Health-Related Physical Fitness, Knowledge, and Administration of the Canadian

Physical Activity, Fitness, and Lifestyle Approach

by

Marc Dylan Faktor

B. Sc. Kinesiology, York University

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE DEGREE OF

MASTER OF SCIENCE

in

THE FACULTY OF GRADUATE STUDIES

(Human Kinetics)

THE UNIVERSITY OF BRITISH COLUMBIA

July, 2009

© Marc Dylan Faktor, 2009

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ABSTRACT

Research suggests that individuals who have increased fitness knowledge via

health education are more likely to be physically active and fit. In addition, an

individual’s health literacy is suggested to play a substantial role towards the

acquisition of health knowledge. However, literature delineating the relationship

between health knowledge, health literacy, and the components of health-related

physical fitness is scarce and inconsistent. The Canadian Physical Activity,

Fitness and Lifestyle Approach (CPAFLA) represents a series of standardized

fitness testing procedures developed by the Canadian Society for Exercise

Physiology. In addition, the CPAFLA provides important health-related information

to individuals intended to promote healthy lifestyle activities. To-date, the influence

of the CPAFLA on health-related physical fitness knowledge and the components

of the Theory of Planned Behaviour (TPB) regarding physical activity has yet to be

examined. One large study examining two distinct sub-questions was conducted.

The first question examined objectively the relationship between health-related

physical fitness knowledge, health literacy, and health-related physical fitness in

34 participants (18 F, 16 M; 19-49 years). Knowledge was examined using the

FitSmart, while health literacy and physical fitness were assessed via the Newest

Vital Sign and the CPAFLA, respectively. Results indicated that knowledge was a

significant correlate (r=O.40, p<O.05) to and the strongest individual predictor

(standardized-B=O.59, p<O.05) of musculoskeletal fitness. In addition, health

literacy was a significant correlate (r = 0.63, p’<0.05) to and the strongest predictor

(standardized-B=0.47, p<0.05) of knowledge. The second question examined

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objectively the influence of administering the CPAFLA on knowledge and the

components of the TPB in relation to physical activity (via a 7-point bipolar

adjective survey) in 40 participants (20 F, 20 M; 19-49 years). The results showed

that the administration of the CPAFLA functioned to increase health knowledge

[Wilks Lambda = 0.82, F (1, 32) = 6.9, p = 0.013], as well as important

components of the TPB including: instrumental attitude [Wilks Lambda = 0.984, F

(1, 32) = 8.36, p = 0.007], perceived behavioral control [Wilks Lambda = 0.861, F

(1, 32) = 5.18, p = 0.030], and intention [Wilks Lambda = 0.667, F (1, 32) = 15.96,

p = 0.00]. Taken together, these results demonstrate the important contribution of

knowledge and health literacy to level of physical fitness, as well as the significant

contribution of the CPAFLA to knowledge development and the promotion of

regular physical activity participation in adulthood.

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TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS iv
LIST OF TABLES viii
LIST OF FIGURES ix
ACKNOWLEDGEMENTS xvi
DEDICATION xviii
CO-AUTHORSHIP STATEMENT xix
CHAPTER 1 I
Introduction to Thesis 1
Overview of Thesis Investigation 5
References 10
CHAPTER 2 15
The Relationship between Health Knowledge and Measures of Health-Related
Physical Fitness 15
Methods 21
Participants 21
Assessment of Health-Related Physical Fitness Knowledge 22
Assessment of Health Literacy 23
Assessment of Health-Related Physical Fitness 24
Procedure 28
Statistical Analysis 29
Results 30
Participants 30
Health-Related Physical Fitness Knowledge 31
Health-Related Physical Fitness Assessment 32
Health-Related Physical Fitness Knowledge and Health-Related Physical
Fitness 34
Health Literacy and Health-Related Physical Fitness Knowledge 34
Discussion 35
Health-Related Physical Fitness Knowledge 36
Health-Related Physical Fitness 37
 V

Health-Related Physical Fitness Knowledge and Health-Related Physical

Fitness 40
Health Literacy and Health-Related Physical Fitness Knowledge 43
Conclusion 45
References 65
CHAPTER 3 72
The Effects of Administering the Canadian Physical Activity Fitness & Lifestyle
Approach (CPAFLA) on Health-Related Physical Fitness Knowledge as well
as Beliefs, Attitudes, and Intentions towards Regular Physical Activity
Participation 72
Methods 79
Participants 79
Procedure 80
Assessment of Health-Related Physical Fitness Knowledge 81
Assessment of the Theory of Planned Behavior Components Concerning
Regular Physical Activity 82
CPAFLA Assessment 85
Statistical Analysis 86
Results 87
Participants 87
Health-Related Physical Fitness Knowledge 88
Components of the Theory of Planned Behavior 89
Discussion 90
Health Knowledge 92
Theory of Planned Behaviour Components 93
Conclusion 96
References 107
CHAPTER4 112
Conclusion 112
References 122
APPENDIXA 124
Extended Review of Literature 124
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Health and Fitness Knowledge. 124

Defining Health and Health Knowledge 125
Rationale for Health Knowledge Assessment 127
Health Knowledge and Behaviour Change 129
Health-Related Knowledge Assessment 131
Assessment of Health-Related Beliefs, Attitudes, and Intentions 136
Impact of Health Knowledge 138
Health Literacy 139
Summary 142
Health-Related Physical Fitness 142
Defining Health-Related Physical Fitness and Primary Contributors 143
Importance of Health-Related Physical Fitness Assessment 144
Assessment of Health-Related Physical Fitness 145
Impact of Health-Related Physical Fitness 145
Summary 147
Health Knowledge in Relation to Health-Related Physical Fitness 148
Health Knowledge and Physical Fitness in Adults 148
Health Knowledge and Physical Fitness in the Elderly 151
Summary 152
References 155
APPENDIX B 165
UBC Clinical Research Ethics Board Certificate of Approval 165
APPENDIX C 167
Sample FitSmart Health Knowledge Examination Questions 167
APPENDIXD 168
Theory of Planned Behaviour Component Assessment 168
APPENDIXE 175
The Newest Vital Sign (NVS) health literacy assessment 175
Nutrition Label 175
Score Sheet 176
APPENDIX F 177
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CFAFLA Preliminary Instructions for Participants 177

APPENDIXG 178
Physical Activity Readiness Questionnaire (PAR-Q) 178
APPENDIX H 179
Physical Activity Readiness Medical Examination (PARmed-X) 179
APPENDIX I 183
CPAFLA Adult Consent Form 183
APPENDIXJ 184
Healthy Physical Activity Participation Questionnaire 184
APPENDIX K 185
Detailed Anthropometric Measurements 185
Body Mass Index (BMI) 185
Waist circumference (WC) 185
Skinfold Measurement (SO5S) 185
APPENDIXL 186
mCAFT Detailed Procedures 186
APPENDIXM 187
Detailed Musculoskeletal Fitness Assessment Procedures 187
Grip Strength 187
Push-ups 187
Sit-and-Reach 187
Partial Curl-ups 188
Vertical Jump and Leg power 188
Back Extension 189
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LIST OF TABLES

Table 2.1: Participant Physical Characterisitics 4

Table 2.2: FitSmart Health-Related Physical Fitness Knowledge Scores 47
Table 2.3: CPAFLA Health-Related Physical Fitness Composite Scores 48
Table 2.4: Health-Related Physical Fitness Knowledge and Physical Fitness
Correlations 49
Table 2.5: Health Knowledge and Musculoskeletal Component Correlations.... 50
Table 2.6: The Newest Vital Sign Health Literacy Scores 51
Table 2.7: The Health Literacy and Health-Related Physical Fitness Knowledge
Correlations 52
Table 3.1: Physical Activity Participation 98
Table 3.2: FitSmart Health-Related Physical Fitness Knowledge Scores 99
Table 3.3: Theory of Planned Behaviour Scores 100
Table A.1: Components of the Canadian Physical Activity, Fitness and Lifestyle
Approach (CPAFLA) 153
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LIST OF FIGURES

Figure 2.1: FitSmart Health-Related Physical Fitness Knowledge Scores 53

Figure 2.2: Healthy Physical Activity Participation Questionnaire 54
Figure 2.3: Composite Musculoskeletal Fitness 55
Figure 2.4: Resting Heart Rate as a Function of Age and Gender 56
Figure 2.5: Height as a Function of Age and Gender 57
Figure 2.6: Weight as a Function of Age and Gender 58
Figure 2.7: Waist Circumference as a Function of Age and Gender 59
Figure 2.8: Aerobic Fitness Scores as a Function of Age and Gender 60
Figure 2.9: Grip Strength as a Function of Age and Gender 61
Figure 2.10: Flexibility as a Function of Age and Gender 62
Figure 2.11: Vertical Jump as a Function of Age and Gender 63
Figure 2.12: Leg Power as a Function of Age and Gender 64
Figure 3.1: Schematic of Research Design 101
Figure 3.2: Time by Treatment Effects for Components of Physical Fitness. ... 102
Figure 3.3: Time by Treatment Effects for Instrumental Attitude 103
Figure 3.4: Time by Treatment Effects for Perceived Behavioural Control 104
Figure 3.5: Time by Treatment Effects for Intention 105
Figure 3.6: Time by Treatment Effects for Intention to Participate in Vigorous
Physical Activity 106
Figure A.1: Schematic of the Theory of Reasoned Action/Planned Behaviour 154
Figure A.2: CPAFLA Vertical Jump 188
Figure A.3: CPAFLA Back Extension 189
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OPERATIONAL DEFINITIONS

Aerobic Fitness: A measure of the combined efficiency of the lungs, heart,

bloodstream, and exercising muscles in getting oxygen to the muscles and

putting it to work (CSEP, 2003).

Body Composition: The relative amounts of muscle, fat, bone, and other

anatomical components that contribute to a persons total body weight (U.S.

Department of Health and Human Services, 1999).

Body Mass Index (BMI): The ratio of body weight divided by height squared

) (CSEP, 2003).
2
(KgIm

Canadian Society for Exercise Physiology (CSEP): A voluntary organization

composed of professionals interested and involved in the scientific study of

exercise physiology, exercise biochemistry, fitness and health (for more

information see www.csep.ca (national information) or

www.csephealthfitnessbc.ca (BC information)).

Composite Body Composition: A heafth-related fitness measure of body

composition which focuses on three specific indicators: body mass index

(BMI), sum of (five) skinfolds (SO5S), and waist circumference (WC) (CSEP,

2003).

The Canadian Physical Activity, Fitness and Lifestyle Approach (CPAFLA): The

CSEP Health and Fitness Program’s 3’ Edition health-related appraisal and

counselling strategy. It is a health-related fitness assessment protocol which

incorporates measures of physical activity participation, body composition

and metabolism, aerobic fitness, and musculoskeletal (including back)

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fitness. The CPAFLA is a client centered approach which focuses on the

promotion of positive health behaviours, and is administered to over one

million Canadians every year (CSEP, 2003).

Exercise: Planned and structured physical activity which incorporates repetitive

bodily movement geared towards improving or maintaining one or more

components of physical fitness (Caperson, Powell, & Christenson, 1985).

Flexibility: The range of movement in a joint or series of joints (CSEP, 2003).

Health: A construct that has physical, social, and psychological dimensions, each

characterized on a continuum with positive and negative poles. Positive

health is associated with a capacity to enjoy life and to withstand challenges;

it is not merely the absence of disease. Negative health is associated with a

decreased capacity to enjoy life and withstand challenges (CSEP, 2003).

Health Knowledge: A knowledge base that enables individuals to identify the

symptoms and communicability of diseases, allows individuals to select and

participate in appropriate preventative health strategies, and gives individuals

and understanding of where to obtain health services (Freimuth, 1990). This

knowledge base should encompass the basics of: aging, anatomy and

physiology, drug use and abuse, illness, nutrition and metabolism, physical

exercise and activity, health care utilization, as well as safety and first aid

(Beier & Ackerman, 2003).

Health Literacy: The degree to which people have the capacity to obtain,

process, and understand basic health information and services needed to

make appropriate health decisions (Parker, Ratzan, & Lurie, 2003).

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Health Promotion: The aggregate of all purposeful activities designed to improve

personal and public health through a combination of strategies, including the

competent implementation of behavioural change strategies, health education

measures, risk factor detection, health enhancement and health maintenance

(Amesetal., 1991).

Health-Related Physical Fitness: Encompasses the components of physical

fitness that are related to health status, including cardiovascular fitness,

musculoskeletal fitness, body composition and metabolism (Warburton et al.,

2006b).

Health-Related Physical Fitness Knowledge (specific to this investigation): A

knowledge base that encompasses basic fitness concepts, which is

comprised of six sub-domain components including: concepts of fitness;

scientific principals of exercise; components of physical fitness; effects of

exercise on chronic disease risk factors; exercise prescription; as well as

nutrition, injury prevention, and consumer issues (Zhu, Safrit, & Cohen,

1999).

Heart Rate Reserve (HRR): A method used to prescribe exercise intensities.

HRR is calculated by subtracting resting heart rate from maximum heart rate

(Powers & Howley, 2004).

Hypokinetic Disease: Disease states that are directly related to low levels of

activity (e.g. heart disease, type II diabetes) (Kraus & Raab, 1961).

Intensity: The level of energy required to perform a specified physical activity. It

is most commonly depicted in terms of maximal oxygen consumption

 xlii

(VO
m
2 ax), percent of age predicted maximum heart rate (HRmax=220-age in

years), percent heart rate reserve (HRR), or metabolic equivalents (METs)

expressed in mlxkg
xmin (1 MET= 3.5 ml of oxygen consumption per
1

kilogram of body mass per minute) (U.S. Department of Health and Human

Services, 1999).

Metabolic Equivalent (MET): Used to describe the energy costs associated with

exercise. One MET is equal to resting V0

, which is approximately
2

3.5m1/kg/min (Powers & Howley, 2004).

Modified Canadian Aerobic Fitness Test (mCAFT): A predictive, submaximal,

and progressive exercise test designed specifically for the general population.

The test is employed in the CPAFLA health-related fitness assessment

(CSEP, 2003) as an indicator of aerobic fitness.

Muscular Endurance: The ability of the musculoskeletal system to maintain or

repeatedly develop force (CSEP, 2003).

Musculoskeletal Fitness: The fitness of the musculoskeletal system,

encompassing muscular strength, muscular endurance, muscular power,

flexibility, back fitness and bone health (Warburton, Whitney, & Bredin,

2006b).

Muscular Power: The combination of muscular strength and speed, which

corresponds to the maximum rate of force that can be generated in a single

rapid contraction (CSEP, 2003).

Muscular Strength: The maximum tension or force a muscle can exert in a single

contraction (CSEP, 2003).

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Obesity: A condition of excessive body fat that results from a chronic energy

imbalance whereby intake exceeds expenditure (Katzmarzyk, 2002).

Physical Activity: Any bodily movement produced by skeletal muscles that

results in energy expenditure (EE) and is positively correlated with physical

fitness (Caperson et al., 1985).

Physical Fitness: A term that encompasses a set of attributes that people

possess or achieve relating to their ability to perform physical activity.

Physical fitness is comprised of five health-related components which

include: (1) body composition, (2) cardiovascular endurance, (3) flexibility, (4)

muscular endurance, and (5) muscular strength (U.S. Department of Health

and Human Services, 1999).

Predicted Maximum Heart Rate (HRmax): An age based predication of maximum

heart rate, referred to in beats per minute (bpm). Calculated by subtracting

one’s age from 220 (220-age = HRmax). Intensity can also be defined by

utilizing percent of predicted HRmax. For example: 70% of HRmax = .7(220-

age) (CSEP, 2003).

Skinfold: The thickness of the fold of skin plus the underlying fat determined by

the use of a high quality Harpenden TMskinfold caliper (CSEP, 2003).

Socioeconomic Status (SES): A complex phenomenon predicted by a broad

spectrum of variables that is often conceptualized as a combination of

financial, occupational, and educational influences (Winkleby, Jatulis, Frank,

& Fortmann, 1992).

 xv

Sum of Five Skinfolds (SO5S): An estimate of subcutaneous fat which is

determined by the addition of the triceps, biceps, subscapula, iliac crest, and

medial calf skinfolds (CSEP, 2003).

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ACKNOWLEDGEMENTS

There are numerous individuals who have assisted me in various ways

throughout the course of my Masters. First and foremost I would like to thank my

primary supervisor Dr. Shannon S.D. Bredin and close collaborator Dr. Darren

E.R. Warburton for their continuous support, knowledgeable guidance,

inspiration, and empathy throughout the course of my degree. Dr. Bredin and Dr.

Warburton opened up many doors for me as a health and fitness professional.

They provided an abundance of exciting, challenging, and fulfilling professional

development opportunities (e.g., professional certification pathways, field testing

and counselling opportunities with large health-related organizations, exciting

research excursions, multiple employment opportunities, and the list goes on!). I

am now exceptionally equipped to pursue a career in the health sciences thanks

to these unique, challenging, and memorable experiences. Moreover, my

supervisor, Dr. Bredin, was always there to push me further, was exceptionally

astute when it came down to editing my work, and never settled for a subpar

product. In addition, I would like to thank Dr. Ryan E. Rhodes for his meaningful

contribution to my thesis work. Dr. Rhodes was never too busy to assist me with

any questions or concerns I had regarding the research at hand, and continually

provided me with valuable sources of information which significantly contributed

to this thesis and my overall knowledge base.

Secondly, I would like to thank the LEARN and CPR lab members for their

mentorship, camaraderie, and continual support throughout the course of my

degree. In alphabetical order (first name) I would like to thank: Ashley Charlebois
 xvii

(MSc. Student), Anita Cote (PhD. Student), Ashlee McGuire (MSc. Student), Ben

Esch (PhD. Student), Dominik Zbogar (MSc. Student), Jessica Scott (PhD.

Student), Lindsay Nettlefold (PhD. Student), Mika Johnson (MSc. Student),

Mischa Harris (CSEP BC undergraduate champion), Dr. Sarah Charlesworth

(post doctoral fellow), Stephanie Gatto (previous research coordinator), Shirley

Wong (MSc. Student), and Tim Lebas (CSEP BC Renewals Officer & Admin

Coordinator).
 xviii

DEDICATION

I would like to dedicate this work to my parents (Brenda & Gary Faktor),

sisters (Cand ice & Lisa), and all of my closest friends who substantially

contributed to my upbringing shaped me into the man I have become (Adam

Miller, Amy Blumenkranz, Ben Kreaden, Brad Saltz, Daniel Cohen, Eva Kalmar,

Evan Marcus, Gavin Karpel, Jeff Lippa, John Dsouza, Jordan Ohayon, Lesley

Spitzen, Mandy Joseph, Marwan Hamam, Mike Smith, Mona Maghsoodi, Rachel

Glazer, Richard Arluck, Ryan Abramowitz, Selina Chan, Serj Markarians,

Stephen Abrahamson, Stephanie Sternberg, Tracey Kunz, Vahid Assadpour, &

Zack Saltzberg). As Tony Robbins once said: “A person is a direct reflection of

the expectations of their peer group”. Mom, Dad, Lisa, Candice, and all my

auxiliary brothers and sisters: thank you all for showing me the way!
 xix

CO-AUTHORSHIP STATEMENT

Two manuscripts are presented in this document in Chapters 2 and 3,

respectively:

1. Faktor, M.D., Warburton, D.E.R., Rhodes, R.E., & Bredin, S.S.D. The

Relationship between Health Knowledge and Measures of Health-Related

Physical Fitness. To be submitted in July/August 2009.

2. Faktor, M.D., Warburton, D.E.R., Rhodes, R.E., & Bredin, S.S.D. The Effects

of Administering the Canadian Physical Activity Fitness & Lifestyle Approach

(CPAFLA) on Health-Related Physical Fitness Knowledge as well as Beliefs,

Attitudes, and Intentions towards Regular Physical Activity Participation. To be

submitted in July/August 2009.

More specifically, Marc D. Faktor and Dr. Shannon Bredin were primarily

responsible for the identification and design of the research program with input

from Dr. Darren Warburton and Dr. Ryan Rhodes. Marc D. Faktor collected and

analyzed all of the data presented in these manuscripts. The manuscripts in

present form were also prepared by Marc D. Faktor with major contributions

made by Dr. Shannon Bredin. Dr. Warburton and Dr. Rhodes made significant

contributions following initial preparation of the manuscripts.

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CHAPTER 1

Introduction to Thesis

There is incontestable evidence supporting regular physical activity participation

(structured and unstructured) in the primary and secondary prevention of numerous

chronic diseases and premature death (Warburton, Whitney, & Bredin, 2006a). Physical

inactivity is a primary modifiable risk factor for cardiovascular disease and an increasing

assortment of accompanying chronic hypokinetic (insufficient movement or activity)

diseases, including: obesity, diabetes mellitus, cancer (breast and colon), bone and joint

diseases (osteoporosis and osteoarthritis), depression, and hypertension (Katzmarzyk,

1998; Katzmarzyk, Gledhill, & Shephard, 2000; Katzmarzyk, Perusse, Rao, & Bouchard,

2000; Warburton et al., 2006a).

Recent research estimates that 53.5% of adult Canadians are physically inactive

and 14.7% are obese (Katzmarzyk & Janssen, 2004). Within British Columbia, the

physical inactivity prevalence is substantially lower (as low as 37%) in comparison to

the rest of the average Canadian population. Five British Columbia health service

regions are in the top ten for most physically active Canadian regions, with the top three

all being British Columbia regions (Canadian Fitness and Lifestyle Research Institute,

2005). However, the average Canadian physical inactivity prevalence ranks higher than

all other existing and modifiable chronic hypokinetic disease risk factors (Warburton et

a)., 2006a) and is predicted to rise along with current obesity rates. In 2001, 9.6 billon

dollars were directly accredited to physical inactivity and obesity in Canada (Katzmarzyk

& Janssen, 2004). These data confirm that physical inactivity and obesity are chief

contributors to the Canadian public health care burden. Health promotion efforts,
 2

guided by relevant research, that function to increase physical activity and reduce

obesity would significantly lower unnecessary health care spending and increase the

health status of Canadians (Katzmarzyk & Janssen, 2004).

The assessment of health-related physical fitness is of major importance (Oja,

1995). The Canadian Society for Exercise Physiology (CSEP) health-related fitness

appraisal and counselling strategy (the Canadian Physical Activity, Fitness & Lifestyle

Approach (CPAFLA)) represents a series of standardized testing procedures. When

administered by trained and certified CSEP health and fitness professionals, the results

of the appraisal allow for the evaluation of current health status in accordance to

Canadian normative data. Moreover and above all, the appraisal process and findings

provide vital health-related information to individuals. A humanistic goal of this approach

is to provide motivation to appraisal participants to develop healthier lifestyles and to

increase their physical activity participation (Canadian Society for Exercise Physiology,

2003). However, previous scientific investigation has yet to explore whether or not the

CPAFLA functions to increase health-related physical fitness knowledge or provide

empirical evidence suggesting that it motivates individuals to participate in regular

physical activity.

A number of theories have been used to explain and predict individual’s health

related behaviours. Becker’s Health Belief Model (1988) stipulates that an individual’s

health-related lifestyle is dictated by his or her perception of the consequences of a

potential illness (e.g., cardiovascular disease) and the benefits of engaging in a

behaviour (e.g., aerobics) that would eliminate the threat of such illness (Rosenstock,

Strecher, & Becker, 1988; Seefeldt, Malina, & Clark, 2002). These perceptions are

shaped in part by the knowledge base that one possesses. Prochaska and Diclimente’s
 3

Transtheoretical Model of Behaviour Change (1992) accentuates this notion. In order for

a behavioural change to occur, the rudimentary step is to educate with the intention of

increasing knowledge and awareness of the particular behavioural actions and

reactions (Prochaska, DiClimente, & Norcross, 1992). Dominant among these is the

Theory of Planned Behaviour (TPB, formerly the Theory of Reasoned Action (TRA)

(Ajzen, 1988, 1991). The TPB proposes that the most immediate and significant

forecaster of behaviour is an individual’s intention to execute a behaviour. This

behavioural intention is predicted by three major factors: attitude towards the behaviour,

subjective norm, and perceived behavioural control. The knowledge base of an

individual, in relation to the behaviour, is considered a background variable which

influences the three variables that form behavioural intentions (Ajzen & Manstead,

2007). Accordingly, research suggests that individuals who understand the concepts of

health-related physical fitness are more likely to be physically active and demonstrate

higher fitness levels (Zhu, Safrit, & Cohen, 1999; Petersen, Byrne, & Cruz, 2003). Thus,

important processes in becoming physically fit while endorsing constructive behaviours

in relation to fitness are: obtaining, learning, and applying the concepts and principles of

health-related physical fitness (Miller & Housner, 1998).

Health knowledge permits individuals to acknowledge the warning signs and

propagation of diseases, select and partake in suitable preventative health strategies

(e.g., physical activity), and provides individuals with an understanding of where and

how to obtain health services and assistance (Freimuth, 1990). Health-related physical

fitness knowledge is a knowledge base that encompasses basic fitness concepts

related to health status as well as disease risk, prevention, and treatment (Zhu et al.,

1999). The examination of health knowledge has important policy implications as health
 4

knowledge and its dependants are major utilities to public health promotion agencies

(Nayga, 2001). Empirical evidence regarding the influence of health knowledge on

health-related physical fitness, as well as variation in health knowledge across socio

demographic groups should be utilized in the development of future health promotion

and education programs. However, literature delineating the relationship between

health-related physical fitness knowledge and health-related physical fitness is scarce

and inconsistent. Investigations have suggested a positive relationship between

knowledge base and health-related fitness in adolescence (Keating, 2007), adulthood

(Petersen et al., 2003), as well as in older adulthood (Fitgerald, Singleton, Neale,

Prasad, & Hess, 1994). Conversely, investigations have also shown no relationship

between fitness knowledge and components of physical fitness (e.g., physical activity)

(Morrow, Krzewinski-Malone, Jackson, Bungum, & and FitzGerald, 2004).

A significant factor associated with the acquisition of health knowledge is health

literacy. Health literacy is defined as the degree in which people have the competence

to obtain, process, and understand basic health information and services needed to

make appropriate health decisions (Parker, Ratzan, & Lurie, 2003). It is a contemporary

and well warranted topic of concern for the advancement of high quality health care.

Health literacy is pivotal to numerous health care system initiatives including quality

assurance, cost maintenance, safety, and patient’s active involvement in health care

decisions (Parker, Ratzan, & Lurie, 2003). Inadequate health literacy is associated with

several health-related consequences, as literacy is correlated to numerous aspects of

health including: health knowledge, health status, and use of health services (Ad Hoc

Committee on Health Literacy for the Council on Scientific Affairs, American Medical

Association, 1999). Patients with low literacy are generally 1.5-3 times more likely to
 5

experience inferior health outcomes inclusive of health knowledge, transitional disease

indicators, morbidity measures, utilization of health resources, and general health status

(DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004). In terms of health-related

knowledge, there exists a positive and significant relationship between literacy levels

and knowledge of health services or health outcomes (DeWalt et al., 2004). Studies

indicate that individuals with low literacy and chronic or infectious diseases such as

diabetes (Williams, Baker, & Parker, 1998), hypertension (Williams et al., 1998), asthma

(Williams, Nurss, Baker, Honig, Lee, & Nowlan, 1998), or HIV/AIDS (Kalichman,

Benotsch, Suarez, Catz, Miller, & Rompa., 2000) have inferior knowledge concerning

their disease and its recommended treatment. Furthermore, research has indicated that

poor health literacy alone is the most significant predictor of disease prevention

knowledge when compared to ethnicity or education (Lindau, Tomori, Lyons, Langseth,

Bennett, & Garcia, 2002). Nevertheless, to the best of our knowledge, the relationship

between health literacy and health-related physical fitness knowledge has yet to be

examined.

Overview of Thesis Investigation

One large study examining two distinct sub-questions was conducted. The first

research objective was to examine the relationship between health-related physical

fitness knowledge and health-related physical fitness in young and middle adulthood. A

secondary purpose of this sub-question was to examine the relationship between health

literacy and health-related physical fitness knowledge. Knowledge was assessed via the

FitSmart, a standardized health-related physical fitness knowledge examination. Health

related physical fitness was assessed and interpreted using the Canadian Physical
 6

Activity, Fitness and Lifestyle Approach (CPAFLA); while health literacy was assessed

via the Newest Vital Sign, a brief yet formal standardized health literacy assessment.

We hypothesized that individuals who scored higher on the FitSmart would also

demonstrate higher levels of health-related physical fitness in comparison to individuals

who scored lower on the FitSmart examination. This hypothesis was based on the idea

that knowledge is considered a critical factor in establishing human behaviour (Andrade,

1999). Furthermore, people who understand the concepts of physical fitness are also

more likely to incorporate physical activity and exercise into their everyday life (Zhu et

al., 1999). Therefore, we predicted that individuals with increased fitness knowledge

would display higher levels of health-related physical fitness because regular physical

activity participation is often assumed as a significant predictor of health-related

physical fitness (Katzmarzyk, 1998). We also hypothesized that there would be a

positive and significant correlation between health literacy and health-related physical

fitness knowledge. It was expected that individuals who scored higher on the Newest

Vital Sign would also demonstrate higher scores on the FitSmart (in comparison to

individuals who scored lower on the health literacy assessment). Given that health

literacy has been shown to be a positive and significant correlate to and predictor of

health-related knowledge as well as health outcomes (DeWalt et al., 2004; Lindau et al.,

2002), it is reasonable to postulate a positive and significant relationship between health

literacy and health-related physical fitness knowledge. In summary, our findings showed

that health-related physical fitness knowledge was positively and significantly correlated

to health-related physical fitness in adulthood. Specifically, knowledge was a significant

correlate to and the strongest individual predictor of musculoskeletal fitness. In addition,

health literacy was found to be a significant correlate to and the strongest predictor of
 7

knowledge. These findings have been compiled into a manuscript titled, “The

relationship between health knowledge and measures of health-related physical

fitness”, which is presented in Chapter 2 of this thesis document.

The second research objective of this investigation was to examine objectively the

effects of administering the CPAFLA on health knowledge and the Theory of Planned

Behaviour components (i.e., attitude, subjective norm, perceived behavioural control,

and intention) concerning regular physical activity participation in adulthood. The

Theory of Planned Behaviour constructs were assessed via a written survey containing

a series of 7-point bipolar adjective scales concerning regular physical activity

participation. We hypothesized that individuals receiving the CPAFLA would

demonstrate improved scores on the post-test FitSmart knowledge examination. More

specifically, individuals would demonstrate higher scores on the ‘Components of

Physical Fitness’ section of the test in comparison to baseline measures. This

hypothesis was generated because the administration of the CPAFLA strategically

identifies major physical fitness components in a sequential order and highlights their

individual and aggregative impacts on health and well being. Furthermore, the CPAFLA

strategy emphasizes education and counselling concerning appropriate evidence based

tactics designed to augment fitness through a variety of exercises and activities. These

tactics are based on the interpretation of fitness results (CSEP, 2003). As such, we

predicted that participants will demonstrate improvements on the FitSmart examination

following administration of the CPAFLA on questions specific to the health-related

physical fitness component of the examination. We also predicted that the theory of

planned behaviour components (i.e., individual beliefs, attitudes, and intentions) related

to physical activity participation would improve in comparison to baseline measures

 8

following the administration of the CPAFLA. The CPAFLA appraisal process is

designed to increase knowledge and awareness concerning health-related physical

fitness while highlighting the health benefits of physical activity in an attempt to motivate

individuals to develop healthier lifestyles and increase physical activity participation

(CSEP, 2003). As such, improvements in the relevant Theory of Planned Behaviour

components were expected following the administration of the CPAFLA. Our results

supported these hypotheses, whereby administration of the CPAFLA functioned to

increase health knowledge, as well as important components of the TPB. These effects

were demonstrated via increases in instrumental attitude, perceived behavioural control,

and intention. The findings have been compiled into a manuscript titled, “The effects of

administering the Canadian Physical Activity Fitness & Lifestyle Approach (CPAFLA) on

health-related physical fitness knowledge as well as beliefs, attitudes, and intentions

towards regular physical activity participation”, which is presented in Chapter 3 of this

thesis document.

Overview of Document

This thesis is comprised of four Chapters. Chapter 1 serves as a general

introduction to the thesis. The findings of the thesis investigation are then presented in

the form of two manuscripts. The purpose of the first manuscript is to examine the

relationship between health knowledge and health-related physical fitness; while, the

second manuscript focuses on the effects of administering the CPAFLA on health

related physical fitness knowledge, as well as beliefs, attitudes, and intentions towards

regular physical activity participation. These manuscripts are presented in Chapters 2

and 3, respectively. The conclusion is then presented in Chapter 4. This thesis also

includes Appendices A through M. More specifically, the Appendix section includes: A)

 9

an extended review of literature directly pertinent to the investigation B) the required

certificate of research ethics, C) a sample of the FitSmart health-related physical fitness

knowledge examination questions, D) the health-related physical activity belief and

attitude assessment, E) the Newest Vital Sign (NVS) health literacy assessment, F) the

CPAFLA preliminary instruction template, G) the Physical Activity Readiness

Questionnaire (PAR-Q), H) the Physical Activity Readiness Medical Examination

(PARmed-x) template, I) the CPAFLA consent form, J) the Physical Activity Participation

Questionnaire used in the CPAFLA, K) the detailed CPAFLA anthropometric protocols,

L) the detailed modified Canadian Aerobic Fitness Test (mCAFT) procedure, and M) the

detailed CPAFLA m uscu loskeletal fitness assessment protocols.

 10

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 12

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 14

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 15

CHAPTER 2

The Relationship between Health Knowledge and Measures of Health-Related Physical

1
Fitness

Knowledge is considered to be a major determinant of human behaviour

(Andrade et aL, 1999). Health-related knowledge permits individuals to acknowledge the

warning signs and propagation of diseases, select and partake in suitable preventative

health strategies (e.g., physical activity), and provides individuals with an understanding

of where or how to obtain health assistance (Freimuth, 1990).

A number of theories have been used to explain and predict individual’s health-

related behaviours. Becker’s Health Belief Model (1988) stipulates that an individual’s

health-related lifestyle is dictated by his/her perception of the consequences of a

potential illness (e.g., cardiovascular disease) and the benefits of engaging in a

behaviour (e.g., aerobics) that would eliminate the threat of such illness (Rosenstock,

Strecher, & Becker, 1988; Seefeldt, Malina, & Clark, 2002). These perceptions are

shaped in part by the knowledge base that one possesses. Prochaska and Diclimente’s

Transtheoretical Model of Behaviour Change (1992) accentuates this notion. In order for

a behavioural change to occur, the rudimentary step is to educate with the intention of

increasing knowledge and awareness of the particular behavioural actions and

reactions (Prochaska, DiClimente, & Norcross, 1992). Dominant among these is the

Theory of Planned Behaviour (TPB, formerly the Theory of Reasoned Action (TRA))

(Ajzen, 1988, 1991). The TPB proposes that the most immediate and significant

1
A version of this chapter will be submitted for publication. Faktor, M.D., Warburton, D.E.R., Rhodes,
R.E., & Bredin, S.S.D. The Relationship between Health Knowledge and Measures of Health-Related
Physical Fitness.
 16

forecaster of behaviour is an individual’s intention to execute a behaviour. This

behavioural intention is predicted by three major factors: attitude towards the behaviour,

subjective norm, and perceived behavioural control. The knowledge base of an

individual, in relation to the behaviour, is considered a background variable which

influences the three variables that form behavioural intentions (Ajzen & Manstead,

2007). Accordingly, research suggests that individuals who understand the concepts of

health-related physical fitness are more likely to be physically active and demonstrate

higher fitness levels (Zhu, Safrit, & Cohen, 1999; Petersen, Byrne, & Cruz, 2003a).

Thus, important processes in becoming physically fit while endorsing constructive

behaviours in relation to fitness are obtaining, learning, and applying the concepts and

principles of health-related physical fitness (Miller & Housner, 1998).

Health-related fitness encompasses the components of physical fitness that are

related to health status, including physical activity participation, cardiovascular fitness,

musculoskeletal fitness, body composition, and metabolism (Warburton, Whitney, &

Bredin, 2006b). Additionally, it is regularly assumed that health-related physical fitness

is a product of habitual physical activity participation (Katzmarzyk, Malina, Song, &

Bouchard, 1998). Thus, a positive correlation is expected between participation in

physical activity (i.e., any bodily movement produced by skeletal muscles that results in

energy expenditure (EE)) and measures of physical fitness (e.g., body composition,

aerobic fitness, and musculoskeletal fitness) (Caspersen, Powell, & Christenson, 1985).

Another quantifiable component of physical fitness is cardiovascular or aerobic fitness.

It is commonly defined as a measure of the combined efficiency of the lungs, heart,

bloodstream, and exercising muscles in getting the oxygen to the muscles and putting it

to work (CSEP, 2003). Individuals must then rely on the musculoskeletal system for
 17

movement and to perform work. Musculoskeletal fitness refers to the fitness of the

musculoskeletal system, encompassing muscular strength, muscular endurance,

muscular power, flexibility, back fitness and bone health (Warburton, Whitney, & Bredin,

2006b). Based on this definition, it is apparent that musculoskeletal fitness is essential

to maintain as it provides the basis for our activities of daily living and determines our

ability to perform a wide variety of physical challenges. Finally, body composition is an

essential component of health-related fitness. The relative amounts of muscle, fat, bone

and other anatomical components that contribute to a person’s total body weight (U.S.

Department of Health and Human Services, 1999) are what make up an individual’s

body composition and contribute to metabolic capacity.

To-date, the literature examining the relationship between health knowledge and

health-related physical fitness remains limited and inconsistent. Evidence supporting a

positive relationship between health-related physical fitness knowledge and the

components of health-related physical fitness has been suggested in adolescence

(Keating, 2007), and limitedly shown in adulthood (Avis, McKinlay, & Smith, 1990; Liang

et al., 1993) and within elderly populations (Fitgerald, Singleton, Neale, Prasad, & Hess,

1994). Moreover, investigations have also shown no significant relationship between

fitness knowledge and components of physical fitness (e.g., health-related physical

activity) (Morrow, Krzewinski-Malone, Jackson, Bungum, & FitzGerald, 2004). More

specifically, the research literature has shown that cardiovascular risk factor knowledge

is positively related to level of education, being female, and amount of exercise (Avis,

McKinlay, & Smith, 1990). In addition, exercise beliefs and knowledge have been

suggested to influence exercise habits of healthy females (Fitgerald et al., 1994). Liang

et al. (1993) have shown that health knowledge influenced medical student’s fitness
 18

levels; however, attitudes concerning health promotion and disease prevention were

stronger predictors of fitness levels. In contrast, Morrow et al. (2004) showed that

knowledge of exercise recommendations had no effect on exercise behaviours; yet,

ethnicity, education level, and age were significantly correlated to health knowledge.

A significant factor associated with the acquisition of health knowledge is health

literacy. Health literacy is defined as the degree in which people have the competence

to obtain, process, and understand basic health information and services needed to

make appropriate health decisions (Parker, Ratzan, & Lurie, 2003). It is a contemporary

and well warranted topic of concern for the advancement of high quality health care.

Specifically, health literacy is pivotal to numerous health care system initiatives

including quality assurance, cost maintenance, safety, and patient’s active involvement

in health care decisions (Parker et al., 2003).

The International Adult Literacy and Skills Survey (IALS) is the primary and

current source of literacy measures of the general population in Canada and in other

countries (Rootman, 2005). Most recently, the IALS highlighted major deficiencies in

the literacy levels of the Canadian population (Statistics Canada, 2005). Almost half of

the Canadian adult population fell into the lowest 2 of 5 literacy levels with regards to

their ability to read and comprehend prose (48%) and documents (49%). The majority of

the population fell into the two lowest levels concerning problem solving ability (72%)

and numeracy (55%). Correspondingly, 22% of the Canadian adult population were

shown to be seriously challenged in terms of literacy and another 26% displayed skills

considered to be inadequate for the successful participation in today’s “knowledge

economy” (Rootman, 2005; Statistics Canada, 2005).

 19

There are several consequences of inadequate levels of health literacy. Literacy

is related to numerous aspects of health including health knowledge, health status, and

use of health services (Ad Hoc Committee on Health Literacy for the Council on

Scientific Affairs, American Medical Association, 1999). When related to health

outcomes, patients with low literacy are generally 1.5-3 times more likely to experience

inferior health outcomes inclusive of knowledge, transitional disease indicators,

morbidity measures, utilization of health resources, and general health status (DeWalt,

Berkman, Sheridan, Lohr, & Pignone, 2004). In terms of knowledge, there exists a

positive and significant relationship between literacy levels and knowledge of health

services or health outcomes (DeWalt et al., 2004). Research indicates that individuals

with low literacy and chronic or infectious diseases (e.g., diabetes, hypertension,

asthma (Williams et al., 1998), or HIV/AIDS (Kalichman et al., 2000)) have inferior

knowledge concerning their disease and its recommended treatment. Furthermore,

research has indicated that poor health literacy alone is the most significant predictor of

disease prevention knowledge when compared to ethnicity or education (Lindau et al.,

2002). To-date, health literacy has not been examined in relation to health-related

physical fitness knowledge.

The examination of health knowledge in relation to physical fitness (as well as

health literacy in relation to health-related physical fitness knowledge) has important

policy implications for preventative health care schematics. This is especially applicable

to health promotion programs that employ education as a primary objective. Currently,

the prevalence of physical inactivity (51 % of adult Canadians) ranks higher than all

other existing and modifiable hypokinetic (insufficient movement) disease risk factors

(Statistics Canada, 2003; Warburton, Whitney, & Bredin, 2006a). Moreover, overweight
 20

and obesity within Canada has reached epidemic measures (Katzmarzyk, Perusse,

Rao, & Bouchard, 2000; Katzmarzyk, 2002a; Katzmarzyk, 2002; Katzmarzyk, &

Janssen, 2004) Direct health care expenditures and indirect costs associated with
.

physical inactivity and obesity in Canada are conservatively estimated to provide an

economic burden totalling 9.6 billion: 5.3 billion for inactivity (1.6 and 3.7 billion in direct

and indirect costs, respectively), and 4.3 billion for obesity (1.6 and 2.7 billion in direct

and indirect costs, respectively) (Katzmarzyk, & Janssen, 2004). Provincially, the health

care productivity losses and obesity costs associated with inactivity are conservatively

estimated to cost British Columbia between $730 and $830 million per annum (Deacon,

2001). Given these data and the notion that health knowledge and its dependants are

major utilities to public health promotional agencies (Nayga, 2001), the generation of

empirical evidence regarding the influence of health knowledge on health-related

physical fitness is clearly warranted.

The primary purpose of the present investigation was to examine the relationship

between health-related physical fitness knowledge and objective measures of health-

related physical fitness in young and middle adulthood. Health-related physical fitness

knowledge was assessed via the FitSmart, a standardized health-related physical

fitness knowledge examination, whereas, health-related physical fitness was assessed

and interpreted using the Canadian Physical Activity, Fitness and Lifestyle Approach

(CPAFLA). We hypothesized that individuals who scored higher on the FitSmart would

also demonstrate higher levels of health-related physical fitness as determined by the

CPAFLA in comparison to individuals who scored lower on the objective assessment of

health-related physical fitness knowledge. Knowledge is a critical factor for establishing

human behaviour (Andrade, 1999); and, moreover, people who understand the
 21

concepts of physical fitness are also more likely to incorporate physical activity and

exercise into their everyday life (Zhu et al., 1999). Regular physical activity participation

is often assumed as a significant predictor of health-related physical fitness

(Katzmarzyk, 1998), therefore, we postulated that individuals with increased fitness

knowledge would display higher levels of health-related physical fitness.

The secondary purpose of this investigation was to examine the relationship

between health literacy and health-related physical fitness knowledge in young and

middle adulthood. Health literacy was assessed via the Newest Vital Sign. We

hypothesized a positive and significant correlation between health literacy and health-

related physical fitness knowledge. That is, individuals who scored higher on the

Newest Vital Sign would also demonstrate higher scores on the FitSmart in comparison

to individuals displaying lower scores on the health literacy assessment.

Methods

Participants

Written informed consent was received from 18 female and 16 male participants.

Participants were recruited according to two age groups: (a) 19 to 29 years (young

adulthood, n = 9 F, 9 M; mean age = 24.3 ± 2.6), and (b) 39 to 49 years (middle

adulthood, n = 9 F, 7 M; mean age = 42.6 ± 3.7). Individuals that were pregnant, were in

poor health (illness or fever) at time of data collection, or were unable to provide

documented physician clearance for physical activity in accordance with the CPAFLA

pre-appraisal screening process were not permitted to participate. This investigation

was executed in exact accordance with the ethical guidelines set forth by the University
 22

of British Columbia’s Clinical Research Ethics Board for research involving human

participants (see Appendix B for certificate of research ethics).

Assessment of Health-Related Physical Fitness Knowledge

The FitSmart written examination (Form 1) was used to assess the health-related

physical fitness knowledge of each participant. Developed by Zhu, Safrit, and Cohen

(1999), the FitSmart consists of 50 multiple choice items, measuring six sub-domain

components: concepts of fitness; scientific principles of exercise; components of

physical fitness; effects of exercise on chronic disease risk factors; exercise

prescription; as well as nutrition, injury prevention, and consumer issues. Concepts of

fitness make up 20% of the FitSmart examination and incorporate questions pertaining

to fitness definitions, and the relationship(s) between fitness, physical activity, and

health. The scientific principles of exercise component also makes up 20% of the exam

and includes questions relating to the acute/chronic physiological and psychological

adaptations to exercise. Questions associated with cardiovascular, respiratory and

pulmonary function; muscular strength and endurance; flexibility; and body composition

are addressed in the components of physical fitness section and comprise 20% of the

exam. Five percent of the exam includes questions relating to the effects of exercise on

chronic disease risk factors. Exercise prescription makes up 20% of the exam and

takes into account the concepts of frequency, intensity, duration, mode, self-evaluation

and exercise adherence. Last, 15% of the FitSmart examination consists of items

pertaining to nutrition, injury prevention and consumer issues. Participants were

allocated 45 minutes to complete the examination. Raw scores out of 50, overall
 23

percentages, and categorical percentage scores for each fitness component were

generated via the FitSmart software for data analysis.

According to Zhu et al. (1999), the FitSmart is an established, valid, and reliable

test to measure knowledge of the fundamental health and fitness concepts at the high

school level of education. As such, the FitSmart written examination was used in this

investigation to establish whether young and middle-aged adults possess the level of

health-related knowledge expected at a high school level. The FitSmart has been

implemented as the primary measure of health-related physical fitness knowledge in

well educated adult populations (Losch & Strand, 2004; Petersen, Byrne, & Cruz,

2003b). Researchers have also utilized sections of the FitSmart as adjuncts to series of

self report measures to incorporate health knowledge (Zizzi, Ayers, Watson, & Keeler,

2004).

Assessment of Health Literacy

The Newest Vital Sign was used to assess level of health literacy (Weiss et al.,

2005). The Newest Vital Sign was administered to measure essential general literacy

constructs (prose literacy, numeracy and document literacy) applied to health

information in under five minutes. The Newest Vital Sign assessment is based on a

nutritional label from an ice cream container, whereby participants were provided the

label and asked to read, comprehend, and apply the available information to answer six

content based questions. The six questions were asked orally and participant responses

were recorded on a specialized score sheet. Time constraints were not placed on

participants when answering the six questions. The number of correct responses (0-6)
 24

was used to estimate the participant’s level of health literacy, with higher scores

indicating superior health literacy.

Assessment of Health-Related Physical Fitness

Health-related physical fitness was assessed and interpreted using the CPAFLA.

The CPAFLA represents a series of standardized testing and counselling procedures

developed by the Canadian Society for Exercise Physiology (CSEP). The assessment

is commonly used as a measure for the health-related fitness of the general population

and is administered on over a million Canadians each year by trained CSEP health and

fitness professionals (CSEP, 2003).

The CPAFLA appraisal included pre-appraisal screening and objective measures

of physical activity participation, metabolic fitness, body composition, aerobic fitness,

musculoskeletal fitness, and back fitness. The administration of the CPAFLA took an

average of 1-1.5 hours to complete.

Pre Appraisal Screening: Each participant was screened in accordance to the

CPAFLA pre-appraisal screening protocol which includes: the Physical Activity

Readiness Questionnaire (PAR-Q), subjective observation (e.g., is the participant

pregnant? or exhibiting difficulty breathing at rest?), measurement of resting heart rate

(bpm) and resting blood pressure (mmHg). Resting heart rate and blood pressure were

measured after five minutes of seated rest. Resting heart rate was evaluated via the use

of a Polar TM heart rate monitor. Resting blood pressure was manually assessed with a

standard sphygmomanometer and stethoscope (Almedic) on the left arm.

Individuals were momentarily prohibited from participating in the appraisal if they

answered yes to one or more of the questions on the PAR-Q, were ill or had a fever,
 25

had difficulty breathing at rest, coughed persistently, were currently on certain

medications contraindicated with the assessment, had lower extremity swelling, retained

a resting heart rate 100 bpm, or a resting blood pressure 144/94 mmHg.

Participants who were screened out in the pre-appraisal were referred to their physician

for a medical examination and clearance before proceeding with the appraisal. These

participants were given a CPAFLA Physician Summary and a Physical Activity

Readiness Medical Examination (PARmed-X) form. Participants who required physician

clearance and did not receive it were excluded from the investigation.

Healthy Physical Activity Participation: Current physical activity levels were

measured via the Healthy Physical Activity Participation Questionnaire. The

questionnaire examines three characteristics of participation: frequency, intensity, and

perceived fitness. For each of these characteristics there is a statement followed by a

list of options. Participants were instructed to choose the option that most closely

described them. Based on the participant’s answers to the three questions they were

given a score ranging from 0-11, which was then converted into a one of five health

benefit ratings/zones from 0-4 pertaining to their current level of physical activity

participation. These health benefit zones are standardized throughout the CPAFLA

composite measures and are translated as follows: 0 = Needs Improvement

(considerable health risks); I = Fair (some health benefits but also some health risks); 2

= Good (many health benefits); 3 = Very Good (considerable health benefits); and 4 =

Excellent (optimal health benefits).

Healthy Body Composition: Composite body composition was calculated by

combining Body Mass Index (BMI, 2

kg/rn
) , Waist circumference (WC, cm), and the sum

of five skin folds (505S, mm) according to the CPAFLA fitness assessment protocol.
 26

Height (cm) was measured to the nearest 0.5 cm with a wall mounted stadiometer

(SECA). Weight (kg) was recorded to the nearest 0.1 kg using an electronic scale

(SECA). The participant’s shoes were removed and light clothing (e.g., shorts and a T

shirt) was worn for both of these measures. The ratio of body weight in kilograms

divided by height in meters squared was used to determine BMI.

Waist circumference was determined by positioning the anthropometric tape

horizontally mid-way between the iliac crest and the bottom of the rib cage to the

nearest 0.5 cm. All measurements for the sum of five skinfolds were landmarked

according to CPAFLA protocol and made on the right side of the body to the nearest 0.2

mm with TM
Harpenden calipers. The five skinfolds in order of measurement were:

Triceps, Biceps, Subscapular, Iliac Crest and Medial Calf. The mean of two

measurements for each skinfold was recorded.

Each participant received a score ranging from 0-4 pertaining to their body

composition. This score was converted into a health benefit rating ranging from Needs

Improvement (0) to Excellent (4).

Healthy Aerobic Fitness: Cardiovascular fitness was assessed using the modified

Canadian Aerobic Fitness Test (mCAFT). The mCAFT is a valid and reliable, predictive,

submaximal, and progressive exercise test designed specifically for the general

population (CSEP, 2003). The test consists of one or more sessions of three minutes of

stepping at predetermined speeds based on gender and age. At the end of each three

minute stage, immediate post-exercise heart rate was recorded via the use of a high

quality Polar heart rate monitor. If the individual’s heart rate was below their

predetermined post-exercise ceiling heart rate [85% of predicted maximum (220-age)]

at the end of the three minute stage they continued onto the next stage at a more
 27

intense cadence. The test was terminated once the participant reached their

predetermined post-exercise ceiling heart rate. Other criteria for test termination can

include: complaints of dizziness, noticeable staggering, inability to maintain cadence,

extreme leg pain, nausea, chest pain, or signs of facial pallor. An aerobic fitness score

was then generated via the following equation: lOx [17.2+ (1.29 x O2cost) - (.09 x wt. in

Kg) — (.18x age in years)] (CSEP, 2003, pg.7-31). This score was converted into a

health benefit score/rating ranging from Needs Improvement (0) to Excellent (4).

Healthy Musculoskeletal Fitness: Composite musculoskeletal fitness was calculated

by combining weighted scores from a set of 6 measures: grip strength, push-ups, sit

and reach, partial curl-ups, leg power, and back extension. Maximum grip strength was

determined in kilograms (kg) by summing the maximum score from the greater of two

trials of the right and left hand with the use of an Almedic hand dynamometer.

Individuals were asked to complete as many push-ups as possible. Females followed

the same push-up procedure as males except their knees were used as the fulcrum.

Sit-and-reach scores were determined with the use of a standard flexometer by the

maximum distance (cm) reached (forward trunk flexion) over two trials. Prior to the sit-

and-reach participants were instructed to stretch their hamstrings (modified hurdler

stretch) and remove their shoes. For partial curl-ups, participants lay supine with their

knees bent at a 90° angle with both feet on the floor and performed as many 10 cm

partial curl-ups, at a 50 beat/mm cadence, as possible in one minute to a maximum of

25. Vertical jump was assessed from the maximum of 3 trials with the use of the Vertec
TM
The jump height (cm) was determined by the participant jumping as high as possible

from a semi squat position (knees bent at 90°, arms and shoulders maximally

extended). Peak leg power, in watts (W), was then determined with the use of the
 28

Sayers Equation (Peak Leg Power (W) = [60.7 x jump height (cm)] + [45.3 x body mass

(kg)] 2055). Due to the amount of stress the back extension measure places on the
-

back, a screening test was performed prior to administration. If participants felt any

discomfort during the screening test, the back extension was not completed. For the

test, participants were asked to support their upper torso (iliac crest and above) in a

horizontal position from a 46 cm elevation with no rotation or lateral shifting for as long

as possible to a maximum of 180 seconds. The number of seconds the horizontal

position was maintained was recorded.

Each participant received a score ranging from 0-4 relating to their

musculoskeletal fitness. This score was then converted into a health benefit rating

ranging from Needs Improvement (0) to Excellent (4).

Healthy Back Fitness: Weighted scores for the following CPAFLA components:

physical activity participation, waist circumference, sit-and-reach, partial curl-ups, and

back extension, were combined to provide an indication of composite back fitness.

These components are the best discriminators for healthy or unhealthy back fitness

(CSEP, 2003). Each participant received a score ranging from 0-4 relating to their back

fitness. This score was then converted into a health benefit rating ranging from Needs

Improvement (0) to Excellent (4).

Procedure

Participants took part in two data collection days. On day 1, health-related

physical fitness knowledge was assessed via the FitSmart, as well as general and

health literacy using the Newest Vital Sign. Day I also functioned to familiarize the

participants with the CPAFLA health-related fitness assessment protocols and

 29

preliminary instructions as per CPAFLA protocol. On day 2, participants completed the

CPAFLA assessment of health-related physical fitness. Recommendations and

guidance pertaining to each CPAFLA measure were provided by a Canadian Society for

Exercise Physiology Certified Exercise Physiologist (CSEP-CEP) at the end of the

-

fitness appraisal as required by standardized CPAFLA protocols. The CSEP-CEP is the

most advanced health and fitness practitioner certification in Canada allowing members

to work with high performance athletes, the general population (across the lifespan),

and varied clinical populations. A CSEP-CEP is sanctioned to perform

assessments/evaluations, prescribe conditioning exercise, provide exercise

supervision/monitoring, counseling, healthy lifestyle education, and outcome evaluation

for “apparently healthy” individuals and/or populations with medical conditions,

functional limitations or disabilities through the application of physical activity/exercise,

for the purpose of improving health, function and work or sport performance (CSEP,

2007).

Statistical Analysis

Statistical significance was set a priori at p < 0.05 for all analyses. All figures and

tabular values are reported as the mean ± standard deviation. Each variable was tested

for normal distribution (i.e., skewness or kurtosis) and was transformed if necessary. A

general linear model (GLM) univariate analysis of variance (ANOVA) was implemented

to examine the differences between age groups (young adulthood, middle adulthood)

and gender (female, male) for each dependant variable. Regression analyses,

incorporating age, gender, income, and education, as well as bivariate correlations were

employed to examine the relationship(s) between health-related physical fitness

 30

knowledge (FitSmart) and health-related physical fitness (CPAFLA) scores. The same

analyses were performed to examine the relationship(s) between health literacy

(Newest Vital Sign) and health-related physical fitness knowledge scores.

Health-related physical fitness knowledge percentage scores (x/1 00) were used

as the primary indicators of health knowledge. Indicators of physical fitness were

analyzed as composite scores (Healthy Physical Activity Participation (x14), Healthy

Body Composition (x/4), Healthy Aerobic Fitness (x14), Healthy Musculoskeletal Fitness

(x/4), Healthy Back Fitness (x/4)) and compartmentalized (e.g., Healthy Musculoskeletal

Fitness (grip strength (x/4), push-ups (x/4), sit and reach (x/4), partial curl-ups (x/4), leg

power (x/4), and back extension (x/4)) if significance was identified. Lastly, the Newest

Vital Sign scores (x/6) were used as the primary indicators of health literacy.

Resu Its

Participants

All participants resided in Vancouver, British Columbia or the Greater Vancouver

Region. Most participants (79.4%) were currently enrolled in or had completed post

secondary education (8.8% college diploma, 47% undergraduate degree, 23.5%

graduate degree). The remaining one fifth (20.6%) of the participants were currently

enrolled in or had completed a secondary level of school education. With respect to

ethnicity: 47.1% were Caucasian, 8.8% were Mid Eastern, 14.7% were East Indian,

23.5% were Asian, and 2.9% were Aboriginal Canadian. For income: 61.8% grossed

$ 39000/year (32.35% $ 20000; 29.4% = $ 20-39000), and 32. 3% grossed $

40000/year (11.76% = $ 40-59,000, 17.6 % = 60-79000, 2.9% = $ 80-90000). The
remaining 6% did not disclose their income. Participant physical characteristics (e.g.,
 31

height, weight, body mass index, waist circumference, heart rate, and blood pressure)

are outlined in Table 2.1 as a function of age and gender.

No adverse effects were exhibited by any of the participants during the physical

fitness appraisal. However, three individuals (1 young female adult, 1 middle-aged

female adult, and I middle-aged male adult) were not permitted to participate in this

investigation due to contraindications with exercise that could not be cleared by a

physician in a timely fashion (i.e., unknown severe chronic abdominal pain, surgery of

the eye musculature causing bleeding during exertion, and undiagnosed yet reoccurring

chest pains). In addition, a total of 4 participants were screened out of select physical

fitness measures due to the CPAFLA protocol and the professional discretion of the

CSEP-CEP during testing. One female middle-aged adult was excluded from the

vertical jump test and the back extension test due to a previous yet treated lumber

nerve impingement. Another female middle-aged adult was excluded from the aerobic,

vertical jump, partial curl-up, and back extension tests due to complaints of transient

light headedness. A young adult male was screened out from performing the back

extension test due to noticeable pain sensed during the back extension pre-screening

test. A second young adult male did not perform the vertical jump test due to a previous

ankle injury. With regard to the health-knowledge assessment, participants

demonstrated no problems completing the FitSmart within the allotted timeframe.

Health-Related Physical Fitness Knowledge

Table 2.2 lists the FitSmart overall raw scores, overall percentage scores, as well

as the sub-domain component percentage scores for the total sample and according to

age group and gender. The average test score out of the maximum 50 was 35.9 ± 5.8.
 32

The lowest score achieved on the test was 25 while the highest score was 46. Figure

2.1 displays the FitSmart overall percentage scores by age and gender. Analysis of the

sub-domain components showed that participants scored highest on the Concepts of

Fitness section (mean = 78.9%) and lowest on the Scientific Principles of Exercise

component (mean = 67.9%) and the Effects of Exercise on Chronic Disease Risk

Factors (mean = 66.0%). No significant differences were found between males and

females or young and middle adult groups for overall, as well as sub-component health-

related physical fitness knowledge FitSmart scores.

Health-Related Physical Fitness Assessment

The composite mean scores (out of 4) were: Healthy Physical Activity

Participation (1.9 ± 1.2), Healthy Body Composition (2.6 ± 1.1), HealthyAerobic Fitness

(2.1 ± 0.9), Healthy Musculoskeletal Fitness (1.8 ± 1.0), and Healthy Back Fitness (2.0 ±

1.0).

Table 2.3 shows the CPAFLA composite scores for the total sample, as well as

by age and gender. Significant differences were found for healthy physical activity

participation as well as healthy musculoskeletal fitness as a function of gender. Males

engaged in significantly greater levels of physical activity when compared to females in

both young and middle adulthood (Figure 2.2). In contrast, female’s musculoskeletal

fitness levels were superior to males in both age groups (Figure 2.3). Female resting

heart rate was significantly higher in comparison to males (Figure 2.4), while there was

no main effect for age. Analysis also revealed no significant difference for systolic and

diastolic blood pressure as a function of age and gender (refer to Table 2.1 for sample

and group values).

 33

The body composition measures of height, weight, body mass index, waist

circumference, and sum of five skinfold values are reported in Table 2.1 as a function of

age and gender. Significant differences were shown for height, weight, and waist

circumference between males and females. Waist circumference was the only measure

to demonstrate a significant difference between young and middle adulthood.

Characteristically, all male values for height, weight, and waist circumference were

significantly elevated in comparison to females (refer to Figures 2.5, 2.6, and 2.7

respectively). In terms of age, middle-aged adults showed significantly larger waist

circumference measures in comparison to young adults (Figure 2.7).

The mean aerobic fitness score was 413.5. Based on mean age group values,

aerobic fitness raw scores significantly declined (19.8 %) from young adulthood to

middle adulthood, 454.3 to 364.6 respectively (Figure 2.8). In addition, male’s raw

aerobic scores were significantly greater than females in both age groups (Figure 2.8).

No significant differences were found between age and gender for composite aerobic

fitness health benefit ratings.

Grip strength values were significantly higher for males in both young and middle

adulthood (Figure 2.9). Flexibility was significantly different between males and females

in both young and middle adulthood with females having increased scores across age

(Figure 2.10). Vertical jump measurements significantly decreased (23.8 %) from young

(38.0 cm) to middle (29.0 cm) adulthood, with an aggregate sample mean equal to 34.2

cm (Figure 2.11). Moreover, female vertical jump measurements were significantly

lower than males in both young and middle adulthood (Figure 2.11). Significant

differences were found as a function of gender for leg power, with males generating
 34

more power then woman (Figure 2.12). No significant differences were found for age

group or gender for push-ups, abdominal endurance, and back extension measures.

Health-Related Physical Fitness Knowledge and Health-Related Physical Fitness

Pearson correlations for each CPAFLA composite measure and the overall

Health-related Physical Fitness Knowledge score are listed as a matrix in Table 2.4. Our

analysis showed that composite musculoskeletal fitness was significantly correlated (r =

0.40) with knowledge (FitSmart score). Additionally, when controlling for socio

demographic variables (age, gender, income, and education) in the regression analysis,

results indicated that health-related physical fitness knowledge was the strongest

unique contributor to musculoskeletal fitness (standardized B = 0.59, p < 0.05). Upon

further inspection within musculoskeletal fitness, health-related physical fitness

knowledge was significantly correlated to musculoskeletal fitness measures of muscular

endurance (refer to Table 2.5). Specifically, there was a positive and significant

correlation between health-related physical fitness knowledge and push-ups (r = 0.37),

as well as knowledge and partial curl-ups (r = 0.41).

Health Literacy and Health-Related Physical Fitness Knowledge

Table 2.6 lists the Newest Vital Sign health literacy scores for age group, gender,

and the total sample. No significant differences were found between age group or

gender for health literacy. With respect to knowledge, our analysis demonstrated that

health literacy was positively and significantly correlated to health-related physical

fitness knowledge (r = 0.63). Moreover, when controlling for sociodempgraphic variables

(age, gender, income and education), our regression analysis indicated that health

literacy was the strongest individual predictor of health-related physical fitness

 35

knowledge (standardized B = 0.47, p < 0.05). Upon FitSmart sub-domain component

analysis health literacy was significantly correlated, in increasing order, to scientific

principles of exercise (r = 0.44), components of physical fitness (r = 0.45), concepts of

fitness (r = 0.49), nutrition injury prevention and consumer issues (r = 0.62), and effects

of exercise on chronic disease risk factors (r = 0.67). Refer to Table 2.7 for Pearson

correlations of health literacy for overall and sub-domain component health-related

physical fitness knowledge scores.

Discussion

Currently, the literature delineating the relationship between health-related

physical fitness knowledge, measures of health related physical fitness, and health

literacy is limited as well as inconsistent. As such, the purpose of this investigation was

to examine the relationship between: 1) health-related physical fitness knowledge and

objective measures of health-related physical fitness in young and middle adulthood,

and 2) health literacy and health-related physical fitness knowledge in young and middle

adulthood. Strength of the present investigation was the utilization of objective

measures of both health knowledge and physical fitness. First, a holistic and

standardized measure of health-related physical fitness knowledge (the FitSmart) was

administered as opposed to open ended/lobbied questions (Avis et al., 1990), bimodal

surveys (Liang et al., 1993), telephone interviews (Morrow et al., 2004) or a single

question (Fitzgerald, Singleton, Neale, Prasad, & Hess, 1994). In addition, we used a

health-related physical fitness assessment systematically developed and standardized

for use within the general Canadian population. To examine health literacy, the Newest

Vital Sign was employed, which is a brief yet valid and reliable measure of the general

literacy constructs applied to health information.

 36

Health-Related Physical Fitness Knowledge

Results from the FitSmart examination illustrate that participants were most

capable at identifying the basic definitions of fitness and the positive relationship

between physical activity and health (Concepts of Fitness (x = 79%)); however, they

were least capable at correctly answering questions related to acute/chronic

physiological/psychological processes and bodily adaptations to exercise (Scientific

Principles of Exercise (x = 68%) as well as Effects of Exercise on Chronic Disease Risk

Factors (x = 66%)). These results support findings in the current literature, whereby

physical education majors demonstrated the lowest scores on Scientific Principles of

Exercise (x = 68%) (Peterson et al., 2003). These results are not surprising as the

content matter of the scientific principles component of the FitSmart is generally more

complex, requires a fundamental base of knowledge, and fits into a higher taxonomic

educational category (i.e., application) (Bloom & Krathwohl, 1956). For example, to

successfully answer the question,

“Which of the following is a characteristic of the blood of highly fit

individuals?
A) Greater blood volume and more red blood cells,
B) Greater blood volume and fewer red blood cells,
C) Less blood volume and more red blood cells, and
D) Less blood volume and fewer red blood cells”,

individuals are required to apply previously acquired knowledge (e.g., blood

components, and the haematological or physiological adaptations to exercise) in

four different ways (options A-D) to correctly choose the one best answer. This is

clearly more challenging and complex than being asked a question that falls into

a lower taxonomic educational level (e.g., knowledge) which requires the

 37

exhibition of previously memorized basic concepts, facts and or terminology to

identify the correct answer.

Peterson et al. (2003) collected data regarding previous academic experiences

(i.e., number of exercise physiology courses taken) to substantiate their findings.

Physical education majors who participated in more than one exercise physiology

course were more likely to score higher on the knowledge exam. Practically, in-depth

exercise physiology courses are not an option for most individuals, regardless of

education. In addition, only 10% of the physical education majors in Peterson’s

investigation opted to take more than the one required exercise physiology course. A

solid foundation of exercise physiology content knowledge is essential for all health care

practitioners and educators to ensure the appropriate translation to students, clients,

patients, and/or participants (Bulger, Mohr, Carson, Robert, & Wiegand, 2000). Thus it

is important to consistently encourage and provide the opportunity for all individuals to

learn foundational and higher-order concepts by publishing them repeatedly via creative

and comprehendible media vehicles, as well as integrating them into appropriate

educational curricula (Bulger et al., 2000).

Health-Related Physical Fitness

It is clear that most participants in this investigation failed to achieve levels of

physical fitness associated with optimal health status (i.e., achieving an excellent rating

of 4.0) on the components of the CPAFLA. This is consistent with other data that shows

that the majority of Canadians are failing to meet the physical activity requirements set

forth by Health Canada (Statistics Canada, 2003; Warburton, Whitney, & Bredin,

2006a). Moreover, based on the low socio-economic status of this sample, as indicated
 38

by income (61 % earned $390001yr), and the documented relationship between low

socioeconomic status, poor health behaviours (e.g., malnutrition, physical inactivity,

inadequate health care utilization) and poor health outcomes (increased morbidity and

mortality), our results are consistent with previous literature (Adler et al., 2002;

(Feinstein, 1993).

With respect to age, significant differences were revealed for measures of body

composition (waist circumference), aerobic fitness (mCAFT score), and m uscu loskeletal

fitness (vertical jump). For each of these measures the middle adulthood group

demonstrated significantly worse health-related scores in comparison to the young

adulthood group. Waist circumference was significantly larger (12 %), aerobic fitness

scores were significantly lower (20 %), and vertical jump measurements were

significantly less (24 %). These results provide insight into the relationship between age

and health-related physical fitness. Decrements in fitness that result as a function of

increasing age are common and have the ability to produce substantial and detrimental

effects towards health and wellbeing if not mediated appropriately during the aging

process (WHO, 2002). Thus, there is an imperative need to stress the importance of

regular physical activity participation and healthy lifestyle behaviours (e.g., nutrition,

stress relief, personal hygiene) to middle and older adulthood cohorts (Galloway & Joki,

2000). Moreover, given that physical activity behaviours track from childhood to

adolescence and into adulthood, preventative health promotion measures that target

children are strongly recommended (Malina, 1996). A suggested primary action should

be to increase people’s health-related knowledge base. Knowledge is a background

factor which contributes to the formation of behavioural intentions (Ajzen & Manstead,

2007), as well as a recommended first step in the Transtheoretical model of behaviour

 39

change (Prochaska, DiClimente, & Norcross, 1992). Importantly, our results suggest

that knowledge is a significant correlate to and predictor of health-related physical

fitness measures. Therefore, health care practitioners at all levels should aim to

increase people’s health-related knowledge. Unfortunately, many primary care

physicians (who care for middle-aged adults) frequently overlook the importance of

prescribing physical activity and/or educating patients on the benefits of regular health-

related physical activity participation (Galloway & JokI, 2000). Insufficient physical

fitness knowledge and lack of time are two major barriers physicians report when

discussing their lack of exercise counselling (Abramson, Stein, Schaufele, Frates, &

Rogan, 2000).

In addition, the 39-49 age range is one where individuals generally endure

extreme levels of stress (e.g., work, family, finances, and first occurrences of health

problems). Likewise, this is a recognized age range where past negative health

behaviours (e.g., smoking, poor diets, physical inactivity) start to take a more substantial

role in health degradation. In extreme cases this is an age where the previous negative

health behaviours cause severe debilitation (e.g., cardiovascular disease,

musculoskeletal impairments) leading to impinged quality of life until death (WHO,

2002). In summary, the findings of this investigation support the need to provide

children, adolescents, and adults with knowledge concerning health-related physical

fitness. We recommend health promotion initiatives that highlight the relationship

between health knowledge, physical fitness, and health outcomes.

 40

Health-Related Physical Fitness Knowledge and Health-Related Physical Fitness

Based on our results, musculoskeletal fitness was shown to be a significant

correlate to health-related physical fitness knowledge and health-related physical fitness

knowledge was the strongest individual contributor to musculoskeletal fitness. Within

musculoskeletal fitness, health-related physical fitness knowledge was correlated to

muscular endurance measures: specifically, push-ups and partial curl-ups. These

findings are very compelling, applicable, and important given the documented indirect

and direct relationship(s) between musculoskeletal fitness and health status. Indirectly,

musculoskeletal fitness is related to health status via body composition as well as

cardiovascular fitness (Warburton, Gledhill, & Quinney, 2001a). In terms of body

composition, musculoskeletal strength and endurance training is known to result in

significant improvements in fat free mass attributable to muscular hypertrophy. The

increases in fat free/muscle mass have the ability to augment metabolic capacities (i.e.,

increased resting metabolic rates (RMR)) which, in turn, contribute to a healthier body

composition via increased fat oxidation and energy expenditure (Ballor & Poehlman,

1992; Poehlman et al., 1992). Significant improvements in cardiovascular/aerobic

fitness (maximal oxygen consumption, VO2m) are rarely documented due to

improvements in musculoskeletal fitness alone (Warburton, Gledhill, & Quinney, 2001a).

However, it is important to acknowledge that improvements in the functionality of the

musculoskeletal system operate to enhance an individual’s capability to engage in

physical activity pursuits and active lifestyle behaviours. Additionally, these

improvements in functional status are of significant importance to the elderly, disabled,

and or diseased populations as they serve to increase the capacity to execute activities

of daily living (e.g., household cleaning, shovelling snow, carrying shopping bags) and
 41

therefore, provide functional independence (Warburton, Gledhill, & Quinney, 2001a;

Warburton, Gledhill, & Quinney, 2001b).

Directly, improvements in musculoskeletal fitness (strength and endurance) may

have a positive and significant impact on the risk factors for cardiovascular disease;

namely, blood based lipid and lipoprotein profiles, hypertension, abdominal obesity,

RMR, and glucose homeostasis (Warburton, Gledhill, & Quinney, 2001a). This is of

major importance given that chronic diseases, including cardiovascular disease (CVD),

cancer, and diabetes, are the leading causes of morbidity and death in Canada (Stone

& Arthur, 2005). Cardiovascular disease was the single greatest cause of death in 2001

(men and woman combined, all ages), accounting for one in three (36%), or

approximately 75,000 total deaths (Stone & Arthur, 2005). Additionally, the economic

burden of cardiovascular disease is exorbitant. Cardiovascular disease remains the

single most expensive diagnostic category on the health care budget, and the direct and

indirect CVD related costs in Canada currently exceed $18 billion/annum (Stone &

Arthur, 2005). In addition to the physiological benefits, improved musculoskeletal fitness

may improve multiple components of psychological well being, including self efficacy,

mood state, anxiety, perceptions of anger, and tension (Warburton, Gledhill, & Quinney,

2001 a).

In summary, “high levels of musculoskeletal fitness are associated with positive

health status and health, and low levels of musculoskeletal fitness are associated with

lower health status” (Warburton, Gledhill, & Quinney, 2001b, p. 217). Correspondingly,

perceived health has also been associated with levels of musculoskeletal fitness in both

men and women. In general, lower levels of musculoskeletal fitness are associated with

reduced perceptions of health and higher levels of musculoskeletal fitness are

 42

associated with elevated perceptions of health (Suni et al., 1998). It is essential for

preventative health practitioners to highlight the musculoskeletal fitness to health and

health-related physical fitness knowledge to musculoskeletal fitness relationships in an

attempt to educate individuals to adopt healthy and active lifestyles that function to

increase health status.

The following points should be considered to discuss why musculoskeletal fitness

was the only composite fitness measure to be significantly correlated with health-

knowledge. Firstly, other components (e.g. aerobic fitness) were close to reaching

significance. Given that this investigation only utilized 34 participants, it is reasonable to

assume that we were slightly underpowered. A study examining this relationship with a

much larger sample is recommended to enhance the current findings. Secondly,

another potential contributor to these findings is the actual measurements being taken.

For example: musculoskeletal fitness is a composite measure devised from six

challenging measurements (i.e., grip strength, push-ups, curl-ups, flexibility, vertical

jump, and back extension). Provided that musculoskeletal fitness incorporates the

greatest amount of testing elements, the composite scores should be more reflective of

fitness levels and as a result may have been more indicative of health knowledge.

Moreover, musculoskeletal fitness may be a better determinant of current physical

fitness levels as other measures (e.g. aerobic fitness) are known to show large

detraining and consistent aging effects in comparison (CSEP, 2003).

When looking into how an individual’s knowledge of health-related physical

fitness translates into behaviours that promote the development, maintenance, and

improvement of fitness, the Theory of Planned Behaviour is a viable framework. The

theory suggests a model stipulating how human action is generated given that the
 43

active behaviour is intentional. Behavioural intentions are assumed to result sensibly

from beliefs (behavioural, normative, and control) about performing the behaviour

(Ajzen & Fishbein, 2005). It is important to note the beliefs people possess regarding

the performance of a particular behaviour are influenced by a broad assortment of

situational, cultural, and personal background factors (knowledge being one of them).

These beliefs can be accurate, inaccurate, biased, and even illogical. Nevertheless, this

set of beliefs is the cognitive foundation that guides human action, which is influenced

by three major factors: a positive or negative assessment of the behaviour (attitude

regarding the behaviour), perceived societal influence to execute or not execute the

behaviour (social norm), and perceived ability to execute the behaviour (perceived

behavioural control). Thus, accurate knowledge pertaining to the behaviour at hand is

essential in guiding human action. The amalgamation of attitude towards the behaviour,

subjective norm, and perception of behavioural control leads to the formation of the

behavioural intention (strongest predictor of human behaviour). In general, the more

favourable the attitude and subjective norm, in combination with increased perceived

behavioural control, a person’s intention to perform the desired behaviour will be

greatest. Lastly, given a significant degree of actual control over the behaviour,

individuals are expected to execute their intentions when presented with an opportunity.

Health Literacy and Health-Related Physical Fitness Knowledge

To the best of our knowledge, this is the first investigation to incorporate the

assessment of health literacy in relation to physical fitness knowledge. Our results

suggest that health literacy is a significant correlate to and predictor of health-related

physical fitness knowledge. These results are in line with previous health literacy
 44

research looking at the relationship between health literacy and other subsets of health

knowledge (e.g., disease prevention, disease treatment and management, and health

care utilization) (Weiss et al., 2005; DeWalt et al., 2004; Lindau et al., 2002; Ad Hoc

Committee on Health Literacy for the Council on Scientific Affairs, American Medical

Association, 1999; Williams et al., 1998). Given that health literacy is broadly defined as

an individual’s ability to obtain, process, and understand basic health-related

information in order to navigate the health care system and make appropriate health-

related decisions, its relevance is of much importance to the health-care practitioners in

all disciplines (Parker et al., 2003). Individuals with limited literacy have less knowledge

concerning their health problems, elevated health care costs, more hospitalizations, and

inferior health status than those with sufficient literacy (Weiss et al., 2005). These

relationships are uniform across studies and continually exist when adjusting for

possible confounding socio-demographic factors (Weiss et al., 2005). In light of our

results and the supporting literature, the value of health literacy assessment within the

health and fitness discipline should be acknowledged. Health literacy assessments

(such as the Newest Vital Sign) are generally brief (e.g., 3-5 minutes) and provide the

ability to increase knowledge translation in an individually tailored fashion (Weiss et al.,

2005). This in turn, has the potential to result in increased client to practitioner

communication leading to increased client knowledge retention. This increased

retention then has the capacity to translate into improvements of essential health

constructs specific to the knowledge being provided.

 45

Conclusion

Given the empirical evidence relating musculoskeletal fitness to health status and

the findings from the present investigation relating health-related physical fitness

knowledge to musculoskeletal fitness, it is imperative that individuals are provided

opportunities to access and acquire knowledge pertaining to health-related physical

fitness. It is important to integrate education of this knowledge into multidimensional

health promotion and education initiatives whenever possible. Additionally, it is essential

for the advanced concepts relating to the scientific principles of exercise (acute/chronic

physiological and psychological changes that our bodies endure via exercise) to be

addressed in educational materials to the general population. Moreover, the relationship

between health literacy, health outcomes, and health knowledge is one of much value

and should be promoted throughout the health and fitness industry. Health care

practitioners should make use of brief standardized assessments like the Newest Vital

Sign in order to individually tailor the communication and guidance provided to clients,

patients, and students.

 46

Table 2.1. Participant Physical Characteristics (mean ± SD)

Female Male
(n=18) (n=16)

Physical Young Middle-Age Young Middle-Age Total

Measurements (n = 9) (n = 9) (n = 9) (n 7) (n = 34)

161.3 ± 7.9 162.3 ± 6.98 174.9 ± 6.2 176.3 ± 7.8 168.3 ± 9.8
Height (cm)*

59.5 ± 20.0 67.4 ± 11.9 75.6 ± 13.7 87.3 ± 16.5 71.6 ± 18.1
Weight (kg)*

22.7 ± 6.4 25.5 ± 3.0 24.7 ± 4.0 28.0 ± 5.2 25.1 ± 5.0
BMI (kgm
)
2

Waist
71.6 ± 11.8 83.3 ± 9.4 87.9 ± 15.1 96.0 ± 13.0 84.0 ± 14.8
Circumference
**
(cm)

Resting Heart 76.4 ± 7.2 73.1 ± 10.8 64.7 ± 7.6 63.7 ± 8.8 69.8 ± 10.0
Rate (bpm) *

Resting Systolic
101.8± 12.8 110.9±15.4 110.2±9.8 113.1 ± 11.8 108.8±12.9
Blood Pressure
(mmHg)

Resting Diastolic
68.9 ± 5.6 72.9 ± 8.8 74.2 ± 8.4 77.1 ± 8.3 73.1 ± 8.0
Blood Pressure
(mmHg)

Note. *significant difference for gender (p <0.05); **

significant difference for age and
gender (p <0.05).
 47

Table 2.2. FitSmart Health-Related Physical Fitness Knowledge Scores (mean ± SD)

Female Male
(n=18) (n=16)

Measurement Young Middle-Age Young Middle-Age Total

(n=9) (n=9) (n=9) (n=7) (n=34)

OveraN Score
36.8 ± 7.2 35.6 ± 4.5 35.6 ± 5.4 35.6 ± 6.8 35.9 ± 5.8

Overall Score
(%) 74.1 ± 14.3 71.1 ±9.0 71.1 ± 10.9 71.1 ± 13.6 71.9±11.6

Concepts of
Fitness (%) 77.7 ± 14.0 77.2 ± 18.1 79.9 ± 15.2 81.6 ± 12.9 78.9 ± 14.7
Scientific
Principals of 69.9 ± 20.1 61.3 ± 10.5 68.6 ± 14.7 72.9 ± 10.8 67.9 ± 14.7
Exercise (%)

Components
of Physical 74.4 ± 20.4 78.6 ± 13.7 67.9 ± 11.7 63.7 ± 18.3 71.6 ± 16.5
Fitness (%)

Exercise on
Chronic 72.3 ± 21.0 59.2 ± 19.7 69.4 ± 18.2 62.0 ± 26.6 66.0 ± 20.9
Disease Risk
Factors (%)

Exercise
Prescription 72.2±44.1 72.2±44.1 55.6±52.7 100±0.0 73.5±43.1
(%)
Nutrition Injury
Prevention 68.8 ± 17.7 69.6 ± 15.3 70.4 ± 16.6 70.1 ± 26.8 69.7 ± 18.2
and Consumer
Issues (%)
 48

Table 2.3. CPAFLA Health-Related Physical Fitness Composite Scores (mean ± SD)

Female Male
(n=18) (n=16)

Composite Young Middle-Age Young Middle-Age Total

Measurement (n = 9) (n = 9) (n = 9) (n = 7) (n = 34)

Healthy
Physical
Activity 1.4± 1.0 1.2± 1.1 2.6± 1.1 2.7± 0.8 1.9± 1.2
Participation *

Healthy Body
Composition 2.9 ± 1.3 2.4 ± 1.0 2.8 ± 1.2 2.1 ± 1.1 2.6 ± 1.1

HealthyAerobic
Fitness t 2.1 ± 1.2 2.1 ± 1.4 2.1 ±0.8 1.9± 0.7 2.1 ± 1.0

Healthy
Musculoskeletal 1.9±0.9 2.4± 1.2 1.1 ±0.6 1.7±0.95 1.8± 1.0
Fitness *

HealthyBack
Fitness 1.9±0.9 2.0± 1.5 1.9±0.8 2.1 ±0.7 2.0± 1.0

Note: * significant difference for gender (p < 0.05; t n = 33 (1 female middle-aged adult
did not complete aerobic fitness test due to light headedness).
 49

Table 2.4. Health-Related Physical Fitness Knowledge and Physical Fitness

Correlations

Healthy
Physical Composite Healthy Composite Composite
Activity Body Aerobic Musculoskeletal Back
Measure Participation Composition Fitness Fitness Fitness

395*
PC -.063 .169 .249 .178

FitSmart
Score Sig. .725 .340 .162 .021 .313

N 34 34 33 34 34

PC
Note: Pearson Correlation. *
Correlation is significant at the 0.05 level (2-tailed).
 50

Table 2.5. Health Knowledge and Musculoskeletal Component Correlations

Grip Partial Curl- Vertical

Push-ups Flexibility
Measure Strength ups Jump

PC .329 .368* .291 4j3*

.238
FitSmart
Score Sig. .057 .035 .100 .019 .198

N 34 33 33 32 31

• Note: Pearson Correlation. *

Correlation is significant at the 0.05 level (2-
tailed).
 u6i 184!A
[ F9 61. F 617 01. F VL. F 917 EO F L9
4SM9N OqJ
(17=u) (L=u) (a=u) (6=u) (6=u)
ieoi e
V
6 -9IPPWJ 6
u noA a6y-eppij 6
u noA
uwa nsej
(9L. = u) (81= u)
I1oJ-
(as i uEow) S8JOOS A3EJO1!1 L.14180H u6 Ie1!A 1S9MeN 1I! 9 icii
Ic
 52

Table 2.7. The Health Literacy and Health-Related Physical Fitness Knowledge Correlations

Effects
of
Scientific Exercise Nutrition
Overall Concepts Injury
Score of Principals Components on Exercise
Measure of of Physical Chronic Prevention
(%) Fitness Prescription
Exercise Fitness (%) Disease and
(%) Consumer
(%) Risk
Factors Issues (%)
(%)

Newest PC .632* .491** .491** .451** .674** -.008 .173

Vital
Sign Sig. .000 .004 .004 .008 .000 .964 .337
Score
N 33 33 33 33 33 33 33

Note: ‘ Pearson Correlation. * Correlation is significant at the 0.05 level (2-tailed). **

Correlation is significant at the 0.01 level (2-tailed).

 iepue
eieipj eiewe
0
o
Ot CD
-‘
C,
CD
D
08
pOO1IflpVeIpp!J I I
UnOA
pooimnpv 6
00 1
9111 cq p9uiwJee se sejooS e6peMou)j lflIE9H V Jfl
d
6
 54

Figure 2.2. Physical Activity Participation Scores as a Function

of Age and Gender
4

Young Adulthood
‘ IMiddleAdulthood

Female
I
Male

Gender

*
Note: Significant Difference (p < 0.05).
 55

Figure 2.3. Composite Musculoskeletal Fitness

4
-
Young Adulthood
I I Middle Adulthood

3.

Female Male
Gender
*
Note: Significant Difference (p < 0.05).
 56

Figure 2.4. Resting Heart Rate as a Function

of Age and gender
100 -

Young Adulthood
I I Middle Adulthood
80
1*1
a
m *1
60

I.
a)
a- 40
Cl)
4-
Cu
ci)

20

0-
Female Male
Gender

*
Note: Significant Difference (p <0.05).
 57

Figure 2.5. Height as a Function of Age and Gender

200
Young Adulthood
I Middle Adulthood

T*I
150

0
(1)
U)
100
2
4-.

ci
0

50 -

0- - ——

Female Male
Gender
*
Note: Significant Difference (p < 0.05).
 58

Figure 2.6. Weight as a Function of Age and Gender

120

Young Adulthood
I I Middle Adulthood
100 -

80-

60
LI
0)
0

4o

20

0• —r ——

Female Male

Gender

Note: * Significant Difference (p < 005).

 59

Figure 2.7. Waist Circumference as a Function of Age and Gender

120 -

* Young Adulthood
.
I i Middle Adulthood
100- *_L
80-
*t *

C-)

I—

E
C
ci
C-) 40-

20 -

0 ——

Female Male
Gender

Note: *
Significant Diference (p < 0.05).
 60

Figure 2.8. Aerobic Fitness Raw Scores as a Function

of Age and Gender
600

Young Adulthood
500
I I Middle Adulthood
*

400

a)
I.
0 300
C)
0

200-

100 -

0-
Female Male

Gender

Note: *
Significant Difference (p <0.05).
 61

Figure 2.9. Grip Strength as a Function of Age and Gender

140

Young Adulthood
120 I I Middle Adulthood

100• 1
— 80
Cl)
2 *

60

40

20

0 ——

Female Male

Gender

Note: *
Significant Difference (p < 0.05).
 62

Figure 2.10. Flexibility as a Function of Age and Gender

50 -

Young Adulthood

1*1 *1
I I Middle Adulthood
40 -

1)
30 -

C’)

a,
E
.1
C
a, 20
C-)

10

0•

Gender

*
Note: Significant Difference (p < 0.05).
 63

Figure 2.11. Vertical Jump as a Function of Age and Gender

70
Young Adulthood
I I Middle Adulthood
60

50

C.)

Cl)
C)
40 *1
-

C)
E 30
C
ci)
C)
20

10

0- 1

Female Male

Note: Significant Difference (p < 0.05).

 64

Figure 2.12. Leg Power as a Function of Age and Gender

6000 -

Young Adulthood
5000 -
T i Middle Adulthood

4000

3000
*1
2000

1000

0 ——

Female Male
Gender

*
Note: Significant Difference (p < 0.05).
 65

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 72

CHAPTER 3

The Effects of Administering the Canadian Physical Activity Fitness & Lifestyle

Approach (CPAFLA) on Health-Related Physical Fitness Knowledge as well as Beliefs,

Attitudes, and Intentions towards Regular Physical Activity Participation 2

The assessment of health-related physical fitness is of major importance (Oja,

1995). The Canadian Society for Exercise Physiology (CSEP) health-related fitness

appraisal and counselling strategy, the Canadian Physical Activity, Fitness & Lifestyle

Approach (CPAFLA), represents a series of systematic and standardized testing

procedures designed to promote the health benefits of physical activity (CSEP, 2003).

The assessment is commonly used as a measure for the health-related fitness of the

general population and is administered on over a million Canadians each year by

trained and certified CSEP health and fitness professionals (CSEP, 2003). When

administered, the results of the appraisal allow for the evaluation of current health status

in accordance to Canadian normative data. Most importantly, the appraisal process and

findings provide vital health-related information to individuals. The appraisal is designed

to educate, increase knowledge, and raise awareness of personal health indicators

while highlighting the components of health-related physical fitness. During the

appraisal, participants are provided with evidence based guidance aimed towards

increasing current physical and mental wellbeing. Specifically, the goal of the appraisal

and counselling session of the CPAFLA is to provide information as well as motivation

2
A version of this chapter will be submitted for pubIcation. Faktor, M.D., Warburton, D.E.R., Rhodes,
RE., & Bredin, S.S.D. The Effects of Administering the Canadian Physical Activity Fitness & Lifestyle
Approach (CPAFLA) on Health-Related Physical Fitness Knowledge as well as Beliefs, Attitudes, and
Intentions towards Regular Physical Activity Participation.
 73
to individuals to develop healthier lifestyles and to increase their physical activity

participation (CSEP, 2003). However, previous scientific investigation has yet to

examine the effectiveness of the CPAFLA. An aim of this investigation was to examine

whether the CPAFLA contributes to the immediate promotion of physical activity and

health-related physical fitness in young and middle adulthood.

The promotion of health-related physical activity as well as fitness are essential

preventative public health measures (Suni et al., 1998), as inseparable relationship(s)

exist between physical activity, physical fitness, and positive health status (Erikssen,

2001). An important development in recent years has been a change in the

understanding of how much physical activity is required to derive health-related benefits

(CSEP, 2003). There is now a distinction regarding physical activity as it relates to

health versus fitness (American College of Sports Medicine, 1998). Previous fitness

specialists recommended engaging in exercise (planned and structured physical

activity) at vigorous intensities (60-84% of heart rate reserve (HRR), or 6-8 metabolic

equivalents (METS)) to improve one’s cardiovascular endurance. Health-related

benefits of physical activity participation were only assumed if cardiovascular

endurance, a performance related measure, was improved (CSEP, 2003). The dose

dependent relationship between physical activity volume, health variables (e.g., blood

pressure, triglycerides, lipoproteins), and fitness outcomes (e.g., VO2max) has aided in

the shift from performance-based physical fitness activity guidelines and

recommendations to health-related, for the general population (CSEP, 2003). Research

has supported this shift by emphasizing the considerable health benefits of engaging in

light to moderate intensity physical activity (Oja, 1995; Warburton et al., 2006b).

Moreover, it has been stated that health benefits occur with weekly volumes of physical
 74

activity (energy expenditures) as low as 700kcal (2940kJ, light intensity activity on most

days of the week), with additional benefits occurring at higher levels (American College

of Sports Medicine, 1998).

There is undeniable evidence supporting regular physical activity participation

(structured and unstructured) in the primary and secondary prevention of numerous

chronic diseases and premature death (Warburton, Whitney, & Bredin, 2006a). Physical

inactivity is a primary modifiable risk factor for cardiovascular disease and an increasing

assortment of accompanying chronic hypokinetic (insufficient movement or activity)

diseases, including: obesity, diabetes mellitus, cancer (breast and colon), bone and joint

diseases (osteoporosis and osteoarthritis), depression and hypertension (Katzmarzyk et

al., 1998; Katzmarzyk, Gledhill, & Shephard, 2000; Katzmarzyk, Perusse, Rao, &

Bouchard, 2000; Warburton et aL, 2006a). The most recent research estimates that

53.5% of adult Canadians are physically inactive and 14.7% are obese (Katzmarzyk &

Janssen, 2004). This physical inactivity prevalence ranks higher than that of all other

existing and modifiable hypokinetic disease risk factors (Warburton et al., 2006a). In

2001, 9.6 billion health care dollars were directly accredited to physical inactivity and

obesity in Canada (Katzmarzyk & Janssen, 2004). This confirms that physical inactivity

and obesity are chief benefactors of the Canadian public health care burden. Health

promotional efforts, guided by relevant research, that function to increase physical

activity and reduce obesity are essential mechanisms towards improving the health of

all Canadians and significantly reducing health care expenditures (Katzmarzyk &

Janssen, 2004).

Research suggests that individuals with increased health-related physical fitness

knowledge are more likely to be physically active and fit (Zhu, Safrit, & Cohen, 1999).
 75

Health-related knowledge permits individuals to acknowledge the warning signs and

propagation of diseases, select and partake in suitable preventative health strategies

(e.g., physical activity), and provides individuals with an understanding of where or how

to obtain health assistance (Freimuth, 1990). According to Zhu et al., health-related

physical fitness knowledge is a knowledge base that encompasses basic fitness

concepts, which is comprised of six sub domain components including: concepts of

fitness; scientific principles of exercise; components of physical fitness; effects of

exercise on chronic disease risk factors; exercise prescription; as well as nutrition, injury

prevention, and consumer issues (Zhu et al., 1999). Previous research has suggested a

positive and significant correlation between health-related physical fitness knowledge

and measures of health-related physical fitness in adulthood (See Chapter 3, Faktor,

Warburton, Rhodes & Bredin, 2009). The first purpose of the present investigation was

to empirically examine the influence of administering the CPAFLA health-related

physical fitness appraisal and counseling strategy on health-related physical fitness

knowledge in young and middle adulthood. Health-related physical fitness knowledge

was assessed via the FitSmart, a standardized health-related physical fitness

knowledge examination. As indicated by Zhu et al. (1999), the FitSmart is an

established, valid, and reliable test to measure knowledge of the fundamental health

and fitness concepts at the high school level of education. As such, the FitSmart written

examination was used in this investigation to establish whether young and middle-aged

adults possess the level of health-related knowledge expected at a high school level.

The FitSmart has been implemented as the primary measure of health-related physical

fitness knowledge in well educated adult populations (Losch & Strand, 2004; Petersen,

Byrne, & Cruz, 2003b). Researchers have also utilized sections of the FitSmart as
 76

adjuncts to series of self report measures to incorporate health knowledge (Zizzi, Ayers,

Watson, & Keeler, 2004). We hypothesized that participants would demonstrate

improvements in the sub-domains of aerobic fitness, muscular strength and endurance,

flexibility, and body composition for the assessment of health-related physical fitness

knowledge in comparison to baseline measures. The administration of the CPAFLA

strategically identifies these major physical fitness components and highlights their

individual and aggregative impacts on health and well being. Furthermore, the CPAFLA

strategy emphasizes education and counselling concerning appropriate evidence based

tactics designed to augment fitness through a variety of exercises and activities. These

tactics are based on the interpretation of fitness results (CSEP, 2003). As such, we

hypothesized that participants will demonstrate improvements on the FitSmart

examination following administration of the CPAFLA on questions specific to the health-

related physical fitness component of the examination.

The Theory of Planned Behaviour elements are significant predictors (some

stronger than others) towards the initiation, alteration, and or maintenance of a vast

array of behaviours. Developed by Ajzen (1988, 1991) as an evolution of the Theory of

Reasoned Action (Fishbein, 1967), this theory has successfully provided a greater

understanding of diverse health-related behaviors such as exercising, adhering to low

fat diets, contraceptive use, illicit drug use, and numerous more (Ajzen & Fishbein,

2005). It is the most prominent conceptual model for thinking about the determinants of

particular behaviours to date (Ajzen, 2007). The Theory of Planned Behaviour suggests

a framework about how human action is generated. It estimates the incidence of a

particular behavior given that the behavior is intentional. It is suggested that behavioral

intentions are assumed to result sensibly from beliefs (behavioral, normative, and
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control) about performing the behavior (Ajzen & Fishbein, 2005). It is important to note

that the behavioral, normative and control beliefs people possess regarding the

performance of a particular behavior are influenced by a broad assortment of

situational, cultural, and personal background factors. These beliefs can be accurate,

inaccurate, biased, and even illogical. Nevertheless, this set of beliefs is the cognitive

foundation that guides human action, which is influenced by three major factors: a

positive or negative assessment of the behavior (attitude regarding the behavior),

perceived societal influence to execute or not execute the behavior (social norm), and

perceived ability to execute the behavior (perceived behavioral control). The

amalgamation of attitude towards the behavior, subjective norm, and perception of

behavioral control leads to the formation of a behavioral intention (the strongest

predictor of human behavior).

Traditionally, the attitude, subjective norm, and perceived behavioral control

components are measured as single concepts; however, Ajzen (2002) suggests that

each concept comprises two subcomponents each of which are hypothesized to be

influenced by a single general factor. This is referred to as a second order model

(Rhodes & Courneya, 2003). However; Rhodes & Courneya (2003) believe that this

second order model is more likely to be conceptualized as a “sub compartment” model

whereby the individual theory of planned behavior subcomponents are capable of

having direct effects on the general factor and any relationship between each

subcomponent may arise from external common causes. Attitude is said to be

composed of affective (e.g., unpleasureable/ pleasurable) and instrumental (e.g.,

harmful/beneficial) evaluations concerning a behavior. This two component attitude

structure has been supported across various attitude measurement methodologies and
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conceptual modeling’s (Rhodes & Courneya, 2003). Likewise, subjective norm research

has indicated that the distinct components of self efficacy (e.g. ease. difficulty,

confidence) and controllability (e.g., personal behavioral control and or assessment of

whether or not the behavior is volitionally determined by the actor). Lastly, subjective

norm is thought to include the more traditional measurement of the injunctive

component (e.g., does one believe that their social network wants them to perform a

specific behavior?) as well as a descriptive component (e.g. does ones social network

perform a specific behavior?).

The second purpose of this investigation was to examine the influence of

administering the CPAFLA health-related physical fitness appraisal and counseling

strategy on the components of the Theory of Planned Behavior (i.e., attitude, subjective

norm, perceived behavioural control, and intention) in relation to regular physical activity

participation in young and middle adulthood. The Theory of Planned Behaviour

constructs were assessed via a written survey containing a series of 7-point bipolar

adjective scales concerning regular physical activity participation. The instrument used

in the present investigation was developed by Rhodes and Courneya (2003) and is an

established, valid and reliable method to assess the Theory of Planned Behaviour

constructs. Rhodes and Courneya utilized this instrument to investigate the components

of attitude, subjective norm, perceived control, and intention in clinical and healthy

populations with relation to exercise. We postulated that individual beliefs, attitudes,

and intentions towards participating in regular health-related physical activity would also

improve in comparison to baseline measures following the administration of the

CPAFLA. This hypothesis is based on the premise that the CPAFLA appraisal process

is designed to increase knowledge and awareness concerning health-related physical

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fitness while highlighting the health benefits of physical activity in an attempt to motivate

individuals to develop healthier lifestyles and increase physical activity participation

(CSEP, 2003).

Methods

Participants

Written informed consent was received from 20 female and 20 male physically

inactive participants. Physically inactive was defined as engaging in 20-30 minutes of

vigorous or 30-60 minutes of moderate physical activity less than 3 times per week. The

Godin leisure time exercise questionnaire functioned as the screening instrument

(Godin & Shephard, 1985). Participants were recruited according to two age groups: (a)

19 to 29 years (young adulthood, n = 10 F, 10 M; mean age = 24.3 ± 2.5), and (b) 39 to

49 years (middle adulthood, n = 10 F, 10 M; mean age = 42.7 ± 3.9). Participants were

randomly assigned to either the control group (n = 20; 10/age group) or the

experimental group (n = 20; 10/age group). Individuals that maintained a regular

physical activity regimen (i.e., 20-30 minutes of vigorous or 30-60 minutes of moderate

physical activity at least 3 times per week during leisure time over the past month), were

pregnant, were in poor health (illness or fever) at time of data collection, or were unable

to provide documented physician clearance for physical activity upon being screened

out in the CPAFLA pre-appraisal screening process were not permitted to participate.

This investigation was executed in exact accordance with the ethical guidelines set forth

by the University of British Columbia’s Clinical Research Ethics Board (CREB) for

research involving human participants (see Appendix B for certificate of research

ethics).
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Procedure

Participants took part in two data collection days with a one week interval

between days. The purpose of the one week delay was to decrease the carry over

effects associated with psychological, educational, and cognitive assessments (e.g.,

knowledge retention) (Portney & Watkins, 2000). Additionally, since physiological

fatigue is a common consequence of fitness testing and fatigue is known to have

detrimental effects on cognitive function (Afari & Buchwald, 2003), the day 2 (post-test)

was scheduled to occur one week following the collection of baseline measures. Each

of the two testing sessions consisted of: 1) an assessment of health-related physical

fitness knowledge (FitSmart), and 2) an assessment of beliefs, attitudes and intentions

(TPB components) towards regular health-related physical activity participation. On Day

1, participants randomly assigned to the experimental group were also administered the

Canadian Physical Activity, Fitness & Lifestyle Approach health-related physical fitness

assessment and counselling strategy. Recommendations and guidance pertaining to

physical activity participation, body composition, aerobic fitness, musculoskeletal fitness

(muscular strength, muscular power, muscular endurance, and flexibility) and back

fitness were provided by a Canadian Society for Exercise Physiology-Certified Exercise

Physiologist (CSEP-CEP) directly following the fitness assessment according to

standardized CPAFLA protocol. The CSEP-CEP is the most advanced health and

fitness practitioner certification in Canada allowing members to work with high

performance athletes, the general population (across the lifespan), and varied clinical

populations. A CSEP-CEP is sanctioned to perform assessments and evaluations,

prescribe conditioning exercise, provide exercise supervision/monitoring, counselling,

healthy lifestyle education, and outcome evaluation for “apparently healthy” individuals
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and/or populations with medical conditions, functional limitations or disabilities through

the application of physical activity/exercise, for the purpose of improving health, function

and work or sport performance (CSEP, 2007). Additionally, Health Canada physical

activity and nutrition guides were provided to the participants during the appraisal and

consultation session. Refer to Figure 3.1 for a schematic of the research design.

Assessment of Health-Related Physical Fitness Knowledge

The FitSmart written examination was used to assess the health-related physical

fitness knowledge of each participant. Developed by Zhu, Safrit, and Cohen (1999), the

FitSmart written examination consists of two equivalent examinations (Forms I and 2)

containing 50 multiple choice items, measuring six sub-domain components: concepts

of fitness; scientific principles of exercise; components of physical fitness; effects of

exercise on chronic disease risk factors; exercise prescription; as well as nutrition, injury

prevention, and consumer issues. The content based equivalency of the two

examinations was carefully dictated by a panel of experts in the health-related physical

fitness discipline (Zhu et al., 1999). All participants were required to complete both

forms of the FitSmart, one for each test day based on random assignment. Concepts of

fitness make up 20% of the FitSmart examination and incorporate questions pertaining

to fitness definitions, and the relationship(s) between fitness, physical activity, and

health. The scientific principles of exercise component also makes up 20% of the exam

and includes questions relating to the acute/chronic physiological and psychological

adaptations to exercise. Questions associated with cardiovascular, respiratory and

pulmonary function, muscular strength and endurance, flexibility, as well as body

composition are addressed in the components of physical fitness section and comprise
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20% of the exam. Five percent of the exam includes questions relating to the effects of

exercise on chronic disease risk factors. Exercise prescription makes up 20% of the

exam and takes into account the concepts of frequency, intensity, duration, mode, self-

evaluation, and exercise adherence. Last, 15% of the FitSmart examination consists of

items pertaining to nutrition, injury prevention and consumer issues. Participants were

allocated 45 minutes to complete the examination. Raw scores out of 50, overall

percentages, and categorical percentage scores for each fitness component were

generated via the FitSmart software for data analysis.

Assessment of the Theory of Planned Behavior Components Concerning Regular

Physical Activity

We modified the instrument developed by Rhodes and Courneya (2003) by

replacing the word and definition of “exercise” with “physical activity” and its

corresponding definition to reflect the aims of the present investigation. Regular health-

related physical activity was defined as leisure-time activity performed at least 3 times

per week for at least 20-30 minutes in duration at a vigorous intensity (e.g., hard

breathing, heart beats rapidly, heavy sweating); or leisure-time activity performed at

least 3 times per week for at least 30-60 minutes in duration at a light-moderate

intensity (e.g., increased breathing, faster than normal heart beat, light sweating, can

keep a conversation going). Participants were provided with common examples of

activities corresponding to these definitions of regular physical activity and were asked

to use these definitions and examples when answering all physical activity related

questions. The same assessment was provided to both experimental and control

participants during both (pre, post) testing sessions.

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Attitudes towards regular physical activity participation: Seven-point bipolar

adjective scales were used to assess regular physical activity participation attitudes.

Two components of attitude were assessed, instrumental and affective attitude, via

three items each. The three items used to investigate instrumental attitude were:

beneficial-harmful, useful-useless, and important-unimportant. The three items used to

assess the concept of affective attitude were: enjoyable-u nenjoyable, fun-boring,

pleasurable-painful. The stem preceding these bipolar adjectives was: ‘for me,

participating in regular physical activity over the next month would be...’. Participants

received a score out of 21 for each attitude component with increased scores indicative

of favourable attitudes towards participation in regular health-related physical activity.

Subjective Norm: Two components of subjective norm were assessed, injunctive

and descriptive norm, via the use of 7-point bipolar adjective scales. Three items were

used for each component of subjective norm. For injunctive norm, the following

preceding stem was utilized: ‘I think that if I were to participate in regular physical

activity over the next month, most people who are important to me would be...’. This

stem was followed by the following adjective pairs: approving-disapproving, supportive

unsupportive, encouraging-discouraging. For the concept of descriptive norm,

participants were asked to rate, on 7-point bipolar adjective scales, how active important

people in their lives were likely to be over the next month. The following three question

stems were used: (1) ‘I think that over the next month, most people who are important to

me will be...’, (2) ‘I think that over the next month, most people who are important to me

will participate in regular physical activity...’, and (3) ‘I think that over the next month,

the regular physical activity participation levels of most people who are important to me

will be...’. These stems were followed by the following pairs of adjectives in their
 84

respective order: extremely active-extremely inactive, extremely agree-extremely

disagree, and extremely high-extremely low. Participants received a score out of 21 for

each subjective norm component with increased scores suggestive of favourable

subjective norms towards participation in regular health-related physical activity.

Perceived Behavioural Control: The concept of perceived behavioural control

was measured by six items, each of which consisted of a stem and a 7-point bipolar

adjective scale. The following six question stems were used: (1) ‘If you were really

motivated, how controllable would it be for you to participate in regular physical activity

over the next month?’, (2) ‘If you were really motivated, how easy or difficult would it be

for you to participate in regular physical activity over the next month?’, (3) ‘If you were

really motivated, do you feel that whether or not you participate in regular physical

activity over the next month would be completely up to you?’, (4) ‘If you were really

motivated, how confident are you that you could participate in regular physical activity

over the next month?’, (5) ‘If you were really motivated, do you feel you would have

complete control over whether or not you were physically active over the next month?’,

and (6) If you were really motivated, how certain or uncertain would you be that you

could participate in regular physical activity over the next month?’. These stems were

followed by the following pairs of adjectives in their respective order: extremely

controllable-extremely uncontrollable, extremely easy-extremely difficult, extremely

agree-extremely disagree, extremely confident-extremely u nconfident, extremely true

extremely untrue, and extremely certain-extremely uncertain. Participants received a

score out of 42 for perceived behavioural control, with increased scores indicative of

higher levels of perceived control towards participation in regular health-related physical

activity.
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Intention: Intention to participate in regular physical activity was measured with

five items; three question stems followed by 7-point bipolar adjective scales, and 2 open

ended questions. The three question stems were as follows: (1) ‘How motivated are you

to participate in regular physical activity over the next month?’ (2) ‘I strongly intend to do

everything I can to participate in regular physical activity over the next month...’, and (3)

‘How committed are you to participating in regular physical activity over the next

month?’. The corresponding bipolar adjectives were: extremely motivated-extremely

unmotivated, extremely true-extremely untrue, and extremely committed-extremely

uncommitted. Participants received a score of out of 21 for the first three questions

concerning intention to participate in regular physical activity with higher scores

suggestive of increased intention to partake in physical activity over the next month. The

two open ended questions asked the participants to stipulate the number of days per

week (0-7) as well as minutes per session (0-60) that they intended to participate in; (1)

vigorous intensity physical activity, and (2) light-moderate intensity physical activity over

the next month.

CPAFLA Assessment

The CPAFLA appraisal included pre-appraisal screening and objective measures

of physical activity participation, metabolic fitness, body composition, aerobic fitness,

musculoskeletal fitness, and back fitness. The CPAFLA appraisal was conducted using

the exact procedures as described in Chapter 2, with the inclusion of an individually

tailored physical activity participation counselling session that focused on the results of

the CAPAFLA assessment. The counselling session functioned to: (1) educate

participants regarding the health-related importance of each and every component

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within the CPAFLA and the health benefits associated with physical activity

participation, (2) provide participants with Canadian standardized health-related

interpretations of their personal fitness results, and (3) set specific measurable

attainable realistic and time oriented (SMART) health-related goals based on individual

measurements with reference to: (i) Canadian normative fitness data, (ii) Canada’s

physical activity guide, (iii) Canada’s food guide, and (iv) personal issues (e.g., income,

activity preference) and personal daily/weekly schedules. The administration of the

CPAFLA assessment and counselling session took an average of 1.75 hours to

complete.

Statistical Analysis

Statistical significance was set a priori at p <0.05 for all analyses. All figures and

tabular values are reported as the mean ± standard deviations (SD). Each variable was

tested for normal distribution (i.e., skewness or kurtosis) and was transformed if

necessary. A multivariate repeated measure analysis (mixed between-within subjects

ANOVA) was employed to look at the individual and aggregative effects of time (pre

test, post-test), treatment group (control, experimental), gender (female, male), and age

(young adulthood, middle adulthood) on each dependant variable. To answer the

hypotheses of this investigation, the interaction effect of time by group was utilized as

the primary indicator of the CPAFLA assessment’s effect(s) on the dependant variables

of interest. Health-related physical fitness knowledge (overall and sub domain

component) percentage scores (x/100) were used as the primary indicators of health

knowledge. The theory of planned behaviour component scores/responses

(instrumental attitude (x121), affective attitude (x121), injunctive norm (x/21), descriptive
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norm (x/21), perceived behavioural control (x/42) and intention (x/21, days per week

and minutes per session)) were used as the main indicators of beliefs, attitudes and

intentions towards participation in regular physical activity.

Results

Participants

All participants resided in Vancouver, British Columbia or the Greater Vancouver

Region. The control group consisted of 20 participants: 10 young adulthood (5F, 5M;

mean age = 24.2 ± 2.1) and 10 middle adulthood (5F, 5M; mean age = 43.4 ± 3.9). The

experimental group was also comprised of 20 participants: 10 young adulthood (5F, 5M;

mean age = 24.3 ± 2.9) and 10 middle adulthood (5F, 5M; mean age = 42 ± 3.9). Table

3.1 lists physical activity participation as a function of intensity (vigorous, moderate, and

light), duration (times/week, and minutes per session), age (young, middle adulthood),

gender (male, female), and treatment group (control, experimental). Half the

participants (50.0%) were Caucasian, 22.5% were Asian, 12.5% were East Indian,

10.0% were Mid Eastern, 2.5% were Pilipino, and 2.5% were Aboriginal Canadian. Most

participants (80.0%) were currently enrolled in or had completed post secondary

education (12.5% college diploma, 47.5% undergraduate degree, 20% graduate

degree). The remaining one fifth (20.0%) of the participants were currently enrolled in or

had completed a secondary level of school education. For income: 67.5% grossed $
39000/year (37.5% $ 20000; 30.0% = $ 20-39000), and 27.5% grossed $
40000/year (10% = $ 40-59,000, 15% = 60-79000, 2.5% = $ 80-90000). The remaining
5.0% did not disclose their income. During the CPAFLA, two male experimental

participants (1 young adult, 1 middle-aged adult) were screened out from performing the
 88

back extension measurement during the standardized back extension pre-screening

assessment.

Health-Related Physical Fitness Knowledge

The means and standard deviations for the FitSmart health-related physical

fitness knowledge, overall and component, scores are presented in Table 3.2 as a

function of time and treatment group. There was a statistically significant interaction

effect for time and group for the Components of Physical Fitness section of the FitSmart

[Wilks Lambda = 0.82, F (1, 32) = 6.9, p = 0.013]. The average score for the control

group declined over time while the mean score for the experimental group increased

(Figure 3.2). The time by group interaction effects for overall FitSmart score [Wilks

Lambda = 0.91, F (1, 32) = 3.14, p = 0.086], Concepts of Fitness [Wilks Lambda = 0.91,

F (1, 32) = 3.11, p = 0.088], Scientific Principals of Exercise [Wilks Lambda = 0.974, F

(1, 32) = 0.866, p = 0.359], Effects of Exercise on Chronic Disease Risk Factors [Wilks

Lambda = 0.931, F (1, 32) = 2.38, p = 0.133], Exercise Prescription [Wilks Lambda =

0.999, F (1, 32) = 0.023, p = 0.88], as well as Nutrition Injury Prevention and Consumer

Issues [Wilks Lambda = 0.998, F (1, 32) = 0.074, p = 0.787] did not reach statistical

significance. Significant interaction effects for time by group by gender were found for:

Concepts of Fitness [Wilks Lambda = .774, F (1, 32) = 9.36, p = 0.004] and Nutrition

Injury Prevention and Consumer Issues [Wilks Lambda = 0.856, F (1, 32) = 5.37, p =

0.027]. A significant interaction effect was also shown for time by group by age for the

Effects of Exercise on Chronic Disease Risk Factors [Wilks Lambda = 0.84, F (1, 32) =

6.11, p = 0.019].
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Components of the Theory of Planned Behavior

The means and standard deviations for the Theory of Planned Behavior

Component scores are listed in Table 3.3 with respect to time and treatment group.

There was a statistically significant interaction effect of time and group for instrumental

attitude [Wilks Lambda = 0.984, F (1, 32) = 8.36, p = 0.007], perceived behavioral

control [Wilks Lambda = 0.861, F (1, 32) = 5.18, p = 0.030], intention [VVilks Lambda

0.667, F (1, 32) = 15.96, p = 0.00], and number of minutes intended to participate in

vigorous intensity physical activity per session [Wilks Lambda = 0.790, F (1, 32) = 8.51,

p = 0.006]. Instrumental attitude declined over time in the control group while increasing

in the experimental group following the CPAFLA (Figure 3.3). Perceived behavioral

control declined over time in the control group and increased in the experimental group

(Figure 3.4). Intention to participate in regular health-related physical activity declined in

the control group and increased in the experimental group over time (Figure 3.5).

Likewise, experimental participants intended to participate in more minutes of vigorous

health-related physical activity following the CPAFLA while control participants showed

decrements in the number of minutes indented to participate vigorous physical activity

per session (Figure 3.6). These results support our hypothesis and suggest that

individuals possess more favorable beliefs, have more perceived control, and have

more intention towards participation in regular health-related physical activity after the

administration of the CPAFLA health related physical fitness assessment and

counseling strategy. The time by group interaction effects for affective attitude [Wilks

Lambda = 0.99, F (1, 32) = 0.321, p = 0.575], injunctive norm [Wilks Lambda = 0.974, F

(1, 32) = 0.87, p = 0.358], descriptive norm [Wilks Lambda = 0.943, F (1, 32) = 1.921, p

= 0.175], number of days intended to participate in vigorous physical activity [Wilks

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Lambda = 0.902, F (1, 32) = 3.49, p = 0.071], and number of days [Wilks Lambda =

0.942, F (1, 32) = 1.98, p = 0.169] as well as minutes [Wilks Lambda = 0.992, F (1, 32)

= .255, p = 0.617] intended to participate in light to moderate physical activity did not

reach statistical significance. Significant interaction effects were found for time by age

for number of minutes intended to participate in light-moderate health-related physical

activity per session [Wilks Lambda = 0.866, F (1, 32) = 4.95, p = 0.033], with the young

adult cohort showing increases in minutes and the middle adulthood cohort showing

decreases in minutes over time. Significant interaction effects were found for time by

group by age by gender for injunctive norm [Wilks Lambda = 0.865, F (1, 32) = 5.0, p =

0.032], and intention [Wilks Lambda = 0.809, F (1, 32) = 7.55, p = 0.011.

Discussion

To the best of our knowledge, this is the first investigation to empirically examine

the effects of administering the Canadian Physical Activity, Fitness and Lifestyle

Approach health-related physical fitness assessment and counselling strategy on health

knowledge, as well as the Theory of Planned Behaviour components concerning regular

physical activity participation. A significant time by group interaction effect was found

for both hypotheses. For health knowledge, our results showed improvements in

knowledge specific to the components of physical fitness following administration of the

CPAFLA assessment and counselling strategy. In contrast, participants who did not

receive the CPAFLA assessment and counselling session displayed lower scores on

the Components of Physical Fitness questions. In addition, individual beliefs, attitudes,

and intentions towards participating in regular health-related physical activity improved

in comparison to baseline measures following the administration of the CPAFLA.

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Specifically, these effects were demonstrated via increases in measures of instrumental

attitude, perceived behavioural control, and intention.

The significance of this investigation adds to the documented importance

regarding the objective measurement of health-related physical fitness. Researchers,

especially in the public health domain, value the data that is generated from the

assessment of health-related physical fitness. These data substantially contribute to the

epidemiological knowledge health scientists utilize to evaluate populations in terms of

health status, disease risks, and functional capacities (Malmberg et al., 2002; Oja,

1995). In addition, the accurate quantification of health-related physical fitness

measures is essential when evaluating the effectiveness of interventions designed to

augment physical fitness (Vanhees et al., 2005). Furthermore, the evaluation and

application of the data provided by standardized health-related fitness measures

provides useful informatics which are vital towards the design and implementation of

population based health promotion and preventative care initiatives and interventions

(Suni et al., 1998; Shephard, 1986). The current investigation supports previous

research; however, it uniquely contributes by analyzing the immediate benefit(s)

participants receive from taking part in standardized fitness assessment and counseling

procedures. Our results suggest that after participating in the CPAFLA (a holistic

assessment of health-related physical fitness) individuals demonstrate greater

inclination towards for integrating physical activity and healthy lifestyle behaviors into

their daily schedules. These findings promote the usefulness of professional fitness

assessments.
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Health Knowledge

Health depends on our understanding of its determinants, and the application of

this knowledge in the prevention and treatment of disease (Pakenham-Walsh &

Priestley, 2002). In accordance, health knowledge enables individuals to identify the

symptoms and communicability of diseases, allows individuals to select and participate

in appropriate preventative health strategies (e.g., resistance training), and gives

individuals an understanding of where and how to obtain health assistance (Freimuth,

1990). Moreover, fitness knowledge (a component of health knowledge) is understood

to influence the health and exercise behaviors of individuals (Zhu et al., 1999).

Research suggests that individuals who have increased fitness knowledge via health

education are more likely to be active and fit (Petersen, Byrne, & Cruz, 2003). Our

results suggest that the administration of the CPAFLA assisted individuals in

understanding the components of an essential determinant of health (i.e., physical

fitness). These components include knowledge pertaining to the health-related

importance and functionality of: the cardiovascular system; the respiratory and

pulmonary systems; musculoskeletal strength, endurance, power, and flexibility; as well

as body composition (Zhu et al., 1999). These results are in line with the CPAFLA

objectives, as the administration of the holistic assessment by a knowledgeable health

and fitness professional incorporates the evaluation of each major physical fitness

component and provides participants with substantial amounts of valuable information

pertaining to the importance and function of each element in a reasonable timeframe.

Moreover, even though there is a lot of information being provided to participants, this

information is being presented, acquired, and stored as a result of an experiential

learning process. Research has suggested that knowledge acquisition and retention is
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superiorly accomplished via experiential education versus the traditional methods of

knowledge translation (Lewis & Williams, 1994). Even if other methods have been

identified as significant contributors towards health-related knowledge, for example:

single lectures (Andrade et al., 1999), physical education courses (Adams, Higgins,

Adams, & Graves, 2004; Nahas, 1992), and media campaigns (Marcus, Owen, Forsyth,

Cavill, & Fridinger, 1998); the experience of participating in a fitness assessment and

counselling session is unique and therefore, not easily forgotten. Fitness professionals,

health care providers, and health promotion agencies should aim to create unique

learning experiences like the CPAFLA that allow individuals to holistically engage in the

subject matter at hand in an attempt to foster greater knowledge acquisition and

retention. In addition, further research that functions to examine the long-term retention

and transfer of health knowledge and this interventional approach is warranted.

Theory of Planned Behaviour Components

The Theory of Planned Behavior offers a valuable framework to investigate

beliefs, attitudes and intentions towards the participation in regular health-related

physical activity (Tsorbatzoudis, 2005). The theory suggests that the most immediate

and significant determinant of volitional behavior is an individual’s intention to participate

in the behavior (Ajzen, 1991). The motivational factors that stimulate a behavior are

assumed to be wrapped up in an individual’s intentions (Ajzen, 1991). These intentions

are indices of how hard someone is willing to try, or how much effort one is willing to put

forth towards the performing a particular behavior (Ajzen, 1991). Intentions are

assumed to result logically from behavioral, normative, and control beliefs concerning a

particular behavior (Ajzen & Fishbein, 2005). This multidimensional belief set, which
 94

leads to the formation of behavioral intentions, is influenced by attitudes (positive or

negative assessment of the behavior), social norms (perceived societal standards

relating to the behavior) and perceived behavioral control (perceived ability to execute

the behavior) each of which can be divided into the respective sub components (Ajzen,

2002) (i.e. instrumental/affective attitude, injunctive/descriptive norm, self

efficacy/controllability). Our results indicate that after the administration of the CPAFLA

fitness assessment and counseling session participants were more inclined to

participate in regular physical activity. This was indicated by increases in instrumental

attitude, perceived behavioral control, and intention concerning regular physical activity

participation. These results provide the first empirical data that supports one of the

primary objectives the CPAFLA (physical activity promotion) (CSEP, 2003). Previous

investigations have successfully increased the Theory of Planned Behavior components

relating to physical activity participation (Tsorbatzoudis, 2005); however, this is, to the

best of our knowledge, the first Canadian investigation to examine the changes in these

components as a result of participating in a standardized health-related physical fitness

assessment such as the CPAFLA. In addition, these findings provide evidence refuting

the second order model proposed by Ajzen (2002) whereby the components (e.g.

instrumental and or affective attitude) of each theory of planed behavior construct are

hypothesized to be caused from a common general factor (e.g. overall attitude). This

evidence is substantiated by the individual and significant change found for instrumental

vs. affective attitude as a result of participation in the CPAFLA intervention. Specific to

our results, it makes conceptual sense that the CPAFLA was able to target instrumental

vs. affective attitude. This distinctively shows that the CPAFLA intervention was

successful in formulating belief systems concerning the health benefits associated with
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regular physical activity participation as the assessment of instrumental attitude

encompassed beliefs and attitudes concerning the benefits and harms associated with

physical activity. More importantly, these findings support the subcomponent

conceptualization by Rhodes & Courneya (2003). This model assumes that the Theory

of Planed behavior subcomponents (e.g. injunctive and or descriptive norm) have direct

effects upon the general concept (e.g. subjective norm) and relationships between

subcomponents may arise from exogenous common causes (e.g. past experience,

personality, belief systems) versus a second order concept. This subcomponent

modeling makes greater conceptual sense as traits such as attitude and perceived

behavioral control are more dynamic and changeable social cognitive concepts (Rhodes

& Courneya, 2003).

The measurement of responses outlining or promoting a particular behavior (e.g.,

physical activity participation) has the ability to facilitate behavior change. This is

commonly referred to as ‘the mere measurement effect’ (Morwitz, Johnson, &

Schmittlein, 1993). Theoretically, actions that increase an individual’s commitment to a

behavior generally have a strong effect on the behavior. These ‘mere measurement

effects’ occur because an individual’s responses to questions outlining a specific

behavior have the capacity to generate ‘psychological commitment’ toward the

behavior. For example; interventions that provide opportunities to express personal

views (e.g., survey completion) could aid in increasing motivation and the initiation of

behavior change (Maio et al., 2007). The trends within our data suggest that mere

measurement effects were not present. Even though formal statistical procedures were

not performed to rule out these effects, the documented declines in the control group for
 96

instrumental attitude, perceived behavioral control, as well as intention during the post

test were enough evidence to support this notion.

Conclusion

Given that the CPAFLA has been acknowledged as the most widely used

standardized health-related fitness appraisal throughout Canada (Katzmarzyk, 2002), is

accepted as Canada’s primary health-related physical assessment tool (Warburton et

al., 2006b), and is administered on over a million Canadians every year (CSEP, 2003),

the results of this investigation provide important evidence substantiating one of the

primary purposes of the CPAFLA (i.e., physical activity promotion and motivation).

Thus, when thinking of innovative ways to combat the Canadian health care burden

(Katzmarzyk & Janssen, 2004) the CPAFLA should be seriously considered. After

participating in the Canadian Physical Activity, Fitness & Lifestyle Approach individuals

showed increases in health knowledge, as well as instrumental attitude, perceived

behavioural control and intention regarding health-related physical activity participation.

These results suggest that participants benefit from participating in an all encompassing

fitness appraisal and counselling session such as the CPAFLA. As a result individuals

should be more able to integrate positive health behaviours (e.g., physical activity) into

their lifestyles. Therefore, providing increased access to health-screening and

counselling is essential to combat the health care burden which arises from physical

inactivity, obesity, and the increasing variety of chronic hypokinetic disease states

associated with sedentary behaviour. Primary health care providers should routinely

send their patients to certified personal trainers and certified exercise physiologists for

habitual physical fitness checkups and counselling. This investigation suggests that

fitness appraisals and counselling sessions provide participants with motivation to

 97

increase their physical activity participation and healthy lifestyle behaviours at the same

time as providing valuable and standardized information concerning health status and

disease risks to both the practitioner and participant. Future research is warranted to

investigate the long term effects of participating in standardized health-related physical

fitness appraisals like the CPAFLA on behaviour.

 98

Table 3.1. Physical Activity Participation

Control Experimental

(n =20) (n = 20)

Physical Activity Young Middle-Age Young Middle-Age

Measurement
(n10) (n=10) (n=10) (n=10)

Female Male Female Male Female Male Female Male

(n=5) (n=5) (n=5) (n=5) (n=5) (n=5) (n=5) (n=5)

Vigorous 0.4±0.5 1.0±0.7 0.6±0.9 0.6±0.9 0.5 ± 0.5 0.4 ± 0.5 0.5 ± 0.9 0.2 ± 0.4
(Times/Week)

Vigorous 35 ±
9.0 ± 13.4 11±17.6 9±13.4 30±36.7 11±17.5 14±26 15±33.5
(Minutes/Session) 25.5

Moderate
1.4±1.1 1.2±.84 1.6±1.1 1.0±1.0 0.4±0.5 1.0±1.0 1.3±0.7 0.6±0.9
(Times/Week)

Moderate 22 ±
30±28.3 27±1.7 14±13.4 18±26.8 26±26.1 26±5.5 14±26.1
(Minutes/Session) 15.25

Light
7.0 ± 8.2 3.4 ± 2.9 3.6 ± 2.2 2.6 ± 0.9 2.8±2.7 5.2±6.1 1.2±1.3 3.8±2.7
(Times/Week)

Light
27±13 21±5.2 24±15.2 17±7.6 17±8.4 30±22.4 45±49.7 26±20.4
(Minutes/Session)
 99

Table 3.2. FitSmart Health-Related Physical Fitness Knowledge Scores

Control Experimental

(n=20) (n=20)
Measurement

Test Day I Test Day 2 Test Day I Test Day 2

Overall Score (%)

75.0 ± 9.3 72.5 ± 8.3 69.0 ± 12.4 70.6 ± 10.4

Concepts of 84.9 ± 8.5 81.0 ± 17.4 74.3 ± 16.3 79.5 ± 17.7

Fitness (%)

Scientific
Principals of 68.6 ± 15.0 63 ± 21.4 64.3 ± 8.1 66.3 ± 17.4
Exercise (%)

Components of
Physical Fitness 75.2 ± 15.0 64.0 ± 12.4 67.4 17.6 68.0 ± 13.0
(%)*

Effects of Exercise
on Chronic
66.0 ± 19 .4 77.7 ± 15.0 65.3 ± 22.7 67.5 ± 19.5
Disease Risk
Factors (%)

Exercise 80.0±41.0 82.5±24.5 75.0±41.3 80.0±29.9

Prescription (%)

Nutrition Injury
Prevention and 73.5 ± 15.1 75.4 ± 13.5 67.5 ± 20.0 67.8 ± 16.0
Consumer Issues
(%)

*
Note: significant time by treatment group interaction effect (p < 0.05).
 100

Table 3.3. Theory of Planned Behaviour Scores

Control Experimental

(n20) (n=20)
Measurement

Test Day I Test Day 2 Test Day 1 Test Day 2

Instrumental Attitude
(x121) * 18.9 ± 1.7 18.2 ± 2.8 17.1 ± 2.9 18.4 ± 1.7

Affective Attitude (x121)

15.4 ± 3.5 15.5 ± 2.6 15.6 ± 2.8 16.2 ± 2.1

Injunctive Norm (x/21) 17.5 ± 3.1 16.9 ± 3.1 17.5 ± 2.4 17.9 ± 2.3

Descriptive norm (x/21) 13.0 ± 4.7 13.6 ± 3.8 13.5 ± 3.5 15.5 ± 3.2

Perceived Behavioural
31.9 ± 6.2 30.7 ± 7.3 33.2 ± 6.0 35.2 ± 3.9
Control (x/42)*

Intention (x/21)* 17.0 ± 2.5 16.3 ± 3.3 14.9 ± 2.8 17.3 ± 1.8

Vigorous Physical
Activity Intention 2.7 ± 1.8 2.4 ± 1.8 2.4 ± 1.7 2.8 ± 1.4
(Days/week)

Vigorous Physical
Activity Intention 34.8 ± 20.8 24.0 ± 17.7 36.0 ± 21.8 42.3 ± 18.2
(Minutes/Session)*

Light-moderate
Physical Activity 3.9 ± 1.6 3.9 ± 1.8 2.8 ± 1.7 3.4 ± 1.5
Intention (DaysNVeek)

Light-moderate Physical
Activity Intention 32.5 ± 16.4 35.5 ± 14.7 38.5 ± 17.8 39.0 ± 17.9
(Minutes/Session)

*
Note: significant time by treatment group interaction effect (p <0.05).
Figure 3.1. Schematic of Randomized Block Design with Delayed Repeated Measures

I Week
Interim

Note: TPB, Theory of Planned Behavior CPAF1JI, Canadian PhyskaI Activity Fitness & UfestyleApproach..
 102

Figure 3.2. Time by Treatment Effects for

Components of Physical Fitness Score

80
—
—t
75
‘I.—

70
65 H Contro’

60 4 Experimental
LU 55
w
Pe-Test Post-Test
Time
 Si-SOd
m
9t
1eWWIJdX3 P1 —
—
IOUODS LI
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8I
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61
z
apn3y IeWaa1fl41I Jo1
spaJ43 UW3I?.IJ Aq ew
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 LULL
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6
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ii tD 0
IO3UOD IeJflO!AeLI ag paAapiad ioj
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 105

Figure 35. Time by Treatment Effects

for Intention

18
C, 17
aJ_ ,
16
—
0. 4. 8 Control
h4
C, 14 Experimental
. 0 13
0
C,
Pre-Test PostTest
w — Time
 106

Figure 3.6. Time by Treatment Effects for

Intention to Participate in Vigorous Physical
Activity
C

C A 40
0 30
IC onr
tot
h4 Experimental
,,-, 10
Lu
0
PreTest PostTest

Time
 107

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CHAPTER 4

Conclusion

This thesis entitled “Health-Related Physical Fitness, Knowledge, and

Administration of the Canadian Physical Activity, Fitness, and Lifestyle Approach” was

conducted to fulfill the requirements pertaining to a Master’s of Science degree through

the Department of Human Kinetics within the Faculty of Education at the University of

British Columbia. One large study examining two distinct sub-questions was conducted

by Marc D. Faktor with intellectual input (scientific and editorial) provided by Dr.

Shannon S.D. Bred in (largest contribution), Dr. Darren E.R. Warburton, and Dr. Ryan E.

Rhodes.

The first line of investigation was to examine the relationship between health-

related physical fitness knowledge and health-related physical fitness in young and

middle adulthood. We also examined the relationship between health literacy and

health-related physical fitness knowledge. Our findings showed that health-related

physical fitness knowledge was positively and significantly correlated to health-related

physical fitness in adulthood. Specifically, knowledge was a significant correlate to and

the strongest individual predictor of musculoskeletal fitness. In addition, health literacy

was found to be a significant correlate to and the strongest predictor of knowledge.

These findings have been compiled into a manuscript titled, “The relationship between

health knowledge and measures of health-related physical fitness” (See Chapter 3).

Given the empirical evidence relating musculoskeletal fitness to health status

(Warburton, 2001) and our findings relating health-related physical fitness knowledge to

musculoskeletal fitness, it is imperative that individuals are provided opportunities to

 113

access and acquire knowledge pertaining to health-related physical fitness. It is

important to integrate education of this knowledge into multidimensional health

promotion programs, educational systems and other learning initiatives whenever

possible. Additionally and more specifically, the results presented in Chapter 3 support

other research findings (e.g., Petersen, Byrne, & Cruz, 2003) that highlight the

importance of addressing and promoting advanced concepts (e.g., scientific principles

of exercise) in educational materials designed for both health care professionals and the

general population.

The impact of health-related knowledge on lifestyle is important to acknowledge.

Individuals with less education, lower incomes, and blue collar employment are more

likely to be physically inactive than those with more education and higher paying white-

collar employment (Draheim, 2002). Correspondingly, research indicates that people

who are educated in fitness concepts are more likely to be physically active and fit

(Petersen et al., 2003). The consequences of a sedentary lifestyle are well documented

and contribute to a myriad of hypokinetic diseases (Warburton et al., 2006a).

Additionally, a large number of health economic studies have ascertained that higher

education is associated with positive health outcomes, even when factors like income

are controlled for (Kenkel, 1991). One explanation for this is that schooling helps people

choose healthier lifestyles by improving their understanding of the relationships between

health behaviour and health outcomes (Kenkel, 1991). The current British Columbia

physical education secondary curriculum (developed by the British Columbia Ministry of

Education, Skills and Training in 1998), provides students opportunities to engage in

and acquire health-related physical fitness learning objectives. For example, under the
 114

curriculum organizer ‘Active Living’, the grade 11 and 12 prescribed learning outcomes

state that student’s are expected to be able to (adapted from p. A-3 and A-5):

• Design, implement, evaluate, and monitor plans for a balanced, healthy lifestyle

(e.g., nutrition, exercise, rest, work), taking into consideration factors that affect

the choice of physical activity (e.g., age, gender, culture, environment, and body-

image perceptions) throughout life;

• Describe strategies, as well as analyse and design plans for stress management

and relaxation;

• Adapt physical activities to minimize environmental impact;

• Design, Implement, evaluate, monitor, and adapt coaching plans for exercise

programs for themselves and others, that apply the principles of training (i.e.,

progression, overload, specificity);

• Demonstrate an understanding of physiology and performance modifiers such as

how the cardiovascular, muscular, and skeletal systems relate to human motor

performance;

• Develop a plan to maximize personal motor performance for themselves and

others;

• Demonstrate a willingness to use community-based recreational and alternative

environment opportunities to develop a personal functional level of physical

fitness;

• Evaluate the influence of consumerism and professional athletics on personal

perception of body image; and

• Analyse and describe the effect of professional sports role models on the choice

of personal lifetime activities.

 115

The strengths in this curriculum stem from the active engagement in the material at

hand. Students are expected to work in groups, relate the material being presented to

themselves, and then adapt it to others within the group. This allows the student to gain

perspective of the information being presented and empathize with others in a variety of

situations. In addition, students are evaluated on the real life application of the

teachings presented in school (e.g., students are required to demonstrate a willingness

to utilize community resources in an attempt to bolster physical fitness and health). This

real life application has the potential to have a profound effect on one’s health

knowledge and literacy. It provides students with experiences that show where and how

to engage in preventative health measures within their communities. It also increases

the probability of students receiving and responding to new and up to-date sources of

health information that are usually present in community fitness based dwellings. This

continual interaction with health and fitness practices and educational materials has the

potential to increase health knowledge in addition to health literacy. However, when

students reach the end of high school (e.g., grade 11 and 12) physical education is no

longer a mandatory subject. This is a definite weakness in the curriculum that needs to

be revised. Students at this age are able to comprehend and apply information to a

much greater extent; thus, could potentially benefit the most from health education in

the later high school years. Research that functions to investigate the relationship

between health-related physical fitness knowledge, health literacy, and physical

education participation in the later high school years needs to be utilized to promote

making physical education compulsory at all grade levels.

In our findings, as well as in other investigations, it has been shown that

individuals lack knowledge specific to the scientific principles of exercise. Peterson et al.
 116
(2003) suggested that individuals should be provided with more opportunities to

strengthen existing content knowledge, rather than relying on individuals to take specific

and elective exercise physiology courses. Simple and repeated teachings of the acute

and chronic adaptations that our bodies endure in response to physical activity and

exercise should be implemented at a young age to ensure individuals understand the

modifications that occur in the body as a result of physical activity or inactivity (e.g.,

blood pressure adaptations and ramifications, triglyceride profile changes, insulin

sensitivity as well as resistance). Simple adaptations to curriculum that function to

integrate these teachings across multiple mandatory course offerings at all educational

levels should function to translate this essential knowledge for greater retention and

transfer. Moreover, lectures and tutorials should be held to help students identify the

relationships between health knowledge and behaviour as individual’s that possess low

levels of health knowledge will have a limited understanding of the benefits of engaging

in healthy lifestyle behaviours. This limited understanding leads to a decreased

awareness of: disease symptomoogy and risk, preventative health care approach’s

(e.g., proper nutrition and physical activity), and other sources of medical treatment

(Freimuth, 1990). These health knowledge issues have been documented in individuals

with intellectual disabilities (Graham, 2000; Stanish, 2006) and low levels of health

literacy (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs,

American Medical Association, 1999; Davis, 2004).

If individuals do not learn from health promotion efforts designed to highlight the

relationships between health behaviours and health outcomes their ability to partake in

a healthy and active lifestyle will be compromised. Thus, it is essential for health

promotion efforts to target individuals based on their individual capabilities and needs
 117

(Fish & Nies, 1996). For example, cohorts with increased knowledge will be able to

receive and respond appropriately to more complex health promotional messages and

services than those with less knowledge and intellectual capabilities. This example

emphasizes the need to assess the health knowledge of people in order to maximize

and target the effects of a health promotional intervention. Furthermore, health literacy

is a contemporary and well warranted topic of concern for the advancement of high

quality health care (Parker et al., 2003). It is recommended for health care practitioners

to assess health literacy, in an attempt to further individually tailor health education and

counselling. For example: if a health care professional determines a client to have

limited health literacy, their knowledge translational activities should be adjusted to an

elementary level which suites the client’s capabilities. This will then aid in ensuring

adequate knowledge acquisition and retention on the clients end.

This present investigation adapted the concept of health literacy assessment,

which is usually performed in primary care, to the health and fitness domain. Our health

literacy findings (see Chapter 3 Results) and the relationship(s) between health literacy,

health outcomes, and health knowledge are a great value and should be utilized in the

health and fitness industry. Health care practitioners of all scopes should administer and

apply the results of brief standardized health literacy assessments in order to

individually tailor the communication and guidance provided to clients, patients, and

students (Weiss et al., 2005). In addition, our research group designed a health-literacy

assessment specific to the health and fitness discipline to pilot in this investigation (the

results will be disseminated in a short communication piece via the CSEP Health &

Fitness BC). We utilized a modified Weiss method that incorporates essential health

related physical fitness documents. Participants were given a 2 page physical activity
 118

readiness questionnaire document (PAR-Q and You) (CSEP, 2003), and were asked to

read, comprehend, apply and analyze the available information to answer six content

based questions. The questions were asked orally, the responses were recorded on a

separate score sheet and time constraints did not apply. This tool did not have a

categorical score scale like the NVS does, nevertheless the literacy concepts measured

do parallel each other and lower scores were indicative of low literacy.

Further scientific investigation into the relationship(s) between health literacy,

health-related physical fitness knowledge, and the components of health-related

physical fitness is warranted. Investigations that function to determine how to maximize

knowledge retention and translation need to be conducted in order to fully apply these

findings. Interdisciplinary collaborations should be made to investigate the most

appropriate media vehicles health promotion and education programs can utilize to

circulate health-related knowledge. These media vehicles should operate to

disseminate health-related knowledge in insighiful, meaningful, and sustainable ways

that function to ensure knowledge retention and application.

The second research objective of this investigation was to examine objectively

the effects of administering the CPAFLA health-related physical fitness assessment and

counselling strategy on health knowledge and the Theory of Planned Behaviour

components (i.e., attitude, subjective norm, perceived behavioural control, and

intention) concerning regular physical activity participation in adulthood. Our findings

showed that administrating the CPAFLA increased health knowledge related to the

components of physical fitness, as well as important elements of the TPB (i.e.,

instrumental attitude, perceived behavioural control, and intention). These findings have

been compiled into a manuscript titled, “The effects of administering the Canadian
 119

Physical Activity Fitness & Lifestyle Approach (CPAFLA) on health-related physical

fitness knowledge as well as beliefs, attitudes, and intentions towards regular physical

activity participation” (see Chapter 4).

Provided that the CPAFLA is administered on over one million Canadians every

year (CSEP, 2003) and considered to be the most widely utilized standardized health-

related fitness appraisal within Canada (Katzmarzyk, 2002; Warburton et al., 2006b);

the results generated by this investigation are of much importance when thinking of

innovative ways to reduce the health care expenditures associated with physical

inactivity and obesity (Katzmarzyk & Janssen, 2004). The increases in health

knowledge and beliefs, attitudes, and intentions concerning regular physical activity that

were demonstrated after participating in the CPAFLA suggest that participants

considerably benefit from its administration. Consequently, CPFALA participants ought

to be better off integrating positive health behaviours (e.g. physical activity) into their

lifestyles. Therefore, providing increased access to health-screening and counselling is

essential to combat the health care burden which arises from the increasing variety of

chronic hypokinetic disease states associated with sedentary behaviour. Primary health

care providers should utilize health and fitness practitioners as valuable resources by

referring their patients to certified personal trainers and exercise physiologists for fitness

appraisals and counselling. It must be widely recognized that these types of referrals

should function to motivate individuals to increase their physical activity participation

and healthy lifestyle behaviours. Moreover, the standardized and Canadian normative

referenced information generated by a holistic assessment like the CPAFLA can provide

primary health care practitioners with valuable information that can positively contribute

to treatment plans.
 120

In view of the fact that the Canadian Society for Exercise Physiology’s mission

statement (i.e., “To promote the generation, synthesis, transfer and application of

knowledge and research related to exercise physiology (encompassing physical activity,

fitness, health, nutrition, epidemiology, and human performance)”) highlights the need

for continuous application and adaptation, this thesis investigation has the potential to

significantly contribute to the CPAFLA revisions process. Based on the methodology

and the results generated; some potential adaptations to the CPAFLA could include:

I. A brief assessment of health-related physical fitness knowledge

II. A health literacy assessment specific to the health and fitness domain

Ill. The assessment of the Theory of Planned Behaviour constructs relating to

physical activity participation

In collaboration, these additions to the CPAFLA would assist with the knowledge

translation and education objectives. Specifically, the results of these cognitive

assessments will provide fitness professionals with an ammunition of personalized data

that will function to enhance the quality of information provided to participants. This in

turn should lead to increased retention and application on the participants end. Given

that the information provided to participants during the CPAFLA is intended to assist

individuals in increasing their physical activity participation and healthy lifestyle

behaviours these proposed adaptations warrant serious consideration.

Taken together, the results from this thesis provide empirical evidence

substantiating the relationship(s) between health-related physical fitness knowledge,

health literacy, and the components of health-related physical fitness. In addition, these

findings support one of the primary objectives that the Canadian Physical Activity

Fitness and Lifestyle Approach health-related physical fitness assessment and

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counselling strategy conforms to (i.e., health promotion through regular physical activity

participation). Future research that investigates the long term effects of retention and

application associated with these findings is warranted.

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References

Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American

Medical Association (1999). Health literacy: Report of the council on scientific

affairs. The Journal of the American Medical Association, 281(6), 552-557.

British Columbia Ministry of Education, Skills and Training (1997). Physical Education

11 and 12 Integrated Resource Package. British Columbia: BC Ministry of

Education.

Canadian Society for Exercise Physiology (2003). The Canadian Physical Activity,

Fitness & Lifestyle Approach. Ottawa, ON: Canadian Society for Exercise

Physiology.

Davis, T. C. (2004). Health literacy: Implications for family medicine. Family medicine,

36(8), 595-598.

Draheim. (2002). Prevalence of physical inactivity and recommended physical activity in

community-based adults with mental retardation. Journal of Mental Retardation,

40(6), 436-444.

Fish., & Nies. (1996). Health promotion needs of students in a college environment.

Public Health Nursing, 13(2), 104-111.

Freimuth, V. S. (1990). The chronically uninformed: Closing the knowledge gap in

health, pp. 171-1 86. In E.B. Ray, L. Donohew (Ed.), Communication and Health:

Systems and Applications. Hillsdale, NJ: Erlbaum.

Graham. (2000). Physical fitness of adults with an intellectual disability: A 13-year

follow-up study. Research Quarterly for Exercise and Sport, 71(2), 152-161.
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Katzmarzyk, P. T. (2002). Musculoskeletal fitness and risk of mortality. Medicine and

science in sports and exercise, 34(5), 740-744.

Katzmarzyk, P.T, & Janssen, I. (2004). The Economic Costs Associated with Physical

Inactivity and Obesity in Canada: An Update. Canadian Journal of Applied

Physiology, 29(1), 90-115.

Kenkel, D.S. (1991). Health behavior, health knowledge, and schooling. Journal of

Political Economy, 99(2), 287-305.

Parker, R. M., Ratzan, S. C., & Lurie, N. (2003). Health literacy: A policy challenge for

advancing high-quality health care. Health Affairs, 22(4), 147-153.

Petersen, S., Byrne, H., & Cruz, L. (2003). The reality of fitness for pre-service teachers:

What physical education majors ‘know and can do’. Physical Educator, 60(1), 5-19.

Stanish, H.l., Temple, V.1., & Frey, G.C. (2006). Health-promoting physical activity of

adults with mental retardation. Mental Retardation and Developmental Disabilities

Research Reviews, 12, 13-21.

Warburton, D.E., et al. (2006a). Health benefits of physical activity: The evidence.

Canadian Medical Association Journal, 174(6), 80 1-809.

Warburton, D.E., et al. (2006b). Prescribing exercise as preventive therapy. Canadian

MedicalAssociation Journal, 174(7), 961-974.

Warburton, D. E. (2001). The effects of changes in musculoskeletal fitness on health.

Canadian MedicalAssociation Journal, 26(2), 161.

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., et al.

(2005). Quick assessment of literacy in primary care: The newest vital sign. Annals

of Family Medicine, 3(6), 5 14-522.

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APPENDIX A

Extended Review of Literature

In the following review, relevant literature pertaining to health knowledge, health-

related fitness, as well as the influence of health knowledge on health-related fitness is

discussed. This chapter functions as a condensed review of the current literature related

to health knowledge, health-related physical fitness, and the relationship between these

two variables of interest. Although the review of literature presented here is considered

to be condensed, it provides greater depth than what is provided in the introductory

sections of each respective manuscript. As such, the purpose of this chapter is to

provide the reader a broader perspective on the concepts focused on within this thesis.

Health and Fitness Knowledge

To provide an overview of the literature concerning health and fitness knowledge,

definitions of health, health knowledge, as well as health and fitness knowledge will be

provided. Rationale will then be given as to why health knowledge should be assessed.

Following the basis for health knowledge assessment, health knowledge and its

contribution to behaviour change will be discussed in relation to the Theory of

Reasoned Action/Planned Behaviour (the dominant health-related behaviour change

model). The next section will outline how health knowledge and health-related beliefs,

attitudes and intentions should be assessed within a research setting and relevant

examples of such assessments will be provided. The impact of health knowledge will

also be presented briefly followed by a discussion of health literacy.

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Definini Health and Health Knowledge

Health depends on our understanding of its determinants, and the application of

this knowledge in the prevention and treatment of disease (Pakenham-Walsh &

Priestley, 2002). It is imperative for definitions of health and its conditions to be detailed

and meaningful (Awofeso, 2005), as scientific research abides by the principles of

comparability and reproducibility (Ustün, 2005). The most commonly quoted definition of

health, sanctioned by the World Health Organization (WHO) over 50 years ago, states

that health is: “a complete state of physical, mental and social well-being, and not

merely the absence of disease or infirmity” (WHO, 1999, p, 10). Accordingly, each

dimension of health (physical, mental and social) can be characterized on a continuum

with positive and negative poles. Positive health is associated with the ability to enjoy

life and endure its impediments. Negative health is associated with a decreased

capacity to enjoy life and withstand its obstacles. Therefore, positive health is not only

the absence of disease. (CSEP, 2003). The WHO definition of health is broad enough

to be applied equally to both genders as well as developed and developing countries.

Health is a cumulative state, which must be promoted throughout life to ensure benefits

in the later phases of life (WHO, 1999).

In today’s health care environment accurate knowledge pertaining to health is

essential for the required prevention and treatment of illness and disease (Beier &

Ackerman, 2003). Health knowledge enables individuals to identify the symptoms and

communicability of diseases, allows individuals to select and participate in appropriate

preventative health strategies, and gives individuals an understanding of where to

obtain health services (Freimuth, 1990). Fitness knowledge (a component of health

knowledge) is understood to influence the health and exercise behaviours of individuals

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(Zhu et al., 1999). Health-related physical fitness knowledge can be discussed

according to several sub-domains such as: concepts of fitness; scientific principles of

exercise; components of physical fitness; effects of exercise on chronic disease risk

factors; exercise prescription; as well as nutrition, injury prevention, and consumer

issues (e.g., Zhu et al., 1999). Concepts of fitness refers to knowledge pertaining to

fitness definitions, and the relationship(s) between fitness, physical activity, and health,

whereas scientific principles of exercise includes knowledge relating to the

acute/chronic physiological and psychological adaptations to exercise. Components of

physical fitness addresses knowledge pertaining to cardiovascular, respiratory and

pulmonary function; muscular strength and endurance; flexibility; and body composition.

The chronic disease risk factor component focuses on knowledge pertaining to the

common chronic hypokinetic disease states (e.g., cardiovascular disease), the risk

factors associated with them (e.g., physical inactivity, obesity, smoking), and the

positive effects exercise elicits on the chronic diseases and their risk factors.

Knowledge related to exercise prescription takes into account the concepts of

frequency, intensity, duration, mode, self-evaluation, and exercise adherence. Last, the

items pertaining to nutrition, injury prevention and consumer issues, address common

issues fitness consumers encounter (e.g., best times view a gym when thinking of

becoming a member), basic nutritional information, and evidence based ways to

decrease the chance of injury (e.g., warm up, cool down, progression).
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Rationale for Health Knowledge Assessment

Within health education the four basic educational outcomes are: knowledge,

attitudes, behaviours, and skills. Despite the fact that behaviour is the outcome of most

interest in the health education and promotion sector, knowledge can be assessed with

increased accuracy over a variety of settings (Kilander, 2001). Health knowledge is

associated with health-promoting behaviours (Courtenay, 1998), and acquired

knowledge contributes to the initial stimuli required to prompt behaviour change by

aiding individuals in the development of beliefs, attitudes, and intentions, all of which

shape behaviour (CSEP, 2003; Ajzen & Fishbein, 2005). Once behaviour change has

commenced, further knowledge improvements can reinforce the stimuli for change.

Furthermore, the provision of health knowledge is a major tool of public health

promotion organizations (Nayga, 2001). Health education and promotional activities are

guided by the influence of health knowledge on health conditions, as well as variation in

health knowledge across socio-demographic groupings (Nayga, 2001).

Within education (especially physical education) the assessment of health

knowledge is common in the research world and these findings and should be

considered essential to program evaluation and development; however, this is

commonly overlooked in actual practice. According to Miller and Berry (2000), one goal

of a good fitness curriculum is to provide students with adequate knowledge and skills

that will provide encouragement for them to develop habits for a healthy and active

lifestyle. Research has demonstrated that teachers are instrumental in developing

health-related knowledge of students (Miller & Berry, 2000). Moreover, assessments

are employed to determine the knowledge and capabilities of prospective physical

educators, in-service physical educators, and health professionals (Castelli & Williams,
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2007; Kilander, 2001; Miller, 1998). Health knowledge assessments are also valid

instruments in assessing the product of health or physical education (i.e. student

knowledge) (Keating, 2007; Kilander, 2001). The results of such assessments should be

utilized in curriculum revision to enhance level of contemporary health education

(Kilander, 2001; Miller & Berry, 2000).

Health knowledge evaluation is also important for health care enhancement,

especially in terms of effective patient-physician communication (Williams, 2002). The

doctor-patient relationship is a bond that requires unambiguous, precise and complete

transfer of information for effective health advice (Samora, 1961). A patient’s level of

health knowledge can provide health practitioners and physicians with important

information that can positively affect the influence they have on their clients or patients.

Numerous studies have documented that physician’s use of scientific jargon in

combination with patient’s limited health knowledge and vocabulary, results in

ineffective health care advice and confused patients (Williams, 2002). For example,

Lerner et al. (2000) revealed limited understanding of medical terminology (47%) when

assessing the health knowledge of participants in urban and suburban American

hospital emergency rooms. Although medical terms are used as part of normal

conversation between health care providers, it was suggested that when communicating

with patients, medical terminology should be carefully explained (especially to patients

with low health knowledge) in order to ensure optimal health care and advice.

In summary, the assessment of health knowledge can benefit health care

practitioners and clients in all disciplines (e.g., exercise physiology, dentistry, physical

education); however, actual assessment protocols and procedures are lacking in many

health care settings. Thus, it is important for practitioners to consider assessing their
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client’s knowledge base specific to the discipline or specialty being provided. In terms of

health-related physical fitness and activity prescription, the evaluation of fitness

knowledge evaluation is a critical first step towards the effective delivery of information

for improved health status.

Health Knowledge and Behaviour Change

Developed by Ajzen (1988, 1991) as an evolution of the Theory of Reasoned

Action (Fishbein, 1967), the Theory of Planned Behaviour has been utilized as the

explicit theoretical basis for several hundred published scientific investigations since

1985 (Francis et al., 2004). This theory has successfully provided greater understanding

of diverse health-related behaviours such as: exercising, adhering to low-fat diets,

contraceptive use, illicit drug use, as well as numerous more health behaviours (see

Ajzen & Fishbein, 2005 for a current review), It is the most prominent conceptual model

for thinking about the determinants of particular behaviours to-date (Ajzen, 2007). The

Theory of Planned Behaviour suggests a framework about how human action is

generated. It estimates the incidence of a particular behaviour given that the behaviour

is intentional. It is suggested that behavioural intentions are assumed to result sensibly

from beliefs (behavioural, normative, and control) about performing the behaviour

(Ajzen & Fishbein, 2005). It is important to note that the behavioural, normative and

control beliefs people possess regarding the performance of a particular behaviour are

influenced by a broad assortment of situational, cultural, and personal background

factors. These beliefs can be accurate, inaccurate, biased, and even illogical.

Nevertheless, this set of beliefs is the cognitive foundation that guides human action,

which is influenced by three major factors: a positive or negative assessment of the

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behaviour (attitude regarding the behaviour), perceived societal influence to execute or

not execute the behaviour (social norm), and perceived ability to execute the behaviour

(perceived behavioural control). The amalgamation of attitude towards the behaviour,

subjective norm, and perception of behavioural control leads to the formation of a

behavioural intention (the strongest predictor of human behaviour). In general, the more

favourable the attitude and subjective norm, in combination with increased perceived

behavioural control, a person’s intention to perform the desired behaviour will be

greatest. Lastly, given a significant degree of actual control over the behaviour,

individuals are expected to execute their intentions when presented with an opportunity.

A schematic representation of the Theory of Planned Behaviour is presented in Figure

A.1.

According to Ajzen and Fishbein (2005) a reasoned action/planned behaviour

approach does have its limits. Inaccurate information has the ability to produce

unrealistic beliefs, attitudes, and intentions which can result in unwanted behaviours;

lack of volitional control can inhibit individuals from executing intended behaviours;

strong emotions can activate beliefs and attitudes that are not part of one’s everyday

cognitive processes; and unanticipated circumstances may lead to deviations in

intentions. Therefore, in terms of health-related physical fitness knowledge, if an

individual possesses inaccurate information pertaining to the constructs of fitness the

individual’s fitness behaviours can be compromised by unfavourable attitudes and

beliefs towards the behaviour. According to Ajzen (2007) knowledge, or correct factual

information plays no direct role in the process of the TRAITPB because behaviour

relevant beliefs will be formed regardless of whether or not the information one

possesses is correct or incorrect. Thus, the behaviour will still be initiated; however, the
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health-related outcome depends on whether the information works for or against the

behaviour.

Health-Related Knowledge Assessment

One of the most popular methods for collecting descriptive data is the survey

approach. Surveys are composed of a series of questions, relating to the research

question, which are posed to a group of participants and may be conducted in the form

of an oral interview, written questionnaire or examination, or computer based

questionnaire or examination (Portney, 2000). Surveys are often concerned with

describing the levels of knowledge a specific group possesses (Portney, 2000). In terms

of health and fitness knowledge, the most popular assessment tools are self report

questionnaires or examinations. These methods have been used to have assess the

health and fitness knowledge of children (Mobley, 1996), adolescents (Haltiwanger,

1994; Keating, 2007; Merkle & Treagust, 1993), adults (Beier & Ackerman, 2003; Losch

& Strand, 2004; Miller, 1998; Petersen et al., 2003) and the elderly (Fitgerald et al.,

1994).

When constructing an assessment tool the reliability and validity should always

be taken into account. Content validity of a health knowledge assessment tool ensures

that the items provide an adequate sampling of health knowledge for the relevant health

education standards (Morrone, 2007). Measures of a tools internal consistency provide

an index of the overall reliability of an assessment device (Portney, 2000). To establish

acceptable levels of content validity and internal consistency for a health knowledge

assessment tool the following steps are recommended (Morrone, 2007; Portney, 2000):

(1) identify the relevant health education standards;

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(2) develop questions based on the research question and results from a literature

review conducted to identify validated outcomes;

(3) have a panel of experts review the items;

(4) revise the document based on the panels comments;

(5) pilot test the instrument and conduct interviews or focus groups; and

(6) revise the document based on results from the pilot testing and interviews/focus

groups.

Developed by Zhu, Safrit, and Cohen (1999) and made available by Human

Kinetics TMthe FitSmart is an established, valid and reliable test to accurately measure

knowledge of fundamental health and fitness concepts at the high school level of

education. It can be written as a computer based or pencil and paper test. The

development of this knowledge examination was in accordance with the

recommendations provided by Morrone and Portney (as mentioned above); thus, the

FitSmart has undergone rigorous reliability and validity tests, as well as numerous pilot

investigations (Zhu et al., 1999). The FitSmart consists of two equivalent versions

(Forms I and 2) containing 50 multiple-choice items, measuring six sub-domain

components. Normally, scores for this test are reported on a standard score scale

ranging from 20-80. This score scale was developed using an appropriate item

response theory model with results from 4,025 high school students. A cut off score of

50 on the standard score scale is used to indicate a Healthy Fitness Knowledge Zone

appropriate for high school students. However, all scores (overall and categorical) can

be converted into raw scores to gain percentage values for knowledge translational

purposes. The sub-domain components, tested in equal numbers of questions within

both forms, include: concepts of fitness; scientific principles of exercise; components of

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physical fitness; effects of exercise on chronic disease risk factors; exercise

prescription; as well as nutrition, injury prevention, and consumer issues. Since both

forms contain an equal number of questions and the content within these questions has

been equally balanced it is possible to directly compare the scores on the two forms

(Zhu et al., 1999). The FitSmart has been used as a valid and reliable health and

fitness knowledge assessment toot for adolescents (Keating, 2007) and adults (Losch &

Strand, 2004; Petersen et aL, 2003). Furthermore, other investigations have

incorporated items from the FitSmart into their multidimensional assessment protocols

due to the tests established validity in the assessment of exercise knowledge (Zizzi,

Ayers, Watson, & Keeler, 2004).

Employing Form 1 of the FitSmart, Keating and colleagues (2007) examined the

health and fitness knowledge of 185 ninth grade students in a metropolitan area school

district. The overall mean raw score of the ninth graders (16/50) indicated serious

deficiencies in health and fitness knowledge. These findings suggest that health

promotion efforts that function to increase health and fitness knowledge are needed

within the educational system (Keating, 2007).

Peterson, Byrne, and Cruz (2003) employed the FitSmart to assess the health

related fitness knowledge of 63 pre-service physical education teachers. Peterson et al.

chose the FitSmart because the concepts being evaluated are ones that pre-service

teachers will be expected to communicate to high school students. Results of the health

knowledge assessment were not especially impressive for educated college seniors

who are expected to teach this material in the near future. Pre-service physical

educators scored an average of 75.2% on the FitSmart. Component analysis revealed

that pre-service educators were most competent in the exercise prescription domain
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(mean = 92.0%) and weakest in the domains of physical fitness (mean = 67.7%) and

scientific principles of exercise (mean = 67.7%). The various university level courses

that each participant had taken during their course of study were also examined.

Exercise physiology was identified as the primary course responsible for pre-service

physical educator’s in-depth knowledge of health and fitness concepts. The majority of

the participants (90.5%) had only taken one course in exercise physiology and the

grades received were judged as substandard. Approximately half (49%) of the

participants reported earning grades of “C” or lower, 15% could not remember their

grades, and only 4.8% of the participants earned “A” grades. To overcome these

knowledge deficiencies, Petersen et al. (2003) suggested that future educational

curriculums should integrate and reinforce fitness concepts across a variety of courses

to ensure knowledge retention of the subject matter.

In an investigation similar to Peterson et al’s (2003), Losch and Strand (2004)

revealed comparable findings when assessing the health and fitness knowledge level of

36 male and female physical education teaching majors. The average score for the

FitSmart test was 69.4%. Compartmental analysis of the scores also paralleled

Peterson et al’s investigation with the highest scores occurring on the exercise

prescription component (mean = 85.9%), and the lowest scores occurring in the

components of physical fitness (mean = 63.9%), scientific principals of exercise (mean

= 65.3%), as well as the nutrition injury prevention, and consumer issues (mean=

64.5%). In parallel with Peterson et al, the remodelling of post-secondary course

curriculum to integrate health and fitness concepts into a variety of core courses is

warranted to reinforce the retention of these deficient knowledge areas.

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Miller and Berry (2000) measured the health-related physical fitness knowledge

of student allied health professions (i.e., Physical Therapy, Athletic Training, and

Nursing) via a multiple-choice test. This test was constructed by a panel of experts who

had specific educational training and experience in exercise physiology and physical

education. The assessment spanned five health-related fitness domains including body

composition, flexibility, muscular strength, muscular endurance, and cardiovascular

conditioning. The multiple-choice test consisted of a total of 40 questions spanning 20

health-related fitness concepts (agreed on via expert consensus), with 8 questions for

each domain. The study utilized a pre-test post-test design with a 2 year time interval

(time taken from beginning to completion of professional program) between tests.

Results indicated that student athletic trainers earned significantly higher total scores, in

comparison to the nursing and physical therapy groups, on the post-test in relation to

baseline measures. In addition, both the athletic training and physical therapy group’s

post-test scores were significantly higher in comparison to the nursing groups total post

test score. This data demonstrates the impact that curriculum has on the basic content

knowledge of its graduates. Moreover, this highlights the importance of curriculum

reviews and identifying gaps in essential knowledge. When designing health curriculum,

it is essential to ensure that students in all health disciplines acquire the pre-requisite

knowledge to function as reputable allied-health professionals (Miller & Berry, 2000).

Beier and Ackerman (2003) utilized a health knowledge battery to assess a wide

sampling of health information available to the general public. The battery consisted of

ten subscales, which included: aging, orthopaedic and dermatological concerns,

common illnesses, childhood and early life, serious illnesses, mental health, nutrition

and exercise, reproductive health, safety and first aid, and the treatment of illness and
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disease. Beier and Ackerman showed that the inter-correlations among the ten health

subscales were significant and large. Factor analysis suggested that those who know

more about one health domain are more likely to be highly knowledgeable concerning

other domains. The significant inter-correlations between the health scales allowed a

composite knowledge score to be generated by summing the scores of individual health

scales (Beier & Ackerman, 2003). When examining the gender differences in health

knowledge, women (on average) performed superior to men on each health knowledge

domain, with the largest gender differences occurring for the reproductive and early life

scales.

In summary, health knowledge can be readily assessed with tools that have been

devised to ensure proper content validity, internal consistency, and reliability. Moreover,

the FitSmart is an assessment tool that has under gone tests of validity, consistency,

and validity. To-date it has been utilized as a primary measure of health-related physical

fitness knowledge in multiple age groupings with varying educational backgrounds. The

results of health knowledge assessments provide substantial information to researchers

and educators that should be used to evaluate the educational outcomes of students

and health-related professionals to optimize knowledge retention and translation.

Assessment of Health-Related Beliefs, Attitudes, and Intentions

The reasoned action/planned behaviour approach has been used in attitude

behaviour research for decades as specific behaviours are reasonably determined by

ones beliefs, attitudes, and intentions (Ajzen and Fishbein, 2005). However, early

attempts in attitude-behaviour research to outline the determinants of specific

behaviours usually produced poor correlation and unsatisfactory results. Recent

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research has shifted focus from broad to specific behavioural dispositions to attitudes

toward behaviour. This was due to the notion that general attitudes are poor predictors

of single behaviours; however, they correlate strongly with behavioural aggregates.

Thus, current attitude assessments based on the reasoned action/planned behaviour

model have turned to behaviour-focused attitudes that are congruent with behavioural

criterion in terms of action, target, context, and time elements (Ajzen and Fishbein,

2005). Accordingly (and of interest to this thesis), Rhodes and Courneya (2003) have

recognized these important considerations and have implemented them into their

assessment protocols for use with a variety of population samples (e.g., young, old,

healthy, and clinical). Specifically, Rhodes and Courneya (2003) developed a tool to

investigate multiple components of the Theory of Planned Behaviour constructs (i.e.,

instrumental attitude, affective attitude, injunctive norm, descriptive norm, self efficacy,

controllability, and intention) in the exercise domain within clinical and healthy

population samples (i.e., cancer survivors, and university undergraduate students).

In 2004, a manual was developed in response to health service researcher’s

requests to predict and understand behaviour (Francis et al., 2004). The manual is

based on the Theory of Planned Behaviour (Ajzen, 1988, 1991) and it is designed to

assist psychologists and non-psychologists involved in health-related research to

produce effective questionnaires to measure the constructs of the Theory of Planned

Behaviour. For more information on the assessment of health-related beliefs, attitudes,

and intentions refer to this manual.

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lmjact of Health Knowledge

Individuals with less education, lower incomes, and blue collar employment are

more likely to be physically inactive than those with more education and higher paying

white-collar employment (Draheim, 2002). Correspondingly, research indicates that

people who are educated regarding fitness are more likely to be physically active and fit

(Petersen et al., 2003). The consequences of a sedentary lifestyle are well documented

and contribute to a myriad of hypokinetic diseases (Warburton et al., 2006a).

Additionally, a large number of health economic studies have ascertained that higher

education is associated with positive health outcomes, even when factors like income

are controlled for (Kenkel, 1991). One explanation for this is that schooling helps people

choose healthier lifestyles by improving their understanding of the relationships between

health behaviour and health outcomes (Kenkel, 1991). Individual’s that possess low

levels of health knowledge will have a limited understanding of the benefits of engaging

in healthy lifestyle behaviours. They will also have trouble identifying the symptoms and

communicability of diseases, selecting appropriate preventative health strategies, and

understanding where and how to select appropriate medical treatment (Freimuth, 1990).

These health knowledge issues have been documented in individuals with intellectual

disabilities (Graham, 2000; Stanish, 2006) and low levels of health literacy (Ad Hoc

Committee on Health Literacy for the Council on Scientific Affairs, American Medical

Association, 1999; Davis, 2004).

If individuals do not learn from health promotion efforts designed to highlight the

relationships between health behaviours and health outcomes their ability to partake in

a healthy and active lifestyle will be compromised. Thus, it is essential for health

promotion efforts to target individuals based on their individual capabilities and needs
 139

(Fish & Nies, 1996). For example, cohorts with increased knowledge will be able to

receive and respond appropriately to more complex health promotional messages and

services than those with less knowledge and intellectual capabilities. This example

emphasizes the need to assess the health knowledge of people in order to maximize

and target the effects of a health promotion intervention.

Health Literacy

According to the United Nations Educational, Scientific and Cultural Organization

(UNESCO), a functionally literate individual is one who possesses adequate knowledge

in reading and writing which allows them to successfully participate in activities in which

literacy is culturally assumed (United Nations Educational, Scientific and Cultural

Organization, 1970). Literacy is directly related to overall health status and mental

health status (Rootman, 2005). Health literacy includes dimensions additional to reading

and writing abilities. It is referred to as the degree in which people have the competence

to obtain, process, and understand basic health information and services needed to

make appropriate health decisions (Parker et al., 2003). It is a contemporary and well

warranted topic of concern for the advancement of high quality health care (Parker et

al., 2003). Health literacy is pivotal to numerous health care system initiatives including

quality assurance, cost maintenance, safety, and patient’s active involvement in health

care decisions (Parker et aL, 2003).

The International Adult Literacy and Skills Survey (IALS) is the primary and current

source of literacy measures of the general population in Canada and in other countries

(Rootman, 2005). The most recent IALS results (circulated in 2005) highlighted major

deficiencies in the literacy levels of the population (Statistics Canada, 2005). Almost half
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of the Canadian adult population falls into the lowest 2 of 5 literacy levels (outlined on

p.16-17 (Statistics Canada, 2005)) in regards to their ability to read and comprehend

prose (48%) and documents (49%). The majority of the population falls into the two

lowest levels concerning problem solving ability (72%) and numeracy (55%) (Statistics

Canada, 2005). Correspondingly, 22% of the Canadian adult population is seriously

challenged in terms of literacy and another 26% have skills inadequate for what is

required to successfully participate in today’s “knowledge economy” (Rootman, 2005;

Statistics Canada, 2005). Furthermore, special populations, such as the elderly,

aboriginal people, immigrants, and francophones, were deemed to have significantly

lower levels of literacy (Statistics Canada, 2005). In the United States, the American

Medical Association has identified the high prevalence of inadequate health literacy

among the elderly as a concern (Ad Hoc Committee on Health Literacy for the Council

on Scientific Affairs, American Medical Association, 1999). In a study measuring

patient’s functional health literacy at two public hospitals via the Test of Functional

Health Literacy (TOFHLA) (Parker, Baker, & Williams, 1995), 81.3% of English speaking

patients equal to or above 60 years of age possessed inadequate or marginal levels of

health literacy (Williams et al., 1995). This places considerable concern towards the

health and well being of senior citizens given that the aging process is associated with a

myriad of chronic degenerative co-morbidities which commonly result in increased

health care utilization and dependency (WHO, 2002).

Inadequate health literacy can and usually is associated with several health-related

consequences. Literacy is related to numerous aspects of health inclusive of health

knowledge, health status and use of health services (Ad Hoc Committee on Health

Literacy for the Council on Scientific Affairs, American Medical Association, 1999).
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When related to health outcomes, patients with low literacy are generally 1.5-3 times

more likely to experience inferior health outcomes inclusive of knowledge, transitional

disease indicators, morbidity measures, utilization of health resources, and general

health status (DeWalt et al., 2004). Using self report measures, patients with inadequate

health literacy are more likely to report their health as poor (Baker et al., 1997). There

exists an independent association between insufficient functional health literacy

(determined via the TOFHLA) and hospital admissions (Baker et al., 1998). Previous

investigation has showed that patients with inadequate functional health literacy were

twice as likely to be hospitalized then patients with adequate literacy levels (Baker et al.,

1998).

In terms of knowledge, there exists a positive and significant relationship between

literacy levels and knowledge of health services or health outcomes (DeWalt et al.,

2004). Studies indicate that individuals with low literacy capabilities and chronic or

infectious diseases such as diabetes (Williams et al., 1998), hypertension (Williams et

al., 1998), asthma (Williams et al., 1998), or HIV/AIDS (Kalichman et al., 2000) have

inferior knowledge concerning their disease and its recommended treatment.

Furthermore, research has indicated that poor health literacy alone is the most

significant predictor of disease prevention knowledge when compared to ethnicity or

education (Lindau et aL, 2002). Uniformly, a study analyzing the relationship between

literacy levels and asthma knowledge and self care (Williams et al., 1998) indicated that

literacy level was the strongest correlate of health knowledge and disease management

skills (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs,

American Medical Association, 1999).

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Summary

Health knowledge is a key determinant of health status. It is a valuable construct

to assess as the findings can be used to improve health education initiatives in many

disciplines. The Theory of Planned Behaviour has been utilized as the theoretical basis

in hundreds of scientific investigations, and has aided in understanding a diverse array

of health related behaviours. Assessments of the Theory of Planned Behaviour

Constructs have become more specific over the years and can be utilized in the

exercise domain with confidence. Based on the health literacy findings it is evident that

health knowledge itself is an important factor in determining health status and health

management skills. Even though literacy is a primary determinant of health knowledge,

it is health knowledge itself which has a primary impact on the health behaviours and

status of individuals. A preventative health care approach that incorporates low literacy

interventions in collaboration with health education (low knowledge intervention) would

be a viable initiative to accentuate health status across the lifespan. In order to

construct a health promotional intervention as such, the individual capabilities and

needs of individuals must be targeted. Research that functions to assess the current

levels of health knowledge is a prudent elementary step in the process of tailoring an

evidence based health promotion intervention.

Health-Related Physical Fitness

In this section, health-related physical fitness will be defined along with its

components and primary contributors. The importance of conducting health-related

fitness assessments will be discussed followed by an outline of the methods used to

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evaluate health-related physical fitness. The impact of health-related fitness will also be

summarized.

Defining Health-Related Physical Fitness and Primary Contributors

Health-related physical fitness encompasses the components of physical fitness

that are related to health status, including cardiovascular fitness, musculoskeletal

fitness, body composition and metabolism (Warburton et al., 2006b). Health-related

physical fitness is different than performance-related physical fitness, whereby

performance-related physical fitness encompasses a set of attributes that people

possess or achieve relating to their ability to perform specific physical challenges which

can provide the fundamentals for sport or performance. Health-related physical fitness

focuses on the health risks and benefits associated with each of its components in

relation to the general population (CSEP, 2003).

More specifically, cardiovascular or aerobic fitness is a measure of the combined

efficiency of the lungs, heart, bloodstream, and exercising muscles in getting oxygen to

the muscles and putting it to work (CSEP, 2003). Musculoskeletal fitness refers to the

fitness of the musculoskeletal system, encompassing muscular strength, muscular

endurance, muscular power, flexibility, back fitness and bone health (Warburton et al.,

2006). Muscular strength is referred to as the maximum tension or force a muscle can

exert in a single contraction, while muscular endurance is the ability of the

musculoskeletal system to maintain or repeatedly develop contractile force. Muscular

power is a combination of strength and speed corresponding to the maximum rate of

force generation within a single rapid contraction of the musculature. The range of

motion in a joint or series of joints is known as flexibility (CSEP, 2003). The relative
 144

amounts of muscle, fat, bone and other anatomical components that contribute to a

person’s total body weight (U.S. Department of Health and Human Services, 1999) are

what make up an individual’s body composition and contribute to their metabolic

capacity.

It is regularly assumed that health-related physical fitness is a product of habitual

physical activity participation (Katzmarzyk, 1998). Physical Activity refers to any bodily

movement produced by skeletal muscles that results in energy expenditure (EE) and is

positively correlated with physical fitness (Caperson et al., 1985). When physical activity

is planned, structured, and incorporates repetitive bodily movement geared towards

improving or maintaining one or more components of physical fitness, it is referred to as

exercise (Caperson et al., 1985).

Importance of Health-Related Physical Fitness Assessment

Health—related physical fitness is considered a significant component of health

status (Katzmarzyk, 1998). The results of a stringent and standardized health-related

fitness assessment can provide individuals with a lot of valuable information pertaining

to their health status. This information is expected to educate individuals on their current

health condition and contains evidence-based guidance on how to enhance current

health by focusing on improvements in the lowest ranked fitness components. The

provision of this information is intended to motivate individuals to develop healthier

lifestyles and increase their physical activity participation in a safe, efficient and

progressive fashion (CSEP, 2003). Aside from the individual benefits of a health-related

fitness assessment, population health can be targeted by tailoring health promotion

interventions to accommodate trends in epidemiological fitness data (Shephard, 1986).

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Assessment of Health-Related Physical Fitness

The assessment of health-related physical fitness can be easily accomplished

with the use of well established appraisal protocols from agencies such as the Canadian

Society for Exercise Physiology (CSEP, 2003) and the American College of Sports

Medicine (ACSM, 2005) ( Warburton et al., 2006b). These assessments have been

established based on normative regional data and are designed to appraise the

individual elements of health-related physical fitness (see previous section) (Warburton

et al., 2006b).

Specific to this investigation, the Canadian Physical Activity, Fitness and Lifestyle

Approach (CPAFLA) (see Table A. 1.) (CSEP, 2003), has been acknowledged as the

most widely used standardized health-related fitness appraisal throughout Canada

(Katzmarzyk, 2002). Furthermore, it is accepted as Canada’s primary health-related

physical assessment tool (Warburton et al., 2006b). This health-related fitness

assessment protocol is administered on over a million Canadians every year (CSEP,

2003).

Impact of Health-Related Physical Fitness

While the risk of death for the most sedentary individuals is approximately twice

as high as that of the most active individuals, the respective risk of low-fitness

individuals is seven to eight times higher than that of high-fitness individuals (Oja,

1995). There appears to be a graded effect regarding the impact of physical fitness on

the risk of premature death, such that even small improvements in physical fitness are

associated with a decreased risk. An increase in physical fitness will reduce the risk of

premature cardiovascular-related death, and a decrease in physical fitness will increase

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the risk. Regular physical activity participation in collaboration with high fitness levels

are correlated to a decreased risk of premature fatality from any cause (especially

cardiovascular related diseases) among asymptomatic men and women. Routine

physical activity participation aids in the primary and secondary prevention of

cardiovascular-related diseases, diabetes mellitus, cancer (colon and breast in

particular), osteoporosis, depression, and obesity (see Warburton et al., 2006a for a

more complete review of the literature).

Provided that aerobic fitness is defined as the combined efficiency of the lungs,

heart, bloodstream, and exercising muscles in getting oxygen to the muscles and

putting it to work, the health-related impact of aerobic fitness is significant and should

not be overlooked, Improved aerobic fitness can be achieved by a variety of exercises

and sporting activities, is essential for continual functional independence, and reduces

the risks of cardiovascular-related diseases (e.g., heart failure) and risk factors (e.g.,

hypertension) (CSEP, 2003).

Composite body composition is assessed by combining BMI, skinfold

measurement (approximation of body fat) and waist circumference. Unhealthy BMI

values (either too low (< 18.5) or too high (> 24.9)) statistically increase one’s risk of

premature death (CSEP, 2003). Obesity is now a pandemic affecting many people

worldwide, It is a condition of excess body fat that results from a chronic energy

imbalance whereby intake exceeds expenditure. Too much body fat significantly

increases a person’s risk of premature death from chronic diseases such as coronary

artery disease, stroke, type 2 diabetes mellitus, gallbladder disease and some cancers

(Katzmarzyk, 2002). Obesity in collaboration with physical inactivity places a significant

 147

burden on the Canadian health care system by accrediting $9.6 billon towards their

treatment and management (Katzmarzyk, 2004).

There is increasing evidence that inferior musculoskeletal fitness is associated

with a decline in overall health status and an increase in the risk of chronic disease and

disability (Warburton, 2001). Longitudinal investigations have discovered that individuals

with low levels of muscular strength have increased functional limitations and higher

incidences of chronic diseases including diabetes, stroke, coronary artery disease,

arthritis, and pulmonary disorders (Rantanen, 1998). Furthermore, deficient

musculoskeletal fitness is positively associated with functional dependence, immobility,

glucose intolerance, poor bone health, psychological disturbances and decreased

quality of life, increased risk of falls, illness and premature death (Warburton et al.,

2006a).

Summary

The health-related physical fitness components (physical activity participation,

body composition, aerobic and musculoskeletal fitness) and their contributors are

essential to one’s health status. There are many benefits associated with the

assessment of health-related physical fitness. Moreover, the CPAFLA is a standardized

and well recognized approach to the assessment of health-related physical fitness in the

general population. Since the CPAFLA appraisal process is designed to increase one’s

knowledge and awareness concerning health-related physical fitness we hypothesize

that individuals who participate in the CPAFLA will increase components of their health

related physical fitness knowledge base. Investigations that function to assess health-
 148

related physical fitness are of much relevance to health care practitioners and agencies

promoting health.

Health Knowledge in Relation to Health-Related Physical Fitness

Knowledge is considered one of the essential factors in establishing human

behaviour (Andrade, 1999). People who understand the concepts of physical fitness are

also more likely to incorporate physical activity and exercise into their everyday life (Zhu

et al., 1999). Thus, an important step in becoming physically fit and endorsing

constructive attitudes in relation to fitness is learning the concepts and principles of

health-related physical fitness (Miller & Housner, 1998). Evidence supporting a positive

relationship between health-related physical fitness knowledge and health-related

physical fitness has been suggested in adolescents (Keating, 2007), limitedly shown in

adulthood (Avis, McKinlay, & Smith, 1990; Liang et al., 1993), and within elderly

populations (Fitgerald, Singleton, Neale, Prasad, & Hess, 1994). However, literature

delineating the relationship between health knowledge base and health-related physical

fitness is inconsistent. For example, investigations have shown no significant

relationship between fitness knowledge and components of physical fitness (i.e.,

physical activity) (Morrow et al., 2004). This section will outline the pertinent

investigations that highlight the relationship between health-related physical fitness

knowledge base and health-related physical fitness.

Health Knowledge and Physical Fitness in Adults

Avis et al. (1990) examined the level of cardiovascular risk factor knowledge and

its relationship to behaviour in females. On average, the participants were more

educated and had higher incomes in comparison to the general population. In addition,
 149

only a small portion was not Caucasian. Cardiovascular risk factor knowledge was

assessed by asking participants to outline the specific steps an individual could take to

decrease the risk of a stroke or heart attack. Interviewers lobbied respondents to

mention all actions of which they were aware. The risk factors and health behaviours

measured included smoking (self report # cigarettes per day), weight status (BMI),

cholesterol (venous blood sample), physical activity (kilocalories expended via Harvard

alumni scale (Paffenbarger, Wing, & Hyde, 1978)), blood pressure (standard

sphygmomanometer), and stress (self report). Health knowledge was positively related

to education (p < .01), being female (P < .01), and amount of exercise (p <.05). The

authors suggested that the positive relationship between the health-related physical

fitness components and health knowledge may have been mediated by the sampling of

a higher socioeconomic bracket. Further investigation incorporating well established

and standardized assessment measures is needed to quantify this relationship in

representative samples of the general population. In addition, the results of this

investigation suggest that education and knowledge are necessary to prevent negative

health behaviours, but not sufficient to influence behavioural change once health

damaging behaviours (e.g., smoking) have been established. Thus, evidence based

health promotion programs focusing on prevention are needed to educate and increase

knowledge regarding the positive relationship between health behaviours and health

outcomes.

Liang et al. (1993) examined whether or not first year medical student’s

knowledge and attitudes concerning health and exercise affected physical fitness. The

fitness assessment took into account body fat (hydrostatic weighing) and cardiovascular

fitness (maximal aerobic fitness test 2 ax)). A questionnaire was utilized to assess
(VO
m
 150

knowledge and attitudes regarding health promotion, disease prevention, and exercise.

Results showed that health knowledge influenced medical student’s fitness levels;

however, attitudes concerning health promotion and disease prevention were stronger

predictors of fitness levels

Morrow et al. (2004) studied the influence of exercise knowledge on the physical

activity behaviours of American adults. All data was generated via random digit dialling

phone interviews. A 20 item verbal questionnaire incorporating exercise prescription,

traditional physical activities, and lifestyle activities was used to determine levels of

health-related exercise knowledge. Physical activity behaviour was assessed by asking

participants to select one of eight responses that functioned to best describe their

current behaviour (Martin, Morrow, Jackson, & Dunn, 2000). Results indicated that

knowledge of exercise recommendations had no effect on exercise behaviours;

however, ethnicity, education level, and age were significantly correlated to health

knowledge. The authors suggest that the results could support the concept of

knowledge being required yet not sufficient for behaviour change. Other factors (e.g.,

self motivation, attitudes or perceived benefits) could be interacting with knowledge to

influence behaviour change (Morrow et al., 2004). Nevertheless, it is recommended for

health promotion programs to emphasize aspects of knowledge that are directly related

to the behaviour change of interest. Rutledge et al. (2001) showed that greater

knowledge concerning breast cancer and its detection methods was significantly

correlated to breast self examination behaviours. Thus, individuals that possess specific

knowledge regarding health-related physical fitness should be better predisposed to

engage in these fitness behaviours. Unfortunately, even though many adults are aware
 151

of the benefits related to physical activity, many lack specific knowledge of how to be

physically active for a health benefit (Morrow, Jackson, Bazzarre, Milne, & Blair, 1999).

Health Knowledcie and Physical Fitness in the Elderly

Fitzgerald et al. (1994) examined physical activity (self report), measured fitness

status, exercise knowledge, and exercise beliefs of African American and Caucasian

females (ages 50-80) in good health. One question addressed in this investigation

asked, “What are the exercise knowledge and beliefs of this group and how do exercise

knowledge and beliefs relate to measured fitness status and exercise behaviour?”. The

degree to which exercise knowledge and beliefs are related to physical activity in the

elderly is of much relevance to geriatric practitioners as preventative measures are

essential to halt the aging process and increase longevity (Fitgerald et al., 1994).

Fitness status was determined via a sub-maximal treadmill test (up to 70% predicted

maximum heart rate). A 7-day physical activity recall estimating frequency and duration

of significant aerobic exercise was utilized to assess physical activity. The exercise

knowledge assessment consisted of three questions derived from the American College

of Sport Medicine guidelines for cardiovascular fitness. Results indicated that exercise

beliefs and knowledge do influence exercise habits. Fitzgerald et al. suggested that the

regression model implemented for the statistical analysis was a poor fit of the data,

meaning that the independent variables did not significantly explain fitness status

(Fitgerald et al., 1994). This was most likely due to the variability in the measures used.

A more rigorous fitness assessment along with knowledge assessment is

recommended to examine the relationship of interest.

 152

Summary

Knowledge is considered one of the critical factors in establishing human

behavior (Andrade, 1999.) Furthermore, people who understand the concepts of

physical fitness are also more likely to incorporate physical activity and exercise into

their everyday life (Zhu et al., 1999). Thus, since regular physical activity participation is

often assumed as a significant predictor of health-related physical fitness (Katzmarzyk,

1998), we postulate that individuals who possess superior levels of health-related

physical fitness knowledge will demonstrate higher levels of health-related physical

fitness.

To-date, literature demonstrating a positive relationship between fitness

knowledge and health-related physical fitness in adulthood is limited. When analyzing

why these previous investigations provide inconsistent evidence supporting this

relationship, methodology seems to be the issue. Each investigation utilized different

health knowledge assessments, measures of physical fitness, as well as sampling

methods. Given the deviations in methodology between investigations the limited and

inconsistent evidence is not surprising. A study or set of investigations that implement

similar established, valid, and reliable protocols which function to evaluate this

relationship within a cross-sectional design (e.g., young adulthood vs. middle adulthood)

would make an important contribution to the current body of literature.

 153

Table A.1. Components of the Canadian Physical Activity, Fitness and Lifestyle

Approach (CPAFLA): A Standardized Health-Related Physical Fitness Assessment Tool

(Adapted from CSEP, 2003).

Pre-Appraisal Screening
• The Physical Activity Readiness Questionnaire (PAR-Q)
• A pre-activity screening tool designed to identify people for whom
certain physical activities may be inappropriate and those who
should seek medical advice (e.g., individuals with documented
cardiovascular disease).
• Measurement of resting heart rate and blood pressure
• The Healthy Physical Activity Participation Questionnaire
o Used to assess current levels of physical activity

Composite Body Composition Assessment

• Body mass index
• Waist circumference
• Skinfold thickness (a measure of subcutaneous body fat)

Assessment of Aerobic Fitness

• Modified Canadian Aerobic Fitness Test (mCAFT)
o A valid and reliable, predictive, submaximal, and progressive step
exercise test designed specifically for the general population

Assessment of Musculoskeletal Fitness

• Grip strength
• Push-ups
• Sit-and-reach test
• Partial curl-ups
• Vertical jump
• Back extension endurance

Assessment of back health

• Weighted scores for physical activity participation, waist circumference, sit
and reach, partial curl-ups, and back extension, are combined to provide
an indication of composite back fitness.

Results and Counselling Session

• Individual results generated based on Canadian normative data
• Evidence based guidance provided to stress the health benefits of regular
physical activity participation
• Fitness goals are set based on individual data
 154

Figure A.1. Schematic of the Theory of Reasoned Action/Planned Behaviour (From

Ajzen & Fishbein, 2005).

Background
factors

indMdual
Personality
Mood, emotion
Intelligence
Values, stereotyper
General attitudes
Experience /
F
Social
Education
Age, gender
Income
Religion
\
Race, ethnicity
Culture

Th/rmation
Knowledge
Media
intervention
 155

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 163

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 164

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 165

APPENDIX B

UBC Clinical Research Ethics Board Certificate of Approval

iJC The University ofBritish Columbia

-

Office of Research Services

Clinical Research Ethics Board — Room 210,
828 West 10th Avenue, Vancouver, BC V5Z
1L8

ETHICS CERTIFICATE OF FULL BOARD APPROVAL

‘RINCIPAL INVESTIGATOR: LNSTITUTION / DEPARTMENT: UBC CREB NUMBER:
shannon S.D. Bredin IUBC/Educationllluman Kinetics 1H08-00468
LNSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT:
Institution I Site
UBC Vancouver (excludes UBC Hospital)
Other locations where the research will be conducted:
N/A

DO-INVESTIGATOR(S):
4arc D. Faktor
)arren Warburton
yan Rhodes
SPONSORING AGENCIES:

‘ROJECT TITLE:
E-IEALTH-RELATED PHYSICAL FITNESS KNOWLEDGE: THE INFLUENCE OF PHYSICAL FITNESS AND
DMINISTRATION OF THE CANADIAN PHYSICAL ACTIVITY FITNESS & LIFESTYLE APPROACH.

[‘HE CURRENT UBC CREB APPROVAL FOR THIS STUDY EXPIRES: April 8, 2009
The full UBC Clinical Research Ethics Board has reviewed the above described research project, including
ssociated documentation noted below, and finds the research project acceptable on ethical grounds for research
[nvolving human subjects and hereby grants approval.

REB FULL BOARD MEETING I

EVIEW DATE: I
pril 8, 2008
)OCUMENTS INCLUDED IN THIS APPROVAL:
I
)ATE DOCUMENTS
APPROVED:
Document Name I Version I Date
Protocol:
Condensed Research Proposal February 21, Fune 20, 2008
1
2008
Consent Forms:
 166
Informed Consent Form 2 June 4, 2008
Advertisements:
Recruitment Notice 2 June 6, 2008
Questionnaire, Questionnaire Cover Letter, Tests:
FitSmart: Health-Related Physical Fitness Knowledge
Examination Forms 1 and 2 N/A March 7,2008
Health Literacy Assessment (Newest Vital Sign Score
Sheet) 1 June 6, 2008
Health Literacy Assessment (Newest Vital Sign
Nutrition Label) 1 June 6, 2008
PAR-Q 2 June 4, 2008
PARmed-X January 9,
1
2008
Physical Activity Beliefs and Attitudes Survey 2 April21, 2008
Health Literacy Assessment (PAR-Q) I June 13, 2008
Letter of Initial Contact:
Letter of Initial Contact 2 June 6, 2008
Other Documents:
External Peer Review Report February 19,
2008

DERTIFICATION:
In respect of clinical trials:
1. The membership of this Research Ethics Board complies with the membership requirementsfor Research Ethics
9oards defined in Division 5 of the Food and Drug Regulations.
?. The Research Ethics Board carries out itsfunctions in a manner consistent with Good Clinical Practices.
3. This Research Ethics Board has reviewed and approved the clinical trial protocol and informed consentform for
the trial which is to be conducted by the qua fl/led investigator named above at the specfled clinical trial site. This
pproval and the views ofthis Research Ethics Board have been documented in writing.

fhe documentation included for the above-named project has been reviewed by the UBC CREB, and the research
study, as presented in the documentation, was found to be acceptable on ethical grounds for research involving
mman subjects and was approved by the UBC CREB.

Approval ofthe Clinical Research Ethics Board by one of

Dr. Gail Beliward,

Chair
 167

APPENDIX C

Sample FitSmart Health Knowledge Examination Questions

1. The most accurate indicator of cardiorespiratory fitness is

A. percent body fat.

B. maximum oxygen uptake.
C. resting heart rate.
D. vital capacity.

2. Which of the following principles about physical fitness is most accurate?

A. It is reversible and needs continuous exercise through moderate to vigorous activity.

B. It is a permanent quality which carries over from youth into adulthood.
C. It is maintained through heavy exercise.
D. it is maintained through a person’s normal lifetime activities

3. What is the relationship between physical fitness and health?

A. People who are highly fit are always healthier; people who have poor fitness are always unhealthier.
B. People who are moderately fit typically enjoy good health.
C. The relationship is more important for children than adults.
D. There is no relationship between physical fitness and health.

4. An individual’s heart rate immediately after exercise indicates

A. the recovery rate of the heart.

B. the strength of the heart.
C. the intensity of the exercise.
D. all of the above.

5. Which of the following occurs to muscle fibers with regular weight training?

A. Increase in number
B. Increase in size
C. Increase in length
D. Increase in fat

6. Threshold of training refers to the effort needed to increase fitness. It applies to which of the
following?

A. Minimum effort required

B. Maximum effort required
C. Level of effort when fitness begins to decline
D. Level of effort associated with decreasing intensity of exercise
 168

APPENDIX D

Theory of Planned Behaviour Component Assessment

Identification #__________

Regular Physical Activity Beliefs and Attitudes Survey

Instructions

In this survey, we are going to ask you a series of questions about your beliefs and attitudes
towards regular physical activity. There are no right or wrong answers and all we ask is that you
provide responses that are as honest and accurate as possible. The questionnaire should take
about 15 minutes for you to complete. All responses are completely confidential and will never
be used in any way that could link them to you. It is important to answer all questions so that we
can include your responses in our analyses. If you have any questions please ask the research
assistant. When your questionnaire is completed, please raise your hand and the research
assistant will collect your questionnaire.

Definition of Regular Physical Activity

All the questions in this survey ask you about regular physical activity. Here, we define regular
physical activity as:
A) leisure-time activity performed at least 3 times per week, for at least 20-30 minutes in
duration (can include multiple daily sessions of 10 minutes), at a vigorous intensity (i.e., hard
breathing, heart beats rapidly, heavy sweating). Some examples of vigorous physical activities
are running, jogging, aerobics, circuit weight training, and vigorous sports such as hockey or
soccer. Or,
B) leisure-time activity performed at least 3 times per week, for at least 3 0-60 minutes in
duration (can include multiple daily sessions of 10 minutes) at a moderate intensity (i.e., slightly
increased breathing, faster then normal but not rapid heart beat, light sweating, can keep a
conversation going). Some examples of moderate intensity physical activities are brisk walking,
yoga, house work, bicycling 5 to 9 mph, water aerobics and sports such as baseball, golf while
carrying clubs, and archery.
 169

The following question asks you to rate how you feel about participating in regular physical activity on 6
different scales. Pay careful attention to the words and descriptors at the end of each scale and place an “X”
over the line that best represents how you feel about participating in regular physical activity. Please
answer all items from a) to f).

1. For me, participating in regular physical activity over the next month would be:

a)

extremely quite slightly neutral slightly quite extremely

harmful harmful harmful beneficial beneficial beneficial

b)

extremely quite slightly neutral slightly quite extremely

useless useless useless useful useful useful

c)

extremely quite slightly neutral slightly quite

extremely
unimportant unimportant unimportant important important
important

d)

extremely quite slightly neutral slightly quite

extremely
unenjoyable unenjoyable unenjoyable enjoyable enjoyable
enjoyable

e)

extremely quite slightly neutral slightly quite extremely

boring boring boring fun fun fun

f)

extremely quite slightly neutral slightly quite

extremely
painful painful painful pleasurable pleasurable
pleasurable

This next set of questions ask you to rate how other people in your life may feel about you participating in
regular physical activity over the next month. Pay careful attention to the words and descriptors at the end
of each scale and place an “X” over the line that best represents what you think about their feelings. Please
answer all items from a) to c).

2. I thinic that if I were to participate in regular physical activity over the next month, most people who are
important to me would be:

a)
 170

extremely quite slightly neutral slightly quite

extremely
disapproving disapproving disapproving approving approving
approving

b)

extremely quite slightly neutral slightly quite

extremely
unsupportive unsupportive unsupportive supportive supportive
supportive

c)

extremely quite slightly neutral slightly quite

extremely
discouraging discouraging discouraging encouraging encouraging
encouraging
 171

This next set of questions ask you to rate how active you think other people in your life are likely to be over
the next month. Pay careful attention to the words and descriptors at the end of each scale and place an “X”
over the line that best represents their physical activity levels.

3. I think that over the next month, most people who are important to me will be:

extremely quite slightly neutral slightly quite extremely

inactive inactive inactive active active active

4. I think that over the next month, most people who are important to me will participate in regular physical
activity.

extremely quite slightly neutral slightly quite extremely

disagree disagree disagree agree agree agree

5. I think that over the next month, the regular physical activity participation levels of most people who are
important to me will be:

extremely quite slightly neutral slightly quite extremely

low low low high high high

This next set of questions ask you to rate how likely you feel it is that you will be able to participate in
regular physical activity over the next month if you were really motivated. Pay careful attention to the
words and descriptors at the end of each scale and place an “X” over the line that best represents your
feelings.

6. If you were really motivated, how controllable would it be for you to participate in regular physical
activity over the next month?

extremely quite slightly neutral slightly quite

extremely
uncontrollable uncontrollable uncontrollable controllable
controllable controllable

7. If you were really motivated, how easy or difficult would it be for you to participate in regular physical
activity over the next month?

extremely quite slightly neutral slightly quite extremely

difficult difficult difficult easy easy easy

8. If you were really motivated, do you feel that whether or not you participate in regular physical activity
over the next month would be completely up to you?

extremely quite slightly neutral slightly quite extremely

disagree disagree disagree agree agree agree

9. If you were really motivated, how confident are you that you could participate in regular physical
activity over the next month?

extremely quite slightly neutral slightly quite

extremely
 172

unconfident unconfident unconfident confident confident

confident

10. If you were really motivated, do you feel you would have complete control over whether or not you
were physically active over the next month?

extremely quite slightly neutral slightly quite extremely

untrue untrue untrue true true true

11. If you were really motivated, how certain or uncertain would you be that you could participate in
regular physical activity over the next month?

extremely quite slightly neutral slightly quite extremely

uncertain uncertain uncertain certain certain certain

This next set of questions ask you to rate how motivated you are to participate in regular physical activity
over the next month. Pay careful attention to the words and descriptors at the end of each scale and place an
“X” over the line that best represents your motivation.

12. How motivated are you to participate in regular physical activity over the next month?

extremely quite slightly neutral slightly quite

extremely
unmotivated unmotivated unmotivated motivated motivated
motivated

13. I strongly intend to do everything I can to participate in regular physical activity over the next month.

extremely quite slightly neutral slightly quite extremely

untrue untrue untrue true true true

14. How committed are you to participating in regular physical activity over the next month?

extremely quite slightly neutral slightly quite

extremely
uncommitted uncommitted uncommitted committed
committed committed

15. I intend to participate in vigorous physical activity times per week over the next month for
minutes each time.
(please place a number between 0 and 7) (please place a number
between 0 and 60)

16. I intend to participate in light-moderate physical activity times per week over the next month for
minutes each time. (please place a number between 0
and 7) (please place a number between 0 and 60)
 173

For this next question, we would like you to recall your average weekly physical activity participation yç
the past month. How many times per week on average did you do the following kinds of physical activity
over the past month?

When answering these questions please:

H consider your average over the past month.

H only count physical activity sessions that lasted 10 minutes or longer in duration.

H note that the main difference between the three categories is the intensity of the exercise.

H please write the average frequency on the first line and the average duration on the second line.

Times Per Week Average

Duration Per Session

a. STRENUOUS
(HEART BEATS RAPIDLY, SWEATING)

(e.g., running, jogging, hockey, soccer, squash, cross

country skiing, judo, roller skating, vigorous swimming,
vigorous long distance bicycling, vigorous aerobic dance
classes, heavy weight training)

b. MODERATE EXERCISE
(NOT EXHAUSTING, LIGHT PERSPIRATION)

(e.g., fast walking, baseball, tennis, easy bicycling,

volleyball, badminton, easy swimming, alpine skiing,
popular and folk dancing)

c. MILD EXERCISE
(MINIMAL EFFORT, NO PERSPIRATION)

(e.g., easy walking, yoga, archery, fishing, bowling,

lawn bowling, shuffleboard, horseshoes, golf,
snowmobiling)
 174

This last part of the questionnaire is needed to help understand the characteristics of the people
participating in the study. For this reason it is very important information. All information is held in strict
confidence and its presentation to the public will be group data only.

1. Age:

2. Sex: Male_____ Female

3. With which ethnic group do you identif,’?

4. Education Level (Highest formal education diploma/certificate received or in-progress)

5. Annual Income (If supported by parents please select their annual income): < $20,000
$20-39,000 $40-59,000

$60-79,000 $80-99,000 > $100,000

 175

APPENDIX E

The Newest Vital Sign (NVS) health literacy assessment

Nutrition Label

Nu1tIon Facts

SeMiga per ntahier 4

ArnJnt per IeMng
Cak1ee 250 FitC 120
%DV
Tot.IF.t 13 20%
8tF1$n 40%
Choleaterol 2&nç 12%
Sodium 55mg 2%
TotI Carbatwdrte 30g 12%
Dietary Fiber 2g
SugerB 23g
Prolaki 4g
Peirnia Dhjea (DV ‘e bed cni
2000 c.rh dial. )rd.Iyu may
b. ghercr vn ur
caJo needi.
hiedIiflh crrr. Jm MI Lhid
Si.r. Yii EIIka Dwi
IHt PwiutOiSuer. Bufler. Sat.
Vib E*tracL
 176

The Newest Vital Sign (NVS) health literacy assessment

Score Sheet

Score Sheet for the Newest Vital Sign

Questions and Answers
READ TO SUBJECT: This information is on the back ANSWER CORRECT?
of a container of a pint of ke cream. yes no

1. If you eat the entire container, how many calories will you eat?
Answer: 11000 is the only correct answer

2. If you are allowed to eat 60 grams of carbohydrates as a snack.

how much ice cream could you have?
Answer: Any ofthe following is correct: 1 cup (or any amount upto 1 cup).
Half the container Nate: Ifpatient answers “two servings,Uask “How much
ice cream would that be ifyou were to measure it into a bowL

3. Your doctor advises you to reduce the amount of saturated fat in your diet,
You usually have 42 g of saturated fat each day, which includes one serving
of ice cream. If you stop eating ice cream, how many grams of saturated fat
would you be consuming each day?
Answer: 33 is the only correct answer

4. If you usually eat 2500 calories in a day, what percentage of your daily
value of calories will you be eating if you eat one serving?
Answer: 10% is the only correct answer

READ TO SUBJECT: Pretend that you are allergic to the following

substances: Penicillin, peanuts, latex gloves, and bee stings.

5. Is it safe for you to eat this ice cream?

Answer: No

6. (Ask only if the patient responds question 5):Why not?

Answer: Because it has peanut oiL

Interpretation Number of correct answers:

Score of 0-i suggests high likelihood (50% or more) of limited literacy
Score of 23 indicates the possibility of limited literacy.
Score of 4-6 almost always indicates adequate literacy.
 177

APPENDIX F

CFAFLA Preliminary Instructions for Participants

Name of Participant__________________________________ Age______________

Appraisal Date___________________ Time____________ Location________________

Name of Appraiser

Please adhere to thefollowing conditionsfor the appraisal:

Dress Requirements: Shorts and short-sleeved or sleeveless shirt/blouse should be worn.

Running shoes are the recommended footwear.

Food and Beverages: Do not eat for at least two hours prior to your appraisal. Also
refrain from drinking caffeine beverages for two hours and alcoholic drinks for six hours
prior to the appraisal.

Smoking: Do not smoke during the two hours prior to the appraisal

Physical Activity: Strenuous physical activity should be avoided for six hours prior to
the appraisal.

Note:
Failing to adhere to the above conditions may affect your results negatively.

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 178

APPENDIX G

Physical Activity Readiness Questionnaire (PAR-Q)

PAR-Q & YOU

(A Que tionnaiee foi ro,Ie *qed IS to 69)

Regic phpk sc2r z d hesIfl w me pecçle sie bscmt mo scuo tery da Beq nn s ‘ eiy !50 fr
pee Mane o pncle thnck Ith do bdxc wtbecce nn *Ø anne
f J1I1fl9 h !T JDQEy I1O CiJ Je rou rt by s qiodi thj
o 13 nd 6, the A-Q .1 Id yw f u Ai theck ath , doc be yo o 6ê
1 sec od uu n rdtD bár*
wry theck )O4i
Conn me it .our butt gtie her u uoerthesu quent Thmoe resdth, qnesboe csrut od eech iie% deck 5 or

1 90
Q [] t. atas your doctor suer said Teat you havit heart coadMian atbat you Ituuld on’y do pbyclcst attIuUy
by o dodd?
2. Do you tool pain Ia ynec chest lhan you do ybysicol ectbety?

[] Q 3. In the past rnontb, hair yea bed best pale when yen sane net ie4n pbpkal odhety?

Q Q 4. Do you hoe yner halmece because of azzffiess or do ye. ever ide caa,ctaernesa?

D Q 3. Do yen bo a bane or J.Tet pesbie. tier esampie, bach, bane or tip) tuat coal to .11. ow,. by e
cbaaqe hi yow peydral ocdoy?

Q Q Is yourS dacbar rweeuNy presceiblag drags (fur ueto $Iu io. your 040.4 preane or heart c.o

[] [] 7, Do yea .1 an, .thoo yen shoal net do physlcas acthlty?

If YES to one or more questions

?áaih yos for bykoe wn ptrtor B tatZgrnnhiem d fEiw hairs hea rãd. N
you clsrLcul thc l%4 aid d*i tsc aeoood
e do ur,ohki yoleot arloigai eu daàdi4ipaà4I <kyni eq odtomcti aithtt
answered *h a’s táaync NcI yercIx aid the”’ etyináh tpo1kdothsdu. ldtierthAt,
aid heWib

cwa OUtIf HO ACT1VE

NO to all questions fle,*T

2 P booie cai buiaweny nesyoi g

r —

. 6n cndkdgbecasect tcepxeydteutsabo
t freec
tbereuthoepbyikwtht *I’ ed bfl gth4 1thl dye
tt aid eeetuui sirt b.ce.ige.e K*ee.
pat sbioo awra
cai pai th eet**ryo b h3 Uto N.EA5E WWL hdithaigi,r e thr yo but an
b odWunitLed. kowr 144, I wöx U f ,oo ecMun rhicst hei
bekreynslu1 bucorg esch Øc edie. cdiuig yai *9

itbe I(do Cfl,d ber e&iei.t uedi Ifbhi ppU* II

b

lo h.aqca purii*ted You ii. eacouraged to phetecapy he P*iLQ but ouly if yea use the e.4ire be

Qa bIq ub nehabu I. jatou ie Lit4 er q ‘aid hiudg

1 ,reed, uidoaid ad qiwiad Aiqettaie kid isode mydl sii

ole Tbk pbyskdl adhtty clearance o walld Too a marimian .1 11 eaaI bern tbe doTe It Is co.Ipte*ed and
becernet beafli 11 yo caeUee hes so tur ea wcedd ar Y€t to any at tbe saran quesdcos

•o. Heeffl aItó

V W •I Canacia or

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 179

APPENDIX H

Physical Activity Readiness Medical Examination (PARmed-X)

PhaisalAstiaty Raadiseas
Maded Esiatatitri
lanoadZOLttt — PHYSICAL ACTIVITY READINESS
MEDICAL EXAMINATION
The PARmed-X is a physical actIvIty-specIfic checkllst to be used by a physician with patients
who have had positive responses to the Physical ActMty Readiness QuestIonnaire PARQ). In addition, the
Canveyanc&Reterrai Form In the PARmed-X can be used to convey clearance tar physical actIvity participation.
otto make a reterrat to a medically-supervised exercIse program.
Regular physical activity is fun and heaI1Iv and easingly mote people are slatting To become more active every day. Being more active
is very safe tar mart peopla. The PAR-Li by itself provides adequate screening tot the rmaority at people. However, some individuals may
require a medical evaluation and specific advice (exercise prescription) due to one or more positive responses to the PAR-Li.
Following the participants evaluation by a physician, a physical activity plan should be devised in conauttaliort with a physical activity
prateaskirtal (OSEP-Protesalanal Fitness & Lifestyle Consultant or OSEP-Exercise Therapist”). Ta assist In this, the following irtstructlons
are provided:
PAGE 1: - Sections A, B, C. and 0 should be completed by the participant BEFORE the examination by the physician. The bottom
section is to be completed by the examining physician.
PAGES 2 & 3: -Achecldist of medical oonditioaa requiring special consideration and management
PAGE 4: -Physical Activity & Litesayle Advice for people who do. not require specific instructions or prescrihed exercise.
Physical Activity Readiness CotweysncelReferral Form an optional tear-off tab foi the physician to convey clearance tar
-

physical activity participation, or to make a jelerral to a medically-supervised exercise program.

This section to be completed by the participant

PERSONAL iNFORMATION:
B PAR-O: Please indicate the PAR-Cl questions to
which you answered YES

Li 01 Heart condition
ci 02 Chest pain during activity
ci 03 Chestpainatretrt
Li Cl 4 Loss of balance, dexinesa
TIEPROIIIE —
Li 05 Bone or joint problem
ci 06 Blood pressure at heart drugs
BIRTHOATE — —— GENOER ci 07 Other lesson:

OlCAL No.

C RISK FACTORS FOR CARDIOVASCULAR DISEASE;

Cit eck all tltaz sppiy

Li Less than 30 minutes cit moderate physical U Excessive accumulation of tat around
PHYSICAL ACTIVITY
INTENTIONS;

What physical activity do you Intend to do?

activity most days of the week waist.
U Currently smoker (tobacco smoking 1 or Li Family history of heart disease.
mare times per weak).
Li High blocd pressure reported Please uole Manyof#reae ,‘isk facte,s
by physician after repeated nteasuremertta. are mo&lthIa. Please refer to page 4
Ci High cholesterol level reported by physician. and discuss siLt your plijericlsn.

This section to be completed by the examining physician

Physical Exam: PhysIcal Activity Readiness Conveyance/Referral:

lit a I) i Based upon a current review of health t’ueter Iritormaten:
status, 1 reCommend: Attactiad
p Ii) I 1Tobelorwsrdad
Li t’io physical activity ) AsaS&ila on request
Li Only a medically-supervised exercise program wail further
Conditions limiting physIcal activity; medicsi C seance
Li Carcilovasculai Li Respiratory Li Other Progressive physical actMty:
Li Musculoskeletal Li Abdominal LI with avoidance at:
Li with inclusion of:
Tests required:
Li under the supervision at a CSEP-Prrrfeasionai Fitness S
Li ECS Li Exercise Test Li X-Ray Lifestyle Consuitnt or CSEP-Eserciae Therapist”
LI Blood Ci Utinalysis Li Other Li Unrestricted physical activity—start slowly arid held up gradually

s,ed.:
• Caiac &tisiy to, Exese. Rysidogy • Canada Canada
1

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 180

Appendix G

Physical Activity Readiness Medical Examination (PARmed-X)

Ph Activity Resdatees
M.dical Exesittaenn

PA Rrned—X PHYSICAL ACTIVITY READINESS

MEDICAL EXAMiNATION
Foowfng is a cheoldist of medical conditions for which a degtee of precaution andior spec(s) advice shoutd be considered for those who
answered YES’ to one or more questions on the PAR-O, and people over the age of €9. Conditions are grouped by system. The
categories of precautions are provided. Comments under Adstce are general, since detalls and alternatives require clinical judgernertt in
each indlvtOual instance.

AbDolute Rebtive Speci& Preccrptive

Sornraindiction Centraindioation conditlon2
Peteanent etrictins ert porrey Ht5y vwvte. Value ewercise tttdividized pry r(ive atleice
reatrictien witit cenr ic1tet.d. tesieg andktr pregran rrray netyapptagttato:
stsb*e. sndtir peat were phase. exceed die. otivityotaybe
trntiabonn tinpased; i1dJct
epeitetcisee preenbed.
tswvaleto maxtinize trcnkrtt af
May rc*quie medical nestlerbig
Direct cv titdtiect rnacat ic v ernmion Ft
tJterx{eicn of exetce feogiwe eseenea psani
may be d.iele ADVICE
CdiovascuIar ;t asrecerawynin 1&easting) U stain atenoern (roedersta) o acrØ, pehertary) clatical exercise teal nr be
U atcatanoas (sewas) at.noam—rrlild arrgirrepectora warranted et yelacteitcarse.
U er,icaorlic stanoac (severe)
teal other mandaetalicireof Icr apealfie erernreson
U ccttgewtwe heart liclure tU marked c&tdlsa enlargweecrt coronary inacdttciency (e.g. of tretirtronel capealty and
U crvscerrth angrna U stgireveraitcuIordysb4hmse
prahecute — fimiteriors arid precatiliore
(if any).
U eyneat infarction )alute) )urrcor5rc8ed rrrttir rate) (3 ogenotic hestrdleesae
alas pg a alec of errecciae
U myccardtiie )actve cc recaph U ventricular spic activity o ehuilfa ftirtvrrTent cv fixed)
to IevvL baxud ret test.
or trequers)
U prtlmonerycreysternc U centhrcticrr deairiswcee pnrterntwrce and indidduid
(3 vet Let Srtet5(’SS Itictartee.

U throiribophiIie Ulerinos—entreatador • fellB8B retarder aieetiiual need for

urxareokd severe (s*emic • Wo$PathilOtat.Wlutt indict concddartiig program
U vanlficsfw t.drycatda and ot*nOnary) order medical is4taNtOicn
c (rodicect or direct).
(e.g. mi*i4ocal veneicrdar hyp.rttopiie csritcrryop o dd—ccnoo8ad
adiety) U otrrenaated con alive heart (3tXed tale pacenrykeca
failure
U inenr1ttdaritlcadOn ptogreaave eaere totrilerarmce
o hyperxei.irtn: apic — exetcae; save asit
et-1ao: dlastriirr l+ rrredlcatlcre (astern alecti’&ylse;
poarsexerres synceps etc..)

(3 entity ictecticue ese (.1 oubetteakhronicltecuarent U throes irrlar5crra vax to condition

infections
(regatrthaa of etiolagy) tidactiouy deeaeee(e.g.,
U ISV
meteifa others)
o urrcontrobd rmrytabotic 0 ran rapeticanther
Metabolic deciders (a4en meus, matebciictnoufllciecrcy
thynonsanda rnyxed.ma)
U otiealiy dietary rnotleretrar. and tinted 45

Pregnancy
— ,— U corirpoetad peegrasary
(e.g.. tcaenas. trenorthoge.
0 air4e Iddtwy

o .th.’antred pregnancy { 3rd

tnmexlar)
eeecee edhilow pragrerroete
(walring wmintrydeig(

reSet to the “PARmed-X for

PREGNANCY
incetweearrl cervix, etc.l

The PAR-Q and PARmed-X were developed by the British Colombia

ArcWnc GA. W4e. Dt. Mao. Y. (i2. Rti& Axaaearrrern of Phyicl Ministry of Health. They have bean revised by art Expert Advisory
Activity end Physical Fitness in the Canada Health Survey Folow.
Up Siucty. J. C5n Epidemiot. 45:4 41-$2& Committee of the Canadian Cociely for Exercise Physiology chaired
Motteila. M., Wolfe, LA. )1a94). Active Living and Pregrrarroy, In:
by Dr. N. Gledhlfl (2002).
A. C)uirvneat L Caucisi, T. Wal eda.). Toward Active Lilvingi
Proceedings of the trntyraxtiornel Conference ott Physical No changes peronlited. You are encouraged to
Acvisisy Fitness end I4eetth. Champaign. IL: Human I(inetlos.
photocopy the PARmed-X, but only If you
PAR-U Validation Report, Ertind Colwnbis Ministry of Health. 178.
use the entire form.
Thomas. S., Reade’ng, .L, Shepherd, R..J. (1002). Ffevioion of the Physical
Acidly Reediness Uueeticvrneilrr (PAR-U). Clitti. 3. SpL SrI. 17:
$ 338445. Diapanthle an Iiançais eons Ia litre
•Evs)uanon rnédloale de raptitude a t’actdté physatpee (X-AP)”

Contixcted on page 3.

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 181

Physical Activity Readiness Medical Examination (PARmed-X)

PhAodvdy Readineec
Madin EaatnEwhon
(teveed 2002)

SpcciaI Precr1ptivc
Conditionc ADVICE
Lung i dvanianeerdondew epe ra nd breedng exercinee

2 etture kat diseane bwa r1tot ctoring endiaance cee ro4srsnocc anod pobled

Q aelhme

t3 azeofae-tnduced baxdiospan eeoc bpereera di3nr!g rewee: avrnd ew’ewely mi : im

e sprepne t

Muscubskeletal ine ba&neiwlleno (pa oloicd. tundanal) zaoid ml ea.qcU. that patse at ex tee&.. inmedauuasvte8einun
eelenaian. and entlwisdng oolrecl pauture, pner bank exercises
i athtdie—eunte nferdue, .rheresebigout tremere,pudieabtsnd afreat, spblrn8 end gentle renusman

Lt athrtle—adiectde pmgtasete bexeaee of wtixe aniherapy

l axthrtlu—dmrad ofltwitls end eboxe relenanee of mofile’ ael amength: eret- hdweeing exercwee to iiza(dwrtfrsuma
idbiona) {xopdag,cantNtl5t atc4
3 orthapeedia highly xw.Is and indieidiee8zed
(1 hernia o*wuze ‘airMeig and in tdce:elregthei al,duniaral musotee
U GOtuOtOO r inw b eenmpandteerk
eeoc exerun.ealr high rts fraeureaich sepodi-qw. au,t-4a,
lornand tleeinn .ag. at -inpact w 1e-beering’a.e and resenanne riannmg

CNS oiwuliaye disorder nntoomçtlalaly ooctlrod by nanin’or anoid seercae in hia e ira.atrtexering alone (eg.
rrwdicefbn swñrsrthg. moti cfrrg, atc)
U recant ruexuanon thcxosgh ananrflasen4 lryofso creana.ans ,rAewlor decontiajalion of content
apart 8 three concaee. depanig on hasionof anoanedeunneax, retrograde an’awsia,
pareatam headed and other objeotina evidence ci cerebral damage

Blood u atiera—ewer. 1< II) Grntj cuntrrerted:exetda. ax tolerated

electrolyte disturbance.

Medications l aaasrginel U al-rthotic NOTE canceler uridedyingcondhcn. Parenthil fxr eterdoetal cynoope, rAolyts
r enenaam itobalence, bredycercisa. dyuthythnriac hopiarerfoordin cad reaoeicn hone, bean
J ntOfltoheflt
intoleranax. May alex reeetg and enema. ECG’u and tr eateteet prfcmnnioe.
2 batablodrern U digitaho preparefiono

t diuretec U gblcckera

3 cthem

Other U IOI O’aOI moderate trog

U heel rotatarera. picking coal-doom with it cctivdiae avoid aseeca. in aettlattre beet
U tterynwwr lneae paotpCenB ienid recounted

Cl cancer tlpotundat rtta. teat by opale ergomamy. caneider nor nib aingexoeoae.
e.ueraaeat kiwen and of preecdptwa ring. (40-65% o neerirate meeter.), depaserthig
an carnebon and recant treatment tr.di.hen. cite ençy) ma.tar hamogloden and
lymphocyte coreva: add dynen*r htdrrg exetelt rength.n muadec, earing roacliawe
rather than esigrla

Refer to nipedel p ineifone far brnelion an carpEted

The IdloetWig compecionfarme are eradabte order.: 1W.ceeO.C&teqTnB.

The Physical Autirity Reeide’aeee Oteonaaece PAR-Ot - a qu a mire for people ed 154 to oonnplaee before bacoelny much inane plnyeicody

The Phyolcel Activity Reedineac Medical Exetnenetion for Fr ocy tPAflmed-X for PREGNANCY) to be used by jityaceane ninth plegrana
pedant. who wiob to become morn phyincetly aorive

Pot roars bntormadon, pleeae cort the:

Genadien Society for Exercise Physiology

202 185 Sorrrerset St.. Want
-

Ottawa. ON: fi2P (1J2

Tel. i-877-01-755 FAX (513) 224-3565 OnlIne; wwwicepca

Note to physical activity profes&onala..

It In a prudent practice to retain the completed Phynilcat Activity a Canadian Socreri’ far Exercies Phraeakegy
Readiness Conveyninc&Referrat Form in the psoticipanttr
by I HaIth Sante
•‘ Canada Canada Co. bawd art pepe4

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach.
 182

Physical Activity Readiness Medical Examination (PARmed-X)

.yics1Aa Ft.
Med
d 2002)

PAR in ed—X PHYSICAL ACTIVITY READINESS

MEDICAL EXAMINATION

Get Actiw Your Wa Evety Day-For Life!

tea. lOot CCy r, loSt 00 eL,rae ylytfele aelly
P.amty Of Prraht.0 your rat. AC
ywu preou 0 StereO 0t3C you too CitOotat
SO riCa,. 4 lrauWrc1,. Ar.-ucyisa hctlOtttC patina
1. •S!bp j, tie. £1.1.. oto era CC Cleat alit’ Ctalrtlrmiy.. C wJft
-

lime aeeded dtpentt. en efttt

Pltysicetl ectivity improvar. health. ‘S-’.
-
at p.nw. sStt fla.a. b.t
...,
‘att
,..aa.. ,dhit
lttleIt onyx Ill wt.e iota a.,
btttr-ee,ynecanWtitl

€.txthrayourwoy
b4d y45.ofacZCty
yea
theta
atsd,r.L City I hull, let tea
arlulfiep er. your dAy Oat
iwa ,flnw*ut, yr. Ste wIetto remit war.
III ewomitolyt Ofll PetIt., grt.tty rnctaswtelwa
1.0,01 OtPtfltAOIul FeO all
Paujee tracputy tI Itey cyctoy patti neway an
yaltes, IkeecOttIty IV it. taCt
Odaptrc.tr ye 10101, am ‘ctca,veaylyctai raCy
aeetc’ eel mtrwtw l,01,taatyw,,eaPy II.
awtse,e’ey our. lyOnet0a,t—ycO4ce I
Play htlt.ely tt Slut hilt 1St 01015tPrm
Cleat. twa, ala, Or tce,mtmem.
cycle tft.zflta itta actkycocrPitt,g
,00 0,t 05.0.
Eutiity ski. At.
ioyo.tatt RObe
iceS teSs SutOiCt if rq01bsyw t.eStb tieS. if tebi1
5

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Soutce Canada P alMvdj Guide to HealthyActive Uvm Heath Canada 1996 h02JMwwhcoc.o
etReptoduced pvsion ot the tnister of Pui,licWwks and vernmee Setvicet Canada, 2J0P.

PARmed-X Physical Activity Readiness Conveyance/Referral Form

eased upon a cwtert review of the health fecOfflfli

U No physical activity
Fuithar lalceenatico:
U Only a meckally-supervised exeecise ptogram until teether medical cleateae
U Peogtsssive physical activity
l Avail.bie on reptiewy

U with avoidance ol:__________ Phyaientrlt*ntanp:

U with inclusion of: ——____________

U teidet the superilsion ol a CcEP-Ptolesaionai Fitness &

Lifestyle Consultant or CSEP-Exegcise Theraplet
10
U Unrestricted physical activity — steel sksaly anti toudd a graduay

NOTh: Th sphysicalactivityGlearancels valid

Mfl. for s tnaximttm of six months horn the date
it )s completed anti becomes invalid if your
20 medcaI condition becomes worse.
4

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 183

APPENDIX I

CPAFLA Adult Consent Form

I, the undersigned, do hereby acknowledge:
• my consent to perform a health-related fitness appraisal consisting of stepping on
double 20 cm steps at speeds appropriate for my age and gender, measurements of
standing height, weight, circumference, and skinfolds, and tests of grip strength,
push-ups, sit and reach, curl-ups, vertical jump and back extension test, the results of
which will assist in determining the type and amount of physical activity most
appropriate for my level of fitness;
• my understanding that heart rate and blood pressure will be measured prior to and at
the completion of the appraisal;
• my consent to answer questions concerning my physical activity participation and my
lifestyle;
• my consent to the appraisal measures conducted by an appraiser who has been trained
to administer the Canadian Physical Activity, Fitness and Lifestyle Approach. I
understand that the interpretation of results is limited to placing my scores in the
appropriate Health Benefit Zones and providing information on physical activity
participation and other healthy lifestyle topics.
• my understanding that there are potential risks; i.e., episodes of transient light
headedness, loss of consciousness, abnormal blood pressure, chest discomfort, let
cramps, and nausea, and that I assume wilfully those risks;
• my obligation to immediately inform the appraiser of any pain, discomfort, fatigue, or
any other symptoms that I may suffer during and immediately after the appraisal;
• my understanding that I may stop or delay any further testing if I so desire and that
the appraisal may be terminated by the appraiser upon observation of any symptoms
of undue distress or abnormal response;
• my understanding that I may ask any questions or request further explanation or
information about the procedures at any time before, during, and after the appraisal;
• that I have read, understood, and completed the Physical Activity Readiness
Questionnaire (PARQ) and answered NO to all the questions or received clearance to
participate from my physician.

Signature Date

Witness Date

NOTE: This form must be completed, signed and submitted to the appraiser, along with
the completed PAR-Q, at the time of testing. This form must also be witnessed at the time
of signing and the witness must be of the age of majority and independent of the
organization administering the appraisal. The fitness appraiser/professional cannot be the
witness.

Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach
 184

APPENDIX J

Healthy Physical Activity Participation Questionnaire

DETERMINING THE HEALTH BENEFITS OF YOUR PHYSICAL ACTIVITY

PARTICIPATION IS AS EASY AS A, B, C
A. Answer the following questions
Frequency
Over a typical 7-day period (1 week), how many times do you engage in physical activity
that is sufficiently prolonged and intense to cause sweating and a rapid heart beat?
Li At Least three times
Li Normally once or twice
Li RareLy or never
intensity
When you engage in physicaL activity, do you have the impression that you:
Li Make an intense effort
Li Make a moderate effort
Li Make a Light effort
Perceived fitness
In a generaL fashion, wouLd you say that your current physical fitness is:
Li Very good
Li Good
Li Average
Li Poor
Li Very poor
B. Circle your score below for each answer and total your score
Item Male Female Male Female Male Female
Frequency RareLy or ne’er NormaLly once or twice At Least 3 times
0 0 2 3 3 5
Intensity Light effort Moderate effort Intense effort
0 0 1 2 3 3
Perceived fitness Very poor or poor Average Good or very good
0 0 3 1 5 3

Total score:

C. Determine the health benefits of your physical activity

based on your total score
Total score Health benefit
9-11 Excellent
6-8 Very good
4-5 Good
1-3 FaIr
0 Needs improvement
Source: (CSEP, 2003). The Canadian Physical Activity, Fitness & Lifestyle Approach.
 185

APPENDIX K

Detailed Anthropometric Measurements

Body Mass Index (BMI)

Standing Height
Height will be measured with a valid and reliable wall mounted
stadiometer. Participants without footwear will stand erect, arms hanging by their
sides, feet together, heals and back touching the wall. Participants will be
instructed to look straight ahead, stand as tall as possible and take a deep
breath. At the point of maximal inhalation the height measurement will be taken
to the nearest 0.5 cm (CSEP, 2003).

Body Mass (Weight)

Weight will be measured with a valid and reliable digital SECA TM spring
scale designed for research settings. Participants will be instructed to step onto
the scale without footwear and in light clothing (shorts and a T-shirt or blouse for
women). Weight will be recorded in kilograms to the nearest 0.1kg (CSEP, 2003).

The ratio of body weight in kilograms divided by height in meters squared will
equal the BMI (kg/rn
).
2

Waist circumference (WC)

Participants will be instructed to stand erect in a relaxed fashion with their
arms hanging loosely at the sides. The anthropometric tape will be positioned
horizontally mid-way between the iliac crest and the bottom of the rib cage.
Participants will be asked to take a normal inhalation and the measurement will
then be taken at the end of normal expiration to the nearest 0.5 cm (CSEP,
2003).

Skinfold Measurement (SO5S)

All measurements will be land marked according to the CPAFLA protocol
and made on the right side of the body to the nearest 0.2 mm. Two sets of
measurements will be taken. Each full set will be taken before starting the next
round of measurements. The mean of the two measurements for each skinfold
will be recorded unless the difference between the first and second measure for
a particular skinfold is greater then 0.4mm. In this case a third measurement will
be taken and the closest two measurements will be averaged. If all three
measurements are equidistant -18.6, 19.4 and 19.0, for example, the mean of all
three values will be used. Participants will be asked to relax the underlying
musculature as much as possible during each measurement (CSEP, 2003). The
five skinfolds in order of measurement are: Triceps, Biceps Subscapular, Iliac
Crest and Medial Calf. For details on precise location of each of these skinfolds
please refer to the 3’ Edition of the CPAFLA (CSEP, 2003 pg. 7-14 to 16). The
sum of five skinfolds (S055) will be determined by adding the mean values for
each skinfold in millimeters.
 186

APPENDIX L

mCAFT Detailed Procedures

Participants will be instructed to stretch their Hamstrings, Calf’s and

Quadriceps, technical assistance will be provided if required. Participants will
then be shown the proper stepping technique and pattern (CSEP, 2003 pg. 7-
26). They will be given adequate time to perfect this technique before test
execution. Then, post exercise Ceiling Heart Rate will be Calculated using the
formula [.85 x (220-age)].
The mCAFT companion CD will set the cadence and allocate 10 seconds
after each stage for the appraiser to acquire immediate post-exercise heart rate
(HR). Throughout the test the CSEP health and fitness professional will
communicate with the participant to ensure safety.
All participants will begin the stepping sequence on double 20.3 cm steps.
Fitter (and younger) participants may complete their appraisal with a single step
sequence on a 40.6 cm step. For men, stages 1-6 will be done using the two step
pattern and stages 7 and 8 will be done using the one step. Women will only be
required to use the one step pattern for stage 8.
At the end of each three minute stage, immediate post-exercise HR will be
recorded via the use of a high quality Polar TM heart rate monitor. If the
participant’s HR is below their predetermined post-exercise ceiling HR (85% of
predicted maximum (220-age)) at the end of the three minute stage they will
proceed onto the next stage at a more intense cadence.
The test is designed so the first three minute stage is usually at a cadence
intensity of 65-70% of the average aerobic power expected by a person 10 years
older. The second three minutes of stepping is then performed at 65-70% of the
average aerobic power expected for ones own age. The third and following
stages are respectively set at a cadence intensity equivalent to 65-70% of the
average person ten years younger.
The test is terminated once the participant has reached their
predetermined post-exercise ceiling HR. Other criteria for test termination
include; complaints of dizziness, noticeable staggering, inability to maintain
cadence, extreme leg pain, nausea, chest pain, or signs of facial pallor.
Once participants have completed the last stepping session, determined
by the post-exercise HR response they will be instructed to walk around slowly
for two minutes and then to sit down. At this point post-exercise blood pressure
(BP) will be measured between 2-2.5 minutes post and 3.5-4 minutes post. A
second post-exercise HR will then be recorded at 4-4.5 minutes post. These
post-exercise measurements are taken as a safety precaution to ensure
participants HR and BP fall below resting ceiling levels in an appropriate fashion
(CSEP, 2003).
 187

APPENDIX M

Detailed M usculoskeletal Fitness Assessment Procedures

Grip Strength
The participant will stand holding the dynamometer in their hand with the
arm holding the dynamometer abducted 45° from their body. Participants will be
instructed to squeeze as vigorously as possible in an attempt to exert maximum
force. To avoid build up of intrathoracic pressure participants will be told to
exhale while generating force. Two measurements will be taken for each hand
and the maximum score on either hand will be recorded to the nearest kilogram
(CSEP, 2003).

Push-ups
Any participants who suffer from any lower back ailment will not perform this test.
General Procedure:
The participant will complete as many consecutive push-ups as possible in
a rhythmical fashion. The push-up assessment will be terminated for the
following reasons: volitional fatigue, incorrect technique for more than two
consecutive push-ups, or inability to maintain a rhythmical pace (CSEP, 2003).

Males:
The participant will start on his stomach, legs together, hands pointing
forward and positioned under the shoulders. Participants will then be instructed
to push up from the ground by fully extending their elbows, using their toes as the
fulcrum, while keeping their upper body in a straight line. The participant will then
return to the starting position, chin to the mat. The maximum number of correct
push-ups will be recorded (CSEP, 2003).

Females:
Females will follow the same procedure as males except their knees will
be used as the fulcrum. Participants lower legs will remain in contact with the
ground, ankles plantar flexed, and feet touching the mat (CSEP, 2003).

Sit-and-Reach
The participant will begin by performing two 20 second modified hurdler
stretches per leg before proceeding to the sit and reach measurement. The
participant will remove their shoes and sit with their feet flat against the sit and
reach block (flexometer). Their feet will be placed just wider than the width of the
sliding mechanism. The participant will place one hand on top of the other and
situate their fingertips at the edge of the sliding mechanism. As they breathe out,
the participant will reach forward as far as possible keeping their legs straight.
This measurement will be repeated and the highest score (cm) will be recorded.
If improper form is used (ex: bending of knees, bouncing or jerky motions)
participants will be asked to repeat the flawed measurement (CSEP, 2003).
 188

Partial Curl-ups
The participant will lie supine with their arms at their sides, knees bent to
900, feet together and flat on the floor. They
will curl their body upwards while
sliding their fingers along the ground towards their feet. The participant will curl-
up until their fingers have traveled 10cm from their starting position. Curl-ups will
be performed at a cadence of 50 bpm set by a metronome. The participants will
perform as many curl-ups as possible in one minute to a maximum of 25. The
curl-up assessment will be terminated for the following reasons: volitional fatigue,
inability to curl-up the required 10 cm, inability to maintain the 50 bpm cadence
intensity, or a maximum of 25 has been achieved (CSEP, 2003).

Vertical Jump and Leg power

Any participants who suffer from any back ailment will not perform this test.

Vertical jump will be assessed with the use of the Vertec TM where the
jump height is determined by the participant jumping as high as possible from a
semi squat position to push the slats from a starting position (See figure 1
below). The bottom slat will be set at the participants maximum standing reach
height. Jump height will be determined from the amount of slats displaced. Each
slat is positioned .5 inches apart. Participants will be given 3 trials with a one
minute break in-between trials. The maximum jump height of the 3 trials will be
recorded in centimeters.

.A Vertical Jump

Peak leg power, in watts, will be determined with the use of the Sayers
Equation (Peak Leg Power (W) = [60.7 x jump height (cm)] + [45.3 x body mass
(kg)] 2055) which takes into account body mass as well as maximum jump
-

height (CSEP,2003).
 189

Back Extension
Any participants who suffer from any back ailment will not perform this test.

Due to the amount of stress this measure places on the back a screening
test will be performed prior to administration. If participants feel any discomfort
during the screening test, the back extension will not be done.
The test will be done using the portable steps used for the mCAFT. For
participants comfort a cushioned mat will be placed on top of the portable steps.
The participant will lie face down on the mat with their iliac crest positioned at the
edge of the steps with the rest of their body aligned. The appraiser will then
secure the participants lower torso by strapping down the upper calves and lower
thighs.
Once secure the participant will be instructed to cross their arms on their
chest and support their upper torso in the horizontal position with no rotation or
lateral shifting for as long as possible to a maximum of 180 seconds (see figure 2
below). The test will be terminated if the participant drops their torso below the
horizontal (allowing for one warning repositioning), or if they experience any
pain/discomfort. The number of seconds the horizontal position is maintained will
be recorded (CSEP, 2003).

A. 2. GF,-
--A Back L.nsion
1