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Maternal health literacy and physical fitness in early motherhood, child motor development, and home… Dickson, Danika Brooke 2012

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MATERNAL HEALTH LITERACY AND PHYSICAL FITNESS IN EARLY MOTHERHOOD, CHILD MOTOR DEVELOPMENT, AND HOME AFFORDANCES by Danika Brooke Dickson B.Kin., University of the Fraser Valley, 2005 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (Kinesiology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  August 2012  © Danika Brooke Dickson, 2012  ii Abstract Health literacy and health-related physical fitness are important variables affecting health across one’s lifespan. Importantly, certain lifespan periods are more vulnerable to changes in health behaviour than others. Due to lifestyle changes and the perception of increased barriers to exercise, regaining prepregnancy fitness levels is often difficult. To-date, little is known regarding health literacy and physical fitness in the early years of motherhood. Therefore, the first purpose was to examine differences in health-related physical fitness of health literate mothers with children between the ages of 18 to 36 months compared to health literate non-mothers. In addition, little is known about the influence of health literacy and the home affordances that mothers may provide. As such, the second purpose was to examine whether health literate mothers provide environments with greater opportunities for child development (vs. mothers with low literacy). Sixteen mothers (31.9±3.8y) with a child between the age of 18 and 36 mo and 15 childless women (28.6±5.1y) completed a health literacy battery (Newest Vital Sign (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA)), the Canadian Physical Activity, Fitness, and Lifestyle Approach (CPAFLA), and a physical activity questionnaire. Mothers also completed an Affordances of the Home Environment Motor Development (AHEMD) assessment. Sixteen toddlers (31±6mo) were assessed for motor development using the Peabody Developmental Motor Scales, 2 nd Edition (PDMS-2). Results showed that all women demonstrated high health literacy levels. Non-mothers demonstrated greater health related physical fitness  iii for push-ups (p=.009), partial curl-ups (p=.007), and vertical jump (p=.033) vs. mothers. In contrast, mothers performed significantly better on grip strength (p=.043). There was a trend between higher reading scores (REALM) with greater total variety of stimulation (r(15)=0.73, p=0.060) in the home environment. Increased variety of stimulation was positively correlated with locomotion (r(15)=0.88, p=0.008), object manipulation (r(15)=0.95, p=0.001), and visual-motor integration (r(15)=0.85, p=0.015) scores (PDMS-2). Despite similar health literacy levels, non-mothers demonstrated greater physical fitness; while mothers exhibited fitness levels associated with suboptimal health. Health literate mothers are more likely to expose their children to an environment that leads to greater proficiency on motor development tests.  iv Preface This thesis was written by Danika Dickson, with significant contributions from her supervisor, Dr. Shannon S. D. Bredin. All data was collected in the Cognitive and Functional Learning Laboratory, Physical Activity and Chronic Disease Prevention Unit at the University of British Columbia. Conceptualization of this research investigation was done by Danika Dickson and Dr. Shannon Bredin. Danika Dickson was responsible for all aspects of participant recruitment and data collection. The statistical analysis of the data that appears in this thesis was also conducted by Danika Dickson. This research received approval from the University of British Columbia Behavioural Research Ethics Board (UBC BREB Number: H11-00269). Two manuscripts will be submitted for publication at the completion of this thesis: 1) Dickson, D. B., Warburton, D. E. R., & Bredin, S.S.D. Health-related physical fitness between mothers and non-mothers with high health literacy. (Corresponding author: S.S.D. Bredin); and 2) Dickson, D. B., Warburton, D. E. R., & Bredin, S. S. D. The influence of health literacy in early motherhood on home affordance and child motor development. (Corresponding author: S.S.D Bredin).  v Table of Contents Abstract................................................................................................................. ii Preface ................................................................................................................ iv Table of Contents.................................................................................................. v List of Tables ....................................................................................................... xi List of Figures ..................................................................................................... xii Glossary..............................................................................................................xiii 1.0 CHAPTER ONE .............................................................................................. 1 Introduction ........................................................................................................... 1 1.2  Overview of Thesis Investigation ............................................................. 7  1.3  Overview of Thesis Document ................................................................. 9  2.0 CHAPTER TWO ........................................................................................... 10 Extended Review of Literature: ........................................................................... 10 Maternal Age, Health Literacy, and Health-Related Physical Fitness ................. 10 2.1  Health Literacy ....................................................................................... 10  2.1.1  Definition of Health Literacy ............................................................ 10  2.1.2  Current Status of Health Literacy in Canada ................................... 12  2.1.3  The Assessment of Health Literacy ................................................. 13  2.2  2.1.3.1  The Rapid Estimate of Adult Literacy in Medicine (REALM) ..... 14  2.1.3.2  Test of Functional Health Literacy in Adults (TOFHLA) ............ 14  2.1.3.3  The Newest Vital Signs (NVS) .................................................. 15  Maternal Age ......................................................................................... 16  2.2.3  Trends in Maternal Age ................................................................... 16  vi 2.2.4 2.3  The Relationship Between Age, Education, and Health Literacy .... 16  Physical Activity, Health-Related Physical Fitness, and Health Status in  Early Motherhood ............................................................................................ 18 2.3.1  Benefits of Physical Fitness ............................................................ 18  2.3.2  Prevalence of Physical Activity in New Parents .............................. 18  2.3.3  Barriers to Exercise in New Mothers ............................................... 19  2.3.4  Social Constructivism Theory .......................................................... 20  2.3.5  Health-Related Physical Fitness ..................................................... 21  2.3.6  Measurement of Health-related Physical Fitness via the Canadian  Physical Activity, Fitness and Lifestyle Approach (CPAFLA) ....................... 22 2.3.6 2.4  Benefits of Health-Related Physical Fitness.................................... 23  Summary: Maternal Age, Health Literacy, and Physical Fitness............ 28  3.0 CHAPTER THREE........................................................................................ 30 Extended Review of Literature: Secondary Research Objective ......................... 30 3.1.1  Motor Skill Development ................................................................. 32  3.1.2  Critical Periods of Development ...................................................... 34  3.2  The Ecological Perspective.................................................................... 36  3.2.2  Perception-Action Theory ................................................................ 39  3.2.3  Environmental Affordances ............................................................. 40  3.2.4  Affordances in the Home Environment for Motor Development ...... 41  3.3  Physical Activity Behaviour .................................................................... 42  3.3.3 3.4  Parental Influence on Physical Activity ............................................ 43  Measurement of Gross and Fine Motor Skill Development .................... 43  vii 3.5  Summary: Child Motor Development and Home Affordance ................. 44  4.0 CHAPTER FOUR.......................................................................................... 46 Health-Related Physical Fitness Between Mothers and Non-Mothers with High Health Literacy .................................................................................................... 46 4.1 Introduction................................................................................................ 46 4.2 Methods..................................................................................................... 50 4.2.1 Participants ......................................................................................... 50 4.2.2  Assessment of Health Literacy ........................................................ 51  4.2.2.1  Newest Vital Sign...................................................................... 51  4.2.2.2  Rapid Estimate of Adult Literacy in Medicine ............................ 52  4.2.2.3  Test of Functional Health Literacy in Adults .............................. 52  4.2.4  Assessment of Health Related Physical Fitness ............................. 53  4.2.4.1  Pre-screening ........................................................................... 53  4.2.4.2  Healthy Body Composition ....................................................... 54  4.2.4.3 Healthy Aerobic Fitness ............................................................... 54 4.2.4.4 Healthy Musculoskeletal Fitness .................................................. 55 4.2.5 Background Questionnaire ................................................................. 57 4.2.6  Procedure........................................................................................ 57  4.2.7  Statistical Analysis........................................................................... 57  4.3  Results ................................................................................................... 57  4.3.1  Participant Characteristics............................................................... 57  4.3.2  Health Literacy ................................................................................ 58  viii 4.3.2.1 Newest Vital Sign (NVS) .............................................................. 58 4.3.2.2 Rapid Estimate of Adult Literacy in Medicine (REALM)................ 58 4.3.3  Health Related Physical Fitness ...................................................... 61  4.3.3.1 Physical Characteristics and Body Composition .......................... 61 4.3.3.2 Musculoskeletal Fitness ............................................................... 61 4.3.3.3 Aerobic Fitness ............................................................................ 67 4.4  Discussion ............................................................................................. 67  4.5  Summary ............................................................................................... 75  5.0 CHAPTER FIVE ............................................................................................ 77 The Influence of Health Literacy in Early Motherhood on Home Affordance and Child Motor Development ................................................................................... 77 5.1 Introduction................................................................................................ 77 5.2 Methods..................................................................................................... 80 5.2.1 Participants ......................................................................................... 80 5.2.2  Assessment of Health Literacy ........................................................ 81  5.2.2.1  Newest Vital Sign...................................................................... 81  5.2.2.2  Rapid Estimate of Adult Literacy in Medicine ............................ 82  5.2.2.3  Test of Functional Health Literacy in Adults .............................. 82  5.2.2  Assessment of Home Affordances ..................................................... 83  5.2.3  Assessment of Motor Development .................................................... 83  5.2.4  Procedure ........................................................................................... 84  5.2.6  Statistical Analysis........................................................................... 84  ix 5.3  Results ................................................................................................... 84  5.3.1  Participants: Mothers....................................................................... 84  5.3.4  Maternal Health Literacy and Motor Development.............................. 86  5.3.5  Home Affordances and Motor Development ....................................... 89  5.4  Discussion ............................................................................................. 89  5.4.3  Summary ......................................................................................... 94  6.0 CHAPTER SIX .............................................................................................. 94 6.1 Health Literacy and Health Related Physical Fitness ................................ 95 6.2 Health Literacy and Home Affordances ..................................................... 97 6.3 Strengths and Weaknesses of the Investigation........................................ 98 6.5 Conclusions ............................................................................................. 101 References ....................................................................................................... 103 Appendix A: The Newest Vital Sign (NVS) Health Literacy Assessment .......... 114 Nutrition Label ................................................................................................... 114 Appendix B: The Newest Vital Sign (NVS) Health Literacy Assessment .......... 115 Appendix C: The Rapid Estimate of Adult Literacy in Medicine (REALM) Health Literacy Assessment ......................................................................................... 116 Appendix D: Physical Activity Readiness Questionnaire (PAR-Q+) .................. 117 Appendix E: Participation Consent Form .......................................................... 120 Appendix F: Canadian Physical Activity, Fitness and Lifestyle Assessment (CPAFLA) ......................................................................................................... 123 Appendix G: Background Information Questionnaire for Nullipara Women ...... 124 Appendix H: Background Information Questionnaire for Women with Children 134  x  xi List of Tables  Table 4.1 Participant Demographics ................................................................... 59 Table 4.2 Amount and Type of Physical Activity and Activities of Daily Living (ADL) Per Week .................................................................................................. 60 Table 4.3 Participant Physical Characteristics .................................................... 62 Table 5.1 Participant Demographics ................................................................... 85  xii  List of Figures  Figure 2.1 Mothers Age Represented in Relation to Education and Socioeconomic Status at Birth of First Child in Canada (adapted from Statistics Canada, 2008). ................................................................................................... 17 Figure 3.1 Bronfenbrenner Environmental Systems (adapted from Bronfenbrenner, 1979). ....................................................................................... 37 Figure 3.2 Newell's Model of Constraints (adapted from Newell, 1986). ............. 38 Figure 4.1 Push-Up Scores by Age and Motherhood Status. ............................. 64 Figure 4.2 Partial Curl-Up Scores by Age and Motherhood Status ..................... 65 Figure 4.3 Vertical Jump Scores by Age and Motherhood Status ....................... 66 Figure 4.4 Grip Strength Scores by Age and Motherhood Status ....................... 68 Figure 4.5 Aerobic Fitness Scores by Age and Motherhood Status .................... 69 Figure 5.1 Fine Motor Toy Availability by Toddler Gender .................................. 87 Figure 5.2 Gross Motor Toy Availability by Toddler Gender ............................... 88  xiii Glossary Aerobic Fitness: An objective measure of the combined efficiency of the heart, lungs, blood vessels, and exercising muscles to meet the demands of exercise and supply oxygen to working muscles (Canadian Society for Exercise Physiology (CSEP), 2003). Affordance: Refers to the function or opportunity an environmental object, surface, place, or event provides to an individual to perform potentially an action. Affordances of the Home Environment for Motor Development (AHEMD): A validated research tool to assess the opportunities for motor development in the home during early childhood (Rodrigues & Gabbard, 2009). Body Composition: The amount of fat, muscle, bone, and anatomical components in relation to a person’s total mass (CSEP, 2003). Body Mass Index (BMI): The ratio of a person’s body weight (kg) divided by their height (m) squared (CSEP, 2003). Canadian Society for Exercise Physiology (CSEP): A professional organization representing the gold standard for health and fitness professionals in Canada (Health and Fitness Program), whose principle focus is on physical activity, health and fitness research, and personal training. A primary objective of the CSEP is to foster the generation, growth, synthesis, transfer, and application of quality research, education, and training related to exercise physiology and science (www.csep.ca).  xiv The Canadian Physical Activity, Fitness, and Lifestyle Approach (CPAFLA): A standardized health-related physical fitness assessment administered on over a million Canadians each year by trained and certified Canadian Society for Exercise Physiology health and fitness professionals. Assessments include physical activity participation, body composition and metabolism, aerobic fitness, and musculoskeletal fitness (Gledhill & Jamnik, 2003). Exercise: Planned, repetitive physical activity for the purpose of improving or maintaining at least one component of physical fitness (Casperson, Powell, & Christenson, 1985). Flexibility: The degree of movement around a joint or series of joints (CSEP, 2003). Fundamental Motor Skills: Motor skills that serve as building blocks for the acquisition and development of more complex and specialized skills and are generally classified as: locomotor (e.g., walking, running, skipping, galloping, sliding, and leaping), nonlocomotor (e.g., stretching, bending, twisting, swaying, turning, and balancing), and manipulative (e.g., hitting, kicking, striking, dribbling, catching, and throwing). Health Knowledge: The level of knowledge a person possesses regarding aging, anatomy and physiology, drug use and abuse, illness, nutrition, physical activity, physical exercise, as well as safety and first aid, that allows them to identify disease symptoms and communicability, choose appropriate health decisions, and understand health services (Beier & Ackerman, 2003).  xv Health Literacy: An individual’s capacity to obtain, process, and understand simple health information and make appropriate health decisions (Parker, Ratzan, & Lurie, 2003). Health-Related Physical Fitness: The components of physical fitness specific to an individual’s health status and include cardiovascular fitness, musculoskeletal fitness, body composition, and metabolism (Warburton et al., 2006). Literacy: An individual’s basic capability to read and write, including the basic components of: reading ability, prose literacy, document literacy, and numeracy. Modified Canadian Aerobic Fitness Test (mCAFT): A predictive, progressive, submaximal exercise test for the general population; it is used by the CPAFLA as an assessment of aerobic fitness (CSEP, 2003). Motor Development: The sequential, continuous age-related process whereby movement behaviour changes (Haywood & Getchell, 2001). Multipara: A woman that has given birth to more than one viable fetus. Muscular Endurance: The ability of the musculoskeletal system to maintain or create force (CSEP, 2003). Musculoskeletal Fitness: The overall fitness of the musculoskeletal system encompassing muscular strength, muscular endurance, muscular power, flexibility, back fitness, and bone health (Warburton et al., 2006). Muscular Power: The maximum rate of force that can be created through the combination of muscular strength and speed (CSEP, 2003).  xvi Muscular Strength: The maximum amount of force that a muscle can exert (CSEP, 2003). Newest Vital Sign (NVS): A brief, 6 question oral test assessing one’s capability to read and understand information from an ice cream nutritional label (Weiss et al., 2005). Nullipara: A woman that has never given birth. Obesity: Excessive body fat that results from an energy imbalance (Katzmarzyk, 2002). Peabody Developmental Motor Scales, 2nd Edition (PDMS-2): A standardized test procedure to assess the fine and gross motor development in young children from birth to 5 years old. It contains 6 sub-tests assessing: reflexes, stationary abilities, locomotion, object manipulation, grasping, and visual motor integration. Physical Activity: Bodily movement produce by skeletal muscles, resulting in energy expenditure (Casperson et al., 1985). Primipara: a woman that has given birth to one viable fetus. Rapid Estimate of Adult Literacy in Medicine (REALM): A short assessment tool that tests an individual’s reading capability by assessing word recognition. The standard REALM test includes a list of 66 medical words and provides an indication of grade reading level (Davis et al., 1993). Skinfold: The thickness of the fold of skin and underlying fat as measured by a skin caliper.  xvii Sum of Five Skinfolds: The cumulative score of measurements from the triceps, biceps, subscapula, iliac crest and medial skinfolds. The sums of five skinfolds are measured in the CPAFLA as an estimate of subcutaneous fat (CSEP, 2003). Test of Functional Health Literacy in Adults (TOFHLA): Refers to a measure of one’s functional literacy, by assessing an individual’s capability to read and comprehend text, and then perform a health-related task (Osborn et al., 2007).  xviii Acknowledgements  There were many people that helped and supported me throughout my Master’s program. I would like to first thank my supervisor, Dr. Shannon S. D. Bredin for her support, knowledge, empathy, and encouragement throughout my program. I would also like to thank my committee member and close collaborator, Dr. Darren D. E. Warburton, for his support and contribution. Both Dr. Bredin and Dr. Warburton’s encouragement helped me through my degree, provided valuable research opportunities and professional experience. I would also like to thank Dr. Marcel Bouffard for his contribution to my thesis work and expertise in this area. Secondly, I would like to thank all the LEARN and CPR lab students, for their support, encouragement, and friendship.  xix Dedication  For Tim, Maddox and Hunter  1  1.0 CHAPTER ONE Introduction  1.1  Introduction to Thesis Health literacy and physical fitness play an important role for health status  across the lifespan. Health literacy is an individual’s competency to understand and use basic health information to maintain his or her own health and make appropriate health decisions (Parker, Ratzan & Lurie, 2003). Health literacy is associated with health status, as well as an individual’s level of health knowledge, and their use of health services (American Medical Association, 1999). Although reports show that health literacy levels are higher in Canada when compared to data from the United States, Canadian health literacy levels are still considered low, with an estimated 60% of adults lacking the ability to make health decisions on their own, and to obtain important health information (Canadian Council on Learning, 2007). Therefore, a sufficient level of health literacy is needed to increase one’s likelihood of achieving at least a minimal level of health. Health literacy levels are related to both age and level of education (Canadian Council on Learning, 2007), with higher levels of health literacy possessed by those, as expected, with more education. The average level of health literacy amongst Canadian adults peaks during the period of 26 to 35 years (Canadian Council on Learning, 2007). Therefore, individuals with higher levels of education  2 are more likely to possess higher levels of health literacy and, on average, their health literacy level will peak between 26 to 35 years. Importantly, the health literacy levels of parents affect their ability to make appropriate health decisions for their child (DeWalt & Hink, 2009). For example, a parent needs to be able to read and comprehend the instructions on a child’s medication label to safely administer the correct dosage to his or her child. This generally requires the parent to be able to calculate the correct dosage according to their child’s body weight (Yin, Dreyer, Foltin, Van Schaick, & Mendelsohn, 2007). As such, it is important to consider parental characteristics for the enhancement of knowledge regarding contemporary developmental issues in children. In Canada, along with other developed countries, there has been a shifting trend to older maternal age (Luke & Brown, 2007a; Sword et al., 2009). For example, the Canadian average age of first time mothers is 29.2 years, compared to 26.7 three decades ago (Statistics Canada, 2009). More specifically, 2008 statistics revealed that 54.2% of women giving birth in British Columbia were over the age of 30 years (Statistics Canada, 2008). Further, women that have children at an older age tend to attain higher levels of education and have higher average household incomes in comparison to women that have children at a younger age (Statistics Canada, 2008). This increase in maternal age may have a significant effect on the average level of health literacy in the early motherhood years in developed countries; however, the influence of  3 health literacy during the childbearing years is largely unknown and remains a relatively unexplored area of investigation. In Canada, two-thirds of the population is considered inactive (Health Canada, 2009). A particularly vulnerable period of the lifespan for inactivity is the early years of parenthood. Compared to non-parents, parents are less active, with mothers being even less active than fathers (Bellows-Reicken & Rhodes, 2007). Although it has been shown that women with children engage more frequently in activities of daily living and household activities compared to women without children, these activities are performed at significantly lower intensity levels (Sternfeld, Ainsworth, & Queensbury, 1999). Engaging in an appropriate level of physical activity is especially important in early motherhood for a number of reasons (see Bredin, 2012). One of the most notable reasons pertains to the potential long-term effect of gestational weight gain or weight retention post partum. For example, a 25 to 35 pound weight gain is recommended for a normal weight woman with a singleton pregnancy (Health Canada, 2009). However, evidence suggests that the average woman retains permanently some of the weight gained during gestation and retention of weight occurs with each child (Weng et al., 2004). Therefore, the amount of post-pregnancy weight retained increases with each subsequent child and multipara women (i.e., a woman that has given birth to more than one viable fetus) are at the greatest risk for long term weight gain and associated risk factors such as cardiovascular-related diseases, obesity, and diabetes mellitus (Warburton et al., 2006).  4 According to the Society of Obstetricians and Gynaecologists of Canada (2003), it is safe to begin walking and moderate stretching shortly after delivery with a gradual increase in levels of physical activity as early as 4 to 6 weeks postpartum for an uncomplicated vaginal delivery (Wolfe & Davies, 2003). However, postpartum women report consistently an increase in barriers to exercising, such as lack of time and childcare availability, which persists 12 months after childbirth (Evenson, Aytur, & Borodulin, 2009) and longer (Chapman & Bredin, in press). It is clear that changes in lifestyle demands and the various barriers that emerge in the early years of motherhood contribute to an increased risk of becoming overweight or obese as a result of the pregnancy period (Larson-Meyer, 2002; Linne, Barkeling, & Rossner, 2002; Ohlin & Rossner, 1990a, 1990b). This is further compounded by increases in maternal age, whereby losing weight becomes more difficult with increasing age (Warburton et al., 2001). A critical factor for achieving good health status is one’s level of physical fitness. More specifically, health-related physical fitness includes all aspects of physical fitness related to health status (cardiovascular fitness, musculoskeletal fitness, body composition, and metabolism). Health-related physical fitness factors are important variables to examine because they are more strongly related to health outcomes (i.e., cardiovascular disease, diabetes, obesity) than examining one’s levels of physical activity (Warburton, Nicol, & Bredin, 2006). Health-related physical fitness is also an especially important variable to study in the early years of motherhood. Unfortunately, achieving optimal levels of physical  5 fitness may be difficult during this lifespan period. As stated earlier, the early years of motherhood are associated with major changes in lifestyle and a number of barriers to exercise often emerge. In women, physical fitness levels are also influenced by the pregnancy period itself. For example, during pregnancy, numerous cardiovascular, metabolic, thermal, and postural changes occur to support normal, healthy fetoplacental growth and consequently, the body responds differently to exercise demands. Total blood volume increases and splanchnic blood flow increases up to 75% (Clapp and Little, 1995) to enhance placental growth, resulting in resting heart rates that are 10 to 15 beats per minute higher than non-pregnant women (Lotgering et al., 1992; Avery et al., 2001). The combination of increased blood volume and resting heart rate increases cardiac output, but reduces the cardiac reserve, reducing the magnitude in which heart rate can increase (Hammer et al., 2000). The growing fetus also changes center of gravity and limits possible positions for exercise (i.e., it is not recommended to lay supine in later stages of pregnancy). This means that due to the physiological changes, and length of gestation, women can experience a decline in the level of health-related physical fitness. Although a number of significant changes occur, there is no evidence todate of exercise-related adverse events associated with moderate to vigorous exercise during pregnancy (Charlesworth, Foulds, Burr, & Bredin, 2011). However, many women hold onto the fallacy that they cannot exercise during pregnancy.  6 While a relationship between health literacy and health status has been established for the adult population (Weiss, 2005; Canadian Council on Learning, 2007), this does not mean that this relationship is generalizable to unique subsections of the population. One such population may be women during their early motherhood years. To-date, little is known about the effect of health literacy as it relates to health-related physical fitness in the early motherhood years. For example, do women with higher levels of health literacy also demonstrate higher levels of health-related physical fitness during early motherhood? Is there a relationship between age and health-related physical fitness during the early years of motherhood? Further investigation into this area of study is warranted. The health literacy of mothers in the early years of parenthood is also important to investigate in relation to health status and behaviour of the child. The physical activity behaviour of a child influences both the acquisition of fundamental motor skills and the development of more complex motor skills (O'Connor, 2000). During the toddler period, between18 to 36 months, a child’s environment is influenced largely by their parents. Since parents control primarily the home environment, they have a significant influence on the affordances available to their child (i.e., the structure of the physical environment and the opportunity it provides an individual to perform an action). The amount and types of toys, and various floor surfaces are both examples of home affordances. For instance, small toys such as shape sorters, will provide different movement opportunities in comparison to a modern walker, which will require the recruitment of different muscles for motor skill execution. While one type of  7 affordance may not be better than another, they do have differential effects on motor skill development. The degree of health literacy that a mother possesses, will likely affect the choices made regarding home affordances for their child. The choices and behaviour that a mother makes to fulfill certain roles in the family will depend largely on her belief system and what she considers to be most important. For example, a mother with higher levels of health literacy may provide different toys, play spaces, and movement opportunities for her child compared to a mother with low health literacy. To-date, the relationship of maternal health literacy to the types of affordances found within the home environment and toddler motor development has not been researched; thereby, representing an important gap in the literature. 1.2  Overview of Thesis Investigation One research investigation addressing two sub-questions was conducted.  The first research objective was to examine differences in health-related physical fitness of mothers with children between the ages of 18 to 36 months compared to women with no children in a cohort of participants with high levels of health literacy. Health literacy was assessed via a battery of assessments including: the Newest Vital Sign (NVS), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Test of Functional Health Literacy in Adults (TOFHLA). Healthrelated physical fitness was assessed using the Canadian Physical Activity, Fitness and Lifestyle Approach (CPAFLA). Specifically, we hypothesized that:  8 1. Women over the age of 30 will score significantly higher on the TOFHLA, NVS, and REALM compared to women under the age of 30 2. Nullipara women (women with no children) will display higher levels of health-related physical fitness (as measured by the CPAFLA) compared to women with children even when possessing high levels of health literacy.  The second research objective was to examine the relationship between health literacy on affordances in the home environment and toddler motor development. Home affordance was assessed using the Affordances of the Home Environment for Motor Development (AHEMD); while, toddler motor development was assessed using the Peabody Developmental Motor Scale, 2 nd edition (PMDS-2). We hypothesized that: 1. Mothers with higher levels of health literacy (as measured by the NVS, REALM, and TOFHLA) will provide greater affordances for their children within the home (as determined by the AHEMD) compared to mothers with lower levels of health literacy. 2. Higher levels of motor skill proficiency in gross and fine motor skills as measured by the PMDS-2 will be exhibited from children with mothers possessing higher levels of health literacy, and/or those providing greater affordances within their home environment (as determined by the NVS, REALM, TOFLA, and the AHEMD, respectively).  9 1.3  Overview of Thesis Document This document is comprised of six chapters. The first chapter is introductory  in nature and serves to identify the research questions driving the proposed investigation and the layout of the document. The second and third chapters provide an extended review of literature, which was used to develop the research direction and determine the design of this thesis. The research conducted for this thesis is presented in chapters four and five, in the form of two manuscripts. The final chapter discusses the conclusions and implications of this research, as well as its limitations and recommendations for future investigations.  10 2.0 CHAPTER TWO Extended Review of Literature: Maternal Age, Health Literacy, and Health-Related Physical Fitness  The first purpose of this research investigation was to examine the influence of maternal age on health literacy and health-related physical fitness. In this chapter, a general review of the literature is presented for each of the three major topics areas: health literacy, maternal age, and health-related physical fitness.  2.1  Health Literacy  2.1.1 Definition of Health Literacy Health Literacy refers to one’s capability to use health information, in order to maintain their own basic health and make necessary health decisions (Canadian Council on Learning, 2007; Parker, Ratzan, & Lurie, 2003). Importantly, health literacy is correlated to various aspects of health such as: health knowledge, health status, and use of health services (American Medical Association, 1999). Although often overlooked, health literacy is a central concept to health status as those individuals demonstrating higher levels of health literacy are also more likely to exhibit better health status (Canadian Council on Learning, 2007). In parents of young children, this also includes the capability to maintain the basic health of their dependents (DeWalt & Hink, 2009; Sanders, Shaw, Guez, Baur, & Rudd, 2009b).  11 To put the importance of health literacy into context, consider a patient receiving vital medical information from his or her physician. Health literacy includes: being able to understand and correctly follow instructions (e.g., pertinent prescription information), seek appropriate health professionals and services as needed, and the capability to read and interpret information from labels to make appropriate healthy choices (Hironaka & Paasche-Orlow, 2008). Health literacy for mothers also includes such responsibilities as following immunization schedules, booking baby check-ups, and giving appropriate doses of medicine (Abrams, Klass, & Dreyer, 2009; Tran, Robinson, Keebler, Walker, & Wadman, 2008). Health literacy is also related to health knowledge, which is an individual’s knowledge base of aging, anatomy and physiology, first aid and safety, drug use, illness, nutrition, metabolism, physical activity, and health care utilization (Beier & Ackerman, 2003). Health knowledge also encompasses an individual’s capability to choose appropriate health prevention strategies, understand where to obtain health services, and identify symptoms and communicability of diseases (Freimuth, 1990). There is also evidence that shows that lower levels of health knowledge is related to lower health status, increased health care costs, as well as an increased use of health care services (Weiss, 2005).  12 2.1.2 Current Status of Health Literacy in Canada In Canada, it is estimated that 60% of adults demonstrate poor health literacy as reported by the Canadian Council on Learning (2007). This means that a majority of Canadians do not possess the minimal capabilities required to obtain and interpret health information, or make suitable health decisions to maintain optimal health and reduce health risks (Canadian Council on Learning, 2007). With higher levels of health literacy, it is shown that there is a reduced prevalence of diabetes and high blood pressure, as well as fewer reported injuries (Canadian Council on Learning, 2007). Notably, the average health literacy score across Canada varies with age and level of education attained. According to the Canadian Council on Learning (2007) the average level of health literacy is highest in adults between the ages of 26 to 35, then decreases with age. In addition, health literacy scores increase with level of education, whereby adults with less than a high-school education perform at significantly lower levels of health literacy than adults with higher levels of education. Importantly, this gap or difference in level of health literacy widens as a function of age (i.e., aging amplifies inequalities in education). Health literacy also varies significantly by province. British Columbia demonstrated the 4th highest health literacy score in Canada (higher than the national average), based on results of the 2003 International Adult Literacy and Skills Survey (n = 23,038). However, the issue remains that these results still reveal that the majority of Canadians across all the provinces do not possess sufficient knowledge to maintain basic levels of health.  13 2.1.3 The Assessment of Health Literacy Literacy refers to the basic ability to read and write, and includes several basic components: reading ability, prose literacy, document literacy, and numeracy. Health literacy includes the same components of literacy, but in a more complex manner. Prose literacy is related to continuous text, such as a book or newspaper article, whereas document literacy is related to discontinuous text, such as a chart or table. Numeracy is the ability to understand numbers and mathematical concepts (e.g., calculating medication dosages). Therefore, health literacy involves using additional skills above the basic concepts of literacy. For example, in addition to reading (literacy), an individual must comprehend the content, and then apply the information or make a decision in relation to his or her health (health literacy). This is evident when an individual must read a medication dose chart and then determine the correct dosage; or, when identifying symptoms of an illness and deciding on a course of action such as making an appointment with a physician. Approximately half of Canadians (48%) demonstrate low literacy levels, whereas 60% exhibit low health literacy levels (Canadian Council on Learning, 2007). The difference between the two statistics demonstrates the more complex nature of health literacy. Health literacy can be assessed several ways, each measuring varying components, related to prose literacy, document literacy, and numeracy. Commonly administered assessments include such validated tests as: The Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS).  14 2.1.3.1  The Rapid Estimate of Adult Literacy in Medicine (REALM)  The Rapid Estimate of Adults Literacy in Medicine (REALM) is a short assessment tool that evaluates an individual’s reading capability by assessing his or her word recognition performance. The standard REALM test includes a list of 66 medical words and is shown in Appendix C. The results are based on a scoring of 0 to 66, with higher scores reflecting a higher reading ability. Score ranges are then used to predict an approximate grade level reading ability: 0 to 18 (3rd grade reading level), 19 to 44 (4th to 6th grade reading level), 45 to 60 (7th to 8th grade), and 61 to 66 (9th grade and above). Obtaining an estimate of grade level reading ability is important because research suggests that asking an individual his or her level of attained education does not accurately represent actual level of reading (Davis, 1993). The REALM test shows excellent concurrent validity, as demonstrated with high correlations to longer tests of reading ability (SORT-R, 0.96; PIAT-R, 0.97; WRAT-R, 0.88) (Murphy, Davis, Long, Jackson, & Decker, 2003). The test-retest reliability of the REALM is 0.99 (Davis, 1993). 2.1.3.2  Test of Functional Health Literacy in Adults (TOFHLA)  The Test of Functional Health Literacy in Adults (TOFHLA) is a measure of one’s functional literacy. That is, an individual’s ability to read and comprehend text, and then perform a health-related task (Osborn et al., 2007). The TOFHLA demonstrates good correlation with a longer test of reading ability (WRAT-R, 0.74) (Parker et al., 1995). The TOFHLA takes up to 22 minutes to complete, and contains 50 comprehension items and 17 numeracy items (Parker, Baker,  15 Williams, & Nurss, 1995). The numeracy items are weighted to a score out of 50, for a total possible score of 100. The questions are scored as 1 for correct and 0 for incorrect, which provides a total score that can be converted to one of three categories of functional literacy: inadequate (score of 0 to 59), marginal (60 to 74), and adequate (75 to 100). The categories correspond to individuals ability to appropriately respond to health-related tasks and questions. 2.1.3.3  The Newest Vital Signs (NVS)  The Newest Vital Signs (NVS) test is a rapid assessment designed for health settings to detect limited literacy. The NVS is shown in Appendix A. It is a brief, 6 question oral test assessing one’s ability to read and understand information from an ice cream nutritional label (Weiss et al., 2005). It evaluates general essential literacy (prose literacy, numeracy, and document literacy), by assessing an individual in math, reading, and comprehension (Weiss et al., 2005). While there is no time limit, the test is relatively brief and is generally administered in 3 to 5 minutes. The NVS is scored with a range of 0 to 6, with higher scores reflecting a higher estimate of health literacy. A score of 0 to 1 suggests a high likelihood of limited literacy, a score of 2 to 3 indicates limited literacy and a score of 4 or greater indicates adequate literacy. The NVS has been shown to be reliable (Crombach  = 0.76) in English (Weiss, 2005), and has also shown high sensitivity (Osborn et al., 2007).  16 2.2  Maternal Age  2.2.3 Trends in Maternal Age The average age of first time mothers in Canada is 29.2 years, a number that has increased from 26.7 years over the past three decades (Statistics Canada, 2008). In 1974, only 19.5% of births in Canada were to mothers over the age of 30, which has now increased to 48.9% nationally. In fact, women between the ages of 30-34 make the largest annual contribution to number of births in Canada (107, 524 births in 2005 versus 105, 566 to mothers between the ages of 25 to 29 y). In British Columbia, the mean age for first time mothers is 29.9 years and 54.1% of all births are to women over the age of 30. Further, the proportion of women in their 40’s with young children has more than doubled, from 4.3% in 1986 to 8.9% in 2006 (Statistics Canada, 2008). 2.2.4 The Relationship Between Age, Education, and Health Literacy Health literacy levels change as a function of age and education level (Canadian Council on Learning, 2007). Those with less than a high school education demonstrate the lowest levels, followed by high school and nonuniversity post-secondary levels of education. Individuals with a university degree demonstrate the highest health literacy scores. Within each category of education, overall scores of health literacy decrease with older age; however the difference in scores between education levels is amplified with increasing age. Therefore, those with lower levels of health literacy experience a greater decrease as they age (Canadian Council on Learning, 2007).  17 Women that have children at an older age tend to attain higher levels of education, have higher average household incomes and own their own home (owner-occupied dwelling) in comparison to women that have children at a younger age (Statistics Canada, 2008) (see Figure 2.1). The secular trend of increasing maternal age, and the attainment of higher levels of education may have an important impact on the level of maternal health literacy in Canada. As older mothers tend to have higher levels of education, and one’s level of education is related to health literacy levels, we suggest that older mothers will be more likely to demonstrate higher levels of health literacy compared to younger mothers.  Figure 2.1 Mothers Age Represented in Relation to Education and Socioeconomic Status at Birth of First Child in Canada (adapted from Statistics Canada, 2008).  18 2.3  Physical Activity, Health-Related Physical Fitness, and Health Status in Early Motherhood  2.3.1 Benefits of Physical Fitness Engaging in physical activity is important for the primary and secondary prevention of numerous chronic diseases (e.g., cardiovascular disease, Type 2 Diabetes), as well as premature death (Warburton, Whitney, & Bredin, 2006). For example, being physically active has been associated with an over 50% reduction in risk of death from cardiovascular disease (Myers, Kayha, & George, 2004). The amount of physical activity an individual engages in has a doseresponse relationship with risk for cardiovascular disease, whereby greater amounts of physical activity leads to reduced risk (Oguma & Shinoda-Tagawa, 2004). In contrast, physical inactivity has been linked to an increase in healthrelated risk factors. For example, inactive middle-age women that engaged in less than one hour of aerobic exercise a week had a 52% increase in all-cause mortality, a 29% increase in cancer-related mortality, and their risk of cardiovascular-related mortality doubled (Blair et al., 1996). Thus, physical activity is associated with a decrease in risks for chronic disease, while physical inactivity is associated with greater health risks. 2.3.2 Prevalence of Physical Activity in New Parents The transition to parenthood leads to considerable lifestyle changes, one of which is a change in physical activity levels themselves. Growing evidence suggests a relatively permanent increase in BMI during the childbearing years (Bellows-Reicken & Rhodes, 2007). When comparing parents to non-parents,  19 multiple studies have shown an inverse relationship between physical activity and becoming a parent. Parents are less active than non-parents, and mothers are less active than fathers (Bellows-Reicken & Rhodes, 2007). For example, Sternfeld et al. (1999) found that women with children exercised 37% less than women without children, but engaged in more household activities and activities of daily living. Brown and Trost (2003) showed a negative relationship between parenthood and physical inactivity in a 4 year longitudinal study. Further, the type of physical activity varied between women with and without children. In this investigation, women with children were more likely to expend energy from household activities rather than exercise. While household activities and activities of daily living are important for overall health benefits, they are generally executed at a lower intensity than exercise. It is suggested that the lower intensity exercise may not provide high enough cumulative energy expenditure to effect health status within this phase of the lifespan (Brown & Trost, 2003) . Therefore, during the period of becoming a parent, there is a decrease in the amount and type of physical activity. 2.3.3 Barriers to Exercise in New Mothers Parents, in particular new mothers, are at greatest risk for physical inactivity. However, research to-date has tended to focus on the barriers to exercise (e.g., lack of time, lack of childminding); rather than assessing objective measurements such as health-related physical fitness. Despite the importance of physical activity for an individual’s health, the majority of Canadian adults are inactive (Katzmarzyk & Janessen, 2004). Physical activity during the postpartum period is  20 especially important as the risk of becoming overweight or obese is relatively high (Linne, Barkeling, & Rossner, 2002; Siega-Riz, Evenson, & Dole, 2004). Despite the health benefits associated with physical activity, new mothers face a number of barriers to engaging in physical activity to improve their health status or level of physical fitness. For example, Evenson, Aytur, and Borodulin (2009) identified lack of time (47% of participants at 3 months postpartum; 51% at 12 months), and issues with childcare (26% of participants at 3 months postpartum; 22% at 12 months) as the greatest barriers to exercise. However, 89% of participants identified that physical activity was appropriate, in that it was safe for them to engage in, and would be beneficial to their health. Therefore, despite the belief that physical activity would be good for their health, new mothers face barriers that may prevent them from engaging in physical activity. 2.3.4 Social Constructivism Theory Social Constructivism is a theory of knowledge based on individuals looking for common forms of understanding, or “constructs” to view the world (Slife & Williams, 1995). Therefore, thoughts and interpretations are socially constructed by one’s surroundings. During the transition to parenthood, mothers must develop and construct meaning about their new social role and the perceived expectations surrounding it (Hamilton & White, 2010b). The importance one places on a particular role, and the commitment to it, will affect behaviour (Stryker, 2007). In the context of families, if a mother is limited on what tasks or roles can be fulfilled, the ones deemed most important are most likely to be executed. For example, if there is not enough time to exercise (taking time for  21 one’s self) and take one’s child to music class (putting the child first), the mother will make a choice based on what she determines to be the most important. Mothers will prioritize actions based on what they feel is most important to do, and what they feel important is influenced by society and culture. Research shows generally that individuals with higher levels of health literacy also demonstrate a higher level of health status (Weiss, 2005). However, new mothers face barriers to exercise (as a results of lifestyle changes), and those with higher levels of health literacy may not necessarily demonstrate higher levels of health status in comparison to mothers with lower levels of health literacy . Therefore, knowing and/or believing that physical activity is important is often not enough motivation for mothers to engage in activities or do things for their own health. The relationship between health literacy, and health status for the general adult population is well established (Weiss, 2005); however, research specific to new mothers is lacking, warranting further investigation. 2.3.5 Health-Related Physical Fitness The terms physical activity and physical fitness are not interchangeable. Health-related physical fitness refers to a physiologic state of well-being that allows one to meet the demands of daily living. Therefore, health-related physical fitness involves the components of physical fitness that relate to health status and include: cardiovascular fitness, musculoskeletal fitness, body composition, and metabolism (Warburton, Whitney, & Bredin, 2006). In contrast, physical activity refers to the gross body movements produced by skeletal muscles that increase energy expenditure.  22 2.3.6 Measurement of Health-related Physical Fitness via the Canadian Physical Activity, Fitness and Lifestyle Approach (CPAFLA) The CPAFLA is a standardized battery of tests measuring health-related physical fitness. It was designed by Dr. Norman Gledhill and Dr. Veronica Jamnik, and used by the Health and Fitness Program of the Canadian Society for Exercise Physiology (CSEP) to assess the health-related physical fitness of the general population, with high levels of validity and reliability (Tremblay, Shephard, McKenzie, & Gledhill, 2001). More specifically, the CPAFLA is a detailed assessment of specific components of health-related physical fitness. The individual components can be combined to provide composite scores. For example, healthy musculoskeletal fitness can be assessed by compiling scores from push-ups, sit and reach, partial curl-ups, vertical jump leg power, and back extension. The composite scores can be calculated and then compared to Canadian normative data. The scores provide feedback to individuals about their relative health risks, as well as potential benefits associated with increasing their current fitness level. Collectively it provides a detailed measure of an individual’s level of health-related physical fitness. The CPAFLA takes approximately 60 to 90 minutes to administer. The CPAFLA is administered by a CSEP-Certified Personal Trainer or CSEPCertified Exercise Physiologist. The use of a qualified exercise professional ensures the test is administered according to exact protocol to provide accurate and meaningful results. The details of the individual tests of the CPAFLA will be described in Chapter 4.  23 2.3.6 Benefits of Health-Related Physical Fitness Participation in physical activity is positively correlated with increases in levels of physical fitness (Caspersen, Powell, & Christensen, 1985). Physical activity is also similar to physical fitness in its relationship to morbidity and mortality. However, physical fitness is more strongly predictive of health outcomes than physical activity. For example, research has shown generally a reduction of at least 50% in mortality among people considered to be highly fit when compared to low fit people (Warburton et al., 2006). As such, physical fitness may be a more important (and more objectively measured) variable for examining one’s health status in comparison to physical activity. Therefore, an important outcome measure of the present investigation is on the major components of healthrelated physical fitness, namely: cardiovascular fitness, musculoskeletal fitness, and body composition. Cardiovascular fitness is a term that is used in reference to the efficiency of the heart, lungs, and vascular system (CSEP, 2003). It can be measured several ways, including direct measurement of oxygen uptake, or indirect tests that estimate the efficiency of the cardiovascular system. Cardiovascular health is important for the prevention of several chronic diseases and premature death (Warburton, Nicol, & Bredin, 2006). During the postpartum period, cardiovascular fitness levels will be reduced as a result of the physiological changes that occur (reduced capacity to exercise during pregnancy), and the reduction or absence of exercise in many pregnant women. Previously, pregnant women had been advised not to engage in exercise; for active women to reduce their exercise  24 exertion levels, and for inactive women to abstain from engaging in exercise (Davies et al., 2003). Therefore, this reduction may be due to the false belief that exercise is not safe, and/or difficulties exercising because of the growing fetus. In the early motherhood period, we anticipate cardiovascular levels of mothers will remain lower compared to women without children, despite an absence of physiological limitations. The difference in cardiovascular fitness levels will be due to lifestyle changes for these women and apparent (i.e., lack of childcare) and perceived barriers (i.e., not considering it important) to exercise. Musculoskeletal fitness is a broad term describing the overall fitness of the musculoskeletal system, encompassing muscular strength, endurance, and power, as well as flexibility (Warburton, Whitney & Bredin, 2006). Muscular strength is the maximum force that a muscle can exert in a single contraction, while muscular endurance is the ability to maintain or repeat force. Muscular power is the combination of both strength and speed, and refers to the maximum rate of force production (CSEP, 2003). Flexibility is the range of movement around a joint, or group of joints (CSEP, 2003). Healthy musculoskeletal fitness is important for engaging in activities of daily living as well as for participating in more vigorous challenges such as sport and exercise. Musculoskeletal fitness is often assessed using several measures. Within the CPAFLA (the gold standard assessment in Canada) musculoskeletal fitness is tested by assessing grip strength, push-ups, partial curl-ups, vertical jump, and sit and reach (see the methods section of the manuscripts enclosed in this thesis for specific details of each assessment). Each test of musculoskeletal fitness is critical for optimal  25 health status across the lifespan. There is evidence that lower levels of musculoskeletal strength is associated with a decrease is health status, and increased risk of chronic disease (Warburton, 2001). Musculoskeletal fitness is important for maintaining functional independence in older people (Warburton et al, 2006), and their capacity to do activities of daily living unassisted. As muscular strength decreases with age, having a higher level will allow an individual to maintain functional independence for longer (Warburton et al., 2001). The push-up, partial curl-up, and back extension components assess one’s muscular strength and endurance. Specifically: the triceps and shoulders (pushups), abdominal muscles (curl-ups) and back muscles. The vertical jump assessment reflects the muscular strength of the quadriceps and gluteus maximus and grip strength is the maximum strength of the flexor muscles in the forearm and hand. The sit and reach assessment reflects the flexibility of an individual for forward trunk flexion. Collectively, they represent an individual’s muscular fitness levels and are linked to important health benefits. Both the push-up and partial curl-up assessments are important for repetitive tasks and activities of daily living. Abdominal muscular endurance is predictive of mortality in the Canadian population (Katzmarzyk & Craig, 2002). The vertical jump, a reflection of quadriceps strength, is associated with mortality risk, and life expectancy (Newman et al., 2006; Rantanen, 2003), Further, quadriceps strength has been associated with osteoporosis risk in women, as older women with the lowest percentile of strength have a higher incidence of osteoporosis than  26 women in the highest percentile (Nyugen et al, 2000). Quadriceps strength is also associated with risk for a fracture due to falling (Nyugen et al., 2000). Importantly, quadriceps strength is essential for activities of daily living, such as getting into and up from a chair. If an individual has a higher level of quadriceps strength, they are at a reduced risk of injury and mortality as they age. Independent of age, sex, current BMI, and cardiorespiratory fitness, a low level of musculoskeletal fitness is associated with a significantly greater occurrence of a long term weight gain of at least 10 kg (22 lbs) (Mason et al., 2007). Grip strength may be predictive of life expectancy and independent living (Metter, Talbot, Schrager, & Conwit, 2002). Grip strength (maximal isometrics strength of flexor muscles in the forearm and hand) has been linked to health status, whereby there is a negative relationship between hand strength and total cholesterol/HDL cholesterol lipoprotein related risk factors (Ortega et al., 2004). Most simply, grip strength is important for activities of daily living, and women that engage in greater amounts of such activities may show higher levels of grip strength versus less active women. Comparing Canadian women from 1981 to present, average grip strength ratings have decreased from very good to good (62 to 56 kg). However, unlike other physical fitness measures taken in this line of research, we suggest that mothers with young children will demonstrate good grip strength. While mothers may be engaging in less physical activity, the demands of their current lifestyle (e.g., lifting and carrying infant car seats, carrying consistently infants and small children between10 and 35 pounds) on a daily basis may facilitate the development of muscular strength in the upper  27 body. This may represent a notable difference between nullipara and primi- and multipara woman, in that women with children will have greater grip strength than women without children, and younger mothers will have greater grip strength than older mothers. Body composition refers to the relative amounts of muscle, fat, bone, and anatomical components that sum to an individual’s total weight (Services, 1999). Body composition is important because it is a strong predictor of health risk, regardless of age, race, and gender. Excessive body fat increases one’s chance of premature death due to chronic diseases such as coronary artery disease, stroke, and type two diabetes (Katzmarzyk, 2003). Body composition can be measured directly, such as with hydrodensitometry (underwater) weighing, or indirectly, using anthropometric (skinfold) measures. Women’s health status in Canada has changed significantly in the past 20 years (Mason, 2007). Comparing 1981 to present, women demonstrate higher average body weights (63.2 kg to 68.4 kg). There has also been an associated change in body composition classification. More women are classified as ‘overweight’ (as determined by BMI) compared to women falling into the normal weight classification (25.8 kg/m2 vs. 24.1 kg/m2 respectively). Further, women currently exhibit a greater waist (76.3 cm to 83.4 cm) and hip (98.5 cm to 102.5 cm) circumference; and thus, a greater waist to hip ratio (0.81 vs. 0.77). The change in BMI classifications and waist to hip ratio has led to a subsequent change in risk stratification (increased risk now vs. lower risk in 1981).  28 As a result of the shifting trends described above, women in Canada exhibit lower levels of health status when compared to previous decades. The period of pregnancy and the transition to parenthood will further affect a woman’s physical fitness levels and subsequent physical health status. Even with a healthy pregnancy (with no complications), there will be a decrease in the amount of time and intensity of physical activity, as well as the types of activities that a woman engages in during gestation (Wolfe & Davies, 2003). The reduction in physical activity will have an effect on cardiovascular endurance, as well as on muscular strength and muscular endurance (Wolfe & Weissgerber, 2003b). While physical fitness can be regained in the postpartum period, women face a change in lifestyle and there now exists new barriers to exercise that may limit this. 2.4 Summary: Maternal Age, Health Literacy, and Physical Fitness Health literacy levels reflect an individual’s ability to utilize health information to maintain their own basic health and make appropriate health decisions. With trends showing an increase in average maternal age, coupled with a decrease in women’s health status, Canadian mothers are not only older, but less fit compared to several decades ago. In a general population, there is a positive correlation between health literacy levels and specific health outcomes (e.g., there is a decrease in the prevalence of diabetes and high blood pressure with higher levels of health literacy). However, the relationship between health literacy and health outcomes may not hold for mothers with young children. With a change in lifestyle, and new barriers to engage in exercise, mothers in the early parenthood years may not achieve optimal levels of health-related physical  29 fitness. To-date, examining the relationship between health literacy and maternal age in the early years of motherhood has received scant attention. Therefore, investigation is warranted given the importance of this phase in a women’s lifespan for long-term health and well-being.  30 3.0 CHAPTER THREE Extended Review of Literature: Secondary Research Objective  A second purpose of this investigation was to examine the relationship between maternal health literacy and health-related physical fitness on child motor development and home affordances. As such, the purpose of this chapter was to present literature pertaining to the development and importance of fundamental motor skills to lifelong physical activity behaviour. In addition, early childhood motor development is discussed in relation to the effect of the toddler’s environment in general, and on home affordances specifically. In this document, a toddler refers to a child who is between the chronological age of 18 and 36 months.  3.1  Physical Activity of Toddler-Aged Children Physical activity is integral to many aspects of physical growth and motor  development during the early childhood period. Physical activity affects social, cognitive, and physical development. The act of physical movement facilitates an increase in muscular strength, muscular endurance, and cardiovascular endurance. The dynamics of being physically active also stimulates cognitive and social development. For example, the ability to utilize visual cues, proprioception, and auditory senses during physical activity enhances cognitive development. Additionally, physical activity facilitates the development of balance and  31 coordination, both of which are critical to the acquisition and performance of motor skills. Psychosocial aspects of play, including playing with others or playing independently, can affect a toddler’s sense of autonomy by feeling confident in the capability to accomplish tasks; as well as facilitate the acquisition of social dynamics, such as taking turns. During the toddler period, the term physical activity is often used interchangeably with active play. Active play is the spontaneous, unstructured gross body movements that children engage in during play. Active play can emerge in either structured (or organized) activities (e.g., swimming class) as well as in unstructured play (e.g., time spent at a playground). Both structured and unstructured activities play important roles in a child’s level of physical activity and provide important opportunities for motor skill development. Motor, perceptual, and cognitive development all interact and thus, contribute to a child’s motor development (Diamond, 2000; Thelen & Smith, 1994). Many factors influence a toddlers overall level of physical activity. Biological, psychosocial, and environmental aspects will all interact to influence children differently. Examples of biological factors include age, sex, Body Mass Index (BMI), and family risk of obesity. Environmental influences include physical constraints such as the size of available play space and access to parks perceived as safe, types of toys available to play with, as well as enrolment in preschool or child care programs. Examples of psychosocial factors include the amount of encouragement and discouragement that a child receives, the amount  32 of physical activity that parents engage in, as well as gender differences (Timmons, 2005). From a young age, a child will develop early patterns of physical activity behaviour that continues throughout their childhood and adolescence (Timmons, 2005). Therefore, multiple factors contribute to a child’s motor development. 3.1.1  Motor Skill Development  Motor development is a critical factor in a child’s overall development. A number of theories discuss the progression of motor skill development, the importance of interaction with one’s environment, and its role in influencing readiness (i.e., reaching a stage in development, whereby the system is ‘ready’ or has the capacity to learn). As described by Gallahue (2002), motor development can be described as a progression through four hierarchical phases. The initial movements of an infant are reflexive in nature, then transition through three phases of voluntary movements: rudimentary, fundamental, and specialized motor skills. Each phase progresses into more mature, coordinated movements. Initial reflexive movements (involuntary physical responses to stimuli) may serve as a foundation for the development of future motor skills (Zelazo, 1983). For example, the stepping reflex is triggered when an infant is held in an upright position with his or her feet on a surface. The infant’s subsequent response is to lift his or her legs as if stepping. It has been postulated that the stepping reflex serves as a foundation for gross voluntary rudimentary movements such as walking (Zelazo, 1983). When an object (such as an adult’s finger) is placed in the palm of a young infant, (s)he will exhibit a  33 triggered response and grasp onto this object. It has been suggested that this palmar grasp reflex serves as a foundation for the development of rudimentary movements involving object manipulation such as reaching and grasping. Although this is an area still open to debate, there are many proponents who support the idea that reflexes (such as locomotor reflexes) serve as a foundation for future voluntary movements. The initial voluntary movements that emerge in the first year of life are rudimentary in nature. While the age at which children obtain each skill will vary, most follow a universal, predictable sequence. They include such gross locomotor movements as creeping, crawling, and early phases of independent walking (Werry, Carlielle, & Fitzpatrick, 1983). Growth typically occurs in a cephalocaudal (head to feet) and proximodistal (from center of the body outward). Motor development also progresses in a similar manner. For example, children gain control of their upper limbs before their lower limbs, or children will learn to sit and stand before they can begin to walk. The rudimentary phase is essential for further maturation and attainment of fundamental motor skills. The fundamental movement phase begins during the toddler period. Fundamental motor skills classifications include generally: nonlocomotor (e.g., stretching, bending, twisting, swaying, turning, and balancing), locomotor (e.g., walking, running, skipping, galloping, sliding, and leaping), and manipulative (e.g., hitting, kicking, striking, dribbling, catching, and throwing) skills. Fundamental motor skills have specific, observable patterns which may develop into more mature, coordinated movements. Skills can be qualitatively described  34 along a continuum of phases. For example, fundamental motor skills can be described according to three stages: initial, elementary, and mature; with specific, distinguishable movement characteristics for each stage. Most importantly however, is that the development of fundamental motors skills is not an innate process. Appropriate environmental stimulation plays a critical role for optimal development during the early years. Opportunities to engage in large, gross body movements will affect a child’s development of fundamental motor skills (Diamond & Hopson, 1998). Movement opportunities will also further the development of specialized movement skills. Development of specialized movement skills depends on the ability to combine multiple fundamental motor skills in a more complex, specialized manner. That is, skills required in games, sport, or dance are combinations and sequences of basic fundamental motor skills. For example, dribbling around an opponent and kicking the ball in soccer, or twisting, jumping, and balancing in dance are sequences of fundamental motor skills. The fundamental movement phase is an important period for developing high proficiency in movements. 3.1.2 Critical Periods of Development A critical period of development, or window of opportunity, refers to a limited time period in which an individual must learn a particular task in order for development to be optimized. To acquire basic motor movements, it is suggested that this window opens in utero and continues to approximately 5 years of age (Gabbard, 1998). If the appropriate stimuli do not occur during the critical period, it will be more difficult to acquire proficiently later in life. In essence, the window  35 of opportunity narrows and the potential for optimizing one’s development is lost (Gabbard and Rodrigues, 1998). These periods are important because experience serves as the foundation for the establishment of brain circuitry dedicated to motor control (Gabbard, 1998). For example, motor circuits to the cerebellum forge during the first two years, which are essential for posture and coordination (Gabbard, 1998). For a child, the best possible learning opportunities (appropriate stimuli) during critical periods are essential to achieve optimal development. Critical periods also relate to sensitive periods, which are periods when systems are especially receptive to stimulation. The difference between the two concepts is subtle, but a sensitive period refers to times when individuals are particularly receptive to stimuli and interactions, whereas critical periods are opportunities to facilitate development (given the appropriate experiences) while the individual still possesses a level of plasticity. Both concepts depend on the concept of ‘readiness’, wherein a child cannot learn a new skill unless the appropriate cognitive, physical, and emotional skills are in place. A child’s readiness is largely affected by the surrounding environment and the developmental opportunities presented to the child (Newell, 1986). During critical and sensitive periods, each experience and associated movement skill a child learns helps him/her become ready for the next stage of development.  36 3.2  The Ecological Perspective The ecological perspective encompasses the theory and research involving  human development and the surrounding environment – the social, physical, and psychological (Tudge, Shanahan, & Valsiner, 1997). Two theorists have contributed significantly to this field of study, Urie Bronfenbrenner and James Gibson. Considering a child’s surrounding environment, Bronfenbrenner (1979) proposed five environmental systems that interact to influence a child’s development (Figure 3.1). The smallest system, the micro-system, is the setting in which the child lives and is the most influential of the five systems. Next is the meso-system, which refers to the relationship between the micro-system and their context, such as family, school, and peer experiences. The exo-system, refers to indirect social contexts, such as a parents work; while, the macrosystem is related to culture, and includes socioeconomic status and ethnicity. The largest system, the chrono-system, surrounds the exo-system and is identified as events and transitions over one’s lifespan. According to Bronfenbrenner (1979), each system has roles and norms that will be different from one person to the next and depends on a unique set of circumstances. Therefore, the experiences within one family, living in environments with different rules, norms, and expectations, may vary significantly from another family. While each family will differ from one another, the microsystem in which the child lives has the most influence on their development. This suggests the importance of the home environment, and the role of the adult  37  Figure 3.1 Bronfenbrenner Environmental Systems (adapted from Bronfenbrenner, 1979).  responsible for it, for overall optimal development. The fundamental principle underlying this particular ecological perspective is that the individual, environment, and characteristics of the task all interact to influence development. 3.2.1 Dynamical Systems Theory One branch of investigation within an ecological paradigm is the dynamical systems perspective. Dynamical systems theory is based on the principles that the individual body (and systems within it), the environment they are in, and the demands of each task interact to influence development. As development progresses, the systems within the body spontaneously self-organize, in a discontinuous (nonlinear) manner (Thelan & Smith, 2000). Under this dynamical systems perspective, Newell (1986) proposed a Model of Constraints, in which motor development can be examined as a dynamic process involving the interaction between three factors: the individual, the task, and the environment. The interaction between these three factors influences the outcome of the  38 movement, whereby each factor is considered to be a constraint, which can either limit or encourage the development, acquisition, or performance of a movement. A schematic of Newell’s Model of Constraints is represented in Figure 3.2  Figure 3.2 Newell's Model of Constraints (adapted from Newell, 1986).  Individual constraints are made in reference to those constraints found within the body and can be classified as either structural or functional in nature. Structural constraints are related to body structure, such as physical height or body mass, whereas a functional constraint relates to an individual’s behaviour, such as attention or motivation. In contrast, environmental constraints are constraints that influence an outcome from outside the body, such as a physical constraint (e.g., type of surface) or a sociocultural constraint (e.g., gender roles). An environmental constraint does not include constraints related to the task itself;  39 rather, there is a separate category referred to as task constraints that are specific to the task or activity being performed (e.g., specific rules of the task and equipment used). Collectively, the interactions between these constraints influence what movement will result. That is, this interaction will either encourage the emergence of a particular movement or discourage its emergence. Rate limiters, are individual constraints of one or more systems within the body, which limit the development of a particular motor skill. For example, before a child can master the skill of sitting unassisted, many systems within their body must attain a certain level of development. This involves such systems as the musculoskeletal system, in which a minimum level of postural (muscular) strength must be present, as well as muscular endurance to hold the position. A child must not only have the motivation to try, but the neurological systems for balance and coordination must also be developed; all necessary systems must be present for the emergence of the skill (Haywood & Getchell, 2001). 3.2.2 Perception-Action Theory The second branch of the ecological perspective, relates human development in terms of an individual’s perception to his or her action. According to this perspective, actions are intentional and purposeful, and will be affected by the environmental context (Adolph & Berger, 2006; Adolph & Berger). For example, consider an infant learning to walk: the goal may be to walk to their mom, but this action will be influenced by the environment they are executing the task in (e.g., distance to walk, type of surface). Environmental affordances (possibilities for action) are deeply rooted to this perspective.  40 3.2.3 Environmental Affordances An affordance refers to the structure of the environment (objects and events) and the opportunity it provides an individual to potentially perform an action. Research has provided evidence about the relationship between various surfaces (affordances) and motor development in the first two years of life; and that both perceptual information (information about the environment perceived by the child and his or her own physical abilities) and social information (encouragement from a parent) will influence motor actions (Tamis-LeMonda et al., 2008). For example, walking infants are more likely to attempt to cross a slope if they are encouraged by their mother, if there is a toy, or if there is a food incentive, compared to those that do not receive social encouragement (Adolph, Tamis-LeMonda, Ishak, Karasik, & Lobo, 2008). Further, more experienced walkers avoid risky slopes more often than novice walkers, suggesting better judgment (Adolph et al., 2008). The size of a play area, the type of flooring, as well as the amount and type of toys available are just a few examples of affordances found in the home. Therefore, a child’s home affordances consist of the possible actions he or she can take based on what is available. A child that spends more time in a large, open play space will have different opportunities to engage in gross motor movements compared to a child that has a smaller play space, or is confined to a sitting position (such as in a stroller). Considering play spaces, hard surfaces versus soft carpet or squishy mats will require different balance skills and muscle recruitment. The availability of toys that encourage physically active play, such as ride-on cars, pushing toys and tunnels, will elicit  41 different activity levels than the availability of books, puzzles, and stuffed animals. While one scenario may not be “better” than another, they will have differential effects on the development of fine and gross motor skills. To date, there is no research examining the effect of maternal age and health literacy on environmental affordances within the home. As discussed in chapter 2, health literacy increases between early to middle adulthood, and women that have children at an older age tend to have higher levels of education. Mothers with higher levels of health literacy and education levels may provide different affordances for their children, either in play space and surfaces, or the type or amount of toys available. This, in turn, may affect a child’s level of motor proficiency and development. From this perspective, the caregiver plays a critical role in providing an optimal, developmentally appropriate learning environment for the child. 3.2.4 Affordances in the Home Environment for Motor Development The Affordances in the Home Environment for Motor Development (AHEMD) is a validated parental self-report research tool to assess the opportunities for motor development in the home during early childhood (Rodrigues & Gabbard, 2009). Two, age-related questionnaires are currently available for administration in homes with children 3-18 months and homes with children 18-42 months. The latter is a good questionnaire that tests several broad aspects of the home environment: outside space (outside surfaces, outside apparatus), inside space (inside space, inside apparatus, inside play space), variety of stimulation (play stimulation, freedom of movements, encouragement of stimulation, daily  42 activities), fine motor toys (replica toys, educational toys, games, construction toys, real materials), and gross motor toys (others, musical materials, manipulative materials, locomotor materials, body exploration materials). The AHEMD has been previously used in other research investigations, for example: assessment of physical activity levels of children in family child care settings (Temple, Naylor, and Rhodes, 2009). The AHEMD has also created a shortened version, and is currently being developed for further use: for content validity in multiple cultural settings (Rodrigues and Gabbard, 2009), and as an infant assessment tool for younger age groups (Cacola et al., 2011). The AHEMD is a good assessment that has been tested for both construct and content validity (Rodrigues, Saraiva, & Gabbard, 2005b). 3.3  Physical Activity Behaviour Development of physical activity behaviours during the toddler period may  also affect a child’s likelihood of activity later in life. A behaviour is a chosen action, therefore a physical activity behaviour is the amount and intensity of physical activity that an individual, parent or child, chooses to engage in. In toddlers, this can be seen in the amount of time and intensity of the active play they engage in. Physical activity behaviours will vary between individuals, although one’s environment will influence greatly activity level.  43 3.3.3 Parental Influence on Physical Activity Parental influence contributes to physical activity of a child. For example, Moore et al. (1991) found that children were 5.8 times more likely to be physically active if both of their parents were active compared to non-active parents. Parental support and facilitation of their children’s physical activity may be a key influence at the toddler age. Young children cannot express interest or intention the same way an older child can and have fewer opportunities to choose their own activities (compared to elementary-aged children). Therefore, parents make these choices and influence greatly the types of activities their child/children are engaged in. Unfortunately, physical activity levels of new parents may be compromised as the demands of parenthood often necessitate major lifestyle changes. For example, women with children exercise 37% less than women without children, but engage in more household activities and activities of daily living (Sternfeld, Ainsworth, and Quesenberry, 1999).There are several ways in which parents can influence a child’s behaviour, such as modeling healthy physical activity patterns themselves, encouraging physical activity in their children, or creating opportunities through structured activities or unstructured free play. 3.4  Measurement of Gross and Fine Motor Skill Development Motor skills can be classified based on certain aspects of the movement. A  common two-dimensional classification system is based on the size of musculature required to complete the movement. Gross motor skills require large muscle groups, such as the large muscles required for crawling and walking;  44 whereas fine motor skills require the activation of smaller muscle units, such as those required when grasping a toy or when writing. Motor development in young children can be assessed in several ways. One common assessment is the PeaBody Developmental Motor Scales, 2 nd edition (PDMS-2), which is a standardized test procedure to assess the fine and gross motor development in young children from birth to 5 years old. It contains 6 subtests assessing: reflexes, stationary abilities, locomotion, object manipulation, grasping, and visual motor integration. The scoring system utilizes a 3 point scale to provide a fine motor quotient, a gross motor quotient, and a total motor quotient, based on normative data from over 2000 individuals (Fewell & Folio, 2000). The PDMS-2 has been shown to possess high levels of both reliability and validity (Wiart & Darrah, 2001). Test-retest reliability and inter-rater reliability on the fine motor skill quotient has been classified as excellent in the literature (r = .84 and.99, respectively) (van Hartingsveldt, Cup, & Oostendorp, 2005). The Peabody Developmental Motor Scale, 2nd Edition, can be used to assess children with or without developmental delays (e.g., delays that often appear in young for date infants) or other neurological conditions (e.g., cerebral palsy). In the present research, the PDMS will be utilized as an assessment tool and administered to typically developing children (Folio & Fewell, 2000). 3.5  Summary: Child Motor Development and Home Affordance  During a child’s early years, rapid and extensive development occurs. A child’s physically active play has a significant role in the development of fundamental motor skills, which serve as a foundation for further development of more  45 specialized movements and lifelong physical activity behaviour. One influencing factor of motor development in general (and in the acquisition of fundamental motor skills specifically) is the environmental affordances that are provided to a child. While investigations have examined the relationship between environmental affordances and motor development (e.g., Adolph, Joh, & Eppler, 2010; Adolph et al., 2008; Berger & Adolph, 2007), the relationship between maternal health literacy, and affordances in the home has not. Mothers with higher levels of health literacy may provide different affordances for their children compared to mothers with lower levels of health literacy (e.g., size of play space; range, type, or quantity of toys available). This, in turn, may influence level of motor development. The lack of research in this area warrants further investigation and is also a focus of the present investigation.  46 4.0 CHAPTER FOUR Health-Related Physical Fitness Between Mothers and Non-Mothers with High Health Literacy Health literacy and health-related physical fitness are important variables affecting health across one’s lifespan. The period of early motherhood is a particularly vulnerable time for changes in one’s health-related physical fitness and subsequent changes on long term chronic disease risk. Due to the changes in lifestyle demands and barriers to exercise, regaining pre-pregnancy levels of fitness is often difficult. The purpose of this investigation was to examine the relation between health literacy and health-related physical fitness of mothers with children between the ages of 18 to 36 months compared to women with no children. Participants were 16 mothers (31.9 ± 3.8yrs) with at least one child between the ages of 18 to 36 months and 15 non-mothers (28.6 ± 5.1yrs). All participants completed a battery of health literacy assessments, the Canadian Physical Activity, Fitness, and Lifestyle Approach, and a questionnaire about their amounts and types of physical activity. While all women had high levels of health literacy, there were significant main effects for push-ups (F(1,27) = 8.058, p = .009), partial curl-ups (F(1,27) = 8.665, p=.007), and vertical jump (F(1,27) = 5.071, p=.033) based on motherhood status whereby nonmothers showed higher performance scores. In contrast, there was a significant main effect for grip strength (F(1,27) = 4.520, p=.043) in which mothers demonstrated higher scores. Non-mothers demonstrated superior performance compared to mothers on many aspects of health-related physical fitness despite similar levels of health literacy. Moreover, mothers did not exhibit fitness levels that were associated with optimal health. 4.1 Introduction Health literacy and health-related physical fitness play an important role for health status across one’s lifespan. Health literacy is an individual’s competency to understand basic health information and to make appropriate health decisions (Parker, Ratzan & Lurie, 2003). It involves such measures as reading ability, prose literacy (related to continuous text, such as a book or newspaper article), document literacy (related to discontinuous text, such as a chart or table, e.g.,  47 nutrition label), and numeracy (one’s ability to understand numbers and mathematical concepts, e.g., calculating medication dosages). One’s level of health literacy is related generally to education, whereby individuals with more education demonstrate a higher level of health literacy (Canadian Council on Learning, 2007). Moreover, the acquisition of skills of literacy is shown to increase with age peaking generally between 26 to 35 years, then gradually decreases (Canadian Council on Learning, 2007). The attainment of literacy skills is important, as individuals with higher health literacy demonstrate better health status (Weiss, 2005). Despite as association between these variables, recent findings suggest that an estimated 60% of Canadian adults possess low levels of health literacy which as not sufficient to maintain optimal health(Canadian Council on Learning, 2007), which is similar when compared to data from the United States (National Center for Education Statistics, 2005). These levels are low and represent a significant issue within contemporary society. In Canada, along with other developed countries, there is a shifting trend toward older maternal age (Luke and Brown, 2007). Further, women that have children at an older age tend to attain higher levels of education and have higher average household incomes in comparison to women that have children at a younger age. Therefore, women that have children at an older age are more likely to possess higher levels of health literacy. However, it is not known how health status differs for mothers during the period of early motherhood compared to non-mothers amongst women with high levels of literacy.  48 A key factor in determining health status is health-related physical fitness, which considers such components as body composition, cardiovascular fitness, and musculoskeletal fitness. These components are important for achieving optimal health and minimizing risk for disease. For example, a minimal level of musculoskeletal fitness is essential to perform activities of daily living (ADL). Activities of daily living refer to basic self-care tasks such as personal hygiene and feeding, as well as tasks for independent living (i.e. housework and preparing meals). Importantly, muscular strength decreases with increasing age, therefore having a higher level of strength in early adulthood (20’s and 30’s) will allow an individual to maintain functional independence for longer (Warburton et al., 2001). However, Canadian women currently demonstrate lower levels of health-related physical fitness than in previous decades (Mason, 2007). These decreasing levels represent another significant health issue within contemporary society. A method to increase health-related physical fitness is through increased level of physical activity (e.g., amount or intensity of physical activity). However, the early years of parenthood, especially for women, is a particularly vulnerable period, whereby new barriers to physical activity participation now exist. For example, lack of available childcare, increased constraints on time, and changing priorities to caring for one’s child all represent barriers to engaging in physical activity (Hamilton & White, 2010a). Research has also shown that women with children engage more frequently in activities of daily living, which are at lower intensity levels than planned exercise (Sternfeld et al. 1999; Wolf and Davies,  49 2003). Consequently, the change from one’s pre-pregnant to postpartum lifestyle may reduce the amount and type of physical activity a woman engages in. During the period from pre-pregnancy through to postpartum, a woman’s body goes through significant physiological changes. During pregnancy, numerous cardiovascular, muscular and metabolic changes occur (to support normal, healthy fetoplacental growth), which reduces a woman’s capacity to engage in moderate to vigorous intensity exercise (Wolfe & Weissgerber, 2003a). The combination of physiological changes that occur during pregnancy (reduced capacity to exercise), and the reduction or absence of exercise in many pregnant women will lead to a decrease in overall health-related physical fitness levels, irrespective of level of fitness prior to pregnancy (Wolfe & Weissgerber, 2003a). While there are no physiological barriers preventing one from regaining previous physical fitness levels following pregnancy, achieving pre-pregnancy fitness may be a challenge for many women. For example, average self-reported weight retention for a singleton pregnancy is 0.5 to 1.5 kg at one year postpartum compared to pre-pregnancy. However, up to 20% of women maintain 5 kg above their preconception weight at one year postpartum (Rooney, Schauberger, & Mathiason, 2005). Evidence also shows that 45% of women begin a pregnancy overweight or obese, an increase of 24% from 1983 (Prevention, 2009). Moreover, the risk of long term weight retention and further weight gain increases with each pregnancy, whereby the pregnancy will reduce fitness levels, and in combination with the change in lifestyle demands creates a vulnerable period for women’s health. Thus women with multiple children are at greatest risk for long  50 term gestational weight retention. As a result of the physical and lifestyle changes, regaining physical fitness during early motherhood can be difficult. Independently, the variables of health literacy and health status are important. This is the first investigation to examine the effects of health literacy levels on health-related physical fitness in early parenthood years. The purpose of this investigation was to explore the differences in health-related physical fitness for women with children between the ages of 18 to 36 months compared to women with no children in a cohort of women with high levels of health literacy. We hypothesized that women with non-mothers would have higher levels of healthrelated physical fitness compared to mothers within a cohort of women with high levels of health literacy. The effect of these contemporary issues on women’s health status in early motherhood has not been explored and represents an important research gap. 4.2 Methods 4.2.1 Participants Written informed consent was obtained from mothers with at least one toddler-aged child between the age of 18 and 36 months of age (n = 16) and non-mothers (n = 15). Women with children included both mothers who have given birth to one child, as well mothers who have given birth to more than one child (primipara = 7, multipara = 9, respectively). Both mothers (mean age = 31.9±3.8 y), and non-mothers (mean age = 28.6±5.2 y) were recruited across an age continuum of 20 to 39 years. Mothers were recruited according to two categories: (a) Young Mothers (n = 8), who were 29 y or younger when their first  51 child was born (mean age = 29.3±3.1 y; mean age at birth of first child = 25.5±2.9 y); and (b) Older Mothers (n = 9), who had their first child at the age of 30 or older (mean age = 34.6±2.2 y; mean age at birth of first child = 31.6±1.6 y). All women possessed proficiency in English. Women who were currently pregnant, had a child under the age of 6 months, were in poor health (i.e., illness), or were unable to provide documented clearance to participate in physical activity (in accordance with CPAFLA pre-screening procedures) were excluded from participation. The investigation was approved by and completed in exact accordance to the guidelines set forth by the University of British Columbia’s Research Board of Ethics for research involving human participants. 4.2.2 Assessment of Health Literacy A health literacy battery was administered, which included: the Newest Vital Sign (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM), and the Test of Functional Health Literacy in Adults (TOFHLA). 4.2.2.1  Newest Vital Sign  The Newest Vital Signs (NVS) was administered to assess the general literacy constructs of prose literacy, numeracy, and document literacy, as applied to health information. Participants were asked to read a nutritional label of an ice cream container, and then asked to answer correctly 6 questions. Although there is no set time limit to complete the test, the NVS is designed to be administered in less than 5 minutes. A total score between 0 and 6 was recorded with higher scores representing a higher level of health literacy (score of 0 to 1 = limited literacy; score of 2 to 3 = limited literacy; score of 4 or greater = adequate  52 literacy). The NVS has been shown to be reliable (Crombach  = 0.76) in English (Weiss, 2005), and has also shown high sensitivity for detecting limited literacy (Osborn et al., 2007). 4.2.2.2  Rapid Estimate of Adult Literacy in Medicine  The Rapid Estimate for Adult Literacy in Medicine (REALM) was administered to estimate grade level reading ability. The REALM is a short screening tool, comprised of 66 medical words, separated into 3 lists. The words are arranged in ascending order of increasing difficulty and number of syllables. Participants were asked to orally read the words on the list, at a rate of 5 seconds per word. The raw scores for number of correctly pronounced words were recorded for a total possible score of 66, which was then used to estimate grade reading range. Higher scores reflected a higher level of estimated reading ability. The REALM test shows excellent concurrent validity, as demonstrated with high correlations to longer tests of reading ability (SORT-R, 0.96; PIAT-R, 0.97; WRAT-R, 0.88) (Murphy, Davis, Long, Jackson, & Decker, 2003). The test-retest reliability of the REALM is 0.99 (Davis, 1993). 4.2.2.3  Test of Functional Health Literacy in Adults  The Test of Functional Health Literacy in Adults (TOFHLA) was administered as a measurement of functional literacy. The TOFHLA contains 67 questions consisting of 50 reading comprehension items and 17 numeracy items. The TOFHLA demonstrates good correlation with a longer test of reading ability (WRAT-R, 0.74) (Parker et al., 1995). To determine reading comprehension, participants were asked to read sentences that represented medical instructions  53 that might be seen in a hospital setting. For each sentence, one or more words were missing and the individual was required to select the word that correctly completed the sentence from 4 options. For numeracy, participants were provided with prompts such as fake prescription bottles and asked oral questions about the content of the information provided on the prompt. Each question was scored as 1 for correct or 0 for incorrect; the numeracy scores were weighted to obtain a score out of 50, for a total score of 100. This provided a total score that was associated with one of three categories of functional literacy: inadequate (score of 0 to 59), marginal (60 to 74), and adequate (75 to 100). Participants were provided 22 minutes to complete the TOFLA. 4.2.4 Assessment of Health Related Physical Fitness Participant’s level of health-related fitness was assessed using the Canadian Physical Activity, Fitness, and Lifestyle Approach (CPAFLA) and administered by a Canadian Society for Exercise Physiology-Certified Exercise Physiologist® (CSEP-CEP). The test included pre-screening, followed by measurements of health-related physical fitness, including: body composition, aerobic fitness, and musculoskeletal fitness. The CPAFLA was administered in a 60 to 90 minute time period. 4.2.4.1 Pre-screening Each participant was pre-screened in accordance to the CPAFLA protocol which included: administration of the Physical Activity Readiness Questionnaire Plus (PAR-Q+) (Warburton et al., 2011), subjective observation, measurement of resting heart rate (bpm), and resting blood pressure (mmHg). Resting heart rate  54 and blood pressure were recorded after 5 minutes of rest, using a research grade BPTru Automated Blood Pressure Machine (BPTru Medical Devices, Coquitlam, BC) on the left arm. 4.2.4.2 Healthy Body Composition Body composition was calculated based on Body Mass Index (BMI, kg/m 2), waist circumference (cm), and the sum of 5 skin folds (mm). Height was measured to the nearest 0.5 cm with the participants shoes removed using a wall mounted Tanita stadiometer (Tanita Corporation of America, Inc., Arlington Heights, Il). Weight (kg) was assessed on a research grade, Seca electronic scale (Seca North America, Chino, CA), with the participants’ shoes removed and wearing only light clothing. The ratio of body weight to height was then used to calculate BMI. Waist circumference was measured with an anthropometric tape placed midway between the iliac crest and lower rib cage (cm), to the nearest 0.5 cm. Skin fold measurements were taken according to CPAFLA protocol, on the right side of the body. Triceps, Biceps, Subscapular, Iliac Crest and Medial Calf sites were measured twice using skin calipers and a mean value for each location was recorded. 4.2.4.3 Healthy Aerobic Fitness Aerobic fitness was assessed via the Modified Canadian Aerobic Fitness Test (mCAFT) following the step test protocol. Participants were asked to complete at least one, three minute stage of predetermined step speeds, according to their age and gender. After each stage, immediate post exercise heart rates were recorded. Successive stages had an increased cadence and participants  55 continued completing stages until their heart rate reached 85% of their agepredicted maximum heart rate. Other criteria to stop the test included: inability to maintain cadence, reports of dizziness, chest pain, or noticeable staggering. An aerobic fitness score was obtained using the following equation: 10 x [17.2 + (1.29 x O2 Cost) – (0.9 x wt (in kg)) – (0.18 x age in years)] (CSEP, 2003). The results of the level attained for each participant, and the aerobic fitness score was recorded. 4.2.4.4 Healthy Musculoskeletal Fitness Musculoskeletal fitness was measured by a combination of 6 assessments: combined grip strength (kg), maximum push-ups, sit and reach (cm), partial curlups, vertical jump (cm), peak leg power (watts), and back extension (s). Grip Strength: Participants were asked to squeeze an Almedic hand dynamometer (Almedic, St. Laurent, QB) with maximal effort. Measures were repeated twice for both hands. Values for grip strength were recorded (in kg) for each trial and a total score determined by taking the sum of the highest value for both the left and right hand. Push-ups: Participants were asked to complete as many push-ups as possible. Participants started with their legs together and knees on the ground, and their arms extended with their hands underneath their shoulders. Participants were instructed to complete as many push-ups as possible in succession, without pausing for a rest. The number of push-ups completed with correct form was recorded.  56 Sit and Reach: Sit and Reach scores were measured using a standard flexometer with shoes removed. Participants had an opportunity to stretch their hamstring muscles prior to completing the sit and reach. Once stretched, participants were asked to align their feet flat against the flexometer and place their index fingers on the slider, then stretch as far as possible without bouncing for two trials. Values of both trials were recorded and the furthest distance reached (cm), was used for statistical analysis. Partial Curl-ups: Laying supine with knees at 90° and feet flat on the floor, participants were asked to execute as many 10 cm curl-ups in succession as possible in one minute, at the speed of 50 beats per minute. The total number of partial curl-ups completed at the correct cadence was recorded. Vertical Jump: Participants were asked to jump as high as possible from a semi-squatted position (knees bent to 90°, arms extended) using a Vertec Jump Apparatus (Sports Imports, Columbus, OH), to record jump height (cm). Participants were provided three trials, and the highest value was used for statistical analysis. Back Extension: Participants were asked to hold their upper torso in a prone horizontal position for as long as possible, up to a maximum of 180 seconds. The participants hips and legs were supported on a bench and they were required to hold their torso stabilized while suspended over the ground. The total time (in seconds) was recorded.  57 4.2.5 Background Questionnaire Background information for the participants was collected via an online survey. The questionnaire collected such participant information as: education level, marital status, household income, number of children, general health, perceived importance exercise and self-reported frequency of physical activity, and barriers to exercise. 4.2.6 Procedure After providing informed consent and completing the pre-screening for physical activity readiness (PAR-Q+, www.healthandfitnessjournalofcanada.com) each participant completed the health literacy test battery, followed by the CPAFLA, and the online background questionnaire. 4.2.7 Statistical Analysis A 2 (Motherhood status: nullipara, primipara or multipara) x 2 (Age: younger, older) between-groups ANOVA was conducted for each health literacy assessment and fitness test. The relationship between each dependent variable of health literacy (NVS, REALM, TOFHLA), and each dependent variable of the CPAFLA (healthy body composition, aerobic fitness, musculoskeletal fitness) was investigated using a Pearson product-moment correlation coefficient analysis. The level of significance was set a priori at p < 0.05. All figures are reported as mean ± SD. 4.3  Results  4.3.1 Participant Characteristics  58 The participant demographics for marital status, education, ethnicity, income, employment status, and current work hours are summarized in Table 4.1. The majority of the sample was Caucasian (86%), while 87% of women were considered to be well-educated with a college or university education. Seventyfive percent of participants reported the total amount of physical exercise and activities of daily living (min/week) they completed (Table 4.2). Physical exercise was described as light intensity, moderate intensity, or vigorous intensity. 4.3.2 Health Literacy 4.3.2.1 Newest Vital Sign (NVS) All participant groups were categorized as having adequate health literacy scores. There were no statistically significant main effects based on age or motherhood status and no interactions were found. 4.3.2.2 Rapid Estimate of Adult Literacy in Medicine (REALM) There were no statistically significant main effects for age or motherhood status between groups for the REALM. All groups were categorized with the highest possible reading level, which was a 9th grade reading ability. 4.3.2.3 Test of Functional Health Literacy in Adults (TOFHLA) There were no statistically significant main effects for age or motherhood status on the TOFHLA. Statistics were compared for total scores, as well as individually for numeracy (weighted) and reading comprehension. All groups were categorized as having ‘adequate’ health literacy, which was the highest possible rating.  59 Table 4.1 Participant Demographics Marital Status (n) Single Married Common-law Undisclosed Education (n) High School Diploma College Diploma University Undergraduate Degree Masters (or equivalent)  Women without Children 15 (48.4%) 15 7 (46.7%) 2 (13.3%) 4 (22.2%) 2 (13.3%) 14 1 (7.1%) 3 (21.4%)  Women with Children 16 (51.6%) 16 1 (6.3%) 7 (43.8%) 7 (43.8%) 1 ( 6.3%) 16 3 (18.8%) 7 (43.8%)  7 (50.0%)  5 (31.3%)  3 (21.4%) 0 (0%) 0 (0%)  0 (0%) 1 (6.3%) 1 (6.3%)  PhD (or equivalent) Other* Ethnicity (n)  14  Asian Other** Undisclosed Income  13  $10-$25,000 $25,000-$50,000 $50,000-$75,000  8 hours or less 8-16 hours 17-24 hours 25-32 hours 33-40 hours >40 hours  13 (86.7%) 1 (7.1%) 1 (7.1%) 0 (0%) 15 0 (0%) 0 (0%) 2 (13.3%) 5 (33.3%) 8 (86.7%)  2 (15.4%) 2 (15.4%) 1 (7.7%) 3 (23.0%) 4 (30.8%)  <$10,000  >$75,000 Employment Status Currently in the workforce Does not work Current Work Hours/Week  15 12 (85.7%) 0 (0%) 1 (7.1%) 1 (7.1%)  Caucasian  13  15 10 (76.9%)  10 (66.7%)  3 (23.1%) 10  5 (33.3%) 10  1 (10.0%) 1 (10.0%) 1 (10.0%) 0 (0.0%) 2 (20.0%) 5 (50.0%)  * Other education was specified as one year certificate program (Special Education Assistant) ** Other ethnicity was described as (1) European decent, and (2) mix of Asian and Caucasian  1 (10.0%) 0 (0%) 2 (20.0%) 2 (20.0%) 3 (30.0%) 6 (20.0%)  60  Table 4.2 Amount and Type of Physical Activity and Activities of Daily Living (ADL) Per Week  Non-Mothers  Mothers  (n=12)  (n=12)  Minutes of physical exercise  763.3 ± 451.6  556.6 ± 506.3  Minutes of ADL  961.3 ± 1009.2  722.1 ± 583.0  Minutes of light intensity exercise  441.7 ± 316.5  465.4 ± 343.6  Minutes of moderate intensity exercise  962.5 ± 950.8  619.6 ± 566.4  Minutes of vigorous intensity exercise  285.4 ± 336.6  154.0 ± 200.8  Type of Physical Activity  Intensity of Physical Activity  61 4.3.3 Health Related Physical Fitness No exercise-related adverse effects occurred during the appraisal of healthrelated physical fitness. During pre-screening, one participant answered “yes” on the PAR-Q+ and did not proceed with further assessments. One participant exhibited high blood pressure readings (greater than 160/90 mmHg) and was excluded from participation. Two women declined to participate in the measurement of waist circumference and skinfolds. One participant chose to stop the mCAFT because of problems maintaining cadence, even with assistance. 4.3.3.1 Physical Characteristics and Body Composition The general physical characteristics of the participants are illustrated in Table 4.3. The mean BMI scores for the younger and older non-mothers was 23.4±4.6kg/m2 and 22.3±3.4kg/m2, respectively, which corresponded to a normal body composition classification (WHO, 1995). In contrast, the mean BMI of mothers was 25.2±3.7 kg/m2 and 27.0±5.6 kg/m2 for the younger and older women, respectively, which would both be classified as overweight. However, the Body Mass Index (BMI) scores were not statistically significant, F(1,27) = 3.864, p = .06 for motherhood status, but there was a partial eta squared of .125, indicating a large effect size. There was no significant main effect for age. 4.3.3.2 Musculoskeletal Fitness Several musculoskeletal differences were observed based on motherhood status. The nullipara participants displayed superior performance in comparison to mothers on several health-related tests of physical fitness. Analysis revealed a  62  Table 4.3 Participant Physical Characteristics  Non-Mothers (n=15)  Measure  Mothers (n=16)  Weight (kg)  62.1  ±  10.9  70.7  ±  16.7  Height (m)  1.6  ±  0.1  1.6  ±  0.1  BMI (kg/m2)  23.0  ±  4.1  26.1  ±  4.7  Waist Circ. (cm)  75.4  ±  9.9  82.0  ±  13.3  RHR (bpm)  61.3  ±  11.8  68.5  ±  6.9  Systolic (mmHg)  110.3  ±  9.6  114.0  ±  11.2  Diastolic (mmHg)  71.3  ±  10.5  73.8  ±  8.7  63 statistically significant main effect for maximum push-ups (F(1,27) = 8.058, p = .009), whereby the younger and older non-mothers achieved more push-ups compared to both the younger and older mothers. The scores corresponded with health ratings of ‘good’ for the nullipara participants, and ‘needs improvement’ for the mothers, according to the CPAFLA health benefit ratings. There was no main effect for age. The results for maximum push-ups are shown in Figure 4.1. There was a significant main effect for partial curl-ups (F(1,27) = 8.665, p=.007). Non-mothers demonstrated a greater number of partial curl-ups than the mothers. The results corresponded to health benefit rating scores of excellent and very good for the nullipara groups, respectively; whereas the young and older mothers were classified as ‘good’. There was no main effect for age. The results for partial curl-ups are shown in Figure 4.2. Analysis also revealed a significant main effect for vertical jump for both motherhood status (F(1,27) = 5.071, p=.033) and age (F(1,27) =9.923, p=.004), whereby non-mothers achieved higher scores than mothers, and younger women achieved higher scores than older women. These scores corresponded with health rankings of very good for the younger non-mothers, and fair for the younger mothers, older mothers and older non-mothers. The results for vertical jump are shown in Figure 4.3. There were no statistically significant differences for back extension or sit and reach based on motherhood status or age. In contrast, a significant main effect was found for grip strength F(1,27) = 4.520, p=.043, whereby mothers demonstrated higher scores in comparison to  64  Figure 4.1 Push-Up Scores by Age and Motherhood Status. * = significant main effect for motherhood  65  Figure 4.2 Partial Curl-Up Scores by Age and Motherhood Status * = significant main effect for motherhood  66  Figure 4.3 Vertical Jump Scores by Age and Motherhood Status * = significant main effect for motherhood, ** = significant main effect for age  67  non-mothers. The younger and older mothers both scored very good. The younger non-mothers were also very good, while the older mothers were classified as good. Grip strength results are shown in Figure 4.4. 4.3.3.3 Aerobic Fitness Non-mothers significantly outperformed mothers with respect to aerobic fitness. There was a significant main effect for aerobic fitness score (F(1,27) = 8.011, p=.009) based on motherhood status. Both the younger (495.2±72.9 ml/kg/min) and older (463.7±73.4 ml/kg/min) non-mother groups performed better than the younger (420.4±66.3 ml/kg/min) and older (389.4±77.4 ml/kg/min) mother groups. These corresponded to health ratings of very good for both nonmother groups, and good for the mother groups. There was no significant difference for aerobic fitness based on age. Scores for each group are summarized in Figure 4.5. 4.4  Discussion  This is the first investigation to explore the variables of maternal health literacy and health-related physical fitness in early motherhood. Approximately 60% of Canadian adults have low levels of health literacy (Canadian Council on Learning, 2007). Health literacy is an individual’s ability to understand and use basic health information to maintain his or her own health and make appropriate health decisions (Parker, Ratzan & Lurie, 2003). However, it is not known how health literacy affects women during the period of early motherhood. In a cohort of women with high health literacy, does health-related physical fitness differ between mothers and non-mothers? Based on our results, we provide evidence  68  Figure 4.4 Grip Strength Scores by Age and Motherhood Status *= significant main effect for motherhood  69  Figure 4.5 Aerobic Fitness Scores by Age and Motherhood Status * = significant main effect for motherhood  70 that irrespective of high health literacy levels, mothers demonstrate lower levels of health-related physical fitness compared to health literate non-mothers. In this investigation, all participants possessed relatively high levels of health literacy. Despite the high levels of health literacy, not all women demonstrated high levels of health-related physical fitness. The higher than average levels of health literacy was due largely to the homogeneity of the sample population, with education levels higher than the average population (78.6% had at least a college education). The economic status of our participants was more diversified. For example, incomes ranged from less than $10,000 per year to greater than $75,000 per year. However, the women with lower incomes also identified themselves as students. Therefore, their education levels would not reflect normative data for their corresponding economic status. This also means that despite some variance in education and household income, the women in this sample demonstrated similar levels of health literacy. Even with high levels of health literacy, our data revealed significant differences in healthrelated physical fitness between mothers and non-mothers. Previous literature has shown mothers to be less active than non-mothers of a similar age (Bellows-Reicken and Rhodes 2007). These results show mothers to be less fit that non-mothers of a similar age. Considering the homogeneity of the participants in regards to health literacy, the outcomes of the health-related physical fitness assessments may be indicative of the changes due to motherhood status. Notably, the mean time since giving birth was 30.6 months for all mothers, which is significantly past the postpartum period during which  71 exercise is restricted and women are advised to gradually increase physical activity (Wolfe & Weissgerber, 2003a). The mothers in our sample were on average 30 months past childbirth. Therefore, there should be no physiological barriers to participating in exercise and achieving optimal levels of health-related fitness as a result of the pregnancy itself. Typically, individuals demonstrating higher levels of health literacy are also more likely to exhibit better health (Canadian Council on Learning, 2007). Despite having high levels of health literacy, mothers still showed lower levels of health-related physical fitness. Results indicated a trend in which non-mothers had lower BMI’s and a better health classification (normal weight compared to overweight classification) compared to mothers. Body composition is important because it is a strong predictor of health risk, and excessive body fat increases one’s chance of premature death due to chronic diseases (Katzmarzyk, 2003). Despite this variable not reaching significant levels based on motherhood status, possibly due to lack of power (F(1,27) = 3.864, p=.06), the partial eta squared (.125) indicated a moderate to large effect size. This means that motherhood status has a moderate effect on the variance of BMI scores. However, a limitation of this investigation is sample size. Irrespective of statistical significance, this trend in the data is important because individuals with higher BMI values are at higher risk for chronic diseases (such as coronary artery disease, stroke, and type two diabetes) (Warburton et al., 2006). Our results also showed a trend towards increasing waist circumference based on motherhood status, with non-mothers having lower scores than mothers (F(1,27) = 2.691, p=.11). However, not all  72 participants were comfortable completing all the body composition analysis and two women chose not to have their waist measured following the weight assessment. These were all mothers with overweight BMI classifications. Therefore the mean waist circumference scores recorded did not reflect all participants and the results may have reached significance if all possible data was recorded. The partial eta squared for this effect size was .091, indicating a moderate to large effect size. Despite a lack of statistically significant differences for body composition, the results indicated moderate to large effect sizes based on body mass index and waist circumference. Women that do not return to a healthy body weight within 6 months postpartum are at significantly higher risk for chronic diseases (i.e. cardiovascular disease, obesity, metabolic syndrome) compared to women that reach a health body weight (Davenport, Girous, Sopper, & Mottola, 2011). A recent investigation showed that a postpartum exercise intervention targeting weight loss improved chronic disease risk factors compared to women that did not receive the intervention, regardless of exercise intensity (Davenport et al., 2011). A larger investigation including a greater range of health literacy levels may indicate the extent to which health literacy is related to body composition in early motherhood. Mothers scored significantly lower compared to non-mothers on maximum push-ups, partial curl-ups, jump height, and aerobic fitness. These differences are important as these assessments are linked to health outcomes. The scores for push-ups suggested the non-mothers musculoskeletal fitness was within a  73 range associated with health benefits. However, the mothers scores fell within a range that was associated with health risks. This means that non-mothers may have a ‘protective’ effect on their health due to their higher levels of musculoskeletal fitness, while mothers may be at an increased risk. Push-ups are relevant because they reflect the muscular strength and endurance of the triceps and shoulder muscles. The partial curl-up scores of mothers reflected good fitness; however the nonmothers outperformed both groups and demonstrated scores that were associated with greater benefits. Partial curl-ups reflect the muscular strength and endurance of the abdominal muscles. Both push-ups and partial curl-ups are important for repetitive tasks and for activities of daily living. Similarly, the younger non-mothers outperformed all other groups for jump height scores, with health ratings of very good compared to fair for the older nonmothers, and both age groups of mothers. Vertical jump reflects the muscular strength of the quadriceps, and is associated with mortality risk, and life expectancy (Newman et al., 2006; Rantanen, 2003). Importantly, quadriceps strength is essential for activities of daily living, such as getting into and up from a chair. Individuals with higher levels of quadriceps strength are at a reduced risk of injury and mortality as they age. Collectively, the mothers have a poorer average score on multiple health-related musculoskeletal fitness outcomes, suggesting they are at a greater health risk. The difference in grip strength scores between mothers and non-mothers were as anticipated. Grip strength is related to activities of daily living, and is an  74 important component of musculoskeletal fitness and may be predictive of life expectancy and independent living (Metter et al., 2002). As discussed by Sternfeld et al. (1999), women with children engage in physical activity for exercise less frequently than women without children, but do more activities of daily living (Sternfeld, Ainsworth, & Quesenberry, 1999). In addition to regular activities of daily living, mothers’ duties include all aspects of childcare, such as feeding, changing diapers, and soothing their child as they grow from an infant to toddler. Not only does this include lifting and carrying the child, but a mother may also carry the child for periods while tending to other activities of daily living such as household chores. The average weight of the children in our sample was 13.9 kg. The trend for higher grip strength in women with children suggests that changes in lifestyle (i.e., carrying children) may facilitate the development of some areas of muscular strength, and is an important difference between mothers and non-mothers. Non-mothers outperformed mothers with aerobic fitness levels. While the results of the mothers still corresponded with a ‘good’ health rating, non-mothers achieved a ‘very good’ rating. The non-mothers achieved scores that were associated with protective health benefits, which the mothers did not reach. As aerobic fitness reflects the health of the cardiovascular system, this is an important result. A woman’s aerobic capacity decreases during pregnancy as a result of the physiological changes occurring to support the growing fetus. The combination of decreased fitness during pregnancy, and change in lifestyle  75 during the postpartum period and into early motherhood may be contributing factors to the difference in aerobic fitness scores. Across a population, increased health literacy is generally associated with an increased health status. In this investigation, all women had high levels of health literacy; however mothers still performed at significantly lower levels on many aspects of health-related physical fitness. However, what is not known is the relationship between mothers with high literacy and mothers with low literacy on measures of health-related physical fitness. Health literate mothers may still be achieving a higher health status than lower literate mothers. This is an important concept to examine in future research. 4.5  Summary The results of this investigation provide important evidence regarding  differences in health-related physical fitness during the early motherhood period. The results show that women with children are more likely to have lower levels of musculoskeletal strength, musculoskeletal power, musculoskeletal endurance, and aerobic fitness. Clearly, mothers (both younger and older) failed to reach physical fitness levels that are associated with optimal health. Non-mothers, with the exception of grip strength, consistently outperformed mothers, with fitness levels that were associated with greater benefits. Our results provide evidence that women in the early motherhood period may be at higher risk for changes in their health-related physical fitness and possess a greater risk for chronic disease later in life as a result of these changes. Despite having high levels of  76 health literacy, mothers did not demonstrate health-related physical fitness levels that are comparable with non-mothers with similar levels of health literacy.  5.0 CHAPTER FIVE The Influence of Health Literacy in Early Motherhood on Home Affordance and Child Motor Development Mothers have a primary influence on the home environment and the opportunities that it provides a child for movement experiences. One factor that may influence the availability of home affordances is maternal health literacy, whereby health literate mothers may provide environments that afford greater opportunities for child development (vs. those with low literacy). The purpose of this study was to investigate the influence of health literacy on home affordances and motor development. Sixteen mothers (age = 32 ± 4 yr) with a child between 18 and 36 mo completed a health literacy battery (Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA); as well as an Affordances of the Home Environment Motor Development (AHEMD) assessment. The toddler (Age = 31 ± 6 mo) of each mother was assessed for motor development using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2). Results revealed a trend between maternal reading scores (REALM) and greater total variety of stimulation on the AHEMD (r(15)=0.73,p=0.060). Increased variety of stimulation was shown to be positively correlated with locomotion (r(15)=0.88,p=0.008), object manipulation (r(15 =0.95,p=0.001), and visual-motor integration (r(15)=0.85 p=0.015) scores on the PDMS-2. Mothers with higher health literacy levels are more likely to provide home environments that include toys that offer a greater variety in overall stimulation. Moreover, children exposed to a variety of affordances demonstrate more proficient scores on components of motor development. 5.1 Introduction Health literacy (one’s capability to enable, access, comprehend, and utilise health information) plays an important role for health status across one’s lifespan and is a critical factor in the context of parenthood, whereby the parent is responsible for making health decisions on behalf of the child (Sanders, Shaw, Guez, Baur, & Rudd, 2009a). In Canada, along with other developed countries, there is a shifting trend toward older maternal age (Luke & Brown, 2007b). 77  Women that have children at an older age tend to attain higher levels of education and have higher average household incomes. This would also suggest that older mothers are more likely to possess higher levels of health literacy than younger mothers. Importantly, mothers have a primary influence on the structure of the home environment, as well as the movement opportunities provided to the child. Mothers with higher health literacy levels may provide environments that afford greater opportunities for the development of motor skills in early childhood compared to mothers with low health literacy. To-date, there has not been any investigations that examine the relationship between maternal health literacy and the availability of affordances for motor development within the home. A child’s environment is an important factor for motor development in the early years. Specifically, affordances (or possibilities for action) provided to the child in the home environment may affect motor development. Within an environment, both perceptual information (information about the environment perceived by the child and his or her own physical abilities) and social information (encouragement from a parent) will influence motor actions (TamisLeMonda et al., 2008). Based on the perception-action theory, actions are intentional and purposeful, and will be affected by the environmental context (Adolph & Berger, 2006). In other words, both the physical structures of the environment as well as encouragement from parents will influence motor actions. For example, research has shown evidence about the relationship between various surfaces (affordances) and motor development in the first two years of life. For example, Adolph, Karasik, and Tamis-LeMonda (2010) showed that 78  infants (18 mo) responded to social signals from their mom, and were more likely to attempt to walk on a sloped surface if encouraged, and were less likely to attempt to walk if they were discouraged. Another study showed that exposure to shallow and steep slopes led a change in gait patterns (Gill, Adolph, & Vereijken, 2009). Specifically, when infants were repeatedly exposed to movement opportunities (varying slopes), different gait patterns emerged in response to changing slop angles. Social cues from parents, and exposure to varying surfaces is important because a child’s physically active play has a significant role in the development of fundamental motor skills, which serve as a foundation for further development of more specialized movements and lifelong physical activity. Environmental affordances are a contemporary concept, and no research has been conducted including the variable of maternal health literacy. It is important to understand the link between motor development and the home environment (Rodrigues, Saraiva, & Gabbard, 2005a). A home with more physical space to move in and a greater variety of games, toys, and apparatus may elicit different movements than a more restricted space with less variety. However, the relationship between these affordances and motor development remains largely unexplored. One factor that may influence the availability of affordances in the home is maternal health literacy. Mothers with higher health literacy levels may provide differing amounts and types of toys, a greater variety of play spaces, and more encouragement of play compared to mothers with low health literacy. However, research examining the influence of maternal health literacy in this area is limited. 79  Independently, the variable of health literacy is important, however, little is known about the effects on maternal health literacy levels in early parenthood years. The relationship between maternal health literacy and affordances in the home, or the relationship to child motor development has not been investigated. This is the first investigation to examine the effects of health literacy levels on home affordances and motor development in the early parenthood years. The purpose of this investigation was to explore the differences in home affordances and motor development in a cohort of women with a child between the ages of 18 to 36 months. We hypothesized that: (1) women with the highest levels of health literacy would provide home environments with a greater number and type of affordances, and (2), that higher levels of motor skill proficiency in gross and fine motor skills will be exhibited from children with mothers possessing higher levels of health literacy and/or those providing greater affordances within their home environment. Given the significance of health literacy in other areas of child care, this is an important area to explore further. This is part of a larger investigation examining maternal health literacy and health-related physical fitness in early motherhood as presented in Chapter 4. 5.2 Methods 5.2.1 Participants Written informed consent was obtained from mothers with at least one toddler-aged child between the age of 18 and 36 months (n = 16). mothers included both women who have given birth to one child, as well as women who have given birth to more than one child (primipara = 7, multipara = 9, 80  respectively). Both primi- and multipara women (mean age = 31.9±3.8 y) were recruited across an age continuum of 20 to 39 years. All women possessed proficiency in English. Women who were pregnant, had a child under the age of 6 months, or were in poor health (i.e., illness) were excluded from participation. A total of 16 toddlers (n = 7 male, mean age = 29.3±7.3 mo; and n = 9 female, mean age = 31.8±6.8 mo) also participated in the investigation. All toddlers were in good health at the time of the time of data collection and each toddler was selfreported as typically developing by the respective mother. The investigation was approved by and completed in exact accordance to the guidelines set forth by the University of British Columbia’s Behavioural Research Board of Ethics for research involving human participants. 5.2.2 Assessment of Health Literacy A health literacy battery was administered, which included: the Newest Vital Sign (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM), and the Test of Functional Health Literacy in Adults (TOFHLA). 5.2.2.1  Newest Vital Sign  The Newest Vital Signs (NVS) was administered to assess the general literacy constructs of prose literacy, numeracy, and document literacy, as applied to health information (Weiss et al., 2005). Participants were asked to read a nutritional label of an ice cream container, and then asked to answer correctly 6 questions. Although there is no set time limit to complete the test, the NVS is designed to be administered in less than 5 minutes. A total score between 0 and 6 was recorded with higher scores representing a higher level of health literacy 81  (score of 0 to 1 = limited literacy; score of 2 to 3 = limited literacy; score of 4 or greater = adequate literacy). 5.2.2.2  Rapid Estimate of Adult Literacy in Medicine  The Rapid Estimate for Adult Literacy in Medicine (REALM) was administered to estimate grade level reading ability. The REALM is a short screening tool, comprised of 66 medical words, separated into 3 lists (Davis, 1993). The words are arranged in ascending order of increasing difficulty and number of syllables. Participants were asked to orally read the words on the list, at a rate of 5 seconds per word. The raw scores for number of correctly pronounced words were recorded for a total possible score of 66, which was then used to estimate grade reading range. Higher scores reflected a higher level of estimated reading ability. 5.2.2.3  Test of Functional Health Literacy in Adults  The Test of Functional Health Literacy in Adults (TOFHLA) was administered as a measurement of functional literacy (Osborn et al., 2007). The TOFHLA contains 67 questions consisting of 50 reading comprehension items and 17 numeracy items. To determine reading comprehension, participants were asked to read sentences that represented medical instructions that might be seen in a hospital setting. For each sentence, one or more words was missing and the individual was required to select the word that correctly completed the sentence from 4 options. For numeracy, participants were provided with prompts such as fake prescription bottles and asked oral questions about the content of the information provided on the prompt. Each question was scored as 1 for correct or 82  0 for incorrect; the numeracy scores were weighted to obtain a score out of 50, for a total score of 100. 5.2.2 Assessment of Home Affordances The Affordances in the Home Environment for Motor Development (AHEMD) was administered to assess environmental opportunities within the home (Rodrigues & Gabbard, 2009). Mothers were asked to complete the questionnaire, which consists of questions pertaining to: Child Characterization, Family Characterization, Physical Space in the Home, Daily Activities, and toys available within the home. Affordance items were scored according to groups: outside space, inside space, variety of stimulation, fine motor toys, and gross motor toys. For simple questions, each ‘yes’ answer was scored as a single point, and a ‘no’ answer was scored as zero. For questions that asked for the quantity (or availability) of different types of toys, each item available in the environment counted as one point, up to a maximum of 5 points per question. Raw cumulative scores for each group was used for statistical analysis. 5.2.3 Assessment of Motor Development The Peabody Developmental Motor Scales, 2nd Edition (PDMS-2) was administered to assess the level of motor skill development for each toddler (Fewell & Folio, 2000). The PDMS-2 is a standardized test, designed to evaluate both fine and gross motor skills in infants from birth to 71 months of age (Darrah, Magill-Evans, Volden, Hodge, & Kembhavi, 2007). Children were assessed using both the fine and gross motor scales. Each scale consists of multiple sub-tests. The Gross Motor Scale contains 5 different skill categories (reflexes, balance, 83  nonlocomotion, locomotion, and receipt and propulsion of objects); while the Fine Motor Scale has 4 skill categories (grasp, hand functions, eye-hand coordination, and manual dexterity). Each category has an age-specific level, and items are scored on a 3 point scale: 0 (not present), 1 (emerging), and 2 (successful performance of item). 5.2.4 Procedure The investigation consisted of two days of testing. On Day one, the mothers completed the background questionnaire, followed by the health literacy test battery: REALM, NVS, and TOFLHA. This was followed by completion of the AHEMD. On Day Two, the toddlers returned to complete the Peabody Developmental Motor Scale, 2nd Edition under the supervision of their mothers. 5.2.6 Statistical Analysis The relationship between each dependent variable of health literacy (NVS, REALM, TOFHLA), and each dependent variable of the AHEMD and PDMS-2 was analyzed using Pearson product-moment correlation coefficient analysis. The level of significance was set a priori at p < 0.05. All figures and tables are reported as mean ± SD. 5.3  Results  5.3.1 Participants: Mothers Participant demographics for marital status, education, ethnicity, income, employment status and current work hours are presented in Table 5.1. The majority of the sample was Caucasian (87.0%) and well-educated (81.3%).  84  Table 5.1 Participant Demographics Participants (16) Demographics Marital Status (n)  16 1 (6.3%) 7 (43.8%) 7 (43.8%) 1 ( 6.3%)  Single Married Common-law Undisclosed Education (n)  16  College Diploma  3 (18.8%) 7 (43.8%)  University Undergraduate Degree  5 (31.3%)  Masters (or equivalent)  0 (0.0%) 1 (6.3%) 1 (6.3%)  High School Diploma  PhD (or equivalent) Other Ethnicity (n)  15 13 (86.7%) 0 (0.0%) 1 (7.1%) 1 (7.1%) 0 (0%)  Caucasian Mid-Eastern Asian Other Undisclosed Household Income  15 0 (0%) 0 (0%) 2 (13.3%) 5 (33.3%) 8 (86.7%) 0 (0%)  <$10,000 $10-$25,000 $25,000-$50,000 $50,000-$75,000 >$75,000 Undisclosed Employment Status  15 10 (66.7%) 5 (33.3%)  Currently in the workforce Does not work Current Work Hours 8 hours or less 8-16 hours 17-24 hours 25-32 hours 33-40 hours >40 hours  10 1 (10.0%) 0 (0%) 2 (20.0%) 2 (20.0%) 3 (30.0%) 2 (20.0%)  85  5.3.3 Maternal Health Literacy and Home Affordances for Motor Development  Despite the overall high level of health literacy, findings revealed a strong relationship between mother’s reading scores and overall variety of stimulation (r(15)=.735, p=.060). That is, there was a trend in which higher reading scores on the REALM was related to greater total variety of stimulation, including play stimulation, freedom of movement, encouragement activities, and overall daily activities on the AHEMD. Further, higher TOFHLA numeracy scores were positively correlated to the availability of fine and gross motor toys (r(15)=.727, p=.064; and r(15)=.658,p=.108, respectively) in the home environment, in which there was a strong relationship despite not reaching statistically significant values. The availability of fine and gross motor toys based on gender is shown in Figures 5.1 and 5.2.There were no statistically significant differences in the amount or type of toys for toddlers based on gender. 5.3.4 Maternal Health Literacy and Motor Development. Results showed a statistically significant positive correlation between reading scores and object manipulation (r(15)=.775,p=.041). Specifically, increased reading ability (as per the REALM) was associated with higher scores of object manipulation, including kicking and throwing a ball, catching a ball, and hitting a target (on the PDMS-2). There was also a statistically significant relationship between reading ability and visual-motor integration (r(15)=.893,p=.007), in which higher reading scores on the REALM was related to better scores on the PDMS2 visual-motor integration test. That is, higher maternal reading scores on the REALM was associated with improved eye-to-hand coordination on tasks such 86  30  Females  Males  25  Quantity  20  15  10  5  0  Replica Toys  Educational Toys  Games  Construction Toys  Real Materials  Fine Motor Toys  Figure 5.1 Fine Motor Toy Availability by Toddler Gender  87  12  10 Females  Quantity  8  Males 6  4  2  0 Others *  Music Materials  Gross Manipulative Locomotor Materials Body Exploration Materials Materials  Gross Motor Development Toys  Figure 5.2 Gross Motor Toy Availability by Toddler Gender * ‘Other’ category refers to items that do not fall into a specific category  88  as stacking blocks, matching shapes and turning pages on a book. There were no statistically significant differences in fine or gross motor development based on gender of the toddlers. 5.3.5 Home Affordances and Motor Development Findings revealed statistically signification correlations between total variety of stimulation on the AHEMD, and locomotion (r(15)=.883, p=.008), Object Manipulation (r(15)=.949,p=.001) ,and Visual-Motor Integration (r(15)=.853,p=.015) raw scores of the PDMS-2. Higher scores on variety of stimulation were related to higher motor development scores for locomotion, object manipulation, and visual-motor integration. 5.4  Discussion Health literacy is an important variable across one’s lifespan. In general,  individuals with higher levels of health literacy are more likely to demonstrate better health status (American Medical Association, 1999). Importantly, the health literacy levels of parents affect their ability to make appropriate health decisions for their child (DeWalt & Hink, 2009). From the ecological perspective, motor development is strongly affected by the interaction between the environment and social, physical, and psychological stimulus. In the early childhood period, parents play a primary role in the structure of a child’s environment. For example, parents influence the toys and play areas available, they encourage or discourage particular movements and behaviors, as well as play a role in the socialization of the child. Previous research has shown evidence that a greater number of affordances in the environment influences 89  motor development of the child (Adolph, Karasik, et al., 2010; Adolph & Robinson, 2008; Adolph et al., 2008; Berger & Adolph, 2007). For example, walking infants are more likely to attempt to cross a slope if they are encouraged by their mother, or if there is a toy or food incentive, compared to those that do not receive social encouragement (Adolph et al., 2008). Further, more proficient walkers avoid risky slopes more often than novice walkers, suggesting better judgment as a result of their experience (Adolph et al., 2008). To-date, maternal health literacy has not been examined in relation to the amount and type of affordances, and overall variety of stimulation within the home. Our data provides support for the idea that maternal health literacy may play an influential role in the availability of affordances in the home. Data from this investigation suggests that there is a greater variety of movement opportunities provided within the home environment by mothers that possess higher levels of health literacy (in comparison to those with lower health literacy). This includes opportunities for both gross and fine motor activities; thus, offering different movement possibilities compared to mothers with lower levels of health literacy. While all mothers scored high results on the administered health literacy battery, those with the highest scores on reading ability (REALM) also provided greater total variety of stimulation within the home. This is important because total variety of stimulation is a reflection of several activities, including time spent with parents, other adults, as well as other children; as well as variables that include the ability for a toddler to choose their own toys to play with, and wearing comfortable clothes that allow freedom of movement. This 90  findings is also important because variety of stimulation does not necessarily relate to quantity or ‘how much’ is available to the child, but rather highlights the importance of parental interaction in the development of the child. In addition to reading ability, our findings also revealed a relationship between maternal performance in numeracy and availability of toys that encourage fine and gross motor movements. Availability of toys in the environment for fine motor development included toys such as stuffed toys, books, dolls and action figures, puppets, play materials that stimulate adult home activities, puzzles, stacking or nesting toys; while gross motor toys included: auto-propelled toys (ride on cars), swings and twisting toys, balls of different sizes and colours, and throwing targets. Our toddler population included a relatively even mix of male (n=7) and female (n=9) toddlers. Toy availability included both gender stereotyped toys (i.e., feminine-defined = dolls; masculine-defined = action figures) and gender neutral toys (i.e., puzzles). There was no evidence to suggest differences in toy availability, or overall variety of stimulation based on the sex of the toddler. While these particular findings were revealed in the present investigation, this may not be demonstrated in a broader population with a range of health literacy scores and may represent an important direction for further research. Our data revealed that several aspects of the AHEMD was related to motor development as measured by the PDMS-2. Specifically, total variety of stimulation was related to toddlers’ fine and gross motor development, in that stimulation was related to locomotion (such as walking, running, and jumping), object manipulation (such as kicking and throwing), and visual-motor integration 91  (stacking blocks and doing puzzles). Total variety of stimulation encompasses aspects of both physical movement and social interaction. It is not a reflection of how much is available, but rather how much movement is allowed and encouraged, and the interaction with parents, other adults and children. Time spent with adults could include reading books, playing with puzzles, or playing with a toy tool bench, or could include taking a ride on car (auto-propelled) to the yard or nearby park. Newell’s Model of Constraints (1986) describes motor development as a dynamical process based on the interaction of the individual, the task, and the environment. That is, each factor can either limit or encourage the development, acquisition or performance of a movement. Our results support the idea that greater play stimulation is related to greater motor development. This is important because the quality of the environment (as it is related to motor development) is enriched because of the quality of time spent, and not the quantity of toys that are available. A large number of toys does not necessarily mean that a child will develop more proficient motor skills. The participants’ standard scores on the AHEMD were considered adequate or high in regards to quantity of toys available. The questionnaire did not differentiate based on numbers greater than 5 of a particular item. It is possible that there was not enough variety at the lower range to detect differences within this sample. A sample group with broader range of health literacy levels may show differences in number of toys including a broader range of scores, as well as type of stimulation, and overall interaction. The results of this investigation suggest that once a certain quantity of toys is 92  available, overall variety of stimulation and movement opportunities is more important for development than the amount of toys afforded. There were several aspects of the PDMS-2 that did demonstrate a statistically significant relationship to home affordances. Neither stationary gross motor scores, nor grasping fine motor scores were related to the AHEMD. Stationary scores reflected gross motor skills such as balancing on one foot, standing on tiptoes, imitating movements, and sitting up from the mat. These skills may not necessarily be improved by the availability of particular toys, which tend to either elicit gross motor movements (such as a modern walker, or balls). The category of grasping reflected fine motor hand skills. Both male and female toddlers had high number of ‘replica’ toys available (such as dolls, and action figures), but had fewer educational toys, games, and construction toys. There may not have been enough of those types of toys (such as puzzles and shape sorters) eliciting fine motor movements to further develop that particular motor skill. Based on the findings from this investigation, recommendations for an enriched environment would include a combination of stimulation from other adults and children, and a variety of toys. Toys should elicit both fine motor skills (such as puzzles and stacking toys), and gross motor movements (such as balls to throw and toys to push). Importantly though, toddlers should be able to choose which toys to play with, and have access to space to move around in. Appropriate stimulation would include one-on-one time with parents, spending time with other adults, and playing with other children. This could include visiting local parks, community centers, drop in play groups, or daycare facilities. All 93  events would not have to occur in the home, rather the mother could influence which local resources are utilized, or which daycare to attend. Providing more information may be challenging, as individuals with lower levels of health literacy may not be able to accurately interpret and apply. 5.4.3 Summary In summary, health literate mothers provided a greater amount of stimulation and variety of toys within the home environment. Importantly, the variety of stimulation was related to motor development. While the mothers provided more toys and more variety, results indicated it was the quality (time with adults/children, stimulation, that influenced motor development. The results of this investigation provide preliminary evidence highlighting the importance of maternal health literacy and the availability of affordances within the home. Despite all women having high levels of health literacy, those with the highest reading scores were more likely to have greater affordances available to their child. While a greater number of affordances is not necessarily an indicator of an enriched environment, our results also showed that children with a greater number of affordances also exhibited higher scores on various measures of child motor development.  6.0 CHAPTER SIX Conclusion Across ones lifespan, health literacy levels and health-related physical fitness are an important influence on one’s health status. During the early motherhood 94  period, maternal health literacy may be related to health-related physical fitness. That is, mothers show lower levels of performance on several aspects of physical fitness compared to non-mothers with similar health literacy levels. Further, maternal health literacy may influence the home affordances available to their child, which could lead to differences in the development of fine and gross motor skills. To-date, there has been limited investigation examining the influence of maternal health literacy on such issues as health-related physical fitness, home affordances, or child motor development. As such, the purpose of this investigation was twofold. First, an investigation was conducted to examine the differences in health-related physical fitness in a cohort of mothers and nonmothers with high levels of health literacy. Second, additional assessments were completed for the mothers and their toddlers to examine the influence of maternal health literacy on home affordances, and child motor development in early motherhood. 6.1 Health Literacy and Health Related Physical Fitness Individuals, who do not possess higher health literacy, are more likely to have lower fitness levels; and consequently, those with lower health-related physical fitness are at greater risk for lifestyle related chronic diseases such as cardiovascular disease (Warburton et al., 2006). Across Canada, approximately 60% of adults have low levels of health literacy (Canadian Council on Learning 2007). Our results showed that, comparing mothers to non-mothers, mothers demonstrated significantly lower levels of health-related physical fitness (maximum push-ups, partial curl-ups, maximum jump height, and aerobic 95  fitness), but significantly higher levels of combined grip strength. Statistically, the smaller range of health literacy scores limits r values. However, a relationship to health-related physical fitness was seen despite similar levels of health literacy. Therefore, our findings showed that even women with higher levels of health literacy were at risk for lower levels of health-related physical fitness in the period of early motherhood. The CPAFLA provides feedback for results based on associated health risks. That is, lower scores are associated with an increased health risk due to lower levels of physical fitness, while are associated with reduced risks because of more optimal physical fitness. The non-mothers exhibited higher scores that were related to a reduction in health risks because of their higher fitness scores, while the mothers did not. Therefore, even with high levels of health literacy, achieving optimal health-related physical fitness is an obstacle in the period of early motherhood. The trend of differences in BMI reflects the difference in body compositions. Comparing women of similar age and similar levels of health literacy levels, women with children had higher BMI values and therefore, are at a higher risk stratification level. The mean scores of nullipara women corresponded with a ‘normal weight’ classification, versus the BMI of primipara and multipara women, which corresponded to a classification of overweight. This shows that the nonmothers not only have lower BMI values, but also lower associated health-risks. While a woman’s capacity to exercise is reduced during pregnancy, there are no contraindications for a woman presenting with a singleton, uncomplicated pregnancy to engage in low to moderate-intensity exercise during that time. 96  Further, there are no physiological barriers to regaining physical fitness levels following a normal pregnancy; rather, the resulting lifestyle change presents new barriers, both real (e.g., childcare) and perceived (e.g., lack of motivation) that inhibit the attainment of higher physical fitness levels. The results of this investigation (in Chapter 4) highlights the period of early motherhood as a vulnerable time in which mothers have significantly lower levels of health-related physical fitness compared to non-mothers, even when posessing high levels of health literacy. 6.2 Health Literacy and Home Affordances Addressing the secondary research question, our results showed statistically significant correlations between: mothers reading ability and home affordances and mothers reading ability and child motor development. The results presented in Chapter 5 illustrate the relationship between maternal health literacy on important aspects pertaining to child motor development. Within the first 3 years of life, a toddler goes through a large amount of motor development, which is strongly influenced by the environment. Parents have a primary influence on the child’s environment, influencing the home, toys and play areas available in it, encouragement and discouragement of movements and behaviors, and child socialization. A mother’s level of health literacy may influence her actions and choices to develop/create the home environment. Parents can influence a child’s behavior in several ways: modeling health physical activity patterns themselves, encouraging physically active behavior in their children, and creating opportunities for structured activities or unstructured free play. Women with 97  higher levels of health literacy may influence children differently. There were moderate and strong correlations between a mother’s level of health literacy and several aspects of home affordances. Increased reading ability (REALM) was related to increased variety of stimulation, and higher levels of numeracy (TOFHLA) was related to an increase in the availability of fine and gross motor toys. In addition, the children of mothers with higher levels of reading ability showed more advanced development in the areas of both fine and gross motor skills. It is not known if this relationship is present for mothers with lower levels of health literacy. Evidence from this investigation suggests a relationship between health literate mothers and home affordances 6.3 Strengths and Weaknesses of the Investigation The exploratory nature of these investigations have both strengths and weakness. For both manuscripts, the investigations utilized multiple, objective measures to obtain a large amount of information from each participant. The battery of health literacy assessments was administered to obtain an accurate score of each participant across the various assessments of health literacy (reading ability, prose literacy, document literacy, and numeracy), which are commonly employed in both a research and an applied setting. This was an important design element in the current investigation. For example, reading ability was shown to be the most predictive of home affordances (total variety of stimulation) rather than overall health literacy. Using only a single method of assessment may have missed this important information. In addition, the CPAFLA is considered to be the gold standard for the measurement of health98  related physical fitness. Having high levels of both validity and reliability, it provides accurate information reflecting the status of participant’s health-related physical fitness. Despite having a relatively small sample size within this investigation, multiple statistically significant results were found. Considering the quality of assessment used, we have confidence in the information presented in our results. A limitation of this investigation was the number of participants. As stated above, this investigation was exploratory in nature. To-date it is the first investigation to examine the influence of maternal health literacy on healthrelated physical fitness, home affordances, and child motor development. With this in mind, sample size was kept small to collect information on a large range of areas. However, several interested participants had difficulties coming in for testing, even though very flexible times and childcare were offered. Being able to offer participants the option of completing the assessments in their own home and/or in the laboratory could increase the ease of participation, as well as allow for a more diverse sample population. For example, some women declined to participate because of difficulty in transporting their child(ren) to the laboratory (i.e., lack of car, or too much time required for traveling). For women with multiple children, other commitments prevented them from participating in the investigation. 6.4 Future Directions of Research Future studies should address the limitations of the current investigation, as well as explore new directions. While participant numbers were smaller for this 99  exploratory study, it is important to consider barriers that might prevent more women from participating in future investigations (i.e., motivation, time, transportation), as well as address the inherent difficulties of recruiting women with lower levels of health literacy. Within this study, feedback about participant health and child development was incentive. However, the question remains as to whether this was enough motivation for some. Offering financial compensation as an incentive, may appeal to more participants. For mothers, two testing periods totalling several hours of time at a laboratory was required. A smaller battery of studies could be utilized, such as a shortened version of the Affordances of the Home Environment for Motor Development (AHEMD-SR). The option of completing assessments within their home may have led to a more diversified sample with a greater range of health literacy levels, as women would not be required to transport themselves to the laboratory. In addition to shorter assessments, the overall number of tools could be reduced. Instead of studying health-related physical fitness and home affordances, one could look at health literacy and home affordances only, in which women would only be required to complete questionnaires, and children would not need to be included in the testing. Future investigations should examine the variables of interest with more specifically-defined research questions and one-directional hypotheses. For example, with preliminary evidence that increased reading ability is linked to an increase in the total variety of stimulation found in the home, a future study could use a one-directional hypothesis to examine this relationship further. 100  In addition to reducing barriers for participation and increasing the number of participants, related studies could address questions that arose during this investigation, such as: How does the relationship of motherhood status and health-related physical fitness apply to women with lower levels of health literacy? Do these relationships exist for women at a lower socioeconomic status? Is there a difference in motor development based on toddler gender for mothers with lower health literacy? How do home affordances vary for health literate mothers with younger infants? In addition, a greater diversity of participants based on ethnicity and/or socioeconomic status would provide additional insight into this important area of study. 6.5 Conclusions The results of this work further highlight the vulnerability of the early years of motherhood on health status. Non-mothers demonstrated superior performance compared to mothers on many aspects of health-related physical fitness despite similar levels of health literacy. Importantly, mothers did not exhibit fitness levels that were associated with optimal health. The results also indicate a relationship between maternal health literacy and affordances in the home environment. Mothers with higher health literacy levels are more likely to provide home environments that include a greater number of toys that facilitate fine and gross motor development, as well as a greater variety in overall stimulation. 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(2006). Health benefits of physical activity: the evidence. CMAJ, 174(6), 801-809. doi: 174/6/801 [pii] 10.1503/cmaj.051351 Warburton, D. E. R., Jamnik, V. K., Bredin, S. S. D., & Gledhill, N. on behalf of the PAR-Q+ Collaboration (2011). The Physical Activity Readiness Questionnaire (PAR-Q+) and Electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health and Fitness Journal of Canada, 4(2), 3-23. Weiss, B. D. (2005). Epidemiology of Low Health Literacy. In J. B. VanGeest & C. C. Wang (Eds.), Understanding Health Literacy: Implications for Medicine and Public Health. United States: American Medical Association.  111  Weng, H. H., Bastian, L. A., Taylor Jr, D. H., Moser, B. K., & Ostbye, T. (2004). Number of children associated with obesity in middle-aged women and men: results from the health and retirement study. J Womens Health, 13(1), 85-91. Werry, J. S., Carlielle, J., & Fitzpatrick, J. (1983). Rhythmic motor activities (stereotypies) in children under five: etiology and prevalence. J Am Acad Child Psychiatry, 22(4), 329-336. WHO. (1995). Physical status: The use and interpretation of anthropometry. In R. o. a. W. E. Committee (Ed.), WHO Technical Report Series 854. Geneva: World Health Organization. Wiart, L., & Darrah, J. (2001). Review of four tests of gross motor development. Developmental Medicine & Child Neurology, 43, 279-285. Wolfe, L., & Davies, G. A. (2003). Canadian Guidelines for Exercise in Pregnancy. Clinical Obestetrics and Gynecology, 46(2), 488-495. Wolfe, L. A., & Davies, G. A. (2003). Canadian guidelines for exercise in pregnancy. Clin Obstet Gynecol, 46(2), 488-495. Wolfe, L. A., & Weissgerber, T. L. (2003a). Clinical physiology of exercise in pregnancy: A literature review. J Obstet Gynaecol Can, 25(6), 473-483. Wolfe, L. A., & Weissgerber, T. L. (2003b). Clinical physiology of exercise in pregnancy: a literature review. J Obstet Gynaecol Can, 25(6), 473-483. Yin, H. S., Dreyer, B. P., Foltin, G., Van Schaick, L., & Mendelsohn, A. L. (2007). Association of low caregiver health literacy with reported use of  112  nonstandardized dosing instruments and lack of knowledge of weightbased dosing. Ambul Pediatr, 7(4), 292-298. Zelazo, P. R. (1983). The development of walking: New findings and old assumptions. The journal of motor behavior, 15, 99-137.  113  Appendix A: The Newest Vital Sign (NVS) Health Literacy Assessment Nutrition Label  114  Appendix B: The Newest Vital Sign (NVS) Health Literacy Assessment Score Sheet  115  Appendix C: The Rapid Estimate of Adult Literacy in Medicine (REALM) Health Literacy Assessment  116  Appendix D: Physical Activity Readiness Questionnaire (PAR-Q+)  117  118  119  120  Appendix E: Participation Consent Form INFORMED CONSENT FORM (CHILD) Title of Project:  The Influence of Maternal Age on Health Literacy, and Physical Fitness in Early Motherhood, Child Motor Development, and Home Affordances Investigator: Shannon S. D. Bredin, Ph.D. Research Assistant: Danika Dickson (MSc student) Institution: School of Human Kinetics, the University of British Columbia Contact Person: Danika Dickson, 604-505-6656 , d.dickson@telus.net Dr. Shannon Bredin, Office: 604-822-8257, bredin@interchange.ubc.ca  I,  , have been informed of the purpose (Please print your name) and procedures of this study, and my questions have been answered to my satisfaction. I, (Please print your name) this investigation.  , consent to my child’s participation in  I have been informed of the purpose and procedures of this study and I agree to have my child participate voluntarily in this investigation, which will be conducted by the Cognitive and Functional Learning Laboratory at the University of British Columbia. I have been told that at any time during the study, I will be free to withdraw my child without jeopardizing any medical management, employment or educational opportunities. I have been told that I do not waive legal rights by signing the consent form. I have read the contents of the consent form, the proposed procedures, and the possible risks. I have had the opportunity to ask questions and have received satisfactory answers to all inquiries regarding this investigation. I have received a copy of the consent form.  Name of Participant (Child)  Date  Signature of Legal Guardian  Date  Signature of Investigator  Date 121  INFORMED CONSENT FORM (ADULT) Title of Project:  The Influence of Maternal Age on Health Literacy, and Physical Fitness in Early Motherhood, Child Motor Development, and Home Affordances Investigator: Shannon S. D. Bredin, Ph.D. Research Assistant: Danika Dickson (MSc student) Institution: School of Human Kinetics, the University of British Columbia Contact Person: Danika Dickson, 604-505-6656 , d.dickson@telus.net Dr. Shannon Bredin, Office: 604-822-8257, bredin@interchange.ubc.ca  I,  , have been informed of the purpose  (Please print your name) and procedures of this study, and my questions have been answered to my satisfaction. I,  , consent to my participation in this  (Please print your name) investigation. I have been informed of the purpose and procedures of this study and I agree to participate voluntarily in this investigation, which will be conducted by the Cognitive and Functional Learning Laboratory at the University of British Columbia. I have been told that at any time during the study, I will be free to withdraw without jeopardizing any medical management, employment or educational opportunities. I have been told that I do not waive legal rights by signing the consent form. I have read the contents of the consent form, the proposed procedures, and the possible risks. I have had the opportunity to ask questions and have received satisfactory answers to all inquiries regarding this investigation. I have received a copy of the consent form.  Name of Participant (Adult)  Date  Signature of Participant  Date  Signature of Investigator  Date  122  Appendix F: Canadian Physical Activity, Fitness and Lifestyle Assessment (CPAFLA)  123  Appendix G: Background Information Questionnaire for Nullipara Women  124  125  126  127  128  129  130  131  132  133  134  Appendix H: Background Information Questionnaire for Women with Children  135  136  137  138  139  140  141  142  143  144  145  146  147  

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