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Health-related physical fitness, knowledge, and administration of the Canadian physical activity, fitness.. Faktor, Marc Dylan 2009

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Health-Related Physical Fitness, Knowledge, andAdministration of the CanadianPhysical Activity, Fitness, and Lifestyle ApproachbyMarc Dylan FaktorB. Sc. Kinesiology, York UniversityA THESIS SUBMITTED IN PARTIAL FULFILLMENTOF THEREQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCEinTHE FACULTY OF GRADUATE STUDIES(Human Kinetics)THE UNIVERSITY OF BRITISH COLUMBIAJuly, 2009© Marc Dylan Faktor, 200911ABSTRACTResearch suggests that individuals whohave increased fitness knowledge viahealth education are more likelyto be physically active and fit. In addition, anindividual’s health literacy is suggestedto play a substantial role towards theacquisition of health knowledge. However,literature delineating the relationshipbetween health knowledge, health literacy,and the components of health-relatedphysical fitness is scarce andinconsistent. The Canadian Physical Activity,Fitness and Lifestyle Approach (CPAFLA)represents a series of standardizedfitness testing proceduresdeveloped by the Canadian Societyfor ExercisePhysiology. In addition, the CPAFLA providesimportant health-related informationto individuals intended to promote healthylifestyle activities. To-date, the influenceof the CPAFLA on health-related physicalfitness knowledge and the componentsof the Theory of Planned Behaviour(TPB) regarding physical activity has yetto beexamined. One large study examining twodistinct sub-questions wasconducted.The first question examinedobjectively the relationship betweenhealth-relatedphysical fitness knowledge, health literacy,and health-related physical fitness in34 participants (18 F, 16 M; 19-49years). Knowledge was examined usingtheFitSmart, while health literacy andphysical fitness were assessed via theNewestVital Sign and the CPAFLA, respectively.Results indicated that knowledge wasasignificant correlate (r=O.40,p<O.05) to and the strongest individual predictor(standardized-B=O.59,p<O.05) of musculoskeletal fitness. In addition,healthliteracy was a significant correlate(r = 0.63, p’<0.05) to and the strongest predictor(standardized-B=0.47, p<0.05)of knowledge. The second question examined111objectively the influence of administeringthe CPAFLA on knowledge and thecomponents of the TPB in relationto physical activity (via a 7-point bipolaradjective survey) in 40 participants (20F, 20 M; 19-49 years). The results showedthat the administration of the CPAFLAfunctioned to increase health knowledge[Wilks Lambda = 0.82, F (1, 32)= 6.9,p= 0.013], as well as importantcomponents of the TPB including: instrumentalattitude [Wilks Lambda = 0.984, F(1, 32) = 8.36,p= 0.007], perceived behavioralcontrol [Wilks Lambda = 0.861, F(1, 32) = 5.18,p= 0.030], and intention [Wilks Lambda= 0.667, F (1, 32) = 15.96,p = 0.00]. Taken together, these results demonstratethe important contribution ofknowledge and health literacyto level of physical fitness, as wellas the significantcontribution of the CPAFLA toknowledge development and the promotionofregular physical activity participation inadulthood.ivTABLE OF CONTENTSABSTRACTTABLE OF CONTENTS ivLIST OF TABLES viiiLIST OF FIGURES ixACKNOWLEDGEMENTS xviDEDICATION xviiiCO-AUTHORSHIP STATEMENT xixCHAPTER 1 IIntroduction to Thesis 1Overview of Thesis Investigation 5References 10CHAPTER 2 15The Relationship between Health Knowledge and Measures of Health-RelatedPhysical Fitness 15Methods 21Participants 21Assessment of Health-Related Physical Fitness Knowledge 22Assessment of Health Literacy 23Assessment of Health-Related Physical Fitness 24Procedure 28Statistical Analysis 29Results 30Participants 30Health-Related Physical Fitness Knowledge 31Health-Related Physical Fitness Assessment 32Health-Related Physical Fitness Knowledge and Health-Related PhysicalFitness 34Health Literacy and Health-Related Physical Fitness Knowledge 34Discussion 35Health-Related Physical Fitness Knowledge 36Health-Related Physical Fitness 37VHealth-Related Physical Fitness Knowledge andHealth-Related PhysicalFitness40Health Literacy and Health-Related Physical FitnessKnowledge 43Conclusion45References65CHAPTER 372The Effects of Administering the Canadian PhysicalActivity Fitness & LifestyleApproach (CPAFLA) on Health-RelatedPhysical Fitness Knowledge as wellas Beliefs, Attitudes, and Intentions towards RegularPhysical ActivityParticipation72Methods79Participants79Procedure80Assessment of Health-Related Physical FitnessKnowledge 81Assessment of the Theory of Planned BehaviorComponents ConcerningRegular Physical Activity82CPAFLA Assessment85Statistical Analysis86Results87Participants87Health-Related Physical Fitness Knowledge88Components of the Theory of PlannedBehavior 89Discussion90Health Knowledge92Theory of Planned Behaviour Components93Conclusion96References107CHAPTER4112Conclusion112References122APPENDIXA124Extended Review of Literature124viHealth and Fitness Knowledge.124Defining Health and Health Knowledge125Rationale for Health Knowledge Assessment127Health Knowledge and BehaviourChange129Health-Related KnowledgeAssessment131Assessment of Health-Related Beliefs,Attitudes, and Intentions136Impact of Health Knowledge138Health Literacy139Summary142Health-Related Physical Fitness142Defining Health-Related PhysicalFitness and Primary Contributors143Importance of Health-Related PhysicalFitness Assessment 144Assessment of Health-Related PhysicalFitness 145Impact of Health-RelatedPhysical Fitness145Summary147Health Knowledge in Relationto Health-Related Physical Fitness148Health Knowledge and PhysicalFitness in Adults148Health Knowledge and Physical Fitnessin the Elderly 151Summary152References155APPENDIX B165UBC Clinical Research Ethics BoardCertificate of Approval165APPENDIX C167Sample FitSmart Health KnowledgeExamination Questions167APPENDIXD168Theory of Planned Behaviour ComponentAssessment 168APPENDIXE175The Newest Vital Sign (NVS) healthliteracy assessment175Nutrition Label175Score Sheet176APPENDIX F177viiCFAFLA Preliminary Instructions forParticipants177APPENDIXG178Physical Activity Readiness Questionnaire (PAR-Q)178APPENDIX H179Physical Activity Readiness MedicalExamination (PARmed-X) 179APPENDIX I183CPAFLA Adult Consent Form183APPENDIXJ184Healthy Physical Activity ParticipationQuestionnaire 184APPENDIX K185Detailed Anthropometric Measurements185Body Mass Index (BMI)185Waist circumference (WC)185Skinfold Measurement (SO5S)185APPENDIXL186mCAFT Detailed Procedures186APPENDIXM187Detailed Musculoskeletal Fitness AssessmentProcedures 187Grip Strength187Push-ups187Sit-and-Reach187Partial Curl-ups188Vertical Jump and Leg power188Back Extension189viiiLIST OF TABLESTable 2.1: Participant Physical Characterisitics4Table 2.2: FitSmart Health-RelatedPhysical Fitness Knowledge Scores47Table 2.3: CPAFLA Health-RelatedPhysical Fitness Composite Scores48Table 2.4: Health-Related PhysicalFitness Knowledge and Physical FitnessCorrelations49Table 2.5: Health Knowledge and MusculoskeletalComponent Correlations.... 50Table 2.6: The Newest Vital Sign HealthLiteracy Scores51Table 2.7: The Health Literacy andHealth-Related Physical Fitness KnowledgeCorrelations52Table 3.1: Physical Activity Participation98Table 3.2: FitSmart Health-RelatedPhysical Fitness Knowledge Scores99Table 3.3: Theory of Planned BehaviourScores100Table A.1: Components of the CanadianPhysical Activity, Fitness and LifestyleApproach (CPAFLA)153ixLIST OF FIGURESFigure 2.1: FitSmart Health-Related Physical Fitness Knowledge Scores 53Figure 2.2: Healthy Physical Activity Participation Questionnaire 54Figure 2.3: Composite Musculoskeletal Fitness 55Figure 2.4: Resting Heart Rate as a Function of Age and Gender 56Figure 2.5: Height as a Function of Age and Gender 57Figure 2.6: Weight as a Function of Age and Gender 58Figure 2.7: Waist Circumference as a Function of Age and Gender 59Figure 2.8: Aerobic Fitness Scores as a Function of Age and Gender 60Figure 2.9: Grip Strength as a Function of Age and Gender 61Figure 2.10: Flexibility as a Function of Age and Gender 62Figure 2.11: Vertical Jump as a Function of Age and Gender 63Figure 2.12: Leg Power as a Function of Age and Gender 64Figure 3.1: Schematic of Research Design 101Figure 3.2: Time by Treatment Effects for Components of Physical Fitness. ... 102Figure 3.3: Time by Treatment Effects for Instrumental Attitude 103Figure 3.4: Time by Treatment Effects for Perceived Behavioural Control 104Figure 3.5: Time by Treatment Effects for Intention 105Figure 3.6: Time by Treatment Effects for Intention to Participate in VigorousPhysical Activity 106Figure A.1: Schematic of the Theory of Reasoned Action/Planned Behaviour 154Figure A.2: CPAFLA Vertical Jump 188Figure A.3: CPAFLA Back Extension 189xOPERATIONAL DEFINITIONSAerobic Fitness: A measure of the combinedefficiency of the lungs, heart,bloodstream, and exercising musclesin getting oxygen to the muscles andputting it to work (CSEP, 2003).Body Composition: The relative amounts of muscle,fat, bone, and otheranatomical components that contributeto a persons total body weight (U.S.Department of Health and Human Services,1999).Body Mass Index (BMI): The ratio of body weightdivided by height squared(KgIm2)(CSEP, 2003).Canadian Society for ExercisePhysiology (CSEP): A voluntary organizationcomposed of professionals interestedand involved in the scientific study ofexercise physiology, exercise biochemistry,fitness and health (for moreinformation see www.csep.ca(national information) orwww.csephealthfitnessbc.ca (BC information)).Composite Body Composition: A heafth-related fitness measureof bodycomposition which focuseson three specific indicators: body massindex(BMI), sum of (five) skinfolds (SO5S), andwaist circumference (WC) (CSEP,2003).The Canadian PhysicalActivity, Fitness and LifestyleApproach (CPAFLA): TheCSEP Health and Fitness Program’s3’ Edition health-related appraisal andcounselling strategy. It is a health-relatedfitness assessment protocol whichincorporates measures of physicalactivity participation, body compositionand metabolism, aerobic fitness,and musculoskeletal (including back)xifitness. The CPAFLA is a client centeredapproach which focuses on thepromotion of positive health behaviours,and is administered to over onemillion Canadians every year(CSEP, 2003).Exercise: Planned and structuredphysical activity which incorporates repetitivebodily movement geared towards improvingor maintaining one or morecomponents of physical fitness(Caperson, Powell, & Christenson,1985).Flexibility: The range of movement in a joint or seriesof joints (CSEP, 2003).Health: A construct that hasphysical, social, and psychological dimensions,eachcharacterized on a continuumwith positive and negative poles. Positivehealth is associated with acapacity to enjoy life and to withstand challenges;it is not merely the absence ofdisease. Negative health is associatedwith adecreased capacity to enjoy lifeand withstand challenges (CSEP,2003).Health Knowledge: A knowledgebase that enables individualsto identify thesymptoms and communicabilityof diseases, allows individuals toselect andparticipate in appropriate preventativehealth strategies, and givesindividualsand understanding of whereto obtain health services (Freimuth, 1990).Thisknowledge base should encompassthe basics of: aging, anatomyandphysiology, drug use and abuse,illness, nutrition and metabolism,physicalexercise and activity, healthcare utilization, as well as safety and firstaid(Beier & Ackerman, 2003).Health Literacy: The degreeto which people have the capacityto obtain,process, and understand basichealth information and servicesneeded tomake appropriate health decisions(Parker, Ratzan, & Lurie, 2003).xliHealth Promotion: The aggregateof all purposeful activities designedto improvepersonal and public healththrough a combination of strategies, includingthecompetent implementation of behaviouralchange strategies, health educationmeasures, risk factor detection,health enhancement and health maintenance(Amesetal., 1991).Health-Related Physical Fitness: Encompassesthe components of physicalfitness that are related to healthstatus, including cardiovascular fitness,musculoskeletal fitness, body compositionand metabolism (Warburtonet al.,2006b).Health-Related Physical FitnessKnowledge (specific to thisinvestigation): Aknowledge base that encompassesbasic fitness concepts, which iscomprised of six sub-domaincomponents including: concepts offitness;scientific principals of exercise;components of physical fitness; effectsofexercise on chronic diseaserisk factors; exercise prescription; as wellasnutrition, injury prevention, andconsumer issues (Zhu, Safrit,& Cohen,1999).Heart Rate Reserve(HRR): A method used to prescribe exerciseintensities.HRR is calculated by subtractingresting heart rate from maximumheart rate(Powers & Howley, 2004).Hypokinetic Disease: Disease states thatare directly related to low levels ofactivity (e.g. heart disease, type IIdiabetes) (Kraus & Raab, 1961).Intensity: The level of energy required to performa specified physical activity. Itis most commonly depicted in terms ofmaximal oxygen consumptionxlii(VO2max), percent of age predictedmaximum heart rate (HRmax=220-ageinyears), percent heart rate reserve (HRR), or metabolicequivalents (METs)expressed in mlxkg1xmin (1 MET=3.5 ml of oxygen consumption perkilogram of body mass perminute) (U.S. Department of Health andHumanServices, 1999).Metabolic Equivalent(MET): Used to describe the energy costs associated withexercise. One MET is equalto resting V02,which is approximately3.5m1/kg/min (Powers& Howley, 2004).Modified Canadian Aerobic Fitness Test(mCAFT): A predictive, submaximal,and progressive exercise test designedspecifically for the general population.The test is employed in the CPAFLA health-relatedfitness assessment(CSEP, 2003) as an indicator of aerobicfitness.Muscular Endurance: Theability of the musculoskeletal systemto maintain orrepeatedly develop force (CSEP,2003).Musculoskeletal Fitness: Thefitness of the musculoskeletal system,encompassing muscular strength, muscularendurance, muscular power,flexibility, back fitness andbone health (Warburton, Whitney,& Bredin,2006b).Muscular Power: The combinationof muscular strength and speed, whichcorresponds to the maximum rate offorce that can be generated in a singlerapid contraction (CSEP, 2003).Muscular Strength: The maximum tensionor force a muscle can exert ina singlecontraction (CSEP, 2003).xivObesity: A condition of excessive body fat that resultsfrom a chronic energyimbalance whereby intake exceeds expenditure(Katzmarzyk, 2002).Physical Activity: Any bodily movement producedby skeletal muscles thatresults in energy expenditure (EE)and is positively correlated with physicalfitness (Caperson et al., 1985).Physical Fitness: A term that encompassesa set of attributes that peoplepossess or achieve relating to their abilityto perform physical activity.Physical fitness is comprised of fivehealth-related components whichinclude: (1) body composition, (2) cardiovascularendurance, (3) flexibility, (4)muscular endurance, and(5) muscular strength (U.S. Department ofHealthand Human Services, 1999).Predicted Maximum Heart Rate (HRmax):An age based predication of maximumheart rate, referred to inbeats per minute (bpm). Calculated by subtractingone’s age from 220 (220-age = HRmax).Intensity can also be defined byutilizing percent of predicted HRmax.For example: 70% of HRmax = .7(220-age) (CSEP, 2003).Skinfold: The thickness of the foldof skin plus the underlying fat determinedbythe use of a high quality HarpendenTMskinfoldcaliper (CSEP, 2003).Socioeconomic Status(SES): A complex phenomenon predicted bya broadspectrum of variables thatis often conceptualized as a combinationoffinancial, occupational, and educationalinfluences (Winkleby, Jatulis,Frank,& Fortmann, 1992).xvSum of Five Skinfolds(SO5S): An estimate of subcutaneous fat which isdetermined by the additionof the triceps, biceps, subscapula, iliaccrest, andmedial calf skinfolds (CSEP, 2003).xviACKNOWLEDGEMENTSThere are numerous individuals whohave assisted me in variouswaysthroughout the course of my Masters. Firstand foremost I would like to thank myprimary supervisor Dr. ShannonS.D. Bredin and close collaborator Dr. DarrenE.R. Warburton for their continuous support,knowledgeable guidance,inspiration, and empathy throughoutthe course of my degree. Dr. Bredin andDr.Warburton opened up manydoors for me as a health and fitnessprofessional.They provided an abundance of exciting,challenging, and fulfilling professionaldevelopment opportunities(e.g., professional certification pathways,field testingand counselling opportunities withlarge health-related organizations, excitingresearch excursions, multipleemployment opportunities, and the listgoes on!). Iam now exceptionally equippedto pursue a career in the health sciencesthanksto these unique, challenging, and memorableexperiences. Moreover, mysupervisor, Dr. Bredin, was alwaysthere to push me further, was exceptionallyastute when it came down to editingmy work, and never settled for a subparproduct. In addition, I would liketo thank Dr. Ryan E. Rhodes for hismeaningfulcontribution to my thesis work. Dr.Rhodes was never too busy to assistme withany questions or concernsI had regarding the research at hand,and continuallyprovided me with valuable sourcesof information which significantly contributedto this thesis and my overall knowledgebase.Secondly, I would like to thankthe LEARN and CPR lab membersfor theirmentorship, camaraderie, and continualsupport throughout the course of mydegree. In alphabetical order (firstname) I would like to thank: Ashley Charleboisxvii(MSc. Student), Anita Cote (PhD. Student),Ashlee McGuire (MSc. Student),BenEsch (PhD. Student), Dominik Zbogar(MSc. Student), Jessica Scott (PhD.Student), Lindsay Nettlefold (PhD. Student), MikaJohnson (MSc. Student),Mischa Harris (CSEP BC undergraduatechampion), Dr. Sarah Charlesworth(post doctoral fellow), Stephanie Gatto (previousresearch coordinator), ShirleyWong (MSc. Student), and Tim Lebas(CSEP BC Renewals Officer & AdminCoordinator).xviiiDEDICATIONI would like to dedicate this work to myparents (Brenda & Gary Faktor),sisters (Cand ice & Lisa), and all ofmy closest friends who substantiallycontributed to my upbringing shaped meinto the man I have become (AdamMiller, Amy Blumenkranz, Ben Kreaden,Brad Saltz, Daniel Cohen, Eva Kalmar,Evan Marcus, Gavin Karpel,Jeff Lippa, John Dsouza, Jordan Ohayon, LesleySpitzen, Mandy Joseph, Marwan Hamam,Mike Smith, Mona Maghsoodi, RachelGlazer, Richard Arluck, Ryan Abramowitz,Selina Chan, Serj Markarians,Stephen Abrahamson, Stephanie Sternberg,Tracey Kunz, Vahid Assadpour,&Zack Saltzberg). As Tony Robbinsonce said: “A person is a direct reflectionofthe expectations of theirpeer group”. Mom, Dad, Lisa, Candice,and all myauxiliary brothers and sisters: thankyou all for showing me the way!xixCO-AUTHORSHIP STATEMENTTwo manuscripts are presented in thisdocument in Chapters 2 and 3,respectively:1. Faktor, M.D., Warburton, D.E.R.,Rhodes, R.E., & Bredin, S.S.D. TheRelationship between Health Knowledgeand Measures of Health-RelatedPhysical Fitness. To be submitted in July/August2009.2. Faktor, M.D., Warburton, D.E.R., Rhodes,R.E., & Bredin, S.S.D. The Effectsof Administering the Canadian PhysicalActivity Fitness & Lifestyle Approach(CPAFLA) on Health-Related PhysicalFitness Knowledge as well as Beliefs,Attitudes, and Intentions towards RegularPhysical Activity Participation. Tobesubmitted in July/August 2009.More specifically, Marc D. Faktor andDr. Shannon Bredin were primarilyresponsible for the identification anddesign of the research program with inputfrom Dr. Darren Warburtonand Dr. Ryan Rhodes. Marc D. Faktor collectedandanalyzed all of the data presented inthese manuscripts. The manuscripts inpresent form were alsoprepared by Marc D. Faktor with major contributionsmade by Dr. Shannon Bredin.Dr. Warburton and Dr. Rhodes made significantcontributions following initialpreparation of the manuscripts.1CHAPTER 1Introduction to ThesisThere is incontestable evidence supporting regularphysical activity participation(structured and unstructured) in theprimary and secondary prevention of numerouschronic diseases and prematuredeath (Warburton, Whitney, & Bredin, 2006a).Physicalinactivity is a primary modifiable risk factorfor cardiovascular disease and an increasingassortment of accompanying chronic hypokinetic(insufficient movement or activity)diseases, including: obesity, diabetesmellitus, cancer (breast and colon), boneand jointdiseases (osteoporosis and osteoarthritis),depression, and hypertension (Katzmarzyk,1998; Katzmarzyk, Gledhill, & Shephard,2000; Katzmarzyk, Perusse, Rao,& Bouchard,2000; Warburton et al., 2006a).Recent research estimatesthat 53.5% of adult Canadians are physicallyinactiveand 14.7% are obese (Katzmarzyk& Janssen, 2004). Within British Columbia, thephysical inactivity prevalenceis substantially lower (as low as 37%)in comparison tothe rest of the average Canadian population.Five British Columbia health serviceregions are in the top tenfor most physically active Canadian regions,with the top threeall being British Columbia regions (CanadianFitness and Lifestyle Research Institute,2005). However, the average Canadianphysical inactivity prevalence ranks higherthanall other existing and modifiable chronichypokinetic disease risk factors (Warburtoneta)., 2006a) and is predicted to risealong with current obesity rates. In 2001,9.6 billondollars were directly accredited to physicalinactivity and obesity in Canada (Katzmarzyk& Janssen, 2004). These data confirm that physicalinactivity and obesity are chiefcontributors to the Canadianpublic health care burden. Health promotionefforts,2guided by relevant research, that functionto increase physical activity andreduceobesity would significantly lowerunnecessary health care spendingand increase thehealth status of Canadians (Katzmarzyk& Janssen, 2004).The assessment of health-relatedphysical fitness is of major importance(Oja,1995). The Canadian Society forExercise Physiology (CSEP) health-relatedfitnessappraisal and counselling strategy(the Canadian Physical Activity, Fitness& LifestyleApproach (CPAFLA)) representsa series of standardized testing procedures.Whenadministered by trainedand certified CSEP health andfitness professionals, the resultsof the appraisal allow for the evaluationof current health status in accordancetoCanadian normative data. Moreoverand above all, the appraisalprocess and findingsprovide vital health-relatedinformation to individuals. A humanisticgoal of this approachis to provide motivation to appraisalparticipants to develop healthierlifestyles and toincrease their physical activityparticipation (Canadian Societyfor Exercise Physiology,2003). However, previous scientificinvestigation hasyet to explore whether or not theCPAFLA functions to increasehealth-related physical fitnessknowledge or provideempirical evidence suggesting thatit motivates individuals to participate inregularphysical activity.A number of theories have beenused to explain and predict individual’shealthrelated behaviours. Becker’sHealth Belief Model (1988) stipulatesthat an individual’shealth-related lifestyle is dictatedby his or her perception of theconsequences of apotential illness (e.g.,cardiovascular disease) and thebenefits of engaging in abehaviour (e.g., aerobics)that would eliminate the threatof such illness (Rosenstock,Strecher, & Becker, 1988;Seefeldt, Malina, & Clark, 2002). Theseperceptions areshaped in part by the knowledgebase that one possesses. Prochaskaand Diclimente’s3Transtheoretical Model of Behaviour Change (1992)accentuates this notion. In order fora behavioural change to occur, the rudimentarystep is to educate with the intention ofincreasing knowledge and awarenessof the particular behavioural actions andreactions (Prochaska, DiClimente, & Norcross,1992). Dominant among these is theTheory of Planned Behaviour (TPB, formerlythe Theory of Reasoned Action (TRA)(Ajzen, 1988, 1991). The TPB proposesthat the most immediate and significantforecaster of behaviour is an individual’sintention to execute a behaviour. Thisbehavioural intention is predictedby three major factors: attitude towards the behaviour,subjective norm, and perceived behaviouralcontrol. The knowledge base of anindividual, in relation to the behaviour,is considered a background variable whichinfluences the three variablesthat form behavioural intentions (Ajzen& Manstead,2007). Accordingly, research suggeststhat individuals who understand theconcepts ofhealth-related physical fitness are morelikely to be physically active anddemonstratehigher fitness levels (Zhu,Safrit, & Cohen, 1999; Petersen, Byrne,& Cruz, 2003). Thus,important processes in becomingphysically fit while endorsing constructivebehavioursin relation to fitness are: obtaining,learning, and applying the concepts andprinciples ofhealth-related physical fitness (Miller& Housner, 1998).Health knowledge permits individualsto acknowledge the warning signs andpropagation of diseases, select andpartake in suitable preventative healthstrategies(e.g., physical activity), and provides individualswith an understanding of whereandhow to obtain health services and assistance(Freimuth, 1990). Health-relatedphysicalfitness knowledge is a knowledgebase that encompasses basic fitness conceptsrelated to health status as wellas disease risk, prevention, and treatment(Zhu et al.,1999). The examination of health knowledgehas important policy implications as health4knowledge and its dependants are majorutilities to public health promotion agencies(Nayga, 2001). Empirical evidence regardingthe influence of health knowledge onhealth-related physical fitness, as wellas variation in health knowledge across sociodemographic groups should be utilized in the developmentof future health promotionand education programs. However, literaturedelineating the relationship betweenhealth-related physical fitnessknowledge and health-related physical fitness is scarceand inconsistent. Investigations havesuggested a positive relationship betweenknowledge base and health-related fitnessin adolescence (Keating, 2007), adulthood(Petersen et al., 2003), as well as inolder adulthood (Fitgerald, Singleton, Neale,Prasad, & Hess, 1994). Conversely,investigations have also shown no relationshipbetween fitness knowledge and componentsof physical fitness (e.g., physical activity)(Morrow, Krzewinski-Malone, Jackson,Bungum, & and FitzGerald, 2004).A significant factor associated with the acquisitionof health knowledge is healthliteracy. Health literacy is defined as thedegree in which people have the competenceto obtain, process, and understand basic healthinformation and services needed tomake appropriate health decisions (Parker,Ratzan, & Lurie, 2003). It is a contemporaryand well warranted topic of concern forthe advancement of high quality healthcare.Health literacy is pivotal to numerous healthcare system initiatives including qualityassurance, cost maintenance, safety,and patient’s active involvement in healthcaredecisions (Parker, Ratzan, & Lurie,2003). Inadequate health literacyis associated withseveral health-related consequences,as literacy is correlated to numerousaspects ofhealth including: health knowledge,health status, and use of health services (AdHocCommittee on Health Literacy forthe Council on Scientific Affairs, American MedicalAssociation, 1999). Patients with low literacyare generally 1.5-3 times more likelyto5experience inferior health outcomes inclusiveof health knowledge, transitional diseaseindicators, morbidity measures, utilizationof health resources, and general health status(DeWalt, Berkman, Sheridan, Lohr,& Pignone, 2004). In terms of health-relatedknowledge, there exists a positive andsignificant relationship between literacy levelsand knowledge of health services or healthoutcomes (DeWalt et al., 2004). Studiesindicate that individuals with low literacyand chronic or infectious diseasessuch asdiabetes (Williams, Baker, & Parker, 1998), hypertension(Williams et al., 1998), asthma(Williams, Nurss, Baker, Honig,Lee, & Nowlan, 1998), or HIV/AIDS (Kalichman,Benotsch, Suarez, Catz, Miller, & Rompa.,2000) have inferior knowledge concerningtheir disease and its recommendedtreatment. Furthermore, research hasindicated thatpoor health literacy alone is the mostsignificant predictor of disease preventionknowledge when compared to ethnicityor education (Lindau, Tomori, Lyons,Langseth,Bennett, & Garcia, 2002). Nevertheless,to the best of our knowledge, therelationshipbetween health literacy and health-relatedphysical fitness knowledge has yet to beexamined.Overview of ThesisInvestigationOne large study examining twodistinct sub-questions was conducted. The firstresearch objective wasto examine the relationship between health-relatedphysicalfitness knowledge and health-relatedphysical fitness in young and middleadulthood. Asecondary purpose of this sub-questionwas to examine the relationship between healthliteracy and health-related physical fitnessknowledge. Knowledge was assessedvia theFitSmart, a standardized health-relatedphysical fitness knowledge examination.Healthrelated physical fitness was assessedand interpreted using the CanadianPhysical6Activity, Fitness and LifestyleApproach (CPAFLA); while health literacywas assessedvia the Newest Vital Sign, a brief yetformal standardized health literacy assessment.We hypothesized that individuals who scored higheron the FitSmart would alsodemonstrate higher levels of health-relatedphysical fitness in comparison to individualswho scored lower on the FitSmart examination.This hypothesis was based onthe ideathat knowledge is considereda critical factor in establishing human behaviour(Andrade,1999). Furthermore, people who understandthe concepts of physical fitness are alsomore likely to incorporate physical activityand exercise into their everyday life(Zhu etal., 1999). Therefore, we predicted thatindividuals with increased fitness knowledgewould display higher levels of health-relatedphysical fitness because regular physicalactivity participation is often assumedas a significant predictor of health-relatedphysical fitness (Katzmarzyk, 1998). Wealso hypothesized that there wouldbe apositive and significant correlationbetween health literacy and health-relatedphysicalfitness knowledge. It was expected thatindividuals who scored higher onthe NewestVital Sign would also demonstrate higherscores on the FitSmart (in comparisontoindividuals who scored loweron the health literacy assessment).Given that healthliteracy has been shownto be a positive and significant correlateto and predictor ofhealth-related knowledge aswell as health outcomes (DeWaltet al., 2004; Lindau et al.,2002), it is reasonable to postulatea positive and significant relationshipbetween healthliteracy and health-related physical fitnessknowledge. In summary, our findingsshowedthat health-related physical fitnessknowledge was positively and significantlycorrelatedto health-related physical fitness in adulthood.Specifically, knowledge was a significantcorrelate to and the strongestindividual predictor of musculoskeletal fitness.In addition,health literacy was found to be a significantcorrelate to and the strongest predictorof7knowledge. These findingshave been compiled into a manuscripttitled, “Therelationship between health knowledgeand measures of health-related physicalfitness”, which is presented in Chapter2 of this thesis document.The second research objectiveof this investigation was to examine objectivelytheeffects of administering the CPAFLAon health knowledge and the Theory ofPlannedBehaviour components (i.e., attitude,subjective norm, perceived behavioural control,and intention) concerning regular physicalactivity participation in adulthood. TheTheory of Planned Behaviourconstructs were assessed via a writtensurvey containinga series of 7-point bipolar adjective scales concerningregular physical activityparticipation. We hypothesized that individualsreceiving the CPAFLA woulddemonstrate improved scoreson the post-test FitSmart knowledgeexamination. Morespecifically, individuals woulddemonstrate higher scores on the‘Components ofPhysical Fitness’ section ofthe test in comparison to baseline measures.Thishypothesis was generatedbecause the administration of the CPAFLAstrategicallyidentifies major physical fitnesscomponents in a sequential order andhighlights theirindividual and aggregative impactson health and well being. Furthermore,the CPAFLAstrategy emphasizes education andcounselling concerning appropriateevidence basedtactics designed to augment fitness througha variety of exercises and activities.Thesetactics are based on the interpretationof fitness results (CSEP, 2003). As such,wepredicted that participantswill demonstrate improvements on theFitSmart examinationfollowing administration of theCPAFLA on questions specificto the health-relatedphysical fitness componentof the examination. We also predictedthat the theory ofplanned behaviour components (i.e., individualbeliefs, attitudes, and intentions)relatedto physical activity participation would improvein comparison to baseline measures8following the administration of the CPAFLA.The CPAFLA appraisal process isdesigned to increase knowledge andawareness concerning health-related physicalfitness while highlighting the health benefitsof physical activity in an attempt to motivateindividuals to develop healthier lifestylesand increase physical activity participation(CSEP, 2003). As such, improvements in the relevantTheory of Planned Behaviourcomponents were expected following the administrationof the CPAFLA. Our resultssupported these hypotheses, wherebyadministration of the CPAFLA functionedtoincrease health knowledge, aswell as important components of the TPB. Theseeffectswere demonstrated via increasesin instrumental attitude, perceived behavioural control,and intention. The findings have beencompiled into a manuscript titled, “Theeffects ofadministering the Canadian Physical ActivityFitness & Lifestyle Approach (CPAFLA) onhealth-related physical fitness knowledgeas well as beliefs, attitudes, and intentionstowards regular physical activityparticipation”, which is presented in Chapter3 of thisthesis document.Overview of DocumentThis thesis is comprised of four Chapters.Chapter 1 serves as a generalintroduction to the thesis. Thefindings of the thesis investigation arethen presented inthe form of two manuscripts.The purpose of the first manuscript isto examine therelationship between health knowledgeand health-related physical fitness;while, thesecond manuscript focuseson the effects of administering the CPAFLAon healthrelated physical fitness knowledge, aswell as beliefs, attitudes, and intentionstowardsregular physical activity participation.These manuscripts are presented inChapters 2and 3, respectively. The conclusionis then presented in Chapter 4. This thesis alsoincludes Appendices A through M. Morespecifically, the Appendix section includes: A)9an extended review of literature directlypertinent to the investigation B) therequiredcertificate of research ethics, C) a sampleof the FitSmart health-related physicalfitnessknowledge examination questions, D)the health-related physical activity beliefandattitude assessment, E) the Newest VitalSign (NVS) health literacy assessment,F) theCPAFLA preliminary instruction template,G) the Physical Activity ReadinessQuestionnaire (PAR-Q), H) the Physical ActivityReadiness Medical Examination(PARmed-x) template, I) the CPAFLAconsent form, J) the Physical Activity ParticipationQuestionnaire used in the CPAFLA,K) the detailed CPAFLA anthropometric protocols,L) the detailed modified Canadian AerobicFitness Test (mCAFT) procedure, andM) thedetailed CPAFLA m uscu loskeletal fitnessassessment protocols.10ReferencesAd Hoc Committee on Health Literacy for the Councilon Scientific Affairs, AmericanMedical Association (1999). Health literacy:Report of the council on scientificaffairs. The Journal of the American MedicalAssociation, 281(6), 552-557.Ajzen, I. (1988). Attitudes, personalityand behavior. Chicago: Dorsey Press.Ajzen, I. (1991). The theory of plannedbehavior. Organizational Behaviorand HumanDecision Processes, 50, 179-211.Ajzen, I., & Manstead, A. S. R.(2007). Changing health-related behaviors: Anapproachbased on the theory of planned behavior.In K. van den Bos, M. Hewstone, J.deWit, H. Schut & M. Stroebe (Eds.), Thescope of social psychology: Theotyandapplications (pp. 43-63). New York:Psychology Press.Ames, E. E., etal. (1991). Reportof the 1990 joint commission on health educationterminology. Journal of School Health,61(6), 251-254.Beier, M. E., & Ackerman, P. L. (2003).Determinants of health knowledge:Aninvestigation of age, gender, abilities,personality, and interests. Journal of Personalityand Social Psychology, 84(2), 439-448.Canadian Fitness and LifestyleResearch Institute (2005). Rating Canada’sRegionalHealth. Retrieved June 6, 2009, fromwww.cflri .ca/enq/regionalhealth/index.php.Canadian Society for Exercise Physiology(2003). The Canadian Physical Activity,Fitness & Lifestyle Approach. Ottawa,ON: Canadian Society for ExercisePhysiology.Caperson C.J., Powell K.E., ChristensonG.M. (1985). Physical activity, exercise,andphysical fitness: Definitions and distinctionsfor health-related research. PublicHealth Reports, 100(2), 126-131.11DeWalt, D. A., Berkman, N. D., Sheridan,S., Lohr, K. N., & Pignone, M. P. (2004).Literacy and health outcomes. Journalof General Internal Medicine, 19(12), 1228-1239.Fitgerald, J. T., Singleton, S. P., Neale, A.V., Prasad, A. S., & Hess, J. W. (1994).Activity levels, fitness status, exerciseknowledge, and exercise beliefs amonghealthy, older african american and white women.Journal of Aging and Health,6(3), 296-313.Freimuth, V. S. (1990). The chronicallyuninformed: Closing the knowledge gap inhealth,pp.171-186. In E.B. Ray, L. Donohew(Ed.), Communication and Health:Systems and Applications. Hillsdale, NJ: Eribaum.Kalichman, S., Benotsch,E., Suarez, T., Catz, S., Miller, J.,& Rompa, D. (2000). Healthliteracy and health-related knowledgeamong persons living with HIV/AIDS.American Journal of PreventiveMedicine, 18(4), 325-331.Katzmarzyk, P.T, & Janssen,I. (2004). The Economic Costs Associatedwith PhysicalInactivity and Obesity in Canada:An Update. Canadian Journal of AppliedPhysiology, 29(1), 90-115.Katzmarzyk, P. T. (1998). Physicalactivity and health-related fitness inyouth: amultivariate analysis. Medicine and Science inSports and Exercise, 30(5), 709-7 14.Katzmarzyk, P. T., Gledhill, N.,& Shephard, R. J. (2000). The economic burden ofphysical inactivity in canada.Canadian Medical Association Journal, 163(11),1435-1440.Katzmarzyk, P. T., Perusse,L., Rao, D. C., & Bouchard, C. (2000). Familial riskofoverweight and obesity in the canadianpopulation using the WHO/NIH criteria.Obesity, 8(2), 194-1 97.12Katzmarzyk, P.T. (2002). The canadianobesity epidemic, 1985-1 998. CanadianMedical Association Journal, 166(8),1039-1040.Keating, X. (2007). An examination ofninth-grade students’ fitness knowledge inametropolitan area. Research Quarterlyfor Exercise and Sport, 78(1), pA-62.Kraus, H., & Raab, W. (1961). HypokineticDisease: Diseases Produced by LackofExercise. Springfield: Thomas.Lindau, S., Tomori, C., Lyons, T.,Langseth, L., Bennett, C., & Garcia, P. (2002).Theassociation of health literacy with cervicalcancer prevention knowledge and healthbehaviors in a multiethnic cohort of women.American Journal of ObstetricsandGynecology, 186(5), 938-943.Miller, M. G., & Housner, L. (1998).A survey of health-related physical fitnessknowledge among preservice andinservice physical educators. Physical Educator,55(4), 176-187.Morrow, J. R. J., Krzewinski-Malone,J. A., Jackson, A. W., Bungum,T. J., & andFitzGerald, S. J. (2004). American adults’knowledge of exercise recommendations.Research Quarterly for Exercise andSport, 75(3), 231-237.Nayga, R. (2001). Effect of schoolingon obesity: Is health knowledge a moderatingfactor? Education Economics,9(2), 129-138.Oja, P. (1995). Descriptive epidemiologyof health-related physical activity andfitness.American Alliance for Health, PhysicalEducation and Recreation.Parker, R. M., Ratzan, S. C., & Lurie,N. (2003). Health literacy: A policy challengeforadvancing high-quality health care. HealthAffairs, 22(4), 147-1 53.Petersen, S., Byrne, H.,& Cruz, L. (2003). The reality of fitness for pre-serviceteachers:What physical education majors ‘knowand can do’. Physical Educator, 60(1),5-19.13Powers, S., & Howley, T. (2004). Exercisephysiology: Theoiy and applicationto fitnessand performance (Fifth Editioned.). New York: McGraw-Hill.Prochaska, J.O., DiClimente, C.C.,& Norcross J.C. (1992). In Search of How PeopleChange: Applications to Addictive Behaviors.American Psychologist, 47(9), 1102-1114.Rosenstock, I. M., Strecher, V. J., & Becker,M. H. (1988). Social learning theoryandthe health belief model. Health Education& Behavior, 15(2), 175-1 83.Seefeldt, V., Malina, R.M., & Clark M.A.(2002). Factors affecting levels of physicalactivity in adults. Sports Medicine,32(3), 143-168.U.S. Department of Health and HumanServices, Public Health Service, CentersforDisease Control and Prevention, NationalCenter for Chronic Disease Preventionand Health Promotion, Division of Nutritionand Physical Activity (1999). PromotingPhysicalActivity: A guide for CommunityAction.Champaign, IL: Human Kinetics.Warburton, D. E. R., Whitney,N. C., & Bredin, S. S. D. (2006a). Healthbenefits ofphysical activity: The evidence.Canadian Medical Association Journal,174(6), 801-809.Warburton, D. E. R., Whitney,N. C., & Bredin, S. S. D. (2006b).Prescribing exercise aspreventive therapy. Canadian MedicalAssociation Journal, 174(7), 961-974.Williams, M., Baker, D., Parker, R.,& Nurss, J. (1998). Relationship of functionalhealthliteracy to patients’ knowledgeof their chronic disease: A study ofpatients withhypertension and diabetes.Archives of Internal Medicine, 158(2),166-172.Williams, M., Baker, D., Honig, E.,Lee, T., & Nowlan, A. (1998). Inadequateliteracy is abarrier to asthma knowledge andself-care. Chest, 114(4), 1008-1015.14Winkleby, M. A., Jatulis, D. E.,Frank, E., & Fortmann, S. P. (1992).Socioeconomicstatus and health: How education, income,and occupation contribute to risk factorsfor cardiovascular disease. AmericanJournal of Public Health, 82(6), 816-820.Zhu, W., Safrit, M., & Cohen, A.(1999). FitSmart test user manual-high schooledition.Champaign, IL: Human Kinetics.15CHAPTER 2The Relationship between Health Knowledgeand Measures of Health-RelatedPhysicalFitness1Knowledge is considered to bea major determinant of human behaviour(Andrade et aL, 1999). Health-relatedknowledge permits individuals to acknowledgethewarning signs and propagationof diseases, select and partakein suitable preventativehealth strategies (e.g., physical activity),and provides individuals with an understandingof where or how to obtain healthassistance (Freimuth, 1990).A number of theories have beenused to explain and predict individual’s health-related behaviours. Becker’sHealth Belief Model(1988) stipulates that an individual’shealth-related lifestyle is dictatedby his/her perception of the consequencesof apotential illness (e.g., cardiovasculardisease) and the benefits of engagingin abehaviour (e.g., aerobics) thatwould eliminate the threat of suchillness (Rosenstock,Strecher, & Becker, 1988; Seefeldt,Malina, & Clark, 2002). These perceptionsareshaped in part by the knowledgebase that one possesses. Prochaskaand Diclimente’sTranstheoretical Model of BehaviourChange (1992) accentuates thisnotion. In order fora behavioural change to occur, therudimentary step is to educate withthe intention ofincreasing knowledgeand awareness of the particularbehavioural actions andreactions (Prochaska, DiClimente,& Norcross, 1992). Dominant among theseis theTheory of Planned Behaviour(TPB, formerly the Theoryof Reasoned Action (TRA))(Ajzen, 1988, 1991). The TPBproposes that the most immediateand significant1A version of this chapter willbe submitted for publication. Faktor, M.D., Warburton,D.E.R., Rhodes,R.E., & Bredin, S.S.D. The Relationshipbetween Health Knowledge and Measuresof Health-RelatedPhysical Fitness.16forecaster of behaviour is an individual’s intentionto execute a behaviour. Thisbehavioural intention is predictedby three major factors: attitude towardsthe behaviour,subjective norm, and perceived behaviouralcontrol. The knowledge base ofanindividual, in relation to the behaviour,is considered a background variable whichinfluences the three variables that formbehavioural intentions (Ajzen & Manstead,2007). Accordingly, research suggeststhat individuals who understand the conceptsofhealth-related physical fitness are morelikely to be physically active and demonstratehigher fitness levels (Zhu,Safrit, & Cohen, 1999; Petersen, Byrne,& Cruz, 2003a).Thus, important processes in becomingphysically fit while endorsing constructivebehaviours in relation to fitness areobtaining, learning, and applying the conceptsandprinciples of health-related physicalfitness (Miller & Housner, 1998).Health-related fitness encompassesthe components of physical fitness thatarerelated to health status, includingphysical activity participation, cardiovascularfitness,musculoskeletal fitness, bodycomposition, and metabolism (Warburton,Whitney, &Bredin, 2006b). Additionally,it is regularly assumed that health-relatedphysical fitnessis a product of habitual physical activityparticipation (Katzmarzyk, Malina, Song,&Bouchard, 1998). Thus,a positive correlation is expected betweenparticipation inphysical activity (i.e., any bodily movementproduced by skeletal muscles that resultsinenergy expenditure (EE))and measures of physical fitness (e.g.,body composition,aerobic fitness, and musculoskeletalfitness) (Caspersen, Powell,& Christenson, 1985).Another quantifiable componentof physical fitness is cardiovascular oraerobic fitness.It is commonly defined as a measureof the combined efficiency of the lungs,heart,bloodstream, and exercisingmuscles in getting the oxygen to the musclesand putting itto work (CSEP, 2003). Individuals mustthen rely on the musculoskeletalsystem for17movement and to perform work.Musculoskeletal fitness refersto the fitness of themusculoskeletal system, encompassingmuscular strength, muscular endurance,muscular power, flexibility, back fitnessand bone health (Warburton, Whitney,& Bredin,2006b). Based on this definition, it is apparentthat musculoskeletal fitnessis essentialto maintain as it provides the basis for ouractivities of daily living and determinesourability to perform a wide varietyof physical challenges. Finally,body composition is anessential component of health-relatedfitness. The relative amountsof muscle, fat, boneand other anatomical componentsthat contribute to a person’s total bodyweight (U.S.Department of Health and HumanServices, 1999) are what makeup an individual’sbody composition and contributeto metabolic capacity.To-date, the literature examiningthe relationship between healthknowledge andhealth-related physical fitnessremains limited and inconsistent.Evidence supporting apositive relationship betweenhealth-related physical fitnessknowledge and thecomponents of health-relatedphysical fitness has been suggestedin adolescence(Keating, 2007), and limitedlyshown in adulthood (Avis, McKinlay,& Smith, 1990; Lianget al., 1993) and within elderlypopulations (Fitgerald, Singleton, Neale,Prasad, & Hess,1994). Moreover, investigationshave also shown no significantrelationship betweenfitness knowledge and componentsof physical fitness (e.g., health-relatedphysicalactivity) (Morrow, Krzewinski-Malone,Jackson, Bungum, & FitzGerald,2004). Morespecifically, the research literaturehas shown that cardiovascular risk factorknowledgeis positively related to level ofeducation, being female, and amountof exercise (Avis,McKinlay, & Smith, 1990).In addition, exercise beliefs andknowledge have beensuggested to influence exercise habitsof healthy females (Fitgerald et al., 1994).Lianget al. (1993) have shown that health knowledgeinfluenced medical student’sfitness18levels; however, attitudes concerninghealth promotion and disease preventionwerestronger predictors of fitness levels.In contrast, Morrow et al. (2004) showedthatknowledge of exercise recommendationshad no effect on exercise behaviours;yet,ethnicity, education level, andage were significantly correlatedto health knowledge.A significant factor associatedwith the acquisition of health knowledgeis healthliteracy. Health literacy is definedas the degree in which people have the competenceto obtain, process, and understand basichealth information and services neededtomake appropriate health decisions(Parker, Ratzan, & Lurie, 2003). It isa contemporaryand well warranted topic of concernfor the advancement of high quality healthcare.Specifically, health literacy is pivotalto numerous health care system initiativesincluding quality assurance,cost maintenance, safety, andpatient’s active involvementin health care decisions (Parkeret al., 2003).The International AdultLiteracy and Skills Survey (IALS) is theprimary andcurrent source of literacy measuresof the general population in Canadaand in othercountries (Rootman, 2005). Mostrecently, the IALS highlightedmajor deficiencies inthe literacy levels of the Canadianpopulation (Statistics Canada,2005). Almost half ofthe Canadian adult populationfell into the lowest 2 of 5 literacy levelswith regards totheir ability to read and comprehendprose (48%) and documents(49%). The majority ofthe population fell into the twolowest levels concerning problem solvingability (72%)and numeracy (55%). Correspondingly,22% of the Canadian adultpopulation wereshown to be seriously challengedin terms of literacy and another26% displayed skillsconsidered to be inadequatefor the successful participation intoday’s “knowledgeeconomy” (Rootman, 2005; StatisticsCanada, 2005).19There are several consequencesof inadequate levels of health literacy. Literacyis related to numerous aspectsof health including health knowledge,health status, anduse of health services (Ad Hoc Committeeon Health Literacy for the Council onScientific Affairs, American MedicalAssociation, 1999). When relatedto healthoutcomes, patients with low literacyare generally 1.5-3 times more likelyto experienceinferior health outcomes inclusiveof knowledge, transitional diseaseindicators,morbidity measures, utilizationof health resources, and generalhealth status (DeWalt,Berkman, Sheridan, Lohr, &Pignone, 2004). In terms of knowledge,there exists apositive and significant relationshipbetween literacy levels and knowledgeof healthservices or health outcomes (DeWaltet al., 2004). Research indicates thatindividualswith low literacy and chronic orinfectious diseases (e.g., diabetes,hypertension,asthma (Williams et al., 1998),or HIV/AIDS (Kalichmanet al., 2000)) have inferiorknowledge concerning their diseaseand its recommended treatment. Furthermore,research has indicated that poorhealth literacy alone isthe most significant predictor ofdisease prevention knowledge whencompared to ethnicity or education (Lindauet al.,2002). To-date, health literacyhas not been examined in relationto health-relatedphysical fitness knowledge.The examination of healthknowledge in relation to physicalfitness (as well ashealth literacy in relationto health-related physical fitness knowledge)has importantpolicy implications for preventativehealth care schematics. Thisis especially applicableto health promotion programsthat employ education asa primary objective. Currently,the prevalence of physical inactivity(51 % of adult Canadians) ranks higherthan allother existing and modifiable hypokinetic(insufficient movement) diseaserisk factors(Statistics Canada, 2003; Warburton,Whitney, & Bredin, 2006a). Moreover,overweight20and obesity within Canada hasreached epidemic measures (Katzmarzyk,Perusse,Rao, & Bouchard, 2000; Katzmarzyk,2002a; Katzmarzyk, 2002; Katzmarzyk,&Janssen, 2004) . Direct healthcare expenditures and indirectcosts associated withphysical inactivity and obesityin Canada are conservatively estimatedto provide aneconomic burden totalling 9.6 billion:5.3 billion for inactivity (1.6 and3.7 billion in directand indirect costs, respectively),and 4.3 billion for obesity (1.6 and 2.7billion in directand indirect costs, respectively)(Katzmarzyk, & Janssen, 2004). Provincially,the healthcare productivity losses and obesitycosts associated with inactivity are conservativelyestimated to cost British Columbiabetween $730 and$830 million per annum (Deacon,2001). Given these dataand the notion that health knowledgeand its dependants aremajor utilities to public healthpromotional agencies (Nayga, 2001),the generation ofempirical evidence regardingthe influence of health knowledgeon health-relatedphysical fitness is clearly warranted.The primary purposeof the present investigation wasto examine the relationshipbetween health-relatedphysical fitness knowledge andobjective measures of health-related physical fitness in youngand middle adulthood. Health-relatedphysical fitnessknowledge was assessedvia the FitSmart, a standardizedhealth-related physicalfitness knowledge examination,whereas, health-related physicalfitness was assessedand interpreted using theCanadian Physical Activity, Fitnessand Lifestyle Approach(CPAFLA). We hypothesizedthat individuals who scored higheron the FitSmart wouldalso demonstrate higher levels ofhealth-related physicalfitness as determined by theCPAFLA in comparisonto individuals who scored loweron the objective assessment ofhealth-related physical fitnessknowledge. Knowledge isa critical factor for establishinghuman behaviour (Andrade,1999); and, moreover, people whounderstand the21concepts of physical fitness are alsomore likely to incorporate physical activityandexercise into their everydaylife (Zhu et al., 1999). Regular physical activity participationis often assumed as a significant predictor of health-relatedphysical fitness(Katzmarzyk, 1998), therefore, wepostulated that individuals with increased fitnessknowledge would display higher levelsof health-related physical fitness.The secondary purpose of this investigationwas to examine the relationshipbetween health literacy andhealth-related physical fitness knowledgein young andmiddle adulthood. Healthliteracy was assessed via the NewestVital Sign. Wehypothesized a positive andsignificant correlation between health literacyand health-related physical fitness knowledge.That is, individuals who scored higheron theNewest Vital Sign would also demonstratehigher scores on the FitSmartin comparisonto individuals displaying lower scoreson the health literacy assessment.MethodsParticipantsWritten informed consent wasreceived from 18 female and16 male participants.Participants were recruited accordingto two age groups: (a) 19 to 29 years(youngadulthood, n = 9 F,9 M; mean age = 24.3 ± 2.6), and(b) 39 to 49 years (middleadulthood, n = 9 F, 7 M; meanage = 42.6 ± 3.7). Individualsthat were pregnant, wereinpoor health (illness or fever)at time of data collection, or were unableto providedocumented physician clearance for physicalactivity in accordance with the CPAFLApre-appraisal screening processwere not permitted to participate. This investigationwas executed in exact accordancewith the ethical guidelines setforth by the University22of British Columbia’s Clinical Research EthicsBoard for research involving humanparticipants (see Appendix B for certificateof research ethics).Assessment of Health-RelatedPhysical Fitness KnowledgeThe FitSmart written examination (Form 1) wasused to assess the health-relatedphysical fitness knowledge of each participant.Developed by Zhu, Safrit, and Cohen(1999), the FitSmart consists of 50 multiplechoice items, measuring six sub-domaincomponents: concepts of fitness; scientificprinciples of exercise; components ofphysical fitness; effects of exercise onchronic disease risk factors; exerciseprescription; as well as nutrition, injuryprevention, and consumer issues. Conceptsoffitness make up 20% of the FitSmartexamination and incorporate questionspertainingto fitness definitions, and the relationship(s)between fitness, physical activity, andhealth. The scientific principles ofexercise component also makes up 20%of the examand includes questions relating to theacute/chronic physiological and psychologicaladaptations to exercise. Questionsassociated with cardiovascular, respiratory andpulmonary function; muscularstrength and endurance; flexibility; andbody compositionare addressed in the components ofphysical fitness section and comprise 20%of theexam. Five percent of theexam includes questions relating to the effectsof exercise onchronic disease risk factors. Exerciseprescription makes up 20% of the examandtakes into account theconcepts of frequency, intensity, duration,mode, self-evaluationand exercise adherence. Last, 15%of the FitSmart examination consistsof itemspertaining to nutrition, injury preventionand consumer issues. Participants wereallocated 45 minutes to completethe examination. Raw scores out of 50,overall23percentages, and categorical percentagescores for each fitness component weregenerated via the FitSmart software fordata analysis.According to Zhu et al. (1999), theFitSmart is an established, valid, and reliabletest to measure knowledge of the fundamentalhealth and fitness concepts at the highschool level of education. As such, theFitSmart written examination was usedin thisinvestigation to establish whether youngand middle-aged adults possess the level ofhealth-related knowledge expectedat a high school level. The FitSmart hasbeenimplemented as the primary measure ofhealth-related physical fitness knowledgeinwell educated adult populations (Losch& Strand, 2004; Petersen, Byrne, & Cruz,2003b). Researchers have also utilizedsections of the FitSmart as adjuncts to seriesofself report measures to incorporatehealth knowledge (Zizzi, Ayers, Watson,& Keeler,2004).Assessment of HealthLiteracyThe Newest Vital Sign was usedto assess level of health literacy (Weisset al.,2005). The Newest Vital Signwas administered to measure essentialgeneral literacyconstructs (prose literacy, numeracyand document literacy) appliedto healthinformation in under five minutes.The Newest Vital Sign assessment isbased on anutritional label froman ice cream container, whereby participantswere provided thelabel and asked to read, comprehend,and apply the available informationto answer sixcontent based questions. Thesix questions were asked orally and participantresponseswere recorded on a specializedscore sheet. Time constraints were not placedonparticipants when answering the sixquestions. The number of correct responses(0-6)24was used to estimate the participant’slevel of health literacy, with higher scoresindicating superior health literacy.Assessment of Health-RelatedPhysical FitnessHealth-related physical fitness was assessedand interpreted using the CPAFLA.The CPAFLA represents a series of standardizedtesting and counselling proceduresdeveloped by the Canadian Society for ExercisePhysiology (CSEP). The assessmentis commonly used as a measure for thehealth-related fitness of the general populationand is administered on over a million Canadianseach year by trained CSEP healthandfitness professionals (CSEP,2003).The CPAFLA appraisal included pre-appraisalscreening and objective measuresof physical activity participation, metabolicfitness, body composition, aerobic fitness,musculoskeletal fitness, and backfitness. The administration ofthe CPAFLA took anaverage of 1-1.5 hours to complete.Pre Appraisal Screening: Each participantwas screened in accordance to theCPAFLA pre-appraisal screeningprotocol which includes: the Physical ActivityReadiness Questionnaire (PAR-Q), subjectiveobservation (e.g., is the participantpregnant? or exhibiting difficulty breathingat rest?), measurement of resting heartrate(bpm) and resting bloodpressure (mmHg). Resting heart rate andblood pressure weremeasured after five minutesof seated rest. Resting heart rate was evaluatedvia the useof a PolarTMheart rate monitor. Restingblood pressure was manuallyassessed with astandard sphygmomanometerand stethoscope (Almedic) on theleft arm.Individuals were momentarilyprohibited from participating inthe appraisal if theyanswered yes to one or more of thequestions on the PAR-Q, were ill or hada fever,25had difficulty breathing at rest,coughed persistently, were currently oncertainmedications contraindicated withthe assessment, had lower extremityswelling, retaineda resting heart rate 100bpm, or a resting blood pressure 144/94mmHg.Participants who were screenedout in the pre-appraisal were referredto their physicianfor a medical examinationand clearance before proceedingwith the appraisal. Theseparticipants were given a CPAFLAPhysician Summary anda Physical ActivityReadiness Medical Examination(PARmed-X) form. Participantswho required physicianclearance and did notreceive it were excluded from theinvestigation.Healthy Physical ActivityParticipation: Current physicalactivity levels weremeasured via the Healthy PhysicalActivity Participation Questionnaire.Thequestionnaire examinesthree characteristics of participation:frequency, intensity, andperceived fitness. For eachof these characteristics thereis a statement followedby alist of options. Participantswere instructed to choose theoption that most closelydescribed them. Based onthe participant’s answers to thethree questions they weregiven a score rangingfrom 0-11, which was thenconverted into a oneof five healthbenefit ratings/zones from0-4 pertaining to their currentlevel of physical activityparticipation. These healthbenefit zones are standardizedthroughout the CPAFLAcomposite measuresand are translated asfollows: 0 = Needs Improvement(considerable health risks);I = Fair (some health benefitsbut also some health risks);2= Good (many health benefits);3 = Very Good (considerable healthbenefits); and 4 =Excellent (optimal healthbenefits).Healthy Body Composition:Composite body compositionwas calculated bycombining Body Mass Index(BMI, kg/rn2),Waist circumference(WC, cm), and the sumof five skin folds(505S, mm) according to the CPAFLAfitness assessment protocol.26Height (cm) was measuredto the nearest 0.5 cm witha wall mounted stadiometer(SECA). Weight (kg) was recordedto the nearest 0.1 kg using an electronicscale(SECA). The participant’s shoeswere removed and light clothing(e.g., shorts and a Tshirt) was worn for both of thesemeasures. The ratio of body weightin kilogramsdivided by height in meterssquared was used to determineBMI.Waist circumference was determinedby positioning the anthropometric tapehorizontally mid-way betweenthe iliac crest and the bottom ofthe rib cage to thenearest 0.5 cm. All measurementsfor the sum of five skinfoldswere landmarkedaccording to CPAFLA protocoland made on the right sideof the body to the nearest0.2mm with HarpendenTM calipers.The five skinfolds in order ofmeasurement were:Triceps, Biceps, Subscapular,Iliac Crest and Medial Calf. Themean of twomeasurements for each skinfoldwas recorded.Each participant received ascore ranging from0-4 pertaining to their bodycomposition. This score wasconverted into a health benefitrating ranging from NeedsImprovement (0) to Excellent(4).Healthy Aerobic Fitness: Cardiovascularfitness was assessed usingthe modifiedCanadian AerobicFitness Test (mCAFT). ThemCAFT is a valid and reliable,predictive,submaximal, and progressiveexercise test designed specificallyfor the generalpopulation (CSEP,2003). The test consistsof one or more sessions of threeminutes ofstepping at predeterminedspeeds based on gender andage. At the end of each threeminute stage, immediate post-exerciseheart rate was recorded viathe use of a highquality Polar heartrate monitor. If the individual’sheart rate was below theirpredetermined post-exerciseceiling heart rate [85% of predictedmaximum (220-age)]at the end of the three minutestage they continued onto thenext stage at a more27intense cadence. The test wasterminated once the participantreached theirpredetermined post-exercise ceiling heartrate. Other criteria for test terminationcaninclude: complaints of dizziness,noticeable staggering, inabilityto maintain cadence,extreme leg pain, nausea, chestpain, or signs of facial pallor. Anaerobic fitness scorewas then generated via the followingequation: lOx [17.2+ (1.29 xO2cost) - (.09 x wt. inKg) — (.18x age in years)] (CSEP,2003, pg.7-31). This score wasconverted into ahealth benefit score/rating rangingfrom Needs Improvement(0) to Excellent (4).Healthy Musculoskeletal Fitness:Composite musculoskeletalfitness was calculatedby combining weighted scoresfrom a set of 6 measures:grip strength, push-ups, sitand reach, partial curl-ups,leg power, and back extension.Maximum grip strength wasdetermined in kilograms(kg) by summing the maximumscore from the greater oftwotrials of the right and lefthand with the use of anAlmedic hand dynamometer.Individuals were askedto complete as many push-upsas possible. Females followedthe same push-up procedureas males except their kneeswere used as the fulcrum.Sit-and-reach scores weredetermined with the useof a standard flexometerby themaximum distance(cm) reached (forward trunk flexion)over two trials. Priorto the sit-and-reach participantswere instructed to stretch theirhamstrings (modified hurdlerstretch) and remove theirshoes. For partial curl-ups, participantslay supine with theirknees bent at a 90° anglewith both feet on the floor andperformed as many10 cmpartial curl-ups, at a 50 beat/mmcadence, as possible inone minute to a maximumof25. Vertical jump wasassessed from the maximumof 3 trials with the use of theVertecTMThe jump height (cm) was determinedby the participant jumping as highas possiblefrom a semi squat position(knees bent at 90°, armsand shoulders maximallyextended). Peak leg power,in watts (W), was thendetermined with the use ofthe28Sayers Equation (Peak Leg Power(W) = [60.7 x jump height (cm)]+ [45.3 x body mass(kg)] - 2055). Due to the amountof stress the back extension measureplaces on theback, a screening test was performedprior to administration. Ifparticipants felt anydiscomfort during the screeningtest, the back extension wasnot completed. For thetest, participants were asked to supporttheir upper torso (iliac crest andabove) in ahorizontal position froma 46 cm elevation with no rotationor lateral shifting for as longas possible to a maximum of 180seconds. The numberof seconds the horizontalposition was maintained wasrecorded.Each participant receiveda score ranging from 0-4 relatingto theirmusculoskeletal fitness.This score was then convertedinto a health benefit ratingranging from NeedsImprovement (0) to Excellent(4).Healthy Back Fitness: Weightedscores for the following CPAFLAcomponents:physical activity participation,waist circumference, sit-and-reach,partial curl-ups, andback extension, were combinedto provide an indicationof composite back fitness.These components arethe best discriminatorsfor healthy or unhealthyback fitness(CSEP, 2003). Eachparticipant received a scoreranging from 0-4 relatingto their backfitness. This score wasthen converted intoa health benefit rating rangingfrom NeedsImprovement (0) toExcellent (4).ProcedureParticipants took partin two data collectiondays. On day 1, health-relatedphysical fitness knowledgewas assessed via the FitSmart,as well as general andhealth literacy using theNewest Vital Sign. Day Ialso functioned to familiarize theparticipants with the CPAFLAhealth-related fitness assessmentprotocols and29preliminary instructions as per CPAFLAprotocol. On day 2, participantscompleted theCPAFLA assessment ofhealth-related physical fitness.Recommendations andguidance pertaining to each CPAFLAmeasure were provided bya Canadian Society forExercise Physiology - CertifiedExercise Physiologist (CSEP-CEP)at the end of thefitness appraisal as required bystandardized CPAFLA protocols. The CSEP-CEPis themost advanced health and fitnesspractitioner certificationin Canada allowing membersto work with high performanceathletes, the general population(across the lifespan),and varied clinical populations.A CSEP-CEP is sanctionedto performassessments/evaluations,prescribe conditioning exercise, provideexercisesupervision/monitoring,counseling, healthy lifestyle education,and outcome evaluationfor “apparently healthy” individualsand/or populations with medicalconditions,functional limitations or disabilitiesthrough the applicationof physical activity/exercise,for the purpose of improvinghealth, function and work or sportperformance (CSEP,2007).Statistical AnalysisStatistical significance wasset a priori at p < 0.05 for all analyses.All figures andtabular values are reportedas the mean ± standard deviation. Eachvariable was testedfor normal distribution (i.e.,skewness or kurtosis) and was transformedif necessary. Ageneral linear model (GLM) univariateanalysis of variance (ANOVA) wasimplementedto examine the differences betweenage groups (young adulthood, middle adulthood)and gender (female, male)for each dependant variable. Regressionanalyses,incorporating age, gender,income, and education, as wellas bivariate correlations wereemployed to examine therelationship(s) between health-related physicalfitness30knowledge (FitSmart) and health-relatedphysical fitness (CPAFLA) scores. Thesameanalyses were performed to examinethe relationship(s) between health literacy(Newest Vital Sign) and health-relatedphysical fitness knowledge scores.Health-related physical fitness knowledgepercentage scores (x/1 00) were usedas the primary indicators of health knowledge.Indicators of physical fitness wereanalyzed as composite scores (HealthyPhysical Activity Participation (x14), HealthyBody Composition (x/4), Healthy AerobicFitness (x14), Healthy Musculoskeletal Fitness(x/4), Healthy Back Fitness (x/4)) andcompartmentalized (e.g., Healthy MusculoskeletalFitness (grip strength (x/4), push-ups(x/4), sit and reach (x/4), partial curl-ups (x/4),legpower (x/4), and back extension (x/4))if significance was identified. Lastly, theNewestVital Sign scores (x/6)were used as the primary indicators ofhealth literacy.Resu ItsParticipantsAll participants resided in Vancouver,British Columbia or the Greater VancouverRegion. Most participants (79.4%)were currently enrolled in orhad completed postsecondary education (8.8%college diploma, 47% undergraduatedegree, 23.5%graduate degree). The remainingone fifth (20.6%) of the participants werecurrentlyenrolled in or had completeda secondary level of school education. Withrespect toethnicity: 47.1% were Caucasian,8.8% were Mid Eastern, 14.7% were EastIndian,23.5% were Asian, and 2.9% were AboriginalCanadian. For income: 61.8% grossed$39000/year (32.35%$ 20000; 29.4% = $ 20-39000), and 32. 3% grossed$40000/year (11.76%= $40-59,000, 17.6 % = 60-79000,2.9%= $80-90000). Theremaining 6% did not disclose theirincome. Participant physical characteristics(e.g.,31height, weight, body mass index,waist circumference, heart rate,and blood pressure)are outlined in Table 2.1 as a functionof age and gender.No adverse effects were exhibited byany of the participants during the physicalfitness appraisal. However,three individuals (1 young femaleadult, 1 middle-agedfemale adult, and I middle-aged maleadult) were not permittedto participate in thisinvestigation due to contraindicationswith exercise that could not be clearedby aphysician in a timely fashion (i.e., unknownsevere chronic abdominal pain, surgeryofthe eye musculature causing bleeding duringexertion, and undiagnosedyet reoccurringchest pains). In addition, a total of 4participants were screened out ofselect physicalfitness measures due to the CPAFLAprotocol and the professional discretionof theCSEP-CEP during testing. Onefemale middle-aged adult wasexcluded from thevertical jump test and theback extension test due to a previousyet treated lumbernerve impingement. Another femalemiddle-aged adult was excluded fromthe aerobic,vertical jump, partial curl-up,and back extension tests dueto complaints of transientlight headedness. A young adultmale was screened out from performingthe backextension test due to noticeablepain sensed during the back extensionpre-screeningtest. A second youngadult male did not perform the verticaljump test due to a previousankle injury. With regardto the health-knowledge assessment,participantsdemonstrated no problemscompleting the FitSmart withinthe allotted timeframe.Health-Related Physical FitnessKnowledgeTable 2.2 lists theFitSmart overall raw scores, overall percentagescores, as wellas the sub-domain componentpercentage scores for the totalsample and according toage group and gender. Theaverage test score out of the maximum50 was 35.9 ± 5.8.32The lowest score achievedon the test was 25 while the highestscore was 46. Figure2.1 displays the FitSmart overallpercentage scores by ageand gender. Analysis of thesub-domain components showedthat participants scored highest onthe Concepts ofFitness section (mean = 78.9%)and lowest on the Scientific Principlesof Exercisecomponent (mean = 67.9%)and the Effects of Exerciseon Chronic Disease RiskFactors (mean = 66.0%). Nosignificant differences were foundbetween males andfemales or young and middleadult groups for overall, aswell as sub-component health-related physical fitness knowledgeFitSmart scores.Health-RelatedPhysical Fitness AssessmentThe composite meanscores (out of 4) were: HealthyPhysical ActivityParticipation (1.9 ± 1.2), HealthyBody Composition (2.6± 1.1), HealthyAerobic Fitness(2.1 ± 0.9), Healthy MusculoskeletalFitness (1.8 ± 1.0), and Healthy BackFitness (2.0 ±1.0).Table 2.3 shows the CPAFLAcomposite scores forthe total sample, as wellasby age and gender. Significantdifferences were foundfor healthy physical activityparticipation as well as healthymusculoskeletal fitnessas a function of gender. Malesengaged in significantly greaterlevels of physical activity whencompared to females inboth young and middleadulthood (Figure 2.2). In contrast,female’s musculoskeletalfitness levels were superiorto males in both age groups(Figure 2.3). Female restingheart rate was significantly higherin comparison to males (Figure2.4), while there wasno main effect for age.Analysis also revealed no significantdifference for systolic anddiastolic blood pressureas a function of age and gender (referto Table 2.1 for sampleand group values).33The body compositionmeasures of height,weight, body mass index, waistcircumference, and sumof five skinfold valuesare reported in Table 2.1as a function ofage and gender. Significantdifferences were shownfor height, weight, and waistcircumference betweenmales and females. Waistcircumference was theonly measureto demonstrate a significantdifference between youngand middle adulthood.Characteristically, all malevalues for height, weight,and waist circumferenceweresignificantly elevated in comparisonto females (refer to Figures 2.5,2.6, and 2.7respectively). In terms ofage, middle-aged adults showedsignificantly larger waistcircumference measuresin comparison to youngadults (Figure 2.7).The mean aerobicfitness score was 413.5.Based on mean age groupvalues,aerobic fitness raw scoressignificantly declined(19.8 %) from young adulthoodtomiddle adulthood, 454.3to 364.6 respectively (Figure2.8). In addition, male’srawaerobic scores were significantlygreater than females inboth age groups (Figure2.8).No significant differenceswere found betweenage and gender for compositeaerobicfitness health benefit ratings.Grip strength values weresignificantly higher for malesin both young and middleadulthood (Figure 2.9).Flexibility was significantlydifferent between malesand femalesin both young and middleadulthood with femaleshaving increased scoresacross age(Figure 2.10). Verticaljump measurements significantlydecreased (23.8 %) fromyoung(38.0 cm) to middle(29.0 cm) adulthood, withan aggregate samplemean equal to 34.2cm (Figure 2.11). Moreover,female vertical jump measurementswere significantlylower than males in bothyoung and middle adulthood(Figure 2.11). Significantdifferences were foundas a function of gender forleg power, with males generating34more power then woman (Figure 2.12). No significantdifferences were found for agegroup or gender for push-ups, abdominal endurance,and back extension measures.Health-Related Physical FitnessKnowledge and Health-Related Physical FitnessPearson correlations for each CPAFLA compositemeasure and the overallHealth-related Physical Fitness Knowledgescore are listed as a matrix in Table 2.4. Ouranalysis showed that composite musculoskeletalfitness was significantly correlated (r=0.40) with knowledge (FitSmart score). Additionally,when controlling for sociodemographic variables (age, gender, income,and education) in the regression analysis,results indicated that health-related physicalfitness knowledge was the strongestunique contributor to musculoskeletalfitness (standardized B = 0.59,p< 0.05). Uponfurther inspection within musculoskeletalfitness, health-related physical fitnessknowledge was significantly correlatedto musculoskeletal fitness measures of muscularendurance (refer to Table 2.5). Specifically,there was a positive and significantcorrelation between health-related physicalfitness knowledge and push-ups (r =0.37),as well as knowledge and partialcurl-ups (r = 0.41).HealthLiteracy and Health-Related Physical FitnessKnowledgeTable 2.6 lists the Newest Vital Signhealth literacy scores for age group,gender,and the total sample. No significantdifferences were found betweenage group orgender for health literacy. With respectto knowledge, our analysis demonstrated thathealth literacy was positively and significantlycorrelated to health-related physicalfitness knowledge (r = 0.63). Moreover,when controlling for sociodempgraphicvariables(age, gender, income and education),our regression analysis indicated thathealthliteracy was the strongest individualpredictor of health-related physical fitness35knowledge (standardized B =0.47,p< 0.05). Upon FitSmart sub-domain componentanalysis health literacy was significantlycorrelated, in increasing order, to scientificprinciples of exercise (r = 0.44), componentsof physical fitness (r = 0.45), conceptsoffitness (r = 0.49), nutrition injury preventionand consumer issues (r = 0.62), and effectsof exercise on chronic disease risk factors (r= 0.67). Refer to Table 2.7 for Pearsoncorrelations of health literacy for overalland sub-domain component health-relatedphysical fitness knowledge scores.DiscussionCurrently, the literature delineating therelationship between health-relatedphysical fitness knowledge,measures of health relatedphysical fitness, and healthliteracy is limited as well as inconsistent.As such, the purpose of this investigationwasto examine the relationship between: 1)health-related physical fitness knowledgeandobjective measures of health-related physicalfitness in young and middle adulthood,and 2) health literacy and health-relatedphysical fitness knowledgein young and middleadulthood. Strength of the present investigationwas the utilization of objectivemeasures of both health knowledgeand physical fitness. First, a holisticandstandardized measure of health-relatedphysical fitness knowledge (the FitSmart)wasadministered as opposed to openended/lobbied questions (Aviset al., 1990), bimodalsurveys (Liang et al., 1993),telephone interviews (Morrowet al., 2004) or a singlequestion (Fitzgerald, Singleton,Neale, Prasad, & Hess, 1994).In addition, we used ahealth-related physical fitnessassessment systematically developedand standardizedfor use within the general Canadianpopulation. To examine health literacy,the NewestVital Sign was employed, which isa brief yet valid and reliable measureof the generalliteracy constructs applied tohealth information.36Health-Related Physical FitnessKnowledgeResults from the FitSmart examinationillustrate that participants were mostcapable at identifying the basic definitionsof fitness and the positive relationshipbetween physical activity and health(Concepts of Fitness (x = 79%)); however,theywere least capable at correctly answeringquestions related to acute/chronicphysiological/psychological processes andbodily adaptations to exercise (ScientificPrinciples of Exercise (x = 68%)as well as Effects of Exercise on Chronic DiseaseRiskFactors (x = 66%)). These resultssupport findings in the current literature, wherebyphysical education majorsdemonstrated the lowest scores onScientific Principles ofExercise (x = 68%) (Petersonet al., 2003). These results are not surprisingas thecontent matter of the scientific principlescomponent of the FitSmart is generallymorecomplex, requires a fundamentalbase of knowledge, and fits intoa higher taxonomiceducational category (i.e., application)(Bloom & Krathwohl, 1956).For example, tosuccessfully answer the question,“Which of the following isa characteristic of the blood of highlyfitindividuals?A) Greater blood volumeand more red blood cells,B) Greater blood volume and fewerred blood cells,C) Less blood volume and morered blood cells, andD) Less blood volume and fewerred blood cells”,individuals are required to apply previouslyacquired knowledge (e.g., bloodcomponents, and thehaematological or physiological adaptationsto exercise) infour different ways(options A-D) to correctly choose theone best answer. This isclearly more challenging andcomplex than being asked a questionthat falls intoa lower taxonomic educational level(e.g., knowledge) which requiresthe37exhibition of previously memorizedbasic concepts, facts and or terminologytoidentify the correct answer.Peterson et al. (2003) collected data regardingprevious academic experiences(i.e., number of exercise physiology courses taken)to substantiate their findings.Physical education majors who participatedin more than one exercise physiologycourse were more likely to score higher onthe knowledge exam. Practically, in-depthexercise physiology courses are notan option for most individuals, regardless ofeducation. In addition, only 10% ofthe physical education majors in Peterson’sinvestigation opted to take more thanthe one required exercise physiologycourse. Asolid foundation of exercise physiologycontent knowledge is essential for all health carepractitioners and educators to ensurethe appropriate translation to students,clients,patients, and/or participants (Bulger, Mohr,Carson, Robert, & Wiegand, 2000). Thus itis important to consistently encourage and providethe opportunity for all individuals tolearn foundational and higher-order conceptsby publishing them repeatedly via creativeand comprehendible media vehicles,as well as integrating them into appropriateeducational curricula (Bulger et al.,2000).Health-RelatedPhysical FitnessIt is clear that most participants inthis investigation failed to achieve levelsofphysical fitness associated with optimalhealth status (i.e., achieving an excellentratingof 4.0) on the components of the CPAFLA.This is consistent with other data that showsthat the majority of Canadians are failingto meet the physical activity requirementssetforth by Health Canada (Statistics Canada,2003; Warburton, Whitney, & Bredin,2006a). Moreover, based on the lowsocio-economic status of this sample, as indicated38by income (61 % earned $390001yr),and the documented relationshipbetween lowsocioeconomic status, poor healthbehaviours (e.g., malnutrition,physical inactivity,inadequate health care utilization)and poor health outcomes(increased morbidity andmortality), our results are consistentwith previous literature (Adleret al., 2002;(Feinstein, 1993).With respect to age, significantdifferences were revealed formeasures of bodycomposition (waist circumference),aerobic fitness (mCAFT score),and m uscu loskeletalfitness (vertical jump).For each of these measuresthe middle adulthood groupdemonstrated significantly worsehealth-related scores incomparison to the youngadulthood group. Waist circumferencewas significantly larger (12%), aerobic fitnessscores were significantlylower (20 %), and verticaljump measurements weresignificantly less (24%). These results provideinsight into the relationship betweenageand health-related physicalfitness. Decrements in fitnessthat result as a functionofincreasing age are commonand have the abilityto produce substantial and detrimentaleffects towards healthand wellbeing if not mediatedappropriately during the agingprocess (WHO, 2002).Thus, there is an imperativeneed to stress the importanceofregular physical activityparticipation and healthy lifestylebehaviours (e.g., nutrition,stress relief, personal hygiene)to middle and older adulthoodcohorts (Galloway& Joki,2000). Moreover, given that physicalactivity behaviours trackfrom childhood toadolescence and intoadulthood, preventativehealth promotion measuresthat targetchildren are strongly recommended(Malina, 1996). A suggestedprimary action shouldbe to increase people’shealth-related knowledgebase. Knowledge is a backgroundfactor which contributesto the formation of behaviouralintentions (Ajzen & Manstead,2007), as well asa recommended first step in theTranstheoretical modelof behaviour39change (Prochaska, DiClimente, & Norcross,1992). Importantly, our results suggestthat knowledge is a significant correlateto and predictor of health-related physicalfitness measures. Therefore, healthcare practitioners at all levels should aim toincrease people’s health-related knowledge.Unfortunately, many primary carephysicians (who care for middle-agedadults) frequently overlook the importanceofprescribing physical activity and/or educatingpatients on the benefits of regular health-related physical activity participation (Galloway& JokI, 2000). Insufficient physicalfitness knowledge and lack of timeare two major barriers physicians reportwhendiscussing their lack of exercise counselling(Abramson, Stein, Schaufele,Frates, &Rogan, 2000).In addition, the 39-49 age range is onewhere individuals generally endureextreme levels of stress (e.g., work, family,finances, and first occurrences of healthproblems). Likewise, this isa recognized age range wherepast negative healthbehaviours (e.g., smoking, poordiets, physical inactivity) startto take a more substantialrole in health degradation.In extreme cases this is an age wherethe previous negativehealth behaviours cause severedebilitation (e.g., cardiovasculardisease,musculoskeletal impairments)leading to impinged qualityof life until death (WHO,2002). In summary, thefindings of this investigationsupport the need to providechildren, adolescents, andadults with knowledge concerninghealth-related physicalfitness. We recommend healthpromotion initiatives that highlightthe relationshipbetween health knowledge, physicalfitness, and health outcomes.40Health-Related Physical FitnessKnowledge and Health-Related Physical FitnessBased on our results, musculoskeletalfitness was shown to be a significantcorrelate to health-related physicalfitness knowledge and health-related physicalfitnessknowledge was the strongest individualcontributor to musculoskeletal fitness. Withinmusculoskeletal fitness, health-relatedphysical fitness knowledge was correlatedtomuscular endurance measures: specifically,push-ups and partial curl-ups. Thesefindings are very compelling,applicable, and important given the documentedindirectand direct relationship(s) between musculoskeletalfitness and health status. Indirectly,musculoskeletal fitness is relatedto health status via body compositionas well ascardiovascular fitness(Warburton, Gledhill, & Quinney, 2001a).In terms of bodycomposition, musculoskeletal strengthand endurance training is knownto result insignificant improvements infat free mass attributable to muscularhypertrophy. Theincreases in fat free/muscle masshave the ability to augment metaboliccapacities (i.e.,increased resting metabolic rates(RMR)) which, in turn, contributeto a healthier bodycomposition via increasedfat oxidation and energy expenditure(Ballor & Poehlman,1992; Poehlman et al., 1992).Significant improvements incardiovascular/aerobicfitness (maximal oxygen consumption,VO2m) are rarely documented due toimprovements in musculoskeletalfitness alone (Warburton, Gledhill,& Quinney, 2001a).However, it is important to acknowledgethat improvements in thefunctionality of themusculoskeletal system operateto enhance an individual’s capabilityto engage inphysical activity pursuits andactive lifestyle behaviours.Additionally, theseimprovements in functional statusare of significant importanceto the elderly, disabled,and or diseased populationsas they serve to increase the capacityto execute activitiesof daily living (e.g., householdcleaning, shovelling snow, carryingshopping bags) and41therefore, provide functional independence(Warburton, Gledhill, & Quinney, 2001a;Warburton, Gledhill, & Quinney, 2001b).Directly, improvements in musculoskeletal fitness(strength and endurance) mayhave a positive and significant impacton the risk factors for cardiovascular disease;namely, blood based lipid and lipoproteinprofiles, hypertension, abdominalobesity,RMR, and glucose homeostasis(Warburton, Gledhill, & Quinney, 2001a).This is ofmajor importance given that chronicdiseases, including cardiovasculardisease (CVD),cancer, and diabetes, are the leadingcauses of morbidity and death inCanada (Stone& Arthur, 2005). Cardiovascular diseasewas the single greatest causeof death in 2001(men and woman combined,all ages), accounting for onein three (36%), orapproximately 75,000 total deaths(Stone & Arthur, 2005). Additionally, theeconomicburden of cardiovascular diseaseis exorbitant. Cardiovasculardisease remains thesingle most expensive diagnosticcategory on the health care budget,and the direct andindirect CVD related costs in Canadacurrently exceed$18 billion/annum (Stone &Arthur, 2005). In addition tothe physiological benefits, improvedmusculoskeletal fitnessmay improve multiple componentsof psychological well being, includingself efficacy,mood state, anxiety, perceptionsof anger, and tension (Warburton,Gledhill, & Quinney,2001 a).In summary, “high levels ofmusculoskeletal fitness are associatedwith positivehealth status and health,and low levels of musculoskeletal fitnessare associated withlower health status”(Warburton, Gledhill, & Quinney, 2001b,p.217). Correspondingly,perceived health has also beenassociated with levels of musculoskeletalfitness in bothmen and women. In general,lower levels of musculoskeletalfitness are associated withreduced perceptions of healthand higher levels of musculoskeletalfitness are42associated with elevated perceptionsof health (Suni et al., 1998). It is essentialforpreventative health practitionersto highlight the musculoskeletal fitnessto health andhealth-related physical fitness knowledgeto musculoskeletal fitness relationships in anattempt to educate individuals to adopthealthy and active lifestyles that functiontoincrease health status.The following points should be consideredto discuss why musculoskeletal fitnesswas the only composite fitness measureto be significantly correlated with health-knowledge. Firstly, other components(e.g. aerobic fitness) were close to reachingsignificance. Given that thisinvestigation only utilized 34 participants,it is reasonable toassume that we were slightlyunderpowered. A study examiningthis relationship with amuch larger sample is recommendedto enhance the current findings. Secondly,another potential contributor tothese findings is the actual measurementsbeing taken.For example: musculoskeletalfitness is a composite measuredevised from sixchallenging measurements (i.e.,grip strength, push-ups, curl-ups, flexibility,verticaljump, and back extension). Providedthat musculoskeletal fitness incorporatesthegreatest amount of testing elements,the composite scores should bemore reflective offitness levels and as a resultmay have been more indicative of healthknowledge.Moreover, musculoskeletalfitness may be a better determinantof current physicalfitness levels as othermeasures (e.g. aerobic fitness)are known to show largedetraining and consistentaging effects in comparison (CSEP,2003).When looking intohow an individual’s knowledgeof health-related physicalfitness translates into behavioursthat promote the development, maintenance,andimprovement of fitness, the Theoryof Planned Behaviour is a viable framework.Thetheory suggests a modelstipulating how human actionis generated given that the43active behaviour is intentional. Behavioural intentionsare assumed to result sensiblyfrom beliefs (behavioural, normative, andcontrol) about performing the behaviour(Ajzen & Fishbein, 2005). It is importantto note the beliefs people possess regardingthe performance of a particular behaviour are influencedby a broad assortment ofsituational, cultural, and personal background factors(knowledge being one of them).These beliefs can be accurate, inaccurate,biased, and even illogical. Nevertheless, thisset of beliefs is the cognitive foundation that guideshuman action, which is influencedby three major factors: a positive or negative assessmentof the behaviour (attituderegarding the behaviour), perceivedsocietal influence to execute ornot execute thebehaviour (social norm), and perceivedability to execute the behaviour (perceivedbehavioural control). Thus, accurateknowledge pertaining to the behaviour at handisessential in guiding human action. Theamalgamation of attitude towards thebehaviour,subjective norm, and perception of behaviouralcontrol leads to the formation of thebehavioural intention (strongest predictorof human behaviour). In general, themorefavourable the attitude andsubjective norm, in combination with increasedperceivedbehavioural control, a person’s intentionto perform the desired behaviour willbegreatest. Lastly, given a significantdegree of actual control over the behaviour,individuals are expected to executetheir intentions when presentedwith an opportunity.Health Literacy and Health-RelatedPhysical Fitness KnowledgeTo the best of our knowledge, thisis the first investigation to incorporatetheassessment of health literacy in relationto physical fitness knowledge. Ourresultssuggest that health literacy is a significantcorrelate to and predictor of health-relatedphysical fitness knowledge. These resultsare in line with previous health literacy44research looking at the relationshipbetween health literacy and other subsets ofhealthknowledge (e.g., disease prevention,disease treatment and management,and healthcare utilization) (Weiss et al., 2005; DeWaltet al., 2004; Lindau et al., 2002; Ad HocCommittee on Health Literacy forthe Council on Scientific Affairs, AmericanMedicalAssociation, 1999; Williamset al., 1998). Given that health literacyis broadly defined asan individual’s ability to obtain, process, andunderstand basic health-relatedinformation in orderto navigate the health care system and make appropriatehealth-related decisions, its relevance isof much importance to the health-carepractitioners inall disciplines (Parker et al., 2003).Individuals with limited literacy have lessknowledgeconcerning their health problems,elevated health care costs, more hospitalizations,andinferior health status thanthose with sufficient literacy (Weiss etal., 2005). Theserelationships are uniform acrossstudies and continually exist when adjustingforpossible confounding socio-demographicfactors (Weiss et al., 2005). In lightof ourresults and the supporting literature,the value of health literacy assessmentwithin thehealth and fitness disciplineshould be acknowledged. Health literacyassessments(such as the Newest Vital Sign) aregenerally brief (e.g., 3-5 minutes) andprovide theability to increase knowledgetranslation in an individuallytailored fashion (Weiss et al.,2005). This in turn, has the potentialto result in increased clientto practitionercommunication leading to increasedclient knowledge retention. This increasedretention then has the capacityto translate into improvementsof essential healthconstructs specific to the knowledgebeing provided.45ConclusionGiven the empirical evidence relating musculoskeletalfitness to health status andthe findings from the present investigationrelating health-related physicalfitnessknowledge to musculoskeletal fitness,it is imperative that individuals are providedopportunities to access and acquireknowledge pertaining to health-related physicalfitness. It is important to integrate educationof this knowledge into multidimensionalhealth promotion and educationinitiatives whenever possible. Additionally,it is essentialfor the advanced concepts relatingto the scientific principles of exercise(acute/chronicphysiological and psychologicalchanges that our bodies endure via exercise)to beaddressed in educational materialsto the general population. Moreover,the relationshipbetween health literacy, healthoutcomes, and health knowledgeis one of much valueand should be promoted throughoutthe health and fitness industry.Health carepractitioners should makeuse of brief standardized assessmentslike the Newest VitalSign in order to individuallytailor the communication andguidance providedto clients,patients, and students.46Table 2.1. Participant Physical Characteristics(mean ± SD)Female Male(n=18) (n=16)Physical Young Middle-AgeYoung Middle-Age TotalMeasurements (n = 9)(n = 9) (n = 9) (n 7) (n= 34)161.3 ± 7.9 162.3 ± 6.98 174.9 ± 6.2176.3 ± 7.8 168.3 ± 9.8Height(cm)*59.5 ± 20.0 67.4 ± 11.9 75.6± 13.7 87.3 ± 16.5 71.6 ± 18.1Weight(kg)*22.7 ± 6.4 25.5 ± 3.0 24.7± 4.0 28.0 ± 5.2 25.1 ± 5.0BMI (kgm2)Waist71.6 ± 11.8 83.3 ± 9.4 87.9± 15.1 96.0 ± 13.0 84.0 ± 14.8Circumference(cm)**Resting Heart 76.4 ± 7.2 73.1 ±10.8 64.7 ± 7.6 63.7 ± 8.869.8 ± 10.0Rate (bpm)*Resting Systolic101.8± 12.8 110.9±15.4110.2±9.8 113.1 ± 11.8 108.8±12.9Blood Pressure(mmHg)Resting Diastolic68.9 ± 5.6 72.9 ± 8.8 74.2± 8.4 77.1 ± 8.3 73.1 ± 8.0Blood Pressure(mmHg)Note.*significantdifference for gender(p <0.05);**significant difference for age andgender(p<0.05).47Table 2.2. FitSmart Health-Related PhysicalFitness Knowledge Scores (mean ± SD)Female Male(n=18) (n=16)Measurement Young Middle-AgeYoung Middle-AgeTotal(n=9) (n=9) (n=9)(n=7) (n=34)OveraN Score36.8 ± 7.2 35.6 ± 4.5 35.6 ± 5.435.6 ± 6.8 35.9 ± 5.8Overall Score(%) 74.1 ± 14.3 71.1 ±9.071.1 ± 10.9 71.1 ± 13.6 71.9±11.6Concepts ofFitness (%) 77.7 ± 14.0 77.2± 18.1 79.9 ± 15.2 81.6 ± 12.9 78.9± 14.7ScientificPrincipals of 69.9 ± 20.161.3 ± 10.5 68.6 ± 14.7 72.9± 10.8 67.9 ± 14.7Exercise (%)Componentsof Physical 74.4 ± 20.4 78.6± 13.7 67.9 ± 11.7 63.7 ± 18.371.6 ± 16.5Fitness (%)Exercise onChronic 72.3 ± 21.059.2 ± 19.7 69.4 ± 18.2 62.0± 26.6 66.0 ± 20.9Disease RiskFactors (%)ExercisePrescription 72.2±44.1 72.2±44.155.6±52.7 100±0.0 73.5±43.1(%)Nutrition InjuryPrevention 68.8 ±17.7 69.6 ± 15.3 70.4 ± 16.670.1 ± 26.8 69.7 ± 18.2and ConsumerIssues (%)48Table 2.3. CPAFLA Health-RelatedPhysical Fitness Composite Scores (mean± SD)Female Male(n=18) (n=16)Composite YoungMiddle-Age Young Middle-AgeTotalMeasurement (n= 9) (n = 9) (n = 9)(n = 7) (n = 34)HealthyPhysical1.4± 1.0 1.2± 1.1 2.6±1.1 2.7± 0.8 1.9± 1.2ActivityParticipation*Healthy Body2.9 ± 1.3 2.4 ± 1.0 2.8± 1.2 2.1 ± 1.1 2.6 ± 1.1CompositionHealthyAerobic2.1 ± 1.2 2.1 ± 1.4 2.1±0.8 1.9± 0.7 2.1 ± 1.0FitnesstHealthyMusculoskeletal 1.9±0.92.4± 1.2 1.1 ±0.6 1.7±0.951.8± 1.0Fitness*HealthyBack1.9±0.9 2.0± 1.51.9±0.8 2.1 ±0.72.0± 1.0FitnessNote:*significant difference for gender(p < 0.05;tn = 33 (1 female middle-aged adultdid not complete aerobicfitness test due to light headedness).49Table 2.4. Health-Related Physical FitnessKnowledge and Physical FitnessCorrelationsHealthyPhysical Composite HealthyComposite CompositeActivity Body AerobicMusculoskeletal BackMeasure Participation CompositionFitness Fitness FitnessPC -.063 .169 .249395*.178FitSmartScore Sig..725 .340.162 .021 .313N 34 3433 34 34Note:PCPearson Correlation.*Correlation is significant at the0.05 level (2-tailed).50Table 2.5. Health Knowledgeand Musculoskeletal ComponentCorrelationsGripPartial Curl- VerticalPush-ups FlexibilityMeasure Strengthups JumpP C .329.368*.2914j3*.238FitSmartScore Sig. .057.035 .100 .019.198N 3433 3332 31• Note: Pearson Correlation.*Correlation is significantat the 0.05 level (2-tailed).u6i184!A[F961.F61701.FVL.F917EOFL94SM9NOqJ(17=u)(L=u)(a=u)(6=u)(6=u)ieoie 6 V-9IPPWJ6 unoAa6y-eppij6 unoAI1oJ-(9L.=u)(81=u)uwansej(asiuEow)S8JOOSA3EJO1!1L.14180Hu6Ie1!A1S9MeN1I!9iciiIc52Table 2.7. The Health Literacyand Health-Related Physical Fitness KnowledgeCorrelationsEffectsofNutritionScientific ExerciseInjuryOverall ConceptsScore ofPrincipals Components on ExercisePreventionMeasureof of Physical Chronic Prescriptionand(%) FitnessExercise Fitness (%) DiseaseConsumer(%)(%) RiskIssues (%)Factors(%)Newest PC.632* .491** .491** .451**.674**-.008 .173VitalSign Sig. .000.004 .004 .008.000 .964 .337ScoreN 3333 33 3333 33 33Note:‘Pearson Correlation.*Correlation is significantat the 0.05 level (2-tailed).**Correlation is significantat the 0.01 level (2-tailed).iepueeieipjeieweOt0oCD-‘C,CDD08001pOO1IflpVeIpp!JIIpooimnpv6 UnOA9111cqp9uiwJeesesejooSe6peMou)jlflIE9HVJfl 6 d54Figure 2.2. Physical ActivityParticipation Scores asa Functionof Age and Gender4____Young AdulthoodI‘ IMiddleAdulthoodFemale MaleGenderNote:*Significant Difference(p < 0.05).55Figure 2.3. CompositeMusculoskeletal Fitness4-Young AdulthoodI I Middle Adulthood3.*Female MaleGenderNote:*Significant Difference (p < 0.05).56100 -Figure 2.4. Resting Heart Rateas a Functionof Age and gender1*1____Young AdulthoodI I Middle AdulthoodamI.a)a-Cl)4-Cuci)*1806040200-FemaleGenderMaleNote:*Significant Difference(p<0.05).57Figure 2.5. Height as a Function ofAge and Gender200____Young AdulthoodI Middle AdulthoodT*I1500(1)U)10024-.ci050 -0- - ——MaleGenderFemaleNote:*Significant Difference (p < 0.05).58Figure 2.6. Weight asa Function of Age and Gender120____Young AdulthoodI I Middle Adulthood100 -80-LI600)04o200•—r ——Female MaleGenderNote:*Significant Difference(p < 005).59Figure 2.7. Waist Circumferenceas a Function of Age and Gender120 -*____Young Adulthood.Ii Middle Adulthood100-*_L*t80-*C-)I—ECciC-) 40-20 -0——Female MaleGenderNote:*Significant Diference(p < 0.05).a)I.0C)060Figure 2.8. Aerobic FitnessRaw Scores as a Functionof Age and Gender_____Young AdulthoodI I MiddleAdulthood*600500400300200-100 -0-*Female MaleGenderNote:*Significant Difference(p<0.05).61Figure 2.9. Grip Strengthas a Function of Age and Gender140____Young Adulthood120I I Middle Adulthood100•1— 80Cl)2*6040200 ——Female MaleGenderNote:*Significant Difference (p < 0.05).62____Young AdulthoodI I Middle AdulthoodFigure 2.10. Flexibility as a Functionof Age and Gender1*11)C’)a,E.1Ca,C-)50 -40 -30 -20100•*1GenderNote:*Significant Difference (p< 0.05).63C.)Cl)C)-C)ECci)C)706050403020100-Figure 2.11. Vertical Jump as a Function of Age and Gender____Young AdulthoodI I Middle Adulthood*11Female MaleNote: Significant Difference (p < 0.05).64Figure 2.12. Leg Power asa Function of Age and Gender6000 -____Young AdulthoodT i Middle Adulthood5000 -*40003000*1200010000 ——Female MaleGenderNote:*Significant Difference (p < 0.05).65ReferencesAbramson, S., Stein, J., Schaufele,M., Frates, E., & Rogan,S. (2000). 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ActiveAgeing: A Policy Framework.The World Health Organization.Zhu, W., Safrit, M.,& Cohen, A. (1999). FitSmarttest user manual-high schooledition.Champaign, IL: HumanKinetics.Zizzi, Ayers, Watson,& Keeler. (2004). Assessingthe impact of new studentcampusrecreation centers.NASPA Journal, 41(4),588-630.72CHAPTER 3The Effects of Administeringthe Canadian Physical Activity Fitness& LifestyleApproach (CPAFLA) on Health-RelatedPhysical Fitness Knowledgeas well as Beliefs,Attitudes, and Intentions towardsRegular Physical Activity Participation2The assessment of health-relatedphysical fitness is of majorimportance (Oja,1995). The Canadian Societyfor Exercise Physiology (CSEP)health-related fitnessappraisal and counselling strategy,the Canadian Physical Activity, Fitness& LifestyleApproach (CPAFLA), representsa series of systematic andstandardized testingprocedures designed to promotethe health benefits of physicalactivity (CSEP, 2003).The assessment is commonlyused as a measure for the health-relatedfitness of thegeneral population andis administered on over amillion Canadians each yearbytrained and certified CSEPhealth and fitness professionals(CSEP, 2003). Whenadministered, the resultsof the appraisal allowfor the evaluation of currenthealth statusin accordance to Canadiannormative data. Mostimportantly, the appraisalprocess andfindings provide vital health-relatedinformation to individuals.The appraisal is designedto educate, increase knowledge,and raise awareness of personalhealth indicatorswhile highlightingthe components of health-relatedphysical fitness. During theappraisal, participantsare provided with evidencebased guidance aimed towardsincreasing current physicaland mental wellbeing. Specifically,the goal of the appraisaland counselling sessionof the CPAFLA is to provideinformation as well as motivation2A version of this chapterwill be submitted for pubIcation.Faktor, M.D., Warburton, D.E.R.,Rhodes,RE., & Bredin, S.S.D. The Effectsof Administering the CanadianPhysical Activity Fitness & LifestyleApproach (CPAFLA) onHealth-Related Physical FitnessKnowledge as well as Beliefs, Attitudes,andIntentions towards RegularPhysical Activity Participation.73to individuals to develop healthierlifestyles and to increasetheir physical activityparticipation (CSEP, 2003).However, previous scientificinvestigation has yet toexamine the effectivenessof the CPAFLA. An aimof this investigation wasto examinewhether the CPAFLAcontributes to the immediatepromotion of physical activityandhealth-related physical fitnessin young and middle adulthood.The promotion ofhealth-related physicalactivity as well as fitnessare essentialpreventative public healthmeasures (Suni et al., 1998),as inseparable relationship(s)exist between physicalactivity, physical fitness,and positive healthstatus (Erikssen,2001). An importantdevelopment in recentyears has beena change in theunderstandingof how much physicalactivity is required toderive health-related benefits(CSEP, 2003). Thereis now a distinction regardingphysical activity as it relatestohealth versus fitness(American College of SportsMedicine, 1998). Previousfitnessspecialists recommendedengaging in exercise(planned and structuredphysicalactivity) at vigorous intensities(60-84% of heart ratereserve (HRR), or 6-8metabolicequivalents (METS))to improve one’s cardiovascularendurance. Health-relatedbenefits of physical activityparticipation were onlyassumed if cardiovascularendurance, a performancerelated measure,was improved (CSEP, 2003).The dosedependent relationshipbetween physicalactivity volume, healthvariables (e.g., bloodpressure, triglycerides,lipoproteins), andfitness outcomes (e.g.,VO2max) has aidedinthe shift from performance-basedphysical fitnessactivity guidelines andrecommendationsto health-related, forthe general population(CSEP, 2003). Researchhas supported this shiftby emphasizing the considerablehealth benefits of engaginginlight to moderate intensityphysical activity (Oja, 1995;Warburton et al., 2006b).Moreover, it has been statedthat health benefits occurwith weekly volumes ofphysical74activity (energy expenditures) aslow as 700kcal (2940kJ, light intensity activityon mostdays of the week), with additionalbenefits occurring at higher levels (AmericanCollegeof Sports Medicine, 1998).There is undeniable evidence supportingregular physical activity participation(structured and unstructured) in theprimary and secondary preventionof numerouschronic diseases and premature death(Warburton, Whitney, & Bredin, 2006a).Physicalinactivity is a primary modifiable riskfactor for cardiovascular diseaseand an increasingassortment of accompanyingchronic hypokinetic (insufficient movementor activity)diseases, including: obesity,diabetes mellitus, cancer(breast and colon), bone andjointdiseases (osteoporosisand osteoarthritis), depressionand hypertension (Katzmarzyketal., 1998; Katzmarzyk,Gledhill, & Shephard, 2000;Katzmarzyk, Perusse, Rao,&Bouchard, 2000; Warburtonet aL, 2006a). The most recent researchestimates that53.5% of adult Canadians arephysically inactive and 14.7%are obese (Katzmarzyk&Janssen, 2004). This physicalinactivity prevalence rankshigher than that of all otherexisting and modifiable hypokineticdisease risk factors (Warburtonet al., 2006a). In2001, 9.6 billion healthcare dollars were directlyaccredited to physical inactivityandobesity in Canada (Katzmarzyk& Janssen, 2004). This confirmsthat physical inactivityand obesity are chief benefactorsof the Canadian public healthcare burden. Healthpromotional efforts, guidedby relevant research, thatfunction to increase physicalactivity and reduce obesityare essential mechanismstowards improving thehealth ofall Canadians and significantlyreducing health care expenditures(Katzmarzyk &Janssen, 2004).Research suggests thatindividuals with increasedhealth-related physical fitnessknowledge are morelikely to be physically activeand fit (Zhu, Safrit, & Cohen, 1999).75Health-related knowledge permitsindividuals to acknowledge the warningsigns andpropagation of diseases, selectand partake in suitable preventativehealth strategies(e.g., physical activity), and providesindividuals with an understandingof where or howto obtain health assistance (Freimuth,1990). According to Zhuet al., health-relatedphysical fitness knowledge isa knowledge base that encompasses basicfitnessconcepts, which is comprisedof six sub domain componentsincluding: concepts offitness; scientific principles ofexercise; components of physicalfitness; effects ofexercise on chronic disease riskfactors; exercise prescription;as well as nutrition, injuryprevention, and consumerissues (Zhu et al., 1999). Previousresearch has suggestedapositive and significantcorrelation between health-relatedphysical fitness knowledgeand measures of health-relatedphysical fitness in adulthood(See Chapter 3, Faktor,Warburton, Rhodes & Bredin,2009). The first purposeof the present investigation wasto empirically examine the influenceof administering the CPAFLAhealth-relatedphysical fitness appraisaland counseling strategyon health-related physical fitnessknowledge in young andmiddle adulthood. Health-relatedphysical fitness knowledgewas assessed via the FitSmart,a standardized health-relatedphysical fitnessknowledge examination.As indicated by Zhu etal. (1999), the FitSmart is anestablished, valid, and reliabletest to measure knowledge of thefundamental healthand fitness conceptsat the high school level of education.As such, the FitSmartwrittenexamination was used inthis investigation to establish whetheryoung and middle-agedadults possess the levelof health-related knowledge expectedat a high school level.The FitSmart has beenimplemented as the primary measureof health-related physicalfitness knowledge in welleducated adult populations (Losch& Strand, 2004; Petersen,Byrne, & Cruz, 2003b).Researchers have alsoutilized sections of the FitSmartas76adjuncts to series of self report measuresto incorporate health knowledge (Zizzi,Ayers,Watson, & Keeler, 2004). We hypothesizedthat participants would demonstrateimprovements in the sub-domainsof aerobic fitness, muscular strengthand endurance,flexibility, and body composition forthe assessment of health-related physicalfitnessknowledge in comparison tobaseline measures. The administrationof the CPAFLAstrategically identifies thesemajor physical fitness componentsand highlights theirindividual and aggregative impactson health and well being. Furthermore,the CPAFLAstrategy emphasizes educationand counselling concerningappropriate evidence basedtactics designed to augmentfitness through a variety ofexercises and activities. Thesetactics are based on the interpretationof fitness results (CSEP, 2003). Assuch, wehypothesized that participantswill demonstrate improvementson the FitSmartexamination following administrationof the CPAFLA on questionsspecific to the health-related physical fitness componentof the examination.The Theory of Planned Behaviourelements are significant predictors(somestronger than others) towardsthe initiation, alteration,and or maintenance ofa vastarray of behaviours. Developedby Ajzen (1988, 1991) as anevolution of the Theory ofReasoned Action (Fishbein,1967), this theory has successfullyprovided a greaterunderstanding of diversehealth-related behaviorssuch as exercising, adhering tolowfat diets, contraceptive use,illicit drug use, and numerousmore (Ajzen & Fishbein,2005). It is the most prominentconceptual model for thinkingabout the determinants ofparticular behaviours todate (Ajzen, 2007). The Theoryof Planned Behaviour suggestsa framework about how humanaction is generated. It estimatesthe incidence of aparticular behavior given thatthe behavior is intentional.It is suggested that behavioralintentions are assumed toresult sensibly from beliefs (behavioral,normative, and77control) about performing the behavior(Ajzen & Fishbein, 2005). It is importantto notethat the behavioral, normative and controlbeliefs people possess regarding theperformance of a particular behaviorare influenced by a broad assortment ofsituational, cultural, and personal backgroundfactors. These beliefs can be accurate,inaccurate, biased, and even illogical.Nevertheless, this set of beliefs is thecognitivefoundation that guides human action,which is influenced by three majorfactors: apositive or negative assessmentof the behavior (attitude regardingthe behavior),perceived societal influenceto execute or not execute the behavior(social norm), andperceived ability to execute thebehavior (perceived behavioralcontrol). Theamalgamation of attitude towardsthe behavior, subjective norm,and perception ofbehavioral control leadsto the formation of a behavioralintention (the strongestpredictor of human behavior).Traditionally, the attitude,subjective norm, and perceivedbehavioral controlcomponents are measuredas single concepts; however, Ajzen(2002) suggests thateach concept comprises twosubcomponents each of which arehypothesized to beinfluenced by a single generalfactor. This is referredto as a second order model(Rhodes & Courneya,2003). However; Rhodes& Courneya (2003) believe thatthissecond order model is more likelyto be conceptualized asa “sub compartment” modelwhereby the individualtheory of planned behavior subcomponentsare capable ofhaving direct effectson the general factor andany relationship between eachsubcomponent may arisefrom external common causes.Attitude is said to becomposed of affective(e.g., unpleasureable/ pleasurable)and instrumental (e.g.,harmful/beneficial) evaluationsconcerning a behavior. Thistwo component attitudestructure has been supportedacross various attitude measurementmethodologies and78conceptual modeling’s (Rhodes& Courneya, 2003). Likewise, subjectivenorm researchhas indicated that the distinct componentsof self efficacy (e.g. ease. difficulty,confidence) and controllability(e.g., personal behavioral controland or assessment ofwhether or not the behavioris volitionally determined by theactor). Lastly, subjectivenorm is thought to include themore traditional measurement ofthe injunctivecomponent (e.g., does one believethat their social network wantsthem to perform aspecific behavior?) as wellas a descriptive component (e.g.does ones social networkperform a specific behavior?).The second purpose ofthis investigation was to examinethe influence ofadministering the CPAFLAhealth-related physical fitnessappraisal and counselingstrategy on the componentsof the Theory of PlannedBehavior (i.e., attitude,subjectivenorm, perceived behaviouralcontrol, and intention) inrelation to regular physical activityparticipation in young andmiddle adulthood. The Theoryof Planned Behaviourconstructs were assessedvia a written survey containinga series of 7-point bipolaradjective scales concerningregular physical activityparticipation. The instrumentusedin the present investigationwas developed by Rhodesand Courneya (2003) andis anestablished, valid andreliable method to assessthe Theory of Planned Behaviourconstructs. Rhodes andCourneya utilized this instrumentto investigate the componentsof attitude, subjective norm,perceived control, andintention in clinical andhealthypopulations with relationto exercise. We postulatedthat individual beliefs,attitudes,and intentions towardsparticipating in regularhealth-related physical activitywould alsoimprove in comparisonto baseline measures followingthe administration of theCPAFLA. This hypothesisis based on the premisethat the CPAFLA appraisalprocessis designed to increaseknowledge and awarenessconcerning health-related physical79fitness while highlighting thehealth benefits of physical activityin an attempt to motivateindividuals to develop healthierlifestyles and increase physicalactivity participation(CSEP, 2003).MethodsParticipantsWritten informed consentwas received from 20 femaleand 20 male physicallyinactive participants. Physicallyinactive was defined as engagingin 20-30 minutes ofvigorous or 30-60 minutesof moderate physical activityless than 3 times per week. TheGodin leisure time exercisequestionnaire functionedas the screening instrument(Godin & Shephard, 1985). Participantswere recruited accordingto two age groups: (a)19 to 29 years (young adulthood,n = 10 F, 10 M; mean age= 24.3 ± 2.5), and (b) 39 to49 years (middle adulthood,n = 10 F, 10 M; mean age= 42.7 ± 3.9). Participants wererandomly assigned to eitherthe control group (n =20; 10/age group) or theexperimental group(n = 20; 10/age group).Individuals that maintained aregularphysical activity regimen(i.e., 20-30 minutesof vigorous or 30-60 minutes of moderatephysical activity at least3 times per week duringleisure time over thepast month), werepregnant, were in poorhealth (illness or fever)at time of data collection,or were unableto provide documented physicianclearance for physical activityupon being screenedout in the CPAFLA pre-appraisalscreening process were notpermitted to participate.This investigation wasexecuted in exact accordancewith the ethical guidelinesset forthby the University of British Columbia’sClinical Research Ethics Board(CREB) forresearch involving humanparticipants (see AppendixB for certificate of researchethics).80ProcedureParticipants took part in twodata collection days witha one week intervalbetween days. The purposeof the one week delay wasto decrease the carry overeffects associated with psychological,educational, and cognitive assessments(e.g.,knowledge retention) (Portney& Watkins, 2000). Additionally, since physiologicalfatigue is a common consequenceof fitness testing and fatigueis known to havedetrimental effects on cognitivefunction (Afari & Buchwald,2003), the day 2 (post-test)was scheduled to occurone week following the collectionof baseline measures. Eachof the two testing sessionsconsisted of: 1)an assessment of health-related physicalfitness knowledge (FitSmart),and 2) an assessment ofbeliefs, attitudes and intentions(TPB components) towardsregular health-related physicalactivity participation.On Day1, participants randomlyassigned to the experimentalgroup were also administeredtheCanadian PhysicalActivity, Fitness & LifestyleApproach health-related physicalfitnessassessment and counsellingstrategy. Recommendations andguidance pertaining tophysical activity participation,body composition, aerobic fitness,musculoskeletal fitness(muscular strength, muscularpower, muscular endurance,and flexibility) and backfitness were provided bya Canadian Society for ExercisePhysiology-Certified ExercisePhysiologist (CSEP-CEP)directly following the fitnessassessment accordingtostandardized CPAFLAprotocol. The CSEP-CEPis the most advancedhealth andfitness practitionercertification in Canada allowingmembers to work with highperformance athletes,the general population(across the lifespan), andvaried clinicalpopulations. A CSEP-CEPis sanctioned to performassessments and evaluations,prescribe conditioningexercise, provide exercisesupervision/monitoring, counselling,healthy lifestyle education,and outcome evaluationfor “apparently healthy” individuals81and/or populations with medicalconditions, functional limitationsor disabilities throughthe application of physicalactivity/exercise, for the purposeof improving health, functionand work or sport performance(CSEP, 2007). Additionally,Health Canada physicalactivity and nutrition guideswere provided to the participantsduring the appraisal andconsultation session. Referto Figure 3.1 for a schematicof the research design.Assessment of Health-RelatedPhysical Fitness KnowledgeThe FitSmart writtenexamination was usedto assess the health-relatedphysicalfitness knowledge of eachparticipant. Developedby Zhu, Safrit, and Cohen(1999), theFitSmart written examinationconsists of two equivalentexaminations (Forms I and2)containing 50 multiple choiceitems, measuring sixsub-domain components:conceptsof fitness; scientific principlesof exercise; componentsof physical fitness; effectsofexercise on chronicdisease risk factors;exercise prescription;as well as nutrition, injuryprevention, and consumerissues. The contentbased equivalency of thetwoexaminations was carefullydictated by a panelof experts in the health-relatedphysicalfitness discipline (Zhuet al., 1999). All participantswere required to completebothforms of the FitSmart,one for each test daybased on random assignment.Concepts offitness make up 20%of the FitSmart examinationand incorporate questionspertainingto fitness definitions,and the relationship(s)between fitness, physicalactivity, andhealth. The scientific principlesof exercise componentalso makes up 20% of theexamand includes questionsrelating to the acute/chronicphysiological and psychologicaladaptationsto exercise. Questions associatedwith cardiovascular, respiratoryandpulmonary function, muscularstrength and endurance,flexibility, as well asbodycomposition are addressedin the componentsof physical fitness sectionand comprise8220% of the exam. Five percentof the exam includes questionsrelating to the effects ofexercise on chronic disease riskfactors. Exercise prescriptionmakes up 20% of theexam and takes into account theconcepts of frequency, intensity,duration, mode, self-evaluation, and exercise adherence.Last, 15% of the FitSmart examinationconsists ofitems pertaining to nutrition, injuryprevention and consumer issues.Participants wereallocated 45 minutes to completethe examination. Raw scoresout of 50, overallpercentages, and categoricalpercentage scores for eachfitness component weregenerated via the FitSmartsoftware for data analysis.Assessment of theTheory of Planned BehaviorComponents Concerning RegularPhysical ActivityWe modified the instrumentdeveloped by Rhodes andCourneya (2003) byreplacing the word and definitionof “exercise” with “physicalactivity” and itscorresponding definitionto reflect the aims of the presentinvestigation. Regular health-related physical activitywas defined as leisure-timeactivity performed at least 3 timesper week for at least 20-30 minutesin duration at a vigorous intensity(e.g., hardbreathing, heart beats rapidly,heavy sweating); or leisure-timeactivity performed atleast 3 times per weekfor at least 30-60minutes in duration at a light-moderateintensity (e.g., increasedbreathing, faster than normalheart beat, light sweating,cankeep a conversation going).Participants were providedwith common examplesofactivities correspondingto these definitions of regularphysical activity and wereaskedto use these definitionsand examples when answeringall physical activity relatedquestions. The same assessmentwas provided to both experimentaland controlparticipants during both(pre, post) testing sessions.83Attitudes towards regularphysical activity participation: Seven-pointbipolaradjective scales were usedto assess regular physical activity participationattitudes.Two components of attitude wereassessed, instrumental andaffective attitude, viathree items each. The threeitems used to investigate instrumentalattitude were:beneficial-harmful, useful-useless,and important-unimportant. Thethree items used toassess the concept of affectiveattitude were: enjoyable-unenjoyable, fun-boring,pleasurable-painful. Thestem preceding these bipolaradjectives was: ‘for me,participating in regular physicalactivity over the next monthwould be...’. Participantsreceived a score out of21 for each attitude componentwith increased scores indicativeof favourable attitudestowards participation inregular health-related physicalactivity.Subjective Norm: Twocomponents of subjective normwere assessed, injunctiveand descriptive norm,via the use of 7-point bipolaradjective scales. Three itemswereused for each componentof subjective norm. Forinjunctive norm, the followingpreceding stem was utilized:‘I think that if I were toparticipate in regular physicalactivity over the next month,most people who are importantto me would be...’. Thisstem was followed by the followingadjective pairs: approving-disapproving,supportiveunsupportive, encouraging-discouraging.For the concept of descriptivenorm,participants were askedto rate, on 7-point bipolaradjective scales, how activeimportantpeople in their lives werelikely to be over the nextmonth. The followingthree questionstems were used: (1)‘I think that over the nextmonth, most peoplewho are important tome will be...’, (2)‘I think that over the next month,most people who are importantto mewill participate inregular physical activity...’,and (3) ‘I think that overthe next month,the regular physical activityparticipation levels of most peoplewho are important to mewill be...’. These stemswere followed by the followingpairs of adjectives in their84respective order: extremelyactive-extremely inactive, extremelyagree-extremelydisagree, and extremely high-extremelylow. Participants receiveda score out of 21 foreach subjective norm componentwith increased scores suggestiveof favourablesubjective norms towards participationin regular health-related physicalactivity.Perceived Behavioural Control:The concept of perceived behaviouralcontrolwas measured by six items,each of which consisted of a stemand a 7-point bipolaradjective scale. The followingsix question stems were used:(1) ‘If you were reallymotivated, how controllablewould it be for you to participatein regular physical activityover the next month?’,(2) ‘If you were really motivated,how easy or difficult wouldit befor you to participatein regular physical activityover the next month?’,(3) ‘If you werereally motivated,do you feel that whether ornot you participate in regularphysicalactivity over the next monthwould be completelyup to you?’, (4) ‘If you were reallymotivated, how confidentare you that you couldparticipate in regular physicalactivityover the next month?’,(5) ‘If you were really motivated,do you feel you would havecomplete control over whetheror not you were physically activeover the next month?’,and (6) If you werereally motivated, how certainor uncertain wouldyou be that youcould participate inregular physical activity overthe next month?’. Thesestems werefollowed by the following pairsof adjectives in their respectiveorder: extremelycontrollable-extremely uncontrollable,extremely easy-extremelydifficult, extremelyagree-extremely disagree,extremely confident-extremelyu nconfident, extremely trueextremely untrue, andextremely certain-extremelyuncertain. Participants receivedascore out of 42 for perceivedbehavioural control, with increasedscores indicative ofhigher levels of perceived controltowards participation in regularhealth-related physicalactivity.85Intention: Intention to participate inregular physical activity wasmeasured withfive items; three questionstems followed by 7-point bipolaradjective scales, and 2 openended questions. The three questionstems were as follows: (1)‘How motivated are youto participate in regular physical activityover the next month?’ (2) ‘Istrongly intend to doeverything I can to participatein regular physical activity over thenext month...’, and (3)‘How committed areyou to participating in regular physicalactivity over the nextmonth?’. The correspondingbipolar adjectives were: extremelymotivated-extremelyunmotivated, extremelytrue-extremely untrue, andextremely committed-extremelyuncommitted. Participantsreceived a score of outof 21 for the first three questionsconcerning intentionto participate in regular physicalactivity with higher scoressuggestive of increasedintention to partakein physical activity over the nextmonth. Thetwo open ended questionsasked the participantsto stipulate the number of daysperweek (0-7) as wellas minutes per session (0-60)that they intended to participatein; (1)vigorous intensity physicalactivity, and (2) light-moderateintensity physical activityoverthe next month.CPAFLA AssessmentThe CPAFLA appraisalincluded pre-appraisal screeningand objective measuresof physical activity participation,metabolic fitness, body composition,aerobic fitness,musculoskeletal fitness,and back fitness. The CPAFLAappraisal was conductedusingthe exact proceduresas described in Chapter2, with the inclusion ofan individuallytailored physical activityparticipation counselling sessionthat focused on the resultsofthe CAPAFLA assessment.The counselling sessionfunctioned to: (1) educateparticipants regardingthe health-related importanceof each and everycomponent86within the CPAFLA and the healthbenefits associated with physicalactivityparticipation, (2) provide participantswith Canadian standardized health-relatedinterpretations of their personalfitness results, and (3) set specificmeasurableattainable realistic and time oriented(SMART) health-related goalsbased on individualmeasurements with referenceto: (i) Canadian normativefitness data, (ii) Canada’sphysical activity guide, (iii)Canada’s food guide, and (iv)personal issues (e.g., income,activity preference) and personaldaily/weekly schedules. The administrationof theCPAFLA assessmentand counselling sessiontook an average of 1.75 hours tocomplete.Statistical AnalysisStatistical significancewas set a priori atp<0.05 for all analyses. All figuresandtabular values are reportedas the mean ± standard deviations(SD). Each variable wastested for normal distribution (i.e.,skewness or kurtosis)and was transformed ifnecessary. A multivariaterepeated measure analysis (mixedbetween-within subjectsANOVA) was employedto look at the individualand aggregative effects of time(pretest, post-test), treatmentgroup (control, experimental),gender (female, male), andage(young adulthood, middle adulthood)on each dependantvariable. To answer thehypotheses of this investigation,the interaction effect of timeby group was utilized asthe primary indicator ofthe CPAFLA assessment’seffect(s) on the dependant variablesof interest. Health-relatedphysical fitness knowledge (overalland sub domaincomponent) percentage scores(x/100) were used asthe primary indicators of healthknowledge. The theoryof planned behaviour componentscores/responses(instrumental attitude(x121), affective attitude (x121),injunctive norm (x/21), descriptive87norm (x/21), perceived behaviouralcontrol (x/42) and intention (x/21,days per weekand minutes per session)) wereused as the main indicators of beliefs, attitudesandintentions towards participationin regular physical activity.ResultsParticipantsAll participants resided in Vancouver,British Columbia or the GreaterVancouverRegion. The control group consistedof 20 participants: 10 young adulthood(5F, 5M;mean age = 24.2 ± 2.1) and 10middle adulthood (5F, 5M;mean age = 43.4 ± 3.9). Theexperimental group wasalso comprised of 20 participants:10 young adulthood (5F, 5M;mean age = 24.3 ± 2.9)and 10 middle adulthood(5F, 5M; mean age = 42 ± 3.9). Table3.1 lists physical activity participationas a function of intensity (vigorous,moderate, andlight), duration (times/week,and minutes per session),age (young, middle adulthood),gender (male, female), and treatmentgroup (control, experimental). Halftheparticipants (50.0%) were Caucasian,22.5% were Asian, 12.5% wereEast Indian,10.0% were Mid Eastern,2.5% were Pilipino, and 2.5%were Aboriginal Canadian. Mostparticipants (80.0%) were currentlyenrolled in or had completedpost secondaryeducation (12.5% collegediploma, 47.5% undergraduatedegree, 20% graduatedegree). The remainingone fifth (20.0%) of the participantswere currently enrolled inorhad completed a secondarylevel of school education.For income: 67.5% grossed$39000/year (37.5%$ 20000; 30.0% =$20-39000), and 27.5% grossed$40000/year (10%= $40-59,000, 15% = 60-79000,2.5%= $80-90000). The remaining5.0% did not disclosetheir income. During theCPAFLA, two male experimentalparticipants (1 youngadult, 1 middle-aged adult)were screened out from performingthe88back extension measurement during thestandardized back extension pre-screeningassessment.Health-Related Physical FitnessKnowledgeThe means and standard deviationsfor the FitSmart health-relatedphysicalfitness knowledge, overall andcomponent, scores are presentedin Table 3.2 as afunction of time and treatmentgroup. There was a statisticallysignificant interactioneffect for time and group for theComponents of Physical Fitnesssection of the FitSmart[Wilks Lambda = 0.82, F (1, 32)= 6.9,p= 0.013]. The average score forthe controlgroup declined over timewhile the mean score for theexperimental group increased(Figure 3.2). The time by groupinteraction effectsfor overall FitSmart score [WilksLambda = 0.91, F (1, 32)= 3.14,p= 0.086], Concepts of Fitness[Wilks Lambda = 0.91,F (1, 32) = 3.11, p = 0.088],Scientific Principals of Exercise[Wilks Lambda = 0.974, F(1, 32) = 0.866,p= 0.359], Effects of Exercise onChronic Disease Risk Factors[WilksLambda = 0.931, F(1, 32) = 2.38,p= 0.133], Exercise Prescription[Wilks Lambda =0.999, F (1, 32) = 0.023,p= 0.88], as well as Nutrition InjuryPrevention and ConsumerIssues [Wilks Lambda =0.998, F (1, 32) = 0.074,p= 0.787] did not reach statisticalsignificance. Significant interactioneffects for time by group by genderwere found for:Concepts of Fitness [WilksLambda = .774, F (1,32) = 9.36,p= 0.004] and NutritionInjury Prevention andConsumer Issues [WilksLambda = 0.856, F (1, 32) =5.37,p =0.027]. A significant interactioneffect was also shown for timeby group by age for theEffects of Exercise on ChronicDisease Risk Factors [Wilks Lambda= 0.84, F (1, 32) =6.11,p= 0.019].89Components of theTheory of Planned BehaviorThe means and standard deviationsfor the Theory of Planned BehaviorComponent scores are listedin Table 3.3 with respect totime and treatment group.There was a statistically significantinteraction effect of time and groupfor instrumentalattitude [Wilks Lambda = 0.984,F (1, 32) = 8.36,p= 0.007], perceived behavioralcontrol [Wilks Lambda = 0.861,F (1, 32) = 5.18,p= 0.030], intention [VVilks Lambda0.667, F (1, 32) = 15.96,p= 0.00], and number of minutes intendedto participate invigorous intensity physicalactivity per session [Wilks Lambda= 0.790, F (1, 32) = 8.51,p = 0.006]. Instrumental attitudedeclined over time in the controlgroup while increasingin the experimental groupfollowing the CPAFLA (Figure3.3). Perceived behavioralcontrol declined over timein the control group and increasedin the experimental group(Figure 3.4). Intentionto participate in regular health-relatedphysical activity declined inthe control group andincreased in the experimental groupover time (Figure 3.5).Likewise, experimental participantsintended to participate in moreminutes of vigoroushealth-related physical activityfollowing the CPAFLA while controlparticipants showeddecrements in the numberof minutes indented to participatevigorous physical activityper session (Figure3.6). These results supportour hypothesis and suggestthatindividuals possessmore favorable beliefs,have more perceived control,and havemore intention towards participationin regular health-related physicalactivity after theadministration of the CPAFLAhealth related physical fitnessassessment andcounseling strategy. Thetime by group interactioneffects for affective attitude [WilksLambda = 0.99, F (1,32) = 0.321,p= 0.575], injunctive norm [WilksLambda = 0.974, F(1, 32) = 0.87,p= 0.358], descriptive norm [WilksLambda = 0.943, F (1, 32) = 1.921,p= 0.175], number of days intendedto participate in vigorous physicalactivity [Wilks90Lambda = 0.902, F (1, 32) = 3.49,p= 0.071], and number of days [WilksLambda =0.942, F (1, 32) = 1.98,p= 0.169] as well as minutes[Wilks Lambda = 0.992, F (1,32)= .255,p= 0.617] intended to participate inlight to moderate physicalactivity did notreach statistical significance. Significantinteraction effects were found fortime by agefor number of minutes intendedto participate in light-moderatehealth-related physicalactivity per session [Wilks Lambda= 0.866, F (1, 32) = 4.95,p= 0.033], with the youngadult cohort showing increasesin minutes and the middleadulthood cohort showingdecreases in minutes overtime. Significant interactioneffects were found for timebygroup by age by gender forinjunctive norm [WilksLambda = 0.865, F (1, 32)= 5.0,p =0.032], and intention [WilksLambda = 0.809, F (1,32) = 7.55,p= 0.011.DiscussionTo the best of our knowledge,this is the first investigationto empirically examinethe effects of administeringthe Canadian PhysicalActivity, Fitness and LifestyleApproach health-related physicalfitness assessmentand counselling strategy onhealthknowledge, as well asthe Theory of Planned Behaviourcomponents concerningregularphysical activity participation.A significant time by groupinteraction effect was foundfor both hypotheses. Forhealth knowledge, our resultsshowed improvements inknowledge specific to thecomponents of physicalfitness following administrationof theCPAFLA assessmentand counselling strategy.In contrast, participants whodid notreceive the CPAFLA assessmentand counsellingsession displayed lower scoresonthe Components of PhysicalFitness questions. Inaddition, individual beliefs,attitudes,and intentions towardsparticipating in regular health-relatedphysical activity improvedin comparison to baselinemeasures following theadministration of the CPAFLA.91Specifically, these effects weredemonstrated via increases in measuresof instrumentalattitude, perceived behaviouralcontrol, and intention.The significance of this investigationadds to the documented importanceregarding the objective measurementof health-related physical fitness. Researchers,especially in the public health domain,value the data that is generatedfrom theassessment of health-related physicalfitness. These data substantiallycontribute to theepidemiological knowledge healthscientists utilize to evaluate populationsin terms ofhealth status, disease risks, andfunctional capacities (Malmberget al., 2002; Oja,1995). In addition, the accuratequantification of health-relatedphysical fitnessmeasures is essential when evaluatingthe effectiveness of interventions designedtoaugment physical fitness (Vanheeset al., 2005). Furthermore, the evaluationandapplication of the data providedby standardized health-relatedfitness measuresprovides useful informatics whichare vital towards the design and implementationofpopulation based health promotionand preventative care initiativesand interventions(Suni et al., 1998; Shephard, 1986).The current investigationsupports previousresearch; however,it uniquely contributes by analyzingthe immediate benefit(s)participants receive fromtaking part in standardizedfitness assessment and counselingprocedures. Our resultssuggest that after participatingin the CPAFLA (a holisticassessment of health-relatedphysical fitness) individualsdemonstrate greaterinclination towards forintegrating physical activityand healthy lifestyle behaviors intotheir daily schedules.These findings promote the usefulnessof professional fitnessassessments.92Health KnowledgeHealth depends on our understandingof its determinants, and the applicationofthis knowledge in the prevention and treatmentof disease (Pakenham-Walsh &Priestley, 2002). In accordance,health knowledge enables individualsto identify thesymptoms and communicability ofdiseases, allows individuals to selectand participatein appropriate preventative health strategies(e.g., resistance training), and givesindividuals an understandingof where and how to obtain health assistance(Freimuth,1990). Moreover, fitness knowledge(a component of health knowledge) isunderstoodto influence the health and exercisebehaviors of individuals (Zhuet al., 1999).Research suggests that individualswho have increased fitnessknowledge via healtheducation are more likely to beactive and fit (Petersen, Byrne,& Cruz, 2003). Ourresults suggest that the administrationof the CPAFLA assistedindividuals inunderstanding the componentsof an essential determinantof health (i.e., physicalfitness). These components includeknowledge pertaining to the health-relatedimportance and functionalityof: the cardiovascular system;the respiratory andpulmonary systems; musculoskeletalstrength, endurance, power,and flexibility; as wellas body composition (Zhuet al., 1999). These results are in line withthe CPAFLAobjectives, as the administrationof the holistic assessmentby a knowledgeable healthand fitness professionalincorporates the evaluationof each major physical fitnesscomponent and provides participantswith substantial amounts ofvaluable informationpertaining to the importanceand function of each element ina reasonable timeframe.Moreover, even though thereis a lot of information being providedto participants, thisinformation is being presented,acquired, and stored asa result of an experientiallearning process. Research hassuggested that knowledge acquisitionand retention is93superiorly accomplished via experientialeducation versus the traditional methodsofknowledge translation (Lewis& Williams, 1994). Even if other methodshave beenidentified as significant contributorstowards health-related knowledge, forexample:single lectures (Andrade et al., 1999), physicaleducation courses (Adams, Higgins,Adams, & Graves, 2004; Nahas,1992), and media campaigns (Marcus,Owen, Forsyth,Cavill, & Fridinger, 1998); the experienceof participating in a fitness assessmentandcounselling session is uniqueand therefore, not easily forgotten.Fitness professionals,health care providers, andhealth promotion agenciesshould aim to create uniquelearning experiences like theCPAFLA that allow individualsto holistically engage in thesubject matter at hand in anattempt to foster greater knowledgeacquisition andretention. In addition, furtherresearch that functions toexamine the long-term retentionand transfer of health knowledgeand this interventional approachis warranted.Theory of Planned BehaviourComponentsThe Theory of Planned Behavioroffers a valuable frameworkto investigatebeliefs, attitudes and intentionstowards the participation in regularhealth-relatedphysical activity (Tsorbatzoudis,2005). The theory suggeststhat the most immediateand significant determinantof volitional behavior is an individual’sintention to participatein the behavior (Ajzen, 1991).The motivational factors that stimulatea behavior areassumed to be wrappedup in an individual’s intentions(Ajzen, 1991). These intentionsare indices of how hardsomeone is willing to try,or how much effort one is willingto putforth towards the performinga particular behavior (Ajzen, 1991).Intentions areassumed to result logicallyfrom behavioral, normative,and control beliefs concerningaparticular behavior (Ajzen& Fishbein, 2005). Thismultidimensional belief set, which94leads to the formation of behavioralintentions, is influenced by attitudes(positive ornegative assessment of the behavior),social norms (perceived societalstandardsrelating to the behavior) and perceivedbehavioral control (perceived abilityto executethe behavior) each of whichcan be divided into the respectivesub components (Ajzen,2002) (i.e. instrumental/affective attitude,injunctive/descriptive norm, selfefficacy/controllability). Ourresults indicate thatafter the administration of the CPAFLAfitness assessment and counselingsession participants were moreinclined toparticipate in regular physicalactivity. This was indicatedby increases in instrumentalattitude, perceived behavioralcontrol, and intention concerningregular physical activityparticipation. Theseresults provide the first empiricaldata that supports oneof theprimary objectivesthe CPAFLA (physical activitypromotion) (CSEP, 2003).Previousinvestigations have successfullyincreased the Theory of PlannedBehavior componentsrelating to physical activityparticipation (Tsorbatzoudis,2005); however, thisis, to thebest of our knowledge, thefirst Canadian investigationto examine the changes inthesecomponents as a resultof participating in a standardizedhealth-related physical fitnessassessment suchas the CPAFLA. In addition,these findings provide evidencerefutingthe second ordermodel proposed by Ajzen(2002) whereby the components(e.g.instrumental and oraffective attitude) ofeach theory of planed behaviorconstruct arehypothesized to be causedfrom a common generalfactor (e.g. overall attitude).Thisevidence is substantiatedby the individual and significantchange found for instrumentalvs. affective attitude asa result of participation inthe CPAFLA intervention.Specific toour results, it makesconceptual sense thatthe CPAFLA was able totarget instrumentalvs. affective attitude. Thisdistinctively shows thatthe CPAFLA intervention wassuccessful in formulatingbelief systems concerningthe health benefits associatedwith95regular physical activityparticipation as the assessmentof instrumental attitudeencompassed beliefs and attitudesconcerning the benefits and harms associatedwithphysical activity. More importantly,these findings support the subcomponentconceptualization by Rhodes &Courneya (2003). This model assumesthat the Theoryof Planed behavior subcomponents(e.g. injunctive and or descriptivenorm) have directeffects upon the general concept(e.g. subjective norm) and relationshipsbetweensubcomponents may arise fromexogenous common causes(e.g. past experience,personality, belief systems)versus a second order concept.This subcomponentmodeling makes greaterconceptual sense as traits suchas attitude and perceivedbehavioral control are moredynamic and changeablesocial cognitive concepts (Rhodes& Courneya, 2003).The measurementof responses outlining or promotinga particular behavior (e.g.,physical activity participation)has the ability to facilitatebehavior change. This iscommonly referredto as ‘the mere measurement effect’(Morwitz, Johnson, &Schmittlein, 1993). Theoretically,actions that increase an individual’scommitment to abehavior generally havea strong effect on the behavior.These ‘mere measurementeffects’ occur because anindividual’s responses toquestions outlining a specificbehavior have the capacityto generate ‘psychological commitment’toward thebehavior. For example;interventions that provideopportunities to express personalviews (e.g., surveycompletion) could aid inincreasing motivation and the initiationofbehavior change(Maio et al., 2007). The trendswithin our data suggestthat meremeasurement effects werenot present. Even though formalstatistical procedureswerenot performed to rule outthese effects, the documenteddeclines in the controlgroup for96instrumental attitude, perceivedbehavioral control, as well as intentionduring the posttest were enough evidence to supportthis notion.ConclusionGiven that the CPAFLA hasbeen acknowledged as the mostwidely usedstandardized health-related fitnessappraisal throughout Canada (Katzmarzyk,2002), isaccepted as Canada’s primary health-relatedphysical assessment tool (Warburtonetal., 2006b), and is administeredon over a million Canadians everyyear (CSEP, 2003),the results of this investigationprovide important evidence substantiatingone of theprimary purposes of the CPAFLA(i.e., physical activity promotionand motivation).Thus, when thinking of innovativeways to combat the Canadianhealth care burden(Katzmarzyk & Janssen,2004) the CPAFLA shouldbe seriously considered. Afterparticipating in the CanadianPhysical Activity, Fitness &Lifestyle Approach individualsshowed increases in healthknowledge, as well as instrumentalattitude, perceivedbehavioural control and intentionregarding health-related physicalactivity participation.These results suggestthat participants benefit from participatingin an all encompassingfitness appraisal and counsellingsession such as the CPAFLA.As a result individualsshould be more able tointegrate positive health behaviours(e.g., physical activity) intotheir lifestyles. Therefore,providing increased accessto health-screening andcounselling is essentialto combat the health care burdenwhich arises from physicalinactivity, obesity, andthe increasing variety of chronic hypokineticdisease statesassociated with sedentarybehaviour. Primary health care providersshould routinelysend their patients to certifiedpersonal trainers and certifiedexercise physiologists forhabitual physical fitnesscheckups and counselling. Thisinvestigation suggests thatfitness appraisals and counsellingsessions provide participantswith motivation to97increase their physical activity participationand healthy lifestyle behavioursat the sametime as providing valuable and standardizedinformation concerning health statusanddisease risks to both the practitionerand participant. Future research is warrantedtoinvestigate the long term effectsof participating in standardizedhealth-related physicalfitness appraisals like the CPAFLAon behaviour.98Table 3.1. Physical Activity ParticipationControl(n =20)Experimental(n = 20)Vigorous(Times/Week)0.4±0.5 1.0±0.7 0.6±0.9 0.6±0.9Female Male Female Male(n=5) (n=5) (n=5) (n=5)0.5 ± 0.5 0.4 ± 0.5 0.5 ± 0.9 0.2 ± 0.4Vigorous(Minutes/Session)35 ±9.0 ± 13.425.511±17.6 9±13.4 30±36.7 11±17.514±26 15±33.5Moderate(Times/Week)1.4±1.1 1.2±.84 1.6±1.11.0±1.0 0.4±0.5 1.0±1.0 1.3±0.7 0.6±0.9Moderate(Minutes/Session)30±28.3 27±1.722 ±15.2514±13.4 18±26.8 26±26.1 26±5.514±26.1Light(Times/Week)Light7.0 ± 8.2 3.4 ± 2.9 3.6 ± 2.2 2.6± 0.927±13 21±5.2 24±15.2 17±7.62.8±2.7 5.2±6.1 1.2±1.3 3.8±2.717±8.4 30±22.4 45±49.7 26±20.4Physical ActivityMeasurementYoung Middle-AgeYoung Middle-Age(n10) (n=10)(n=10) (n=10)Female Male Female Male(n=5) (n=5) (n=5) (n=5)(Minutes/Session)99Table 3.2. FitSmart Health-Related PhysicalFitness Knowledge ScoresControl Experimental(n=20)(n=20)MeasurementTest Day I Test Day 2Test Day I Test Day 2Overall Score (%)75.0 ± 9.3 72.5 ±8.3 69.0 ± 12.4 70.6 ± 10.4Concepts of84.9 ± 8.5 81.0 ± 17.474.3 ± 16.3 79.5 ± 17.7Fitness (%)ScientificPrincipals of68.6 ± 15.0 63 ± 21.464.3 ± 8.1 66.3 ± 17.4Exercise (%)Components ofPhysical Fitness75.2 ± 15.0 64.0 ± 12.467.4 17.6 68.0 ± 13.0(%)*Effects of Exerciseon Chronic66.0 ± 19 .4 77.7 ± 15.065.3 ± 22.7 67.5 ± 19.5Disease RiskFactors (%)Exercise80.0±41.0 82.5±24.575.0±41.3 80.0±29.9Prescription (%)Nutrition InjuryPrevention and73.5 ± 15.1 75.4 ± 13.567.5 ± 20.0 67.8 ± 16.0Consumer Issues(%)Note:*significant time by treatmentgroup interaction effect (p< 0.05).100Table 3.3. Theory of PlannedBehaviour ScoresControl Experimental(n20) (n=20)MeasurementTest Day I Test Day 2Test Day 1 Test Day 2Instrumental Attitude(x121)*18.9 ± 1.7 18.2 ± 2.8 17.1 ± 2.918.4 ± 1.7Affective Attitude (x121)15.4 ± 3.5 15.5 ± 2.6 15.6 ± 2.816.2 ± 2.1Injunctive Norm (x/21)17.5 ± 3.1 16.9 ± 3.1 17.5 ± 2.417.9 ± 2.3Descriptive norm (x/21)13.0 ± 4.7 13.6 ± 3.813.5 ± 3.5 15.5 ± 3.2Perceived Behavioural31.9 ± 6.2 30.7 ± 7.333.2 ± 6.0 35.2 ± 3.9Control(x/42)*Intention(x/21)* 17.0 ± 2.516.3 ± 3.3 14.9 ± 2.8 17.3 ± 1.8Vigorous PhysicalActivity Intention2.7 ± 1.8 2.4 ± 1.82.4 ± 1.7 2.8 ± 1.4(Days/week)Vigorous PhysicalActivity Intention34.8 ± 20.8 24.0 ± 17.736.0 ± 21.8 42.3 ± 18.2(Minutes/Session)*Light-moderatePhysical Activity3.9 ± 1.6 3.9 ± 1.8 2.8 ± 1.73.4 ± 1.5Intention (DaysNVeek)Light-moderate PhysicalActivity Intention32.5 ± 16.4 35.5 ± 14.7 38.5± 17.8 39.0 ± 17.9(Minutes/Session)Note:*significant time bytreatment group interaction effect(p<0.05).Figure3.1.SchematicofRandomizedBlockDesignwithDelayedRepeatedMeasuresIWeekInterimNote:TPB,TheoryofPlannedBehaviorCPAF1JI,CanadianPhyskaIActivityFitness&UfestyleApproach..102——t‘I.—LUwFigure 3.2. Time byTreatment Effects forComponents of PhysicalFitness Score807570656055Pe-Test Post-TestH Contro’4 ExperimentalTimeSi-SOdm——z1eWWIJdX3P1IOUODS9tLISLI8Icst61apn3yIeWaa1fl41IJo1spaJ43UW3I?.IJAqew 1 j.aJn2£01LULL07Q_—-6OS1€ESzaVtiitD04SL-SOdSL-aJdIe4uaw!Jadx3nO4UaDIO3UODIeJflO!AeLIagpaAapiadiojspajiwaw3eaJiAqawj,,1701105C,aJ_ ,—0. 4.h4C,. 0C,0w —Figure 35. Timeby Treatment Effectsfor Intention1817168 Control14 Experimental13Pre-Test PostTestTime106Figure3.6. Time by Treatment Effects forIntention to Participate inVigorous PhysicalActivityCCA40030IC totonrh4 Experimental,,-, 10Lu0PreTest PostTestTime107ReferencesAdams, T. M., Higgins, P. M., Adams,H. J., & Graves, M. M. (2004). Effectsof aRequired Conceptually-BasedBasic Physical Education Courseon UniversityStudents’ Attitudes, Exercise Habits,and Health-Related Fitness Knowledge.Poster, New Orleans, LA.Afari, N., & Buchwald, D. (2003).Chronic Fatigue Syndrome:A Review. 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Canadian physical activity,fitnessand lifestyle approach(3rd ed.). Ottowa: The Society.108Erikssen, G. (2001). PhysicalFitness and Changes inMortality: The Survival oftheFittest. Sports Medicine,31(8), 571-576.Fishbein, M. (1967). Attitudeand the prediction of behavior.Readings in attitude theoryand measurement, 477-492.Francis, J. J., Eccies,M. P., Johnston, M., Walker,A., Grimshaw, J., Foy, R., etal.(2004). Constructingquestionnaires based onthe Theory of Planned Behaviour:A manual for health servicesresearchers. University ofNewcastle.Freimuth, V. S.(1990). The ChronicallyUninformed: Closing theKnowledge Gap inHealth. In Communicationand health: systems andapplications (Vol. 1,pp.171-186). Hillsdale, NJ: Eribaum.Godin, G., & Shephard,R. J. (1985). A simple methodto assess exercise behaviorinthe community. CanadianJournal ofApplied SportSciences. Journal CanadienDes Sciences AppliqueesAu Sport, 10(3), 141-6.Katzmarzyk, P. T.(2002). 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Champaign, IL: Human Kinetics.111112CHAPTER 4ConclusionThis thesis entitled “Health-RelatedPhysical Fitness, Knowledge,andAdministration of the CanadianPhysical Activity, Fitness,and Lifestyle Approach” wasconducted to fulfill the requirementspertaining to a Master’s ofScience degree throughthe Department of Human Kineticswithin the Faculty ofEducation at the UniversityofBritish Columbia. One largestudy examining two distinctsub-questions was conductedby Marc D. Faktor with intellectualinput (scientific and editorial)provided by Dr.Shannon S.D. Bred in (largestcontribution), Dr. DarrenE.R. Warburton, andDr. Ryan E.Rhodes.The first line of investigationwas to examine therelationship between health-related physical fitnessknowledge and health-relatedphysical fitness inyoung andmiddle adulthood. Wealso examined the relationshipbetween health literacyandhealth-related physicalfitness knowledge.Our findings showed that health-relatedphysical fitness knowledgewas positively and significantlycorrelated to health-relatedphysical fitness in adulthood.Specifically, knowledgewas a significant correlateto andthe strongest individualpredictor of musculoskeletalfitness. In addition, healthliteracywas found to be a significantcorrelate to and thestrongest predictor of knowledge.These findings havebeen compiled intoa manuscript titled, “The relationshipbetweenhealth knowledge and measuresof health-related physical fitness”(See Chapter 3).Given the empirical evidencerelating musculoskeletalfitness to health status(Warburton, 2001) andour findings relating health-relatedphysical fitness knowledgetomusculoskeletal fitness,it is imperative that individualsare provided opportunitiesto113access and acquire knowledge pertainingto health-related physical fitness. It isimportant to integrate education of thisknowledge into multidimensionalhealthpromotion programs, educationalsystems and other learning initiativeswheneverpossible. Additionally and more specifically,the results presented in Chapter3 supportother research findings (e.g.,Petersen, Byrne, & Cruz, 2003)that highlight theimportance of addressing andpromoting advanced concepts(e.g., scientific principlesof exercise) in educational materialsdesigned for both health care professionalsand thegeneral population.The impact of health-relatedknowledge on lifestyle is importantto acknowledge.Individuals with less education,lower incomes, and blue collaremployment are morelikely to be physicallyinactive than those withmore education and higher payingwhite-collar employment (Draheim, 2002).Correspondingly, researchindicates that peoplewho are educated in fitnessconcepts are more likelyto be physically active and fit(Petersen et al., 2003).The consequences of asedentary lifestyle are well documentedand contribute to a myriadof hypokinetic diseases (Warburtonet al., 2006a).Additionally, a large number ofhealth economic studies haveascertained that highereducation is associatedwith positive health outcomes,even when factors like incomeare controlled for (Kenkel,1991). One explanationfor this is that schooling helpspeoplechoose healthier lifestylesby improving their understandingof the relationshipsbetweenhealth behaviour andhealth outcomes (Kenkel,1991). The current BritishColumbiaphysical education secondarycurriculum (developed bythe British Columbia MinistryofEducation, Skills and Trainingin 1998), provides studentsopportunities to engage inand acquire health-relatedphysical fitness learning objectives.For example, under the114curriculum organizer ‘Active Living’,the grade 11 and 12 prescribed learningoutcomesstate that student’s are expectedto be able to (adapted from p. A-3 and A-5):• Design, implement, evaluate,and monitor plans for a balanced, healthylifestyle(e.g., nutrition, exercise, rest, work), takinginto consideration factors thataffectthe choice of physical activity (e.g.,age, gender, culture, environment, andbody-image perceptions) throughoutlife;• Describe strategies,as well as analyse and design plans forstress managementand relaxation;• Adapt physical activities tominimize environmental impact;• Design, Implement,evaluate, monitor, and adapt coachingplans for exerciseprograms for themselvesand others, that apply the principles oftraining (i.e.,progression, overload, specificity);• Demonstrate an understandingof physiology and performance modifierssuch ashow the cardiovascular, muscular,and skeletal systems relate to humanmotorperformance;• Develop a plan to maximizepersonal motor performance forthemselves andothers;• Demonstratea willingness to use community-based recreationaland alternativeenvironment opportunitiesto develop a personal functional levelof physicalfitness;• Evaluate the influence of consumerismand professional athletics on personalperception of body image;and• Analyse and describethe effect of professional sportsrole models on the choiceof personal lifetime activities.115The strengths in this curriculum stem fromthe active engagement in the materialathand. Students are expected towork in groups, relate the material beingpresented tothemselves, and then adapt it to otherswithin the group. This allows the studentto gainperspective of the information being presentedand empathize with others in avariety ofsituations. In addition, students are evaluatedon the real life application of theteachings presented in school(e.g., students are required to demonstratea willingnessto utilize community resourcesin an attempt to bolster physicalfitness and health). Thisreal life application has the potentialto have a profound effect on one’shealthknowledge and literacy. It providesstudents with experiences thatshow where and howto engage in preventative healthmeasures within their communities.It also increasesthe probability of students receivingand responding to new and upto-date sources ofhealth information that are usuallypresent in community fitness baseddwellings. Thiscontinual interaction with healthand fitness practices and educationalmaterials has thepotential to increase healthknowledge in additionto health literacy. However, whenstudents reach the end of highschool (e.g., grade 11 and12) physical education is nolonger a mandatorysubject. This is a definiteweakness in the curriculum thatneeds tobe revised. Students atthis age are able to comprehendand apply informationto amuch greater extent; thus,could potentially benefitthe most from health educationinthe later high school years.Research that functionsto investigate the relationshipbetween health-relatedphysical fitness knowledge,health literacy, and physicaleducation participation inthe later high school years needsto be utilized to promotemaking physical education compulsoryat all grade levels.In our findings, as wellas in other investigations, it hasbeen shown thatindividuals lack knowledgespecific to the scientific principlesof exercise. Peterson etal.116(2003) suggested thatindividuals should be providedwith more opportunitiestostrengthen existingcontent knowledge, ratherthan relying on individualsto take specificand elective exercise physiologycourses. Simple and repeatedteachings of the acuteand chronic adaptations thatour bodies endurein response to physicalactivity andexercise should beimplemented at a youngage to ensure individualsunderstand themodificationsthat occur in the body asa result of physical activityor inactivity (e.g.,blood pressure adaptationsand ramifications, triglycerideprofile changes, insulinsensitivity as wellas resistance). Simpleadaptations to curriculumthat function tointegrate these teachingsacross multiple mandatorycourse offerings at all educationallevels should functionto translate this essentialknowledge forgreater retention andtransfer. Moreover,lectures and tutorialsshould be held to helpstudents identifytherelationships betweenhealth knowledgeand behaviour as individual’sthat possess lowlevels of health knowledgewill have a limitedunderstandingof the benefits of engagingin healthy lifestylebehaviours. Thislimited understanding leadsto a decreasedawareness of: diseasesymptomoogyand risk, preventative healthcare approach’s(e.g., proper nutrition andphysical activity),and other sourcesof medical treatment(Freimuth, 1990). Thesehealth knowledge issueshave been documentedin individualswith intellectual disabilities(Graham, 2000; Stanish,2006) and low levelsof healthliteracy (Ad Hoc Committeeon Health Literacy forthe Council on ScientificAffairs,American MedicalAssociation, 1999;Davis, 2004).If individuals donot learn from healthpromotion effortsdesigned to highlighttherelationships betweenhealth behaviours andhealth outcomes theirability to partake ina healthy and activelifestyle will be compromised.Thus, it is essentialfor healthpromotion efforts totarget individuals basedon their individual capabilitiesand needs117(Fish & Nies, 1996). For example,cohorts with increased knowledgewill be able toreceive and respond appropriatelyto more complex health promotional messagesandservices than those with less knowledgeand intellectual capabilities. This exampleemphasizes the need to assessthe health knowledge of peoplein order to maximizeand target the effects of a healthpromotional intervention. Furthermore,health literacyis a contemporary and well warrantedtopic of concern for the advancementof highquality health care (Parker et al.,2003). It is recommended for healthcare practitionersto assess health literacy, in anattempt to further individuallytailor health education andcounselling. For example:if a health care professional determinesa client to havelimited health literacy, their knowledgetranslational activities should beadjusted to anelementary level whichsuites the client’s capabilities.This will then aid in ensuringadequate knowledge acquisitionand retention on the clients end.This present investigationadapted the concept of healthliteracy assessment,which is usually performedin primary care, to the healthand fitness domain. Our healthliteracy findings (see Chapter3 Results) and the relationship(s)between health literacy,health outcomes, andhealth knowledge area great value and should be utilizedin thehealth and fitness industry.Health care practitionersof all scopes should administerandapply the results of briefstandardized health literacy assessmentsin order toindividually tailor the communicationand guidance providedto clients, patients, andstudents (Weiss etal., 2005). In addition, ourresearch group designed a health-literacyassessment specific to thehealth and fitness disciplineto pilot in this investigation (theresults will be disseminatedin a short communicationpiece via the CSEP Health&Fitness BC). We utilizeda modified Weiss methodthat incorporates essential healthrelated physical fitnessdocuments. Participantswere given a 2 page physicalactivity118readiness questionnairedocument (PAR-Q and You) (CSEP,2003), and were askedtoread, comprehend, apply and analyzethe available informationto answer six contentbased questions. The questionswere asked orally, the responseswere recorded on aseparate score sheet andtime constraints did notapply. This tool did not haveacategorical score scale likethe NVS does, neverthelessthe literacy concepts measureddo parallel each other andlower scores were indicativeof low literacy.Further scientific investigationinto the relationship(s) betweenhealth literacy,health-related physicalfitness knowledge, andthe components of health-relatedphysical fitness is warranted.Investigations that functionto determine how to maximizeknowledge retention andtranslation need tobe conducted in order to fullyapply thesefindings. Interdisciplinarycollaborations shouldbe made to investigate themostappropriate media vehicleshealth promotionand education programscan utilize tocirculate health-relatedknowledge. These mediavehicles should operatetodisseminate health-relatedknowledge in insighiful,meaningful, and sustainablewaysthat function to ensureknowledge retentionand application.The second researchobjective of this investigationwas to examine objectivelythe effects of administeringthe CPAFLA health-relatedphysical fitness assessmentandcounselling strategyon health knowledge andthe Theory of PlannedBehaviourcomponents (i.e.,attitude, subjectivenorm, perceived behaviouralcontrol, andintention) concerningregular physical activityparticipation in adulthood.Our findingsshowed that administratingthe CPAFLA increased healthknowledge related tothecomponents of physicalfitness, as wellas important elementsof the TPB (i.e.,instrumental attitude,perceived behaviouralcontrol, and intention).These findings havebeen compiled into a manuscripttitled, “The effects of administeringthe Canadian119Physical Activity Fitness& Lifestyle Approach (CPAFLA)on health-related physicalfitness knowledge as wellas beliefs, attitudes, and intentionstowards regular physicalactivity participation” (seeChapter 4).Provided that the CPAFLAis administered on over onemillion Canadians everyyear (CSEP, 2003) and consideredto be the most widely utilizedstandardized health-related fitness appraisalwithin Canada (Katzmarzyk,2002; Warburton etal., 2006b);the results generated bythis investigation are ofmuch importance whenthinking ofinnovative ways to reducethe health care expendituresassociated with physicalinactivity and obesity (Katzmarzyk& Janssen, 2004). The increasesin healthknowledge and beliefs,attitudes, and intentionsconcerning regular physicalactivity thatwere demonstratedafter participating in theCPAFLA suggest that participantsconsiderably benefit fromits administration.Consequently, CPFALAparticipants oughtto be better off integratingpositive health behaviours(e.g. physical activity) intotheirlifestyles. Therefore,providing increasedaccess to health-screeningand counsellingisessential to combat thehealth care burden whicharises from the increasingvariety ofchronic hypokineticdisease states associatedwith sedentary behaviour.Primary healthcare providers shouldutilize health and fitnesspractitioners as valuableresources byreferring their patientsto certified personal trainersand exercise physiologistsfor fitnessappraisals and counselling.It must be widely recognizedthat these types of referralsshould function tomotivate individualsto increase their physicalactivity participationand healthy lifestyle behaviours.Moreover, the standardizedand Canadian normativereferenced informationgenerated by a holisticassessment like the CPAFLAcan provideprimary health carepractitioners with valuableinformation that canpositively contributeto treatment plans.120In view of the fact thatthe Canadian Society for ExercisePhysiology’s missionstatement (i.e., “To promotethe generation, synthesis,transfer and application ofknowledge and research relatedto exercise physiology (encompassingphysical activity,fitness, health, nutrition, epidemiology,and human performance)”)highlights the needfor continuous applicationand adaptation, this thesisinvestigation has the potentialtosignificantly contributeto the CPAFLA revisions process.Based on the methodologyand the results generated;some potential adaptationsto the CPAFLA could include:I. A brief assessmentof health-relatedphysical fitness knowledgeII. A health literacyassessment specificto the health and fitness domainIll. The assessmentof the Theory of PlannedBehaviour constructs relatingtophysical activity participationIn collaboration, theseadditions to the CPAFLAwould assist with theknowledgetranslation and educationobjectives. Specifically,the results of these cognitiveassessments will providefitness professionals withan ammunition ofpersonalized datathat will function toenhance the quality ofinformation providedto participants. This inturn should leadto increased retentionand application onthe participants end. Giventhat the informationprovided to participantsduring the CPAFLAis intended to assistindividuals in increasingtheir physical activityparticipation and healthylifestylebehaviours these proposedadaptations warrantserious consideration.Taken together,the results from thisthesis provide empiricalevidencesubstantiating the relationship(s)between health-relatedphysical fitness knowledge,health literacy, and thecomponents of health-relatedphysical fitness. In addition,thesefindings support oneof the primary objectivesthat the Canadian PhysicalActivityFitness and LifestyleApproach health-relatedphysical fitness assessmentand121counselling strategy conformsto (i.e., health promotion throughregular physical activityparticipation). Future researchthat investigates the long termeffects of retention andapplication associated withthese findings is warranted.122ReferencesAd Hoc Committee on Health Literacyfor the Council on Scientific Affairs,AmericanMedical Association (1999).Health literacy: Report of thecouncil on scientificaffairs. The Journalof the American Medical Association,281(6), 552-557.British Columbia Ministryof Education, Skills and Training(1997). Physical Education11 and 12 Integrated ResourcePackage. British Columbia:BC Ministry ofEducation.Canadian Society for ExercisePhysiology (2003). The CanadianPhysical Activity,Fitness & Lifestyle Approach.Ottawa, ON: Canadian Societyfor ExercisePhysiology.Davis, T. C. (2004). Healthliteracy: Implications for familymedicine. Family medicine,36(8), 595-598.Draheim. (2002).Prevalence of physical inactivityand recommended physical activityincommunity-based adultswith mental retardation. Journalof Mental Retardation,40(6), 436-444.Fish., & Nies. (1996).Health promotion needs ofstudents in a college environment.Public Health Nursing,13(2), 104-111.Freimuth, V. S. (1990).The chronically uninformed:Closing the knowledgegap inhealth,pp.171-1 86. In E.B. Ray,L. Donohew (Ed.), Communicationand Health:Systems and Applications.Hillsdale, NJ: Erlbaum.Graham. (2000). Physicalfitness of adults withan intellectual disability: A 13-yearfollow-up study. ResearchQuarterly for Exerciseand Sport, 71(2), 152-161.123Katzmarzyk, P. T. (2002). Musculoskeletalfitness and risk of mortality.Medicine andscience in sports and exercise,34(5), 740-744.Katzmarzyk, P.T, & Janssen,I. (2004). The Economic CostsAssociated with PhysicalInactivity and Obesity in Canada:An Update. Canadian JournalofAppliedPhysiology, 29(1), 90-115.Kenkel, D.S. (1991). Healthbehavior, health knowledge,and schooling. Journal ofPolitical Economy, 99(2), 287-305.Parker, R. M., Ratzan,S. C., & Lurie, N. (2003).Health literacy: A policy challengeforadvancing high-qualityhealth care. Health Affairs,22(4), 147-153.Petersen, S., Byrne, H.,& Cruz, L. (2003). The realityof fitness for pre-serviceteachers:What physical educationmajors ‘know and cando’. Physical Educator, 60(1),5-19.Stanish, H.l., Temple,V.1., & Frey, G.C.(2006). Health-promoting physicalactivity ofadults with mentalretardation. Mental Retardationand DevelopmentalDisabilitiesResearch Reviews,12, 13-21.Warburton, D.E.,et al. (2006a). Health benefitsof physical activity: The evidence.Canadian Medical AssociationJournal, 174(6), 80 1-809.Warburton, D.E.,et al. (2006b). Prescribingexercise as preventive therapy.CanadianMedicalAssociation Journal,174(7), 961-974.Warburton, D. E.(2001). The effects ofchanges in musculoskeletalfitness on health.Canadian MedicalAssociationJournal, 26(2), 161.Weiss, B. D., Mays,M. Z., Martz, W., Castro,K. M., DeWalt, D. A., Pignone,M. P., et al.(2005). Quick assessmentof literacy in primary care:The newest vital sign.Annalsof Family Medicine, 3(6),5 14-522.124APPENDIX AExtended Review of LiteratureIn the following review,relevant literature pertainingto health knowledge, health-related fitness, as well as theinfluence of health knowledgeon health-related fitnessisdiscussed. This chapterfunctions as a condensedreview of the current literaturerelatedto health knowledge, health-relatedphysical fitness, and therelationship between thesetwo variables of interest.Although the reviewof literature presented hereis consideredto be condensed, it providesgreater depth thanwhat is provided in theintroductorysections of each respectivemanuscript. As such,the purpose of this chapteris toprovide the reader a broaderperspective on theconcepts focused on withinthis thesis.Health and FitnessKnowledgeTo provide anoverview of the literatureconcerning health andfitness knowledge,definitions of health, healthknowledge, as well ashealth and fitness knowledgewill beprovided. Rationalewill then be givenas to why health knowledge shouldbe assessed.Following the basisfor health knowledgeassessment, healthknowledge and itscontribution to behaviourchange will be discussedin relation to the TheoryofReasoned Action/PlannedBehaviour (the dominanthealth-related behaviourchangemodel). The nextsection will outline howhealth knowledgeand health-related beliefs,attitudes and intentionsshould be assessed withina research setting andrelevantexamples of suchassessments will be provided.The impact of healthknowledge willalso be presented brieflyfollowed by a discussionof health literacy.125Definini Health and Health KnowledgeHealth depends on ourunderstanding of its determinants,and the application ofthis knowledge in the preventionand treatment of disease (Pakenham-Walsh&Priestley, 2002). It is imperativefor definitions of healthand its conditions to be detailedand meaningful (Awofeso, 2005),as scientific research abidesby the principles ofcomparability and reproducibility(Ustün, 2005). The most commonlyquoted definition ofhealth, sanctionedby the World Health Organization(WHO) over 50 years ago,statesthat health is: “a completestate of physical, mental andsocial well-being, and notmerely the absenceof disease or infirmity” (WHO,1999, p, 10). Accordingly,eachdimension of health(physical, mental and social)can be characterized on acontinuumwith positive and negativepoles. Positive health is associatedwith the ability to enjoylife and endure its impediments.Negative health is associatedwith a decreasedcapacity to enjoy life and withstandits obstacles. Therefore, positivehealth is not onlythe absence of disease.(CSEP, 2003). TheWHO definition of health isbroad enoughto be applied equallyto both genders as well asdeveloped and developingcountries.Health is a cumulativestate, which mustbe promoted throughout lifeto ensure benefitsin the later phases of life(WHO, 1999).In today’s healthcare environment accurateknowledge pertaining to healthisessential for therequired preventionand treatment of illness anddisease (Beier &Ackerman, 2003). Health knowledgeenables individualsto identify the symptomsandcommunicability ofdiseases, allows individualsto select and participate inappropriatepreventative health strategies,and gives individuals anunderstanding of where toobtain health services(Freimuth, 1990). Fitnessknowledge (a componentof healthknowledge) is understoodto influence the healthand exercise behaviours ofindividuals126(Zhu et al., 1999). Health-relatedphysical fitness knowledgecan be discussedaccording to several sub-domainssuch as: concepts of fitness; scientificprinciples ofexercise; components of physicalfitness; effects of exercise on chronicdisease riskfactors; exercise prescription;as well as nutrition, injury prevention,and consumerissues (e.g., Zhu et al., 1999). Conceptsof fitness refers to knowledgepertaining tofitness definitions, andthe relationship(s) between fitness,physical activity, and health,whereas scientific principlesof exercise includes knowledgerelating to theacute/chronic physiologicaland psychological adaptationsto exercise. Components ofphysical fitness addressesknowledge pertainingto cardiovascular, respiratoryandpulmonary function;muscular strength and endurance;flexibility; and body composition.The chronic diseaserisk factor component focuseson knowledge pertainingto thecommon chronic hypokineticdisease states (e.g., cardiovasculardisease), the riskfactors associated withthem (e.g., physical inactivity,obesity, smoking), and thepositive effects exercise elicitson the chronic diseasesand their risk factors.Knowledge related to exerciseprescription takes intoaccount the concepts offrequency, intensity,duration, mode, self-evaluation,and exercise adherence.Last, theitems pertainingto nutrition, injury preventionand consumer issues,address commonissues fitness consumersencounter (e.g., best timesview a gym whenthinking ofbecoming a member),basic nutritional information,and evidence basedways todecrease the chanceof injury (e.g., warmup, cool down, progression).127Rationale for HealthKnowledge AssessmentWithin health educationthe four basic educationaloutcomes are: knowledge,attitudes, behaviours, and skills.Despite the fact that behaviouris the outcome of mostinterest in the health educationand promotion sector, knowledgecan be assessed withincreased accuracy overa variety of settings (Kilander,2001). Health knowledgeisassociated with health-promotingbehaviours (Courtenay,1998), and acquiredknowledge contributesto the initial stimuli requiredto prompt behaviour changebyaiding individuals in thedevelopment of beliefs,attitudes, and intentions,all of whichshape behaviour (CSEP,2003; Ajzen & Fishbein,2005). Once behaviourchange hascommenced, further knowledgeimprovements can reinforcethe stimuli for change.Furthermore, the provisionof health knowledge isa major tool of public healthpromotion organizations(Nayga, 2001). Healtheducation and promotionalactivities areguided by the influenceof health knowledgeon health conditions, aswell as variation inhealth knowledgeacross socio-demographicgroupings (Nayga, 2001).Within education(especially physical education)the assessment of healthknowledge is commonin the research world andthese findings and shouldbeconsidered essentialto program evaluationand development; however,this iscommonly overlookedin actual practice. Accordingto Miller and Berry (2000),one goalof a good fitness curriculumis to provide students withadequate knowledge andskillsthat will provideencouragement for themto develop habits fora healthy and activelifestyle. Research hasdemonstrated that teachersare instrumental in developinghealth-related knowledgeof students (Miller & Berry,2000). Moreover, assessmentsare employed to determinethe knowledge and capabilitiesof prospective physicaleducators, in-servicephysical educators, andhealth professionals(Castelli & Williams,1282007; Kilander, 2001; Miller,1998). Health knowledgeassessments are also validinstruments in assessingthe product of health or physical education(i.e. studentknowledge) (Keating, 2007;Kilander, 2001). The resultsof such assessments should beutilized in curriculum revisionto enhance level of contemporaryhealth education(Kilander, 2001; Miller& Berry, 2000).Health knowledge evaluationis also important for healthcare enhancement,especially in terms of effectivepatient-physician communication(Williams, 2002). Thedoctor-patient relationship isa bond that requires unambiguous,precise and completetransfer of information for effectivehealth advice (Samora, 1961).A patient’s level ofhealth knowledgecan provide health practitionersand physicians withimportantinformation that can positivelyaffect the influence they haveon their clients or patients.Numerous studies havedocumented that physician’suse of scientific jargon incombination with patient’slimited health knowledgeand vocabulary, results inineffective health care adviceand confused patients (Williams,2002). For example,Lerner et al. (2000)revealed limited understandingof medical terminology(47%) whenassessing the healthknowledge of participants inurban and suburban Americanhospital emergency rooms.Although medical terms areused as part of normalconversation betweenhealth care providers,it was suggested that whencommunicatingwith patients, medicalterminology shouldbe carefully explained (especiallyto patientswith low health knowledge)in order to ensureoptimal health care and advice.In summary, the assessmentof health knowledge canbenefit health carepractitioners and clientsin all disciplines (e.g.,exercise physiology, dentistry,physicaleducation); however,actual assessment protocolsand procedures are lackingin manyhealth care settings. Thus, itis important for practitionersto consider assessing their129client’s knowledge base specificto the discipline or specialtybeing provided. In terms ofhealth-related physical fitnessand activity prescription, theevaluation of fitnessknowledge evaluation isa critical first step towards the effectivedelivery of informationfor improved health status.Health Knowledge and BehaviourChangeDeveloped by Ajzen (1988,1991) as an evolutionof the Theory of ReasonedAction (Fishbein, 1967),the Theory of Planned Behaviourhas been utilized as theexplicit theoretical basis forseveral hundred published scientificinvestigations since1985 (Francis etal., 2004). This theory hassuccessfully provided greaterunderstandingof diverse health-relatedbehaviours such as:exercising, adhering to low-fatdiets,contraceptive use, illicitdrug use, as wellas numerous more healthbehaviours (seeAjzen & Fishbein,2005 for a currentreview), It is the most prominentconceptual modelfor thinking about thedeterminants of particularbehaviours to-date (Ajzen,2007). TheTheory of PlannedBehaviour suggestsa framework about how humanaction isgenerated. It estimatesthe incidence of a particularbehaviour given that the behaviouris intentional. It is suggestedthat behavioural intentionsare assumed to result sensiblyfrom beliefs (behavioural,normative, and control)about performing the behaviour(Ajzen & Fishbein,2005). It is importantto note that the behavioural,normative andcontrol beliefs peoplepossess regarding theperformance of a particularbehaviour areinfluenced by a broadassortment of situational,cultural, and personalbackgroundfactors. These beliefscan be accurate, inaccurate,biased, and even illogical.Nevertheless, thisset of beliefs is the cognitivefoundation that guideshuman action,which is influencedby three major factors:a positive or negative assessmentof the130behaviour (attitude regarding thebehaviour), perceived societalinfluence to execute ornot execute the behaviour(social norm), and perceived abilityto execute the behaviour(perceived behavioural control).The amalgamation of attitudetowards the behaviour,subjective norm, and perceptionof behavioural control leadsto the formation of abehavioural intention(the strongest predictor ofhuman behaviour). In general,the morefavourable the attitudeand subjective norm,in combination with increased perceivedbehavioural control,a person’s intention to performthe desired behaviour willbegreatest. Lastly, givena significant degree of actualcontrol over the behaviour,individuals are expectedto execute their intentions whenpresented with an opportunity.A schematic representationof the Theory of PlannedBehaviour is presented in FigureA.1.According to Ajzenand Fishbein (2005)a reasoned action/plannedbehaviourapproach does have itslimits. Inaccurate informationhas the ability to produceunrealistic beliefs, attitudes,and intentions whichcan result in unwanted behaviours;lack of volitional controlcan inhibit individualsfrom executing intendedbehaviours;strong emotions canactivate beliefs and attitudesthat are not part of one’severydaycognitive processes;and unanticipatedcircumstances may leadto deviations inintentions. Therefore, in termsof health-relatedphysical fitness knowledge,if anindividual possessesinaccurate informationpertaining to the constructsof fitness theindividual’s fitnessbehaviours can becompromised by unfavourableattitudes andbeliefs towards the behaviour.According to Ajzen(2007) knowledge, or correctfactualinformation plays nodirect role in the processof the TRAITPB becausebehaviourrelevant beliefs will beformed regardless ofwhether or not the informationonepossesses is corrector incorrect. Thus, thebehaviour will still be initiated;however, the131health-related outcome dependson whether the informationworks for or against thebehaviour.Health-RelatedKnowledge AssessmentOne of the most popular methodsfor collecting descriptive datais the surveyapproach. Surveys are composedof a series of questions, relatingto the researchquestion, which are posedto a group of participants andmay be conducted in the formof an oral interview,written questionnaire or examination,or computer basedquestionnaire or examination(Portney, 2000). Surveysare often concerned withdescribing the levelsof knowledge a specificgroup possesses (Portney,2000). In termsof health and fitnessknowledge, the most popularassessment tools are selfreportquestionnaires or examinations.These methods havebeen used to have assessthehealth and fitness knowledgeof children (Mobley, 1996),adolescents (Haltiwanger,1994; Keating, 2007; Merkle& Treagust, 1993),adults (Beier & Ackerman,2003; Losch& Strand, 2004; Miller,1998; Petersen et al., 2003)and the elderly (Fitgeraldet al.,1994).When constructingan assessment toolthe reliability and validity shouldalwaysbe taken into account.Content validityof a health knowledgeassessment tool ensuresthat the items providean adequate sampling ofhealth knowledge forthe relevant healtheducation standards(Morrone, 2007). Measuresof a tools internal consistencyprovidean index of the overallreliability of an assessmentdevice (Portney, 2000). Toestablishacceptable levels ofcontent validity andinternal consistency fora health knowledgeassessment tool thefollowing steps are recommended(Morrone, 2007; Portney,2000):(1) identify the relevanthealth education standards;132(2) develop questions basedon the research question and resultsfrom a literaturereview conducted to identify validatedoutcomes;(3) have a panel of experts reviewthe items;(4) revise the document basedon the panels comments;(5) pilot test the instrument andconduct interviews or focus groups;and(6) revise the document basedon results from the pilot testingand interviews/focusgroups.Developed by Zhu, Safrit, andCohen (1999) and made availableby HumanKineticsTMtheFitSmart is an established,valid and reliable testto accurately measureknowledge of fundamentalhealth and fitness conceptsat the high school level ofeducation. It can be writtenas a computer based or penciland paper test. Thedevelopment of this knowledgeexamination was in accordancewith therecommendations providedby Morrone and Portney (asmentioned above);thus, theFitSmart has undergonerigorous reliability and validitytests, as well as numerouspilotinvestigations (Zhuet al., 1999). The FitSmartconsists of two equivalent versions(Forms I and 2) containing50 multiple-choice items, measuringsix sub-domaincomponents. Normally,scores for this testare reported on a standardscore scaleranging from 20-80. Thisscore scale was developedusing an appropriate itemresponse theorymodel with results from 4,025high school students. A cutoff score of50 on the standard scorescale is used to indicatea Healthy Fitness KnowledgeZoneappropriate for highschool students. However,all scores (overall andcategorical) canbe converted into rawscores to gain percentagevalues for knowledge translationalpurposes. The sub-domaincomponents, tested in equalnumbers of questions withinboth forms, include: conceptsof fitness; scientific principlesof exercise; componentsof133physical fitness; effects ofexercise on chronic diseaserisk factors; exerciseprescription; as well as nutrition,injury prevention, andconsumer issues. Since bothforms contain an equal number ofquestions and the contentwithin these questions hasbeen equally balanced it ispossible to directly comparethe scores on the two forms(Zhu et al., 1999). The FitSmarthas been used as a validand reliable health andfitness knowledge assessment tootfor adolescents (Keating, 2007)and adults (Losch &Strand, 2004; Petersenet aL, 2003). Furthermore, otherinvestigations haveincorporated items fromthe FitSmart into their multidimensionalassessment protocolsdue to the tests establishedvalidity in the assessmentof exercise knowledge (Zizzi,Ayers, Watson, & Keeler, 2004).Employing Form 1 of theFitSmart, Keating and colleagues(2007) examined thehealth and fitness knowledgeof 185 ninth grade studentsin a metropolitan area schooldistrict. The overall meanraw score of the ninth graders(16/50) indicated seriousdeficiencies in healthand fitness knowledge. These findingssuggest that healthpromotion efforts that functionto increase health and fitness knowledgeare neededwithin the educationalsystem (Keating, 2007).Peterson, Byrne, andCruz (2003) employedthe FitSmart to assess the healthrelated fitness knowledgeof 63 pre-service physicaleducation teachers. Petersonet al.chose the FitSmartbecause the concepts beingevaluated are ones thatpre-serviceteachers will be expectedto communicateto high school students. Resultsof the healthknowledge assessmentwere not especially impressivefor educated college seniorswho are expected toteach this material in the nearfuture. Pre-service physicaleducators scored anaverage of 75.2% onthe FitSmart. Component analysisrevealedthat pre-service educatorswere most competentin the exercise prescriptiondomain134(mean = 92.0%) and weakestin the domains of physicalfitness (mean = 67.7%) andscientific principles of exercise(mean = 67.7%). The various universitylevel coursesthat each participant had takenduring their course ofstudy were also examined.Exercise physiology was identifiedas the primary course responsiblefor pre-servicephysical educator’s in-depthknowledge of health and fitnessconcepts. The majority ofthe participants (90.5%)had only taken one coursein exercise physiology andthegrades received werejudged as substandard. Approximatelyhalf (49%) of theparticipants reportedearning grades of “C” or lower,15% could not remembertheirgrades, and only 4.8%of the participantsearned “A” grades. To overcometheseknowledge deficiencies,Petersen et al. (2003)suggested that future educationalcurriculums shouldintegrate and reinforce fitnessconcepts across a variety ofcoursesto ensure knowledgeretention of the subjectmatter.In an investigation similarto Peterson et al’s (2003),Losch and Strand (2004)revealed comparablefindings when assessing thehealth and fitnessknowledge level of36 male and femalephysical educationteaching majors. The averagescore for theFitSmart test was 69.4%.Compartmental analysisof the scores also paralleledPeterson et al’s investigationwith the highest scores occurringon the exerciseprescription component(mean = 85.9%), and thelowest scores occurring inthecomponents of physicalfitness (mean = 63.9%),scientific principals of exercise(mean= 65.3%), as well as the nutritioninjury prevention,and consumer issues (mean=64.5%). In parallel with Petersonet al, the remodellingof post-secondary coursecurriculum to integratehealth and fitnessconcepts into a variety ofcore courses iswarranted to reinforcethe retention of these deficientknowledge areas.135Miller and Berry (2000) measuredthe health-related physicalfitness knowledgeof student allied health professions(i.e., Physical Therapy, Athletic Training,andNursing) via a multiple-choice test.This test was constructedby a panel of experts whohad specific educational trainingand experience in exercise physiologyand physicaleducation. The assessmentspanned five health-relatedfitness domains includingbodycomposition, flexibility, muscularstrength, muscular endurance, andcardiovascularconditioning. The multiple-choicetest consisted of a total of 40 questionsspanning 20health-related fitnessconcepts (agreed on via expertconsensus), with 8 questionsforeach domain. The study utilizeda pre-test post-test design witha 2 year time interval(time taken from beginningto completion of professionalprogram) between tests.Results indicated that studentathletic trainers earnedsignificantly higher total scores,incomparison to the nursingand physical therapygroups, on the post-test in relationtobaseline measures. In addition,both the athletic trainingand physical therapy group’spost-test scores were significantlyhigher in comparisonto the nursing groups total posttest score. This data demonstratesthe impact that curriculumhas on the basic contentknowledge of its graduates.Moreover, this highlightsthe importance of curriculumreviews and identifyinggaps in essential knowledge.When designing health curriculum,it is essential to ensure thatstudents in all health disciplinesacquire the pre-requisiteknowledge to functionas reputable allied-health professionals(Miller & Berry, 2000).Beier and Ackerman(2003) utilized a health knowledgebattery to assess a widesampling of health informationavailable to the general public.The battery consisted often subscales, which included:aging, orthopaedic anddermatological concerns,common illnesses, childhoodand early life, serious illnesses,mental health, nutritionand exercise, reproductivehealth, safety and firstaid, and the treatment of illnessand136disease. Beier and Ackermanshowed that the inter-correlationsamong the ten healthsubscales were significantand large. Factor analysissuggested that those who knowmore about one health domainare more likely to be highlyknowledgeable concerningother domains. The significantinter-correlations betweenthe health scales allowedacomposite knowledge scoreto be generated by summing thescores of individual healthscales (Beier & Ackerman,2003). When examiningthe gender differences in healthknowledge, women (on average)performed superior tomen on each health knowledgedomain, with the largestgender differences occurringfor the reproductive and earlylifescales.In summary, healthknowledge can bereadily assessed with toolsthat have beendevised to ensure propercontent validity, internal consistency,and reliability. Moreover,the FitSmart is an assessmenttool that has under gonetests of validity, consistency,and validity. To-dateit has been utilized asa primary measure of health-relatedphysicalfitness knowledge in multipleage groupings with varyingeducational backgrounds.Theresults of health knowledgeassessments providesubstantial informationto researchersand educators that should beused to evaluate the educationaloutcomes of studentsand health-related professionalsto optimize knowledgeretention and translation.Assessment of Health-RelatedBeliefs, Attitudes,and IntentionsThe reasoned action/plannedbehaviour approachhas been used in attitudebehaviour research fordecades as specific behavioursare reasonably determinedbyones beliefs, attitudes,and intentions (Ajzenand Fishbein, 2005). However,earlyattempts in attitude-behaviourresearch to outline the determinantsof specificbehaviours usually producedpoor correlation andunsatisfactory results. Recent137research has shifted focus frombroad to specific behaviouraldispositions to attitudestoward behaviour. This was due tothe notion that general attitudes arepoor predictorsof single behaviours; however, theycorrelate strongly with behaviouralaggregates.Thus, current attitude assessmentsbased on the reasoned action/plannedbehaviourmodel have turned to behaviour-focusedattitudes that are congruent with behaviouralcriterion in terms of action,target, context, and time elements(Ajzen and Fishbein,2005). Accordingly (and of interestto this thesis), Rhodes and Courneya(2003) haverecognized these importantconsiderations and have implementedthem into theirassessment protocols for usewith a variety of populationsamples (e.g., young, old,healthy, and clinical). Specifically,Rhodes and Courneya(2003) developed a tool toinvestigate multiplecomponents of the Theory ofPlanned Behaviour constructs(i.e.,instrumental attitude, affectiveattitude, injunctive norm, descriptivenorm, self efficacy,controllability, and intention)in the exercise domain withinclinical and healthypopulation samples (i.e., cancersurvivors, and universityundergraduate students).In 2004, a manualwas developed in responseto health service researcher’srequests to predict andunderstand behaviour (Franciset al., 2004). The manual isbased on the Theory ofPlanned Behaviour (Ajzen,1988, 1991) and it is designedtoassist psychologistsand non-psychologists involvedin health-relatedresearch toproduce effectivequestionnaires to measurethe constructs of the Theoryof PlannedBehaviour. For more informationon the assessment of health-relatedbeliefs, attitudes,and intentions refer to thismanual.138lmjact of Health KnowledgeIndividuals with less education,lower incomes, and blue collaremployment aremore likely to be physically inactivethan those with more educationand higher payingwhite-collar employment (Draheim,2002). Correspondingly, researchindicates thatpeople who are educatedregarding fitness are more likely tobe physically active and fit(Petersen et al., 2003). Theconsequences of a sedentarylifestyle are well documentedand contribute to a myriad ofhypokinetic diseases (Warburtonet al., 2006a).Additionally, a large numberof health economic studieshave ascertained that highereducation is associated withpositive health outcomes,even when factors like incomeare controlled for (Kenkel, 1991).One explanation for this isthat schooling helps peoplechoose healthier lifestylesby improving their understandingof the relationshipsbetweenhealth behaviour and healthoutcomes (Kenkel, 1991).Individual’s that possess lowlevels of health knowledgewill have a limited understandingof the benefits of engagingin healthy lifestylebehaviours. They will alsohave trouble identifyingthe symptoms andcommunicability of diseases,selecting appropriate preventativehealth strategies, andunderstanding whereand how to select appropriatemedical treatment (Freimuth,1990).These health knowledgeissues have been documentedin individuals with intellectualdisabilities (Graham, 2000;Stanish, 2006) andlow levels of health literacy(Ad HocCommittee on HealthLiteracy for the Council onScientific Affairs, AmericanMedicalAssociation, 1999;Davis, 2004).If individuals donot learn from healthpromotion efforts designedto highlight therelationships betweenhealth behaviours andhealth outcomes their abilityto partake ina healthy and active lifestylewill be compromised. Thus,it is essential for healthpromotion efforts totarget individuals basedon their individual capabilitiesand needs139(Fish & Nies, 1996). For example,cohorts with increased knowledgewill be able toreceive and respond appropriatelyto more complex health promotionalmessages andservices than those with less knowledgeand intellectual capabilities.This exampleemphasizes the need to assessthe health knowledge ofpeople in order to maximizeand target the effects ofa health promotion intervention.Health LiteracyAccording to the UnitedNations Educational, Scientificand Cultural Organization(UNESCO), a functionallyliterate individual is one whopossesses adequate knowledgein reading and writingwhich allows them to successfullyparticipate in activities inwhichliteracy is culturally assumed(United Nations Educational,Scientific and CulturalOrganization, 1970).Literacy is directly relatedto overall health status andmentalhealth status (Rootman,2005). Health literacy includesdimensions additional to readingand writing abilities. Itis referred to as the degreein which people have thecompetenceto obtain, process, and understandbasic health information andservices needed tomake appropriate healthdecisions (Parkeret al., 2003). It is a contemporaryand wellwarranted topic of concernfor the advancementof high quality health care(Parker etal., 2003). Health literacyis pivotal to numerous healthcare system initiatives includingquality assurance,cost maintenance,safety, and patient’s activeinvolvement in healthcare decisions (Parkeret aL, 2003).The International AdultLiteracy and Skills Survey(IALS) is the primaryand currentsource of literacy measuresof the general population inCanada and in other countries(Rootman, 2005). Themost recent IALS results(circulated in 2005) highlightedmajordeficiencies in theliteracy levels of the population(Statistics Canada, 2005). Almosthalf140of the Canadian adult populationfalls into the lowest 2 of5 literacy levels (outlined onp.16-17 (Statistics Canada,2005)) in regardsto their ability to read and comprehendprose (48%) and documents (49%).The majority of the populationfalls into the twolowest levels concerning problemsolving ability (72%) and numeracy(55%) (StatisticsCanada, 2005). Correspondingly,22% of the Canadian adult populationis seriouslychallenged in terms of literacyand another 26% have skills inadequatefor what isrequired to successfully participatein today’s “knowledge economy”(Rootman, 2005;Statistics Canada, 2005).Furthermore, special populations,such as the elderly,aboriginal people, immigrants,and francophones, weredeemed to have significantlylower levels of literacy(Statistics Canada, 2005).In the United States,the AmericanMedical Associationhas identified the highprevalence of inadequatehealth literacyamong the elderly asa concern (Ad Hoc Committeeon Health Literacy for theCouncilon Scientific Affairs, AmericanMedical Association, 1999). Ina study measuringpatient’s functionalhealth literacy at two publichospitals via the Test ofFunctionalHealth Literacy (TOFHLA)(Parker, Baker, &Williams, 1995), 81.3%of English speakingpatients equal to orabove 60 years of age possessedinadequate or marginallevels ofhealth literacy (Williamset al., 1995). This placesconsiderable concerntowards thehealth and well beingof senior citizens giventhat the aging processis associated with amyriad of chronic degenerativeco-morbidities whichcommonly result in increasedhealth care utilizationand dependency (WHO,2002).Inadequate healthliteracy can and usuallyis associated with severalhealth-relatedconsequences. Literacyis related to numerousaspects of health inclusiveof healthknowledge, healthstatus and use of healthservices (Ad Hoc Committeeon HealthLiteracy for the Councilon Scientific Affairs, AmericanMedical Association, 1999).141When related to health outcomes,patients with low literacy are generally1.5-3 timesmore likely to experience inferiorhealth outcomes inclusive of knowledge,transitionaldisease indicators, morbidity measures,utilization of health resources,and generalhealth status (DeWalt etal., 2004). Using self report measures,patients with inadequatehealth literacy are more likelyto report their health as poor (Bakeret al., 1997). Thereexists an independent associationbetween insufficient functionalhealth literacy(determined via the TOFHLA)and hospital admissions(Baker et al., 1998). Previousinvestigation has showedthat patients with inadequate functionalhealth literacy weretwice as likely to be hospitalizedthen patients with adequateliteracy levels (Baker et al.,1998).In terms of knowledge, thereexists a positive and significantrelationship betweenliteracy levels and knowledgeof health services or healthoutcomes (DeWalt et al.,2004). Studies indicatethat individuals with low literacycapabilities and chronicorinfectious diseases suchas diabetes (Williamset al., 1998), hypertension(Williams etal., 1998), asthma (Williamset al., 1998), or HIV/AIDS(Kalichman et al., 2000)haveinferior knowledge concerningtheir disease and its recommendedtreatment.Furthermore, researchhas indicated that poorhealth literacy alone is the mostsignificant predictor ofdisease prevention knowledgewhen compared toethnicity oreducation (Lindau et aL,2002). Uniformly,a study analyzing the relationshipbetweenliteracy levels andasthma knowledge and selfcare (Williams et al., 1998)indicated thatliteracy level was the strongestcorrelate of health knowledgeand disease managementskills (Ad Hoc Committeeon Health Literacy for theCouncil on Scientific Affairs,American Medical Association,1999).142SummaryHealth knowledge isa key determinant of healthstatus. It is a valuableconstructto assess as the findings can beused to improve health educationinitiatives in manydisciplines. The Theoryof Planned Behaviour hasbeen utilized as the theoreticalbasisin hundreds of scientific investigations,and has aided in understandinga diverse arrayof health related behaviours.Assessments of the Theoryof Planned BehaviourConstructs have becomemore specific over theyears and can be utilized intheexercise domain with confidence.Based on the healthliteracy findings it is evidentthathealth knowledge itselfis an important factorin determining healthstatus and healthmanagement skills. Eventhough literacyis a primary determinantof health knowledge,it is health knowledgeitself which has a primaryimpact on the healthbehaviours andstatus of individuals.A preventative healthcare approach that incorporateslow literacyinterventions in collaborationwith health education(low knowledge intervention)wouldbe a viable initiative to accentuatehealth status acrossthe lifespan. In ordertoconstruct a healthpromotional interventionas such, the individualcapabilities andneeds of individualsmust be targeted. Researchthat functions to assess thecurrentlevels of health knowledgeis a prudent elementarystep in the processof tailoring anevidence basedhealth promotion intervention.Health-RelatedPhysical FitnessIn this section,health-related physicalfitness will be definedalong with itscomponents and primarycontributors. The importanceof conducting health-relatedfitness assessmentswill be discussedfollowed by an outlineof the methods usedto143evaluate health-related physicalfitness. The impact of health-relatedfitness will also besummarized.Defining Health-Related Physical Fitnessand Primary ContributorsHealth-related physicalfitness encompasses thecomponents of physical fitnessthat are related to health status,including cardiovascularfitness, musculoskeletalfitness, body compositionand metabolism (Warburtonet al., 2006b). Health-relatedphysical fitness is different thanperformance-related physicalfitness, wherebyperformance-related physicalfitness encompassesa set of attributes that peoplepossess or achieve relatingto their ability to perform specificphysical challenges whichcan provide the fundamentalsfor sport or performance.Health-related physicalfitnessfocuses on the health risksand benefits associatedwith each of its componentsinrelation to the generalpopulation (CSEP, 2003).More specifically, cardiovascularor aerobic fitness is a measureof the combinedefficiency of the lungs,heart, bloodstream,and exercising musclesin getting oxygen tothe muscles andputting it to work (CSEP,2003). Musculoskeletalfitness refers to thefitness of the musculoskeletalsystem, encompassingmuscular strength, muscularendurance, muscularpower, flexibility, back fitnessand bone health (Warburtonet al.,2006). Muscular strengthis referred to as themaximum tension or forcea muscle canexert in a single contraction,while muscular enduranceis the ability of themusculoskeletal systemto maintain or repeatedlydevelop contractile force.Muscularpower is a combinationof strength and speed correspondingto the maximum rate offorce generation withina single rapid contraction ofthe musculature. The rangeofmotion in a joint or seriesof joints is known as flexibility(CSEP, 2003). The relative144amounts of muscle, fat, boneand other anatomical componentsthat contribute to aperson’s total body weight(U.S. Department of Health and HumanServices, 1999) arewhat make up an individual’sbody composition and contributeto their metaboliccapacity.It is regularly assumedthat health-related physical fitnessis a product of habitualphysical activity participation(Katzmarzyk, 1998). PhysicalActivity refers to any bodilymovement produced by skeletalmuscles that results in energyexpenditure (EE) and ispositively correlated with physicalfitness (Caperson et al., 1985).When physical activityis planned, structured, andincorporates repetitive bodilymovement geared towardsimproving or maintainingone or more componentsof physical fitness, it is referredto asexercise (Capersonet al., 1985).Importance of Health-RelatedPhysical Fitness AssessmentHealth—related physical fitnessis considered a significantcomponent of healthstatus (Katzmarzyk, 1998).The results of a stringentand standardized health-relatedfitness assessmentcan provide individuals witha lot of valuable informationpertainingto their health status. Thisinformation is expectedto educate individuals on theircurrenthealth condition andcontains evidence-based guidanceon how to enhance currenthealth by focusingon improvements in thelowest ranked fitness components.Theprovision of this informationis intended to motivateindividuals to develop healthierlifestyles and increasetheir physical activityparticipation in a safe, efficientandprogressive fashion(CSEP, 2003). Aside fromthe individual benefits ofa health-relatedfitness assessment,population health canbe targeted by tailoring healthpromotioninterventions to accommodatetrends in epidemiologicalfitness data (Shephard, 1986).145Assessment of Health-RelatedPhysical FitnessThe assessment of health-relatedphysical fitness can be easilyaccomplishedwith the use of well establishedappraisal protocols from agenciessuch as the CanadianSociety for Exercise Physiology(CSEP, 2003) and the AmericanCollege of SportsMedicine (ACSM, 2005)(Warburton et al., 2006b).These assessments havebeenestablished based on normativeregional data and aredesigned to appraise theindividual elements of health-relatedphysical fitness (see previoussection) (Warburtonet al., 2006b).Specific to this investigation,the Canadian Physical Activity,Fitness and LifestyleApproach (CPAFLA) (see TableA. 1.) (CSEP, 2003), has beenacknowledged as themost widely used standardizedhealth-related fitness appraisalthroughout Canada(Katzmarzyk, 2002). Furthermore,it is accepted as Canada’sprimary health-relatedphysical assessmenttool (Warburton et al., 2006b).This health-relatedfitnessassessment protocol isadministered on overa million Canadians every year (CSEP,2003).Impact of Health-RelatedPhysical FitnessWhile the risk of deathfor the most sedentary individualsis approximately twiceas high as that of the mostactive individuals, the respectiverisk of low-fitnessindividuals is seven toeight times higher thanthat of high-fitness individuals(Oja,1995). There appearsto be a graded effect regardingthe impact of physicalfitness onthe risk of prematuredeath, such that even smallimprovements in physicalfitness areassociated with a decreasedrisk. An increase in physicalfitness will reduce the risk ofpremature cardiovascular-relateddeath, and a decrease in physicalfitness will increase146the risk. Regular physicalactivity participation in collaborationwith high fitness levelsare correlated to a decreasedrisk of premature fatality from anycause (especiallycardiovascular related diseases)among asymptomatic menand women. Routinephysical activity participationaids in the primary and secondaryprevention ofcardiovascular-related diseases,diabetes mellitus, cancer (colonand breast inparticular), osteoporosis, depression,and obesity (see Warburton et al.,2006a for amore complete review of the literature).Provided that aerobic fitnessis defined as the combinedefficiency of the lungs,heart, bloodstream, and exercisingmuscles in getting oxygento the muscles andputting it to work,the health-related impact ofaerobic fitness is significantand shouldnot be overlooked, Improvedaerobic fitness canbe achieved by a variety of exercisesand sporting activities, isessential for continual functionalindependence, and reducesthe risks of cardiovascular-relateddiseases (e.g., heart failure)and risk factors (e.g.,hypertension) (CSEP, 2003).Composite body compositionis assessed by combiningBMI, skinfoldmeasurement (approximationof body fat) and waist circumference.Unhealthy BMIvalues (either too low(<18.5) or too high (> 24.9))statistically increase one’srisk ofpremature death (CSEP,2003). Obesity is now a pandemicaffecting many peopleworldwide, It is acondition of excess body fatthat results from a chronicenergyimbalance whereby intakeexceeds expenditure. Toomuch body fat significantlyincreases a person’s riskof premature death from chronicdiseases such as coronaryartery disease, stroke,type 2 diabetes mellitus, gallbladderdisease and some cancers(Katzmarzyk, 2002).Obesity in collaboration withphysical inactivity placesa significant147burden on the Canadian healthcare system by accrediting$9.6 billon towards theirtreatment and management (Katzmarzyk,2004).There is increasing evidence thatinferior musculoskeletal fitnessis associatedwith a decline in overall healthstatus and an increase in the riskof chronic disease anddisability (Warburton, 2001). Longitudinalinvestigations have discoveredthat individualswith low levels of muscularstrength have increased functional limitationsand higherincidences of chronic diseasesincluding diabetes, stroke, coronaryartery disease,arthritis, and pulmonary disorders(Rantanen, 1998). Furthermore,deficientmusculoskeletal fitness is positivelyassociated with functional dependence,immobility,glucose intolerance, poor bonehealth, psychologicaldisturbances and decreasedquality of life, increased risk offalls, illness and premature death(Warburton et al.,2006a).SummaryThe health-related physicalfitness components (physicalactivity participation,body composition, aerobicand musculoskeletal fitness)and their contributors areessential to one’s healthstatus. There are manybenefits associated with theassessment of health-relatedphysical fitness. Moreover,the CPAFLA is a standardizedand well recognized approachto the assessment of health-related physicalfitness in thegeneral population. Sincethe CPAFLA appraisal processis designed to increase one’sknowledge and awarenessconcerning health-related physicalfitness we hypothesizethat individuals whoparticipate in the CPAFLA will increasecomponents of their healthrelated physical fitnessknowledge base. Investigationsthat function to assesshealth-148related physical fitness areof much relevance to health carepractitioners and agenciespromoting health.Health Knowledge in Relationto Health-Related Physical FitnessKnowledge is considered one ofthe essential factors in establishinghumanbehaviour (Andrade, 1999).People who understand the conceptsof physical fitness arealso more likely to incorporatephysical activity and exerciseinto their everyday life (Zhuet al., 1999). Thus, an importantstep in becoming physically fitand endorsingconstructive attitudes in relationto fitness is learning theconcepts and principlesofhealth-related physicalfitness (Miller & Housner,1998). Evidence supportinga positiverelationship between health-relatedphysical fitness knowledgeand health-relatedphysical fitness has beensuggested in adolescents(Keating, 2007), limitedly showninadulthood (Avis, McKinlay,& Smith, 1990; Liang et al., 1993),and within elderlypopulations (Fitgerald, Singleton,Neale, Prasad, & Hess,1994). However, literaturedelineating the relationshipbetween health knowledgebase and health-related physicalfitness is inconsistent. Forexample, investigations have shownno significantrelationship between fitnessknowledge and componentsof physical fitness (i.e.,physical activity) (Morrowet al., 2004). This sectionwill outline the pertinentinvestigations that highlightthe relationship betweenhealth-related physical fitnessknowledge base and health-relatedphysical fitness.Health Knowledge andPhysical Fitness in AdultsAvis et al. (1990)examined the level of cardiovascularrisk factor knowledge andits relationship to behaviourin females. On average, theparticipants were moreeducated and had higherincomes in comparison tothe general population. Inaddition,149only a small portion was not Caucasian.Cardiovascular risk factor knowledgewasassessed by asking participantsto outline the specific steps an individualcould take todecrease the risk of a strokeor heart attack. Interviewerslobbied respondents tomention all actions of whichthey were aware. The risk factorsand health behavioursmeasured included smoking(self report # cigarettes perday), weight status (BMI),cholesterol (venous blood sample),physical activity (kilocaloriesexpended via Harvardalumni scale (Paffenbarger, Wing,& Hyde, 1978)), blood pressure(standardsphygmomanometer), andstress (self report). Health knowledgewas positively relatedto education (p < .01), beingfemale (P < .01), and amount ofexercise(p<.05). Theauthors suggested thatthe positive relationshipbetween the health-related physicalfitness components andhealth knowledge may havebeen mediated by the samplingofa higher socioeconomicbracket. Further investigationincorporating well establishedand standardized assessmentmeasures is needed to quantifythis relationship inrepresentative samples ofthe general population.In addition, the results of thisinvestigation suggestthat education and knowledgeare necessary to preventnegativehealth behaviours, but notsufficient to influence behaviouralchange once healthdamaging behaviours(e.g., smoking) have beenestablished. Thus, evidencebasedhealth promotion programsfocusing on preventionare needed to educate andincreaseknowledge regarding thepositive relationship betweenhealth behaviours andhealthoutcomes.Liang et al. (1993)examined whether ornot first year medical student’sknowledge and attitudesconcerning health and exerciseaffected physical fitness.Thefitness assessment tookinto account body fat (hydrostaticweighing) and cardiovascularfitness (maximal aerobicfitness test(VO2max)). A questionnaire was utilized to assess150knowledge and attitudes regarding healthpromotion, disease prevention, and exercise.Results showed that health knowledgeinfluenced medical student’s fitnesslevels;however, attitudes concerning health promotionand disease prevention were strongerpredictors of fitness levelsMorrow et al. (2004) studied theinfluence of exercise knowledgeon the physicalactivity behaviours of American adults.All data was generated via randomdigit diallingphone interviews. A 20 item verbalquestionnaire incorporating exerciseprescription,traditional physical activities, andlifestyle activities was used to determinelevels ofhealth-related exercise knowledge.Physical activity behaviourwas assessed by askingparticipants to select oneof eight responses that functionedto best describe theircurrent behaviour (Martin, Morrow,Jackson, & Dunn, 2000). Resultsindicated thatknowledge of exerciserecommendations had no effecton exercise behaviours;however, ethnicity, education level,and age were significantly correlatedto healthknowledge. The authorssuggest that the results could supportthe concept ofknowledge being requiredyet not sufficient for behaviour change.Other factors (e.g.,self motivation, attitudesor perceived benefits) couldbe interacting with knowledgetoinfluence behaviour change(Morrow et al., 2004). Nevertheless,it is recommended forhealth promotion programsto emphasize aspects of knowledgethat are directly relatedto the behaviour change of interest.Rutledge et al. (2001) showedthat greaterknowledge concerningbreast cancer and its detectionmethods was significantlycorrelated to breast selfexamination behaviours.Thus, individuals that possessspecificknowledge regardinghealth-related physical fitness shouldbe better predisposed toengage in these fitness behaviours.Unfortunately, even though manyadults are aware151of the benefits related to physical activity,many lack specific knowledgeof how to bephysically active fora health benefit (Morrow, Jackson, Bazzarre, Milne,& Blair, 1999).Health Knowledcie andPhysical Fitness in the ElderlyFitzgerald et al. (1994) examinedphysical activity (self report),measured fitnessstatus, exercise knowledge,and exercise beliefs of African Americanand Caucasianfemales (ages 50-80) in good health.One question addressed in this investigationasked, “What are the exercise knowledgeand beliefs of this group and howdo exerciseknowledge and beliefs relateto measured fitness status and exercisebehaviour?”. Thedegree to which exercise knowledgeand beliefs are related to physical activityin theelderly is of much relevanceto geriatric practitioners as preventativemeasures areessential to halt the aging processand increase longevity (Fitgeraldet al., 1994).Fitness status was determined viaa sub-maximal treadmill test(up to 70% predictedmaximum heart rate). A 7-dayphysical activity recall estimatingfrequency and durationof significant aerobic exercisewas utilized to assess physicalactivity. The exerciseknowledge assessment consistedof three questions derived fromthe American Collegeof Sport Medicine guidelinesfor cardiovascular fitness. Results indicatedthat exercisebeliefs and knowledge do influenceexercise habits. Fitzgerald et al.suggested that theregression model implementedfor the statistical analysiswas a poor fit of the data,meaning that the independentvariables did not significantly explain fitnessstatus(Fitgerald et al., 1994). Thiswas most likely dueto the variability in the measures used.A more rigorous fitnessassessment along with knowledgeassessment isrecommended to examinethe relationship of interest.152SummaryKnowledge is considered one of thecritical factors in establishing humanbehavior (Andrade, 1999.) Furthermore,people who understand the concepts ofphysical fitness are also more likely toincorporate physical activity and exerciseintotheir everyday life (Zhu et al., 1999).Thus, since regular physical activity participationisoften assumed as a significant predictorof health-related physical fitness (Katzmarzyk,1998), we postulate that individuals whopossess superior levels of health-relatedphysical fitness knowledge will demonstratehigher levels of health-related physicalfitness.To-date, literature demonstrating apositive relationship between fitnessknowledge and health-related physicalfitness in adulthood is limited. When analyzingwhy these previous investigations provideinconsistent evidence supporting thisrelationship, methodologyseems to be the issue. Each investigation utilizeddifferenthealth knowledge assessments, measuresof physical fitness, as well as samplingmethods. Given the deviationsin methodology between investigationsthe limited andinconsistent evidence is not surprising.A study or set of investigations thatimplementsimilar established, valid, and reliableprotocols which function to evaluate thisrelationship within a cross-sectionaldesign (e.g., young adulthood vs.middle adulthood)would make an important contributionto the current body of literature.153Table A.1. Components of the CanadianPhysical Activity, Fitness and LifestyleApproach (CPAFLA): A StandardizedHealth-Related Physical FitnessAssessment Tool(Adapted from CSEP, 2003).Pre-Appraisal Screening• The Physical Activity ReadinessQuestionnaire (PAR-Q)• A pre-activity screening tool designedto identify people for whomcertain physical activities may be inappropriateand those whoshould seek medical advice(e.g., individuals with documentedcardiovascular disease).• Measurement of resting heartrate and blood pressure• The Healthy Physical ActivityParticipation Questionnaireo Used to assess current levelsof physical activityComposite Body CompositionAssessment• Body mass index• Waist circumference• Skinfold thickness(a measure of subcutaneous bodyfat)Assessment of AerobicFitness• Modified Canadian AerobicFitness Test (mCAFT)o A valid and reliable, predictive,submaximal, and progressivestepexercise test designed specificallyfor the general populationAssessment of MusculoskeletalFitness• Grip strength• Push-ups• Sit-and-reach test• Partial curl-ups• Vertical jump• Back extension enduranceAssessment of backhealth• Weighted scores forphysical activity participation,waist circumference, sitand reach, partial curl-ups,and back extension, are combinedto providean indication of compositeback fitness.Results and CounsellingSession• Individual results generatedbased on Canadian normativedata• Evidence based guidanceprovided to stress the health benefitsof regularphysical activity participation• Fitness goals are setbased on individual dataBackgroundfactorsindMdualPersonalityMood, emotionIntelligenceValues, stereotyperGeneral attitudesExperienceSocialEducationAge, genderIncomeReligionRace, ethnicityCultureTh/rmationKnowledgeMediainterventionFigure A.1. 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NASPAJournal, 41(4), 588-630.165APPENDIX BUBC Clinical Research Ethics BoardCertificate of ApprovaliJC The University ofBritish Columbia-Office ofResearch ServicesClinical Research Ethics Board — Room 210,828 West 10th Avenue, Vancouver, BCV5Z1L8ETHICS CERTIFICATEOF FULL BOARDAPPROVAL‘RINCIPAL INVESTIGATOR:LNSTITUTION / DEPARTMENT: UBC CREBNUMBER:shannon S.D. BredinIUBC/EducationlllumanKinetics1H08-00468LNSTITUTION(S) WHERE RESEARCHWILL BE CARRIED OUT:InstitutionI SiteUBCVancouver (excludes UBC Hospital)Other locations where the research will be conducted:N/ADO-INVESTIGATOR(S):4arc D. Faktor)arren Warburtonyan RhodesSPONSORING AGENCIES:‘ROJECT TITLE:E-IEALTH-RELATED PHYSICALFITNESS KNOWLEDGE: THE INFLUENCEOF PHYSICAL FITNESS ANDDMINISTRATION OF THECANADIAN PHYSICAL ACTIVITYFITNESS & LIFESTYLE APPROACH.[‘HE CURRENT UBC CREB APPROVALFOR THIS STUDY EXPIRES: April8, 2009The full UBC Clinical Research Ethics Boardhas reviewed the above described research project,includingssociated documentation noted below,and finds the research project acceptableon ethical grounds for research[nvolving human subjects and herebygrants approval.REB FULL BOARD MEETING IEVIEW DATE: Ipril 8, 2008I)OCUMENTS INCLUDED IN THISAPPROVAL:)ATE DOCUMENTSAPPROVED:Document NameIVersionIDateProtocol:Condensed Research Proposal1February 21,Fune 20, 20082008Consent Forms:Informed Consent FormAdvertisements:Recruitment NoticeQuestionnaire, QuestionnaireCover Letter, Tests:FitSmart: Health-Related Physical FitnessKnowledgeExamination Forms 1 and 2Health Literacy Assessment (Newest VitalSign ScoreSheet)Health Literacy Assessment (Newest VitalSignNutrition Label)PAR-QPARmed-XPhysical Activity Beliefs and Attitudes SurveyHealth Literacy Assessment (PAR-Q)Letter of Initial Contact:Letter of Initial ContactOther Documents:External Peer Review ReportDERTIFICATION:In respect of clinical trials:1. The membership ofthis Research EthicsBoard complies with the membership requirementsfor Research Ethics9oards defined in Division 5 ofthe Foodand Drug Regulations.?. The Research Ethics Board carriesout itsfunctions in a manner consistent withGood Clinical Practices.3. This Research Ethics Board has reviewedand approved the clinical trial protocol andinformed consentform forthe trial which is to be conductedby the quafl/led investigator named aboveat the specfled clinical trial site. Thispproval and the views ofthis ResearchEthics Board have been documentedin writing.fhe documentation included forthe above-named project has been reviewedby the UBC CREB, and the researchstudy, as presented in the documentation,was found to be acceptable on ethical grounds forresearch involvingmman subjects and was approvedby the UBC CREB.Approval ofthe Clinical ResearchEthics Board by one ofDr. Gail Beliward,Chair1662 June 4, 20082 June 6, 2008N/A March 7,20081 June 6, 20081 June 6, 20082 June 4, 20081January 9,20082 April21, 2008I June 13, 20082 June 6, 2008February 19,2008167APPENDIX CSample FitSmart Health KnowledgeExamination Questions1. The most accurate indicator of cardiorespiratory fitnessisA. percent body fat.B. maximum oxygen uptake.C. resting heart rate.D. vital capacity.2. Which of the following principles about physicalfitness is most accurate?A. It is reversible and needs continuous exercisethrough moderate to vigorous activity.B. It is a permanent quality which carries overfrom youth into adulthood.C. It is maintained through heavy exercise.D. it is maintained through a person’s normallifetime activities3. What is the relationship between physical fitnessand health?A. People who are highly fit are always healthier;people who have poor fitness are always unhealthier.B. People who are moderately fit typicallyenjoy good health.C. The relationship is more important for childrenthan adults.D. There is no relationship betweenphysical fitness and health.4. An individual’s heart rate immediatelyafter exercise indicatesA. the recovery rate of the heart.B. the strength of the heart.C. the intensity of the exercise.D. all of the above.5. Which of the following occursto muscle fibers with regular weight training?A. Increase in numberB. Increase in sizeC. Increase in lengthD. Increase in fat6. Threshold of training refersto the effort needed to increase fitness. Itapplies to which of thefollowing?A. Minimum effort requiredB. Maximum effort requiredC. Level of effort when fitness beginsto declineD. Level of effort associated with decreasingintensity of exercise168APPENDIX DTheory of Planned Behaviour ComponentAssessmentIdentification #__________Regular Physical Activity Beliefs and AttitudesSurveyInstructionsIn this survey, we are going to askyou a series of questions about your beliefsand attitudestowards regular physical activity. There areno right or wrong answers and all we ask isthat youprovide responses that are as honest and accurateas possible. The questionnaire should takeabout 15 minutes for you to complete. Allresponses are completely confidential and willneverbe used in any way that could link them toyou. It is important to answer all questionsso that wecan include your responses in our analyses.If you have any questions please ask theresearchassistant. When your questionnaireis completed, please raise your handand the researchassistant will collect your questionnaire.Definition of Regular Physical ActivityAll the questions in this survey askyou about regular physical activity.Here, we define regularphysical activity as:A) leisure-time activity performedat least 3 times per week, forat least 20-30 minutes induration (can include multiple dailysessions of 10 minutes),at a vigorous intensity (i.e., hardbreathing, heart beats rapidly, heavysweating). Some examples ofvigorous physical activitiesare running, jogging, aerobics, circuitweight training, and vigorous sportssuch as hockey orsoccer. Or,B) leisure-time activity performedat least 3 times per week, for at least3 0-60 minutes induration (can include multiple dailysessions of 10 minutes) ata moderate intensity (i.e., slightlyincreased breathing, faster thennormal but not rapid heart beat,light sweating, can keep aconversation going). Someexamples of moderate intensity physicalactivities are brisk walking,yoga, house work, bicycling5 to 9 mph, water aerobics and sportssuch as baseball, golf whilecarrying clubs, and archery.169The following question asks you to rate howyou feel about participating in regular physical activity on6different scales. Pay careful attention to the wordsand descriptors at the end of each scale and placean “X”over the line that best represents how you feel aboutparticipating in regular physical activity. Pleaseanswer all items from a) to f).1. For me, participating in regular physical activityover the next month would be:a)______ ______ ______ ______ ____________ ______extremely quite slightly neutral slightlyquite extremelyharmful harmful harmful beneficialbeneficial beneficialb)_____ _____ _____ _____ _____ __________extremely quite slightly neutralslightly quite extremelyuseless useless uselessuseful useful usefulc)extremely quite slightlyneutral slightly quiteextremelyunimportant unimportant unimportantimportant importantimportantd)extremely quite slightlyneutral slightly quiteextremelyunenjoyable unenjoyable unenjoyableenjoyable enjoyableenjoyablee)______ ______ ______ ______ ______ ____________extremely quite slightly neutralslightly quite extremelyboring boring boringfun fun funf)extremely quite slightlyneutral slightly quiteextremelypainful painful painfulpleasurable pleasurablepleasurableThis next set of questions ask you to rate how otherpeople in your life may feel about you participating inregular physical activity over the next month. Paycareful attention to the words and descriptors at theendof each scale and place an “X” over the line thatbest represents what you think about their feelings. Pleaseanswer all items from a) to c).2. I thinic that if I were to participate in regularphysical activity over the next month, most peoplewho areimportant to me would be:a)170extremely quite slightlyneutral slightly quiteextremelydisapproving disapproving disapprovingapproving approvingapprovingb)_____ _____ _____ _____ _____ _____extremely quite slightlyneutral slightly quiteextremelyunsupportive unsupportive unsupportivesupportive supportivesupportivec)_______ _______ _______ _______ _______ _______extremely quite slightlyneutral slightly quiteextremelydiscouraging discouraging discouragingencouraging encouragingencouraging171This next set of questions ask you to rate how activeyou think other people in your life are likely to be overthe next month. Pay careful attention to the wordsand descriptors at the end of each scale and place an “X”over the line that best represents their physicalactivity levels.3. I think that over the next month, most peoplewho are important to me will be:extremely quite slightly neutralslightly quite extremelyinactive inactive inactive active activeactive4. I think that over the next month, most peoplewho are important to me will participate in regular physicalactivity.extremely quite slightly neutral slightly quiteextremelydisagree disagree disagree agree agreeagree5. I think that over the next month, the regularphysical activity participation levels of most people who areimportant to me will be:extremely quite slightly neutralslightly quite extremelylow low low high highhighThis next set of questions ask youto rate how likely you feel it is that you will be able to participate inregular physical activity over the next month ifyou were really motivated. Pay careful attention to thewords and descriptors at the end of each scale and place an “X” overthe line that best represents yourfeelings.6. If you were really motivated, how controllable wouldit be for you to participate in regular physicalactivity over the next month?extremely quite slightlyneutral slightly quiteextremelyuncontrollable uncontrollable uncontrollablecontrollablecontrollable controllable7. If you were really motivated, how easy or difficult wouldit be for you to participate in regular physicalactivity over the next month?extremely quite slightlyneutral slightly quite extremelydifficult difficult difficulteasy easy easy8. If you were really motivated, do you feel thatwhether or not you participate in regular physical activityover the next month would be completelyup to you?extremely quite slightly neutralslightly quite extremelydisagree disagree disagreeagree agree agree9. If you were really motivated, how confident areyou that you could participate in regular physicalactivity over the next month?extremely quite slightlyneutral slightly quiteextremely172unconfident unconfident unconfidentconfident confidentconfident10. If you were really motivated, doyou feel you would have complete control over whether or notyouwere physically active over the next month?extremely quite slightly neutralslightly quite extremelyuntrue untrue untruetrue true true11. If you were really motivated, how certainor uncertain would you be that you could participateinregular physical activity over the next month?extremely quite slightly neutralslightly quite extremelyuncertain uncertain uncertaincertain certain certainThis next set of questions ask you to ratehow motivated you are to participate in regular physical activityover the next month. Pay careful attention to the wordsand descriptors at the end of each scale and placean“X” over the line that best represents your motivation.12. How motivated are you to participatein regular physical activity over the next month?extremely quite slightlyneutral slightly quiteextremelyunmotivated unmotivated unmotivatedmotivated motivatedmotivated13. I strongly intend to do everything I can toparticipate in regular physical activity over the nextmonth.extremely quite slightly neutralslightly quite extremelyuntrue untrue untruetrue true true14. How committed are you to participating in regularphysical activity over the next month?extremely quite slightlyneutral slightly quiteextremelyuncommitted uncommitted uncommittedcommittedcommitted committed15. I intend to participate in vigorous physicalactivity_____times per week over the next month forminutes each time.(please place a number between 0 and7) (please place a numberbetween 0 and 60)16. I intend to participate in light-moderatephysical activity_____times per week over the next month for______minutes each time.(please place a number between0and 7) (please place a number between0 and 60)173For this next question, wewould like you to recall your averageweekly physical activityparticipation yçthe past month. How many times perweek on average did youdo the following kinds of physical activityover the past month?When answering these questions please:H consider your average over thepast month.H only count physical activity sessionsthat lasted 10 minutes or longerin duration.H note that the main difference betweenthe three categories is theintensity of the exercise.H please write the average frequencyon the first line and the average durationon the second line.Times Per Week AverageDuration Per Sessiona. STRENUOUS(HEART BEATS RAPIDLY, SWEATING)(e.g., running, jogging, hockey, soccer,squash, crosscountry skiing, judo, roller skating,vigorous swimming,vigorous long distance bicycling,vigorous aerobic danceclasses, heavy weight training)b. MODERATE EXERCISE(NOT EXHAUSTING, LIGHTPERSPIRATION)(e.g., fast walking, baseball, tennis,easy bicycling,volleyball, badminton, easy swimming,alpine skiing,popular and folk dancing)c. MILD EXERCISE(MINIMAL EFFORT, NOPERSPIRATION)(e.g., easy walking, yoga, archery,fishing, bowling,lawn bowling, shuffleboard,horseshoes, golf,snowmobiling)174This last part of the questionnaire is needed tohelp understand the characteristics of the peopleparticipating in the study. For this reason it is very important information.All information is held in strictconfidence and its presentation to the public willbe group data only.1. Age:_____2. Sex: Male_____ Female3. With which ethnic group do you identif,’?_______________4. Education Level (Highest formal education diploma/certificatereceived or in-progress)________5. Annual Income (If supported by parents please select theirannual income): < $20,000$20-39,000_____$40-59,000_____$60-79,000_____$80-99,000 > $100,000175APPENDIX EThe Newest Vital Sign (NVS) healthliteracy assessmentNutrition LabelNu1tIon FactsSeMiga per ntahier 4ArnJnt perIeMngCak1ee 250 FitC 120%DVTot.IF.t 1320%8tF1$n 40%Choleaterol 2&nç12%Sodium 55mg 2%TotI Carbatwdrte 30g 12%Dietary Fiber 2gSugerB 23gProlaki 4gPeirnia Dhjea (DV ‘e bed cni2000 c.rh dial. )rd.Iyu mayb. ghercr vn urcaJo needi.hiedIiflh crrr. Jm MI LhidSi.r. Yii EIIka DwiIHt PwiutOiSuer. Bufler. Sat.Vib E*tracL176The Newest Vital Sign (NVS) healthliteracy assessmentScore SheetScore Sheet forthe Newest Vital SignQuestions and AnswersREAD TO SUBJECT: This informationis on the backANSWER CORRECT?of a container of a pint of ke cream.yes no1. If you eat the entire container, how many calories will youeat?Answer: 11000 is the only correct answer2. If you are allowed to eat 60 grams ofcarbohydrates as a snack.how much ice cream could you have?Answer: Any ofthe following is correct:1 cup (or any amount upto 1 cup).Half the container Nate: Ifpatient answers “twoservings,Uask“How muchice cream would that be ifyou wereto measure it into a bowL3. Your doctor advises you to reduce theamount of saturated fat in your diet,You usually have 42g of saturated fat each day, which includes one servingof ice cream. If you stop eating ice cream,how many grams of saturated fatwould you be consuming each day?Answer: 33 is the only correct answer4. If you usually eat 2500 calories in aday, what percentage of your dailyvalue of calories will you be eatingif you eat one serving?Answer: 10% is the only correct answerREAD TO SUBJECT: Pretend thatyou are allergic to the followingsubstances: Penicillin, peanuts,latex gloves, and bee stings.5. Is it safe for you to eat this ice cream?Answer: No6. (Ask only if the patient respondsquestion 5):Why not?Answer: Because it has peanut oiLInterpretation Number of correctanswers:Score of 0-i suggests high likelihood (50% ormore) of limited literacyScore of 23 indicates the possibility of limitedliteracy.Score of 4-6 almost always indicates adequateliteracy.177APPENDIX FCFAFLA Preliminary Instructions for ParticipantsName of Participant__________________________________Age______________Appraisal Date___________________ Time____________Location________________Name of AppraiserPlease adhere to thefollowing conditionsforthe appraisal:Dress Requirements: Shorts and short-sleevedor sleeveless shirt/blouse should be worn.Running shoes are the recommended footwear.Food and Beverages: Do not eat for at least twohours prior to your appraisal. Alsorefrain from drinking caffeine beverages fortwo hours and alcoholic drinks for six hoursprior to the appraisal.Smoking: Do not smoke during thetwo hours prior to the appraisalPhysical Activity: Strenuous physical activityshould be avoided for six hours prior tothe appraisal.Note:Failing to adhere to the above conditionsmay affect your results negatively.Source: (CSEP, 2003). The CanadianPhysical Activity, Fitness & Lifestyle ApproachAPPENDIX GPhysical Activity Readiness Questionnaire (PAR-Q)178PAR-Q & YOU(A Que tionnaiee foi ro,Ie *qed IS to 69)Regic phpk sc2r z dhesIfl w me pecçle sie bscmtmo scuo tery da Beq nns‘ eiy !50 frpee Mane opncle thnck Ith do bdxcwtbecce nn *Øannef J1I1fl9 h !T JDQEy I1O CiJ Je rourt by s qiodi thjo 13 nd 6, the A-Q .1 Id yw f uAi theck ath,docbeyo o 6ê1 sec od uu n rdtD bár*wry theck )O4iConn me it .our butt gtie her u uoerthesu quent Thmoe resdth,qnesboe csrut od eech iie% deck 5 or2 Pbooiecai buiaweny nesyoi gtbereuthoepbyikwtht *I’ ed bflgth4 1thlttaid eeetuuipatsbioo awra_______________________________________cai pai th eet**ryo b h3 UtoN.EA5E WWL hdithaigi,r e thryo butanb odWunitLed. kowr144,IwöxUf,oo ecMun rhicst heibekreynslu1 bucorg esch Øc edie.cdiuigyai *9itbe I(doCfl,dbere&iei.tuediIfbhi ppU* IIblo h.aqca purii*ted You ii. eacouraged to phetecapyhe P*iLQ but ouly if yea use the e.4ire beQa bIqub nehabu I. jatou ie Lit4erq ‘aid hiudg1 ,reed, uidoaid ad qiwiad Aiqettaiekid isode mydlsiiole Tbk pbyskdl adhtty clearance o walld Too a marimian.1 11 eaaI bern tbe doTe It Is co.Ipte*ed andbecernet beafli 11 yo caeUeehesso turea wcedd arY€t to any at tbe saran quesdcos•o. Heeffl aItóVW•I Canacia or1 90Q []t. atas your doctor suer said Teat you havit heart coadMianatbat you Ituuld on’y do pbyclcst attIuUyby o dodd?2. Do you tool pain Ia ynec chest lhan you do ybysicol ectbety?[] Q3. In the past rnontb, hair yea bed best pale when yen sanenet ie4n pbpkal odhety?Q Q4. Do you hoe yner halmece because of azzffiess or do ye.ever ide caa,ctaernesa?D Q3. Do yen bo a bane or J.Tet pesbie.tier esampie, bach, bane or tip) tuat coal to .11. ow,. by ecbaaqe hi yow peydral ocdoy?Q QIs yourS dacbar rweeuNy presceiblag drags (fur ueto $Iuio. your 040.4 preane or heart c.o[] []7, Do yea .1 an, .thoo yen shoal net do physlcasacthlty?IfyouansweredYES to one or more questions?áaih yos for bykoe wn ptrtor B tatZgrnnhiemd fEiw hairs hea rãd. NclsrLcul thc l%4 aid d*i tsc aeooode do ur,ohki yoleot arloigai eu daàdi4ipaà4I<kyni eq odtomcti aithtt*h a’s táaync NcI yercIxaid the”’ etyináh tpo1kdothsdu. ldtierthAt,aid heWibNO to all questionsrfle,*T cwa OUtIf HO ACT1VE—. 6n cndkdgbecasect tcepxeydteutsabot freecdyesirt b.ce.ige.e K*ee.Source: (CSEP, 2003). The Canadian PhysicalActivity, Fitness & Lifestyle ApproachAPPENDIX HPhysical Activity Readiness Medical Examination(PARmed-X)179PhaisalAstiaty RaadiseasMaded EsiatatitrilanoadZOLttt— PHYSICAL ACTIVITY READINESSMEDICAL EXAMINATIONThe PARmed-X is a physical actIvIty-specIfic checkllst to be used by a physicianwith patientswho have had positive responses to the Physical ActMty Readiness QuestIonnairePARQ). In addition, theCanveyanc&Reterrai Form In the PARmed-X can be used to convey clearancetar physical actIvity participation.otto make a reterrat to a medically-supervised exercIseprogram.Regular physical activity is fun and heaI1Iv and easingly mote peopleare slatting To become more active every day. Being more activeis very safe tar mart peopla. The PAR-Li by itself provides adequate screening tot the rmaorityat people. However, some individuals mayrequire a medical evaluation and specific advice (exercise prescription) due to one or morepositive responses to the PAR-Li.Following the participants evaluation by a physician, a physical activityplan should be devised in conauttaliort with a physical activityprateaskirtal (OSEP-Protesalanal Fitness & Lifestyle Consultant or OSEP-Exercise Therapist”).Ta assist In this, the following irtstructlonsare provided:PAGE 1: - Sections A, B, C. and 0 should be completed by the participant BEFOREthe examination by the physician. The bottomsection is to be completed by the examining physician.PAGES 2 & 3: -Achecldist of medical oonditioaa requiring special consideration and managementPAGE 4: -Physical Activity & Litesayle Advice for people who do. not require specificinstructions or prescrihed exercise.Physical Activity Readiness CotweysncelReferral Form - an optional tear-off tab foi the physicianto convey clearance tarphysical activity participation, or to make a jelerral to a medically-supervisedexercise program.This section to be completed by the participantPERSONAL iNFORMATION:TIEPROIIIE —BIRTHOATE — —— GENOERLi 01 Heart conditionci 02 Chest pain during activityci 03 ChestpainatretrtLi Cl 4 Loss of balance, dexinesaLi 05 Bone or joint problemci 06 Blood pressure at heart drugsci 07 Other lesson:CRISK FACTORS FOR CARDIOVASCULAR DISEASE;PHYSICAL ACTIVITYCiteck all tltaz sppiyINTENTIONS;Li Less than 30 minutes cit moderate physical U Excessive accumulation of tataroundWhat physical activity do you Intend to do?activity most days of the week waist.U Currently smoker (tobacco smoking 1 or Li Family history ofheart disease.mare times per weak).Li High blocd pressure reported Please uole Manyof#reae ,‘isk facte,sby physician after repeated nteasuremertta.are mo&lthIa. Please refer to page 4Ci High cholesterol level reported by physician. and discuss siLt yourplijericlsn.This section to be completed by the examining physicianPhysical Exam: PhysIcal Activity Readiness Conveyance/Referral:lit a I) i Based upon a current review of health t’ueter Iritormaten:status, 1 reCommend:AttactiadpIi) I1TobelorwsrdadLi t’io physical activity ) AsaS&ila on requestLi Only a medically-supervised exercise program wail furtherConditions limiting physIcal activity;medicsi C seanceLi Carcilovasculai Li Respiratory Li Other Progressive physical actMty:Li Musculoskeletal Li AbdominalLI with avoidance at:Li with inclusion of:Tests required:Li under the supervision at a CSEP-Prrrfeasionai Fitness SLi ECS Li Exercise Test Li X-Ray Lifestyle Consuitntor CSEP-Eserciae Therapist”LI Blood Ci Utinalysis Li OtherLi Unrestricted physical activity—start slowly arid held up graduallys,ed.:•Caiac &tisiy to, Exese. Rysidogy• Canada CanadaBPAR-O: Please indicate the PAR-Cl questions towhich you answered YESOlCAL No.1Source: (CSEP, 2003). The Canadian Physical Activity, Fitness& Lifestyle ApproachAppendix GPhysical Activity Readiness MedicalExamination (PARmed-X)180Ph Activity ResdateesM.dical ExesittaennPA Rrned—XPHYSICAL ACTIVITY READINESSMEDICAL EXAMiNATIONFoowfng is a cheoldist of medical conditions for which a degtee of precaution andiorspec(s) advice shoutd be considered for those whoanswered YES’ to one or more questions on thePAR-O, and people over the age of €9. Conditions are grouped by system. Thecategories of precautions are provided. Comments under Adstce aregeneral, since detalls and alternatives require clinical judgernertt ineach indlvtOual instance.2Contixcted on page 3.AbDolute Rebtive Speci&PreccrptiveSornraindiction Centraindioationconditlon2Peteanent etrictins ert porreyreatrictien witit cenr ic1tet.d.stsb*e. sndtir peat were phase.Ht5y vwvte. Value ewercisetesieg andktr pregran rrrayexceed die. otivityotaybetswvaleto maxtinize trcnkrtt afDirect cv titdtiect rnacattJterx{eicn of exetce feogiwemay be d.ieleCdiovascuIartttdividized pry r(ive atleicenetyapptagttato:trntiabonn tinpased; i1dJctepeitetcisee preenbed.May rc*quie medical nestlerbigic v ernmion Fteseenea psaniADVICE;t asrecerawynin 1&easting)U atcatanoas (sewas)U ccttgewtwe heart liclureU crvscerrth angrnaU eyneat infarction )alute)U myccardtiie )actve cc recaphU prtlmonerycreysterncU throiribophiIieU vanlficsfw t.drycatda and(e.g. mi*i4ocal veneicrdaradiety)U stain atenoern (roedersta)U er,icaorlic stanoac (severe)tU marked c&tdlsa enlargweecrtU stgireveraitcuIordysb4hmse)urrcor5rc8ed rrrttir rate)U ventricular spic activityor trequers)(3 vet Let Srtet5(’SSUlerinos—entreatadorurxareokd severe (s*emicot*nOnary)c hyp.rttopiie csritcrryopU otrrenaated con alive heartfailureo acrØ, pehertary)at.noam—rrlild arrgirrepectorateal other mandaetalicireofcoronary inacdttciency (e.g.prahecute —(3 ogenotic hestrdleesaeo ehuilfa ftirtvrrTent cv fixed)U centhrcticrr deairiswcee• fellB8B• Wo$PathilOtat.Wlutto dd—ccnoo8ad(3tXed tale pacenrykecaclatical exercise teal nr bewarranted et yelacteitcarse.Icr apealfie erernresonof tretirtronel capealty andfimiteriors arid precatiliore(if any).alas pg a alec of errecciaeto IevvL baxud ret test.pnrterntwrce and indidduidItictartee.retarder aieetiiual need forindict concddartiig programorder medical is4taNtOicn(rodicect or direct).U inenr1ttdaritlcadOn ptogreaave eaeretotrilerarmceo hyperxei.irtn: apicet-1ao: dlastriirr l+(.1 oubetteakhronicltecuarenttidactiouy deeaeee(e.g.,meteifa others)(3 entity ictecticue eseinfections(regatrthaa of etiolagy)Metabolic—,—PregnancyU throes irrlar5crraU ISV—exetcae; save asitrrredlcatlcre (astern alecti’&ylse;poarsexerres synceps etc..)o urrcontrobd rmrytaboticdeciders (a4en meus,thynonsanda rnyxed.ma)vax to condition0 ran rapeticanthermatebciictnoufllciecrcyU otiealiy0 air4e IddtwyU corirpoetad peegrasary(e.g.. tcaenas. trenorthoge.incetweearrl cervix, etc.lo .th.’antred pregnancy{ 3rdtnmexlar)dietary rnotleretrar. and tinted 45eeecee edhilow pragrerroete(walring wmintrydeig(reSet to the “PARmed-X forPREGNANCYArcWnc GA. W4e. Dt. Mao. Y. (i2. Rti& Axaaearrrern of PhyiclActivity end Physical Fitness in the Canada Health Survey Folow.Up Siucty. J. C5n Epidemiot. 45:4 41-$2&Motteila. M., Wolfe, LA. )1a94). Active Living and Pregrrarroy, In:A. C)uirvneat L Caucisi, T. Wal eda.). Toward Active LilvingiProceedings of the trntyraxtiornel Conference ott PhysicalAcvisisy Fitness end I4eetth. Champaign. IL: Human I(inetlos.PAR-U Validation Report, Ertind Colwnbis Ministry of Health. 178.Thomas. S., Reade’ng, .L, Shepherd, R..J. (1002). Ffevioion of the PhysicalAcidly Reediness Uueeticvrneilrr (PAR-U). Clitti. 3. SpL SrI. 17:$ 338445.The PAR-Q and PARmed-X were developed by the British ColombiaMinistry of Health. They have bean revised by art Expert AdvisoryCommittee of the Canadian Cociely for Exercise Physiologychairedby Dr. N. Gledhlfl (2002).No changes peronlited. You are encouraged tophotocopy the PARmed-X, but only If youuse the entire form.Diapanthle an Iiançais eons Ia litre•Evs)uanon rnédloale de raptitude a t’actdté physatpee (X-AP)”Source: (CSEP, 2003). The Canadian PhysicalActivity, Fitness & Lifestyle ApproachPhAodvdy ReadineecMadin EaatnEwhon(teveed 2002)Physical Activity Readiness Medical Examination(PARmed-X)SpcciaI Precr1ptivcConditionc ADVICELung i dvanianeerdondew eperand breedng exercinee2 etture kat diseane bwa r1tot ctoring endiaance ceero4srsnocc anod pobledQ aelhmet3 azeofae-tnduced baxdiospan eeoc bpereera di3nr!g rewee: avrnd ew’ewely mi: imesprepnetMuscubskeletal ine ba&neiwlleno (pa oloicd. tundanal) zaoid ml ea.qcU. that patse at ex tee&.. inmedauuasvte8einuneelenaian. and entlwisdng oolrecl pauture, pner bank exercisesi athtdie—eunte nferdue, .rheresebigout tremere,pudieabtsnd afreat, spblrn8 end gentle renusmanLt athrtle—adiectde pmgtasete bexeaee of wtixe aniherapyl axthrtlu—dmrad ofltwitls end eboxe relenanee of mofile’ ael amength: eret- hdweeing exercwee to iiza(dwrtfrsumaidbiona) {xopdag,cantNtl5t atc43 orthapeedia highly xw.Is and indieidiee8zed(1 hernia o*wuze ‘airMeig and in tdce:elregthei al,duniaral musoteeU GOtuOtOO r inw b eeoc exerun.ealr high rtsfraeureaich sepodi-qw. au,t-4a, eenmpandteerklornand tleeinn .ag. at -inpact w1e-beering’a.e and resenanne riannmgCNSoiwuliaye disorder nntoomçtlalaly ooctlrod by nanin’or anoid seercae inhiae ira.atrtexering alone (eg.rrwdicefbn swñrsrthg. moti cfrrg, atc)U recant ruexuanon thcxosgh ananrflasen4 lryofso creana.ans ,rAewlor decontiajalion of contentapart 8 three concaee. depanig on hasionof anoanedeunneax, retrograde an’awsia,pareatam headed and other objeotina evidence ci cerebral damageBloodu atiera—ewer. 1< II) Grntj cuntrrerted:exetda. ax toleratedelectrolyte disturbance.Medications l aaasrginel U al-rthotic NOTE canceler uridedyingcondhcn. Parenthil fxr eterdoetal cynoope, rAolytsritobalence, bredycercisa. dyuthythnriac hopiarerfoordin cad reaoeicn hone, beanJ enenaam ntOfltohefltintoleranax. May alex reeetg and enema. ECG’u and tr eateteet prfcmnnioe.2 batablodrern U digitaho preparefionot diuretec U gblcckera3 cthemOtherU IOI O’aOI moderatetrogU heel rotatarera. picking coal-doom with it cctivdiaeavoid aseeca. in aettlattre beetU tterynwwr lneae paotpCenB ienid recountedCl cancer tlpotundat rtta. teat by opale ergomamy. caneider nor nib aingexoeoae.e.ueraaeat kiwen and of preecdptwa ring. (40-65% o neerirate meeter.), depaserthigan carnebon and recant treatment tr.di.hen. cite ençy) ma.tar hamoglodenandlymphocyte coreva: add dynen*r htdrrg exetelt rength.n muadec, earing roacliawerather than esigrlaRefer to nipedel p ineifone far brnelion an carpEtedThe IdloetWig compecionfarme are eradabte order.: 1W.ceeO.C&teqTnB.The Physical Autirity Reeide’aeee Oteonaaece PAR-Ot - a qu amire for people ed 154 to oonnplaee before bacoelny much inane plnyeicodyThe Phyolcel Activity Reedineac Medical Exetnenetion for Fr ocy tPAflmed-X for PREGNANCY)to be used by jityaceane ninth plegranapedant. who wiob to become morn phyincetly aorivePot roars bntormadon, pleeae cort the:Genadien Society for Exercise Physiology202 - 185 Sorrrerset St.. WantOttawa. ON: fi2P (1J2Tel. i-877-01-755 FAX (513) 224-3565 OnlIne; wwwicepcaNote to physical activity profes&onala..It In a prudent practice to retain the completed Phynilcat Activitya Canadian Socreri’ far Exercies PhraeakegyReadiness Conveyninc&Referrat Form in the psoticipanttrbyIHaIth Sante____________________________________________________•‘ Canada CanadaCo. bawd art pepe43Source: (CSEP, 2003). The Canadian PhysicalActivity, Fitness & Lifestyle Approach.181Physical Activity ReadinessMedical Examination (PARmed-X)182.yics1Aa Ft.Medd2002)PARined—XPHYSICAL ACTIVITY READINESSMEDICAL EXAMINATIONSoutce Canada P alMvdj Guideto HealthyActive Uvm Heath Canada 1996 h02JMwwhcoc.oet Reptoduced pvsion otthe tnister of Pui,licWwks and vernmeeSetvicet Canada, 2J0P.City I hull, let teaarlulfiep er. your dAy Oatiwa ,flnw*ut, yr.Ste wIetto remit war.III ewomitolyt Ofll PetIt., grt.tty rnctaswtelwa1.0,01 OtPtfltAOIul FeO allPaujee tracputy tI Itey cyctoy patti neway anyaltes, IkeecOttIty IV it. taCtOdaptrc.tr ye 10101, am ‘ctca,veaylyctai raCyaeetc’ eel mtrwtw l,01,taatyw,,eaPy II.awtse,e’ey our. lyOnet0a,t—ycO4ce IPlay htlt.ely tt Slut hilt 1St 01015tPrmCleat. twa, ala, Or tce,mtmem.cycle tft.zflta itta actkycocrPitt,g,00 0,t 05.0.ad,•5ltCt.tStS*m•ttt.PARmed-X Physical ActivityReadiness Conveyance/ReferralForm________________________________________________fecOfflfliNOTh: Th sphysicalactivityGlearancelsvalidMfl. fors tnaximttm of six months horn the dateit )s completed anti becomes invalidif your20 medcaI condition becomes worse.1. •S!bp j, tie. £1.1..Pltysicetl ectivity improvar. health.lttle It onyx Ill wt.e iotabtttr-ee,ynecanWtitl€.txthrayourwoyb4d y45.ofacZCtyyeathetaatsd,r.LGet Actiw Your Wa Evety Day-For Life!tea. lOot CCy r, loSt 00 eL,rae ylytfele aellyP.amty Of Prraht.0 your rat. ACywu preou 0 StereO 0t3C you too CitOotatSO riCa,. 4 lrauWrc1,. Ar.-ucyisa hctlOtttC patinaoto era CC Cleat alit’ Ctalrtlrmiy.. - C wJftlime aeeded dtpentt. en efttt‘S-’.at p.nw. sStt fla.a. b.t ‘att- ...,,..aa.. ,dhita.,Eutiity ski. At.ioyo.tatt RObeiceS teSsSti theta...IROta Stre• c staSutOiCt if rq01bsyw t.eStb tieS. if tebi15______eased upon a cwtert review of the healthU No physical activityU Only a meckally-supervised exeecise ptogramuntil teether medical cleateaeU Peogtsssive physical activityU with avoidance ol:_____________________U with inclusion of: ——__________________________U teidet the superilsion ol a CcEP-Ptolesaionai Fitness&Lifestyle Consultant or CSEP-Exegcise Theraplet10U Unrestricted physical activity — steel sksalyanti toudd a graduayFuithar lalceenatico:l Avail.bie on reptiewyPhyaientrlt*ntanp:4Source: (CSEP, 2003). TheCanadian Physical Activity,Fitness & Lifestyle Approach183APPENDIX ICPAFLA Adult Consent FormI, the undersigned, do herebyacknowledge:• my consent to perform a health-relatedfitness appraisal consisting ofstepping ondouble 20 cm steps at speeds appropriatefor my age and gender, measurementsofstanding height, weight, circumference,and skinfolds, and testsof grip strength,push-ups, sit and reach, curl-ups,vertical jump and back extensiontest, the results ofwhich will assist in determiningthe type and amount of physical activitymostappropriate for my level of fitness;• my understanding that heart rateand blood pressure will be measuredprior to and atthe completion of the appraisal;• my consent to answer questionsconcerning my physical activityparticipation and mylifestyle;• my consent to the appraisal measuresconducted by an appraiser who hasbeen trainedto administer the CanadianPhysical Activity, Fitness andLifestyle Approach. Iunderstand that the interpretationof results is limited to placingmy scores in theappropriate Health Benefit Zonesand providing information on physicalactivityparticipation and other healthy lifestyletopics.• my understanding that thereare potential risks; i.e., episodesof transient lightheadedness, loss of consciousness,abnormal blood pressure, chestdiscomfort, letcramps, and nausea, and thatI assume wilfully those risks;• my obligation to immediatelyinform the appraiserof any pain, discomfort, fatigue,orany other symptoms that I maysuffer during and immediatelyafter the appraisal;• my understanding thatI may stop or delay any furthertesting if I so desire and thatthe appraisal may be terminatedby the appraiser upon observationof any symptomsof undue distress or abnormalresponse;• my understanding thatI may ask any questions or requestfurther explanation orinformation about the proceduresat any time before, during, andafter the appraisal;• that I have read, understood,and completed the Physical ActivityReadinessQuestionnaire (PARQ) and answeredNO to all the questions or receivedclearance toparticipate from my physician.SignatureDateWitnessDateNOTE: This form mustbe completed, signed and submittedto the appraiser, along withthe completed PAR-Q,at the time of testing. This formmust also be witnessed at the timeof signing and the witness mustbe of the age of majorityand independent of theorganization administering theappraisal. The fitnessappraiser/professional cannot bethewitness.Source: (CSEP, 2003). The CanadianPhysical Activity, Fitness & LifestyleApproach184APPENDIX JHealthy Physical Activity ParticipationQuestionnaireDETERMINING THE HEALTHBENEFITS OF YOURPHYSICAL ACTIVITYPARTICIPATION IS AS EASYAS A, B, CA. Answer the following questionsFrequencyOver a typical 7-day period(1 week), how many times do you engage in physical activitythat is sufficiently prolonged andintense to cause sweating anda rapid heart beat?Li At Least three timesLi Normally once or twiceLi RareLy or neverintensityWhen you engage in physicaL activity,do you have the impressionthat you:Li Make an intense effortLi Make a moderate effortLi Make a Light effortPerceived fitnessIn a generaL fashion, wouLd you saythat your current physical fitness is:Li Very goodLi GoodLi AverageLi PoorLi Very poorB. Circle your score below for eachanswer and total your scoreMale Female Male FemaleFrequency RareLyor ne’er NormaLly once or twiceAt Least 3 times0 0 23 3 5Intensity Lighteffort Moderate effortIntense effort0 0 12 3 3Perceived fitness Verypoor or poor AverageGood or very good0 0 31 5 3ItemMale FemaleTotal score:_______C. Determine the health benefitsof your physical activitybased on your total scoreTotal scoreHealth benefit9-11Excellent6-8 Verygood4-5 Good1-3 FaIr0 NeedsimprovementSource: (CSEP, 2003). TheCanadian Physical Activity, Fitness& Lifestyle Approach.185APPENDIX KDetailed Anthropometric MeasurementsBody Mass Index (BMI)Standing HeightHeight will be measuredwith a valid and reliablewall mountedstadiometer. Participants withoutfootwear will stand erect,arms hanging by theirsides, feet together, heals andback touching the wall. Participantswill beinstructed to look straight ahead,stand as tall as possible andtake a deepbreath. At the point of maximalinhalation the height measurementwill be takento the nearest 0.5 cm (CSEP, 2003).Body Mass (Weight)Weight will be measuredwith a valid and reliable digitalSECATMspringscale designed for researchsettings. Participants will be instructedto step ontothe scale without footwear andin light clothing (shorts and a T-shirtor blouse forwomen). Weight will be recordedin kilograms to the nearest0.1kg (CSEP, 2003).The ratio of body weight inkilograms dividedby height in meters squared willequal the BMI (kg/rn2).Waist circumference (WC)Participants will be instructedto stand erect in a relaxed fashionwith theirarms hanging looselyat the sides. The anthropometrictape will be positionedhorizontally mid-way betweenthe iliac crest and thebottom of the rib cage.Participants will be askedto take a normal inhalation andthe measurement willthen be taken at the endof normal expiration tothe nearest 0.5 cm (CSEP,2003).Skinfold Measurement(SO5S)All measurements will be landmarked according to the CPAFLAprotocoland made on the right side ofthe body to the nearest 0.2mm. Two sets ofmeasurements will be taken. Eachfull set will be takenbefore starting the nextround of measurements.The mean of the two measurementsfor each skinfoldwill be recorded unless the differencebetween the first and secondmeasure fora particular skinfold is greater then0.4mm. In this case a thirdmeasurement willbe taken and the closest twomeasurements will be averaged.If all threemeasurements areequidistant -18.6, 19.4 and 19.0,for example, the meanof allthree values will be used.Participants will be askedto relax the underlyingmusculature as muchas possible during each measurement(CSEP, 2003). Thefive skinfolds in orderof measurement are: Triceps,Biceps Subscapular,IliacCrest and Medial Calf. Fordetails on precise location of eachof these skinfoldsplease refer to the 3’ Editionof the CPAFLA (CSEP, 2003pg. 7-14 to 16). Thesum of five skinfolds (S055) willbe determined by adding the meanvalues foreach skinfold in millimeters.186APPENDIX LmCAFT Detailed ProceduresParticipants will be instructedto stretch their Hamstrings, Calf’sandQuadriceps, technical assistancewill be provided if required.Participants willthen be shown the properstepping technique and pattern(CSEP, 2003 pg. 7-26). They will be given adequatetime to perfect this techniquebefore testexecution. Then, post exerciseCeiling Heart Rate will beCalculated using theformula [.85 x (220-age)].The mCAFT companionCD will set the cadence andallocate 10 secondsafter each stage for the appraiserto acquire immediate post-exerciseheart rate(HR). Throughout the testthe CSEP health andfitness professional willcommunicate with the participantto ensure safety.All participants will beginthe stepping sequence ondouble 20.3 cm steps.Fitter (and younger) participantsmay complete their appraisalwith a single stepsequence on a 40.6cm step. For men, stages1-6 will be done using the twosteppattern and stages 7 and8 will be done using theone step. Women will onlyberequired to use theone step pattern for stage8.At the end of each three minutestage, immediate post-exerciseHR will berecorded via the use ofa high quality PolarTMheart rate monitor. If theparticipant’s HR isbelow their predeterminedpost-exercise ceiling HR(85% ofpredicted maximum(220-age)) at the end ofthe three minute stage theywillproceed onto the nextstage at a more intense cadence.The test is designedso the first three minutestage is usually at a cadenceintensity of 65-70%of the average aerobic powerexpected by a person10 yearsolder. The second three minutesof stepping is then performedat 65-70% of theaverage aerobicpower expected for onesown age. The third andfollowingstages are respectivelyset at a cadence intensityequivalent to 65-70% oftheaverage person tenyears younger.The test is terminatedonce the participanthas reached theirpredetermined post-exerciseceiling HR. Other criteriafor test terminationinclude; complaintsof dizziness, noticeablestaggering, inability to maintaincadence, extreme leg pain,nausea, chest pain, or signsof facial pallor.Once participants have completedthe last steppingsession, determinedby the post-exercise HRresponse they willbe instructed to walk around slowlyfor two minutes and thento sit down. At this pointpost-exercise bloodpressure(BP) will be measured between2-2.5 minutes post and 3.5-4minutes post. Asecond post-exerciseHR will then be recordedat 4-4.5 minutes post.Thesepost-exercise measurementsare taken as a safetyprecaution to ensureparticipants HR andBP fall below restingceiling levels in an appropriatefashion(CSEP, 2003).187APPENDIX MDetailed M usculoskeletal Fitness AssessmentProceduresGrip StrengthThe participant will stand holdingthe dynamometer in their hand with thearm holding the dynamometer abducted45° from their body. Participants willbeinstructed to squeeze as vigorouslyas possible in an attempt to exert maximumforce. To avoid build up of intrathoracicpressure participants willbe told toexhale while generating force. Twomeasurements will be taken for eachhandand the maximum score on eitherhand will be recorded to the nearestkilogram(CSEP, 2003).Push-upsAny participants who suffer fromany lower back ailment will not performthis test.General Procedure:The participant will completeas many consecutive push-ups as possibleina rhythmical fashion. Thepush-up assessment will be terminated forthefollowing reasons: volitional fatigue,incorrect technique for more thantwoconsecutive push-ups, or inabilityto maintain a rhythmical pace (CSEP, 2003).Males:The participant will start on his stomach,legs together, hands pointingforward and positioned under theshoulders. Participants will then beinstructedto push up from the ground by fullyextending their elbows, using their toesas thefulcrum, while keeping their upper bodyin a straight line. The participant will thenreturn to the starting position,chin to the mat. The maximum numberof correctpush-ups will be recorded(CSEP, 2003).Females:Females will follow the sameprocedure as males except their kneeswillbe used as the fulcrum. Participantslower legs will remain in contact withtheground, ankles plantar flexed,and feet touching the mat (CSEP, 2003).Sit-and-ReachThe participant will begin by performingtwo 20 second modified hurdlerstretches per leg before proceedingto the sit and reach measurement.Theparticipant will remove theirshoes and sit with their feet flat againstthe sit andreach block (flexometer).Their feet will be placed just wider thanthe width of thesliding mechanism. The participantwill place one hand on top of theother andsituate their fingertips atthe edge of the sliding mechanism. As they breatheout,the participant will reachforward as far as possible keepingtheir legs straight.This measurement will be repeatedand the highest score (cm) will be recorded.If improper form is used(ex: bending of knees, bouncing orjerky motions)participants will be askedto repeat the flawed measurement (CSEP, 2003).188Partial Curl-upsThe participant will lie supine with their armsat their sides, knees bent to900,feet together and flat on the floor.They will curl their body upwardswhilesliding their fingers along theground towards their feet. The participantwill curl-up until their fingers have traveled10cm from their starting position. Curl-upswillbe performed at a cadence of 50bpm set by a metronome. The participants willperform as many curl-ups aspossible in one minute to a maximumof 25. Thecurl-up assessment will be terminatedfor the following reasons: volitional fatigue,inability to curl-up the required10 cm, inability to maintain the 50 bpmcadenceintensity, or a maximum of25 has been achieved (CSEP, 2003).Vertical Jump and Leg powerAny participants who suffer fromany back ailment will not perform this test.Vertical jump will be assessedwith the use of the VertecTMwhere thejump height is determined bythe participant jumping as high as possible fromasemi squat position to push the slatsfrom a starting position (See figure1below). The bottom slat willbe set at the participants maximum standingreachheight. Jump height willbe determined from the amount of slats displaced.Eachslat is positioned .5 inchesapart. Participants will be given3 trials with a oneminute break in-between trials. The maximumjump height of the 3 trials willberecorded in centimeters..A Vertical JumpPeak leg power, in watts,will be determined with the use ofthe SayersEquation (Peak Leg Power(W) = [60.7 x jump height(cm)] + [45.3 x body mass(kg)] - 2055) which takesinto account body mass as wellas maximum jumpheight (CSEP,2003).189Back ExtensionAny participants who suffer from anyback ailment will not perform this test.Due to the amount of stress this measure placeson the back a screeningtest will be performed prior to administration.If participants feel any discomfortduring the screening test, the backextension will not be done.The test will be done using the portable stepsused for the mCAFT. Forparticipants comfort a cushioned mat will be placedon top of the portable steps.The participant will lie face downon the mat with their iliac crest positioned attheedge of the steps with the rest of their bodyaligned. The appraiser will thensecure the participants lower torso by strappingdown the upper calves and lowerthighs.Once secure the participant will be instructedto cross their arms on theirchest and support their upper torso inthe horizontal position with no rotation orlateral shifting for as long as possibleto a maximum of 180 seconds (see figure 2below). The test will be terminatedif the participant drops their torso below thehorizontal (allowing for one warning repositioning),or if they experience anypain/discomfort. The number of seconds thehorizontal position is maintained willbe recorded (CSEP, 2003).A. 2. GF,-1--A Back L.nsion

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