center Physical Activity Questionnaire (Kohl, Blair, Paffenbarger, Macera, & Kronenfeld, 1988) for this sample of women (R2 = .346, p < .001), but that self-efficacy was the only significant single predictor. Additional regressions were conducted to examine the indirect relationships between these variables and physical activity level. The constructs of selfesteem, depression, and knowledge seemed to have indirect, rather than direct, effects on physical activity that were mediated by self-efficacy. Goals and outcome expectations also did not seem to directly predict physical activity level but were related to some of of the other variables. Implications of the interrelationships between these variables for planning physical activity interventions include enhancing self-efficacy for exercising while at the same time assessing for depressive symptomatology and using incentives and motivators that are age appropriate. / Master of Science

Regular physical activity is associated with improved physiological and psychological wellbeing, by reducing the risk of chronic illnesses such as cardiovascular disease, cancer, obesity, diabetes, osteoporosis and depression. There is a common perception that physical activity levels in the population are declining, and one of the biggest changes affecting this is occupational based activity. Since adults spend on average over 50% of their waking hours at work, work sites have the potential to be an important setting for health promotion initiatives. Cognitions and behaviours are key causal factors behind many of today s most widespread health problems and illnesses. The stage of change model has been highlighted as having intuitive appeal because it considers the dynamic nature of attitudes and behaviour change. This thesis is concerned with the application of the stage of change model to an occupational health intervention promoting physical activity. Several research studies were undertaken to explore the experiences of employees with workplace health initiatives and investigate the strategies and practices used by occupational health to promote healthy behaviours. These research studies highlighted the barriers and facilitators to successful health interventions and contributed towards the design, development and implementation of an activity promotion intervention. Additional research was also conducted to develop information materials based on the stage of change model. The stage approach was simplified and intervention materials were classified based on whether employees were thinking about making a change or not thinking about making a change to their activity levels. In order to test the materials, a twelve month intervention was implemented in ten work sites across the UK that were allocated to one of three groups. Two groups received information materials and one group received no information during the intervention period (control group). The difference between the two groups who received information was that one group received standard activity promotion information (standard group) and the second group received tailored information based on their stage of change construct (staged group). Participants in the staged intervention group demonstrated significant decreases in body mass index, fat percentage, waist circumference, blood pressure and resting heart rate following the twelve month intervention. In contrast, reductions were identified for the standard intervention group for waist circumference and diastolic blood pressure. Finally, there were no long-term significant improvements identified for the control group. However, group comparisons revealed there were no significant differences between the intervention conditions. The intervention also recorded self-reported psychological outcomes, which demonstrated variations throughout the intervention period for all groups. The potential reasons for these inconsistent outcomes are discussed. A process evaluation following the intervention demonstrated employees valued the health screenings and identified issues relating to knowledge, behaviour change and health implications that were important outputs of the intervention. Based on these findings, the research concludes there is scope to make physical activity interventions in the workplace more effective by applying the stage of change approach. Using the process of simplifying the stages and focusing on whether employees want to change their behaviours or not allows occupational health to deliver information that could be more meaningful and have a significant impact on behaviour change. By understanding employees readiness to change their activity behaviours and targeting information based on their beliefs, attitudes and intentions to change may produce significant improvements in health outcome measures compared to standard information. The results also suggest there is potential for this type of tailored intervention to be extended to other occupational health issues.

Thesis advisor: Lauren Saenz / Methods for classifying and treating an outcome variable are critical to explore in health research and evaluation, given the potential impact the choice of method may have on the findings and subsequent recommendations (Merbitz, Morris, & Grip, 1989). Further, given the prominent application of the Transtheoretical Model in health research, the stages of change construct continues to be a critical outcome measure concept used in various applied evaluation studies (Bridle et al., 2005; Nigg, 2002; Prochaska, DiClemente, & Norcross, 1992). The purpose of this dissertation study was to determine if findings differ depending on the approach to categorizing and analyzing a stage of change outcome variable, and if so, to highlight how these may affect policy and programmatic decision-making. Using data from a study on evidence-based program adoption decisions, this dissertation examined five approaches to treating and analyzing a single Decision to Adopt outcome variable. These different approaches were compared from both a methodological and pragmatic perspective. Hypothetical stakeholder illustrations were used to highlight differences in decision-making priorities and use of findings based on role, background, and organizational priorities. In comparing methods for classifying and treating the stage of change outcome variable, findings revealed notable differences in effect size, estimation, implication of major findings, and limitations of approach. The hypothetical stakeholder illustrations stressed the significance of personal values and preferences as key influential factors in decision-making and use of evaluation results. This dissertation highlighted how decisions are inextricably linked to the logic model and underlying theory, particularly as it relates to defining evaluation questions, determining how to categorize constructs, and assigning value to codes. Further, it reinforces the significance of contextual considerations in evaluation and how these cannot be ignored in the decision-making process (e.g., budgetary limitations, practical constraints, political factors). The proposed directions for future research seek to continue advancing this understanding of the impact of methodological decisions in different contexts and help improve the utility of evaluations more broadly. / Thesis (PhD) — Boston College, 2014. / Submitted to: Boston College. Lynch School of Education. / Discipline: Educational Research, Measurement and Evaluation.

Smoking remains a leading cause of premature, preventable death in South Africa killing 44 000 South Africans each year. Through the introduction of comprehensive tobacco control policies, the South African government has tried to reduce the death toll and a significant reduction in tobacco use has been recorded since its peak in the 1990’s. Smoking among women, however have remained unchanged, which calls for actions. Pregnant mothers are specifically vulnerable as their smoking detrimentally affects their own health as well as the health of their babies. This thesis gives an account of the role the antenatal care system could play in reducing the burden caused by cigarette smoking.   The overall aim was to contribute to an understanding of how a person-centred approach to smoking cessation among disadvantaged pregnant women with high smoking rates may influence smoking behaviour. The specific objectives were to confirm the high smoking rates of the target population, assess their readiness to quit, explore existing barriers and promoting factors towards smoking cessation efforts within the public antenatal health care system, and to qualitatively assess the attitudes and perceptions of disadvantaged pregnant women regarding a personcentred smoking cessation intervention.   The high smoking rates of the target population was confirmed based on a cross-sectional study at antenatal clinics in four main cities of South Africa. It focused on the prevalence of smoking during pregnancy and used the stages of change theory to identify their readiness to quit. Additional questions concerned pregnancy related disease experiences, socio-economic determinants of continued smoking as well as attitudes towards the existing clinic services and its possible role in smoking cessation. A qualitative interview study analyzed more in-depth barriers for two-way communication between pregnant mothers and midwives. Both these studies informed the design and development of a person-centred smoking cessation intervention delivered at four public sector antenatal clinics in Cape Town. The intervention was subjected to a comprehensive evaluation based on a combination of quantitative and qualitative measures. This thesis utilizes data from the qualitative process assessment part, comprising individual interviews and focus group discussions with pregnant women during the implementation period of the intervention.   The survey results pointed out a high prevalence of smoking of 46% amongst disadvantaged pregnant women, with varying readiness for behaviour change. Most women were in the contemplation stage of behaviour change and thus ready to quit. Many of the women felt positive about the role of the midwife as an antenatal care provider, but they did not have confidence in midwives concerning encouraging or supporting women to change addictive behaviour be it smoking, alcohol or other illegal substances. The qualitative research highlighted the need for revised curricula for health education and counselling. The analysis illustrated how the current situation created tension between clinic staff and pregnant women making women feel unworthy and thus leaving little room for changing behaviour. The in-depth interviews and the focus group discussions provided an analytical account of how the person-centred approach in this population was perceived by the women themselves. It illustrated that a multifaceted intervention programme, using peer counselors and educational material designed specifically for a given target population, can successfully bring about behaviour change. The intervention succeeded in shifting women’s perceptions of hopelessness into feelings of being empowered to face their addictions and competent to make a change. Though the intervention meant greater rapport with the midwives, involving peer counsellors was rated highly by the participating women. The women reported having used the educational material and attached a great value to the appropriateness of the material to their life situations, and the effectiveness of having it combined with counselling from a peer counsellor. This qualitative evaluation showed the importance of a multifaceted intervention approach, in helping women identify with their behaviour change.   The thesis highlights the importance of designing smoking cessation interventions that are specific to the needs of target populations. When smoking cessation efforts are included into routine antenatal services it is important that the target group inform the nature and specific components of the intervention.

The project described in this thesis was designed to investigate HIV preventive behaviour in heterosexual adolescents from a social-cognitive perspective. The project consisted of three studies. The design of each study was guided by a theory of human decision making, the Theory of Reasoned Action (TRA), and its extension, the Theory of Planned Behaviour (TPB). In the first phase, an elicitation study was conducted in which characteristics of the population were identified. This study consisted of a series of semi-structured interviews in which participants' sexual behaviours, beliefs and normative influences were elicited. This information was required in order to enable studies two and three to target beliefs and behaviours relevant to the population being examined. In the second study, a large-scale survey of 417 university aged adolescents was conducted. This study was designed, primarily, to examine quantitatively the determinants of safe sex intentions and behaviours within the targeted population. Determinants of behaviour examined were those included in the TRA/TPB. Hierarchical multiple regression analyses were conducted to determine the amount of variance in safe sex intentions and behaviours accounted for by TRA/TPB variables. In addition, a number of methodological issues related to criticisms of the TRA/TPB in the context of prediction of sexual behaviours were investigated. These issues included the utility of examining preference for alternative safe sex strategies in accounting for non-use of condoms, the importance of considering behaviour change as a process rather than an outcome, the importance of heat of the moment decision-making in the prediction of condom use behaviour, and the importance of consistent specification of partner type in survey instruments examining condom use behaviour. The third phase of the project consisted of an intervention study designed to modify HIV-risk related beliefs and behaviours. Design and evaluation of the intervention were guided by the TRA/TPB. The intervention was conducted using 102 participants, randomly assigned to intervention or control conditions. Methodological issues examined in study 2 were further explored in this study. Overall, it was found that the Theories of Reasoned Action and Planned Behaviour provided a useful framework for understanding, predicting, and modifying HIV-related sexual behaviours. The theories were found to explain between 67 and 73% of variance in condom use intentions, and between 52 and 55% of variance in behaviour. The theories were also found to be applicable to other safe sex behaviours with 50% of variance accounted for in monogamy intentions, and 34% of variance explained in behaviour, and 40% of the variance in non-penetrative sexual intentions, but only 6% of variance in non-penetrative sexual behaviour explained. In addition, a behaviour modification intervention based on the theories was found to lead to change in both predictor variables and behaviours, relative to controls. These changes were maintained over a 6-month follow-up period. That is, a series of mixed factorial Analyses of Variance revealed that the percentage of encounters in which a condom was used was significantly greater for the four weeks prior to follow-up compared with the four weeks prior to the intervention. In addition, the number of 'slip-ups' into unsafe behaviours was found to be significantly less. Change in TRA/TPB predictor variables which accompanied these behavioural changes included increased perceptions of behavioural control, more positive attitudes towards sexuality and safe sex behaviours, and more positive normative perceptions. These results were seen to provide strong support for the theories of reasoned action and planned behaviour and for their relevance to the study of HIV-preventive behaviour. However, prediction of safe sex behaviours was found to be enhanced in most cases by consideration of the methodological issues explored in each study. Thus, it was found that consideration of safe sex strategies other than condom use and the type of partner with whom the behaviour was occurring were important in both the prediction and evaluation of efforts to modify condom use behaviour. In addition, prediction of condom use behaviour and evaluation of intervention effects were enhanced by the consideration of behaviour change as a stage-like process, rather than as an all or nothing outcome. Results relating to the importance of heat of the moment decision making were less clear, and further research is recommended to clarify the issue. Overall, these results have important implications for safe sex education, and should be considered in efforts to modify unsafe behaviour as well as efforts to evaluate the effects of this modification.

Researchers have noted that 70% of diseases are preventable (Ballard et al., 2007) yet few individuals use preventive services (Wang et al., 2005). The purpose of this study was to examine differences between students who seek preventive services at a university wellness center and those who do not and explore variables that impact readiness for change and health-related behavior. The Wellness Center at Southern Illinois University provides numerous direct services to students, such as alcohol and drug counseling, stress management counseling, nutrition counseling, STD testing, pregnancy counseling, biofeedback, and relationship counseling. Healthy People 2010 is a national initiative, developed by the U.S. Department of Health and Human Services, involving various efforts to promote health and prevent disease in the United States. The developers introduced Leading Health Indicators, which reflect major dimensions of health behavior and factors that affect health. These indicators, including physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, and injury and violence, are used as a guide to examine the health behaviors in college students. Seventy-nine university wellness center clients and 80 participants from the general student population completed a demographic questionnaire that included questions about participants' risky health behaviors, the Perceived Wellness Scale (Adams, Benzer & Steinhardt, 1997), the Attitudes toward Seeking Professional Psychological Help Scale- Short Form (Fischer & Farina, 1995), the Outcome Questionnaire-45.2 (Lambert et al., 1996), and the Stages of Change Scales (McConnaughy, Prochaska, & Velicer, 1983). Participants who used wellness services reported more risky health behaviors and psychological distress than the general sample. Health behaviors from this sample were compared to a national data set (YRBSS; CDC, 2005) and, although differences between specific rates of behavior were found, there was no difference in total risk score. Wellness service users were more likely to be in the contemplation stage, whereas those from the general sample were more likely to be in the action stage. Participants who were actively making a change were more likely to feel less psychological distress and have more perceived wellness than those in the contemplation stage. Participants in the maintenance stage reported having more negative wellness perceptions compared to participants in all other stages.