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An evaluation of health promotion workshops for nurses Edwards, Joy 1977

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AN EVALUATION OF HEALTH PROMOTION WORKSHOPS FOR NURSES B.N.Sc., Queen's University, 1969 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING THE FACULTY OF GRADUATE STUDIES School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1977 by JOY EDWARDS in Joy Edwards, 1977 In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t 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 representative. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada V6T 1W5 i i ABSTRACT AN EVALUATION OF HEALTH PROMOTION WORKSHOPS FOR NURSES The purpose of this research project was to investigate the effectiveness of the two-hour and the one-day Health Promotion Workshops offered to nurses in British Columbia as part of a four month pilot pro-ject. The Registered Nurses' Association of British Columbia (RNABC) employed a nurse as special project director to develop and present Health Promotion Workshops to nurses. The goals of the workshop were: 1. To sensitize nurses to their own needs to optimize their own health. 2. To sensitize nurses to their role of sensitizing other to their need to optimize their own health. 3. To motivate nurses to make changes in their personal health behaviours. 4. To motivate nurses to make changes in their role as health promoters. The workshops were offered to a l l RNABC chapters throughout the province. Seventeen chapters chose the two-hour workshop and 5 chose the one-day workshop. Eight of the two-hour and three of the one-day workshop groups were used for the evaluation. The workshops were eva-luated by observation, discussion with some participants, and with res-ponses obtained through questionnaires. The questionnaires were designed to obtain information regarding knowledge, awareness, perceptions of the workshop, and behaviours of the nurses related to physical activity. Control groups were chosen by randomly selecting from the RNABC chapters, nurses who had not attended the workshop. Using analysis of variance, the control groups were found to be equivalent to the workshop groups prior to each session when comparing the questionnaire responses. Multivariate analysis of variance was done to determine differences between the workshop groups and their appropriate control groups six weeks i i i following the workshops. The results Indicated that: 1. There was a significant increase in reported exercise behaviours for both.the two-hour and one-hour workshop groups. 2. There were no significant differences in reported habits relating to physical activity. 3. There were no significant differences in reported be-haviours as a health promoter. Analysis of variance was done to determine significant differences among means for the knowledge test scores of each group. The results indicated that both workshop groups had a significantly higher mean score when compared to their control groups. Seventy-five percent of the participants reported that they identi-fied changes they would like to make in their own fitness and forty^rfive percent indicated they were able to accomplish changes in this area. Seventy percent indicated they had an increased awareness of their role as health promoters in their work. It was concluded that the Health Promotion Workshops were effective in 1) sensitizing nurses to their own needs to optimize their own health, 2) motivating nurses to make changes in their health behaviours, and 3) sensitizing nurses to their role as health promoters. i v TABLE OF CONTENTS CHAPTER PAGE I INTRODUCTION TO THE STUDY 1 Introduction 1 Statement of the Problem 1 2 Statement of Purpose 3 Approach 3 Definition of Terms 4 Assumptions 4 Hypotheses 4 Description of the Following Chapters . . . 5 II REVIEW OF SELECTED RELATED LITERATURE 6 Selected Literature Related to Health . . . 6 Selected Literature Related to Behaviours Affecting Health 7 Selected Literature Related to Modification of Human Behaviours 10 Summary 17 III RESEARCH METHODOLOGY 18 Overview 18 Development of the Workshop Content . 18 Overview of the Evaluation Strategy 22 Development of the Questionnaires 23 Selection of the Sample 25 Evaluation Plan and Procedures 27 Summary 31 IV FINDINGS AND DISCUSSION 32 Description of the Sample . 32 Discussion of the Goals of the Project and Observations of the Investigator 40 Follow-up Workshop Evaluation . . . . 43 Analysis of Data From Questionnaires In Relation to Each Hypothesis . 44 Summary 52 V SUMMARY, LIMITATIONS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 53 Summary 53 Limitations 54 Conclusions 54 Implications 56 Recommendations 56 V SELECTED BIBLIOGRAPHY 58 APPENDIX Al PRESENT ACTIVITY QUESTIONNAIRE ...... 62 A 2 KNOWLEDGE QUESTIONNAIRE 66 A3 GENERAL INFORMATION QUESTIONNAIRE FOR THE WORKSHOP GROUPS 68 A 4 GENERAL INFORMATION QUESTIONNAIRE FOR THE CONTROL GROUPS 69 A5 POST WORKSHOP EVALUATION QUESTIONNAIRE 70 A 6 FOLLOW-UP WORKSHOP EVALUATION QUESTIONNAIRE 72 A 7 COVERING AND FOLLOW-UP LETTERS FOR THE WORKSHOP GROUPS . 74 A 8 COVERING AND FOLLOW-UP LETTERS FOR THE CONTROL GROUPS . . 76 B INTRODUCTORY SELF-LEARNING PACKAGE 78 Ci OUTLINE OF THE TWO-HOUR WORKSHOP 130 C 2 OUTLINE OF THE ONE-DAY WORKSHOP 131 D OBSERVATION CHECKLIST 132 Ei NON-RESPONSE BIAS CHECK FOR THE TWO-HOUR WORKSHOP GROUPS 133 -E 2 NGN-RESPONSE BIAS CHECK FOR THE ONE-DAY WORKSHOP GROUPS 138 E 3 THE RESULTS OF ANALYSIS OF VARIANCE PERFORMED TO DETERMINE GROUP EQUIVALENCE PRIOR TO THE WORKSHOPS . 143 E4 PERCENTAGE RESPONSES FOR THE FOLLOW-UP WORKSHOP EVALUATION QUESTIONNAIRE . . . . 148 E5 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 2 151 E 6 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 3 152 E 7 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 5 155 VITA 157 v i LIST:; OF TABLES TABLE PAGE 1 Workshops Given During the Health Promotion Project 20 2 Outline of the Difference in Presentation Between The Two-Hour and the One-Day Workshops 21 3 Data Collection Schedule 23 4 Mailed Questionnaire: Frequencies and Response. Rates For Each Group 33 5 Comparison of the Mean Age for Each Group 33 6 Comparison of Fu l l Time Employment for Each Group . . 34 7 Comparison of Education for Each Group 35 8 , Group Distribution for Place of Employment 36 9 Group Distribution for Major Work Responsibility 36 10 Percentage Responses for Each Group Indicating What Has Influenced Their Interest in Health Promotion 37 11 Percentage of Responses for Each Group Indicating What Has Influenced their Desires to be Active in Regular Physical Exercise. . . .. 38 12 Percentage of Responses for Each Group Indicating How Many People Use The Following Techniques to Encourage Them to Exercise •.. ....... 39 - 13 Percentage Responses for Each Group Indicating Their Primary Reasons for Attending the Workshops . . . . . . . . . 40 14 Sample Size Used to Test Each Hypothesis 45 115 Hypothesis 1: Results of Multivariate and Univariate Analysis of Variance 47 16 Summary Statistics for Each Variable Related to Hypothesis 1 . 48 17 Hypothesis 2: Results of Multivariate and Univariate Analysis of Variance 50 18 Comparison of Mean Scores on the Knowledge Test for the Experimental and Control Groups 51 19 Non-Response Bias Check for the Two-Hour Workshop Groups . . . 133 v i i 20 Non-Response Bias Check for the One-Day Workshop Groups . . . . 138 21 The Results of Analysis of Variance 'Performed to Determine Group Equivalence Prior to the Workshops 143 22 Percentage Responses for the Follow-Up Workshop Evaluation . . 148 23 Summary Statistics for Items Pertaining to Hypothesis 2 . . . 151 24 Summary Statistics for Items Pertaining to Hypothesis 3 . . . 152 25 Summary Statistics for Items Pertaining to Hypothesis 5 -... . 155 v i i i LIST,' OF FIGURES FIGURE PAGE 1 Model for Evaluation 22 2 Workshop Locations 26 3 Non-Response Bias Check for the Two-Hour Workshop 29 4 Non-Response Bias Check for the One-Day Workshop . 29 5 To Determine Whether the Groups Were Equivalent Prior to the Workshop . 30 6 Data Analysis Following the Workshops 30 ix ACKNOWLEDGMENTS I was fortunate to have the support, encouragement, and assistance of many people while conducting this evaluation. I would especially like to thank the following people: Dr. Julia Quiring, chairman of my Thesis Committee, gave me the encour ment I required to begin and follow through with this study. I am thankful for her capable guidance, constructive criticism, support and friendship. Other members of my Thesis Committee were Professor Helen Elfert and Dr. Todd Rogers. Professor Elfert has shown sincere interest and has contributed sound advice and practical suggestions. Dr. Rogers provided invaluable assistance with research design and analysis of data. He has inspired in me an interest in sta t i s t i c s , and faith in my own beginning a b i l i t i e s in research. Miss E l l i e Robson, the Director of the Health Promotion Workshops, shared her love of health and i t s promotion. Without her encouragement and willingness for an evaluation of the workshops, this study would not have been possible. I am grateful to the RNABC and to Miss Ann Taylor, Assistant Executive Director of the RNABC for allowing me to have a part in this pilot project on Health Promotion. Miss Taylor was helpful in asking pertinent questions and in providing assistance with some of the practical concerns regarding the questionnaires. Miss Claudia Farman has helped in numerous ways throughout the study, giving encouragement and support as well as typing the thesis. My thanks to a l l the nurses who completed questionnaires and made i t possible to carry out this study. X I would like to thank my family for their constant support. My thanks to my friends and classmates whose encouragement contributed significantly to the completion of this study. v. CHAPTER I INTRODUCTION TO THE STUDY Introduction In past ages men have often regarded problems which befell them such as storms, f i r e , illness, and defeat in battle as caused by their own sins and poor living. Men began to look for outward causes of these events and were rewarded by finding many cause agents. This further led to the discov-ery of many cures and preventive measures. The disease model has gained wide acceptance. Indeed, the conquest of disease has so absorbed our inter-est that we have built our health care system on the premise that the elimination and treatment of disease w i l l lead to a healthier nation. The costs of our health care system have escalated rapidly making i t necessary to examine the traditional view of health care. Good health is an important factor for the individual, for society, and for progress. Health has often been defined as the absence of disease, but i t must be seen that some diseases have many causes and a variety of precipitating agents, including man's behaviour. In the Canadian Government Working Document, "A New Perspective on the Health of Canadians", Marc Lalonde examines some of these issues. He emphasizes the need for each individual to take more responsibility for his own health care. He states: self-imposed risks and the environment are the principal or important underlying factors in each of the five major causes of death between age one and age seventy. (Lalonde, 1974, p. 15). He further points out that the health services in Canada are admirable in comparison with many other countries, but there is l i t t l e doubt that further improvements in the health of Canadians l i e in improving the environment, adding knowledge in the f i e l d of human biology, and in moder-ating self-imposed risks. The report also states that: The Government of Canada now intends to give to human biology, the environment, and l i f e styles as much attention as i t has to the financing of the health care organization so that a l l four avenues to improve health are pursued with equal vigour. Its goal w i l l continue to be not only to add years to our l i f e but l i f e to our years, so that a l l can enjoy the opportunities offered by increased economic and social justice, (Lalonde, 1974, p. 6). Statement of the Problem Central to the concept of Health Promotion is the understanding that personal health behaviours and l i f e styles must change i f people are to progress to a higher level of health. The government has recognized the necessity of raising the public's consciousness that poor l i f e style can b a health hazard. Nurses could be a valuable resource in this area. This supported by Lalonde's suggestion that one strategy for improving the over a l l health of Canadians i s : The continued extension of the role of nurses and nurse practitioners . . . in family counselling on preventive health measures, both mental and physical, and in the abatement of environmental hazards and self-imposed risks,-, (Lalonde, 1974, p. 71). In response to these needs, the Registered Nurses Association of British Columbia (RNABC) recognized the necessity of examining the nurses' role as a health promoter. A committee on Health Assessment and Promotion was formed. They have developed a position paper in which they state: 1. Nurses must accept responsibility for optimizing their own health. 2. Nurses must accept their role and responsibility to sensitize others to the need to optimize their own health (RNABC Position Paper, 1976, p. 1). 3 The committee on Health Assessment and Promotion f e l t that nurses required stimulation and assistance in accepting these responsibilities. The RNABC employed a nurse to conduct a four month pilot project which would consist of the development of an educational program for nurses to sensitize them to their personal and professional needs in the area of health promotion. This study was designed to investigate whether the workshops met these goals. Statement of Purpose The purpose of the study was to investigate the effectiveness of the two-hour and the one-day workshops on Health Promotion offered to nurses in British Columbia as part of a four month pilot project. Approach The nurse employed to be the special project director for the pilot project in Health Promotion prepared an Introductory Self-Learning Program in Health Promotion for the Registered Nurse. This was developed in consult-ation with professionals ^in areas of nutrition, physical education, and exercise physiology. The project took the form of workshops which were offered to the chapters of the RNABC in a l l areas of the province. The writer examined the effects of the workshops on the knowledge, awareness, and behaviours of the nurses who attended. The workshop participants were asked to complete a questionnaire immed-iately prior to the workshop and to complete and return a questionnaire which was sent to them six weeks following the workshop. A control group was also chosen and requested to complete and return a mailed questionnaire. The questionnaire asked for information concerning demographic variables, present activity pattern, and knowledge. Statistical procedures were done to determine differences between treatment and control groups with respect to the above data. 4 Definition of Terms Habits Relating to Physical Activity: Deals with habits of daily l i f e and w i l l be self reported in response to questions 15, 16, and 17 of the Present Activity Questionnaire. (Appendix A). Regular Exercise: Exercise or physical activity which is done on a regular basis. The amount of exercise w i l l be self reported in response to questions 1, 3, 4, and 5 of the Present Activity Questionnaire. (Appendix A). Role of Health Promoter: A measure of the nurse's involvement in talking with individuals regarding fitness, nutrition, and risk factors. This w i l l be self reported in response to questions 18 and 19 of the Present Activity Questionnaire. (Appendix A). Knowledge of Physical Fitness and Health Promotion: Knowledge in relation to the content of the workshop as measured by the score on the Knowledge Questionnaire. (Appendix A). Assumptions 1. Personal health behaviours are under the control of each individual. 2. Change in health behaviour can occur. 3. Knowledge alone is not sufficient to promote change. Hypotheses The following null hypotheses were tested: 1. There w i l l be no significant difference in reported regular exercise behaviours six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups b) with each other. 2. There w i l l be no significant differences in reported habits relating to physical activity six weeks following the workshop when comparing the workshop groups a) with itheir appropriate control groups, b) with each other. 5 3. There w i l l be no significant differences in reported behaviour as a health promoter six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups, b) with each other. 4. There w i l l be no significant differences in test scores of know-ledge of physical fitness and health promotion six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups, b) with each other. 5. There w i l l be no difference in nurses' evaluation of the workshop immediately following the workshop when comparing the two workshop groups. Description of the Following Chapters This thesis i s organized into five chapters and an appendix. The review of selected literature appears in Chapter II under three major headings. The headings are selected literature (1) related to the definition of health, (2) related to behaviours affecting health, and (3) related to modification of human behaviour. Chapter III contains the research methodology and discussion of the development of the workshop content, questionnaires, and the evaluation plan and procedures. The results of the workshop evaluation appear in Chapter IV. Chapter V includes a summary of the previous chapters and conclusions based on the research findings. Forms, questionnaires, and the content of the workshop appear in the Appendix. 6 CHAPTER II REVIEW OF SELECTED RELATED LITERATURE The review of selected literature w i l l be considered under three major headings: A. Selected literature related to the definition of health. Health is a complex phenomenon consisting of many interrelated parts. The d i f f i c u l t i e s of defining and measuring health as a whole are discussed in this section. B. Selected literature related to behaviours affecting health. The problems associated with defining and measuring health have led health professionals to consider factors and behaviours which affect health. This section discusses some of these factors and specifically refers to studies which deal with the effects of physical fitness on the body. G. Selected literature related to modification of human behaviour. Knowledge of the relationship between behaviour and health is not often sufficient to motivate individuals to change their attitudes and behaviours. Some of the factors relevant to the promotion of physical activity and positive health behaviours are considered here. Selected Literature Related to the Definition of Health Many attempts have been made to define health and most definitions have considered health in reference to physical well-being. Traditionally health has been defined by the presence or absence of disease (Siegel, 1973). There have however, been attempts to define health in relation, not only to physical, but also to mental and social well-being. The World Health Organization's definition of health is an example of this: Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (Dunn, 1961). 7 This definition was included in the preamble to the constitution of the World Health Organization in 1946 and has been widely accepted. Dunn (1961) emphasizes the importance of the spiritual dimension of man as another factor contributing to health. He feels that man cannot achieve high-level wellness unless there is a reason for living, a purpose in l i f e . The definitions of health to date contain aspects of health but they are not complete and do present problems in the measurement of health. Siegel (1973) writes that health is d i f f i c u l t to understand because i t is a value judgement, a subjective state, and an abstraction which is d i f f i c u l t to measure objectively. He feels health is culturally determined and that there is a spectrum or continuum from illness, to health, to optimal health. The problems of defining or measuring health are complex. Attempts to develop an instrument to measure health have encountered d i f f i c u l t i e s . Balinsky and Berger (1975), in their review of research on general health status indices based on (1) Mortality, (2) Morbidity, (3) Unified Mortality/ Morbidity, discuss some of. these d i f f i c u l t i e s . Many health professionals have directed their attentions to factors which appear to contribute to health status. Selected Literature Related to Behaviours Affecting Health Our Health Care System based on the disease model, has primarily focused on acute care, diagnosis, and treatment. The high cost of this type of health system has forced governments to examine the Health Care System. Leon White (1975) states that in the United States four and one half times as much money was spent on health care in 1975 as in 1960 with very l i t t l e impact on health status. He feels: 8 It is time we confronted the true health problem of our times - the way we live - and started doing something about it, (White, 1975, p. 774). Meade (1975) discusses the high cost of health care in England and the necessity of increasing the preventative program. He expresses a fear that the government won't really change their emphasis and put more money into environment, l i f e styles, and human biology. The Government of Canada has also examined the Health Care System. The working document, "A New Perspective on the Health of Canadians" (Lalonde, 1974 (b)) advocates a Health Field Concept which involves: 1. Human Biology: This relates to the biological make-up of man. 2. Environment and i t s influence on health: This is external to the body and the individual has l i t t l e or no control. 3. Lifestyle: This involves the individual decisions which affect health. 4. Health Care Organization: This is the organization of the health care services. (Lalonde, 1974 (b), p. 31-32). Tones (1975) atates that the major health problems are largely behavioural in nature, and therefore, in principle, preventable. A recent report of the Joint Working Party of the Royal College of Physicians of London and -.the British Medical Journal, (1976) states that there is considerable evidence that the causes of Coronary Heart Disease are largely environmental and are rooted in the modern affluent way of l i f e . Many people continue to impose on themselves high risks to health. Marc Lalonde (1974 (a)) states that there is a need to look closely at health promotional activities to develop ways of increasing public aware-ness of the need for healthy l i f e styles. Lalonde (1974 (b)) l i s t s some self-imposed risks and the possible results of taking those risks. 1. Drugs a. alcohol addiction: leading to cirrhosis of the live r , encephalopathy and malnutrition. 9 b. social excess of alcohol: leading to motor vehicle accidents and obesity. c. cigarette smoking: causing chronic bronchitis, emphysema and cancer of the lung, and aggravating coronary-artery disease. d. abuse of pharmaceuticals: leading to drug dependence and drug reactions. e. addiction to psychotropic drugs: leading to suicide, homicide, malnutrition and accidents. f. social use of psychotropic drugs: leading to social withdrawal and acute anxiety attacks. 2. Diet and Exercise a. over-eating: leading to obesity and i t s consequences. b. high-fat intake: possibly contributing to atherosclerosis and coronary artery disease. c. high carbohydrate intake: contributing to dental caries. d. fad diets: leading to malnutrition. e. lack of exercise: aggravating coronary-artery disease, leading to obesity, and causing lack of physical fitness. f. malnutrition: leading to numerous health problems. g. lack of recreation and lack of r e l i e f from work and other pressures: associated with stress diseases such as hypertension, coronary-artery disease and peptic ulcers. 3. Others a. careless driving and failure to wear seat-belts: leading to accidents and resultant deaths and injuries. b. promiscuity and carelessness: leading to syphilis and gonorrhea. (Lalonde, 1974 (b), pp. 16-17). The concept- that l i f e style could affect a person's health is not new. J. Nash (1938) stated that physicians were primarily concerned with diagnosis and treatment. He f e l t that they should also be concerned with what could be done to make healthy people healthier. He stated: The backbone of health is a way of living and this is an educational concern of the home, the school, and the community, and each member of the community. . . you can add years to l i f e but what is i n f i n i t e l y more important, we can add l i f e to the years.- (Nash, 1938, p. 240). Today, many physicians, nurses, politicians, educators, and other professionals are concerning themselves with these issues. Individuals and communities need to become aware of the factors which influence their health. 10 They may also require motivation towards desired changes in behaviour. It is d i f f i c u l t to change poor health habits as there is often no noticeable effect for decades (Pomerleau, 1975). Many may not be willing to sacrifice present pleasures for future health. Increased physical activity has frequently been recommended as a means to better health. Physical fitness influences many areas of l i f e . Heinzelman (1970) found that men involved in a regular physical activity program reported increased work performance, more positive reactions to work, a feeling of better health, increased stamina, weight reduction, and a greater a b i l i t y to cope with stress and tension. Franklin (1976) found that a twelve-week physical conditioning program for lean and over-weight middle-aged women had the effect of lowering pulse rates, increasing the heart stroke volume, and a moderate loss in weight. Smith (1975) studied a group of women in their early twenties and the effects of a nine-week jogging program. He found that the percent of body fat decreased significantly while the lean body mass increased slightly. He also found a significant drop in heart rate following the program. These three studies indicate the positive effects of regular physical activity and provide support to the focus of the workshop on physical fitness. Selected Literature Related to Modification of Human Behaviours Knowledge of the relationship between behaviour and health is not often sufficient to motivate individuals to change their attitudes and behaviours. Pomerleau (1975) advocates the necessity of applying some of the principles o.f behavioural science to the promotion of health. He asserts that: The successful application of behavioural principles to problems in preventive medicine may prove to be as important a contribution to medical practice as the devel-opment of effective antibacterial agents was in the f i r s t half of the century (Pomerleau, 1975, p. 1277).' Factors Relevant to the Promotion of Physical Activity Health Education has been defined (Tones, 1974) as the application of behavioural science to health problems with a view to modifying behaviour and preventing s e l f - i n f l i c t e d diseases. Many factors have been found to have an influence on attitude and behaviour change. Some of the factors relevant to the promotion of physical activity are as follows. Approach. The face-to face presentation was found as more effective than the mass presentation l (Leventhal, 1973; Berkanovic, 1976). Fear. Leventhal (1973) found that a strong fear inducing message led to strong beliefs in the seriousness and personal susceptibility to the disease and strong intentions to act. They also found that fear was not necessarily the motivating factor but the knowledge about the fear was the important fact. Indeed, they showed that a strong threat may in fact inhibit response and changed behaviour. A change in attitude was not seen to necessarily produce a change in behaviour. A meaningful plan for action to link attitude and behaviour was found to be important by Leventhal (1973) and Berkanovic (1976). Social Influence. Social structural influences, as they are mediated by social networks, affect both health beliefs and health behaviour. Social influence can be used to increase the possibility of behavioural change by forming new groups which individuals can identify with and receive support from. Physical activity done as a regular group activity can provide needed encouragement and support. The support of significant others is also seen to be important (Berkanovic, 1976; McAlister, 1976). 12 Setting Goals. The setting of personal goals and a schedule have been found important in following through with an exercise program. A system of self-recording of activity and perhaps occasional monitoring by others is seen to be helpful in attaining the desired goals (Berkanovic, 1976; McAlister, 1976). Guided Practice. Guided practice is seen to be important and can be composed of specific demonstrations and immediate guided practice in the recommended ac t i v i t i e s . This allows for specific teaching, assessment and encouragment of the individual's involvement in the activity (McAlister, 1976). Self-Cueing. The individual may need to be reminded to participate in the exercise and self-cueing techniques may be helpful. These could consist of notes or displaying running shoes in a prominent place in order to remind the individual of his/her intentions to act. This system may help to speed the rate at which the conditioning exercises could become part of the person's regular routine (McAlister, 1976). Contract System. It may be helpful to have a contract system to aid in the maintenance of the exercise program. "E ach exercise session "can be set to precede a desirable activity identified as a reward" (McAlister, 1976, p. 54). One study shows that a system of mild self-administered penalties may be useful for some individuals (McAlister, 1976). Integration of Exercise and Ac t i v i t i e s . The integration of physical exercise with routine activities is advantageous when possible. For example, the person should be encouraged to avoid unnecessary use of car or elevators. Examination of daily events could possibly reveal ways in which more physically demanding activities could replace sedentary habits (McAlister, 1976) . 13 Time. Learning i s an important factor in promoting change in behaviour. Carroll's (1963) model for school learning states five factors which influence learning. Three of these are expressed in terms of time. The time allowed for learning, the time the learner is willing to give, and the time required for learning interact in the degree of learning which w i l l take place. Factors Relevant to the Promotion of Positive Health Behaviours. Assessment. Individuals may need assistance to identify areas in his own l i f e which may affect his health. The Health Hazard Appraisal (HHA) has been developed as a tool to assess an individual's risk behaviours in relation to his health. It is hoped that i t w i l l provide information and motivation to assist people towards changes in behaviour. It is based on mortality data and risk factors in the individual's behaviour. The Health Hazard Appraisal uses information about the person's age, sex, medical history, health risks, and l i f e style to predict his/her chances of dying in the next ten years. This was developed by Dr. Lewis Robbins and his colleagues at the Methodist Hospital of Indiana in Indianapolis and has been used in Canada through the Department of National Health and Welfare. However, Colburn cautions: The ultimate value of the HHA as a predictive or motivational tool has not been proven and i t is therefore s t i l l very much an experimental technique (Colburn, 1973, p. 491). The HHA does demonstrate the qualitative nature of risk taking and makes i t personally relevant. Health Beliefs. The Health Belief Model is a comprehensive model which has been developed to explain health behaviour at the level of individual decision making. It was formulated in an attempt to understand the use of preventive services. This model postulates that in order for an individual to take action to avoid a disease he would need to believe: 14 1. that he was personally susceptible to i t 2. that the occurrence of the disease would be serious enough to affect his l i f e 3. and that taking action would effectively help in reducing his susceptibility to the disease or by reducing i t s severity should i t occur. (Rosenstock, 1974, p. 330). The model also takes into account that various demographic variables (age, sex, race, ethnicity), socio-psychological variables (personality, social class, peer and reference group pressure), and structural variables (knowledge about the disease, prior contact with the disease) a l l influence the person's perception of the threat of disease to himself. Beliefs in themselves do not necessarily lead to changed behaviour. The model, therefore, looks also at cues to action such as mass media campaigns, advice from others, illness of family member or friend, newspaper articles etc. which may stimulate a person to act on his beliefs. The perceived benefits of the preventive action minus the barriers to this action further influence the likelihood of taking the recommended preventive health action. Many studies have been done in which one or more of the causal variables identified in the model have been examined for their effect on a wide range of health behaviours. Although the Health Belief Model has been applied extensively to the prediction of preventive health behaviour, the specific behaviours studied have almost exclusively dealt, with the use of services such as examinations for disease, or the seeking of vaccines. In a recent review of research using the Health Belief Model, Rosenstock (1974) gives only one example of a study where the model was applied to personal health behaviour that didnriot involve seeking professional help. In that study, Heinzelmann and Bagley (1970), showed that engaging in physical exercise was related to the perceived benefit of reducing their risk of heart disease. The Health Belief Model may not be sufficient to explain factors that 15 are relevant to changing health patterns of daily l i f e . There may be many non-health related factors which also influence a person's actions. Attitudes Relevant to Present Behaviour The Behavioural Intention Model developed by Fishbein (1963) identifies two factors as the major determinants of health behaviour. One factor is the attitudinal influence^.on intention. This comprises the individual's beliefs about certain consequences of the behaviour as well as his evaluation of the outcome related to the behaviour. Thus, the attitudes under consid-eration are those concerned not with the object of the behaviour but with the attitude about performing the behaviour. The second aspect of the model considers the behavioural expectations which important reference groups or individuals are perceived to hold as well as the motivation to comply with these expectations. The f i r s t component of the theory refers to an attitudinal influence on intentions as studied by psychologists, while the second represents a normative influence on intentions often studied by sociologists. Fishbein's model regards behavioural intention as an intervening variable between a person's beliefs and his actual behaviour (Jaccard, 1975). Programs for Health Promotion The research indicates that attitude and behaviour change is a complex process and that people are motivated to change in response to a variety of strategies. Berkanovic emphasizes that: the well-controlled f i e l d study, applying the principles of behavioural science, would seem to offer the best hope for improving our a b i l i t y to design effective programs aimed at inducing change in personal health behaviour (Berkanovic, 1976, p. 104). One f i e l d study applying behavioural science techniques to prevention 16 is the Stanford Heart Study (Maccoby, 1975). Stanford University conducted a study with three small towns having similar characteristics. In each community 600 men and women between ages 35 and 60 were screened for risk of heart disease. One town was used as a control group and the other two as experimental groups. One of the experimental towns was given a mass media campaign about risk factors in heart disease and possible changes which could be made. In the second experimental town, in addition to the media campaign, 100 individuals at high risk were invited to participate in an intensive instruction program designed to teach about smoking, diet, weight, and physical activity. The techniques used in this program included a credible change agent, a fear inducing message, a face-to-face presentation, and a specific activity which could reduce the possibility of the feared event occurring. The preliminary results showed significant changes in risk behaviours in both experimental groups, with higher levels of risk reduction among those who participated in the intensive groups. Despite the number of studies carried out to measure the causal relationships of exercise • ;to improved, health, .there is a lack of research into evaluating the process of health promotion. Therefore, program evaluation is necessary to determine whether the behavioural interventions are indeed helpful in assisting people to make positive changes in their health behaviours. Hence, programs are frequently designed and implemented without any evidence that they are effective in meeting the needs for which they are intended. The potential for wasted resources is apparent. From the point of view of improving the personal health behaviour of the general public, i t is apparent that health education efforts have been less successful than we might have hoped. The well-controlled f i e l d study applying the principles of behavioural science would seem to offer the best hope for improving our a b i l i t y to design effective programs aimed at inducing change in personal health behaviour (Berkanovic, 1976, pp. 103-104). 17 Summary The review of selected literature indicates some of the d i f f i c u l t i e s in defining and measuring health. Although i t is d i f f i c u l t to measure health as a whole, i t is possible to look at various aspects of health and factors which contribute positively or negatively to health in relation to these aspects. Four basic areas, each containing many factors, influence health. These are 1. Human Biology 2. Environment 3. Lifestyle 4. Health Care Organization. Some of the factors related to li f e s t y l e are discussed with their effects on health. Specific reference is made to the effects of physical fitness on health. The long range effects of a sedentary l i f e s t y l e may be detrimental to health. It is d i f f i c u l t to change one's l i f e s t y l e . Some of the principles of behavioural science are discussed which may be helpful to the promotion of health by helping to change attitudes and behaviour. Specific reference is made to factors relevant to the promotion of physical activity and positive health behaviours. 18 CHAPTER III RESEARCH METHODOLOGY Overview The purpose of this study was to evaluate the effects of two-hour and one-day Health Promotion Workshops for nurses in terms of the goals and objectives of the program. The workshops were evaluated by observation, discussion with some participants, and with responses obtained through questionnaires. The questionnaires contained items designed to obtain information regarding knowledge, awareness, perceptions of the workshop, and behaviours of the nurses who attended. Questionnaires were administered to participants prior to the workshop and then mailed to workshop participants and control groups six weeks following the workshop. Development of the Workshop Content J" - The RNABC employed a nurse as the special project director for the Pilot Project on Health Promotion. Her function was to develop a workshop on Health Promotion to be offered to RNABC chapters throughout the province. The goals of the workshop followed from the RNABC position paper, developed by the Committee on Health Promotion and Assessment, which was previously discussed in Chapter I (p. 2). The goals are: 1. To sensitize nurses to their own needs to optimize their own health. 2. To sensitize nurses to their role of sensitizing others to their need to optimize their own health. 3. To motivate nurses to make changes in their personal health behaviours, i . 4. To motivate nurses to make behaviour changes in relation to their role as health promoters. The director of the workshops developed an Introductory Learning Program on Health Promotion for the Graduate Nurse. She chose the focus of'"the 19 program to be physical fitness as this has a far reaching effect on several aspects of health. This was discussed in the literature review (Chapter II, p. 10). The f u l l context of the Self-Learning Program appears in Appendix B. A summary of the content of the Self-Learning Program is as follows: The f i r s t section is an introduction to the importance and relevance of health promotion and the need for nurses to be involved personally and professionally. The next section deals with a variety of assessment tools for different aspects of health such as nutrition, mental health, and a risk factor analysis. The third part consists of defining physical fitness, assessments, and ways to improve fitness levels. The final section indicates several behaviour modification techniques which could be helpful in promoting change. Participants had the use of this program during the workshop and were given the opportunity of purchasing a copy. The Health Promotion Workshops were offered to the RNABC chapters through-out the Province of British Columbia. Table 1 indicates the dates, type of workshop given during the project and how they were used in the study. A two-hour and a one-day workshop were developed. Each workshop incorporated several techniques indicated in the literature as helpful for the modification of behaviour. These factors include a face-to-face presentation, assessments, social influence, goal setting, guided practice, contract system, self-cueing suggestions, and a reward program. The differences between the two workshops are indicated in Table 2. The increase in time in the one-day session allowed for more discussion, participation in further fitness tests, exercises, completion of assessment forms, as well as time to counsel one another regarding fitness or other health related topics. The outline for each workshop is included in Appendix C. 20 TABLE 1 WORKSHOPS GIVEN DURING THE HEALTH PROMOTION PROJECT GROUP DATE TYPE OF WORKSHOP HOW THE GROUP WAS USED FOR THE STUDY 1 Sept. 13, 1976 Two-Hour 'Not Used in the Study 2,. Oct. 4 Two-Hour Pilot Test 3, Oct. 5 Two-Hour Pilot Test 4 Oct. 6 Two-Hour Pilot Test 5 Oct. 7 . Two-Hour Pilot Test 6 Oct. 9 One-Day- Pilot Test 7 Oct.:. 12 Two-Hour 'Not Used in the Study 8 Oct. 14 Two-Hour Not Used in the Study 9 Oct. 16 One-Day Not Used in the Study 10 Oct. 18 Two-Hour Not Used in the Study 11 Oct. 23 Two-Hour Used in the Study 12 Oct. 25 Two-Hour Not Used in the Study 13 Oct. 29 One-Day Used in the Study 14 Nov. 1 Two-Hour Used in the Study 15 Nov. 53 Two-Hour Used in the Study 16 Nov. 8 Two-Hour Used in the Study 17 Nov. T9 Two-Hour Used in the Study 18 Nov. 16 Two-Hour Used in the Study 19 Nov. 20 One-Day Used .in the Study 20 Dec. 4 One-Day Used in the Study 21 Dec. 7 Two-Hour Used in the Study 22 Dec. 9 Two-Hour Used in the Study 1. This group was not used in the study because the questionnaires were not yet available? 2. Groups 7 through 10 were not used in the study as the workshops were held during the time when the results of the pilot test were analyzed and the questionnaires were revised. 21 TABLE 2 OUTLINE OF THE DIFFERENCE IN PRESENTATION BETWEEN THE TWO-HOUR AND THE ONE-DAY WORKSHOPS FACTOR TWO-HOUR ONE-DAY Approach Face-to-face presenta-tion Face-to-face presenta-tion General Assessments Risk Factor Analysis (Audience Participa-tion) Risk Factor Analysis (Audience participa-tion) Risk Factor Analysis Score Sheet) Nutritional Assessment Imaginary Trip Fitness Assessments Cardiovascular Fitness Test Cardiovascular Fitness Test F l e x i b i l i t y Test Guided Practice Armchair exercises Armchair exercises Thirty minute walk Exercise routine Goal Setting Presented by lecture Presented by lecture, discussion and time given to relate these factors to oneself. Contract System As above As above Reward Program As above As above Social Influence As above As above Counselling Suggestions given of ways to counsel others Time given to apply what was taught by counselling someone e l s e 22 Overview of the Evaluation Strategy The evaluation was based on the following model which is adapted from the model proposed by Robert E. Stake (1967, p. 118). INPUT PROCESS OUTCOME GOALS Intent t congruence 1, Observed Intent t congruence Observed Intent t congruence 4 Observed Figure 1. Model for Evaluation Information was obtained about the goals of the program and the intended input, process, and outcome by talking with the persons responsible for the project. The input included the situation, personnel, expected participants and available material. The process was considered to be the plan for the workshop and the manner of presentation. The outcome consisted of measures to represent the desired goals and objectives. The intentions in each of these areas were compared with what was observed in reality. The congruence between what was intended and what was observed was discussed. Whether the goals could be achieved through the intended process was considered on the basis of logic. Whether the goals were obtained through the workshops was considered on the basis of empirical evidence. In order to accomplish this task the following basic units of work were necessary: (1) discussion with persons responsible for the project, (2) description of the Workshops, (3) collection of data from participants and 23 control groups and, (4) analysis of data. Each of these are discussed in more detail at the end of this chapter. The data collection schedule appears in Table 3. TABLE 3 DATA COLLECTION SCHEDULE INSTRUMENT SOURCE TIME Interview with personnel responsible for the project Investigator Prior -to. .the Workshop General Information, Present Activity and Knowledge Questionnaire Participants Prior to the Workshop Observation of Workshops using the Checklist Investigator During the Workshop Interviews with some participants Investigator Immediately following the Workshop Post Workshop Evaluation Participants Immediately following the Workshop Present Activity and Knowledge Questionnaires Participants Six weeks following the Workshop Follow-up Workshop Evaluation Participants Six weeks following the Wlorkshop Present Activity and Knowledge Questionnaires Control Group One Month after the fina l Workshop was given Development of the Questionnaires Present Activity and Knowledge Questionnaires. These contain questions concerning present activity behaviours, attitude towards physical activity, 24 role as a health promoter, and knowledge regarding physical fitness and health promotion. The questions were developed by considering the goals, objectives, and content of the workshop, as well as consideration of relevant factors indicated in the review of the literature. The questionnaires were reviewed by a panel of four judges. One judge was a faculty member in the School of Nursing, another was an exercise physiologist, and two were students in the master's program in nursing. Pilot Testing. The Present Activity and Knowledge Questionnaires were pilot tested with ten students in their f i n a l year of the Bachelor of Nursing Science Program. The wording of some of the questions -was changed on the basis of their comments. The questionnaires were pil o t tested a second time by the 105 participants in five out of the f i r s t six workshops given. These programs were given to chapters from four medium sized towns in the northern central area of B.C. and the f i f t h chapter represents a small town in the northwest coastal region. The participants in the pilot test indicated that the questionnaires were too long and that the questions regarding attitude towards physical activity were d i f f i c u l t to understand. The attitude section of the questionnaire was deleted because of the length of the questionnaire and the fact that f i f t y percent of the participants expressed d i f f i c u l t y in completing this section. An item analysis was performed for the Knowledge Questionnaire, using the pilot test samples. As a result of this analysis, and the length of the questionnaires, the Knowledge Questionnaire was reduced from twenty-two items to ten items. General Information Questionnaires. This questionnaire was developed to obtain demographic information from the workshop groups and control groups. The form used with participants of the workshops contained an additional question concerning their primary reasons for attending the workshop. 25 Post Workshop Evaluation Questionnaire> The items on this form were designed to obtain information about the workshop presentation, relevance, and interest to participants. This questionnaire was reviewed by two judges, one a faculty member from the School of Nursing, and the other a staff member from the RNABC. Pilot Testing. The form was pilot tested by the 105 participants of the f i r s t five workshops mentioned previously. They found the form easy to complete and no suggestions were made for revision. Follow-up Workshop Evaluation Questionnaire. This contains items asking for the nurses' perceptions of the effects of the workshop on their behaviours, awareness, and knowledge. The questionnaire was reviewed by the same panel of two judges mentioned previously. It was accepted without revision. Selection of the Sample The workshops were offered to a l l RNABC chapters in British Columbia. This was done by letters sent to each chapter president and by an advertise-ment in the RNABC News. The Workshop director hoped that almost an equal number of chapters would choose each workshop. In this project seventeen chapters chose the two-hour workshop while five chose the one-day workshop. Five out of the f i r s t six groups were used for the pilot study to test the questionnaires. The questionnaires were revised and the last eleven workshops were included in the study. Eight of these groups chose the two-hour sessionxand three chose the one-day session. The location of the chapters included in;the study is indicated in Figure 2. The participants in the two-hour program were considered to be the two-hour workshop group with a total number of 149 nurses. The participants MAP OF BRITISH COLUMBIA Legend • Two-Hour Workshop not used in study, g Two-Hour Workshop used in the study. O One-Day Workshop not used in the study • One-Day Workshop used in the study. • Q Figure 2. Workshop Locations 27 in the one-day program were considered to be the one-day workshop group with a total of 48 nurses. For each chapter in the study, a control group of nurses who had not attended the workshop, was randomly selected from the chapter membership. In each chapter, the number of nurses selected for the control group equalled the number of nurses in the workshop group. The control groups chosen from chapters having the two-hour program were considered as one control group for the purpose of comparison with participants of the two-hour program. Similarly, the control group chosen from chapters having the one-day program was-: considered as the control for this group. It was f e l t this would provide control groups, not having the workshop, but representing the same geographical locations. Evaluation Plan and Procedures The plan and procedures for evaluation involved four basic units of work, each of which is summarized bri e f l y below. A. Discussion with Persons Responsible for the Project. An essential step in the evaluation was to understand the goals and objectives of the program, the content, and the intention of how the workshops would be presented. This was accomplished by discussion with the assistant executive director of the RNABC who was responsible for the project, by discussion with the nurse giving the workshops, and by reading the self-learning package. B. Description of the Workshops. Observation of the workshops was essential for c l a r i f i c a t i o n of what content was actually taught and the manner in which i t was presented. The Observation Checklist used appears in Appendix D. The investigator was able to attend a l l workshops in the 28 study with the exception of three of the two-hour programs. C. Collection of Data from Participants and Control Groups. The Present Activity and Knowledge Questionnaires along with the General Information Questionnaire were given to a l l participants immediately prior to the workshop. Six weeks following the program the Present Activity, Knowledge, and Follow-up Workshop Evaluation Questionnaires were sent to each participant' along with a covering letter. One month following the last workshop the Present Activity, Knowledge and General Information Questionnaires were sent to the control groups,with a covering letter. Appropriate techniques of maximizing response rates were used, including follow-up letters and, for the workshop groups, telephone contact with a representative from each area. Copies of the covering letters and follow-up letters appear in Appendix A. A Post Workshop Evaluation Questionnaire was completed by each participant immediately following the workshop. The data collection schedule was- presented in Table 3 (see- p. 23) . D. Data Analysis. A l l questionnaires returned were coded and a -10 percent random .subsample recoded to check for coder r e l i a b i l i t y . The data were key punched and verified 100 percent. The numerical data were analyzed by standard computer programs which yielded means, standard deviations, frequencies and percentages for items and item response options. Preliminary analyses were performed to determine the comparability of the workshop group who returned the mailed questionnaire, those who did not return i t , and the corresponding control group. More sp e c i f i c i a l l y , each item on the questionnaires given immediately prior to the workshop was analyzed separately. - A one-way analysis of variance test with three levels was used to determine significant differences among the.means on the responses to the f i r s t questionnaire for the a) two-hour 29 workshop respondent group, the non-respondent group, and the control groups (Figure 3) and b) the one-day workshop respondent group, the non-respondent group, and the control group (Figure 4 ) . Use of univariate analysis of variance in this way results in a very liberal test of no significant differences. Time 1 Time 2 Two-Hour Respondents n— Two-Hour Non-Respondents 0 Two-Hour Control Group Figure 3+. Non-Response Bias Check For the Two-Hour Workshop Time 1 Time 2 One-Day Respondents One-Day Non-Re sponden t s One-Day Control Group 0 0 Figure 4. Non-Response Bias Check For the One-Day Workshop The results of the preliminary analyses summarized in Appendix E indicated no differences among the corresponding samples. Therefore the workshop and control samples were considered "equivalent" prior to the workshop and were consequently treated as independent random samples. The response groups were also considered "equivalent" to the non-response groups. Only the responses for groups returning the mailed questionnaire *For both sets of analyses there were differences among means for only four variables out of f i f t y . The alpha level was set at .10 and therefore these differences could be due to chance alone and were disregarded. 30 were considered for further analyses.' This non-response bias check indicates that the findings for the response group can be generalized to a l l participants. A second set of preliminary analyses was carried out. The questionnaires given prior to the workshop were analyzed using a one way analysis of variance to test for significant differences among means for each ttem on the questionnaires for the following groups: (1) the two-hour workshop respondent group, (2) two-hour control group, (3) one-day workshop respondent group, (4) one-day control group (Figure 5). The results of these analyses indicated no significant differences" among the corresponding samples; therefore, the workshop groups were considered "equivalent" to the corresponding control group. Time 1 Time 2 Two-Hour Respondents Two-Hour Control One-Day Control One-Day Respondents Figure 5;., To Determine Whether the Groups Were Equivalent Prior to the Workshop The data analysis of the mailed questionnaire corresponded to a one factor design with the following levels: (1) two-hour workshop group, (2) two-hour control group (3) one-day workshop group, and (4) one-day control group (Figure 6;) . Time 1 Time 2 Two-Hour Two-Hour One-Day One-Day Respondents Control Respondents Control 0 0 0 0 0 0 Figure 6\ Data Analysis following the Workshops *There was only one significant difference among means for the questionnaire items. With an alpha of .10 this could be due to chance alone and was therefore disregarded. 31 Hypotheses 1, 2, and 3 were analyzed using multivariate analysis of variance. Subjects with missing data on any of the dependent variables included by each hypothesis were deleted from the analyses corresponding to that hypothesis. Use of multivariate procedures permits the analysis of multiple scores with appropriate consideration given to the correlations among them and to the control of the Type I error rate. If, as a result of the multivariate global test, the null hypothesis of no difference;: was rejected, the corresponding univariate F statistics were tested individually to de-termine which groups had significant group - mean differences (Finn, 1974; Hummel and Sligo, 1971). If the null hypothesis of no difference was not rejected, then the conclusion was that no group-mean difference existed. For hypothesis 4, involving only one variable, a single factor one-way analysis of variance test was done for the same four levels to test for significant mean differences. For hypothesis 5, multivariate analysis of variance was done to test for significant mean differences on responses to the Post Workshop Evaluation Questionnaires between the two-hour workshop group and the one-day workshop group. Use of analysis of variance was considered appropriate in this study even though the dependent measures had a limited number of score values (Hsu and Feldt, 1969, pp. 515-527). Summary This study was designed to evaluate the two-hour and one-day Health Promotion Workshops for nurses sponsored by the RNABC. The research methodology and evaluation plan and procedures are presented in this chapter. 32 CHAPTER IV FINDINGS AND DISCUSSION The results from the analyses of the questionnaires are presented in this chapter in four sections. A description of the sample is presented in the f i r s t section. The second consists of a discussion of the goals and intentions for the workshops in relation to the observations made of the workshops. Information obtained from the follow-up workshop evaluation form is presented in the third section. The fi n a l section contains analyses of the data in relation to the;v hypotheses of the study. Description of the Sample The data were obtained through the questionnaires given immediately prior to the workshop and the questionnaires mailed to participants and control groups. The numbers of forms mailed and the numbers that were returned and used in the analyses are indicated in Table 4, along with response rates for each category. A non-response bias check was done to determine whether the experimental groups responding to the mailed questionnaires were similar to those who did not respond. The groups were found to be "equivalent" as was discussed in Chapter III. Therefore, the description of the sample is based on responses of individuals who replied to the mailed questionnaire. Data on age, employment, place of employment, primary role, and education were tabulated. Analysis of variance and Duncan's test were done to determine differences in item means between the experimental and control groups for age, employment, and education. The results of these tests appear in Tables 5 through 7. Table 5 indicates that there were no significant differences in the mean age for each group. A l l groups had a mean age greater than 37 years indicating 33 that young nurses were not the only group concerned with the topic of Health Promotion. TABLE 4 MAILED QUESTIONNAIRE: FREQUENCIES AND RESPONSE' RATES FOR EACH GROUP P. o u o o CO CD U •H id c c o U v-l T3 CD -U CD •8 03 g CD -H 3 3 « 53 o-S T3 CD CD 60 C CO I H 4J C P C O W CD -H CD O 4J Ctf S-l CD CD CD CO CM 3 CD <y u 4J * 0 »r-i O C <W CO H ID O C O l-l CD ! CO CD 1^ •H P cO ,Q C C T3 •W T3 CD CO CD CO C C + J O CD CD C 00 T4 M cO I CD -W C 13 , n C O CD B <D -i-1 co 3 53 U u O in i-t CO >H CD CD CO CO 2 a r t z H PM 3 CD >> CO O M T-J 4J T3 O C >W H n! O CO CO C C <J 1. Two-Hour Workshop 149 103 3 100 (71.0) (67.1) 2. Two-Hour Control 149 98 9 89 (65.8) (59.7) 3. One-Day Workshop 48 35 1 34 (72.9) (70.8) 4. One-Day Control 48 34 1 :33 (70.8) (68.7) Questionnaires shown in this column are those which (1) were returned entirely blank, (2) were il l e g i b l e , or (3) were returned too late to be included in the analysis. TABLE 5 COMPARISON OF THE MEAN AGE FOR EACH GROUP Group X S F 1. Two-Hour Workshop 2. Two-Hour Control 3. One-Day Workshop 4. One-Day Control (N=100) (N=89) (N=34) (N=33) 38.5 38.4 42.3 37.6 10.6 11.1 11.7 11.6 1.3 34 Table 6 shows the differences among the groups concerning f u l l time employment. A low score indicates that a higher proportion of persons are employed on a f u l l time basis. Significant differences between means occurred between the two-hour control group and both workshop groups. This is considered by the writer to be a reasonable division as individuals who are working are more likely to attend RNABC chapter meetings. TABLE 6 COMPARISON OF FULL TIME EMPLOYMENT FOR EACH GROUP Group X s F Prob. 1. Two-Hour Workshop 1.4 a .64 5.38 P< .01 (N = 100) 2. Two-Hour Control 1.8 .80 Duncan's (N = 89) test. 3. One-Day Workshop 1.3 .54 Alpha = (N = 34) .05 4. One-Day Control 1.6 .75 (3,1,4) (N = 331 (4,2) aA low score indicates that more persons are employed f u l l time. The comparison of the amount of education for each group appears in Table 7. A score greater than one indicates that some participants have had formal education beyond the R.N. diploma. The one-day workshop group had significantly higher proportion of persons with more formal education than the one-day and two-hour control groups. This may be due to the fact that approximately 50 per cent of those attending the one-day sessions were public health nurses who are usually required to have education beyond the R.N. diploma. The percentages of persons employed in different types of work settings are summarized in Table 8 for each group. The largest proportion of nurses in each 35 TABLE 7 COMPARISON OF EDUCATION FOR EACH GROUP Group X s F Prob. 1. Two-Hour Workshop 1.4a (N = 100) 2. Two-Hour Control 1.2 (N = 89) :.. 3. One-Day Workshop 1.6 (N = 34) 4. One-Day Control 1.3 (N = 33) aA high score indicates that more persons had education beyond the R.N. diploma. work in hospital settings with the exception of the one-day workshop group. More than one half of the participants in the one-day workshop group were public health nurses employed in a health unit. The group distribution for major work responsibility appear in Table 9. The largest number of nurses from each group are employed in general duty nursing with smaller numbers in administration and teaching. The groups appear relatively similar with respect to their work responsibilities. Several questions were asked concerning the nurses' interest in health promotion and their motivation for exercise. Each group was asked what had influenced their interest in health promotion. The percentages of those who responded yes to the various categories are indicated in Table 10. It is clear that personal interest and work involvement have been the major factors influencing an interest in health promotion. .71 3.5 P<-05 .85 Duncan's test. .75 Alpha = .05 .52 (2.4,1) (1.3) 36 TABLE 8 GROUP DISTRIBUTION FOR PLACE OF EMPLOYMENT o u O CD CO C O P. co <l) Pi I c -•1-1 p< to , O t 4J •l-l c 1=) CD o +J o o o 00 c to 53 o o •s t/1 u O) 1. Two-Hour Workshop 9 .0 51 .0 13.0 1.0 2.0 24. 0 (N = 100) 2. Two-Hour Control 16 .9 41 .6 6.7 4.5 1.1 29. 2 (N = 89) 3. One-Day Workshop 5 .9 35 .3 55.9 2.9 0.0 0. 0 (N = 34) 4. One-Day Control 9 .1 66 :7 6.1 0.0 6i0 12. 1 TABLE 9 GROUP DISTRIBUTION FOR MAJOR WORK RESPONSIBILITY o u O CD CO I C cfl o !-i P. 4J 60 CO CD C CU CO •H •i-i Pi c ji 1 CD •H c o a c e O . " ~ N cfl O 8-5 CD XI •H 5-S <D S5 ^ Q +J ^ H CD 1. Two-Hour Workshop (N = 100) 10.0 50.0 14.0 4 .0 22.0 2. Two-Hour Control (N = 89) 15.7 49.4 9.0 2 .3 23.6 3. One-Day Workshop (N - 34) 8.8 73.5 5.9 0 .0 11.8 4. One-Day Control 6.1 ; . 60.6 18.2 3 .0 12.1 37 TABLE 10 PERCENTAGE RESPONSES FOR EACH GROUP INDICATING WHAT HAS INFLUENCED THEIR INTEREST IN HEALTH PROMOTION3 O O <f ^ \ r-l II o> 00 CO II CO CO 53 II 53 II 53 53 n a. CO P O P T-I 5^  o >»>-• c c O J3 o o Cfl O o o Hi to Q CD Q ^ a. -H 1 4J " AS ii; 4J CO 4-1 O SJ •-s O C CU }j •"N CU (3 /"N & O 8-S js o s«s C O 6^  C O B~2 M O t-i rs-^ o ts ^ O O ^ CNA Convention 5.0 RNABC Convention 16.0 Government Programs 22.0 Professional Magazines 37.0 Personal Interest 77.0 Work Involvement 55.0 Other 19.0 1.1 2.9 0.0 5.6 17.6 0.0 28.1 35.3 21.2 59.5 44.1 42.4 75.3 76.5 72.7 67.4 55.9 48.5 11.2 17.6 6.1 aThis information was obtained from responses to item 10 on the General Information Questionnaire. The respondents were asked to respond to a l l options that applied to them. Therefore the sum of the percentages for each group total more than 100. Table 11 shows what has influenced the different groups to be active in regular physical exercise. The desire to feel healthy appears to be the strongest motivating influence for each group. The percentage of people using either personal goals for fitness, recording their activity, or using reminders to promote exercise appears in Table 12. Personal goals for fitness were indicated as being used most often for each group. 38 TABLE ,11 PERCENTAGE OF RESPONSES FOR EACH GROUP INDICATING WHAT HAS INFLUENCED THEIR DESIRES TO BE ACTIVE IN REGULAR PHYSICAL EXERCISE.3 o o II v ova 1^ ft CO !!i 3 O C C O J2 o o ES 03 1 ^ , CO w O !-i X-N > O B*8 pi o •—s <r o-\ co 00 cx) II CO II II v ' IS P. >> o o o CD ,fi cfl O Q co 1 4J l A ! • -U o c ^ CD S-l •<u n 15 O C O C O >2 H U ^ o rs w o o ^ Family- 26.0 29.2 29.4 18.2 Friends 20.0 20.2 23.5 21.2 Colleaques 8.0 11.2 8.8 "6,1 Fear of Heart Disease 12.0 13.5 5.9 15.2 Desire to Feel Healthy 71.0 68.5 58.8 57.6 Books 13.0 12.4 8.8 t 12.1 Newspapers and Magazines 9.0 23.6 14.7 15.1 Research 13.0 13.5 5.9 15.1 This information was obtained from response to question 7 on the Present Activity Portion of the Questionnaire. ^The respondents were asked to respond to a l l options that applied to them. Thus the sum of the percentages total more than 100. The participants were asked what their primary reasons were for attending the workshop. The most frequently stated reasons for attending were a desire to gain new s k i l l s or knowledge and to increase their effectiveness-as health promoters. The desire to change health habits was the factor motivating 39 TABLE 12 PERCENTAGE OF RESPONSES FOR EACH GROUP INDICATING HOW MANY PEOPLE USE THE FOLLOWING TECHNIQUES TO ENCOURAGE THEM TO EXERCISE.3 v -o /" \ o < ^ <f I - l oo CO CO II II II CO 55 55 55 II 55 CD CO P o p I-t >» o > » l - l c c O ,C o o ra & cfl O o o IS co ffi u P CO P ^ ' A2 1 4-1 1 A ! 1 4J CO 4-1 O U O C /-\ J) fi<-\ CD ft 5 O B~S & O C O 6-2 C O B-2 pi O H & H U ^ O & ^ O Personal Goals for 59.0 Fitness Record of Physical 4.0 Activity Done Reminders to 20.0 Exercise 62.9 73.5 57.6 2.3 8.8 0.0 10.1 8.8 18.2 aThis information was obtained from responses to questions 8, 9, and 10 on the Physical Activity portion of the questionnaire. ^Respondents were asked to mark a l l options that applied to them. Therefore, the sum of the percentages may not equal 100. the fewest number of individuals. The percentage responses for each item appear in Table 13. Summary. The participants indicated that a desire to feel healthy was the strongest motivating force influencing their participation in regular exercise. Personal Goals for fitness was the most common technique used to encourage regular exercise. Personal interest and work involvement were reported as being the factors that have most influenced their interest in health promotion. The most 40 TABLE 13 PERCENTAGE RESPONSES FOR EACH GROUP INDICATING THEIR PRIMARY REASONS FOR ATTENDING THE WORKSHOPS3 Response Two-Hour Workshop One-Day Workshop Option 0 N = 100 (7„) N = 34 (%) To gain new s k i l l s or 77.0 85.3 knowledge To Improve existing 61.0 85.3 knowledge To Change health habits 39.0 47.1 To gain awareness of 60.0 67.6 health promotion To increase effectiveness 73.0 82.4 as a health promoter Other reasons 16.0 8.8 aThis information was obtained from responses to item 11 on the General Information Sheet of the questionnaire. Respondents were asked to check a l l options that applied to them. Therefore, the sum of the percentages for each group is greater than 100. common reasons given for attending the workshops were to gain new s k i l l s or knowledge and to increase their affectiveness as health promoters. Discussion of the Goals of the Project and Observations of the Investigator Goals. The goals of the project were identified by the director of the workshops. There were as follows: 1. to sensitize nurses to their own needs to optimize their own health, 2. to sensitize nurses to their role of sensitizing others to their need to optimize their own health, 41 3. to motivate nurses to make changes in their health behaviours and, 4. to motivate nurses to make changes in their role as health promoters. These goals are consistent with the RNABC position paper on Health Promotion and Assessment as discussed in Chapter I (p. 2). Goals one and three reflect the f i r s t goal, stated in the RNABC position paper, and goals two and four are parallel to the second goal in the position paper. Input and Process Intentions Personnel. One nurse was employed by the RNABC to develop and present workshops on health promotion to RNABC chapters throughout British Columbia. Her travelling expenses were to be covered by the RNABC and there would be no charge for participants. Expected Participants. The two-hour and a one-day workshops were advertised through the RNABC news and letters were sent to each RNABC chapter president. It was hoped by the director of the project that a similar number of chapters would choose each workshop. Situation. The chapters requesting workshops were to advertise the workshop and arrange the location and time of the meeting. Material. The nurse directing the workshops developed a self-learning package on Health Promotion for the Graduate Nurse (Appendix B), which she planned to use as a basis for each workshop. Each participant would have the use of the learning package during the session and have the opportunity of purchasing one following the session. Presentation. The differences in presentation between the two workshops were discussed in Chapter l i t (p.19). The most significant difference in presentation was the length of the workshop;-the longer workshop allowing more time for discussion, active participation, more content, and time for exercises and counselling. 42 Input and Process Observations Twenty-two workshops representing 4,2 percent of the chapters were held during the four-month phase of this project. Of the 22 workshops, 17- were two-hour programs and five were one-day programs. Eleven out of the last 12 workshops were used for the study: eight were two-hour programs and three were one-day programs. The investigator was able to observe a l l but three of the two-hour programs used for the study. The dates, type of workshop, and whether i t was used in the study were indicated in Table I (p.20). Participants. The two-hour workshop was requested more frequently than the one-day workshop. This was not congruent with what was anticipated. This may have been due to the fact that the invitations were sent to RNABC chapters and i t was easier to arrange for a two-hour program in conjunction with a regular meeting than to make arrangements for a f u l l day workshop. The participants did express much interest in the program and actively participated in the workshop through discussion and questions. Situation. Seven of the eight two-hour workshops were held in conjunction with RNABC chapter meetings. The workshops followed the chapter meetings which varied in length from five to sixty minutes. The sessions were most frequently held in the evening following a f u l l day's wprk which may not have been.the most conducive for learning. Eighty-five percent of the participants were able to remain for the total workshop. The one-day workshops were held during the day and 88 percent of the participants stayed for the entire session. There was more opportunity for discussion, questions, and the experiential aspects of the program in the one-day workshop when compared to the two-hour workshop. Summary. Was?it logical to assume that the plans for the workshops would achieve the desired goals? In the view of the investigator, i t was considered 43 possible to achieve some change in personal health habits and in role behaviour as a result of the workshop. It was not certain i f change in role behaviour would be apparent after only the six week period. It was f e l t that the one-day program would be more effective in promoting change than the two-hour program. Follow-up Workshop Evaluation A follow-up workshop evaluation was sent to participants with the questionnaire sent six weeks following the session. The percentage responses for each workshop group to each item on the evaluation questionnaire appear in Appendix E. The pertinent information obtained is discussed here. About 75 percent in each group identified changes they would like to make in their behaviours pertaining to cardiovascular fitness. Forty-five percent said they were able to accomplish changes in that area. Of those who attempted changes in cardiovascular fitness 60 percent indicated they had more energy for activities of daily living and could breathe easier on exertion. Twenty-five percent indicated they could sleep better and were better able to deal with stress. The behaviour modification techniques that the groups found most helpful in assisting them to make changes in their own behaviour were: 1) setting short term goals (45 percent of the two-hour group and 75 percent of the one-day group), ; 2);participating in activity with family and close friends (41 percent of each group) and, 3) having the support and encouragement of others (31 percent of the two-hour group and 38 percent of the one-day group). Ninety-five percent of the participants agreed that regular physical exercise is important for better health and over 80 percent f e l t that a physical fitness program was worth the effort, pain and hard work. More than 80 percent from each group perceived their knowledge of fitness to be 44 increased as a result of the workshop. The same percentage f e l t they were more aware of the possibilities for health promotion with friends and family. More than 70 percent f e l t they had an increased awareness of their role as a health promoter in their work. Summary. The evaluation of the workshops by participants indicates that several goals have been met. Two of the goals were to sensitize nurses to their own needs to optimize their own health and to motivate them to make changes in their behaviours. Seventy-five percent of the participants reported that they identified changes they would like to make in their own fitness. Forty-five percent indicated they were able to accomplish changes in this area. The other^goals were to sensitize nurses to their role as health promoters and to motivate them to make changes in their role. Eighty percent of the participants stated they perceived their knowledge of health promotion had increased and that their awareness of the possibilities of health promotion with family and friends had increased. Seventy percent indicated they had an increased awareness of their role as health promoters in their work. - Thus the nurses were sensitized to their role as health promoters. Specific questions were not asked regarding change of behaviour with respect to role and therefore i t was not possible to obtain a clear indication of this change from the questionnaire. Analyses of Data From Questionnaires In Relation to Each Hypothesis Preliminary Analyses were performed to determine the comparability of the workshop groups with the corresponding control groups prior to the workshops. The results of the analysis, as discussed in Chapter III, indicated the experimental and control samples were considered "equivalent" 45 prior to the workshop and were consequently treated as independent random samples. The workshop groups' responses to the mailed questionnaires were compared to the responses of the appropriate control groups. Multivariate analysis was used to test Hypotheses 1, 2, 3, and 5. Cards that had missing data on any measures pertinent to each hypothesis were removed in order to test that specific hypothesis. Table 14 indicates the sample size without missing data in each group used for the analysis of each hypothesis. TABLE 14 SAMPLE SIZE USED TO TEST EACH HYPOTHESIS Group r-t CO •H co cu .e •u o 1 Hypothesis 2 Hypothesis 3 Hypothesis 4 m CO •r-i CO CU & O 1. Two-Hour Workshop 97 99 78 100 113 2. Two-Hour Control 81 89 61 88 3. One-Day Workshop 33 33 31 _-.34 39 4. One-Day Control 31 33 25 33 If the multivariate F was significant, univariate analysis was performed to determine where significant differences were. Several comparisons between groups were possible. The comparisons that were of specific interest to this study were the comparison between 1) the two-hour workshop group and its control, 2) the one-day workshop group and i t s control, 3) the two-hour 46 workshop group and the one-day workshop group. The results are discussed relevant to each hypothesis. Hypothesis 1: There w i l l be no significant difference in reported regular exercise behaviours six weeks following the workshop when comparing the workshop groups a) with their'appropriate control groups, b) with each other. Multivariate analysis of variance was performed to determine significant differences among group means for items 1, 3, 4, and 5 of the Present Activity Questionnaire. The results of the analysis appear in Table 15. The F-ratio for the multivariate test of equality of mean vectors was 2.88 which was significant at p^.01. As the multivariate global test was significant, the null hypothesis was rejected in favour of the alternate. Differences among the groups were tested for each question using Duncan's multirange test. The results of the analysis appear in Table 16. The results indicate there were significant differences among group means for item 1 (Participation in Regular Physical Activity) and item 5 (Participation in Exercise which increases their heart rate into the target area for training). A low score on item 1 indicates greater participation in regular physical activity. Both experimental groups had significantly more persons participating in regular physical activity than their control groups indicating that the workshop did help to motivate participants to increase their regular activity patterns. A high score on item 5 shows that persons are engaging more often in regular exercise where they get their heart rate up to the target rate for training. The one-day workshop group was significantly different from the appropriate control group while the two-hour workshop group was not. This may indicate that the one-day workshop was more potent than the two-hour workshop in motivating for change in this exercise. However, this cannot TABLE 15 HYPOTHESIS 1: RESULTS OF MULTIVARIATE AND UNIVARIATE ANALYSIS OF VARIANCE Source Multivariate Univariate Test l. aRegular 3. Work 4. Leisure 5. Target Test F (df) df - Physical Activity Activity Rate Activity Between 3.70* (12,622) 3 8.86* 2.61 1.30 7.18* Within 238 aThe numbers correspond to the items on the Present Activity Questionnaire. *sig. p<.01. 48 TABLE 16 SUMMARY STATISTICS FOR EACH VARIABLE RELATED TO HYPOTHESIS 1 Item Group S F l . a Regular Physical Activity 1. Two-Hour Workshop (N=97) 2. Two-Hour Control (N=81) 3. One-Day.Workshop(N=33) 4. One-Day Control (N=31) 1.31 1.52 1.15 1.64 0.46 • 0.50 0.36 0.49 * 8.86 Duncan': test alpha = 0.01 (3,1)(2,4) 3. Work 1. Two-Hour Workshop (N=97) 3.27 1.33 2.61 Activity 2. Two-Hour Control (N= 81) 3.71 1.08 3. One^Day Workshop (N=33) 3.48 1.03 4. One-Day Workshop (N=31) 3.74 1.18 4. Leisure 1. Two-Hour Workshop (N=97) 3.35 0.85 1.30 Activity 2. Two-Hour Control (N=81) 3.48 0.88 3. One-Day Workshop(N=33) 3.58 0.75 4. One-Day Control (N= 31) 3.23 0.72 5. Target 1. Two-Hour Workshop (N=97) 2 .19 0. 88 7.18* 2. Two-Hour Control (N=81) 1 .90 0. 92 Duncan's 3. One-Day Workshop (N=33) 2 .51 0. 91 test 4. One-Day Control (N=31) 1 .61 0. 72 Alpha = 0.01 (4,2)(2,1) (1,3) aThe numbers correspond to the items on the Present Activity Questionnaire. **A low mean for item 1 indicates a greater participation in Physical activity. A high mean for items 3, 4, and 5 indicate greater activity. * s i g . p<.01. 49 definitely be (Concluded as the results may be due to variations across RNABC chapters. The F-ratio for the multivariate test was significant and the null hypothesis was rejected. It is concluded that there is a significant difference in reported regular physical exercise behaviours following the workshop when comparing the workshop groups with their control groups. Hypothesis 2. There w i l l be no significant differences in reported habits relating to physical activity six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups, b) with each other. Multivariate analysis of variance was done to determine significant i differences among means for items 15, 16, and 17 of,;the Present Activity Questionnaire in order to test this hypothesis. The results of the analysis appear in Table 17. Summary statistics for each item appear in.Appendix E. No significant differences were found among means and therefore, Hypothesis 2 was not rejected. It is important to be able to incorporate aspects of fitness into the activities of our lives. The particular habits referred to in items 15, 16, and 17 were not specifically dealt with in the workshop. This may have resulted in no apparent changes in the habits relating to physical activity. Hypothesis 3. There w i l l be no significant differences in reported behaviour as a health promoter six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups, b) with each other. Multivariate analysis of variance was done to determine significant differences among means for items 18 and 19 of the Present Activity Question-naire. The multivariate F-ratio was 0.99 with degrees of freedom (72, 502). This was not significant at p ^.05. Summary statistics for each item appear 50 TABLE 17 HYPOTHESIS 2: RESULTS OF MULTIVARIATE AND UNIVARIATE ANALYSIS OF VARIANCE Source Multivariate Univariate 15.aUse of 16. Parking 17. Walk Test F(df) Test df Stairs Car or Ride Between 1.05 3 1.38 0.95 0.89 (9,603) Within 250 aThe numbers correspond to questions 15, 16, and 17 of the Present Activity Que s t i onna i r e . in Appendix E. No significant differences in reported behaviour as a health promoter were found and therefore Hypothesis 3 was not rejected. Although-no significant behaviour changesewere found the Follow-Up Work-shop Evaluation indicated that nurses f e l t they were more aware of their role as health promoters. There are two possible explanations for the discrepancy between awareness of need to change and the lack of change in role performance; 1) six weeks was not a long enough time span to allow for change in this area and 2) the workshop may have been too short to adequately prepare nurses to incorporate health promotion into their work. Hypothesis 4. There w i l l be no significant differences in test scores of knowledge of physical fitness and health promotion six weeks following the workshop when comparing the workshop groups a) with their appropriate control groups, b) with each other. Analysis of variance was done to determine significant differences among means for the knowledge test scores of each group. The results of the analysis, summarized in Table 18, reveal a significant difference among the groups (F = 23.79, p<.01). Duncan's test shows that both the two-hour and the one-day workshop groups had a significantly higher mean score when compared to their control groups. This is supported by the participants' perceptions as reported in the Follow-Up Workshop Evaluation, that their knowledge of fitness and health promotion had increased as a result of the workshop. TABLE 18 COMPARISON OF MEAN SCORES ON THE KNOWLEDGE TEST FOR THE EXPERIMENTAL AND CONTROL GROUPS Group X S F Prob. (Total ~ 10) 1. Two-Hour Workshop 6.04 1.8 23.79 p <.01 N = 100 2. Two-Hour Control N = '89 3. One-Day Workshop N = 34 4. One-Day Control 3.94 1.37 N = 33 Hypothesis 5. There w i l l be no difference in nurses' evaluation of the workshop immediately following the workshop when comparing the two workshop groups. Multivariate analysis of variance was performed for a l l items on the post workshop evaluation form. The F-ratio for the multivariate test was 1.70 4.56 1.48 Duncan's test Alpha = .01 (4,2) 6.29 1.96 (1,3) 52 with 14 and 137 degrees of freedom. This was significant at p4«06. The results of the univariate analysis of variance indicate that the only significant F ratio is in relation to whether the workshop was long enough to cover the topic adequately. The summary statistics appear in Appendix E. Inspection of the means reveals that the two-hour group (X = 3.88 differed significantly from the one-day group (X = 3.25). The two-hour group f e l t the time was too short to cover the topic adequately. Summary The analyses of the data and findings are presented in this chapter. The results support the conclusion that the health promotion workshops were helpful in 1) sensitizing nurses to their own needs to optimize their own health, 2) motivating nurses to make changes in their health behaviours, and 3) sensitizing nurees to their role as health promoters. Although the data did not show that nurses made significant behaviour changes in their role as health promoters, the participants did state that they were more aware of the poss i b i l i t i e s of health promotion in their work. 53 I CHAPTER V SUMMARY, LIMITATIONS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Summary The overall goal of this study was to investigate the effectiveness of two types of health promotion workshops for nurses. The effectiveness was evaluated with respect to the goals! of the project related to the desired and observed outcomes. The following major hypotheses were delineated for this investigation: 1. There w i l l be no significant difference in reported regular exercise behaviours six weeks following the workshop when comparing the workshop groups a)with appropriate control groups, b) with each other. 2. There w i l l be no significant differences in reported habits relating to physical activity six weeks following the workshop when comparing the workshop groups a) with appropriate control groups, b)with each other. 3. There w i l l be no significant differences in reported behaviour as a health promoter six weeks following the workshop when comparing the workshop groups a) with appropriate control groups, b) with each other. 4. There w i l l be no significant differences in test scores of knowledge of physical fitness and health promotion six weeks following the workshop when comparing the workshop groups - a) with appropriate control groups,.?b) with each other. 5. There w i l l be no difference in nurses' evaluation of the workshop immediately following the workshop when comparing the two workshop groups. The literature reviewed for this study revealed that health promotion is of current concern in Canada. Nurses are a large group who have the potential to promote the health status of Canadians. The RNABC initiated a program of two-hour and one-day health promotion workshops for nurses throughout the province to assist them in taking responsible action as health promoters. In order to determine the effectiveness of the workshops, eight .two-hour workshops and three one-day workshops were studied. Pre- and 54 post measures were obtained on their present activity behaviours as well as their knowledge of physical fitness and health promotion. The same measures were obtained for control groups randomly chosen from the RNABC chapter memberships where the workshops were held. The responses of the workshop groups and control groups were compared using multivariate analysis of variance. The results of the analyses were related to the knowledge and behaviours of nurses. The perceived awareness of nurses to their personal and professional needs in the area of health promotion was self-reported iri response to items on the follow-up workshop evaluation questionnaire. Limitations The study was subject to the following limitations: 1. I t was not possible to obtain control groups who had expressed a desire for the program, indicating that there may be basic differences between the groups with regard to motivation. 2. The control group completed only one questionnaire, therefore i t is not possible to determine whether the pretest alone contributed to change. 3. Information was obtained through the use of questionnaires and is therefore subject to the limitations of self-reported data. 4. Most two-hour workshops were held in conjunction with an RNABC chapter meeting which altered the amount of time l e f t for the workshop. Conclusions The following conclusions are warranted based on the finds of this investigation: 55 1. The two-hour and one-day health promotion programs contributed to an increase in the number of persons participating in reported regular exercise behaviours. Both workshop groups showed a significant increase in the number of persons participating in regular physical activity when compared to their control groups. Both groups showed that nurses were doing exercise which raised their heart rate into the target zone for training more frequently following the workshop than before. The one-day group showed a significant difference when compared to i t s control group. 2. The workshops did not result in a significant change in reported habits relating to physical activity as reported by participants. 3. The workshops did not result inra significant change in reported behaviour as a health promoter. It is recognized by the investigator through observation of the workshops that there was not sufficient time to deal with this aspect of the program adequately. 4. The workshops contributed to the nurses' knowledge of physical fitness and health promotion. This is supported by self-report of the nurses and by a significant increase in the knowledge test scores for both experimental groups when compared to the control groups. 5. The workshops increased nurses' awareness of the p o s s i b i l i t i e s of health promotion in their work and with family and friends. 6. The two-hour workshop was not long enough to cover the topic adequately. 56 Implications It has been demonstrated by this project that health promotion workshops were able to 1) sensitize nurses to their own needs to optimize their own health, 2) to sensitize nurses to their role of sensitizing others to their need to optimize their own health and, 3) to motivate nurses to make behaviour changes in their personal health behaviours. The study did not demonstrate that nurses made behaviour changes in their role as health promoters. The findings of this study have the following implications: 1. Further work should be done to assist nurses in taking a more active role in health promotion. 2. Health promotion workshops -should continueto be offered to interested groups of nurses. 3. Schools of nursing should include in their curriculum, aspects of health promotion with a personal and professional emphasis. 4. Two-hour workshops should be a f u l l two hours and should not be held in conjunction with chapter meetings. Recommendations Based on the findings of the present study the following recommendations for further research are suggested. 1. Studies to determine the effectiveness of workshops in health promotion in areas other than physical fitness, could be done. 2. It would be helpful to study the long term effect of health promotion workshops on health behaviours. 3. Further research comparing the effectiveness of a workshop program and a weekly program of several months duration would be of value. 4. Studies to compare the effects of programs designed to assist nurses in taking a more active role as health promoters would be of value. 5. It would be helpful to study the effects of health promotion programs in basic educational programs and in schools of nursing. 58 SELECTED BIBLIOGRAPHY Ajzen, I., and Fishbein, M. 1973. 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Outline of the Two-Hour Workshop 2. Outline of the One-Day Workshop Observation Checklist 1. 2. 3. 5. 6. 7. Non-Response Bias Check for the Two-Hour Workshop Groups Non-Response Bias Check for,.the -One-Day Workshop Groups The Results of Analysis of Variance Performed to Determine Group Equivalence Prior to the Workshops Percentage Responses for the Follow-Up Workshop Evaluation Questionnaire Summary Statistics for Items Pertaining to Hypothesis 2 Summary Statistics for Items Pertaining to Hypothesis 3 Summary Statistics for Items Pertaining to Hypothesis 5 62 APPENDIX A1 PRESENT ACTIVITY QUESTIONNAIRE Are you participating in any regular physical activity program? 1. Yes 2. No If yes, please describe: How physically f i t do you feel at present? Unfit 1 2 3 4 5 F i t How would you rate your average level of physical activity at work? (e.g. Consider a desk job to have a low level of activity and a job where you are on your feet and active most of the time as having a high level of activity). Low Activity 1 2 3 4 5 High Activity How would you rate your average level of physical activity during your leisure time? (E.G. consider watching TV as a low activity level, normal housecleaning as moderate, and heavy housecleaning and strenuous aports as high activity). Low Activity 1 2 3 4 5 High Activity How often do you engage in regular physical exercise where you get your heart rate up to the target rate for training? (Target heart rate: upper limit - Pulse of 200 minus age lower limit - Pulse of 170 minus age) 1. Seldom or never 2. 1-2 times per week 3. 3-4 times per week 4. 5-7 times per week Indicate the usual length of time you engage in the above exercise. I f you have answered seldom or never to question 5 please omit this question. 1. 5 minutes 2. _10 minutes 3. 15 minutes 4. 20 minutes 5. 30 minutes 6. more than 30 minutes 63 If you are participating in regular physical exercise, what has contributed to your interest in this area and your desire to be active in this way? Check a l l that apply. 1. Family 2. Friends 3. Colleagues 4. Fear of Heart Disease 5. Desire to feel healthy 6. Books 7. Newspapers and Magazines 8. Research 8. Do you have personal goals for fitness? 1. v Yes 2. No 9. Do you keep a record of your physical activity? 1. Yes 2. No 10. Do you use any special ways of reminding yourself to exercise? 1. Yes 2. No 11. Do you consider yourself susceptible fo heart disease? 1. Strong possibility 2. Moderate possibility 3. Slight possibility 4. No possibility 12. Do you believe that regular physical exercise decreases the risk of heart disease? 1. Strong belief 2. Moderate belief 3. Slight belief 4. Do not believe 13. How many cigarettes do you smoke? 1. None 2. 1-10 per day 3. 10-20 per day 4. More than 20 per day 14. How much alcohol do you drink? (include wine and beer) 1. None 2. 1-2 drinks per week 3. 3-7 drinks per week 4. 8-16 drinks per week 5. More than 16 drinks per week 6. Have stopped drinking 64 15. Do you usually take the stairs rather than the elevator to ascend 1-3 flights of stairs? 1. seldom 2. occasionally 3. f re quen t ly 4. usually 16. How frequently do you park your car as close as possible to your destination? 1. Seldom 2. Occasionally 3. Frequently 4. Usually 5. I do hot have a car 17. If your destination was less than a mile away would you normally choose to walk rather than ride? (assure that you do not have anything heavy to carry). 1. Seldom 2. Occasionally 3. Frequently 4. Usually 18. How often do the following groups ask you for suggestions and advice on: A. Fitness Never Seldom Occasionally Frequently 1. Family •  2. Friends ..  3. Patients 4. Colleagues B. Nutrition 1. Family 2. Friends 3. Patients 4. Colleagues C. Risk Factors 1. Family 2. Friends 3. Patients 4. Colleagues 65 With the following groups, how often have you initiated conversation for the purpose of teaching, encouraging, and motivating others towards better health habits on: A. Fitness Never Seldom Occasionally Frequently 1. Family 2. Friends 3. Patients 4. Colleagues B. Nutrition 1. Family 2. Friends 3. Patients 4. Colleagues C. Risk Factors 1. Family 2. Friends 3. Patients 4. Colleagues 66 APPENDIX A 2 KNOWLEDGE QUESTIONNAIRE THERE IS ONLY ONE CORRECT RESPONSE. CIRCLE THE MOST APPROPRIATE LETTER FOR EACH ITEM. The average age of 1 Male Female A. 50 60 B. 48 58 C. 42 52 D. 46 56 2. Which three of the cr i t e r i a for physical fitness listed above most need to be emphasized today? A. Co-ordination, Speed, A g i l i t y B. Strength, Speed, Power C. Strength, Cardiovascular Endurance, F l e x i b i l i t y D. Strength, Speed, F l e x i b i l i t y 3. The cardiovascular training effect is accomplished chiefly by: A. anaerobic activities B. aerobic activities C. isometric activities D. isotonic activities 4. The minimum exercise requirement to show a significant increase in fitness i s : A. 3 times a week for 30 minutes B. 2 times a week for 30 minutes C. 4 times a week for 15 minutes 5. An individual runs on the spot for 3 minutes and raises her pulse rate into the target area. Three minutes after the end of the run, her pulse is 120. This would indicate: A. good cardiovascular fitness B. average cardiovascular fitness C. poor cardiovascular fitness 6. Body f l e x i b i l i t y is least promoted by which of the following? A. holding a position at the end point of a range of motion action B. using small pushing and releasing actions at the end point of the range of motion activity C. contracting the muscle group to be stretched before the stretching action D. moving rapidly through f u l l range of motion activity 67 Which of the following would not be classified as a potentially dangerous exercise? A. chinup B. toe touching C. deep knee bend D. leg l i f t E. body arch Physical fitness is best defined as: A. being able to jog five miles B. decreasing risk of coronary heart disease C. being able to perform daily activities with energy to handle additional activity D. increasing muscular strength and endurance In modifying poor health practices -- which of the following statements about change would not be accurate? A. change is more readily accepted when i t is clearly understood B. change is more readily accepted when i t follows a series of failures rather than a series of successful experiences C. planned change is more acceptable than surprise change D. people more readily accept change when they start a new job rather than when they have been at a job for a long time. Assessment materials are useful in the promotion of health because they: A. provide information relative to a individual's state of health B. pinpoint interventive techniques to improve health 68 APPENDIX A3 GENERAL INFORMATION QUESTIONNAIRE FOR THE WORKSHOP GROUPS 1. Name 2. Address 3. Phone Number 4. RNABC Chapter and District 5. Age ( 6. Employment: 1. Working f u l l time 2. Working part time 3. Not working at present 7. Presently employed in: 1. Hospital 2. Health Unit 3. Doctor's Office 4. Nursing School 5. Other 8. Primary Role: 1. General Duty 2. Administration 3. Teaching 4. Other ?;. Education: 1. R.N. 2. B.N. 3. Other 10. Have any of the following influenced your interest in health promotion? Check a l l that apply. 1. CNA Convention 2. RNABC Convention 3. Government sponsored program 4. Professional magazines 5. Personal interest and involvement 6. Work involvement 7. Other 11. What are your primary reasons for attending this workshop? Check a l l that apply. 1. Desire to gain new s k i l l s or knowledge of health promotion. 2. Desire to improve existing knowledge. 3. Desire to change your health habits. 4. Desire to gain general awareness of health promotion. 5. Desire to be more effective as a health promoter in the profession. 6. Other 69 APPENDIX A4 GENERAL INFORMATION QUESTIONNAIRE FOR THE CONTROL GROUPS Age Employment: Presently employed in: Primary Role: Education: 1. 2. 3. 1. 2. 3. 4. 5. 1. 2. 3. 4. 1. 2. 3. _Working f u l l time _Working part time _Not working at present _Hospital _Health Unit JDoctor's Office _Nursing School Other jGeneral Duty _Administration Teaching Other R.N. J&-N. Other Have any of the following influenced your interest in health promotion? Check a l l that apply. 1. CNA Convention 2. RNABC Convention 3. Government sponsored programs 4. Professional magazines 5. Personal interest and involvement 6. Work involvement 7. Other 70 APPENDIX A 5 POST WORKSHOP EVALUATION QUESTIONNAIRE 1. How relevant do you feel this workshop was to you? Personally: Relevant 1 2 3 4 5 Irrelevant Professionally: Relevant 1 2 3 4 5 Irrelevant 2. Did you feel the topic of health promotion was dealt with.; sufficiently? Yes 1 2 3 4 5 No 3. The planning and organization of the workshop was: Excellent 1 2 3 4 5 Poor 4. From the broad topic of health promotion do you feel that the focus on physical fitness was a good choice of emphasis? Excellent 1 2 3 4 5 Poor 5. How would you rate the content as applied to physical fitness? Too much 1 2 3 4 5 Too l i t t l e 6. How would you rate the workshop according to the following methods of presentation? Lecture: Too much 1 2 3 4 5 Too l i t t l e Discussion: Too much 1 2 3 4 5 Too l i t t l e Time for practical application: Personally: Too much 1 2 3 4 5 Too l i t t l e Professionally: Too much 1 2 3 4 5 Too l i t t l e 7. Was the workshop long enough to cover the topic adequately? Too long 1 2 3 4 5 Too short 8. Did the advertising give you a clear picture of what to expect from the workshop? Yes 1 2 3 4 5 No 9. Would you be interested in attending further workshops in health promotion? Yes 1 2 3 4 5 No 71 10. Which best describes your overall reaction to the workshop? Very favourable 1 2 3 4 5 Very unfavourable 11. Additional comments or suggestions': 72 APPENDIX A, 6 FOLLOW-UP WORKSHOP EVALUATION QUESTIONNAIRE I was able to stay for: 1. the total workshop 2. more than half of the workshop 3. less than half of the workshop Following the workshop, I read the self learning program on health promotion. 1. completely 2. more than half 3. less than half 4. I did not read i t The workshop helped me to identify areas in my own health in which I would like to make some changes. These were in the following areas. Check a l l that apply. 1. cardiovascular fitness 4. 2. strength 5. 3. f l e x i b i l i t y 6. I was able to accomplish changes in apply. 1. cardiovascular fitness 4. 2. strength 5 . 3. f l e x i b i l i t y 6. nutrition risks to health mental health the following areas. Check a l l that nutrition risks to health mental health What factors have you found helpful in working towards accomplishing desired changes? Please use the following code to answer. Circle your response. 1 2 3 4 5 Did not try No help Some help Moderate help Great help 1. Setting short term goals 1 2 3 4 5 2. Support and encouragement of others 1 2 3 4 5 3. Participating in activity with others 1 2 3 4 5 4. Using a reward system 1 2 3 4 5 5. Using reminders 1 2 3 4 5 6. Keeping records of activity 1 2 3 4 5 Considering what you learned in the workshop and the results of the three minute run, how would you assess your level of fitness at the time of the workshop? 1 2 3 4 5 Unfit Below Average Average Above Average F i t 73 The workshop stressed cardiovascular fitness. Have you made an attempt to improve in this area? 1. Yes 2. No If your response to the above was yes, what have you noticed in terms of results? 1. more energy for activities of daily li v i n g 2. increased a b i l i t y to deal with stress 3. better sleep 4. easier breathing on exertion 5. other Please use the following code to indicate your responses to the following statements. Circle your response. SA A N D SD Strongly agree Agree Neutral Disagree Strongly disagree 1. My knowledge of fitness has increased. SA A N D SD 2. A physical fitness program is not worth the effort, pain, and hard work. SA A N D SD 3. I have found the assessment tools helpful in talking to people about their health and l i f e styles. SA A N D SD 4. Regular physical exercise is important for better health SA A N D SD 5. I am not more aware of my role as a health promoter in my work. SA A N D SD 6. I am more aware of possi b i l i t i e s for health promotion with friends and family. SA A N D SD Are there any comments which you would like to make regarding the effects of the program for yourself personally or professionally? Comment on goals you have set for yourself and what you have done in working towards meeting them. 74 APPENDIX A 7 COVERING AND FOLLOW-UP LETTERS FOR THE WORKSHOP GROUPS TO: Workshop Participant FROM: Ann Taylor, RN, Assistant Executive Director DATE: October 1976 The RNABC has recognized the importance of examining' and strengthening the nurses role in Health Assessment and Promotion. It is in response to this that the Association has madeathis workshop available to you. We would like to gather some information from you prior to the workshop which w i l l help in the planning of future programs. We would appreciate having you complete the following questionnaires. Please work through the questions in order. Your f i r s t response is often the best so do not spend a lot of time on each question. This information w i l l be kept confidential. Your name is on the form as we wish to be in touch with you following the workshop. 75 APPENDIX A 7 COVERING AND FOLLOW-UP LETTERS FOR THE WORKSHOP GROUPS December, 1976 Dear Workshop Participant, It has been over six weeks since you attended the Health Promotion Workshop presented by E l l i e Robson, sponsored by the RNABC. We are planning to continue offering workshops in succeeding months and would appreciate any suggestions you might have for modification. There are three questionnaires enclosed, Present Activity, Knowledge, and Workshop Evaluation. Your responses to the knowledge questionnaire w i l l help us review the program content. Please do not refer to your learning package when answering these questions. You will-note that some of the questions are the same as those in the questionnaire you completed during the workshop. Please answer the questions in accord with your activity as i t is now. Your responses to the workshop evaluation questionnaire w i l l assist us in general program modifications. Upon completion please return the questionnaires in the stamped envelope. You w i l l notice that there is a number on the questionnaire. This number w i l l be checked against a numbered mailing l i s t . Your responses w i l l be kept anonymous. It would be appreciated i f you would complete the questionnaire and return i t to this office within ten days. Thank you for your assistance with this project. Best wishes for a Happy New Year. Sincerely, E l l i e Robson Special Project Director Joy Edwards Evaluation Assistant Ann Taylor Assistant Executive Director 76 APPENDIX As COVERING AND FOLLOW-UP LETTERS FOR THE CONTROL GROUPS January, 1976 Dear Member, The RNABC has recognized the importance of examining and strengthening the role of the nurse in Health Assessment and Promotion. In response to this the RNABC has made workshops on Health Promotion available to it s members. To assist in the evaluation of this program we are conducting a survey of sever&l randomly chosen members who were not able to attend a workshop. We would appreciate i t i f you would complete the enclosed questionnaire and return i t in the stamped envelope. There are three parts to the questionnaire, Present Activity, Knowledge, and General Information. Please answer these questions according to your present activity and knowledge. You w i l l notice that there is a number on the questionnaire. This number w i l l be checked against a numbered mailing l i s t . Your response w i l l be kept anonymous. It would be appreciated i f you would complete the questionnaire and return i t to this office within ten days. Thank you for your help with this project. Best wishes for a Healthy New Year. Sincerely, E l l i e Robson Special Project Director Joy Edwards Evaluation Assistant Ann Taylor Assistant Executive Director 77 APPENDIX Ag COVERING AND FOLLOW-UP LETTERS FOR THE CONTROL GROUPS February, 1977 Dear Member, The RNABC has made Workshops on Health Promotion available to i t s members. To assist in the evaluation of this program questionnaires were sent to several members who were randomly chosen from those who were unable to attend a workshop. A questionnaire was sent to you. It is possible that you did not receive i t . If this is the case, please write to Joy Edwards c/o RNABC, and she w i l l send you another questionnaire. You may have received the questionnaire and put i t aside to complete later. We would like to encourage you to send your completed questionnaire to this office as soon as possible. I f you have already returned the questionnaire, thank you for your help. Your responses w i l l enhance the evaluation of the program. Sincerely, E l l i e Robson Special Project Director Joy Edwards Evaluation Assistant Ann Taylor Assistant Executive Director 78 APPENDIX B THE REGISTERED NURSES' ASSOCIATION OF BRITISH COLUMBIA An Introductory Self-Learning Program In Health Promotion For the Registered Nurse ILLNESS HEALTH OPTIMAL HEALTH Materials Prepared By: Consultant in Education Design: E l l i e Robson, RN, BN Dr. Juli a Quiring, UBC Special Project Coordinator (Health Promotion) Consultant in Exercise Physiology: F a l l , 1976 Nancy Gruber, YWCA 79 Health Promotion for the Registered Nurse -A Self-Learning Package ^ The following broad general statements introduce the content of each section. Specific goal statement and objectives are found listed within each section. Self Pre-test Quiz Section I Section II Section III Section IV Footnotes Introduction Assessment Tools in Health Promotion Assessment & Promotion of Fitness Goal Establishing Page 80-83 84-102 103-121 122-128 129 80 SECTION I Specific Goals This section is designed to explain the overall direction of the program and the approach emphasis and guideslines chosen to accomplish these goals. It then outlines the guidelines for actualizing the learning of this program. Specific Objectives 1. Discuss the relevancy of a course in physical fitness promotion, for the nurse. 2. Discuss the problem-solving area of Health Promotion on the Health Continuum. 3. Discuss the relationship of physical activity to cardiovascular health. 81 Section I Overview of Goals The RNABC p o s i t i o n paper on The Nurse's Role i n Health Assessment and Promotion has been used as a guide f o r t h i s program. This paper defines health promotion as "the process which encourages i n d i v i d u a l s to adopt l i f e s t y l e s compatible with optimal health". Further, i t out l i n e s optimal health as "the highest degree of p h y s i c a l , mental and s o c i a l well-being achievable by an i n d i v i d u a l at any given time". It states, "that nurses have a role i n health assessment arid promotion seems hardly a matter for debate. The problem i s preparing and encoura-ging nurses to f u l f i l l t h i s r o l e " . The f i r s t aim of t h i s program i s to continue the s e n s i t i z a t i o n of the nurse to her ro l e i n health assessment and promotion. The second aim i s to take some beginning steps i n preparing her to do t h i s . Overview of Approach,and Emphasis The approach of t h i s program i s a dual consideration of the nurse personally and p r o f e s s i o n a l l y i n r e l a t i o n to health promotion. The personal emphasis was chosen to deal with the f i r s t o u t l i n e d function of the nurse i n r e l a t i o n to health promotion as o u t l i n e d i n the aforementioned paper that the nurse "be a ro l e model of health". The elements of the promotion of health are many, from which s e l e c -t i o n had to be made f o r t h i s introductory program. P r i o r i t y consi-deration has been given to the one aspect of p h y s i c a l f i t n e s s , because of i t s r e l a t i o n to cardiovascular disease, our* major health problem. Contained i n t h i s program are assessment and promotional knowledge and s k i l l s to enable the nurse to be a ph y s i c a l f i t n e s s health promo-te r with people who are a b l e 2 t o be p h y s i c a l l y a c t i v e . The Par Q A c t i -v i t y Readiness questionnaire i s suggested to be used by the nurse to screen out any "at r i s k " people before embarking on a f i t n e s s program. Some current assessment tools are shared from the other areas of health promotion such as n u t r i t i o n , mental health, r i s k f a c t o r a n a l y s i s , but the promotional knowledge and s k i l l s i n r e l a t i o n to these areas are not part of t h i s i n s t r u c t i o n . Guidelines to a c t u a l i z e the Learning of t h i s Program Se l e c t one or two people from the group with whom you can get together to: 1. complete any assessments suggested by the program 2. state your goals 3. encourage each other towards the goals. I t i s suggested that you meet with t h i s person at l e a s t once to e s t a b l i s h your goals and then get together i n 2 months (a selected period of time to a c t u a l i z e some of the learning of t h i s program) to re-assess your pro-gress towards your goals. 82 We are suggesting making changes i n our l i f e s t y l e s and health r e l a t e d habits to e s t a b l i s h more creative ways of l i v i n g . We need to be r e a l i s -t i c i n the changes we propose. Aim not to make major changes i n your l i f e , but minor changes, which you can carry out. In the long run, they w i l l r e s u l t in the major differences to you. Objective #1 The Relevancy of a Course i n Physical Fitness Promotion for the Nurse Poor body condition has been neglected as a serious health problem because i t has been sneaking up on us over some time. We have f a i l e d to c l e a r l y recognize that there have been s i g n i f i c a n t changes i n the a c t i v i t y patterns of people and that these changes pose a r i s k to our health. We need to develop awareness that u n d e r u t i l i z e d bodies can threaten good health and p o s s i b l y mental equilibrium. The nurse can a i d i n d i -viduals i n planning t h e i r personal f i t n e s s programs and help them c l e a r l y see that p h y s i c a l a c t i v i t y not only used to be a matter of s u r v i v a l , but that i t s t i l l i s . 3 Lalonde states " I n d i v i d u a l blame must be accepted by many f o r the deleterious e f f e c t on health of respective l i f e s t y l e s , sedentary l i v i n g (...) and these (...) contribute to i l l n e s s f o r which the i n d i v i d u a l must accept some r e s p o n s i b i l i t y " . I t i s relevant to the health needs of today for nurses to be p a r t of c l a r i f y i n g the res-p o n s i b i l i t y of the i n d i v i d u a l f o r h i s own health and p h y s i c a l f i t n e s s . Objective #2 The Problem-Solving Area of Health Promotion on the Health Continium We, as nurses, are t r a d i t i o n a l l y used to problem-solving from i l l n e s s to health, but less f a m i l i a r with the t e r r i t o r y from health to o p t i -mal health. I t i s d i f f i c u l t problem-solving because of the lack of drama and the subtleness of the problems. The incubation periods are long f o r the e f f e c t s of too much st r e s s , food, and lack of exercise to have t h e i r i l l e f f e c t s on health. We are problem-solving towards optimal health and i n t h i s program considering w e l l people, or as Lalonde c a l l s them, "the worried w e l l " , who need d i r e c t i o n in how to promote t h e i r own health. There are many health promotion a c t i v i t i e s to be considered f o r people "at r i s k " , but that i s not the emphasis of t h i s introductory program. ILLNESS HEALTH OPTIMAL HEALTH 83 Objective #3 The Relationship of Phy s i c a l A c t i v i t y to Cardiovascular Health In many countries, cardiovascular disease accounts f o r more than 50% of a l l deaths. Morris , a pioneer i n the study of the epidemiology of cardiovascular disease emphasizes that "habitual p h y s i c a l a c t i v i t y i s a general f a c t o r of cardiovascular health i n middle age and that coronary heart disease i s i n some respects a deprivation syndrome or a de f i c i e n c y disease". There have been a number of projects sponsored by the United States Pu b l i c Health Disease Control Program that have i n d i c a t e d the r e l a -tionship between exercise and coronary heart disease. Trends i n these studies a l l seem to in d i c a t e that the i n d i v i d u a l who p a r t i c i -pates i n regular periods of p h y s i c a l a c t i v i t y has a lower incidence of heart disease, as w e l l as lower mortality rates when heart attacks do occur. The average age of heart attacks i n males i n the U.S.A. i s a s t a r t l i n g 42. Women t r a i l men i n coronary diseases by about 10 years, but the gap i s narrowing because of increased c i g a r e t t e smoking and the tension-producing conditions that women now experience. Two of the most convincing of a l l heart disease exercise research projects are the Framingham Study and the H.I.P. study of 110,000 people covered by the health insurance plan of greater New York. In Framingham, the researchers followed the health of more than 5,000 adult residents f o r more than 10 years and found that most sedentary people had a d i s t i n c t l y worse outlook than those people who were more moderately a c t i v e . They suffer e d more heart attacks and the attacks were more l i k e l y to be f a t a l . Based on the findings of the H.I.P study, the s c i e n t i s t s reported that (1) the f i r s t heart attack i s more prevalant i n p h y s i c a l l y i n a c t i v e men than i n men who are more a c t i v e . That i s true among both c i g a r e t t e smokers and non-smokers. (2) i n a c t i v e men who smoke c i g a r e t t e s show a mortality experience more than 5 times that of more active non-smokers of a s i m i l a r age. (3) men s u f f e r i n g a f i r s t myocardial i n f a r c t i o n i n the course of the study were divided i n t o walkers and non-walkers. F i f t y - s e v e n percent of those who neit h e r walked nor engaged i n other forms of phy s i c a l a c t i v i t y were dead within four weeks, as compared to sixteen percent of those who both walked and exercised i n other ways. These studies i n d i c a t e that the promotion of p h y s i c a l a c t i v i t y and f i r n e s s i s a p r i o r i t y health need. 84 Section II Assessment Tools i n Health Promotion S p e c i f i c Goal Statement This section i s designed to emphasize the important place assessment to o l s play as the f i r s t step i n the promotion of health. I t w i l l expose you to c e r t a i n tools and then ask you to e s t a b l i s h short-term goals (for a p e r i o d of 2 months) in r e l a t i o n to the assess-ment tools you have used. To f u l f i l l the personal goal, e s t a b l i s h a minimum of one goal i n r e l a t i o n to each t o o l used. To f u l f i l l the p r o f e s s i o n a l goal, administer t h i s t o o l to another. See Section IV f o r goal Establishment Sheet. S p e c i f i c Objectives 1. Describe the important place of assessment tools i n health promotion 2. Explain the purpose of the s p e c i f i c assessment tools used 3. E s t a b l i s h and l i s t personal goals in areas assessed 4. Administer p r o f e s s i o n a l l y the assessment t o o l . As i d e n t i f i e d i n the RNABC p o s i t i o n paper on Health Promotion, "assess-ment i s the f i r s t step i n any program or plan f o r health promotion". Health assessment was defined i n t h i s paper as " c o l l e c t i n g and i n t e r -p r e t i n g information r e l a t i v e to an i n d i v i d u a l ' s state of p h y s i c a l , mental and s o c i a l well-being". S p e c i f i c assessment tools are p a r t of t h i s b a s i c program. Others w i l l be supplemented according to the length of time a v a i l a b l e f o r the requested presentation. The following i s an o u t l i n e of the s e l e c t e d assessment t o o l s . Instructions for t h e i r use accompany the t o o l . 85 S p e c i f i c Assessment Tools used i n t h i s introductory Program a. Audience P a r t i c i p a t i o n , Risk. Factor Analysis b. Your Real Age vs. Your Chronological Age c. Exercise Recording f o r 7 days d. Audience P a r t i c i p a t i o n , Imaginary T r i p to a Healthy Spot e. N u t r i t i o n a l Assessment f. Mental Health Assessment 86 Risk Factor Analysis Explanation and Assessment — This i s an audience participation assessment tool which makes people consciously aware of some risks they are taking to their health. It also identifies and commends the health promoters who are s t i l l standing at the end of the analysis. To Conduct the Assessment: Audience standing, requested to s i t down i f any of these apply to them: 1. Smoke cigarettes — 10 or more per day 2. Eat more than 7 eggs per week 3. Overweight by 15 lbs. 4. Don't participate in any active type of recreation eg. walking, gardening 5. Don't do exercise of endurance type 3 times a week for 30 minutes 6. Don't wear seat belts 7. Don't have annual dental check up and don't use dental floss 8. Don't have a pap smear regularly 9. Don't do se l f breast exmination 10. Don't have some quiet time of reflection and relaxation 3 times a week for 30 minutes Source: Prepared by E. Robson 87 Your Real Age vs. Your Medical Age Are you older or younger than your chronological age? Find out by taking this simple test. Explanation of the Assessment — This assessment t o o l i s a s i m p l i f i e d health hazard appraisal. The H.H.A. i s a new t o o l of preventative medical, a by product of the census, whose v i t a l s t a t i s t i c s reveal how many people died, at what ages, and from what. From t h i s information, further breakdown by age, sex and race can then allow the r a t i n g of l i f e expectancies. The developers of the H.H.A. took t h i s data one step further. They fed in information on body condition, family h i s t o r y , and l i f e s t y l e . . They also added r i s k modifiers which can turn bad news to good. To Conduct the Assessment: The purpose of gi v i n g the H.H.A. i s not to scare people to death. Rather i t i s to help them to see more c l e a r l y the r i s k s they are taking to t h e i r l i v e s . When people are more aware of these r i s k s , which i s dramatized i n the statement of a person's r e a l age vs. h i s chronological age, many are then motivated to change. At t h i s time, you with your counselling s k i l l s could then help people make some r e a l i s t i c goals towards l i f e s t y l e changes. See Section IV f o r goal E s t a b l i s h i n g . Source: Your Real Age vs. Your Chronological Age, Keith Sehnert and Howard Eisenberg, Family C i r c l e , 19 75 88 Your Real Age vs. Your Medical Age Scoresheet How to keep score: If uncertain, leave blank. Place scores (in the parentheses) on the lines. Enter subtotals and divide as noted (round off numbers). Enter totals and compare current age with medical age. I. Personal history: 1. Weight. "Ideal weight at age 20 was . If current weight is greater than 20 pounds over that, score (+6) for each 20 pounds. If same as age 20 or less gain than 10 pounds (-3) . 2. Blood pressure. Under 40 yrs. i f above 130/80 (+12); over 40 yrs. i f above 140/90 (+12). 3. Cholesterol. If above 220 (+6). 4. Heart murmur. Not an "innocent" type (+24). 5. Heart murmur with history of rheumatic fever (+48). 6. Pneumonia. If bacterial pneumonia more than three times in l i f e (+6). 7. Asthma (+6). 8. Rectal polyps (+6). 9. Diabetes. Adult onset type (+18). 10. Depressions. Severe, frequent (+12). 11. Regular^ dental checkup (-3). Total (Part I) ^Regular in this question refers to well people who have thorough medical exams at a minimum according to this age/frequency: 60, every year; 50-60, every two years; 40-50, every three years; 30-40, every five years; 25-30, as required for jobs, insurance, military, college and so on. More frequent medical checkups are recommended by some authorities. Dental exams twice yearly. II. Life-style and family or social history: A. Life-style: 1. Disposition. Exceptionally good-natured, easy-going (-3); average (0); extremely tense and nervous most of time (+6). 2. Exercise. Sedentary work, no exercise program (+12); sedentary with moderate regular exercise (0) physically active employment or sedentary job with well-planned exercise program (-12) . 3. Home environment. Unusally pleasant, better than average family l i f e (-6); average (0); unusual tension, family st r i f e common (+9). 4. Job satisfaction. Above average (-3); average (0); less than average (+6). 5. Exposure to air pollution. Substantial (+9). 6. Smoking habits. Non-smoker (-6); occasional (0); moderate, regular smoking 20 cigarettes, 5 cigars or pipefuls (+12); heavy smoking 40 or more cigarettes daily (+24). 7. Alcohol habits. None or seldom (-6); moderate with less than 2 beers or 8 oz. wine or 2 oz. whisky or hard liquor daily (+6); heavy, with more than above (+24). 8. Eating habits. Drink skim or low fat milk only (-3); heavy meat eater (+6); over 2 pats butter daily (+6); over 4 cups coffee/tea/cola daily (+6) usually add salt at table (+6): add and total. 89 9. Auto driving. Regular less than 20,000 miles and seat belt always worn (-3); regular less than 20,000 miles and seat belt not always worn (0); more than 20,000 (+6). 10. Drug habits. Use of street drugs (+36). B. Family/Social History: 1. If your father is over 68 or lived beyond 68 (-3) for each five years he lived beyond 68; i f he died of medical causes before 68 (+3); i f he is under 68 (0). 2. Mother. If less than 73 (0); i f she is over 73 or lived beyond 73 (-3) for each five years she lived beyond 73; i f she died of medical causes before 73 (+3). 3. Marital status. If married (0); unmarried and over 40 (+6). 4. Home location. Large city (+6); suburb (0); farm or small town (-3). Total (Part II) III. For women only: 1. Family history of breast cancer in mother or sisters (+6). 2. Examines breasts monthly (-6). 3. Yearly breast exam by physician (-6). 4. Pap smear yearly (-6). Total (Part III) CALCULATIONS 1. Totals: Total Parts I and II (+ or - ) . Total part III (women only) (+ or - ) . TOTAL (+ or -) Then divide by 12 for FINAL TOTAL. 2. Enter .'current age here: 3. From current age, add or subtract final total. 4. Enter medical age here: General Instructions for completing this form: There is a range in many of these questions in which you need to use your own judgement. Eg. See Question #1. If your are 30 lbs. over your ideal weight, mark down +9. 90 Exercise Record Day Type of Activity Pulses] after A c t i v i t y Immediate ly 1 min 2 min Comment on feelings prior to/after act. After completing this Exercise Record, see Section IV for goal establishing. Source: Prepared by E. Robson 91 Imaginary Trip to a Healthy Spot Explanation and Assessment — We a l l have experienced different degrees of health and wholeness, when we're feeling our best. Sometimes people forget elements which go into bringing about this optimal state. This assessment seeks to remind them of these elements of their own experiences of optimal health, in the hopes that being more aware of them, they w i l l the r e a l i s t i c a l l y be able to build more of these elements into their daily lives. To Conduct the Assessment: Step I — have people s i t comfortably, well-supported in a quiet environment. T e l l them to close their eyes, and ask them to let you take them on a trip to their most natural healthy spot. As they s i t quietly, help them to put other thoughts aside, and t e l l them to concentrate on only their breathing. Take time to help them relax.... allow some silence to concentrate on their breathing. Through your voice, direct them to think of this t r i p they are going to take to their most natural healthy spot. Give them time: 1. To think of where this place would be 2. To prepare for i t (pack) 3. To travel to i t 4. To arrive and settle Then direct them to explore this spot. Make a l l kinds of observations about their environment, what's around them, what they are doing, who, i f anyone, is with them, and how do they feel? Allow them some time in quiet there, and then suggest they return back to their place here and now, guiding them with your voice through the same steps of preparing to leave and travelling back. Step II — After this imaginary tr i p i s .over, allow people to share where they went and a l l the observations they made. Ask them questions, eg. were you smoking, drinking, or rushing about? was there noise or ai r pollution? how did you feel? etc. Step III —. Have people close their eyes again and refle c t on the past week they have just lived. Guide them with your voice to r e c a l l the things . they did and some of the feelings of each day. Give them time in silence to rec a l l this. Step IV — After this reflecting time, allow people to share i n one or two words some of the past week's a c t i v i t i e s and feelings. Step V — Now ask people to problem-solve for themselves how they could r e a l i s t i c a l l y build in more of their most natural healthy spot into the week they have just lived. Allow discussion. Step VT — See Section IV for goal Establishing. Source: Modified from, Human Life Styling, Keeping Whole in the 20th Century, John C. McCamy and James Aesley Harper & Row, New York, 19 75 92 N u t r i t i o n a l Assessment Explanation Assessment — The N u t r i t i o n Canada National Survey of 19 72 i n d i c a t e d that many Canadians are overweight. They stated: " C a l o r i c intakes alone do not seem to account for this problem. People who are overweight and those who are not, do not d i f f e r greatly i n the number of c a l o r i e s they consume. Two factors may be involved; f i r s t , small c a l o r i c excesses over long periods of time, and secondly a sedentary l i f e s t y l e . Again, the subtleness of the health promotion problem i s revealed, the differences i n overweight vs. non-overweight people being small c a l o r i c excesses over a long p e r i o d of time, compounded by a change i n our a c t i v i t y patterns to a more sedentary l i f e s t y l e . S i g n i f i c a n t changes have also occurred i n our eating patterns. Today 40% of the American food d o l l a r i s being spent on food served away from home, food often of questionable n u t r i t i o n a l value for our optimal n u t r i t i o n a l health. S p e c i f i c Guidance — 1) F i l l i n the Rate Your N u t r i t i o n score sheet. A score of between 30-40 seems average, but i average good enough for optimal n u t r i t i o n a l health? Aim for the low side of t h i s average. See Section V for goal statement. 2) Keep a record of your food intake for one week using the attached r e c a l l form. See Section IV f o r goal E s t a b l i s h i n g . 93 RATE YOUR NUTRITION - REACH LIFESTYLE QUESTIONNAIRE Score Plus Minus Is your weight normal f o r your height and b u i l d ? ( C i r c l e the number beside the best answer) yes 3 no — too heavy 1 — too l i g h t 1 don't know 1 The questions below r e f e r to some of the types of things we put i n t o our bodies. Think about the things that you would normally consume over a 2-3 week period. To t e s t your intake read each question and put a c i r c l e around the score next to the answer that f i t s you best. Plus Minus How many b o t t l e s of pop do you drink? none 3 one per week 1 2-7 per week 1 more than one a day 2 I f you drink pop i s i t us u a l l y (omit i f you don't drink pop) sugar free 2 low c a l o r i e s 1 regular - noncola 1 regular c o l a 2 Do you eat unsweetened whole g r a i n c e r e a l s 3 packaged, dry cere a l s 1 sweetened ce r e a l s 1 doughnuts - p l a i n 1 doughnuts - ic e d , f i l l e d , sugared 1 How many teaspoons of sugar or honey do you put on your cereal? none 3 1 teaspoon 1 more than 1-2 teaspoons 1 more than 1 tablespoon 2 How many teaspoons of sugar or honey do you put i n your coffee? none 2 1 teaspoon 1 more than 1 teaspoon 1 94 Plus Minus cont. How many cups of coffee do you drink per day? none 2 1 or 2 cups 1 more than 2 cups How much chocolate or candy do you eat? never or rarely 3 once or twice a month 2 once or twice a week 1 once a day 1 more than once a day 3 Do you add salt to your food? no 2 yes - in cooking only 1 yes - at the table as well 1 Do you use iodized salt? yes no Do you use butter regularly ? no yes Do you use polyunsaturated margarine? yes, only 3 yes, sometimes 1 no i don't know 1 How many eggs do you eat per week - including those used in cooking fewer than 4 2 5-6 1 more than 7 What kind of milk do you normally drink? skim or buttermilk 3 2% butterfat (partial skim) 2 regular milk 1 none 1 Do you cut the fat off meat? always 2 usually 1 never 1 95 con t. What kind of bread do you normally cat? only 100% whole grain both whole grain and white white only none Plus 3 2 1 Minus What do you usually snack on? no in-between meal snacks f r u i t , raw vegetables, juice sandwich, crackers, cheese pop and sweetened beverages cakes, cookies, pie chips, cheezies, popcorn How many alcoholic drinks do you usually have? none 1 or 2 a week 1 or 2 a day more than 2 a day How many cigarettes do you smoke? none less than 1/2 a pack per day 1/2 - 1 pack per day more than a pack per day How often do you take pain k i l l e r s ? (aspirin or aspirin l i k e compounds) never or occasionally more than once a week daily How often do you take nerve p i l l s ? (tranquilizers) never or occasionally more than once a week daily How often do you take laxatives? never or occasionally more than once a week daily 3 2 1 3 1 1 1 1 1 2 1 2 3 1 2 1 2 1 2 Add up your score Total Plus -Subtract Total Minus -YOUR SCORE s questionnaire does not take into consideration that you are on a special diet. NUTRITIONAL RECALL Date Breakfast Lunch Dinner Snacks Exercise Relaxation Firs t Day Second Day Third Day Fourth Day Fifth Day Sixth Day Seventh Day Prepared by E. Robson 97 CALORIES REQUIREMENTS We ight Pounds Activity Levels Sedentary Moderate 111 1750 2200 124 1900 2400 136 2050 2550 144 158 176 2150 2300 2500 2650 2850 3100 Related to metabolic body size, age, growth, sex and physical activity ',CH0 PROTEIN FAT ALCOHOL 4 cal/gm 4 cal/gm 9 cal/gm 7 cal/gm To determine caloric level for weight maintenance: Body weight (in lbs.) x 10 = Basal Body weight (in lbs.) x 15 = Sedentary Body weight (in lbs.) x 20 = Moderate IDEAL BODY WEIGHT Rule of Thumb 100 lbs. @ 5' + 5 lbs each additional inch + 10% for body frame 106 lbs. @ 5' + 6 lbs. each additional inch + 107o for body frame To Lose Weight - Must have caloric intake less than body expenditure - Generally recommend 1-2 lbs.loss/week -Loss of 1 lb. requires 3500 calorie d e f i c i t - 500 calorie decrease/day - 1 lb. weight loss per week SOURCE OF CALORIES PROTEIN Requirements - Maintenance: .7 gm/kg of body weight. - Additional amounts have no further biological value. Excess amino acids are broken down and used as expensive source of energy. -High protein diets are generally high in fat (usually saturated). - Twice the calories are obtained from fat as protein in such a diet. FAT Requirements - Contributes about 1/3 total calories. - Necessary to carry fat soluble vitamins (A,D, E,K) and supply essen-t i a l fatty acids. - I f serum lipids are elevated, control of amounts and kinds of fats would be suggested by: a) increased use of polyunsaturates b) reduction of total fat intake to 357o of total calories. CARBOYHDRATE Requirements 60 gms. appears minimal to avoid ketosis. Less than 100 gm.may produce toxicity. -Economical source of en-ergy (especially grains) serves to spare proteins. About 1/2 caloric intake should be: breads and cereals, fruits and ve-getables, milk. Rather than empty calorie foods such as: sugars (jams, honey, syrups), candy, soft drinks. 98 Mental Health S e l f Assessment Explanation of Assessment — In Lalonde's book, i t i s estimated that about h a l f the burden of i l l n e s s i s psychological i n o r i g i n and the proportion i s growing. Therefore, we need to have a general idea of how mentally f i t we are. Instructions for Administering the Tool: F i l l i n the assessment t o o l and the graph. See Section IV for goal statement. Numerically l i s t your scores i n the areas assessed on your personal goal sheet and state one goal. For Reference See E. Robson 99 MENTAL HEALTH SELF ASSESSMENT Put a check beside each item which is true ofyou: I. Physical Needs a. Food; Well balanced diet (+1) Poorly balanced diet (-1) Usually three meals a day (+1) Usually no breakfast (-1) Starve un t i l dinner (-1) Often feel irritable or lack energy (-1) Usually feel energetic (+1) Eat with moderation (+1) Overeat (-1) Undereat (-1) b. Sleep: Feel tired every morning (-1) Wake up feeling bright usually (+1) Plan work to get enough sleep (+1) Assess fatigue before going out in evening (+1) Often get overtired (-1) Get enough sleep usually (+1) Take nap when necessary (+1) c. Exercise: Sedentary work with no exercise (-1) Sedentary work with moderate regular exercise (+1) Sedentary work with well planned exercise program (+2) Physically active work (+2) Often feel tense and nervous (-1) Usually feel relaxed (+1) Usually feel about average (+1) Usually feel extremely good (+2) II. Self Concept Feel OK most of the time (+1) Feel NOT OK most of the time (-1) Easy-going attitude towards myself (+1) Over conscientious (-1) Underestimate my a b i l i t i e s (-1) Overestimate my a b i l i t i e s (-1) Realistic about my a b i l i t i e s (+1) Accept my shortcomings (+1) Kick myself for my mistakes (-1) 100 Self-Assessment - continuted. Have self respect (+1) Don't stand up for myself (-1) Get satisfaction from simple pleasures (+1) Require 'things' to make me feel good about myself (-1) Usually accept criticism well (+1) Often feel personally attacked by criticism (-1) Accept praise gracefully (+1) Feel unworthy of praise (-1) Consider the interests of others (+1) Self-centered (-1) Like and trust others (+1) Worry that people are after me (-1) Respect people's differences (+1) Intolerant (-1) Stand up for myself (+1) Push people around (-1) III. Stress a. Personal: Have many friends (+1) Have a few good friends (+1) Have an average number of friends (+1) Have few friends (-1) Usually feel like a good parent (+1) Usually feel inadequate as a parent (-1) Usually feel like 'somebody' (+1) Usually feel like 'nobody' (-1) Usually am an individual (+1) Usually successful in what I do (+1) Usually feel a failure (-1) Lost loved one recently Usually feel independent (+1) Usually feel dependent (-1) Know who I am (+2) Don't know who I am (-2) Feel in control of my environment (+1) Feel powerless (-1) b. Family: Good relationship with relatives;; (+1) Poor relationship with relatives (-1) Average relationship with relatives (+1) Pleasant home environment (+1) Average family l i f e (+1) Unusual tension, family fights common (-1) . Usually feel close to spouse (+1) Usually feel alienated from spouse (-1) Can communicate well with spouse (+1) 101 Self-Assessment - continued. Poor communication with spouse (-1) Usually get along with children (+1) Often misunderstand or argue with children (-1) c. Occupational: (including housewives) Above average job satisfaction (+1) Average job satisfaction (+1) Poor job satisfaction (-1) Creative job (+1) Non-creative job (-1) Pleasant relaxed relations with co-workers (+1) Quarrels and conflict with co-workers (-1) Recognition for good work (+1) Constructive criticism (+1) Criticism without praise (-1) Average control over own work (+ 1) No control over own work (+1) Friendly work environment (+1) Cold alienating work environment (-1) d. Social: Suburban living (-1) Urban apartment living (-2) Urban single dwelling living (+1) Rural or small town living (+1) Wait in lineups often (-1) Occassionally wait in lineups (+1) Married (+1) Unmarried over 40 years old (-1) Unmarried under 40 years old (+1) FOR EACH SECTION ADD UP SCORES FOR EACH ITEM YOU CHECKED. For example: (-1) + (+1) 4 0 (-1) + (-1) = "2 (+1) + (+1) = +2 ADD THE SCORES FOR FOOD, SLEEP, EXERCISE, SELF CONCEPT, PERSONAL STRESS, FAMILY STRESS, OCCUPATIONAL STRESS, AND SOCIAL STRESS. 102 Self Assessment - continued. DRAW A LINE ON THE GRAPH AT THE LEVEL CORRESPONDING TO THE SCORE YOU CALCULATED FOR EACH SECTION. COMPARING YOURSELF WITH THE STANDARD YOU WILL BE ABLE TO SEE WHERE YOUR STRENGTHS ARE AND WHERE YOU COULD USE IMPROVEMENT. THE LINES FOR THE STANDARD CORRESPOND TO THE MAXIMUM AND MINIMUM VALUES POSSIBLE. THE CLOSER YOUR SCORE COMES TO THE MAXIMUM VALUE POSSIBLE THE BETTER YOU ARE DOING IN THAT SPECIFIC SECTION. CO M W o pi o H CO to 3 Z CO O CO l-H W H Pi <3 H FU CO :=> u u O a co CO CO w Pi . H fn CO p-3 C O <j CO o 3 CO H frf CO w P4 co a o u p o o co a N H O O M ! O N v O i n - J c n N H O H N n < - l / l v D N C O O \ O H f < ) H H H H H H + + + + + + + + + + + + I CO 103 Section III Assessment and Promotion of Physical Fitness S p e c i f i c Goals This section i s designed to provide you with an i n t e l l e c t u a l under-standing and a personal e x p e r i e n t i a l assessment of p h y s i c a l f i t n e s s . I t then suggests ways you can achieve t h i s and help others to t h i s end. Safety i s a concern when.you are being encouraged and encouraging others to be more p h y s i c a l l y a c t i v e . The ParQ i s a handy screening t o o l to use f i r s t on ourselves and then with others. Take a look at the i n s t r u c t i o n s "How to use i t " and f i l l i n the questionnaire yourself. As you use t h i s t o o l i n your p r o f e s s i o n a l ro l e , f o r your own safety make sure anyone who has any "yes" answers seeks medical evaluation before they take any p h y s i c a l f i t n e s s assess-ment or you make suggestions f o r them to be more p h y s i c a l l y a c t i v e . S p e c i f i c Objectives A. Objectives r e l a t e d to C.V. Fitness 1. Define Physical F i t n e s s . 2. Define the 3 main elements to be emphasized i n adult f i t n e s s . 3. Explain cardiovascular f i t n e s s as the most s i g n i f i c a n t contributor to a well-conditioned body. 4. Explain how to compute target heart rate f o r C.V. f i t n e s s . 5. Describe 2 simple t e s t s for C.V. f i t n e s s . 6. Discuss how to promote C.V. f i t n e s s . Objective #1 D e f i n i t i o n of Physical Fitness Many misconceptions e x i s t as to the d e f i n i t i o n of p h y s i c a l f i t n e s s . Any youngster can put i t in simple words such as "strong, f a s t or wind" and be remarkably accurate. However, i t must be agreed that p h y s i c a l f i t n e s s i s but one part of what might be c a l l e d t o t a l f i t n e s s , which includes mental, emotional, and s o c i a l f i t n e s s . P h y s i c a l f i t n e s s r e f e r s to the p h y s i c a l — i t may be c a l l e d p h y s i c a l f i t n e s s , organic f i t n e s s , or p h y s i o l o g i c a l f i t n e s s . Physical f i t n e s s cannot be represented by any one item, rather i t i s made up of many items. Too often p h y s i c a l f i t n e s s i s thought to be synonomous with strength. A strong man may not n e c e s s a r i l y be p h y s i c a l l y f i t , since strength i s but one a t t r i b u t e of f i t n e s s . The strong man may t i r e e a s i l y , have high blood pressure, and be incapable of doing work f o r a prolonged period of time. Broad shoulders, narrow hips and a lack of external f a t may be desirable; however, t h i s i s not n e c e s s a r i l y an i n d i c a t i o n of t h i s p h y s i c a l f i t n e s s . 104 PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)* A Self-administered Questionnaire for Adults I P A R - Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of P A R - Q is a sensible first step to take if you are planning to increase the amount of physical activity in your l i fe. For most people physical activity should not pose any problem or hazard. P A R - Q has been designed to identify the small number of adults for whom physical activity might be inappropriate • or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read them care-fully and check the 0 YES opposite the question if it applies to you. YES • 1. • 2. • 3. • 4 • 5. • 6. • 7. Do you frequently have pains in your heart and chest? Do you often feel faint or have spells of severe d izz iness? Has a doctor ever said your blood pressure was too high? Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise? Is there a good physical reason not mentioned here why you should not follow an activity program even if.you wanted to? Are you over age 65 and not accustomed to vigorous exercise? you have not recently done so, consult with your personal physician by telephone or in person B E F O R E increasing your physical activity and/or taking a fitness test, Te l l him what questions you answered Y E S on P A R - Q , or show him your copy. After medical evaluation, seen advice from your physician as to your suitabil i ty for: q unrestricted physical act iv i ty, probably on a gradually increasing bas is . 8 restricted or supervised activity to meet your specif ic needs, at least on an initial basis. Check in your community for special programs or services. If you answered P A R - Q accurately, you have reasonable assurance of your present suitability for: 9 A G R A D U A T E D E X E R C I S E PROGRAM -A gradual increase in proper exercise pro-motes good fitness development while mini-mizing or eliminating discomfort. © AN E X E R C I S E TEST - Simple tests of fit-ness (such as the Canadian Home Fitness Test) or more complex types may be under-taken if vou so desire. % f f & & r S » « B » » ^ ^ - Developed by the British Columbia Department ot Health. Conceptualized and critiqued Dy the Multidiscipllnary Advisory Board on fcxer-cise (MABE). Translation, reproduction and use In its entirety Is encouraged. Modifications by written permission only. Not to be used for commercial advertising in order to solicit business from the public. Reference: P A R — Q Validation Report, British Columbia Department of Health, June, 1975. , 105 The PAR-Q & You -- What i t is and How to Use It  WHY PHYSICAL ACTIVITY? The human body needs regular physical activity in order to function at it s best. Disease states related to lack of sufficient activity are Proliferating. There has been a steady rise in cardio-vascular disease, tension related complaints, obesity, low back pain and problems which result from musculo-skeletal weakness. On the other hand, physical and mental health, and social benefits can be enhanced from regular participation in individual, group and family recreation, sports, and/or fitness programs. PAR-Q AND YOU PAR-Q is a sensible f i r s t step to take i f one is planning to increase the amount of physical activity in his or her l i f e . For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate, or those who should have medical advice concerning the type of activity most suitable for them. PAR-Q i s : - a Physical Activity Readiness Questionnaire - a sensible pre-exercise checklist for adults - a suitable exercise test preliminary - easily self-administered PAR-Q is not: - an activity or fitness program - a substitute for those needing a medical evaluation - time consuming ORIGINS PAR-Q arose out of concept of the Multi-disciplinary Advisory Board on Exercise (MABE), as a' simple, yet safe, method of assisting the entry of sedentary adults to physical activity programs. Research and development was under-taken by the British Columbia Department of Health. Intensive medical and physiological evaluation of over 1,200 persons, and fi e l d use by an additional 4,000 persons, has substantiated the value of such an approach. WHO ADMINISTERS PAR-Q 1. SELF-ADMINISTRATION - home use - motivational campaigns (eg. conferences and other gatherings) 2. CONTROLLED ADMINISTRATION - community exercise programs - exercise establishments 106 - sports and recreation clubs - employee fitness programs 3. MEDICAL ADMINISTRATION - physicians' offices ----- health centres and other medical settings 107 The elements which make up p h y s i c a l f i t n e s s are: Strength, cardiovascular endurance,speed, a g i l i t y , power, f l e x i b i l i t y ,  balance and coordination. An i n d i v i d u a l must be above average i n  a i l of these areas to be considered p h y s i c a l l y f i t . A p r a c t i c a l l y r e l a t e d d e f i n i t i o n of f i t n e s s i s : when you are p h y s i c a l l y f i t , i t means you have the f u n c t i o n a l capacity to meet the days usual demands with a reserve capacity to meet the unusual. Objective #2 Define the 3 Main Elements to be Emphasized i n Adult Fitness Cardiovascular endurance r e f e r s to the e f f i c i e n c y by which oxygen i s taken i n t o the lungs and i n t o the blood stream and c a r r i e d to the various parts of the body where i t i s needed. In a t h l e t i c s t h i s type of endurance i s important to the runner, swimmer, or anyone whose a c t i v i t i e s require great amounts of oxygen. The i n d i v i d u a l who has d i f f i c u l t y i n breathing while climbing s t a i r s , or when running for a bus or t r a i n , or when swimming a l i t t l e too f a r or long, demonstrates a lack of cardiovascular endurance. Muscular strength — a strong muscle i s a powerful muscle, capable of a maximum explosive force and also a muscle which can endure, r e -peat the same strength action many times. F l e x i b i l i t y means a b i l i t y to move the j o i n t s , the opposite of being s t i f f or having l i m i t e d range of movement. A f l e x i b l e body can e a s i l y handle a broad range of movements. Objective #3 Cardiovascular F i t n e s s : The Most S i g n i f i c a n t Contributor to a Well-Conditioned Bod; Although many things contribute to a well-conditioned body, the key to a l l i s c i r c u l a t i o n of the blood. We may survive, but not t h r i v e , i f the supply of blood, even though s u f f i c i e n t f o r bare existence i s i n s u f f i c i e n t to support a c t i v i t y and growth. Unfortunately, cardio-vascular f i t n e s s i s not r e a d i l y apparent and therefore to many i t does not rank as the most important reason to be f i t . The uninformed person i s usually more i n t e r e s t e d i n h i s weight and appearance. The r e a l difference between a tr a i n e d heart and an untrained heart  i s the r e s t i n g heart rate. A low pulse rate i n a healthy person i n d i c a t e s that the heart i s beating more slowly and e f f i c i e n t l y . To t e s t cardio-vascular f i t n e s s , the pulse rate i s elevated through p h y s i c a l a c t i v i t y and then i t s return to normal i s measured. A trained heart w i l l reco-ver from a c t i v i t y f a s t e r than an untrained heart. These recovery rates w i l l improve at any time in our l i f e t i m e when we begin a per-sonal f i t n e s s program with a cardiovascular emphasis. The actual e f f e c t of t h i s program i s that the muscle mass, blood volume, power of the heart a l l increase, as do the number of blood vessels. To further understand some of the processes which occur i n C.V. t r a i n i n g , we need to understand how the body produces energy. A e r o b i c a l l y , (with oxygen), nutrients and Oxygen are brought to the muscle by the blood stream and t h i s process continues as long as the oxygen and n u t r i e n t supplies are met. Anaerobically, (without oxygen), 108 the second way the body creates energy i s a process i n which the body uses energy stores r i g h t at the muscle themselves. In t h i s process a great deal of l a c t i c a c i d i s produced which eventually fatigues and i n h i b i t s the muscle. As the oxygen uptake(which i s simply the measure of the body's a b i l i t y to take in oxygen, combine i t with nu t r i e n t s and l i b e r a t e energy) of the body improves through aerobic t r a i n i n g , the person w i l l be able to perform the same amount of work only using le s s energy because t h i s process for cre a t i n g energy becomes more e f f i c i e n t . I t ' s e a s i e r than you may think to achieve t h i s e f f e c t . Objective #4 Explanation of Target Heart Rate for C.V. Training 5 The diagram i l l u s t r a t e s the zone area you should be working within to achieve the C.V. t r a i n i n g e f f e c t . I t i s also within t h i s range that your pulse rate should r i s e i n a t e s t of C.V. f i t n e s s . Heart Rate Target Zone B- -B 40 50 60 Upper Limit (200 minus your age) Lower Limit (170 minus your age) For t r a i n i n g and t e s t i n g purposes, the lower l i n e (170 - Age) i s the threshold below which t r a i n i n g w i l l not occur. I f you are j u s t begin-ning a personal f i t n e s s t r a i n i n g program, you may have to spend several weeks to gradually r a i s e your pulse to t h i s l e v e l . The top l i n e (200 - Age) i s the maximum heart rate above which you should not proceed for safety purposes. 109 Objective #5 Explanation of the Tests for C.V. Fitness *N.B. Do either (a) or (b) to assess your C.V. fitness. If doing test (a) you must elevate your pulse sufficiently high,(125-150, higher for younger, lower for older) before you take your recovery heart rates. Your pulse should ideally be within the heart target range before you take your recovery heart rates, but as was stated before, you need to  proceed gradually towards this heart range i f you are just beginning C.V.  Training. People just beginning C.V. Training should not aim to have their heart rate within the target zone before taking recovery rate pulses. Therefore, select a piece of music to which beat you w i l l jog on the spot, which w i l l challenge you, but not exhaust you. People who have begun C.V. training should aim to raise their heart rate to the target zone before taking recovery rates. XXX a. The three minute run in place test - take your resting pulse - begin your run on the spot for 3 minutes to the music ( i f i t is too strenuous, stop and walk in place for the remaining time) - l i f t your feet at least 4" off the floor - stop when music finishes and immediately take your pulse - take pulse 1 minute after run - take pulse 2 minutes after run Some norms indicating good cardiovascular fitness are: a. A return to a pulse of 120, 3 minutes after exercise b. A return to a pulse of 100, 5 minutes after exercise A pulse rate which returns to normal 5 minutes after this exercise probably indicates good C.V. fitness. Anyone's pulse which did not return to normal in 10 minutes indicates poor C.V. fitness. XXX b. The Canada Home fitness test - Take your resting pulse - perform the test as instructed on the record - record your pulses 3 minutes after the exercise - record your pulse 6 minutes after the exercise See Section III for fitness profile. Objective #6 Discuss how to Promote C.V. Fitness A variety of activities could be used for your cardiovascular fitness emphasis. For example, brisk walking, jogging, swimming, cycling, ski-110 touring. These a l l involve exercises for an extended period of time maintain-ing the heart rate at a reasonably high rate. A. Suggested Jogging Program Following this procedure makes i t d i f f i c u l t for the jogger to over-exert himself. This type of program is well suited to those who enjoy complete freedom from formal, competitive ac t i v i t i e s . How to Jog Make sure you jog relaxed and natural. Choose a style easiest for you: a. Heel-to-toe-technique -- Land f i r s t on the heel of your foot and then rock your body forward to take off on the bal l of the foot. This detailed action is used by most long distance runners, since i t ' s not t i r i n g . b. Flat-footed — Instead of hitting f i r s t with the heel, the entire foot lands on the surface at the same time. This method distributes pressure over the entire foot, and often eliminates potential bruising when running overland or on a hard surface. A Jogging Program Start slowly by alternately walking and jogging a quarter mile the f i r s t week. For example, alternate jogging and walking 110 yard distances to complete the quarter mile. (Quarter mile equals 440 yards). Continue using the jogging/walking sequence and gradually build up to one mile by the end of week five. The sixth week jog 330 yards and walk 110 yards. The seventh week, start jogging a mile at a speed which would permit you to talk easily with a running companion. I l l B.Objectives Related to Fat Storage 1. Discuss the body's f a t storage areas 2. Describe and perform the pinch t e s t f o r f a t measurement 3. Describe how to deal with excessive body f a t . Objective #1 Discuss the Body's Fat Storage Areas I t would seem that our bodies have t h e i r favourite spots i n which they can s a f e l y store f a t . The f i r s t step i n dealing with t h i s un-s i g h t l y problem i s in c l e a r l y i d e n t i f y i n g these spots. Therefore, l e t ' s take a good look at ourselves. Body f a t i s stored i n several places i n the body and measurements can be taken i n these areas. a. the back of the arm midway between the shoulder and the elbow j o i n t a diagonal f o l d on the i n t e r i o r angle of the lower t i p of the scapula a diagonal f o l d a t the c r e s t o f the i l i u m i . e . the highest peak on the side of the p e l v i c bone a v e r t i c a l f o l d approximately 1" to the r i g h t of the umbilicus a v e r t i c a l f o l d on the f r o n t of the thigh, midway between the h i p and knee j o i n t s f. the chest (for men only) a diagonal f o l d on the p e c t o r a l l i n e , midway between the a x i l l a r y f o l d and the nipple Objective #2 Describe and Perform the Pinch Test f o r Fat Measurement A simple measurement — the Pinch Test - take a pinch of skin i n any of these areas, p r e f e r a b l y the back of the. arm - be c a r e f u l to take i t i n the r i g h t spot, as mentioned above and take only the underlying f a t , not the muscle tis s u e - the wider the s k i n f o l d , the thi c k e r the layer of subcutaneous f a t The norms f o r women f o r the pinch t e s t : 1/2" of f a t good 1" of f a t average, but f a t 1 1/2" of f a t obese b. the back c. the hip d. the abdomen e. the thigh 112 The norm of 1 1/2" of fat for women, 1" of fat for men has been found by research to be a reliable indication that 30% of the person's body weight i s adipose tissue. The average amount of fat in body composition is 18-227o (women) , 16-207o (men) . Remember — our aim is to the optimal, not the average norms!! See Section III for fitness profile. Objective #3 Dealing with Excessive Body Fat The only way we are going to lose fat is to force the body to burn up these favourite holding spots. This means simply that we must eat less so that these stores w i l l be pilfered. Exercise for these spots alone w i l l not do the trick although i t w i l l help to tone up muscles in .this area. Learn to think like a diabetic, balance your daily activity and food intake wisely. Think of the areas where specific exercise to tone up muscles would complement your nutritional efforts. . C. Objectives Related to F l e x i b i l i t y Assessment and Promotion 1. Discuss f l e x i b i l i t y as an aspect of fitness 2. Describe and perform the 4 quick measures of bodily f l e x i b i l i t y 3. Describe how to promote bodily f l e x i b i l i t y Objective #1 F l e x i b i l i t y — an Aspect of Fitness There is a marked incidence of lower back pain and disability among middle aged people. In many cases, this reduced f l e x i b i l i t y could be greatly helped by a program of exercise. Objective #2 Four quick tests of bodily f l e x i b i l i t y There is no general f l e x i b i l i t y test representative of total body f l e x i b i l i t y because f l e x i b i l i t y is specific to the joint in question. However, the following are some quick assessments. However, these are broad norms. XXX Test 1. Head F l e x i b i l i t y - you should be able to turn your head so that your chin is over your shoulder 2. Shoulder F l e x i b i l i t y - hold a yardstick with both hands out in front of you. Take the yardstick right over your head, continuing to hold i t with both hands, to behind your back. You should be able to do this. Note the number of inches apart your hands are on the ruler. The fewer the inches apart, the greater the shoulder f l e x i b i l i t y . 113 4. Trunk F l e x i b i l i t y (a) (simple test) Trunk F l e x i b i l i t y (b) (detailed test) (There is a limited danger that the subject could pull a muscle or strain his back with too vigorous a movement in this test. It i s re-commended that a short warm-up of stretching exercises precede the actual measurement, and the sub-ject refrain from fast, jerky movements.) stand with your legs together, knees locked and bend at the waist to touch the toes. Women should be able to touch the floor with the palms of their hands. Men should be able to touch the floor with their fingertips. Caution: If you can't touch the floor as indicated, don't try to force by bouncing. assume a si t t i n g position on the floor with the legs extended at right angles to a line drawn on the floor. The heel should touch the near edge of the line and be about 5 inches apart. Slowly reach with both hands as far forward as possible on the yardstick and hold the position momentarily. The yard-stick is placed between the legs .of the subject so that i t rests on the floor with the 15 inch mark restin on the near edge of the heel line. The score i s the most distant point i n inches reached on the yardstick by the fingertips in the best of three t r i a l s . Compare results to norms: Men Women Excellent Good Ave rage Fair Poor 22-23 inches 20-21 inches 14-18 inches 12-13 inches 10-11 inches Excellent Good Average Fair Poor 24-27 inches 21-23 inches 16-20 inches 13-16 inches 10-12 inches See Section III for fitness p r o f i l e . Objective #3 Fl e x i b i l i t y Promotion F l e x i b i l i t y or suppleness, is the a b i l i t y of the joints and muscles of your body to produce a wide range of motions from toe-touching to smooth and graceful walking. People with poor f l e x i b i l i t y tend to be more accident prone and usually tire more easily. Strangely enough, strength and endurance exercises,while essential to physical fitness, act to shorten muscles and reduce f l e x i b i l i t y . That's why i t ' s important to include muscle stretching movements and ones that move our joints. 114 Muscle tears, p u l l s and s t r a i n s occur because of a lack of f l e x i b i l i t y . Even muscle problems which are diagnosed as rheumatism or a r t h r i t i s are often the r e s u l t of severely l i m i t e d f l e x i b i l i t y . Any s t r e t c h i n g , bending, reaching or t w i s t i n g motion improves f l e x i b i l i t y . Touching the toes, slowly, and c a r e f u l l y at f i r s t , can "loosen up" j o i n t s . Research shows that j o i n t s become more mobile when a regular program i s followed using s t a t i c holding p o s i t i o n s at the end points of the range of motion or using very small pushing and r e l e a s i n g actions at  the end point. Large swinging actions not only can be harmful to connective t i s s u e , but often don't even reach the end point where act u a l s t r e t c h i n g occurs. Whenever po s s i b l e , a contraction of the muscle group to be stretched w i l l a i d i n r e l e a s i n g i t f o r the s t r e t c h i n g action to follow. You now know the p r i n c i p l e s of promoting b o d i l y f l e x i b i l i t y . Now think o f some actual exercises to accomplish t h i s y ourself. D. Objectives Related to Strength Assessment and Promotion 1. Discuss muscle strength as an aspect of f i t n e s s 2. Describe and perform a simple strength t e s t 3. Describe how to promote b o d i l y muscle strength Objective #1 Muscle Strength — an Aspect of Fitness Symptoms of weak muscles are flabby hips 'and arms, pot b e l l y , round shoulders are often the r e s u l t of unexercised muscles. A strong muscle i s capable of a maximum explosive force and r e p e t i t i o n of the same action many times. Muscle strength f o r the e n t i r e body cannot be measured p r e c i s e l y because there are so many muscle groups to consider. What we do i s measure the strength of i n d i v i d u a l muscle qroups which w i l l give a rough idea of the muscle strength of the body. A muscle has the p o s s i b i l i t y of working i n 2 d i f f e r e n t ways — I s o t o n i c a l l y and Isometrically. I s o t o n i c a l l y r e f e r s to a contraction i n which the muscle i s changing i t s length eg. a chin-up. Isome t r i c a l l y r e f e r s to a contraction i n which the muscle does not change i t s length eg. pushing against the door frame. Many exercises incorporate both contractions. I s o t o n i c a l l y f i r s t to get the body i n t o p o s i t i o n and isometric to overload or fatigue the muscle as you hold f o r 6 seconds. This aspect of f i t n e s s has a small chance f o r development i n today's way of l i f e . I t has even been s a i d to run a c o l l i s i o n course to femininity. However, Dr. Dorothy Harris of Penn. State U n i v e r s i t y , an expert on the e f f e c t s of conditioning through sports, says that women develop b e t t e r contour l i n e s as they develop more strength. 115 Muscle s i z e i s determined by a genetic and hormonal p r e d i s p o s i t i o n and therefore, unless already predisposed to t h i s , through t r a i n i n g alone, g i r l s do not develop unsightly muscles. Objective #2 Describe and Perform a Simple Strength Test Lie face down on the f l o o r . Place your hands on the f l o o r at shoulder l e v e l . F u l l y extend the arms to r a i s e the body with back, legs and head s t r a i g h t . Lower body u n t i l the chest i s 1" from the f l o o r . Re-peat without bending. Norms: Women should be able to do 4-6 Men should be able to do 8-10 See Section I I I f o r f i t n e s s p r o f i l e . Objective #3 Strength Promotion The quickest way to strengthen a muscle i s to overload i t as much as pos s i b l e . Without weights, the only way to achieve an overload i s by holding a p a r t i c u l a r p o s i t i o n f o r a period of time which puts the muscle in t o fatigue. ( A quivering muscle i s a good i n d i c a t i o n of the desired fatigue which develops muscle strength.) Each exercise need only be repeated 5 times as long as i t i s being h e l d for 6 seconds each time. You now know the p r i n c i p l e s of the promotion of muscle strength. Now think of some exercises to accomplish t h i s yourself.  Be c a r e f u l not to hold your breath when doing these exercises of strength promotion and e s p e c i a l l y exercises of the chest,as t h i s could cause a r i s e i n B.P. which might be dangerous, e s p e c i a l l y to older people. Objectives Related to Dangerous Exercises 1. Discuss why the exercises of toe-touching, back bending, standing on toes, l e g l i f t i n g , and deep knee bends are considered danger-ous,and suggest supplements. Objective #1 Discuss Dangerous Exercises What are dangerous exercises? Why are some people more prone to i n j u r y than are others? Why do some people get hurt as a r e s u l t of exercises and others not? These questions are quite c o n t r o v e r s i a l and extremely d i f f i c u l t to answer. In f a c t , some of them j u s t cannot be answered conclusively because of our present lack of knowledge. The subject of safe and unsafe exercises has been clouded by emotions, incomplete information, t r a d i t i o n and i n some instances, a lack of good, s o l i d research. Many ph y s i c a l educators and medical doctros have disagreed on the value of c e r t a i n exercises and have f a l l e n back on statements such as " I t worked f or me and i t w i l l work f o r others". 116 and "Ilearned that exercise when I was i n c o l l e g e , so i t must be a l l r i g h t " . Although almost any exercise can be harmful i f done i n c o r r e c t l y , toe- touching, back bending, standing on toes, leg l i f t i n g and deep knee  bends are the most talked-about p o t e n t i a l v i l l a i n s . Toe-touching Toe-touching has been c r i t i c i z e d because i t does not do what most people expect — t r i m the w a i s t l i n e . The action of bending forward and bouncing i n an attmept to touch the toes forces the knees to over-extend and places tremendous amounts of pressure on the lumbar vertebrae, a f a c t o r b e l i e v e d by many to have an e f f e c t on low back complaints. Dr. W.H. Fahrni, a s s i s t a n t i n orthopedics, U n i v e r s i t y of B r i t i s h Colum-b i a Medical Faculty, has advocated ab o l i s h i n g t h i s exercise. He has been c r i t i c a l of toe-touching because of i t s p o s s i b l t detrimental e f f e c t on the discs of the v e r t e b r a l column. Others l e s s adamant have s a i d that toe-touching i s a l r i g h t i f a person c u r l s down gradually or bends t h e i r knees while touching t h e i r toes. S t i l l other f i t n e s s experts do not caution people about t h i s exercise at a l l . Leg L i f t s Leg l i f t s -— supine l y i n g , l e g r a i s i n g — have been c r i t i c i z e d because they can increase the s e v e r i t y of low back ailments. Although often recommended as a w a i s t l i n e trimmer, research has demonstrated that other forms of exercise are more e f f e c t i v e f o r trimming the abdominal area than are leg l i f t s . Deep Knee Bends Deep knee bends have been c r i t i c i z e d because the f o r c e f u l deep squatting stretches the l a t e r a l ligaments of the knee. I f the s t r e t c h i n g i s excess-ive, the natural protection of the knee i s a l l but eliminated. Also, i n some instances, the c a r t i l a g e o f the knee can be pinched by the deep squatting. One important po i n t should be considered. F u l l knee bends or deep knee bends r e f e r to going a l l the way — that i s , having the buttocks touch the heels of the f e e t . Many people have the mistaken idea that anything beyond half-way i s dangerous. I t i s important to p o i n t out that bending the knees so that the thighs are p a r a l l e l to the f l o o r i s acceptable and w i l l not cause any damage to the knees. Body Arches The body arch has been c r i t i c i z e d because i t forces the back i n t o over-extension. Such s t r e s s exaggerates the condition of swayback or l o r d o s i s i f i t i s present. Also, the a n t e r i o r l o n g i t u d i n a l ligament of the verte-brae i s stretched. I f i t i s stretched repeatedly, i t w i l l become perma-nently lengthened. The lengthening w i l l weaken the j o i n t s t r u c t u r e . 117 Standing on Toes or Toe Raises This exercise has been c r i t i c i z e d because i t stretches the structures of the f e e t and w i l l weaken the arch. I t has a l s o been condemned because i t develops muscular imbalance. That i s , muscles of^the back of the l e g are not s t r etched properly. This i s true of any exercise.You should be c a r e f u l about e x e r c i s i n g one muscle group e x c l u s i v e l y . E x e r c i s i n g one muscle group produces a muscle imbalance t h a t can cause i n j u r y . Replacement Exercises What are the a l t e r n a t i v e s ? In place of toe-touching f o r trimming the w a i s t l i n e , s i t - u p s with V-seats can be f a r more e f f e c t i v e . Some people do toe-touching to strengthen the low back. The s i t t i n g bend and s t r e t c h and the s i t t i n g toe-touch w i l l be more e f f e c t i v e and without the r i s k s . To do the s i t t i n g bend and s t r e t c h , s i t on the f r o n t edge of a c h a i r , f e e t on the f l o o r , shoulder width apart, and your hands on your hips. Inhale deeply and exhale while bending forward, p l a c i n g the hands on the f l o o r . Inhale while r e t u r n i n g to the s t a r t i n g p o s i t i o n . For the s i t t i n g toe-touch, s i t on the f l o o r with your legs out i n f r o n t of you. Gradually bend forward from the waist and move your forehead down toward your knees. Do t h i s e x e r c i s e very slowly and without any bouncing movement. Return to the s i t t i n g p o s i t i o n . Most people do l e g l i f t s to strengthen t h e i r abdominal muscles. Research and p r a c t i c a l experience have c o n c l u s i v e l y shown that t h i s exercise has not been as e f f e c t i v e as s i t - u p s with -the knees bent and V-seats. Deep knee bends should be e l i m i n a t e d by everyone. Replace them with three-quarter knee bends. That means the knees can be bent u n t i l the thighs are p a r a l l e l to the f l o o r . Three-quarter knee bends are j u s t as e f f e c t i v e as deep knee bends, except the ligaments are not stretched e x c e s s i v e l y . Most people r e l y on the body arch to improve back strength and f l e x i b i l i t y . A b e t t e r choice i s the s i t t i n g bend and s t r e t c h and the s i t t i n g toe touch. The movement should be r a p i d — not f o r c e f u l , however. Toe r a i s e s can be done s a f e l y with the toes inverted s l i g h t l y . To help s t r e t c h the heel cord, the exercise can be done while standing with the toes on an inch-thick board. The c a l f - s t r e t c h should also be used to s t r e t c h the cord. I t i s done by standing erect, hands on hips, l e f t foot placed forward i n s t r i d e p o s i t i o n . The toes of both feet should be pointed s t r a i g h t ahead. Now lean forard as f a r as p o s s i b l e , keeping the heel of the rear foot i n contact with the f l o o r . Be c e r t a i n to repeat with the other l e g forward and the opposite leg back. 118 Your Decision Is the whole matter o f dangerous exercises a tempest i n a tea cup? Some would say yes -- but obviously they are not among those who have been in j u r e d doing the wrong exercises. .Decisions on what exercises you want to do are yours to make. With the exception of forced or deep knee bends, i f you have not encountered any d i f f i c u l t y with the exercises you are doing, you needn't be p a r t i -c u l a r l y concerned. I f you have low back pains, a shortening of the heel cord,or are plagued with knee problems and musculo-skeletal i n j u r i e s , you w i l l be very wise to avoid the p o t e n t i a l l y dangerous exercises. As the c l i c h e has i t , " I f i n doubt — don't!!". F. Objectives Related to Your Own Fitness Program 1. Describe the 3 ba s i c elements of a personal f i t n e s s program 2. Describe how often and how long a person needs to exercise 3. Design your Own Personal Fitness Program Objective #1 The Three Basic Elements of a Personal Fitness Program 1. S t a r t with a warm-up. In order to prepare the body f o r strenous work, as good warm-up i s highly recommended. A combination of rhyth-mical and relaxed a c t i v i t i e s — walking, slow jogging, arm c i r c l e s , e t c . - w i l l stimulate c i r c u l a t i o n and r a i s e body temperature, thereby warming the muscles i n preparation f o r the st r e t c h i n g and f l e x i n g to follow. This aspect combined with s t r e t c h i n g of ligaments and mobilization of j o i n t s , i s h e l p f u l i n the prevention of muscle sore-ness or i n j u r y during heavier exercises. The length of the warm-up depends on the type of a c t i v i t y to follow, but 5-8 minutes should be considered the minimum necessary. See Astrad, Health and Fitness, p 34-37. 2. Include your cardiovascular emphasis. Running may not be your s t y l e — that's o.k., but think of what i s your s t y l e . . . . i s i t swirrrming, b i k i n g or cross-country s k i i n g , or skating or hiking? Be c r e a t i v e . See Astrad, Health and Fitness, p. 38-40. Test y o u r s e l f to see i f you are achieving your target heart rate throughout t h i s a c t i v i t y . I t i s r e l a t i v e l y simple to assess whether or not you are working hard enough to improve your c a r d i o r e s p i r a t o r y f i t -ness. When beginning your program, determine your Heart Rate (per minute) Target Zone and monitor your heart rate at i n t e r v a l s throughout each exercise period. The quickest method i s to stop and take your pulse f o r 10 seconds, m u l t i p l y by 6 to get your heart rate per minute, and then continue e x e r c i s i n g immediately so as not to lose the sus-tained nature. A word of caution Heart rate monitoring i s a valuable t o o l i n the ea r l y stages of a t r a i n i n g program, but don't overdo i t . A f t e r a while y o u ' l l have a natural f e e l f o r the appropriate l e v e l s of a c t i v i t y and won't need to use the monitoring technique. 119 3. End with a cool down. A c o l l i n g - o f f period should always follow a workout. I t i s a gradual slowing down from high a c t i v i t y to low a c t i v i t y which allows for proper heat d i s s i p a t i o n so that s h i l l s and cramps do not develop. Objective #2 Discuss How Often and How Long a Person need Exercise The i d e a l s i t u a t i o n f o r imporving o v e r a l l f i t n e s s would be to exercise every day f o r 30 minutes or more; however, the minimum exercise re- quirement to show a s i g n i f i c a n t increase i n f i t n e s s i s 3 times per  week f o r 30 minutes each time. Of t h i s 30 minutes, at l e a s t one quarter hour should be r e l a t i v e l y high i n t e n s i t y exertion (based on "target"  heart rate as per #3 below.) This portion should always be preceded by an adequate warm-up, and followed by a "cooling down" period of about 5 minutes of lessened a c t i v i t y . The e x e r c i s i n g should be continuous for the e n t i r e h a l f hour or more, and the i n t e n s i t y of the i n d i v i d u a l exercises should be increased week to week. One common misconception i s that an extra-long bout of heavy exercise once per week can take the place of the 3 times per week program. However, the e f f e c t s of an exercise period are l o s t within a few days, unless the exercise i s repeated. Objective #3 Design Your Own Fitness Program I t ' s now time to design your own personal program incorporating the 3 emphasized elements of f i t n e s s . This i n s t r u c t i o n program suggest a period of 2 months i n which you should "follow through" with your own program and then get together with your partner to re-assess your progress. Your e f f o r t s should be: a. enjoyable - do i t because you l i k e i t , not because i t ' s j u s t good f o r you b. i n v i g o r a t i n g - you should f e e l p l e asantly relaxed, not excessively t i r e d afterwards c. regular - f o r improved f i t n e s s , e x e r c i s i n g 3 times a week i s twice as good as 2 times a week. 120 PHYSICAL FITNESS PROFILE I. Cardiovascular Tests F i r s t Assessment Second Assessment Resting Pulse A. The 3 minute jog on spot. Pulses After Jog Immedi-ately minutes 5 minutes Pulses After Jog Immedi-| ately 3 minutes 5 minutes Fi r s t Assessment Second Assessment Resting Pulse Pulses After Stopping 3 minutes B. The Canada Home Fitness! Test 6 minutes Pulses After Stopping 3 minutes 6 minutes Instructions: Do either test (A) or Test (B). If using test (A) use the same music for your f i r s t and second assessment. II. Body Fat Measurement Fir s t Assessment Second Assessment A. Identify the fat storage area and measure. I l l . F l e x i b i l i t y 121 Fi r s t Assessment Second Assessment A. Head B. Shoulder C. Truck (simple test) D. Trunk (detailed test) IV. Muscular Strength Fi r s t Assessment Second Assessment A. Number of push-ups 122 Section IV Goal Establishing Specific Goals This section is designed to help you i n the development of your personal health goals. Several different tools to aid i n this process are presented and suggestions are given for u t i l i z i n g them in real l i f e situations. From this personal experience i n goal setting, i t is hoped you w i l l then be better able to help others i n this process. Specific Objectives 1. Suggest seven points i n establishing H.P. goals. 2. Describe the key to your cr e d i b i l i t y as a health promoter. 3. Apply the seven step creative problem solving process to one aspect of your own health needing promoting. 4. L i s t ten principles of the acceptance of change and apply to one professional situation needing the promotion of health. 5. Describe the process of urge-management. 6. Outline the reward program. Objective #1 Seven Points in Establishing Health Promotion Goals a. Make specific plans with another person to get together for your mutual encouragement. It has also been demonstrated that support and encourage-ment from a significant other person (family or friend) significantly helps people to continue towards their goals. b. Keep your schedule for exercise and goal sheet i n an easily-seen spot. c. Keep i n touch with the group counsellor. Ask her for help i f you need i t or just l e t her know how you are doing. d. Develop your own reminding system eg. Notes to yourself on the fridge, as "what, you again?", keep your exercise clothes in plain sight. Keep a record of your behaviour. e. Think i n very specific and practical ways of how to build i n this change of behaviour into your daily a c t i v i t i e s . f. F i l l in your reward system and use i t . g. Where appropriate, use the urge-management approach. 123 Objective #2 The Key to Your Credibility as a Health Promoter If you are working on your own personal goals through this instruction you are working on the f i r s t identified c r i t e r i a in the RNABC position paper in Health Promotion, "Be a Role Model for Health". This is the  key to your credibility as a health promoter. Along with the knowledge you have gained, this action of yours should help you to share what you know of the path to optimal health with others. This would f u l f i l l the second and third c r i t e r i a of the paper, 'Act as a Change Agent for Others', "Encourage l i f e s t y l e activities compatible with optimal health". Objective #3 Apply the Seven Step Creative Problem Solving Process to One Aspect of Your Own Health Needing Promoting.  1. Confronting the Mess - acknowledge the predicament and dissatisfied feelings (we are more creative and efficient i f we accept and understand what's happening) eg. I am not feeling good about myself. I am often depressed and i r r i t a b l e . 2. Clarify the Fuzzy Problem - write out a factual, not emotional explanation of the s i t u -ation. Answer questions, who, what, when, where, why, how. eg. I have put on 5 lbs. over the summer. My job is very much more time consuming. 3. Fact Finding - write out information you need to have related to the described situation. eg. I need information and help to lose weight. I need to learn how to handle the elements of my work. 4. Idea Finding - l i s t a l l the creative solutions you think of. Eg. i n answer to the question "In what ways might I?" eg. In what ways might I lose weight or handle the pressures of work better? Answer: Increase my activity each day and plan relaxing times. Cut out cookie snacks. 5. Solution Selection - select the most practical and r e a l i s t i c solution. eg. I w i l l swim three times a week and walk on the days I am not swimming for relaxation. I w i l l keep carrot sticks cut up i n the fridge for snacks. 6. Solution Implementation eg. I w i l l try this idea for four weeks using "the suggestions for Establishing Health Promotion Goals" to keep me fa i t h -f u l to myself. 124 7. Evaluation eg. In four weeks I w i l l reassess the situation looking particularly at how I feel, how I am handling my work, how I look and what I weigh. Reference - footnote #8 Objective #4 List Ten Principles of the Acceptance of Change A l i s t of some of the principles of the acceptance of change might help us in our role as change agents. 1. Change is more accepted when i t is understood than when i t is not. 2. Change is more accepted when i t does not threaten security than when i t does. 3. Change is more acceptable when i t results from the application of previously established impersonal principles than when i t is dictated by personal order. 4. Change is more acceptable when those affected have helped create i t than when i t is externally imposed. 5. Change is more acceptable when i t follows a series of successful changes than when i t follows a series of failures. 6. Change is more acceptable when i t is inaugurated after prior change has been assimilated than when i t is inaugurated during the confusion of other major changes. 7. Change is more acceptable i f i t is planned than i f i t is experimental. 8. Change is more acceptable to people new on the job than to people old on the job. 9. Change is more acceptable to people who share i n the benefits of change. 10. Change is more acceptable i f the organization (or person) has been trained to accept change. To i l l u s t r a t e the application of these principles of change, consider this family profile outlined below or develop a family or individual profile of staff worker or patient.of your own. Guidelines: 1. Pick out the areas in this pr o f i l e needing health promo-tion. 2. Establish your promotional goals - highlight the promo-tion of physical fitness. 3. Apply these principles of the acceptance of change in your promotional plan. A Family Profile: Both of your parents are now i n their late f i f t i e s . Your father, hoping to retire at age 60 s t i l l invests most of his time and efforts i n his work, which is of a high stress nature. His relaxa-tion is watching T.V. through the week and light activity around the house on the weekend. He is 20 lbs. overweight. Your mother has made the home her l i f e . Having raised five children, she found l i t t l e time to develop other outside interests. She prepares meals high in carbohydrate and low i n bulk. Her relaxation i s sewing. She is 30 lbs. overweight. An area needing your professional health promotion s k i l l s might exist in your own family. Make up your own profile and follow the above guidelines. 125 Objective #5 Describe the Process of Urge Management Changing how you think about behaviour you wish to change, and strengthen-ing your abi l i t y to make the decision not to succumb to this behaviour, are important steps i n learning how to stand firm with yourself. You can change "thinking habits" just as you can change actual undesired behaviour. The rule is simple: you systematically follow a thought you want to weaken with negative consequences and systematically follow the thinking you want to strengthen with positive consequences. It works like this: Each time you get an urge to behave in this way, you should immediately think about negative consequences of going this way. That w i l l serve to weaken the urge, so that i t w i l l be less intense and less of a problem in the future. Then, you make the decision to not behave i n this way. That is a response you want to s trengthen, so you should immediately think about the positive benefits of doing this activity. So, there are four steps i n changing your thinking about behaviour. Fir s t comes the urge, then the thought of negative association, then the decision not to, and then fi n a l l y the thought of some rewards for not going this way. What you need to do now is to plan good negative and positive thoughts to use in relation to the undesired behaviour. S i t down and draw up two l i s t s , writing down as many possible positive and negative associations to this behaviour as you can. Both positive and negative associations can be of different kinds. One kind of association to use is a vivid mental picture of how things look, taste, smell, or feel. Associations can also take the form of saying something to yourself. You may not want to say i t out loud, but you can say things to yourself. Once you've made a complete l i s t of a l l the possible positive and negative associations for yourself, you should go through these l i s t s and pick out between five and ten associations, for each positive and negative, which are the strongest or best ones for you. Then start systematically using these positive and negative associations to strengthen your decision to not behave i n this way, and to weaken the negative urge. Each time you do follow the urge with negative associations and follow the decision with positive associations, you w i l l find i t i s just a l i t t l e b i t easier to not perform the undesired behaviour the next time. State Undesired Behaviour: Your List of Positive Thoughts. Your List of Negative Thoughts. 126 Objective #6 Outline the Reward Programme Changing behaviour is not easy. It is c r i t i c a l that we do what we can to make this change as satisfying as possible. Learning how to change requires active effort and you should be rewarded for those efforts. You can think of changing your behaviour as a set of s k i l l s you learn. They are alternative ways of coping. People learn better when they are  rewarded. This is the principle of reinforcement: those things we do which prove successful and give satisfaction, we tend to do again, find-ing them easier to do the next time around. If behaving i n the desired way proves stressful, unsatisfying, or unpleasant, i t ' s harder to change. This is the reason for a reward programme. It's a very important part of any behaviour change. You need to design a reward programme for your-se l f , but f i r s t you must plan some rewards and reinforcers for yourself. A reinforcer i s anything positive you can give yourself for right behav-iour. It can be things you like to buy, people you enjoy being with, or activities you find pleasurable. For example, i t i s l i k e l y that at least some of the things i n the following l i s t are reinforcing for you. going out to dinner movies or plays buying clothes not having to do the dishes mountain climbing taking breaks from work a walk after supper bubble baths spending time at hobbies buying records free time from the kids watching TV eating favorite foods sports long weekends listening to music parties spending money being alone reading making decisions about how the family w i l l spend the weekend Reinforcement i s a very individual thing. Your reinforcers have to be rewarding for you. Think of good reinforcers and write them down. L i s t as many reinforcers as you can, the more the better. Then pick a combin-ation of the best ones for you. When you are trying to decide on rein-forcers to l i s t , ask yourself these questions: 127 What do you enjoy that you never get enough of? How would you spend $10. you got for your birthday? If you had a whole afternoon free, how would you spend it? Who would you spend i t with? What makes you feel good? What do you really hate doing and wish you could get out of more often? Are there things you consider luxuries and normally don't allow yourself to buy? What do you do to get away from i t all? How do you like to spend time alone? What could your family do for you as a special treat? Who do you most like to be with? What do you do to relax? >What would be a present you'd like? What things do you do everyday and enjoy (eg., read before bed, eat dessert, play with the kids, have a second cup of coffee, kiss your spouse, l i s t e n to the car radio?) Which of these things would you least like to do without? What do you do for fun? By now, you may have thought of quite a few reinforcers. A good rein-forcer has several important properties. F i r s t , as we've said, i t ' s pleasurable for you. The more pleasurable or rewarding, the better. You must be able to count on i t for enjoyment and reward. Another property a good reinforcer has is that i t comes f a i r l y soon. Going to a play after supper may be a better reinforcer than Christmas i n Hawaii because i t ' s more immediate. So, have fun l i s t i n g some possible reinforcers. Then design a reward program for yourself to keep you with your behaviour change. Your l i s t of reinforcers: Your reward program: 128 GENERAL HEALTH PROMOTION GOALS CONCERNING ASSESSMENT TOOLS Assessment Tool Statement of Personal Goal Plans for Professional Use of Tool Reassessment of Goals Your real age vs your chronological age Exercise recording 7 days Imaginary trip to a healthy spot Nutritional Score Card 7 Day Nutritional Recall Mental Health Assessment i 129 F o o t n o t e s Registered Nurses' Association of British Columbia Position Paper on the Nurses' Role in Health Assessment and Promotion, R.N.A.B.C., 1976 P.l. Physical Activity Readiness Questionnaire, B. C. Department of Health, June, 19 75. Lalonde, Marc. A New Perspective on the Health of Canadians, 0 Hawa, Government of Canada, 1974. Y.M.C.A. Fitness Finders Program, National Y.M.C.A., Emmaus, Pennsylvania. The Canadian Home Fitness Test, Leaders Manual, Health and Welfare, Canada. Op.cit Fitness Finders Program. Conditioning for Stress in Sport, Dr. Dorothy Harris, Pennsylvania State University. Murray and Zenther Nursing Concepts for Health Promotion, Englewood C l i f f s , Prentice Hall, 1975. 130 APPENDIX Ci OUTLINE OF THE TWO-HOUR WORKSHOP Introduction: Fitness Emphasis: Assessment Tools: Goal Setting: 1. Greetings 2. Completion of Pretest Questionnaire 3. Explanation of the Program 4. Armchair Exercises 1. Definition 2. Par-Q General Assessment 3. Cardiovascular Fitness Test 4. Discussion of Ways to Increase Fitness 1. Use of Tools 2. Audience Participation in Risk Factor Analysis 1. Brief Discussion of the Importance of Goals 2. Techniques Found Helpful in Achieving Goals Conclusions: Completion of Post Workshop Evaluation 131 APPENDIX C 2 OUTLINE OF THE ONE-DAY WORKSHOP Introduction: 1. Greetings 2. Completion of Pretest Questionnaire 3. Explanation of the Program 4. Armchair Exercises Fitness Emphasis 1. Definition 2. Par-Q General Assessment 3. Cardiovascular Fitness Test 4. Discussion of Ways to Increase Cardiovascular Fitness * * •* Break * * * 5. Strength and f l e x i b i l i t y tests 6. Discussion of Exercises to Increase Strength and F l e x i b i l i t y Assessment Tools: 1. Imaginary Trip 2. Discussion of Insights * * * Lunch * * * * * * Thirty Minute Walk * * * 3. Discussion of the Importance of Assessment Tools 4. Risk Factor Analysis - Audience Participation and Score Sheet 5. Discussion of Risks and Effects on Health 6. Nutritional Assessment 7. Discussion of How the Assessment Tools could be used * * •* Exercise Routine * * * Goal Setting: 1. Realistic Goal Setting 2. Behavioural Management Techniques Which May 'be Helpful in Achieving Goals 3. Counselling Someone .else Regarding Goals and a Program which could be used to reach the Goals Wrap Up: 1. Conclusions 2. Completion of the Post Workshop Evaluation 132 APPENDIX D OBSERVATION CHECKLIST DATE  LOCATION ; CHAPTER AND DISTRICT  TYPE OF WORKSHOP NUMBER ATTENDING WORKSHOP DID THE GROUP: APPEAR INTERESTED PARTICIPATE IN DISCUSSION GET INVOLVED IN PERSONAL APPLICATION GET INVOLVED IN PROFESSIONAL APPLICATION ASK QUESTIONS ENVIRONMENT: SIZE OF ROOM VENTILATION LIGHT SEATING EXTRANEOUS SOUNDS SPEAKER: INTERESTED IN TOPIC SPOKE CLEARLY RESPONSIVE TO THE GROUP 133 APPENDIX Ei_ TABLE 19 NON-RESPONSE BIAS CHECK FOR THE TWO-HOUR WORKSHOP GROUPS Item Anova Results Two-Hour Response Group N = 99 Two-Hour Non-Response Group N.= 48 Two-Hour Control Group N = 89 X S F 0.86 1.52 0.50 1.62 0.49 1.50 0.50 X s F 5.37 3.10 1.11 3.37 1.20 3.61 0.94 X S F = 2.76 3.47 1.21 3.92 1.11 3.73 1.07 X S F 0.58 3.36 0.88 3.40 1.03 3.51 0.87 X S F 0.13 1.89 0.84 1.85 0.80 1.93 0.94 X S F 1.21 3.69 1.77 3.10 1.71 3.49 1.65 X S F 0.01 1.37 0.49 1.37 0.49 1.36 0.48 X S F 0.16 1.98 0.28 1.96 0.20 1.98 0.50 134 TABLE 19 - Continued Item An ova Results Two-Hour Response Group N = 99 Two-Hour Non-Response Group N = 48 Two-Hour Control Group N = 89 10. X S F 1.48 1.8.1 0.42 1.88 0.33 1.90 0.31 11. X S F 0.61 2.69 0.75 2.84 0.72 2.73 0.81 12. X S F 1.50 0.63 1.63 0.75 1.33 0.54 3.97 13. X S F 1.68 1.28 0.65 1.51 0.87 1.39 0.75 14. X S F 1.22 2.05 0.75 2.27 0.89 2.12 0.81 15. X 3.28 3.43 3.40 S 0.95 0.74 0.85 F 0.68 16. X 3.19 3.23 3.26 S 0.98 1.08 0.97 F 0.11 17, X S F 2.34 1.07 2.41 1.24 2.75 1.13 3.38 18. A.l X S F 2.48 1.02 2.54 0.98 2.47 0.94 0.09 135 TABLE 19 - Continued Item Anova Results Two-Hour Response Group N = 99 Two-Hour Non-Response Group N = 48 Two-Hour Control Group N = 89 18. A.2 X S F 2.62 0.84 2.49 0.74 2.65 0.85 0.53 18. A.3 X S F 2.67 0.95 2.75 0.94 2.83 0.96 0.56 18. A.4 X 2.28 2.14 2.21 S 0.94 0.76 0.92 F . 0.31 18. B.l X 2.99 2.89 2.76 S 0.89 0.82 0.96 F 1.34 18. B.2 X S 2.91 0.73 2.71 0.63 2.83 0.82 1.13 18. B.3 X S F 3.11 0.89 3.05 1.00 3.13 0.92 0.91 18. B.4 X 2.32 2.13 2.34 S 0.90 0.66 1.00 F 0.77 18. C.l X 2.53 2.64 2.66 •S 0.92 0.73 1100 F 0.49 18. C.2 X S F 2.57 0.82 2.52 0.67 2.80 0.90 2.31 136 TABLE 19 - Continued Item An ova Results Two-Hour Response Group N = 99 Two-Hour Non-Response Group N = 48 Two-Hour Control Group N = 89 18. C.3 X S F 2.40 2.80 0.94 2.97 0.76 3.10 0.91 18. C.4 X S F 0.28 2.09 0.80 2.16 0.79 2.19 0.97 19. A.l X S F 0.03 3.18 0.85 3.15 0.74 3.16 0.91 19. A.2 X S F 1.87 3.01 0.69 2.74 0.79 2.86 0.86 19. A;3 X s F 0.12 3.28 0.78 3.20 0.88 3.24 1*00 19. A.4 X S F 2.15 2.69 0.78 2.54 0.82 2.41 0.98 19. B.l X S F 0.09 3.37 0.77 3.43 0.68 3.37 0.87 19. B.2 X S F 0.88 3.03 0.72 2.84 0.75 2.98 0.89 19. B.3 X S F 0.28 3.39 0.71 3.37 0.83 3.30 0.94 137 TABLE 19 - Continued Item Anova Results Two-Hour Response Group N = 99 Two-Hour Two-Hour Non-Response Control Group Group N = 48 N = 89 19. B.4 X S F 1.12 2.62 0.75 2.45 0.81 2.44 0.91 19. C.l X S F 0.54 3.14 0.84 3.06 0.68 3.22 0.91 19. C.2 X S F 1.83 2.84 0.73 2.58 0.66 2.82 0.87 19.C.3 X S F 0.03 3.18 0.75 3.18 0.79 3.15 0.98 19. C.4 X S F 1.05 2.50 0.83 2.25 0.75 2.41 0.94 a The numbers correspond to the items on the Present Activity Questionnaire. * sig. p<.01 138 APPENDIX E 2 TABLE 20 Non-Response Bias Check For the One-Day Workshop Groups Item An ova Results One-Day Response Group N = 34 One-Day One-Day Non-Response Control Group Group N = 14 N = 33 X S F 1.47 0.51 1.40 1.64 0.50 1.67 0.48 X S F 3.09 1.07 1.68 2.64 1.15 3.26 0.96 X S F 3.11 3.15 0.96 3.07 1.07 3.73 1.14 X S F 0.23 3.29 0.72 3.43 1.02 3.26 0.73 5. X 2.06 1.79 1.58 S 0.97 0.80 0.72 F 2.58 6. X 3.61 3.62 3.14 S 1.83 1.30 1.46. F 0.40 X S F 1.22 0.42 1.74 1.43 0.51 1.42 0.50 9. X S F 1.91 0.29 1.93 0.27 2.00 0.00 1.34 139 TABLE 20 - Continued Item An ova Results One-Day Response Group N = 34 One-Day Non-Response Group N =14 One-Day Control Group N = 33 10. X S F 1.91 0.29 2.00 0.00 1.80 0.41 2.12 11. X S F 0.59 2.97 0.85 2.93 0.83 2.74 0.89 12. X S F 0.58 1.44 0.66 1.64 0.63 1.45 0.57 13. X S F 1.32 1.35 0.81 1.71 0.99 1.32 0.65 14. X S F 0.08 2.24 0.90 2.21 0.80 2.16 0.73 15. X S F 0.80 3.12 0.88 3.07 0.92 3.03 0.79 17, X S F 0.11 2.53 1.21 2.57 0.94 2.42 1.15 18. A.l X S F 0.59 2.50 1.02 2.42 0.90 2.23 0.97 18. A.2 X S , F 0.69 2.60 0.83 2.50 0.94 2.34 0.90 140 TABLE 20 - Continued Item Anova Results One-Day Response Group N = 34 One-Day One-Day Non-Response Control Group Group N = 14 N = 33 18. A. 3 X 2.87 S 0.92 F 1.03 3.00 0.91 2.58 1.06 18. A.4 X 2.09 S 0.99 F 0.07 2.15 1.21 2.04 0.76 18. B.l X 3.21 S 0.73 F 1.85 2.83 1:03 2.83 0.89~ 18. B.2 X 3.18 S • 0.68 F 2.18 2.71 0.91 2.93 0.70 18. B.3 X 3.41 S 0.84 F 3.74 3.43 0.75 2.89 0.75 18. B.4 X 2.47 S 0.82 F 0.77 2.15 1.07 2.23 0.86 18. CU X 2.59 S 0.84 F 0.72 2.33 0.98 2.35 0.88 18. C.2 X 2.75 S 0.84 F 1.19 2.36 1?84 2.52 0.78 18. C.3 X 3.07 S 0.94 F 1.34 2.93 0.73 2.68 0.94 141 ' TABLE 20 - Continued Item Anova Results One-Day-Response Group N = 34 One-Day One-Day Non-Response Control Group Group N = 14 N = 33 18. C.4 X 2.23 S 0.96 F 0.95 1.83 0.94 2.00 0.83 19. A.l X 3.23 S 0.92 F 0.20 3.07 1.14 3.13 0.68 19. A.2 X 2.97 S 0.94 F 0.83 2.64 1.01 2.79 0.63 19. A.3 X 3.57 S 0.63 F 3.31* 3.21 0.97 3.08 0.69 19. A.4 X 2.50 S 0.97 F 0.90 2.36 1.08 2.16 0.80 19. B.l X 3.53 S 0.66 F 0.10 3.50 0.94 3.45 0.62 19. B.2 X 3.00 S 0.88 F 0.35 2.79 1.05 2.96 0.58 19. B.3 X 3.62 S 0.66 F 2.01 3.64 0.63 3.28 0.79 19. B.4 X 2.75 S 0.95 F 1.86 2.79 1.05 2.32 0.80 142 TABLE 20 - Continued Item Anova Results One-Day Response Group N = 34 One-Day Non-Response Group N = 14 One-Day Control Group G = 33 19. C.l X 3.09 S 0.62 F 1.19 2.92 1.25 3.29 0.64 19. C.2 X 2.91 S 0.80 F 1.48 2.46 1.05 2.79 0.63 19. C.3 X 3.37 S 0.87 F 1.15 3.08 0.64 3.08 0.81 19. C.4 X 2.53 S 0.86 F 0.73 2.53 1.05 2.28 0.68 a The numbers correspond to items on the Present Activity Questionnaire. * sig. p <.05. 143 APPENDIX E 3 TABLE 21 THE RESULTS OF ANALYSIS OF VARIANCE PERFORMED TO DETERMINE GROUP EQUIVALENCE PRIOR TO THE WORKSHOPS Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 99 N = 89 N = 34 N = 33 l . a X 1.52 1.50 1.47 1.62 S 0.50 0.50 0.51 0.49 F 0.63 X 3.10 3.61 3.09 3.30 S 1.11 0.94 1.07 0.95 F 4.41** X 3.47 3.73 3.15 3.72 S 1.21 1.07 0.96 1.17 F 2.54 4. X ' 3.36 3.51 3.29 3.24 S 0.88 0.87 0.72 0.71 F 1.09 X 1.89 1.93 2.06 1.61 S 0.84 0.94 0.97 0.70 F 1.62 6. X 3.69 3.49 3.61 3.12 S 1.77 1.65 1.83 1.41 F 0.51 X 1.37 1.36 1.22 1.42 S 0.49 0.48 0.42 0.50 F 1.10 9. X 1.98 1.98 1.91 2.00 S 0.28 0.15 0.29 0.00 F 1.02 144 TABLE 21 - Continued Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 99 N = 89 N = 34 N = 33 10. X 1.81 1.90 1.91 1.80 S 0.42 0.31 0.29 0.41 F 1.41 11. X 2.69 2.73 2.97 2.70 S 0.75 0.81 0.85 0.88 F 1.07 12. X 1.50 1.33 Um 1.45 S 0.63 0.54 0.66 0.56 F 1.32 13. X 1.28 1.39 1.35 1.39 S 0.65 0.75 0.81 0.70 F 0.46 14. X 2-T05 2.12 2.24 2.18 S 0.75 0.81 0.90 0.73 F 0.59 15. X 3.28 3.40 3.12 3.03 S 0.95 0.85 0.88 0.81 F 1.81 16. X 3.19 3.26 3.47 3.24 S 0.98 0.97 0.89 1.17 F 0.68 17. X 2.34 2.75 2.53 2.42 S 1.07 1.13 1.21 1.12 F 2.23 18. A.l X 2.48 2.47 2.50 2.19 S 1.02 0.94 1.02 0.96 F 0.82 145 TABLE 21 - Continued Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 99 N = 89 N = 34 N = 33 18. A.2 X S F 0.96 2.62 0.84 2.65 0.85 2.61 0.83 2.35 0.88 18. A.3 X S F 0.85 2.67 0.95 2.83 0.96 2.87 0.92 2.57 1.03 18. A.4 X 2.28 2.21 2.09 2.07 S 0.94 0.92 0.99 0.75 F 0.54 18. B.l X S F 2.36 2.99 0.89 2.76 0.96 3.21 0.73 2.81 0.87 18. B.2 X S F 1.70 2.91 0.73 2.83 0.82 3.18 0.68 2.90 0.70 18. B.3 X 3.11 3.13 3.41 2.93 S 0.89 0.92 0.84 0.75 F 1.56 18. B.4 X 2.32 2.34 2.47 2.25 S 0.90 1.00 0.82 0.84 F 0.29 18. C.l X 2.53 2.66 2.59 2.33 S 0.92 1.00 0.84 0.85 F 1.03 18. C.2 X 2.57 S 0.82 F 1.68 2.80 0.90 2.75 0.84 2.48 0.77 146 TABLE 21 - Continued Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = .99 N = 89 N = 34 N = 33 18. C..3 X 2.80 3.10 3.07 2.70 S 0.94 0.91 0.94 0.95 F 2.30 18. C.4 X 2.09 2.19 2.22 2.03 S 0.80 0.97 0.96 0.82 F 0.40 19. A.l X 3.18 3.16 3.23 3.89 S 0.85 0.91 0.92 0.69 F 0.16 19. A.2 X 3.01 2.86 2.97 2.77 S 0.69 0.86 0.94 0.63 F 0.99 19. A.3 X 3.28 3.24 3.57 3.11 S 0.78 1.00 0.63 0.68 F 1;63 19. A.4 X 2.69 2.41 2.50 2.18 S 0.78 0.98 0.97 0.79 F 2.74* 19. B.l X 3.37 3.37 3.53 5.42 S 0.78 0.87 0.66 0.61 F 0.41 19. B.2 X 3.03 2.98 3.00 2.97 S 0.72 0.89 0.88 0.56 F 0.09 19. B.3 X 3.39 3.29 3.62 3.33 S 0.71 0.94 0.66 0.78 F 1.33 147 TABLE 21 - Continued Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 99 N = 89 N = 34 N = 33 19. B.4 X 2.62 2.44 2.75 2.33 S 0.75 0.91 0.95 0.78 F 1.81 19. C.l X 3.14 3.22 3.09 3.24 S 0.84 0.91 0.62 0.66 F 0.34 19. C.2 X 2.84 2.82 2.91 2.77 S 0.73 0.87 0.80 0.63 F 0.18 19. C.3 X 3.18 3.15 3.37 3.11 S 0.75 0.98 0.87 0.80 F 0.64 19. C.4 X 2.50 2.41 2.53 2.30 S 0.83 0.94 0.86 0.67 F 0.52 a The numbers correspond to items on the Present Activity Quextionnaire. * sig. p <.05 **si g . p <.01 148 APPENDIX e4 TABLE 22 PERCENTAGE RESPONSES FOR THE FOLLOW-UP WORKSHOP EVALUATION Item Group b Non-Response l . a 1. Two-Hour Workshop 1.0 N = 100 2. One-Day- Workshop 0.0 N - 34 85.-0 29.0 5.0 88.2 5.9 5.9 1. Two-Hour Workshop 2.0 N = 100 2. One-Day Workshop 0.0 N = 34 41.0 29.0 17.0 11.0 50.0 41.2 5.9 2.9 1. Two-Hour Workshop 0.0 N = 100 2. One-Day Workshop 0.0 N = 34 85.0 29.0 48.0 36.0 33.0 19.0 44.1 11.8 44.1 35.3 14.7 14.7 1. Two-Hour Workshop 0.0 N = 100 2. One-Day Workshop 0.0 N = 34 48.0 17.0 26.0 26.0 12.0 14.0 44.1 11.8 44.1 35.3 14.7 14.7 5.1 1. Two-Hour Workshop 17.0 N = 100 2. One-Day Workshop. 2.9 N = 34 16.0 ,6.0 16.0 23.0 22.0 11.8 0.0 14.7 55.9 14.7 5.2 1. Two-Hour Workshop 17.0 N = 100 2. One-Day Workshop 8.8 N = 34 13.0 8.0 31.0 13.0 18.0 17.6 11.8 23.5 20.6 17.7 5.3 1. Two-Hour Workshop 16.0 N = 100 2. One-Day Workshop 5.9 N = 34 16.0 6.0 21.0 18.0 23.0 26.5 8.8 17.6 23.5 17.7 5.4 1. Two-Hour Workshop 22.0 N = 100 2. One-Day Workshop 14.7 N = 34 39.0 7.0 21.0 7.0 4.0 29.4 14.7 5.9 23.5 11.8 149 TABLE 22 - Continued Item Group Non-Response 1 2 3 4 5 6 a) a) a) a> a) a) co 5.5 1. Two-Hour Workshop 19.0 34.0 6.0 18.0 14.0 -9.0 -N = 100 2. One-Day Workshop 11.8 38.2 8.8 26.5 8.8 5.9 -N = 34 5.6 1. Two-Hour Workshop 20.0 49.0 3.0 15.0 5.8 8.0 -N = 100 2. One-Day Workshop 2.9 44.1 8.8 11.8 17.7 14.7 -N - 34  6. 1. Two-Hour Workshop 1.0 9.0 21.0 42.0 22.0 5.0 -N = 100 2. One-Day Workshop 0.0 2.9 17.7 50.0 23.5 5.9 -N = 34  7.A 1. Two-Hour Workshop 3.0 71.0 26.0 -N - 100 2. One-Day Workshop 2.9 70.6 26.5 -N = 34 7.B 1. Two-Hour Workshop 0.0 45.0 19.0 27.0 38.0 13.0 -N = 100 2. One-Day Workshop 0.0 44.1 23.5 17.7 44.1 20.6 -N = 34 8.1 1. Two-Hour Workshop 3.0 19.0 65.0 12.0 1.0 0.0 -N - 100 2. One-Day Workshop 8.9 29.4 52.9 8.8 0.0 0.0 -N = 34 8.2 1. Two-Hour Workshop 3.0 1.0 1.0 4.0 27.0 64.0 -N = 100 2. One-Day Workshop 5.9 5.9 2.9 2.9 17.7 64.7 -N =34 8.3 1. Two-Hour Workshop 6.0 7.0 60.0 25.0 2.0 0.0 -N = 100 2. One-Day Workshop 8.8 23.5 55.9 8.8 0.0 3.0 -N = 34  8.4 1. Two-Hour Workshop 2.0 74.0 23.0 0.0 0^.0 I'.O -N = 100 2. One-Day Workshop 5.9 73.5 20.6 0.0 0.0 0.0 -N =34 150 TABLE 22 - Continued Item Group Non-Response 1 2 3 4 5 6 a) a: ) a: ) a) (%) a: ) a) 8.5 1. Two-Hour Workshop 6.0 0 .0 7 .0 15.0 48.0 24 .0 -N = 100 2. One-Day Workshop 5.9 2 .9 5 .9 11.8 38.2 35 .3 -N = 34 8.6 1. Two-Hour Workshop 3.0 16 .0 68 .0 11.0 2.0 0 .0 -N = 100 2. One-Day Workshop 5.9 32 .4 50 .0 8.8 2.9 0 .0 -N = 34 3 The numbers correspond to the questions on the Follow-Up Workshop Evaluation. The Non-Response and numbers 1 through 5 are the response options for each item. Blanks (-) indicate that the response option was not applicable for that question. 151 APPENDIX E 5 TABLE 23 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 2 Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 99 N = 89 N = 34 N -: 33 15.a X 3.27 3.40 3.24 3.03 S 0.99 0.85 0.97 0.81 F 1.38 16. X 3.03" 3.26 3.09 3.24 S 0.98 0.97 0.91 1.17 F 0.96 17. X 2.56 2.75 2.61 2.42 S 1.10 1.13 1.00 1.12 F. 0.89 a The numbers refer to items on the Present Activity Questionnaire. i. 152 APPENDIX E6 TABLE 24 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 3 Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N = 78 N = 61 N = 31 N = 25 18. A . l a X i<2:53 2.46 2.64 2.20 S 0.98 0.92 0.91 0.96 F 1.11 18. A.2 X 2.67 2.66 2.71 2.44 S 0.75 0.81 0.69 0.82 F 0.68 18. A.3 X 2.69 2.92 2.90 2.68 S 0.90 0.99 0.94 0.99 F 0.91 18. A.4 X 2.21 2.21 2.64 2.08 S 0.86 0.91 1.52 0.70 F 1.94 18. B.l X 2.97 2.74 3.16 2.68 S 0.84 0.91 0.78 0.90 F 2.41 18. B.2 X 2.85 2.79 2.93 2.80 S 0.68 0.80 0.77 0.70 F 0.30 18. B.3 X 3.06 3.15 3.06 3.00 S 0.79 0.93 0.81 0.71 F 0.23 18. B.4 X 2.25 2.28 2.45 2.24 S 0.81 0.97 0.85 0.83 F 0.45 153 TABLE 24 ..- Continued. Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control 'N = 78 N = 61 N = 31 N = 25 18. C.l X 2.67 2.70 2.55 2.32 S 0.88 1.01 0.92 0.85 F 1.18 18. C. 2 X 2.67 2.82 2.58 2.60 S 0.73 0.87 0.89 0.71 F 0.86 18. C.3 X 2.83 3.08 2.81 2.84 S 0.89 0.95 0.91 0.89 F 1.08 18. C.4 X 1.96 2.20 2.29 2.08 S 0.80 0.93 0.94 0.81 F 1.43 19. A.l X 3.13 3.11 3.45 3.08 S 0.84 0.88 0.72 0.76 F 1.46 19. A.2 X. 2.97 'S 0.74 F 1.66 2.80 0.87 3.10 0.75 2.72 0.68 19. A.3 X S F 0.72 3.27 1.06 3.25 1.03 3.42 0.89 3.12 0.72 19. A.4 X S F 2.34 2.58 0.89 2.39 0.95 2.68 0.87 2.12 0.78 19. B.l X 3.22 3.28 3.45 3.40 S 0.86 0.95 0.72 0.64 F 0.70 154 TABLE 24 - Continued Item Anova Two-Hour Two-Hour One-Day One-Day Results Workshop Control Workshop Control N - 78 N = 61 N = 31 N = 25 19. B. 2 X 2.97 2.84 2.97 2.92 S 0.64 0.86 0.60 0.57 F 0.49 19. B.3 X 3.38 3.25 3.48 3.36 S 1.01 0.99 0.81 0.81 F 0.48 19. B.4 X 2.55 2.34 2.52 2.28 S 0.85 0.89 0.89 0.79 F 1.05 19. C.l X 3.06 3.21 3.19 3.20 S 0.93. 0.89 0.91 0.71 F 0.39 19. C.2 X 2.67 2.82 2.74 2.68 S 0.73 0.85 0.85 0.63 F 0.48 19. C.3 X 3.06 3.18 3.26 3.12 S 0.90 0.99 1.00 0.83 F 0.37 19. C.4 X 2.33 2.36 2.35 2.24 S 0.80 0.93 0.98 0.66 F 0.12 a The numbers correspond to items on the Present Activity Questionnaire. 155 APPENDIX E7 TABLE 25 SUMMARY STATISTICS FOR ITEMS PERTAINING TO HYPOTHESIS 5 Item Anova Two-Hour Workshop One-Day Workshop Results N = 113 N = 39 1. A. a X 1.27 1.33 S 0.66 0.58 F 0.25 1. B X 1.55 1.56 S 0.88 0.75 F 0.01 2. x l 1.69 1.49 S 0.93 0.72 F 1.55 3. X 1.45 1.43 S 0.64 0.64 F 0.02 4. X 1.19 1.20 S 0.46 0.64 F 0.01 5. X 2.55 2.54 S 0.87 0.79 F 0.01 6. A. X 2.84 2.72 S 0.69 0.65 F 0.95 6.B. X 2.91 2.90 S 0.79 0.68 F 0.01 156 TABLE 25 - Continued Item Anova Two-Hour Workshop One-Day Workshop Results N = 113 N = 39 6. C X 3.22 3.13 S 0.93 0.66 F 0.33 6. D X 3.37 3.44 S 0.94 0.82 F 0.14 7. X 3.80 3.10 S 1.04 0.79 F 14.35* 8.' X 2.63 3.00 S 1.60 1.57 F 1.58 9. X 1.49 1.38 S 0.89 0.78 F 0.41 10. X 1.33 1.31 S 0.62 0.65 - F 0.03 ,a. The numbers correspond to the questions on the Post Workshop Evaluation. * Sig. p <.01. 

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