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R E S E A R C H P A P E R

The role of motivation and self-efficacy on the practice of health promotion behaviours in

the overweight and obese middle-aged American women

Kathleen Fisher FNP-BC DNP RN Lecturer II, Nursing, University of Michigan-Flint, Flint, Michigan, USA

Suha Al-Oballi Kridli PhD RN Associate Professor, School of Nursing, Oakland University, Rochester, Michigan, USA

Accepted for publication January 2013

Fisher K, Kridli S A-O. International Journal of Nursing Practice 2014; 20: 327–335. The role of motivation and self-efficacy on the practice of health promotion behaviours in the

overweight and obese middle-aged American women

The study investigated the relationship between motivation, self-efficacy and demographic variables, and determined if they affect the performance of health promotion behaviours in overweight or obese middle-aged American women. The sample consisted of middle-aged American women from a small town in Michigan. Two groups of women aged 30–65, one with a body mass index (BMI) range of 25–29, and the second with a BMI of ≥ 30, completed the Health Self-Determinism Index, the General Self-Efficacy Scale and the Health Promoting Lifestyle Profile-II. Self-efficacy was found to be a significant predictor in the performance of health-promoting behaviours in both the overweight and obese participants in this study. Motivation was not found to be a significant predictor of performance of health promotion behaviours in either participant group. Education was found to be a significant predictor of performance of health promotion behaviours in the obese participants only. Nurses need to develop effective methods of supporting self-efficacy in both the overweight and obese middle-aged American women. Nursing-based research focusing on interventions to improve self-efficacy, as well as studies identifying effective educational techniques to improve the practice of health promotion behaviours in this population is necessary. Further investigation into the effect of motivation and demographics on the performance of health promotion behaviours is also needed.

Key words: female, health promotion, motivation, obese, overweight, self-efficacy.

Overweight and obesity are a major health problem in America. It is estimated that about 66% of American adults are overweight, and one in three are obese.1,2

Body mass index (BMI) is a standard that correlates body weight with the risk of developing chronic health conditions that are associated with obesity.1–3 A BMI between 18 and 24.9 is considered normal, whereas a BMI between 25 and 30 is considered overweight, and a BMI > 30 is considered obese. A BMI of ≥ 40 is consid- ered super obese.3,4

Correspondence: Suha Al-Oballi Kridli, School of Nursing, Oakland University, Rochester, MI 48309, USA. Email: [email protected].

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International Journal of Nursing Practice 2014; 20: 327–335

Being overweight or obese can raise an individual’s risk for multiple conditions including sleep apnea, diabetes, hypertension, heart disease and depression.5–7 Those with excess weight also encounter increased surgical risks, fer- tility problems and difficulty completing daily chores.3,4

There are several causative factors of overweight and obesity, including biological, environmental, social, psychological and socio-economic.4,8

Sedentary lifestyle, larger food portion sizes and easy access to food have all been found to increase Americans’ waistlines.1,9 Genetic predisposition, unhealthy eating and low self-esteem have also been cited as causes of excess weight.3,6 As they assume a more sedentary life- style because of career demands, marriage and running a family, middle-aged women are especially vulnerable to excess weight gain.10

To achieve success at weight loss and maintenance, a woman must have motivation and must enact permanent lifestyle change.11,12 Motivation has been indicated as a key predictor in the practice of health promotion activ- ities,13 and the importance of motivation in determining successful weight loss and maintenance has been estab- lished in several studies.11,14–16 Motivation is a complex concept that includes the beliefs, values and attitudes regarding the accomplishment of a desired behaviour or behaviours.10

Self-efficacy has also been identified as an important predictor for weight loss and maintenance.11,17 It has been found to be one of the strongest predictors of a health- promoting lifestyle.11 Self-efficacy is a complex concept that is believed to result from an interaction between personal, behavioural and environmental factors. It includes perceived confidence about the ability to utilize personal resources of motivation, cognition and action to complete a given task.18

Health-promoting lifestyles include activities that encourage or improve overall general health.19 Behaviours that are considered health promoting include: nutrition, physical activity, stress management, health responsibil- ity, spiritual growth and interpersonal relations.19–22

Nursing has been described as a human science with a socially conscious focus.23 Because of their multiple func- tions and job descriptions, nurses are in a unique position to address overweight and obesity. Nurses must be adept at tailoring interventions specifically to the individual,24 and because of the complexity of the overweight and obesity problem in America, the nurse must fully understand its cause.

PURPOSE The purpose of this study was to investigate the relation- ship between motivation, self-efficacy and demographic variables, and how they affect the performance of health promotion behaviours in overweight or obese middle- aged American women. The following research questions were explored: 1. What is the relationship between motivation and

health promotion behaviours in the overweight and obese middle-aged American women?

2. What is the relationship between self-efficacy and health promotion behaviours in the overweight and obese middle-aged American women?

3. What is the relationship between motivation and self- efficacy and health promotion behaviours in the over- weight and obese middle-aged American women?

4. Is there a relationship between BMI or demographics (age, race, education, marital status, economic status) and levels of motivation, self-efficacy, or performance of health promotion behaviours in the overweight and obese middle-aged American women?

LITERATURE REVIEW There are limited studies investigating the relationship between motivation and self-efficacy and their effects on practice of health promotion behaviours. Most studies evaluate the determinants of health promotion behaviour. In 2006, Butler and Mellor investigated the role of moti- vation, emotion and self-efficacy on level of participation and perseverance in weight management activities. Moti- vation was found to be the only variable contributing uniquely and significantly to prediction of participation which confirmed the importance of motivation in partici- pation in weight loss behaviours, but self-efficacy was not identified as a significant determinant.25 In 2009, Furia et al. also investigated the effect of motivation and self- efficacy on maintaining normal weight in a group of normal weight and overweight college students. Normal weight students were found to have greater self-efficacy and intrinsic motivation to maintain normal body weight, whereas overweight women were found to be driven to maintain normal weight by more extrinsic factors.10

The role of self-efficacy on weight loss in overweight and obese adult men and women over the course of 18 months was examined by Warziski et al.26 Findings revealed that the greatest weight loss occurred during the same time frame that demonstrated the greatest increase in self-efficacy. The mediators of weight loss and weight

328 K Fisher and SA-O Kridli

loss maintenance in middle-aged overweight and obese women were evaluated by Teixiera et al. in 2010.11 The results indicated that both short-term and long-term success of weight loss and weight loss maintenance centre around supporting self-efficacy. Increasing confidence and reinforcing flexibility and adaptation were found to be key in promoting weight loss success.

O’Dougherty, Kurzer and Schmitz found that women’s performance of health promotion behaviours shifts over time.15 They found that societal values and cultural trends play a large role in maintaining health practices, and that using external motivators might be useful until levels of intrinsic motivation increase. In a 2009 study, Gavin, Rodbard, Fox and Grandy found that overweight and obese adults had a great desire to lose weight but had a more pessimistic view of their health and performed health behaviours less than their normal weight counterparts.27 Overweight and obese participants were found to need more specific health goals and interventional aids than their normal weight counterparts, and development of detailed exercise and weight loss programmes, and behaviour toolkits to increase weight loss success in overweight and obese populations were recommended.

METHODS Measures

Motivation for health behaviour was measured using the Health Self-Determinism Index (HSDI).28 The HSDI is a 17-item scale, consisting of four subscales that measure self-determined health judgment, self-determined health behaviour, perceived competency in health matters and internal–external cue responsiveness using a five-point ordinal scale format. Possible scores range 17–85, with scores 17–51 being more extrinsically motivated, whereas scores 52–85 are more intrinsic in nature.29

Cronbach’s alpha of internal consistency for the entire HSDI range 0.82–0.78.30,31 Reliability of the overall HSDI was found to range from 0.81 to 0.87, and short-term stability has been demonstrated to be 0.86 via 2 week, test–retest correlation.31

Self-efficacy for health behaviour was measured using General Self-Efficacy Scale (GSE).32 The scale assesses a general sense of self-efficacy and is a 10-item ordinal scale, with responses ranging from 1 (not at all true) to 4 (exactly true). Scores might range 10–40, with higher scores reflecting higher levels of self-efficacy.33

Cronbach’s alpha reliability for the GSE has ranged 0.76–

0.90, with most being in the high 0.8s.34 Its validity has been supported in over 26 cultures.33,35

Performance of health promotion behaviours was measured by the Health-Promoting Lifestyle Profile II (HPLP-II).34 The HPLP-II measures health-promoting lifestyles, focusing on self-initiated actions and percep- tions that maintain or enhance wellness. It is a 52-item scale composed of six subscales that measure nutrition, physical activity, health responsibility, stress manage- ment, interpersonal relations and spiritual growth. The HPLP-II is scored using an ordinal four-point scale, with options ranging from 1 (never) to 4 (routinely). Possible scores on the HPLP-II range 52–208, with higher scores indicating more consistent practice of the health behav- iour.36 Alpha reliability for the total instrument has been shown to be 0.92, with subscales ranging 0.70–0.90.37

Construct validity has been confirmed via factor analysis.38

An instrument developed by the principal investigator was used to measure demographic variables in this study. The variables included BMI, age, race, education, marital status and economic status.

Setting and sample The convenience sample consisted of 70 overweight (BMI 25–30) and 70 obese (BMI > 30) women, ages 30–65, recruited from the patient population at a family practice office in Lapeer, Michigan. Inclusion criteria consisted of any woman examined during the data collection period that had a calculated BMI of ≥ 25 and between the age 30 and 65 years of age. Exclusion criteria included women currently pregnant, those who had been pregnant within the last year or women unable to complete the scales because of mental or physical impairment. Human sub- jects’ approval was obtained prior to implementing the study from Oakland University.

RESULTS Data analysis was completed using Statistical Package for the Social Sciences (spss) version 19.0 (IBM Corp., Armonk, NY, USA). Mean age for the overweight par- ticipants (BMI 25–29) was 45.80 and 49.91 in the obese participants (BMI ≥ 30). Most of the participants were Caucasian, and 86% of overweight participants were married, compared with 70% of those who were obese. Most participants in both groups had graduated high school, and many had some college education. Both groups had the majority of participants in the $31 000– 50 000 income range (34 and 33%, respectively), but the

Motivation and self-efficacy 329

overweight group did have more in the highest income class (27 vs. 11% earning over $71 000). Demographic information is listed in Table 1.

Both participant groups had low mean scores for intrin- sic motivation on the HSDI. The overweight participants had a mean of 52.20, whereas the obese participants’ mean was 53.64. Because both means were greater than 51, scores indicate intrinsic motivation, but the scores are very low on the intrinsic scale. GSE scores indicated high levels of self-efficacy, with mean scores of 32.21 (BMI 25–29) and 31.51 (BMI ≥ 30). Finally, both groups had mean HPLP-II scores that were mid-range: 135.09 (BMI 25–29) and 129.46 (BMI ≥ 30). Scores that are low indi- cate an inconsistent performance of health behaviours, whereas scores toward the maximum indicate consistent performance of health promotion behaviours. Because both groups scored toward the middle of the scale (65 and 62% of maximum, respectively), results indicate that both groups performed health behaviours intermittently. Indi- vidual scale results are shown in Table 2.

Paired t-test analysis of demographic factors and score on individual scale (GSE, HSDI and HPLP-II) found sig- nificant differences (P < 0.05) between the two groups in age, marital status and income. As seen in Table 3, those with a BMI ≥ 30 were older than those in the BMI 25–29 group and were also more likely to be single, divorced or widowed. Those in the BMI 25–29 group had a higher income overall.

Pearson’s correlation of demographic factors and score on individual scale (GSE, HSDI and HPLP-II) revealed several significant relationships. For the overweight (25– 29) BMI group, BMI, education and motivation (HSDI score) were found to have an inverse correlation with self-efficacy (GSE score), whereas income and self- efficacy (GSE) had a positive correlation. For the obese group, income and motivation (HSDI) were inversely cor- related, whereas education and self-efficacy (GSE), marital status and motivation (HSDI), and education and performance health promotion behaviours (HPLP-II) were positively correlated. Correlation results for the two BMI groups are listed in Tables 4 and 5.

Multiple regression analysis was completed using HPLP score (performance of health promotion behav- iours) as the dependent variable, and scores on the GSE (self-efficacy), HSDI (motivation) and the demographic factors (age, race, education, marital status and income) as independent variables. For the BMI 25–29 group, 26.3% of the variance was explained by all independent variables. When examining individual predictors, only the GSE score was found to be significant (P = 0.001) and was found to have a significant impact on use of health promotion behaviours (β = 0.436). Multi-collinearity was not found to be an issue, as tolerance for all variables was > 0.3, and variance inflation factor (VIF) was < 10.

For the BMI ≥ 30 group, regression analysis revealed that demographic variables, and score on GSE and HSDI explained 31.3% of the variance of performance of health promotion behaviours. Again, score on the GSE was found to be a significant individual predictor (P = 0.001, β = 0.417), but in the obese group, education was also found to be significant (P = 0.009, β = 0.332). As in the overweight group, self-efficacy was found to have the most influence on use of health promotion behaviours. Regression results are listed in Table 6.

DISCUSSION The majority of participants in this study were married, Caucasian, of modest income and had completed high

Table 1 Subject demographic data

Characteristic BMI 25–29 BMI ≥ 30 (n = 70) (%) (n = 70) (%)

Age (Mean) 45.80 49.91 Race

Caucasian 64 (92) 69 (99) Hispanic 3 (4) 0 African American 0 1 (1) Other 3 (4) 0

Marital status Married 60 (86) 49 (70) Divorced 7 (10) 5 (7) Single 2 (3) 10 (14) Widow 1 (1) 6 (9)

Education level Some high school 3 (4) 3 (4) High school graduate 17 (24) 27 (39) Some college 28 (40) 21 (30) College graduate 19 (27) 16 (23) Advanced college degree 3 (4) 3 (4)

Income $10 000–30 000 15 (21) 29 (41) $31 000–50 000 24 (34) 23 (33) $51 000–70 000 12 (17) 10 (14) ≥ $71 000 19 (27) 8 (11)

BMI, body mass index.

330 K Fisher and SA-O Kridli

school. Obese participants were found to be slightly older, have lower income and were less likely to be married. These findings are consistent with previous studies. The literature indicates that obesity rates decline with increasing education and income but increase with advancing age.5 Previous research found that those with higher education generally have lower risk behaviours and practice more preventative health behaviours.39

Analysis of education levels for all participants revealed that almost all had a high school diploma, with the majority having at least some college education. Income levels for all participants had varied distribution, but 55% (n = 39) of those who were overweight and 74% (n = 52) of those who were obese had an annual income of ≤ $50 000. Causes of obesity in those with lower income, unmarried status and less education are varied but might

include less access to healthy foods and activities, as well as less understanding of the importance of healthy behav- iours.40,41 Single women might also be less likely to prepare healthier meals than those with families.41

Both overweight and obese participants had low levels of intrinsic motivation, indicating they lacked significant internal desire to complete health behaviours. Their levels were just outside of the range of extrinsic motivation, which indicate their decision to perform health behaviours might have some outside (reward-based) foundation. These findings are consistent with previous literature.10,15

Current results indicate that this population might benefit from incentives to start and continue health promotion behaviours.

When looking at performance of health promotion behaviours, both the overweight and obese participants were found to exhibit inconsistent health promotion prac- tices. These findings are uniform with earlier litera- ture.27,42 Present results indicate that overweight or obese women might benefit from education about the impor- tance of practice of healthy behaviours and also might benefit from a screening to identify potential negative personality traits that might inhibit their practice of health promotion behaviours.

In terms of self-efficacy, both overweight and obese participants scored high.

That is, they decidedly demonstrated the capability and confidence to accomplish the practice of health promotion behaviours. This finding was also consistent with previous literature.11,26 This indicates that overweight and obese middle-aged women need support for their ability and confidence while trying to establish and maintain the practice of healthy behaviours.

For the overweight participants, self-efficacy decreased as BMI and education climbed, but it increased as income

Table 2 Range of individual scales

Scale (Range) BMI 25–29 BMI ≥ 30

Range Mean (% max score) SD Range Mean (% of max score) SD

HSDI (17–85) 27–63 52.20 (61) 5.93 40–74 53.64 (63) 6.16 GSE (10–40) 23–40 32.21 (81) 3.99 16–40 31.51 (79) 4.57 HPLP-II (52–208) 98–196 135.09 (65) 19.89 92–176 129.46 (62) 19.75

BMI, body mass index; GSE, General Self-Efficacy Scale; HPLP-II, Health-Promoting Lifestyle Profile-II; HSDI, Health Self-Determinism

Index; SD, standard deviation.

Table 3 Paired t-test results BMI 25–29/BMI ≥ 30

t-Test pairing (95% CI) t P d.f.

BMI −3.29 0.000 69 GSE 0.93 0.354 69 HSDI 1.38 0.173 69 HPLP-II 1.73 0.089 69 Age −2.82 0.006 69 Race 1.74 0.086 69 Education 1.16 0.252 69 Marital status −2.73 0.008 69 Income 3.26 0.002 69

BMI, body mass index; CI, confidence interval; d.f., degrees

of freedom; GSE, General Self-Efficacy Scale; HSDI, Health

Self-Determinism Index; HPLP-II, Health-Promoting Lifestyle

Profile-II.

Motivation and self-efficacy 331

escalated. The literature supports the described links between self-efficacy and BMI and income but not with that of increased education.11,26,43 Although more studies are needed, this finding does not appear to be consistent with previous results.

Obese participants demonstrated decreased levels of motivation with rising income. Because increased income level often requires high levels of motivation, this finding does not seem to support that found in the literature. A previous study found that low income might impact motivation, but literature supporting the link between high income and low motivation was lacking.44 Thus, the negative relationship in this study might have occurred because of low sample size and the uniform income level. Further research needs to be completed to confirm present results.

Unlike the overweight participants, the obese partici- pants had a positive relationship between education and self-efficacy. The positive relationship between increased education level and greater level of self-efficacy has been documented in previous studies.11,18,39,45 Current findings indicate that obese women might benefit from targeted education about how to increase their ability and confi- dence to perform healthy behaviours.

A positive relationship between marital status and motivation was found among obese participants. There is a very limited literature reviewing the relationship between motivation and marital status in obese women. One available study, completed in 1993, found no link between marital status and motivation to change diet or exercise in obese adults.46 Current results demonstrate the need for continued investigation into the effect of

Table 4 Individual scale correlation BMI 25–29

Variable HSDI GSE HPLP-II

r P r P r P

BMI −0.071 0.560 −0.312 0.009 −0.201 0.095 Age 0.218 0.070 −0.122 0.315 0.111 0.359 Race −0.044 0.719 −0.129 0.288 −0.024 0.843 Education −0.287 0.016 0.068 0.573 −0.093 0.443 Marital status 0.067 0.582 −0.007 0.957 −0.150 0.215 Income 0.053 0.665 0.321 0.007 0.168 0.166

BMI, body mass index; GSE, General Self-Efficacy Scale; HPLP-II, Health-Promoting Lifestyle Profile-II; HSDI, Health Self-Determinism

Index.

Table 5 Individual scale correlation for BMI ≥ 30

Variable HSDI GSE HPLP-II

r P r P r P

BMI 0.034 0.780 −0.115 0.343 −0.059 0.627 Age 0.094 0.438 0.065 0.594 0.108 0.373 Race −0.013 0.917 −0.199 0.098 0.003 0.978 Education −0.109 0.370 0.266 0.026 0.337 0.004 Marital status 0.324 0.006 0.194 0.107 0.127 0.295 Income −0.329 0.005 0.110 0.363 0.020 0.872

BMI, body mass index; GSE, General Self-Efficacy Scale; HPLP-II, Health-Promoting Lifestyle Profile-II; HSDI, Health Self-Determinism

Index.

332 K Fisher and SA-O Kridli

marital status on motivation in overweight or obese middle-aged population.

A positive relationship between education and perfor- mance of health promotion behaviours was noted in obese participants. Results are consistent with those reported in previous studies.39,47 Current results reflect the importance of educating overweight and obese women about the importance of practicing health promotion behaviours.

In this study, motivation was not found to be a signifi- cant predictor of the performance of health promotion behaviours among overweight and obese middle-aged American women. These findings differed from previous studies that found motivation to be the only variable pre- dicting participation in weight loss behaviours.25 Because motivation’s importance in weight loss and maintenance has been established in several studies,11,14–16 current results must be interpreted with caution. Results might have not supported motivation’s importance because of small sample size.

In terms of self-efficacy, this study supported its impor- tance in the performance of health promotion behaviours among overweight and obese middle-aged American women. Self-efficacy was found to be the strongest individual predictor for both the overweight and obese participants and was the only significant predictor of per- formance of health promotion behaviours for those in the overweight category. Self-efficacy is central to both short- term and long-term success of weight loss and weight loss maintenance.11,26 Current results underline the need to develop specific interventions to improve self-efficacy in

this population, particularly when trying to improve their performance of health promotion behaviours.

Though education was found to be significant for the obese participants, it was not as strong a predictor as self-efficacy. The positive effect that education has on performance of health promotion behaviours has been confirmed by previous authors.39,47 The results support the need to develop educational interventions that support the performance of health promotion behaviours in the overweight and obese middle-aged American women.

Implications for nursing practice Based on current population trends, nurses will continue to encounter great numbers of overweight and obese American women. Although additional research is needed to verify current findings, the significance of both self- efficacy and education in performance of health promo- tion behaviours has been supported. Gaining insight into why overweight or obese women do not practice healthy behaviours can help to understand the epidemic of excess weight in this population. In addition, developing effec- tive methods of supporting self-efficacy in the overweight and obese middle-aged American women is needed. Research focusing on interventions that will improve self- efficacy, as well as studies identifying effective educational techniques to improve the practice of health promotion behaviours in this population, is necessary.

Once effective methods have been investigated, nurses may undertake educational measures that will highlight

Table 6. Regression calculations

BMI 25–29 (R2 = 0.263) BMI ≥ 30 (R2 = 0.313)

β P VIF Multi-collinearity β P VIF Multi-collinearity

HSDI −0.061 0.609 1.17 0.856 −0.120 0.327 1.30 0.769 GSE 0.436 0.001 1.29 0.778 0.417 0.001 1.35 0.744 BMI −0.175 0.161 1.26 0.796 0.068 0.537 1.08 0.930 Age 0.199 0.124 1.35 0.741 0.203 0.083 1.18 0.846 Race 0.067 0.554 1.05 0.956 0.139 0.227 1.16 0.865 Education −0.092 0.458 1.26 0.791 0.332 0.009 1.33 0.752 Marital status −0.199 0.099 1.18 0.850 0.036 0.776 1.38 0.723 Income −0.063 0.625 1.34 0.745 −0.137 0.284 1.43 0.701

BMI, body mass index; GSE, General Self-Efficacy Scale; HSDI, Health Self-Determinism Index; VIF, Variance inflation factor.

Motivation and self-efficacy 333

the importance performing healthy behaviours. Nurses can also intervene to help overweight or obese women incorporate healthy behaviours into daily life which might result in a lower BMI over time.

Further studies are also needed to support the role of motivation in the practice of health promotion behaviours in the overweight and obese middle-aged American women, and on the effect of demographics on the per- formance of health promotion behaviours. Once this has been done, nurses can identify successful motiva- tional techniques to improve performance of health promotion behaviours and, ultimately, lower BMI in this population.

Only when all contributing factors surrounding perfor- mance of health promotion behaviours in the overweight or obese middle-aged American women are understood can nurses expect success. It will take persistence, patience and time to overcome this epidemic, but it is a vitally important task. With all the risks and detriments that overweight and obesity present, there is so much more than just weight to lose.

REFERENCES 1 Alters S, Schiff W. Body weight and its management. In:

Alters S, Schiff W (eds). Essential Concepts for Healthy Living, 5th edn. Sudbury, MA, USA: Jones and Bartlett, 2009; 256–281.

2 Seals JG. Integrating the transtheoretical model into the management of overweight and obese adults. Journal of the American Academy of Nurse Practitioners 2007; 19: 63–71. doi:10.1111/j.1745-7599.2006.00196.x.

3 Edlin G, Golanty E. Managing a healthy weight. In: Edlin G, Golanty E (eds). Health & Wellness, 9th edn. Sudbury, MA, USA: Jones and Bartlett, 2007; 130– 151.

4 Azarbad L, Gonder-Frederick L. Obesity in women. Psychi- atric Clinics of North America 2010; 33: 423–440. doi: 10.1016/j.psc.2010.01.003.

5 Baum CL, Ruhm CJ. Age, socioeconomic status, and obesity growth. 2007. Available from URL: http://www .kelley.iu.edu/BEPP/documents/AgeSocioeconomic StatusandObesityGrowth.pdf. Accessed. Feburary 2010.

6 Coe S. Nutrition related to obesity and diabetes as a public health issue. Nurse Prescribing 2010; 8: 376–381.

7 Graves G. Fat. Health 2009; 4: 108–113. 8 Shay LE, Shobert JL, Seibert D, Thomas LE. Adult weight

management: Translating research and guidelines into practice. Journal of the American Academy of Nurse Practitioners 2007; 21: 197–206.

9 American Public Health Association. Poor diet, inactivity on the rise as a leading cause of Death. Nation’s Health 2004; 34: 1–20.

10 Furia AC, Lee RE, Strother ML, Huang TTK. College students’ motivation to achieve and maintain a healthy weight. American Journal of Health Behavior 2009; 33: 256– 263.

11 Teixiera PJ, Silva MN, Coutinho SR et al. Mediators of weight loss and weight loss maintenance in middle-aged women. Obesity 2010; 18: 725–735. doi: 10.1038/oby .2009.281.

12 Vanderharr JM, Campbell BM. A model for delivering exercise interventions to address overweight and obesity in adults: Recommendations from the American Kine- siotherapy Association. Clinical Kinesiology: Journal of the American Kinesiotherapy Association 2005; 59: 39–42.

13 Schelling S, Munsch S, Meyer AH, Newark P, Biedert E, Margraf J. Increasing the motivation for physical activity in obese patients. International Journal of Eating Disorders 2009; 42: 130–138. doi.org/10.1002/eat.20595.

14 Blacksher E. Carrots and sticks to promote healthy behaviors: A policy update. Hastings Center Report 2008; 38: 13–16. doi: 10.1353/hcr.0.0002.

15 O’Dougherty M, Kurzer MS, Schmitz KH. Shifting moti- vations: Young women’s reflections on physical activity over time and across contexts. Health Education & Behavior 2010; 37: 547–567.

16 Santosa S, Demonty I, Jones PJH, Lichtenstein AH. Mod- erate weight loss: A self-directed protocol for women. Canadian Journal of Dietetic Practice and Research 2008; 69: 23–27.

17 Hankonen N, Vollmann M, Renner B, Absetz P. What is setting the stage for abdominal obesity reduction? A comparison between personality and health-related social cognitions. Journal of Behavioral Medicine 2010; 33: 415– 422. doi: 10.1007/s10865-010-9271-y.

18 Chang MW, Brown RL, Baumann LJ, Nitzke SA. Self- efficacy and dietary fat reduction behaviors in obese African-American and white mothers. Obesity 2008; 16: 992–1001.

19 Grzywacz JG, Keyes CLM. Toward health promotion: Physical and social behaviors in complete health. American Journal of Health Behavior 2004; 28: 99–111.

20 Homish GG, Leonard KE. Spousal influence on general health behaviors in a community sample. American Journal of Health Behavior 2008; 32: 754–763.

21 Lee CJ. A comparison of health promotion behaviors in rural and urban community-dwelling spousal caregivers. Journal of Gerontological Nursing 2009; 35: 34–40.

22 Sanchez A, Norman GJ, Sallis JF, Calfas KJ, Rock C, Patrick K. Patterns and correlates of multiple risk behaviors in overweight women. Preventative Medicine 2008; 46: 196– 202. doi.org/10.1016/j.ypmed.2007.10.005.

334 K Fisher and SA-O Kridli

23 Newman MA. Prevailing paradigms in nursing. Nursing Outlook 1991; 40: 10–32.

24 Salazar SS. Assessment and management of the obese adult female: A clinical update for providers. Journal of Midwifery & Women’s Health 2006; 51: 202–207.

25 Butler P, Mellor D. Role of personal factors in women’s self-reported weight management behavior. Public Health 2006; 120: 383–392. doi:10.1016/j.puhe.2005.11.006.

26 Warziski MT, Sereika SM, Styn MA, Music E, Burke LE. Changes in self-efficacy and dietary adherence: The impact on weight in the PREFER study. Journal of Behavioral Medi- cine 2008; 31: 81–92. doi: 10.1007/s10865-007-9135-2.

27 Gavin JR, Rodbard HW, Fox KM, Grandy S. Association of overweight and obesity with health status, weight manage- ment, and exercise behaviors among individuals with type 2 diabetes mellitus or with cardiometabolic risk factors. Risk Management and Health Care Policy 2009; 2: 1–7.

28 Cox CL. The health self-determinism index. Nursing Research 1985; 34: 177–183.

29 Loeb SJ, O’Neill J, Gueldner SH. Health motivation: A determinant of older adults attendance at health promotion programs. Journal of Community Health Nursing 2001; 18: 151–165.

30 Cox CL. The interaction model of client health behavior: Application to the study of community-based elders. Advances in Nursing Science 1986; 9: 40–57.

31 Cox CL, Miller EH, Mull CS. Motivation in health behav- ior: Measurement, antecedents, and correlates. Advances in Nursing Science 1987; 9: 1–15.

32 Schwarzer R, Jerusalem M. Generalized self-efficacy scale. In: Weinman J, Wright S, Johnston M (eds). Measures in Health Psychology: A User’s Portfolio. Causal and Control Beliefs. Windsor, England: NFER-NELSON, 1995; 35–37.

33 Kvarme LG, Haraldstad K, Helseth S, Sorum R, Natvig GK. Associations between general self-efficacy and health- related quality of life among 12–13-year-old school chil- dren: A cross sectional survey. Health and Quality of Life Outcomes 2009. Available from URL: http://www.ncbi .nlm.nih.gov/pmc/articles/PMC2757020/. Accessed February 2010.

34 Walker SN, Hill-Polerecky DM. Psychometric evaluation of health promoting lifestyle II. Unpublished manu- script, University of Nebraska Medical Center, College of Nursing, Lincoln, 1997.

35 Sukmak V, Sirisoonthon A, Meena P. Validity of the general perceived self-efficacy scale. Journal of the Psychiatric Associa- tion Thailand 2001; 47: 31–37.

36 Stufibergen AK. Predicting continued employment in persons with multiple sclerosis. The Free Library 2006. Available from URL: http://www.thefreelibrary.com/

Predicting%20continued%20employment%20in%20 persons%20with%20multiple%20sclerosis-a0144013050. Accessed February 2010.

37 Nies MA, Buffington C, Cowan G, Hepworth JT. Compari- son of lifestyles among obese and nonobese african Ameri- can and European American women in the community. Nursing Research 1998; 47: 251–257.

38 Walker SN, Volkan K, Sechrist KR, Pender NJ. Health- promoting lifestyles of older adults: Comparisons with young and middle-aged adults, correlates and patterns. Advances in Nursing Science 1987; 11: 76–90.

39 Cutler DM, Lleras-Muney A (eds). Education and health: Evaluating theories and evidence. National Poverty Center Working Series 2006. Available from URL: http://www .nber.org/papers/w12352.pdf. Accessed January 2011.

40 Mancino L, Lin BH, Bellanger N. The role of economics in eating choices and weight outcomes (Report No. 33781). 2004. Available from URL: http://purl.umn.edu/33781. Accessed January 2011.

41 Gomis-Porqueras P, Peralta-Alva A. A macroeconomic analysis of obesity in the U.S. (Working Papers 0606). 2005. Avail- able from URL: http://moya.bus.miami.edu/~pgomis/ macroeconomicsofobesity.pdf. Accessed January 2011.

42 Provencher V, Begin C, Gagnon-Girouard MP, Tremblay A, Boivin S, Lemieux S. Personality traits in overweight and obese women: Associations with BMI and eating behaviors. Eating Behaviors 2008; 9: 294–302.

43 United States Department of Health and Human Services. The surgeon general’s call to action to prevent and decrease overweight and obesity. 2007. Available from URL: http://www.surgeongeneral.gov/library/calls/obesity/ index.html. Accessed January 2011.

44 Laitinen L, Power C, Ek E, Sovio U, Jarvelin MR. Unem- ployment and obesity among young adults in a northern Finland 1966 birth cohort. International Journal of Obesity 2002; 26: 1329–1338.

45 Annesi JJ. Relations of changes in exercise self-efficacy, physical self-concept, and body satisfaction with weight changes in obese white and African American initiating a physical activity program. Ethnicity & Disease 2007; 17: 19–22.

46 Silagy C, Muir J, Coulter A, Thorogood M, Roe L. Cardio- vascular risk and attitudes to lifestyle: What do patients think. British Medical Journal 1993; 306: 1657–1660.

47 Rashad I, Grossman M, Chou SY. The super size of America: An economic estimation of body mass index and obesity in adults (NBER Working Paper No. 11584). 2005. Available from URL: National Bureau of Econo- mic Research: http://www.nber.org/papers/w11584. Accessed January 2011.

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