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•Predictors of six-month change in physical and mental HRQoL were investigated.•Predictors were assessed at clinic entry for a three-week rehabilitation stay.•Physical HRQoL and depressive mood predicted six-month change in physical HRQoL.•Mental HRQoL and time since diagnosis predicted six-month change in mental HRQoL.•The regression models explained 18.6 % (physical) and 26.8 % (mental) of the variance.

Considering the interdependence of human’s and nature’s health within the planetary health concept, we evaluated how physical activity (PA) can be conceptualized as sustainable behavior (SuB) and how PA relates to other types of SuBs within the United Nations’ sustainable development goal (SDG) framework. Regarding social SDGs, PA contributes to improving malnutrition (SDG 2), health behaviors (SDG 3), education (SDG 4), reducing inequalities (SDG 10), sustainable cities (SDG 12), and peace (SDG 16). For ecological SDGs, PA contributes to sustainable consumption (SDG 11) and combating climate change (SDG 13). Therefore, PA is more than a health behavior, it contributes to planetary health and sustainable development. However, caution is warranted as PA also has the potential to contribute and reinforce unsustainability. Thus, PA as a SuB requires an own research agenda, investigating (a) PA as social and ecological SuB, (b) sustainable PA promotion, (c) sustainable PA measurement, (d) common underlying constructs of PA and SuB, and (e) technology’s role to assess and promote PA and SuB.Physical activity is very likely to lead to sustainable behaviors and sustainable development, however, non-sustainable effects of physical activity should also be investigated.

Increased community collective efficacy (CE), defined as social cohesion among neighbors and their willingness to intervene for common good, is associated with improved community health outcomes. However, processes to increase CE and estimate its dose within an intervention are not well understood. The 2 year Children's Healthy Living (CHL) intervention aimed to improve child behaviors known to affect obesity. We used data from CHL to estimate CE dose and examine its association with a successful outcome from CHL-reduction in children's recreational screen time. Monthly reports from nine intervention communities were quantified, and CE dose was calculated for each community overall, at 4 time intervals (6, 12, 18, and 24 months), and for each CE building block-social bonding, social bridging, social leveraging, empowerment, and civic engagement. CE dose at each time interval and change in screen time was correlated using Spearman's rho. Next, communities were categorized as having a high CE dose or a low CE dose, and differences between four high-dose and five low-dose communities were compared using a two-tailed t-test. The correlation between change in screen time and CE dose was significant (rs = 0.83, p = .003). Significantly more activities facilitating empowerment and civic engagement were conducted in high-dose communities, which were more likely to show improvements in screen time, than in low-dose communities. This method of estimating an intervention's CE dose and examining change over time and effect of CE and its building blocks on intervention outcomes shows promise.

Schoolyard renovations and a physical activity recess curriculum alone and in combination did not have an effect on children’s physical activity.Understanding the impacts of the built environment on physical activity (PA) is essential to promoting children’s PA. The purpose of this study was to investigate the effects of schoolyard renovations and a PA recess curriculum alone and in combination on children’s PA. This was a 2 (learning landscape [LL] vs. non-LL) × 2 (curriculum intervention vs. no curriculum intervention) factorial design with random assignment to the curriculum intervention, and six elementary schools per condition. PA outcomes were assessed preprogram, mid-program, immediate postprogram, and one year postprogram. No meaningful intervention effects were found. Lack of an effect may be due to the brief dose of recess, the curriculum not being integrated within the schoolyard, the LL implementation occurring prior to the study, or the already high levels of PA. Potential avenues to promote PA include making recess longer, integrating recess into the school curricula, and developing recess PA curricula integrating schoolyards.

Research on links between social, geographic, and cultural determinants of health has been thwarted by inadequate measures of culture. The purpose of this study was to improve the measurement of community culture, defined as shared patterns of attitudes and behaviors among people within a neighborhood that distinguish it from others, and to examine dimensions of culture, independent of socioeconomic and demographic factors, and their relationships with health.

Opioid use has become an epidemic in the USA. Although there are safe uses for opioids to help manage acute pain, the effects of long-term use and any misuse of opioids can have grave outcomes, including death. To provide an empirically based "ask" for increased funding from the federal government to increase the reimbursement for and the integration of the behavioral component of Medication-Assisted-Treatment (MAT) for opioid use disorders, current policy was reviewed and important gaps in funding and treatment fidelity were identified. Current barriers to treatment include a dearth of treatment programs and a greater emphasis on and reimbursement for the pharmacological component of MAT only, leaving the behavioral component largely underfunded. We recommend additional funding to (a) increase the availability of and coverage for MAT that combines both pharmacological and behavioral components and (b) support the scientific inquiry into the factors that contribute to, maintain, and exacerbate opioid-related issues. We also recommend declaring the opioid epidemic a national emergency and not just a public health emergency, which would provide immediate access to billions of dollars in federal dollars to fund treatment programs.

In spite of the well-known benefits of physical activity, the vast majority of children in North America do not meet current international guidelines for accumulating sufficient health-enhancing physical activity. Indeed, despite considerable attention to this population health crisis, the current prevalence of inactivity, along with its concomitant health consequences, shows little sign of abating. In this paper, we identify acknowledged barriers to wide scale physical activity adoption and maintenance at the population level among children and propose a viable tripartite framework (albeit one that would require political support) that we hope will provide the basis for debate and implementation. We emphasize that each of these considerations, in isolation, would be insufficient to substantively address the problem, but when combined would ensure that all elementary school children (without any medical contraindication) are sufficiently active, rather than the minority of this population.

Objectives:Pacific Islander children’s obesity-risk demands attention, particularly via physical activity (PA). SPARK (Sports, Play, and Active Recreation for Kids) is proven to increase students’ PA, but has limited application with Pacific Islanders. We evaluated the SPARK program implementation in the Commonwealth of the Northern Mariana Islands Public School System (CNMI-PSS). Methods: Fourteen elementary, four junior high, and five senior high schools from CNMI-PSS were invited with 2–5 representatives to SPARK trainings. The System for Observing Fitness Instruction Time was utilized to observe a random sample of classes within a random sample of schools representing each level and was validated with pedometers. Results:Students increased their walking and vigorous activity during PE classes by 10% over the school year. Increases were found for lesson contexts of fitness activities and game play; and teacher interactions of promoting fitness, and managing. Teacher interactions in demonstrating fitness, instructing, and observing decreased. Conclusions: SPARK’s success in changing PE instruction and increasing PA time of CNMI students during the PE highlight suggests SPARK programs should be disseminated to other Pacific Islands and potentially beyond.

Multiple health behavior change (MHBC) approaches are understudied. The purpose of this study is to provide strategic MHBC research direction. This cross-sectional study contacted participants through the Society of Behavioral Medicine email listservs and rated the importance of 24 MHBC research topics (1 = not at all important, 5 = extremely important) separately for general and underserved populations. Participants (n = 76) were 79 % female; 76 % White, 10 % Asian, 8 % African American, 5 % Hispanic, and 1 % Native Hawaiian/Pacific Islander. Top MHBC research priorities were predictors of behavior change and the sustainability, long-term effects, and dissemination/translation of interventions for both populations. Recruitment and retention of participants (t(68) = 2.17, p = 0.000), multi-behavioral indices (t(68) = 3.54, p = 0.001), and measurement burden (t(67) = 5.04, p = 0.001) were important for the underserved. Results identified the same top research priorities across populations. For the underserved, research should emphasize recruitment, retention, and measurement burden.

AbstractBackground:The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention.Methods:Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth.Results:The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI z-score (zBMI) increased at postintervention for both intervention (mean = 0.60; standard deviation [SD], 1.16; n= 114) and delayed-intervention groups (mean = 0.35; SD, 1.17; n= 132), change in zBMI was not significantly different between the groups (p= 0.50; p= 0.48).Conclusions:These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

Addressing complex chronic disease prevention, like childhood obesity, requires a multi-level, multi-component culturally relevant approach with broad reach. Models are lacking to guide fidelity monitoring across multiple levels, components, and sites engaged in such interventions. The aim of this study is to describe the fidelity-monitoring approach of The Children's Healthy Living (CHL) Program, a multi-level multi-component intervention in five Pacific jurisdictions. A fidelity-monitoring rubric was developed. About halfway during the intervention, community partners were randomly selected and interviewed independently by local CHL staff and by Coordinating Center representatives to assess treatment fidelity. Ratings were compared and discussed by local and Coordinating Center staff. There was good agreement between the teams (Kappa = 0.50, p < 0.001), and intervention improvement opportunities were identified through data review and group discussion. Fidelity for the multi-level, multi-component, multi-site CHL intervention was successfully assessed, identifying adaptations as well as ways to improve intervention delivery prior to the end of the intervention.

AbstractBackground:Pacific Kids DASH for Health (PacDASH) aimed to improve child diet and physical activity (PA) level and prevent excess weight gain and elevation in blood pressure (BP) at 9 months.Methods:PacDASH was a two-arm, randomized, controlled trial (ClinicalTrials.gov: NCT00905411). Eighty-five 5- to 8-year-olds in the 50th–99th percentile for BMI were randomly assigned to treatment (n=41) or control (n=44) groups; 62 completed the 9-month trial. Sixty-two percent were female. Mean age was 7.1±0.95 years. Race/ethnicity was Asian (44%), Native Hawaiian or Other Pacific Islander (28%), white (21%), or other race/ethnicity (7%). Intervention was provided at baseline and 3, 6 and 9 months, with monthly supportive mailings between intervention visits, and a follow-up visit at 15 months to observe maintenance. Diet and PA were assessed by 2-day log. Body size, composition, and BP were measured. The intervention effect on diet and PA, body size and composition, and BP by the end of the intervention was tested using an Ftest from a mixed regression model, after adjustment for sex, age, and ethnic group.Results:Fruit and vegetable (FV) intake decreased less in the treatment than control group (p=0.04). Diastolic BP (DBP) was 12 percentile units lower in the treatment than control group after 9 months of intervention (p=0.01). There were no group differences in systolic BP (SBP) or body size/composition.Conclusions:The PacDASH trial enhanced FV intake and DBP, but not SBP or body size/composition.

AbstractBackground:Almost 40% of children are overweight or obese by age 8 years in the US-Affiliated Pacific, inclusive of the five jurisdictions of Alaska, Hawaii, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. This article describes how the Children's Healthy Living (CHL) Program used the ANGELO (Analysis Grid for Environments/Elements Linked to Obesity) model to design a regional intervention to increase fruit and vegetable intake, water consumption, physical activity, and sleep duration and decrease recreational screen time and sugar-sweetened beverage consumption in young children ages 2–8 years.Methods:Using the ANGELO model, CHL (1) engaged community to identify preferred intervention strategies, (2) reviewed scientific literature, (3) merged findings from community and literature, and (4) formulated the regional intervention.Results:More than 900 community members across the Pacific helped identify intervention strategies on importance and feasibility. Nine common intervention strategies emerged. Participants supported the idea of a regional intervention while noting that cultural and resource differences would require flexibility in its implementation in the five jurisdictions. Community findings were merged with the effective obesity-reducing strategies identified in the literature, resulting in a regional intervention with four cross-cutting functions: (1) initiate or strengthen school wellness policies; (2) partner and advocate for environmental change; (3) promote CHL messages; and (4) train trainers to promote CHL behavioral objectives for children ages 2–8 years. These broad functions guided intervention activities and allowed communities to tailor activities to maximize intervention fit.Conclusions:Using the ANGELO model assured that the regional intervention was evidence based while recognizing jurisdiction context, which should increase effectiveness and sustainability.

Purpose. There is little scholarship on physical activity among children within outdoor spaces and work is needed to advance the design of these spaces from “best practices” towards evidence-based design. This project examined how playground feature density relates to children's physical activity.Design. We used the System for Observing Play and Leisure Activity to observe children's physical activity.Setting. We observed children during school recess on 24 school grounds in the Denver metropolitan area of Colorado, in spring of 2010 and 2011.Subjects. A total of 31,069 observations were made from an estimated 9900 children aged 5 to 12. These were aggregated and analyzed in 397 playground zones.Measures. We examined utilization, the number of children present in a particular activity zone during an observation, and the percentage of children engaged in moderate to vigorous physical activity as they relate to the density of constructed features on school playgrounds.Analysis. Ordinary least-squares linear regression model assessed the relationship between playground feature density and the utilization and moderate to vigorous physical activity.Results. Significant positive associations were observed between utilization and feature density among all children (β = .20; p < .001) and a statistically significant but small association was observed between moderate to vigorous physical activity and feature density for girls (β = .12; p = .013), but not for boys.Conclusion. This analysis contributes to evidence that design features of play spaces may influence children's behavior within school grounds.

Purpose. We assessed the effectiveness of a worksite management intervention (the 3W program) for overweight and obese hotel employees.Design. The program was tested in a 2-year cluster-randomized trial involving 30 hotels that employed nearly 12,000 individuals.Setting. All participating hotels were on Oahu, Hawaii. The intervention was implemented within hotel worksites.Subjects. Participants were included in the analysis if they had an initial body mass index (BMI) ≥ 25, were assessed at least twice, were not missing other data needed for the analysis, and did not switch to employment at a hotel in a different experimental condition. Of the 6519 employees we assessed, data from 1207 individuals (intervention: 598; control: 610) met these criteria and contributed to the analysis.Intervention. The intervention had two components: (1) group meetings and (2) a workplace environment intervention.Measures. Weight and waist to height ratio (WHtR) were measured at three annual assessments.Analysis. The effect of the intervention on change in BMI and WHtR was estimated in hierarchical mixed regression models using full maximum likelihood to estimate model parameters.Results. The effects on change in BMI and WHtR were in the expected direction but were not statistically significant.Conclusion. The 3W program was not effective. The low intensity of the intervention may have contributed to its ineffectiveness.

The purpose of this systematic review was to catalogue and synthesize published studies that have examined the effects of peer-delivered physical activity interventions on physical activity behavior. Ten published studies were identified that met the inclusion criteria. The following information was extracted from each study: study design and duration; characteristics of the sample, peers, and interventions; and physical activity outcomes. In all articles reporting within-groups analyses, peer-delivered interventions led to increases in physical activity behavior. When compared to alternatives, peer-delivered interventions were just as effective as professionally delivered interventions and more effective than control conditions for increasing physical activity. Only three studies included measures of social cognitive variables, yielding some evidence that peers may enhance self-efficacy and self-determined forms of motivation. Based on these findings, interventionists are encouraged to include peer mentors in their intervention delivery models. Investigators are encouraged to pursue a more comprehensive understanding of factors that can explain and maximize the impact of peer-delivered activity interventions.

Purpose. To determine if changes in physical activity were associated with changes in fruit and vegetable intake.Design. Prospective cohort.Setting. Hawaii.Subjects. Seven hundred adults (18+ years) sampled from the general population.Measures. Computer-assisted telephone interviews conducted at 0, 3, 6, 9, 12, 18, and 24 months; the International Physical Activity Questionnaire; the National Cancer Institute's Fruit and Vegetable Screener.Analysis. Between-individual correlations of each individual's mean physical activity and mean fruit and vegetable intake were estimated with Pearson correlations. Correlations of physical activity and fruit and vegetable intake within individuals over time were calculated from analysis of covariance models to factor out the variation between individuals.Results. Individuals with a higher mean physical activity duration tended to eat more fruits and vegetables (r =.30, p < .0001). Within individuals, no average correlation between physical activity and intake of fruit and vegetables was observed over time (r =.03). The variation was great in that some individuals, these behaviors changed simultaneously, but in others, they did not.Conclusion. Although individuals who are more physically active tend to eat more fruits and vegetables (i.e., there is a weak correlation between individuals), on average, individuals do not simultaneously change these behaviors. Implications are that health behaviors may not covary, or that intervention is necessary to bring about covariation in health behaviors. The great variation from individual to individual in the extent to which these two behaviors covaried needs to be studied to determine if the individual tendency for behaviors to covary could be measured and used to individually tailor multiple behavior interventions.

Purpose. To determine whether Transtheoretical Model (TTM) constructs differ between individuals making successful versus unsuccessful stage transitions for consumption of five or more servings of fruit and vegetables each day and thus provide a useful basis for designing health promotion interventions.Design. Longitudinal, observational study. A randomly selected, multiethnic cohort of adults assessed at 6-month intervals over 2 years.Setting. General community, Hawaii.Subjects. There were 700 participants (62.6% female; mean = 47 ± 17.1 years; 31.1% Asian, 22.1% Native Hawaiian/Pacific Islander, 35.0% Caucasian; 25.1% participation rate).Measures. Stage of readiness, experiential and behavioral processes of change, pros, cons, self-efficacy, and self-reported fruit and vegetable consumption.Analysis. The study used t-tests to determine which TTM variable scores differed consistently between those making “successful” versus “unsuccessful” stage transitions from precontemplation, preparation, and maintenance. Sample sizes for contemplation and action prohibited similar analyses.Results. Compared to those remaining in precontemplation, individuals successfully progressing from precontemplation showed significantly greater use of behavioral processes (collectively and self-liberation) and consciousness raising (p < .001). However, only self-liberation demonstrated significant differences consistently over time.Conclusion. This longitudinal investigation reveals that TTM behavioral processes, particularly self-liberation, predict successful transition out of precontemplation for adult fruit and vegetable consumption, suggesting that public health messages tailored according to these TTM variables may be effective for this group. However, for adults prepared to adopt or maintain fruit and vegetable consumption, tailoring based on variables from other theories is needed.

Purpose. To examine if spatial access to healthy and unhealthy outlets comprising the local food environment was associated with fruit and vegetable consumption.Design. Cross-sectional.Setting. Population-based sample residing in Hawaii.Subjects. Three hundred and eighty-four adults (36% Asian-American, 33% non-Hispanic white, 31% other/mixed race).Measures. A spatial model of the local food environment was constructed using radial buffers extending from participants' place of residence. Fruit and vegetable intake was estimated using the National Cancer Institute Fruit and Vegetable All-Day Screener.Analysis. Mean intakes of fruits and vegetables were compared for spatial access to total, healthy, and unhealthy food outlets at distances of .5 to 3.5 km. Multiple linear regression was used to estimate differences in fruit and vegetable intake for residing further from a food outlet or for residing in an area with a greater number of food outlets.Results. Residing in an area with a greater density of total or healthy food outlets was associated with a higher mean intake of fruits and vegetables (p < .05) at .5 km. No differences in mean intakes were detected for distances beyond .5 km or for regression models.Conclusion. Findings suggest that greater spatial accessibility to food outlets comprising the local food environment in Hawaii may not be meaningfully associated with fruit and vegetable consumption; however, associations were detected for the smallest spatial scale examined, warranting further investigation.

Multiple behavior change is widely used to reduce targeted health behaviors; however, its effect on behaviors such as physical activity, nutrition, and alcohol and tobacco use among older adults remains inconclusive. The primary purpose of this systematic review was to evaluate the effects of single health behavior change (SHBC) interventions vs. multiple health behavior change (MHBC) interventions among older age individuals. PubMed was searched for publications on health behavior interventions from 2006 to 2011. Twenty-one randomized clinical trials assessed the effects of health behavior change in older individuals. Results were reviewed by a number of health behaviors and effectiveness. Results revealed that within SHBC interventions, physical activity or exercise behavior revealed that interventions were the most common and showed the most promise in influencing positive outcomes in physical activity behavior among community-dwelling older adults. There were too few MHBC studies identified to allow confident comparison to SHBC interventions. The MHBC field is still at an early stage within the older adult literature, and more attention is recommended to investigate if the benefits of MHBC apply to this age group.

Combat exposure among military personnel results in increased risk of posttraumatic stress disorder (PTSD), major depression, substance use, and related health risks. PTSD symptoms require innovative approaches to promote effective coping postdeployment. PTSD's nature and scope requires an approach capable of integrating multiple health risks while reaching large populations. This article provides the rationale and approach to adapt and evaluate a Pro-Change computerized tailored intervention (CTI) targeted at behavioral sequelae (i.e., smoking, stress, and depression) for veterans with or at risk for PTSD. The three-phase approach includes: 1) focus groups to review and, subsequently, adapt content of the existing CTI programs; 2) usability testing; and 3) feasibility testing using a three-month pre-postdesign. Effective, theory-based, real-time, multiple behavior interventions targeting veterans' readiness to quit smoking, manage stress, and depression are warranted to provide potential health impact, opportunities for learning veteran-specific issues, and advance multiple health behavior change knowledge.

Purpose. Test the applicability of the transtheoretical model (TTM) to adult fruit/vegetable consumption.Design. Cross-sectional random-digit dial survey.Setting. Hawaii.Subjects. 700 (62.6% female; age [mean ± SD], 47 ± 17.1 years; education [mean ± SD], 14.6 ± 2.8 years; 35.0% white, 31.1% Asian, 22.1% native Hawaiian/Pacific Islander, 11.8% other).Measures. Stages, processes, self-efficacy, decisional balance, and self-reported fruit/vegetable consumption.Analysis. Confirmatory factor analysis tested the factor structure. Analyses of variance were used to explore stage differences in constructs.Results. Stage distribution was precontemplation (33%), contemplation (4%), preparation (37%), action (3%), and maintenance (23%). A 10-factor process model with two higher-order correlated factors (experiential and behavioral) provided the best data fit (X2= 1446.12; df = 366; p < .0001; comparative fit index [CFI] = .89; standardized root mean square residual [SRMR] = .05). The self-efficacy structure fit the data well (X2= 81.86; df = 9; p < .0001; CFI = .94; SRMR = .04), as did the decisional balance structure (X2= 37.42; df = 19;p = .007; CFI = .99; SRMR = .02). Processes, self-efficacy, decisional balance, and fruit/vegetable consumption behavior differed significantly by stage, with medium effect sizes for most variables.Conclusion. The variables revealed adequate fit to the theorized measurement models. TTM predictions regarding stage differences in self-efficacy, pros and cons, and fruit/vegetable consumption were confirmed; however, most experiential and behavioral processes increased in the early stages and then leveled off.

The purpose of this pilot study was to evaluate the Readiness to Manage Arthritis Questionnaire (RMAQ), a new multibehavior measure of readiness for change in arthritis management. Data were obtained from 46 patients with chronic inflammatory arthritis admitted for intensive treatment. Test‐retest reliability, correlations with clinical variables and theoretically related constructs, and responsiveness to change were assessed. Test‐retest reliability indicated reasonable stability, with intraclass correlation coefficients ranging from 0.30 to 0.75. A significant association was observed between psychological well‐being and readiness status. Clinical variables of disease duration, disease severity, pain, and function were not related to readiness status. Correlations between stages‐of‐change scores and self‐efficacy for managing arthritis symptoms were mostly nonsignificant, with the exception of modest agreement between readiness to engage in physical activity and exercise self‐efficacy (0.43). Significant changes were observed in mean RMAQ scores from initial assessment to 12 weeks post‐treatment for the behaviors of using joint protection, dealing with frustration, learning about arthritis, engaging in physical activity, and stress management. Findings from this pilot study suggest that the RMAQ has adequate psychometric properties in patients with chronic inflammatory arthritis and can be used to assess an individual's readiness to adopt important arthritis self‐management behaviors.

A central construct of the transtheoretical model is stages of change, which describes progression through five stages that reflect behavioral and cognitive indicators. This article examines the usefulness of the stages of exercise to address various intensities of physical activity. It also documents support for intention, the second construct contained within the stages, which is rarely included in validations.

Purpose. To examine whether the stages of change of exercise adoption appropriately address strenuous, moderate, and mild intensities of physical activity.Design and Setting. Secondary analysis of four data sets investigating transtheoretical model (TTM) constructs for exercise adoption.Subjects. Four samples of differing age groups (adolescents, n = 400; college students, n = 240; adults, n = 346; seniors, n = 504).Measures. Stage of change algorithm for exercise adoption and self-reported physical activity.Results. Multivariate analysis of variance (MANOVA) results showed that stages of change were distinguished by strenuous and moderate but not mild exercise in the adolescent, college student, and adult sample. In the senior sample, stage differences were found in the frequency of exercising (equivalent for moderate to strenuous exercise) and the frequency of walking (equivalent for mild exercise). Bivariate correlation coefficients as well as sensitivity, specificity, and related quality indices decreased respectively from strenuous to moderate to mild exercise and from exercising to walking.Conclusions. Results provide additional support for the construct validity of the stages of change for strenuous and moderate intensities of physical activity. Development of a new stage assessment instrument for mild intensities of physical activity is recommended. Limitations include use of a different validation measure of exercise behavior in the senior sample.

The Transtheoretical Model (TTM) has been shown to be a powerful basis for describing and explaining behavior change and designing effective interventions. Previous research has documented its usefulness in the context of smoking cessation as well as other areas but predominantly in US samples. The goal of this study was to provide further data on the applicability of the TTM and the relationship of some of its core constructs (stage of change, self-efficacy, decisional balance) in a German sample of smokers and ex-smokers. Participants (N = 401) were ever-smokers (age M = 47 years, range 35-65, 62% male) who participated in a health check-up for cardiovascular risk factors at their general practitioner's office. For current smokers, significant differences in the number of quit attempts across the stages of change supported the criterion validity of the staging algorithm; differences in number of cigarettes per day were non-significant. Self-efficacy for non-smoking behavior showed an almost linear increase across the stages of change, with significant differences between pre-action and action stages. The pros for smoking cessation also increased significantly across the stages, mainly due to a significantly lower perception of pros by participants in the Precontemplation stage. As expected, the cons for smoking cessation decreased significantly, being lower in Action and Maintenance than in earlier stages. Although the generalizability of the results for the stage distribution is limited by the selectivity of the sample, the results underline the applicability and replicability of these TTM core constructs for smoking cessation with newly developed instruments in a German sample.