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Development and evaluation of a worksite health promotion program : application of critical self-directed… Hubball, Harry Thomas 1996

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Development and Evaluation of a Worksite Health Promotion Program: Application of C r i t i c a l Self-Directed Learning for Exercise Behaviour Change By HARRY THOMAS HUBBALL B.Sc. (Hons), The University of Brighton, 1990 MA, The University of British Columbia, 1994 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Interdisciplinary Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1996 Harry Hubball in presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of HoMA^ fcnogTtCS The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT Low p a r t i c i p a t i o n i n and poor adherence to regular exercise presents a major challenge for health promotion programs (Centers for Disease Control, 1990; Dishman, 1994). The workplace provides a unique context to reach a large proportion of society for multiple health promotion programs. E f f e c t i v e workplace interventions are l i k e l y those combining environmental and behavioural change models from a va r i e t y of f i e l d s , and are t a i l o r e d as much as resources w i l l allow to the needs and circumstances of the workplace culture and to in d i v i d u a l s p a r t i c i p a t i n g i n the program (Green and Cargo 1994). Few studies i n the workplace context, however, have focused on integrated programs drawn from a va r i e t y of f i e l d s to f a c i l i t a t e exercise behaviour change. Even less evidence exists about application of learning following worksite health promotion programs. The purpose of t h i s study was to examine application of learning following an integrated worksite health promotion program. The aim of the program was to empower partic i p a n t s i n d i v i d u a l l y and c o l l e c t i v e l y with knowledge, attitudes, s k i l l s and experiences to think c r i t i c a l l y and to s e l f - d i r e c t exercise behaviour change. Green and Kreuter's (1991) Precede-Proceed model was used as the guiding framework for the planning and evaluation processes i n a worksite s e t t i n g . Twenty-six c l e r i c a l employees i n the University of B r i t i s h Columbia's Department of Housing and Conferences p a r t i c i p a t e d i n a four-week intervention program and twenty-two c l e r i c a l employees p a r t i c i p a t e d i n a w a i t i n g - l i s t control group. An e c l e c t i c set of quantitative and q u a l i t a t i v e tools examined par t i c i p a n t experiences and outcome measures pertaining to exercise behaviour change. Structural changes occurred i n the workplace environment to f a c i l i t a t e h e a l t h f u l behaviours. Quantitative findings indicated that p o s i t i v e changes occurred for the experimental group during the program and at a three-month follow-up with respect to exercise s e l f - e f f i c a c y , exercise stages of change and exercise behaviour (p<0.05). Qualitative analysis revealed that a myriad of i n d i v i d u a l , s o c i a l and other contextual factors shaped whether and how learning was applied. Motives to attend the program, previous experiences, c r i t i c a l thinking and s e l f - d i r e c t e d learning s k i l l s , and power to influence s i g n i f i c a n t others and resources i n the context of application influenced exercise behaviour. Furthermore, ap p l i c a t i o n varied by type, frequency, i n t e n s i t y and duration to s u i t s p e c i f i c needs and circumstances. Learning was applied to enhance motivation for brisk walking, f i t n e s s classes, h o l i s t i c health behaviours and time with s i g n i f i c a n t others. Two conclusions are drawn from t h i s study. F i r s t , a worksite health promotion program developed by integrating behaviour change models drawn from a va r i e t y of f i e l d s can be e f f e c t i v e for exercise behaviour change. Second, i n the context of a p p l i c a t i o n i n d i v i d u a l and s o c i a l contextual strategies are required to enhance exercise behaviour. Theoretical concepts and intervention strategies to f a c i l i t a t e c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change are discussed. TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i v . LIST OF TABLES v i LIST OF FIGURES v i i ACKNOWLEDGEMENTS v i i i DEDICATION ix 1. INTRODUCTION 1 Purpose of Study 8 Significance of Study 10 Glossary of Terms . . . 1 2 2. LITERATURE REVIEW 15 PROGRAM DEVELOPMENT 16 (a) Exercise Behaviour Change 16 Psychological Approaches to Behaviour Change 16 S e l f - E f f i c a c y and Exercise Behaviour 23 Developing Exercise S e l f - E f f i c a c y . 47 Self-Regulation and Evaluation Literature 51 Educational Approaches to Behaviour Change.. 60 Adult Learning Theory 60 Self-Directed Learning 62 C r i t i c a l Self-Directed Learning 72 Program Content Framework 77 (b) Program Implementation 83 Worksite Health Promotion 88 Planning Models and Health Promotion 99 Adult Teaching Theory 107 Program Evaluation Theory. 119 Program Implementation Framework. 127 Summary. 129 3. METHODOLOGY 131 Research Perspective. 131 Subject Population 135 Design 139 Procedures 144 Instruments 148 Data Analysis 153 TABLE OF CONTENTS (Continued) 4. RESULTS 157 Quantitative Analyses 158 Exercise Behaviour 158 Exercise s e l f - E f f i c a c y 163 Stages of Exercise Behaviour Change 169 Qualitative Analyses 175 Factors A f f e c t i n g Application 176 Process of Application 190 Alter n a t i v e Post-Educational Outcomes 206 Summary 210 5. DISCUSSION 212 Experimental Findings ....212 Exercise Behaviour 212 Exercise s e l f - E f f i c a c y 215 Stages of Exercise Behaviour Change 219 Qualitative Analyses 224 Factors A f f e c t i n g Application 224 Process of Application 241 Alter n a t i v e Post-Educational Outcomes 24 9 6. SUMMARY, CONCLUSIONS, IMPLICATIONS 255 Review 255 Conclusions 260 Implications for Workplace Pol i c y 262 Implications for Instructors of Worksite Programs.... 265 Implications for Post-Educational Application 271 Limitations of the Study 274 Recommendations for Future Research 279 7. REFERENCES ....281 8. APPENDICES 30 9 APPENDIX A Intervention Program 309 APPENDIX B Exercise Behaviour Questionnaire 319 APPENDIX C Learning Experience Evaluation Form 322 APPENDIX D Semi-Structured Interview Format....* 324 APPENDIX E Journal Entry Form .325 APPENDIX F Questioning Strategies 327 APPENDIX G Ethics Approval & Consent Forms ....328 vi Tables Table 1. Self-Regulatory Cognitive and Behavioural Intervention Strategies and Exercise Behaviour 38 Table 2. Relapse Prevention Training: Self-Regulatory Cognitive and Behavioural Intervention Strategies and Exercise Behaviour 42 Table 3. Stages of Exercise Behaviour Change: S e l f -Regulatory Cognitive-Behavioural Intervention Strategies and Exercise Behaviour 45 Table 4. S e l f - E f f i c a c y : Self-Regulatory Cognitive and Behavioural Intervention Strategies 4 9 Table 5. Cost-Effectiveness of Workplace Programs ..... 94 Table 6. Demographic Cha r a c t e r i s t i c s 136 Table 7. Program Outline 146 Table 8. Mean Scores for Exercise Behaviour 158 Table 9. ANOVA Summary Table for Exercise Behaviour..159 Table 10. Mean Scores for Exercise S e l f - E f f i c a c y 163 Table 11. ANOVA Summary Table for S e l f - E f f i c a c y 164 Table 12. Correlation C o e f f i c i e n t s for Exercise Behaviour and S e l f - E f f i c a c y 168 Table 13a. Stages of Exercise Behaviour 170 Table 13b. Changes i n Stages of Exercise Behaviour 171 Table 14. Chi-square Summary Table for Stages of Exercise Behaviour Change 172 Table 15. Post-Educational Evaluation Components 184 Table 16. Broad Motivational Strategies for Exercise Adherence * 272 vii Figures Figure 1. Lifespan Interaction Model 4 Figure 2. H e u r i s t i c Model of Implementation of Worksite Health Promotion Programs 87 Figure 3. Precede-Proceed Model...... 103 Figure 4a. Data C o l l e c t i o n Processes 141 Figure 4b. Data C o l l e c t i o n Processes 142 Figure 5. Quasi-Experimental Design 144 Figure 6. Comparative Exercise Behaviour and Exercise S e l f - E f f i c a c y l e v e l s ...160 Figure 7. Instructional Framework for F a c i l i t a t i n g C r i t i c a l Self-Directed Learning i n Worksite Health Education 266 Figure 8. Motivational Framework for F a c i l i t a t i n g Post-Educational Application 272 ACKNOWLEDGEMENTS I would l i k e to express my gratitude to a l l those who have assi s t e d and taken part i n t h i s research project. This work would not have been completed without t h e i r support. Special thanks are extended to my research supervisors Dr. Lawrence Green and Dr. Daniel Pratt, and supervisory committee members, Dr. Alan Martin and Dr. Judith Ottoson for t h e i r generous support, expertise and advice throughout the course of t h i s research project. My appreciation i s also offered to Mary Riseborough and employees with the Department of Housing and Conferences at the University of B r i t i s h Columbia, for t h e i r co-operation and administrative support throughout the promotion and implementation of t h i s research project. Further, I would l i k e to thank my family i n England, e s p e c i a l l y my Dad and my brothers for always being there when I need them. Last, but by no means least, I am thankful to my wife Kay, for sharing and t o l e r a t i n g yet another whirlwind and enlightening phase of our l i v e s . We a l l survived and survived well. Thank you for your love, patience and understanding. DEDICATION I dedicate this dissertation to two special sisters, Alma and Josie, and two special brothers, Harvey and Thomas. Mothers and sons, connecting one generation to another. 1 CHAPTER 1 INTRODUCTION Dramatic changes in l i f e s t y l e s which have had profound e f f e c t s on the status of people 's heal th have taken place over the l a s t century. Notably, one of those changes has been the s i g n i f i c a n t reduction in d a i l y energy expenditure i n the home and i n the workplace, r e s u l t i n g from labour-saving technologies and mechanised t ranspor ta t ion . Further, the increas ing popu lar i ty of convenient, consumer-based entertainment technologies i n the home, such as t e l e v i s i o n , v ideo, stereo and computers have a lso had a s i g n i f i c a n t impact on sedentary behaviour i n l e i s u r e t ime. Green and Ottoson (1994) noted that " in 1850 human muscles suppl ied near ly one t h i r d of the energy used by workshops, f ac to r ies and farms. Today the comparable estimate i s l ess than one percent" (p.282). Reduced phys i ca l a c t i v i t y has contr ibuted to the increase i n hypokinet ic diseases and premature death due to card iovascular d isease, colon cancer i n males, low back pain, anxiety, depression, and low bone density i n post-menopausal women (Bouchard, Shephard, Stephens, Sutton, & McPherson, 1990). These diseases are c h a r a c t e r i s t i c of contemporary i n d u s t r i a l s o c i e t i e s . Studies have suggested that both p h y s i c a l f i t n e s s and habi tua l phys i ca l a c t i v i t y are inverse ly r e l a t e d to coronary heart disease r i s k i n adults (B la i r et a l . , 1993; Morr is , Everett & Semmence, 1987; Powell , Thompson, Caspersen, & Kendrick, 1987), although the magnitude of each remains to be determined. 2 Both physiological (Bouchard et a l . , 1990) and psychosocial benefits of regular exercise (Biddle, 1995) have been recorded extensively. Furthermore, Shephard (1989, 1992) i d e n t i f i e d s p e c i f i c benefits to be gained from a f i t and healthy workforce. In order to a t t a i n the phys i o l o g i c a l benefits of exercise, however, the American College of Sports Medicine (ACSM)(1990) guidelines recommended that aerobic exercise should be performed at an exercise i n t e n s i t y of 60-90% of maximum heart rate and at a frequency of 3-5 times each week, for a duration of 15-60 minutes each time. Exercise p r e s c r i p t i o n , from t h i s perspective, may well have over emphasised the t r a i n i n g zone, contributing to the high drop-out figures. Recent guidelines published from the ACSM (1995) embrace the concept of active l i v i n g and advocate an increase i n o v e r a l l d a i l y physical a c t i v i t y with less emphasis placed on exercise i n t e n s i t y . According to Marcus ( 1995 ) , "simple programs to improve f i t n e s s , such as walking, are rarely offered i n courses yet these may be the type of programs more suitable for a large section of the population" (p. 3 2 0 ) . Marcus, Pinto, Simkin, Audrain and Taylor (1994) noted that older adults and women are less l i k e l y to endorse p a r t i c i p a t i o n i n vigorous exercise, but frequently report p a r t i c i p a t i o n i n l i g h t and moderate a c t i v i t i e s . S t a t i s t i c s of physical a c t i v i t y l e v e l s vary according to region and population demographics. Studies have shown that despite a greater public awareness of the importance of exercise, i n i n d u s t r i a l i s e d countries as l i t t l e as 8-20% of the population are s u f f i c i e n t l y active to a t t a i n maximum health 3 benefits, while 30-59% are e s s e n t i a l l y sedentary (Centers for Disease Control, 1 9 9 0 ; Marcus, Simkin, Rossi, & Pinto, 1 9 9 6 ; Stephens, Jacobs, & White, 1 9 8 5 ) . In addition, Dishman (1991) reported that the t y p i c a l dropout rate from exercise programs around the world has remained approximately 50% within the f i r s t six months. If adoption and adherence rates remain low the p o t e n t i a l health-related benefits of exercise w i l l be l i m i t e d . Low p a r t i c i p a t i o n and poor adherence to regular exercise presents a major challenge for health promotion programs. Dishman ( 1 9 9 0 ) , i n an e f f o r t to explain the complexity of exercise adherence, proposed a Life-Span Interaction model (see Figure 1) that takes into account diverse d i s c i p l i n e s (psychological, physiological and socio-environmental) and i d e n t i f i e s a number of determinants. Dishman's model i l l u s t r a t e d that there are various l e v e l s and stages of involvement i n exercise p a r t i c i p a t i o n . Stages are both stable and dynamic i n nature (Marcus et a l . , 1 9 9 6 ) . Further, multiple strategies can be used as p o t e n t i a l interventions to increase exercise p a r t i c i p a t i o n throughout t h i s h e u r i s t i c model. Intervention approaches, to enhance exercise adherence, have been shown to be e f f e c t i v e when they focus on the use of s e l f - r e g u l a t i o n techniques (Marcus, 1 9 9 5 ) . In addition, a growing body of evidence suggests that health education programs that are developed using the p r i n c i p l e s of Bandura's (1986) s e l f - e f f i c a c y theory have shown success i n maintaining a v a r i e t y of health related behaviours (Jemmott & Jemmott, 1 9 9 2 ; Jones et a l . , 1 9 9 0 ; Kasen, 1 9 9 2 ; Leviton, 1 9 8 9 ; Magura et a l . , 1 9 9 1 ; Rose, 1 9 9 2 ) . 4 2". w O to </? O b25 .7 a s " Q W — tJ o < ^ td '< > as on "lo - J . F i g u r e 1. The L i f e s p a n I n t e r a c t i o n M o d e l f o r E x e r c i s e B e h a v i o u r (Dishman 1990) 5 Psychological approaches, however, tend to centre the control for a behaviour change on the i n d i v i d u a l . In contrast, contemporary adult educational approaches to behaviour change situate the i n d i v i d u a l i n a broader s o c i a l , h i s t o r i c , economic, p o l i t i c a l , organisational and c u l t u r a l context. S o c i o l o g i c a l perspectives of adult learning theory, p a r t i c u l a r l y , c r i t i c a l s e l f - d i r e c t e d learning has received widespread attention i n adult education and provides guidance for broad s o c i a l and other contextual interventions i n a worksite health promotion program. Green and Cargo (1994) c a l l e d for greater collaboration between the d i s c i p l i n e s i n academia to close the gap between theory and practice and to develop and test progressive innovations. They stated, "As yet such integration has not emerged as a standard i n health promotion, l e t alone workplace health promotion" (p.512). The workplace context provides a unique s e t t i n g to reach a large proportion of society for multiple health promotion i n i t i a t i v e s . E f f e c t i v e workplace interventions are l i k e l y to be those that combine environmental and behavioural change models from a v a r i e t y of f i e l d s and are t a i l o r e d , as much as resources w i l l allow, to the needs and circumstances of the workplace culture and the i n d i v i d u a l s p a r t i c i p a t i n g i n the program (Green & Cargo, 1994). "State of the a r t " education programs that are packaged and exported to worksite venues f a i l to consider, however, the needs and circumstances of those l o c a l employees wishing to benefit from the learning experience. In addition to psychosocial concepts for behaviour change, an i n t e g r a l part of 6 program development i n health promotion should take into account the contextual application of an educational program by addressing t h e o r e t i c a l concepts and frameworks from the l i t e r a t u r e i n worksite health promotion, program planning, adult teaching, and program evaluation. For the purpose of t h i s study, the researcher developed a worksite health promotion program ( L i f e s t y l e S k i l l s Motivation) by combining the l i t e r a t u r e on exercise science, health promotion and adult education.' The aim of the program was to empower partic i p a n t s i n d i v i d u a l l y and c o l l e c t i v e l y with the knowledge, attitudes and s p e c i f i c s k i l l s to think c r i t i c a l l y and to s e l f - d i r e c t an exercise behaviour change. A learner-centred approach was central to the worksite L i f e s t y l e S k i l l s Motivation program. Learners were encouraged to be active p a r t i c i p a n t s i n the learning process. Furthermore, i t was assumed that people learn i n a vari e t y of ways, they are at d i f f e r e n t stages of learning and they progress at d i f f e r e n t rates. From t h i s perspective of teaching, the teacher focused on enhancing c r i t i c a l thinking and s e l f - d i r e c t e d learning s k i l l s through a challenging, supporting and guiding environment (Pratt, 1992). Learning was thus viewed as an i n d i v i d u a l and s o c i a l contextual process. Few studies i n the workplace context have focused on integrated programs, combining behaviour change models drawn from a va r i e t y of f i e l d s to f a c i l i t a t e exercise behaviour change. Even less i s known about the application of learning a f t e r the completion of worksite health promotion programs. A 7 v a r i e t y of related l i t e r a t u r e has been used to address a p p l i c a t i o n . For example, program evaluation (Sork, 1 9 9 0 ) , d i f f u s i o n (Rogers, 1 9 8 3 ) and transfer of learning (Baldwin & Ford, 1 9 8 8 ) . Ford ( 1 9 9 4 ) defined application as the extent to which knowledge, attitudes and s k i l l s from an educational program are subsequently used. Application i n the classroom context i s r e l a t i v e l y easy to assess. Implicit i n educational programs, however, i s that change i s expected beyond the classroom context and into the home, workplace or community set t i n g . Post-educational application thus occurs i n contextually-bound, dynamic and r e l a t i v e l y unpredictable patterns of human in t e r a c t i o n . Post-educational application i s where learning outcomes from educational programs and intentions of adult p a r t i c i p a n t s interface with the r e a l i t i e s of everyday l i f e . M u l t i d i s c i p l i n a r y and multiparadigmatic research i s , therefore, required to study t h i s phenomenon (Ottoson, 1 9 9 5 ) . The study of post-educational application i n complex s o c i a l settings offers a unique insight into factors and processes that influence how program intentions became transformed into behavioural and non-behavioural outcomes. The purpose of t h i s study was to gain a better understanding of post-educational application following an integrated worksite health promotion program. Green and Kreuter's ( 1 9 9 1 ) Precede-Proceed model for health promotion was used as the guiding framework for the planning and evaluation processes. The Precede phase of the model ensured that the program was t a i l o r e d to the needs and circumstances of employees 8 attending the worksite health promotion program. The Proceed phase i s a r e a l i s t i c and f l e x i b l e framework to investigate post-educational application because of i t s emphasis on process and broad perspective on context. The p r i n c i p l e of p a r t i c i p a t i o n was applied throughout the twelve-month implementation of t h i s research project. The L i f e s t y l e S k i l l s Motivation program has shown evidence of success i n a community set t i n g (Hubball, 1994) and i n p i l o t studies that have been implemented i n a u n i v e r s i t y and a corporate workplace se t t i n g . For the purpose of t h i s study, data were gathered pertaining to post-educational a p p l i c a t i o n of a worksite program offered to c l e r i c a l employees i n the Department of Housing and Conferences at the University of B r i t i s h Columbia (UBC). Purpose of Study The purpose of t h i s study was to gain a better understanding of the e f f e c t s of, and the application of learning following, an integrated worksite health promotion program that was developed from t h e o r e t i c a l concepts and intervention strategies drawn from a v a r i e t y of f i e l d s . The following objectives and research questions, guided by Green and Kreuter's (1991) Precede-Proceed framework, f a c i l i t a t e d t h i s i n v e s t i g a t i o n : 9 Ob-iectives and Research Questions ( 1 ) To identify changes in selected outcome variables. Exercise s e l f - e f f i c a c y , exercise behaviour and the stages of exercise behaviour change are considered key variables i n the exercise motivation l i t e r a t u r e and they are an in t e g r a l part of the learning outcomes for t h i s worksite L i f e s t y l e S k i l l s Motivation program. To compare changes i n these outcome variables at various time periods and between pa r t i c i p a n t s from the intervention program and those from a " w a i t i n g - l i s t " control group, provides additional evidence to support the data gathered with respect to post-educational application. (Ql) What changes occurred with respect to exercise behaviour, self-efficacy and the stages of exercise behaviour change that can be measured quantitatively throughout the duration of the four-month investigation period? (2) To describe factors that affect post-educational application. This provides understanding of multiple factors that influence whether and how learning i s applied i n the context of post-educational a p p l i c a t i o n . (Q2) What factors f a c i l i t a t e d or hindered exercise participation in the context of application? 10 (3) To describe whether and how learning i s applied. The program i s considered a complex set of processes as well as a complete unit. A richness of learner feedback pertaining to the process of application provides a better understanding about how and why p a r t i c u l a r knowledge, attitudes, s k i l l s and behaviours embedded within the worksite health promotion program are applied i n a v a r i e t y of l o c a l settings. (Q3) How and why was learning applied i n the context of application? (4) To describe a l t e r n a t i v e post-educational outcomes. Information regarding intended and unintended outcomes provides a better understanding about why c e r t a i n aspects of the program, or the program as a whole, had meaning to program parti c i p a n t s and workplace o f f i c i a l s beyond t h e i r u t i l i t y to enhance c r i t i c a l s e l f -d irected learning for an exercise behaviour change. (Q4) What were a l t e r n a t i v e outcomes from the worksite health promotion program? Significance of Study Research can o f f e r much assistance i n planning and implementing programs, e s p e c i a l l y i n providing a meaningful i n t e r d i s c i p l i n a r y analysis that has d i r e c t implications for p r a c t i c e (Vertinsky, 1989). Combining t h e o r e t i c a l concepts and 11 intervention strategies from a variety of f i e l d s to implement i n t e r d i s c i p l i n a r y worksite health promotion programs, however, i s generally seen as an innovation. As such, there i s a need to describe program development and study post-educational a p p l i c a t i o n . Single variable research i s inadequate to capture the complexities of the multifaceted process of post-educational a p p l i c a t i o n . Ottoson (in press) analysed post-educational applications and concluded that adult educators cannot take for granted that well-intended p o l i c i e s and well-planned programs achieve intended outcomes. This study applied a multifaceted approach to the development and evaluation of an integrated worksite health promotion program. Behaviour change models and intervention strategies from health promotion, adult education and human ki n e t i c s were integrated to develop the intervention program. Second, evaluation research for t h i s study was situated i n a post-empiricist perspective, however, intervention and data c o l l e c t i o n strategies from multiple epistemologies were employed. The findings of t h i s research could make a s i g n i f i c a n t contribution to the m u l t i d i s c i p l i n a r y f i e l d of program development and research methodology pertaining to worksite interventions for exercise behaviour change. Furthermore, these findings have d i r e c t implications for health professional t r a i n i n g i n order to f a c i l i t a t e c r i t i c a l thinking and s e l f -directed learning for health behaviour change. 12 Glossary of Terms C r i t i c a l S e l f - D i r e c t e d Learning In the context of t h i s study, c r i t i c a l s e l f - d i r e c t e d learn ing re fe rs to r igorous, c reat ive and c r i t i c a l l y r e f l e c t i v e thoughts p e r t a i n i n g to i n d i v i d u a l and c o l l e c t i v e exerc ise behaviour change. Exerc ise "Exerc ise i s l e i sure- t ime phys i ca l a c t i v i t y which a person chooses to undertake during h is or her d i sc re t ionary time with the in tent ion of developing phys ica l .and/or p h y s i o l o g i c a l f i t n e s s " (Bouchard et a l . , 1990, p . 6 ) . Health Education "Any combination of learn ing opportunit ies designed to f a c i l i t a t e voluntary act ions conducive to the heal th of i n d i v i d u a l s , groups, or communities" (Green and Ottoson, 1994, p.669) . Health Promotion "Any planned combination of educat ional , p o l i t i c a l , regulatory and organ isat iona l supports for act ions and condit ions of l i v i n g conducive to the health of i n d i v i d u a l s , groups, or communities" (Green and Kreuter, 1991, p.432). 13 Implementation "Implementation i s an i t e r a t i v e process i n which ideas, expressed as p o l i c y , are transformed into behaviour, expressed as a s o c i a l action" (Ottoson and Green, 1987, p.362) . Intervention In the context of t h i s study, intervention refers to any process that engages subjects, i n some degree, to think c r i t i c a l l y and s e l f - d i r e c t exercise behaviour change. L i f e s t y l e "Any combination of s p e c i f i c practices and environmental conditions r e f l e c t i n g patterns of l i v i n g influenced by family history, culture, and socio-economic circumstances" (Green & Ottoson, 1994, p.670) . Application "The extent to which knowledge, attitudes and s k i l l s from an educational program are subsequently used" (Ford, 1994, p.22) . Program Evaluation "the c o l l e c t i o n and use of information to make decisions about an educational program where many types of decision are to be made and many v a r i e t i e s of information are u s e f u l " (Cronbach, 1963, p.672) 14 S e l f - E f f i c a c y "Individuals' s p e c i f i c confidence i n t h e i r use of t h e i r s k i l l s and a b i l i t i e s to overcome b a r r i e r s to perform a p a r t i c u l a r behaviour at the l e v e l that w i l l lead to an expected outcome" (Bandura, 1986). Self-Regulation " S e l f - r e g u l a t i o n implies the s o l i t a r y pursuit of goal-directed behaviour without immediate external control while minimising the l i m i t a t i o n s imposed by one's physical and s o c i a l environment" (Kirschenbaum & Wittrock, 1984, p.82). 15 CHAPTER 2 LITERATURE REVIEW Introduction Various conceptual models and frameworks inform us that multiple factors influence one's p a r t i c i p a t i o n i n regular exercise (Dishman, 1990; Green & Kreuter, 1991) . The m u l t i d i s c i p l i n a r y nature of t h i s study requires c a r e f u l consideration and organisation of the relevant l i t e r a t u r e pertaining to the development and evaluation of worksite health promotion programs for exercise behaviour change. The following review examines the l i t e r a t u r e i n exercise psychology, adult education and health promotion for broad t h e o r e t i c a l concepts and intervention strategies to enhance post-educational application of exercise behaviour change. The review i s organised into two areas of program development: intervention strategies for exercise behaviour change and program implementation. Intervention strategies for exercise behaviour change focuses on behavioural and broad educational approaches, i n p a r t i c u l a r , s e l f - e f f i c a c y and c r i t i c a l s e l f -d irected learning. Program implementation examines organisational approaches and t h e o r e t i c a l frameworks and concepts i n the l i t e r a t u r e from worksite health promotion, program planning, adult teaching and program evaluation. The l i t e r a t u r e i s assessed to provide guidance for the development and evaluation of a worksite health promotion program for application of exercise behaviour change. 16 PROGRAM DEVELOPMENT (Part I) Intervention strategies f o r exercise behaviour change The l i t e r a t u r e i n exercise psychology and adult education w i l l be examined to provide guidance for psychosocial behaviour change strategies to enhance post-educational application of exercise behaviour change. (a. PSYCHOLOGICAL APPROACHES TO BEHAVIOUR CHANGE Research on behavioural change has been a core area i n the study of exercise psychology. A number of theories have evolved i n the l i t e r a t u r e that have attempted to explain how human beings change behaviour. This review presents various approaches to behaviour change that have influenced health promotion interventions. C l a s s i c a l conditioning A c l a s s i c a l conditioning approach to behavioural change was introduced by Pavlov (1920), a Russian physiologist. He demonstrated that a refl e x could be e l i c i t e d automatically from a stimulus without any cognitive processing. This became known as the stimulus-response r e f l e x . Exercise behaviour change, from t h i s perspective, has been seen i n many forms, for example, providing worksite exercise classes, providing exercise equipment, exercise with a personal t r a i n e r or time-imposed exercise expectations. The l i m i t a t i o n of t h i s approach 17 i s that i t c l e a r l y focuses on shaping the environment by external means rather than taking into account the needs of the i n d i v i d u a l or e f f o r t s to empower the i n d i v i d u a l toward s e l f - d i r e c t e d regular exercise behaviour. Consequently, i f the i n d i v i d u a l i s not predisposed to the s p e c i f i c exercise behaviour and/or i f the exercise behaviour i s not reinforced, the exercise behaviour i s u n l i k e l y to be i n i t i a t e d or sustained through t h i s approach to behaviour change. Operant conditioning An operant conditioning approach to behavioural change developed from c l a s s i c a l conditioning. Operant behaviour refers to a f r e e l y emitted response pattern to bring about changes r e s u l t i n g i n reward or reinforcement (Skinner, 1938) . E s s e n t i a l l y , t h i s approach to behaviour change i s characterised through p a i r i n g a stimulus with a reward. This approach thus focuses on the re l a t i o n s h i p between a behaviour and i t s consequences through the use of p o s i t i v e or negative reinforcements. The more often a conditioned stimulus i s paired with a reward and the closer i n time that the reward follows the stimulus, the more r e i n f o r c i n g i t becomes. Exercise behaviour change intervention strategies that have originated from t h i s perspective have included c o l l e c t i n g "points" for exercise behaviour that can be subsequently used toward a personal treat (e.g., buying new clothes). Operant conditioning, therefore, assumes that a behaviour w i l l be repeated i f the consequences of performing that behaviour are rewarding. A l i m i t a t i o n of t h i s approach to 18 behaviour change, however, i s that rapid e x t i n c t i o n i s c h a r a c t e r i s t i c when there i s no further p a i r i n g of stimulus and reward. Although t h i s approach builds on c l a s s i c a l conditioning and may do so by involving the i n d i v i d u a l somewhat i n a cognitive capacity, the locus of control remains, to some extent, external. Consequently, the motivation to i n i t i a t e and sustain exercise behaviour r e l i e s simply on r e i n f o r c i n g factors rather than empowering the in d i v i d u a l toward the s e l f - d i r e c t e d implementation of regular exercise. Theory of reasoned action The Theory of Reasoned Action (TRA) has also been used extensively to explain health behaviour. This model was proposed by Ajzen and Fishbein (1980) and i s concerned with the causal antecedents of v o l i t i o n a l behaviour. The theory was named a f t e r Its underlying assumptions that people are r a t i o n a l , make systematic use of information that i s available to them, and consider the implications of a p a r t i c u l a r behaviour before engaging i n i t . The TRA thus interprets s o c i a l behaviour at the l e v e l of i n d i v i d u a l decision making (Godin, 1994). Central to the TRA i s the concept of behavioural intentions. These are seen as the f i n a l step before subsequent behaviour. The TRA proposes that s p e c i f i c measures of attitude, i n conjunction with s o c i a l influences, w i l l predict behavioural intentions. The attitude component of the model i s a function of the b e l i e f s held about a s p e c i f i c behaviour as 19 wel l as the value placed on the l i k e l y outcome. The s o c i a l normative component i s comprised of the b e l i e f s of s i g n i f i c a n t others and the extent that one i s motivated to comply with these b e l i e f s . Research tends to support that the a t t i tude component i s a more powerful p red ic tor of intent ions than the s o c i a l normative component. The r e l a t i v e importance of e i t h e r the a t t i t u d e or the normative component, however, w i l l l a r g e l y depend on the s i t u a t i o n . For example, some adolescent hea l th behaviours may be strongly inf luenced by the s o c i a l normative component though w i l l be less so i n adulthood. Godin et a l . (1986) appl ied t h i s model to c h i l d r e n ' s exerc ise behaviour. They found that the normative component was less p r e d i c t i v e of intent ions than the a t t i t u d i n a l component. Furthermore, a c h i l d ' s in tent ion to exerc ise was found to be r e l a t e d to h is or her mother's in tent ion to p a r t i c i p a t e i n phys ica l a c t i v i t y , f a t h e r ' s current a c t i v i t y l e v e l and fami ly ' s socio-economic s ta tus . In a review of twelve publ ished studies using the TRA, Godin (1994) found that the c o r r e l a t i o n between in tent ion and exerc ise behaviour averaged 0 . 5 5 , i . e . , 30% of the v a r i a b i l i t y i n behaviour was explained by in tent ion alone. In general , however, studies have shown equivocal r e s u l t s when using t h i s model to p r e d i c t exerc ise behaviour. A number of l i m i t a t i o n s are inherent when using t h i s model to understand exerc ise behaviour. F i r s t , the TRA i s based on a "snap-shot" of exerc ise behaviour and therefore does not take into account a person's previous experience or 20 stage of exerc ise involvement. Second, the u n i d i r e c t i o n a l nature of t h i s model f a i l s to recognise that var iab les in the model can act i n a r e c i p r o c a l manner. Th i rd , the TRA was developed for behaviours under v o l i t i o n a l cont ro l and therefore may not pred ic t behaviours where other factors (soc ia l contextual bar r ie rs) may be considered more i n f l u e n t i a l . Fourth, poor measures of exerc ise behaviour ( s e l f - r e p o r t , intent ions to exercise) that have been used in previous studies have escalated the problems when using t h i s model to expla in exerc ise behaviour. F i n a l l y , i t a lso requires tedious r e p e t i t i o n in the questionnaire to measure the components of the model, and i t does not lend i t s e l f e a s i l y to in tervent ion p lanning. E s s e n t i a l l y , the TRA r e l i e s predominantly on cogni t ive factors ( intent ions, knowledge and b e l i e f s i n the expectancy value) to pred ic t exerc ise behaviour. Research and p r a c t i c e , however, suggest that changes i n knowledge, b e l i e f s and a t t i tudes may be necessary but they are not s u f f i c i e n t to induce or susta in an exerc ise behaviour change. The TRA does provide some guidance, however, for exp la in ing and e laborat ing the dynamics of predisposing factors i n broader conceptual frameworks for exp la in ing exerc ise behaviour. Soc ia l Learning Theory The s o c i a l inf luence on learn ing behaviour was f i r s t introduced by M i l l e r and Do l la rd (1941). Using animals and humans, they showed how behaviour could be learned from i m i t a t i o n . Bandura and Walters (1963) invest igated t h i s Idea 21 further and found that children could learn a s p e c i f i c behaviour by observing other children perform that behaviour and receive a reward. Rotter (1966) applied these p r i n c i p l e s of s o c i a l learning theory to c l i n i c a l psychology and developed the concepts of "generalised expectancies" and "locus of c o n t r o l . " "Generalised expectancies" refers to the value a person places on the results of a p a r t i c u l a r behaviour. "Locus of c o n t r o l " refers to whether the person perceives rewards for the behaviour to be controlled by oneself ("internal locus") or by others ("external locus"). Building on previous research and Rotter's work s p e c i f i c a l l y , Bandura (1977) developed a conceptual foundation for the theory of Social Learning and renamed Social Learning Theory to "Social Cognitive Theory" (SCT). Social Cognitive Theory (SCT) According to Bandura (1986b), two main organising themes characterise SCT: r e c i p r o c a l determinism and vicarious learning. Reciprocal determinism refers to the interdependent and i n t e r a c t i v e r e l a t i o n s h i p between the person, environment and behaviour factors. Bandura thus viewed behaviour change as a dynamic and m u l t i d i r e c t i o n a l process such that a change i n one of the factors w i l l lead to a change i n the other two. He postulated, however, that indiv i d u a l s are not simply passive recipie n t s of the environment, but instead are capable of s e l f - r e g u l a t i n g t h e i r environment as well as t h e i r own behaviour. The second main organising theme i n SCT i s vicar i o u s learning. Bandura described vicarious learning as 22 the mediation of imaginal and verbal codes that become condit ioned to external s t i m u l i . He suggested that v i c a r i o u s learn ing occurs when an i n d i v i d u a l constructs a schema of a behaviour and i t s consequences from observing another person(s) go through the same, "actua l" process. Bandura noted, however, that the ef fect iveness of v i c a r i o u s learn ing i s increased when a model has a s i m i l a r demographic p r o f i l e to that of the learner and when the model's l e v e l of competence or experience i s not perceived as too superior to or too d i f f e r e n t from that of the learner . Maiman, Green, Gibson and MacKenzie (1979) supported t h i s assert ion from study f ind ings with heal th aides for an adult asthma health education program. SCT thus provides mult ip le intervent ion opportuni t ies to a f f e c t behaviour. Perry, Baronowski and Parce l (1990), however, pointed out that a common f a u l t with the a p p l i c a t i o n of t h i s theory in heal th promotion i s to focus on too few v a r i a b l e s and to exclude too many. This i s symptomatic of experimental research which often permits the ana lys is of only a few i s o l a t e d var iab les and therefore tends to overs impl i fy r e a l i t y . Perry et a l . recommended a three-stage process to apply s o c i a l learn ing theory adequately in health promotion p r o j e c t s : (1) i d e n t i f y the goal of the program, (2) i d e n t i f y the p r i n c i p l e s of s o c i a l learn ing theory most l i k e l y to lead to change in the behaviour, and (3) match s t rateg ies to the p r i n c i p l e s of s o c i a l learn ing theory. 23 Dzewaltowski (1989) found that the SCT accounted for a higher proportion of variance in exercise behaviour than the Theory of Reasoned Action and thus concluded that SCT was a superior t h e o r e t i c a l model for predicting exercise behaviour. Compared to previous psychological approaches, s o c i a l cognitive theory provides a broad conceptual framework to explain and understand the process of behavioural change. It i s important to note, however, that within the broad causal t r i a d i c system, SCT places an emphasis on examining cognitive processes (Dzwaltowski, 1994). Furthermore, SCT assumes that indiv i d u a l s are capable of engaging i n a r a t i o n a l analysis of t h e i r exercise behaviour, are capable of s e l f - r e g u l a t i n g exercise behaviour, and can learn through vicarious experience. S e l f - E f f i c a c y Theory and exercise behaviour Bandura ( 1 9 7 7 , 1 9 8 6 ) postulated the existence of a key motivational construct i n the SCT of human thought and action which he termed " s e l f - e f f i c a c y . " SCT i s thus seen as the "parent" theory of S e l f - E f f i c a c y Theory (SET). According to Bandura (1986a), s e l f - e f f i c a c y refers to "an ind i v i d u a l ' s s p e c i f i c confidence i n t h e i r use of t h e i r s k i l l s and a b i l i t i e s to overcome b a r r i e r s to perform a p a r t i c u l a r behaviour at the l e v e l that w i l l lead to an outcome"(p. 2). An ind i v i d u a l ' s s e l f - e f f i c a c y i s viewed as central to his or her decision to p a r t i c i p a t e i n a s p e c i f i c behaviour. 24 Bandura (1986a) c l e a r l y d i f f e r e n t i a t e d between e f f i c a c y expectations and outcome expectancies. In terms of exerc ise motivat ion, e f f i c a c y expectations re fe r to an i n d i v i d u a l ' s b e l i e f i n h is or her own c a p a b i l i t y to p a r t i c i p a t e in regular exerc i se . Consequently, exerc ise e f f i c a c y expectations in f luence the a c t i v i t i e s chosen, the e f f o r t expended, the degree of pers istence exh ib i ted in the face of obstacles or b a r r i e r s , emotional react ions ( e . g . , joy, anxiety, e t c . ) , and are therefore subject to change as a funct ion of environmental f a c t o r s . In contrast , outcome expectations re fe r to one's b e l i e f that regular exerc ise w i l l produce a p a r t i c u l a r r e s u l t ( e . g . , reduce anxiety, increase f i t n e s s , reduce weight) . High e f f i c a c y b e l i e f s regarding one's c a p a b i l i t y to p a r t i c i p a t e s u c c e s s f u l l y and adhere to exerc ise are l i k e l y to lead to p o s i t i v e mastery experiences, and, depending on the outcome of those mastery experiences, should therefore inf luence one's future exerc ise p a r t i c i p a t i o n and expectat ions. A growing body of l i t e r a t u r e addresses the problem of adherence to exerc ise c lasses by focusing on exerc ise s e l f -e f f i c a c y ( S a l l i s , Haske l l , Fortmann, Vranizan, Taylor , & Solomon, 1 9 8 6 ; Garcia & King, 1991; McAuley, Courneys, & Let tun ich , 1991; McAuley & Jacobson, 1991; and Marcus et a l . , 1992). Bouchard et a l . (1990) concluded that ac t ive people tend to be well-motivated to p e r s i s t with exerc ise , and possess problem-solving s k i l l s which focus on s e l f regulatory s t r a t e g i e s that can be learned ( e . g . , goal s e t t i n g , exerc ise s t r a t e g i e s , minimising environmental b a r r i e r s to 25 implementation, and monitoring and r e i n f o r c i n g t h e i r a c t i o n s ) . Supporting t h i s view, studies have ind icated that health education programs based on Bandura's p r i n c i p l e s of s e l f -e f f i c a c y theory have shown success in maintaining a v a r i e t y of health behaviours, such as condom-use (Jemmott & Jemmott, 1992); drug r e f u s a l (Jones et a l . , 1990); AIDS preventat ive behaviour (Kasen, 1992, Magura et a l . , 1991); smoking cessat ion (DiClemente et a l . , 1985); adult and adolescent health (Leviton, 1989, Sprunger & Pel laux, 1989); heart disease prevention (Rose, 1992); and weight cont ro l (Bernier & Avard, 1986). Strecher et a l . (1986), in a l i t e r a t u r e review regarding s e l f - e f f i c a c y and health behaviour change, found a cons i s tent ly p o s i t i v e r e l a t i o n s h i p between s e l f - e f f i c a c y and heal th behaviour change and maintenance. The appeal of SET i s that i t expresses the dominant purpose of hea l th promotion of enabl ing people to increase cogni t ive contro l over, and to improve t h e i r hea l th . Furthermore, i t provides d i r e c t i o n for the design of in tervent ion s t rateg ies that are intended to increase and maintain health behaviour. S e l f - r e g u l a t i o n and exerc ise s e l f - e f f i c a c y Inherent i n the theory of s e l f - e f f i c a c y i s the idea that people are capable of learn ing how to s e l f - r e g u l a t e t h e i r own behaviour. S e l f - r e g u l a t i o n can be described as a s e l f - o r i e n t e d feedback loop invo lv ing a v a r i e t y of complex in te rac t ions between systematic and continuous se l f -observat ion of performance, cogn i t ion , emotional s tates , physiology and environmental constra ints (Zimmerman & Schunk, 1989). S e l f -26 regulation, therefore, incorporates diverse and interconnected cognitive-behavioural s k i l l s where an i n d i v i d u a l i s able to monitor the effectiveness of his or her strategies and respond to t h i s feedback by changes i n self-perception (e.g., imagery selection) or changes i n behaviour (e.g., time management), thus becoming an active participant i n his or her own learning. According to Weber and Wertheim (1989), poor s e l f -regulatory cognitive and behavioural s k i l l s for overcoming b a r r i e r s are a main reason why many people who intend to be active remain sedentary. Many reasons for not exercising are given by those who intend to exercise regularly, but who do not. It appears that a number of r e a l and perceived b a r r i e r s including inconvenience, inaccessible locations, exercise boredom, a c t i v i t y cost, work c o n f l i c t s , lack of self-motivation, and a lack of time or energy tend to hinder long-term exercise p a r t i c i p a t i o n . Biddle and Mutrie (1991) suggested, however, that adequate self-regulatory strategies (e.g., time management, goals setting, self-monitoring, tension control, imagery) for overcoming these b a r r i e r s , can increase s e l f -e f f i c a c y and therefore reduce the d i f f i c u l t y that people experience i n adhering to regular exercise. A l t e r n a t i v e l y , inadequate self-regulatory strategies can lead to decreased feelings of s e l f - e f f i c a c y , a period of i n a c t i v i t y , and possible feelings of g u i l t and lack of control, which i n turn would undermine s e l f - e f f i c a c y and could increase the p r o b a b i l i t y of sustained i n a c t i v i t y . Although t h i s view tends 27 to underscore the importance of adverse environments or lack of s o c i a l support, s e l f - e f f i c a c y i s considered to be an important factor i n maintaining habitual physical a c t i v i t y . Schunk and Carbonari (1984) concluded that a strong sense of e f f i c a c y for behaving i n a healthful fashion i s central to the se l f - r e g u l a t i o n of one's l i f e . The following examples of s e l f -regulatory cognitive and behavioural s k i l l s have shown evidence i n the l i t e r a t u r e to influence exercise behaviour. E n l i s t i n g s o c i a l support. One of the many reasons given for dropping out of regular exercise i s the lack of s o c i a l support from s i g n i f i c a n t others. This tends to act as negative reinforcement, but can be overcome by encouraging a partner to share the exercise commitment or e n l i s t i n g s o c i a l support from someone who has a p o s i t i v e attitude to exercise. Thow and Newton (1990) suggested that mutual support can be encouraged when one attends a class meeting as part of an exercise plan. Co-operative learning a c t i v i t i e s i n health education classes also fosters a supportive network that can a s s i s t with the motivation to overcome ba r r i e r s that prevent exercise p a r t i c i p a t i o n . Decision-balance sheet, A decision-balance sheet can be used to i d e n t i f y a person's motives and personal cost-benefit analysis for p a r t i c i p a t i n g i n regular exercise. This can help people to c l a r i f y the value they place on p a r t i c i p a t i n g i n regular exercise and recognise the advantages and disadvantages of increasing t h e i r l e v e l s of physical a c t i v i t y . Wankel (1985) suggested that a decision balance sheet can also 28 be used i n i t i a l l y to help people i d e n t i f y the b a r r i e r s that may prevent t h e i r goals from being achieved. Stimulus c o n t r o l , A v a r i e t y of exerc ise cues ( e . g . , reminders i n d iary , c lo th ing prepared before hand and placed in a v i s i b l e p lace, slogans or posters) p laced at s t r a t e g i c places in one's environment may act as mot ivat ional prompts to increase the l i k e l i h o o d of exerc ise p a r t i c i p a t i o n . Brownwell, Stunkard and Albaum (1980) used a poster campaign at prominent places i n a workplace s e t t i n g and found that t h i s technique was successfu l for increas ing the use of s t a i r s rather than the e levator . Goal setting,. According to Bandura (1986), performance achievement and the fee l ings that accompany success are a main determinant of s e l f - e f f i c a c y . Appropriate goal s e t t i n g provides a means for d i r e c t i n g behaviour toward the achievement of tasks and therefore can be an e f f e c t i v e strategy for enhancing health behaviour change (Strecher et a l . , 1996). Atkins et a l . (1984), found that subjects i n an experimental group who declared t h e i r goals in a pub l i c way, or by "contract ing" had s i g n i f i c a n t l y higher l e v e l s of commitment and adherence to exerc ise than those subjects i n cont ro l groups who d id not sign agreements or declare t a r g e t s . It i s important to note however, that external reinforcements need to be gradual ly phased out to the point that the exerc ise behaviour i s being maintained by i n t r i n s i c reinforcement from the exerc ise experience i t s e l f (Green, Wilson and Lovato, 1986). Cooper's (1982) aerobic po ints system was also shown to 29 increase exercise adherence. This method allocated s p e c i f i c points for p a r t i c i p a t i n g in d i f f e r e n t a c t i v i t i e s (depending upon the duration and intensity) such that the weekly goal was to score a t o t a l of 30 points. E f f e c t i v e goal s e t t i n g begins with the i d e n t i f i c a t i o n of a long term goal (e.g., to brisk, walk regularly for 20 minutes and at least 3 times per week) which i s then broken down into intermediate and short term goals. Goals should be time-phased, s p e c i f i c , but be set i n a f l e x i b l e way so that they can be achieved r e a l i s t i c a l l y and progressively. Martin et a l . (1984) showed that subjects who were randomly assigned to receive encouragement to set t h e i r own f l e x i b l e goals had a greater adherence to regular exercise than those subjects who had f i x e d goals. F l e x i b l e goal s e t t i n g and time management ensures that regular p a r t i c i p a t i o n i n exercise can be achieved without increasing self-imposed pressure to meet set deadlines or targets. This also tends to appeal to those people who do not respond to t i g h t l y structured plans. Self-monitoring,. Self-monitoring provides a valuable source of information regarding the progress towards the achievement of personal goals. According to Juneau, Rogers, Desantos, Yee, Evans and Bohn (1987), periodic monitoring and reviewing of exercise behaviour can be a powerful means of p o s i t i v e reinforcement. Self-monitoring can take the form of: exercise d i a r i e s , heart rate monitoring, Borg rating of perceived exertion or assessing thoughts and feelings about the exercise experience etc. Exercise diary information 30 t y p i c a l l y inc ludes : times, a c t i v i t y type, d istances, e f f o r t , weather, mood state , and other subject ive appra i sa l s . To t h i s extent however, se l f -moni tor ing can be onerous to some people and require yet further motivation in addi t ion to that of the demands of exerc ise p a r t i c i p a t i o n . Therefore less demanding a l t e r n a t i v e s without wr i t ten requirements can include pulse rate monitoring to re in force e f f o r t given, or mentally noting perceived exert ion , thoughts and f e e l i n g s . Rejeski and Kenney (1988) found that se l f -moni tor ing in the form of thoughts and fee l ings was a usefu l way to analyse and rest ructure negative thought patterns which could cause drop-out. Success in s e l f -regu lat ion i s l a r g e l y dependent on the accuracy of s e l f -observation as t h i s process provides the necessary information to make appropriate changes and enhance performance. Zimmerman and Schunk (1989) noted, however, that s e l f - r e g u l a t i o n often requires more preparat ion time, v i g i l a n c e , and e f f o r t . Therefore, unless the outcomes of these e f f o r t s are s u f f i c i e n t l y a t t r a c t i v e , people may not be motivated to s e l f -regu late . Time management, Perceived lack of time i s a main concern for those who intend to exerc ise , but do not (Godin, 1986). Studies, however, found no evidence to suggest that people who d id not exerc ise had any less time than people who exerc ised (Canadian Nat ional Health Promotion Survey, 1988, Shephard, 1985). This may suggest that the problem i s less about having time a v a i l a b l e but rather about making bet ter use of ava i lab le time through time management techniques. It could also be 31 interpreted as a simple case of post-hoc r a t i o n a l i s a t i o n . People who set t h e i r p r i o r i t i e s i m p l i c i t l y rather than e x p l i c i t l y probably use time as an excuse for not doing the things lower on t h e i r i m p l i c i t hierarchy of p r i o r i t i e s . I f i t i s a matter of poor time management, however, then weekly and d a i l y time management strategies have the p o t e n t i a l to be e f f e c t i v e methods of ensuring that regular exercise w i l l take place and hence be part of a person's l i f e s t y l e . The process of time management involves an i n d i v i d u a l i d e n t i f y i n g his or her f i x e d and desired commitments that he or she would l i k e to f i t into a d a i l y or weekly schedule. These commitments are then placed into a detailed and structured schedule i n order of p r i o r i t y . P r i o r i t i s i n g i s thus a major component of time management. If no free time i s available for exercise then a l t e r n a t i v e methods of increasing e x i s t i n g a c t i v i t y time can be achieved (e.g., walking or c y c l i n g either part or a l l of the way to work, using the s t a i r s regularly rather than using an elevator, and walking during the lunch hour period). Buffone, Sachs and Dowd (1984), suggested that an advantage of exercising on s p e c i f i c days and even at s p e c i f i c times i s that exercise becomes an i n t e g r a l part of a person's day. Implicit i n t h i s view i s that the l i k e l i h o o d of missing exercise i s reduced as the habit becomes reinforced. This approach used i n i s o l a t i o n , however, tends to underscore the importance of predisposing factors, i n p a r t i c u l a r , thoughts, feelings and sensations of the actual exercise experience. 32 Tension contro l The judgement of p h y s i o l o g i c a l arousal and emotional states i s an important source of s e l f - e f f i c a c y information (Bandura, 1986). Hagberg (1990) suggested that exerc ise i s a natura l release mechanism for e f f e c t i v e l y deal ing with s t ress and tens ion . However, i t i s a lso a phys i ca l s t ressor , thus the nature of the exerc ise session w i l l determine whether t h i s i s perceived as a p o s i t i v e or a negative s t r e s s o r . It i s widely be l ieved that there i s an inverted "U" r e l a t i o n s h i p between phys i ca l performance and arousal l e v e l s . According to Albinson and B u l l (1988), there i s an i d e a l range of arousal at the centre of t h i s curve where one achieves an optimal performing state , though t h i s w i l l vary between s i tuat ions and between people. At an optimal range of arousal , one's performance i s character ised by r a t i o n a l , c r e a t i v e , relaxed and f luent movements, and e f f i c i e n t cogn i t ion . As arousal further increases, however, there i s an assoc iated performance decrement that i s character ised by overload, tens ion, discomfort, reduced sensory acu i ty , narrowing of a t t e n t i o n a l focus, and negative emotions (Albinson & B u l l , 1988). Conversely, too l i t t l e arousal can a lso produce a performance decrement. This i s character ised by a lack of goals, f r u s t r a t i o n , boredom, lack of stimulus and reduced e f f i c i e n c y . Therefore managing one's l e v e l of arousal during exerc ise p a r t i c i p a t i o n can a f fec t the fee l ings that accompany the exerc ise experience. Hardy and Rejeski (1989) concluded that both e f f o r t percept ion and the fee l ings assoc iated with such e f f o r t were important factors 33 that could inf luence the perceived enjoyment, reinforcement and l i k e l i h o o d of maintaining habi tua l phys i ca l a c t i v i t y . There are many ways to contro l arousal l e v e l s using sensory input and re laxat ion methods. However, i t requires regular p r a c t i c e to become p r o f i c i e n t at managing one's l e v e l of a rousa l . The fo l lowing examples are e f f e c t i v e methods for increas ing or decreasing arousal l e v e l s : (1) sounds / s e l f t a l k / music i n the exerc ise environment (2) s ights / imagery / l i g h t or dark exerc ise environment (3) smells i n the exerc ise environment (4) deep slow breathing (5) a t tent ion focus (d i ssoc ia t ion strategies) (6) speed of exercise movements (slow, rhythmic). These methods depend on the person and the nature of the s p e c i f i c sensory stimulus during the p a r t i c i p a t i o n i n h e a l t h -r e l a t e d exerc i se . For example, one may f e e l less tension during a b r i sk walk by maintaining a constant sustainable speed, attending to pleasurable thoughts, or the fresh a i r and f o l i a g e of the surrounding environment, than focusing on negative emotions, the exert ion of the exerc ise experience, or focusing on one feature in the v i c i n i t y of the exerc ise sess ion . Imagery Imagery re fers to the i n t e r n a l process of using v i s u a l , verbal and k inaesthet ic images to create thoughts, images, sensations, and fee l ings (Albinson & B u l l , 1988). This technique can be used i n many d i f f e r e n t ways and has been very success fu l with the use of ath letes to improve t h e i r 34 performance and increase t h e i r coping strategies to face errors (Vealey, 1986). In a similar way, p o s i t i v e imagery has a p o t e n t i a l role i n enhancing exercise adherence. For example, a person could imagine a potential disruption to p a r t i c i p a t i n g in exercise and then use imagery to imagine possible successful solutions that overcome t h i s disruption. Second, a person may use imagery to reinforce his or her adherence to exercise by creating successful images of themselves with: muscle tone, slimness, and more energy i f they adhere to regular exercise. Third, the use of imagery has a potent role to play i n the thought processes that occur during p a r t i c i p a t i o n i n exercise. For example, one can dissociate to pleasurable thoughts and create the optimal performing state which i s enjoyable, comfortable and evokes well-being. Fourth, imagery can be used as an e f f e c t i v e method of modelling. According to Bandura (1986), seeing and modelling other people of s i m i l a r d i s p o s i t i o n who successfully perform the desired behaviour ( p a r t i c i p a t i o n in^exercise) can increase s e l f -e f f i c a c y . Vicarious learning through imagery can thus reduce the resistance that stems from the uncertainty of the outcome and allows the learner to extract the e s s e n t i a l elements from the observation to adopt regular exercise behaviour. Attention control Attention control i s the a b i l i t y to select and focus one's attention on the relevant information (sight, sounds, thoughts), while being aware of the non relevant information but paying no attention to i t , i . e . , l e t t i n g those thoughts go out of one's mind. Association and 35 d i s s o c i a t i o n are at tent ion s t ra teg ies used during phys i ca l a c t i v i t y . In assoc ia t ion , performers focus on t h e i r bod i ly sensations ( resp i ra t ion , temperature, muscular fee l ings and abdominal sensations e t c . ) . Assoc ia t ing to one's perceived l e v e l of exert ion i s l i k e l y to maintain appropriate i n t e n s i t y l e v e l s and s e l f - p a c i n g for performance-related exerc ise , thus avoiding the negative consequences of fat igue or in jury (Buffone et a l . , 1984). However, in terms of h e a l t h - r e l a t e d exerc ise , the l i t e r a t u r e supports greater adherence when people d i s s o c i a t e and purposely cut themselves o f f from sensory feedback, and instead focus on d i s t r a c t i n g thoughts such as aspects of the route ahead, t a l k i n g , s ing ing, p leasurable or successfu l problem-solving thoughts, e t c . (Martin et a l . , 1984). Johnson and S iega l (1992) examined the e f f e c t of d i f f e r e n t assoc iat ion and d i s s o c i a t i o n techniques on e f f o r t percept ion . They found that groups who employed d i s s o c i a t i o n s t rateg ies during aerobic exerc ise perceived the e f f o r t to be much less during submaximal exerc ise than the group who used an assoc iat ion s t rategy . Thus, i t appears that d i s s o c i a t i o n s t rateg ies can enhance exerc ise adherence by reducing the perception of e f f o r t , the phys i ca l discomfort, and exerc ise boredom. D i ssoc ia t ion i s most e a s i l y achieved at a gentle slow pace, once the body i s locked into a steady state speed and ga i t or rhythm the person i s re laxed. P o s i t i v e th ink ing Bandura (1986) suggested that s i t u a t i o n a l factors dominate over personal t r a i t factors i n determining se l f - conf idence . Confidence i s t a s k - s p e c i f i c and 36 can be described as a state of thinking, f e e l i n g , and behaving. Attributions are the way that people t y p i c a l l y explain behaviour. Thus, i n terms of exercise p a r t i c i p a t i o n , a t t r i b u t i o n s can p o t e n t i a l l y affect future emotions, thoughts and subsequent exercise behaviour. For example, i f people perceive that the reasons why they are inactive are due to factors beyond t h e i r control (e.g., lack of a b i l i t y ) , they are l i k e l y to remain i n a c t i v e . In contrast, i f they a t t r i b u t e t h e i r lack of a c t i v i t y to controllable factors (e.g., i n e f f e c t i v e time management, poor goal setting, and inappropriate focusing), they are more l i k e l y to f e e l confident and thus succeed at making changes i n the future. According to Kendzierski and Johnson (1993), cognitive behaviour theory implies that to change behaviour, one must f i r s t i d e n t i f y and then modify the maladaptive thoughts which support i t . Verbal persuasion, i n the form of p o s i t i v e s e l f -t a l k , i s i d e n t i f i e d as an important source of s e l f - e f f i c a c y information. Wilkes and Summers (1984) found that personal s e l f - t a l k and personal perceptions of the costs and benefits of exercise were an e f f e c t i v e strategy for increasing exercise s e l f - e f f i c a c y and influencing behaviour. Buffone, Sachs and Dowd (1984) suggested that maladaptive self-statements that dwell on self-doubt or obstacles are detrimental to exercise adherence, e.g., "I'm just not the active type" or "I've got no w i l l power." Studies have shown that cognitive restructuring (re-phrasing negative statements to p o s i t i v e and a t t r i b u t i n g set-backs to unstable factors rather than stable 37 personality c h a r a c t e r i s t i c s ) coupled with immediate rescheduling of the missed walking/jogging session enhanced exercise adherence (Atkins et a l . , 1984; King et a l . , 1988). For example, "I can walk to work at least once each week", "I fe e l good a f t e r I have been exercising", " I f I'm covered up, I can go out i n any weather", or "It's great to be outdoors and in the fresh a i r , whatever the weather." Gauvin (1990) concluded that exercise adherers tended to engage i n po s i t i v e and motivational s e l f - t a l k while drop-outs and sedentary people engaged i n negative and derogatory s e l f - t a l k . Table 1 represents a summary of studies following index searches on Medline, Psych Abstracts, ERIC, CD Rom (Sportsdiscus), and a personal l i b r a r y search of relevant publications, pertaining to evaluations of i n d i v i d u a l and combined self-regulatory cognitive and behavioural s k i l l s programs on exercise behaviour. 38 Table 1. Self-Regulatory Cognitive and Behavioural Intervention Strategies and Exercise Behaviour Author, Date Subjects/ Sample Size/ Context Physical Activity Setting/ Duration Intervention Strategies Design Outcomes Atkins et al. (1984) 76 male and female, COPD patients Daily walking X 3 months Cognitive modification, behavioural modification, cognitive-behavioural modification and attention control Experimental Significant increase and maintenance of walking in cognitive-behavioural group Baile and Engel (1979) 7male,CHD patients Walking, 12-16 weeks Goal setting, self-monitoring Pre-experimental Increase in self-report exercise levels Brownwell et al. (1980) 24,603 male and female, community adults Stair-climbing, 1 month observations Stimulus control (poster prompts) Quasi-experimental Increase in stair-climbing, maintenance at 1 month, 3-month follow-up. Hoyt and Janis (1975) 50 females, faculty and graduate students Exercise class, ACSM, 7 weeks Decision-balance sheet Experimental Increase in attendance for 5 weeks Jarvie and Thompson (1985) 16 overweight males and females Home exercise cycle 17-22 weeks Self-monitoring Quasi-experimental Slight increase in exercise frequency Johnson and Siegal (1993) 44 college females Bicycle ergometre, 60% V02 max Attention control, dissociation/as sociation and rating of perceived exertion (RPE) Experimental Dissociation was significantly related to reduced RPE. while no significant differences in heart rate Juneau et al. (1987) 120 male and female Lockheed employees Home based walk/jog program, 24 weeks Self-monitoring , goal setting Experimental Increase in V02 max., male decrease in weight Martin et al. (1984) 143 male and female adults, community Walk/jog, 2 X per week, 10-12 weeks Goal setting, modelling, feedback, attention control Quasi-experimental Increase in attendance and maintenance of exercise at 3-month follow-up 39 Oldridge and Jones (1983) 120 male CHD patients Walking ACSM, 6 months Goal setting, self-monitoring Experimental Increase in attendance Wankel et al. (1985) 52 female adults, community Exercise class X 1 per week, 5 weeks Decision-balance sheet, social support Experimental Increase in attendance Weber and Wertheim (1989) 55 female adults, community Exercise class X 12 weeks Self-monitoring, social reinforcement Experimental Increase in attendance (self-monitoring) In a review of the behaviour modification and exercise adherence l i t e r a t u r e , Leith and Taylor (1992) concluded that c e r t a i n interventions designed to develop a vari e t y of s e l f -regulatory cognitive and behavioural s k i l l s have contributed s i g n i f i c a n t l y to increasing and maintaining physical a c t i v i t y l e v e l s (e.g., self-monitoring and feedback, Martin, Dubbert, K a t e l l , Thompson, Raczynski, Lake, Smith, Webster, Sikova, & Cohen, 1984, Oldridge & Jones, 1983, and Owen, Lee, & Sedgewick, 1987; decision making, Wankel, Yardley, & Graham, 1985; and relapse prevention t r a i n i n g , B e l i s l e , Roskies, & Levesque, 1987) . Dishman (1991) reported that when these techniques are compared with no-treatment control groups, they are usually associated with a 10-25% increase i n frequency of pa r t i c i p a t i o n , but t h e i r impact on changes i n i n t e n s i t y and duration of physical a c t i v i t y are less c l e a r . Atkins, Kaplan, Timms, Reinsch, and Loftback (1984) compared d i f f e r e n t methods of self-regulatory cognitive and behavioural modification strategies (behaviour modification, cognitive modification, cognitive behavioural modification, attention control and no treatment group) to increase adherence to a walking program 40 for patients s u f f e r i n g from chronic obstructive pulmonary disease. They found that the most e f f e c t i v e method was the combined approach of self-regulatory cognitive and behavioural modification. In c r i t i c i s m of the studies cit e d , they have focused almost exclusively on the application of self-regulatory cognitive-behavioural s k i l l s in a prescribed exercise s e t t i n g rather than on s p e c i f i c health education approaches to develop these s k i l l s i n d i v i d u a l l y and s o c i a l l y for s e l f - d i r e c t e d regular exercise. Further, Kendzierski and Johnson (1993, p.208) noted that, "the cognitive behavioural approach focuses attention not on the myriad of obstacles a would-be exerciser may face as he or she contemplates exercising at any given time, but on the thoughts the i n d i v i d u a l has i n regard to these obstacles." In terms of behavioural change, t h i s perspective c l e a r l y places an emphasis on predisposing factors and only i n d i r e c t l y on enabling and r e i n f o r c i n g factors. It does not, however, address environmental factors that influence a behaviour change. Relapse prevention t r a i n i n g and s e l f - e f f i c a c y Relapse Prevention Training (Marlatt & Gordon, 1985) i s an example of s e l f - r e g u l a t i o n and incorporates a v a r i e t y of cognitive and behavioural strategies for behaviour change. This was developed i n i t i a l l y i n an e f f o r t to explain the lack of adherence to abstinence i n r e l a t i o n to addictions associated with smoking, alcohol and drugs. It i s i n f e r r e d that the process of exercise adherence may bear some 41 resemblance to the relapse e f f e c t studied i n these other health contexts. However, Knapp (1988) noted that unlike those other health behaviours, the desired exercise behaviour i s a low frequency yet desired behaviour. Furthermore, exercise behaviour i s often more time consuming and requires more e f f o r t than most other health behaviours. The extent, therefore, to which a p a r a l l e l can be drawn between exercise and addictive behaviour remains as yet unclear. Relapse Prevention Training i s based on acquiring coping strategies for unexpected disruptions which can interrupt or end previously continuous exercise. Marlatt and Gordon (1985) suggested that a lack of coping response w i l l lead to a decrease i n s e l f - e f f i c a c y and therefore an expectancy of further relapse. This could lead to the abstinence v i o l a t i o n e f f e c t ( i . e . , feelings of g u i l t and lack of control) and, depending upon the degree, could sustain relapse. Therefore, the magnitude of these disruptions and the p r o b a b i l i t y of relapse w i l l be reduced i f the i n d i v i d u a l develops s e l f -regulatory s k i l l s and i n turn increases s e l f - e f f i c a c y . Following index searches on Medline, Psych Abstracts, ERIC, and CD Rom (Sportsdiscus), and a personal l i b r a r y search of relevant publications, Table 2 represents a summary of studies pertaining to evaluations of relapse prevention t r a i n i n g programs on exercise behaviour. 42 T a b l e 2 . R e l a p s e P r e v e n t i o n T r a i n i n g : S e l f - R e g u l a t o r y C o g n i t i v e and B e h a v i o u r a l I n t e r v e n t i o n S t r a t e g i e s and E x e r c i s e B e h a v i o u r Author, date Subjects/ Sample Size/ Context Physical Activity Setting/ Duration Intervention Strategies Design Outcomes Belisle et al. (1987) 350 male and female, adults community Exercise class X 2 sessions per week, 10 weeks Relapse prevention training (RP.T.) Quasi-experimental Increase in attendance and 12 week maintenance of exercise King and Frederiksen (1984) 58 student females Jogging ACSM X 5 weeks R.P.T. Experimental Increase in jogging and self-reported maintenance at 2 months King et al. (1988) 52 male and female Lockheed employees Home-based walk/jogging X 1 year R.P.T. Experimental Increase in frequency of exercise Marcus and Stanton (1993) female adults Exercise class ACSM R.P.T. Experimental No difference in attendance levels or exercise behaviour Owen et al. (1987) Male and female adults Walk/jogging RP.T. Quasi-experimental No difference in exercise behaviour Intervention studies with exercise classes have reported greater increases i n both short-term frequency and long-term adherence to exercise for experimental groups who have received relapse prevention t r a i n i n g than for control groups who received standard health information ( B e l i s l e et a l . , 1987; King & Fredericksen, 1984; King, Taylor, Haskell, & Debusk, 1988; and Vogel-Burger, 1990). Marcus and Stanton (1993) d i d not support these findings, however, and c a l l e d for 43 more research to be conducted before conclusions on the ef f i c a c y of the relapse prevention model for increasing exercise behaviour can be reached. Stages of behaviour change and s e l f - e f f i c a c y It i s often easier to i n i t i a t e a behavioural change than i t i s to maintain one. Prochaska and DiClemente's (1985) tran s t h e o r e t i c a l (addressing diverse psychological theories) model emphasises dynamic processes and stages as core dimensions for understanding how people develop toward a behavioural change. This model postulates that indi v i d u a l s engaging i n a new behaviour do not move sequentially, but rather progress i n a c y c l i c a l pattern through f i v e stages of behaviour change. This c y c l i c a l model i s consistent with evidence that success for many i s achieved only a f t e r several relapses. Relapse i s thus acknowledged as the norm throughout the process of a behaviour change rather than the exception. Relapse, however, can be viewed less negatively because people may r e f l e c t on the experience and gain a useful insight to strategies that may be useful to prevent relapse i n the future. Evidence i s accumulating to support the e f f i c a c y of the stages of behaviour change when the tran s t h e o r e t i c a l model i s applied to a variety of health behaviours (e.g., cessation of smoking, alcohol and drug use, weight control and breast cancer screening). This framework takes into account both actual health behaviour and intentions regarding future health behaviour. It has i n t u i t i v e appeal for many p r a c t i t i o n e r s i n 44 health promotion who are under pressure to show some evidence of change following p a r t i c u l a r interventions. Rather than r e l y on i n s e n s i t i v e behavioural measurements, the stages of behaviour change provides a r e l a t i v e l y simple and robust measure of change that can be used to p a r t l y assess an intervention. Marcus, Selby, Niaura and Rossi (1992) adapted t h i s model to exercise p a r t i c i p a t i o n and proposed that indiv i d u a l s move in a c y c l i c a l manner through the stages of: Precontemplation (no intention of exercising regularly), Contemplation (intention to exercise regularly), Preparation (not only thinking about doing exercise, but has started a l i m i t e d amount of i t ) , Action (recently involved i n regular exercise as recommended by the American College of Sports Medicine, 1990), and Maintenance (engaged i n regular exercise for at least s i x months). Within each stage of behaviour change, an i n d i v i d u a l experiences ten p r i n c i p l e processes of change: consciousness r a i s i n g , s e l f - l i b e r a t i o n , dramatic r e l i e f , environmental reevaluation, helping relationship, stimulus control, counter-conditioning, s o c i a l l i b e r a t i o n , s e l f -reevaluation, and reinforcement management (Prochaska & DiClemente, 1985). Table 3 represents a summary of yet another group of studies based on the same search strategy as with Tables 1 and 2 but with a l t e r n a t i v e key words pertaining to evaluations of stages of behaviour change intervention programs. 45 Table 3. Stages of Exercise Behaviour Change: Self-Regulatory Cognitive and Behavioural Intervention Strategies and Exercise Behaviour Author, Subjects/ Program Intervention Design Outcomes Date Sample Format / Strategies Size/ Physical Context Activity Marcus et al. 610 male and Self- Developing Pre- Increase in (1992) female management self-efficacy, experimental stages of employees program for social support, exercise (77% Female) exercise behavioural behaviour behaviour in contracting change, self-the workplace, efficacy and 2 sessions per self-reported weekX 1 exercise month behaviour Prochaska et 184 male and Self- Developing Quasi- Increase in al. (1992) female management self-efficacy, experimental stages of employees program for social support change and (90% female) weight control weight control in the self-efficacy workplace, 10 week program and 4 follow-up sessions Marcus et al. ? Staged- Developing Experimental At 3-month (In Press) matched self- self-efficacy, follow-up management social support, subjects in the program for behavioural staged-exercise contracting matched behaviour in intervention the workplace, showed 2 sessions per positive weekX 1 change in month comparison to subjects in a standard self-management program In a workplace exercise behaviour study with 431 women, Marcus, Pinto, Simkin, Audrain and Taylor (1994) found that 8.2% were i n the precontemplation stage, 30.4% were i n the 46 contemplation stage, 33.9% were in the preparat ion stage, 12.4% were in the act ion stage and 15.1% in the maintenance stage. Stages of change encompass both behaviour and behavioural intent ions (Marcus et a l . , 1996). An assumption when using the stages of behaviour change model, however, as with most models, i s that one's intent ions and s e l f - r e p o r t e d heal th p rac t i ces cor re la te h ighly with actual behaviour. In add i t ion , i t i s not known as yet which time frame (six months i s t y p i c a l l y used) would be appropriate for instruments to d i s t i n g u i s h between the stages of behaviour change. It i s postulated that people vary i n the time they spend in each stage before progress ing. There i s uncerta inty in the l i t e r a t u r e , however, as to exact ly which processes are involved and when s p e c i f i c processes are involved among the stages of behaviour change. Worksite evaluat ion s tud ies , assessing s t a g e - s p e c i f i c s e l f - e f f i c a c y and stages of behaviour change intervention programs for weight control and exercise p a r t i c i p a t i o n (Marcus, P into , Simkin, Audrain, & Taylor , 1994; Marcus, Selby, Niaura, & Ross i , 1992; Prochaska, Norcross, Fowler, F o l l i c k , & Abrams, 1992), have found s u f f i c i e n t evidence to advocate for the d i f f e r e n t i a l employment of se lected change processes at s t r a t e g i c times i n the course of change, i n order to meet the s p e c i f i c needs of those who are expected to change. Marcus et a l . (1992) studied 1,063 governmental employees and found that employees could be d i f f e r e n t i a t e d by the stages of exerc ise behaviour change and exerc ise s e l f - e f f i c a c y . A 47 s i g n i f i c a n t r e l a t i o n s h i p between s e l f - e f f i c a c y and the stages of exerc ise behaviour change suggests that intervent ion programs should focus on developing a range of s e l f - r e g u l a t o r y cogni t ive and behavioural s k i l l s in order to increase s e l f -e f f i c a c y for i n d i v i d u a l s who are at d i f f e r e n t stages of exerc ise involvement. Research has recent ly demonstrated the u t i l i t y of in tegra t ing theor ies of s e l f - e f f i c a c y , stages of behaviour change and reasoned act ion i n the p red ic t ion of regular exerc ise (Courneya, 1995; Dzewaltoski, 1993; Godin, 1994; McAuley & Courneya, 1993). Developing exercise s e l f - e f f i c a c y According to Bandura (1986), there are four main sources whereby s e l f - e f f i c a c y can be increased: performance attainment, v i c a r i o u s experience, verbal and s o c i a l persuasion, and contro l of p h y s i o l o g i c a l and emotional s t a t e s . These sources are described and examples of s e l e c t i v e s e l f -regulatory cogn i t ive and behavioural s k i l l s are i d e n t i f i e d that can be developed to increase p a r t i c u l a r sources of s e l f -e f f i c a c y . Performance attainment i s the most i n f l u e n t i a l source of s e l f - e f f i c a c y information and i s based on authentic mastery experiences by the i n d i v i d u a l . This can be developed through the use of the fo l lowing examples of s e l f - r e g u l a t o r y cogni t ive and behavioural s t r a t e g i e s : a decis ion-balance sheet, a t t e n t i o n a l focus, e n l i s t i n g s o c i a l support, goal s e t t i n g , imagery, p o s i t i v e th ink ing , se l f -moni tor ing , stimulus c o n t r o l , tension contro l and time management; v i ca r ious 48 experience refers to learning a behaviour through v i s u a l i s i n g or watching others perform successfully. This can be developed through the use of the following examples of self-regulatory cognitive and behavioural s k i l l s : attentional focus, e n l i s t i n g s o c i a l support, imagery, p o s i t i v e thinking and tension control; verbal and s o c i a l persuasion refers to o r a l feedback from s i g n i f i c a n t others or by using p o s i t i v e s e l f - t a l k . This can be developed through the use of the following examples of self-regulatory cognitive and behavioural s k i l l s : attentional focus, e n l i s t i n g s o c i a l support, goal setting, imagery, p o s i t i v e thinking, self-monitoring and tension control; and control of emotional and physiological states refers to an awareness and management of in t e r n a l body states. This can be developed through the use of the following examples of s e l f -regulatory cognitive and behavioural s k i l l s : a ttentional focus, goal-setting, imagery, p o s i t i v e thinking, s e l f -monitoring and tension control. A review of the l i t e r a t u r e reveals few studies that have focused s p e c i f i c a l l y on evaluating worksite health education programs that are intended to develop exercise s e l f - e f f i c a c y and increase p a r t i c i p a t i o n i n regular exercise. A number of related studies i n other settings, however, provide some di r e c t i o n to assess developments i n t h i s f i e l d . Table 4 represents a summary of studies following the same index searches as Tables 1-3 and a personal l i b r a r y search of relevant publications pertaining to evaluations of intervention programs directed at increasing s e l f - e f f i c a c y . 49 Table 4. S e l f - E f f i c a c y : Self-Regulatory Cognitive and Behavioural Intervention Strategies Author, Date Subjects/ Sample Size/ Context Program Format / Physical Activity Intervention Strategies Design Outcomes Allegrante et al. (1993) 92 male and female adult osteoarthritis patients Walking and education program, 3 X 1.5 hour sessions per week X 8 weeks Self-efficacy, relapse prevention training, behavioural contracting Experimental Increase in walking distance and frequency, decrease in pain and medication use Jemmot and Jemmot (1992) 109 single black women Self-management of condom-use, 3 sessions X 1.5 hours Imagery, modelling, social support, communicatio n skills, goal setting Pre-experimental Increase in self-efficacy and perceived partner support Long and Gonzalez (1992) 597 adult arthritis patients Self-management of arthritis and physical activity Imagery, planning, tension control, verbal persuasion Experimental Increase in self-efficacy and health status McAuley and Courneya (1995) 114 middle-aged males and females Walking program, 20 weeks Developing self-efficacy Experimental Increase in attendance, duration of physical activity and walking distance Rose (1992) 155 elderly male and female Peer-education program to reduce CHD and increase SE, 2 sessions per week X 1 month and 2 follow-up sessions Imagery, modelling, self-talk, tension control, goal setting Quasi-experimental Increase in CHD knowledge, increase in dietary and exercise self-efficacy Lorig and Gonzalez (1992) compared 500 subjects i n a general a r t h r i t i s s e l f - h e l p program to 97 subjects i n a program designed on the p r i n c i p l e s of developing s e l f -50 e f f i c a c y . They found that the s e l f - e f f i c a c y program showed a greater increase i n health status and s e l f - e f f i c a c y . Lorig and Gonzalez noted, however, that there was no evidence to suggest d i r e c t causality, hence the inte r a c t i o n of other mechanisms may be involved to change both factors or that a change i n health status may affe c t s e l f - e f f i c a c y . They c a l l e d for more interventions to integrate theory with p r a c t i c e . Allegrante, Kovar, MacKenzie, Peterson and Gutlin (1993) studied a hospital-based patient education program, based on the Precede-Proceed Model, designed to enhance the functional capacity of patients with o s t e o a r t h r i t i s of the knee. The program consisted of an 8-week walking and education program that focused on developing exercise s e l f - e f f i c a c y . F o r t y - f i v e subjects entered a control group while forty-seven subjects received the intervention program. The res u l t s indicated that the intervention group increased exercise s e l f - e f f i c a c y and showed c l i n i c a l l y meaningful improvements i n functional status that were s i g n i f i c a n t l y greater than the control group. Research has made a s i g n i f i c a n t contribution thus far toward the assessment of s e l f - e f f i c a c y based health education programs that are intended to increase and maintain health behaviour. The l i m i t a t i o n s of outcome-based research of t h i s nature, however, i n the absence of field-based randomised f a c t o r i a l design studies, are that they do not inform us as to why p a r t i c u l a r self-regulatory strategies within the program are more e f f e c t i v e than others during post-program implementation, neither i s i t clear how p a r t i c u l a r strategies 51 are appl ied in the context of l o c a l implementation. Furthermore, the context of worksite health education programs with 20-30 p a r t i c i p a n t s requires the cons iderat ion of more r igorous planning, teaching and learn ing frameworks than do those studies c i t e d regarding i n d i v i d u a l i s e d pat ient education programs. S e l f - r e g u l a t i o n of exercise behaviour: A summary and c r i t i c a l analysis Tables 1-4 represent a summary of 23 studies fo l lowing index searches per ta in ing to evaluat ions of exerc ise behaviour change intervent ions using Medline, Psych Abstracts , ERIC, and CD Rom (Sportsdiscus) , and a personal l i b r a r y search of re levant p u b l i c a t i o n s . The review i s l i m i t e d to studies employing approaches from the t r a d i t i o n s of psycholog ica l behaviour modi f i cat ion in c l i n i c a l , community and workplace s e t t i n g s . Studies are c l a s s i f i e d by intervent ion type and l i s t e d a l p h a b e t i c a l l y . Subjects and context Studies have used d i f f e r e n t sample s izes ( e . g . , n = 7 -24, 603), d iverse subjects ( e . g . , males and/or females, u n i v e r s i t y students, ch i ld ren , pat ients , employees and f i t n e s s c lass par t i c ipants) and have been conducted in a v a r i e t y of s e t t i n g s . From an experimental ist perspect ive , t h i s inconsistency has not aided the g e n e r a l i z a b i l i t y of these f ind ings and thus presents equivocal guide l ines for increas ing exerc ise adherence. It could be argued, however, that 52 extensive p o s i t i v e outcome data across a v a r i e t y of set t ings does add considerable support for the e f f i c a c y of exerc ise behaviour in tervent ions . Caution i s warranted, however, i n the i n t e r p r e t a t i o n of these data since the f indings are not conclusive due to methodological concerns reported with a l l of the studies c i t e d . Phys ica l a c t i v i t y and durat ion The type of phys i ca l a c t i v i t y var ied from study to study ( e . g . , exerc ise c l a s s , walking programs, s t a i r c l i m b i n g ) . Only two studies (Jarvie & Thompson, 1985; Juneau, 1987) reported evaluat ing unsupervised aerobic exerc ise programs ( e . g . , home-based walking, jogging), the remainder focused on supervised programs t y p i c a l l y i n exerc ise c lasses or f i t n e s s programs. Research by Stephens, Jacobs and White (1985), found that people prefer ( p a r t i c u l a r l y among those who are i n i t i a l l y un f i t ) moderate i n t e n s i t y a c t i v i t i e s ( e . g . , b r i s k walking) and those they can perform i n d i v i d u a l l y , as opposed to more vigorous a c t i v i t i e s or a f i t n e s s regime in a s t ructured s e t t i n g . This was supported by the Canadian F i tness and L i f e s t y l e Research I n s t i t u t e (1990), who found that the majority of Canadians ind icated that t h e i r main involvement i n phys i ca l a c t i v i t y for f i t n e s s was through t o t a l l y unstructured a c t i v i t i e s such as walking, gardening, swimming and c y c l i n g . Green and Ottoson (1994) reported i n t h e i r survey of the l i t e r a t u r e that increas ing phys ica l f i t n e s s through a 30-60 minute d a i l y walk may reduce an u n f i t man's and an u n f i t woman's r i s k of ear ly death by 37% and 50% r e s p e c t i v e l y . It 53 would appear, therefore, that promoting brisk walking has considerable advantages to sustaining an individual's p a r t i c i p a t i o n i n regular exercise. It i s important to note, however, that people's needs and preferences do d i f f e r and change over time, thus promoting a range of aerobic a c t i v i t i e s that present minimal barr i e r s to p a r t i c i p a t i o n (e.g., unsupervised cycling, jogging, swimming) i s l i k e l y to appeal to a range of people i n health education programs over a long period of time. Intervention strategies A c r i t i q u e of intervention strategies has been addressed e a r l i e r i n the l i t e r a t u r e review for s p e c i f i c c l a s s i f i c a t i o n s of intervention. E s s e n t i a l l y , studies showed an inconsistent use of s p e c i f i c intervention strategies, rather, a v a r i e t y of strategies were employed. Furthermore, multi-component intervention programs have been evaluated as a single comprehensive program. Consequently, the l i t e r a t u r e i s not yet clear as to which self-regulatory cognitive and behavioural s k i l l s are best for s p e c i f i c people i n p a r t i c u l a r settings and how s p e c i f i c strategies are applied i n the context of l o c a l implementation. It would appear, however, that a range of self-regulatory cognitive and behavioural s k i l l s developed for people i n d i f f e r e n t stages of exercise behaviour w i l l increase s e l f - e f f i c a c y and therefore enhance the p a r t i c i p a t i o n i n regular.exercise. 54 Design Studies were categorised using Campbell and Stanley's (1963) c l a s s i f i c a t i o n s of experimental design. Experimental designs provide optimal i n t e r n a l and external v a l i d i t y . Random assignment of participants to groups and randomised groups to treatments are c h a r a c t e r i s t i c of t h i s type of design. These designs include pre-posttest control group designs, Solomon four-group designs and post-test only control group designs. Quasi-experimental designs include time series designs and are characterised by non-equivalent control groups. Pre-experimental designs include pre-and post-test designs with no control or comparison groups against which to gauge the changes i n the treatment group. Of the studies cited, t h i r t e e n studies involved experimental designs, seven studies involved quasi-experimental designs and three studies involved pre-experimental designs. Despite the rigorous s u p e r i o r i t y of experimental designs, no single intervention emerged as a better strategy. S p e c i f i c l i m i t a t i o n s and methodological concerns, however, were reported within each type of intervention c l a s s i f i c a t i o n . Quasi-experimental designs enable research to be conducted i n the f i e l d context and therefore have more appeal to p r a c t i t i o n e r s . The absence of randomising subjects to groups however, requires caution i n in t e r p r e t i n g outcomes from these studies. Pre-experimental designs that use pre- and post-test data are favoured i n unique settings where i t i s not possible to include s u f f i c i e n t subjects i n studies 55 for a control or a no-treatment control group. Research of t h i s nature lends i t s e l f to focusing program evaluation from alte r n a t i v e epistemological perspectives, i n which c o n t r o l l i n g for i n t e r n a l and external v a l i d i t y are not considered c r i t e r i a for q u a l i t y research. Outcomes Despite the number of studies that have investigated exercise behaviour change, there i s l i t t l e agreement i n the l i t e r a t u r e with respect to a consistent d e f i n i t i o n of exercise adherence. This has resulted i n multiple i n d i r e c t and d i r e c t measures of exercise adherence including self-reported exercise behaviour, physiological monitoring, self-reported exercise behaviour change and s e l f - e f f i c a c y , maximum oxygen uptake, exercise frequency, exercise duration, points accumulation and attendance at exercise classes. In spite of acknowledged l i m i t a t i o n s i n self-report data, few studies a t t e m p t e d to triangulate data c o l l e c t i o n f r o m multiple perspectives. Evidently, the measures of exercise behaviour need to be standardised before the l i t e r a t u r e can claim with any r e p l i c a t i o n that behaviour change strategies do af f e c t exercise behaviour for diverse people i n a vari e t y of settings. Studies have tended to focus on health outcomes for evaluating behaviour change interventions, yet many of the studies were of less than a 12-week duration. According to the American College of Sports Medicine (1990), r e l i a b l e f i t n e s s changes require substantial increases i n exercise i n t e n s i t y 56 for periods of 8-20 weeks or longer times at lower i n t e n s i t i e s of exerc i se . Furthermore, the r e l i a b i l i t y of behaviour change intervent ions would be enhanced i f studies were repeated using the same subjects i n the same environmental s e t t i n g . C l e a r l y , t h i s presents a major challenge to researchers since t h i s i s p r a c t i c a l l y impossible to implement in f i e l d s e t t i n g s . The complexity and t rans ient nature of people 's needs and circumstances ra re ly match those of an experimental research agenda. With the exception of one study (Marcus & Stanton, 1993), a l l studies reported increases in measures of exerc ise adherence. It i s poss ib le , however, that so many p o s i t i v e outcomes reported from studies conducted in a v a r i e t y of set t ings with d iverse subjects may be suscept ib le to the Hawthorne e f f e c t (attention from a health pro fess iona l rather than the actual in f luence of a s p e c i f i c i n t e r v e n t i o n ) . Studies employing experimental design methods have not been able to adequately contro l for t h i s e f f e c t . Scr iven (1993), however, c a l l e d for more at tent ion to integrate personnel evaluat ion into program evaluat ion as t h i s i s a key factor in program outcomes. He suggested that good program evaluat ion should uncover and c o r r e c t l y report poor management and great c reat ive ta lent i n some aspect of the program. Conclusion This review analyses the p o t e n t i a l of psychological-based behaviour change intervent ions to increase and maintain regular exerc i se . S p e c i f i c a l l y , the review traces the h i s t o r i c 57 development of psycholog ica l based intervent ions from pre-Soc ia l Learning Theory to Bandura's (1986) S e l f - E f f i c a c y Theory and s e l f - r e g u l a t i o n for exerc ise behaviour change. A l t e r n a t i v e t h e o r e t i c a l frameworks have emerged in the psycho log ica l l i t e r a t u r e . Relapse prevention t r a i n i n g (Marlatt & Gordon, 1985), for example, received widespread a p p l i c a t i o n during the 1980's in preventing relapse from undesired heal th r e l a t e d behaviours. This framework, however, has been less successfu l for exerc ise behaviour change poss ib ly because exerc ise behaviour i s a des i red behaviour t y p i c a l l y requ i r ing more time and s o c i a l support than other health r e l a t e d behaviours. The Theory of Planed Behaviour (TPB), which superseded the Theory of Reasoned Act ion (TRA), has emerged in the l i t e r a t u r e with i n t u i t i v e appeal. E s s e n t i a l l y , t h i s framework has combined TRA, the stages of behaviour change and s e l f - e f f i c a c y i n an attempt to gain incremental explanation for exerc ise behaviour. Bandura (1995), however, i s very c r i t i c a l of the TPB, descr ib ing i t as " c a f e t e r i a s t y l e t h e o r i s i n g " at the expense of t h e o r e t i c a l coherency. Bandura argued that the number of var iab les inherent i n the TPB not only presents a methodological b a r r i e r for f i e l d research quest ionnaires but a lso ra i ses more' questions than provides guidance for understanding health behaviour change. Furthermore, he argued that the a r b i t r a r y stages of behaviour change do not capture transformational or q u a l i t a t i v e changes inherent i n a stage theory. Thus more research i s required on TPB before i t s widespread app l i ca t ion for exerc ise behaviour 58 change. Despite the c r i t i c i s m s aimed at the stages of behaviour change, i t presently provides a popular t o o l i n the f i e l d , which, when used in conjunction with other instruments provides useful feedback i n which to assess the e f f i c a c y of health promotion programs. A review of empirical studies suggests that s e l f -regulatory cognitive and behavioural intervention strategies enhance exercise behaviour change. Inadequacies i n methodological approaches to evaluating exercise behaviour change interventions, however, cast some doubt on the effectiveness and g e n e r a l i z a b i l i t y of s p e c i f i c behaviour change interventions. There i s a need, therefore, for more stringent research methodology combined with a willingness to embrace epistemological perspectives from a l t e r n a t i v e paradigms. This i s more l i k e l y to provide a greater insight to the process and outcomes of exercise behaviour change interventions. Future research would thus benefit by evaluating s e l f - e f f i c a c y based health education programs i n worksite settings with moderately large groups of employees, and focusing on factors and processes i n the context of post-educational a p p l i c a t i o n . To'conclude, the l i t e r a t u r e suggests, i n spite of methodological l i m i t a t i o n s , that developing self-regulatory s k i l l s and enhancing knowledge about the outcome benefits of p a r t i c i p a t i n g i n regular exercise, w i l l increase s e l f - e f f i c a c y and, therefore, reduce the d i f f i c u l t y that people experience i n adhering to regular exercise. This approach thus provides a 59 foundation for the core development of the proposed worksite L i f e s t y l e S k i l l s Motivat ion program (see Appendix A ) . It i s important to note, however, that s e l f - e f f i c a c y approaches centre the contro l for an exerc ise behaviour change on the i n d i v i d u a l , with p a r t i c u l a r emphasis on changes i n predisposing f a c t o r s . Contemporary adult learn ing theory from a s o c i o l o g i c a l perspect ive , in contrast , s i tuates the i n d i v i d u a l in a broad s o c i a l context. From t h i s perspect ive , mul t ip le factors in the s o c i a l environment are thought to . a f fec t the subject ive values placed on an expected outcome and one's b e l i e f to overcome b a r r i e r s , and are l i k e l y , therefore , to enable or re in force a behavioural change. Rudman (1986), for example, claimed that one's personal circumstances and s o c i a l i s i n g experiences are l i k e l y to play an important ro le i n determining how act ive one would tend to be over the l i f e course. Thus a s s i s t i n g people to overcome b a r r i e r s to exerc ise (enabling), as wel l as prov id ing phys ica l and s o c i a l supports (re inforc ing) i s l i k e l y the best way to a s s i s t those people who intended to do more exerc ise (Boothe', M a c a s k i l l , Owen, Oldenburg, Marcus, & Bauman, 1993). It would appear, therefore , that i n combination with other broader perspect ives of behaviour change, s e l f - e f f i c a c y and the stages of exerc ise behaviour change o f fe r d i r e c t i o n for reconceptual is ing the planning and assessment of worksite health education programs. 60 (b) EDUCATIONAL APPROACHES TO BEHAVIOUR CHANGE Educational perspectives, i n p a r t i c u l a r , adult learning theory have contributed to our understanding of the nature of adult learning for behaviour change. Contemporary adult learning theory, from a s o c i o l o g i c a l perspective, provides an a l t e r n a t i v e way of viewing and thinking about t h i s process. E s s e n t i a l l y , a s o c i o l o g i c a l perspective of adult learning situates i n d i v i d u a l s i n a s o c i a l , h i s t o r i c a l , geographical, p o l i t i c a l , economic and c u l t u r a l context and, therefore, these factors are key to adult learning for behaviour change. Contemporary adult learning theory provides guidance for broad intervention strategies i n a worksite health promotion program to a f f e c t change i n exercise behaviour. Adult learning theory There i s currently a lack of evidence to support adult learning as s i g n i f i c a n t l y d i f f e r e n t from pre-adult learning. Mezirow's (1990) perspective transformation, however, requires learners to become c r i t i c a l l y aware of how and why they attach the meanings the way they do to r e a l i t y . Individual development i s both a s o c i a l and psychological phenomenon (Tennant, 1 9 9 3 ). This l e v e l of maturity and experience i s t y p i c a l of adulthood. Si m i l a r l y , contemporary views of s e l f -d irected learning require a l e v e l of autonomy coupled with sophisticated c r i t i c a l r e f l e c t i o n that i s also commensurate with the s p e c i f i c c h a r a c t e r i s t i c s of adulthood. A growing number of adult learning theories (andragogy, s e l f - d i r e c t e d 61 learn ing and perspect ive transformation), therefore have suggested that the def in ing c h a r a c t e r i s t i c s of adult learn ing are the q u a l i t a t i v e d i f ferences between the adult learner and the c h i l d learner , and between the context of adulthood and the context of chi ldhood. No s ing le theory or perspect ive of learn ing i s adequate to expla in t h i s process, but rather , a v a r i e t y of theor ies have evolved in the l i t e r a t u r e that place a d i f f e r e n t emphasis on one or more of the fo l lowing fac tors : the' learner c h a r a c t e r i s t i c s , the process of learn ing and the. in f luence of context on l earn ing . Ear ly adult learning theory o r ig inated from a psycholog ica l perspect ive , s p e c i f i c a l l y the behaviour ist t r a d i t i o n . For example, Thorndike, Bregman, T i l t o n and Woodyard (1928) conducted laboratory research that focused on the r e l a t i o n s h i p between age and learn ing behaviour. They constructed a learn ing curve to show how the rate of learn ing , often determined by a s p e c i f i c t e s t - t a k i n g performance was found to dec l ine with age. Merriam and C a f f a r e l l a (1991), however, have since shown that dec l ines in the rate of learn ing are functions of non-cognit ive factors ( e . g . , s p e c i f i c t r a i n i n g , l e v e l of education, heal th and speed of response). Behaviour ist research gave way i n the seventies to a humanistic perspect ive of adult learn ing (Knowles, 1975). This p laced an emphasis on the c h a r a c t e r i s t i c s of adult learners and on formulating an a d u l t - s p e c i f i c "theory" of learn ing that focused on s e l f - d i r e c t e d learn ing . The fo l lowing review out l ines the development of s e l f - d i r e c t e d learn ing from 62 Knowles' (1970) concept of andragogy to broader s o c i a l contextual perspect ives of c r i t i c a l s e l f - d i r e c t e d learn ing . C r i t i c a l s e l f - d i r e c t e d learn ing provides the framework for the teaching and learn ing processes of the worksite heal th education program. S e l f - d i r e c t e d learn ing and adult education Knowles (1970, 1975, 1980) has been c red i ted by many adult educators with the o r i g i n and widespread p r a c t i c e of "andragogy". Knowles (1970) descr ibed andragogy as the art and science of he lp ing adults to learn and suggested that s e l f -d i r e c t e d learn ing should be the beacon to focus a l l adult l earners . He def ined s e l f - d i r e c t e d learn ing as, "a process in which i n d i v i d u a l s take the i n i t i a t i v e , with or without the help of others, in diagnosing t h e i r learn ing needs, formulat ing learn ing goals, i d e n t i f y i n g human and mater ia l resources for learn ing , choosing and implementing appropriate learn ing s t r a t e g i e s , and evaluat ing learn ing outcomes" (p.18). In contrast , he i n i t i a l l y re fer red to "pedagogy" as the art and science of help ing ch i ld ren to learn through a teacher-centred approach. In c r i t i c i s m , E l i a s (1979) countered that andragogy was simply a smoke screen for attempting, to j u s t i f y a separate f i e l d of adult education. He suggested that t h i s concept was no more than "progressive education", a term used throughout education to descr ibe a s h i f t i n g trend away from teacher-centred l e a r n i n g . Others in the l i t e r a t u r e were less concerned with Knowles 1 c la im for an a d u l t - s p e c i f i c theory, but rather , 63 andragogy's implied exclusive reliance on learner-centred education. It was argued that there are circumstances when teacher-centred adult learning i s appropriate, p a r t i c u l a r l y during the introduction and early phases of a learning project. In these circumstances some learners may have l i m i t e d p r i o r experience i n the subject area to draw upon. Thus, during t h i s period a teacher-centred approach would enhance the a c q u i s i t i o n of the basic knowledge and s k i l l s to help those learners become more s e l f - d i r e c t e d i n the future. The attention that andragogy received and the concerns that were raised i n the l i t e r a t u r e regarding the e x c l u s i v i t y of andragogy to adults and the comprehensiveness of t h i s theory, caused Knowles (1975) to modify his p o s i t i o n . He declared, instead, that andragogy was a technique that existed at one end of a learning continuum, with teacher-centred learning at the other. Knowles i n s i s t e d that learning should be a c t i v e l y constructed by the learner. Some learners, however, may not always prefer to be "active" p a r t i c i p a n t s i n the physical sense of the learning process (discussion, p r a c t i c a l , role play) a l l of the time. A strong case can be argued for the merit and value of learning from observation and reflecting.on Information or an event i n c e r t a i n circumstances. S e l f - d i r e c t e d learning has been described as a complex, rugged, haphazard, and non-linear endeavour that varies from person to person and according to the learning experience. Knowles (1980) found that adults move toward s e l f -64 directedness at d i f f e r i n g rates and not necessar i l y i n a l l dimensions of l i f e . Grow (1991) suggested that s e l f - d i r e c t e d learn ing fol lows four progressive stages (dependant, in teres ted , involved and se l f -d i rec ted) with mult ip le cogni t ive processes used throughout each stage in a learn ing endeavour. This model was inf luenced by Vygotsky's concept (1978) of the "zone of proximal development" - the degree of change that st imulates learn ing (Grow, 1994). Knowles (1984) developed seven guiding p r i n c i p l e s for learners and teachers to f a c i l i t a t e s e l f - d i r e c t e d l earn ing : c l imate s e t t i n g , mutual planning, a s s i s t i n g p a r t i c i p a n t s in diagnosing t h e i r needs, supporting learners i n formulating t h e i r learn ing object ives , helping learners to develop learn ing plans, a s s i s t i n g learners to carry out t h e i r p lans, and invo lv ing learners i n evaluat ing t h e i r l ea rn ing . Centra l to the process of s e l f - d i r e c t e d learn ing i s learner-centred c o n t r o l . This impl ies that learners p a r t i c i p a t e i n the contro l over the var iab les associated with the learn ing p r o j e c t . That i s , they are given the opportunity to choose what they want to learn , how they want to learn i t and how they want learn ing to be evaluated. Furthermore, Brookf ie ld (1995) argued that learner-centred contro l that i s t r u l y s e l f - d i r e c t i o n a l must include access to the resources needed to act on r e f l e c t i v e l y informed d e c i s i o n s . P o t e n t i a l l y , t h i s presents a major challenge to adult educators. Pratt (1988) noted however, that learner contro l can come i n many d i f f e r e n t forms, from wanting the i n s t r u c t o r to provide more support and s t ructure , to 65 learners being h ighly capable of prov id ing t h e i r own structure and support. S e l f - d i r e c t e d learn ing , therefore , can operate with var ious degrees of autonomy. Andragogy c l e a r l y focuses on choice and a co l l abora t i ve car ing r e l a t i o n s h i p between the f a c i l i t a t o r and the learner . Tennant (1986) cautioned that the preoccupation with maintaining a pleasant r e l a t i o n s h i p with the learner may prevent the l e v e l of c r i t i c a l d iscuss ion that can f a c i l i t a t e l e a r n i n g . The widespread p r a c t i c e of andragogy i s c lear testimony, however, that for many adult educators, i t i s seen as the hallmark of contemporary adult education. B rookf ie ld (1993) noted that s e l f - d i r e c t e d learn ing i s now comfortably ensconced in the c i t a d e l , f i rmly part of the conceptual and p r a c t i c a l mainstream. This e s s e n t i a l l y humanistic psycho log ica l approach to adult learn ing , however, has aroused a number of concerns. Andragogy i s s e e n to develop the fo l lowing c h a r a c t e r i s t i c s : independence, an a b i l i t y to make choices, an a b i l i t y to formulate goals and plans, the se l f -mot ivat ion to overcome b a r r i e r s , and a strong sense of personal values and b e l i e f s . The values underlying these assumptions about adult learn ing inc lude: s e l f - r e l i a n c e , self-improvement, s e l f -r e s t r a i n t , s e l f - f u l f i l m e n t , s e l f - d i s c i p l i n e , s e l f -a c t u a l i s a t i o n and, what Pratt (1993) re fer red to as an "entrepreneur ia l democracy". Pratt (1993) suggested that the i n t u i t i v e appeal and widespread at tent ion that andragogy has rece ived among many adult educators has occurred because i t 66 speaks the language and epistemological b e l i e f s of a f f luent white middle c lass Americans regarding the purpose of adult education. C l e a r l y , t h i s ra i ses the question of the appropriateness of the un iversa l and widespread p r a c t i c e of andragogy for adult learners in a p l u r a l i s t i c and heterogeneous soc ie ty . The humanistic values inherent in andragogy c l e a r l y focus the ro le of adult learn ing on the " s e l f " and on personal development. According to Grow (1994), the concept of an i s o l a t e d " s e l f " that i s " s e l f - d i r e c t i n g " leaves out techno log ica l , p o l i t i c a l , c u l t u r a l , b i o l o g i c a l , s p i r i t u a l and other interconnect ions that should be core concerns i n education. A psycholog ica l perspect ive of adult l earn ing assumes that learn ing occurs in i s o l a t i o n from the world i n which the learner l i v e s and, therefore , tends to ignore the vast in f luence of the h i e r a r c h i c a l and structured context of r e a l i t y on adult l e a r n i n g . An emphasis on the i n d i v i d u a l can lead to "v ic t im blaming" rather than a c r i t i c a l r e f l e c t i o n and cons iderat ion of contextual s t ructures . Candy (1991) asserted that the context of the learn ing environment was a key determinant of autonomous behaviour. Psychologica l approaches a lso downplay the s o c i a l inf luence on l earn ing . Sternberg (1990) noted that even wisdom, considered by many, to be the p innacle of cogn i t ive development, i s e x p e r i e n t i a l l y def ined and c u l t u r a l l y bound. Family, f r iends , col leagues and the community, therefore , a l l provide experiences and information that contr ibute to a l e a r n e r ' s understanding of the world. In 67 many situations, adult learners prefer to compare and discuss t h e i r ideas and understanding of topics with others. Thus, an i n d i v i d u a l does not simply construct meaning i n a vacuum, but rather, learning i s an i n d i v i d u a l and s o c i a l contextual process. Law and Rubenson (1988) c a l l e d for a re-orientation of adult education away from psychological and developmental foundations and instead, towards a s o c i o l o g i c a l perspective that would "rehumanise" adult education to the context of society rather than on the i n d i v i d u a l . A s o c i o l o g i c a l perspective takes into account the s o c i a l , p o l i t i c a l , economic, c u l t u r a l and h i s t o r i c a l context that influences adult learning. From t h i s perspective, issues of power become more central to learning, rendering naive, i f not redundant, the language of psychologically focused s e l f - d i r e c t i o n (Law & Rubenson, 1988). In recent years, not s u r p r i s i n g l y therefore, adult learning theories have been formulated by drawing on the work from other d i s c i p l i n e s and perspectives (sociology, c r i t i c a l theory and anthropology). These perspectives take a broader focus on the s o c i a l and e x p e r i e n t i a l context of learning. C r i t i c a l theory and adult learning for behaviour change C r i t i c a l theory challenges educators to think broadly and more c r i t i c a l l y about learning for behaviour change. According to Bernstein (1976), c r i t i c a l theory aspires to bring people to f u l l consciousness of the contradictions i m p l i c i t i n t h e i r material existence, to penetrate the i d e o l o g i c a l 68 mystifications and forms of f a l s e consciousness that d i s t o r t the meaning of s o c i a l existence. C r i t i c a l theory developed h i s t o r i c a l l y along a path from Marxism, to c r i t i c a l thinkers and scholars (Adorno, Marcuse) from the Frankfurt School i n Germany and presently to contemporary approaches as are evident i n the work of Habermas (e.g., 1972, 1984, 1987). Contemporary approaches to c r i t i c a l theory have embraced the Marxist notion that to explain and understand the world i s not enough, but one must t r y to change i t for the better. C r i t i c a l theory, therefore, does not claim to be value-free or divorced from action (Habermas, 1972). Habermas (1984, 1987) asserted that communication and information are.defined and dominated by an e l i t i s t minority and i n turn, shape a consumer-based society. He claimed that d i s t o r t e d communication of t h i s nature focuses western thought (e.g., pertaining to exercise behaviour change) on instrumental r a t i o n a l i t y (individualism, personal development, material gain or p r o f i t ) . To counteract t h i s , he developed a theory of communicative i n t e r a c t i o n i n which a society i s , instead, seen as a community of s o c i a l action and i n t e r a c t i o n . There are two central concepts to Habermas1 theory: communicative r a t i o n a l i t y and communicative action. Habermas postulated that people e s s e n t i a l l y engage i n s o c i a l i n t e r a c t i o n (e.g., adult education) for reasons to construct meaning ("communicative r a t i o n a l i t y " ) . Implicit i n one's a b i l i t y to communicate i s a b e l i e f that an agreement or understanding can be reached based on the merits of d i f f e r i n g 69 points of view. Habermas asserted, however, that an agreement or understanding can only be t r u l y achieved i n non-coercive, non-manipulative and open communication. Under these conditions, unlike "instrumental r a t i o n a l i t y " , a l l parties have an equal opportunity to speak and to select the optimal course of action which ensures that knowledge i s validated u n i v e r s a l l y . Clearly, i n reality,, communication of t h i s nature i s r a r e l y achieved. Habermas believed, however, that indiv i d u a l s do have the a b i l i t y to think c r i t i c a l l y , which i s key to a f f e c t behaviour change. After a l l , he noted, everyday consumer-based s o c i a l exchanges i n western society necessitate c r i t i c a l thinking s k i l l s for one to consider the comprehensibility, s i n c e r i t y , appropriateness and truthfulness of the communicative information before one acts on i t . He postulated that a learner has the p o t e n t i a l to acquire three types of knowledge: technical, p r a c t i c a l and emancipatory to become a r e f l e c t i v e thinker. Habermas thus, c a l l e d for greater c r i t i c a l r e f l e c t i o n on how we make meaning i n the way that we do (e.g., for exercise behaviour change) i n order to enhance a communicative r a t i o n a l i t y . Supporting t h i s view, Pietrykowski (1996) cautioned adult educators not to lose sight of the connection between knowledge and power. She urged adult educators to, "help i d e n t i f y the multiple sources of power that are linked to knowledge construction, suggest alternative meanings and help develop c r i t i c a l competencies oriented at diverse micro-technologies of power" (p.95). 70 Habermas' other main concept was "communicative action". In r e l a t i o n to exercise behaviour change, t h i s views people as f i n i t e objects that can think, f e e l , speak and act c o l l e c t i v e l y for a better world. In contrast, he argued that "instrumental action" views nature and people as discrete objects that are expendable and which can be manipulated. For example, science and technology both dominate i n mass communications to promote s p e c i a l i s e d exercise behaviour over public health messages for active l i v i n g . C r i t i c a l t h e o r i s t s point out that preoccupation with technological domination (e.g., exclusive f i t n e s s equipment and f a c i l i t i e s ) fosters individualism and disconnects the means of production (e.g., habitual exercise behaviour) from human needs. Consequently, natural resources become unregulated commodities, people i n low socio-economic groups are often exploited to buy exercise products and r e l a t i v e l y few people have access to education and health f a c i l i t i e s . In contrast, therefore, the concept of communicative action i s based on the p r i n c i p l e s of collaboration, involvement, co-operation and community empowerment for behaviour change. Habermas provided a powerful means of understanding the unity i n the d i v e r s i t y of the human condition. Further, he developed a way of thinking c r i t i c a l l y about t h i s process i n a broader s o c i a l context. For example, i n worksite health education, c r i t i c a l r e f l e c t i o n of s t r u c t u r a l and power re l a t i o n s can help c l a r i f y the reasons for a behaviour change and encourages one to consider multiple s o c i a l and other 71 contextual factors that shape his or her p a r t i c i p a t i o n i n exercise behaviour. Wallerstein and Bernstein (1988) proposed an empowerment model for e f f e c t i v e health education that promoted health i n d i v i d u a l l y as well as c o l l e c t i v e l y . They defined empowerment as a s o c i a l action process that promotes p a r t i c i p a t i o n of people, organisations, and communities i n gaining control over t h e i r l i v e s i n t h e i r community and larger society. In other words, focusing on c o l l e c t i v e power to e f f e c t change. This perspective of empowerment has a dual focus on p a r t i c i p a t o r y r e f l e c t i o n and action, therefore, taking health promotion beyond simply focusing on improving s e l f - e f f i c a c y and self--development, toward an emphasis on prevention, community connectedness, improved quality of l i f e and s o c i a l j u s t i c e . A C r i t i c a l theory for adult learning about exercise behaviour change, therefore, does not take the s o c i a l world as a given. From a c r i t i c a l p e r s p e c t i v e , oppressive s o c i a l , economic, p o l i t i c a l , c u l t u r a l and h i s t o r i c a l images, myths and structures (access, opportunity, choice, power, customs, s o c i a l i s a t i o n , etc.) are revealed that discriminate and prevent i n d i v i d u a l s from reaching t h e i r true p o t e n t i a l . C r i t i c a l t h e o r i s t s postulate that people have the capacity to be r e f l e c t i v e thinkers and to act contrary to d i s t o r t e d communications. They also s t r i v e to f i n d ways to empower people i n d i v i d u a l l y and c o l l e c t i v e l y to change and l i b e r a t e s o c i e t y ( F r e i r e , 1970; Habermas, 1972). 72 An inherent problem with c r i t i c a l theory, however, i s the implied b e l i e f that one can separate oneself from the h i s t o r i c a l and c u l t u r a l context to analyse d i s t o r t e d communication and false consciousness. The challenge thus remains for c r i t i c a l t h e o r i s t s to define c l e a r l y the normative boundaries of c r i t i c a l theory. Cervero and Wilson (1994), noted that, c r i t i c a l theory should not function as a doctrine, i t can only remind us of what we care about and how to embody those cares into educational practices to enhance change. C r i t i c a l theory thus centres adult learning on experiences that play a progressive role i n creating a more equal and humane society. E s s e n t i a l l y , i t develops a s o c i a l consciousness, s p e c i f i c a l l y a c r i t i c a l awareness of the context, which i n part influences adult learning and behaviour change. C r i t i c a l self-directed learning Knowles' andragogical perspective of s e l f - d i r e c t e d learning has recently been revised and developed to include a more integrative and explanatory view of adult learning (Brookfield, i993; Garrison, 1992; Grow, 1994; Hammond & C o l l i n s , 1991). In p a r t i c u l a r , t h i s can be seen from the amalgamation of Knowles' andragogy with c r i t i c a l theory by embracing the concepts of both learner-centred control and a c r i t i c a l analysis of r e s p o n s i b i l i t y . Learner-centred control thus becomes coupled with interdependence and 73 interconnectedness as necessary a t t r i b u t e s of c r i t i c a l s e l f -d i rec ted learners in soc iety (Boucouvalas, 1988). C r i t i c a l ana lys is of r e s p o n s i b i l i t y encourages the learner to go beyond r igorous and creat ive a p p l i c a t i o n of i n d i v i d u a l motivation s t rateg ies toward th ink ing about how commonly-held assumptions, i n s t i t u t i o n s , s o c i a l s t ructures and the condit ions of people 's l i v e s may prevent them from developing i n d i v i d u a l l y and c o l l e c t i v e l y for behaviour change. C a f f a r e l l a (1993) noted that chal lenging such assumptions can help adult learners bet ter understand and respond to the context that shapes, at least in part , what and how they l e a r n . Many people i n routine households or workplace se t t ings , for example, have very l i t t l e opportunity to be s u f f i c i e n t l y p h y s i c a l l y act ive (as recommended by the guide l ines from the American Col lege of Sports Medicine, 1990) in order to a t t a i n the benef i t s of regular exerc i se . For these learners in worksite heal th education, s o c i a l support and c r i t i c a l r e f l e c t i o n can be l i b e r a t i n g experiences to acknowledge s t r u c t u r a l b a r r i e r s and thus focus t h e i r e f f o r t s on s t r u c t u r a l changes, e s p e c i a l l y for those learners who have otherwise f e l t the inadequacy of psycholog ica l s t ra teg ies to overcome personal b a r r i e r s to exerc i se . Thus, c r i t i c a l s e l f -d i r e c t e d learn ing can be interpreted , i n part , as an inherent ly p o l i t i c a l Idea by examining c o n t r o l , the condit ions required to access resources and an a lertness to the p o s s i b i l i t y of hegemonic forces (Brookf ie ld , 1993). 74 Most r e f l e c t i o n in adult education takes place within the context of problem-solving and d iscuss ion (Fre ire , 1970; Mezirow, 1994). Brookf ie ld (1993) noted that c r i t i c a l r e f l e c t i o n can be a lengthy, t i r i n g and often contentious process. Although c r i t i c a l th ink ing i s not a new concept to the adult education l i t e r a t u r e , i t i s , however, a complex and mult i faceted process that i s represented through the lenses of mul t ip le perspect ives ( c r i t i c a l theory, construct iv ism, p o s i t i v i s m , post-modernism). Central to various perspect ives of. c r i t i c a l th ink ing i s an evaluat ion of c laims, objects , processes and/or outcomes. Each perspect ive contr ibutes to our broad understandings of c r i t i c a l th ink ing though each has p a r t i c u l a r impl icat ions for curriculum and i n s t r u c t i o n (Wright 1992, 1995). For the purpose of t h i s study, an e c l e c t i c approach i s taken that embraces mult ip le perspect ives of c r i t i c a l t h i n k i n g . C r i t i c a l th ink ing i s thus considered an i n d i v i d u a l and s o c i a l contextual process. C r i t i c a l th ink ing i s , therefore , def ined as r igorous, c reat ive and c r i t i c a l l y r e f l e c t i v e thoughts per ta in ing to the problem under cons iderat ion ( e . g . , exerc ise behaviour change). C r i t i c a l s e l f - d i r e c t e d learn ing, not only compliments p r i n c i p l e s embedded i n s e l f - e f f i c a c y for i n d i v i d u a l behaviour change, but i t a lso provides broad s o c i o l o g i c a l in tervent ion s t ra teg ies for c o l l e c t i v e exercise behaviour change. Concepts of c r i t i c a l ana lys is of r e s p o n s i b i l i t y and s o c i a l act ion provide guidance for changes in enabl ing, r e i n f o r c i n g and environmental s t ra teg ies for exercise behaviour change. 75 C r i t i c a l s e l f - d i r e c t e d learn ing can be operat iona l i sed in worksite health education through problem-solving a c t i v i t i e s that focus on app l i ca t ion as an i n d i v i d u a l and s o c i a l contextual process. This process focuses on depth and breadth of c r i t i c a l th ink ing and s e l f - d i r e c t e d learn ing s t ra teg ies regarding the macro ( s o c i e t a l ) , meso (workplace) and micro (immediate appl icat ion) environments. Role p lay ing , case study problem so lv ing exerc ises and small and large group d iscuss ion with respect to a l t e r n a t i v e perspect ives , i d e a l s , personal experiences, myths and underly ing assumptions are examples of authentic a c t i v i t i e s that can be implemented to achieve these outcomes. E s s e n t i a l l y , t h i s perspect ive assumes learners br ing to the learn ing s i t u a t i o n diverse experiences and a v a r i e t y of e x p e r i e n t i a l bases: they are at various stages of l earn ing , they learn at d i f f e r e n t rates and they learn i n mul t ip le ways. E s s e n t i a l l y , adult learn ing for exerc ise behaviour change i s viewed as an i n d i v i d u a l and s o c i a l contextual process. Knowles (1975) asserted that adult learn ing that i s meaningful i s assoc iated with the everyday problems of adults i n t h e i r s o c i a l world. Worksite heal th education i s thus seen as a co-operat ive venture to empower learners toward i n d i v i d u a l and c o l l e c t i v e exerc ise behaviour change. According to Merriam (1993), the l i f e l o n g a b i l i t y and wi l l ingness to be s e l f - d i r e c t e d i s c r i t i c a l to s u r v i v a l and prosper i ty i n a world of continuous personal , community and s o c i e t a l changes. This b e l i e f i s consistent with contemporary views of health promotion. A broad view of s e l f - d i r e c t e d 76 learning that takes into account the interconnectedness of high l e v e l s of autonomy, c r i t i c a l r e f l e c t i o n of s o c i a l and other contextual factors i s , therefore, central to the design of the worksite health promotion program. Merriam cautioned that a singular perspective of adult learning should not be i d e a l i s e d as the only guiding beacon for adult learning. A p l u r a l i s t i c and e c l e c t i c approach to adult learning i s necessary to prevent the hegemony of u n i v e r s a l l y representing the i n t e r e s t s and values of a dominant group. Adult learning i s thus presented as a dynamic and complex phenomenon. Multiple perspectives of adult learning inform us that f a c i l i t a t i n g t h i s process i s not value-free. Pratt (1993) noted that, the philosophical, t h e o r e t i c a l and empirical claims to t r u t h regarding the c h a r a c t e r i s t i c s of adults as learners and the means to f a c i l i t a t e adult learning are dependant on the concept of learning. Conclusion Contemporary educational approaches to adult learning for behaviour change increasingly draw on s o c i o l o g i c a l perspectives to understand learning i n diverse settings. This approach takes a broad perspective of human behaviour and assumes that the underlying order and pattern of adult learning i s s o c i a l l y , rather than i n d i v i d u a l l y determined, as evident from psychological perspectives. S o c i o l o g i c a l approaches, too, however, have t h e i r l i m i t a t i o n s . C r i t i c i s m aimed at t h i s approach focuses on the lack of s p e c i f i c guidelines for intervention strategies, the i m p l i c i t 77 powerlessness of the i n d i v i d u a l to control change and the lack of empirical evidence to support such claims of the complexity of human behaviour. Furthermore, the complexity, breadth and depth of analysis that i s offered by s o c i o l o g i c a l approaches does not lend i t s e l f to the manipulation of independent va r i a b l e s . Neither does i t allow for the randomisation of subjects to s p e c i f i c groups that are t y p i c a l of psycho-experimental approaches to behaviour change. An e c l e c t i c approach, therefore, combining psychosocial perspectives to behaviour change, provides a more complete understanding of t h i s process. This perspective i s consistent with s i g n i f i c a n t advances that have occurred recently i n contemporary adult learning theory by integrating humanistic psychological theories of learning with broader s o c i o l o g i c a l theories of learning that resulted i n c r i t i c a l s e l f - d i r e c t e d learning. Program content framework Rather than attempting to shape i n d i v i d u a l s ' behaviour by external means, programs designed to enhance maintenance of p a r t i c i p a t i o n should be t a i l o r e d to i n d i v i d u a l s ' needs, helping them to recognise and implement strategies that prevent relapse (Lovato & Green, 1 9 9 0 ) . Burdine and McLeroy (1992) cautioned that no single theory i s adequate to t i e together the multiple lev e l s of influence and to i d e n t i f y p o t e n t i a l points of intervention for health education programs. Thus, with the l i t e r a t u r e considered, a worksite health promotion program was developed by the researcher that 78 combined the l i t e r a t u r e i n exercise psychology and adult education. The worksite L i f e s t y l e S k i l l s Motivation program was intended to empower participants i n d i v i d u a l l y and c o l l e c t i v e l y with the knowledge, attitudes and s p e c i f i c s k i l l s to c r i t i c a l l y s e l f - d i r e c t regular health related exercise (brisk walking, jogging, cycling, swimming, exercise-bicycle or stairmaster). The program focused on a broad and c r i t i c a l perspective for developing s e l f - e f f i c a c y to enhance i n d i v i d u a l and c o l l e c t i v e exercise behaviour change. The question arises as to which self-regulatory s k i l l s should be incorporated i n a health education program and how these s k i l l s should be sequenced and integrated with broader intervention strategies from contemporary perspectives of adult learning theory. As the l i t e r a t u r e revealed, there i s no best combination for a l l persons, groups or s i t u a t i o n s . Therefore, an e c l e c t i c approach was taken that embraced concepts and intervention strategies drawn from a v a r i e t y of behaviour change models, p a r t i c u l a r l y , S e l f - E f f i c a c y Theory and c r i t i c a l s e l f - d i r e c t e d learning. This approach acknowledges exercise behaviour change as an i n d i v i d u a l and s o c i a l contextual process. S i n c l a i r and S i n c l a i r (1994) suggested that e f f e c t i v e mental management of one's physical performance requires the a b i l i t y to set r e a l i s t i c long and short-term goals with clear d a i l y practice objectives. Attention must be focused s p e c i f i c a l l y on relevant cues, and when t h i s attention control s t a r t s to d r i f t , i t must be refocused. The appropriate l e v e l 79 of arousal for one's idea l performing state must be learned and regulated. In add i t ion , one must develop thought cont ro l s k i l l s that provide support for a p o s i t i v e and enabling s e l f image. Boutcher and R o t e l l a ' s (1987) psychologica l s k i l l s program i s t y p i c a l of mental s k i l l s programs to increase s e l f -e f f i c a c y through the development of s e l f - r e g u l a t o r y s t r a t e g i e s . They suggested the fo l lowing key ingredients of t h e i r four-phase program: analyse the nature of the task ( e . g . , the p h y s i o l o g i c a l and psycholog ica l benef i ts of exerc ise , knowledge about the components of phys ica l f i t n e s s , the issue of exerc ise adherence, and the ro le of s e l f -regulatory cognit ive-behavioura l s k i l l s ) ; i n d i v i d u a l assessment ( e . g . , p r o f i l i n g using quest ionnaires, and s e l f -monitoring of an a c t i v i t y d iary , exerc ise s e l f - e f f i c a c y , recovery heart r a t e ) ; motivat ional phase ( e . g . , goal s e t t i n g , time management, exerc ise game p l a n ) ; and the mental s k i l l development phase ( e . g . , mental preparat ion, a t tent ion focus, imagery, tension contro l and b u i l d i n g exerc ise conf idence) . F u l l a n (1991) presented a framework for educational programs to help teachers empower learners toward post-educat ional implementation. This model guides teachers to attend to the combination of s ix main themes: v i s i o n b u i l d i n g , evolut ionary planning, i n i t i a t i v e - t a k i n g and empowerment, resource and ass istance mob i l i sa t ion , problem-coping, and r e s t r u c t u r i n g . F u l l a n pointed out that educational change induces the transformation of subject ive r e a l i t i e s by learn ing new ways of th ink ing and doing, new s k i l l s , knowledge, 80 attitudes and b e l i e f s . He warned, however, that when change i s interpreted i n an oversimplified way and neglects these aspects i t can lead to an erroneous perception of change (false c l a r i t y ) . Rick Hansen's innovative L i f e S k i l l s Motivation program i d e n t i f i e s six fundamental s k i l l s as e s s e n t i a l to health career and personal development: self-awareness, accessing and u t i l i z i n g information, communicating with and r e l a t i n g to others, goal s e t t i n g and planning e f f e c t i v e l y , i n i t i a t i n g and managing change, and decision making and problem solving. Drawing on several frameworks and a review of the l i t e r a t u r e , therefore, the worksite L i f e s t y l e S k i l l s Motivation program combined and adapted psychological approaches and contemporary adult educational perspectives to incorporate i n d i v i d u a l , s o c i a l and other contextual intervention strategies (Garrison, 1992; Hammond & C o l l i n s , 1991) throughout the duration of an eight-session program. The program began by establishing a comfortable learning environment that fostered interaction, c r i t i c a l thinking and collaborative problem solving. Multiple factors that influence one's involvement i n exercise p a r t i c i p a t i o n , together with a va r i e t y of outcome benefits following the p a r t i c i p a t i o n i n regular exercise were presented and discussed. During each session, opportunities were provided for i n d i v i d u a l , partner, small and large group discussion that encouraged c r i t i c a l r e f l e c t i o n of contextual factors that were l i k e l y to hinder or f a c i l i t a t e p a r t i c i p a t i o n i n regular exercise. Thus each 81 session allowed individuals a valuable opportunity to share and draw from personal experience and provide input regarding authentic b a r r i e r s that could prevent the p a r t i c i p a t i o n i n regular exercise. In addition to psychological based intervention strategies, therefore, a key component of the worksite L i f e s t y l e S k i l l s Motivation program focused on mobilising the workplace community toward c o l l e c t i v e exercise behaviour change. By the end of the program, representatives were elected to co-ordinate wellness a c t i v i t i e s i n the workplace context. Cognitive and behavioural motivation strategies were presented as part of on-going application a c t i v i t i e s for exercise behaviour change. I n i t i a l sessions began with the introduction of behavioural strategies (e.g., goal s e t t i n g and self-monitoring) before progressing to cognitive strategies which completed the s e l f - r e g u l a t i o n of exercise behaviour. A pre-requisite for the e f f e c t i v e use of cognitive strategies i s the a b i l i t y to control tension l e v e l s (Albinson & B u l l , 1 9 8 8 ) . Thus, tension control preceded the imagery component. Imagery provided the foundation for both focusing s k i l l s and p o s i t i v e thinking strategies, therefore, t h i s component was suitably scheduled p r i o r to these other two components. The session related to p o s i t i v e thinking brought together Bandura's (198 6) components for developing s e l f - e f f i c a c y and therefore was appropriately situated at the end of the program. Each session focused on the application of key motivational strategies for exercise behaviour change. The f i n a l session r e - v i s i t e d a l l 82 strategies and t h e i r p o t e n t i a l application to overcome exercise b a r r i e r s . The program was drawn to a close with the application and formulation of a personal exercise game-plan that took into account i n d i v i d u a l , s o c i a l and other contextual strategies for post-educational application. To conclude, an e c l e c t i c approach was taken.to develop the worksite L i f e s t y l e S k i l l s Motivation program by combining psychosocial concepts and intervention strategies to enhance c r i t i c a l s e l f - d i r e c t e d application of exercise behaviour change. A d e t a i l e d i n s t r u c t i o n a l manual was developed by the researcher which contained guidelines for teaching c r i t i c a l s e l f - d i r e c t e d learning, examples of overheads, worksheets, questionnaires, self-monitoring tasks, problem solving a c t i v i t i e s , learning outcomes for each session, and a formative and summative program evaluation form. The core structure of the program involved eight, one-hour sessions over a four week period (see Appendix A). The format for each session included a review of the previous session; an introduction to a motivational s k i l l ; small group i n t e r a c t i o n with an emphasis on c r i t i c a l thinking, problem solving and s k i l l application; a summary; and f i n a l l y , an i n d i v i d u a l i s e d , take-home, p r a c t i c a l assignment. Program support a c t i v i t i e s and sessions continued to be available for the program partic i p a n t s on completion of the formal four-week program. This L i f e s t y l e S k i l l s Motivation program has shown evidence of success i n p i l o t programs that have been implemented i n a community, a univ e r s i t y and a corporate workplace s e t t i n g . 83 PROGRAM DEVELOPMENT (PART II) Worksite health promotion; Program implementation The l i t e r a t u r e from implementation, worksite health promotion, program planning, adult teaching and program evaluation was examined to provide guidance for implementing the L i f e s t y l e S k i l l s Motivation program i n a workplace set t i n g . Imp1ementat ion Implementation theory offers unique insight into the role of the s o c i a l system and the nature of change i n the implementation of new programs and practices. This theory takes a broad and long perspective to understanding behavioural change and offers considerable guidance for the analysis of t h i s process. Implementation i s grounded i n the p o l i t i c a l and s o c i a l sciences and i s represented i n the l i t e r a t u r e from multiple perspectives: P o l i t i c a l - e.g., community program intentions, communication networks and enforcement (Berman, 1 9 7 8 ) ; Organisational - e.g., organisational systems and communication networks (Elmore, 1 9 7 8 ) ; Interpersonal - e.g., an exchange between people with respect to knowledge, s k i l l s and evaluation (Weiss, 1 9 8 0 ) ; and Planned Change - e.g., strategies to f a c i l i t a t e successful implementation (Fullan, 1 9 9 1 ; L i p p i t t , 1 9 7 3 ) . Implementation i s also embedded i n a variety of related l i t e r a t u r e since i t 84 i s often assumed to be the same, or i f not part of other change processes (e.g., application, d i f f u s i o n , evaluation, knowledge U t i l i s a t i o n , planning and the transfer of learning). The l i t e r a t u r e , however, distinguishes between the nature of the variables that influence these change processes. Different perspectives of implementation have generated several meanings i n the l i t e r a t u r e to describe t h i s process. According to Fullan (1991), implementation i s the means of accomplishing desired objectives. For Berman (1978), i t i s a change process with i d e n t i f i a b l e p o l i t i c a l levers and s o c i a l i n t e r a c t i o n . Marjone and Wildavsky (1979) viewed i t as a struggle over the r e a l i s a t i o n of ideas and Wharf and Callahan (1984) described implementation as the process that brings about a behavioural change i n the future. Ottoson and Green (1987) concluded from a review of d e f i n i t i o n s that had been ascribed to implementation, that "implementation i s an i t e r a t i v e process i n which ideas, expressed as po l i c y , are transformed into behaviour, expressed as a s o c i a l action"(p. 362) . The implementation l i t e r a t u r e recognises that program implementation i s shaped by multiple factors ( s o c i a l , p o l i t i c a l , economic, organisational, c u l t u r a l and individual) and involves multiple actors (policy makers, program managers, instr u c t o r s , and clients) i n complex settings. Very often, i n d i v i d u a l s who are involved i n the change are not necessarily the same as those who conceived of the idea. Ottoson and. Green (1987) suggested that "as part of a larger process of change, 85 implementation connects and responds to the ideals and intents of those who shaped i t , and the needs and circumstances of those who are to benefit from i t " (p.5). Pressman and Wildavsky (1984) asserted that context plays an important role i n shaping programs p a r t i c u l a r l y during implementation. Social, p o l i t i c a l and c u l t u r a l norms and factors i n the workplace context that are l i k e l y to shape programs include the organisational structure, the union-management-employee p o l i t i c s . w i t h respect to program implementation, the l o y a l and r i v a l opponents of the program and t h e i r concerns, employee and management commitments toward the program, available communication channels that existed i n the department to disseminate programmatic information, degree to which the organisation was involved i n health promotion programs, and the a v a i l a b i l i t y of a suitable venue and scheduling opportunities to conduct t h i s program. These factors cannot be understood except through intensive involvement with that context. Adaptation i s c l e a r l y central between theory-driven intentions and behavioural and non-behavioural outcomes. For example, t h e o r e t i c a l ideas are translated into program a c t i v i t i e s and program deliverers and/or teachers interact d i r e c t l y with the service needs of program parti c i p a n t s and are u n l i k e l y to implement a program at the practice l e v e l i n ways that s t r i c t l y adhere to the goals of the program. F i n a l l y , program parti c i p a n t s have to interact d i r e c t l y with t h e i r l o c a l environment and may not implement learning 86 a c t i v i t i e s at the practice l e v e l i n ways that s t r i c t l y adhere to classroom experiences. According to Marjone and Wildavsky (1979), f a i t h f u l implementation i s sometimes undesirable, impossible, and often unforeseeable since implementation depends on what people bring to i t , as well as what i t contains. Implementation, therefore, necessitates mutual adaptation between the concept and the context so that programs can be adapted to l o c a l situations and changing circumstances. The complexity of implementation has contributed to a lack of agreement i n the l i t e r a t u r e with respect to a s p e c i f i c conceptual framework for t h i s process. Implementation has been approached as a top-down synthesis (Roberts-Gray, 1985) and a bottom-up synthesis (Green, 1986). In contrast, Green and Kreuter's (1991) Precede-Proceed model and F u l l a n 1 s (1991) model of implementation proposed an i n t e r a c t i v e and on-going c o l l a b o r a t i v e v e n t u r e that i n t e g r a t e s b o t h t o p - d o w n a n d bottom-up processes. Timing i s c r u c i a l to the success of implementation. It requires an analysis of when, where, and who i s responsible for implementation (Green & Ottoson, 1994). Nevertheless, the power to influence people, and the f i n a n c i a l and economic resources required during program implementation are l i k e l y to have a s i g n i f i c a n t e f f e c t on the outcome. It could be argued, however, that ultimate power to implement programs r e s t s with the i n d i v i d u a l "doers" throughout the process from policy/idea to action. 87 Program implementation i s c l e a r l y a long and complex process from o r i g i n a l intent to f i n a l action. It has both a s t a r t i n g and an ending point though where planning and p o l i c y formulation end and implementation begins i s v i r t u a l l y indefinable (Green & Kreuter, 1991). Implementation should not be considered simply i n terms of a series of discrete steps or stages rather, i t progresses in a dynamic, loose coupling and continuous c y c l i c a l process of planning, action and evaluation. Figure 2 conceptualises the broad process of program implementation i n a workplace context. SOCIAL MILIEU Figure 2. H e u r i s t i c Model of Program Implementation i n a S o c i a l Context -88 Program implementation i s thus viewed as an i n d i v i d u a l and s o c i a l contextual process. Worksite health promotion l i t e r a t u r e , program planning theory, adult teaching theory and program evaluation theory o f f e r insight for implementation frameworks to implement a worksite health promotion program for exercise behaviour change. Workplace health promotion A review of workplace health promotion l i t e r a t u r e reveals the factors that shape the implementation of a worksite health promotion program. The l i t e r a t u r e w i l l be examined to describe the rationale for, and p a r t i c i p a t i o n i n , workplace health promotion. The p o t e n t i a l benefits from workplace exercise programs w i l l be considered and, f i n a l l y , l i t e r a t u r e pertaining to worksite health promotion w i l l inform us about the influences of employee exercise behaviour and the role of worksite health promotion. Rationale for emerging workplace health promotion "Health promotion works through concrete and e f f e c t i v e community action i n s e t t i n g p r i o r i t i e s , making decisions, planning strategies, and implementing them to achieve better health. At the heart of t h i s process i s the empowerment of communities, t h e i r ownership and control of t h e i r own endeavours and d e s t i n i e s " (Ottawa Charter, 1986). For many people i n i n d u s t r i a l s o c i e t i e s , the worksite has become the foc a l point for community and s o c i a l i d e n t i t y . Green and Kreuter (1991) pointed out that, " i t i s where most daylight 89 hours are spent, where f r iendships are made, where many of the rewards that make one fee l worthy are dea l t , and where one can be re in forced by peers and s i g n i f i c a n t others . It i s a lso a place where one fee ls pressure to perform and d e l i v e r " (p. 309). This s e t t i n g , therefore, has the advantage and p o t e n t i a l to reach a large proport ion of soc iety for mult ip le heal th promotion i n i t i a t i v e s . Studies have suggested that pos i t ions with high demands and low dec is ion making author i ty i n occupational set t ings are more suscept ib le to a range of health r e l a t e d i l l n e s s e s (Gardel l , 1982; Holt , 1993). This i s p a r t i c u l a r l y relevant with the growth in c l e r i c a l and serv ice occupations whose employees are t y p i c a l l y i s o l a t e d by computer terminals and software innovations which encourages low c o n t r o l , s o c i a l i s o l a t i o n , r e p e t i t i o n and high demands that often r e s u l t i n increased absenteeism, reduced p r o d u c t i v i t y and increased burn-out and fat igue (Holt, 1993). The Johnson and Johnson company (1991) found that stress r e l a t e d d i s a b i l i t y claims were the most rap id ly growing form of occupational i l l n e s s with in the workers compensation system i n the USA. Various incent ives lead employers to implement workplace health promotion programs. These may include reduced health care costs , reduced i n j u r i e s , reduced s t a f f turn-over and absenteeism, increased product iv i ty , improved corporate image, increased employee morale, increased a b i l i t y to a t t r a c t and r e t a i n good employees, improved labour r e l a t i o n s and a p o s i t i v e return on investment (Lovato, Green and Stainbrook, 90 1993). According to Don Champion, Vice president of Human Resources for BC Telephone Company, " i t doesn't take much l o g i c to know that a healthy person w i l l do better work than an unhealthy one, who i s going to cost you money i n absenteeism, a lack of commitment, and in not th ink ing on your behal f . . .Employee health promotion r e s u l t s i n longevity and an increased v i t a l i t y in the workplace" (Health Promotion i n the Workplace, 1991). Despite cost -e f fect iveness being a primary motive for worksite heal th promotion, the continued growth of programs since the 1980's in the absence of such evidence suggests the importance of other factors , such as concern for employee heal th and wel l -be ing (Green & Cargo, 1994). An i m p l i c i t b e l i e f in t h i s statement i s that a f i t t e r workforce i s the way forward for a business to remain successfu l i n competit ive markets while a lso meeting employee demands for less job-r e l a t e d st ress and greater job s a t i s f a c t i o n . Sc iaccu, Seehafer, Reed and Mulvaney (1993) d id not f i n d that program p a r t i c i p a t i o n was associated with reduced medical costs and, therefore , advocated caution about health costs savings e f f e c t s from workplace health promotion programs. From a comprehensive review of broad-based health promotion and disease prevention programs in major companies, P e l l e t i e r (1993) found evidence, however, to suggest that they are both hea l th and cost e f f e c t i v e . He argued that , "When anyone c a v a l i e r l y dismisses 48 studies with the g l i b d i smissa l of •there i s no ev idence ' , they are simply ignorant of more than 91 13 years of increasingly sophisticated research with documentation of both health and cost outcomes" (p. 52). Green and Cargo (1994) i d e n t i f i e d multiple factors that have evolved and converged to influence the growth i n workplace health promotion, including, the changing demographic p r o f i l e s i n the workplace, r i s i n g medical costs that place a burden on industry and an increasing awareness of the p o t e n t i a l to influence behavioural and environmental precursors of health. P a r t i c i p a t i o n i n workplace health promotion programs P a r t i c i p a t i o n i n workplace health promotion programs may i n t e r f e r e with work-related a c t i v i t i e s and create disruptions in scheduling or employee r e l a t i o n s . A number of b a r r i e r s can, therefore, prevent the implementation of worksite health promotion programs. For example, management may be s c e p t i c a l about the cost-benefit analysis of supporting such programs; trade unions can be suspicious that workplace health promotion programs are top-down management ploys to divert r e s p o n s i b i l i t y of employee health from poor environmental working conditions to the behaviour of the employees; and some employees may be reluctant to engage in programs that deal with personal issues and non-employment a c t i v i t i e s with other workplace personnel. Glasgow, McCaul and Fisher (1993), i n a review of the workplace health promotion l i t e r a t u r e , suggested four key factors for increasing worksite p a r t i c i p a t i o n i n health promotion: a f l e x i b l e program, match intervention with organisational culture, t a i l o r to s p e c i f i c needs and circumstances, and multiple promotion and recruitment methods. 92 They suggested that the resource a l l o c a t i o n and management/union support for the worksite program can be used as a measure of worksite organisat iona l readiness to change. Furthermore, l o g i s t i c a l factors within the workplace may a lso r e s t r i c t access to programs such as s t a f f i n g and release time i n work time, a f t e r work t ransportat ion and domestic organisat ion and the cost of implementing programs. Thus, programs may be condoned but not supported by key personnel in the workplace s e t t i n g . Despite these obstacles , Glasgow et a l . (1993) reported that approximately 66% of worksites with 50 or more employees of fered at least one type of heal th promotion a c t i v i t y . In terms of enhancing employee p a r t i c i p a t i o n in worksite hea l th promotion programs, Henry and Bas i l e (1994) found that knowledge for i t s own sake and.meeting new people were weak mot ivat ional f a c t o r s . In contrast , they found that s o c i a l and i n s t i t u t i o n a l factors to meet i n d i v i d u a l needs were the main in f luence on the dec is ion to p a r t i c i p a t e . Studies have shown that employees, who enrol i n worksite health promotion programs are more l i k e l y to be female rather than male, healthy rather than unhealthy (unless an i n d i v i d u a l has been c l a s s i f i e d as high r i s k ) , and tend to have been inact ive during t h e i r youth (Conrad, 1987; Glasgow et a l . , 1993; Steinhardt & C a r r i e r , 1989). F i e l d i n g (1984) found that p a r t i c i p a t i o n rates i n workplace health promotion programs ranged from 20%-40% for programs of fered on s i t e to 10% to 25% for programs of fered o f f - s i t e . It would appear, therefore , that employee 93 p a r t i c i p a t i o n i n a worksite health promotion program i s enhanced when the program i s located on-site and i s offered i n work time but not through coercion, i s financed by the workplace and i s f l e x i b l e to meet the needs and circumstances of those who attend the program (Anspaugh, Hunter & Savage, 1996; Emmons, Linnan & Abrams, 1996). Workplace health promotion and physical a c t i v i t y The workplace context appears to o f f e r a convenient and c o s t - e f f e c t i v e environment i n which to promote regular exercise and physical f i t n e s s . This view appears to be consistent with the considerable expansion of corporate health / f i t n e s s / wellness programs i n the workplace since the 1980's. In a review of eleven worksite studies, Shephard (1989) found that ten studies showed increases i n productivity, and eighteen out of nineteen studies showed a trend toward reduced absenteeism following corporate f i t n e s s interventions. Table 5 represents a summary of current studies from Medline, Psych Abstracts, CD Rom (Sportdiscus), and a personal search of relevant publications that have investigated the cost-effectiveness of f i t n e s s programs i n the workplace. Table 5 . Cost-Effectiveness of Worksite Fitness P r o g r a m s Author, Date Company Time Period Workplace Benefits Bertera (1993) DuPont 3 years Reduced medical costs (12%) Doherty (1989) Tenneco 1 year Reduced staff turn-over (13%) Edington (1994) DuPont 6 years Positive return on investment ($2.05 per $1) Edington (1994) DuPont 6 years Reduced absenteeism (47.5%) Henritz et al. (1989) The Coors Brewing Co. 6 years Reduced medical costs ($1.4 million) Johnson etal. (1990) Saatchi and Saatchi Advertising Co. • • Increased productivity (63% self-report) Leatt etal. (1988) The Canadian Life Assurance Co. 7 years Reduced staff turn-over (32.4%) Leutzinger et al. (1991) Union Pacific Railroad - Increased concentration (78%) Pelletier (1993) Blue Cross Blue Shield 5 years Positive return on investment ($2.51 per $1) Shephard (1992) Toronto Life Assurance 7 years Reduced staff turn-over (8.1%) Shephard (1992) Toronto Life Assurance 6 months Reduced absenteeism (22%) Shephard (1992) DuPont 6 months Increased productivity (7% in performance) Wood etal. (1989) General Mills 2 years Positive return on investment ($3.50 per $1) Wood etal. (1989) General Mills 2 years Reduced absenteeism (44%) Yen etal. (1991) Steelcase 6 years Reduced medical costs (55%) Evaluation l i t e r a t u r e , however, supporting workplace benefits from fitness i n i t i a t i v e s i s not without i t s l i m i t a t i o n s . F i r s t , studies t y p i c a l l y d i f f e r i n t h e i r d e f i n i t i o n s of fitness programs, from on-site equipment f a c i l i t i e s to supervised aerobic classes. Second, workplace 95 outcomes were defined i n a variety of ways and measured using d i f f e r e n t instruments from self-report questionnaires to the observation of workplace records. Third, interpretations from outcome measures were often made in the absence of c o n t r o l l i n g for other variables that may have had a s i g n i f i c a n t e f f e c t on the recorded changes, such as the downsizing of companies, sel e c t i o n c r i t e r i a for new personnel, new technologies i n the workplace and a vari e t y of innovative s t a f f incentive schemes. Fourth, programs that were part of a comprehensive health promotion program may involve the syn e r g i s t i c i n t e r a c t i o n of the d i f f e r e n t components. These l i m i t a t i o n s have led to continual c a l l s i n the workplace evaluation l i t e r a t u r e to employ more s c i e n t i f i c and rigorous evaluation designs that include random assignment to experimental and control groupings. F i e l d research i s fraught with complexity and changing circumstances that make true experimental methods v i r t u a l l y impossible. These r e a l i t i e s are further compounded i n worksites by employers r e s i s t i n g having the employees randomly assigned to receive or not receive a program. From t h i s epistemological p o s i t i o n of knowledge construction, quasi-experimental designs, therefore, are l i k e l y to be the most r e a l i s t i c and e f f e c t i v e method to employ i n the context of the worksite. Methods of inquiry from alternative epistemological paradigms are also more l i k e l y to inform and best assess the process and outcomes of workplace health promotion programs. 96 In spite of acknowledged methodological l i m i t a t i o n s , research tends to support the view that employee fi t n e s s programs contain costs and produce workplace benefits. Green and Kreuter (1991) advocated caution, however, against o v e r s e l l i n g program benefits since worksite health promotion i s one element of a larger context of change, and benefits accrue from sustained e f f o r t s over a long-term period. It i s of inte r e s t to note that worksite evaluation l i t e r a t u r e has t y p i c a l l y focused on benefits that accrue from f i t n e s s programs with an exercise orientation, rather than classroom-based health education programs that are intended to enhance the s e l f - d i r e c t e d application of regular exercise. Oldenburg, Owen, Parle and Gomel (1995), i n an evaluation of four worksite based cardiovascular r i s k factor interventions i n Au s t r a l i a , found that less-intensive approaches (exercise f a c i l i t i e s and aerobics classes) can be made available at r e l a t i v e l y low-cost, but more intensive and expensive approaches such as ind i v i d u a l behavioural counselling can be as c o s t - e f f e c t i v e and can produce more sustained r i s k factor changes. The worksite L i f e s t y l e S k i l l s Motivation program, therefore, took a middle-ground approach to e f f e c t i n g behaviour change, between educational and environmental e f f o r t s to enhance c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change. Worksite health promotion and exercise behaviour change Health promotion professionals c l e a r l y need to be sensiti v e to c o n f l i c t i n g interests between employer and 97 employee i n terms of the focus and balance between educational and environmental strategies that may enhance health behaviours i n the workplace se t t i n g . Employee physical a c t i v i t y l e v e l s are influenced by in d i v i d u a l and broad macro (s o c i e t a l ) , meso (workplace) and micro (local implementation) s o c i a l and other contextual factors. The most e f f e c t i v e workplace health promotion interventions, therefore, are l i k e l y those combining behaviour change models from these s p e c i f i c l i t e r a t u r e s . According to Green and Cargo (1994), such integration has not yet emerged as a standard i n health promotion, l e t alone workplace health promotion. They c a l l e d for greater collaboration between the d i s c i p l i n e s i n academia to cross conventional b a r r i e r s and to close the gap between theory and practice i n order to develop and test progressive innovations. McLeroy (1993) cautioned, however, that combining theories i n the implementation of health education i s not completely s a t i s f a c t o r y since there are no guidelines for s e l e c t i n g i n d i v i d u a l or combinations of theories. Worksite health education i s u n l i k e l y to have an immediate, d i r e c t impact on exercise behaviour though i t can predispose (enhance knowledge, attitudes and b e l i e f s ) , enable (improve s k i l l s to overcome barriers) and reinforce ( f a c i l i t a t e sources of reward and support) i t . T r a d i t i o n a l worksite approaches to increase physical a c t i v i t y , however, are often targeted at predisposing factors and t y p i c a l l y include: providing information from medical or f i t n e s s screening, health r i s k appraisals, or l i t e r a t u r e concerning 98 the r i s k s to i n a c t i v i t y and guidelines for exercise p r e s c r i p t i o n . Exercise behaviour, however, i s often more time consuming and e f f o r t f u l than most other health-related behaviours that are targeted for change. Consequently, these approaches have tended to stimulate i n i t i a t i o n of physical a c t i v i t y but do not tend to sustain p a r t i c i p a t i o n (Dishman, 1991). This may be because these approaches focus on how to prevent i l l - h e a l t h and on abstract concepts of health or longevity, rather than on po s i t i v e health ( i . e . , well-being and fitness) and developing s k i l l s to overcome contextual b a r r i e r s and the s p e c i f i c b i o l o g i c a l aspects of exertion such as perceptions and sensations that may prompt and reinforce a c t i v i t y or i n a c t i v i t y i n some people. Hardy and Rejeski (1989) asserted that the psycho-physiological consequences that occur during or clo s e l y following exercise behaviour are l i k e l y to be much more powerful influences on subsequent p a r t i c i p a t i o n than those that do not occur u n t i l sometime i n the distant future. Vertinsky (1992) advocated that health promotion approaches should move from intervention to involvement, and ultimately focus upon empowerment and an improved q u a l i t y of l i f e . According to Green and Ottoson (1994), "to e f f e c t behavioural change, health education i n any s e t t i n g requires a planned sequence of experiences and a c t i v i t i e s over time, that are t a i l o r e d as much as resources w i l l allow to the circumstances and p r i o r experiences of s p e c i f i c groups 99 (corporate norms and employee culture) and even i n d i v i d u a l s " (p.75) . Planning models and health promotion Adult educational planning l i n k s intentions with proposed actions and involves a decision-making process and a set of r e l a t e d a c t i v i t i e s that produce educational program s p e c i f i c a t i o n s for one or more adult learners (Sork, 1994; Sork & C a f f a r e l l a , 1989). Multiple planning models exi s t i n adult education which can be described as varying on a continuum from d i r e c t i v e (top-down) to reactive (bottom-up), (Adams, 1991). Directive models at one end of the continuum, are characterised by a top-down l i n e a r process with abstract objectives and a context-free conceptualization. Cervero and Wilson (1994) suggested that these models are epistemologically limited, inaccurate and morally and p o l i t i c a l l y naive. In contrast, reactive models situated at the other end of the continuum focus on a bottom-up planning process that are void of any predetermined agenda, focus or structure. Interactive models, on the other hand combine aspects of d i r e c t i v e and reactive planning. Interactive models are mutually supportive and t y p i c a l l y involve collaboration, negotiation and power sharing to respond to the context of the educational experience. Planning models, therefore, not only vary i n central concepts but are mainly d i f f e r e n t i a t e d by the underlying assumptions about how program planning should take place. 100 An educational program i s thus the product of a complex array of interpersonal and i n s t i t u t i o n a l i nterests which are often i n c o n f l i c t , constantly changing, and sometimes i n v i s i b l e or at odds with the planner's own values and intentions (Cervero & Wilson, 1994). Forester (1989) contended that program planners make p r a c t i c a l judgements about program planning that are based on the s o c i a l context. These include negotiating with others, choosing among c o n f l i c t i n g wants and interes t s , developing tru s t , locating support and opposition, knowing the informal ropes as well as the formal organisational structure and being sensitive to timing. The p o l i t i c a l nature of program planning c l e a r l y i l l u s t r a t e s how some interests become more central and some more down-played than others. Program planing i n adult education, therefore, i s not a value-free process. T r a d i t i o n a l health educational practice i s often driven by p r a c t i t i o n e r ' s perceptions of the e f f i c a c y and appropriateness of s p e c i f i c interventions, rather than by th e o r e t i c a l models (McLeroy et a l , 1993). Models do, however, provide a framework for the application of theories that are relevant to health education design. A number of t h e o r e t i c a l models have been proposed i n the l i t e r a t u r e i n an attempt to explain health behaviour and to guide health education planning. The Health B e l i e f Model (HBM) has been instrumental i n the design of many t r a d i t i o n a l health education programs and has been applied extensively to a wide range of health 101 behaviours. The HBM hypothesises that people w i l l not seek preventative health behaviours unless they possess minimal l e v e l s of health motivation and knowledge, view themselves as p o t e n t i a l l y vulnerable, view the condition as threatening, are convinced of the e f f i c a c y of the treatment and see few d i f f i c u l t i e s i n undertaking action (Becker & Maiman, 1975). A number of studies, however, have shown that the HBM has been r e l a t i v e l y unsuccessful i n explaining exercise behaviour (Biddle & Ashford, 1988; Lindsay-Reid & Osborne, 1980). Exercise behaviour i s a complex process rather than a single behaviour (e.g., contextual influences, p r i o r experience, motives and stages of exercise behaviour) and the benefits from exercise are not necessarily immediate, rather, they are l i k e l y to be accrued i n the distant future. E s s e n t i a l l y , the HBM has a psychological orientation with an emphasis on cognitive factors (knowledge, intentions, attitudes, values and b e l i e f s ) to predict exercise behaviour. Some of these may r e f l e c t perceptions of the s o c i a l context,-but are not d i r e c t i n d i c a t o r s . Thus, a change i n cognitive factors may i n i t i a t e a change i n exercise behaviour but they are u n l i k e l y to be s u f f i c i e n t to enable, reinforce and therefore sustain an exercise behaviour change. The HBM does provide some guidance, however, for explaining the predisposing factors i n Green and Kreuter's (1991) broader conceptual framework for health promotion planning. Other health promotion planning models continue to emerge or evolve, for example, ecological approaches which provide 102 more guidance per ta in ing to intervent ion set t ings (Richard, Potv in , Kishchuk, P r l i c , & Green, 1996). Few studies , however, have been conducted using these a l t e r n a t i v e approaches, un l ike the Precede-Proceed model with hundreds of publ ished app l i cat ions and dozens of formal s tud ies . Precede-Proceed model Green and Kreuter ' s (1991) Precede-Proceed model i s a contemporary approach to health education planning and evaluat ion (see Figure 3) . This i s a f l e x i b l e model that combines both " d i r e c t i v e and react ive" planning (Adams, 1991). According to Green, Richard and Potvin (1996),"some 400 publ ished app l i cat ions of t h i s model have demonstrated i t s u t i l i t y as a framework for planning and evaluat ion i n a wide range of heal th issues at a l l l eve l s from i n d i v i d u a l to n a t i o n a l , encompassing both behavioural and environmental determinants of health and q u a l i t y of l i f e , and prov id ing for s t ra teg ies to match the targets at educat ional , o rgan isat iona l , regulatory, and p o l i c y l e v e l s " (p.277). Precede-Proceed takes into account mult ip le factors that inf luence health status and therefore provides d i r e c t i o n for planning mult ip le approaches for health education programs. 103 PRECEDE PhaseS Administrative and policy diagnosis Phase 4 Educational and organizational diagnosis Phase 3 Behavioral and environmental diagnosis Phase 2 Epidemiological diagnosis Phase 1 Social diagnosis HEALTH PROMOTION Health education Policy regulation organization Phase 6 Implementation Predisposing factors Reinforcing factors Enabling factors Phase 7 Process evaluation Behavior and lifestyle Environment Phase 8 Impact evaluation Quality of life Phase 9 Outcome evaluation PROCEED Figure 3. Precede-Proceed Model (Green and Kreuter, 1991) E s s e n t i a l l y , t h i s i s a problem-focused model that r e l i e s on a varie t y of theories to guide multiple interventions to change health behaviour. The Precede planning phase of the model generates s p e c i f i c objectives based on the needs and circumstances of the population, group or i n d i v i d u a l , while the Proceed phase i s a r e a l i s t i c and f l e x i b l e evaluation framework to assess whether and how health promotion programs made a difference. The Precede phase focuses the planning process i n i t i a l l y on outcomes and then progresses backwards across the several l e v e l s of needs toward the administrative resources that would be required to i n i t i a t e a program so that these needs would be 104 met and the required outcomes achieved. This process encourages health education planners to begin planning by asking why they are providing s p e c i f i c programs before they ask themselves how they are going to do i t (Green & Kreuter, 1991). A needs assessment i s therefore, necessary so that health education programs can be t a i l o r e d to meet the needs and circumstances of the worksite employees. Second, i t serves as a vehicle for promoting health promotion i n the workplace. Third, organisational culture i s believed to influence employee motivation, perceptions, behaviour, job performance, and job s a t i s f a c t i o n . For a program to succeed, therefore, i t i s important that a planning needs assessment i s conducted to match the intervention with the workplace culture (Glasgow et a l . , 1993). E s s e n t i a l l y , Precede begins with a s i t u a t i o n a l analysis to determine the organisational, p o l i t i c a l and interpersonal context i n which the program i s to be planned. These factors can shape the planning of the program i n terms of both the approach to planning and the degree of commitment to the planning process. Health i s not an end i n i t s e l f , but i s a resource for everyday l i v i n g . Thus, the next phase of the planning focuses on a s o c i a l diagnosis by engaging the sponsors and target group to i d e n t i f y t h e i r q u a l i t y - o f - l i f e or s o c i a l and economic concerns. Precede-Proceed i s based on the idea that people have the a b i l i t y to influence t h e i r own health and well-being 105 and i t therefore encompasses the p r i n c i p l e of p a r t i c i p a t i o n and the theory of s e l f - e f f i c a c y . The epidemiological diagnosis phase of the planning process takes into account the available data on the prevalence of p a r t i c u l a r health goals/problems that are l i k e l y to contribute to the previously established quality of l i f e concerns. Health p r i o r i t i e s are expressed as objectives by specifying who w i l l benefit how much of what outcome by when (Green & Kreuter, 1991). A behavioural and environmental diagnosis consists of r e l a t i n g s p e c i f i c behaviours and environmental conditions that may af f e c t the health and s o c i a l or economic issues raised i n the preceding diagnoses. The educational and organisational diagnosis d i r e c t s attention to three key factors that are l i k e l y to be employed i n a health education program to bring about behavioural and environmental changes: predisposing factors are antecedents that provide the motivation for change (knowledge, b e l i e f s , attitudes, values and perceptions); enabling factors are personal or environmental conditions that f a c i l i t a t e or hinder change ( s k i l l s , resources, access, convenience, cost and b a r r i e r s ) ; and re i n f o r c i n g factors occur during or subsequent to behaviour, providing continued reward and incentive for the change to occur i n practice (social forces, external and i n t r i n s i c rewards, recognition, and well-being). F i n a l l y , an administrative diagnosis assesses the finances, resources, venue, scheduling and marketing 106 requirements that would be necessary for the program to operate. Mullen, Hersey and Iverson (1987) compared the effectiveness of three models in explaining exercise behaviour: Precede-Proceed, Theory of Reasoned Action, and the Health B e l i e f Model. They found that the variance accounted for i n physical a c t i v i t y l e v e l by these models was 58%, 57% and 57% respectively and concluded, therefore, that the Precede-Proceed model offers a useful framework to explain involvement i n leisure-time physical a c t i v i t y . The differences favouring Precede-Proceed were greater for other health-related behaviours. A major difference between Precede-Proceed and the other models i n these comparisons was the in c l u s i o n of environmental enabling and re i n f o r c i n g factors i n Precede-Proceed. The r e l a t i v e l y small difference between variance accounted for by the three models i n r e l a t i o n to exercise might suggest that cognitive factors are more important than environmental factors i n determining exercise behaviour. Precede-Proceed model can be used as an educational, organisational and procedural framework to address the needs and circumstances of a s p e c i f i c group. In addition to the growing body of evidence to support the u t i l i t y of the Precede-Proceed model i n a variety of settings, i t also has broad implications for many forms of adult education (Houle, 1992). E s s e n t i a l l y , Precede-Proceed model provides a guiding framework for planning and evaluation of worksite health promotion programs. 107 A d u l t t e a c h i n g t h e o r y Adult teaching theory provides guidance for an i n s t r u c t i o n a l framework i n the context of worksite health education. S i g n i f i c a n t developments have occurred over the la s t twenty-five years i n the approaches that have been taken to the study of teaching adults. A b r i e f review w i l l be presented of the varied approaches that currently contribute to the theory of adult teaching. This w i l l be followed by contrasting d i d a c t i c and learner-centred approaches to the in s t r u c t i o n of worksite health education programs. A learner-centred approach where both teacher and learners are engaged i s central to the delivery of the proposed worksite health education program. A plethora of l i t e r a t u r e has addressed research on teaching. Smith (1987), In his review of the l i t e r a t u r e , i d e n t i f i e d the following d e f i n i t i o n s that had been ascribed to teaching: a process for imparting information; a process for enhancing learning; and an inte n t i o n a l a c t i v i t y to create change. Barrow and Milburn (1990) added that teaching was a polymorphous word that describes a multifaceted phenomenon. The l i t e r a t u r e has suggested multiple roles for the teacher of adults which include: a content s p e c i a l i s t and f a c i l i t a t o r of adult learning (Knowles, 1984); an a r t i s t , f a c i l i t a t o r and c r i t i c a l analyst (Brookfield, 1989); to develop an active and supportive learning environment (Knox, 1986); to help people see things deeply, more c r i t i c a l l y (Apps, 1991); authority, 108 motivator and guide, f a c i l i t a t o r , and consultant (Grow, 1991); and to foster c r i t i c a l r e f l e c t i o n (Mezirow, 1994) . Powell and Beard (1987) indicated i n a review of the l i t e r a t u r e , that multiple approaches have been taken to the study of teaching which include the classroom context, teacher c h a r a c t e r i s t i c s , teaching styles, teacher effectiveness, teacher behaviour modification and teacher evaluation. Dunkin and Biddle's (1974) model, i n p a r t i c u l a r , had a s i g n i f i c a n t influence on the study of teaching. This model was developed to examine the relationships between presage variables ( c h a r a c t e r i s t i c s that a teacher brings to a learning experience), process variables (actual a c t i v i t i e s and i n t e r a c t i o n that occurs i n the classroom), product variables (intended outcomes or unanticipated results of teaching), and/or context variables (circumstances to which the teacher must adjust) i n an i n s t r u c t i o n a l s e t t i n g . Alternative approaches to the study of teaching have focused on a cognitive perspective. Research from t h i s perspective places less emphasis on the behavioural component of teaching and more on the thoughts and strategies that occur throughout t h i s complex decision-making process. Implicit i n t h i s approach to the study of teaching i s that teachers' cognitive processes influence how they plan and make c r i t i c a l judgements concerning the practice of adult education. This l i n e of inquiry has more recently investigated how teaching i s conceived and understood by teachers of adults (Clark & Peterson, 1986; Larson, 1986; Pratt, 1992). Pratt (1992) 109 described conceptions of teaching as abstract, cognitive representations and normative epistemological b e l i e f s about how people think of teaching. According to Hiemstra (1988), a teacher's philosophical values and b e l i e f s about the nature of teaching and learning are r e f l e c t e d i n the way that he or she decides on the desired learning outcomes/goals for a lesson, the s e l e c t i o n and s p e c i f i c use of appropriate content, the se l e c t i o n of i n s t r u c t i o n a l methods and the modes of communication throughout the learning experience. Apps (1989) claimed that c r i t i c a l s e l f - r e f l e c t i o n of one's philosophical foundations was the basis of e f f e c t i v e teaching. Larson (1983) suggested that there were two d i f f e r e n t conceptions of teaching; teacher-centred and learner-centred. In contrast, Pratt (1992) found multiple ways in which teachers of adults conceptualise teaching. He i d e n t i f i e d f i v e conceptions of teaching held by teachers of adults from f i v e d i f f e r e n t countries. The f i v e conceptions of teaching and t h e i r underlying assumptions about teaching and learning were described i n the following way: Transmission (teaching should be systematic to improve the e f f i c i e n t transmission of information and learning i s enhanced by shaping the learning environment); Apprenticeship (teaching should model the knowledge and values of the teacher and learning i s situated i n context); Developmental (teaching should c u l t i v a t e the i n t e l l e c t and learning i s s e l f - d i r e c t e d and involves lev e l s of cognition); Nurturing (teaching should develop the s e l f -concept and personal agency and learning i s i n t e r a c t i v e and 110 conducted in a conducive learn ing environment to enhance s e l f -d i rec ted learn ing) ; and Soc ia l Reform (teaching should seek a better soc iety and learn ing i s chal lenging i m p l i c i t s o c i e t a l assumptions and taking act ion to change s o c i e t y ) . Pratt found that although i n d i v i d u a l s often hold two or more conceptions of teaching, one i s usua l ly more dominant. It i s important to c l a r i f y the d i s t i n c t i o n between conceptions of teaching and teaching s t y l e s . According to Pratt (1992), conceptions of teaching are grounded i n a teacher ' s s o c i a l , c u l t u r a l , h i s t o r i c a l and personal realm of meaning and, therefore , tend to be r e l a t i v e l y stable across teaching s i t u a t i o n s . In contrast , teaching s ty les re fe r to a range of teaching behaviours that vary on a continuum from teacher-centred to learner-centred i n s t r u c t i o n . According to Conti (1985), a teacher 's s t y l e i s the conduit for t r a n s l a t i n g h is or her i n t e r n a l p h i l o s o p h i c a l b e l i e f s into external p r a c t i c a l a c t i o n . Kuchinskas (1970) found that teachers ' a t t i tudes conveyed through s t y l e inf luenced the learn ing environment more than any other f a c t o r . Grow (1991), on the other hand, suggested that teaching s t y l e was an external teacher c h a r a c t e r i s t i c that could be modif ied to respond to students ' learn ing s t y l e s . This impl ies that teaching s ty les are ways of guiding and c o n t r o l l i n g learn ing experiences and should, therefore , vary according to the circumstances of the learn ing s i t u a t i o n . Candy (1991), however, found that teachers often f i n d i t very d i f f i c u l t to make the t r a n s i t i o n from teacher-centred to learner-centred approaches. Tennant (1992) I l l expressed reservation both about a. teacher's a b i l i t y and willingness to adjust according to the s i t u a t i o n . Reluctance to adapt teaching s t y l e may r e f l e c t a teacher's perceived loss of control, being s o c i a l i s e d into the long term practice of a teacher-centred approach or the extent to which a teacher's epistemological b e l i e f s about teaching l i m i t s the range of teaching behaviours. Adult education occurs i n diverse s o c i o - c u l t u r a l and p o l i t i c a l settings. Teachers of adults also come from heterogeneous backgrounds. Multiple conceptions of teaching, therefore, add further support to our understanding of the p l u r a l i s t i c nature of teaching adult education. Grow (1994) stressed that there i s no one way to teach or learn well. Instruction of adult education i s thus presented as a complex and multifaceted process. T r a d i t i o n a l approaches to teaching adult health education The d i d a c t i c approach to teaching tends to be teacher-centred and grounded i n behavioural psychology. From t h i s approach the teachers are the active ones i n an authoritarian transmission of information while the learners are passively educated. In terms of health education, t h i s often means that the teachers are very 'powerful' with the special knowledge, t r a i n i n g , and experience that allow them to control and solve other people's l i f e s t y l e problems. This approach to teaching c l e a r l y places value on the c o n t e n t - c r e d i b i l i t y and expertise of the teacher. However, t h i s perpetuates a widely prevalent 112 but erroneous view that health education teachers possess a l l the necessary information and solutions concerning p a r t i c u l a r health issues. In i t s extreme form, a teacher-centred approach to health education (e.g., as taught by a d r i l l sergeant i n the army, or by a coach i n a gym class on a rainy day at a school without trained health educators) i s characterised by having c l e a r l y defined and r i g i d lesson objectives, and a highly structured agenda. The process of teaching i s represented by a systematic, accurate and e f f i c i e n t teaching "performance" that r e l i e s heavily on precise time management. Preferred methods to disseminate the information include lecture format, video presentation and s e l f - a n a l y s i s questionnaires. These methods lend themselves to minimum inte r a c t i o n and a one-way communication process. T r a d i t i o n a l teachers prefer to employ these methods for control purposes which, i n turn, structure timing and thus ensure that lesson objectives can be achieved. From t h i s approach, learners are perceived as anonymous "mass receivers" and "absorbers" of content. F r e i r e (1992) referred t o t h i s as the "banking concept" of education. I n d i v i d u a l i s i n g the material, therefore, i s given a lower p r i o r i t y than the depth and breadth of coverage of the content. Implicit i n t h i s approach i s that the content i s viewed as the "objective gold-standard" and i t i s the r e s p o n s i b i l i t y of the learner to make sense of i t . Learning i s o f t e n assessed, t h e r e f o r e , i n r e l a t i o n to the s p e c i f i c objectives t h a t were i n i t i a l l y established. It i s important to 113 note, however, that these methods often create a communication vacuum in the classroom and make health education teachers less approachable. Hanna and McGill (1985) cautioned that when learning i s reduced to simply receiving a transmission of knowledge, i t can foster a disregard for the i n t r i n s i c value of learning. A learner-centred approach to adult health education In contrast, a learner-centred approach toward adult education (Knowles, 1984) has i t s roots i n humanistic psychology and more recently has been integrated with a s o c i o l o g i c a l perspective of adult education. This approach takes into account both personal development and broader s o c i a l and other contextual factors that influence behaviour change. E s s e n t i a l l y , a learner-centred approach provides a broad view of teaching worksite health education where teacher and learners are engaged as partners i n the educational process. According to Knowles (1984), although adults are often thought to be s e l f - d i r e c t e d learners, the teacher continues to occupy a s i g n i f i c a n t role i n adult learning and i s considered the most important variable influencing the learning climate. F r e i r e (1970) cautioned that "some educators have a mechanistic, s u p e r f i c i a l approach to climate b u i l d i n g and want to create the appearance but not the r e a l i t y of equal r e l a t i o n s h i p s . He added that we have to be serious about wanting learners to f i n d t h e i r own voice" (p.3). Recent s e l f -114 d i rec ted learn ing frameworks have been developed that o f f e r guidance for student empowerment (Grow, 1991; Hammond & C o l l i n s , 1991; Wal lerste in & Bernstein, 1988). Shor (1993) advocated that a Fre i rean c r i t i c a l teacher i s a problem-poser who asks thought provoking questions and who encourages students to ask t h e i r own quest ions. From a learner-centred approach, therefore , the ro le of the teacher centres on c reat ing a safe environment i n which to guide, support, challenge and st imulate c r i t i c a l th ink ing and problem-solving for i n d i v i d u a l and c o l l e c t i v e exerc ise behaviour change. This process i s thus character ised by a c o l l a b o r a t i v e , co-operat ive, c r i t i c a l l y r e f l e c t i v e , and hands-on i n t e r a c t i v e process with negotiated object ives , methods, and eva luat ive c r i t e r i a . Compared to a d i d a c t i c approach, a learner-centred approach to teaching encourages a much c loser r e l a t i o n s h i p between the teacher and the learner . According to Ulmer (1980), teachers of adults ind icated , in order of p r i o r i t y , the fo l lowing c h a r a c t e r i s t i c s of successfu l teachers: knowledge about the learner , love of people, "knowledge of subject, i n d i v i d u a l i s i n g i n s t r u c t i o n , pat ience, sense of humour, a b i l i t y to communicate and c r e a t i v i t y . Thus, a r e l a t i o n s h i p that i s based on mutual t r u s t and respect creates minimal defensiveness and power d i f f e r e n t i a l s which al low both the teacher and the learner to be more relaxed and open. B i l l s o n and T iber ius (1991) noted that when students f e e l at ease with the teacher they reveal the information and fee l ings 115 that one needs to understand them. Noddings (1988) referred to the q u a l i t y of t h i s r e l a t i o n s h i p as " f i d e l i t y " , which i s guided not by obligation, but from an ethic of caring for the development of the whole person. Aspy and Roebuck (1974) found that people who received high lev e l s of empathy, congruence and p o s i t i v e regard were l i k e l y to a t t a i n more growth than those who were given low l e v e l s . E f f e c t i v e communication, therefore, i s central to the r e l a t i o n s h i p between the teacher and learner. This i s seen as the means to unlock the p o t e n t i a l and power within the learner and to enhance the quality and depth of both teaching and c r i t i c a l s e l f - d i r e c t e d learning. Knox (1983) added that teachers should encourage participants to be resources for t h e i r own learning and for the learning of others. This emphasises the broader role of the teacher to do more than simply cater to the i n d i v i d u a l but also to consider the s o c i a l contextual nature of teaching and learning. A learner-centred approach does not imply that only i n t e r a c t i v e methods would be employed by the teacher, rather, an emphasis would be placed on using multiple methods (e.g., small group discussion, role play, large group discussion, lecture format, case-studies and video presentations). For example, Conti (1989) found that General Educational Development (GED) students learned more i n a teacher-structured environment than those students i n a learner-i n t e r a c t i v e environment. Multiple methods, therefore, acknowledge that learners are at d i f f e r e n t stages of learning, 116 learn at d i f f e r e n t rates and have d i f f e r e n t learn ing s t y l e s . Grow (1994) asserted that d i f f e r e n t s ty les work for d i f f e r e n t learners i n d i f f e r e n t s i t u a t i o n s . Rogers (1983) suggested that the method per se i s not as important in determining e f f e c t i v e teaching as i s the a f f e c t i v e environment that i s created which nurtures success from whatever method the teacher fee ls most comfortable in us ing . A learner-centred approach thus ensures that the learn ing experience i s appropr iate ly p i tched, cha l leng ing , successfu l and enjoyable which can foster a motivat ion for l i f e l o n g l earn ing . It i s important to note, however, that some adult learners may not prefer t h i s approach to teaching, e s p e c i a l l y those who are used to r i g i d formal education and have not had recent educational experiences. In t h i s context, these people may i n i t i a l l y be apprehensive about the perceived openness, c r i t i c a l r e f l e c t i o n , act ive e f f o r t , and r e s p o n s i b i l i t y that i s required for t h e i r own learn ing . Brookf ie ld (1990) pointed out three other p o t e n t i a l problems with t h i s approach to teaching: (1) a f a c i l i t a t o r must always please the learner by meeting h i s or her needs i n the manner that he or she requested; (2) the learners are always the best judges of t h e i r own i n t e r e s t s ; and (3) teacher burn-out. C l e a r l y , when t h i s approach to teaching i s p r a c t i s e d to the extreme, i t can be overly consumerist (Pratt, 1992). Tennant (1986) noted that i t i s unreasonable to expect i n d i v i d u a l needs to be in harmony at a l l times with organisat iona l goals , 117 and i n instances of c o n f l i c t , i n d i v i d u a l needs may well be compromised. A teacher must therefore, f i n d a balance between caring and negotiating learning aims with those that are challenging and go beyond the comfortable ways of thinking and acting i n order to enhance growth. Ad d i t i o n a l l y , i n d i v i d u a l i s e d i n s t r u c t i o n of t h i s magnitude needs to be balanced with s o c i a l and other contextual considerations. A learner-centred teacher must know his or her own personal boundaries between teaching, counselling and f a c i l i t a t i n g learning. This i s p a r t i c u l a r l y relevant when teaching adult health education i n such a way that excessive personal and emotional involvement i n the learners' progression toward a l i f e s t y l e change can be prevented. Tennant (1992) pointed out that too close a r e l a t i o n s h i p between the teacher and the learner can also suppress c o n f l i c t , where some c o n f l i c t may be seen as a natural and desirable outcome of the int e r a c t i o n of two or more inqu i r i n g and challenging minds. A learner-centred approach to teaching, therefore, i s not simply a soft passive approach to teaching adult health education. The teachers are also challenged and develop a r e f l e c t i v e p r actice by taking time to c r i t i c a l l y analyse t h e i r actions, t h e i r e f f e c t s on student learning and on t h e i r own personal b e l i e f s regarding the nature of teaching and learning. R eflective teachers of health education remain current i n the knowledge of the f i e l d , r e f l e c t on t h i s knowledge and thoughtfully incorporate t h i s into t h e i r 118 p r a c t i c e . A c r i t i c a l l y r e f l e c t i v e teaching practice can prevent hegemony i n learning experiences and, therefore, help the program to meet the diverse needs of learners from multiple backgrounds. E s s e n t i a l l y , a contemporary approach to teaching health education values the s o c i a l nature of learning and s t r i v e s to empower students, i n d i v i d u a l l y and c o l l e c t i v e l y , toward s e l f -directed learning and a c r i t i c a l p r a c t i c e . F i n a l l y , the teacher maintains a r e f l e c t i v e practice, remains open to new ideas, r e f l e c t s an enthusiasm for both teaching and learning and avoids the negative habits of burn-out or apathy. For the purpose of t h i s study, a learner-centred approach was taken to the teaching and learning of the worksite health education program. This was operationalised through various classroom contextual strategies (e.g., creating an appropriate physical and s o c i a l environment) and curriculum and i n s t r u c t i o n a l strategies (e.g., varied teaching styles, developing responsive and authentic learning experiences with an emphasis on c r i t i c a l thinking, co-operation, collaboration and s k i l l a p p l i c a t i o n ) . According to Davenport and Davenport ( 1 9 8 5 ), adult education i n s t r u c t i o n that advocates an integrated world view i s l i k e l y to stress unity i n education. This approach to teaching i s consistent with the dominant purpose of health promotion of enabling people to increase control over the self-management of t h e i r own health behaviour. Further, i t expresses the philosophy underlying contemporary views of s e l f - d i r e c t e d learning, S e l f - E f f i c a c y 119 Theory, the stages of behaviour change and the p r i n c i p l e of p a r t i c i p a t i o n that are cent ra l to Green and Kreuter ' s (1991) Precede-Proceed framework. Program evaluation theory The impetus and i n i t i a t i v e for program evaluat ion was born during the s i x t i e s i n western s o c i e t i e s , exempl i f ied during the Johnson and Nixon administrat ions in the USA. This per iod was character ised by huge investments made i n s o c i a l programs for economic, s o c i a l and p o l i t i c a l reasons. Accompanying these s o c i a l p o l i c i e s came concerns about r i s i n g defence and s o c i a l program budgets, increas ing unemployment and claims with respect to gross mismanagement, abuse, and corrupt ion i n Federal programming. This s o c i a l and p o l i t i c a l context created the need for a q u a l i t y contro l approach to program eva luat ion . Ear ly evaluat ion theor ies thus began by emphasising a search for t r u t h about e f f e c t i v e so lut ions to s o c i a l problems through experimental approaches (Campbell, 1969; Campbell & Stanley, 1963; Scr iven, 1967). These theor ies focused p r i m a r i l y on program outcomes (though scr iven advocated goa l - f ree evaluation) and adopted quant i ta t ive methods from the natura l sciences to contro l for b i a s . Relying on program goals or i s o l a t e d quant i tat ive behavioural va r iab les to evaluate a program, however, i s too s i m p l i s t i c and inadequate to reveal the degree to which programs are part of a la rger system of thoughts and act ions . For example, program goals are often vague, are not s e n s i t i v e to on-going 120 changes i n program purpose, and are not un i v e r s a l l y implemented i n a l l settings. Furthermore, t h i s approach tended to be problematic i n the f i e l d , produced equivocal findings, yielded l i m i t e d terminal data with l i t t l e use to improving program processes (Thompson, 1992). Consequently, during the seventies, evaluation theories emphasised the use of evaluation findings and focused on describing the context i n which programs were implemented (Stake, 1975; Weiss, 1973; Wholey, 1977). Implementation analysis o f f e r s a r e a l i s t i c and f l e x i b l e framework i n which to assess the dynamic l i f e of contextually-bound programs. The main task of implementation analysis, according to Ottoson and Green (1987), i s to f i n d the middle ground between the intent of concept and the r e a l i t i e s of the.context. Implementation i s , therefore, c l e a r l y central to the agenda of contemporary program evaluation theory and practice. I n i t i a l methods employed, however, were r e l a t i v e l y costly, s p e c i f i c , susceptible to bias and, therefore, tended to have reduced marketplace appeal or confidence (Shadish, Cook, & Leviton, 1991). Later theories of program evaluation (e.g., Cronbach, 1986b, Rossi, 1982) attempted to integrate and b u i l d on the two previous phases of evaluation theory and to o f f e r an evaluation perspective from alternative paradigms (Guba & Lincoln, 1989). Subsequent perspectives on program evaluation have contributed to our further understanding of how these alt e r n a t i v e paradigms can inform evaluation. 121 Cronbach et a l . (1980) noted that s o c i a l programs are complex, mul t ivar ia te packages that operate in a soc io -p o l i t i c a l context and therefore , detract from t h e o r e t i c a l p u r i t y and the l i k e l i h o o d of exact t rans fer to other s e t t i n g s . To assess the value/merit or worth of a program, thus poses a major chal lenge for program evaluators . Sork (1990) advocated that program evaluat ion should be an on-going and i n t e g r a l part throughout the l i f e of an educational program. Martens (1994) noted, however, that d i f f e r e n t perspect ives of program evaluat ion have shaped mult ip le types of educational evaluat ion p r a c t i c e ( e . g . , formative, implementation, process, impact, e f f i c i e n c y , outcome, cos t -benef i t , summative and o ther ) . Program evaluat ion i s thus a changing and dynamic f i e l d . The l i t e r a t u r e has made several attempts to organise and categor ise program evaluat ion theor ies and frameworks; for example, p o l i t i c a l l y or iented evaluat ion, questions or iented eva luat ion, and values or iented evaluat ion (Stufflebeam & Walker, 1983); fourth generation evaluat ion (Cuba & L i n c o l n , 1989); and stage t h e o r i s t s , and f i v e components of evaluat ion theory (Shadish, Cook, & Levi ton, 1991). According to Thompson (1992), program evaluat ion frameworks " d i f f e r in t h e i r conceptions as to what evaluat ion i s , what the r e l a t i o n s h i p with the primary c l i e n t and other stakeholders should be, who should be making the relevant judgements regarding the program, and the c r i t e r i a for judging the evaluat ion i t s e l f " (p.68). Multiple perspectives on the theory of program 122 evaluat ion has thus inf luenced various ways i n which program evaluat ion has been def ined in the l i t e r a t u r e . For ,Wholey (197 9) program evaluat ion i s the measurement of program performance, the meeting of comparisons based on those measurements, and the use of the r e s u l t i n g information i n p o l i c y making and program management ( p . l ) . According to Cronbach (1963), i t i s the c o l l e c t i o n and use of information to make dec is ions about an educational program where many types of dec is ion are to be made and many v a r i e t i e s of information are u s e f u l . Shadish, Cook and Leviton (1991) noted that program evaluat ion i s only one part of a complex interdependent problem-solving sequence that inc ludes problem d e f i n i t i o n , so lu t ion generation, so lut ion implementation, so lu t ion evaluat ion and so lut ion d isseminat ion. Various d e f i n i t i o n s of program evaluat ion have created d iverse perceptions i n the l i t e r a t u r e regarding the primary purpose of eva luat ion . For example, to construct value statements (Scriven, 1972); to determine causal r e l a t i o n s h i p s between s p e c i f i e d independent and dependent v a r i a b l e s or to judge the r e l a t i v e merits of a l t e r n a t i v e serv ices (Campbell, 1969); to a s s i s t some audience to judge and improve the worth of some program (Stufflebeam & Walker, 1983). The American Evaluat ion Assoc ia t ion (1994) summarised by i d e n t i f y i n g several key purposes of eva luat ion: b e t t e r i n g products, personnel , programs organisat ions, governments, consumers, p u b l i c i n t e r e s t s ; contr ibut ing to informed dec i s ion making and more enl ightened change; p r e c i p i t a t i n g needed change; 123 empowering a l l stakeholders by c o l l e c t i n g data from them and engaging them in the evaluat ion process; and experiencing the excitement of new i n s i g h t s . According to Green and Kreuter (1991), the purpose of process evaluat ion in health promotion should not be seen as f ind ing the perfect program to package and parachute into any s e t t i n g but rather to help improve and adapt the program to the circumstances at hand. The ro le of the evaluator i s e s s e n t i a l l y to construct and provide the best information (from mult ip le perspectives) that might bear on the value of the program. The program evaluat ion l i t e r a t u r e has emphasised two contrast ing ro les to f u l f i l t h i s goa l : as an external operator to discourage co-optat ion (Scriven, 1978) and as an i n t e r n a l act ive p a r t i c i p a n t (Cronbach, 1986; Wholey, 1983). Stake (1975) advocated that evaluators should help l o c a l people discover and construct t h e i r own t ruths , t h e i r own d e f i n i t i o n s of the problem, and t h e i r own s o l u t i o n s . The primary stakeholder from t h i s perspect ive c l e a r l y centres on program p a r t i c i p a n t s . In contrast , Wholey (1983) preferred evaluators to provide feedback that i s immediately usefu l to p o l i c y makers and program management. Cronbach (198 6b) preferred a much broader ro le and advised evaluators to be educators to a l l stakeholders with respect to lessons of experience and c r i t i c a l th ink ing , about program implementation and g iv ing recogni t ion e x p l i c i t l y to the existence and concerns of other perspectives. Guba and Lincoln (1989) added that other information such as that from documentary ana lys i s , from 124 studies i n s i m i l a r contexts and from the professional l i t e r a t u r e should also be provided. Stufflebeam & Walker (1983) cautioned however, that evaluators must be sens i t i v e to t h e i r own agendas as well as those that are held by the c l i e n t and audience. The Program Evaluation Standards (1994) concluded by o f f e r i n g four guiding p r i n c i p l e s for evaluators: u t i l i t y , f e a s i b i l i t y , accuracy, and propriety. Scriven (1986) referred to the program evaluation process as involving a m u l t i p l i c i t y of multiples. Shadish, Cook and Leviton (1991) suggested that program evaluation should take into account methods, philosophy of science, public p o l i c y , value theory and theory of use. It i s important to note, however, that judgements made from program evaluation are not value-free since the p o l i t i c a l world and s o c i a l context Influences the conception, planning, delivery and evaluation processes surrounding s o c i a l programs. This review of the l i t e r a t u r e , therefore, suggests that planning and conducting an evaluation varies with the t h e o r e t i c a l and p o l i t i c a l or id e o l o g i c a l frameworks being employed. Evaluation perspectives and worksite health promotion Evaluators choose among many options to plan and conduct an evaluation based on t h e i r personal b e l i e f s , values, p o l i t i c a l i n c l i n a t i o n s , technical s k i l l s , and the context of the program operation (Thompson, 1992). Green and Kreuter's Proceed model was used as the conceptual framework for the evaluation. This broad framework postulates that a health promotion program can be evaluated at one or more of three 125 l e v e l s : process, impact and outcome. Process evaluation i s conducted on the f i r s t information that becomes available on program implementation (program inputs, program a c t i v i t i e s , c l i e n t reactions, s t a f f performance etc. associated with the administrative and p o l i c y diagnosis and objectives produced during the l a s t planning phase of the Precede model). Impact evaluation refers to the immediate e f f e c t s of a program on the target behaviour or changes i n the predisposing, enabling and r e i n f o r c i n g factors associated with the educational and organisational diagnosis i n Precede. Outcome evaluation refers to distant (follow-up, post-educational behavioural) or ultimate e f f e c t s of the program (health, f i t n e s s , q u a l i t y of l i f e , well-being, etc.) that may have been intended or unintended. Thus t h i s multidimensional framework provides a broad and long view of post-educational application which takes into account both the c h a r a c t e r i s t i c s of the learner and the context i n which the change i s expected to occur. For the purpose of t h i s study, the t h e o r e t i c a l focus for evaluation was drawn primarily from Cronbach's (1986, 1991) perspective of program processes and the context of post-program implementation. This was supplemented by drawing on Campbell's (1988) perspective of program outcomes to determine better programs among multiple a l t e r n a t i v e s . These approaches, however,, both have underlying t h e o r e t i c a l differences about the trade-offs one should make when conducting an evaluation. For example, Cronbach, Ambron, Dornbusch, Hess, Hornik, P h i l l i p s , Walker and Weiner. (1980), argued that s o c i a l 126 programs involve a multivariate world of complex, interdependent causal factors rather than single, b i v a r i a t e pushes and p u l l s . Furthermore, programs ra r e l y completely turn-over but rather are adapted to change incrementally by understanding the context of application and improving program processes. The advantages of including an experimental component focusing on time series data c o l l e c t e d on key outcome variables j u s t i f i e s i t ' s i n c l u s i o n as part of an e c l e c t i c approach to study program evaluation since i t provides p a r t i c u l a r evidence with respect to post-educational a p p l i c a t i o n . For example, pol i c y / d e c i s i o n makers are p o t e n t i a l stakeholders i n t h i s study and often want comparative information on programs (Scriven, 1993). Despite i t s trade-offs and resource i n t e n s i t y an e c l e c t i c framework that combines the art, science and p o l i t i c s of program evaluation i s best suited to understand the phenomenon of post-educational application from diverse and p l u r a l i s t i c perspectives. This approach i s consistent with contemporary knowledge about program evaluation and views knowledge construction as o n t o l o g i c a l l y complex and thus acknowledges multiple epistemologies, methods and p r i o r i t i e s based on multiple stakeholders. According to Green and Kreuter (1991), evaluation that provides for a learning-oriented rather than judgement-oriented approach not only w i l l gain the support of p r a c t i t i o n e r s but w i l l also feed back more quickly and thoroughly into program improvements and p r a c t i c e . 127 Program implementation framework Context. The L i f e s t y l e S k i l l s Motivat ion program was of fered to management, union and employees in the Department of Housing and Conferences at the Un ivers i ty of B r i t i s h Columbia (UBC). The program was provided as a voluntary serv ice from a doctora l student for research purposes. In return , program p a r t i c i p a n t s were requested (at t h e i r convenience) to complete short quest ionnaires , program evaluat ion forms, and p a r t i c i p a t e i n b r i e f telephone interviews at s p e c i f i c time periods throughout the implementation per iod . The c lose proximity and convenience of t h i s worksite s e t t i n g enabled the researcher to mobi l ise the energy and the resources that were necessary to gain s u f f i c i e n t access to the workplace and conduct the planning, de l i very and evaluat ion processes for implementing the L i f e s t y l e S k i l l s Motivat ion program i n t h i s s e t t i n g . This l e v e l of i n t e r a c t i o n and p a r t i c i p a t i o n was consistent with the philosophy of the precede-proceed framework. Planning and evaluat ion D i f fe rent models abound i n health promotion that descr ibe the change process; for example, Green and Kreuter ' s Precede-Proceed Model, Prochaska and DiClemente's Transtheoret ica l Model of the stages of behaviour change, Health B e l i e f Model, Theory of Reasoned Act ion , Dishman's L i fespan Interact ion Model, and Rogers' (1983) D i f f u s i o n Model. Green and Kreuter ' s (1991) Precede-Proceed Model was used as the conceptual framework for the planning and eva luat ion processes for the L i f e s t y l e S k i l l s Motivat ion 128 program i n a worksite se t t i n g . This model i s a useful framework for worksite health promotion programs because of i t s emphasis on process and broad perspective on context. Ideally, when using the Precede planning framework, one begins to determine the most appropriate quality of l i f e and health concerns of the target population by engaging them i n an open-ended s o c i a l diagnosis. For a worksite program, the s o c i a l diagnosis must also take into account the economic concerns of the employer. Green and Kreuter (1991) suggested that for pre-determined programs with l i t t l e f l e x i b i l i t y for change, back-tracking through the model towards the qual i t y of l i f e concerns should help to c l a r i f y the intentions and rationale behind prescribed programs. For the purposes of t h i s study, the health issue, health behaviour and educational program were, to some extent pre-determined, as a lack of physical f i t n e s s (and the associated p o t e n t i a l of hypokinetic diseases), the low p a r t i c i p a t i o n i n and poor adherence to regular exercise and a L i f e s t y l e S k i l l s Motivation program respectively. Despite a predetermined agenda for exercise behaviour change, conducting the Precede phase revealed that program processes needed to be adapted to include weight control and stress management components so that the program was t a i l o r e d to the needs and circumstances of those attending. The worksite health promotion program was thus developed and promoted using the p r i n c i p l e s of p a r t i c i p a t i o n and involvement that are i n t e g r a l to the Precede process. The Proceed phase of the model provides a r e a l i s t i c and f l e x i b l e 129 implementation and evaluation framework to investigate post-educational application during and following a worksite health promotion program. Delivery, A learner-centred approach was central throughout the delivery/teaching/instruction of the worksite L i f e s t y l e S k i l l s Motivation program. This approach employed the p r i n c i p l e of p a r t i c i p a t i o n throughout the implementation process. Thus, program participants were encouraged to be a c t i v e l y involved and the teacher acknowledged that people learn i n a v a r i e t y of ways, are at d i f f e r e n t stages of learning and learn at d i f f e r e n t rates. Emphasis was placed on developing a nurturing though challenging climate to empower learners, i n d i v i d u a l l y and c o l l e c t i v e l y to think c r i t i c a l l y and to s e l f - d i r e c t health behaviour change. Summary T h e r e i s a research need to develop and evaluate progressive worksite health promotion programs that are intended to enhance exercise behaviour change. Health education i s i n t e r d i s c i p l i n a r y by i t s very nature, thus, i t i s necessary to draw upon t h e o r e t i c a l frameworks from exercise science, health promotion and adult education to address t h i s research area. Despite the lack of evidence regarding worksite health education programs and exercise adherence, the l i t e r a t u r e s u g g e s t s t h a t h e a l t h education programs t h a t a r e developed using Bandura's (1986) s e l f - e f f i c a c y theory are e f f e c t i v e i n 130 maintaining a variety of health behaviours. The exercise science l i t e r a t u r e also reports success i n maintaining l e v e l s of exercise when interventions have focused on s e l f - r e g u l a t i o n and the stages of exercise behaviour change. Contemporary s o c i o l o g i c a l approaches to adult learning inform us of s o c i a l and other contextual influences, and thus strategies, for enhancing behaviour change. The l i t e r a t u r e on program implementation takes into account planning, delivery and evaluation processes to ensure that programs are t a i l o r e d to the needs and circumstances of those attending programs. Implementation of exercise behaviour change i s thus viewed as an i n d i v i d u a l and s o c i a l contextual process. The purpose of t h i s study was to gain a better understanding of post-educational application following a worksite health promotion program. Four research questions were generated to guide t h i s investigation. The f i r s t question focused on changes of key outcome variables that were measured qua n t i t a t i v e l y throughout the duration of the study. The second and t h i r d question focused on factors influencing application and the actual process of post-educational a p p l i c a t i o n . F i n a l l y , the fourth question assessed al t e r n a t i v e outcomes stemming from a worksite health promotion program. The following chapter outlines the methodological approach i n a worksite context that was taken to investigate the phenomena of post-educational application. 131 Chapter 3 METHODOLOGY Introduction This chapter describes the research perspective, twelve-month implementation process and methodology used to study post-educational application following an experimental worksite health promotion program. The chapter begins by presenting a rationale for the research perspective taken to investigate a p p l i c a t i o n . The subject population i s described together with the design, procedures and instrumentation u t i l i s e d for t h i s study. The chapter closes by describing the processes by which data were analysed. Research Perspective Research i s t y p i c a l l y situated i n a larger t h e o r e t i c a l and conceptual paradigm. Research paradigms are rooted i n p a r t i c u l a r sets of lenses that guide a l l phases of the research process. Research paradigms d i f f e r i n ontological and epistemological assumptions regarding the nature of r e a l i t y and the construction of knowledge as well as c r i t e r i a used to determine the v a l i d i t y of research. Smith (1992) noted that c r i t e r i a for post-empiricists centre on o b j e c t i v i t y through multiple lenses, as the regulative i d e a l ; for i n t e r p r e t i v i s t s , i t i s co-operative human inquiry with as much intersubjective agreement as possible; and for c r i t i c a l t h e o r i s t s i t i s r a i s i n g the l e v e l of c r i t i c a l consciousness toward oppressive features i n society with a 132 view to s o c i a l action (p.12). Not s u r p r i s i n g l y , therefore, proponents of each paradigm claim to provide valuable information regarding a research phenomenon and suggest that some methods are better than others for constructing knowledge. In a review of research paradigms, Sparks (1994) noted that the h i s t o r i c a l dominance of the empirical paradigm i n educational research i s being challenged by the i n t e r p r e t a t i v e and c r i t i c a l paradigms i n such a way that the focus and methodology of research i s changing. Shadish, Cook and Leviton (1991) pointed out, however, that learning about a complex s o c i a l world requires strong substantive theories and powerful methods, both of which s o c i a l s c i e n t i s t s currently lack. It would seem, therefore, that no paradigm of knowledge construction i s without s i g n i f i c a n t d i f f i c u l t i e s i n epistemological and ontological approaches. Thus, each perspective has i t s own strengths and weaknesses. According to Ottoson (1995), research on application needs to be not only m u l t i d i s c i p l i n a r y , but multiparadigmatic. The multiple lenses of post-positivism, the meanings created i n context as understood by c o n s t r u c t i v i s t s , and the nature of r e a l i t y as c r i t i q u e d by c r i t i c a l theory each provide d i f f e r e n t understandings of the experience of application (p.28). Sparks (1994) viewed a m u l t i p l i c i t y of visions as a sign of growing maturity, confidence and effervescence within the research community. It i s the author's view that despite 133 i n e v i t a b l e t r a d e - o f f s , research embracing mult ip le paradigms i s i n c l u s i v e of d iverse and p l u r a l i s t i c i n t e r e s t s and, therefore , provides considerable ins ight to post-educat ional a p p l i c a t i o n . E s s e n t i a l l y , t h i s approach considers knowledge construct ion to be o n t o l o g i c a l l y complex and thus acknowledges mult ip le epistemologies, methods and p r i o r i t i e s based on an i n c l u s i v e research agenda. This perspect ive i s consistent with Cronbach's (1980) views of evaluat ion research as revea l ing one t ru th among many. Cronbach advised evaluators to use mult ip le data c o l l e c t i o n s t ra teg ies and c r i t e r i a gathered from d i f f e r e n t sources to y i e l d less dependable answers about a broad set of p l u r a l i s t i c a l l y responsive quest ions. According to Shadish, Cook and Leviton (1991), t h i s approach i s ep is temolog ica l ly humble with an openness to new ways and a scept ic ism toward any s ing le perspect ive c la iming to provide superior informat ion. Inherent contrad ic t ions , when in tegrat ing mul t ip le paradigms i n a s ing le study, however, present a major challenge for the research community. From a p o s i t i v i s t perspect ive (Campbell, 1969), t h i s approach Is resource intens ive and y i e l d s too broad a focus. For c r i t i c a l t h e o r i s t s (Merideth, 1994; Poland, 1996; Robertson & Minkler , 1994), however, t h i s approach Is t y p i c a l l y too narrow to adequately examine s o c i a l , economic, h i s t o r i c , p o l i t i c a l and c u l t u r a l factors in f luenc ing a phenomenon. A popular approach, therefore , i s to operate with in a s ing le paradigm and to adhere r igorous ly to estab l i shed c r i t e r i a 134 for q u a l i t y research. To overcome these b a r r i e r s t y p i c a l l y requires researchers to be predisposed, enabled and reinforced i n t h e i r e f f o r t s to think c r i t i c a l l y and to apply s k i l l f u l l y an e c l e c t i c approach to research a phenomenon. Glanz, Lewis and Rimer (1990) urged that health education i s , by i t s very nature, e c l e c t i c . It i s strengthened by being i n c l u s i v e rather than exclusive. For the purpose of t h i s study, research was situated from a post-empiricist perspective to study the phenomena of post-educational application. Intervention and data c o l l e c t i o n strategies, consistent with multiple epistemologies, however, were employed to empower par t i c i p a n t s i n d i v i d u a l l y and c o l l e c t i v e l y for exercise behaviour change. For example, from a post-empiricist perspective, data were gathered from instrumentation i n a quasi-experimental design to make comparisons and i n f e r causal e f f e c t s . From an in t e r p r e t a t i v e perspective, data were gathered pertaining to the meaning and purposes subjects attached to t h e i r post-educational experiences (Denzin and Lincoln 1994). In addition, the dual role of researcher/implementer and s o c i a l context c l e a r l y influenced a l l phases of the research process. The researcher's perspective i s not only grounded i n extensive implementation experience, but i s also p o l i t i c a l l y and s o c i a l l y e t h i c a l and moral i n a system of p l u r a l i s t i c i n t e r e s t s . From a c r i t i c a l perspective, an i m p l i c i t aim of t h i s research project was to r a i s e the l e v e l of c r i t i c a l consciousness and to mobilise a workplace community to engage i n c o l l e c t i v e as well as in d i v i d u a l , s e l f - d i r e c t e d health behaviour change strategies. As part of the intervention processes, findings from t h i s study were shared and implications discussed with members of the workplace community. It i s assumed, therefore, that judgements made from these research findings are not value-free. Post-educational application and the construction of s o c i a l r e a l i t y has been presented as a value-laden endeavour. An e c l e c t i c approach to t h i s process thus recognises the d i f f i c u l t y of making universal knowledge claims about the nature of the human condition. Integrating the art, science and p o l i t i c s of research, therefore, provides a more complete understanding of post-educational a p p l i c a t i o n . Subject Population The worksite L i f e s t y l e S k i l l s Motivation program was offered to employees i n the Department of Housing and Conferences at the University of B r i t i s h Columbia (see Table 6). This department'employs approximately two-hundred-fifty people i n multiple sections located around campus. A t o t a l of four courses were provided to various sections within t h i s department. Employees registered for the program on a voluntary basis. Two s p e c i f i c sections, located within one kilometre of each other, were chosen to act respectively as 136 Table 6. Demographic Data of Subjects i n the Experimental and W a i t i n g - l i s t Control Group DEMOGRAPHICS EXPERIMENTAL N=2 6 N.T.CONTROL N=22 AGE(mean, range) SEX 33 (26-44) 8 5 % F . , 15% M. 31 (23-41) 100% F . MARITAL STATUS Married Div. / Sep. / Wid. Single 14 4 8 7 2 13 NUMBER OF CHILDREN No Children One C h i l d Two or More 9 10 7 15 5 2 EDUCATION / OCCUPATION Years(mean, range) 13(10-15) 13.8 (12-15) ETHNICITY Canadian Chinese Australian E.European B r i t i s h S. American E. Indian * = Born i n Canada 18 4 * * 1 0 2 1 0 18 1 * 0 1 1 0 1 * 137 an experimental and a ^wait ing- l i s t ' contro l group. Distance helped to prevent poss ib le contamination between subjects from both groups. Idea l ly , subjects in a no-treatment cont ro l group cons ist of mul t ip le un i ts comparable to the treatment group in composition, d i s p o s i t i o n and experience. Chi-square analyses revealed that the groups d i f f e r e d s i g n i f i c a n t l y in the number of subjects who were s ing le (Chi-Square value 9.37) and the number of subjects who had ch i ld ren (Chi-square value 5.32) . This b ias , however, was in a conservative d i r e c t i o n i n favour of the w a i t i n g - l i s t cont ro l group. Table 6 ind icated that despite minor d i f ferences between the two groups i n demographic c h a r a c t e r i s t i c s , there were no s p e c i f i c circumstances to suggest that employees from these two s i t e s with in the Department of Housing and Conferences(UBC) d i f f e r e d s i g n i f i c a n t l y . Subjects were c l e r i c a l s t a f f with vary ing l e v e l s of rank and r e s p o n s i b i l i t y and were aged between 23 and 44 years o l d . With the exception of four males In the experimental group (15%), subjects were predominantly female with the majority of these being not s ing le and with c h i l d r e n . Over three-quarters of the subjects were born i n Canada. P a r t i c i p a t i o n i n heal th promotion programs has been def ined i n various ways i n the l i t e r a t u r e , in a comprehensive review of p a r t i c i p a t i o n i n workplace heal th promotion programs, Glasgow et a l . (1993) suggested that a reasonable measure could be based on a requirement of 138 attending 50% or more sessions of a worksite program. C r i t e r i a for data analysis i n t h i s study were that subjects attended at least four sessions (50%) of the L i f e s t y l e S k i l l s Motivation program, were not i n the "maintenance" stage of exercise p a r t i c i p a t i o n (as defined by Marcus et a l . , 1992), and did not have any predisposing i l l n e s s or i n j u r y . T h i r t y - f i v e subjects (76%) at the s i t e of the experimental group registered for the intervention. Of those, 29 attended the program and 26 completed four or more sessions. Twenty-seven subjects (72%) at the s i t e of the w a i t i n g - l i s t control group completed pre-test questionnaires. Two of these subjects, however, were i n the maintenance stage of exercise p a r t i c i p a t i o n and three subjects had l e f t the department by post-test data c o l l e c t i o n . Thus, 26 subjects i n the experimental group and 22 s u b j e c t s i n a w a i t i n g - l i s t control group were c o n s i d e r e d p a r t i c i p a n t s of a purposeful sample i n t h i s study. Interviews were conducted to examine reasons why some par t i c i p a n t s d i d not attend the program and why some did not attend more than four sessions. It appeared from a v a r i e t y of d i r e c t and i n d i r e c t sources that those people who d i d not attend the program were generally i n the precontemplation or maintenance stage of exercise p a r t i c i p a t i o n , or were reluctant to engage i n discussion with peers regarding health issues. Interestingly, these subjects were mainly situated at one work area within t h i s section of the 139 department. Furthermore, the department representative involved i n program development was unable to attend the program as a re s u l t of work commitments and vacation timing. Out of a t o t a l of eight sessions, h a l f of the respondents attended seven or more sessions, nearly one h a l f attended 6 sessions and the remaining person attended 5 sessions. Reasons given for non-attendance included: "no cover at the workstation, sick, completely forgot, a rush of work that needed doing, taking personal holiday leave." Those subjects who did not attend four or more sessions (n=3) c i t e d time, an ear i n f e c t i o n and vacation time factors as b a r r i e r s to p a r t i c i p a t i o n . One participant, however, asserted that three p a r t i c u l a r sessions (the f i r s t , the l a s t and one on mental s k i l l s ) best suited her needs. Design The purpose of t h i s study was to gain a better understanding of the e f f e c t s of, and the application of learning following a worksite health promotion program. Data were gathered on the following concepts and measures: (1 ) selected outcome variables (exercise s e i f - e f f i c a c y , stages of exercise behaviour change and exercise behaviour), ( 2 ) factors a f f e c t i n g post-educational application, (3) the process of post-educational application, and (4) a l t e r n a t i v e post-educational outcomes, 140 A f i e l d experiment was conducted to address the f i r s t research question with respect to key outcome variab l e s . Program evaluation, journal entries and interview data were assessed to help interpret the quantitative data as well as address the second, t h i r d and fourth research questions regarding factors, process and alternative outcomes pertaining to post-educational application. Combining quantitative and q u a l i t a t i v e methods Qualitative and quantitative tools were combined to study the complex and multifaceted process of post-educational applica t i o n . An e c l e c t i c set of quantitative and q u a l i t a t i v e tools reduces the uncertainty on single study evaluations without as p i r i n g to t o t a l certainty (Cronbach et a l . , 1980; 1986a). The weaknesses of one approach are thus balanced by the strengths of the other. For example, a quantitative component allowed high a c c e s s i b i l i t y to data sources, enabled a high degree of standardisation to data sources and provided useful comparative data pertaining to evidence of change over time. Qualitative methods, i n contrast, provided a dynamic q u a l i t y to deal with complex and i n t e r r e l a t e d knowledge about multiple variables related to the experience of post-educational application. Furthermore, the a b i l i t y to make thought processes and circumstances e x p l i c i t provided a r i c h description to understand application from multiple perspectives (Cameron & Taylor, 1996). The l i t e r a t u r e suggests various ways to integrate quantitative and q u a l i t a t i v e methods (Creswell, 1994; Steckler, McLerOy^ 141 Goodman, Bird, & McCormick, 1992). For the purpose of t h i s study, q u a l i t a t i v e methods were employed to help explain quantitative findings as well as used i n p a r a l l e l to assess factors influencing application and the process of applicat i o n . Figures 4a and 4b capture the design of t h i s study i n terms of intervention and data c o l l e c t i o n processes. PRE-TEST POST-TEST FOLLOW-UP. (May - Oct) 1995 Phone/Site V i s i t PRECEDE PLANNING Learners & Worksite O f f i c i a l s (Oct) 1995 Qu a n t i t a t i v e Outcome V a r i a b l e s INTERVENTION Formative Evaluation (Nov - Jan) 1995 / 96 Summative Evaluation Quantitative Outcome V a r i a b l e s DISSEM. RESULTS (May 1996) Figure 4a. Intervention and Data c o l l e c t i o n processes Over the Twelve Month Study 142 P R E -TEST POST-TEST FOLLOW- DISSEM. (May - Oct) 1995 (Oct) 1995 (Nov - Jan) 1995 / 96 (May 1996) Workplace Wellness Board A c t i v i t i e s & Networking Generic E-Mail Weekly Reminders S On-Site V i s i t s Post-Ed. Journal E n t r i e s Post-Program Evaluation Questionnaire Questionnaire Outcome Va r i a b l e s Phone/Site V i s i t PROCEED FACTORS Learners S Worksite O f f i c i a l s Results Dissemination to Workplace Community Figure 4b. Intervention and Data c o l l e c t i o n processes Over the Twelve Month Study Professionals i n the f i e l d i d e n t i f y the d i f f i c u l t y of applying rigorous s c i e n t i f i c standards in. the workplace as a b a r r i e r to evaluation (Johnston, 1991). Randomised designs 143 to i d e n t i f y comparisons and i n f e r causal e f f e c t s are often not f e a s i b l e i n f i e l d settings due to the cost, complexity, delay and prohibitiveness i n organisational environments. Campbell and Boruch (1975), however, i d e n t i f i e d the following biases that tend to operate i n pre-test, post-test non-equivalent groups designs that cannot be adjusted by s t a t i s t i c s : regression artefacts due to matching, d i f f e r e n t i a l growth rates, r e l i a b i l i t y increases over time due to maturation, advantaged control groups, and c e i l i n g and f l o o r e f f e c t s . In t h i s study, for example, non-randomisation of subjects from the workplace population to experimental or control groups subs t a n t i a l l y reduces the po t e n t i a l to make confident generalisations from the sample population to broader workplace populations (external v a l i d i t y ) . This can be i l l u s t r a t e d by the p o t e n t i a l bias for members of either the experimental or w a i t i n g - l i s t control g r o u p with r e s p e c t t o body c o m p o s i t i o n a n d / o r t h e number of children a person has. These factors are l i k e l y to interact with intervention processes s i g n i f i c a n t l y to e f f e c t exercise behaviour (Bouchard et a l . , 1990). Compounding the problem of non-randomisation, non-random assignment of treatment to groups reduces confidence to i n f e r c a u s a l i t y from the intervention (internal v a l i d i t y ) since one group could have been more receptive to program processes than another. At the request of management, the intervention was implemented i n i t i a l l y at central o f f i c e where p u b l i c i t y and promotion for the health promotion program was most prevalent. 144 Quasi-experimental designs have been successfully implemented i n f i e l d settings and f a c i l i t a t e causal explanation and generalisation (Cronbach et a l . , 1980). For the purpose of t h i s study, a non-equivalent control group quasi-experimental design was used as well as p r i o r i t y given to i n t e r p r e t a t i v e and c r i t i c a l inquiry to gain a better understanding of contextually-bound post-educational ap p l i c a t i o n of a worksite health promotion program. Figure 5 depicts the design of t h i s study based on Campbell and Stanley's (1963) perspective of experimental design. PRE POST FOLLOW-TEST TEST UP 0 Xe 0 0 0 0 0 Xc 0 = Observations Xe = Experimental Intervention Xc = N.T. Control group - Post-study Intervention Figure 5 . Diagram I l l u s t r a t i n g a Non-Equivalent Control Group Quasi-Experimental Design Procedures Planning phase A needs assessment was conducted at both s i t e s between January and October 1995 using a va r i e t y of sources as part of an on-going process throughout the Precede planning phase. Multiple methods were employed to r e c r u i t subjects 145 and to ensure that the program was t a i l o r e d to s u i t the needs and circumstances of those involved i n the worksite L i f e s t y l e S k i l l s Motivation program. A series of interactions occurred between the researcher and worksite personnel including researcher observations and perceptions, an informal needs assessment survey, b r i e f but frequent s i t e v i s i t s , b r i e f telephone interviews with management, unions and employees, fo c a l group meetings with employee representatives and potential program participants, an oral presentation of program processes, d i s t r i b u t i o n of promotional l i t e r a t u r e and a series of workplace newsletter a r t i c l e s describing the rationale and processes within the worksite L i f e s t y l e S k i l l s Motivation program. Workplace records regarding previous workplace health promotion i n i t i a t i v e s were not available for examination. Program phase The worksite L i f e s t y l e S k i l l s Motivation program involved eight, one-hour sessions. Two sessions were given per week for a one-month period. Table 7 indicates the course outline for the eight sessions. 146 Table 7. Course Outline f o r the Worksite L i f e s t y l e S k i l l s Motivation program Session (1) Introduction, Motivation for Active L i v i n g Session (2) Fitness Monitoring and Active L i v i n g Session (3) Weight Management and Active L i v i n g Session (4) Tension Control and Active L i v i n g Session (5) Planning Strategies for Active L i v i n g Session (6) Mental S k i l l s Strategies for Active L i v i n g Session (7) Evaluation Strategies for Active L i v i n g Session (8) Applied Motivation Strategies & Active L i v i n g Two intervention programs were offered on each day, before and afte r lunch, to accommodate shift-work requirements of a l l c l e r i c a l employees i n the experimental group. The intervention program was held during the month of October 1995, i n multiple and often last-minute venues located around the workplace environment. On completion of the four-week program, program support a c t i v i t i e s continued to be available for program p a r t i c i p a n t s . These included weekly on-site v i s i t s by the course instructor, generic e-mail reminders to complete weekly journal entries, a s i x -week post-program evaluation and workplace wellness board a c t i v i t i e s with networking opportunities. 147 E s s e n t i a l l y , a 'no treatment' control group showed what might have happened to respondents i n the absence of the program. A ' w a i t i n g - l i s t ' control group can be problematic since members may be less motivated or may overcompensate i n t h e i r response to the perceived benefits from an i n f e r i o r service. To compensate for t h i s , the ' w a i t i n g - l i s t ' control group was offered an opportunity to take the L i f e s t y l e S k i l l s Motivation program on completion of the follow-up period (January, 1996). Research phase Data were gathered throughout the four-month investigation period (October, 1995 to January, 1996) to gain a better understanding of post-educational applicatio n following the worksite L i f e s t y l e S k i l l s Motivation program. Data from program evaluation questionnaires were c o l l e c t e d at mid-program, post-program and at six weeks following the program. A random sample of 50% of program pa r t i c i p a n t s was selected to gather s p e c i f i c data pertaining to post-educational a p p l i c a t i o n . Journal entries were c o l l e c t e d on a four-weekly basis from completion of the program to a three month follow-up. At follow-up, subjects were contacted by telephone or through on-site v i s i t s for a semi-structured interview. In some cases multiple mini-interviews were conducted as a r e s u l t of participant work commitments and interruptions. An i n i t i a l telephone c a l l was made p r i o r to the interview to prepare the respondent for questions pertaining to post-educational application. The interview 148 was semi-structured in nature and lasted from 15-45 minutes. The researcher asked each pa r t i c i p a n t to be as honest and f o r t h r i g h t as possible to enhance future programs. Journal entries served as a stimulus for s p e c i f i c questioning and further probing. The questioning format was c y c l i c a l rather than l i n e a r . This enabled continuous opportunities to cross-check responses as well as to c l a r i f y agreement with i n t e r p r e t a t i o n . The researcher made f a i t h f u l and rigorous notes during the interview and then thanked each respondent for his or her time and co-operation. On completion of the interview, a detailed r e c a l l was conducted to expand and c l a r i f y notes that had been taken. Data were also gathered from interviews with senior workplace management o f f i c i a l s to obtain t h e i r perspectives regarding implementation processes and outcome perceptions. As a continuous part of the intervention processes, findings and implications from t h i s study were recycled back to subjects involved i n the worksite L i f e s t y l e S k i l l s Motivation program. Instruments A v a r i e t y of quantitative and q u a l i t a t i v e tools were employed i n t h i s study to address the research objectives and to gain a better understanding of post-educational ap p l i c a t i o n of a worksite health promotion program. Objective 1: Selected Outcome Variables (a) 7-Day Recall Exercise Behaviour Questionnaire. There are various methods to assess l e v e l s of exercise 149 behaviour, from d i r e c t observation, which i s objective but very expensive and impractical, to respondent r e c a l l questionnaires. In a review of the questionnaires that measure leisure-time physical a c t i v i t y , Lamb and Brodie ( 1 9 9 0 ) concluded that the selection of the most appropriate instrument i s often based on a trade-off between p r a c t i c a l , f i n a n c i a l and qu a l i t y considerations. For the purpose of t h i s study, exercise behaviour was measured using the 7-Day Recall Exercise Behaviour Questionnaire developed by Godin and Shephard ( 1 9 8 5 ) . This i s a r e l a t i v e l y simple questionnaire that presents a minimal burden to the respondent (see Appendix B). It included a range of a c t i v i t i e s , categorised by intensity, and subjects indicated the number of times per week that they p a r t i c i p a t e d i n any of the a c t i v i t i e s for longer than 1 5 minutes during the previous seven days. This provided a measure of t o t a l exercise p a r t i c i p a t i o n i n terms of type, frequency, int e n s i t y , and duration of exercise p a r t i c i p a t i o n . The questionnaire was validated using measures of aerobic f i t n e s s and the reported t e s t - r e t e s t r e l i a b i l i t y was 0 . 7 4 (N= 5 8 , £ < 0 . 0 0 1 ) . Research has shown that s e l f - r e p o r t questionnaires are a v a l i d method to assess general patterns of exercise behaviour and to d i s t i n g u i s h between those who exercise and those who do not (Blair et a l . , 1 9 8 9 , Gionet & Godin, 1 9 8 9 , M i l l e r , Freedson, & Kline, 1 9 9 4 ) . (b) Exercise S e l f - E f f i c a c y Scale. Exercise s e l f - e f f i c a c y was measured using the Exercise S e l f - E f f i c a c y Scale that was 150 developed by Marcus et a l . (1992). This questionnaire was developed using the guidelines suggested by Bandura (1977) and i s composed of f i v e items that r e f l e c t the respondent's b e l i e f s i n his or her c a p a b i l i t y to continue exercising successfully i n the face of p o t e n t i a l b a r r i e r s (see Appendix B). The items represent the most meaningful exercise s e l f -e f f i c a c y factors that were found and validated by S a l l i s et a l . (1988), namely, r e s i s t i n g relapse and making time for exercise. A 7-point Like r t scale, from 1 not at a l l confident to 7 very confident i s used to rate each of the f i v e items. Subjects can also choose 0, "does not apply to me". This questionnaire was used i n the study by Marcus et a l . (1992) and the t e s t - r e t e s t (product moment) r e l i a b i l i t y was reported to be 0.9 (N = 20, p_ < 0.001) (c) Stages of Exercise Behaviour Change Scale. This scale was developed along the guidelines suggested by Prochaska and DiClemente (1985) and adapted for exercise p a r t i c i p a t i o n by Marcus et a l . (1992). This i s a f i v e item questionnaire (stages of Precontemplation, Contemplation, Preparation, Action and Maintenance) where one rates each item on a 5-point L i k e r t scale, with 1 i n d i c a t i n g strongly disagree and 5 strongly agree (see Appendix B). Stage of exercise behaviour change was thus determined by noting the stage with the highest value recorded. This scale has a Kappa index of r e l i a b i l i t y for the stages-of-change instrument over a two-week period of 0.78 (n = 20). According to F l e i s s (1981), a value of Kappa above 0.75 indicates strong 151 agreement. This scale i s more robust than the 7-Day Recall Questionnaire and, therefore, was s t r a t e g i c a l l y placed before the former questionnaire to a s s i s t with more accurate s e l f - r e p o r t i n g of exercise behaviour. This was established by the researcher from findings i n a previous study conducted i n a community setting (Hubball, 1994). Objectives 2-4: Post-Educational Application Green and Kreuter's (1991) Proceed framework was used to gather data pertaining to the multidimensional process of change. This framework takes into account the c h a r a c t e r i s t i c s of the learner and the context i n which the change i s expected to occur. There i s a growing body of evidence to support the u t i l i t y of t h i s model i n a v a r i e t y of settings and i t has broad implications for many forms of adult education (Mullen, Hersey and Iverson, 1987; Houle, 1992, p.275). Program parti c i p a n t s are one of the most important and accountable data sources (Stufflebeam & Walker, 1983) . Data gathered from the learners provides information regarding t h e i r reactions to the learning experience, factors a f f e c t i n g a p p l i c a t i o n and the process of application, and can y i e l d information regarding unintended outcomes. Formative and summative data pertaining to the learning experience was gathered using the Group Report Reactionnaire and the Post-Program Evaluation Questionnaire (see Appendix C). The Reactionnaire i s a session/program evaluation form that was adapted from Gorman (1974). It i s an open ended 152 questionnaire that i s intended to develop r e f l e c t i v e teaching and learning experiences. A respondent indicates his or her r e f l e c t i o n s regarding the following aspects of the learning experience: the learner's perception regarding his or her active involvement i n the learning process, perceived learning outcomes, perceived confidence to apply learning, presentation of learning experience, and suggestions for how the session/program could be improved. The Post-Program Evaluation Questionnaire was adapted from Kingery, Holcomb, Jibaja-Rusth, P r u i t t , and Buckner's (1994) program processes and s e l f - e f f i c a c y evaluation format. No psychometric properties are reported with t h i s instrument. The evaluation was administered to a l l subjects six weeks aft e r completion of the intervention program and required respondents to rate the perceived usefulness of various components of the program toward post-educational a p p l i c a t i o n . Data from these two sources focused on the i n t e r a c t i v e process of the learning experience and, therefore, provided a r i c h c r i t i q u e of the nature of classroom processes and program outcome perceptions. Gathering q u a l i t a t i v e information of t h i s nature at mid-program, post-program and at a six-week follow-up, was not onerous for program pa r t i c i p a n t s . Journal entries, (see Appendix F) pertaining to the process of application were examined on a four-week basis from completion of the program u n t i l the three months following the program. At follow-up, a semi-structured, on^ 153 s i t e or telephone interview (see Appendix D) with program partic i p a n t s and workplace o f f i c i a l s was guided primarily by the factors i n the proceed framework. According to Denzin and Lincoln (1994), "interviews are situated understandings grounded i n s p e c i f i c i n t e r a c t i o n a l episodes" (p.353). Respondents were also given an opportunity to discuss al t e r n a t i v e outcomes following the worksite L i f e s t y l e S k i l l s Motivation program. Data Analysis Objective 1: Selected Outcome Variables The following research hypotheses were examined through quantitative data. HI. The experimental group w i l l p a r t i c i p a t e i n a higher frequency of exercise behaviour than the w a i t i n g - l i s t control group across the duration of t h i s study. H2. The experimental group w i l l have higher l e v e l s of exercise s e l f - e f f i c a c y than the w a i t i n g - l i s t control group across the duration of t h i s study. H3. There w i l l be a difference i n the pattern of the stages of exercise behaviour change between the two groups across the duration of t h i s study. Data were analysed using a Systat 5 s t a t i s t i c a l software program. Data were i n i t i a l l y analysed for pre-program group differences. Hypotheses 1 and 2 were then 154 analysed using a two-way analysis of variance, group (two) by time (three) f a c t o r i a l design with repeated measures on the second factor for each of the dependent variables (exercise behaviour and s e l f - e f f i c a c y ) . The advantages of f a c t o r i a l designs are ( 1 ) e f f i c i e n c y , i n terms of an analysis of two independent variables (2 ) control over additional variables, and (3 ) the study of i n t e r a c t i o n among independent variables (Hinkle & Wiersma, 1 9 8 8 , p . 4 2 5 ) . Hypothesis 3 , consisting of nominal data on an ordinal scale, was analysed using a two-way, group by time Chi-square analysis on each of the stages of exercise behaviour change. Nonparametric tests are applied to nominal data when the parametric assumptions of normality and homogeneity of variance are not met. Chi-square s t a t i s t i c i s a nonparametric t e s t that i s frequently used to compare two or more groups i n the analysis of nominal data i n which observed frequencies of occurrence are compared with t h e o r e t i c a l or expected frequencies (Shavelson, 1 9 8 8 , p . 5 6 0 ) . Objectives 2 - 4 : Post-Educational Application According to Miles and Huberman ( 1 9 9 4 ) , " q u a l i t a t i v e analysis consists of three concurrent flows of a c t i v i t y : data reduction, data display, and conclusion drawing/verification" ( p . 1 0 ) . A random sample of 50% of program pa r t i c i p a n t s was selected to provide s p e c i f i c data from journal entries and to be interviewed about post-educational a p p l i c a t i o n . Continued debate i n the l i t e r a t u r e 155 exists with respect to v a l i d a t i o n of q u a l i t a t i v e research (Kvale, 1995, Smith, 1992, Denzin & Lincoln, 1994). Lincoln (1995) advocated " r e l a t i o n a l i t y " as central to c r i t e r i a for q u a l i t a t i v e research. That i s , research rooted i n emerging conceptions of community, shared governance and decision making, and equity. For the purpose of t h i s study, q u a l i t y of data was ensured throughout the interview process by c y c l i c a l or cross-checking questioning techniques and multiple opportunities for researcher-respondent summarisation and c l a r i f i c a t i o n . Extensive t r i a n g u l a t i o n between journal entries, program evaluations, researcher experience (Patton, 1980), f i e l d notes and quantitative data were employed with a l l q u a l i t a t i v e data. Data from program evaluation questionnaires, journal entries and interview notes were then analysed for common or i s o l a t e d experiences, r e p e t i t i o n , themes, intent, contradictions and discrepancies. Concepts were categorised and described within the factors of the Proceed framework. To provide a meaningful understanding and int e r p r e t a t i o n of data, each factor was analysed i n terms of the majority and minority of responses to p a r t i c u l a r issues. Qualitative data reported i n the next chapter r e f l e c t the responses from a cross-section of respondents to p a r t i c u l a r issues that emerged. Data qu a l i t y i n t h i s study was considered to be good. The findings of t h i s study were integrated, analysed, interpreted, and discussed with respect to the l i t e r a t u r e pertaining to c r i t i c a l s e l f - d i r e c t e d learning for exercise 156 behaviour change following a worksite health promotion program. The findings and implications of t h i s study were discussed i n an open forum with participants from the worksite community. The results of t h i s study are reported in the following chapter. 157 CHAPTER 4 Introduction This chapter includes a quantitative and q u a l i t a t i v e analysis pertaining to application of c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change. The chapter begins by presenting a quantitative analysis of key outcome variables i n the exercise adherence l i t e r a t u r e (exercise behaviour, exercise s e l f - e f f i c a c y and the stages of exercise behaviour change). Each dependent variable was analysed separately with respect to both groups (experimental and w a i t i n g - l i s t c o n t r o l ) . The dependent variable was i n i t i a l l y analysed for pre-program group differences and descriptive data were recorded regarding the group mean scores at pre-program, post-program and at the three-month follow-up. These mean scores were then analysed using a two-way analysis of variance, group (two) by time (three) f a c t o r i a l design with repeated measures on the second factor and appropriate post-hoc analyses. A Chi-square analysis was performed on the stages of exercise behaviour change data. The chapter closes by presenting process, journal and interview data pertaining to multiple factors influencing application, and post-educational experiences following the worksite health promotion program. 158 Quantitative Analysis 7-Dav Recall of Exercise Behaviour Data were c o l l e c t e d for the subjects in both groups with respect to exerc ise behaviour using the Godin and Shephard (1985) quest ionnaire . These data were recorded at pre-program, post-program and at a three-month follow-up p e r i o d . The mean exerc ise behaviour l e v e l s at these data c o l l e c t i o n points are d isp layed in Table 8. These r e s u l t s were then analysed using repeated measures ana lys is of var iance. A summary of the ANOVA can be seen i n Table 9. Table 8 . The Mean 7-Day Recall Exercise Behaviour (Frequency) f o r Both Groups at Three Points i n Time GROUP P R E - P O S T - F O L L O W - MEAN T E S T T E S T UP Experimental 1 . 9 2 . 9 2 . 5 2 . 4 SD (1.7) (1.6) (1.3) N=26 N.T .Contro l 2 . 4 2.2 1.8 2.1 SD (2.1) (1.9) (1.7) N=22 MEAN 2 . 2 2 . 6 2 . 3 2 . 3 159 Table 9. Summary of the Analysis of Variance Comparing the Groups fo r Exercise Behaviour (N=48) EFFECT df £ * E Group 1 0.31 0.58 Time 2 0.93 0.40 Group X Time 2 3.58 0.03 * alpha = 0.05 * Repeated measures ANOVA v i o l a t i o n of assumptions: non-random assignment of both individuals to group and treatment to group. Two-way analysis of variance, however, i s robust to the v i o l a t i o n s of assumptions, p a r t i c u l a r l y when population variances i n a l l c e l l s are equal and there are equal number of observations i n each c e l l of the f a c t o r i a l design (Hinkle & Weisma, 1988; Shavelson, 1988). Research suggests that when the largest variance i n a f a c t o r i a l i s less than four times the smallest variance (as found i n t h i s study), the ANOVA i s most l i k e l y to be v a l i d (Wilcox, 1987; Winer, 1971) . 160 Figure 6 . Mean Exercise Behaviour fFreouencv Per Week) and Mean Exercise Self-Efficacv for Both Groups as a Function of Time 161 Pre-program Group Differences An independent t - t e s t was performed to test for group differences i n the pre-test mean scores for exercise behaviour. The results indicated than the means (1.9 and 2.4) were not s i g n i f i c a n t l y d i f f e r e n t . Two-way analysis of variance (Exercise Behaviour) Group E f f e c t S t a t i s t i c a l analysis E(l,43) = 0.31 £=0^58 indicated that the mean values (2.4 and 2.1 times per week) of exercise frequency for the d i f f e r e n t groups (when averaged over time) were not s i g n i f i c a n t l y d i f f e r e n t . The mean exercise frequency score for the experimental group was 15% higher than the mean exercise frequency score for the w a i t i n g - l i s t control group from pre-program to follow-up. Time E f f e c t S t a t i s t i c a l analysis £(2, 86) = 0.93 p_=0.40 indicated that the mean values for the three points i n time (2.2, 2.6 and 2.3 times per week), when averaged over both groups, were not s i g n i f i c a n t l y d i f f e r e n t from each other. Interaction E f f e c t S t a t i s t i c a l analysis F(2, 86) = 3.57 p_=0.03 indicated a s i g n i f i c a n t i n t e r a c t i o n between group and time factors. The response patterns for each group across the time factors were d i f f e r e n t . Figure 6 i l l u s t r a t e s a very small difference 162 between the groups i n i t i a l l y at pre-test (0 .45 times per week) in favour of a higher score for the w a i t i n g - l i s t control group. On completion of the four-week program, however, the difference between the groups had increased i n magnitude (0 .74 times per week) and also a d i r e c t i o n a l s h i f t i n favour of a higher score for the experimental group. The experimental group p a r t i c i p a t e d i n exercise approximately one t h i r d more frequently per week than the w a i t i n g - l i s t control group at the end of the four-week program. From post-program to follow-up the groups tended to converge s l i g h t l y and showed a decrease in exercise behaviour from post-program to the follow-up period. The difference between the groups at the follow-up period was 0 .68 times per week. The mean exercise frequency for the experimental group was 36% higher than the waiting-l i s t control group at the follow-up. The Scheffe post-hoc comparison test was c a r r i e d out on the i n t e r a c t i o n e f f e c t . Tobs i s the test s t a t i s t i c for the Sheffe method. The Scheffe analysis indicated that the mean differences between the experimental and the w a i t i n g - l i s t control group at the pre-program and post-program period (0 .45 and 0 .74) and also at the pre-program and follow-up (0 .45 and 0.68) were s i g n i f i c a n t Tobs (1 ,86) = 2 . 1 9 p_<0.05 and Tobs (1 ,86) = 2 . 1 0 p_<0.05 respectively. Looking at the graph i n Figure 6, one can see that although both groups tended to decrease from post-program to follow-up l e v e l s , the experimental group maintained a higher frequency of exercise than the waiting-l i s t control group. This suggests that the intervention 163 program was e f f e c t i v e in terms of improving exerc ise adherence. Exercise S e l f - E f f i c a c y Data were c o l l e c t e d for the subjects i n both groups with respect to exerc ise s e l f - e f f i c a c y . These data were recorded at pre-program, post-program and at three-month fol low-up. The mean exerc ise s e l f - e f f i c a c y scores for these points in time are d isp layed in Table 10. These r e s u l t s were analysed using repeated measures ana lys is of var iance . A summary of the ANOVA can be seen in Table 11. T a b l e 10. The Mean E x e r c i s e S e l f - E f f i c a c y S c o r e s f o r B o t h Groups a t T h r e e P o i n t s i n Time GROUP PRE- POST- FOLLOW- MEAN TEST TEST UP Experimental 19.69 SD (6.11) N=26 25.81 (4.81) 26.40 (4.36) 23.97 N.T Control 21 .64 SD (7.11) N=22 22.00 (7.29) 19.82 (6.69) 21.15 MEAN 20.40 24.20 23.54 22.56 164 Table 1 1 . Summary of the Analysis of Variance Comparing Both Groups for Exercise Self-Efficacy EFFECT df E * B Group 1 3.48 0.069 Time 2 12.70 <0.001 Group X Time 2 19.07 <0.001 * alpha =0.05 * Repeated measures ANOVA v i o l a t i o n of assumptions: non-random assignment of both individuals to group and treatment to group. Two-way analysis of variance, however, i s robust to the v i o l a t i o n s of assumptions, p a r t i c u l a r l y , when population variances i n a l l c e l l s are equal and there are equal number of observations i n each c e l l of the f a c t o r i a l (Hinkle & Weisma, 1988; Shavelson, 1988). Research suggests that when the largest variance i n a f a c t o r i a l i s less than four times the smallest variance (as found i n t h i s study), the ANOVA i s most l i k e l y to be v a l i d (Wilcox, 1987; Winer, 1971). Pre-Program Group Differences An independent t - t e s t was performed to tes t for group differences i n the pre-test mean scores for exercise s e l f -e f f i c a c y . The re s u l t s indicated than the mean exercise s e l f -e f f i c a c y scores (19.69 and 21.64) were not s i g n i f i c a n t l y 165 d i f f e r e n t . These mean scores were comparable to those reported by Marcus et a l . (1992) for 429 male and female government employees. Two-way analysis of variance (Exercise Self-Efficaev) Group E f f e c t S t a t i s t i c a l analysis F(l,43) =3.48 p=0.07 indicated that the mean exercise s e l f - e f f i c a c y scores for the two groups when averaged over time (23.97 and 21.15 respectively) were approaching s i g n i f i c a n c e . The mean s e l f - e f f i c a c y score for the experimental group was 13% higher than the mean s e l f - e f f i c a c y score for the control group. Time E f f e c t S t a t i s t i c a l analysis £(2,86) = 12.70, p<0.001 indicated that the mean exercise s e l f - e f f i c a c y scores for three points i n time (pre-program = 20.4, post-program = 24.2 and follow-up = 23.54) when averaged over both groups were s i g n i f i c a n t l y d i f f e r e n t from each other. Looking at these means, one can see a greater increase from pre-program to post-program, than between post^program to follow-up. This may suggest that the increase was larg e l y attributable to the concurrent influence of the intervention program and that continued increase i n s e l f - e f f i c a c y slows or halts a f t e r the exposure to the program ends. The decline from post-program to follow-up suggests that averaged over both groups no further development of s e l f -166 e f f i c a c y took place. A Tukey pairwise comparison test was ca r r i e d out to see where the differences occurred i n the main time e f f e c t while maintaining the experimental alpha l e v e l (0.05) at the pre-established l e v e l . Q i s the test s t a t i s t i c for the Tukey method. The Tukey post-hoc analysis indicated that a s i g n i f i c a n t difference occurred for both groups between pre-program and follow-up 0.(3, 86) = 6.69, p<0.01 and between pre-program and post-program 0.(3, 86) = 8.09, p_<0.01). Therefore, when averaged over both groups, the exercise s e l f -e f f i c a c y scores s i g n i f i c a n t l y increased from pre-program to post-program, however, there was not a s i g n i f i c a n t difference from post-program to follow-up where a l e v e l l i n g o f f occurred. Interaction E f f e c t S t a t i s t i c a l analysis F(2,86) = 19.07 p<0.01 indicated a s i g n i f i c a n t i n t e r a c t i o n between group and time factors. The response patterns for each group across the time factors was d i f f e r e n t . One can see from the graph i n Figure 6 that the experimental group tended to increase i n s e l f - e f f i c a c y whereas the w a i t i n g - l i s t control group tended to decrease over the same time period. I n i t i a l l y , at pre-program a small (nonsignificant) difference exists between the groups (1.94) i n favour of the w a i t i n g - l i s t control group, and then at the end of the four week program, the difference between the groups had increased i n magnitude (3.81) and also a d i r e c t i o n a l s h i f t i n favour of the intervention program. From post-program to the follow-up period, the groups continued to 167 diverge with the experimental group continuing to improve s l i g h t l y while the w a i t i n g - l i s t control group showed a decline to below pre-program l e v e l s . The mean exercise s e l f - e f f i c a c y score of the intervention group at follow-up was 33% higher than that of the w a i t i n g - l i s t control group. The Scheffe post-hoc comparison test was c a r r i e d out on the i n t e r a c t i o n e f f e c t . The Scheffe analysis indicated that the mean differences between the experimental and the control group at the pre-program and the post-program periods (1.94 and 3.81 respectively), at the pre-program and follow-up (1.94 and 6.59 respectively) and also at post-program and follow-up were s i g n i f i c a n t Tobs(l, 86) = 4.23 p_<0.01, Tobs(l,86) = 6.40 P<0.01 and Tobs 2.04 p_<0.05 respectively. The graph i n Figure 6, shows that the experimental group maintained s e l f - e f f i c a c y from post-program lev e l s whereas the control group decreased i n s e l f - e f f i c a c y l e v e l s by approximately 10% between post-program and follow-up. Therefore i n terms of exercise adherence, i t would appear that the experimental program was e f f e c t i v e for increasing exercise s e l f - e f f i c a c y during the intervention period and at least maintaining exercise s e l f -e f f i c a c y for a three-month period following the intervention. Correlation Matrix The Pearson-product moment correlations quantify the r e l a t i o n s h i p between the 7-day r e c a l l of exercise behaviour and exercise s e l f - e f f i c a c y . The moderately high correlations found i n t h i s study (Table 12) between exercise frequency and 168 Table 12. Pearson Correlation C o e f f i c i e n t s f o r Exercise Frequency and Exercise S e l f - E f f i c a c y as a Function of Time FREQ1 FREQ2 FREQ3 SEl SE2 SE3 FREQ1 1.00 FREQ2 .46 1.00 FREQ3 .44 .45 1.00 SEl .78 .54 0.40 1.00 SE2 .63 .57 0,65 .75 1.00 SE3 .28 .33 0.67 .36 0.75 * N = 45 FREQ1 = Pre-program exercise frequency. FREQ2 = Post-program exercise frequency. FREQ3 = Follow-up exercise frequency. SEl = Pre-program exercise s e l f - e f f i c a c y . SE2 = Post-program exercise s e l f - e f f i c a c y . SE3 = Follow-up exercise s e l f - e f f i c a c y . exercise s e l f - e f f i c a c y at each time period (0.78, 0.57, and 0.67 p<0.01) supported the findings by McAuley and Jacobson (1991) that s e l f - e f f i c a c y appears to be correlated with exercise p a r t i c i p a t i o n . For the duration of t h i s study, i t would appear from the temporal relationships of c o r r e l a t i o n c o e f f i c i e n t s i n Table 12, that exercise s e l f - e f f i c a c y 169 correlations with frequency of exercise behaviour are higher than frequency correlations with subsequent frequency of exercise behaviour. However, exercise self-efficacy correlations with frequency of exercise behaviour are generally lower than exercise frequency correlations with exercise self-efficacy, and exercise self-efficacy correlations with subsequent exercise self-efficacy. These data suggest, therefore, that participation in exercise tends to increase exercise self-efficacy, more than exercise self-efficacy tends to increase participation in exercise behaviour. Stages of Exercise Behaviour Change Table 13a indicates the frequency of subjects from each group at pre-program, post-program and follow-up in the contemplation, preparation and action stages of exercise behaviour change. Subjects volunteered to participate in the eight-session, workplace health education program hence were unlikely to be in the precontemplation stage of exercise behaviour change. Furthermore, data from subjects in the maintenance stage of exercise behaviour change were screened and eliminated for purposes of data analysis. An item on the stages of exercise behaviour questionnaire assessed relapse history with respect to regular exercise. Data indicated that 80% of the experimental group, and 73% of the waiting-list control group had experienced some history of relapse from regular exercise. Table 13b indicates the number of 170 Table 13a. Frequency of Stages of Exercise Behaviour Change for Both Groups at Pre-, Post-Program and Follow-up Periods C EXPERIMENTAL (N=26) PREP. A C NT CONTROL (N=22) PREP. A PRE-PRO. ! 8 16 2 6 15 1 POST-PRO. '. 3 15 8 8 10 1 * FOLLOW-UP ! 3 18 5 9 12 1 C = I c u r r e n t l y do n o t e x e r c i s e , b u t I am t h i n k i n g a b o u t s t a r t i n g t o e x e r c i s e i n t h e n e x t 6 m o n t h s ( c o n t e m p l a t i o n s t a g e ) . P R E P . = I c u r r e n t l y e x e r c i s e some, b u t n o t r e g u l a r l y ( p r e p a r a t i o n s t a g e ) . A = 1 c u r r e n t l y e x e r c i s e r e g u l a r l y , b u t I h a v e o n l y b e g u n d o i n g s o w i t h i n t h e l a s t 6 m o n t h s ( a c t i o n s t a g e ) . > * = M i s s i n g d a t a ** = R e g u l a r e x e r c i s e r e f e r s t o m o d e r a t e l e i s u r e - t i m e p h y s i c a l a c t i v i t y 3 o r more t i m e s p e r week f o r 20 m i n u t e s o r more e a c h t i m e . 171 Table 13b. Individual Change i n Stages of Exercise Behaviour for Both Groups Between Pre- and Post-Program, and Between post-Program and Follow-up Periods Pre-Program to Post-Program Post-Program to Follow-up Pre-Program to Follow-up Exp. Gp. C > P = 5 P > A = 2 C > p = 5 (N = 26) P > A = 3 P < A = 5 P > A = 3 NT C. Gp. C > P = 1 C < P = 2 c > P = 3 (N = 22) C < P = 3 c < P = 6 C = Contemplation stage P = Preparation stage A = Action stage > = Progressive Change < = Regressive Change Exp. Gp. = Experimental Group NT C. Gp. = No-Treatment Control Group individ u a l s for each group who reported change i n stages of exercise behaviour between pre and post-program, and between post-program and follow-up time periods. A summary of the Chi-square analysis i s shown i n Table 14. Chi-square i s a continuous d i s t r i b u t i o n . When more than 20% of c e l l s have expected frequencies less than f i v e , the researcher i s advised to combine adjacent rows; Furthermore, 172 Table 14. Summary of Chi-Square Analysis f o r the Stages of Exercise Behaviour Change Condition Chi-Square * c E (pre) - N.T. (pre) 0.32 >0 .05 E (post) - N.T. (post) 4.03 <0 .05 E (f. up) - N.T. (f. up) 4.09 <o .05 E (pre) - E (post/f. up) 5.17 <0 .05 N.T. (pre) - N.T. (post/f. up) 0.45 >0 .05 * = alpha, 0.05 E = Experimental group N.T. = No-Treatment control group Chi-square calculations for one degree of freedom (e.g., 2 X 2 contingency tables) require an adjustment for continuity using Yate's correction for continuity (Shavelson, 1988). Thus, for Chi-square analysis, data from subjects i n preparation and action stages of exercise behaviour change for each group were combined. The analysis of the pre-program group differences using Chi-square indicated that the calculated value (Chi-square = 0.0025) was less than the c r i t i c a l value (Chi-square = 3.84) and therefore the n u l l hypothesis, which stated that there would be no differences i n the pattern of the stages of exercise behaviour change between the two groups at pre-173 program, was supported. Thus the d i s t r i b u t i o n of subjects in each group for the stages of exerc ise behaviour change at pre-program was not s i g n i f i c a n t l y d i f f e r e n t . The ana lys is of the post-program group d i f ferences using Chi-square ind icated that the ca l cu la ted value (Chi-square = 4 .03) was more than the c r i t i c a l value (Chi-square = 3 .84) and therefore the n u l l hypothesis, that there would be no d i f ferences in the pattern of the stages of exerc ise behaviour change between the two groups at post-program, was re jec ted . Thus the d i s t r i b u t i o n of subjects i n each group for the stages of exerc ise behaviour change at post-program were s i g n i f i c a n t l y d i f f e r e n t . The ana lys is of three-month fol low-up group d i f ferences using C h i -square ind icated that the ca l cu la ted value (Chi-square = 4 .09) was more than the c r i t i c a l value (Chi-square = 3 .84) and therefore the n u l l hypothesis, that there would be no d i f ferences i n the pattern of the stages of exerc ise behaviour change between the two groups at fol low-up, was r e j e c t e d . Thus the d i s t r i b u t i o n of subjects i n each group for the stages of exerc ise behaviour change at the three-month fol low-up was s i g n i f i c a n t l y d i f f e r e n t . Chi-square analyses of the changes from pre- to post-program as wel l as post-program to follow-up for the experimental group ind icated that the ca l cu la ted value (Chi-square = 5.17) was more than the c r i t i c a l value (Chi-square = 3.84) and therefore the n u l l hypothesis that stated that the pattern of the stages of exerc ise behaviour change for the 174 experimental group would not be s i g n i f i c a n t l y d i f f e r e n t from pre- to post-program was rejected. Thus the d i s t r i b u t i o n of subjects i n the intervention program from pre- to post-program and to follow-up for the stages of exercise behaviour change was s i g n i f i c a n t l y d i f f e r e n t . In comparison, Chi-square analyses indicated a none s i g n i f i c a n t change for subjects i n the w a i t i n g - l i s t control group between pre-, post-program and three month follow-up. These r e s u l t s suggest that differences did occur between the two groups with respect to the stages of exercise behaviour change at post-program and at the three-month follow-up period. On the whole, more people from the experimental group progressed from contemplating exercise to the preparation, or action stage of exercise behaviour change than d i d the w a i t i n g - l i s t control group. Summary Quantitative analyses of t h i s study indicate that s i g n i f i c a n t changes, i n favour of an experimental group, occurred i n exercise behaviour, exercise s e l f - e f f i c a c y and the stages of exercise behaviour change (p<0.05). F i r s t , the mean exercise behaviour of the w a i t i n g - l i s t control group, when taken at three points i n time over a three-month period, tended to decrease continually. In contrast, the mean exercise behaviour of the experimental group increased from pre- to post-program before declining at the follow-up period to a l e v e l s t i l l s i g n i f i c a n t l y above that of pre-program exercise 175 behaviour. Second, the experimental group tended to increase and maintain exercise s e l f - e f f i c a c y over the three-month period whereas the w a i t i n g - l i s t control group showed a decrease i n exercise s e l f - e f f i c a c y from post-program to follow-up. Third, subjects i n the experimental group tended to progress forward from the contemplation stage of exercise behaviour toward the preparation and action stages of exercise behaviour change than did subjects from a w a i t i n g - l i s t control group. Q u a l i t a t i v e Analysis The author employed a q u a l i t a t i v e analysis to the study of application of learning following the worksite health promotion program. Course evaluation documentation, journal entries and a semi-structured interview process were sc r u t i n i s e d through q u a l i t a t i v e procedures. Research questions pertaining to the application of learning were guided by Green and Kreuter*s (1991) Precede-Proceed framework. The multi-i n t e r a c t i o n of s o c i a l contextual, health promotion and i n d i v i d u a l factors influenced whether and how learning was applied. The following sections are a synthesis of d e t a i l e d narrative information gathered over a three-month period from a random sample of f i f t y percent of participants (N=13) who took part i n the intervention program. 176 Factors a f f e c t i n g the application of learning (1) Social contextual factors Individuals face an array of complex and dynamic factors in the s o c i a l environment that can f a c i l i t a t e or hinder application. Nearly three quarters of the respondents described family/social issues as being main factors influencing t h e i r p a r t i c i p a t i o n i n exercise. In many cases these issues came before being able to attend to personal needs and included before-and-after-work c h i l d care commitments, home-based roles and r e s p o n s i b i l i t i e s for caring and providing for others, and serious family concerns/problems that tended to render issues of exercise p a r t i c i p a t i o n as unimportant. For example, comments included, my s i s t e r i s going through a t r i c k y divorce right now and she and my two nephews have moved i n with us for a while, everyone else's things to do at home seem to come before mine, my [teenage] daughter i s having some problems at home and school so I'm worried about her and don't seem to be able to think about much else right now, on top of a f u l l - t i m e job here, my husband and I are also t r y i n g to get a business o f f the ground so we have been channeling a l l our spare time into t h i s for quite a while now. Si m i l a r l y , busy s o c i a l r e s p o n s i b i l i t i e s for some single employees, active i n voluntary work or s i t t i n g on a va r i e t y of community committees were also c i t e d as factors that allowed l i t t l e free time for exercise. Nearly pne h a l f of respondents, however, claimed that a s o c i a l support system from s i g n i f i c a n t 177 family or workplace colleagues was key to p a r t i c i p a t i o n i n exercise. Over one t h i r d of respondents attributed t h e i r i n a c t i v i t y to conditions i n the workplace. Comments such as, "increasing workloads, boredom, constant changes... and c o n f l i c t s to deal with, there's too many unhealthy celebrations... drinks, cakes etc. It's nice but we a l l f e e l bad afterwards and i t doesn't r e a l l y h e l p . " I n addition, nearly one t h i r d c i t e d access issues i n the workplace as a b a r r i e r to exercise. For example, some complained that management had t h e i r own changing and showering f a c i l i t i e s that were awkward for employees to make use of. This was considered "unfair" and a hindrance for those p r e f e r r i n g to jog at.lunch time rather than walk or j o i n the Student Recreation Centre (SRC). Others commented that a lack of money prevented them from being able to use s p e c i f i c f a c i l i t i e s e.g., "the SRC and f i t n e s s club memberships are a l l right i f you can afford i t , I wouldn't mind going swimming at lunch times but i t ' s about $ 5 each time." There was a strong b e l i e f among these respondents that s t a f f should be allowed l i m i t e d free opportunities to attend campus sporting and f i t n e s s f a c i l i t i e s . In contrast, an equal number commented that the workplace context f a c i l i t a t e d exercise p a r t i c i p a t i o n . For example, i f i t wasn't for the SRC I'm not sure i f I'd be able to do as much or as regular as I am, flexi-time allows me to indulge at lunchtimes on nice days for a long walk...but I usually make i t up l a t e r anyway, well i f you can't 178 enjoy the walks around t h i s place where can you?, to be able to drive to the beach at lunchtimes, i f I f e e l l i k e i t , i s just great, I f e e l reasonably safe around here but I wouldn't go into the t r a i l s by myself, i t ' s quite lucky to have a l l these gardens, mountains and bay views to look at on a walk, when I do go jogging at lunchtimes, I l i k e the [nearby] forest t r a i l s because I see enough of buildings and t r a f f i c where I l i v e , every now and then I manage a lunchtime swim at the aquatics centre. Over h a l f of the respondents c i t e d commuting as a b a r r i e r to regular exercise. This was variously described as follows: in order to l i v e i n a nice and affordable family home around here invariably means that you have got to spend a long time t r a v e l l i n g to and from work each day, I don't get enough time at home as i t i s without having further time used up aft e r work going for exercise, I'm committed to a car-pool arrangement so we have pretty f i x e d times to come and go, aft e r a f u l l day at work and being i n commuter t r a f f i c , exercise i s the l a s t thing that I f e e l l i k e doing, t r a v e l l i n g to work takes up most of my free time, I don't l i k e the d r i v i n g i t doesn't make me f e e l l i k e doing much afterwards. For many t h i s often meant that the lunch-time period or weekends were the most l i k e l y times available to engage i n leisure-time physical a c t i v i t y . Several respondents commented on the id e a l Vancouver environment for p a r t i c i p a t i n g i n exercise. In p a r t i c u l a r , 179 access to skiing, hiking, tennis, mountain and beach t r a i l s . Nearly one t h i r d of respondents, however, c i t e d the cold or rainy Vancouver winter weather as being a key factor i n determining whether lunch-time or weekend exercise was probable. Further, over one t h i r d of respondents who said that they would l i k e to do more walking a c t i v i t y reported that they did not f e e l t o t a l l y secure by themselves either i n secluded areas or outside of busy daylight hours. C h i l d care organisation and finding exercise partners with si m i l a r schedules presented a major problem. Some reported getting around t h i s by using various kinds of home-based exercise machinery while one person reported having the convenience of being able to use a f i t n e s s room i n his apartment complex. Respondents are thus presented with a myriad of obstacles in the s o c i a l environment that can hinder p a r t i c i p a t i o n i n regular exercise. The cumulative e f f e c t of these obstacles originate from s o c i a l issues, the community environment, the workplace environment and the t r a n s i t i o n between the home and the workplace were, for some respondents, lar g e l y beyond t h e i r personal control. The locus of control was viewed to be external with family members or s i g n i f i c a n t others surrounding the workplace context. S i g n i f i c a n t people who thus influenced exercise p a r t i c i p a t i o n i n the context of application included: l o c a l community, extended family members, partners, spouses, off-spring, management, workplace supervisors and colleagues. 180 (2) Health Promotion Factors Health promotion factors refer to environmental (e.g., workplace policy, the learning context) and educational (program content, program processes, presentation and perceived learning outcomes) processes that influenced post-educational application. Sensitive negotiations with senior management personnel, p r i o r to the program, were c r i t i c a l to gain t h e i r support and allow the program to take place i n work-time/ thus, ensuring high p a r t i c i p a t i o n . Departmental p r i o r i t i e s for room bookings, however, t y p i c a l l y meant that multiple venues were used throughout the duration of the program. Interestingly t h i s was not perceived as a hindrance by any of the respondents, rather, nearly h a l f of the respondents commented that being i n d i f f e r e n t places located around the worksite added to the "fun" nature of the program. One person who worked i n a more is o l a t e d workstation, however, made the following remark, "what venue?...we were a l l over the place." Two people f e l t that one location would have been more i d e a l and over one t h i r d did not think that the course venue was any kind of issue. Nearly one quarter of respondents expressed appreciation for the e f f o r t put i n by the i n s t r u c t o r to personalise each conference room by displaying previous work on walls to look at, before and af t e r each session, and i n rearranging the seating to f a c i l i t a t e group a c t i v i t i e s and discussion. 181 The knowledge, attitudes, s k i l l s and experiences embedded within the context of educational processes were key factors that influenced application. Nearly one t h i r d of respondents commented on the p r a c t i c a l value of the course e.g., "we generated our own solutions, useful indoor and outdoor walking routes around Brock, easy to do relaxation s k i l l s , made me think about my s i t u a t i o n , useful time management t i p s . " Furthermore, over three quarters of the respondents commented on the usefulness of the group int e r a c t i o n throughout the course. Reasons offered included: "sense of support, more enjoyable and motivating, gave i t a r e a l i t y , an informal opportunity to interact with other colleagues that doesn't often arise , . . . b e n e f i t from other peoples' experiences i n s i m i l a r s i t u a t i o n s . " In p a r t i c u l a r , nearly a quarter of the respondents commented on the usefulness of the i n i t i a l 'team work challenge' through question and answer format regarding the previous session: i t was a good way to get our minds onto health and o f f the job issues that we had just l e f t downstairs, i t helped to see the l i n k of i t a l l coming together, i t was a good way to l i v e n us up at the s t a r t . . . you were remarkably patient and understanding with us though. On the other hand, a quarter of the respondents indicated that they would have preferred more discussion opportunities with peers rather than problem-solving a c t i v i t i e s . Equally, a quarter of the respondents did not f e e l that the group in t e r a c t i o n was p a r t i c u l a r l y useful. These people f e l t that 182 the problem-solving a c t i v i t i e s were too biased toward helping people i n early stages of exercise p a r t i c i p a t i o n rather than those looking for motivational ideas to maintain regular exercise. The educational experience was generally evaluated by respondents very highly. Examples of such praise included the following comments: very professional, well organised, good experience, well worth i t , i nteresting, got a l o t of useful t i p s , thought-provoking. .. increased my awareness of what I do and what I don't do!, great, very enjoyable, helped me a l o t , good balance and variety, nice atmosphere, I l i k e d the f r u i t idea. In conjunction with judgements made about the educational experience, the ins t r u c t o r was viewed as being: "highly v i s i b l e , approachable, i n c l u s i v e , motivating, challenging, supportive." Over one h a l f of the respondents claimed that they had not attended anything (health promotion program) l i k e t h i s before. In c r i t i c i s m of the educational experience, over three-quarters commented that they thought that each session was too b r i e f and that the program did not continue for long enough. Nearly one t h i r d of respondents would have preferred more weight control topics. Nearly a quarter of the respondents, however, asserted that fewer sessions may have been just as e f f e c t i v e . These people f e l t that the program was "too basic" for them. Suggestions included, "a separate course for more advanced people, more formal f i t n e s s t e s t i n g 183 opportunities, i n d i v i d u a l consultations." Nearly one quarter of respondents suggested the use of more video materials in the program. Using guidelines from Kingery, Holcomb, Jibaja-Rusth, P r u i t t and Buckner's (1994) program processes and s e l f -e f f i c a c y evaluation format, a l l participants i n the intervention program received a program evaluation form to complete at six weeks following the end of the program. Table 15 indicates the mean responses from 0-10, (10=extremely s a t i s f i e d ) pertaining to the perceived usefulness of various components of the program i n helping p a r t i c i p a n t s to engage i n regular exercise. In summary, respondents' generally p o s i t i v e encountering of a uniform educational experience was often perceived d i f f e r e n t l y i n terms of the processes and outcomes. 184 Table 15. Summary of mean scores pertaining to perceived usefulness of p a r t i c u l a r program processes i n r e l a t i o n to helping p a r t i c i p a n t s engage i n regular exercise Program Processes Mean Score Instructor 8.7 Course Handouts 8.1 Individual, s o c i a l 7.4 and contextual factors that influence motivation Classroom f a c i l i t y 7.4 and venue Group work and 7.3 problem-solving Planning strategies 7.3 Stress management 7.2 strategies Evaluation strategies 7.2 Mental s k i l l s 7.0 (N=20, 77%)" (3) Individual factors The extent to which respondents were predisposed, enabled and reinforced by ind i v i d u a l , educational and s o c i a l contextual factors shaped whether and how learning was applied. Respondents were variously predisposed by demographics, motives, intentions, knowledge, attitudes and 185 b e l i e f s to apply learning. The demographic p r o f i l e of the sample of participants from the intervention group c l o s e l y matched that of the other f i f t y percent and also the entire department. Respondents were c l e r i c a l employees with d i f f e r e n t l e v e l s of rank and r e s p o n s i b i l i t y i n the Department of Housing and Conferences at the University of B r i t i s h Columbia. One of the respondents was a departmental manager. Respondents were aged between 27-42 years old. Over three quarters were female and over two t h i r d s were married with the majority of these having children at day care or public school. Over three quarters of the respondents were born i n Canada. Studies have shown a s i g n i f i c a n t r e l a t i o n s h i p between va r i a t i o n s i n demographic p r o f i l e and exercise behaviour (Biddle, 1995, Dishman, 1994, Rudman, 1986). Typically, males and females at the lower end of the socio-economic scale tend to be less active unless employment positions require sustained periods of moderate to vigorous physical a c t i v i t y . Furthermore, employment positions with high demands and low-decision making authority, such as front-desk c l e r i c a l employees i n t h i s study, are more prone to sedentary behaviour and s t r e s s -related i l l n e s s e s (Holt, 1993) . Respondents expressed a variety of motives for attending the workplace L i f e s t y l e S k i l l s Motivation program, including, i t sounded good, to get some motivation ideas, want to improve my health, i t looked interesting, I needed to do more active l i v i n g , I'm interested i n anything to do with health, I'd never done anything l i k e t h i s before, I 186 wanted to get back into regular exercise, pick something up, I was attracted by the topic on mental s k i l l s , curious to f i n d out what i t was about, anything to do with motivation... I need i t ! Respondents came to the course with varying exercise and motivational experiences. Over three quarters of the respondents claimed to have some past, or recent history of p a r t i c i p a t i n g i n a period of regular exercise. According to questionnaire data using Marcus's (1995) stages of exercise behaviour change, nearly one t h i r d were in the contemplation stage, nearly two t h i r d s were in the preparation stage and the remainder i n the action stage of exercise p a r t i c i p a t i o n . Over h a l f of the respondents indicated that the course reinforced what they already knew, i n p a r t i c u l a r , the importance and benefits of exercise, exercise p r e s c r i p t i o n , heart rate monitoring and even knowledge about i n d i v i d u a l strategies. An equal number commented on the thought-provoking nature of the course with p a r t i c u l a r reference to increasing self-awareness toward a variety of thoughts, feelings and actions, and also to multiple factors that influence motivation. Over three quarters of respondents commented that the course had helped to increase t h e i r confidence to p a r t i c i p a t e i n regular exercise. For example, "I go i n phases but I know that I can get back into i t , I know that I can do more exercise i n my s i t u a t i o n , I f e e l good knowing that there's a few more things that I can do." The remaining people f e l t that t h e i r unique s i t u a t i o n prevented them from 187 p a r t i c i p a t i n g i n exercise though once t h i s had changed they did f e e l more confident that they could do more exercise. Enabling factors refer primarily to s p e c i f i c s k i l l s and ba r r i e r s that shape application. Nearly three quarters of respondents claimed to be f a m i l i a r with the topic areas promoted i n the course outline, either from sports documentaries or various forms of media arid l i t e r a t u r e sources. At some stage, nearly one t h i r d had previously learned s i m i l a r strategies i n c h i l d b i r t h and relaxation courses but had not used them i n t e n t i o n a l l y as general or s p e c i f i c motivational strategies. An equal number commented that aspects of t h e i r work required various forms of planning and record keeping s k i l l s that were inherent i n the motivation strategies, and nearly one quarter of the respondents claimed to be compulsive planners and l i s t makers. In terms of s k i l l a cquisition, nearly three quarters of respondents said that they had gained useful s o c i a l support strategies, an equal number reported acquiring various forms of planning strategies, and over one t h i r d claimed to have acquired useful imagery strategies which had helped them or s i g n i f i c a n t others i n t h e i r e f f o r t s to p a r t i c i p a t e i n exercise. In contrast, nearly one h a l f of respondents indicated that they were not sure i n i t i a l l y what the course topics meant or what they entailed and over one t h i r d commented that they could not r e c a l l ever doing anything l i k e t h i s before. Nearly one t h i r d of respondents stated i n some form, that personal planning was not one of t h e i r stronger 188 points and nearly one h a l f of participants f e l t that more sessions were required before being able to t r u l y master the strategies. A v a r i e t y of s p e c i f i c and general b a r r i e r s were c i t e d by a l l respondents as key factors that hindered p a r t i c i p a t i o n i n regular exercise. Other than those already reported i n s o c i a l contextual factors ( s i g n i f i c a n t others, commuting, workplace and Vancouver environments) nearly one quarter of respondents described l i n g e r i n g health problems such as c o l d s / f l u and back pain. One person commented that, "my hunger timer kicks i n regular at lunch-time so I don't have the time or f e e l l i k e doing exercise then." Other b a r r i e r s c i t e d t y p i c a l l y mirrored those prevalent i n the exercise adherence l i t e r a t u r e . For example, fatigue, W I have t r i e d to walk a f t e r work but most of the time I am just too t i r e d ; self-motivation, I keep meaning to do more but lack will-power, a lack of time, there's never enough hours i n the day!" Interestingly, without prompting, nearly a l l respondents i n the following sentence, consistent with course processes, offered various strategies to overcome these b a r r i e r s . Respondents were variously reinforced i n t h e i r e f f o r t s to apply learning through i n d i v i d u a l , s o c i a l and contextual processes e.g., self-monitoring of thoughts, feelings and actions; feedback from s i g n i f i c a n t others; weekly e-mail reminders to complete exercise d i a r i e s and s i t e v i s i t s by course i n s t r u c t o r ; and six weekly post-course evaluation. Furthermore, respondents were generally cognisant of the 189 wellness representatives and wellness board to help create a he a l t h f u l workplace community. For example, one person commented, "the wellness board idea helped to keep the momentum going from the course... i t often gives us something to t a l k about i n the coffee area too." The workplace Christmas party was also i n d i c a t i v e of course outcomes i n that s t a f f decided that an active s o c i a l gathering at UBC i c e - r i n k would be more b e n e f i c i a l than indulging i n excessive food and alcohol. Interestingly, one of the f i r s t challenges presented to a wellness representative came from a colleague who wanted to address the issue of access to showering and changing f a c i l i t i e s . This was resolved by exploring a variety of options and ensuring that i t was permissible to use alternative f a c i l i t i e s . Many respondents, however, f e l t that since Christmas the Wellness Board had been changed too infrequently and was beginning to lose i t s impact. O n e w e l l n e s s r e p r e s e n t a t i v e c o m m e n t e d t h a t h e w a s o f t e n too busy with other things to remember to change the Board. The other representative commented that, "my section i s quite active anyway so i t doesn't seem that important." Respondents were thus variously predisposed with d i f f e r e n t motives, intentions and l e v e l s of s e l f - e f f i c a c y for application; enabled by an array of b a r r i e r s , opportunities and s k i l l s from previous or current experiences related to exercise behaviour change; and reinforced through personalised s e l f - r e f l e c t i o n and monitoring, s o c i a l networking and/or 190 environmental g r a t i f i c a t i o n i n t h e i r e f f o r t s to apply learning. Summary Data r e f l e c t e d the varied post-educational experiences of diverse p a r t i c i p a n t s who attended the workplace L i f e s t y l e S k i l l s Motivation program. E s s e n t i a l l y , the m u l t i - i n t e r a c t i o n of i n d i v i d u a l (e.g., motives, intentions, experiences, c r i t i c a l thinking and s e l f - d i r e c t e d learning s k i l l s ) health promotion (e.g., workplace policy, learning venues, workplace wellness network, inst r u c t o r f a c i l i t a t i o n , responsive programming, s o c i a l interaction) and s o c i a l contextual (e.g., workplace f a c i l i t i e s and s o c i a l climate, family and s o c i a l issues, commuting si t u a t i o n , safety considerations and opportunities for exercise p a r t i c i p a t i o n i n the s e t t i n g of application) factors shaped whether and how learning was applied following a worksite health promotion program. P r o c e s s of Application Despite the uniformity of the workplace health education-program, learning, i n the form of knowledge, attitudes, s k i l l s and behaviours was generally applied i n a v a r i e t y of intended and unintended ways. The following i s a synthesis of c o l l e c t i v e accounts regarding how and why learning was applied in the context of application. Knowledge Over one h a l f of the respondents commented that the course had stimulated them to think c r i t i c a l l y about exercise 191 p a r t i c i p a t i o n . For example, in terms of rigorous thoughts pertaining to exercise behaviour change, I'm a l i t t l e more conscientious now about thinking through my day so that I can f i n d some, or a few opportunities for extra val&img, I tend to be more aware at the weekends about how mrocb. exercise I have done i n the week, i t [the program] inelped get me going and make my fi t n e s s more of a p r i o r i t y . . . makes me f e e l good and prevent heart disease and a l l that. Creative thoughts were evident by taking into account d i f f e r e n t perspectives and makirag various connections between exercise and other r e l a t e d betiaviours: I'm t r y i n g to lose weight too so I've found the strategies h e l p f u l for t h i s too, I'm more conscious now I think about my thoughts and feelings during exercise... i t helps make i t a useful, i f mot a more enjoyable experience, just knowing tfctat others want to do m o r e too and also face s i m i l a r deamamrils makes i t a l i t t l e easier...makes you r e a l i s e that you're not alone and you don't f e e l t o t a l l y useless f o r not doing i t as much as you should, t h e usual noise that goes on inside my head makes more sense n o w ! I dtan't: f e e l such an odd-ball and I didn't r e a l i s e h o w useful i t can be. Respondents reported various forms of c r i t i c a l l y r e f l e c t i v e thoughts about exercise behavioinx change. I'm more s c e p t i c a l o f f i t n e s s products on TV, I think that UBC could d o more f o r people who work here i n terms 192 of o f f e r i n g l i m i t e d free swims or use of the f i t n e s s f a c i l i t i e s etc, I'm a l o t more aware of the influence of others on my physical a c t i v i t y . w e l l , i t often means that I have to get things going so that we do go for a walk after supper. Over one t h i r d of the individuals referred to the motivation strategies as " b a s i c a l l y common sense." Nearly three quarters of the respondents, however, commented that they had not previously thought of these "things" before as being c o l l e c t i v e motivational strategies, which, for a va r i e t y of reasons and to varying degrees added to t h e i r personal resource base. Nearly one quarter of respondents commented that t h e i r increased knowledge about d i f f e r e n t components of physical f i t n e s s had helped them make connections with t h e i r f i t n e s s class and better understand why c e r t a i n exercises were being performed. Attitudes Respondents' described a variety of ways which helped t h e i r confidence to p a r t i c i p a t e i n exercise e.g., I t r y to think more p o s i t i v e l y about what I can do... otherwise i t ' s easy to s l i p into reasons why I can't do i t , se t t i n g r e a l i s t i c goals that I am able to achieve...I know that I ' l l have something to show for i t , making i t enjoyable, by switching o f f from work or personal problems... i t helps me to keep looking forward to i t the next time I guess, there's a few more people 193 active around here now...it's something to ta l k about, and, i f they can do i t , so can I. Personal commitment, group discussion and problem-solving a c t i v i t i e s during the course as well as the atmosphere i n the workplace environment were c i t e d as key factors that f a c i l i t a t e d these b e l i e f s . Over one t h i r d commented that they were enjoying walking a l i t t l e more than they had previously. This was attr i b u t e d to the confirmation and value placed during the course, on walking as a multi-benefit form of physical a c t i v i t y , cognitive disassociation strategies and also personal and jo i n t commitments that had been made to pa r t i c i p a t e i n walking a c t i v i t i e s . S k i l l s / S t r a t e g i e s The process and rationale for the application of p a r t i c u l a r strategies w i l l be described within the factors of the conceptual application framework. Social Context Nearly one h a l f of respondents suggested that networking strategies were useful for them. Respondents' approaches to networking strategies were variously described as jo i n t p a r t i c i p a t i o n i n physical a c t i v i t y (e.g., two or more people walking together) versus i n d i v i d u a l p a r t i c i p a t i o n i n a group physical a c t i v i t y (e.g., drop-in v o l l e y b a l l ) , group p a r t i c i p a t i o n i n a physical a c t i v i t y (e.g., belonging to a regular team), lobbying (e.g., discussion and organisation for a workplace Christmas ice-r i n k party), supporting colleagues with active l i v i n g intentions, sharing of health intentions 194 verbally with s i g n i f i c a n t others, mutual sharing of health intentions, and c o l l e c t i v e health commitments with s i g n i f i c a n t others. For example, I tend to share most things with my s i s t e r . We are both t r y i n g to lose weight right now too... we usually ask how each other i s getting on...this helps to motivate me to keep up my walks, well, i n the house I'm always going on that we need to spend more qual i t y time together... our evening walks together as a family contribute to t h i s otherwise we end up watching too much TV and regret i t , we walk b r i s k l y together and t a l k most of the way so you don't even notice much about the exercise... i t s more natural I think than some of the other strategies, i t ' s a sort of j o i n t thing we do...its one more thing that helps to keep my daughter and I close. Others focused on the opportunity to connect with nature or make use of environmental f a c i l i t i e s . there's a small group of us who make use of the SRC at lunchtimes... i t ' s a general topic of discussion amongst us which helps to keep up the pressure...! don't think that I am d i s c i p l i n e d enough to do i t regularly by myself, I l i k e to walk at lunchtimes i n the nearby gardens. I can see the bay, trees and mountains which a l l make me f e e l good. Negotiation was part of networking strategies. Negotiation experiences could be described on a continuum from autocratic at one end, e.g., 195 i t can be quite a bat t l e sometimes to get everyone out [of the house afte r supper] but sometimes i t s a case of switching o f f the TV and throwing coats at people!...we sometimes have to try and think of some fun things (tag, I spy etc) to do along the way otherwise the kids w i l l get bored e a s i l y . They are a l l g r a t e f u l afterwards though...in t h e i r own way!., to democratic on the other, e.g., "we [family] usually plan weekend a c t i v i t i e s together and tend to go with the option that s u i t s the majority unless one of us hasn't had t h e i r choice for a while." Interestingly, the males (n=3) and only one female tended to engage i n s o l i t a r y physical a c t i v i t y . Of these, only one male suggested that t h i s experience was shared verbally with, and was supported through encouragement by a s i g n i f i c a n t other. Planning Phase Connected to networking strategies, nearly one quarter of respondents f e l t that communication and negotiation s k i l l s were c r i t i c a l for exercise p a r t i c i p a t i o n e.g., we take i t i n turns to decide the early morning walk route otherwise we'd never agree, I have to give them [family] plenty of warning that we're.going for a walk af t e r supper and l e t them choose the time so they don't miss a program or whatever, as part of our routine we'll often discuss what we need to get from the store which helps our motivation. 196 Nearly three quarters of respondents commented that scheduling strategies were the most useful strategies that enabled them to p a r t i c i p a t e i n exercise. When respondents were asked how they used scheduling strategies, the following aspects were noted: (1) goal s e t t i n g for v a r i e t y and l o c a l circumstances e.g., developing the walking options around 'Brock' was a good idea. I haven't used them s p e c i f i c a l l y but I do have a few walking routes around home now which I use depending on how much time I have..." i t adds more vari e t y depending on how I f e e l and i s something tangible and challenging to get going on, before lunch I think about where I'm going to walk based on how I f e e l and e s p e c i a l l y with t h i s weather i t might well be indoors...it helps me to b u i l d up to i t I guess, I usually get up early i n the morning before the kids and t h i s gives me a chance to think about my day and combine a walk to the store, with what we need for the house etc. (2) time management, Sunday evenings are usually the time that I plan for the week ahead. I just include SRC i n c a p i t o l s on my diary and t h i s reminds me on those mornings to pack my exercise s t u f f . . . i t ' s right there on the diary so I have to do i t ! , making i t part of our routine i s the only way that I can manage to do so many things at once: work, sort family out, time with my daughter, look a f t e r myself and get the groceries!, I usually plan at night-time for the 197 next day. It's an endless process of juggling multiple p r i o r i t i e s . . . I t r y to f i t i n at least one decent walk around whatever else I have to do... i t ' s the only way I can f i t i n so many things. (3) stimulus control, I have " a c t i v i t y " written on a sheet with my other " l i s t of things to do for the day." This i s displayed at my work station so i t prompts me to have regular stretches, use the s t a i r w e l l and/or walks at lunch times. If i t aint on my ^things to do' l i s t then i t would be u n l i k e l y that I'd get round to doing i t , I guess i t ' s a state of mind r e a l l y , as the alarm goes o f f at 6:05 am I just t e l l myself 'don't think about i t , just do i t ' . . . i t helps to avoid procrastinating. Some people engaged i n continual planning attempts, I often go over my day i n my head i n bed i n between the alarm going o f f and getting up...I f e e l a l i t t l e more i n control over what I end up doing, I often think about the exercise class, what we'll be doing, how to do cert a i n movements, the music etc. This helps me to look forward to i t more I guess. while others opted for more r i g i d structures, there are set days and times that I (and others) go the SRC...it's a sort of a d i s c i p l i n e for me and takes away my option to think of an excuse, I don't bring a l l of my lunch to work anymore which makes me walk to the v i l l a g e to buy a drink or f r u i t etc...I kept meaning to do 198 something so t h i s makes i t more o f f i c i a l , I set the alarm for 6:05am and we get straight into our clothes without a wash and out of the house rain or shine before either one of us can say 'maybe not today'! A l l ' s i t means i s that clothes have to be ready...it eliminates will-power worries. One of us usually decides the route as we head down the drive. We go for about 25 minutes which gives us plenty of time to get back, take a shower, have breakfast and o f f to work...it's a great way to s t a r t the day o f f together, and some combined f l e x i b l e and r i g i d methods of planning, I tend to be quite mechanical about lunchtimes and purposefully s l i p into auto-pilot and walk to the v i l l a g e to get my lunch...I go the d i r e c t way there and choose from a v a r i e t y of routes to r e t u r n . . . i t gives me some time for myself, my weekly routine i s f a i r l y stable so lunchtime exercise on Tuesdays and Thursdays and also on Sunday mornings seems to f i t i n for me. I alternate between a brisk walk, jogging or swimming depending how I f e e l . For many respondents, planning t y p i c a l l y included a v a r i e t y of i n d i v i d u a l , s o c i a l and contextual strategies. In contrast, nearly one quarter of respondents stated that they didn't have any exercise plan, rather, they based t h e i r decision to exercise on immediate feelings or socio-environmental factors (invitations by others, nice weather, 'special days'). These respondents reported that they would 199 l i k e to do more exercise but f e l t that exercise planning strategies were "too r i g i d , " "pressurising," " u n r e a l i s t i c , " and "took the fun out of i t . " Action Phase During Physical A c t i v i t y Respondents indicated a v a r i e t y of coping strategies during physical a c t i v i t y that helped t h e i r motivation to p a r t i c i p a t e . Nearly one quarter of respondents preferred the use of a 'walkman* to enhance t h e i r enjoyment of the exercise experience. Those people who t y p i c a l l y engaged i n brisk walking described t h e i r coping strategies i n the following ways: ( 1 ) relaxed and unfocused thoughts, I just l e t my mind wander...I l i k e the freedom that t h i s brings for a change rather than having to concentrate on reports or f i l e s etc, I t r y and l e t my brain rest and think of nothing...it sort of helps f e e l l i k e I'm balancing things up a f t e r working at the desk a l l day, by purposefully switching o f f from work and having nice things to think about helps me to unwind otherwise I end up thinking about a l l of my worries and don't f e e l relaxed a f t e r i t either!. (2) s o c i a l and environmental focusing, we t a l k most of the time...it takes our mind o f f the e f f o r t , I prefer to switch o f f and just look around at the bay...I think that there's something s p i r i t u a l about nature that we a l l need but don't f u l l y understand yet, I love the trees around here that's what I mostly look at...I l i k e to reminisce. It reminds me of when I was 200 young growing up on the Island [Vancouver] and the fun we used to have i n the f i e l d s , I f anything, I concentrate on the fresh a i r and the nice f e e l i n g of being i n the outdoors. (3) problem-solving thoughts, I usually think over something that I'm t r y i n g to sort out...there's not the d i s t r a c t i o n s l i k e at home or work so i t allows me to think more c l e a r l y about things, I l i k e to think about things that I have got to work out ei t h e r at home or work when I am walking...I f i n d that my head i s clearer and i t helps to work these things out better. (4) l i b e r a t i o n thoughts, I enjoy the time to myself to relax and go where I please, I often say to myself, 'oh, t h i s i s the l i f e ' . . . i t ' s a welcome f e e l i n g of space and freedom i n contrast t o t h e usual h a s s l e s and confines of work, I think to myself, 'I deserve t h i s ' . . . I constantly f e e l l i k e I am doing things for others so since t h i s course I decided to t r y and have a l i t t l e more time for myself and my own health for a change. Interestingly, those people engaged i n group f i t n e s s a c t i v i t i e s described t h e i r thought processes i n the following ways: I just think about the beat of the music and t r y to keep my body i n synch...it's something to focus on so that I'm i n tune with i t a l l to get a good work-out, I think of 201 what i t w i l l be l i k e i n the summer... looking forward to wearing summer clothes and being on the beach again gives me a buzz and also a big incentive to do i t , depending on the 'move' [in my f i t n e s s class] I t r y to figure out what the exercise i s doing for me... i t makes the session more interesting, I t e l l myself to 'just keep going'...it helps me to keep up the energy, I often fantasise about being a professional dancer...it gives me a l o t more energy and makes me f e e l great when I'm doing i t . To summarise, respondents p a r t i c i p a t i n g i n various forms of physical a c t i v i t y generally engage i n an assortment of verbal, v i s u a l , and kinaesthetic imagery and behavioural strategies. Nearly one.quarter of respondents, however, were not aware of any p a r t i c u l a r strategy when engaged i n physical a c t i v i t y . Evaluation Phase Four major evaluation strategies were reported by respondents that helped t h e i r p a r t i c i p a t i o n i n exercise: subjective evaluation of the exercise experience, physical appearance, comparisons made with behavioural patterns of s i g n i f i c a n t others and personal diary r e f l e c t i o n s . Nearly three quarters commented on using an informal subjective evaluation of the exercise experience e.g., I score i t between 1 and 10 based on whether or not I had a good workout...it helps keep the continuity going, I might think 'how was I today* ... based on what energy I had...it helps to i d e n t i f y things that influence my 202 energy l e v e l s , I t r y and think how much better I f e e l a f t e r having been out i n the fresh a i r and the nice environment... i t helps to reinforce the benefits, I just have that sense of 'feeling more on top of things' a f t e r my walk...it reminds me how good i t i s for me, at the end of the day at work I usually f e e l a l o t less t i r e d i f I have gone to the exercise class funnily enough, by saying 'well done, that was great' to myself...I give myself recognition for the accomplishment of doing i t , we usually say 'thanks' to each other afterwards...kind of appreciation for doing i t together. Nearly one h a l f of respondents tended to monitor t h e i r physical appearance frequently. For example, a f t e r a shower, I usually look i n the mirror to see that I'm not expanding!, I tend to jump on the scales nearly every morning... to check that I'm the same hopefully, I know when I have stopped doing exercise because my clothes f e e l t i g h t e r . Nearly one t h i r d of respondents tended to use the behaviour of s i g n i f i c a n t others as t h e i r base-line for exercise p a r t i c i p a t i o n . For example, "by going with the others helps me to keep track of how I am getting on, I tend to do a b i t more than the others i n the o f f i c e , I don't want to be as u n f i t as my husband." Others used an a r b i t r a r y standard, e.g., "I l i k e to have done some exercise each day so I use t h i s as a bench mark at the end of the day to see how I have done, I know that we're supposed to do exercise about three times per week so I 203 kind of go by t h i s at the end of the week." F i n a l l y , nearly one quarter r e l i e d on r e f l e c t i v e scheduling strategies, e.g., I l i k e d having an exercise sheet to complete at the beginning of each week, i t helped me ensure that I had something to put down on i t ! , having my exercise scheduled into my diary also adds to the amount of things that I f e e l that I've accomplished each week. In summary, no respondent claimed to have applied a l l strategies though the majority had applied some of the strategies. The majority of respondents tended to favour various forms of planning strategies. Most of the respondents, however, tended to report applying strategies unconsciously rather than a conscious decision to use them. Interviews did not reveal clear omission of strategies due to i n d i v i d u a l attendance patterns i n the course. This may be due larg e l y to the pa r t i c i p a n t network system i n the workplace and f i l l i n g colleagues i n who had missed a p a r t i c u l a r session, supported by class handouts and a recap at the beginning of each session. Exercise behaviour Respondents varied by type, frequency, in t e n s i t y , duration and r e g u l a r i t y of exercise behaviour following the workplace L i f e s t y l e S k i l l s Motivation program. Nearly one t h i r d of respondents combined brisk walking with either v o l l e y b a l l , jogging, gardening or using a weights room f a c i l i t y as t h e i r main form of leisure-time physical a c t i v i t y . For example, one person commented, w a t the end of the F a l l we 204 moved onto three quarters of an acre of land so I've been busy a l l day at the weekends doing vigorous gardening." Furthermore, one quarter of respondents p a r t i c i p a t e d exclusively i n brisk walking as t h e i r primary source of leisure-time physical a c t i v i t y . Brisk walking occurred before, during and a f t e r work as well as at the weekends. The majority of brisk walkers used t h i s occasion to be active with s i g n i f i c a n t others outside of work-time. Lunch-hour walking was t y p i c a l l y a spontaneous decision to either walk alone or with a colleague. One quarter of respondents had been using the SRC over the l a s t three months with varying degrees of r e g u l a r i t y and one other had taken up using the f i t n e s s room i n his r e s i d e n t i a l complex. Interesting comments surrounding p a r t i c i p a t i o n at the SRC included: i t ' s very convenient, I l i k e the music and the energy there, It can be a l i t t l e intimidating over there. I'd prefer an older age group but then i t i s the SRC!, I'd rather be more active i n the day than s i t here at the desk but for my schedule the SRC offers a q u i c k - f i x workout, I f e e l great afterwards, Well, at least I don't have to worry about the weather. Nearly one t h i r d reported that they were generally p a r t i c i p a t i n g i n moderate to vigorous a c t i v i t y at least three times per week, and nearly one quarter reported that they were generally p a r t i c i p a t i n g i n moderate exercise on a d a i l y basis. The remainder were equally divided between generally p a r t i c i p a t i n g i n moderate physical a c t i v i t y at least f i v e 205 times per week, twice per week and those who had not engaged i n any form of leisure-time physical a c t i v i t y . Non-pa r t i c i p a n t s i n leisure-time physical a c t i v i t y each expressed intentions to st a r t i n the spring when they hoped personal matters were more s e t t l e d . Respondents pursued physical a c t i v i t y with varying lev e l s of i n t e n s i t y . Over one t h i r d commented that they p a r t i c i p a t e d in a vigorous fashion, p a r t i c u l a r l y those attending the SRC, nearly one h a l f described d i f f e r e n t l e v e l s of brisk walking and the remainder reported walking at a pace that they could just sustain a conversation. Respondents also varied i n duration of exercise from twenty to forty minutes continuously, though walkers were less consistent than those attending f i t n e s s classes. When respondents were asked how stable t h e i r exercise patterns were, fewer than one quarter claimed that t h e i r routine did not change. Most of these people were committed to fi t n e s s classes. Other respondents suggested that locations, routes, frequency and durations tended to be f l e x i b l e to suit t h e i r needs and circumstances. One quarter claimed that t h e i r exercise pattern was mostly stable, an equal number claimed that i t was about 50% stable and the remainder claimed that i t was generally unpredictable from one week unto the next. In summary, over three quarters of the respondents believed that they and others i n the workplace were p a r t i c i p a t i n g i n more exercise since the workplace L i f e s t y l e S k i l l s Motivation program. Nearly one t h i r d of respondents, 206 however, attributed behavioural outcomes to the opening of the nearby Student Recreation Centre (SRC) and only i n d i r e c t l y to the workplace health promotion program. Alt e r n a t i v e outcomes The intervention program was a multifaceted process primarily intended to empower participants to think c r i t i c a l l y and s e l f - d i r e c t an exercise behaviour change. A v a r i e t y of alt e r n a t i v e outcomes, however, were expressed by respondents in the form of knowledge, attitudes, s k i l l s and behaviours. Knowledge and attitudes Nearly one quarter commented that the course had challenged them as much to think about t h e i r health and well-being i n an h o l i s t i c manner. An equal number had gained knowledge and attitudes i n other ways e.g., " i t has been a long ti m e . . . i t f e l t good to learn something i n t e r e s t i n g again, I can put a few more names to faces, now at work, I'd l i k e to do more of these courses." Over one t h i r d of the respondents commented that they f e l t better, f i t t e r and less stressed since taking the program. Nearly one quarter of the respondents, however, pointed out that the strategies themselves required a l o t of time and thought, which made them problematic. Behaviours Nearly a l l respondents commented that they had gained some useful stress management techniques from the program. 207 Over one t h i r d of respondents commented on using breathing strategies. For example, I have probably done the simple breathing exercises more than anything else...I t r y to do 3 - 5 deep breaths a f t e r I have saved something on the computer and while i t does i t s thing, af t e r I have had a d i f f i c u l t person at the front-desk I t r y to breathe away my frustrations, I t r y to be more aware of the tightness about my breathing now. Nearly one t h i r d of respondents used various modes of exercise to relax. These were described i n the following ways, I make a point of having a l i t t l e walk around the o f f i c e to fetch stationary or go to the photocopier a f t e r I've been on the computer for some time. This gives me a chance to stretch and unwind a l i t t l e , I keep a squeezy b a l l by the telephone and use i t during conversation...like now! I don't know what i t does but i t feels good!, I have made i t a personal p o l i c y to walk to and from meetings on campus and I f i n d that I'm a l o t calmer for i t , before and after, I tend to do too much. I r e a l l y need to relax more. I wish I was more d i s c i p l i n e d to walk every lunch time because when I do, I f e e l a l o t better, when I do get into my regular walks and remember the breathing exercises It does help. I tend to have phases at i t though, e s p e c i a l l y when things are r e a l l y getting on top of me,- rather than doing i t consistently, my evening walks to the store give me some time for 208 myself for a change otherwise I am on the go a l l of the time. One person commented on using imagery as a method to relax, "I never r e a l i s e d how natural v i s u a l i s a t i o n was to me so I do i t more often now to relax. I t r y to think only nice thoughts and have a few precious moments i n the bathtub without worrying about a thing." Nearly one quarter f e l t that the course had contributed to the organisation and practice of spending more qual i t y time with family members. Furthermore, these part i c i p a n t s tended to share course processes and handout materials with t h e i r partners or family members as topics for meaningful discussion. One person commented that she had been making a concerted e f f o r t to improve her s i t t i n g , standing and l y i n g posture throughout the day. F i n a l l y , nearly one t h i r d of respondents commented on the value of the program as a break from the usual work routine e.g., "glad to get away from my desk, i t was something to look forward to on Mondays and Thursdays, i t made a nice change." Worksite management perspective Three senior personnel from management were interviewed regarding t h e i r perception of program outcomes. They were p a r t i c u l a r l y impressed with the manner in which the program had been implemented over several months from conception to follow-up. Comments included: I thought that the whole program was done very pro f e s s i o n a l l y , one of my biggest concerns i n i t i a l l y was 209 the disruption t h i s was l i k e l y to create, e s p e c i a l l y to enable a l l of my s t a f f the opportunity to p a r t i c i p a t e . However, the way that the s t a f f involvement was handled during the pre-planning and o f f e r i n g f l e x i b l e course scheduling caused minimal disruptions to s t a f f i n g , you e a s i l y f i t into the o f f i c e dynamics, the program actually f i t i n n i c e l y with our management goals of f a c i l i t a t i n g collaboration and presenting a caring image to employees, much involved i n the course i s rather l i k e what we encourage i n s t a f f t r a i n i n g e.g., planning, evaluation, communication s k i l l s etc. Based on general perceptions, informal feedback from employees and personal experiences from attending the course, the managers were unanimous i n t h e i r b e l i e f that the workplace health promotion program had been "worth i t . " One manager, however, f e l t that i t could have been just as e f f e c t i v e with fewer sessions. When asked about s p e c i f i c outcomes that they were aware of, comments were as follows: increased networking among s t a f f , increased morale, I know some of my s t a f f have started walking more, healthier s t a f f Christmas party!, v i s i b i l i t y and attention toward the wellness board aptly located i n the rest area, there's a few who have pursued memberships to various f i t n e s s clubs. One manager was quick to point out, " i t s d i f f i c u l t to say whether i t was the program or i f i t was the opening of the Student Recreation Centre (SRC) that has caused the recent 210 i n t e r e s t i n exercise p a r t i c i p a t i o n , . . . maybe a b i t of both?" Two managers commented that those people i n t h e i r section that perhaps needed the program the most did not attend. They suggested that these people tended to have chronic i l l n e s s , poor l i f e s t y l e practices and high absenteeism. Management had not received any formal complaints by those who did not attend the program but two of the managers suspected that despite no additional work being burdened on non-attenders, some were l i k e l y to be resentful of the time given to those from the section who did attended the program. As a d i r e c t r e s u l t of the management's perceived success of the workplace L i f e s t y l e S k i l l s Motivation program, a jo i n t proposal was developed between the inst r u c t o r and the Director of the Department of Housing and Conferences for u n i v e r s i t y funding to implement further courses for employee resident advisors. Second, from workplace recommendations, the course i n s t r u c t o r was i n v i t e d to present a seminar at the 'TOPS' Weight Control annual conference at UBC i n May, 1996. .Despite program intentions, management and employees t y p i c a l l y adapted and shaped program processes to suit t h e i r personal needs and circumstances. A variety of unintended behavioural and non-behavioural outcomes were thus reported from the educational experience. Summary Application i s c l e a r l y a complex, dynamic and multifaceted process. Data r e f l e c t e d respondents' various 211 attempts at thinking c r i t i c a l l y and s e l f - d i r e c t i n g exercise behaviour change. Over half of the respondents proudly revealed some accomplishment gained i n t h e i r e f f o r t s to p a r t i c i p a t e i n regular exercise, nearly half, however, expressed g u i l t and some were even apologetic that they were not doing more exercise. Respondents t y p i c a l l y applied knowledge, attitudes and motivation strategies to a v a r i e t y of physical a c t i v i t i e s with varying degrees of intention, frequency, in t e n s i t y , duration and r e g u l a r i t y . Application strategies could be categorised by rigorous, creative and c r i t i c a l l y r e f l e c t i v e thoughts pertaining to the broad s o c i a l context, planning, action and evaluation processes. At times, singular strategies were r e l i e d on, at other times a c o c k t a i l of i n d i v i d u a l , s o c i a l and contextual strategies was employed to enhance exercise p a r t i c i p a t i o n . Alternative outcomes from the educational experience included perceived benefits from a break i n the usual work routine, p a r t i c i p a n t s sharing course information with s i g n i f i c a n t others, h o l i s t i c health practices and an active workplace Christmas party. Learning was thus adapted and applied i n a variety of ways to s u i t s p e c i f i c needs and circumstances. The descriptive s t a t i s t i c s , quantitative and q u a l i t a t i v e analyses w i l l be discussed i n the following chapter. 212 CHAPTER 5 DISCUSSION Introduction A meaningful discussion of the findings of t h i s study needs to take into account the quantitative and q u a l i t a t i v e analyses with respect to the research questions as well as consideration for the l i t e r a t u r e pertaining to the development and evaluation of worksite health promotion programs for exercise behaviour change. Discussion: Question (1) Experimental Findings (a) 7-Day Recall of Exercise Behaviour A s i g n i f i c a n t group by time interaction indicates that the response patterns of exercise behaviour for each group across the time factors are d i f f e r e n t (p_<0.05). The Scheffe post-hoc comparison t e s t reveals that the response patterns d i f f e r s p e c i f i c a l l y between pre-program and post-program and also between pre- program and follow-up time periods i n the d i r e c t i o n predicted by hypothesis number 1. Figure 6 shows that the experimental group increased i n exercise behaviour between pre and post-program whereas the w a i t i n g - l i s t control group decreased i n exercise behaviour for the same time period. Both groups, however, decreased i n exercise behaviour at a s i m i l a r rate from post-program to the three-month follow-up period. This i s congruent with other findings reported i n the l i t e r a t u r e that generally show various degrees of decrease i n desired behaviours once 213 formal interventions are terminated. The experimental group, however, did not return to below baseline l e v e l s that occurred with the w a i t i n g - l i s t control group. Seasonal e f f e c t s throughout the duration of t h i s study help explain the continual reduction i n exercise behaviour for the w a i t i n g - l i s t control group. Testing began at the end of September 1995 which was one of the d r i e s t and sunniest months of the year. Post-program t e s t i n g took place at the end of October, as winter began with dark evenings and colder and wetter days. Follow-up t e s t i n g occurred at the end of January i n a cold s p e l l p r i o r to Vancouver's f i r s t heavy snow f a l l of 15 cms. Despite seasonal e f f e c t s , however, people i n the intervention program p a r t i c i p a t e d i n a higher frequency of exercise at post-program and at three-month follow-up than they did at the pre-program time-period. Furthermore, nearly twice as many people i n the intervention group (50%) reported that they p a r t i c i p a t e d i n exercise three or more times per week at the end of the three month follow-up than those people i n the w a i t i n g - l i s t control group (27%). Exercise behaviour reported by the experimental group at post-program and at follow-up suggested that for the duration of t h i s study the intervention program was more e f f e c t i v e i n increasing and maintaining a higher frequency of exercise behaviour. The hypothesis, therefore, s t a t i n g that the experimental group w i l l p a r t i c i p a t e i n a higher 214 frequency of exercise behaviour across the three time-periods than a w a i t i n g - l i s t control group, i s confirmed. In combination with educational and environmental strategies, these results add further support to the b e l i e f that health education programs that are developed using Bandura's (1986) p r i n c i p l e s of s e l f - e f f i c a c y are e f f e c t i v e in increasing a variety of health behaviours, i n t h i s case, exercise behaviour. Furthermore, these findings lend support to the conclusions made by Bouchard et a l . (1990) who suggested that intervention programs focused on s e l f -regulation of exercise behaviour can be e f f e c t i v e for exercise adherence. Lamb and Brodie (1990), however, pointed out several points of caution when inte r p r e t i n g findings from s e l f - r e p o r t exercise behaviour questionnaires. F i r s t , these methods are very l i k e l y to suffer from s o c i a l d e s i r a b i l i t y bias to s a t i s f y the experimenter and, therefore, overestimate actual l e v e l s of exercise p a r t i c i p a t i o n , p a r t i c u l a r l y at post-intervention time periods. This may well have influenced lower follow-up reports for the w a i t i n g - l i s t control group who completed these questionnaires p r i o r to t h e i r intervention. Second, the accuracy of a r e c a l l questionnaire can suffer i f respondents have a poor memory or lack of motivation. Third, a learning e f f e c t can occur when using these questionnaires on multiple occasions. F i n a l l y , due to weekly fluctuations i n exercise behaviour, s e l f - r e p o r t questionnaires can lack the s e n s i t i v i t y to measure improvements accurately. This i s 215 further i l l u s t r a t e d from the interview data and also by the high standard deviations i n exercise frequency recorded by both groups throughout the three time periods. The researcher did attempt to administer .the questionnaire to both groups with s i m i l a r i n s t r u c t i o n s . It would, therefore, be expected that with the exception of s o c i a l d e s i r a b i l i t y bias the remaining issues would occur for both groups simultaneously. (b) Exercise S e l f - E f f i c a c y A s i g n i f i c a n t group-by-time i n t e r a c t i o n indicates that the response patterns of exercise s e l f - e f f i c a c y for each group across the time factors are d i f f e r e n t (p<0.01). The Scheffe post-hoc comparison te s t reveals that the response patterns d i f f e r s p e c i f i c a l l y between pre-program and post-program, post-program and follow-up, and also between pre-program and follow-up time periods i n the directions predicted by hypothesis number 2. Figure 6 shows that the experimental group increased s i g n i f i c a n t l y i n exercise s e l f - e f f i c a c y between pre and post-program. This was as hypothesised since a main aim of the intervention program was to develop s e l f - e f f i c a c y . Course processes were thus designed to incorporate Bandura's (1986) p r i n c i p l e s of s e l f - e f f i c a c y and a variety of s e l f -regulatory strategies to overcome b a r r i e r s that could prevent regular exercise. The most s t r i k i n g difference between s e l f - e f f i c a c y and exercise behaviour data i s shown when comparing the post-program and the three month follow-up period. Unlike 216 exercise behaviour, the experimental group exhibited a s l i g h t increase i n exercise s e l f - e f f i c a c y between the post-program and the follow-up period which suggests that a broad array of strategies focusing on c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change may have a p o s i t i v e and l a s t i n g e f f e c t on exercise s e l f - e f f i c a c y . In contrast, the w a i t i n g - l i s t control group showed a s i g n i f i c a n t decline i n the same time period consistent with that also shown in exercise behaviour. Low exercise behaviour combined with previously c i t e d seasonal effects, help to explain the continual decline i n s e l f - e f f i c a c y for the w a i t i n g - l i s t control group. A l l p a r t i c i p a n t s i n the experimental group, i n comparison to 63% i n the w a i t i n g - l i s t control group, reported at the three month follow-up that they were more than "moderately" confident that they could overcome s p e c i f i c b a r r i e r s c i t e d o n t h e exercise s e l f - e f f i c a c y questionnaire and could p a r t i c i p a t e i n regular exercise. Levels of exercise s e l f - e f f i c a c y reported by the experimental group at post-program and at follow-up suggested that for the duration of t h i s study, the intervention program was more e f f e c t i v e i n increasing and maintaining higher l e v e l s of exercise s e l f - e f f i c a c y . The hypothesis st a t i n g that the experimental group w i l l have higher l e v e l s of exercise s e l f - e f f i c a c y across the three t i m e periods than a w a i t i n g - l i s t control group, i s , therefore, confirmed. 217 These findings lend support to Marcus et al . ' s (in press) conclusions from a workplace study with female employees who found that subjects i n a stage-matched intervention showed posit i v e change i n s e l f - e f f i c a c y i n comparison to subjects i n a standard self-management program. Furthermore, these findings are congruent with other studies i n the l i t e r a t u r e that reported increases i n s p e c i f i c s e l f - e f f i c a c y behaviours following health education programs that were developed using Bandura's (1986) p r i n c i p l e s of s e l f - e f f i c a c y (Allegrante et a l . , 1993; Jemmot & Jemmot, 1992; Lorig & Gonzalez, 1992; Rose, 1992) . It would appear, therefore, that Bandura's (1986) four sources of developing s e l f - e f f i c a c y , i n conjunction with broader educational and environmental strategies are also capable of increasing s e l f - e f f i c a c y i n worksite health education programs that are intended to enhance regular exercise. Self-reported measurements of exercise s e l f - e f f i c a c y , however, need to be treated with the same caution as previously stated i n r e l a t i o n to exercise behaviour questionnaires. S e l f - e f f i c a c y i s based on the in t e r a c t i o n between an individual's estimation of the demands and conditions of a p a r t i c u l a r task, adequate coping strategies they believe they possess, and e s p e c i a l l y t h e i r a b i l i t y to apply these strategies i n a s p e c i f i c exercise s i t u a t i o n (Bouffard et a l . , 1991). It r e l i e s on a perceptual, rather than a r a t i o n a l , estimation of a person's c a p a b i l i t y . For example, a person may perceive his or her a b i l i t y to cope 218 better than or worse than i t actually i s . S i m i l a r l y , a person may perceive that he or she has a lack of time available to do regular exercise when in fact there may be more time available but the person may manage time i n e f f i c i e n t l y , or i t may be a convenient excuse. The lack of available sources to v e r i f y the r e a l i t y of these perceptions, therefore, presents a p o t e n t i a l problem when measuring t h i s construct. A c r i t i c i s m that could be aimed at exercise s e l f -e f f i c a c y scales that have been developed i n the l i t e r a t u r e (Garcia & King, 1991; Marcus et a l . , 1992; S a l l i s et a l . , 1988) and of the instrument used i n t h i s study i s the i n c l u s i o n of "when on vacation" as one of the b a r r i e r s to exercise. For those people who go on vacation once per year and for two weeks in duration, i t would- seem that t h i s item would contribute very l i t t l e as a b a r r i e r to regular exercise. As one item out of a t o t a l of f i v e on the questionnaire, i t may have added some error to the o v e r a l l exercise s e l f - e f f i c a c y scores reported i n t h i s study. Second, the exercise s e l f - e f f i c a c y scale used i n t h i s study omitted the following b a r r i e r s : "a lack of s o c i a l support from s i g n i f i c a n t others", "commuting", " c h i l d care opportunities", and "exercising a f t e r a long relapse". The data from Table 13a (stages of exercise behaviour change) and also from interview data suggested that these b a r r i e r s were i n fact important factors that influenced p a r t i c i p a t i o n i n exercise for the subjects i n t h i s study. 219 (c) Stages of Exercise Behaviour Change Data i n Table 13a are congruent with other studies reported i n the l i t e r a t u r e (Booth et a l . , 1993; Marcus et a l . , 1992; Marcus et a l . , 1994) i n d i c a t i n g that subjects were in various stages of exercise behaviour change at pre, post-program and follow-up. A t pre-program, the d i s t r i b u t i o n of subjects from each group i n the stages of exercise behaviour change was the same. Furthermore, subjects had not been p a r t i c i p a t i n g i n regular exercise within the previous six months. Data gathered from the stages of exercise behaviour change questionnaire (see Appendix B) revealed that approximately three quarters of participants, at some stage p r i o r to t h i s study, had previously p a r t i c i p a t e d i n regular exercise. This i l l u s t r a t e s one of the problems with the l i t e r a t u r e on exercise adherence; that i t often implies that dropping out of a s p e c i f i c exercise s i t u a t i o n results i n a sedentary l i f e s t y l e . An i n d i v i d u a l may cease to p a r t i c i p a t e i n one exercise s i t u a t i o n but go on to continue i n another exercise pursuit depending upon personal preferences, seasons and so forth. These findings support the view held by Lovato and Green ( 1 9 9 0 ) , that bias may be caused by the s e l f - s e l e c t i o n of relapse-prone subjects into experimental studies and also by the tendency for subjects to i n f l a t e post-program behavioural improvements to s a t i s f y the experimenter. The bias i n turn contributes to an increase i n the l i k e l i h o o d of s i g n i f i c a n t decreases i n behaviour between post-program and follow-up time periods. 220 Table 14 indicates a s i g n i f i c a n t change i n the pattern of the stages of exercise behaviour change between the two groups at post-program and at follow-up. By the end of the program 42% of the experimental group, i n comparison to 13% of the w a i t i n g - l i s t control group, reported that they were p a r t i c i p a t i n g i n regular exercise. Table 13b shows that between pre-program to the three month follow-up time period, 20% of the experimental group progressed from contemplating exercise to p a r t i c i p a t i n g in some exercise, although not regularly ( i . e . , preparation stage). Bandura (1986) noted that behavioural intentions to a t t a i n c e r t a i n l e v e l s of performance or engage i n a s p e c i f i c course of action increase the l i k e l i h o o d that the goals w i l l be r e a l i s e d . Interestingly, for the same time period, 27% of the w a i t i n g - l i s t control group regressed from some degree of p a r t i c i p a t i o n i n exercise to contemplating t h i s behaviour. This suggests that program processes focusing on behaviour change models, drawn from a vari e t y of f i e l d s , were e f f e c t i v e i n helping people move and sustain an increased involvement i n exercise p a r t i c i p a t i o n . In addition, being part of a p o s i t i v e group experience, i n i t s e l f , may have helped to move some subjects closer toward contemplating action. Data c i t e d i n Table 13a and i n Table 12, i n conjunction with the results from exercise s e l f - e f f i c a c y , further corroborate the findings from Marcus et a l . (1992) who found a s i g n i f i c a n t r e l a t i o n s h i p between s e l f - e f f i c a c y and the stages of exercise behaviour change. 221 Marcus et a l . (1996) suggested that t a i l o r i n g treatments to p a r t i c u l a r stages of change would accelerate peoples' progress toward exercise maintenance. To some extent, t h i s mirrors contemporary approaches to adult learning theory which recognise that adults are at d i f f e r e n t stages of development and progress at d i f f e r e n t rates. Adult education, however, occurs i n a s o c i a l context and has a broader agenda than i n d i v i d u a l counselling. For example, contemporary approaches to adult education view behaviour change as an i n d i v i d u a l and s o c i a l contextual process. In p a r t i c u l a r , c r i t i c a l s e l f - d i r e c t e d learning challenges mixed-ability learners i n an in c l u s i v e learning environment toward the art, science and p o l i t i c s of behaviour change. This approach i s not only enriched by d i v e r s i t y but i s also more r e a l i s t i c and appropriate than staged-matched programs occurring i n m u l t i c u l t u r a l worksite settings. Conclusion: Question (1) Experimental Findings In response to the f i r s t research question, data indicate that within the seasonal phase and duration of t h i s study, worksite health promotion programs derived from behaviour change models drawn from a va r i e t y of f i e l d s can be e f f e c t i v e i n increasing and maintaining higher lev e l s of exercise behaviour, exercise s e l f - e f f i c a c y and the stages of exercise behaviour change r e l a t i v e to a w a i t i n g - l i s t control group. A small improvement experienced by many people with respect to s e l f - e f f i c a c y , the stages of exercise behaviour 222 change, and exercise behaviour could have a major o v e r a l l impact on well-being and subsequent health care costs. Comparative outcome data broadens the appeal of t h i s study to p o t e n t i a l p o l i c y makers, decision makers, and market forces that have inter e s t i n t h i s sort of information (Scriven, 1993). These results, however, need to be interpreted with caution and the intervention program should not be viewed as a panacea for worksite health promotion programs to increase and maintain exercise behaviour. F i r s t , the study employed a f i e l d experiment i n which neither subjects nor the intervention were randomly assigned to groups. Although both worksite locations had access to a nearby f i t n e s s f a c i l i t y for s t a f f p a r t i c i p a t i o n throughout the study, i t should be noted that the Student Recreation Centre (SRC) opened i n the same week as the intervention program began. The novelty and increased awareness of the opening of t h i s f a c i l i t y close to the s i t e of the intervention group could have had an add i t i o n a l influence on exercise behaviour for these p a r t i c i p a n t s than that of the established f i t n e s s f a c i l i t y i n close proximity to the s i t e of the w a i t i n g - l i s t control group. Second, data r e l i e d on s e l f - r e p o r t measures of exercise behaviour, exercise s e l f - e f f i c a c y and stages of exercise behaviour change which can be influenced by a number of factors as already stated. Third, data c o l l e c t e d over a r e l a t i v e l y short and s p e c i f i c period of time as well as the l i m i t e d number of time periods during which data were 223 c o l l e c t e d do not permit further analysis of whether the exercise behaviour l e v e l s had s t a b i l i s e d by the time of the three month follow-up. To attribute change s p e c i f i c a l l y to the intervention, more rigorous measurements of natural change trends, d i r e c t i o n s , and rates p r i o r to the st a r t of the program would i n s p i r e a greater confidence. Although a w a i t i n g - l i s t control group was used for the purpose of t h i s study, f i n a n c i a l and subject recruitment constraints r e s t r i c t e d the use of multiple base-line measures. Fourth, i t should be noted that the intervention was being compared with a ' w a i t i n g - l i s t ' control group rather than a control group receiving equal attention. At the end of post-program and follow-up time periods, the mean exercise frequency l e v e l for the intervention program (2.54 times per week) was s t i l l less than the guidelines recommended by the American College of Sports Medicine (1990). In addition, only approximately one f i f t h of participants i n the experimental group at t h i s time period reported i n the stages of change questionnaire that they were generally p a r t i c i p a t i n g i n regular exercise. Although quantitative analyses show s t a t i s t i c a l s i g n i ficance, evaluating i s o l a t e d behavioural variables as a r e s u l t of a program neglects valuable information regarding the process of change. In order to understand more f u l l y the probable explanations for the s i g n i f i c a n t quantitative re s u l t s , program evaluation, journal and interview data were analysed to reveal the degree to which these variables were 224 part of a larger system of i n d i v i d u a l , s o c i a l and other contextual factors that shaped application. The following discussion examines possible relationships between the intervention, quantitative findings and broader factors that influenced post-educational application. Discussion: Question 12\ Factors A f f e c t i n g Application Green and Kreuter's (1991) Proceed evaluation framework was used as the guiding framework to assess post-educational experiences of a random sample of 50% of p a r t i c i p a n t s (n=13) from the experimental group. This i s a useful framework for the study of post-educational change experiences because of i t s emphasis on process and i t s broad perspective on context. The Proceed framework makes the thought processes and circumstances e x p l i c i t . It, therefore, offered a r e a l i s t i c and f l e x i b l e framework to describe how program intentions became transformed to the r e a l i s a t i o n of behavioural outcomes. The following sections r e f l e c t the varied experiences of those who attended the intervention program and t h e i r various attempts at applying c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change. (a) Social Contextual Factors Interestingly, most part i c i p a n t s referred to factors i n the s o c i a l context as being key to p a r t i c i p a t i o n i n exercise. None of the p a r t i c i p a n t s i n t h i s study enjoyed the t o t a l luxury of a b a r r i e r - f r e e context of application, teeming with s o c i a l support and with convenient and abundant access to exercise 225 f a c i l i t i e s (Ottoson, in p r e s s ) . A myriad of complex and dynamic s o c i a l , workplace, commuting and environmental factors were reported to shape whether and how learn ing was app l ied . For some respondents, these factors rendered exerc ise p a r t i c i p a t i o n as .a low p r i o r i t y or l a r g e l y beyond t h e i r personal c o n t r o l . They viewed the locus of contro l to be external with family members or s i g n i f i c a n t others in the workplace context. On the other hand, a number of p a r t i c i p a n t s were i n s i tuat ions where they were able to resolve these issues through negot iat ion s k i l l s , most often with other family members, and apply various degrees of c r i t i c a l s e l f - d i r e c t e d learn ing for exerc ise behaviour change. These f indings corroborated with Carron, Hawsenblas and Mack (1996), who conducted a meta-analysis of the impact of s o c i a l inf luence on exerc ise involvement. They found that s o c i a l inf luence of others does make a d i f fe rence in exerc ise in tervent ions . The s o c i a l network that had been estab l i shed from the c lass o f fered add i t iona l opportunit ies to p a r t i c i p a t e i n regular exerc ise and to evaluate attempts at applying l e a r n i n g . The opening of the Student Recreation Centre became an i n t e g r a l part of the in te rvent ion . Not only d id 15-20% of p a r t i c i p a n t s make use of t h i s f i t n e s s f a c i l i t y but c l e a r l y others were motivated to do exerc ise by i t s p u b l i c i t y and by those col leagues who d id use i t . Bandura (1986) postulated that s e l f - e f f i c a c y i s developed through appropriate v i c a r i o u s experience. The opening of the Student 226 Recreation Centre may well have contributed i n d i r e c t l y to the increase i n s e l f - e f f i c a c y reported by the experimental group. Competing inter e s t s , r e s p o n s i b i l i t i e s and p r i o r i t i e s played a key role i n exercise p a r t i c i p a t i o n . For example, car-pooling arrangements or the distance t r a v e l l e d to the workplace by many of the participants t y p i c a l l y l i m i t e d options for d a i l y physical a c t i v i t y . The impact of s o c i a l contextual b a r r i e r s meant that for many parti c i p a n t s , opportunities to p a r t i c i p a t e i n exercise were l i m i t e d to weekends or the r e l a t i v e l y b r i e f period at lunch times. Despite the benefits of fresh a i r , f i t n e s s , weight control and relaxation, very often the thought and will-power required for lunch-hour exercise had to compete with more immediate thoughts and feelings regarding the r e l a t i v e ease and attractiveness of being able to go to the nearby rest area, escape work, s i t down in peace and quiet or enjoy uninterrupted and relaxed s o c i a l i s a t i o n without having to b a t t l e against the weather, self-motivation or the inconvenience of locating appropriate changing and showering f a c i l i t i e s . A l ternative arrangements for exercise were often possible and at times sought by some; however, lunch time exercise was seen as being unnecessarily harder for some than others. Although change occurred at the i n d i v i d u a l l e v e l , change was also required by s i g n i f i c a n t others i n the context of post-educational application to provide the support and stimulation that enhanced exercise behaviour 227 change. A broad cross-section of s i g n i f i c a n t people included: the l o c a l community, extended family members, partners, spouses, off-spring, management, workplace supervisors, and colleagues. (b) Health Promotion Factors, Health promotion factors r e f e r to combined educational and environmental approaches. These factors, and i n p a r t i c u l a r , the educational component are of p a r t i c u l a r i n t e r e s t to program implementers since not only are they key to influencing application but they can also address diverse participant needs and circumstances, and they have the greatest capacity for producing change i n i n d i v i d u a l and s o c i a l contextual factors. The timing of the educational program was an important aspect of the intervention given the opening of the Student Recreation Centre and pa r t i c i p a n t concerns regarding a c t i v i t y l e v e l s , e s p e c i a l l y with long nights and winter approaching. It should be noted, however, that sensitive negotiations with management p r i o r to the course were c r i t i c a l to gain t h e i r support and ensure that the program was made accessible to a l l employees, on-site and i n work time. It was evident from a v a r i e t y of sources during the Precede planning phase that for various reasons participants would not have attended the program i f i t had been offered outside work time. To a s s i s t t h i s process and primarily for research purposes, the program and services of the implementer were provided free of charge. S t i l l , management had to calculate the cost-benefit balance to j u s t i f y the p o t e n t i a l disruption and 228 release time required to enable a l l employees to attend the program. The worksite health education program focused on c r i t i c a l thinking and problem-solving to enhance exercise s e l f - e f f i c a c y . Vicarious learning i s a key component of s e l f - e f f i c a c y (Bandura, 1986b). This was operationalised i n the learning process by the teacher and by the learners themselves. For example, course content included p o s i t i v e s e l f - t a l k and imagery techniques to enhance a learner's a b i l i t y to apply vicarious learning methods. The teacher also provided one example of a role model by sharing personal experiences of learning and health behaviour change that were l i k e l y to be appropriate, meaningful and relevant to the learners. Additionally, the teacher had the opportunity to model health education by demonstrating an enthusiasm for learning, teaching and the practice of health b e h a v i o u r s . T e a c h e r s who show w a r m t h a n d e m p a t h y to the learner are more l i k e l y to foster vicarious learning. F i n a l l y , the teacher encouraged a voluntary s o c i a l network among the learners. This provided a source of reinforcement as well as a peer-modelling opportunity to enhance p a r t i c i p a t i o n i n he a l t h f u l behaviours. Learners were also an excellent source of role models. They shared t h e i r experiences and suggestions for p a r t i c i p a t i n g i n health behaviours through the s o c i a l experience o f learning about health behaviour. Thus multiple role models i n the worksite h e a l t h education program provided a v a r i e t y o f opportunities 229 to increase the p r o b a b i l i t y that a learner would benefit from vicarious experience and enhance exercise s e l f -e f f i c a c y . The educational experience was generally evaluated very highly by respondents. The perceived value of the course was r e f l e c t e d i n the r e l a t i v e l y high attendance throughout. Research indicates that participant s a t i s f a c t i o n plays a major role i n continued employee p a r t i c i p a t i o n and that t h i s increases when employees are a c t i v e l y involved i n planning the programs and where programs show warmth and personal concern i n t h e i r interactions (Green & Kreuter, 1991). The data r e f l e c t e d multiple reasons for the continued high attendance and perceived success of the program. Cu r i o s i t y and no f i n a n c i a l obligation were incentive for some to attend the program i n i t i a l l y . One p a r t i c i p a n t commented, "I probably would not have come [to the program] i f I'd have had to pay. But, having been to the course, [I can now say] i t would have been worth i t . " It appeared that the program was valued as much for i t s s o c i a l value and being an enjoyable break from the usual work routine as i t was for personal development. A number of parti c i p a n t s also reported that they gained a l o t of i n s p i r a t i o n from the discussion with Other colleagues who faced many si m i l a r b a r r i e r s . Bandura (1986, p.191) asserted that i n t e r a c t i o n i s the primary basis for s o c i a l learning. This p r i n c i p l e was applied i n t h i s program by encouraging p a r t i c i p a n t s to be a c t i v e l y involved i n the needs assessment 230 and program development. Further, learning opportunities were provided to engage parti c i p a n t s i n d i v i d u a l l y and s o c i a l l y for c r i t i c a l s e l f - d i r e c t e d learning. Despite organisational problems inherent with multiple learning venues, t h i s process further assisted i n t e r a c t i o n as a r e s u l t of i n s t r u c t o r encouragement for p a r t i c i p a n t s to take r e s p o n s i b i l i t y to remind each other of the weekly locations through a networking support system. The q u a l i t a t i v e data show aspects of the intervention that are not c l e a r l y v i s i b l e i n the quantitative findings; namely, the role and conduct of the i n s t r u c t o r . It was evident from a variety of feedback sources (formative and summative program evaluations, interview data and Table 15), that the i n s t r u c t o r was a s i g n i f i c a n t aspect of the intervention. Many of the p a r t i c i p a n t s commented on the r e l a t i o n s h i p between the i n s t r u c t o r and the outcomes of the program. It should be noted that the i n s t r u c t o r had considerable experience i n adult education and currently teaches i n the Teacher Education program at the University of B r i t i s h Columbia. Providing considerable information regarding progress i s l i k e l y to increase s e l f - e f f i c a c y as well as act as an important source of s o c i a l support (Bandura, 1990). This was achieved by focusing on the a p p l i c a t i o n of motivation strategies for exercise behaviour change, problem-solving, co-operative learning strategies, various questioning techniques, and discussion opportunities, as well as creating a worksite community of 231 c r i t i c a l t h i n k e r s a n d s e l f - d i r e c t e d l e a r n e r s f o r h e a l t h b e h a v i o u r c h a n g e . T h e s e f i n d i n g s a d d f u r t h e r s u p p o r t t o t h e v i e w t h a t a t t e n t i o n must b e p a i d t o i n t e g r a t e p e r s o n n e l e v a l u a t i o n i n t o p r o g r a m e v a l u a t i o n r e s e a r c h ( S c r i v e n , 1 9 9 3 ) . F u r t h e r m o r e , t h e s e f i n d i n g s s u g g e s t t h a t a l e a r n e r - c e n t r e d a p p r o a c h f o c u s i n g on c r i t i c a l s e l f - d i r e c t e d l e a r n i n g i s a n e f f e c t i v e i n s t r u c t i o n a l s t r a t e g y i n a w o r k s i t e h e a l t h e d u c a t i o n s e t t i n g . D e s p i t e h i g h p r a i s e a n d t h e p e r c e i v e d s u c c e s s o f t h i s i n s t r u c t i o n a l a p p r o a c h i n a w o r k p l a c e s e t t i n g , i t s h o u l d b e c o n s i d e r e d one e x a m p l e o f a n e f f e c t i v e l e a r n e r - c e n t r e d a p p r o a c h r a t h e r t h a n t h e p a n a c e a o f i n s t r u c t i o n i n w o r k s i t e s e t t i n g s . T h e r e a r e m u l t i p l e c o n c e p t i o n s o f e f f e c t i v e i n s t r u c t i o n e a c h w i t h d i f f e r e n t i m p l i c a t i o n s f o r c u r r i c u l u m a n d i n s t r u c t i o n ( P r a t t 1 9 9 2 ) . I n c r i t i c i s m o f t h i s a p p r o a c h , h o w e v e r , i t c o u l d b e a r g u e d t h a t a n i n s t r u c t o r ' s p e r f o r m a n c e s h o u l d b e s e c o n d a r y t o l e a r n i n g o u t c o m e s i n t e r m s o f t h e u s e f u l n e s s o f c o u r s e p r o c e s s e s f o r e x e r c i s e b e h a v i o u r c h a n g e . S e c o n d , a few r e s p o n s e s s u g g e s t e d t h a t c o u r s e p r o c e s s e s d i d n o t a d e q u a t e l y c h a l l e n g e some l e a r n e r s , p a r t i c u l a r l y t h o s e who p e r c e i v e d t h e m s e l v e s t o b e more a d v a n c e d i n t h e i r s t a g e o f e x e r c i s e p a r t i c i p a t i o n . I n t e r e s t i n g l y , d u r i n g i n d i v i d u a l c o n s u l t a t i o n s i n t h e P r e c e d e p l a n n i n g p h a s e p r i o r t o t h e w o r k s i t e L i f e s t y l e S k i l l s M o t i v a t i o n p r o g r a m , p a r t i c i p a n t s w e r e g e n e r a l l y l e s s c o n f i d e n t a b o u t t h e i r a b i l i t i e s a n d p a r t i c i p a t i o n l e v e l s . To e n s u r e t h a t a more r e s p o n s i v e n e e d s a s s e s s m e n t i s c a r r i e d 232 out i n future i t i s recommended that greater probing s k i l l s are employed during t h i s interaction which might include how ind i v i d u a l s compare themselves with others who are l i k e l y to attend the program. More attention should also be paid to responses provided on the stages of exercise behaviour change questionnaire p r i o r to the program. Second, teacher-directed heterogeneous learner groupings are more l i k e l y to create s u f f i c i e n t s o c i a l disequilibrium to foster focused attempts at collaboration and enhance co-operative learning. According to Mezirow (1994), the process of learning i s shaped and delimited by our frames of reference. Learning, thus, occurs from a disorientation which leads one to r e f l e c t c r i t i c a l l y on the assumptions and b e l i e f s that have guided his or her l i f e . Therefore, to understand the meaning of our experience we are driven toward viewpoints which are more functional, i n c l u s i v e , discriminating and integrative of our experience. This would minimise s e l e c t i v e homogeneous and cohesive a b i l i t y groupings that can otherwise be established and marginalized. Third, providing a balanced range of case scenarios and even asking part i c i p a n t s to prepare and bring to class s i m i l a r problems to solve would f a c i l i t a t e more meaningful and mixed a b i l i t y learning to occur i n s p e c i f i c and detailed circumstances. Kemerer (1991) pointed out that the key to application resides i n the learner's perception of how important, meaningful and relevant the new learning i s to his or her a b i l i t y to work e f f e c t i v e l y i n the setting where the application must take 233 place. Thus, the multiple meanings and r e a l i t i e s of the learners i l l u s t r a t e s that when teaching, one must f i n d a balance between providing challenging content that retains the long term goals of the program while also meeting the needs of the learner. The range of motivational strategies covered within the L i f e s t y l e S k i l l s Motivation program tended to re-affirm the importance of negotiation, planning and preparation for some, while others found that they offered a new way of organising t h e i r day or week and, therefore, increased the l i k e l i h o o d of p a r t i c i p a t i n g i n regular exercise. In contrast, nearly one quarter of participants commented that they f e l t the strategies were somewhat "technological" or even " u n r e a l i s t i c " and " i d e a l i s t i c " given the context i n which they had to operate. These participants f e l t that many of the demands that they faced together with t h e i r perceived l i m i t e d power were beyond negotiation or planning for change. Many participants expressed a need to spend more time on the contents of the program. This may have r e f l e c t e d why data i n Table 15 indicated that handout materials were also perceived to be p a r t i c u l a r l y useful for respondents i n t h e i r e f f o r t s to apply learning. These materials may have provided a further opportunity to continue course processes beyond the scheduled timings. It appeared that for many of the respondents, what they had learned most from the educational experience was an understanding of a broad motivational framework for exercise behaviour change, to 234 experience how various strategies might be applied and to select those which best suited t h e i r s i t u a t i o n . Ic) Individual Factors, Participants were variously predisposed, enabled and reinforced by multiple factors to apply c r i t i c a l s e l f - d i r e c t e d learning for exercise behaviour change. Individuals were predisposed with varying degrees of knowledge, attitudes, b e l i e f s and values for exercise behaviour change. It i s important to note that behaviour change may and does occur without p r i o r knowledge and attitude change. Motives to attend the L i f e s t y l e S k i l l s Motivation program r e f l e c t e d those found i n the worksite health promotion l i t e r a t u r e (weight control, active l i v i n g and motivational s k i l l s ) . These findings concur with the Canada Fitness Survey (1983) data that reasons for being active are strongly health related. For example, i n the Canada Fitness Survey, 60% reported that to " f e e l better" was a "very important" reason for being active. Other reported motives for being active included "fun", "excitement", " f i t n e s s " , " s o c i a l i n t e r a c t i o n " , "weight control", "improved f l e x i b i l i t y " , and "stress management". Gauvin (1990) concluded that individuals who exercise regularly have two streamlined reasons for p a r t i c i p a t i n g i n regular exercise and physical a c t i v i t y , namely: f i t n e s s and looking good. Ashford and Biddle (1990) found that p a r t i c i p a n t s over 25 years of age were much more l i k e l y to report motives associated with health and relaxation than were younger subjects. Thus, i t would appear that physical 235 fitness and well being are central motives for participation in regular exercise. Although Dishman (1988) suggested that health factors may be important motives in the i n i t i a t i o n stage, exercise adherence is more lik e l y to be related to immediate sensations of enjoyment and well-being, that i s , reinforcing factors more than predisposing factors. Some participants in this study acknowledged that their motives changed as the course progressed and the social aspect became a strong incentive to attend the worksite health education program. Despite contact with every individual prior to the program, i t was evident from some responses that at the individual level the needs assessment was not sufficiently detailed to reveal the diversity of perceived a b i l i t i e s , experiences and stages of exercise behaviour change. This led to the erroneous perception by the course instructor of the stages of some; hence, participants were generally viewed as being in a contemplation or early preparation stage of exercise behaviour and with l i t t l e confidence to sustain regular physical activity. It appeared, however, that those people in a "late" preparation stage of exercise participation tended to want more emphasis during course processes placed on specific motivational strategies for maintaining exercise participation rather than the balance given toward strategies for i n i t i a t i n g as well as maintaining exercise behaviour. 236 The majority of respondents reported that various course processes increased t h e i r sense of control over perceived motivation; for others, i t helped only marginally. Lovato and Green (1990) concluded that, Adopting a healthful practice may show l i t t l e immediate reinforcement other than the s a t i s f a c t i o n of s e l f -c o n t r o l . This may be s u f f i c i e n t for some to override the hassles because the values and b e l i e f s from which the s a t i s f a c t i o n i s derived make the accomplishment of s e l f - c o n t r o l i n t r i n s i c a l l y satisfying(p.77). Those who did not f e e l greatly empowered by the strategies tended to view the locus of control with other members of t h e i r family, " s i g n i f i c a n t others" or with other environmental factors. These people also tended to f e e l more negative about t h e i r own health status and a b i l i t y to control i t . Participants were enabled through various s k i l l s , b a r r i e r s and opportunities to apply learning for exercise behaviour change. The majority commented that they had learned a l o t of useful t i p s from the course. S o c i a l and other contextual factors, combined with varying degrees of previous experience and the number of respondents who commented that more time was required to understand f u l l y the motivational strategies, help to explain the varying degrees of perceived a b i l i t y to apply learning. For some part i c i p a n t s , an exercise game-plan comprised of planning, action and r e f l e c t i o n strategies was a p o s i t i v e framework 237 that enabled them to f e e l more confident that regular exercise would take place. In p a r t i c u l a r , negotiation strategies with s i g n i f i c a n t others to share workloads, intentions and co-ordinate timetable commitments were considered very useful for i n i t i a t i n g exercise and certain imagery strategies also appeared to increase enjoyment of the exercise experience. Many partic i p a n t s commented that the "workplace walking routes sheet" developed for before, during and after-work walking opportunities was a useful process both for the workplace se t t i n g and for stimulating ideas to s e l f - d i r e c t a variety of walking routes around the home environment. This sheet was constructed as part of course processes by participants and tended to act as a t r i g g e r for discussion and a source of motivation for some to t r y new walking routes. For others, however, circumstances i n the l o c a l environment prevented such plans from being formulated or put into action. Participants were thus presented with an array of opportunities and b a r r i e r s to a p p l i c a t i o n . In addition to s p e c i f i c c h a r a c t e r i s t i c s reported i n s o c i a l contextual factors, participants also d i f f e r e d i n perceived health status, energy l e v e l s , s e l f -motivation and available time to think adequately about and prepare for application. Participants reported receiving various sources of reinforcement for post-educational applic a t i o n . The l i t e r a t u r e suggests that both i n t r i n s i c and e x t r i n s i c motivation are important determinants of exercise behaviour. 238 It i s important to note, however, that the exercise a c t i v i t y i t s e l f must be i n t r i n s i c a l l y rewarding as there i s some evidence to suggest that reliance on external motivators may reduce i n t r i n s i c reward i n the long term (Weinberg, 1984). For some participants, the i n t r i n s i c feelings of control, the sense of s a t i s f a c t i o n , perceived f i t n e s s , and the perceived increase i n coping a b i l i t y as a re s u l t of application were reported as in t e r n a l sources of reinforcement. During t h i s study, reinforcement was endorsed by the instructor i n terms of providing encouragement and f a c i l i t a t i n g networking experiences as well as through helping subjects to self-monitor t h e i r thoughts, feelings and actions and encouraging them to recognise t h e i r own successes and to praise themselves through p o s i t i v e s e l f -t a l k . The g e n e r a l i z a b i l i t y of motivational strategies to other health practices and family l i f e were mentioned by many participants as additional reinforcement for t h e i r value and application. This supported the view by Green, Wilson and Lovato (1986) who suggested that when ind i v i d u a l s take a greater i n i t i a t i v e to develop t h e i r system of rewards, behaviour tends to generalise and the reinforcement values are i n t e r n a l i s e d within each ind i v i d u a l ' s own value structure. Respondents reported that external reinforcement came from: s o c i a l forces (colleagues, family and friends), diary pages, pulse-rate monitoring, or v i s i b l y through body image. For example, program processes to develop a worksite 239 community of c r i t i c a l thinkers and s e l f - d i r e c t e d learners for health behaviour change played a major role i n re i n f o r c i n g learning since some participants met regularly outside the class to p a r t i c i p a t e i n a vari e t y of physical a c t i v i t i e s . Interestingly, a lack of s o c i a l support was reported by many participants from diverse circumstances as a main b a r r i e r that hindered post-educational a p p l i c a t i o n . This supported the findings of Dishman (1982) who found that spouse and family support were very important predictors of exercise p a r t i c i p a t i o n . There are, however, points of caution regarding the heavy reliance on s o c i a l support as a means of external reinforcement. Well intended intimidation, for example, may cause s o c i a l f r i c t i o n and i s u n l i k e l y to increase the value a person places on the behaviour or to increase the maintenance of the desired behaviour i n the long term. A host of i n d i v i d u a l factors, therefore, taken separately or i n combination, af f e c t a p p l i c a t i o n . For example, in d i v i d u a l s may possess the appropriate s k i l l s and a strong sense that they can execute them well but s t i l l f a i l to perform because they f e e l no personal commitment to the behaviour. Furthermore, a change i n behaviour t y p i c a l l y involves a temporary surrender of security and the production of some anxiety, and requires d i f f i c u l t decisions and awakenings about p a r t i c u l a r l i f e s t y l e practices that some people may f i n d very d i f f i c u l t to confront and f i n d easier to r e s i s t . It would appear, therefore, that those 240 i n d i v i d u a l s who are more l i k e l y predisposed, enabled and reinforced to apply c r i t i c a l s e l f - d i r e c t e d learning are also more l i k e l y to succeed with exercise behaviour change. Conclusion: Question (2) Factors A f f e c t i n g Application Exercise behaviour change i s c l e a r l y a long and dynamic process that i s shaped by multiple factors. Single variable research i s thus inadequate to capture the complexities of post-educational application. Journal and interview data, guided by the proceed evaluation framework revealed the i n t e r r e l a t i o n s h i p of complex and diverse s o c i a l contextual, educational and policy, and i n d i v i d u a l factors that shaped application following the worksite health promotion program. Ottoson (in press) noted that, "adult education deserves neither a l l the cred i t nor a l l the blame for the l e v e l and qu a l i t y of application following adult education programs since i t i s but one element of a larger context." Although change occurred at the i n d i v i d u a l l e v e l , i t appeared that the power to influence resources, money, and s i g n i f i c a n t others had a s i g n i f i c a n t e f f e c t on whether and how learning was applied. Data indicated that subjects varied i n t h e i r context of application, personal resources and perceived power, s o c i a l support, perceived exercise s e l f - e f f i c a c y , previous experience, motives, understanding, and stage of app l i c a t i o n . As Steuart (1993) pointed out, an understanding of the determinants of change has an i m p l i c i t concern for 241 the obstacles to change which l i e at the heart of the challenge to health education. Discussion: Question (31 Process of Application According to Fullan (1991a), educational change induces the transformation of subjective r e a l i t i e s by learning new ways of thinking and doing, new s k i l l s , knowledge, attitude and b e l i e f s . He warned, however, that when change i s interpreted i n an oversimplified way and neglects these aspects i t can lead to an erroneous perception of change (false c l a r i t y ) . For the purpose of t h i s study, c r i t i c a l s e l f - d i r e c t e d learning was defined as rigorous, creative and c r i t i c a l l y r e f l e c t i v e thoughts ( c r i t i c a l thinking) pertaining to i n d i v i d u a l and c o l l e c t i v e exercise behaviour change. C r i t i c a l thinking and s e l f - d i r e c t e d learning, therefore are considered separate though related and c r i t i c a l components i n the problem-solving process. Data r e f l e c t e d that c r i t i c a l s e l f - d i r e c t e d learning had been applied i n a va r i e t y of ways following the worksite health promotion program. For example, respondents reported thinking c r i t i c a l l y when engaged i n conscientious and care f u l planning and evaluation ( i . e . , what, which when, how, assessment of strengths and weaknesses); assessing a l t e r n a t i v e ways to overcome obstacles as well as making connections with solutions for other health behaviours; and using a va r i e t y df planning, action and evaluation strategies. Furthermore, c r i t i c a l thinking was applied, not 242 only toward the application of problem-solving strategies, but also by respondents increasing t h e i r self-awareness of health practices and the influence of s i g n i f i c a n t others and the l o c a l environment on personal health behaviours. This suggests that intervention processes helped to rai s e the l e v e l of consciousness for exercise behaviour change beyond simply that of the i n d i v i d u a l but also toward the influence of s o c i a l and other contextual factors. It should be noted, however, that with the exception of one pa r t i c i p a n t who lobbied for changing and showering access, others did not report p o l i t i c a l lobbying a c t i v i t i e s at the s o c i a l , worksite or community l e v e l to enhance the p o t e n t i a l for c o l l e c t i v e empowerment with respect to health behaviour change. This may r e f l e c t the p o l i t i c a l apathy, individualism or conservative nature of many North Americans i n employment or, on the other hand, the perceived employment in s e c u r i t y that can lead from engaging i n these types of a c t i v i t y . Many participants suggested that an understanding of the broad motivational framework i n terms of "planning", "doing" and " r e f l e c t i o n " helped them to manage exercise motivation. Some translated t h i s framework into p a r t i c u l a r motivation strategies (e.g., networking, time-management, imagery) that were more relevant to t h e i r s i t u a t i o n . Others commented that a better understanding of the components of physical f i t n e s s added to the enjoyment and relevance of f i t n e s s class a c t i v i t i e s as they were more able to make connections between certa i n exercises that they performed 243 and the " S " factor components: suppleness, strength and stamina. Thus, r e l a t i v e to pre-intervention, for many, having a broad motivation framework to draw upon and a better understanding of the components of f i t n e s s increased t h e i r sense of control over motivational issues and, therefore, enhanced exercise s e l f - e f f i c a c y . When respondents were asked s p e c i f i c a l l y to a r t i c u l a t e how t h e i r confidence had been increased to p a r t i c i p a t e i n more exercise, a number of part i c i p a n t s a t t r i b u t e d t h i s to the combination of program processes (e.g., a p o s i t i v e atmosphere), the application of s p e c i f i c strategies (e.g., networking, scheduling, imagery) and perceived r e l a t i v e increases i n a c t i v i t y l e v e l s . S e l f - d i r e c t e d learning was applied i n the problem-solving process by employing various s o c i a l contextual, planning, action and evaluation strategies for exercise behaviour change. Social contextual strategies were t y p i c a l l y applied through networking processes to e n l i s t the support of s i g n i f i c a n t others and/or negotiation s k i l l s to ensure that both i n d i v i d u a l and s o c i a l needs could be accommodated. Few respondents f e l t completely autonomous with decisions to p a r t i c i p a t e i n exercise. Equally, a minority of p a r t i c i p a n t s opted for s o l i t a r y p a r t i c i p a t i o n i n exercise as a means to take advantage of time out and personal space. Scheduling and developing walking route opportunities appeared to be the most widely applied planning strategies. 244 Scheduling a c t i v i t i e s t y p i c a l l y involved s e t t i n g health p r i o r i t i e s , having d a i l y and/or weekly exercise agendas that were constructed either late at night, early i n the morning and/or on weekends. In some cases, these plans succeeded i n being a fix e d feature i n a person's routine. For others, r e s p o n s i b i l i t i e s and demands were such that constant juggling was required on a d a i l y basis to ensure that exercise p r i o r i t i e s could be best achieved. R e l a t i v e l y few part i c i p a n t s r e l i e d on unplanned and spontaneous exercise p a r t i c i p a t i o n on a regular basis. Those who d i d reported mixed success with t h i s approach. Ty p i c a l l y , planning strategies required c r i t i c a l thinking to ensure that the exercise experience was often multi-purposeful and enjoyable rather than a d u t i f u l and effort-focused experience. These findings corroborated with Strecher et a l . (1996), who suggested that, goal s e t t i n g enhances s e l f - e f f i c a c y , s a t i s f a c t i o n a n d p o s i t i v e a t t r i b u t i o n s f o r causes of successes and f a i l u r e s and empower ind i v i d u a l s to. address new challenges. An assortment of "action" strategies were employed during exercise p a r t i c i p a t i o n as a means to increase motivation and enhance the exercise experience. For those who preferred brisk walking a c t i v i t i e s , strategies most often involved various forms of cognitive and behavioural d i s s o c i a t i o n s k i l l s such as t a l k i n g to others, s e l f - t a l k , problem-solving and/or focusing on pleasurable thoughts or surroundings i n the l o c a l environment. These findings 245 supported the research by Martin et a l . (1984) and Johnson and Siegal (1992) who found that d i s s o c i a t i o n strategies could reduce perceived e f f o r t during health related aerobic exercise and, therefore, enhance the exercise experience. For those people engaged i n fit n e s s class a c t i v i t i e s , a combination of association and d i s s o c i a t i o n strategies were employed to enhance the exercise experience. P a r t i c u l a r association strategies i n t h i s setting included focusing on movement technique, the beat of the music and energy expenditure. Four major evaluation strategies were t y p i c a l l y applied: subjective evaluation of the exercise experience, physical appearance, comparisons made with behavioural patterns of s i g n i f i c a n t others, and personal diary r e f l e c t i o n s . A subjective evaluation of the exercise experience was t y p i c a l l y c a r r i e d out either by a r b i t r a r i l y scoring the exercise process from 1-10, self-evaluation of one's own performance, acknowledgement of multiple benefits of exercise during or af t e r p a r t i c i p a t i o n , and personal and/or s o c i a l praise for accomplishing exercise p a r t i c i p a t i o n . Physical appearance was often assessed through r e f l e c t i o n s i n mirrors, on bathroom scales and one's perceived f i t into clothing. Comparisons made with behavioural patterns of s i g n i f i c a n t others took the form of being aware of others attending f i t n e s s classes or going for lunch-time walks and perceiving f i t n e s s l e v e l s of s i g n i f i c a n t others. Personal diary r e f l e c t i o n s included the 246 monitoring of d a i l y or weekly exercise targets and reviewing d i a r i e s to re-affirm weekly accomplishments. Furthermore, weekly journal entries that were required for research purposes, i n themselves served as a continuing form of intervention. Evaluation strategies provide feedback on progress as well as the strengths and weaknesses of the planning or exercise experience. This can r e s u l t i n a powerful means of enhancing s e l f - e f f i c a c y . These findings concur with Juneau et a l . (1987) who noted that, meaningful and convenient self-monitoring i s a powerful means of p o s i t i v e reinforcement that enhances re-scheduling and thus exercise adherence. Interestingly, none of the p a r t i c i p a n t s reported using heart rate monitoring or the Borg Rating of Perceived Exertion as a regular method of monitoring f i t n e s s l e v e l s . This adds further evidence to support the b e l i e f that a pre-occupation with t r a i n i n g i n the heart rate zone may be inappropriate for health-related exercise adherence (Marcus et a l . , 1 9 9 4 ) . It may well be that such ph y s i o l o g i c a l approaches are viewed generally as less meaningful to p a r t i c i p a n t s than methods that are more tangible and low-tech, requiring l i t t l e s p e c i a l i s e d knowledge. Exercise behaviour as applied by p a r t i c i p a n t s varied according to type, frequency, intensity, duration and r e g u l a r i t y . The majority of p a r t i c i p a n t s preferred b r i s k -walking a c t i v i t i e s . Brisk walking i s an i d e a l form of s e l f -directed exercise since i t can be a useful form of transport 247 and does not require any s p e c i a l i s t equipment, clothing, venue, cost or supervision, a l l of which can act as b a r r i e r s to habitual exercise. The exercise preferences of these subjects substantiated the research by Stephens, Jacobs and White (1985), who found that people prefer ( p a r t i c u l a r l y among those who are i n i t i a l l y unfit) moderate i n t e n s i t y a c t i v i t i e s (e.g., brisk walking) as opposed to more vigorous a c t i v i t i e s and those they can perform i n d i v i d u a l l y rather than i n a structured setting. Studies have shown that unsupervised exercise at r e l a t i v e l y low levels ( i . e . , low to moderate i n t e n s i t y 60-77% maximum heart rate) such as bri s k walking, when performed on a regular basis, was s u f f i c i e n t to increase s i g n i f i c a n t l y the functional capacity i n apparently healthy sedentary adults and was also associated with reduced cardiovascular morbidity and mortality (Bouchard et a l . , 1990; Hardman, 1989; Pate, Pratt & B l a i r , 1995; Rippe et a l . , 1988; Shoenfeld et a l . , 1988). The preferred times (or r e a l i s t i c times) for exercise p a r t i c i p a t i o n appeared to vary between the participants from early morning, to just before bed-time. Others reported that rather than plan a s p e c i f i c exercise session they found i t easier to increase e x i s t i n g d a i l y a c t i v i t y by "doubling" the distance of regular walks during d a i l y tasks. In contrast, approximately one quarter p a r t i c i p a t e d i n a fitness class a c t i v i t y p r e f e r r i n g the music, energetic atmosphere, and quic k - f i x high energy work-out, without having to be concerned about c l i m a t i c and seasonal weather patterns. In 248 terms of supporting quantitative data that was gathered from the Exercise Behaviour Questionnaire, over three quarters of respondents believed that they and others i n the workplace were p a r t i c i p a t i n g i n more exercise since the workplace L i f e s t y l e S k i l l s Motivation program. An i l l u s t r a t i o n of the li m i t a t i o n s of the seven day r e c a l l questionnaire, however, was that only one quarter reported that on a weekly basis t h e i r exercise pattern was mostly stable whereas one h a l f of respondents claimed that i t was generally unpredictable from one week unto the next. C o n c l u s i o n : Q u e s t i o n <3) P r o c e s s o f A p p l i c a t i o n The intervention program was a set of multifaceted processes rather than one component; thus, data provided valuable feedback regarding the perceived contributions made by p a r t i c u l a r aspects within the program. Learning was a d a p t e d a n d applied variously by type, frequency, in t e n s i t y , duration and r e g u l a r i t y to suit i n d i v i d u a l needs and circumstances. Perceived s e l f - e f f i c a c y a f f e c t s one's intentions for change, how hard one t r i e s a f t e r one decides to change, one's r e s i l i e n c e following setbacks, and how well one maintains the gains that he or she achieved (Bandura, 1 9 8 6 ) . During post-educational application, p a r t i c i p a n t s interacted d i r e c t l y with t h e i r l o c a l environment and, therefore, learning was not applied uniformly. Adaptation refers to the degree to which learning that had been applied i n p r actice had deviated from the o r i g i n a l idea. None of the 249 p a r t i c i p a n t s reported using a l l of the motivational strategies promoted i n the course outline. Most parti c i p a n t s used s e l e c t i v e aspects of the program that best suited t h e i r a b i l i t i e s , needs and circumstances, some partic i p a n t s were s t i l l "grappling" with the motivation strategies and others planned to use the strategies at a l a t e r date when they anticipated that t h e i r personal situations would be more s e t t l e d . Furthermore, change did not simply occur at the i n d i v i d u a l l e v e l but was also required by those who interacted i n the context of applicat i o n . These findings concur.with the l i t e r a t u r e on implementation (Marjone & Wildavsky 1979), suggesting that post-educational application necessitates mutual adaptation between the concept and the context so that behaviours can be adapted to l o c a l situations and changing circumstances. Discussion: Question (A) Alternative Outcomes Relative to intended learning outcomes, a vari e t y of al t e r n a t i v e outcomes gathered from a semi-structured interview, i n the form of knowledge, attitudes, s k i l l s and behaviours were expressed by respondents following the worksite L i f e s t y l e S k i l l s Motivation program. For example, respondents on the whole commented that they f e l t better, f i t t e r , less stressed, more able to cope and were having more q u a l i t y time with s i g n i f i c a n t others. A number of par t i c i p a n t s commented that the motivation strategies had been reinforced by t h e i r success i n generalising to a 250 v a r i e t y of h o l i s t i c health behaviours (e.g., stress management, posture p r a c t i c e s ) . Scheduling stress reduction a c t i v i t i e s , i n p a r t i c u l a r , breathing techniques, was es p e c i a l l y popular. Interestingly, s e l f - e f f i c a c y i s assessed i n r e l a t i o n to very s p e c i f i c behavioural referents since each s i t u a t i o n i s d i f f e r e n t (Bandura, 1977); therefore, although s e l f - e f f i c a c y may be s i t u a t i o n a l l y s p e c i f i c , the self-regulatory strategies that contribute to s e l f - e f f i c a c y may to some extent be generalizable to other behaviours of in t e r e s t . This may provide an i n t e r e s t i n g hypothesis for future studies. On the other hand, several respondents commented that the motivational strategies required a l o t of time and e f f o r t which tended to add to the perceived t o t a l amount of e f f o r t required for an exercise experience and thus made them at times problematic. Fullan (1991a) noted that the amount of energy and time required to learn new s k i l l s i s a useful index for the size of the resistance to i t . In the responses from many of the respondents i t was implied that attending the program afforded the benefit of being able to indulge i n an enjoyable and worthwhile break from the usual work routine as well as for personal development. Several respondents commented that the value of the educational experience had rejuvenated an in t e r e s t to pursue further learning a c t i v i t i e s . This i s congruent with a contemporary b e l i e f that educational processes should help empower learners with the motivation and s k i l l s f or l i f e l o n g 251 learning experiences. Signs of apathy, however, became apparent with the a c t i v i t i e s of the workplace wellness representatives. Despite p a r t i c i p a n t s ' desire, volunteer nominations and considerable assistance from the course in s t r u c t o r with informational materials, ideas, prompting and even stage-managing the issue of access to showering f a c i l i t i e s to support and mobilise worksite wellness representatives into action, t h i s role was beginning to be perceived by the two individuals at the three month follow-up as an additional burden to e x i s t i n g workloads. In future, a committee of wellness representatives would be more l i k e l y to share the r e s p o n s i b i l i t y and be more supportive i n t h e i r e f f o r t s to e s t a b l i s h and maintain t h i s process c o l l e c t i v e l y . Management reported that they had not noticed any marked increase or decrease i n absenteeism over the duration of t h i s study. Health education programs are not the panacea of worksite health promotion since they operate as one element i n a larger context of change that i s required i n workplace settings (Green & Kreuter, 1991). Management were aware of an increase i n s t a f f morale and p a r t i c i p a t i o n i n a varie t y of exercise a c t i v i t i e s including the departmental Christmas ice-skating party as well as an increase i n attention that had been given to information on the "Wellness Board" located i n the rest area. Management were not d i r e c t l y consulted with respect to the creation of a worksite wellness board and worksite wellness representatives which, i n hindsight, could both have been a 252 p o t e n t i a l problem. Judging from the rapport between instructor, management and employees, as well as the s p i r i t captured within the program to enhance active l i v i n g i n the worksite, t h i s oversight d i d not, however, develop into a p o t e n t i a l problem. Despite no additional work-burden for those employees who did not attend the worksite health education program, the issues of non-participation and p o t e n t i a l resentment were concerns raised by management. These employees were believed to be i n the most need for l i f e s t y l e change. This concurs with Dishman (1991), who found that those who do not p a r t i c i p a t e i n worksite exercise programs t y p i c a l l y have high CHD r i s k p r o f i l e s . A number of issues, however, r e l a t e to those employees i n the precontemplation stage. F i r s t , t h e i r p o s i t i o n toward exercise involvement should be respected. Vertinsky (1992), for example, warned against f a l l i n g into the trap of health fascism and narcissism i n contemporary health promotion programs. Second, the worksite L i f e s t y l e S k i l l s Motivation program was s p e c i f i c a l l y intended for those employees who were at least i n the contemplation stage of exercise p a r t i c i p a t i o n . In other words, those people who had r a t i o n a l i s e d some intention and desire to p a r t i c i p a t e i n more exercise. Workplace health promotion strategies targeting those employees i n the precontemplation stage of health behaviours require a d i f f e r e n t approach than that used i n t h i s study. Research suggests that s t r a t e g i c poster and newsletter campaigns that 253 are not vi c t i m blaming and aimed at both the advantages of p a r t i c i p a t i o n as well as the disadvantages of non-p a r t i c i p a t i o n i n health behaviours are more e f f e c t i v e for those i n precontemplation than generic programming approaches (Marcus et a l . , 1992; Marcus et a l . , 1994; Prochaska et a l . , 1992). This approach should also be reinforced by the frequency of implementing perceived successful health promotion programs focusing on those who are not i n the precontemplation stage. The instr u c t o r i n t h i s study was thus sensitive to these issues and therefore made a point of being courteous and t a l k a t i v e to a l l employees during frequent on-site v i s i t s throughout the implementation process. Green and Kreuter's (1991) Precede-Proceed model enabled a collaborative venture throughout the implementation process i n order to gain the acceptance of a l l p arties and address t h e i r needs i n the worksite L i f e s t y l e S k i l l s Motivation program. According to Witherspoon (1990), many workplace health promotion programs are not successful because they function i n the absence of a supportive corporate culture. As a d i r e c t r e s u l t of the management's perceived success of the worksite L i f e s t y l e S k i l l s Motivation program, a joi n t proposal was developed and accepted for University funding to conduct further programs within the Department of Housing and Conferences i n 1996-97. 254 Conclusion: Question (4) A l t e r n a t i v e Outcomes Health promotion i n the workplace i s primarily concerned with supporting hea l t h f u l l i f e s t y l e practices that go beyond simple behavioural approaches. According to Steuart (1993), "health education should be concerned with a l l conceivable ways of inducing health related behaviour change associated with which the actual health status of i n d i v i d u a l , family and community i s improved. The influence-attempts of health education are brought to bear on behaviours that, i n themselves, l i e within c u l t u r a l l y defined 'normal' l i m i t s " (p.53). A variety of unintended behavioural and non-behavioural outcomes were reported from the educational experience including: perceived benefits from a break i n the usual work routine, participants sharing course information with s i g n i f i c a n t others, h o l i s t i c health practices and workplace benefits. These findings tend to concur with Sime (1984) who found that exercise p a r t i c i p a t i o n was associated with a good and relaxed f e e l i n g , and an improved qua l i t y of l i f e as well as a sense of accomplishment and well-being which may be derived from s e l f - i n i t i a t i v e and can increase self-esteem, confidence or self-concept. Management and employees t y p i c a l l y adapted and shaped program processes to s u i t t h e i r personal needs and circumstances. 255 CHAPTER 6 SUMMARY. CONCLUSIONS. IMPLICATIONS. RECOMMENDATIONS Review, Despite greater public awareness of the ph y s i o l o g i c a l and psychological benefits of regular exercise, as l i t t l e as 8-20% of the population are s u f f i c i e n t l y active to a t t a i n these health benefits (Centres for Disease Control, 1990). Compounding t h i s problem, the t y p i c a l drop-out rate from exercise programs has remained at approximately 50% (Dishman, 1991). The World Health Organisation has i d e n t i f i e d one of i t s targets for the year 2000 to be the provision of health education programs which should enhance the knowledge, motivation and s k i l l s of people to acquire and maintain health (WHO, 15). This i s an encouraging statement since, c l e a r l y , a major challenge facing health promotion i s to increase p a r t i c i p a t i o n and adherence to regular exercise. This study began with a comprehensive review of l i t e r a t u r e pertaining to concepts, intervention strategies and behaviour change models drawn from a v a r i e t y of f i e l d s to enhance exercise behaviour. Interventions focusing on self-regulatory cognitive and behavioural s k i l l s have contributed s i g n i f i c a n t l y . t o increasing and maintaining physical a c t i v i t y l e v e l s i n an exercise s e t t i n g (Dishman, 1994). Self-regulation emphasises personal r e s p o n s i b i l i t y for developing and maintaining health promoting behaviours on a permanent basis. Bandura*s (1986) s e l f - e f f i c a c y 256 construct i s based on the p r i n c i p l e of s e l f - r e g u l a t i o n . S e l f - e f f i c a c y has shown success i n many health behavioural change programs such as condom-use (Jemmott & Jemmott, 1992), drug re f u s a l (Jones et a l . , 1990), AIDS preventative behaviour (Kasen, 1992 and Magura et a l . , 1991), adult health (Leviton, 1989), heart disease prevention (Rose, 1992), adolescent health (Sprunger & Pellaux, 1989), smoking cessation (DiClemente et a l . , 1985), weight control (Bernier & Avard, 1986), and exercise program p a r t i c i p a t i o n (McAuley & Jacobson, 1991). According to Lawrance and McLeroy (1986), s e l f - e f f i c a c y i s the p r i n c i p a l connection between knowledge and action since i t i s based on knowing what to do, and how and when to do i t . Evidence supporting the g e n e r a l i z a b i l i t y of Bandura's p r i n c i p l e s for developing s e l f - e f f i c a c y i n a worksite health education program to increase p a r t i c i p a t i o n and adherence to leisure-time physical a c t i v i t y , i s as yet unclear. Exercise behaviour i s complex and i s not simply an a l l or nothing phenomena. Marcus, Selby, Niaura, and Rossi (1992) suggested that there are d i f f e r e n t stages of exercise involvement. Thus, the amount of progress a person makes as a r e s u l t of an intervention may also depend upon the stage of exercise involvement they were i n at the st a r t of the program. Intervention programs, therefore, should be se n s i t i v e to the d i f f e r e n t stages and needs of those in d i v i d u a l s whose behaviour i s expected to change. A growing body Of evidence i s accumulating to suggest that s e l f -257 e f f i c a c y i s d i r e c t l y related to the stages of behaviour change (Marcus et a l . , 1992, Marcus et a l . , 1994, Prochaska et a l . , 1992). Researchers have cautioned, however, against the exclusive reliance on psychological approaches and s e l f -development i n adult education (Grow, 1994, Hammond & C o l l i n s , 1991, Law & Rubenson, 1988). Contemporary approaches to adult learning take into account the interconnectedness of learner autonomy and personal development with a c r i t i c a l r e f l e c t i o n of the broad s o c i a l context which i n part shapes the application of a behavioural change. C r i t i c a l l y r e f l e c t i v e , as well as, s e l f -directed learning strategies are thus central to contemporary approaches to adult education programs. An e s s e n t i a l part of program development focuses on program implementation. Green and Kreuter's (1991) Precede-Proceed model i s an educational and environmental approach to health promotion. This model takes process into account and has a broad perspective on context thus providing a f l e x i b l e and r e a l i s t i c framework for planning and evaluating worksite health promotion programs. Program implementation i s not only concerned with planning and evaluation, but also the way i n which programs are delivered. A learner-centred approach to i n s t r u c t i o n that focuses on a nurturing and challenging learning environment enhances c r i t i c a l thinking and s e l f - d i r e c t e d learning. This approach assumes that adults bring a v a r i e t y of needs and experiences to worksite 258 health education programs and, therefore, should be encouraged c o l l e c t i v e l y , as well as i n d i v i d u a l l y , to be resources for t h e i r own and each others' learning (Knox, 1986) . For the purpose of t h i s study, a worksite health promotion program was developed by integrating behaviour change models from the l i t e r a t u r e on exercise science, health promotion-and adult education. The aim of the program was to empower participants i n d i v i d u a l l y and c o l l e c t i v e l y with the knowledge, attitudes and s p e c i f i c s k i l l s to think c r i t i c a l l y and to s e l f - d i r e c t exercise behaviour change. E s s e n t i a l l y , learning a c t i v i t i e s focused on collaboration, i n t e r a c t i o n , c r i t i c a l r e f l e c t i o n and a p p l i c a t i o n . Exercise behaviour change was thus viewed as an i n d i v i d u a l and s o c i a l contextual process. Purpose of study, The purpose of t h i s study was to gain a better understanding of the e f f e c t s of, and the a p p l i c a t i o n of learning following a worksite health promotion program that was developed by integrating behaviour change models from a variety of f i e l d s . Methodology, Multiparadigmatic and m u l t i d i s c i p l i n a r y research i s required to gain a better understanding of the complexities of post-educational application (Ottoson, 1995). This study was situated i n a post-empiricist perspective, however, a broad set of p l u r a l i s t i c research questions, intervention and data c o l l e c t i o n strategies were employed consistent with multiple epistemologies. The 259 p r i n c i p l e of p a r t i c i p a t i o n was employed throughout the twelve-month implementation of t h i s research project (Green, 198 6). Such research i s not as t i d y as i t might appear. Decisions, disappointments, and near-disasters are part of any intervention research, e s p e c i a l l y when i t i s situated i n a f i e l d s e t t i n g as evident i n t h i s study. A f i e l d experiment focused on assessing the following key outcome variables for the duration of the study: exercise behaviour, exercise s e l f - e f f i c a c y and the stages of exercise behaviour change. Appropriate s t a t i s t i c a l analyses were conducted to make comparisons and i n f e r causal e f f e c t s pertaining to post-educational a p p l i c a t i o n . Second, to interpret these findings and gain further insight to the factors a f f e c t i n g application as well as the process of application, a random sample of 50% of the par t i c i p a n t s from the experimental group was tracked and interviewed over a three-month period. Appropriate q u a l i t a t i v e a n a l y s e s w e r e "conducted to i d e n t i f y and categorise key themes within the Proceed framework pertaining to post-educational a p p l i c a t i o n . Therefore, an e c l e c t i c set of quantitative and q u a l i t a t i v e tools was employed to study the complexities of the contextually-bound, dynamic, on-going and multifaceted process of post-educational application. Results, The findings of t h i s study indicated that s t r u c t u r a l changes occurred i n the workplace environment to f a c i l i t a t e h e a l t h f u l behaviours. Quantitative outcome data indicated that changes occurred i n exercise s e l f - e f f i c a c y , 260 exercise stages of change and exercise behaviour (p<0.05). Qualitative analysis revealed that a myriad of i n d i v i d u a l (e.g., experiences, motives and intentions for exercise behaviour change, ba r r i e r s , s k i l l s ) s o c i a l (e.g., colleagues, spouses, family and other forms of s o c i a l support)and other contextual (e.g., home, workplace and community) factors shaped post-educational application of exercise behaviour change. Furthermore, learning was adapted and applied i n a variety of intended and unintended ways to s u i t s p e c i f i c needs and circumstances. As part of the intervention, results and implications of t h i s study were recycled back to participants i n the workplace se t t i n g to further help mobilise the workplace community for exercise behaviour change. Conclusions Conclusions drawn from t h i s study need to be interpreted cautiously, for example, i n l i g h t of the f i e l d methodology, reliance on self-report data and the duration of the i n v e s t i g a t i o n period. Data from t h i s study tends to concur with Green and Cargo's (1995) suggestions that worksite health promotion programs that integrate behaviour change models drawn from a variety of f i e l d s and are t a i l o r e d to the needs and circumstances of those attending the program can be e f f e c t i v e i n increasing health behaviours. This study investigated exercise adherence. Second, multiple factors influenced whether and how learning 261 was applied therefore i n d i v i d u a l (e.g., c r i t i c a l thinking, goal setting, time management, imagery), s o c i a l (e.g., networking, negotiation, advocacy) and other contextual ( c r i t i c a l r e f l e c t i o n , community empowerment) strategies were required to enhance post-educational application of exercise behaviour change. Learning was thus variously adapted and applied i n intended and unintended ways to s u i t s p e c i f i c needs and circumstances. Changes to healt h f u l behaviours were more l i k e l y to occur from incremental, rather than r a d i c a l changes required by individuals and s i g n i f i c a n t others who interacted i n context. E s s e n t i a l l y , post-educational application was an in d i v i d u a l and s o c i a l contextual process. That i s , i n d i v i d u a l motivation connected to and in t e r a c t i n g with contextual factors. For example, c r i t i c a l r e f l e c t i o n and lobbying for change i n the s o c i a l context can enhance exercise behaviour change. Furthermore, high i n d i v i d u a l motivation may be s u f f i c i e n t to overcome moderate contextual b a r r i e r s , and high contextual b a r r i e r s could dampen i f not extinguish moderate motivation. The findings of t h i s study have implications for workplace p o l i c y and program development, workplace health education i n s t r u c t i o n , post-educational application and future research i n the area of post-educational application of exercise behaviour change. These findings, however, need to be interpreted with caution i n l i g h t of the f i e l d research methodology, reliance on se l f - r e p o r t data, involvement of the researcher/Instructor throughout the implementation 262 process and the duration and seasonal time period of the study. Implications f o r workplace p o l i c y and program development Workplace p o l i c y Management, l o c a l supervisor and administrative support, as well as, responsive programming are c r i t i c a l to employee p a r t i c i p a t i o n i n workplace health promotion programs (Anspaugh, Hunter & Savage, 1996; Emmons, Linnan & Abrams, 1996; Glasgow, McCaul & Fisher, 1993; Green & Cargo, 1994). In t h i s study, substantial management support was achieved through a series of meetings and negotiations with management personnel, p r i o r to the program, and continual communications and updating during the implementation process. Management demonstrated t h e i r support by allowing the program to take place on-site and i n work-time. Appropriate venues were provided together with f l e x i b l e s h i f t s for a l l employees within workplace sections to attend the program. Furthermore, program parti c i p a n t s included key management personnel. Program development Worksite health promotion programs f a c i l i t a t e health behaviour change i f they are developed i n accordance with best p r i n c i p l e s and practices offered by the l i t e r a t u r e pertaining to behaviour change and program implementation. Exercise behaviour change requires consideration for p h y s i o l o g i c a l , psychological and socio^environmental 263 intervention strategies (Dishman, 1994). This was operationalised i n t h i s study by integrating macro and micro behaviour change models and using t h e o r e t i c a l concepts and intervention strategies from adult education and exercise psychology respectively (See Table 16). Furthermore, t h i s study supported the concept of active l i v i n g , a contemporary approach to the promotion of physical a c t i v i t y . Active l i v i n g i s a way of l i f e i n which physical a c t i v i t y i s valued and integrated into d a i l y l i v i n g routines and l e i s u r e pursuits (Denny, 1996). In workplace health promotion, for example, t h i s can include minimising the use of transportation (e.g., by using a b i c y c l e or walking before, during and/or aft e r work), parking vehicles at a distance from the workplace station, using a s t a i r w e l l instead of an elevator and engaging i n "active breaks" i n the workplace environment. Active l i v i n g can also include various types and forms of l e i s u r e and recreation a c t i v i t i e s to s u i t i n d i v i d u a l preferences and s i t u a t i o n s . The concept of active l i v i n g thus places less emphasis on exercise i n t e n s i t y , i n d i v i d u a l t e s t i n g and physiological benefits of exercise than on habitual d a i l y physical a c t i v i t y as a p o s i t i v e experience for h o l i s t i c health benefits. Active l i v i n g i s thus promoted as an i n d i v i d u a l , s o c i a l and i n c l u s i v e process. Graham (1996) proposed f i v e key ingredients for promoting active l i v i n g i n a [workplace] community: people, p o l i c i e s , programs, partners and 264 promotion. These factors are embedded within the diagnostic framework of the Precede planning model used i n t h i s study. Embracing the l i t e r a t u r e pertaining to worksite health promotion, program planning, adult teaching, and program evaluation enhances program implementation. Green and Kreuter's (1991) Precede-Proceed model i s an educational and environmental approach to health promotion planning and evaluation. Over 500 applications of t h i s model have been reported i n the l i t e r a t u r e and i t provides a f l e x i b l e and r e a l i s t i c framework for worksite health promotion programs. Central to Precede-Proceed i s the p r i n c i p l e of p a r t i c i p a t i o n . Green and Kreuter (1991) noted that people are more committed to i n i t i a t i n g and upholding those changes that they helped design or adapt to t h e i r own purposes and circumstances. Throughout the implementation of t h i s study, worksite personnel were a c t i v e l y involved i n the planning, learning and evaluation phases of the program. Volunteers within the program shared r e s p o n s i b i l i t y with the course in s t r u c t o r for photocopying learning materials and passing on communications with respect to venue changes. Following the program, elected participants volunteered to co-ordinate a workplace wellness network and b u l l e t i n board to promote s o c i a l events, display health issues and act as an advocacy role for workplace health promotion. E s s e n t i a l l y , the essence of program development for health behaviour change should not be viewed as an exportable box but rather as a process of planning for and 265 i n t e g r a t i n g macro and micro b e h a v i o u r change s t r a t e g i e s t h a t are t a i l o r e d to the needs and c i r c u m s t a n c e s o f those a t t e n d i n g programs . Program development i s thus c o n s i d e r e d as an i n d i v i d u a l and s o c i a l c o n t e x t u a l p r o c e s s . Implications f o r instructors of worksite health education programs The f i n d i n g s o f t h i s s tudy sugges ted t h a t a l e a r n e r -c e n t r e d approach f o c u s i n g on c r i t i c a l s e l f - d i r e c t e d l e a r n i n g f o r e x e r c i s e b e h a v i o u r change, where b o t h t e a c h e r and l e a r n e r s are a p p r o p r i a t e l y engaged, enhances p o s t -e d u c a t i o n a l a p p l i c a t i o n o f a w o r k s i t e h e a l t h promot ion program. C r e a t i n g a w o r k s i t e community o f c r i t i c a l t h i n k e r s and s e l f - d i r e c t e d l e a r n e r s f o r h e a l t h f u l b e h a v i o u r s r e q u i r e s i n s t r u c t o r s o f h e a l t h e d u c a t i o n programs t o a p p l y a range o f s t r a t e g i e s . F i g u r e 7 i l l u s t r a t e s a b r o a d i n s t r u c t i o n a l framework f o r f a c i l i t a t i n g c r i t i c a l s e l f - d i r e c t e d l e a r n i n g f o r h e a l t h b e h a v i o u r change. E s s e n t i a l l y , w o r k s i t e h e a l t h e d u c a t i o n programs o c c u r i n a c l a s s r o o m c o n t e x t , thus v a r i o u s c l a s s r o o m c o n t e x t u a l , as w e l l as c u r r i c u l u m and i n s t r u c t i o n a l s t r a t e g i e s can be employed by i n s t r u c t o r s t o f a c i l i t a t e c r i t i c a l s e l f - d i r e c t e d l e a r n i n g f o r h e a l t h b e h a v i o u r change . The f o l l o w i n g g u i d e l i n e s are i n t e n d e d t o a s s i s t i n s t r u c t o r s w i t h t h i s p r o c e s s : 266 CLASSROOM CONTEXT Figure 7. In s t r u c t i o n a l Framework f o r F a c i l i t a t i n g C r i t i c a l Self-Directed Learning f o r Health Behaviour Change Classroom contextual strategies ( 1 ) P r i o r to the course, conduct a comprehensive "needs assessment". This provides r i c h information regarding authentic health issues that occur i n the context of 267 the workplace setting and l o c a l community. It also reveals p a r t i c i p a n t s ' interests and motives for learning. Moreover, i t provides a valuable insight into the d i v e r s i t y of learners knowledge, attitudes, s k i l l s , behaviour and health status. An i n s u f f i c i e n t needs assessment, as happened i n t h i s study, resulted i n erroneous assumptions about the homogeneity of learners with respect to the stages of exercise behaviour change. This lead some learners to f e e l that the course was not completely targeted to t h e i r s i t u a t i o n . A comprehensive needs assessment, therefore, should be i n t e g r a l to planning course processes to ensure that programs are t a i l o r e d to the needs and circumstances of those attending the program (Green & Kreuter, 1991). Creating an optimal learning environment i s central to f a c i l i t a t i n g a classroom community of c r i t i c a l thinkers and s e l f - d i r e c t e d learners (Brookfield, 1995; Noddings, 1988). In t h i s study, the physical learning environment ( i . e . , walls, furniture) was arranged to f a c i l i t a t e group work and on-going examples of learners' work, as well as, appropriate materials were displayed on walls. The agenda for each session was posted on a board together with provocative t o p i c - s p e c i f i c questions(see Appendix F) related to the previous session, current session and personal experience. An informal s o c i a l environment allowed multiple opportunities for both in s t r u c t o r and learners to share experiences, i n t e r a c t 268 and be a c t i v e l y involved i n the learning process. Each session required learners to work in groups to problem-solve and to generate questions about application of learning. To enhance the s o c i a l learning climate, a s e l e c t i o n of f r u i t was organised and shared among program participants during the learning process. (3) Encourage a c r i t i c a l r e f l e c t i o n of the broad s o c i a l context and p o t e n t i a l solutions for enhancing health behaviour change i n the l o c a l community and workplace s e t t i n g (Garrison, 1992; Wallerstein & Bernstein, 1988). For example, as happened i n t h i s study, opportunities were provided to discuss the following: i n d i v i d u a l and s o c i a l contextual factors that influence exercise behaviour, media practices pertaining to exercise p a r t i c i p a t i o n (e.g., stereotyping, hegemony, consumerism, techno-dependency, individualism), access issues to l o c a l f a c i l i t i e s , and workplace practices and opportunities for active l i v i n g . Furthermore, encouragement and support were given to help mobilise a workplace wellness committee/network and associated a c t i v i t i e s . Curriculum and i n s t r u c t i o n a l strategies (1) Apply p r i n c i p l e s of learning and employ a v a r i e t y of teaching styles and teaching methods throughout the teaching/learning process (Knox, 1986). Participants i n t h i s study perceived active involvement to be very b e n e f i c i a l to a p p l i c a t i o n . In p a r t i c u l a r , problem-269 solving i n s o c i a l groupings allowed individuals to share experiences and adapt strategies for exercise behaviour change. According to Johnson and Johnson (1988), heterogeneous mixed a b i l i t y groupings are most e f f e c t i v e for f a c i l i t a t i n g c r i t i c a l thinking i n problem-solving s i t u a t i o n s . (2) Instructors can help predispose, enable and reinforce p a r t i c i p a n t s i n t h e i r e f f o r t s to think c r i t i c a l l y and to s e l f - d i r e c t health behaviour change. In t h i s study, for example, parti c i p a n t s were predisposed by a l l o c a t i n g appropriate class time to discuss: what i t means to think c r i t i c a l l y and to engage i n s e l f -directed learning, a conceptual framework for exercise motivation, concepts and p r i n c i p l e s of health and f i t n e s s , and developing s e l f - e f f i c a c y . Data indicated that for many learners the broad motivational framework with which to negotiate the complex world of application was what they had gained most from the course. Participants were enabled through multiple opportunities to apply motivational strategies i n authentic problem-solving situations that were developed from experiences within the group. Interactive methods such as informal worksite/community surveys, case studies, personal program development/analysis, discussion, video analysis, role play, b a r r i e r s i d e n t i f i c a t i o n and strategy development were p a r t i c u l a r useful to examine application issues. 270 Ottoson (1995) asserted that, "application needs to be a process not an assumption; i t needs to be made more sa l i e n t , not subsumed; i t needs to be at the forefront of adult education programs, not an afterthought" (p.27). In addition to those strategies c i t e d above pa r t i c i p a n t s were further reinforced to think c r i t i c a l l y and to apply s e l f - d i r e c t e d learning strategies toward the development of a workplace wellness network. Furthermore, frequent opportunities enabled individuals and small groups to engage i n s e l f -evaluations and instructor/course evaluations. E s s e n t i a l l y , teaching and learning i n worksite health education programs should be an i n d i v i d u a l and s o c i a l contextual process. (3) F i n a l l y , develop a c r i t i c a l l y r e f l e c t i v e p r actice throughout the teaching/learning process i n order to balance content and the long-term goals of the program while also meeting the needs of learners (Brookfield, 1995). Throughout t h i s study, to r e t a i n program support, s e n s i t i v i t y was directed to the s o c i a l context i n which the program operated. For example, ca r e f u l consideration was given to continual l i a i s o n with management i n order to meet t h e i r expectations for program implementation. Equally, minor program adaptations were required to empathise with the everyday occupational demands facing program p a r t i c i p a n t s . Evaluation feedback provided a stimulus 271 to acknowledge with participants aspects of the course that were most useful and those aspects, where possible, that could be improved. Implications f o r post-educational a p p l i c a t i o n of exercise behaviour change Post-educational application occurs i n contextually bound and r e l a t i v e l y unpredictable patterns of human int e r a c t i o n (Ottoson, i n press). Data indicated that predisposing, enabling and r e i n f o r c i n g factors influence t h i s process, therefore, a v a r i e t y of i n d i v i d u a l and s o c i a l contextual strategies are required to enhance exercise behaviour change. Figure 8 i l l u s t r a t e s a broad conceptual framework for enhancing post-educational a p p l i c a t i o n . Table 16 provides examples, within t h i s framework,