THE ‘M.A.D.E (MOTHERS AND DAUGHTERS EXERCISING) 4
LIFE’ PILOT RANDOMISED CONTROL TRIAL: A THEORY-
BASED, PHYSICAL ACTIVITY INTERVENTION TARGETING
MOTHERS AND THEIR DAUGHTERS
ALYCE THERESE BARNES (NEE COOK) Bachelor of Teaching (Secondary)/Bachelor of Health and Physical Education (Hons) University of Newcastle, Australia
PhD Thesis Presented in fulfilment of the requirements for the award of
DOCTOR OF PHILOSOPHY
THE UNIVERSITY OF NEWCASTLE, AUSTRALIA AUGUST 2014
Statement of Originality
This thesis contains no material which has been accepted for the award of any other degree or diploma in any university or other tertiary institution, and to the best of my knowledge and belief, contains no material previously published or written by another person, except where due reference has been made in the text. I give consent to the final version of my thesis being made available worldwide when deposited in the University’s Digital Repository, subject to the provisions of the Copyright Act 1968.
Alyce Therese Barnes (nee Cook) ………………………….. Date: 29/08/2014
Supervisors
Primary Supervisor: Professor Philip J Morgan1,3 Supervisor: Professor Clare E Collins2,3 Supervisor: Professor Ronald C Plotnikoff 1,3
1School of Education, University of Newcastle, Faculty of Education and Arts 2School of Health Sciences, University of Newcastle, Faculty of Health and Medicine 3Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Australia
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Statement of Contribution of Others
Co-author statement
I, Professor Philip Morgan, attest that Research Higher Degree candidate Alyce
Barnes (nee Cook) contributed substantially in terms of study concept and design, data collection and analysis, and preparation of the following manuscripts.
Professor Philip J. Morgan ……………………………… Date: 29/08/2014
I, Professor Ronald Plotnikoff, attest that Research Higher Degree candidate
Alyce Barnes (nee Cook) contributed substantially in terms of study concept and design, data collection and analysis, and preparation of the following manuscripts.
Professor Ronald C. Plotnikoff ……………………………… Date: 29/08/2014
I, Professor Clare Collins, attest that Research Higher Degree candidate Alyce
Barnes (nee Cook) contributed substantially in terms of study concept and design, data collection and analysis, and preparation of the following manuscripts.
Professor Clare E. Collins ……………………………… Date: 29/08/2014
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Acknowledgement of Authorship
I hereby certify that the work embodied in this thesis contains a published paper/s/scholarly work of which I am a joint author. I have included as part of the thesis a written statement, endorsed by my supervisor, attesting to my contribution to the joint publication/s/scholarly work.
Alyce Therese Barnes (nee Cook) ………………………….. Date: 29/08/2014
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Disclosure of editing services
Professional editor, Ms Amy Lovat (Bachelor of Arts (Hons)), provided copyediting and proofreading services, according to the guidelines laid out in the university-endorsed national ‘Guidelines for editing research theses’.
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Acknowledgements
I would like to acknowledge the important people who have been involved in, and have significantly contributed to, the completion of this thesis.
First, I would like to thank my supervisors Professor Philip Morgan,
Professor Ronald Plotnikoff and Professor Clare Collins for guiding me through the incredible PhD journey. You have all shared your highly regarded expertise, extraordinary knowledge base and astute advice over the past four years and, in turn, this has thoroughly enriched my educational experience as a PhD student.
Each of you model significant qualities I hope to adopt in shaping myself as an early career researcher.
In particular, I would like to thank Philip for his guidance four years ago when embarking on a life-changing opportunity. Your positive attitude and continued belief in my ability to achieve my goals is something I am eternally grateful for. I have great admiration for your teaching, mentoring and parenting philosophies and these have an immense influence on my goals in life. Thank you for inspiring and encouraging me to be an empowered woman (GIRL
POWER!).
To Erin, you were the perfect fit for the MADE4Life co-facilitator. Your passion for teaching PDHPE, bright attitude and knowledge was truly remarkable.
I am so grateful for your friendship and support.
To the incredible staff in the PRC, in particular Sarah Costigan and Kristen
Saunders for your endless support and special friendships. To Ken Cliff, thank vi
you for guiding me through your area of expertise. To the volunteers Joanne
Graham, Kayla Lawson, Siobhan Handley, Jessie Dunn, Brianne McCabe, Katie
Sylvester, Angela Humphrey and Amanda Williams who assisted in the assessment sessions and MADE4Life sessions. Thank you for your enthusiasm, professionalism and reliability; all were key to the MADE4Life program’s success.
To the mothers and daughters who participated in the MADE4Life program. Without you, the research would not be possible. Your commitment and enthusiasm for the study will always be treasured.
To my PhD bestie, Myles. You make coming to University an absolute delight. I have learnt so much from you and count you as one of my very best friends. Your patience, optimism, and confident yet humble personality is respected by all. Thank you for making my PhD years so meaningful.
To my mum and dad. I believe I have the qualities and characteristics of two incredibly inspiring people, both who have contributed to achieving my goals.
I wouldn’t be here today without your endless support, encouragement and love.
I am so grateful for all of the opportunities you have given me in life. Thank you for always encouraging me to think big and aim high in all aspects of my life.
Finally, to my extremely special husband Matt, my number one fan. Your colossal encouragement and ability to motivate me and maintain focus of achieving my PhD goal has been tremendous. Thank you for your patience,
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learned advice and belief in me. I am extremely grateful for you being by my side in life. I love you to infinity, and beyond.
This thesis was supported by an Australian Postgraduate Award (APA) scholarship.
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Table of Contents
Statement of Originality ...... ii Statement of Contribution of Others ...... iii Acknowledgement of Authorship ...... iv Disclosure of editing services...... v Acknowledgements ...... vi Table of Contents ...... ix List of Tables...... xiii List of Figures ...... xv List of Appendices ...... xvi Abstract ...... xviii List of peer reviewed journal articles from this PhD ...... xxii List of published conference abstracts in refereed journals from this PhD .... xxiii List of published conference abstracts in peer reviewed conference proceedings from this PhD ...... xxv Additional papers during PhD Candidature ...... xxvi List of Abbreviations ...... xxviii Preface and Contribution Statement ...... xxx Chapter 1: Introduction ...... 1 1.1 Background ...... 2 1.1.1 Benefits of Physical Activity ...... 2 1.1.2 Consequences of Physical Inactivity ...... 2 1.1.3 Physical Activity Recommendations For Children ...... 3 1.1.4 Physical Activity Measurement ...... 4 1.1.5 Physical Activity Levels of Children ...... 4 1.2 Potential Influences on Physical Activity ...... 6 1.2.1 Social Cognitive Theory ...... 7 1.3 Parental Influences on Children’s Physical Activity ...... 10 1.3.1 Parental Influences on Girls’ Physical Activity ...... 11 1.3.2 Maternal Influences on Girls’ Physical Activity ...... 12 1.4 Physical Activity Interventions for Children...... 14 1.4.1 Parent Involvement in Interventions ...... 15
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1.5 Physical Activity Interventions for Girls ...... 17 1.6 Purpose of the study ...... 18 1.7 Research Aims and Hypotheses ...... 19 1.7.1 Thesis Aims ...... 19 1.7.2 Thesis Hypotheses ...... 20 1.8 Thesis Structure ...... 21 1.8.1 Overview ...... 21 1.9 Chapter Summary ...... 23 2 Chapter 2: The Effectiveness of Physical Activity, Fitness and/or Dietary Interventions Targeting Mothers and Their Daughters: A Systematic Review ...... 24 2.1 Introduction ...... 25 2.2 Methods ...... 30 2.2.1 Eligibility Criteria ...... 30 2.2.2 Search Strategy ...... 32 2.2.3 Study Selection ...... 33 2.2.4 Data collection process ...... 33 2.2.5 Synthesis of Results ...... 37 2.3 Results ...... 37 2.3.1 Study characteristics ...... 37 2.3.2 Risk of bias within studies ...... 49 2.3.3 Intervention Content and Measurement of Physical Activity ..... 53 2.3.4 Intervention Content and Measurement of Fitness ...... 53 2.3.5 Intervention Content and Measurement of Diet ...... 54 2.3.6 Studies With No Physical Activity or Fitness Measures ...... 55 2.3.7 Types of Interventions ...... 55 2.3.8 Summary of Evidence from RCTs ...... 56 2.3.9 Results of RCTs ...... 63 2.3.10 Summary of Evidence From Other Physical Activity, Fitness or Diet Interventions ...... 66 2.4 Discussion ...... 69 2.4.1 Evidence from RCTs ...... 75 2.4.2 Recommendations for future studies ...... 77
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2.4.3 Strengths and limitations ...... 78 2.5 Conclusion ...... 79 3 Chapter 3: Methods ...... 81 3.1Study Design...... 82 3.1.1 Study Design: Aim Two ...... 82 3.1.2 Study Design: Aim Three ...... 82 3.2 Participants ...... 83 3.2.1 Recruitment ...... 83 3.2.2 Eligibility Criteria ...... 85 3.2.3 Ethical Approval ...... 86 3.2.4 Assessment Sessions ...... 86 3.2.5 Randomisation ...... 86 3.3 Intervention ...... 87 3.3.1 The M.A.D.E 4 Life Program ...... 87 3.3.2 Wait-list control group ...... 96 3.4 Processes ...... 97 3.4.1 Data Collection ...... 97 3.5 Measurement of Study Outcomes ...... 99 3.5.1 Objectively measured Physical Activity ...... 99 3.5.2 Mothers’ questionnaire ...... 102 3.5.3 Physical Measures ...... 109 3.5.4 Demographics ...... 113 3.5.5 Data Entry ...... 114 3.6 Statistical Analysis ...... 114 3.6.1 Maternal Correlates Of Daughters’ Physical Activity ...... 115 3.6.2 Feasibility and Preliminary Efficacy ...... 116 3.7 Chapter Summary ...... 118 4 Chapter 4: Results ...... 119 4.1 Descriptives and Baseline Characteristics ...... 120 4.1.1 Baseline Characteristics of Daughters and Mothers ...... 120 4.2 Maternal correlates of daughters physical activity ...... 125 4.2.1 Hypothesis Two: Correlates ...... 125
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4.3 Feasibility and Preliminary Efficacy ...... 129 4.3.1 Hypothesis Three: Feasibility ...... 129 4.3.2 Hypothesis Four: Preliminary Efficacy – Primary Outcome .... 155 4.3.3 Hypothesis Five: Mothers and Daughters Secondary Outcomes ...... 156 4.4 Chapter Summary ...... 165 5 Chapter 5: Discussion ...... 169 5.1 Systematic Review ...... 169 5.1.1 Aim One: Systematic Review ...... 170 5.1.2 Hypothesis One: Systematic Review...... 170 5.2 Maternal correlates of daughters’ physical activity ...... 172 5.2.1 Aim Two: Maternal Correlates ...... 172 5.2.2 Hypothesis Two: Correlates ...... 172 5.3 Feasibility and Preliminary Efficacy ...... 179 5.3.1 Aim Three: Feasibility and Preliminary Efficacy ...... 179 5.3.2 Hypothesis Three: Feasibility ...... 179 5.3.3 Hypothesis Four: Preliminary Efficacy – Primary Outcome .... 183 5.3.4 Hypothesis Five: Preliminary Efficacy – Mothers and Daughters secondary outcomes ...... 188 5.4 Study Strengths ...... 190 5.5 Study Limitations ...... 192 6 Chapter 6: Summary, Recommendations and Conclusion ...... 195 6.1 Summary ...... 196 6.2 Recommendations ...... 199 6.3 Conclusion ...... 208 7References ...... 210 8Appendices ...... 234
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List of Tables
Table 2.1: Risk of Bias Checklist ...... 36 Table 2.2: Intervention characteristics of mother-daughter PA, fitness and/or diet interventions ...... 41 Table 2.3: Summary of risk of bias assessment of included studies ...... 51 Table 2.4: Results from mother-daughter PA, Fitness and/or Diet Interventions ...... 57 Table 3.1: Intervention content and alignment with SCT ...... 90 Table 4.1: Descriptive statistics of mothers’ and daughters’ demographic, anthropometric, physical activity variables, behaviour characteristics ...... 122 Table 4.2: Bivariate correlations between potential maternal correlates of PA behaviour ...... 126 Table 4.3: Linear regression analyses results of physical activity, % time spent in sedentary behaviour, screen time and BMI z-score in daughters (Daughters n=40; Mothers n=40) ...... 128 Table 4.4: Baseline characteristics of Daughters randomised to the MADE4Life intervention and control groups ...... 132 Table 4.5: Baseline characteristics of Mothers randomised to the MADE4Life intervention and control group ...... 133 Table 4.6: Mothers’ process evaluation from the M.A.D.E 4 Life program ...... 136 Table 4.7: Mothers’ Process Evaluation for the MADE4Life program Part One ...... 137 Table 4.8: Mothers’ Process Evaluation for the MADE4Life program Part Two ...... 138 Table 4.9: Mothers’ Process Evaluation for the MADE4Life program Part Three ...... 141 Table 4.10: Short qualitative answers representing mothers from the MADE4Life intervention group ...... 145 Table 4.11: Short qualitative answers representing mothers from the Wait- list control group ...... 147
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Table 4.12: Changes in outcome variables for daughters by treatment group from baseline to immediate post-intervention and 3- month post-intervention and differences in outcomes among the treatment groups at immediate post-intervention and 3-month post-intervention follow up (ITT analysis) (n= 48) ...... 157 Table 4.13: Changes in outcome variables for mothers by treatment group from baseline to immediate post-intervention and 3-month post- intervention and differences in outcomes among the treatment groups at immediate post-intervention and 3-month post- intervention follow up (ITT analysis) (n= 40) ...... 159 Table 4.14: Overall summary of the study results ...... 166
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List of Figures
Figure 1.1: Social Cognitive Theory: proposed pathways of behaviour change mediators (Bandura, 2004) ...... 9 Figure 2.1: Flow of study selection through the phases of the review ..... 35 Figure 3.1 Study design for the MADE4Life RCT ...... 83 Figure 3.2: MADE4Life resources ...... 88 Figure 3.3: Daughters’ MADE4Life resources ...... 93 Figure 4.1 Participant flow through the trial and analysed for the primary outcome (Daughters’ %MVPA)...... 130 Figure 4.2: Daughters’ mean % time in MVPA in both groups (n=48). MADE4Life group x time (P=0.99)...... 162 Figure 4.3: Daughters’ mean % time in VPA in both groups (n=48). MADE4Life group x time (P=0.67)...... 162 Figure 4.4: Mothers’ mean % time in MVPA in both groups (n=40). MADE4Life group x time(P=0.06)...... 163 Figure 4.5: Mothers’ mean % time in VPA in both groups (n=40). MADE4Life group x time (P=0.04)...... 164
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List of Appendices
Appendix 1: Journal Article ‘Maternal correlates of objectively measured physical activity in girls’, Maternal Child and Health. Under Review ...... 235 Appendix 2: Journal Article ‘Feasibility and Preliminary Efficacy of the M.A.D.E (Mothers and Daughters Exercising) 4 Life program: a pilot randomized controlled trial’, Journal of Physical Activity and Health. In Press ...... 269 Appendix 3: Secondary Publication ‘The ‘Healthy Dads, Healthy Kids’ community randomised controlled trial: A community-based healthy lifestyle program for fathers and their children’. Preventive medicine ...... 298 Appendix 4: Secondary Publication ‘Efficacy of a workplace-based weight loss program for overweight male shift workers: The Workplace POWER (Preventing Obesity Without Eating like a Rabbit) randomized controlled trial’. Preventive Medicine ...... 309 Appendix 5: Secondary Publication ‘The impact of a workplace-based weight loss program on work-related outcomes in overweight male shift workers’. Journal of Occupational and Environmental Medicine...... 319 Appendix 6: MADE4Life Recruitment Flyer ...... 326 Appendix 7: MADE4Life School Newsletter Entry ...... 328 Appendix 8: University of Newcastle Media Release ...... 330 Appendix 9: Media Coverage ...... 332 Appendix 10: Participant Telephone Screen ...... 335 Appendix 11: Sports Medicine Australia Pre Exercise Screening Questionnaire ...... 338 Appendix 12: University of Newcastle Human Research Ethics Committee (HREC) approval ...... 341 Appendix 13: Participant Information Statement and Consent Forms . 345 Appendix 14: Participant Randomisation Outcome Letter ...... 351
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Appendix 15: Daughters’ Booklet/Weekly Worksheets ...... 354 Appendix 16: Daughters’ Pink Slip Tasks ...... 367 Appendix 17: MADE4Life Sticker Chart ...... 371 Appendix 18: Daughters’ Card ...... 373 Appendix 19: MADE4Life Certificate...... 376 Appendix 20: Mothers’ Manual ...... 378 Appendix 21: Mothers’ SMART Goal Setting Sheets ...... 380 Appendix 22: Mothers’ Pedometer Chart ...... 382 Appendix 23: MADE4Life Pathways and Possibilities Resource ...... 385 Appendix 24: Table A1: Education content, physical activities, pink slip tasks and alignment with SCT ...... 406 Appendix 25: MADE4Life Assessment Measurement Sheets ...... 412 Appendix 26: MADE4Life Assessment Protocol ...... 415 Appendix 27: MADE4Life Mother’s Questionnaire Booklet ...... 429 Appendix 28: MADE4Life Activity Information Sheet & Monitor Log .... 445 Appendix 29: MADE4Life Teacher Information Sheet ...... 449 Appendix 30: MADE4Life Process Evaluation Questionnaire ...... 452 Appendix 31: Table A2: MADE4Life Extended Open Ended Questions461 Appendix 32: MADE4Life Amazing Race Resource ...... 467
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Abstract
There is a marked gender difference in physical activity levels, with girls less active than boys at every age. Given the established low physical activity levels of girls, there is a need to develop and evaluate innovative strategies to increase girls’ physical activity levels. It is widely recognised that parents play a key role in the promotion and provision of physical activity opportunities, and mothers might be particularly influential for their daughters. This thesis had three major aims relating to understanding and improving the physical activity levels of mothers and daughters.
Aim One
The first aim of this thesis was to systematically review the literature surrounding the effectiveness of mother-daughter lifestyle interventions to improve physical activity, fitness and/or diet. A systematic search across eight databases was conducted. All 12 studies (11 unique interventions) met the eligibility criteria. There were five Randomised Controlled Trials, one pseudo- randomised controlled trial, one non-randomised controlled trial and five pre-post trials. Half of the studies were conducted in the past five years, and the majority were conducted within the U.S. Overall, study quality was poor, with a high risk of bias apparent in the majority of studies. Significant intervention effects in fitness (n=6) were reported in both mothers and daughters. Although dietary behaviours were only assessed in three studies, intervention findings were generally positive. Statistically significant improvements in physical activity were reported for two out of five studies, although measures of physical activity were less commonly reported overall. Characteristics associated with increases in xviii
mother-daughter fitness were face-to-face, structured physical activity and fitness programs that ran for at least two to three times per week for a minimum of 60 minutes per session. Future high-quality trials in this area are needed to determine the impact of gender-specific interventions that target mothers and daughters in community settings.
Aim Two
The second aim of this thesis was to establish potential associations between maternal measures and girls’ physical activity measures. A cross- sectional design was used to assess 40 girls (mean±SD age 8.8±1.6 years; mean
BMI [body mass index] z-score=0.7±1.2) and their mothers (39.1±4.8 years; mean BMI=27.6±5.5). Maternal correlates of daughters’ accelerometer-assessed physical activity (moderate-to-vigorous physical activity % MVPA; counts per minute, CPM; sedentary behaviour; % SED), screen time and BMI z-score
(objectively measured) included demographic, anthropometric, maternal behaviours, activity-related parenting practices and physical activity cognitions.
Correlates were examined using regression models.
A number of maternal behaviours, social-cognitive and parenting correlates were found to be significantly associated with daughters’ physical activity. A significant relationship was found between daughters’ % MVPA and mothers’ beliefs about the benefits of girls physical activity and explained a weak proportion of variance (R2=0.14). Furthermore, the relationships between daughters’ CPM, mothers’ logistic support (P=0.03), mothers’ CPM (P=0.02) and outcome expectations (P=0.01) were all significant and this model explained a moderate proportion of the variance (R2=0.24). Daughters’ % SED and their
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mothers’ logistic support (P=0.02) was inversely related, and explained a small proportion of the variance (R2=0.11).
Experimental studies targeting mothers as the primary agents of change to increase physical activity and reduce sedentary behaviour among girls may be warranted. Specific maternal targets included their beliefs about the benefits of physical activity for girls, logistic support regarding girls physical activity involvement, and outcome expectations of physical activity.
Aim Three
The final aim of this thesis was to establish both the feasibility and preliminary efficacy of a physical activity program designed specifically to target mothers and their daughters (MADE4Life intervention). A randomised controlled trial (RCT) of 48 primary school-aged girls and their 40 mothers was conducted.
Families were randomised to (i) the ‘Mothers And Daughters Exercising for Life’
(MADE4Life) (n=21 mothers, n=25 daughters) group, or (ii) a wait-list control
(n=19 mothers, n=23 daughters) group. The eight-week program involved eight sessions, 25-minute separate mothers’ and daughters’ education sessions and
60 minutes of physical activity together. Assessments were at baseline, post- intervention (10 weeks) and three-month post-intervention (20 weeks). The primary outcome measure was daughters’ MVPA (seven days of accelerometry).
Secondary outcomes included mother and daughter accelerometer-assessed light/moderate/vigorous physical activity, BMI, waist circumference, body composition, blood pressure, resting heart rate, sedentary behaviours and mothers’ self-reported physical activity, parenting measures and cognitions.
Intention-to-treat analysis was conducted utilising linear mixed models.
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Recruitment and retention goals (>80%) were exceeded. Attendance rates, program acceptability and satisfaction were high (m=4.8/5). There was no significant group-by-time effect for daughters’ % MVPA (-0.08; 95%CI -1.49, 1.33, d=-0.03) or other secondary outcomes for girls (post-intervention range d=0.01–
-0.46). Significant intervention effects were found for mothers’ % VPA (P=0.04, d=0.25) and role modelling (P=0.02, d=0.66). MADE4Life was highly feasible and acceptable for mothers and daughters. Future fully-powered trials targeting physical activity in mothers and daughters are warranted.
The study targeted the topic of intergenerational female physical activity.
Findings from this thesis make an important contribution to the paucity of studies targeting mothers and daughters. However, the primary hypothesis was not supported. Further research is needed that involves larger samples of mothers and daughters in a family-based, gender-specific program in a community setting.
Numerous recommendations were made from the findings in this thesis to assist future program development aiming to improve PA levels of females, in particular mothers and daughters, with regards to intervention design, intervention content and methodological considerations. Of great importance and concern is the growing evidence base for females being less active compared to males and the negative health consequences of physical inactivity. Further exploration of the impact of gender-tailored PA interventions is needed, along with sustained research attention. MADE4Life is one step in developing this evidence base.
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List of peer reviewed journal articles from this PhD
Barnes, A.T., Plotnikoff, R.C., Collins, C.E., Young, M.D., & Morgan, P.J.
(submitted to Sports Medicine). The effectiveness of physical activity, fitness, and/or dietary interventions targeting mothers and their daughters: A systematic review (Chapter 2).
Barnes, A.T., Plotnikoff, R.C., Collins, C.E., & Morgan, P.J. (under revision).
Maternal correlates of objectively measured physical activity in girls. Maternal
Child and Health. (Appendix 1)
Barnes, A.T., Plotnikoff, R.C., Collins, C.E. & Morgan, P.J. (in press). Feasibility and preliminary efficacy of the M.A.D.E (Mothers and Daughters Exercising) 4
Life program: a pilot randomised controlled trial. Journal of Physical Activity and
Health http://dx.doi.org/10.1123/jpah.2014-0331 (Appendix 2)
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List of published conference abstracts in refereed journals
from this PhD
Barnes, A., Collins, C., Plotnikoff, R., & Morgan, P. (2014). Feasibility and preliminary efficacy of the ‘Mothers and Daughters Exercising (M.A.D.E.) 4 Life’ pilot randomised controlled trial. Be Active - Sports Medicine Australia, 15-18
October 2014. Canberra, Australia. Journal of Science and Medicine in Sport, 18
(Supplement 1), e123 ORAL
Cook, A., Morgan, P., Collins, C., & Plotnikoff, R. (2012). An examination of the association between a mother’s parenting practices relating to physical activity and their daughter’s physical activity levels. 4th International Congress on
Physical Activity and Public Health, Australian Conference of Science and
Medicine in Sport, 31 October-3 November 2012, Sydney, Australia. Journal of
Science and Medicine in Sport, 15(6) (Dec 2012 Suppl.), 126. POSTER
Collins, C., Cook, A., Morgan, P., Schumacher, T., & Plotnikoff, R. (2012).
Associations between mother and daughter dietary intakes. Australian and New
Zealand Obesity Society Annual Scientific Meeting, 18-20 October 2012,
Auckland, New Zealand. Obesity Research & Clinical Practice, 6(Supplement1):
80. POSTER
Cook, A.T., Morgan, P.J., Plotnikoff, R.C., Collins, C.E. (2010). Rational and intervention description of the M.A.D.E (Mothers and Daughters Eating
/Exercising) 4 Fun feasibility study: An obesity prevention program for mothers and their daughters. Australian and New Zealand Obesity Society Annual
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Scientific Meeting, 21-23 October 2010, Sydney, Australia. Obesity Research &
Clinical Practice, 4(Supplement 1): S16-S16. POSTER
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List of published conference abstracts in peer reviewed
conference proceedings from this PhD
Cook, A.T., Plotnikoff, R.C., Collins, C.E., & Morgan, P.J. (2014). Feasibility and preliminary efficacy of the mothers and daughters exercising (M.A.D.E) 4 Life pilot randomised controlled trial. Be Active - Sports Medicine Australia, 15-18 October
2014. Canberra, Australia. ORAL
Cook, A.T., Plotnikoff, R.C., Collins, C.E., & Morgan, P.J. (2014). Feasibility and preliminary efficacy of the mothers and daughters exercising (M.A.D.E) 4 Life pilot randomised controlled trial. 2014 Annual Meeting of the International Society for
Behavioural Nutrition and Physical Activity, 21-24 May 2014. San Diego,
California. POSTER
Cook, A., Morgan, P., Plotnikoff, R., & Collins, C. (2011). The M.A.D.E (Mothers and Daughters Exercising) 4 LIFE feasibility study: Description of a theory-based physical activity intervention targeting mothers and their daughters. 2011 Annual
Meeting of the International Society for Behavioural Nutrition and Physical
Activity, 15-18 June 2011. Melbourne, Australia. POSTER
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Additional papers during PhD Candidature
During my PhD candidature, I was involved in two major randomised controlled trials (RCT), as a part-time (one day a week) Research Assistant for The ‘Healthy Dads, Healthy Kids’ community RCT and as Project Manager (two days a week) for The ‘Workplace POWER’ (Preventing Obesity Without Eating like a Rabbit) RCT prior and during the first year of my PhD. The following journal articles are included in Appendix 3, Appendix 4 and Appendix 5 as additional papers. My contribution to each of these papers has been outlined below.
Morgan, P.J., Collins, C.E., Plotnikoff, R.C., Callister, R., Burrows, T., Fletcher,
R., Okely, A.D., Young, M.D., Miller, A., Lloyd, A., Cruickshank, J., Cook, A.T.,
Saunders, K.L. & Lubans, D.R. (2014). The ‘Healthy Dads, Healthy Kids’ community randomised controlled trial: A community-based healthy lifestyle program for fathers and their children. Preventive Medicine, (61), 90-99. doi:
10.1016/j.ypmed.2013.12.019
My contribution to the above paper involved: working as a research assistant; recruiting families, i.e. conducting school presentations, recruiting families; managing assessment sessions across the various community programs at baseline three-, six-, nine-, and 12-month follow-up; data management; and, contributing to the drafting and review of the manuscript.
Morgan, P.J., Collins, C.E., Plotnikoff, R.C., Cook, A.T., Berthon, B., Mitchell, S.
& Callister, R. (2011). Efficacy of a workplace-based weight loss program for overweight male shift workers: The Workplace POWER (Preventing Obesity xxvi
Without Eating like a Rabbit) randomised controlled trial. Preventive Medicine,
52(5), 317-325. doi: 10.1016/j.ypmed.2011.01.031
Morgan, P.J., Collins, C.E., Plotnikoff, R.C., Cook, A.T., Berthon, B., Mitchell, S.,
& Callister, R. (2012). The impact of a workplace-based weight loss program on work-related outcomes in overweight male shift workers. Journal of Occupational and Environmental Medicine, 54(2), 122-127. doi:
10.1097/JOM.0b013e31824329ab
My contribution to the above two papers involved: working as the project manager; assisting with ethics documentation; managing assessment sessions off-site; data entry and management; and drafting of manuscripts.
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List of Abbreviations
Abbreviation Term BMI Body Mass Index BMI z-score Body Mass Index Z-score BPM Beats per minute CI Confidence Intervals CONSORT Consolidated standards of reporting trials CPM Counts per minute d Cohen’s d effect size FFM Fat free mass GEMS Girls enrichment multi-site studies ITT Intention-to-treat Kg Kilogram m Mean M Metre MADE4Life Mothers and Daughters Exercising for Life METs Metabolic equivalent Min Minutes Ml Millimetre mmHg Millimetres of mercury N Number NSW New South Wales % LPA Percent time spent in light physical activity % MPA Percent time spent in moderate physical activity Percent time spent in moderate to vigorous physical % MVPA activity % SED Percent time spent in sedentary behaviour % VPA Percent time spent in vigorous physical activity P Probability (statistical significance level) PA Physical Activity PDHPE Personal Development, Health and Physical Education PE Physical education Priority Research Centre for Physical Activity and PRC Nutrition RCTs Randomised Controlled Trial RHR Resting Heart Rate SCT Social Cognitive Theory Sd standard deviation SEIFA Socio-economic indices for areas SES Socio-economic status SPANS Schools physical activity and nutrition survey SSR Small-screen recreation TV Television Umb Umbilicus WC Waist circumference WC z-score Waist circumference Z-score WHO World Health Organization
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List of Definitions
Term Definition The WHO defines physical activity as any bodily Physical activity movement produced by skeletal muscles that requires energy expenditure (World Health Organization, 2010). Physical inactivity has been identified as the fourth leading risk factor for global mortality causing an Physical inactivity estimated 3.2 million deaths globally (World Health Organization, 2010). VPA has been defined as expending more than 7 Metabolic Equivalents (METs), or a minimum of 7.5 kilo Vigorous physical cal/min, or working at a minimum of 70% of maximum activity heart rate, or 70% of VO2max (e.g., running, sprinting, jumping, skipping) (Janssen & Leblanc, 2010). MPA has been defined as expending 3–4 METs, or approximately 5–7.5 kilo cals per min, or exercising at Moderate physical 60–70% of maximum heart rate, or at 60% of VO2max activity (e.g., swimming, cycling, brisk walking) (Janssen & Leblanc, 2010). In this thesis the term child refers to a young person aged Child between 5-12 years In this thesis the term mother or ‘mum’ refers to a female Mother/Mum parent (Macquarie Dictionary, 2013). In this thesis the term daughter refers to a female child in Daughter relation to her mother (Macquarie Dictionary, 2013).
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Preface and Contribution Statement
Below is an outline of what I, Alyce Therese Barnes (nee Cook), have contributed to the design, development, implementation and evaluation of the program and overall study/thesis. In summary, I led all aspects of the study including program design, development, delivery, assessment and analysis. Further detail is now provided.
Program development and recruitment
I was responsible for the design and the development of the MADE4Life program. I was responsible for the development of program sessions and presentations (weekly educational content for mothers’ and daughters’
PowerPoint presentations, weekly physical activity session content) resource and material development (additional program resources, i.e. daughters’ weekly worksheets, pathways and possibilities to physical activity in the local community document, detailed weekly home tasks, SMART Goal and pedometer recording worksheets, and providing resources such as pedometers, skipping ropes etc). I was also responsible for recruiting the sample of mothers and daughters (i.e. organising school presentations, school gate discussions with parents, school newsletter entries and local media presentations).
Ethics and safety approval
I was responsible for the drafting and submission of the ethics to the
University of Newcastle Human Research Ethics Committee, completing safety procedures and registering the pilot RCT with the Australian New Zealand Clinical
Trial Registry (ANZCTR12611000622909). Tasks involved developing a
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research proposal, submitting all ethical forms, developing participant information statements and consent forms, developing questionnaires, and ensuring all research volunteers and staff had completed their child protection checks and working with children safety check.
Measurement of study outcomes, data collection and data entry
Through collaboration with my three supervisors, the methods and measures were determined. I was responsible for seeking 12 student volunteers, organising training and assessment sessions and coordinating and conducting all assessment sessions. The research assistants were responsible for recording participants’ measurements; however, I was responsible for entering and double checking all data.
Intervention delivery for both intervention and wait-list control groups
I was in charge of organising, delivering and leading the eight-week
MADE4Life program for the intervention group and the wait-list control. For the separate information sessions, a qualified PDHPE teacher led the 25-minute daughter sessions based on my lesson planning and task development.
Analysis of data
Through collaboration with my supervisors and a senior statistician, the statistical analysis plan was developed and I completed all analyses using SPSS,
MeterPlus and Microsoft Excel, interpreting results and presenting results in text, table and figure output.
xxxi
Acquiring of funding
I was responsible for applying for MADE4Life funding as lead chief investigator. I was successful in gaining a grant from the Priority Research Centre in Physical Activity and Nutrition.
‘The M.A.D.E. (Mothers and Daughters Exercising) 4 LIFE pilot randomised controlled trial: A theory-based physical activity intervention targeting mothers and their daughters’. $9,100.
Presentations related to PhD
I was responsible for presenting at both national and international conferences (both poster and oral presentations). In 2012, I placed first in the
School of Education, Faculty of Education and Arts, Three Minute Thesis (3MT) competition and competed as a finalist in the University of Newcastle 3MT final. I have presented on local radio stations on four occasions, one television news story and two print media articles in local newspapers.
xxxii Introduction
Chapter 1: Introduction
A background to the research for this PhD and a rationale for the MADE4Life study is provided in Chapter 1. Literature summarising the importance and benefits of physical activity and prevalence of female physical activity levels is examined. Furthermore, the importance of parental influences on children’s physical activity, specifically maternal influences on girls’ physical activity is examined. Additionally, the behaviour change theory (SCT) used in this study is described. To end, the research aims and hypotheses for this thesis are outlined.
1 Introduction
1.1 Background
1.1.1 Benefits of Physical Activity
In adults, participation in regular physical activity is associated with reduced risk of coronary heart disease (CHD), obesity, high blood pressure, stroke, diabetes, and some cancers (World Cancer Research Fund/American Institute for Cancer
Research, 2007; World Health Organization, 2011). Higher levels of physical activity is also associated with reduced risk of a number of psychological health issues including depression and low self-esteem, stress and anxiety (Parfitt &
Eston, 2005). In addition, it is well established that regular involvement in physical activity also offers significant health benefits for children including physical (obesity prevention, improved cardiovascular fitness, musculoskeletal, and blood pressure) and psycho-social (improved mental health and self-esteem) outcomes (Janssen & Leblanc, 2010; Strong et al., 2005).
1.1.2 Consequences of Physical Inactivity
On a global scale, physical inactivity is identified as a public health concern.
Physical inactivity is the fourth leading cause of mortality (Kohl et al., 2012), with approximately 3.3 million deaths in people around the globe (World Health
Organization, 2009). Physical inactivity is associated with increased risk of CHD, high blood pressure, stroke, type II diabetes and some cancers (Kohl et al., 2012;
World Health Organization, 2009).
2 Introduction
1.1.3 Physical Activity Recommendations For Children
Given the established health benefits of physical activity for children, evidence- based guidelines have been developed which outline the recommended amount of daily physical activity for children and young people. The National Physical
Activity Guidelines for Australian children aged 5 to 12 years old state that young people should:
(i) participate in at least 60 minutes of moderate to vigorous physical
activity per day;
(ii) include some vigorous activities, i.e. aerobic exercise;
(iii) on at least three days per week, engage in activities that strengthen
muscle and bone; and
(iv) engage in more activity to achieve health benefits, i.e. up to several
hours per day (The Department of Health, 2014).
The U.S Department of Health and Human Services recommends a combination of aerobic activity (60 minutes of moderate to vigorous activity per day, with at least three days of vigorous activity), and as a part of this 60 minutes, include muscle-strengthening on at least three days per week and bone strengthening on at least three days per week (United States Department of Health and Human
Services, 2008).
A recent review focused on evidence-based, objectively-monitored, step- defined physical activity guidelines in children and adolescents (Tudor-Locke et al., 2011). Tudor-Locke and colleagues (Tudor-Locke et al., 2011) recommended gender-based step accumulations per day for boys (13,000 to 15,000 steps per day) and girls (11,000 to 12,000 steps per day).
3 Introduction
1.1.4 Physical Activity Measurement
The way in which physical activity is accurately assessed in children is of great importance. Physical activity measurement is commonly categorised into two groups: objective (e.g. accelerometers, pedometers, heart rate or observation); and subjective (e.g. diaries, logs, surveys or questionnaires) (Dollman et al.,
2009). Significant differences in prevalence levels have been found depending on the methods used to assess physical activity (Dollman et al., 2009). In particular, there are inconsistencies between self-reported physical activity (i.e. subjective questionnaire) and objectively-measured physical activity (i.e. collected via an accelerometer or pedometer) (Dollman et al., 2009), and self- report tends to overestimate physical activity (Troiano et al., 2008). Self-reported physical activity has the potential for participants to report desirable answers causing measurement bias and misinterpretation (Adams et al., 2005). Dollman and colleagues (2009) suggest a more comprehensive physical activity summary can be captured by using both an objective measure such as accelerometers
(whereby specific intensity is captured) and a self-report measure (providing type, duration and context).
1.1.5 Physical Activity Levels of Children
Internationally, the percentage of children meeting physical activity recommendations is low, regardless of the measurement protocol. Depending on the measure used (i.e., self-report or objective), the range of physical activity varies from 7%-50%. For example, only 7% of children aged 6-19 years in
Canada (objectively measured) (Active Healthy Kids Canada, 2012), 15.3% aged
4-17 years from Germany (self-reported) (Woll, Kurth, Opper, Worth, & Bos,
4 Introduction
2011) and 29% aged 11-18 years from the US (self-reported) (Centers for
Disease Control and Prevention, 2012) meet already defined physical activity guidelines.
Hardy and colleagues (2010) found that just under 50% of NSW primary school-aged children in Year K, 2, 4 met the physical activity guidelines (Hardy,
King, Espinel, Cosgrove, & Bauman, 2010). However, it is important to note that this was self-reported via questionnaire. Using objective measures, the Australian
Health Survey (2013) reported children and youth achieved an average daily step count of 9,140 steps. Data revealed 8% of females achieved the step count recommendations compared to 25% of males (Australian Bureau of Statistics,
2013a). The latest physical activity report card for Australian children (Schranz et al., 2014) revealed that overall physical activity levels (objectively measured) are low, with only 20% of children aged 5-17 years meeting the physical activity guidelines. This is consistent with the 15 countries that participated in the activity report card for children and youth, where overall poor levels of physical activity in children and youth has been reported (Tremblay et al., 2014).
Of concern is the consistent and compelling evidence for a marked sex difference in physical activity levels, with females having lower activity levels than males at all ages (Hallal et al., 2012; The Department of Health & Ageing, 2007).
Globally, 34% of adult women do not meet the physical activity recommendations of 30 minutes of moderate-to-vigorous physical activity (MVPA) at least five days per week, compared to 28% for men (Hallal et al., 2012). Moreover, recent self- report data from Australia reported a higher proportion of women (37%) to be insufficiently active in comparison to men (34%) (Australian Bureau of Statistics,
2013c). Similarly, while girls are less active than boys at all ages (Hallal et al.,
5 Introduction
2012), this gender activity gap increases with age (Davison, Cutting, & Birch,
2003; Hallal et al., 2012). Internationally, 95% of girls aged 13-15 do not meet the physical activity recommendation of 60 minutes of MVPA per day, compared to
53% of boys (Hallal et al., 2012).
A national survey in the US that used accelerometers to measure physical activity levels reported girls were consistently less active than boys in all age groups (Troiano et al., 2008). For example, for boys and girls aged 6-11 years,
48.9% and 34.7% were meeting the physical activity guidelines respectively.
Alarmingly, the percentage of children meeting the physical activity guidelines reduced dramatically for ages 12-15 years, particularly for females, with 11.9% of males and 3.4% of females meeting the physical activity recommendations
(Troiano et al., 2008). The most recent national physical activity survey from
Australia measured physical activity via interview (self-reported) in children and reported the average time spent in MVPA per day for girls was 67 minutes compared to boys reporting 78 minutes. Notably, when girls reached the age of
12 years, they participated in 21 minutes less of MVPA per week than boys
(Australian Bureau of Statistics, 2013a).
1.2 Potential Influences on Physical Activity
Influences of physical activity are multi-factorial and complex (Plotnikoff,
Lightfoot, Spinola, Predy, & Barrett, 2008). An ecological model provides a broader framework for understanding the factors and behaviours that influence physical activity behaviour (Plotnikoff et al., 2008; Sallis & Owen, 1997). The main
6 Introduction
components of the ecological model include the individual, social, organisational, community, policy and built environments.
While acknowledging the importance of, and context for, physical activity promotion needing to consider multiple levels and spheres of influence, this thesis has focused on the “individual and social influences” of the ecological model.
Specifically, this thesis focused on the individual (females, attitudes and beliefs) and social levels (family, i.e. mothers and daughters) of the ecological framework.
Embedded within the individual level, this thesis uses social-cognitive theory
(SCT) as a framework for understanding physical activity behaviours. For the social level, the focus is on mothers’ parenting-related practices and social support for their daughters’ physical activity and is presented in the following section (see section 1.21).
1.2.1 Social Cognitive Theory
Social-cognitive theories (such as Bandura's Social Cognitive Theory) have been effective in explaining physical activity behaviours amongst youth (Plotnikoff,
Costigan, Karunamuni, & Lubans, 2013) as individual and social determinants influence physical activity behaviour in this population (Plotnikoff et al., 2013).
Bandura's Social Cognitive Theory (SCT) (Bandura, 1986) provides a useful theory to support why individuals adopt and continue behaviours, and has been widely used for intervention development addressing various health behaviours, including physical activity (Baranowski, Perry, & Parcel, 1997;
Young, Plotnikoff, Collins, Callister, & Morgan, in press). In SCT, the principle of
“reciprocal determinism” suggests that behaviour change is influenced by the interaction of environmental, cognitive and behavioural factors. Key constructs of
7 Introduction
SCT include self-efficacy (a central determinant of behaviour in SCT which describes an individual's confidence/belief in their ability to carry out the behaviour), goals (a direct influence on behaviour; individuals who place importance on goals increase their motivation to carry out the behaviour), outcome expectations (include the expected favourable and detrimental outcomes of a behaviour, and are hypothesised to directly and indirectly effect behaviour via goals), and socio-structural factors (refers to perceived, social or structured factors that foster or prohibit behaviour change) (Bandura, 2004).
Figure 1.1 illustrates the pathways of potential behaviour change mediators and how these constructs either directly or indirectly affect behaviour (Bandura,
2004).
As interventions grounded in behaviour change theory have been found to be more effective for behaviour change compared to non-theoretical interventions
(Abraham & Michie, 2008; Anderson-Bill, Winett, & Wojcik, 2011), the current study has operationalised each of the SCT constructs in the development of the intervention. A detailed description of the SCT variables and their operationalisation within the intervention program are detailed in Section 3, Table
3.1.
8 Introduction
Outcome expectations (Physical, social and
self-evaluative)
Self-efficacy Goals Behaviour
Socio-structural factors (Social support)
Figure 1.1: Social Cognitive Theory: proposed pathways of behaviour change mediators (Bandura, 2004)
9 Introduction
1.3 Parental Influences on Children’s Physical Activity
The socio-ecological model framework highlights key social factors affecting physical activity. One such key setting is the family environment and the influence of parents. Parents are a major influence on their children’s physical activity behaviours (Biddle, Atkin, Cavill, & Foster, 2011). Parents provide support and encouragement for their children’s physical activity through both provision of opportunities and role modelling positive attitudes to physical activity and physical activity behaviours (Sleddens et al., 2012). In a review of systematic reviews focusing on physical activity correlates in youth (Biddle et al., 2011), Biddle and colleagues reported that parental support was an important and well-established correlate of physical activity in youth. Similarly, in a recent review of physical activity parenting and child activity (Sleddens et al., 2012), specific parental correlates (e.g. parent support and modelling) were consistently associated with physical activity in children. However, confounding the interpretation of these reviews, most studies measured physical activity via parent proxy or self-report
(Biddle et al., 2011; Sleddens et al., 2012), thereby introducing bias in assessment and interpretation (Sallis & Saelens, 2000), as opposed to using objective measures.
Positive associations between physical activity and parental involvement and active role modelling have also been reported (Edwardson & Gorely, 2010c).
A recent review of parental influences on types and intensities of physical activity in youth reported that maternal role modelling was positively correlated with child
MVPA and parental involvement was positively related to children’s overall physical activity (Edwardson & Gorely, 2010c).
10 Introduction
1.3.1 Parental Influences on Girls’ Physical Activity
Some evidence suggests parental activity and encouragement is more strongly associated with girls’ physical activity than boys (Cleland et al., 2011; Davison et al., 2003; Trost, Kerr, Ward, & Pate, 2001). It may be, for a variety of genetic and environmental reasons, that boys are likely to be active without prompting and encouragement. This could be owing to the different ways in which mothers and fathers influence child physical activity (Davison et al., 2003), and specifically using parenting practices that impact differently on girls and boys (Fogelholm,
Nuutinen, Pasanen, Myohanen, & Saatela, 1999). For example, mothers, as compared to fathers, have been found to provide higher levels of logistic support for girls, i.e. taking girls to sport, enrolling girls in sport and watching them participate in sport (Davison et al., 2003; Edwardson & Gorely, 2010a).
Furthermore, mothers’ participation in physical activity has been found to be important for girls’ physical activity (Cleland et al., 2011). Davison and colleagues
(2003) described fathers reporting higher levels of modelling for their daughters’ physical activity as compared to mothers (Davison, 2004; Davison et al., 2003).
Of the few studies that have focused on parental physical activity influences on daughters’ activity, Davison and colleagues studied activity-related parenting practices in girls only (Davison et al., 2003), and later in a sample of boys and girls (Davison, 2004); both studies used self-report physical activity measures.
Few studies have employed objective measures of physical activity assessment for parental activity-related practices, and few have exclusively examined girls
(Adkins, Sherwood, Story, & Davis, 2004; Davison & Jago, 2009; Davison, Li,
Baskin, Cox, & Affuso, 2011). However, in these studies no objective
11 Introduction
assessments of parental/maternal physical activity were provided. A greater understanding of maternal correlates of physical activity in girls with objective physical activity assessments is needed to guide interventions in this population.
1.3.2 Maternal Influences on Girls’ Physical Activity
In the context of understanding the familial influence on girls’ physical activity levels, a review of parental correlates of physical activity in youth found that mothers may have a more prominent influence on daughters’ physical activity levels rather than sons. Gustafson and Rhodes (Gustafson & Rhodes, 2006) suggest this may be as a result of the unique maternal relationships or bonds the female sex share across generations. For example, authors have reported the mother-daughter relationship to be exceptionally significant (Rastogi & Wampler,
1999). Research shows that, in comparison to other intergenerational relationships, the mother-daughter bond, emotional connection and interdependence are most important for the psychological and social wellbeing of girls (Fischer, 1991; Onayli & Erdur-Baker, 2013). Intergenerational females are more likely to have similar beliefs, habits and motivations and challenges in relation to lifestyle behaviours (Marcus et al., 2006; Wilcox & Storandt, 1996).
Indeed, mothers are the first potentially powerful female role model for their daughters, and their daughters’ beliefs and behaviours can stem directly from those of their mothers (Northrup, 2005). Of importance, evidence suggests that mothers are key in promoting healthy behaviours or, in contrast, modelling negative health behaviours to their children, in particular their daughters
(Aronowitz, Rennells, & Todd, 2005; Biederman, Nichols, & Durham, 2010). For example, a positive mother-daughter relationship with regards to health and
12 Introduction
behaviour can lead to a greater level of self-esteem and increased cognitive ability for girls (Gross & McCallum, 2000), and protect against harmful weight control, low self-esteem and depression (Ackard, Neumark-Sztainer, Story, &
Perry, 2006). This is supported by other studies that have found physically active mothers are likely to have physically active daughters (Aarnio, Winter, Kujala, &
Kaprio, 1997), and Yang and colleagues also reported mothers’ physical activity was correlated with daughters’ physical activity levels (Yang, Telama, & Laakso,
1996).
Therefore, promotion of regular physical activity for women and, in particular, mothers, is of great importance. Research suggests as women progress through life changing events, such as having children, physical activity levels may reduce (Brown, Heesch, & Miller, 2009; Brown & Trost, 2003).
Therefore, evidence-based strategies are needed to ensure women maintain their physical activity levels during life changes like that of having children (Brown et al., 2009; Brown & Trost, 2003), as their physical activity levels have been shown to influence their offspring’s physical activity levels.
To improve our understanding of the factors associated with girls’ physical activity, exploring maternal correlates of girls’ physical activity and sedentary behaviour using objective measures for both generations is important given the paucity of research in this area. This is especially important given the low levels of physical activity in girls and the limited research on the associations between mother-daughter physical activity. Such findings can help inform the design of future interventions.
13 Introduction
1.4 Physical Activity Interventions for Children
As children commonly do not meet physical activity recommendations, interventions targeting physical activity in children have been extensively developed and tested. Numerous reviews conducted have synthesised the evidence for physical activity interventions for children and adolescents, some of which target interventions from the school setting (Dobbins, Husson, DeCorby, &
LaRocca, 2013; Metcalf, Henley, & Wilkin, 2012) and the family and community
(O’Connor, Jago, & Baranowski, 2009; van Sluijs, Kriemler, & McMinn, 2011).
Findings are varied regarding intervention effectiveness reported across these reviews, and many studies are commonly characterised by poor methodological quality.
Two recent reviews of interventions targeting physical activity in children within the school setting (Dobbins et al., 2013; Metcalf et al., 2012) found many studies were methodologically poor and overall programs were largely unsuccessful. One review concluded that interventions led only to an increase in
MVPA of four minutes per day (Metcalf et al., 2012) whilst Dobbins and colleagues (2013) found some positive effects only for the proportion of children engaged in MVPA during school hours. However, school-based interventions generally had little effect on physical activity levels. Both reviews indicated that further research was warranted on the impact of school-based interventions
(Dobbins et al., 2013; Metcalf et al., 2012). Of note, research has distinguished considerable barriers and challenges of school-based interventions. For example, challenges and barriers include primary school teachers’ lack of confidence to teach PE, short supply of equipment, lack of training and
14 Introduction
development and time constraints owing to an overcrowded curriculum (Morgan
& Hansen, 2008a, 2008c). Given the inconclusive evidence for school-based physical activity interventions, it may be effective to target other settings such as family- or community-based settings and, in particular, those that target parents as key agents of change for physical activity.
1.4.1 Parent Involvement in Interventions
As mentioned in Section 1.3, parents play a major role in influencing their children’s physical activity attitudes and behaviours (Jones et al., 2007; Norton,
Froelicher, Waters, & Carrieri-Kohlman, 2003). This influence can be through a number of mediums including role modelling, logistic support, co-physical activity and parenting practices which shape children’s behaviours beyond childhood and adolescence. As a result, it has been widely recommended that parents are involved in interventions to improve physical activity behaviours of their children
(Norton et al., 2003; O’Connor et al., 2009). A systematic review published by
O’Connor et al. (2009) identified studies that had engaged parents to increase their children’s physical activity. Overall study quality varied immensely with only
35% of the RCTs meeting ≥70% of the CONSORT (Consolidated Standards of
Reporting Trials) checklist (O’Connor et al., 2009). In general, the most common procedure for involving parents to increase child physical activity were face-to- face programs and educational materials sent home, family exercise programs, telephone messages, organised activities (O’Connor et al., 2009). The review did not identify a specific method in which family involvement could best optimise child physical activity behaviour change; however, a potential intervention strategy for increasing child physical activity may be to offer parent training, family
15 Introduction
counselling or telephone contact. O’Connor and colleagues (2009) also reported a large number of pilot studies with limitations in their study design, i.e. control groups not randomly assigned. O’Connor et al (2009) provided the following recommendations for future parent-based interventions to increase children’s physical activity:
• interventions should utilise the Consolidated Standards of Reporting
Trials ‘CONSORT’ reporting standards for reporting and study
design;
• interventions should be randomised, utilise a true control group and
be fully powered;
• interventions should be designed with high methodological quality
and clearly report intervention fidelity, dose and exposure; and,
• interventions should be based on theory and utilise evidence-based
strategies.
More recently, Van Sluijs and colleagues (2011) conducted a review of systematic reviews which focused on the effect of family and community interventions on young people’s physical activity levels. The physical activity effects of family-based and community-based interventions were unclear as findings were generally mixed. However, the quality of methodological study had improved over time. Van Sluijs and colleagues (2011) reported family-based interventions involving self-monitoring (e.g. pedometers) within the home were highlighted as being key for physical activity promotion (van Sluijs et al., 2011).
The review strongly recommended that future interventions to be conducted in family- and community-based settings needed to be of high methodological
16 Introduction
quality and to utilise self-monitoring via pedometers targeting child physical activity. Authors were unable to determine the mechanisms of family-based interventions associated with success, therefore calling for future research in the area of family- and community-based settings.
1.5 Physical Activity Interventions for Girls
Given the inconclusive evidence for generic approaches to physical activity promotion and the gender disparity in physical activity levels, targeted interventions for girls might have particular potential (Camacho-Minano, LaVoi, &
Barr-Anderson, 2011; Wiese-Bjornstal & LaVoi, 2007). A paucity of research has explored whether targeting girls alone is more effective than mixed gender interventions (Biddle, Braithwaite, & Pearson, 2014). Most recently, Biddle and colleagues (2014) conducted a review and meta-analysis on the effectiveness of interventions to increase physical activity among pre-adolescent girls (Biddle et al., 2014). It is noteworthy that the review considered studies with generic interventions which included both boys and girls; therefore, a sub-group analysis was performed for these interventions. Biddle and colleagues (2014) reported interventions to increase physical activity in young girls were effective; however, effect sizes were small (average g=0.314). In summary, data from this review suggest multicomponent, educational, high quality, atheoretical, short-term interventions that focus on both physical activity and diet that are exclusively for girls have greater impact on physical activity (Biddle et al., 2014). In contrast, a recent review of interventions to promote physical activity among girls found mixed results (Camacho-Minano et al., 2011), where only seven of 21
17 Introduction
interventions successfully increased physical activity. This review reported only three interventions were community-based, none had a follow-up assessment beyond the post-intervention assessment, and only one used an objective measure of usual physical activity (Rosenkranz, Behrens, & Dzewaltowski,
2010). The review called for further high-quality, community-based interventions targeting girls and that use objective measures of physical activity (Camacho-
Minano et al., 2011).
One novel and potentially appealing approach to increase physical activity levels in girls is the targeting of both mothers and daughters simultaneously. This is particularly important as women are less active than men (Hallal et al., 2012;
World Health Organization, 2011) and maternal involvement in physical activity has been positively associated with child physical activity levels, and has been found to be stronger for daughters (Cleland et al., 2011; Jacobi et al., 2011;
Kargarfard et al., 2012). However, there has not been a systematic review of the impact of mother-daughter interventions and therefore collective knowledge is limited.
1.6 Purpose of the study
This thesis focuses on improving our understanding of the impact of a mother- daughter physical activity intervention. A key focus is the design and evaluation of a pilot Randomised Controlled Trial (RCT), the Mothers and Daughters
Exercising (M.A.D.E) for Life program (referred to from here on as MADE4Life).
The family-based intervention conducted in a community setting is a novel
18 Introduction
approach to targeting health-enhancing physical activity (MVPA) in young girls and their mothers. A unique aspect of the program is the targeting of intergenerational females as they are most likely to have similar beliefs, habits and motivations in relation to lifestyle behaviours (Marcus et al., 2006). As this study’s primary outcome was objectively measured physical activity, and the intervention focus was predominantly physical activity based over an eight-week period, it was decided that dietary content and measures would not be a focus.
1.7 Research Aims and Hypotheses
1.7.1 Thesis Aims
This thesis had three major aims.
1.7.1.1 Aim One
To systematically review the available literature to determine the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters.
1.7.1.2 Aim Two
To examine specific maternal correlates of objectively measured physical activity in girls, including demographic, anthropometric, behavioural, activity-related parenting practices and physical activity cognitions.
1.7.1.3 Aim Three
19 Introduction
To evaluate the
(i) feasibility (recruitment, retention, attendance, acceptability and satisfaction); and,
(ii) preliminary efficacy of a mother-daughter physical activity program targeting improvements in physical activity levels.
1.7.2 Thesis Hypotheses
1.7.2.1 Hypothesis One: Systematic Review
The effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters will be limited due to heterogeneity of current studies and further research will be required targeting girls and women.
1.7.2.2 Hypothesis Two: Correlates
There will be significant associations between some maternal physical activity correlates and daughters’ objectively measured physical activity.
1.7.2.3 Hypothesis Three: Feasibility
The MADE4Life program will be feasible, demonstrated through recruitment, retention and attendance targets being achieved and through participants finding the program acceptable with high satisfaction demonstrated through comprehensive process evaluation from multiple perspectives including mothers and facilitators.
1.7.2.4 Hypothesis Four: Preliminary Efficacy – Primary Outcome
20 Introduction
The MADE4Life program will be efficacious, demonstrated through a moderate effect size for the primary outcome % time in daughters’ MVPA in the intervention group in comparison to the wait-list control group daughters.
1.7.2.5 Hypothesis Five: Preliminary Efficacy – Mothers and Daughters
secondary outcomes
Compared to the wait-list control group, the datum from the mothers and daughters in the MADE4Life intervention will show moderate effect sizes in some secondary outcomes at immediate post-intervention follow-up assessment.
1.8 Thesis Structure
1.8.1 Overview
This thesis is presented in chapter format as listed below.
1.8.1.1 Chapter 1: Introduction
A background and introduction to literature associated with the prevalence of physical activity, theoretical approaches to behaviour change interventions, familial influences on children’s physical activity, and physical activity interventions for children is provided in this chapter. Furthermore, details of the aims and hypotheses of the thesis are provided.
1.8.1.2 Chapter 2: Systematic Review
21 Introduction
This chapter is a stand-alone systematic review on the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and daughters.
1.8.1.3 Chapter 3: Methods
The methods for the MADE4Life program are detailed including the study design, intervention program, data collection procedures, primary and secondary outcome measurements. The statistical analyses plan is detailed for the following sub-categories: Maternal correlates of objectively measured physical activity in girls, and feasibility and preliminary efficacy of the MADE4Life program.
1.8.1.4 Chapter 4: Results
The Results chapter is presented, focusing on the baseline characteristics of the mothers and daughters, maternal correlates of objectively measured physical activity in girls, and the feasibility and preliminary efficacy of the MADE4Life program.
1.8.1.5 Chapter 5: Discussion
The Discussion chapter is presented with an overview addressing the three study aims and five hypotheses; findings are discussed in the context of the current literature. Following this, the thesis strengths and limitations are presented.
1.8.1.6 Chapter 6: Summary, Recommendations and Conclusion
22 Introduction
A summary from the three major aims and study conclusions are presented in this chapter. Furthermore, recommendations based on the findings are given for future research.
1.9 Chapter Summary
The importance and benefits of physical activity and, in particular, the evidence signifying the marked difference for girls and women participating in lower levels of physical activity in comparison to boys and men is provided in this chapter. An outline of parental influences on their children’s physical activity, with specific emphasis on maternal influence was described. Literature drawn upon in Chapter
1 provided a background to the research and a rationale for the study.
Furthermore, theoretical-based physical activity research was described, with a particular emphasis on SCT.
Chapter 1 concluded with an outline of the research aims and hypotheses for this thesis. The thesis structure was summarised, giving an overview of each chapter. Chapter 2 is a stand-alone systematic review which specifically focuses on physical activity, fitness and/or dietary interventions that have exclusively targeted mothers and daughters.
23 Systematic Review
2 Chapter 2: The Effectiveness of Physical Activity, Fitness
and/or Dietary Interventions Targeting Mothers and Their
Daughters: A Systematic Review
Barnes, A.T., Plotnikoff, R.C., Collins, C.E., Young, M.D., & Morgan, P.J.
(submitted to Sports Medicine). The effectiveness of physical activity, fitness, and/or dietary interventions targeting mothers and their daughters: A systematic review
This systematic review has been submitted to Sports Medicine. Aim One of this thesis is addressed in Chapter 2. The methods, results and discussion associated with Aim One are presented in Chapter 2.
24 Systematic Review
2.1 Introduction
Obesity is associated with a vast range of adverse health consequences and is regarded as a serious international health issue (Barr et al., 2005; Ng et al.,
2014). Of concern is data demonstrates obesity prevalence is rising in children and adolescents (Berenson, 2001; Lobstein, Baur, & Uauy, 2004; Ng et al., 2014).
Factors contributing to overweight and obesity include dietary intake, physical activity and sedentary behaviours. Internationally, the increase in child and adult intakes of energy-dense, nutrient-poor foods combined with low fruit and vegetable consumption and high prevalence of physical inactivity is thought to contribute to obesity (Waters et al., 2011).
Physical inactivity in children and adults is a global public health concern and associated with a number of chronic diseases (World Health Organization,
2011). Of particular note is the marked sex difference in physical activity, with girls consistently shown to be less active than boys across all age groups and in adulthood (World Health Organisation, 2010) and the prevalence of physical inactivity in youth is high. Internationally, there is a high percentage of both boys and girls not meeting the physical activity guidelines (World Health Organization,
2011). However, of great concern is that 95% of girls aged 13-15 do not meet the physical activity recommendation of 60 minutes of MVPA per day, compared to
53% of boys (Hallal et al., 2012). In addition to the low levels of physical activity in children, the prevalence of children and youth meeting dietary guidelines for fruit and vegetable intake is poor (Australian Bureau of Statistics, 2014). Results from the 2007 Australian National Children’s Nutrition and Physical Activity
Survey revealed 3% of children aged 4-8 years and 2% of children aged 5-13 years consumed ≥2-4 serves of vegetables per day (not including potatoes) whilst 25 Systematic Review
52% of children aged 4-8 and 59% aged 5-13 years consumed ≥1-3 serves of fruit (excluding fruit juice) per day (CSIRO, 2007).
Many childhood obesity prevention interventions have been conducted in the school (Brown & Summerbell, 2009; De Bourdeaudhuij et al., 2011); however, studies have had varied or limited success. Noted limitations confounding interpretation of study findings include poor study quality and heterogeneity in terms of intervention, participants and outcomes. (Bleich, Segal, Wu, Wilson, &
Wang, 2013).
Given these study limitations in the school and individual settings, and the pressing issue of low levels of physical activity in females and sub-optimal dietary patterns, a potential for increasing physical activity and improving diet is targeting children and parents simultaneously in the community setting. Childhood obesity interventions have had varied success in the individual and family-based setting.
A recent review reported the need for future childhood obesity prevention interventions to be of rigorous design, engage larger sample sizes, follow-up beyond post intervention and increase participant compliance (Ho et al., 2013).
Parents have an important influence on their children’s physical activity and dietary behaviours and are prominent in shaping these behaviours (Biddle et al., 2011; Patrick & Nicklas, 2005). Parents provide support and encouragement for their children’s physical activity and dietary patterns through role modelling positive activity and dietary attitudes and behaviours, provision of opportunities to practise these behaviours and creating a supportive physical and social home environment (Golley, Hendrie, Slater, & Corsini, 2011; Sleddens et al., 2012).
Many interventions have been designed and evaluated to increase physical activity (van Sluijs et al., 2011) and diet quality (Hingle, O'Connor, Dave,
26 Systematic Review
& Baranowski, 2010) in children through settings including schools, family and communities, but with limited success. A recent Cochrane review of childhood obesity prevention interventions found only a small number of community- or home-based studies and these studies were characterised by small sample sizes and limited success (Waters et al., 2011). This review suggested future interventions should engage parents to support physical activity participation, reduce sedentary behaviour and increase the consumption of nutrient-dense foods. A review of family-based physical activity interventions reported a lack of effectiveness of family-based physical activity programs targeting children confounded by poor study quality and a lack of objectively measured physical activity (O’Connor et al., 2009).
A recent review on parental involvement to improve child dietary intake reported promising results for direct methods of engaging parents (Hingle et al.,
2010). However, further research in this area was recommended owing to the majority of studies using indirect methods to engage parents (i.e. newsletters, family fun nights and home activities) vs direct methods (i.e. parent attendance at program sessions), low study quality and lack of valid and reliable measures
(Hingle et al., 2010). Furthermore, a review by Niemeier and colleagues on weight-related health interventions for children and adolescents that focused on parent participation (Niemeier, Hektner, & Enger, 2012) found weight-related health interventions were more successful with parent involvement. Clearly, the evidence demonstrates that interventions that target parents as the “active participants” and children as the “passive beneficiaries” are warranted.
Given the lack of success of generic approaches to lifestyle-related interventions, it has been proposed that targeting specific sub-groups of the
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population could be beneficial. For example, there is a justification for physical activity interventions to focus on young girls in particular (Biddle et al., 2014;
Wardle, Brodersen, Cole, Jarvis, & Boniface, 2006), given the marked gender differences in physical activity. Moreover, there is a biological justification for focusing on intervention outcomes independently for pre-adolescent girls
(Kesten, Griffiths, & Cameron, 2011).
Recent reviews have focused on female-based interventions aimed to prevent obesity in pre-adolescent girls (Kesten et al., 2011) and promotion of physical activity among young and adolescent girls (Biddle et al., 2014;
Camacho-Minano et al., 2011). Kesten and researchers (Kesten et al., 2011) examined studies which involved girls aged 7-11 and were conducted for a minimum of 12 weeks in changing diet and/or physical activity behaviours.
Findings indicate that most interventions did not achieve adequate effect sizes over time for behaviour (i.e. sedentary behaviours/diet) and physical measures
(i.e. weight and adiposity). The majority of interventions were school-based and might not have been successful owing to only focusing on one setting rather than a more holistic approach (e.g. a combination of the family, community and school)
(Kesten et al., 2011). Researchers suggested interventions should be culturally appropriate and include a comprehensive range of social settings (Kesten et al.,
2011).
More recently, Barr-Anderson and colleagues conducted a review to determine the effectiveness of family-focused physical activity, diet and obesity interventions for African American girls (Barr-Anderson, Adams-Wynn, DiSantis,
& Kumanyika, 2013). Most interventions had weight-related outcomes described as encouraging; however, they were not statistically significant. Conclusions as
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to how to best involve family members in obesity prevention treatment for girls were not clear. The authors suggested future theory-based interventions evaluating different levels of family involvement were warranted (Barr-Anderson et al., 2013).
Biddle and colleagues (2014) conducted a review and meta-analysis on the effectiveness of interventions to increase physical activity among young pre- adolescent girls and reported small effect sizes. This review concluded that multicomponent, educational, high-quality, atheoretical, short term interventions that focus on both physical activity and diet that are exclusively for girls have greater success compared to targeting single health behaviours (Biddle et al.,
2014). Camacho-Minano and colleagues examined interventions promoting physical activity in young girls and reported mixed results in terms of intervention effectiveness. Importantly, Camacho-Minano et al. (2001) called for further high- quality, community-based interventions targeting girls and that use objective measures of physical activity.
The promotion of physical activity and diet in young girls is complex and novel approaches might be required. Given the lack of clarity in the evidence for physical activity and dietary interventions and the gender disparity in physical activity levels, targeted interventions for girls could have particular potential. One suggestion that has some potential is targeting mothers and daughters simultaneously. This is especially important given the evidence on a global scale reporting women to be less active than men (World Health Organization, 2011).
Moreover, girls with parental support, in particular maternal support, have greater likelihood of engaging in physical activity (Cleland et al., 2011; Jacobi et al., 2011;
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Ward et al., 2006). The mother-daughter relationship is exceptionally important
(Rastogi & Wampler, 1999) and research shows that in comparison to other intergenerational relationships, the mother-daughter bond, emotional connection and interdependence are crucial (Fischer, 1991). Despite the recognised influence of the parental impact on child health-related behaviours, there is a paucity of research focusing exclusively on girls and their mothers. Similarly, a novel approach to optimise dietary patterns is to target both mothers and daughters via a family-based intervention (Marcus et al., 2006).
No previous review has examined this area. Therefore, the primary aim of this systematic review is to assess the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters.
2.2 Methods
The conduct and reporting of this review adhered to the recommendations and guidelines of the Preferred Reporting Items for Systematic Reviews and Meta- analysis (PRISMA Statement) (Moher, Liberati, Tetzlaff, & Altman, 2010).
2.2.1 Eligibility Criteria
2.2.1.1 Types of Participants
This review considered studies that exclusively involved mothers and their daughter(s). Studies that included mothers and their pre-school-aged (3-5 years of age), primary/elementary/middle school-aged (between 5-12 years of age), or junior high/high school-aged (between 12-19 years of age) daughters were included in the review.
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2.2.1.2 Types of Interventions
This review considered any intervention for mothers and daughters that exclusively focused on physical activity, fitness, and/or diet. The review included interventions implemented in a community setting with the aim of improving physical activity levels, fitness and/or diet for mothers and/or their daughters.
2.2.1.3 Types of Outcomes
Studies were considered that included the following outcome measures:
1. physical activity or fitness-related outcomes (objective: accelerometry
and/or pedometry, and subjective: self-report, type and time);
2. dietary intake (total energy intake, macronutrients (fat, protein,
carbohydrate), fruit and vegetables, energy-dense, nutrient-poor foods),
food-related behaviour; and/or,
3. overweight/obesity related outcomes: weight change (kg, BMI, % loss of
initial weight), waist change (cm) and % body fat change.
2.2.1.4 Types of studies
This review considered randomised controlled trials (RCT) studying the effect of lifestyle interventions (which employed the above outcome measures) against a true or minimal control group. In the absence of RCTs, other research designs, including non-randomised controlled trials and pre-post studies, were considered for inclusion. Pilot studies and feasibility studies were also considered. Studies were excluded for the following reasons:
(i) boys or men were listed as participants;
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(ii) parent-daughter programs did not specify parent sex; and,
(iii) intervention content did not involve physical activity, fitness, and/or diet.
2.2.2 Search Strategy
The search strategy aimed to find published manuscripts in English language from 1980 onwards August 2013. The 1980 cut-off point was selected as the decline in physical activity was recognised from this time point onwards. Studies were identified by searching electronic databases and scanning reference lists of included articles. The database search included PubMed, Psychinfo, EMBASE,
Ovid Medline, SCOPUS, CINAHL, Sportdiscus and Informit. A three-step search strategy was utilised in each component of this review. First, articles were included or excluded based on their title or abstract. Second, full-text articles were retrieved and assessed for relevance. Finally, all references of full-text articles were retrieved and assessed for relevance. Search terms were divided into four areas:
(i) Population (mother OR mum OR mom OR maternal OR female OR
woman) AND (daughter OR girl OR female OR schoolgirl OR child OR
adolescent);
(ii) Intervention type (physical activity OR exercise OR dance OR physical
fitness OR health OR motor activity OR weight loss OR diet OR
nutrition OR obesity OR lifestyle);
(iii) Study design (random* OR clinic* OR trial OR intervention OR
evaluation OR experiment OR program* OR pilot OR feasibility OR
treatment OR intervention); and,
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(iv) Setting (community OR after-school OR
primary/elementary/middle/junior-high/high schools home-based and
community centres and community camps). Articles with the terms
‘men’ or ‘boys’ in the subject heading were excluded.
2.2.3 Study Selection
After the search, all studies identified during the database search were assessed for relevance (ATB). Duplicates were removed and information contained in the title and abstract were screened for relevance in a non-blinded, standardised method. A second author (MDY) checked all decisions and any disagreements were resolved by discussion. In the case of a disagreement, a third independent reviewer was consulted to make the final decision. For all studies that appeared to meet the inclusion criteria, the full text article was retrieved. If it was unclear from the title and abstract whether the study met the inclusion criteria, the full text article was retrieved to clarify. Reference lists were searched for additional relevant articles; however, none were identified. Figure 2.1 displays the flow of study selection through the phases of the review.
2.2.4 Data collection process
Study data were extracted (ATB) relating to methods (e.g. design, sample size and intervention length), participant characteristics (e.g. age, country), intervention description (e.g. focus, mode of delivery, intervention focus, treatment intensity), and outcome measures (e.g. change in physical activity, fitness, diet or weight, standard deviations). Data were checked by another researcher (MDY).
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2.2.4.1 Risk of bias in individual studies
Risk of bias was independently assessed by two reviewers (ATB, MDY) using a nine-item tool adapted from the Consolidated Standards of Reporting Trials
(CONSORT) statement (Schulz, Altman, & Moher, 2010) and previously used quality criteria for methodology and reporting (Lai et al., 2014; Morgan et al.,
2013) (Table 2.1). Each item was scored as “explicitly stated” (), “absent” () or
“unclear or inadequately described” (?). Disagreements were resolved via discussion. The individual items were not numerically summarised to give a final score, and were looked at in isolation as recommended by the PRISMA statement
(Liberati et al., 2009). Inter-rater reliability was calculated on a dichotomous scale
( vs. or ?) using percentage agreement and Cohens k. Depending on the study design, some items were coded as (N/A). These were scored as N/A prior to assessment.
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Records identified through Additional records identified through database searching other sources (n = 5093) (n = 0)
Records after 1516 duplicates removed (n = 3577)
Title/abstracts screened Records excluded (n = 3420) (n = 3577)
Full-text articles assessed Full-text articles excluded (n =145) for eligibility (n = 157) Reasons: Participants (n = 96) Study design (n = 13) Outcomes (n = 2) Not main outcomes paper (n = 16) Review (n = 2) Studies included in review Thesis (n = 14) (n = 12) Not available in English (n = 2)
Figure 2.1: Flow of study selection through the phases of the review
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TABLE 2.1: RISK OF BIAS CHECKLIST Item Description
A Randomisation (generation of allocation sequence, allocation concealment and implementation) clearly described and adequately completed B Valid measure of PA, FI or DI used (validation has been published or validation data was provided by the author) C Blinded outcome assessment (positive when those responsible for assessing PA, FI, or DI were blinded to group allocation of individual participants) D Participants analysed in group they were originally allocated to, and participants not excluded from analyses because of non-compliance to treatment or because of some missing data E Covariates accounted for in analyses (e.g. baseline score, group/cluster for cluster RCTs, and other relevant covariates where appropriate such as age) F Power calculation reported for primary PA, FI, or DI outcome
G Presentation of baseline characteristics separately for treatment groups (age + mothers + daughters + at least one PA, FI or DI outcome measure) H Dropout for PA, FI or DI measure described, with a ≤ 20% dropout for studies with follow-up of ≤ 6-months and ≤ 30% dropout for studies with follow-up > 6-months I Summary results for each group + estimated effect size (difference between groups) + its precision (e.g. 95% confidence interval)
Abbreviations: PA – Physical activity; FI – Fitness; DI = dietary behaviour; RCT – Randomised controlled trial
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2.2.5 Synthesis of Results
Data were collated and described in a narrative summary. After reviewing the small number of RCTs and the variety of measures utilised, it was not possible to perform a meta-analysis for the current review owing to the heterogeneity of studies.
2.3 Results
The flow of studies with detailed reason for exclusion through the literature search process is detailed in Figure 2.1. The electronic literature search yielded 5093 citations. After screening titles and abstracts of potential studies, 157 full text articles were retrieved. After further screening for eligibility, all 12 studies
(representing 11 unique studies) were included for the review.
2.3.1 Study characteristics
Selected characteristics of all eligible studies are provided in Table 2.2. Six studies were published between 2010 and 2013 (Kargarfard et al., 2012;
Kelishadi et al., 2010; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013;
Olvera, Leung, Kellam, Smith, & Liu, 2013; Salimzadeh, Shojaeizadeh, Pashaee,
& Abdollahi, 2010), three between 2000 and 2009 (Ransdell, Dratt, Kennedy,
O'Neill, & De Voe, 2001; Ransdell, Robertson, Ornes, & Moyer-Mileur, 2004;
Ransdell, Taylor, et al., 2003) and three between 1990 and 1999 (Fitzgibbon,
Stolley, & Kirschenbaum, 1995; Stolley & Fitzgibbon, 1997; Wadden et al., 1990).
The majority of studies were conducted in either the United States (Fitzgibbon et al., 1995; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung,
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Kellam, Smith, et al., 2013; Ransdell et al., 2001; Ransdell, Robertson, et al.,
2004; Ransdell, Taylor, et al., 2003; Stolley & Fitzgibbon, 1997; Wadden et al.,
1990) and Iran (Kargarfard et al., 2012; Kelishadi et al., 2010; Salimzadeh et al.,
2010). There were seven interventions that were culturally tailored, targeting subgroups of the population; two were designed to be culturally appropriate for
Iranian mothers and daughters (Kargarfard et al., 2012; Kelishadi et al., 2010), three for African American mothers and daughters (Fitzgibbon et al., 1995; Stolley
& Fitzgibbon, 1997; Wadden et al., 1990), two for low income Latino mothers and daughters (Olvera et al., 2010; Olvera, Leung, Kellam, Smith, et al., 2013), and one for Hispanic and African American mothers and daughters (Olvera, Leung,
Kellam, & Liu, 2013). All studies were conducted in the community setting; two community-based tutoring programs (Fitzgibbon et al., 1995; Stolley &
Fitzgibbon, 1997), two summer-camp programs (Olvera, Leung, Kellam, & Liu,
2013; Olvera, Leung, Kellam, Smith, et al., 2013), four home-based, community- based programs (Ransdell, Detling, Taylor, Reel, & Shultz, 2004; Ransdell et al.,
2001; Ransdell, Taylor, et al., 2003; Wadden et al., 1990), two family-based programs (Ransdell et al., 2001; Wadden et al., 1990) and four after-school programs (Kargarfard et al., 2012; Kelishadi et al., 2010; Olvera et al., 2010;
Salimzadeh et al., 2010).
The age of daughters included in the studies ranged from 7 to 19 years old. The sample sizes for the studies ranged from 17 mother-daughter dyads
(Ransdell, Robertson, et al., 2004) to 206 mothers and 266 daughters (Kargarfard et al., 2012). Some intervention programs focused on physical activity alone, some physical activity and fitness, some diet alone, while others incorporated a combination of the three. Intervention content involving physical activity
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(Kargarfard et al., 2012; Kelishadi et al., 2010; Olvera et al., 2010; Olvera, Leung,
Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Ransdell et al.,
2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003), fitness
(Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Ransdell et al., 2001;
Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003; Salimzadeh et al., 2010) and diet (Fitzgibbon et al., 1995; Olvera, Leung, Kellam, Smith, et al.,
2013; Stolley & Fitzgibbon, 1997; Wadden et al., 1990) interventions were examined using a number of study designs. Five studies were RCTs (Olvera et al., 2010; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003; Stolley
& Fitzgibbon, 1997; Wadden et al., 1990), one was a pseudo-randomised controlled trial (Fitzgibbon et al., 1995), one a non-randomised controlled trial
(Kargarfard et al., 2012) and five were pre-test/post-test designs (where a single group of participants were measured before and after the intervention) (Kelishadi et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Ransdell et al., 2001; Salimzadeh et al., 2010).
The active intervention periods varied from four weeks (Olvera, Leung,
Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013), six to 12 weeks
(Fitzgibbon et al., 1995; Kargarfard et al., 2012; Kelishadi et al., 2010; Olvera et al., 2010; Ransdell et al., 2001; Ransdell, Taylor, et al., 2003; Salimzadeh et al.,
2010; Stolley & Fitzgibbon, 1997), 16 weeks (Wadden et al., 1990) and six months (Ransdell, Robertson, et al., 2004). Of the 12 studies included in the review, only three studies included follow-up assessments beyond the post- intervention assessment; two had a follow-up six months after completing the intervention (Ransdell et al., 2001; Wadden et al., 1990) and another had follow-
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ups at two, three and six months post-intervention (Olvera, Leung, Kellam, Smith, et al., 2013).
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TABLE 2.2: INTERVENTION CHARACTERISTICS OF MOTHER-DAUGHTER PA, FITNESS AND/OR DIET INTERVENTIONS
Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Randomised Control Trials
Ransdell et al. (2004) PA a) PA + FI (home-based a) Designed to improve various aspects of health-related fitness. Lifestyle, [USA]. - Steps [pedometer] group; 2 F2F, SD) [Unclear] aerobic, muscular strength and flexibility activities at least 3 times per week. - PA participation [Physical Best $50 for each participant upon completion of the intervention. Sample: 17 girls (8-13 Activity Questionnaire] Intensity: 2 x 120 minute yrs) + 17 mothers + 17 session, then 3 x per week PA: 2 x 120 minute session, then structured exercise 3 x per week structured grand-mothers. FI structured exercise. exercise. Progressive program that increased in volume and duration by 10% Fitnessgram battery: every 2 weeks starting at 20 minute sessions up to 60 minute continuous Duration: 6 months - Aerobic fitness [1 mile walk] Theory: n/a sessions. - UBMSE [mod push-ups] Setting: Community - AMSE [sit-ups] b) Control condition (N/A) b) Asked not to change their exercise habits over the 6 months. Attended 2 x - Flexibility [sit and reach] [N/A] 2hr classroom sessions informing participants on the procedures. No other - Aerobic capacity [VO2max] intervention. Intensity: N/A A - Body fat [%] Theory: N/A
Ransdell et al (2003) PA a) PA +FI (community a) 2 classroom sessions on appropriate amounts of PA, components of health [USA]. - Participation [Fitnessgram PAQ] based; F2F (group) related fitness, and calculating energy expenditure of various activities, goal [Instructors with degrees in setting and positive-self talk. Sample: 20 girls (14- FI exercise and sports 17 yrs) + 20 mothers. - Flexibility [sit and reach] science] PA: Met 2/week for fitness activities and 1/week for recreational activities or - Muscular strength [mod push- sports. Duration: 12 weeks ups] Intensity: 36 x 60-75 minute - Muscular endurance [sit-ups] session Setting: Community - Aerobic capacity [VO2max] - Blood pressure Theory: SCT
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
b) PA + FI (home based b) 2 classroom sessions on appropriate amounts of PA, components of health A group; 2 F2F, SD) [N/A] related fitness, and calculating energy expenditure of various activities, goal - % fat setting and positive-self talk. Intensity: 36 x 60-75 minute session PA: Package containing calendar of recommended activities, photos of stretches, calisthenics, strength training activities, tips for overcoming barriers, Theory: SCT PA log submitted every 2 weeks.
Stolley et al (1997) DI a) PA + DI (mother/ a) Culturally specific obesity prevention program focused on adopting a low- [USA]. - Eating behaviour [QCF] daughter; F2F (group)) fat, low-calorie diet and increased activity (based on know your body - Sat fat [Female doctoral student in program). Sample: 65 girls (7-12 -% fat calories clinical psychology or a yrs) + 65 mothers - Dietary cholesterol female dietician] DI: Risks of high fat food, benefits of low-fat food, label reading, medical complications of obesity, tasting high and low-fat menu choices, changing Duration: 12 weeks W Intensity: 11 x 60 minute recipes, planning meals, visiting local markets. - % overweight sessions Setting: Community PA: How to incorporate exercise into daily life, low-impact aerobics class and Theory: N/A culturally relevant music and dance
b) Placebo control; (F2F b) General health program including communicable disease control, effective (group)) [Group leaders] communication skills, relaxation techniques and stress reduction.
Intensity: 11 x 60 minute sessions
Theory: N/A
Wadden et al (1990) DI a) PA + DI (mother/ a) Weight Reduction and Pride (WRAP) program with homework assignments, [USA]. - Total cholesterol - LDL daughter; F2F (group)) [2 quizzes, reward systems, monetary incentive to lose weight with mothers and - HDL clinical psychologists] daughters in attending groups together. Mothers participated in weekly Sample: 47 girls (12- reading, homework tasks such as modelling eating and exercise habits, 16 yrs) + 47 mothers W Intensity: 16 x 60 minute praising behaviour change and preparing low calorie meals. Mothers were - BMI sessions given the option of losing weight.
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Duration: 16 weeks A Theory: N/A Sample: Community - Densitometry b) PA + DI (daughter only; b) Weight Reduction and Pride (WRAP) program with homework assignments, F2F (group)) [2 clinical quizzes, reward systems, monetary incentive to lose weight with only psychologists] daughters attending this group.
Intensity: 16 x 60 minute sessions
Theory: N/A
c) PA +DI (mother/ daughter c) Weight Reduction and Pride (WRAP) program with homework assignments, in separate groups; F2F quizzes, reward systems, monetary incentive to lose weight with daughters and (group)) [2 clinical mothers attending different groups. The mothers meeting provided opportunity psychologists] for social support groups.
Intensity: 16 x 60 minute sessions
Theory: N/A
Cluster randomised design
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Olvera et al (2010) PA a) PA + DI (F2F (group)) a) Structured group aerobic/sport session/free play recreational activities, [USA]. - MVPA mins [Accelerometer] Ɨ [child psychologist and nutrition education sessions and behavioural counselling session. - CPM [Accelerometer] Ɨ licensed counsellor, PA: Structured group exercised (e.g. Salsa) or sports session (e.g. basketball) Sample: 46 girls (7-13 - PA level [University of Houston registered dietician/nutrition or free recreational play. yrs) + 46 mothers. Non-Exercise Physical Activity educators, and trained DI: Content-based lectures and participatory activities (e.g. food preparation) Rating]ǂ Cooper Institute Fitness that aimed to reduce sugar sweetened beverages increase water Duration: 12 weeks Specialists] consumption, reduced saturated fat intake through healthier snacking and FI cooking and develop healthy eating strategies when dining away from home. Setting: Community - Aerobic fitness [20-Meter Intensity: 36 x 90 minute Endurance Shuttle Run Test]Ɨ sessions - Peak oxygen consumption [Rockport walk test + Heart rate]ǂ Theory: SCT DI Ɨ - High fat foods [SPAN] b) PA + DI (comparison b) Written education materials on various nutrition and counselling topics and - Sweetened beverages [SPAN] group; F2F (group)) [child light intensity aerobic or sports session. - Fruit / vegetables [SPAN] psychologist and licensed PA: Light intensity aerobic (e.g. samba) or sports session (e.g. basketball) counsellor, registered DI: Received nutrition handout and were encouraged to ask questions about W dietician/nutrition written materials - BMI educators, and trained Cooper Institute Fitness Specialists]
Intensity: 12 x 90 minute sessions
Theory: SCT
Pseudo-randomised control trial
Fitzgibbon et al DI a) DI (treatment group; F2F a) Based on ‘Know your body program", a school based comprehensive health (1995) [USA]. (group)) [Ph.D. Clinical program that combines education and skills training. Nutrition knowledge quiz Psychologist or a clinical
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Sample: 24 girls (8-12 - nutrition knowledge psychology graduate DI: Identification or high and low fat foods, label reading, calculating the yrs) + 24 mothers student] percentage of fat in food, risk of high fat eating, low fat menu planning and Nutrition and food attitude scale preparation, discussion of the problems associated with obesity. Duration: 6 weeks - attitudes toward nutrition Intensity: 4 x 60 minute meetings Setting: Community 24 hour food recall - caloric intake Theory: SLT - fat grams - percentage fat in the diet b) Control group (N/A) b) N/A [N/A] W - Weight Intensity: N/A
Theory: N/A
Non-randomised controlled trial
Kargarfard et FI a) PA +FI (mother/ a) After school aerobic PA including mothers and daughters al a (2012) [Iran]. - RHR [BPM] daughter; F2F (group)) [Qualified female PA PA: PA classes including warm-up aerobic activity, stretching, free group play Sample: 266 girls (7th- Fitnessgram battery instructor] and cool down. 10th grade high - Aerobic fitness [1 mile walk] school) + 204 - UBMSE [push ups] Intensity: 24 x 90 minute mothers. - AMSE [sit ups] sessions - Flexibility [sit and reach] Duration: 12 weeks - Aerobic capacity [VO2 Max] Theory: N/A
Setting: Community W b) PA +FI (daughter only; b) After school aerobic PA including only girls - BMI F2F (group)) [Qualified female PA instructor] PA: PA classes including warm-up aerobic activity, stretching, free group play and cool down. Intensity: 24 x 90 minute sessions
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Theory: N/A
Pre post studies
Olvera et al (2013). A a) PA+ DI BOUNCE a) Intervention incorporating PA, counselling and nutrition session. USA. - Body fat (%) Summer intervention (F2F - Waist circumference (group)) [Dietician, exercise PA: Each day started with a flexibility session, sports skills/game session, Sample: 61 girls (14- physiologist and a traditional fitness session and dance session totally 60 hours of group 19 yrs) + 61 mothers W developmental psychologist exercise over 4 weeks. Handouts on benefits of PA, components of a healthy - BMI led mother's sessions] lifestyle and strategies to overcome barriers. Mothers participated in Duration: 4 weeks 2hr/weekly sessions on exercise training, and parenting strategies to support Intensity: Monday-Friday, healthy behaviours. Setting: Summer 8hours/day for 4 weeks camp DI: Lunch and nutrition session each day. Mothers received nutrition Theory: SCT education in weekly session.
FU: After the 4-week BOUNCE summer program, the Mother–daughter dyads participated in 12 weekly ReBOUNCE afterschool aerobic intervention sessions The weekly sessions were 1.5 hours in duration and included PA (60 min) and supplemental information (30 min) as requested by mothers. The supplemental information included 30 minutes of nutrition education or parenting training, or sometimes both depending on the topic.
Olvera et al (2013). PA a) PA +FI BOUNCE a) Intervention incorporating PA, counselling and nutrition session. USA. - MVPA mins Ɨ [Accelerometers]* Summer intervention group (F2F (group) [A dietician, PA: 3-4 hour exercise sessions; flexibility followed by a sports skills or game Sample: 99 girls (9-14 FI an exercise physiologist session. yrs) + 99 mothers - Aerobic endurance [1 mile and a child psychologist] walk/run]Ɨ DI: Lunch followed by lunch, nutrition session, counselling, dance. Nutrition Duration: 4 weeks Intensity: Monday-Friday, 8 lessons were focused on enhancing self-efficacy, knowledge, and skills A hours/day for 4 weeks related to reducing the intake of sweetened beverages and high-fat foods, and - Body fat (%) increasing the consumption of diverse fruits and vegetables.
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Setting: Summer - BMI Theory: Cognitive The behavioural and counselling component focused on promoting self- camp - Waist circumference behavioural principle esteem, tackling body image concerns, and developing effective coping strategies to deal with stressful situations (i.e., avoiding emotional eating, and practicing healthy techniques for expressing thoughts, feeling, and emotions). Mothers participated in a 2-h weekly session where they received nutrition education, exercise training, and parenting strategies on how to support their daughters’ healthy lifestyle program.
Salimzadhel et al. FI a) PA + FI a) Highly interactive mother and daughter community based program (2010) [Iran]. - Cardiovascular endurance [BPM] treatment group (F2F - Muscle strength [sit ups] (group)) [Physical activity PA: Education on fitness and activity including motor skills, aerobic fitness and Sample: 35 girls (1st- - Flexibility [sit and reach] teacher] strength, 5 min warm up, 20 min moderate to vigorous PA, 15 min strength 3rd grade high school) training and impact loading, 5 min warm down. + 35 mothers A Intensity: 24 x 90 minute - Waist and hip circumference sessions Duration: 12 weeks W Theory: N/A Setting: Community - BMI
Kelishadi et W a) PA treatment group (F2F a) After school aerobic PA al a (2010) [Iran]. - BMI (group)) [Qualified female PA instructor] PA: 20-30 min devoted to didactic presentation or discussion about reasons Sample: 206 girls (7th- A for being active, ways of overcoming barriers and strategies for maintaining 10th grade high - Waist and hip circumference Intensity: 24 x 90 minute active lifestyle, 60-70 minutes of fitness orientated activities. school) + 204 mothers sessions
Duration: 12 weeks Theory: N/A
Setting: Community
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Study (year) [country]. Behaviour measure Intervention focus Content Key study details & outcomes (mode) [provider]
Ransdell et al. (2001) PA a) PA + FI a) 1 weekly session dedicated to participating in physical and recreational [USA]. - Participation [Fitnessgram PAQ] (mother/daughter; F2F activities. 1 weekly session dedicated to classroom topics and activities. (Group)) [Unclear] Designed to involve both mothers and daughters where appropriate and when Sample: 14 girls (11- FI necessary, separated for age-appropriate activities. 17 yrs) + 12 mothers - VO2peak [spirometer] Intensity: 24 x 90-120 minute sessions PA: Participants asked to increase exercise outside of the intervention, Duration: 12 weeks W encouraged to self-monitoring through weekly logs, walking challenge, weekly - lbs Theory: SCT prizes via random draw or contest. Setting: Community
Abbreviations: Ɨ = assessed in daughters only; ǂ = assessed in mothers only; * = collected during intervention; PA = physical activity; DI = diet; FI = Fitness; A = adiposity; W = weight; FU = follow-up; SD, Self-directed = SCT, Social cognitive theory = SLT, Social learning theory; UBMSE = upper body muscular strength and endurance’ AMSE = abdominal muscular strength and endurance; MVPA = moderate to vigorous physical activity; CPM = average counts per minute; FU – follow-up; aThe CASPIAN study was reported in two separate studies, however, use the same group of mothers and daughters in both studies, with the addition of a comparison girls only group in 2012.
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2.3.2 Risk of bias within studies
Table 2.3 displays the risk of bias assessments for all studies. Inter-rater reliability metrics for the risk of bias assessments indicated substantial agreement for all
200 items (percentage agreement 87% k = 0.71). Differences were resolved by discussion. A Cohen’s kappa of 0.61 – 0.80 is classified as ‘substantial agreement’ (Landis & Koch, 1977).
Four of the 12 studies used valid and reliable measures of physical activity for both mothers and daughters (Olvera et al., 2010; Ransdell et al., 2001;
Ransdell, Robertson, et al., 2004) and daughters only (Olvera, Leung, Kellam, &
Liu, 2013), seven studies employed valid measures of fitness for both mothers and daughters (Kargarfard et al., 2012; Olvera et al., 2010; Ransdell et al., 2001;
Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003; Salimzadeh et al., 2010) and daughters only (Olvera, Leung, Kellam, & Liu, 2013) and two studies used valid measures of diet; one for mothers only (QCF) (Stolley &
Fitzgibbon, 1997) and one for daughters only (SPAN survey) (Olvera et al., 2010).
Assessor blinding was not reported in any of the studies. In three studies, participants were analysed in the group they were originally allocated to and not excluded from analyses because of non-compliance to treatment or because of partial missing data (Kargarfard et al., 2012; Kelishadi et al., 2010; Salimzadeh et al., 2010). Four studies accounted for covariates in their analyses (Fitzgibbon et al., 1995; Kargarfard et al., 2012; Olvera et al., 2010; Olvera, Leung, Kellam,
Smith, et al., 2013). The presentation of baseline characteristics provided separately for at least one PA, FI or DI assessment was met by eight studies for both mothers and daughters (Fitzgibbon et al., 1995; Kargarfard et al., 2012;
Olvera et al., 2010; Ransdell et al., 2001; Ransdell, Robertson, et al., 2004;
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Ransdell, Taylor, et al., 2003; Stolley & Fitzgibbon, 1997) and for daughters only
(Olvera, Leung, Kellam, & Liu, 2013). Six studies met the criteria for retention of mothers and daughters (Fitzgibbon et al., 1995; Kargarfard et al., 2012; Kelishadi et al., 2010; Ransdell, Taylor, et al., 2003; Salimzadeh et al., 2010) and retention of daughters only (Stolley & Fitzgibbon, 1997). There were four studies that reported summary results for each group and effect sizes for both mothers and daughters (Fitzgibbon et al., 1995; Olvera et al., 2010; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003). Of the five RCTs, none clearly described randomisation procedures (i.e. general allocation sequence, allocation concealment and implementation). Finally, none of the studies reported a power calculation.
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TABLE 2.3: SUMMARY OF RISK OF BIAS ASSESSMENT OF INCLUDED STUDIES
Study A) B) Valid measure C) D) E) F) Power G) Presentation H) Dropout ≤ I) Summary Randomisation of PA, FI, or DI Assessor Analysed Covariates calculation of baseline 20% for ≤ 6 results, clearly described blinding in group accounted for primary characteristics months follow- estimated and adequately originally for in outcome separately up and ≤ 30% effect size + done allocated analyses > 6 months precision to
Randomized Control Trials
Ransdell, Robertson et al (2004) D (FI, PA) ? (FI, PA) M (FI, PA) ? (FI, PA)
Ransdell, Detling et al (2004), D (FI, PA) ? (FI, PA) Ransdell, Taylor et al (2003) M (FI, PA) ? (FI, PA)
Stolley et al. (1997) D (DI) ? (DI) M (DI) ? (DI)
Wadden et al. (1990) D N/A N/A M N/A N/A
Olvera et al (2010) (Olvera et al., D (FI, DI, PA) ? ? (F, DI, PA) 2010) (Olvera et al., 2010) M (FI, PA) ? ? (F, PA)
Pseudo-randomised control trial
Fitzgibbon et al (1995) D (DI) ? x ? (DI) M (DI) ? x ? (DI)
Non-randomised controlled trial
Kargarfard et al (2012) D (FI) ? (FI) M (FI) ? (FI)
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Study A) B) Valid measure C) D) E) F) Power G) Presentation H) Dropout ≤ I) Summary Randomisation of PA, FI, or DI Assessor Analysed Covariates calculation of baseline 20% for ≤ 6 results, clearly described blinding in group accounted for primary characteristics months follow- estimated and adequately originally for in outcome separately up and ≤ 30% effect size + done allocated analyses > 6 months precision to
Pre post studies
Olvera, Leuing, Kellam, Smith et al D N/A N/A N/A N/A (2013) M N/A N/A N/A N/A
Olvera, Leung, Kellam, & Smith D N/A (PA, FI) (PA) (FI) ? N/A (2013) M N/A N/A N/A ? N/A
Salimzadeh et al (2010) D N/A (FI) N/A M N/A (FI) N/A
Kelishadi et al (2010) D N/A N/A ? N/A N/A M N/A N/A ? N/A N/A
Ransdell et al (2001) D N/A (FI, PA) ? (FI) N/A M N/A (FI, PA) ? (FI) N/A
= explicitly described and present; = absent; ? = unclear or inadequately described; NA= not applicable due to study design; D = daughters’ in study; M = mothers’ in study; FI = Fitness; PA = physical activity; DI = dietary * = Kargafard et al and Kelishadi et al reported on the same mother-daughter dyads in the two papers, however, Kargafard includes a separate comparison group of girls. Kelishadi et al., reported on weight and adiposity measures in the one group of mothers and daughters.
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2.3.3 Intervention Content and Measurement of Physical Activity
From the 12 studies included in this review, physical activity was targeted in the intervention in 10 studies (Kargarfard et al., 2012; Kelishadi et al., 2010; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Ransdell et al., 2001; Ransdell, Robertson, et al., 2004; Ransdell,
Taylor, et al., 2003; Salimzadeh et al., 2010; Stolley & Fitzgibbon, 1997); however, only five studies assessed physical activity (Olvera et al., 2010; Olvera,
Leung, Kellam, & Liu, 2013; Ransdell et al., 2001; Ransdell, Robertson, et al.,
2004; Ransdell, Taylor, et al., 2003). Studies used a variety of measures to assess physical activity in mothers and daughters. Three studies utilised an objective measure of physical activity; two used accelerometers, but in daughters only (Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013) and one assessed physical activity using pedometers in grandmothers, mothers and daughters
(Ransdell, Robertson, et al., 2004). The Fitnessgram physical activity questionnaire (d/wk) was used in three studies for both mothers and daughters
(Ransdell et al., 2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al.,
2003). One study used a self-report physical activity rating scale for mothers’ physical activity (Olvera et al., 2010).
2.3.4 Intervention Content and Measurement of Fitness
Of the 12 studies included in the review, fitness was a focus of the intervention in nine studies (Kargarfard et al., 2012; Kelishadi et al., 2010; Olvera et al., 2010;
Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013;
Ransdell et al., 2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al.,
2003; Salimzadeh et al., 2010) and was measured in seven studies (Kargarfard
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et al., 2012; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Ransdell et al., 2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003;
Salimzadeh et al., 2010). Fitness was assessed via the Fitnessgram, i.e. aerobic capacity, muscular strength, muscular endurance and flexibility in three studies in both mothers and daughters (Kargarfard et al., 2012; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003). The one mile walk was assessed as a measure of fitness in one study for daughters only (Olvera, Leung, Kellam, & Liu,
2013). Vo2 peak was tested in two studies; one using a spirometer for mothers and daughters (Ransdell et al., 2001), and the other via the Rockport walk test for mothers’ fitness (Olvera et al., 2010). The 20-meter shuttle run assessed aerobic capacity in daughters only; however, heart rate in mothers was tested post one mile walk test (Olvera et al., 2010). Muscular strength (sit ups), cardiovascular endurance (heart rate) and flexibility were assessed as a measure of fitness in one study for both mothers and daughters (Salimzadeh et al., 2010).
2.3.5 Intervention Content and Measurement of Diet
Of the 12 studies included in the review, nutrition was targeted in the intervention in six studies (Fitzgibbon et al., 1995; Olvera et al., 2010; Olvera, Leung, Kellam,
& Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Stolley & Fitzgibbon,
1997; Wadden et al., 1990). However, diet was assessed in only three studies
(Fitzgibbon et al., 1995; Olvera et al., 2010; Stolley & Fitzgibbon, 1997), with only one study using a valid measure in mothers (Stolley & Fitzgibbon, 1997), and another for daughters (Olvera et al., 2010). The Quick Check for Fat (QCF) brief food frequency questionnaire was used to estimate fat and cholesterol intakes in both mothers and daughters in one study (Stolley & Fitzgibbon, 1997). Daughters’
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dietary intake was measured using the School Physical Activity and Nutrition
(SPAN) survey assessing a range of self-reported outcomes including consumption of high fat foods, sugar sweetened beverages and fruit/vegetable intake. However, mothers’ diet was not assessed in this study (Olvera et al.,
2010). Nutrition knowledge, nutrition attitude, caloric intake, fat intake and %fat intake were assessed using a 24-hour food recall and a modified version of a pre-post nutrition quiz (by Pillsbury Corporation) in one study for both mothers and daughters (Fitzgibbon et al., 1995).
2.3.6 Studies With No Physical Activity or Fitness Measures
There were two studies that included physical activity, fitness and/or diet
(Kelishadi et al., 2010; Olvera, Leung, Kellam, Smith, et al., 2013) as part of the intervention content; however, these only measured weight or adiposity. Physical activity, fitness and diet were not measured. In total, there were two studies which assessed daughters only and did not assess mothers (Olvera, Leung, Kellam, &
Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013).
2.3.7 Types of Interventions
All interventions were delivered in the community setting, including community- based tutoring, after-school, summer camp, and family- and home-based programs. Most interventions utilised a variety of instructors to deliver the program including people with physical education (Kargarfard et al., 2012;
Kelishadi et al., 2010; Salimzadeh et al., 2010) or exercise science degrees or training (Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al.,
2013; Ransdell, Taylor, et al., 2003), psychologists (Olvera et al., 2010; Olvera,
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Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Wadden et al., 1990), registered dieticians (Olvera et al., 2010; Olvera, Leung, Kellam, &
Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013), or a clinical psychology doctoral student (Fitzgibbon et al., 1995; Stolley & Fitzgibbon, 1997). Two studies were unclear as to who led the sessions (Ransdell et al., 2001; Ransdell,
Robertson, et al., 2004). Only two studies specified the sex of the facilitators and these were female-led sessions (Kargarfard et al., 2012; Stolley & Fitzgibbon,
1997).
2.3.8 Summary of Evidence from RCTs
Table 2.4 summarises the results for all mother-daughter physical activity, fitness and/or dietary interventions (11 studies). A description of the results from the five
RCTs are provided in detail (Schulz et al., 2010). Overall, three of the five RCTs that measured fitness found significant intervention effects for both mothers and daughters (Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003) and daughters only (Olvera et al., 2010). For the three RCTs that measured physical activity, one was successful at increasing mean daily steps in grandmothers/mothers/daughters (Ransdell, Robertson, et al., 2004) whilst the others did not find significant effects for daughters’ MVPA minutes or CPM
(Olvera et al., 2010) or self-reported physical activity (Ransdell, Taylor, et al.,
2003). Significant intervention effects for dietary behaviour were only seen in one
RCT for both mothers and daughters (Stolley & Fitzgibbon, 1997).
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TABLE 2.4: RESULTS FROM MOTHER-DAUGHTER PA, FITNESS AND/OR DIET INTERVENTIONS
Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON)
Baseline 6 months Baseline 6 months Ransdell, 93% for 1) Mothers/ Steps (steps/day) 8422.9 (4304.7) 11517.4 (3563.7) NS 9411.2 (4029.3) 8511.8 (3712.2) NS 0.001 Robertson et home- daughters/ Aerobic activity (d.wk-1) 2.1 (1.9) 4.4 (1.4) NR 3.5 (2.7) 3.4 (2.4) NR NS al (2004) based grandmas Muscular strength (d.wk-1) 1.2 (1.8) 3.6 (2.1) NS 1.3 (1.8) 1.5 (1.4) NS NS group, 43% combined Flexibility (d.wk-1) 1.0 (1.5) 3.9 (2.0) 0.001 1.6 (2.8) 1.4 (2.4) 0.001 <0.001 for control group. Mile time (mins) 15.3 (1.8) 14.6 (1.7) <0.001 18.4 (2.2) 15.7 (2.5) <0.001 0.007 Push-ups (completed) 19.2 (10.2) 31.9 (14.5) <0.001 15.8 (8.3) 18.6 (9.7) <0.001 NS ITT: No Sit-ups (completed) 24.4 (11.8) 37.4 (14.8) <0.001 10.9 (12.1) 16.2 (11.6) <0.001 0.061 Flexibility (cm) 26.8 (10.7) 29.1 (10.6) NS 29.4 (8.7) 28.7 (8.8) NS 0.109 Weight (lbs) 133.0 (43.2) 132.9 (40.1) NS 122.1 (41.7) 122.6 (39.4) NS 0.84 Body fat (%) NR NR NS NR NS NS Baseline 12 weeks Baseline 12 weeks Ransdell, 85% 1) Mothers Push-ups (reps) 14.8 (9.3) 26.2 (13.0) 0.003 13.0 (5.4) 15.9 (6.2) 0.003 0.05 Taylor et al Sit-ups (reps) 23.7 (12.5) 47.4 (18.2) <0.001 25.4 (6.5) 43.0 (9.0) <0.001 0.37 (2003) ITT: No Flexibility (cm) 31.5 (12.3) 34.8 (8.6) 0.008 26.1 (12.8) 30.9 (11.5) 0.008 0.59
Aerobic capacity 25.0 (9.6) 26.6 (9.3) 0.002 27.1 (6.0) 30.1 (4.1) 0.002 0.29
(mlkg-1min-1) Aerobic activity (d.wk-1) 1.0 (1.1) 4.4 (1.0) ≤0.001 0.6 (0.8) 3.0 (2.0) ≤0.001 NS Muscular strength (d.wk-1) 0.6 (1.6) 2.0 (1.3) ≤0.001 2.0 (1.6) 3.0 (2.0) ≤0.001 NS Flexibility activity (d.wk-1) 0.8 (1.6) 3.2 (1.7) ≤0.001 0.1 (0.4) 2.6 (1.8) ≤0.001 NS Systolic BP (mmhg) 127.5 (12.9) 116.5 (16.9) NS 120.7 (11.2) 111.2 (30.6) NS 0.68 Diastolic BP (mmhg) 82.9 (10.8) 74.9 (12.3) 0.008 83.3 (10.8) 77.4 (11.9) 0.008 0.64 Body fat (%) 37.2 (5.2) 36.9 (5.4) NS 35.8 (4.7) 35.7 (3.7) NS 0.82 2) Daughters Push-ups (reps) 22.2 (10.8) 9.2 (12.5) NS 22.0 (12.3) 23.4(7.7) NS 0.23 Sit-ups (reps) 28.9 (17.2) 61.0 (16.7) <0.001 39.1 (11.9) 52.3 (10.4) <0.001 0.03 Flexibility (cm) 34.4 (9.7) 35.5 (7.1) NS 27.6 (13.4) 30.5 (12.7) NS 0.57
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Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON) Aerobic capacity (mlkg- 39.1 (8.1) 40.4 (5.1) NS 42.3 (3.4) 43.6 (3.6) NS 0.99 1min-1)
Aerobic activity (d.wk-1) 2.3 (1.6) 4.3 (1.2) ≤0.001 2.0 (1.8) 2.7 (1.9) ≤0.001 NS Muscular strength (d.wk-1) 1.0 (1.1) 2.4 (1.3) ≤0.001 1.3 (1.8) 3.2(1.9) ≤0.001 NS Flexibility activity (d.wk-1) 2.2 (2.3) 4.0 (1.8) ≤0.001 1.0 (1.2) 4.9 (1.2) <0.001 NS Body fat (%) 30.5 (6.3) 22.2 (6.1) NS 22.2 (6.1) 23.0 (5.5) NS 0.47 Baseline 12 weeks Baseline 12 weeks Stolley et al 83% 1) Mothers Saturated fat 13.6 (2.1) 11.5 (2.7) NR 15.3 (1.3) 15.1 (1.7) NR <0.05 (1997) daughters, Percentage fat 40.7 (4.9) 32.8 (6.6) NR 42.8 (2.8) 41.6 (3.1) NR <0.001 Dietary cholesterol 414.4 (216) 255.0 (93.3) NR 617.9 (365.6) 594.1 (367.0) NR <0.1 78% Parental support and role 27.3 (6.5) 33.5 (7.6) NR 31.6 (6.5) 31.8 (6.7) NR <0.01 mothers modelling
ITT: Yes 2) Daughters Saturated fat 13.9 (2.6) 13.0(2.8) NR 15.0 (2.3) 15.1 (1.8) NR NS Percentage fat 39.1 (5.1) 35.2(7.0) NR 41.9 (4.6) 40.6 (4.6) NR <0.05 Dietary cholesterol 387.0 (228.0) 400.9 (246.0) NR 604.9 (538.0) 638.9 (513.0) NR NS Baseline 16-week Δ/6-month Δ Wadden et 77% 1) Girls Weight 95.9 ± 13.8 -1.6kg/ +3.0kg Unclear N/A N/A NS a al. (1990) [no mother Body fat (%) 41.6 ± 3.5 NR Unclear N/A N/A NS ITT: No partaking] BMI (kg/m2) 35.1 ± 5.4 NR Unclear N/A N/A NS 16 wk, 6-m/o 2) Daughters Weight 87.1 ± 15.0 -3.7kg/ +1.7kg Unclear N/A N/A NS [mother-child Body fat (%) 39.5 ± 5.2 NR Unclear N/A N/A NS together] BMI (kg/m2) 32.8 ± 3.8 NR Unclear N/A N/A NS 3) Daughters Weight 101.4 ± 10.7 -3.1kg/ +3.5kg Unclear N/A N/A NS [mother-child Body fat (%) 40.4 ± 5.6 NR Unclear N/A N/A NS separate] BMI (kg/m2) 36.7 ± 3.7 NR Unclear N/A N/A NS 4) Mothers NR NR NR NR N/A N/A NR
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Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON)
Baseline 12 weeks Baseline 12 weeks Olvera et al. 76% 1) Mothers Exercise heart rate (bpm) 124.1 ± 19.3 129.8 ± 21.6 NR 136.0 ± 12.5 140.7 ± 12.9 NR 0.012 (2010) VO2 peak (ml/kg/min) 36.4 ± 8.1 36.9 ± 5.1 NR 42.9 ± 9.0 42.9 ± 9.0 NR 0.188 ITT: No Physical activity rating 1.4 ± 0.9 2.1 ± 1.6 NR 1.2 ± 1.5 1.2 ± 0.9 NR 0.257 2) Daughters 20-meter shuttle 14.2 ± 4.9 20.7 ± 8.4 NR 11.2 ± 5.3 13.1 ± 5.5 NR 0.044 Average daily counts 340941 ± 86006 368045 ± 131803 NR 229752 ± 93891 266717 ± 56508 NR 0.295 MVPA (min) 64.3 ± 23.9 70.7 ± 31.5 NR 35.4 ± 21.9 38.0, 13.1 NR 0.049 High fat foods 2.2 ± 1.4 1.9 ± 1.6 NR 1.9 ± 1.9 2.6 ± 1.9 NR 0.26 Sweetened beverages 2.0 ± 1.3 1.4 ± 1.4 NR 1.1 ± 1.1 1.7 ± 1.0 NR 0.312 Fruit/vegetables 3.1 ± 1.6 4.1 ± 2.6 NR 3.1 ± 2.0 2.9 ± 2.3 NR 0.343 Baseline 12 weeks Baseline 12 weeks Kargarfard et Unclear 1) Mothers BMI (kg/m2) 27.7(5.6) 27.2(5.3) <0.001 NA NA NA al (2012) RHR (bpm) 78.3(8.3) 76.4(7.3) <0.001 NA NA NA ITT: Unclear 1-mile walk (min) 16.2(3.3) 14.9(2.6) <0.05 NA NA NA VO2max (mL.kg -1.min-1) 32.8(6.9) 34.9(7.5) <0.001 NA NA NA flexibility (cm) 20.5(14.1) 23.9(14.4) <0.001 NA NA NA UBMSE (reps) 18.9(9.1) 21.8(10.1) <0.001 NA NA NA AMSE (reps) 15.2(5.4) 19.6(6.4) <0.001 NA NA NA 2) Daughters BMI (kg/m2) 21.5(3.5) 21.3(3.3) <0.001 21.2(3.5) 21.1(3.4) <0.05 0.74 RHR (bpm) 76.0(5.3) 73.2(4.5) <0.001 76.5(4.5) 74.9(3.7) <0.001 <0.001 1-mile walk (min) 15.6(2.3) 13.9(1.6) <0.001 15.3(2.2) 14.0(1.8) <0.001 <0.05 VO2max (mL.kg -1.min-1) 38.9(7.8) 44.7(6.6) <0.001 38.8(8.4) 43.6(7.4) <0.001 <0.01 flexibility (cm) 23.6(11.6) 29.6(11.5) <0.001 22.6(10.4) 27.1(10.4) <0.001 <0.01 UBMSE (reps) 22.0(10.0) 27.1(10.5) <0.001 21.2(9.3) 25.5(11.2) <0.05 0.29
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Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON) AMSE (reps) 30.7(7.4) 38.8(7.5) <0.001 30.2(7.6) 36.5(6.7) <0.001 <0.001
Baseline 6 months Baseline 6 months Olvera, 18% 1) Mothers NR NR NR NR NR NR Leung, Kelam, ITT: No 2) Daughters Body fat (%) 42.2 (5.8) 39.3 (4.2) 0.072 NA NA NA Smith et al Waist circumference 93.5 (14.6) 84.4 (8.8) 0.074 NA NA NA (2013) Weight (lb) 152.4 (43.2) 139.5 (31.8) 0.096 NA NA NA BMI (kg/m2) 28.9 (6.7) 26.6 (3.7) 0.462 NA NA NA Baseline 4 weeks Baseline 4 weeks Olvera, Unclear 1) Mothers NR NR NR NA NA NA Leung, Kellam & Liu ITT: No 2) Daughters Body fat (%) 42.2 (6.7) 39.7 (7.4) <.001 NA NA NA (2013) Waist circumference 93.9 (14.9) 88.3 (14.1) <.001 NA NA NA Weight (lb) 159.2 (47.2) 157.6 (46.1) <.001 NA NA NA BMI 30.1 (6.4) 29.7 (6.2) <.05 NA NA NA One-mile run/walk (min) 17.4 (3.4) 15.0 (2.8) <.001 NA NA NA Baseline 12 weeks Baseline 12 weeks Salimzadeh 100% 1) Mothers Weight (kg) 69.6 (7.4) 68.1 (6.3) 0.001 NA NA NA et al (2010) Waist circumference (cm) 88.3 (8.5) 86.4 (6.9) 0.02 NA NA NA ITT: Yes Hip circumference (cm) 108.0 (4.9) 104.0 (5.7) 0.007 NA NA NA BMI (kg/m2) 28.0 (4.4) 27.4 (3.6) 0.001 NA NA NA Muscle strength (times) 13.5 (2.6) 18.5 (5.8) NS NA NA NA Cardiovascular endurance 132.0 (13.7) 144.8 (14.3) 0.001 NA NA NA (beats/min) Flexibility (cm) 35.7 (8.6) 36.8 (5.8) 0.002 NA NA NA
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Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON)
2) Daughters Weight (kg) 51.0 (8.3) 50.0 (6.8) 0.001 NA NA NA Waist circumference (cm) 66.5 (9.2) 64.6 (8.7) 0.001 NA NA NA Hip circumference (cm) 89.3 (8.3) 86.2 (5.2) 0.001 NA NA NA BMI (kg/m2) 20.5 (3.0) 19.9 (2.8) 0.001 NA NA NA Muscle strength (times) 20.3 (6.1) 23.5 (5.4) 0.005 NA NA NA Cardiovascular endurance 150.8 (180.0) 166.4 (15.8) 0.001 NA NA NA (beats/min) Flexibility (cm) 30.4 (9.4) 33.2 (6.3) 0.02 NA NA NA Baseline 12 weeks Baseline 12 weeks Kelidashi et Unclear 1) Mothers Weight (kg) 54.7 (9.6) 54.1 (9.4) <0.0001 NA NA NA al (2010) BMI (kg/m2) 21.4 (3.5) 21.2 (3.3) <0.0001 NA NA NA ITT: Unclear Waist circumference (cm) 71.2 (7.8) 69.8 (7.7) <0.0001 NA NA NA Waist to hip ratio 0.8 (0.1) 0.8 (0.1) <0.0001 NA NA NA 2) Daughters Weight (kg) 70.2 (11.5) 69.0 (11.1) <0.0001 NA NA NA BMI (kg/m2) 27.6 (5.5) 27.1 (5.3) <0.0001 NA NA NA Waist circumference (cm) 88.5 (11.8) 86.0 (11.0) <0.0001 NA NA NA Waist to hip ratio 0.8 (0.0) 0.8(0.1) 0.03 NA NA NA Baseline 12 wk / 6 month Ransdell, et 75% 1) Mothers PSP (body attractiveness) 15.9 (1.8) 17.6 (1.3) NR NA NA NA al (2001) ITT: No PSP (sports competence) 12.3 (2.1) 15.9 (1.5) NR NA NA NA PSP (strength/muscularity) 16.7 (1.8) 15.9 (1.5) NR NA NA NA PSP (physical condition) 14.1 (2.0) 18.4 (1.5) NR NA NA NA PSP (physical self-worth) 13.9 (1.8) 16.7 (1.3) NR NA NA NA Exercise (d.wk-1) 3.2 (0.7) 3.4 (0.53) / NR 3.3 (0.50) Weight kg 77.5 (5.2) 78.3 (5.1) NR NA NA NA Highest VO2 peak 26.4 (2.9) 28.2 (2.5) NR NA NA NA
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Author Retention Mothers / Outcome Intervention Results p-value Control Results p-value p-value daughters (Mean, SD/SE/CI, n) within (Mean, SD/SE/CI, n) within between group group group (INT) (CON)
2) Daughters PSP (body attractiveness) 17.3 (2.4) 18.3 (1.8) NA NA NA PSP (sports competence) 16.6 (2.5) 19.0 (1.8) NA NA NA PSP (strength/muscularity) 17.6 (2.1) 21.0 (2.1) NA NA NA PSP (physical condition) 18.2 (2.3) 18.8 (1.8) NA NA NA PSP (physical self-worth) 16.6 (1.3) 17.3 (1.4) NA NA NA Exercise (d.wk-1) 2.6 (0.7) 3.6 (0.50) / NR NA NA NA 3.3 (0.51) Weight kg 60.8 (5.2) 61.9 (5.1) NR NA NA NA Highest VO2 peak 30.8 (3.1) 31.1 (2.7) NR NA NA NA Baseline 6 weeks Baseline 6 weeks Fitzgibbon et 83% 1) Mothers Nutrition knowledge 31.9 (8.5) 38.2 (4.9) <0.01 34.0 (3.7) 35.0 (2.9) NS 0.13 al (1995) Nutrition attitude 42.9 (7.2) 41.5 (8.0) NS 42.4 (7.2) 42.1 (5.7) NS 0.13 ITT: No Caloric intake (% 1961.0 (618.0) 1362.0 (575.0) NS 1677.0 (793) 1746.0 (739.0) NS NS calories/d) Fat intake (g/d) 89.7 (33.8), 45.0 (17.7) <0.05 73.3 (36.0) 74.8 (4.50) NS <0.05 Fat percentage (% 41.9 (7.5), 31.1 (7.3) <0.05 40.1 (13.5) 38.4 (8.20) NS <0.05 calories/d) 2) Daughters Nutrition knowledge 30.6 (6.1) 36.3 (3.0) <0.01 26.0 (5.5) 28.0 (5.7) NS 0.13 Nutrition attitude 42.3 (4.5) 43.0 (6.2) NS 39.0 (6.2) 36.6 (4.4) NS 0.13 Caloric intake (calories/d) 1718.0 (478.0) 1672.0 (37.7) NS 1791.0 (668.0) 1807.0 (904) NS NS Fat intake (g/d) 76.3 (20.2) 63.0 (37.7) <0.05 65.2 (36.0) 74.0 (41.0) NS <0.05 Fat percentage (% 40.2 (4.9) 33.7 (4.8) <0.05 32.0 (7.3) 37.8 (5.4) NS <0.05 calories/d) Abbreviations: INT, intervention; CON, control; Sig; significant; PA, physical activity; FU, follow-up; m/o, month; wk, weeks; mins, minutes; cm, centimetres; mmgh, millimetre of mercury; reps, repetitions; BMI, body mass index; BPM, beats per minute; kg, kilograms; lb, pounds; g/d, grams per day; NS, non-significant; N/A, non-applicable; NR, not-reported; UBMSE, upper body muscular strength and endurance; AMSE, abdominal muscular strength and endurance; MVPA, moderate to vigorous physical activity; CPM, average counts per minute; d.wk-1, days per week; N, no; Y, yes; U, unclear; PSP, physical self-perception. a No true control group; Δ change from baseline
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2.3.9 Results of RCTs
Ransdell et al (2004) compared a home-based (HB) physical activity health- related fitness program with a true control group for three generations of women
(grandmothers, mothers and daughters) known as Generations Exercising
Together to improve fitness or The ‘GET FIT’ study (Ransdell, Robertson, et al.,
2004). The HB intervention involved two 120-minute education sessions, then structured exercise three times per week. The HB program was a progressive program, increasing in volume and duration by 10% every two weeks, starting at
20-minute sessions, up to 60-minute continuous sessions. At post-intervention
(six months), a significant group-by-time interaction was found for self-reported flexibility [d/wk] and objectively measured physical activity (steps/day). An unexpected result was a significant group-by-time interaction reported for aerobic fitness (one mile walk) in favour of the control group. However, no significant group-by-time interaction was reported for aerobic activity (d/wk), muscular strength (d/wk), push-ups (number performed), sit-ups (number performed), and flexibility (cm) fitness measures.
Ransdell’s et al (2003) study known as the ‘Daughters and Mothers
Exercising Together’ (DAMET) compared a community-based (CB) versus home- based (HB) mother-daughter intervention to increase fitness and physical activity
(Ransdell, Taylor, et al., 2003). Physical activity data were detailed in an additional paper and have been drawn upon for this analysis (Ransdell, Detling, et al., 2004). Both groups attended two classroom sessions receiving information on physical activity, health-related fitness activities. The CB group attended sessions three times per week for 12 weeks at a local university; fitness sessions
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were conducted twice a week and lifestyle/sport activities once a week, with sessions lasting 60-75 minutes. The HB group received a package containing activities (i.e. strength, calisthenics, stretches) and tips for overcoming barriers to be completed at home. Participants completed a physical activity log and those were submitted every two weeks to the lead author. A significant group-by-time interaction was found for daughters’ muscular endurance (sit ups), with CB daughters significantly increasing their scores. A significant group-by-time interaction was found for mothers’ muscular strength (push-ups). There was no significant between group differences for any self-reported physical activity or other fitness outcomes (muscular endurance, flexibility, aerobic capacity).
Stolley et al (2003) RCT investigated a 12-week culturally-tailored obesity prevention program based on the “know your body program” for mothers and daughters, focusing on adopting a low-fat, low calorie diet and increasing physical activity levels (Stolley & Fitzgibbon, 1997). Mothers and daughters were allocated to the treatment or an active placebo control. Mothers and daughters in the treatment group attended 11 hourly sessions over 12 weeks, with diet education focusing on the risks of high-fat intakes, benefit of low-fat foods, label reading, impact of obesity, meal planning and an excursion to a local market for food education. The physical activity component involved culturally appropriate dance and low-impact aerobic exercises. The placebo control mothers and daughters received an 11-session “general health” program that did not include any diet or physical activity education. For mothers, significance between group differences was found for saturated fat and percentage fat in favour of the intervention group.
For daughters, significance between group differences was found for daughters’ percentage of fat-intake, in favour of the intervention group.
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Wadden et al (1990) conducted a 16-week obesity prevention RCT known as the ‘Weight Reduction and Price’ (WRAP) program for African American adolescent girls (Wadden et al., 1990). This study randomised three groups: i) a mother-daughter combined group; ii) a daughters-only group; and, iii) mothers and daughters treated separately at concurrent sessions. All groups were “face- to-face” for the 16-week program and received the same treatment for 60 minutes, with the exception of mother involvement, whereby mothers also received a “mother’s manual”. All participants received a manual detailing: measuring food and beverages, recording food and caloric intake, education on balanced meals and macronutrients/vitamins/minerals and ideas for increasing their physical activity. In addition to the manual, homework and quizzes were given and participants were rewarded at the following session. Weight, adiposity, cholesterol and blood pressure were measured. Diet, physical activity or fitness was not measured. Interpretation of data for this study was difficult owing to the inconsistent reporting of post-intervention measurements. There were no statistical differences between groups for weight loss, BMI or fat loss among treatment groups. Weight significantly decreased from baseline to post program in daughters. However, there were no statistically significant differences between groups. Daughters of mothers who regularly attended treatment sessions lost more weight than the daughters of mothers who did not attend or had poor attendance.
Olvera et al (2010) developed and evaluated the ‘Behaviour Opportunities
Uniting Nutrition, Counselling, and Exercise’ (BOUNCE) program, which aimed to increase physical activity and fitness in low-income Latino mothers and daughters (Olvera et al., 2010). Mothers and daughters were randomised to an
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experimental group (EG) and a comparison group (CG). The EG mothers and daughters participated in a total of 36 90-minute sessions consisting of structured group exercise, sport sessions and recreational activities three times a week, nutrition sessions twice a week and a behavioural counselling session once a week. The CG mothers and daughters met once a week for 12 weeks, participating in a 45-minute education session focused on nutrition and counselling followed by 45 minutes of light physical activities (e.g. samba or basketball). physical activity, fitness (mothers and daughters) and dietary intake
(daughters only) were all assessed in this study. A significant between-group difference was found for daughters’ aerobic capacity (P<0.05). No significant changes were found between groups for daughters’ objectively measured physical activity (MVPA mins) or diet outcomes, mothers’ physical fitness, or self- reported physical activity.
2.3.10 Summary of Evidence From Other Physical Activity, Fitness or Diet
Interventions
Table 2.4 summarises results from one pseudo-randomised controlled trial and a non-randomised and six pre-post mother-daughter studies. Overall, similar to the
RCTs, studies that assessed fitness reported significant improvements
(Kargarfard et al., 2012; Kelishadi et al., 2010; Salimzadeh et al., 2010). Dietary improvements were seen in the one study that measured dietary behaviours
(Fitzgibbon et al., 1995) whilst changes in physical activity were not significant
(Ransdell et al., 2001) at post-intervention for one study and significant in another. However, this was only for the duration of the intervention and not assessed at baseline or post intervention (Olvera, Leung, Kellam, & Liu, 2013).
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The pseudo-randomised controlled trial assessed diet in mothers and daughters, indicating a significant between-group difference for total fat-intake and percentage fat intake in favour of both mothers and daughters in the treatment group. No significant between-group differences were found for both mothers’ and daughters’ nutrition attitude and nutrition knowledge data
(Fitzgibbon et al., 1995).
Data from The ‘CASPIAN’ study (Kargarfard et al., 2012; Kelishadi et al.,
2010) were examined in two papers. However, the same group of mothers’ and daughters’ data examined in the pre-post study (Kelishadi et al., 2010) were analysed again in a second, more recent, paper (Kargarfard et al., 2012) comparing the mothers and daughters to an additional girls-only group. In the most recent paper reporting results from the non-randomised controlled trial, significant improvements were found after 12 weeks for fitness outcomes (i.e. resting heart rate, cardiovascular fitness, flexibility, muscular strength and muscular endurance) in daughters from both groups as well as mothers.
Significant between-group differences were seen for all fitness measures besides
UBMSE, revealing statistically significant larger improvements in the daughters from the mother-daughter group compared to the girls-only group.
Results from the pre-post studies should be interpreted with caution as there were no comparison groups and, for most, sample sizes were relatively small. Most of the pre-post studies assessed fitness (Olvera, Leung, Kellam, & Liu, 2013;
Salimzadeh et al., 2010), reporting a significant improvement in daughters’ fitness outcomes (One mile walk) (Olvera, Leung, Kellam, & Liu, 2013) and both mothers’ (cardiovascular endurance, flexibility) and daughters’ (muscular
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strength, cardiovascular endurance and flexibility) fitness outcomes (Salimzadeh et al., 2010). Both physical activity and fitness were found to be non-significant for mothers and daughters in one study at post-test (Ransdell et al., 2001). In one study (Olvera, Leung, Kellam, & Liu, 2013), daughters’ MVPA minutes were assessed via accelerometer. However, data were only collected daily during the intervention (between 9am-5pm, Monday-Friday). Results for daughters’ MVPA indicated a significant increase in daily MVPA from Week 1 to Week 4, although these data were not assessed pre-post intervention. Two of the pre-post studies assessed weight and adiposity in mothers and daughters (Kelishadi et al., 2010;
Olvera, Leung, Kellam, Smith, et al., 2013) and did not assess physical activity or Fitness.
Only three studies included follow-up assessment sessions beyond the post-intervention assessments. The ‘BOUNCE’ summer camp (Olvera, Leung,
Kellam, Smith, et al., 2013) included 12 weekly follow-up sessions known as the
‘Re-BOUNCE’ booster program. However, no significant declines in BMI, %body fat or waist circumference were found. This could be as a result of the high attrition for these booster sessions. As expected, daughters’ involvement in the study was much greater than what was required of mothers (i.e. daughters attending weekly sessions Monday-Friday, 9am-5pm, for four weeks, whereas mothers attended two-hour weekly sessions).
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2.4 Discussion
The aim of this systematic review was to investigate the effectiveness of mother- daughter physical activity, fitness, and/or diet interventions. Of the 12 studies identified (including five RCTs), 11 unique studies focusing on physical activity, fitness or diet were found. Overall, significant improvements in fitness were reported in both mothers and daughters in five out of the 12 studies, and for daughters only in one study. Although dietary behaviours were only assessed in three studies, findings were generally positive. Statistically significant improvements in physical activity were reported for two out of five studies, although measures of physical activity were less commonly reported in other interventions that targeted physical activity. Although some of the findings are promising, the overall methodological quality of these studies was poor, with a high risk of bias in many of the studies.
This is the first systematic review to examine physical activity, fitness or dietary interventions that exclusively targeted mothers and daughters together.
The evaluation of physical activity, fitness and diet interventions exclusively targeting mothers and daughters is a relatively under-explored area of research.
Although three studies were conducted in in the ’90s (Fitzgibbon et al., 1995;
Stolley & Fitzgibbon, 1997; Wadden et al., 1990) and three in the early 2000s
(Ransdell et al., 2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al.,
2003), only six studies were conducted over the last five years (Kargarfard et al.,
2012; Kelishadi et al., 2010; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu,
2013; Olvera, Leung, Kellam, Smith, et al., 2013; Salimzadeh et al., 2010). The lack of studies that have been conducted to improve physical activity, fitness
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and/or diet in mothers and their daughters is of concern, given the low levels of physical activity in females in comparison to males (Hallal et al., 2012), therefore future work in this area is needed. Moreover, all studies included in this review were conducted in the US and Iran, therefore more interventions are needed in other developed countries (Camacho-Minano et al., 2011) to evaluate the effectiveness of mother-daughter intervention addressing low levels of physical activity internationally.
All studies were community-based and conducted in either the US (n=9) or Iran (n=2) and none in Australia. Although there were five RCTs, study quality and mode of delivery varied considerably with some, to a certain extent high quality (n=3) and the majority poor quality (n=9). The majority of the physical activity and fitness sessions were delivered by a physical educator (Kargarfard et al., 2012; Kelishadi et al., 2010; Salimzadeh et al., 2010) or exercise science educator (Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013; Ransdell, Taylor, et al., 2003) and dietary interventions by a nutritionist/dietician, which is a strength given the facilitators are qualified and trained in instructing fitness activities and when advising on dietary behaviour changes. The cultural tailoring of intervention content was a common focus, with seven studies (Fitzgibbon et al., 1995; Kargarfard et al., 2012; Olvera et al., 2010;
Olvera, Leung, Kellam, & Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013;
Stolley & Fitzgibbon, 1997; Wadden et al., 1990) tailoring intervention material for various sub-group populations of Latin American, Hispanic, Iranian or African
American cultures. All of the abovementioned studies that tailored intervention content around participants’ cultural background believed this had a positive impact on the mothers and daughters and was a strength of their interventions.
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However, while most programs targeted females only, there was overall a lack of detail as to whether the information-specific resources and activities were gender-tailored for the unique sociological and physiological characteristics of girls and women.
The majority of positive intervention findings for both mothers and daughters data were reported for fitness outcomes. Fitness was a common intervention target and the evidence suggests targeting mothers and daughters may be an effective strategy. This is an important finding given fitness is a key health outcome independent of overall physical activity and as low levels of fitness is a concern for girls and women alike. The improvements in mother-daughter fitness outcomes may as a result of reciprocal reinforcement, i.e. mothers and daughters encouraging and motivating each other to participate in the intervention.
Moreover, it could be that the mothers and daughters participating in co-high- intensity physical activity was an incentive to make improvements to their health- related fitness.
This review identified similarities in studies which were effective in increasing mothers’ and daughters’ physical activity, fitness and diet. Successful strategies used by interventions that reported significant improvements in fitness were those that engaged mothers and daughters in interactive physical activity and fitness activities at least two (Kargarfard et al., 2012; Salimzadeh et al., 2010) to three times per week (Olvera et al., 2010; Ransdell, Robertson, et al., 2004;
Ransdell, Taylor, et al., 2003). It was evident that face-to-face, structured physical activity and fitness programs that ran for a minimum of 60 minutes per session at least twice a week were commonly associated with increases in fitness in almost
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all studies for both mothers and daughters (Kargarfard et al., 2012; Ransdell,
Taylor, et al., 2003; Salimzadeh et al., 2010) and daughters alone (Olvera et al.,
2010) during intervention periods up to 12 weeks. However, the longer-term impact of programs was rarely assessed and this impact was not sustained.
Although most studies included in this review reported their intervention to have a physical activity focus, the majority of studies assessed fitness (Kargarfard et al., 2012; Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013; Ransdell et al.,
2001; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003;
Salimzadeh et al., 2010) and not physical activity (Olvera et al., 2010; Olvera,
Leung, Kellam, & Liu, 2013; Ransdell et al., 2001; Ransdell, Robertson, et al.,
2004; Ransdell, Taylor, et al., 2003). This makes it difficult to draw conclusions about the effectiveness of interventions to improve physical activity levels in mothers and daughters, exacerbated by a distinct lack of objective physical activity measures such as pedometers and accelerometers. One of the RCTs reported no significant between-group effects for physical activity; however, both the home- and community-based groups reported significant increase in self- reported physical activity. It is difficult to interpret this finding as there was absence of a true control. Future studies should adopt true non-intervention control group. In another RCT that reported statistical improvements for daughters’ fitness, no improvements in physical activity were observed for either mothers or daughters. This might be in light of physical activity only being assessed over a two-day period via accelerometers for daughters and self- reported measure for mothers. Future studies focused on both physical activity and fitness should consider using objective measures such as pedometers,
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accelerometers, and validated fitness testing procedures. Similarly, a previous systematic review regarding the effectiveness of physical activity interventions targeting girls reported the overall findings were mixed, with some studies failing to increase girls’ physical activity and others were somewhat successful reporting modest results (Camacho-Minano et al., 2011). In contrast, most recently, Biddle and colleagues’ (2014) review of the effectiveness of interventions to increase physical activity among young girls found studies were somewhat successful
(Biddle et al., 2014), only for short-term interventions, i.e. less than three months duration, that were educational, multicomponent (i.e. targeting physical activity and diet) and delivered in a girls-only setting. This indicates that future interventions for girls should execute rigorous designs, adopt objective measures, and have longer follow-up assessing potential behaviour change mediators (Biddle et al., 2014).
There were a limited number of studies which included a dietary focus.
Two studies reported significant improvements in diet quality (fat intake and fat%)
(Fitzgibbon et al., 1995; Stolley & Fitzgibbon, 1997). However, in one of the studies, the dietary measure had only been validated in adults (Stolley &
Fitzgibbon, 1997). Common features of the successful dietary interventions included reading food labels, planning and preparing healthy food and mothers being involved in all sessions of the programs which aimed to educate on improving diet quality through a low-calorie diet. It is likely that mothers who change their dietary patterns will influence their daughters’ dietary patterns as well, given their primary influence as food providers and role models. This is consistent with a systematic review by van der Horst and colleagues who reported child fat, fruit and vegetable intake was consistently associated with
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parental dietary intake (van der Horst et al., 2007). However, in another systematic review, such findings were substantially varied across studies (Wang,
Beydoun, Li, Liu, & Moreno, 2011). In the current review, it was stated in both of the successful studies that larger improvements were seen in mothers than daughters. This might have been owing to mothers’ higher levels of motivation and concern for their own health and weight, and other influences outside the home on girls’ dietary behaviours. Of note, however, was that these dietary measures were self-reported, in which participants could report more socially- desirable improvements (Stolley & Fitzgibbon, 1997). In contrast to the success of the above-mentioned dietary interventions that had a sole intervention focus on improving diet, one other study did not significantly change daughters’ behaviour (Olvera et al., 2010), although this program had a large focus on increasing fitness. Three sessions per week were dedicated to fitness activities, compared to the dietary information sessions only occurring once a week. In contrast, the two other studies that measured dietary behaviour reported significant improvements, but were focused on diet more than fitness or physical activity. Therefore, the lack of success for improving dietary behaviours could be owing to a lower emphasis being placed on nutritional dietary content.
Interestingly, in the obesity prevention study ‘WRAP’ (Wadden et al.,
1990), while no significant differences were reported between groups for weight, daughters of mothers who had high attendance had greater weight loss compared to the daughters of mothers who had poor attendance or no attendance at all (daughters-only group). This demonstrates two important points.
First, that promotion of family involvement, in this case maternal involvement, in a face-to-face program is an effective strategy for improving daughters’ health
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outcomes and, second, that encouraging a family member to improve their behaviour can impact positively on their child’s behaviour. A review by Hingle et al on the effectiveness of parent involvement in child dietary interventions found that interventions which directly involved parents showed more favourable effects for dietary outcomes (Hingle et al., 2010).
2.4.1 Evidence from RCTs
Of the five RCTs identified in the current review, two measured both physical activity and fitness (Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al.,
2003), one measured diet alone (Stolley & Fitzgibbon, 1997), and one measured all three: physical activity, fitness and diet. However, diet was only reported for daughters (Olvera et al., 2010) and one did not measure physical activity, fitness nor diet (Wadden et al., 1990). Of the four RCTs that measured fitness, significant improvements in fitness were evident and all interventions had significant intervention effects for mothers’ and daughters’ flexibility (Ransdell, Robertson, et al., 2004), mothers’ muscular strength (Ransdell, Taylor, et al., 2003), daughters’ muscular endurance (Ransdell, Taylor, et al., 2003) and daughters’ aerobic capacity (Olvera et al., 2010). An unexpected finding in one RCT was a significant improvement in the control mothers’ and daughters’ aerobic fitness
(Ransdell, Robertson, et al., 2004). Significant intervention effects were found for physical activity in one study, reporting a significant intervention effect for steps measured objectively via pedometry. It is difficult to separately decipher the effect for the mothers and daughters, as step counts were aggregated as a family average rather than reporting separately for mothers and daughters. Although
MVPA and average counts were measured via accelerometry in one RCT with
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no significant intervention effects, a limitation of this study was the assessment of daughters’ MVPA only, and no objective measure for mothers (Olvera et al.,
2010). Dietary intake change were significant in one of the RCTs, with an intervention effect for mothers’ sat fat, % fat and daughters’ % fat intakes (Stolley
& Fitzgibbon, 1997).
A common theme emerging from the findings of these RCTs is that the studies which reported some form of statistical improvements in physical activity, fitness or dietary measures had mothers and daughters participating in the intervention together, rather than having mothers participate alone in the program. It seems that interventions that target both mothers’ and daughters’ behaviours, allowing mothers and daughters to participate at the same time and complete intervention tasks together, were successful in enhancing health outcomes. This is supported by Barr Anderson and colleagues’ review, who found studies that involved the family member to engage in changing their own behaviour, as opposed to just supporting their child, had positive effects on child behaviour compared to studies that did not target changing the family member’s behaviour (Barr-Anderson et al.,
2013). In a recent longitudinal study, maternal co-physical activity was strongly associated with girls’ physical activity and a brief review by Trost and Loprinzi reported strong evidence for parental support (i.e. parents actively playing with child) associated with children’s physical activity behaviour (Trost & Loprinzi,
2011).
The RCTs included in this review generally had small samples (≤65 mothers and ≤65 daughters) and had large variation in the measures of physical activity, fitness and diet. Moreover, one study assessed daughters’ fitness only
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as opposed to assessing mothers as well (Olvera et al., 2010), and self-reported measures for physical activity (Ransdell, Taylor, et al., 2003), fitness (Ransdell,
Robertson, et al., 2004) and diet (Olvera et al., 2010; Stolley & Fitzgibbon, 1997) were used in most studies. The risk of bias was lower for the RCTs than the other study designs included in the review, with the majority of the RCT studies meeting the “explicitly described” criteria for four out of the nine risk-of-bias categories, therefore highlighting study limitations.
Overall, results must be considered with caution, owing to the lack of RCTs
(less than half of the interventions) and high risk of bias found for each study. All studies had a high risk of bias for blinding of outcome assessment, with no studies meeting this criterion. Additionally, there was a high risk of bias for participants being excluded because of missing data, with only two studies performing ITT.
Only 50% of the studies reported study retention rates, which were in the range of 18%-100% and no study clearly reported randomisation procedures. Criteria such as blinding outcome measures, not performing intention to treat analysis
(ITT) and clearly reporting study retention have a large impact on bias towards the intervention’s effectiveness (Liberati et al., 2009). In the current review, over
60% used a valid measure of at least one of physical activity, fitness or diet outcome. However, no studies reported a power calculation for their primary outcome of physical activity, fitness or diet.
2.4.2 Recommendations for future studies
Successful interventions were those that prompted behaviour change for both mothers and daughters, and interventions where mothers were equally involved
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in the program with their daughters. Highly interactive interventions with face-to- face contact at least two to three times per week for a minimum of 60 minutes per session were associated with positive fitness outcomes in mothers and daughters. Therefore, there is evidence for intervention “dose” of a minimum of bi-weekly sessions combining practical physical activity and fitness as well as educational session. Intervention detail was generally limited; therefore, it is difficult to explain how the interventions engaged mothers and daughters, and strategies used. Therefore, future interventions should explicitly explain this in greater detail. Moreover, future studies should use the CONSORT (Moher,
Hopewell, et al., 2010; Schulz et al., 2010) framework when developing and evaluating interventions. Furthermore, interventions should adopt an RCT design, and ensure randomisation procedures are adequately reported. More evidence is needed using objectively measured physical activity (i.e. via pedometers or accelerometers) and these measures should be used in both mothers and daughters. Dietary interventions should employ validated measures to assess dietary intake in both mothers and daughters. Studies which design intervention content regarding physical activity, fitness, and/or diet should aim to measure these outcomes using objectively validated tools. Future studies should ensure follow-up beyond post-intervention to assess any sustained and long-term effects.
2.4.3 Strengths and limitations
The current review has the following strengths:
(i) a comprehensive search strategy across multiple databases;
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(ii) high agreement levels for risk of bias assessment;
(iii) extensively detailed data extraction to allow for comparison between studies; and,
(iv) alignment with the PRISMA statement (Liberati et al., 2009; Moher,
Liberati, et al., 2010).
There are, however, limitations to acknowledge. First, studies were required to be published in English. Second, this review reported on a relatively small amount of studies, therefore the combination of results via meta-analysis was not possible and hence the review must be interpreted with caution.
2.5 Conclusion
There are limited lifestyle interventions designed exclusively to target mothers and daughters. Existing evidence suggests some mother-daughter interventions have been successful in improving fitness levels in mothers and daughters, but there have been few studies that have objectively measured diet and physical activity. Such findings should, however, be interpreted with caution in light of the limited high-quality studies. Future research is warranted to evaluate high-quality
RCTs and implementing follow-up beyond post-intervention. In addition, interventions should employ the use of objectively measured outcomes, i.e. accelerometers or pedometers for physical activity assessment; objective measures for diet; and, objectively measured fitness such as the Fitnessgram battery of tests validated in children and adults. It is clear that physical activity, fitness and diet are important health behaviours to be targeted, particularly
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among females, and targeting mothers and daughters simultaneously is a novel approach which should be explored in future research.
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3 Chapter 3: Methods
The methods associated with thesis Aim Two (1.7.1.2): ‘To examine specific maternal correlates of objectively measured physical activity in girls, including demographic, anthropometric, behavioural, activity-related parenting practices and physical activity cognitions’, and Aim Three (1.7.1.3): ‘To evaluate the (i) feasibility (recruitment, retention, attendance, acceptability and satisfaction); and,
(ii) preliminary efficacy of a mother-daughter physical activity program targeting improvements in physical activity levels’ is provided in Chapter 3.
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3.1 Study Design
This study was a two-armed pilot randomised controlled trial (RCT) entitled
‘M.A.D.E (Mothers and Daughters Exercising) 4 Life’ (MADE4Life) involving 40 mothers and their 48 primary school-aged daughters (5-12 years).
3.1.1 Study Design: Aim Two
Baseline datum from the mothers and their daughters who were recruited into the
MADE4Life pilot randomised controlled trial were used to address Aim Two of this thesis. Of the 40 families recruited for this intervention, eight families had more than one daughter; therefore datum from these mothers and their eldest daughter were included for the analysis.
3.1.2 Study Design: Aim Three
Mothers and their daughter(s) were stratified by BMI category (Healthy Weight;
18-24.99, Over Weight; 25-29.99, Obese1; 30-34.99, Obese2; 35-39.99,
Obese3; >40) and randomly assigned to either the (i) MADE4Life intervention, or
(ii) a six-month wait-list control group (refer to Section 3.2.5 for randomisation detail). Assessments occurred at baseline, immediate post-intervention (10 weeks) and three-month follow-up (20 weeks). This study data addresses Aim
Three of this thesis. Participants and assessors were blind to group allocation at baseline assessment. The wait-list control group received no information or intervention prior to attending follow-up assessments. The following sections will explain the methods in greater detail.
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3.2 Participants
Mothers and their primary school-aged daughters (5-12 years) were recruited to the MADE4Life program. This study recruited a sample of mothers (n=40), and their daughters (n=48) from the Newcastle/Hunter region in Australia. Of the 40 families recruited for this intervention, eight families had more than one daughter.
Overall, 88 mothers and daughters were included in the study. A study design for the MADE4Life study is presented below in Figure 3.1.
Recruitment
Baseline
Randomisation
MADE4Life Wait-list Control
Immediate post-intervention assessment
Figure3-month 3.1 postStudy-intervention design for the assessmentMADE4Life RCT
3.2.1 Recruitment
Recruitment began approximately three-and-a-half weeks prior to baseline assessments. A host of strategies were utilised to recruit participants for the program which was free of charge to participating families. The PhD Candidate contacted primary schools within the Newcastle region (n=86) and spoke
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personally with the Principal or Assistant Principal for permission to send study recruitment pamphlets (Appendix 6) home with the school newsletter (n=75), attend school assembly presentations (n=10) and meet parents at school gates with program information. MADE4Life information and program dates were printed in school newsletters (Appendix 7). The PhD Candidate and undergraduate research assistant volunteers handed pamphlets to parents at school gates both before and after school hours. The PhD candidate attended school assemblies to present the program information to students, along with additional flyers to take home. The following media recruitment methods were utilised:
• University of Newcastle media release (Appendix 8);
• local television news coverage;
• two local radio station interviews;
• two local newspaper coverage (Appendix 9);
• websites (getnetworking.com.au); and,
• Twitter (Good Health Care and University of Newcastle).
Interested participants were able to contact the research team to conduct a telephone screen to ensure they met the eligibility criteria (Appendix 10).
Participants who passed the eligibility screen were sent, via email/post, the
Participant Information Statement and Consent form, Doctors Clearance form if
>40years or indication of previous condition (as per Sports Medicine Australia guidelines), and a Pre-Exercise Screening Questionnaire (Appendix 11). Consent forms and any additional documentation were required prior to commencement of baseline assessments. There were numerous mothers who contacted the
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study telephone number or email address who were ineligible owing to: daughter(s) having commitments on the set dates (dancing, sport training, swimming lessons, drama, choir practice); mothers having work commitments on the set dates and session times; daughter was too young (attending pre-school,
<5 years old) or too old (attending high school, >12 years old); and/or, childcare accountabilities were an issue for other children. A further 75 mothers are on a waiting list for future programs, as the study target sample size was achieved in just three weeks.
3.2.2 Eligibility Criteria
Mothers were considered eligible for the MADE4Life study if they met the following criteria:
• female;
• aged 21-60 years;
• had a daughter aged 5-12 years (primary school age);
• able to pass a health-screening questionnaire; and,
• available for assessment and intervention sessions (see below for details).
Mothers were deemed ineligible to participate if they met any of the following:
• had a history of major medical problems such as heart disease or diabetes;
• had orthopaedic or joint problems that would be a barrier to completing
physical activities such as walking; and,
• were pregnant.
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3.2.3 Ethical Approval
Approval was sought and obtained by the University of Newcastle Human
Research Ethical Committee (HREC) (Appendix 12) to conduct this study. Where ethical variations were sought, approval was obtained prior to data collection.
Written informed consent was obtained for the mothers, and informed assent was obtained for the daughters for the study (Appendix 13).
3.2.4 Assessment Sessions
Baseline assessments were held one week prior to the program beginning (July
2011). Assessment sessions were held during weekday afternoons and evenings between 3:15-7:30pm. Immediate post-intervention assessments were held at 10 weeks (study’s primary end point; September 2011). Finally, three-month post- intervention assessments were held at 20 weeks (December 2011).
3.2.5 Randomisation
Prior to leaving the baseline assessment session, randomisation was completed by the PhD candidate. The random allocation sequence was generated by a computer-based, random number-producing algorithm in block lengths of six to guarantee an equal chance of allocation to each group. To ensure concealment, the sequence was generated by a statistician and given to a researcher who was not involved in the assessment of participants. The allocation sequence was concealed in envelopes that were categorised by BMI labels, by the researcher who was not involved in the assessment of participants. Randomisation was completed by the PhD candidate at the end of the baseline assessment session, where according to the mother’s BMI [kg]/height[m] the appropriate sealed
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envelope (Healthy Weight; 18-24.99, Over Weight; 25-29.99, Obese1; 30-34.99,
Obese2; 35-39.99, Obese3; >40) was selected that contained the group allocation. Mother-daughter dyad/triads were explained the requirements of their allocated group by the PhD candidate and given a ‘Where to From Here’ information sheet (Appendix 14), i.e. Intervention program beginning the following week, or wait-list control who would return for two additional follow-up assessments and receive the program in six months’ time.
3.3 Intervention
3.3.1 The M.A.D.E 4 Life Program
The MADE4Life program involved mothers and daughters attending weekly after- school sessions over an eight-week period. The sessions were 90 minutes in duration, with the mothers and daughters attending separate education sessions for the first 25 minutes, with the final 60 minutes involving mothers and daughters participating together in the physical activity sessions. The mothers’ education sessions were delivered by the PhD candidate who holds undergraduate qualifications in physical education, while the daughters’ education sessions were conducted by a female qualified physical education teacher. Both teachers led the MADE4Life practical sessions (see Table 3.1 in Section 3.2.1.3).
The aim of the MADE4Life program was to encourage physical activity in girls and their mothers, and to promote positive physical activity role modelling and positive physical activity parenting practices in mothers. MADE4Life was informed by Social Cognitive Theory (Bandura, 1986) by operationalising the theory’s key constructs of self-efficacy, social support and outcome expectations.
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MADE4Life encouraged reciprocal mother-daughter reinforcement (Golan,
Weizman, Apter, & Fainaru, 1998) of physical activity. For example, daughters encouraged their mothers to be active with them, particularly regarding completion of the ‘Pink Slip’ tasks (see section 3.3.1.1.1); and mothers encouraged their daughters to participate in physical activity with them.
Participants received a variety of resources at the beginning of the MADE4Life program, including a pedometer, MADE4Life t-shirt and drink bottle, Lorna
Jane™ exercise hairband, Lululemon Athletica™ exercise tote bag and a skipping rope.
Figure 3.2: MADE4Life resources
The MADE4Life program was based on successful strategies from the
‘Healthy Dads, Healthy Kids’ program (Morgan et al., 2014; Morgan et al., 2011) including family-based activities, goal setting, homework tasks and selected session content for physical activity.
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3.3.1.1 Daughters’ Education Sessions
While the mothers’ education session was being conducted, the daughters’ education session was led in an adjacent room. Session content was based on the NSW K-6 PDHPE Syllabus, Active Lifestyles strand (Board of Studies NSW,
2007). Daughters’ education sessions focused on developing an active lifestyle, benefits of physical activity, fitness, fundamental movement skills and ways to reduce screen time. Details of daughters’ weekly education session content is outlined in Table 3.1.
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TABLE 3.1: INTERVENTION CONTENT AND ALIGNMENT WITH SCT
Session Theory Component Physical Activity Pink Slip Behaviour Change (25minutes) Component task SCT construct (60 minutes) 1 Mums Fun games Game and * Outcome expectations: Provide information about Why are you here?, aims of program creative importance of PA NSW SPANS report, benefits of Rough & tumble dance * Social support: Provide social support & being physically active, importance of play task. encouragement for mums and daughters mothers and PA * Self-efficacy: Develop skills in a range of PA Zumba™ * Self-efficacy: Provide opportunities to develop Daughters self-confidence in a variety of PA skills Aims of program, discussion of what they like doing with their mums, PA interests 2 Mums Aerobics Fitness * Outcome expectations: Provide information about PA recommendations – adults & tasks, inactivity consequences children, why are children inactive? Fitness Circuit pedometer * Goal setting: Prompt goal setting health-related fitness, Mums as role- challenge * Self-efficacy: Develop skills in a range of PA models & facilitators, SMART Signature Dance and * Self-efficacy: Provide opportunities to develop GOALS Move SMART self-confidence in a variety of PA skills goal task. * Social support: Provide opportunities for mother Daughters and daughter to develop PA behaviours PA recommendations (5-12 years), health-related fitness 3 Mums Pilates & Yoga Yoga/Pilat * Outcome expectations: Provide information about Review SMART GOALS, screen time es task, sedentary behaviour consequences recommendations Reducing Resistance pedometer * Goal setting: Self-monitoring skills by setting goals sedentary behaviour, incorporating training challenge, * Self-efficacy: Develop skills in a range of PA incidental PA into everyday Fitballs fitness * Self-efficacy: Provide opportunities to develop
challenge. self-confidence in a variety of PA skills Medicine/soft Daughters * Social support: Provide opportunities for mother volley balls and daughter to develop PA behaviours 90 Methods
Session Theory Component Physical Activity Pink Slip Behaviour Change (25minutes) Component task SCT construct (60 minutes) A balanced lifestyle, screen time Fit Boxing recommendations, imagine life without TV or computers Gymstick (mothers only) 4 Mums Games Utilise * Outcome expectations: Provide information about 100 ways to unplug & play, Fundamental session sedentary behaviour consequences Fundamental Movement Skills, FMS Movement Skills resources, * Goal setting: Prompt goal setting & girls, VPA, Setting new SMART pedometer * Self-efficacy: Develop skills in to decrease screen GOALS challenge, time VPA * Self-efficacy: Provide opportunities to develop Daughters challenge. self-confidence in a variety of PA skills Fundamental movement skills, * Social support: Provide opportunities for mother Importance of FMS being FUN and daughter to develop PA behaviours 5 Mums Games Creative * Outcome expectations: Provide personalised Baseline results (weight, BMI, BP, Rough and tumble game information about BMI category, BP, HR and MVPA HR, MVPA), get in ‘their’ world, rough play task, minutes and compare to recommendations & tumble play for MUMS pedometer * Goal setting: Prompt goal setting in relation to challenge, their baseline results Daughters rough and * Self-efficacy: Develop skills to engage in What is important in ‘their world’, tumble daughter’s world creation of unique game to play with play * Self-efficacy: Provide opportunities to develop Mum for homework challenge. self-confidence in a variety of PA skills * Social support: Provide opportunities for mother and daughter to develop PA behaviours 6 Mums Skipping with Skipping * Outcome expectations: Brainstorm perceived Brainstorming barriers to PA, ropes circuit barriers to PA brainstorming solutions to the challenge, *Self-efficacy: Barrier identification of other mothers barriers, keeping on track Partner drills pedometer in group challenge, Daughters VPA 91 Methods
Session Theory Component Physical Activity Pink Slip Behaviour Change (25minutes) Component task SCT construct (60 minutes) Brainstorm ways to be more active Skipping Circuit & interval * Social support: Discuss barriers and brainstorm with MUM, design a poster to choreograph challenge. solutions to PA with other mothers in similar influence other girls & their mums to skipping to music situations be active *Social support: encourage PA strategies that involve support of mum-daughter *Goal setting: Increase knowledge and skills relating to PA behaviours 7 Mums Backyard games Backyard * Outcome expectations: Provide solutions to Defining realistic solutions to PA games perceived barriers barriers, group support discussion challenge, * Goal setting: Prompt goal setting pedometer * Self-efficacy: Develop skills in to decrease screen Daughters challenge, time Scenarios: couch potato, rainy skipping to * Self-efficacy: Provide opportunities to develop weather, mum is busy, brainstorm music, self-confidence in a variety of PA skills solutions to the barriers, role play SMART * Social support: Provide opportunities for mother goal task. and daughter to develop PA behaviours 8 Mums The Amazing Race N/A * Goal setting: Set goals for post program Where to from here?, recap of all * Social support: Review opportunities for PA and resources & equipment to continue to resources available use to stay active for life *Self-efficacy: Reflect on achievements since beginning of program Daughters * Social support: Encourage known opportunities for Recap of favourite games create a mother and daughter to develop PA behaviours thank you card for Mum
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3.3.1.1.1 Daughter’s Booklet and Pink Slip Tasks
A ‘Daughter’s Booklet’ contained weekly worksheets with activities focusing on group work and problem solving (Appendix 15). Emphasis was given to topics including the importance of physical activity, fun ways to be active, reducing screen time and problem solving activities involving role play (e.g. how to overcome a lack of physical activity equipment). Daughters were asked to complete weekly ‘Pink Slip’ homework tasks that encouraged home physical activity with their mothers (Appendix 16). Pink
Slips were given to daughters for weeks one to seven. Activities included, for example, creating home-based fitness circuits, participating in pedometer challenges and incorporating VPA into their afternoon activities with mum. Pink Slips were reviewed weekly, and daughters were rewarded with a “scratch n smell” sticker to attach to a MADE4Life sticker chart (Appendix 17) on completion. Details of weekly Pink Slip tasks are outlined. At the final session of the MADE4Life program, daughters presented their mothers with a personalised card (Appendix 18). Mothers presented their daughters with a personalised certificate (Appendix 19).
Figure 3.3: Daughters’ MADE4Life resources
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3.3.1.2 Mothers’ Education Sessions
Mothers’ education sessions consisted of evidence-based information on physical activity, e.g. physical activity prevalence, physical activity behaviour change, role modelling and supportive strategies to use with their daughter(s). MADE4Life sessions focused on the importance of girls having mothers who were a positive and active female role model (Ransdell, Robertson, et al., 2004; Stolley & Fitzgibbon,
1997). Mothers were advised on how to overcome perceived physical activity barriers, including low-cost physical activity options. Details of mothers’ weekly education sessions content is outlined in Table 3.1.
3.3.1.2.1 Mother’s Manual
Mothers were given a ‘Mother’s Manual’ with copies of the weekly session outlines
(Appendix 20) and various resources that supported mother-daughter physical activity. Mothers were encouraged to set SMART goals (Appendix 21) and self- monitor their daily physical activity using the pedometers (Appendix 22). Print material resources were given to mothers to file in their manuals including the
National Physical Activity Guidelines (Department of Health and Ageing, 2010),
Heart Foundation resources, e.g. 100 ways to unplug & play, and fitness circuit activity cards. A detailed document ‘Pathways and Possibilities’ was created for
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participants in MADE4Life, detailing local walking, cycling and scooting tracks,
Zumba and Dance classes, Pilates and Yoga studios, Family Fun activities and local sporting clubs (touch football, soccer, futsal, netball, basketball, hockey, little athletics, tennis, AFL, cricket, oz-tag, gymnastics, cheerleading, martial arts, swimming, and exercise DVDs) (Appendix 23). The aim of this document was to increase awareness regarding pathways to a wide variety of physical activity options in the community.
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3.3.1.2.2 Mother-Daughter Physical Activity Sessions
The major focus of the mother-daughter physical activity sessions was on fun active games, health-related fitness (Ortega, Ruiz, Castillo, & Sjöström, 2008), Zumba, aerobics (Donath, Roth, Hohn, Zahner, & Faude, 2013), Pilates, yoga (Jago, Jonker,
Missaghian, & Baranowski, 2006), rough and tumble play (Fletcher, May, St George,
Morgan, & Lubans, 2011) and fundamental movement skills (Lubans, Morgan, Cliff,
Barnett, & Okely, 2010). The aim of the MADE4Life program was to engage mothers and daughters in a wide variety of gender-tailored activities, some of which might be new to them, and some which were designed to challenge the traditional
“stereotypes” of sports activities. For example, mothers and daughters participated in a variety of activities that might have been less common to them, such as rough and tumble play and resistance fitness, i.e. boxing. Education content, physical activities, Pink Slip tasks and alignment with SCT are summarised below (see summary Table 3.1 and detailed table Appendix 24).
3.3.2 Wait-list control group
Mothers and daughters allocated to the wait-list control group were instructed to continue on with their normal lifestyle, i.e. participate in activities as per usual and not deliberately changing their physical activity levels. Control participants were asked to continue to participate in the research by completing the final baseline assessment of wearing their accelerometers. Further to this, control participants were notified of the immediate post-intervention follow-up and three-month post-test
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follow-up assessment sessions. Control participants were informed that in six months’ time they would receive the MADE4Life program, following the aforementioned assessment sessions.
3.4 Processes
3.4.1 Data Collection
3.4.1.1 University Assessment Sessions
On arrival at assessment sessions, mothers and daughters were greeted by the PhD candidate and given a name tag to wear during the assessment session. Participants were encouraged to empty their bladder prior to starting their assessments, to ensure an accurate reading for the bioimpedance body composition analysis. In the laboratory, physical assessments for both mothers and their daughters were performed and recorded on assessment measuring sheets (Appendix 25), as per the assessment protocol (Appendix 26). Participants were then accompanied to an adjacent classroom for further physical measures. While having their blood pressure recorded, mothers completed a ‘Mother Questionnaire Booklet’ (Appendix 27).
On completion of all other assessments, participants were accompanied to a quiet room where the physical activity assessment via accelerometry was explained by the PhD candidate. Each participant was allocated an Actigraph GT3X or GT3X+ accelerometer and an activity monitor log (Appendix 28). Details of the specific
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accelerometer identification number were recorded in two locations: on participants’ assessment sheet and the activity monitor record sheet. The PhD Candidate explained important information that is detailed on the activity monitor information sheet, and an information sheet was provided to the daughters to take to school for their teachers (Appendix 29). Participants were asked to wear the accelerometer for seven days (starting wear-time the day following their assessment) and to complete their activity monitor logs. Participants were asked to return their accelerometers and log sheets back to the HPE building in the MADE4Life drop-box on day eight. Each mother-daughter dyad/triad was supplied with a $10 voucher valid at a national supermarket chain to cover the cost of travel and parking at the end of their assessment session.
All data collection for this pilot RCT took place in the Human Performance
Laboratory, located in the Health and Physical Education Building at The University of Newcastle.
3.4.1.2 Assessor Training
Eight volunteer undergraduate students studying Education, Health and Physical
Education, Health Sciences or Nutrition and Dietetics were recruited for the assessment sessions. All volunteers attended an assessment training session, whereby each volunteer was educated and trained with a MADE4Life assessment protocol (Appendix 26) by an external researcher. The study protocol was supplied to volunteers and step-by-step instructions were detailed for each assessment measured. Where possible, the same assessor carried out the same assessment at 98 Methods
baseline, and immediate post-intervention and three-month post-intervention follow- up to ensure quality control. Trained assessors obtained all measures. All assessors were blind to group allocation at baseline assessment.
3.5 Measurement of Study Outcomes
3.5.1 Objectively measured Physical Activity
The primary outcome for this pilot RCT was daughters’ % time spent in moderate- to-vigorous physical activity (MVPA) at immediate post-intervention assessments.
3.5.1.1 Physical Activity Measure: Actigraph GT3X and GT3X+ Accelerometer
Physical activity was measured objectively via the Actigraph GT3X and GT3X+
(ActiGraph, LLC, Fort Walton Beach, FL, USA) accelerometer on all participants.
Accelerometers are considered to be a valid and reliable tool for both children (Trost,
Loprinzi, Moore, & Pfeiffer, 2011) and adults (Vanhelst et al., 2012). Accelerometers were initialised by the PhD student to collect data in 15-second epochs for daughters and 60-second epochs for mothers (Trost et al., 2011). Separate cut-points were applied for daughters’ physical activity data; sedentary (0-25) light (26-573), moderate (574-1002), vigorous (1003-100000) (Evenson, Catellier, Gill, Ondrak, &
McMurray, 2008; Trost et al., 2011), and mothers’ physical activity data; sedentary
(0-100), light (101-1951), moderate (1952-5724), hard (5725-9498) very hard (9499-
100000) (Freedson, Pober, & Janz, 2005).
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3.5.1.2 Physical Activity Data Collection Procedures
The Actigraph GT3x and GT3X+ accelerometers were used to objectively assess physical activity for seven consecutive days in both mothers and daughters.
Participants were instructed to wear the monitor on their left hip, attached to an elastic belt. Participants were instructed to wear their accelerometer during all waking hours, with the exception of contact with water (showering, bathing, swimming or beach activities) or contact sports (netball or gymnastics). The PhD candidate explained procedures of wearing the monitor to each individual family at baseline, and again at immediate post-intervention and three-month post-test follow- up, and further explanation was provided to each participant on the activity monitor information sheet (Appendix 28). All participants were required to complete a log of additional activities including when the monitor was put on and taken off and any time spent swimming, bicycling or on a trampoline. For daughters who were too young to complete this, mothers were responsible for ensuring the activity log was completed (Appendix 28). To reduce confusion and ensure mothers and daughters did not get their monitors mixed up, serial numbers were recorded on the individual’s activity monitor sheet and daughters’ monitors were identified with a coloured sticker.
To promote participant compliance with wearing the activity monitors, reminder text messages were sent twice over the seven-day monitoring period.
3.5.1.3 Physical Activity Data Reduction and Data Scoring
Once accelerometers were returned, each individual monitor was downloaded as a raw file using Actilife software. Raw files were coded with individual participant 100 Methods
identification numbers and reduced to a .CSV and .DAT file. Reduced files were then opened using MeterPlus (Santech Inc, Version 4.2) and data cleaning was performed. Parameters were applied to the software, whereby data were only considered valid if there was a minimum of ≥ 480 minutes (eight hours) of wear time.
Daughters’ data with ≥20 minutes (Cain, Sallis, Conway, Van Dyck, & Calhoon,
2013; Salmon et al., 2011) and mothers’ data with ≥60 minutes of consecutive zeros were considered non-wear time and excluded from analysis. Batch scoring was then applied separately for mothers and daughters.
Scored files were imported into a Microsoft Excel file (D.P. Cliff, accelerometer workshop, 23rd September 2011) for further variable calculations and assessment of eligibility. Counts per minute (CPM) were calculated which is also referred to as ‘total activity’, and has been validated against doubly labelled water
(Eukelund, et al. 2001). Total counts were divided by total minutes monitored to calculate mothers’ and daughters’ mean counts per minute (CPM). Mean minutes in
SED, LPA, MPA, VPA were calculated by dividing total counts in the respective intensity by the total minutes monitored for that day. To ensure variation in wear time was accounted for, values were calculated for percentage of monitored time spent in sedentary behaviour (% SED), light physical activity (%LPA) moderate physical activity (%MPA), vigorous physical activity (%VPA) and health enhancing or moderate-to-vigorous physical activity (% MVPA) by dividing total valid minutes in the respective intensity by total valid epochs, multiplied by 100.
Participants’ data were only included in the analysis if accelerometers were worn for a minimum of ≥480 minutes on a minimum of ≥4 days (Mattocks et al., 2008; 101 Methods
Salmon et al., 2011) and this criterion has been shown to be acceptable in a recent review (Cain et al., 2013).
As accelerometers do not account for wear time when participating in swimming, bicycling or trampoline activities, participants were prompted to utilise their activity monitor sheets to record activities not captured whilst wearing an accelerometer (Appendix 28). After reviewing participants’ activity monitor log data, additional minutes of swimming, bicycling and trampoline activities were summed and an adjusted minutes column was added to the data set. These adjusted minutes were only calculated for days that were included in the set minimum wear time criteria, i.e. ≥480 minutes and on a valid day. The Compendium of Physical Activities was used to categorise the following activity intensities: swimming (≥ 3 METs) moderate; bicycling (≥ 3 METs) moderate; and, trampoline activity (≥ 3 METs) moderate (Ainsworth et al., 2011). Adjustments were made by adding reported minutes to the total minutes of MVPA for the recorded day. The adjusted % MVPA was calculated by dividing total valid minutes in the respective intensity by total valid epochs, multiplied by 100.
3.5.2 Mothers’ questionnaire
The following sections 3.5.2.1 – 3.5.2.4 were assessed via the Questionnaire
(Appendix 27). Research staff were given an overview of the questions and adhered to the assessment protocol with detailed instructions for the questionnaire administration. Mothers’ Questionnaire Booklets were distributed while mothers were being tested for their blood pressure and resting heart rate. Mothers completed 102 Methods
the questionnaire at baseline assessment, repeating the same process at immediate post-intervention and three-month post-intervention follow-up.
3.5.2.1 Physical Activity Behaviours
3.5.2.1.1 Measure: GODIN Leisure Time Exercise Questionnaire (GLTEQ)
The GODIN Leisure Time Exercise Questionnaire (GLTEQ) (Godin & Shephard,
1985) was used to assess maternal leisure time exercise habits. Mothers self- reported their physical activity via a modified version (Plotnikoff et al., 2010) of the validated Godin Leisure-time Exercise Questionnaire (GLETQ) and reported the number of times per week (average week over the past month) and minutes per session they spent in strenuous (rapid heartbeats, sweating), moderate (not exhausting, light perspiration) and mild (minimal effort and no perspiration) physical activity for a minimum of 10 minutes per session.
Mothers’ responses for “times per week” for strenuous, moderate and mild were multiplied by “minutes per session” according to the category (strenuous, moderate and mild). MET scores (MET-minutes/week) were generated by multiplying reported weekly minutes in each intensity category by each respective
MET-minute value (i.e. moderate intensity minutes multiplied by 4 MET and vigorous intensity by 7.5 MET) (Brown & Bauman, 2000). Mothers’ moderate and vigorous activities were summed to create a total MVPA minutes per week variable. Final
MET-mins were calculated using self-reported Strenuous and Moderate Mets
(excluding mild) representing MVPA. Mild activity was excluded in this case as mild
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activity is not associated with the health benefits of moderate to vigorous activities and for the purpose of this study, the focus was on MVPA.
3.5.2.2 Maternal Parenting for Physical Activity
3.5.2.2.1 Measure: Combination of validated parenting scales
Mothers’ parenting of physical activity was measured by adapting either full scales or selected items of previously validated scales (detailed below). In the current study, principal components factor analysis and reliability analysis were performed for each of the maternal physical activity parenting scales. Items were deleted if they did not adequately load on their intended factor and adversely impacted on internal reliability as assessed by Cronbach’s alpha. The scores for each individual scale were summed and mean scores were calculated. In detail, the following subscales were assessed:
Maternal beliefs about daughters’ physical activity.
Psychosocial measures of parental beliefs were modified from Lee and colleagues (2010), and the title “parents” was changed to “mothers” (Lee et al.,
2010). Five items on maternal beliefs about physical activity were measured on a four-point Likert scale, ranging from “strongly disagree” to “strongly agree”, about the outcomes of physical activity for girls, e.g. ‘Girls who do regular physical activity have more self-confidence’. Cronbach’s α for the maternal beliefs scale was 0.84.
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The Activity Support Scale (ACTS) (Davison et al., 2003) integrates two domains of parents support for children’s physical activity: logistic support and explicit modelling. These scales were adapted from Davison and researchers (2003), and an updated version known as the Activity Support Scale for Multiple Groups
(ACTS-MG) (Davison et al., 2011). For the current study, the logistic support and explicit modelling ACTS were used from Davison and colleagues in their 2003 paper; however, for explicit modelling, an additional item was added as per Davison and colleagues (2011): ‘I encourage my daughter to be physically active by leading by example’. Both logistic support and explicit modelling were answered on a four-point
Likert scale with response items ranging from “strongly disagree” to “strongly agree”.
The logistic support scale consisted of three items, focusing on a mother taking her daughter places to be active, enrolling her in physical activity and watching her participate in physical activity. The Cronbach’s α for mothers’ logistic support scale was 0.80. Explicit modelling was assessed through five items, ranging from mothers’ organisation for family physical activity, frequency of doing activity with her daughter, using behaviour to encourage activity and mothers’ own physical activity. The
Cronbach’s α for mothers’ explicit modelling scale was 0.88.
Mothers’ Self-efficacy (confidence) and Mothers’ Support for physical activity
Parenting activity-related measures for confidence and support were adapted from a previous study (Adkins et al., 2004). The self-efficacy (confidence) scale consisted of five items asking mothers to rate a response on a four-point Likert-type 105 Methods
scale of “very hard” (1) to “not hard at all” (4), focusing on mothers’ confidence to do physical activity with her daughter, e.g. ‘How hard would it be to get your daughter to be physically active, take your daughter to the park, go for a walk with your daughter?’ The Cronbach’s α for mothers’ self-efficacy scale was 0.74. The original support scale by Adkins et al (2004) included six items. However, one item was deleted after factor analysis. The modified support scale consisted of five items, asking mothers to rate on a four-point scale of “almost never” (1) to “almost always”
(4). These questions related to the mother’s level of support for their daughter’s physical activity levels, .e.g. ‘I try to get my daughter to play outside, get her to be active, take her to the park, go for a walk with my daughter.’ The Cronbach’s α for mothers’ support was 0.74.
3.5.2.3 Maternal Social Cognitive Theory Variables
3.5.2.3.1 Measure: Combination of validated SCT variables
Key constructs (i.e. self-efficacy, outcome expectations, social support, and goal setting/intention) of Bandura’s Social Cognitive Theory (Bandura, 1986) relating to mothers’ physical activity were assessed and adapted from validated measures.
Self-efficacy
Mothers’ physical activity self-efficacy related to their confidence to participate in regular physical activity was assessed with five-item response options ranging from “not at all confident” (1) to “completely confident” (5) (Rodgers & Sullivan,
2001). These questions reflected a mother’s confidence when feeling tired, being in 106 Methods
a bad mood, during bad weather, and scheduling regular physical activity into routine. The Cronbach α for mothers’ self-efficacy was 0.94.
Outcome expectations
Outcome expectations related to mothers’ beliefs about the effects of regular physical activity on her health was assessed via three items, with response options ranging from “not at all likely” to “extremely likely” (5) (Sallis, Grossman, Pinski,
Patterson, & Nader, 1987). These questions reflected mothers’ likelihood of increasing fitness, improving health and losing weight. The Cronbach α for mothers’ outcome expectations was 0.86.
Social support
The physical activity social support response asked mothers to report the amount of physical activity support received from people closest to them, ranging from “no support” (1) to “a great deal of support” (5) (Courneya, Plotnikoff, Hotz, &
Birkett, 2001).
Intention
Physical activity intention (goals) was measured using one item which asked mothers to indicate how strongly they agreed with the statement: ‘I intend to participate in regular physical activity over the next two months’, ranging from
“strongly disagree” (1) to “strongly agree” (5) (Courneya et al., 2001).
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3.5.2.4 Sedentary Behaviour and Screen Time
3.5.2.4.1 Measure: Mothers’ Sitting Time Questionnaire
Mothers reported their typical sitting time on a work and non-work day for transport, work, watching TV, using a computer at home, other leisure activities and sleep time using a sitting time questionnaire (Marshall, Miller, Burton, & Brown, 2010; Miller &
Brown, 2004). This measure was adapted previously from sitting time questionnaires and shown to be a valid and reliable measure of sitting time for adults in various domains (Marshall et al., 2010; Miller & Brown, 2004). Hours were converted into minutes and average sitting time for weekdays and weekend days were summed to create a total weekday sitting time and total weekend day sitting time.
3.5.2.4.2 Measure: Daughters’ Sedentary Behaviour and Screen Time Class Survey
Mothers proxy-reported their daughter’s leisure activity over a typical week using the
‘Children’s Leisure Activities Study Survey’ (CLASS) previously validated in children
(Telford, Salmon, Jolley, & Crawford, 2004). Total minutes of sedentary behaviour were reported for a typical week. Time spent in small screen recreation (SSR), including TV and DVD viewing, playing computer games, and using the internet were reported for weekdays (Monday to Friday) and weekend days (Saturday and
Sunday). A total weekly screen time score was calculated. Average screen time was calculated by dividing the total screen score by seven to get daily average screen time minutes. Weekday screen time was also summed as well as weekend day screen time.
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3.5.3 Physical Measures
The following physical measures were taken at the baseline assessment session, and were repeated using the same processes at follow-up assessments. Research staff were trained prior to conducting data collection and adhered to the assessment protocol with detailed instructions for each measure.
3.5.3.1.1 Weight
Weight was measured in light clothing, without shoes, and on a digital scale to 0.1kg
(model CH-150kp, A&D Mercury Pty, Adelaide, Australia). Two measures were taken. If the two values had a difference greater than 0.3cm, a third measure was obtained. Weight values were entered into the SPSS data set and the average of the two closest measures was taken.
3.5.3.1.2 Height
Height was measured to 0.1 cm using the stretch stature method and the Biospace
Stadiometer (BSM370, Seoul, Korea). Two measures were taken. If the two values had a difference greater than 0.3cm, a third measure was obtained. Height measures were entered into the SPSS data set and the average of the two closest measures was taken.
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3.5.3.1.3 BMI
BMI was calculated using the standard equation weight [kg]/height[m]2 using the weight and height values taken on the day of assessment. BMI was calculated from the mean weight and height measurements.
3.5.3.1.4 BMI z-score
BMI z-score was calculated using age-adjusted standardised scores (z-scores) in reference to the UK 1990 reference population (Kuczmarski et al., 2000). BMI z- score is adjusted for age- and sex-related changed in height and weight. BMI z- scores were calculated based on daughters’ age at assessment date. BMI z-score
[(weight-mean)/standard deviation] was calculated using age- and sex-matched mean and standard deviations as given (Kuczmarski et al., 2000) and calculated.
Weight status was derived from Cole and colleagues and reported as ‘”healthy weight”, “overweight” or “obese” (Cole, Bellizzi, Flegal, & Dietz, 2000; Cole, Flegal,
Nicholls, & Jackson, 2007).
3.5.3.1.5 Waist Circumference
Waist circumference was measured at the umbilicus. Measurements were recorded using a non-extensible steel tape (KDSF10-02, KDS, Osaka, Japan). Two measures were taken at the umbilicus, with accepted values within 0.5 cm for the mothers, and
0.3cm for the daughters. Further measures were taken if measurements were outside the acceptable range. Waist circumference measures were entered into the
SPSS data set and the average of the two closest measures were taken. 110 Methods
3.5.3.1.6 Waist z-score
Waist circumferences were measured were used as detailed above (section
3.4.4.1.5) and waist circumference percentiles were constructed and smoothed using the LMS method (McCarthy, Jarrett, & Crawley, 2001). Waist z-scores were calculated for daughters based on data from a British sample due to the unavailability of data for Australian children.
3.5.3.1.7 Body Composition
Bioimpedance was used for the assessment of body composition, including fat mass, fat free mass and total body water and % fat mass. Body composition was assessed by the InBody720 (Biospace Co., Ltd, Seoul, Korea), a multi-frequency bioimpedance device featuring an eight-point tactile electrode system. This device has been shown to be a valid and reliable device for body composition assessment
(Gibson, Holmes, Desautels, Edmonds, & Nuudi, 2008). Direct measures of fat mass, fat free mass and total body water were taken from the bioimpedance machine. A further calculation was derived for participants’ fat mass % by the following formula: Fat mass (kg) / Total body weight * 100.
3.5.3.1.8 Blood Pressure and Resting Heart Rate
Blood pressure and resting heart rate were measured using NISSEI/DS-105E digital electronic blood pressure monitors (Nihon Seimitsu Sokki Co. Ltd., Gunma, Japan) under standardised procedures. Participants were seated for five minutes before the 111 Methods
first blood pressure measurement and a resting period of two minutes between measures was used. Blood pressure was measured three times. Further measurements were taken if the blood pressure or resting heart rate values fell outside of the acceptable ranges, i.e. Systolic within 10 mmHg, diastolic within 10 mmHg (preferably 5 mmHg) and resting heart rate within 5 bpm. However, in the case that a daughter’s blood pressure was not within the range after taking five measures, assessors ceased taking further measurements to avoid discomfort for the daughter. The mean of the two closest systolic pressures and the diastolic pressure paired to them, and the mean of the two lowest resting pulse pressures were used with average of lowest two readings.
3.5.3.2 Feasibility, Acceptability and Satisfaction
3.5.3.2.1 Recruitment, Retention, Attendance, Satisfaction
Process measures including the feasibility, reach, acceptability and satisfaction were assessed via the following metrics:
i) recruitment (40 mother-daughter dyads to be screened and randomised);
ii) retention (a minimum of 80% retention of primary outcome);
iii) attendance (a minimum of 80% attendance over the eight sessions; a weekly roll was taken on mothers and daughters arrival to session); and,
iv) acceptability and satisfaction were measured via a comprehensive mothers’ process evaluation questionnaire (Appendix 30).
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Mothers were asked about the quality of program, the facilitators, program support, enjoyment of activities, impact of program on family members, impact of program on physical activity behaviour and overall satisfaction using a five-point Likert scale
(“strongly disagree to strongly agree”) and Likert-type (“really didn’t enjoy” to “really enjoyed”). Mothers also completed three short, open-ended questions which asked what mothers liked about MADE4Life, what mothers didn’t like about MADE4Life and suggestions useful to the researchers. In addition to mothers evaluating the program, a facilitator’s evaluation of the intervention program was conducted by keeping a weekly journal of what worked and what didn’t work each week and observations for future programs. The facilitator’s evaluation journal notes were categorised into the following themes: (i) intervention content and resources (e.g. was all of the planned content implemented as planned?); (ii) engagement of the mothers and daughters (e.g. things that resonated with the mothers and daughters); and, (iii) procedures (e.g. was the time sufficient?).
3.5.4 Demographics
3.5.4.1 Age, Education and Income
Mothers’ and daughters’ date of birth were recorded at time of consent via the participant information statement forms (Appendix 13). Participants’ age at baseline was calculated. This same procedure was repeated at immediate post-intervention and three-month post-intervention follow-up. For baseline reporting purposes only, mothers’ highest level of education, marital status, and weekly household income were collected via survey. 113 Methods
3.5.4.2 Socioeconomic Status
Information regarding family units’ socioeconomic status (SES) was collected via residency postcode and was reported by mothers at time of screening. The Socio-
Economic Index For Areas (SEIFA) of relative socioeconomic disadvantage was used (Australian Bureau of Statistics, 2008), scale 1 = lowest, to 10 = highest, which summarises characteristics of households within an area. The SEIFA (index) were developed using employment, education, low income, family break-down, financial well-being, family type, housing stress, overcrowding, home ownership, family support, lack of wealth (no telephone or car) foreign birth and indigenous status
(Australian Bureau of Statistics, 2008). Based on each family unit’s postcode, a
SEIFA score was allocated and grouped via the following: 1-2, 3-4, 5-6, 7-8, 9-10.
3.5.5 Data Entry
All data from the MADE4Life study was entered by the PhD Candidate into SPSS,
Microsoft Excel and MeterPlus (accelerometer). To ensure the PhD candidate was blind to participant group allocation, questionnaires were de-identified with participant identification codes replacing names prior to data entry.
3.6 Statistical Analysis
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The statistical program SPSS Statistics v19 and v 20 (IBM Inc. Armonk, NY) was used for all analyses. The following subsections detail the statistical analysis employed throughout this thesis.
3.6.1 Maternal Correlates Of Daughters’ Physical Activity
3.6.1.1 Aim Two: Correlates
To examine specific maternal correlates of objectively measured physical activity in girls, including demographic, anthropometric, behavioural, activity-related parenting practices and physical activity cognitions.
Means and standard deviations were calculated for normally distributed data.
Where data were skewed, medians and interquartile ranges were examined. Percent time in CPM was transformed (square root) to meet normality standards for both mothers and daughters. Pearson correlations were used to determine associations between maternal measures and girls’ objectively measured physical activity and in order to examine the potential maternal correlates for girls’ physical activity measures % MVPA, CPM, and linear regression analysis was utilised for BMI z- score, total screen time and % SED. Statistical significance was set at an alpha level of 0.05 for all analyses. The regression analysis was performed, whereby each significant variable (P<0.05), or close to significance (P<0.20), was entered into the regression model. The regression models were calculated using the backward method; non-significant variables were then dropped, one at a time, least significant first while controlling for covariates that were significantly associated with the outcome variable. When more than one explanatory variable was found, all two-way 115 Methods
interactions between significant independent variables were tested for significance in the multiple linear regression models. Correlations between explanatory variables were checked to investigate potential problems of collinearity in the multiple variable models; however, this was not an issue. The magnitude of effect sizes were interpreted according to Ferguson’s guide for clinicians and researchers (Ferguson,
2009).
3.6.2 Feasibility and Preliminary Efficacy
3.6.2.1 Aim Three: Feasibility and Preliminary Efficacy
To evaluate the
(i) feasibility (recruitment, retention, attendance, acceptability and satisfaction); and,
(ii) preliminary efficacy of a mother-daughter physical activity program targeting improvements in physical activity levels.
Descriptive analysis (percentages and frequency counts) were conducted to assess retention, recruitment, attendance and satisfaction of the MADE4Life program. For mothers’ qualitative answers in the process evaluation, mothers’ answers were analysed by detailing a thematic summary and coded as per the question theme.
Data were presented as mean (SD) for continuous variables and counts
(percentages) for categorical variables. Means and standard deviations were calculated for all normally distributed variables. Characteristics of completers versus dropouts were tested using independent t tests for continuous variables and chi- 116 Methods
squared (χ2) tests for categorical variables. The significance level was set at .05 for all analyses. Analyses were performed separately for mothers’ and daughters’ data and included all randomised participants.
Linear mixed models (LMM) were used to assess all outcomes (primary and secondary) for the impact of group (Intervention and Control), time (treated as categorical with levels baseline and immediate post-intervention, and baseline and
3-month post-intervention) and the group-by-time interaction, with these three terms forming the base model. LMM were fitted with an unstructured covariance structure for all primary and secondary outcomes. 95% confidence intervals (CIs) and differences between means were determined via LMM.
Analyses included all randomised participants. Age, daughter’s age, SES and BMI were examined for mothers; for daughters, age and SES were examined as pre-specified covariates (Bauman et al., 2012) to determine if they contributed significantly to the models. Significant covariates were then examined via two-way interactions with time and treatment, with all significant terms added to the final model to adjust the results for these effects.
The MADE4Life study was designed as a pilot randomised controlled trial; hence, it was not projected to be adequately powered from a statistical perspective.
Therefore, to demonstrate effects and trends, Cohen’s d (Cohen, 1988) was used to calculate effect sizes and was calculated using mean differences from the mixed model and the pooled standard deviation of the two groups at baseline (d=(M1-M2
)/σpooled). 117 Methods
3.7 Chapter Summary
Specific methods for the pilot RCT, MADE4Life, conducted as the major component of this thesis was provided in Chapter 3. The chapter justified and summarised the selection of the validated measures and methods and specific components of the physical activity program designed for mothers and their daughters. Procedures for both primary and secondary outcome measures were described and the specific statistical analyses applied to the data collected. Chapter 4 will detail the results of the statistical analyses, correlates, feasibility and preliminary efficacy, and the process evaluation which in turn addresses the research questions and hypotheses.
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4 Chapter 4: Results
The results for this thesis are presented in three subsections (section 4.1, section
4.2 and section 4.3) and address Aim Two and Aim Three of this thesis.
Section 4.1 reports descriptive statistics and baseline characteristics of the total sample of mothers and daughters who were recruited for the MADE4Life RCT.
Section 4.2 reports the findings for the maternal correlates of objectively measured physical activity in girls using baseline data from the MADE4Life pilot
RCT, which included 40 mothers and 40 daughters (i.e. for those mothers who had more than one daughter enrolled in the study, datum of the eldest daughter were used for analysis). Maternal correlates of daughters’ accelerometer-assessed physical activity (% MVPA; moderate-to-vigorous physical activity, CPM; counts per minute, % SED; sedentary behaviour), screen time (mother-proxy) and BMI-z score
(objectively measured) included demographic, anthropometric, behavioural, activity- related parenting practices and physical activity cognitions, which were assessed using regression models. This analysis aligns with Aim Two of this thesis (see
Section 1.7).
Section 4.3 reports the feasibility and preliminary efficacy findings of a family- based physical activity pilot RCT targeting mothers and daughters (MADE4Life) delivered in a community setting. Assessments were at baseline, post-intervention and three-month post-intervention. The primary outcome measure was daughters’ moderate-to-vigorous physical activity (MVPA) (accelerometry) at post-intervention.
Secondary outcomes included accelerometer-assessed light/moderate/vigorous 119 Results
physical activity, BMI, waist circumference, body composition, blood pressure, resting heart rate, sedentary behaviours and mothers’ self-reported physical activity, parenting measures and cognitions. These analyses align with Aim Three of this thesis (see Section 1.7).
4.1 Descriptives and Baseline Characteristics
4.1.1 Baseline Characteristics of Daughters and Mothers
The demographic, baseline characteristics and summary data for mothers’ and daughters’ physical activity and behaviour variables are summarised in Table 4.1. A total of 40 mothers and 48 daughters were included in all analyses; however, one mother had incomplete accelerometer data so 39 mothers were analysed for the physical activity data.
The mean age (SD) of daughters was 8.5 years (1.7) and mean BMI z-score was 0.7 (1.2). In the daughters group, 100% met the criteria for wearing an accelerometer for a minimum of eight hours on ≥ four days. After adjusting for non- wear time based on self-report accelerometer logs, no differences were found.
Therefore, the non-adjusted wear time is reported. Daughters’ mean accelerometer wear time was 6.6 days (0.8). Total wear time mean was 737.1 mins (61.2).
Daughters’ % time in MVPA and mean MVPA minutes were 5.7 (2.3) and 41.6 (16.8) respectively. At baseline, 81% (n=39) of the daughters did not meet the physical activity guidelines.
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Based on BMI data, 70% of girls were classified as healthy weight, and 30% overweight or obese. Daughters’ average daily sitting time was 372.16 minutes
(163.55) and average daily screen time was 153.54 minutes (80.08).
Mean age (SD) of mothers was 39.1 (4.8) and mean BMI was 27.6 (5.5). Of the 40 mothers, 39 met the criteria for accelerometer wear time. On average, mothers wore activity monitors with at least 8 hours of wear time for 6.6 days (1.0).
On average, mothers total wear time was 854.6 minutes (76.9). Mothers’ % time in
MVPA and mean MVPA minutes were 3.5 (2.1) and 28.0 (15.3) respectively.
Mothers were predominately born in Australia with more than half (57.5%) completing university education, 25% had completed a trade or diploma and 22.5% completed Year 12. Of the 40 mothers, 50% reported their occupation as office- based, 22.5% worked in education, 12.5% worked in allied health, 10% worked in science-related occupations and 5% were full time mothers. Mothers’ marital status ranged from married: 72.5%, separated/divorced: 15%, de facto: 10%, to never married 2.5%. For mothers’ weight category, 67.5% were overweight or obese.
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TABLE 4.1: DESCRIPTIVE STATISTICS OF MOTHERS’ AND DAUGHTERS’ BASELINE DEMOGRAPHIC, ANTHROPOMETRIC, PHYSICAL ACTIVITY VARIABLES, BEHAVIOUR CHARACTERISTICS
Variables Daughters Mothers Total (N=48) Total (N=40) Mean (SD) Mean (SD) Age (years) 8.5 1.7 39.1 4.8 Height (cm) 132.15 11.05 164.3 5.4 Weight (kg) 32.21 9.06 74.32 14.47 BMI (kg/m2) 18.13 2.87 27.58 5.45 BMI z-score 0.71 1.18 N/A N/A Waist (umbilicus cm) 65.14 8.98 93.60 11.74 Waist z-score 2.11 1.75 N/A N/A Systolic blood pressure (mmHg) 94 10 113 12 Diastolic blood pressure (mmHg) 58 8 75 10 Resting heart rate (BPM) 83 12 68 9 Fat mass % 23.50 7.95 35.81 7.53
Physical Activitya Mean CPM 468.45 148.34 345.38 121.24 % time in MVPA 5.65 2.32 3.53 2.10 % time in MPA 3.88 1.35 3.25 1.71 % time in VPA 1.78 1.17 0.29 0.73 % time in LPA 32.67 5.86 37.71 7.00 % time in SED 61.66 7.46 58.76 7.89
Godin Leisure Time (GLTAQ) Total Met Minutes exc mild N/A N/A 514.44 699.82
Daughters Screen timeb Total screen time (min) 1074.75 560.53 N/A N/A Average screen time (min/day) 153.54 80.08 N/A N/A
Daughters’ Sitting time (min/day) Sitting time daily average 372.16 163.55 N/A N/A
Mothers’ Sitting Time (min) Work day N/A N/A 451.3 201.7 Non-work day N/A N/A 355.9 159.0
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Variables Daughters Mothers Total (N=48) Total (N=40) Mean (SD) Mean (SD)
Parenting for physical activityc Confidence N/A N/A 3.45 0.42 General Support N/A N/A 2.74 0.55 Logistic Support N/A N/A 3.25 0.60 Explicit modelling N/A N/A 2.73 0.60 Beliefs N/A N/A 3.52 0.43
Physical activity cognitionsd Self-efficacy N/A N/A 3.62 0.96 Outcomes expectations N/A N/A 4.61 0.58 Social support N/A N/A 3.40 1.35 Intention N/A N/A 4.67 0.52
N % N % BMI category e f Healthy weight 28 70 13 32.5 Overweight 8 20 15 37.5 Obese 4 10 12 30.0 Socio-Economic Statusg 1-2 (lowest) - - 1 2.50 3-4 - - 4 10.00 5-6 - - 11 27.50 7-8 - - 22 55.00 9-10 (highest) - - 2 5.00
Country of birth Australia - - 35 87.5% United Kingdom - - 1 2.5% Other - - 4 10%
Highest level of education School - - 9 22.5% Trade/Diploma - - 23 25.0% University 21 57.5%
Marital status Married - - 29 72.5% De facto - - 4 10% Separated - - 3 7.5% 123 Results
Variables Daughters Mothers Total (N=48) Total (N=40) Mean (SD) Mean (SD) Divorced - - 3 7.5% Never married - - 1 2.5%
Weekly household income <$1000 - - 6 15% $1,000-$1,500 - - 4 10% $1,500 or more - - 28 70% Unknown - - 2 5%
Occupation Fulltime parent - - 2 5% Office - - 20 50% Education - - 9 22.5% Allied health - - 5 12.5% Science - - 2 5% Other - - 2 5% Abbreviations: SD, standard deviation; cm, centimetres; kg = kilograms; BMI, body mass index; min, minutes; umb, umbilicus measurement; mmHg, millimetres of mercury; BPM, beats per minute; CPM, counts per minute; MVPA, moderate/vigorous physical activity; MPA, moderate physical activity; VPA, vigorous physical activity; LPA, light physical activity; SED, sedentary activity; % time in, percent of time accounting for wear time. a mothers n=39; b Reported by mothers for eldest daughter only if more than one child enrolled; c Range 1-4; d Range 1-5; e Representations of BMI categories for daughters based on BMI z-score; f Child grade 1 thinness and healthy weight combined for daughters; g Socio- economic status by population decile for SEIFA Index of Relative Socioeconomic Advantage and Disadvantage.
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4.2 Maternal correlates of daughters physical activity
4.2.1 Hypothesis Two: Correlates
There will be significant associations between some maternal physical activity correlates and daughters’ objectively measured physical activity.
A number of significant correlations were found between daughters’ objectively measured physical activity and mothers’ parenting for physical activity and physical activity behaviour. Bivariate correlations between potential maternal correlates and girls’ physical activity are presented in Table 4.2.
A small to moderate positive correlation was observed between daughters’ % time in MVPA and mothers’ beliefs (R=0.4, P<0.05). A small to moderate positive correlation was observed between daughters’ total activity (CPM), mothers’ logistic support (R= 0.4, P<0.05) and mothers’ beliefs about daughters’ physical activity
(R=0.4, P<0.05). For daughters’ % time in SED, a small to moderate positive correlation was observed for mothers’ % time in SED (R=0.3, P<0.05), and a small to moderate negative correlation was found for mothers’ logistic support (R=-0.4,
P<0.05). For daughters’ total screen time, a moderate to strong positive correlation was found for mothers’ % time in SED (R=0.6, P <0.01) and a small to moderate inverse correlation with mothers’ CPM (R=-0.4, P<0.05). A moderate to strong correlation was observed between daughters’ BMI z-score and mothers’ BMI (R=0.6,
P<0.01).
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TABLE 4.2: BIVARIATE CORRELATIONS BETWEEN POTENTIAL MATERNAL CORRELATES OF PA BEHAVIOUR
Daughters variables (n=40)
Screen Maternal variables % MVPA CPM % SED BMI-z time Background Mothers’ age -0.15 -0.18 0.24 0.04 0.17 Family Seifa decilea -0.05 -0.14 0.30 0.20 -0.07 Mothers’ BMI 0.08 -0.01 -0.05 -0.12 0.57** Mothers’ physical activityb % MVPA 0.17 0.24 -0.13 -0.16 0.05 CPMc 0.20 0.23 -0.24 -0.40* 0.07 % SED -0.27 -0.31 0.34* 0.56** -0.06
Mothers’ sitting time Work day -0.17 -0.05 -0.13 -0.11 0.20 Non-work day -0.24 -0.23 0.09 -0.12 0.06
Parenting for physical activity Confidence 0.20 0.06 -0.02 -0.07 -0.16 Support 0.14 0.15 -0.13 -0.12 0.13 Logistic support 0.31 0.36* -0.37* -0.22 0.04 Explicit modelling -0.02 0.05 -0.15 -0.23 0.04 Beliefs 0.40* 0.40* -0.27 -0.27 0.10
Physical activity cognitions Self-efficacy 0.17 0.12 -0.05 0.03 0.21 Outcomes expectations 0.28 0.25 -0.16 -0.14 0.14 Social support 0.10 0.18 -0.16 0.07 0.07 Intention 0.19 0.26 -0.29 0.03 0.14 ** Correlation is significant at the 0.01 level (2-tailed) * Correlation is significant at the 0.05 level (2-tailed) Abbreviations: SED, sedentary behaviour; MVPA, moderate-to-vigorous intensity physical activity; CPM, counts per minute; %MVPA / %SED, percent of time accounting for wear time. aSEIFA Index of Relative Socioeconomic Advantage and Disadvantage bn=39; cTransformed (square root).
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Linear regression models were used to examine the variance explained and identify significant factors associated with physical activity [% MVPA, CPM], % SED, screen time and BMI z-score (Table 4.3). The model testing daughters’ % time in MVPA, explained a weak proportion of variance (R2=0.14). The relationship between mothers’ beliefs about physical activity (P=0.01, beta=0.40) and daughters’ % time in MVPA were significant. Significant constructs for daughters’ total activity (CPM) included mother’s logistic support (P<0.05, beta=0.32), mothers’ CPM (P<0.05, beta=0.37) and mothers’ outcome expectations (P=0.01, beta=0.40) and this model explained a moderate proportion of the variance (R2=0.24). For the model daughters’
% time in SED, mothers’ logistic support for daughters’ physical activity was the sole correlate of daughters’ % SED, having a weak negative association with daughters’
% SED (P<0.05, beta=-0.37), (R2=0.11). For daughters’ total screen time, mothers’
% time in SED was the sole significant correlate (P<0.001, beta=0.59), explaining a moderate to strong proportion of variance (R2=0.33). Finally, for daughters’ BMI z- score, mothers’ BMI was the only significant correlate (P<0.001, beta=0.57), explaining a moderate to strong proportion of variance (R2=0.31).
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TABLE 4.3: LINEAR REGRESSION ANALYSES RESULTS OF PHYSICAL ACTIVITY, % TIME SPENT IN SEDENTARY BEHAVIOUR, SCREEN TIME AND BMI Z-SCORE IN DAUGHTERS (DAUGHTERS N=40; MOTHERS N=40) Variables in final model Standardised β P value Part R2 R2 Daughters’ % time in MVPA Model R2 = 0.14 Mothers’ beliefs about physical 0.40 0.01 0.40 0.16 activity F(1,38) = 7.17P = 0.01 Daughters’ CPMa Model R2 = 0.24 Mothers’ logistic Support 0.32 <0.05 0.32 0.10 Mothers’ CPMa b 0.37 <0.05 0.33 0.11 Mothers’ outcome expectations 0.40 0.01 0.37 0.13 F(3,36) = 5.20 P = 0.004 Daughters’ % time in SED Model R2 = 0.11 Mothers’ logistic support -0.37 <0.05 -0.37 0.14 F(1,38) = 6.01 P = 0.019 Daughters’ total screen time Model R2 = 0.33 Mothers’ % time in SEDb 0.59 <0.001 0.59 0.34 F(1,38) = 19.74 P<0.001 Daughters’ BMI z-score Model R2 = 0.31 Mothers’ BMI 0.57 <0.001 0.57 0.32 F(1,38) = 18.25 P<0.001
Abbreviations: MVPA, moderate-to-vigorous intensity physical activity; CPM, counts per minute; SED, sedentary behaviour; aTransformed (square root); bn=39
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4.3 Feasibility and Preliminary Efficacy
4.3.1 Hypothesis Three: Feasibility
The MADE4Life program will be feasible, demonstrated through recruitment, retention and attendance targets being achieved and through participants finding the program acceptable with high satisfaction demonstrated through comprehensive process evaluation from multiple perspectives including mothers and facilitators.
One of the aims of this thesis was to determine program feasibility. Figure 4.1 illustrates the flow of participants through the trial. In approximately three weeks, 122 families registered their interest for the program and were screened for eligibility.
The most successful recruitment strategy was via local school newsletters with more than half of mothers reporting this as the primary exposure, followed by local radio, school gate/school presentations, university website, newspaper and television news. The target sample size was met with 40 mothers and 48 daughters attending baseline assessment sessions.
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Assessed for eligibility family Enrolment unit (n=122) Excluded family unit (n=82) ♦ Not meeting inclusion criteria - Program clashed with other activity (n=30) - Mother worked on program day (n=9) - Unavailable Childcare (n=6) - Daughter too young/old (n=8) - No DR clearance (n=3) Randomized mother-daughter - Unknown (n=22) dyads (n=40)* ♦ Declined to participate (n=4)
Allocation
Allocated to intervention (n=25) Allocated to control (n=23) ♦ Received allocated intervention ♦ Received allocated intervention (n=23) (n=23) ♦ Did not receive allocated Did not receive allocated intervention intervention (n=0) - Family commitments (n=2) ♦ Completed minimum PA data (n=23) ♦ Completed minimum PA data
Post-intervention
Lost to follow-up (lost contact) (n=1) Lost to follow-up (give reasons) (n =0) Discontinued intervention (n=0) Discontinued intervention (give Completed minimum PA data (n=19) reasons) (n=0) Completed minimum PA data (n=20)
3-month post-
Lost to follow-up (n=0) Lost to follow-up (give reasons) (n = 0) Discontinued intervention Discontinued intervention (did not like accelerometers);(n=2) (no contact); (n =0) Completed minimum PA data (n=19) Completed minimum PA data (n=21)
Analysis
Analysed (n=25) Analysed (n=23) ♦ Excluded from analysis (n=0) ♦ Excluded from analysis (n=0)
Figure 4.1 Participant flow through the trial and analysed for the primary outcome (Daughters’ %MVPA).
130 * Mothers with two daughters in the study (n=8) Results
The 80% retention target was met for the primary outcome (accelerometer data) with
100%, 81% and 83% at baseline, post-intervention and follow-up, respectively.
Similarly, retention rates for mothers were high with 98%, 85% and 83% at each assessment. The study had excellent retention for assessments with 100% attending baseline assessments, 93% attended post-intervention and 91% at follow-up.
Baseline characteristics of daughters and mothers randomised to the MADE4Life intervention and control groups are reported in Table 4.4 and Table 4.5 respectively.
There were no significant differences in follow-up rates between the MADE4Life and control group daughters at post-intervention (χ2=0.94, df=1, P=0.33) or follow-up
(χ2=2.02, df=1, P=0.15), and for mothers post-intervention (χ2= 0.02, df=1, P=0.894) and follow-up (χ2=1.129, df=1, P=0.270). Daughters who dropped out at post- intervention had higher average minutes per day of screen time (P=0.05) at baseline compared to daughters retained at follow-up. Mothers who dropped out at post- intervention had a lower mean fat mass (P=0.05) at baseline than mothers retained at follow-up.
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TABLE 4.4: BASELINE CHARACTERISTICS OF DAUGHTERS RANDOMISED TO THE MADE4LIFE INTERVENTION AND CONTROL GROUPS MADE4Life Control Total Characteristics program (n = 23) (n = 48) (n = 25) Mean (SD) Mean (SD) Mean (SD) Age (years) 8.63 1.76 8.36 1.72 8.49 1.73 Weight (kg) 33.06 9.88 31.42 8.37 32.21 9.06 Height (m) 132.48 12.09 131.85 10.25 132.15 11.05 BMI (kg/m2) 18.49 3.06 17.80 2.69 18.13 2.87 BMI z-score 0.81 1.09 0.65 1.27 0.71 1.18 Waist [umb] (cm) 65.60 9.47 64.71 8.69 65.14 8.98 Waist z-score 2.12 1.63 2.10 1.89 2.11 1.75 Systolic blood pressure 94 6 94 13 94 10 (mmHg) Diastolic blood pressure 60 7 57 9 58 8 (mmHg) Resting heart rate (BPM) 84 13 83 10 83 12 Fat mass % 24.22 7.76 22.84 8.23 23.50 7.95
Physical activity Mean CPM 452.69 123.97 482.95 168.97 468.45 148.34 % time in MVPA 5.60 1.77 5.71 2.76 5.65 2.32 % time in MPA 3.83 1.00 3.93 1.62 3.88 1.35 % time in VPA 1.77 1.08 1.78 1.27 1.78 1.17 % time in LPA 31.12 5.50 34.02 5.97 32.67 5.86 % time in SED 63.18 6.79 60.27 7.90 61.66 7.46
Sitting time (minutes/day) a,b Sitting time daily average 382.00 187.03 363.30 143.20 372.16 163.55
Screen time (minutes) a, b Screen time (average 162.29 99.49 145.61 58.80 153.54 80.08 minutes/day)
n % N % n %
BMI Category Healthy weight c 14 60.8% 18 72% 32 66.6% Overweight 6 26.1% 3 12% 9 18.8% Obese 3 13.1% 4 16% 7 14.6% Abbreviations: MADE4Life, Mothers and Daughters Exercising for Life; kg, kilograms; BMI, body mass index; umb, umbilicus measurement; mmHg, millimetres of mercury; BPM, beats per minute; CPM, counts per minute; MVPA, moderate/vigorous physical activity; MPA, moderate physical activity, VPA, vigorous physical activity; LPA, light physical activity; SED, sedentary activity; % time in, percent of time accounting for wear time. a Reported by mothers for eldest daughter only if more than one child enrolled; b n=19 (control); n= (21 intervention); c Child grade 1 thinness included (n=2)
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TABLE 4.5: BASELINE CHARACTERISTICS OF MOTHERS RANDOMISED TO THE MADE4LIFE INTERVENTION AND CONTROL GROUP
MADE4Life Control Total Characteristics program (n = 19) (n = 40) (n = 21) Mean (SD) Mean (SD) Mean (SD) Age (years) 39.53 5.26 38.71 4.41 39.10 4.79 Weight (kg) 73.99 15.2 74.63 14.16 74.33 14.47 Height (m) 164.58 6.78 163.98 4.01 164.27 5.44 BMI (kg/m²) 27.35 5.60 27.80 5.45 27.59 5.46 Waist [umb] (cm) 93.43 13.99 93.76 9.62 93.60 11.74 Systolic blood pressure 115 9 112 14 113 12 (mmHg) Diastolic blood pressure 76 7 74 11 75 10 (mmHg) Resting heart rate (BPM) 68 9 69 10 68 9 Fat mass % 34.93 8.42 36.61 6.73 35.81 7.53
Physical activitya Mean CPM 333.03 108.84 355.97 132.67 345.38 121.24 % time in MVPA 3.40 1.82 3.65 2.35 3.53 2.10 % time MPA 3.20 1.40 3.30 1.96 3.25 1.71 % time VPA 0.20 0.47 0.36 0.90 0.29 0.73 % time LPA 37.32 6.58 38.03 7.49 37.71 7.00 % time in SED 59.27 7.11 58.32 8.65 58.76 7.89
Godin Leisure Time (GLTEQ) Total Met Minutes exc mild 592.89 842.96 443.45 551.68 514.44 699.82
Sitting time (min) Work day b 358.81 172.85 529.21 194.77 451.31 201.69 Non-work day 324.74 125.18 345.95 186.95 335.88 158.97
Parenting for PAc,d Maternal role modelling 13.95 3.34 13.38 2.67 13.65 3.03 Maternal logistic support 9.32 2.08 10.14 1.42 9.75 1.79 Maternal beliefs 18.11 2.21 17.17 2.07 17.60 2.16 Maternal self-efficacy 16.95 2.27 17.52 1.94 17.25 2.10 Maternal support 14.00 3.51 13.48 1.89 13.73 2.75
Physical activity cognitionsc,e Self-efficacy 18.37 4.50 17.90 5.18 18.13 4.81 Outcomes expectations 14.42 1.12 13.33 2.03 13.85 1.73 Social support 3.42 1.42 3.38 1.32 3.40 1.35 Intention 4.53 0.61 4.80 0.40 4.67 0.52 n % N % n % BMI Category Healthy weight 7 36.8% 6 28.6% 13 32.5% 133 Results
MADE4Life Control Total Characteristics program (n = 19) (n = 40) (n = 21) Overweight 7 36.8% 8 31.1% 15 37.5% Obese 5 33.4% 7 33.4% 12 30% SESf 1-2 (lowest) 0 0% 0 0% 0 0% 3-4 1 2% 2 4% 3 3% 5-6 16 36% 17 35% 33 36% 7-8 28 62% 29 61% 57 61% 9-10 (highest) 0 0% 0 0% 0 0%
Country of birth Australia 16 84.2% 19 90.5% 35 87.5% United Kingdom 1 5.3% 0 0% 1 2.5% Other 2 10.6% 2 9.6% 4 10%
Highest level of education School 6 31.6% 3 14.3% 9 22.5% Trade/Diploma 4 21.1% 6 28.6% 23 25.0% University 9 47.4% 12 57.1% 21 57.5%
Marital status Married 13 68.4% 16 76.2% 29 72.5% Defacto 1 5.3% 3 14.3% 4 10% Separated 2 10.5% 1 4.8% 3 7.5% Divorced 3 15.8% 0 0% 3 7.5% Never married 0 0% 1 4.8% 1 2.5%
Weekly household income <$1000 4 21.1% 2 9.5% 6 15% $1,000-$1,500 4 21.1% 0 0 4 10% $1,500 or more 9 47.4% 19 90.5% 28 70% Unknown 2 10.6% 0 0 2 5% Abbreviations: MADE4Life, Mothers and Daughters Exercising for Life; kg, kilograms; BMI, body mass index; umb, umbilicus measurement; mmHg, millimetres of mercury; BPM, beats per minute; CPM, counts per minute; MVPA, moderate/vigorous physical activity; MPA, moderate physical activity, VPA, vigorous physical activity; LPA, light physical activity; SED, sedentary activity; % time in, percent of time accounting for wear time. a n=18 (control); n=21 (intervention) N=39; b n=16 (control); n=19 (intervention); N=35 (total); c mean score represented; d Range 1-4; e Range 1-5; f Socio-economic status by population decile for SEIFA Index of Relative Socioeconomic Advantage and Disadvantage.
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Average attendance at program sessions was high (82%). Two families withdrew for reasons not related to the MADE4Life program, i.e. illness and family commitments.
Contact was lost with one additional family, who attended only two sessions. For the remaining 18 families, average attendance was 93%, and median number of sessions attended was eight (range = 6-8). The most common reasons for non- attendance were illness (50%), family commitments (30%) and work commitments
(20%). All eight MADE4Life program sessions and content were implemented as planned (100%).
Process evaluation questionnaires were completed by the MADE4Life group post intervention and by the wait-list control mothers after receiving the program (six months after baseline assessment). Acceptability and Satisfaction results are summarised in Table 4.6. Results presented in Table 4.6 are for the MADE4Life intervention group mothers only (i.e. process evaluation answers from wait-list control mothers are not included in this table). Variables were grouped according to question theme and summary means and standard deviations are presented. Of the
19 intervention mothers, 18 (95%) completed the process evaluation data. Overall, mothers reported MADE4Life was highly acceptable (Table 4.6) which is reflected by the high mean scores. The highest mean overall was achieved for the “quality of facilitators” score (m=4.8, SD=0.4).
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TABLE 4.6: MOTHERS’ PROCESS EVALUATION FROM THE M.A.D.E 4 LIFE PROGRAM Construct Mean Example of item (n= number of items) (SD) Quality of program a (n=4) The M.A.D.E 4 Life program was enjoyable 4.6 (0.5) The facilitators had a high level of knowledge Quality of facilitators a (n=4) 4.8 (0.4) and good communication skills PA session content b (n=8) Rough & tumble play/Boxing/Pilates/Zumba 4.3 (0.2) Impact on family members a The M.A.D.E 4 Life program had a positive 3.7 (0.2) (n=5) impact on my families PA levels As a result of the M.A.D.E 4 Life program I Behaviour change a (n=3) spend more time being active with my 3.9 (0.1) daughter The M.A.D.E 4 Life program taught me how Program support a (n=2) 4.5 (0.1) to increase my PA levels a 1=Strongly disagree to 5= Strongly agree; b 1=Really didn’t like to 5=Really liked; PA = physical activity
Of the 19 wait-list control group mothers, 13 (68%) completed process evaluation questionnaires after receiving the program. Detailed process evaluation data representing both mothers in the MADE4Life intervention (n=18) and mothers in the wait-list control group (n=13) are represented in Table 4.7, Table 4.8 and Table 4.9.
Data are represented separately for each of the groups and a total column represents combined means and standard deviations. Total n% is reported in detail below.
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TABLE 4.7: MOTHERS’ PROCESS EVALUATION FOR THE MADE4LIFE PROGRAM PART ONE
Wait-list MADE4Life Total Item Control (n=18) (n=31) (n=13) Mothers’ thoughts prior to starting MADE4Life n, % n, % n, % Why did you decide to join the M.A.D.E 4 LIFE program? • I wanted to become more active 16 (89%) 8 (62%) 24 (77%) • I wanted to spend more time with my daughter/s 16 (88%) 12 (92%) 28 (90%) • I wanted to learn about improving my daughter(s) health 17 (94%) 8 (62%) 25 (81%) • My daughter(s) encouraged me to sign up 10 (55%) 5 (38%) 15 (48%) • My husband/partner encouraged me to sign up 11 (61%) 3 (23%) 14 (15%) • My friends encouraged me to sign up 7 (38%) 5 (38%) 12 (39%) Have you tried to increase your physical activity levels before? • No 6 (33%) 0 (0%) 6 (19%) • Yes 12 (67%) 13 (100%) 25 (81%) How did you try to increase your physical activity? • Gym membership 4 (22%) 5 (38%) 9 (29%) • Boot camp/outdoor fitness 2 (11%) 1 (8%) 3 (10%) • Dance/Zumba classes 4 (22%) 1 (8%) 5 (16%) • Walking dates with friends 8 (44%) 4 (30%) 12 (39%) • Personal trainer 0 (0%) 0 (0%) 0 (0%) • Social sport competition 4 (22%) 1 (8%) 5 (16%) Abbreviations: a 1=Strongly disagree to 5= Strongly agree; b1=too long to 3=right; c1=Really didn’t like to 5=Really liked; d1= Poor to 5= Excellent; e1=Too much to 3=Right; fAverage amount;
Overall, the main motivations of mothers enrolling were “wanting to spend more time with my daughter” (n=28, 90%), “wanting to learn about improving the health of my daughter” (n=25, 81%) and “wanting to become more active” (n=24, 77%) (Table
4.7). Most mothers had tried to increase their physical activity in the past, through walking with friends (n=12, 39%) and gym memberships (n=9, 29%). Process data revealed that, overall, both groups had high levels of satisfaction for the program and the program was highly acceptable (Table 4.8).
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TABLE 4.8: MOTHERS’ PROCESS EVALUATION FOR THE MADE4LIFE PROGRAM PART TWO Wait-list MADE4Life Total Item Control (n=18) (n=31) (n=13) Quality of the MADE4Life program The program: Mean (SD) Mean (SD) Mean (SD) • The M.A.D.E 4 LIFE program was enjoyablea 4.8 (0.4) 4.7 (0.5) 4.7 (0.3) • The program taught me how to increase my physical 4.8 (0.4) 4.5 (0.6) 4.6 (0.5) activity levelsa • The content of the program was relevant to my lifea 4.4 (0.8) 4.6 (0.5) 4.5 (0.7) • The games/activities were appropriate for myself and 4.6 (0.5) 4.8 (0.5) 4.6 (0.5) my daughter(s)a • The session content was explained in a way that was 4.8 (0.4) 4.9 (0.3) 4.8 (0.4) easy to understanda • The M.A.D.E 4 LIFE program provided me with the support I needed to help me increase my physical 4.4 (0.7) 4.4 (0.6) 4.4 (0.7) activity levelsa • I would recommend the M.A.D.E 4 LIFE program to my 4.7 (0.5) 4.6 (0.6) 4.6 (0.5) friendsa • The timing of the program (4:00- 5:30pm) was 4.0 (1.0) 3.8 (1.2) 3.9 (1.1) convenienta • The weekly session length (approx. 90 minutes) wasb: 2.6 (0.8) 2.1 (0.5) 2.4 (0.7) • The overall number of sessions (8) wasb: 2.5 (0.8) 1.8 (0.4) 2.2 (0.8)
• I would have liked more interactive sessions with my 3.1 (1.3) 3.0 (1.0) 3.1 (1.2) daughtera
Physical Activity Sessions Enjoyment of each Physical Activity session Mean (SD) Mean (SD) Mean (SD) • Zumbac 4.2 (1.1) 4.6 (0.5) 4.3 (1.0) • Mother & Daughter Gamesc 4.5 (0.5) 4.3 (0.6) 4.6 (0.6) • Boxingc 4.6 (0.5) 4.3 (0.8) 4.5 (0.7) • Fitness Circuitc 4.6 (0.7) 4.6 (0.5) 4.6 (0.6) • Gymsticksc 4.2 (0.8) 4.2 (0.7) 4.2 (0.8) • Fitballsc 3.9 (1.1) 3.9 (0.9) 3.9 (1.1) • Pilates & Yogac 4.2 (0.8) 4.5 (0.7) 4.3 (0.8) • Rough & Tumble playc 4.1 (0.9) 4.3 (0.8) 4.1 (1.0) • Skippingc 4.0 (0.8) 3.9 (1.1) 4.0 (0.9) • Backyard Gamesc 4.5 (0.6) 4.5 (0.6) 4.5 (0.6) • The Amazing Racec 4.7 (0.4) 4.9 (0.3) 4.8 (0.4) Education sessions Which of these information session topics did you use to help you increase your physical levels n, (%) n, (%) n, (%) • Physical activity recommendations 10 (56%) 4 (31%) 14 (45%) • Data shown from the NSW Schools Physical Activity 8 (44%) 0 (0%) 8 (26%) Nutrition Survey • Mums as role models & facilitators 6 (33%) 6 (46%) 12 (39%) • Health related components of fitness 4 (22%) 0 (0%) 4 (13%) • Unplug & Play resources 7 (39%) 2 (15%) 9 (29%)
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TABLE 4.8: MOTHERS’ PROCESS EVALUATION FOR THE MADE4LIFE PROGRAM PART TWO
12 • Family ACTIVation Pack 7 (54%) 19 (31%) (68%) • Rough & Tumble Play 5 (28%) 2 (15%) 7 (23%) • Pathways Possibilities for Physical Activity 8 (44%) 5 (38%) 13 (42%) • Reduce your sitting time 8 (44%) 2 (15%) 10 (32%) • Smart Goals 5 (28%) 6 (46%) 11 (35%) • Pedometer chart record 3 (17%) 3 (23%) 6 (19%) • Screen time reaction 2 (11%) 2 (15%) 4 (13%) • Fundamental Movement Skills 7 (39%) 7 (54%) 14 (45%) • Get in ‘their’ world 3 (17%) 1 (8%) 4 (13%) • Barriers to Physical Activity & Solutions 5 (28%) 5 (38%) 10 (32%) Mean The Facilitators Mean (SD) Mean (SD) (SD) • The facilitators had a high level of knowledgea 4.8 (0.5) 4.9 (0.3) 4.8 (0.4) • The facilitators had good communication skillsa 4.9 (0.3) 5.0 (0) 4.9 (0.2) • The facilitators were approachablea 4.9 (0.2) 5.0 (0) 5.0 (0.2) • The facilitators motivated me to apply the principles presented in 4.7 (0.6) 4.8 (0.3) 4.8 (0.5) the programa 4.9 (0.4) • Overall, I would rate the facilitatord 4.9 (0.2) 4.8 (0.5)
Abbreviations: a 1=Strongly disagree to 5= Strongly agree; b1=too long to 3=right; c1=Really didn’t like to 5=Really liked; d1= Poor to 5= Excellent; e 1=Too much to 3=Right; f Average amount;
Mothers rated the quality of the program extremely highly (e.g. “content was enjoyable and explained in a way I could understand”; “the program taught me how to increase my physical activity levels”; appropriate physical activity games”), with all means ≥4.4 out of a total score of 5. The mean score for mothers recommending the MADE4Life program to their friends was 4.6 (SD=0.5). Enjoyment ratings of physical activity sessions were high, with the ‘Amazing Race’ activity scoring the highest (m=4.8, SD=0.4) and ‘Mother-Daughter Games’ and ‘Fitness Circuit’ receiving means of 4.6, (SD=0.6). The ‘Fitballs’ session received the lowest score out of a possible five (m=3.9, SD=1.1). For the mothers’ education sessions topics, the ‘Physical Activity Recommendations and Fundamental Movement Skills’ 139 Results
presentations were the most commonly enjoyed (n=14, 45%) and the ‘Pathways and
Possibilities’ session which focused on identifying physical activity opportunities in the local community for a wide variety of interests was also popular (n=13, 42%).
Sessions on ‘Screen Time Reduction’ and ‘Get in Their World’ were the least popular
(n=4, 13%).
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TABLE 4.9: MOTHERS’ PROCESS EVALUATION FOR THE MADE4LIFE PROGRAM PART THREE Wait-list MADE4Life Total Item Control (n=18) (n=31) (n=13) ‘Pink Slips’ Mean (SD) Mean (SD) Mean (SD) • The ‘Pink Slips’ were valuablea 3.7 (1.0) 3.8 (0.7) 3.8 (0.9) The ‘Pink Slip’ activities were valuable because they: n, (%) n, (%) n, (%) • helped me increase my level of physical activity 10 (56%) 4 (30%) 14 (45%) • helped increase my daughters level of physical activity 12 (67%) 7 (53%) 19 (61%) • helped me increase my active time with my daughters 16 (89%) 8 (62%) 24 (77%) • gave me more ideas about how to be active 12 (67%) 7 (53%) 19 (61%) • helped keep me on track for my SMART goals 7 (39%) 4 (31%) 11 (35%) • The time commitment required to complete ‘Pink Slip’ 2.5 (1.0) 1.7 (0.6) 1.9 (0.9) activities wasb
Daughters’ weekly worksheets Mean (SD) Mean (SD) Mean (SD) • My daughter(s) enjoyed using the completing the weekly 4.2 (0.4) 4.2 (0.7) 4.2 (0.5) worksheeta • The weekly worksheet were a valuable resource for my 4.0 (0.7) 3.9 (0.8) 4.0 (0.7) daughter(s) a • The activities in the weekly worksheet were appropriate for 4.0 (0.7) 4.2 (0.6) 4.1 (0.6) my daughter’s agea • The weekly worksheet activities encouraged my daughter(s) 4.1 (0.5) 4.1 (0.8) 4.1 (0.6) and I to do things togethera • The number of activities in the weekly worksheet wasb 2.6 (0.7) 2.2 (1.1) 2.5 (1.0) The M.A.D.E 4 LIFE Program and my husband/partner Mean (SD) Mean (SD) Mean (SD) • My husband/partner believed that the M.A.D.E 4 Life 4.1 (0.7) 4.6 (0.5) 4.5 (0.7) Program was a positive experience for the familya • The M.A.D.E 4 Life program had a positive impact on my 3.4 (0.9) 3.3 (0.9) 3.2 (0.9) husband’s/partner’s physical activity levelsa • The M.A.D.E 4 Life program had a positive impact on my 3.4 (0.8) 3.4 (1.2) 3.4 (1.0) husband’s/partner’s dietary behavioursa • The M.A.D.E 4 LIFE program changed my husband's/partner’s parenting practices in relation to healthy 3.3 (0.9) 3.6 (0.8) 3.2 (0.9) lifestyles (i.e. role modelling, support) a The M.A.D.E 4 LIFE Program and my other children who did not Mean (SD) Mean (SD) Mean (SD) participate in the program • My other children believed that the M.A.D.E 4 Life Program 3.8 (0.8) 3.6 (1.1) 3.8 (0.9( was a positive experience for the familya • The M.A.D.E 4 Life program had a positive impact on my 3.8 (0.8) 3.9 (0.9) 3.9 (0.8) other children’s physical activity levelsa • The M.A.D.E 4 Life program had a positive impact on my 3.5 (0.6) 3.4 (1.0) 3.5 (0.8) other children’s dietary behavioursa
Have you told your friends/other school mothers about the M.A.D.E 4 n, (%) n, (%) n, (%) Life program? • No 0 (0%) 1 (8%) 1 (3%) 18 (100%) • Yes 12 (92%) 30 (97%)
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TABLE 4.9: MOTHERS’ PROCESS EVALUATION FOR THE MADE4LIFE PROGRAM PART THREE Changes in behaviour Mean (SD) Mean (SD) Mean (SD) As a result of attending the M.A.D.E 4 LIFE program: • My family is more active togethera 4.0 (0.6) 3.9 (0.6) 4.0 (0.6) • I spend more time being active with my daughter(s) a 3.9 (0.5) 4.2 (0.6) 4.0 (0.5) • My role as a mother has changed for the bettera 3.8 (0.7) 4.2 (0.6) 4.0 (0.7) • My family’s eating habits have changed for the bettera 3.2 (0.6) 3.5 (0.9) 3.4 (0.8) What are your family doing differently? • We are more active together 15 (83%) 10 (77%) 25 (81%) • We spend more time together 9 (50%) 7 (54%) 16 (52%) • We use ‘active toys’ more than before the program began 13 (72%) 6 (46%) 19 (61%) Have you changed any of your dietary intake as a result of the M.A.D.E n, (%) n, (%) n, (%) 4 Life program? • No 12 (67%) 8 (62%) 20 (65%) • Yes 6 (33%) 5 (38%) 11 (35%) Would you have liked to receive more information on any of the
following: • Healthy eating 12 (67%) 4 (31%) 16 (52%) • Healthy Cooking 12 (67%) 5 (38%) 17 (55%) • Meal Preparation 11 (61%) 3 (23%) 14 (45%) Do you think people would be willing to pay for the M.A.D.E 4 LIFE n, (%) n, (%) n, (%) program? • No 4 (22%) 2 (8%) 25 (81%) • Yes 14 (78%) 11 (92%) 6 (19%) How much do you think people would be willing to pay for the M.A.D.E 4 LIFE program?f $10/session $10/session $10/session
Abbreviations: a 1=Strongly disagree to 5= Strongly agree; b1=too long to 3=right; c1=Really didn’t like to 5=Really liked; d1= Poor to 5= Excellent; e 1=Too much to 3=Right; fAverage amount;
The satisfaction ratings for program facilitators were extremely high, with mothers rating facilitators as having a high level of knowledge (m=4.8,SD=0.4), good communication skills (m=4.9, SD=0.2) and approachable (m=5.0, SD=0.2). Overall, mothers rated the facilitators as “excellent” (m=4.9, SD=0.4).
Overall, 77% of mothers’ (n=24) believed the ‘Pink Slips’ helped to increase active time with their daughters and 61% of mothers (n=19) believed the ‘Pink Slips’ helped to increase the physical activity of their daughters and that the ‘Pink Slips’
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gave them more ideas about how to be more active. Mothers rated daughters’ weekly worksheets highly with all means ≥4.0 (Table 4.9).
In general, mothers believed the MADE4Life program was a positive experience for the “whole family” (m=4.5, SD=0.7). Mothers rated high scores for the program having an impact on their husband/partner’s physical activity levels (m=3.2,
SD=0.9) and other children’s physical activity levels (m=3.9, SD=0.8). A total of 13 mothers (97%) had told their friends about the MADE4Life program (Table 4.9). High scores were recorded for changes in behaviour as a result of the MADE4Life program, with means ≥4.0 for “families being more active together”, “spending more time being active with daughters” and mothers’ “role as a mother had changed for the good”.
In total 55% of mothers (n=17) reported that they would like to have received more information on healthy cooking and 52% (n=16) on healthy eating. Finally, 81% of mothers (n=25) believe people would be willing to pay for the program, suggesting an average of $10 per session (Table 4.9).
Mothers’ short qualitative answers from the process open-ended questions in the questionnaire are summarised in Table A2 (Appendix 31). Mothers indicated that the preferred program starting time would be 5pm and two sessions per week would have been an ideal number. In general, mothers reported that their husbands/partners had commented that the program was positive, and high levels of support were offered. One mother reported that her husband requested a ‘Dads and Daughters’ program for the future. Mothers reported their friends wanted to find out more information about being involved. There were some concerns from friends 143 Results
of the MADE4Life mothers who questioned adding the after-school program to their already busy schedules. Finally, some mothers reported changing dietary behaviours, including reducing junk food and increasing fruit and vegetable consumption.
Mothers completed three open-ended qualitative questions as part of the process evaluation questionnaire (Table 4.10 and Table 4.11). Mothers’ answers were analysed by detailing thematic coding.
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TABLE 4.10: SHORT QUALITATIVE ANSWERS REPRESENTING MOTHERS FROM THE MADE4LIFE INTERVENTION GROUP
MADE4Life intervention group What did you like about the M.A.D.E 4 LIFE program? • Being active & doing new & different things with daughter • Spending time with my daughter playing games • Having fun with my daughter, being in a group of other mums & daughters, great facilitation in communication/energy • The more dance based activities, like ZUMBA. Fruit salad beforehand good idea for the kids! Researchers were friendly & enthusiastic! • Love the pedometer & being made aware of helping girls to be more active • Doing things together with my daughter and whole family involved to do activities • My daughter motivated me to attend when I felt tired or sick. I loved being active with her, she's my sunshine xx Alyce is beautiful & the other girls made the program great • Mother & daughter time increases the bond. PS presentation at the end was awesome! • It confirmed that a lot of the games I do with the kids is what we did in the program, however, there was more to learn. The interaction & one on one time with XX (daughter) • Mother & Daughter time • The tools received • Made me have fun with my daughter. Made me be more active • Having fun & being active with the girls • Being with my daughters. Enthusiasm of all facilitators & helpers. Need to commit (forced activity). New ideas. New activities – participation • Opportunity for spending time with my daughter-being active-seeing her confidence growing. Having a lot of fun together. It was great to be all 'girls' • All of it except Zumba • The facilitators: they were professional, committed, enthusiastic and a delight to work with. The whole program was planned and executed brilliantly! Well done! Please tell us if there was anything about the MADE4Life program you didn’t like:
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MADE4Life intervention group
• Getting here felt like a bit of a hassle sometimes, but once we were here & doing activities together it was great. Sometimes it was difficult to fit in the ‘Pink Slip’ activities (as ridiculous as that may seem) • Homework • n/a • Maybe too much sitting prior to exercise - 1hr15 minutes better than 1hr 1/2 total. No parking! Need to explain in letter where the free parking bit was - didn't know it existed until the end! • It was sometimes hard to make the time but worth it. The girls got sick of the pedometer after a few weeks. XX (Daughter) was probably a bit young for the program. • Nil • Homework was hard to achieve - 1 week (2 weeks was better) Pedometer was hard to wear & fell off. Prefer a better type of pedometer (arm/waist) & would have then used i.e accelerometer was better to wear. • Trying to do the ‘Pink Slip’ activities at home, having a sibling wanting to join in • Trying to schedule all the tasks into an already busy week • ‘Pink Slip’ times were too long for children. E.g., 2 min stations etc. Once a week was enough fitting in all other family activities • My girls would have liked to do some activities outdoor • Zumba • Parking
Do you have any other comments about the M.A.D.E 4 LIFE program you think might be useful to the researchers? 146 Results
MADE4Life intervention group • I think I would have preferred the information sessions with my daughter so we could discuss together what we learnt together. • There is a great correlation between play/physical activity & parenting/child bonding. The tips/structures of encouraging this were so well targeted! • More dancing, and 15 minutes shorter! Traffic terrible leaving uni! • Nil • FOOD SCIENCE is important education of preservatives & colours is NON EXISTENT & very important to make choices. • Nutritional component would be great. • No - great job! • Healthy Eating • Possible look at 'inking' ideas into a weekly timetable. Work out what could go, what to keep, what the children could do to then allow more time to have fun • Excellent. ‘Pink Slip’ activities were hard to complete-finding the time-not sure how to change this. Maybe only do activities once, and list more, rather than repeating activities • The researcher & support staff were brilliant. They were so supportive and encouraging-acknowledging all efforts. It would be great for a similar program targeting next age level up. Good luck Alyce-you are doing a wonderful job. It has inspired me to join a gym and I participated in a 10km walk. Thankyou • The program not only increased my daughters’ confidence to attempt new physical challenges, but increased her overall confidence in all aspects of her life. An unexpected but very much welcomed 'value-add' for my daughter! Thanks!! Also - timing was great-always on time • While MADE4Life has given ideas on making small changes/doing bite-sized activities, time remains my biggest hurdle, particularly mid-week. My opinion is that even if I can make small changes, it is more than we were doing and we may just need to work on building up slowly. Our inability to complete ‘Pink Slips’ was a bit of a confidence blow, we will work on small changes, and hope that over time these will build up.
TABLE 4.11: SHORT QUALITATIVE ANSWERS REPRESENTING MOTHERS FROM THE WAIT-LIST CONTROL GROUP 147 Results
Wait-list control group What did you like about the MADE4Life program?
• It was very well balanced. The 'theory' was not too long. We both loved the practical sessions the most. All of them were SO MUCH FUN. All staff were friendly and enthusiastic. So creative will all ideas • It was very well structured. Gave out some very beneficial ideas and information. Staff involved were very friendly and helpful • The games/sporting activities, showing my daughter that there are many good reasons for her to eat well and exercise - not just because I want her to • Encouragement and enthusiasm of trainers. Very inspiring. • Alyce & Jo, That it was easy to adapt to fitness levels, the music/fruit/handouts-preparation, exercising with my daughter in a fun environment, the gymsticks - my favourites session • Time with my daughter being active and laughing • Spending time with daughter having fun and exercising together. Great enthusiasm of the course instructors • It was lots of fun and Alyce and the team were really approachable • Personable facilitators, Presentation of the activities (they were relevant, age appropriate, fun & 'do-able') • It was fun, informative and my daughter loved it as well • Quality girl time with my daughter being active and competitive together • The fantastic information and the opportunity to spend time actively with my girls, and free things of course! • It was motivating. It was good to do something with my daughter. It made her feel very special
Please tell us if there was anything about the M.A.D.E 4 LIFE program you didn’t like: 148 Results
Wait-list control group • Our only issue was the distance to travel as the Forum is on the outskirts of town and long way in 'after school peak hour traffic, but that's not your fault. In an ideal world, sessions would be in a variety of local areas, with another program to graduate to involving just the practical sessions on ongoing basis • Nothing, enjoyed it all! • No, all good • Lots of activities we didn't have time for through the week • Lots of interviews and questionnaires (I know it's necessary for the research) • Too much homework-I didn't have time
Do you have any other comments about the M.A.D.E 4 LIFE program you think might be useful to the researchers? • All important areas were covered so very professionally. Lovely extra to have fresh fruit available. It reminded me that 'barriers' are made to be broken. Perhaps sessions could be run thru schools? Couldn't fault it. Well done to all and good luck for such a worthwhile project in the future. Don't forget to let media know how it went. Just a little thought. If someone was taking video/stills of active sessions, perhaps a short 'screening' of what we did/shared/learnt together would be fun and reinforcing. All the best Alyce & crew. WELL DONE TO ALL!. • The researchers did a wonderful job and wish them luck in their future endeavours • I would like further weigh ins and measuring as further motivation • Included in the handouts could have been website where we can purchase items (gymsticks, skipping ropes etc.), A hotline where we could call Alyce - LOL! A website where the mums could also communicate/organise fitness get togethers, Facebook page - as above for showing ideas • More dietary info would be beneficial but all in all it was a really fun professional program
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Wait-list control group • I suspect many mothers would be interested in the findings of the research and may be interested in attending a lecture/seminar which presented the findings • The starting time was difficult. The lack of awareness of mothers’ having other children-especially younger ones to find care for - unrealistic expectations. It was very idealistic which I guess is good. It would've been good to get some individual feedback on what we were doing/eating etc.-to know how much we needed to improve. Individual analysis
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First, mothers reported what they liked about the MADE4Life program. Unanimously, mothers reported spending quality time with their daughters (i.e. mother-daughter bonding) and having fun and increasing activity levels were the most common answers. The facilitators were also a common strong point of the program, notably their energy, motivation and amicable characters. The most common answers regarding things mothers didn’t like about the program included time taken to complete homework tasks (i.e. ‘Pink Slip’ activities), parking, wearing a pedometer and lack of outdoor activities. Finally, mothers provided additional comments about the program. Ideas for future program improvements included adding a healthy eating component, a website/social network whereby mothers could communicate, and reducing ‘Pink Slip’ activities. There were many positive, supportive comments for the lead PhD candidate and one mother gained inspiration to join a gym and participate in a 10km walk with her daughter. One mother also made mention of her daughter’s confidence levels overall increasing which was a “value add” of the program.
4.3.1.1 Facilitators’ Evaluation
The facilitators’ evaluation was completed as a weekly journal by the PhD candidate and the daughters’ co-facilitator. Journal notes were summarised under the following themes:
(i) Intervention content and resources (e.g. was all of the planned content
implemented as planned?);
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• Mothers were very surprised when comprehending the screen time
recommendations and there was discussion about the current
barriers mothers have around limiting screen time at home
• It was evident the daughter’s booklet was a “prized possession”,
and almost all daughters brought their booklet every week to add
in their “daughters worksheets”
• Daughters really liked the “scratch n sniff” stickers, and were keen
to obtain the whole collection for their MADE4Life sticker chart
• There were some daughters who forgot to complete their weekly
‘Pink Slip’ task, and some would comment that their mum didn’t
have time to complete the weekly tasks
• The majority of mothers were very happy to receive the resource
‘100 ways to unplug and play’ and utilised some of these strategies
in their home for their whole family
• Mothers expressed their gratitude for the resource ‘Pathways and
Possibilities’ (Appendix 23) and many mothers were discussing the
option of forming a “Quick Kicks” girls-only soccer team once
MADE4Life had finished
• Mothers and daughters commented positively on the free skipping
rope and many said they had incorporated this resource into their
home activities
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• The final session ‘The Amazing Race’ was by far the most
successful session as it incorporated a suite of activities which were
conducted throughout the MADE4Life program. The map and
passport (Appendix 32) worked really well for the mother-daughter
teams and the idea that mothers and daughters were “racing” to the
end was really empowering for the dyads/triads. The PowerPoint
presentation at the end of the final session was a highlight and
many mothers were overwhelmed with emotion on completion of
the slideshow
(ii) Engagement of the mothers and daughters (e.g. things that resonated with
the mothers and daughters);
• It was evident that the mothers were very interested in hearing the
statistics surrounding the prevalence of girls’ physical activity,
fundamental movement skills (FMS) and screen time. A few
questions were probed by one particular mother who was quite
shocked at the low levels of girls physical activity and FMS,
particularly in comparison to boys
• Mothers were highly engaged with the session task “barriers and
solutions”. Mothers really enjoyed having the opportunity to discuss
in small groups their experiences to one another
• Daughters really liked having their “daughters session” separate to
the mothers as it allowed them to make connections and
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friendships with other daughters and complete tasks that were age-
appropriate before moving on to the physical activity session with
their mothers
• Mothers and daughters of each individual family dyad/triad seemed
to really enjoy the physical activity sessions whereby activities
involved their “family unit” rather than being competitive against
other families.
• Mothers and daughters really enjoyed the fitness circuit and the
resistance training exercises (boxing and gymsticks). It would have
been good to incorporate more of these exercises in the following
weeks as circuit was on a timed rotation and there were many
activities to complete
• For the mother-daughter games, there was a lot of laughter. In
particular, there were many mothers who commented at the end of
the session saying that they hadn’t “played” in years, and it was the
best fun they had had in a long time
• Some of the mothers and daughters made comment that the games
used in MADE4Life were incorporated into their birthday parties
and these games made the party a success
(iii) Procedures (e.g. was the time sufficient).
• Education content that was planned for the mothers’ session in
Week 1 was not covered in its entirety due to the welcoming of all
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participants and getting participants settled. Therefore, some of the
final slides were presented in Week 2, re-capping the main
messages
• As the weeks went along, timing of the education sessions became
more succinct, and content was progressed at an acceptable rate
within the allocated 25 minutes
• Although the PhD candidate had the sport centre permanently
booked over the eight-week period and had set up equipment prior
to the arrival of participants, the time allocated to the physical
activity session in Week 6 was reduced by 10 minutes owing to
other members of the public accessing the basketball court and
removing all equipment without permission.
4.3.2 Hypothesis Four: Preliminary Efficacy – Primary Outcome
The MADE4Life program will be efficacious, demonstrated through daughters’ in the intervention group showing a moderate effect size for the primary outcome % time in MVPA in comparison to the wait-list control group daughters.
There was no significant intervention effect (d=-0.03) for the primary outcome of daughters’ % time in MVPA.
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4.3.3 Hypothesis Five: Mothers and Daughters Secondary Outcomes
Compared to the wait-list control group, the datum from the mothers and daughters in the MADE4Life intervention will show moderate effect sizes in secondary outcomes at immediate post-intervention follow up assessment.
Non-significant and very small effect sizes were reported for daughters’ secondary outcomes of % VPA; d=-0.09, % MPA; d=0.04 and CPM d=-0.09 post- intervention. At follow-up, a small effect size was found for daughters’ CPM d=0.20, with a significant within-group effect for the treatment group at follow-up (with a +75 counts per minute, increase from pre to post; 95%CI 7.17, 144.68). A medium effect size for daughters’ % LPA; d=-0.46 was revealed at both post-intervention and follow-up. Both the treatment and control daughters showed within-group effects for
% LPA at post-intervention and, in addition, the control daughters showed a within- group difference at follow-up. Small-to-medium effect sizes were found in both groups for daughters’ % SED at both post-intervention (d=0.38) and the control group only at follow-up (d=0.36). Small-to-medium effect sizes were found for daughters’ systolic blood pressure at post-intervention (d=0.01) to follow-up (d=0.40) in both groups, and daughters’ diastolic blood pressure at post-intervention (d=0.32) to follow-up (d=0.33) in both groups. Tables 4.12 and 4.13 report the results of primary and secondary outcomes for daughters and mothers respectively, and
Figure 4.2 and Figure 4.3 illustrate daughters’ % MVPA and % VPA in both groups over time.
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TABLE 4.12: CHANGES IN OUTCOME VARIABLES FOR DAUGHTERS BY TREATMENT GROUP FROM BASELINE TO IMMEDIATE POST-INTERVENTION AND 3- MONTH POST-INTERVENTION AND DIFFERENCES IN OUTCOMES AMONG THE TREATMENT GROUPS AT IMMEDIATE POST-INTERVENTION AND 3-MONTH POST- INTERVENTION FOLLOW UP (ITT ANALYSIS) (N= 48)
Treatment group Group * Effect Time a Size Mean change from Baseline (95% CI) (overall)
Time point Outcome Control MADE4Life program Mean difference between (Cohen’s P (n =23 ) (n =25 ) groups (95% CI)a d)
1 0.88 (0.50, 1.27) 0.37 (-0.02, 0.76) -0.52 (-1.06, 0.03) -0.06 Weight (kg) 2 1.90 (1.38, 2.42) 1.69 (1.17, 2.22) -0.20 (-0.94, 0.54) 0.16 -0.02 1 0.45 (-0.08, 0.17) -0.08 (-0.20, 0.05) -0.12 (-0.30, 0.06) -0.10 BMI z-score 2 0.14 (0.02, 0.27) 0.08 (-0.05, 0.21) -0.06 (-0.24, 0.13) 0.39 -0.05 1 0.17 (-0.03, 0.36) 0.34 (0.14, 0.54) 0.17 (-0.11, 0.45) 0.10 Waist z-score 2 0.35 (0.16, 0.54) 0.42 (0.22, 0.61) 0.07 (-0.21, 0.34) 0.44 0.04 1 Systolic blood pressure -5.50 (-9.44, -1.56) -4.64 (-8.62, -0.66) 0.86 (-4.74, 6.46) 0.01 b (mmHg) 2 -8.02 (-11.56, -4.49) -3.84 (-7.60, -0.08) 4.18 (-0.98, 9.34) 0.24 0.40 1 Diastolic blood pressure -8.03 (-12.81, -3.24) -5.36 (-10.16, -0.56) 2.67 (-4.12, 9.46) 0.32 b (mmHg) 2 -9.25 (-12.49, -6.02) -6.50 (-9.83, -3.17) 2.75 (-1.90, 7.40) 0.49 0.33 1 -7.50 (-15.47, 0.47) -5.43 (-13.36, 2.51) 2.07 (-9.17, 13.32) 0.17 Resting heart rate (BPM) 2 -7.17 (-13.30, -1.05) -0.23 (-6.61, 6.15) 6.94 (-1.90, 15.78) 0.24 0.57 1 0.34 (-0.30, 0.98) 0.74 (0.09, 1.40) 0.40 (-0.52, 1.32) 0.05 Fat mass (%) 2 1.76 (0.90, 2.61) 3.23 (2.33, 4.14) 1.48 (0.23, 2.73) 0.07 0.19 1 111.39 (41.95, 180.83) 99.23 (28.08, 170.37) -12.17 (-111.58, 87.25) -0.09 Mean CPM b 2 45.72 (-20.39, 111.83) 75.92 (7.17, 144.68) 30.20 (-65.18, 125.58) 0.69 0.20 1 -5.74 (-8.19, -3.29) -2.90 (-5.40, -0.40) 2.84 (-0.66, 6.34) 0.38 % time in SED b 2 -4.28 (-6.35, -2.21) -1.56 (-3.70, 0.57) 2.72 (-0.25, 5.69) 0.14 0.36 157 Results
Treatment group Group * Effect Time a Size Mean change from Baseline (95% CI) (overall)
% time in LPA b,c 1 4.84 (2.82, 6.85) 2.14 (0.09, 4.20) -2.69 (-5.57, 0.18) -0.46 2 3.99 (2.28, 5.70) 1.31 (-0.47, 3.07) -2.69 (-5.15, -0.22) 0.08 -0.46 1 0.58 (-0.06, 1.23) 0.63 (-0.00, 1.28) 0.05 (-0.87, 0.96) 0.04 % time in MPA b 2 0.35 (-0.013, 0.82) 0.11 (-0.38, 0.60) -0.24 (-0.92, 0.45) 0.73 -0.18 1 0.36 (-0.09, 0.81) 0.26 (-0.20, 0.72) -0.10 (-0.74, 0.54) -0.09 % time in VPA b 2 -0.05 (-0.05, 0.44) 0.16 (-0.34, 0.66) 0.21 (-0.49, 0.91) 0.67 0.18 1 0.96 (-0.03, 1.95) 0.88 (-0.12, 1.88) -0.08 (-1.49, 1.33) -0.03 % time in MVPA b 2 0.28 (-0.57, 1.13) 0.31 (-0.57, 1.19) 0.03 (-1.20, 1.25) 0.99 0.01 1 Daughters sitting time 7 2.78 (-58.03, 63.60) -14.43 (-78.44, 49.58) -17.21 (-105.49, 71.07) -0.11 d day average (min/day) 2 -27.59(-100.27, 45.09) -25.81 (-99.76, 48.14) 1.78 (-101.90, 105.46) 0.87 0.01 1 Daughters mean screen -22.67 (-54.08, 8.74) -7.81 (-40.09, 24.48) 14.86 (-30.17, 59.89) 0.19 d time (min/day) 2 -24.00 (-51.92, 3.93) 2.99 (-25.76, 31.73) 26.98 (-13.09, 67.05) 0.40 0.34 Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; Time point 1 = immediate post-intervention Time point 2 = 3-month post-intervention; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA = moderate to vigorous physical activity; VPA = vigorous physical activity; MPA = moderate physical activity, LPA = light physical activity; SED = sedentary activity; % time in, percent of time accounting for wear time. a intervention minus control; b adjusted for AGE; c adjusted for SES; d reported by mother for eldest daughter if more than one child enrolled
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TABLE 4.13: CHANGES IN OUTCOME VARIABLES FOR MOTHERS BY TREATMENT GROUP FROM BASELINE TO IMMEDIATE POST-INTERVENTION AND 3- MONTH POST-INTERVENTION AND DIFFERENCES IN OUTCOMES AMONG THE TREATMENT GROUPS AT IMMEDIATE POST-INTERVENTION AND 3-MONTH POST-INTERVENTION FOLLOW UP (ITT ANALYSIS) (N= 40)
Treatment group Group Effect
Mean change from Baseline (95% CI) a * Time Size
Mean difference Outcome Time Control MADE4Life program (Cohen’s between groups (95% P point (n =19) (n =23) d) CI)a 1 -0.49 (-1.48, 0.51) 0.45 (-0.57, 1.46) 0.93 (-0.49, 2.35) 0.06 Weight (kg) b 2 0.17 (-0.10, 0.44) 0.49 (0.20, 0.77) 0.32 (-0.08, 0.71) 0.15 0.02 1 -1.48 (-4.41, 1.46) 1.14 (-1.87, 4.15) 2.61 (-1.59, 6.82) 0.22 Waist [umb] (cm) b 2 -0.57 (-2.41, 1.27) 0.95 (-0.96, 2.86) 1.52 (-1.13, 4.18) 0.40 0.13 1 -0.04 (-0.55, 0.46) -0.17 (-0.69, 0.35) -0.13 (-0.85, 0.60) -0.02 BMI (kg/m2) 2 -0.26 (-0.69, 0.18) 0.10 (0.36, -0.36.56) 0.36 (-0.28, 0.99) 0.34 0.07 1 -4.35 (-8.45, -0.24) -2.59 (-6.79, 1.61) 1.76 (-4.11, 7.63) 0.14 Systolic blood pressure (mmHg) b 2 -6.74 (-11.63, -1.85) -2.95 (-7.92, 2.01) 3.79 (-3.18, 10.76) 0.53 0.30
Diastolic blood pressure (mmHg) 1 -4.50 (-7.80, -1.20) -2.15 (-5.51, 1.20) 2.34 (-2.36, 7.05) 0.23 b 2 -5.17 (-8.97, -1.37) -3.95 (-7.84, -0.06) 1.22 (-4.22, 6.66) 0.60 0.12 1 -1.24 (-5.16, 2.69) -0.14 (-4.03, 3.76) 1.10 (-4.43, 6.63) 0.11 Resting heart rate (BPM) 2 -1.94 (-5.03, 1.14) -1.82 (-5.09, 1.46) 0.13 (-4.37, 4.63) 0.91 0.01 1 -0.20 (-1.53, 1.14) -0.62 (-1.20, 0.75) -0.42 (-2.33, 1.49) -0.06 Fat mass % b 2 -0.90 (-2.38,0.59) 0.41 (-1.15, 1.98) 1.31 (-0.85, 3.47) 0.39 0.17 1 -7.07 (-47.39, 33.24) 16.75 (-20.92, 54.41) 23.82 (-31.35, 78.99) 0.20 Mean CPMc 2 -1.32 (-40.64, 38.00) -12.70 (-50.93, 25.52) -11.38 (-66.20, 43.45) 0.33 -0.09 1 0.36 (-2.20, 2.93) 0.91 (-1.50, 3.32) 0.54 (-2.97, 4.06) 0.07 % time in SEDc 2 -1.00 (-2.85, 2.66) -1.23 (-3.93, 1.51) -1.13 (-5.01, 2.75) 0.59 -0.14
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Treatment group Group Effect
Mean change from Baseline (95% CI) a * Time Size
Mean difference Outcome Time Control MADE4Life program (Cohen’s between groups (95% P point (n =19) (n =23) d) CI)a 1 -0.18 (-2.53, 2.18) -1.39 (-3.60, 0.84) -1.21 (-4.44, 2.03) -0.17 % time in LPAc 2 0.18 (-2.42, 2.78) 1.77 (-0.83, 4.38) 1.60 (-2.08, 5.28) 0.20 0.23 1 -0.19 (-0.88, 0.51) 0.20 (-0.44, 0.85) 0.39 (-0.56, 1.33) 0.23 % time in MPAc 2 -0.10 (-0.80, 0.61) -0.50 (-1.18, 0.19) -0.40 (-1.38, 0.58) 0.17 -0.23 1 0.04 (-0.15, 0.22) 0.22 (0.05, 0.39) 0.18 (-0.07, 0.43) 0.25 % time in VPAc 2 0.07 (-0.12, 0.25) -0.07 (-0.25, 0.11) -0.14 (-0.39, 0.12) 0.04 -0.19 1 -0.14 (-0.93 0.65) 0.38(-0.35, 1.12) 0.53 (-0.55, 1.61) 0.25 % time in MVPAc 2 -0.03 (-0.82, 0.76) -0.59 (-1.36, 0.18) -0.56 (-1.67, 0.54) 0.06 -0.27 1 23.52 (-75.64, 122.67) -44.16 (-142.86, 54.54) -71.49 (-209.28, 66.27) -0.35 Mothers sitting time work day b 71.30 (-111.60, (min/day) 2 -53.32 (-228.23, 121.58) 124.62 (-128.44, 377.69) 0.24 0.62 254.20) Mothers siting time non-work day 1 88.16 (-7.54, 183.86) -22.50 (-117.86, 72.86) -110.66 (-245.75, 24.43) -0.70 (min/day) 2 29.21 (-53.79, 112.22) 29.53 (-55.82, 114.89) 0.32 (-118.73, 119.38) 0.15 0.00
Mothers Godin weekly met 1 50.42 (-203.79, 304.64) 346.00 (90.61, 601.40) 295.58 (-64.76, 655.92) 0.42 minutes_excMild 2 71.33 (-302.95, 445.61) 438.76 (62.51, 815.01) 367.43 (-163.27, 898.13) 0.21 0.53 1 0.04 (-1.10, 1.19) 2.05 (0.89, 3.21) 2.00 (0.37, 3.63) 0.66 Parenting for PA Role modelling f 2 0.26 (-0.85, 1.38) 0.62 (-0.55, 1.79) 0.36 (-1.26, 1.97) 0.02 0.12 1 0.32 (-0.73, 1.36) 1.06 (0.01, 2.11) 0.74 (-0.74, 2.23) 0.34 Parenting for PA beliefs f 2 0.21 (-0.78, 1.20) 1.17 (0.16, 2.19) 0.96 (-0.49, 2.38) 0.39 0.44
Parenting for PA Logistic 1 -0.26 (-0.99, 0.47) -0.30 (-1.04, 0.45) -0.03 (-1.08, 1.01) -0.12 f Support 2 0.53 (-0.17, 1.22) 0.27 (-0.44, 0.99) -0.25 (-1.25, 0.74) 0.80 -0.14 Parenting for PA Self Efficacy e,f 1 0.53 (-0.54, 1.59) -0.42 (-1.49, 0.66) -0.94 (-2.46, 0.58) -0.45
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Treatment group Group Effect
Mean change from Baseline (95% CI) a * Time Size
Mean difference Outcome Time Control MADE4Life program (Cohen’s between groups (95% P point (n =19) (n =23) d) CI)a 2 -0.58 (-1.96, 0.80) -1.52 (-2.93, -0.11) -0.94 (-2.91, 1.04) 0.45 -0.45 1 0.53 (-0.54, 1.60) -0.43 (-1.50, 0.65) 0.65 (-0.85, 2.16) 0.24 Parenting for PA Support f 2 -0.58 (-1.96, 0.80) -1.54 (-2.96, -0.13) 0.96 (-2.94, 1.01) 0.43 0.35 1 -1.74 (-4.10, 0.62) -0.41 (-2.78, 1.97) 1.33 (-2.01, 4.68) 0.28 (SCT) Self Efficacy 2 -2.53 (-4.80, -0.29) -1.37 (-3.64, 0.89) 1.15 (-2.03, 4.33) 0.68 0.24 1 -0.05 (-0.84, 0.74) -0.09 (-0.89, 0.72) -0.04 (-1.16, 1.09) -0.02 (SCT) Outcome Expectations d 2 -0.68 (-1.99, 0.62) -1.22 (-2.54, 0.10) -0.54 (-2.39, 1.32) 0.83 -0.31 1 -0.00 (-0.47, 0.47) -0.07 (-0.54, 0.41) -0.07 (-0.74, 0.61) -0.05 (SCT) Social Support b 2 0.04 (-0.46, 0.53) 0.03 (-0.46, 0.54) -0.00 (-0.71, 0.71) 0.97 0.00 1 0.16 (-0.41, 0.01) -0.24 (-0.49, 0.02) -0.08 (-0.44, 0.28) -0.15 (SCT) Intention 2 -0.47 (-0.854, -0.09) -0.47 (-0.86, -0.08) 0.00 (-0.54, 0.55) 0.88 0.00 Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; Time point 1 = immediate post-intervention Time point 2 = 3- month post-intervention; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA, moderate to vigorous physical activity; VPA, vigorous physical activity; MPA, moderate physical activity, LPA, light physical activity; SED, sedentary activity; % time in, percent of time accounting for wear time. a intervention minus control; b adjusted for BMI; c Intervention n=23, Control n=18; d adjusted for ses; e adjusted for age; f reported by mother for eldest daughter if more than one child enrolled
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Daughters %MVPA
MADE 4 LIFE CON 7
6.5
6
%MVPA 5.5
5 BL 10-week 20-week
Figure 4.2: Daughters’ mean % time in MVPA in both groups (n=48). MADE4Life group x time (P=0.99).
Daughters % VIG
MADE 4 LIFE CON
2.5
2
%VIG
1.5
1
BL 10-week 20-week
Figure 4.3: Daughters’ mean % time in VPA in both groups (n=48). MADE4Life group x time (P=0.67).
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Intervention mothers’ % MVPA effect size was d=0.25 at post-intervention.
Intervention mothers increased their % MVPA by 0.4% at post-intervention compared to the control group who decreased by 0.1% (Figure 4.4). A significant intervention effect was found for mothers’ % VPA (P=0.04, d=0.25), with the overall group-by-time effect significant (P=0.04) with the mothers in the MADE4Life group increasing their % VPA (+0.22%, 95% CI; 0.05, 0.39) compared to the control group
(+0.04% 95%CI; -0.15, 0.22) at post-intervention (Figure 4.5). A large (d=0.66) and significant (P<0.05) treatment effect size was found for mothers’ physical activity role modelling at post-intervention.
Mothers %MVPA
MADE 4 LIFE CON
4.5
4
3.5
3
2.5 %MVPA 2
1.5
1 BL 10-week 20-week
Figure 4.4: Mothers’ mean % time in MVPA in both groups (n=40). MADE4Life group x time(P=0.06).
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Mothers %VPA
MADE 4 LIFE CON
1
% VIG 0.5
0 BL 10-week 20-week
Figure 4.5: Mothers’ mean % time in VPA in both groups (n=40). MADE4Life group x time (P=0.04).
Medium effect sizes were found for mothers’ MET minutes at both post-intervention
(d=0.42) and follow-up (d=0.53), with a significant within-group difference in favour of the MADE4Life mothers. MADE4Life mothers also recorded a significant within- group effect for their parenting for physical activity beliefs, with medium effect sizes post-intervention (d=0.34) and follow-up (d=0.44). A large effect size (d=-0.70) was found for mothers’ sitting time on a non-work day post-intervention in favour of the
MADE4Life group. Small effects were found for mothers’ systolic blood pressure for
164 Results
post-intervention (d=0.14) and follow-up (d=0.30) and diastolic blood pressure at post-intervention (d=0.23) and follow-up (d=0.12) in favour of the control mothers.
4.4 Chapter Summary
The first section (section 4.1) of this chapter reported baseline characteristic data from 40 mothers and 48 daughters who were recruited for the MADE4Life pilot RCT.
Following this, section 4.2 reported the maternal correlates of objectively measured physical activity in girls’ baseline data from the MADE4Life Pilot RCT involving 40 mothers and 40 daughters. In the final section (section 4.3) the feasibility and preliminary efficacy findings from the MADE4Life family-based physical activity pilot
RCT in a community setting targeting mothers and daughters were reported.
Table 4.14 provides a summary of the hypotheses and associated results.
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TABLE 4.14: OVERALL SUMMARY OF THE STUDY RESULTS
Hypothesis Results There will be significant associations between A number of maternal behaviours, social-cognitive and parenting some maternal physical activity correlates and correlates were found to be significantly associated with daughters’ daughters’ objectively measured physical physical activity, sedentary behaviours. For daughters’ %MVPA, a small activity. to moderate positive correlation was found for mothers’ beliefs, explaining a weak proportion of variance. For daughters CPM, a small to moderate positive correlation was observed for mothers’ logistic support, mothers’ CPM and outcome expectations, with the model explaining a moderate to strong proportion of the variance. For daughters’ %SED, mothers’ logistic support was negatively associated, with the model explaining a weak proportion of variance. The MADE4Life program will be feasible, MADE4Life was highly feasible. The 80% retention target was met for the demonstrated through recruitment, retention primary outcome (accelerometer data) with 100%, 81% and 83% at and attendance targets being achieved; and baseline, post-intervention and follow-up respectively. Similarly, retention through participants finding the program rates for mothers were high with 98%, 85% and 83% at each assessment. acceptable with high satisfaction The study had excellent retention for assessments with 100% attending demonstrated through comprehensive baseline assessments, 93% attended post-intervention and 91% at follow- process evaluation from multiple perspectives up. Average attendance at program sessions was high (82%). including mothers and facilitators. Mothers reported MADE4Life was highly acceptable. Acceptability and satisfaction were reflected by the high mean scores overall from the
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Hypothesis Results process evaluation questionnaire. Mothers’ qualitative answers indicated program highlights were spending quality time with their daughters in physical activity in a fun, supportive environment with other mothers and daughters. Facilitator journal notes revealed strengths for intervention content and resources, high levels of engagement of mothers and daughters and flexibility needed for some procedures. The MADE4Life program will be efficacious, There was no significant intervention effect, and a very small effect size demonstrated through a moderate effect size was found for the primary outcome of daughters’ % time in MVPA. for the primary outcome % time in daughters’ MVPA in the intervention group in comparison to the wait-list control group daughters. Compared to the wait-list control group, the Very small effect sizes were reported for majority of daughters’ secondary datum from the mothers and daughters in the outcomes at post-intervention. A small effect size was found for MADE4Life intervention will show moderate MADE4Life daughters CPM at follow-up. Medium effect sizes were found effect sizes in some secondary outcomes at for daughters’ % SED at post-intervention and follow-up. Similarly, immediate post-intervention follow up medium effect sizes were found for both groups’ diastolic blood pressure assessment. at post-intervention and follow-up. Intervention mothers’ % MVPA effect size was at post-intervention. A significant intervention effect was found for mothers’ % VPA at post- intervention, with the overall group-by-time effect significant. A large and
167 Results
Hypothesis Results significant treatment effect size was found for mothers’ physical activity role modelling at post-intervention. Moderate effect sizes were found for MADE4Life mothers’ MET minutes at post-intervention and follow-up and PA beliefs at post-intervention and follow-up.
168 Discussion
5 Chapter 5: Discussion
This thesis focused on examining: (i) the effectiveness of mother-daughter physical activity/fitness and/or dietary interventions using a systematic review; (ii) examining maternal correlates of girls objectively measured physical activity; and, (iii) the feasibility and preliminary efficacy of a family-based physical activity program conducted in a community setting, known as MADE4Life, which targeted mothers and their primary school-aged (5-12 years) daughters. In the following sections, an overview addressing the study aims and hypotheses will be provided and findings discussed in the context of current literature. Following this, the study strengths and limitations will be presented.
5.1 Systematic Review
The systematic review was presented as a stand-alone chapter (see Chapter 2). To summarise how this research specifically addressed the aim related to the systematic review and the associated hypothesis (section 5.1.1.), an overall summary is provided in this section.
169 Discussion
5.1.1 Aim One: Systematic Review
To systematically review the available literature to determine the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters.
5.1.2 Hypothesis One: Systematic Review
The effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters will be limited due to heterogeneity of current studies and further research will be required targeting girls and women.
The results from the systematic review supported Hypothesis One, with a limited number (n=11) of unique interventions targeting mother-daughter physical activity, fitness and/or diet. Overall, significant improvements in fitness were reported in most interventions targeting mothers and daughters. Dietary behaviours were generally positive; however, these were only assessed in three studies. For physical activity, measures were inconsistent and statistically significant improvements in physical activity were reported for two out of five studies. Although some of the findings for mother-daughter lifestyle interventions are promising, the overall methodological quality of these studies was low, with a high risk of bias in many of the studies, meaning results must be interpreted with caution. Although there were five RCTs, the mode of delivery varied considerably (i.e. number of sessions per week, duration of session). In addition, overall sample sizes of mothers and daughters were low and four studies were pilot studies with no control arm. 170 Discussion
The cultural tailoring of intervention content was a common focus, tailoring intervention material for subgroup populations of Latin American, Hispanic, Iranian or African American culture. Intervention content was tailored around participants’ cultural background and authors of these studies believed this had a positive impact on the mothers and daughters and was a strength of their interventions. Successful strategies in studies that reported significant improvements in fitness were those that engaged mothers and daughters in highly interactive face-to-face physical activity and fitness activities at least two to three times per week. Promotion of family involvement, in this case maternal involvement in a face-to-face program, may be an effective strategy for improving daughters’ health outcomes and encouraging family members to improve their behaviour, can impact positively on their child’s behaviour.
Overall, the findings suggest that lifestyle interventions that target both mothers and daughters to participate at the same time and complete intervention tasks together could be an appealing and successful strategy to enhance physical activity, fitness and dietary outcomes.
171 Discussion
5.2 Maternal correlates of daughters’ physical activity
5.2.1 Aim Two: Maternal Correlates
To examine specific maternal correlates of objectively measured physical activity in girls, including demographic, anthropometric, behavioural, activity-related parenting practices and physical activity cognitions.
5.2.2 Hypothesis Two: Correlates
There will be significant associations between some maternal physical activity correlates and daughters’ objectively measured physical activity.
One of the aims of this thesis was to examine maternal correlates of objectively measured physical activity in girls. The findings from this cross-sectional analysis supported the research hypothesis. It was found that mothers’ beliefs about physical activity were significantly related to girls’ % time spent in MVPA. A number of maternal parenting practices, cognitions and behaviours were found to be related to daughters’ physical activity. Significant maternal correlates were found for mothers parenting practices, mothers’ sedentary behaviour and mothers’ BMI. However, mothers’ cognitions including self-efficacy, outcome expectations, social support and intention were not significantly correlated.
This appears to be the first study to examine maternal correlates of objectively measured physical activity using accelerometry in both mothers and daughters.
172 Discussion
Mothers’ beliefs about girl’s physical activity were significantly related to daughters’
% time spent in MVPA. Mothers who believed physical activity was important for their daughters were more likely to have daughters who participated in health- enhancing levels of physical activity. It is likely that daughters would be supported and provided with more opportunities to engage in MVPA if their mothers believed it was important and that this may influence behaviour through provision of more physical activity opportunities. It is also possible that girls who are aware of their mother’s beliefs regarding physical activity, seek opportunities to be involved in
MVPA.
Our findings are supported by those of Trost and colleagues of parents in general, who found that parents who believed in the importance of physical activity had more physically active children, compared to parents who did not report strong beliefs in the importance of this behaviour (Trost et al., 2003). However, in their study, physical activity was measured via self-report, and gender-specific intergenerational influences were not explored. Dempsey and colleagues found that parental beliefs about their children’s self-reported MVPA explained only a small (6%) amount of variance (Dempsey, Kimiecik, & Horn, 1993) compared to the current study findings of 14% of the variance explained. This might be attributed to the use of an objective measure of physical activity as regression models commonly explain more variance in self-reported physical activity compared to objective measured (Plotnikoff,
Lubans, Penfold, & Courneya, 2014).
173 Discussion
Mothers’ logistic support, outcome expectations and mothers’ CPM were all significantly related to daughters’ CPM. It is clear that beliefs of mothers appear to be key in terms of how active their daughters are, whether it be their beliefs about physical activity benefits for themselves and/or their daughters. Logistic parental support involves practical tasks such as enrolling a child in sport, transporting them to/from sporting activities and watching them participate in sporting activities
(Davison et al., 2003). The results from the current study suggest that mothers who provide high levels of physical activity-related logistic support to daughters have more active daughters. This association between daughters’ CPM and mothers’ logistic support could also reflect that daughters who are more active might prompt their mothers to provide such logistic support, i.e. through a positive reinforcement cycle (Davison et al., 2003). A recent review by Trost and Loprinzi (2011) on parental influences on physical activity in youth found strong and consistent correlations between parental support for physical activity and children’s physical activity (Trost
& Loprinzi, 2011). In addition, Sleddens et al. (2012) highlighted parental supporting behaviours including role modelling were positively correlated with child physical activity (Sleddens et al., 2012). Other reviews investigating parental correlates and youth physical activity have concluded that parental support (Gustafson & Rhodes,
2006) is correlated to physical activity.
Similar to the current study, mothers’ logistic support has been shown to be associated with girls’ physical activity (Davison et al., 2003), where maternal support explained 12% of the variance in girls self-reported activity (Davison et al., 2003).
174 Discussion
The regression model examined in this thesis for daughters’ CPM explained 24% variance, and the individual contribution of mothers’ logistic support explained 10% of the variance. It has been reported mothers offer higher levels of logistic support for girls than boys (Edwardson & Gorely, 2010a). In a more recent study assessing parenting practices and physical activity in 10- to 11-year-old boys and girls, maternal logistic support was associated with girls’ CPM only (Jago et al., 2011).
Although in the current study maternal logistic support was a correlate of daughters’
CPM, the parenting activity-related measure of support was not significant. Study findings from this thesis align with Adkins and colleagues (2004) who did not find a significant association between maternal support and daughters’ physical activity.
Adkins and colleagues did, however, report parents’ self-efficacy for being active with their daughters was significantly correlated with daughters’ activity.
Although there was a significant correlation between mother-daughter total activity (CPM), there was no significant association between mother-daughter % time in MVPA. A review focusing on parent-child physical activity correlations revealed that overall findings are largely mixed, and interpretation and comparison is problematic due to the lack of objective physical activity measures being adopted
(Gustafson & Rhodes, 2006). It may be that the current study sample of daughters had more opportunity for engaging in MVPA, such as in the after-school period or on weekends, and their mothers are providing the logistic support for this engagement.
For example, mothers who offer logistical support, i.e. by taking their daughter to sport, might be more sedentary while sitting on the sideline or in the car waiting for
175 Discussion
her daughter to finish the physical activity. Mothers might have had less time in their day for engaging in MVPA, as 50% of our mothers reported an office job as their occupation. Evidence suggests working mothers are generally less physically active, and this is owing to perceived and actual barriers to be active in their lives (Brown,
Brown, Miller, & Hansen, 2001). Importantly, research shows working mothers who are surrounded by family and friends whom influence activity levels in a positive way are more likely to feel successful in achieving their set goals (e.g. participating in physical activity) (Brown et al., 2001; Miller, Trost, & Brown, 2002). It is noteworthy that a large proportion of the sample of mothers in the current study was categorised as overweight or obese (67.5%), which is much greater than national averages
(50%).
Further, very little is known about associations between mother-daughter physical activity behaviours. A more recent review also demonstrated that findings are mixed regarding parental physical activity levels and the association with children’s physical activity levels (Trost & Loprinzi, 2011). Evidence from the review conducted by Trost and Loprinzi (2011) revealed weak associations between parental and child physical activity. However, only 31% of these studies used an objective measure of physical activity. In addition, only three out of nine studies reporting a positive significant association between mothers’ and daughters’ physical activity and these studies used self-report measures. In other reviews, Gustafson &
Rhodes’ (2006) review found mothers’ physical activity correlated with daughters’ physical activity, although findings across individual studies were inconsistent and
176 Discussion
differences were exacerbated by the different methods used to assess physical activity.
Mothers’ outcome expectations were also a significant correlate of daughters’
CPM. Mothers were asked to report their beliefs surrounding the benefits of regular physical activity for themselves. The mean score for this scale was high at 4.6 out of five, indicating that the mothers had high expectations about the effects of regular physical activity on their health and this was associated with more active daughters.
It was also found that mothers’ total physical activity level (CPM) was a significant correlate of daughters’ total activity (CPM). This is a novel finding, which is strengthened by the study’s use of an objective measure of physical activity for both mothers and daughters. It could be that the daughters of mothers who have high outcome expectations model higher levels of physical activity owing to their mother’s beliefs.
The regression model for daughters’ sedentary time indicated mothers’ logistic support was significantly inversely associated with daughters’ sedentary time. Therefore, the more logistical support (i.e. physical activity-related support mothers provide to their daughters), the less likely their daughter is to be involved in sedentary behaviours. This suggests logistic support might occur at a time when the daughters would otherwise be sedentary (e.g. taking daughters to sport in the after- school period or weekends). If mothers are providing logistic support for their daughters, this is likely to have a positive effect upon daughters’ behaviour by displacing daughters’ time in sedentary behaviour. Parents who are sedentary might
177 Discussion
be more likely to have daughters who are sedentary (Gustafson & Rhodes, 2006;
Jago, Fox, Page, Brockman, & Thompson, 2010).
In the final model for daughters’ screen time, mothers’ sedentary time was positively associated with daughters’ total screen time. Mothers with higher levels of sedentary behaviour were more likely to have daughters who engaged in higher levels of screen time. This could be explained as parents are important role models for their children. Sedentary behaviours of children might be learned from their parents (Jago et al., 2010). Jago and colleagues (2010) examined associations between objectively measured physical activity, sedentary and screen time practices from a large sample of British children and parents and found parental sedentary minutes predicted girls’ sedentary minutes (Jago et al., 2010). Of note, over 80% of the parent sample was mothers, and authors found that parents who watched two to four hours of TV per day increased their daughters’ risk by over three times of watching more than four hours of TV (Jago et al., 2010).
178 Discussion
5.3 Feasibility and Preliminary Efficacy
5.3.1 Aim Three: Feasibility and Preliminary Efficacy
To evaluate the
(i) feasibility (recruitment, retention, attendance, acceptability and satisfaction); and,
(ii) preliminary efficacy of a mother-daughter physical activity program targeting improvements in physical activity levels.
5.3.2 Hypothesis Three: Feasibility
The MADE4Life program will be feasible, demonstrated through recruitment, retention and attendance targets being achieved and through participants finding the program acceptable with high satisfaction demonstrated through comprehensive process evaluation from multiple perspectives including mothers and facilitators.
Hypothesis Three was largely supported by the MADE4Life program and study methods being highly feasible as demonstrated by successful recruitment, retention, and high levels of satisfaction and acceptability.
Recruitment goals were met promptly within three weeks, utilising a variety of strategies, the most successful being through school newsletter adverts. The recruitment success could be attributed to the appeal and novelty of the MADE4Life program, i.e. engaging content which was advertised on flyers including fun mother-
179 Discussion
daughter games, Zumba, Pilates etc; a girls-only program which appealed to mothers and daughters. In contrast, other studies involving mothers and daughters
(Ransdell, Taylor, et al., 2003) and African American parents and girls (Baranowski et al., 2003) have had difficulties in achieving recruitment targets. In particular, other studies have found recruitment challenging when using wait-list or no intervention control groups as participants can become frustrated if not receiving an intervention
(Lovato, Hill, Hertert, Hunninghake, & Probstfield, 1997). One study involving mothers and children reported the difficulties in recruiting even after utilising a variety of avenues including paid advertising, school newsletters, community flyers, social media, radio, community forums and partnerships with community health workers and local government officers (Gibson, Byrne, & Zubrick, 2013). Reasons provided regarding the difficulties in recruiting the sample of mothers and children for the abovementioned study included mothers being time poor, and that mothers see difficulties in dealing with the issue of overweight and obesity within their family and the associated stigma (Gibson et al., 2013). In contrast to these noted recruitment struggles, it could be that the success of recruitment for the MADE4Life study was as a result of the program being advertised as an opportunity for mothers and daughters to spend quality time together and have fun being active together. There were no direct links to the program targeting “overweight” or “inactive” mothers and daughters, therefore the social stigma of these health issues might not have surfaced for our families. Given we were also able to recruit 100% of girls and mothers,
180 Discussion
research would need to carefully consider how to engage mothers and daughters without stigma or concern regarding the intervention content.
Attendance levels at all sessions were excellent (82%) and much higher than other mother-daughter studies which report attendance ranging from 65% (Ransdell et al., 2001) to 70–77% (Ransdell, Detling, et al., 2004). The high retention in the current study for both mothers and daughters and complying to assessments studies is similar to Ransdell et al, 2003 (Ransdell, Taylor, et al., 2003) (85% compliance) and Ransdell and colleagues, 2004, with a 93% completion rate for the intervention group but only 43% for the control group (Ransdell, Robertson, et al., 2004). It is possible that the high attendance for the MADE4Life program might be as a result of the positive rapport built with the study leader and program staff as the quality of facilitators was rated very highly (average 4.8 out of 5) and mentioned numerous times in the qualitative open-ended responses. It might also be because of the variety of fun and engaging program activities such as the activities that contravene gender stereotypes, like boxing, resistance fitness activities using fitballs, medicine balls and gymsticks, and the emphasis on reciprocal reinforcement of physical activity between mothers and daughters. All of these were rated particularly high in the questionnaires and facilitators’ journals.
Retention rates for the current study were also high, 100%, 81% and 83% at baseline, post-intervention and follow-up respectively for the primary outcome. The
MADE4Life study offered the wait-list control group the program six months post- program which might have contributed to the high retention rates from the control
181 Discussion
group. Considering the difficulties of accelerometer adherence (Audrey, Bell,
Hughes, & Campbell, 2013), this study’s excellent retention rates might be as a result of the reminder text messages sent during assessment weeks, rapport built with the program facilitators, well-established accelerometer protocol and the incentive of a store gift card given for compliance.
Program acceptability and satisfaction was demonstrated through the very positive ratings from mothers on program quality, impact, content and support.
Mothers rated their overall enjoyment of the program close to the maximum possible score. This could be attributed in part to the program alignment with SCT (Bandura,
1986), with an emphasis on self-efficacy, social support and outcome expectations.
In addition, acceptability and high satisfaction could be accredited to the qualifications, teaching experience and pedagogically-designed sessions employed by the facilitators who were skilled in health and physical education teaching.
Furthermore, high program satisfaction might have also been facilitated by the content tailored specifically for females, encouragement of social support, and use of engaging mother-daughter home tasks that were appealing to the whole family.
In comparison with other mother-daughter program evaluations, high levels of satisfaction for program content, instructors and activities have also been reported in Latino mother-daughter dyads (Olvera et al., 2008) and mother-daughter dyads from the US (Ransdell, Oakland, & Taylor, 2003). Daughters and mothers individually reported their high levels of enjoyment for dancing and food-related activities and non-traditional, recreational games including indoor rock climbing and
182 Discussion
self-defence (Ransdell, Oakland, et al., 2003). Of note, one of the main barriers to attending the program was finding appropriate child care (Olvera et al., 2008;
Ransdell, Oakland, et al., 2003) and working schedule (Olvera et al., 2008), which are similar to barriers outlined by mothers in the MADE4Life intervention.
5.3.3 Hypothesis Four: Preliminary Efficacy – Primary Outcome
The MADE4Life program will be efficacious, demonstrated through a moderate effect size for the primary outcome % time in daughters’ MVPA in the intervention group in comparison to the wait-list control group daughters.
The findings were unable to definitively support Hypothesis Four regarding the improvements in the primary outcome of daughters’ objectively measured % MVPA.
Only a small effect size was found for daughters’ % MVPA at post-intervention, with no intervention effect on our primary outcome.
The preliminary efficacy of the MADE4Life program was assessed via the impact of the intervention, relative to the control group, on the primary outcome of physical activity (%MVPA) in daughters. For daughters, only a very small effect size was found. However, as a pilot RCT, the study was underpowered and not designed to detect significant differences and it could be that there was greater variability in the primary outcome than anticipated. The small effect size might also be owing to the study inclusion criteria. The study was open to all girls, as opposed to recruiting
“low active” girls, or those not involved in organised sports or activities, as has been
183 Discussion
the case in previous mother-daughter studies (Kargarfard et al., 2012; Kelishadi et al., 2010; Ransdell, Robertson, et al., 2004; Ransdell, Taylor, et al., 2003), or focusing on recruiting exclusively overweight or obese girls (Olvera, Leung, Kellam,
& Liu, 2013; Olvera, Leung, Kellam, Smith, et al., 2013). Baseline findings from the current study suggest the girls recruited were more active than the general population of girls, compared to other objective physical activity data in boys and girls (Schranz et al., 2014). Therefore, the intervention group might have had less potential for improvement owing to a “ceiling effect” (Corder, Ekelund, Steele,
Wareham, & Brage, 2008). It may be that the daughters involved in the current study replaced their usual after-school activities with the MADE4Life program for an hour each week. The literature on the efficacy of mother-daughter physical activity studies are mixed, with some studies reporting significant increases in daughters’ physical activity (Olvera, Leung, Kellam, & Liu, 2013; Ransdell, Robertson, et al., 2004) while others not (Olvera et al., 2010; Ransdell et al., 2001; Ransdell, Taylor, et al., 2003).
Moreover, literature on the ‘GEMS’ series involving parent-daughter dyads has reported success in increasing girls’ objectively measured physical activity (Beech et al., 2003; Robinson et al., 2010). Comparison to other studies is also problematic given the lack of follow-up beyond post-intervention assessment (Olvera et al., 2010;
Olvera, Leung, Kellam, & Liu, 2013; Ransdell, Robertson, et al., 2004; Ransdell,
Taylor, et al., 2003) and not using objective physical activity measures (Ransdell et al., 2001; Ransdell, Taylor, et al., 2003).
184 Discussion
Only one mother-daughter RCT has assessed MVPA objectively (via accelerometer) in daughters and this study did not find a significant difference between groups for MVPA or mean daily CPM (Olvera et al., 2010). One other RCT objectively assessed grandmothers’, mothers’ and daughters’ physical activity via pedometry, reporting a significant difference in pooled family daily steps in favour of the intervention group (Ransdell, Robertson, et al., 2004). A limitation of this intervention by Ransdell and colleagues was that step count results were aggregated as a family total, therefore independent results for daughters’ and mothers’ physical activity are unknown (Ransdell, Robertson, et al., 2004). In addition to the two mother-daughter RCTs which assessed physical activity objectively, only one pre- post study has used accelerometry in daughters (Olvera, Leung, Kellam, & Liu,
2013). Although Olvera and colleagues assessed daughters’ MVPA via accelerometry, data were only collected during the intervention sessions, i.e. between 9am-5pm Monday to Friday during a summer camp. Results for daughters’
MVPA indicated a significant increase in daily MVPA from Week 1 to Week 4 during the intervention. Limitations of this study included the absence of a control group and no assessment of physical activity at baseline and post-intervention. Hence data only indicated the girls increased MVPA during the intervention period. It is unknown whether the daughters’ MVPA was increased outside the intervention period and whether increases in MVPA would be sustainable. In addition, maternal physical activity was not assessed in this study (Olvera, Leung, Kellam, & Liu, 2013).
185 Discussion
In contrast to other studies involving girls’ physical activity interventions, reported findings are mixed. Recently, Biddle and colleagues’ (2014) systematic review on the effectiveness of interventions to increase girls’ physical activity, effect sizes were small, yet significant, revealing some interventions provided successful strategies to increase physical activity in girls (Biddle et al., 2014). In general, larger effects were found for interventions that targeted girls only and adopted educational and multicomponent approaches. Camacho Minano et al (2011) reported mixed findings in relation to the effectiveness of physical activity interventions targeting girls and highlighted that future research is needed on this topic (Camacho-Minano et al.,
2011). Overall, most studies included in the review which were effective in increasing girls’ physical activity were conducted in the school setting. Of note, family support for girls’ physical activity was less commonly included in interventions, and authors noted the complexities of identifying specific strategies through family-based interventions (Camacho-Minano et al., 2011).
The MADE4Life program may have been unable to increase daughters’ physical activity for other reasons. For example, it is noteworthy that other areas of focus of the MADE4Life intervention included rough and tumble play and fundamental movement skills for mothers and daughters, which are problematic to measure with accelerometers and both have often distinct benefits (Fletcher et al., 2011; Lubans et al., 2010). Although these variables were not measured, the potential impact of the MADE4Life program might also be further explored through assessing these
186 Discussion
aspects. Further, co-physical activity was a focus throughout the physical activity sessions and ‘Pink Slip’ tasks, however this was not assessed. It might have also been that the concept of reciprocal reinforcement needed to be more rigorously operationalised throughout the program, which could have impacted on mothers’ motivation to support increasing their daughters’ physical activity levels and vice versa. This might have been an important part of the program outcomes; however, this was not captured through measuring % time in MVPA. Rough and tumble play was a focus of two MADE4Life sessions, as well as associated ‘Pink Slip’ tasks for the mothers and daughters. There is potential that there were changes in aspects of strength and energy expenditure gained from rough and tumble play; however, this was not captured by measuring % time in MVPA. In addition, although this study had a component of FMS in the physical activity sessions, only one session was devoted to this increasingly important developmental area. A recent review by Lubans and colleagues (2010) reported the strong evidence base for a positive relationship between FMS proficiency and physical activity and that girls lack proficiency in FMS
(Lubans et al., 2010). Therefore, more emphasis should be given to FMS in future mother-daughter studies.
187 Discussion
5.3.4 Hypothesis Five: Preliminary Efficacy – Mothers and Daughters
secondary outcomes
Compared to the wait-list control group, the datum from the mothers and daughters in the MADE4Life intervention will show moderate effect sizes in some secondary outcomes at immediate post-intervention follow-up assessment.
Hypothesis Five was in part supported, with regard to the promising effect sizes for some of the mothers’ secondary outcomes. However, the research hypothesis was not supported for the daughters’ secondary outcomes as small effect sizes were reported for the majority of secondary outcomes.
The findings from this study in regard to the potential efficacy of the program were demonstrated by the encouraging effect sizes for some of the targeted secondary measures for mothers (maternal role modelling, MET mins, maternal beliefs and sitting time). Importantly, the measures used to assess these changes in the mothers would be suitable for use in future studies. However, the findings for the daughters’ secondary outcomes at post-intervention follow up including % MPA, %
VPA, CPM, weight, BMI z-score, waist z-score, % fat mass, sitting time and screen time revealed only small effect sizes. In addition, only moderate effect sizes were found for daughters’ % SED, % LPA and diastolic blood pressure at post-intervention in favour of both the MADE4Life and control groups. Despite the small effect sizes, high variability in change scores were noted. Large decreases in were observed in the intervention daughters’ and mothers’ sitting times and some large improvements
188 Discussion
in the mothers’ self-reported physical activity scores. There may be a possibility that although the objective measures did not capture these changes, the intervention daughters and mothers self-reported notable changes in their behaviour after receiving the program.
A moderate effect size at immediate post-intervention was reported for mothers’ % MVPA and encouraging results were found for mothers’ % VPA, represented by a significant intervention effect and moderate effect size. It may be that the mothers participating in the study replaced their previously sedentary time in the after-school period with an hour of MVPA in conjunction with the MADE4Life program. MADE4Life was a theoretically-grounded program (SCT) and evidence suggests interventions grounded in behaviour change theory are more effective
(Abraham & Michie, 2008; Anderson-Bill et al., 2011). Indeed, very few studies exclusively targeting mothers and daughters have used objective measures of physical activity, i.e. pedometers (Ransdell, Robertson, et al., 2004) or accelerometers (Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013). However, limitations of these particular studies include no objective assessment of physical activity for mothers in the studies, aggregating three-day step counts as the average per family rather than reporting separately for daughters and mothers (Ransdell,
Robertson, et al., 2004) and no follow-up beyond post-intervention assessment
(Olvera et al., 2010; Olvera, Leung, Kellam, & Liu, 2013). Given the decrease in physical activity levels from post-intervention to follow-up in the current study, future
189 Discussion
interventions might need to increase the intervention dose, (for example, bi-weekly sessions) and/or include booster sessions during the maintenance phase.
A large effect size of d=0.66 was found for mothers’ physical activity “role modelling” with mothers in the MADE4Life group, in comparison to the control group, significantly improving their frequency of participating in physical activities with their daughter(s), organisation for family physical activity and using their own behaviour to encourage daughters’ physical activity. This is a novel finding and there are no mother-daughter studies that have measured these or similar constructs in an intervention.
Small effect sizes (d=-0.02-0.28) were found for the SCT cognitions at post- intervention including self-efficacy, outcome expectations, social support and intentions in this study. Despite careful design and implementation of the SCT cognitions in the MADE4Life program, there is a need to better operationalise these constructs in future interventions.
5.4 Study Strengths
As outlined at the beginning of Section 5, this thesis had three major aims. The first aim was to review the available literature to determine the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and their daughters. The second aim examined specific maternal correlates of objectively measured physical activity in girls. The third study aim was to assess the feasibility and preliminary
190 Discussion
efficacy of a novel family-based, mother-daughter physical activity program within a community setting.
Strengths associated with Aim One included the methodologically rigorous systematic review that adhered to the PRISMA statement (Moher, Liberati, et al.,
2010). A comprehensive search strategy was conducted across multiple databases including PubMed, Psychinfo, EMBASE, Ovid Medline, SCOPUS, CINAHL,
Sportdiscus and Informit. In addition, high agreement levels for risk of bias assessment were obtained. The systematic review provides evidence to inform future interventions targeting improvements in physical activity, fitness and/or diet involving mothers and daughters.
The exploration of maternal correlates of girls’ objectively measured physical activity from Aim Two advances the current body of literature, and importantly raises suggestions for future interventions aiming to increase girls’ physical activity to include mothers. This is one of few studies that have examined maternal parenting correlates of girls’ objectively measured physical activity. In addition, the measurement of maternal parenting for physical activity and psychosocial outcomes using validated scales were a strength of the analysis. The associations found from the regression model analyses can be used to inform and tailor future interventions targeting mothers and daughters.
Strengths of the MADE4Life intervention were, first, that the first study focused on intergenerational females to objectively assess physical activity via
191 Discussion
accelerometers in daughters and mothers which, importantly, will inform sample size calculations in future trials involving girls and women. The pilot RCT methodological limitations were identified in the systematic review. It makes an important contribution to the paucity of studies targeting mothers and daughters. Moreover, the study design was a randomised controlled trial, which is considered the “gold standard” to effectively evaluating trials (Kunz, Vist, & Oxman, 2007) and adhered to the CONSORT statement (Schulz et al., 2010). The MADE4Life study had high retention for both mothers and daughters and included follow-up assessments beyond immediate post-intervention. Further, the statistical analysis was an intention-to-treat analysis, which avoids bias such as over-estimating the efficacy of an intervention (Gupta, 2011). A comprehensive process evaluation was conducted from multiple perspectives including mothers and facilitators which gave a descriptive first-hand account of the program strengths, weakness and future suggestions for refinement. The insight given by mothers, in particular, is of great interest for designing physical activity programs targeting intergenerational females.
5.5 Study Limitations
There are a number of study limitations which need to be considered when drawing conclusions from this thesis. Study limitations will be addressed in accordance to the three aims of this thesis.
192 Discussion
Aim One
First, studies were required to be published in the English language. Second, given the paucity of studies on this topic, this review reported on a relatively small amount of studies (n=12), whereby the majority had high risk of bias. The combination of results presented, therefore, must be interpreted with caution. Owing to the low number of studies and the heterogeneity of design and outcome measures, it was not feasible to conduct a meta-analysis as part of the review.
Aim Two
The exploration of the maternal correlates of girls’ objectively measured physical activity was a cross-sectional design. This is a limitation as this design does not allow causality to be examined. The sample size of participants were relatively small, and they were a relatively homogenous sample of mothers and daughters in terms of socio-economic status. A noted limitation of the study was the use of self- reported measures utilised in the mothers’ questionnaire. Mothers self-reported their parenting practices for physical activity. Although these were reported as maternal parenting practices, there might be an impact from the mothers’ partner/husband or father-figure to the daughters involved in the study. Therefore, a further limitation of this study was that the fathers’ perspectives were not accounted for, which might impact upon some of the mothers’ parenting practices.
Aim Three
193 Discussion
The sample of mothers and daughters recruited for the pilot RCT ‘MADE4Life’ was relatively small and participants were motivated volunteers. The study was a pilot RCT, hence it was not adequately powered from a statistical perspective.
Although a comprehensive process evaluation was obtained from the mothers’ perspectives, an evaluation focusing on the daughters’ experiences was not conducted. While the pilot RCT assessed participants at immediate post-intervention and three-month follow-up, no contact or booster/maintenance sessions were offered to the intervention from post-program to final follow-up three months post intervention. Finally, the sample of daughters who were recruited to the study were more active than to the general population; therefore, a “:ceiling effect” might have been present as both study arms could have had less potential to improve their physical activity levels.
194 Summary, Recommendations and Conclusion
6 Chapter 6: Summary, Recommendations and Conclusion
This thesis was undertaken to explore three major aims relating to understanding and improving the physical activity levels of females, specifically daughters and their mothers. The summary, recommendations and conclusion relating to these three aims are explored in Chapter 6.
195 Summary, Recommendations and Conclusion
6.1 Summary
The first aim was to review current literature surrounding mother-daughter interventions and to determine the effectiveness of physical activity, fitness and/or diet interventions. As hypothesised, the effectiveness of physical activity, fitness and/or diet interventions targeting mothers and daughters were limited and studies were of poor quality. The review affirmed that only 12 studies (11 unique interventions) have targeted mothers and daughters together within interventions.
Approximately half of these studies were conducted prior to 2009, and the majority were conducted within the US. It was evident that face-to-face, structured physical activity and fitness programs at least two to three times per week for a minimum of
60 minutes per session at least twice a week were key intervention characteristics that led to increases in fitness in almost all studies for both mothers and daughters.
More evidence is needed using objectively measured physical activity (i.e. via pedometers or accelerometers) and these measures should be used in both mothers and daughters. Future research in this area is needed to design and develop high quality, gender-specific interventions in a community setting.
The second aim was to establish potential maternal factors associated with girls’ physical activity. A number of maternal behaviours, social-cognitive and parenting correlates were found to significantly predict the variation in daughters’ physical activity and sedentary behaviours. Having explored mothers’ parenting practices and girls’ physical activity, it was found that mothers’ beliefs about physical activity were
196 Summary, Recommendations and Conclusion
significantly related to the proportion of girls’ time spent in MVPA. Another key finding was the relationship between girls’ physical activity and provision of logistic support by mothers, so mothers providing support for physical activity opportunities, i.e. taking their daughter to sport was related to daughters’ CPM (total activity). Both outcome expectations and mothers’ CPM were also significantly related to daughters’ total activity. This suggests that a key strategy for future interventions for promoting girls’ physical activity and reducing sedentary time is to educate mothers on the positive health outcomes of physical activity, ways in which they can provide physical activity support for their daughters and ways to increase their total activity.
The findings suggest that for daughters’ sedentary time, mothers’ logistic support was significantly but inversely related, meaning that the more mothers provided physical activity opportunities the less time their daughters were sedentary. The total amount of daughters’ screen time was positively related to mothers’ sedentary time, meaning that the more time a mother spends in sedentary behaviour, the more time her daughter is likely to spend sedentary. This study supports that further studies targeting mothers as the primary agents of change to increase physical activity and reduce sedentary behaviour among their daughters are warranted.
The final aim of this thesis was to establish both the feasibility and the preliminary efficacy of the MADE4Life intervention. While there have been other mother- daughter physical activity programs reported previously, these have not used objective measures for both the mothers’ and daughters’ physical activity. In addition, the MADE4Life intervention was highly successful in terms of recruitment,
197 Summary, Recommendations and Conclusion
retention, attendance and satisfaction. Moreover, the activities and content were highly engaging and process evaluation data revealed the novelty of the gender- tailored program. Furthermore, the MADE4Life intervention specifically focused on reciprocal reinforcement between mothers’ and daughters’ physical activity. For example, daughters encouraging mothers to be active and vice versa during the
‘Pink Slip’ tasks. Although this was a pilot study and hence not adequately powered, some promising effect sizes were still found. For example, in comparison to the control group, mothers significantly improved their % VPA with a moderate effect size and there were significant improvements in maternal physical activity role modelling with a large effect size. It might be that mothers who signed up for the pilot intervention were motivated to make positive changes to their physical activity levels and the program activities (particularly the health-enhancing activities). However, only small effect sizes were found for the primary outcome of daughters’ % MVPA.
This suggests that more thought needs to be put into the construction of the intervention, the operationalisation of the theory, and key messages that are being delivered, i.e. more emphasis could be placed on co-physical activity of the mothers and daughters. Future refinement of the program should also consider the daughters’ perspectives. The feasibility (i.e. recruitment, retention, attendance and satisfaction) was well established, and comprehensive process evaluation by the mothers indicated high levels of satisfaction for MADE4Life. Overall, the MADE4Life program was highly feasible and acceptable to mothers and daughters and larger adequately powered trials are warranted.
198 Summary, Recommendations and Conclusion
6.2 Recommendations
Given the study findings, including both the strengths (see Section 5.4), and limitations (see Section 5.5) identified, a number of recommendations for future research are presented below.
Systematic Review
• Future mother-daughter physical activity fitness and/or dietary RCTs should
use the CONSORT (Moher, Hopewell, et al., 2010; Schulz et al., 2010)
framework when developing and evaluating interventions. Furthermore, high
quality RCTs are needed and these should ensure randomisation procedures
are adequately reported. Future studies are urged to ensure blinding of
outcome assessment, perform ITT, provide a power calculation and account
for covariates in the analyses.
• Future mother-daughter physical activity interventions should measure
physical activity outcomes using objective measures (i.e. via pedometers or
accelerometers). These measures should be reported in both mothers and
daughters. Dietary interventions should use validated measures to assess
dietary intake in both mothers and daughters.
• This review found that studies which involve both mothers and daughters
within the same program are more effective than separate programs for each
of these groups on health outcomes for both the mothers and daughters. 199 Summary, Recommendations and Conclusion
Hence, future studies should include mothers and daughters in the same
program.
• Studies with long-term follow-up are needed and should ensure follow-up
assessments are conducted beyond post-intervention assessment in order to
assess whether there are any sustained and long-term effects.
Maternal Correlates
• A potential strategy to increase girls’ physical activity is to target improving
mothers’ beliefs about the benefits of girls being active including increased
self-confidence, improved physical and mental health, and lasting impact
throughout life. Providing mothers with logistic support strategies such as
ideas on where they can take themselves and their daughters to sports and
activities to reduce their own and their daughters’ screen time needs to be
tested as a strategy to decrease sedentary behaviour, increase total physical
activity, and increase health enhancing activity.
• Furthermore, mothers should be targeted within physical activity interventions
for girls as a novel strategy to engage their daughter in physical activity.
These findings can be used to inform and tailor interventions targeting
mothers and daughters. For example, interventions content should focus
specifically on educating mothers on the benefits of physical activity, which
would assist the improvement of mothers’ beliefs about girls’ physical activity.
Moreover, interventions should target ways in which mothers can provide high 200 Summary, Recommendations and Conclusion
levels of logistic support in their local community. This could be achieved by
creating detailed resources informing mothers and daughters of physical
activity opportunities in their local area.
Feasibility and Preliminary Efficacy
After conducting an eight-week after-school family-based physical activity intervention for mothers and daughters, the following final recommendations are made under the following sub-headings of design characteristics, intervention refinement and methodological improvements in order to facilitate the design and conduct of future high quality RCTs and interventions in this area.
Design characteristics
• Future high-quality, fully-powered trials with larger sample sizes that involve
mothers and daughters are strongly recommended. For example,
interventions should follow the evidence-based reporting guidelines
statement (CONSORT), utilise valid and reliable measures appropriate to the
age group (i.e. adults/children), and adopt objective measures of physical
activity (i.e. pedometers or accelerometers).
• RCTs that assess participants beyond post-intervention assessment should
consider implementing booster sessions or a maintenance phase for mothers
and daughters to sustain their physical activity behaviours adopted from
participating in an intervention program.
201 Summary, Recommendations and Conclusion
Intervention refinement
• The current study focused on “mothers and daughters exercising together” to
improve daughters’ physical activity levels. Although weekly physical activity
sessions were focused on co-physical activity, a larger emphasis on co-
physical activity throughout the whole program (including home-based tasks,
education sessions and practical sessions, and following the intervention) is
strongly advised. In addition, operationalising reciprocal reinforcement (i.e.
having more of a direct focus on the mothers’ participation being the primary
motivator for their daughters’ participation in physical activity and vice versa)
throughout the program could also have a stronger focus, in order to motivate
mothers to increase support for their daughters’ physical activity levels and
vice versa.
• Mothers’ process evaluation questionnaires included a small section for
mothers to comment on their husband/partners’ perspectives and behaviours
in response to seeing their wives and daughters participate in the program.
Overall, the husbands/fathers were highly supportive of the mother-daughter
program. A consideration for future studies is to have more open
communication with the fathers and to have an element of involvement from
fathers at home in terms of providing additional support to their
partners/daughters in terms of physical activity and sedentary behaviours. For
example, the ‘Pink Slip’ activities could be adjusted for the daughters to
202 Summary, Recommendations and Conclusion
facilitate physical activity with their whole family, including fathers and, if
applicable, other siblings. This would also reinforce the concept of co-physical
activity in the home environment.
• In the current study, high satisfaction scores were reported by mothers and
daughters for the two qualified PDHPE teachers who delivered the
MADE4Life program. The efficacy of running this program with other trained
female PDHPE teachers in future needs to be established. A
recommendation for future trials is to assess whether this research trial could
be translated into the wider community using trained facilitators. For example,
trialling the MADE4Life program in a “real world” setting, whereby local
educators such as physical education teachers are trained to deliver the
program in local communities.
• A common theme from the mothers’ process evaluation questionnaire was
that the ‘Pink Slips’ took up a lot of time and some found there were too many
activities to complete and these were seen as “homework”. In future, studies
could evaluate home tasks which are engaging, enjoyable and interesting
and, importantly, not too time consuming. These activities can be simple, yet
stimulating, and also align closely with SCT. One way to achieve this would
be to give daughters more choice as to which home-based activities the
mother-daughter wishes to participate in.
203 Summary, Recommendations and Conclusion
• Findings from the current study found only a small effect size for daughters’
primary outcome %MVPA, as well as other secondary outcomes. An
important recommendation for future studies would be to increase the dose
(e.g. physical activity sessions twice per week), increase the duration of
intervention (e.g. two sessions per week over a minimum of 12 weeks) and
offer booster/maintenance sessions. While additional face-to-face sessions
could be used, other novel approaches could be tested to achieve this via the
use of supplementing technologies such as a web-based program or through
use of smart phones.
• While fundamental movement skills were a component of the MADE4Life
intervention, only one session was dedicated to this which is not enough time
to effectively focus on all 12 FMS. Future interventions should consider
adopting a detailed FMS component which is re-visited throughout the
intervention period on a regular basis, given the established association
between FMS and physical activity and fitness (Lubans et al., 2010).
Additional home tasks and resources to practise locomotor, non-locomotor
and object-control skills for daughters is warranted. Daughters should be
given a sense of autonomy for choice of skills to practise in a fun, non-
competitive environment. Mothers could be given the teaching strategies to
assist in coaching their daughters with the important key teaching points. A
web-based program or mobile app is another avenue for utilising the activities
204 Summary, Recommendations and Conclusion
and key teaching points for mothers to coach their daughters and participate
at a time convenient for them.
• A strong theme from the mothers’ process evaluation questionnaires was
related to not having childcare available for other siblings. In future, the
provision of childcare or activities for other siblings could be offered to families
as a way to increase attendance and to address the barriers the program
would present for larger families or those with limited family support for
alternative child care.
• A common suggestion from the mothers’ process evaluation questionnaire
was the addition of dietary information in conjunction with the physical activity
education sessions. Mothers would like more information on healthy eating,
therefore future trials could address both physical activity and healthy eating
as part of the intervention content.
Methodological improvements
• The current study was a pilot and, hence, not powered to detect statistically
significant differences in the primary and secondary outcomes. Further
research using adequately powered trials is therefore required. Sample size
calculations could be informed based on objectively measured physical
activity using daughters’ data from the current pilot trial in order to evaluate
the efficacy of a physical activity program.
205 Summary, Recommendations and Conclusion
• The current study did not screen baseline activity levels of mothers or
daughters. Future trials could screen participants with low baseline physical
activity levels as a way to target low active mothers and daughters.
• To better understand the program effects in both the short- and long-term
future physical activity intervention targeting mothers and daughters should
have a longer length of follow-up, i.e. beyond post-intervention assessment.
Interventions could run over a three-month period, with active booster
sessions between the follow-up period of six to 12 months.
• Some participants indicated that the accelerometers were uncomfortable to
wear, hence they did not wear them and therefore 100% retention for the
primary outcome was not achieved. A suggestion for future studies would be
to adopt an updated validated activity monitor which, for example, is worn on
a participant’s wrist, such as GENEActiv monitors, fitbits, or jawbone-
wearable during activity.
• A further recommendation is to collect and justify the perspectives of the
daughters in terms of refinement, improvement, and satisfaction. An
extensive qualitative analysis (i.e. focus groups and/or one-on-one interviews)
with mothers and daughters is advisable for a more comprehensive and in-
depth analysis of their perceptions and beliefs.
206 Summary, Recommendations and Conclusion
• While the current study did not explore further detail related to parenting
aspects, such as measuring parenting style, future studies could include
measurement of parenting style of both mothers and fathers. It would be of
interest to analyse the fathers’ perspective in relation to parenting for physical
activity.
• Although the primary outcome of the current study was objectively measured
physical activity, it is recommended that future studies additionally assess
other ways to measure physical activity, i.e. co-physical activity, strength and
FMS. Therefore, it is recommended a greater focus should be placed on the
development of FMS, as well as objectively measuring the skills.
• The assessment of home-based tasks (i.e. ‘Pink Slips’) was not monitored in
detail for the current study. Future studies could collect adherence data to
home tasks which would assist in the measurement of co-physical activity and
hence refine the home component of this program.
• Finally, additional factors regarding real world issues including transport,
access, babysitting for younger siblings, conflicting work hours and other
commitments should be considered for the target group. It may be feasible to
run a mother-daughter program on a weekend day (i.e., Saturday) to
accommodate these additional factors.
207 Summary, Recommendations and Conclusion
6.3 Conclusion
In conclusion, the systematic review indicates a paucity of high-quality mother- daughter physical activity, fitness and/or dietary interventions. The review calls for future well-designed RCTs that adhere to the CONSORT statement and adopt objective measured outcomes and larger sample sizes to detect significant changes.
It was found that maternal beliefs about physical activity were a strong correlate of daughters’ %MVPA. A number of maternal behaviours, social-cognitive and parenting correlates were found to be significantly associated with daughters’ physical activity and sedentary behaviours.
The pilot of the MADE4Life program demonstrated that it was highly feasible, as evidenced by successful recruitment, retention, and high levels of satisfaction and acceptability. The potential efficacy of the program was demonstrated by the encouraging effect sizes for some of the targeted measures (maternal role modelling, MET mins, maternal beliefs and sitting time). However, I did not see an effect on our primary outcome, which would need to be tested in a future adequately- powered RCT.
This research has targeted the topic of intergenerational female physical activity and findings from this thesis make an important contribution to the paucity of studies targeting mothers and daughters. However, the primary hypothesis was not supported. Consequently, further research is needed, based on the recommendations made above for trials that involve a larger sample of mothers and daughters to explore objectively measured physical activity in and after participation 208 Summary, Recommendations and Conclusion
in a community-based gender specific program. Numerous recommendations were made to assist future program development aiming to improve physical activity levels of females, in particular mothers and daughters, with regards to intervention design, intervention content and methodological considerations. Of great importance and concern is the growing evidence base highlighting the low levels of physical activity of females and the negative health consequences of physical inactivity. Further exploration of the impact of gender-tailored physical activity interventions is needed, along with sustained research attention.
209
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233 Appendices
8 Appendices
234 Appendices
Appendix 1: JOURNAL ARTICLE ‘MATERNAL CORRELATES OF OBJECTIVELY MEASURED PHYSICAL ACTIVITY IN GIRLS’, MATERNAL CHILD AND HEALTH. UNDER REVIEW
235 Full title of article: Maternal correlates of objectively measured physical activity in girls
Preferred running head: Correlates of girls physical activity
Section: Original research
1
Abstract
Objectives: Given the low levels of physical activity in girls, it is important to improve our understanding of the factors associated with girls’ physical activity. In particular, exploring maternal correlates of girls’ physical activity for both generations is important, given the paucity of research in this area. The primary aim of this study was to assess maternal correlates of objectively-measured physical activity in girls. Methods: A cross-sectional design was used to assess 40 girls [mean age 8.8 years; mean BMI (body mass index) z- score=0.7] and their mothers (mean age 39.1 years; mean BMI=27.6) prior to an intervention.
Maternal correlates of daughters’ accelerometer-assessed physical activity were evaluated.
Daughters’ outcomes included: % MVPA (moderate-to-vigorous physical activity), CPM
(counts per minute) and % SED (sedentary behavior), screen time (mother-proxy) and BMI z- score (objectively measured). Maternal correlates included demographic, anthropometric, behavioral, activity-related parenting practices, and physical activity cognitions. Correlates were examined using regression models. Results: For daughters’ % MVPA, mothers’ beliefs was significant in the final model (R2=0.14; P=0.01). For daughters’ CPM, mothers’ logistic support (P=0.03), mothers’ CPM (P=0.02) and outcome expectations (P=0.01) were all significant (R2=0.24). For daughters’ % SED, mothers’ logistic support (P=0.02) was significant (R2=0.11). Conclusions: A number of maternal behaviors, social-cognitive and parenting correlates were found to be significantly associated with daughters’ physical activity. Experimental studies are warranted, targeting mothers as the primary agents of change to increase physical activity among girls.
Keywords: parent-child relationship; mother; exercise; accelerometer; females
Significance statement:
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Given the recognised low physical activity levels of girls, there is a need to develop strategies that target females. Parents play a key role in influencing child lifestyle behaviours. Mothers may be particularly influential in terms of attitudes, parenting practices and behaviours, for their daughters.
Our study involved a novel intergenerational sample of mothers and daughters, revealing key predictors of girls’ physical activity in relation to their mothers’ parenting for physical activity. Stronger associations were found for the moderate and vigorous activity levels of girls.
Experimental studies targeting mothers as the primary agents of change to increase physical activity among girls may be warranted. Specific maternal targets include beliefs about the benefits of physical activity for girls, logistic support regarding girls’ physical activity involvement, and outcome expectations.
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Introduction
It is well established that regular physical activity leads to significant physical and psychological health benefits for children (Strong et al., 2005), and is associated with a reduced risk of morbidity and mortality in adults (Lee et al., 2012). Of concern is the consistent and compelling evidence for a marked sex difference in physical activity, with females having lower activity levels than males at all ages (Hallal et al., 2012; The
Department of Health & Ageing, 2007). Globally, 34 percent of adult women do not meet the physical activity recommendations of 30 minutes of moderate-to-vigorous physical activity
(MVPA) at least five days per week, compared to 28 percent of men (Hallal et al., 2012).
Similarly, while girls are less active than boys at all ages (Hallal et al., 2012), this gender activity gap increases with age (Davison, Cutting, & Birch, 2003). The most recent national physical activity survey in Australian children reported that 52 percent did not meet the physical activity recommendation of 60 minutes of MVPA per day, and when girls reached the age of 12 years, they participated in 21 minutes less of MVPA per week, when compared to boys (Australian Bureau of Statistics, 2013).
Factors influencing physical activity are multi-factorial and complex. One established factor is the influential role of parents on their children’s physical activity behaviors (Biddle,
Atkin, Cavill, & Foster, 2011). Parents provide support and encouragement for their children’s physical activity through both provision of opportunities, reinforcement, social support, encouragement, and role modeling positive activity attitudes and behaviors
(Sleddens et al., 2012). In a review of quantitative systematic reviews focusing on physical activity correlates in youth, Biddle et al. found that parental support was an important correlate of physical activity in youth (Biddle et al., 2011). Similarly, in a recent review of
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physical activity, parenting, and child activity (Sleddens et al., 2012), specific parental correlates (e.g. parent support and modeling) were consistently associated with physical activity in children. However, confounding the interpretation of these reviews, is physical activity having been measured via parent proxy or self-report (Biddle et al., 2011; Sleddens et al., 2012), a known bias (Sallis & Saelens, 2000) and most studies have not comprehensively assessed physical activity parenting using reliable measures.
Positive associations for parental involvement and active role modeling have been reported (Edwardson & Gorely, 2010b). Maternal role modeling was positively correlated with child MVPA and parental involvement was positively related to children’s overall physical activity (Edwardson & Gorely, 2010b). Some evidence also suggests parental activity and encouragement may be more strongly associated with girls’ physical activity compared to boys (Davison et al., 2003). This could be due to the different ways in which mothers and fathers influence physical activity in their children (Davison et al., 2003), and particularly the differential influence on girls and boys (Fogelholm, Nuutinen, Pasanen,
Myohanen, & Saatela, 1999).
In the context of understanding the familial influence on girls’ physical activity levels, a review of parental correlates of physical activity in children and young adolescents found that mothers may have a more significant influence on their daughters’ physical activity levels, rather than their sons’. Gustafson and Rhodes (Gustafson & Rhodes, 2006) suggest this may be owing to unique maternal relationships or bonds the female generation share.
This is supported by other studies that have found physically active mothers are likely to have physically active daughters (Aarnio, Winter, Kujala, & Kaprio, 1997). Maternal involvement in physical activity has been positively associated with child physical activity levels, and has been found to be stronger for daughters (Cleland et al., 2011; Jacobi et al., 2011). Mothers
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and fathers may differ in their physical activity-related parenting practices, and further exploration of sex-specific parenting practices is warranted (Davison et al., 2003), owing to mixed findings and the rarity of objective physical activity measures.
It is important to improve our understanding of the factors associated with girls’ physical activity levels. In particular, exploring maternal correlates of girls’ physical activity using objective measures for both generations is important, given the paucity of research in this area. This is also important given the low levels of physical activity in girls and the limited research on the associations between mother-daughter activity.
Few studies have focused on parental physical activity influences on daughters’ activity. Davison and colleagues studied activity-related parenting practices in girls only
(Davison et al., 2003) and later in a sample of boys and girls (Davison, 2004), and both studies used self-report physical activity measures. Of the few studies that employed objective measures of physical activity for parental activity-related practices, few have exclusively examined girls (Adkins, Sherwood, Story, & Davis, 2004; Davison & Jago, 2009;
Davison, Li, Baskin, Cox, & Affuso, 2011). However, in these studies no objective assessments of parental/maternal physical activity were provided. Having a greater understanding of maternal correlates of physical activity in girls could help shape the development of future interventions targeting physical activity. The primary aim of this study, therefore, is to assess maternal correlates of objectively-measured physical activity (%
MVPA, CPM) in girls. Secondary aims include exploring the correlates of sedentary behavior and screen time.
Methods
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Participants
Mothers and their primary school-aged daughters (5-12 years) were recruited into a pilot randomized controlled trial - ‘M.A.D.E (Mothers and Daughters Exercising) 4 Life’. The baseline data from this trial were used for the current study. Of the 40 families recruited, eight had more than one daughter; therefore, mothers and their eldest daughter only were included for the analysis. Participants were recruited through media releases, school newsletter advertisements, school presentations to students and parents, local newspapers, and local television news. Mothers were screened for eligibility by telephone questionnaire.
Eligibility criteria included mothers passing a pre-exercise risk assessment screen, and doctor’s clearance (if age >40 years). Approval was obtained from the University of
Newcastle Human Research Ethics Committee, mothers provided written consent, and daughter(s) provided assent.
Measures
Physical activity
Both mothers’ and daughters’ physical activity were objectively measured for seven consecutive days, using Actigraph GT3X and GT3X+ accelerometers (ActiGraph, LLC, Fort
Walton Beach, FL), which are considered to be valid and reliable for both children (Ekelund et al., 2001) and adults (Kelly et al., 2013). Accelerometers were attached to an elastic belt and worn over the left hip. Monitors recorded 60-second epochs for mothers, and 15-second epochs for daughters (Trost, Loprinzi, Moore, & Pfeiffer, 2011). Activity counts were calculated for time spent in moderate (MPA) (4-5.9 METS) and vigorous (VPA) (≥6 METS) activity. Data with strings of consecutive zeros in bouts of ≥60 minutes were deemed non- wear time for mothers, and ≥20 minutes (Cain, Sallis, Conway, Van Dyck, & Calhoon, 2013)
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for daughters, and retracted from data for analysis. Total counts were divided by total minutes monitored to calculate mothers’ and daughters’ mean count per minute (CPM). Freedson cut- points (Freedson, Pober, & Janz, 2005) were applied to the mothers’ physical activity data and Evenson cut-points (Evenson, Catellier, Gill, Ondrak, & McMurray, 2008) were applied for the daughters (Trost et al., 2011), to determine the amount of time spent in sedentary and
MVPA.
To account for the variation in time spent wearing the accelerometers, values were calculated for percentage of monitored time spent in sedentary behavior (% SED), and health- enhancing or moderate-to-vigorous physical activity (% MVPA). Mothers’ and daughters’ physical activity data were excluded from the analysis if they wore the monitor for ≤480 minutes on ≤4 days (Mattocks et al., 2008). Physical activity measurements were calculated for 39 of the 40 mothers, and all 40 of the daughters, after exclusion of participants with insufficient data.
Self-report sedentary behavior and screen time
Mothers reported their typical sitting time on a work and non-work day for transport, work, watching TV, using a computer at home, other leisure activities, and sleep time, using a sitting time questionnaire (Marshall, Miller, Burton, & Brown, 2010; Miller & Brown, 2004).
This measure was adapted previously from sitting time questionnaires and shown to be a valid and reliable measure of sitting time for adults in various domains (Marshall et al., 2010;
Miller & Brown, 2004).
Mothers proxy-reported their daughter’s leisure activity over a typical week, using the
Children’s Leisure Activities Study Survey (CLASS) previously validated in children
(Telford, Salmon, Jolley, & Crawford, 2004). Total minutes of sedentary behavior were reported for a typical week. For the current analysis, only time spent in small-screen 8
recreation (SSR), including TV and DVD viewing, playing computer games, and using the internet, were reported in the total screen time score.
Assessments of maternal correlates
Body mass index
Weight was measured in light clothing, without shoes, and on a digital scale to 0.1kg (model
CH-150kp, A&D Mercury Pty, Adelaide, Australia). Height was measured to 0.1cm, using the stretch stature method (Mentone Educational Centre, Victoria, Australia) and the
Biospace Stadiometer (BSM370, Seoul, Korea). Mothers’ BMI was calculated using the standard equation, weight kg/height m2. Daughters’ BMI z-score was calculated using age- and sex-adjusted standardized scores (z-scores) (Kuczmarski et al., 2000).
Demographics
Demographic information, including mothers’ age, occupation, education level, marital status, socioeconomic status (SES), and postcode were collected from the mothers. SES was based on postal code of residence, using the Index of Relative Socioeconomic Advantage and
Disadvantage from the Australian Bureau of Statistics census-based Socio-Economic Indexes for Areas (SEIFA) (Australian Bureau of Statistics, 2008).
Maternal parenting for physical activity
Mothers’ parenting for physical activity was measured by adapting either full scales or selected items of previously-validated scales (detailed below). Principal components factor analysis and reliability analysis were performed for each of the maternal physical activity parenting scales in the current study. Items were deleted if they did not adequately load on their intended factor and adversely impacted on internal reliability as assessed by Cronbach’s
9
alpha. The scores for each individual scale were summed and mean scores were calculated. In detail, the following subscales were assessed:
Maternal beliefs about daughters’ physical activity. Psychosocial measures of parental beliefs were modified from Lee et al. (2010), and the title ‘parents’ was changed to ‘mothers’
(Lee et al., 2010). Five items on maternal beliefs about physical activity were measured on a
4-point Likert scale, ranging from ‘strongly disagree’ to ‘strongly agree’, about the outcomes of physical activity for girls, e.g. ‘Girls who do regular physical activity have more self- confidence’. Cronbach’s α for the maternal beliefs scale was 0.84.
Maternal logistic support & maternal explicit modeling. The Activity Support Scale (ACTS)
(Davison et al., 2003) integrates two domains of parents’ support for children’s physical activity: logistic support and explicit modeling. These scales were adapted from Davison,
Cutting, et al. (2003), and an updated version known as the Activity Support Scale for
Multiple Groups (ACTS-MG) (Davison et al., 2011). For the current study, the logistic support and explicit modeling ACTS were used from Davison and colleagues (2003), however, for explicit modeling, an additional item was added as per Davison and colleagues
(2011): ‘I encourage my daughter to be physically active by leading by example’. Both logistic support and explicit modeling were answered on a 4-point Likert scale with response items ranging from ‘strongly disagree’ to ‘strongly agree.’ The logistic support scale consisted of three items, focusing on a mother taking her daughter places to be active, enrolling her in physical activity, and watching her participate in physical activity. The
Cronbach’s α for mothers’ logistic support scale was 0.80. Explicit modeling was assessed through five items, ranging from mother’s organisation for family physical activity, frequency of doing activity with her daughter, using behavior to encourage activity, and
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mother’s own physical activity. The Cronbach’s α for mothers’ explicit modeling scale was
0.88.
Mothers’ Self-efficacy (confidence) and Mothers’ Support for physical activity. Confidence and support parenting activity-related measures were adapted from a previous study (Adkins et al., 2004). The self-efficacy (confidence) scale consisted of five items, asking mothers to rate a response on a 4-point Likert-type scale of ‘very hard’ (1) to ‘not hard at all’ (4), focusing on mothers’ confidence to do physical activity with her daughter, e.g. ‘How hard would it be to get your daughter to be physically active, take your daughter to the park, go for a walk with your daughter?’ The Cronbach’s α for mothers’ self-efficacy scale was 0.74. The original support scale by Adkins et al. (2004) included six items. However, one item was deleted after factor analysis. The modified support scale consisted of five items, asking mothers to rate on a 4-point scale of ‘almost never’ (1) to ‘almost always’ (4). These questions related to the mother’s level of support for their daughter’s physical activity levels, e.g. ‘I try to get my daughter to play outside, get her to be active, take her to the park, go for a walk with my daughter’. The Cronbach’s α for mothers’ support was 0.74.
Maternal social-cognitive variables
Key constructs (i.e. self-efficacy, outcome expectations, social support, and goal setting/intention) of Bandura’s Social Cognitive Theory (Bandura, 1986) relating to mothers’ physical activity were assessed and adapted from validated measures.
Self-efficacy. Mothers’ physical activity self-efficacy related to their confidence to participate in regular physical activity, and was assessed with five-item response options ranging from
‘not at all confident’ (1) to ‘completely confident’ (5) (Rodgers & Sullivan, 2001). These questions reflected a mother’s confidence to participate in physical activity when feeling tired, when in a bad mood, when the weather was bad, add regular physical activity into a 11
daily routine, and arrange a schedule to include regular physical. Cronbach’s α for mothers’ self-efficacy was 0.94.
Outcome expectations. Outcome expectations related to mothers’ beliefs about the effects of regular physical activity on her health was assessed via three items, with response options ranging from ‘not at all likely’ to ‘extremely likely’ (5) (Sallis, Grossman, Pinski, Patterson,
& Nader, 1987). These questions reflected mothers’ likelihood of increasing fitness, improving health and losing weight. Cronbach’s α for mothers’ outcome expectations was
0.86.
Social support. The physical activity social support response asked mothers to report the amount of physical activity support received from people closest to them, ranging from ‘no support’ (1) to ‘a great deal of support’ (5) (Courneya, Plotnikoff, Hotz, & Birkett, 2001).
Intention. Physical activity intention (goals) was measured using one item, which asked mothers to indicate how strongly they agreed with the statement: ‘I intend to participate in regular physical activity over the next two months’, ranging from ‘strongly disagree’ (1) to
‘strongly agree’ (5) (Courneya et al., 2001).
Data Analyses
The statistical program SPSS version 19.0 was used for analyses. Means and standard deviations were calculated for normally distributed data. Where data were skewed, medians and interquartile ranges were examined. Counts per minute (CPM) was transformed (square root) to meet normality standards for both mothers and daughters. Pearson correlations were used to determine maternal associations of girls’ objectively-measured physical activity.
Furthermore, linear regression analysis was utilized to examine the potential maternal correlates for girls’ physical activity measures (primary outcome), sedentary behavior (%
12
SED), adiposity (BMI z-score), and total screen time. Statistical significance was set at an alpha level of 0.05 for all analyses. The regression analysis was performed, whereby each significant variable P<0.05, or close to significance P<0.20, was entered into the regression model. The regression models were calculated using the backward method, where non- significant variables were dropped (least significant first) while controlling for all variables in the model. All two-way interactions between significant independent variables were tested for significance in the multiple linear regression models. Correlations between explanatory variables were checked to investigate potential problems of collinearity in the multiple variable models; however, this was not an issue.
Results
The demographic characteristics and summary data for physical activity variables and maternal correlates of physical activity are summarised in Table 1. A total of 40 mothers and
40 daughters were included in all analyses; however, one had incomplete data, hence, 39 mothers were analysed for the accelerometer data. Mothers were predominately born in
Australia and more than half (57.5%) had completed university education, with 50 percent reporting their occupation as office-based. For mothers’ weight category, 67.5 percent were overweight or obese. Mothers’ marital status ranged from married: 72.5 percent, separated/divorced: 15 percent, de facto: 10 percent, to never married 2.5 percent.
In the daughters’ group, 100 percent met the criteria for wearing an accelerometer a minimum of eight hours on ≥ four days, and of the 40 mothers, 39 met the accelerometer criteria. No significant changes in the physical activity variables were found after adjusting for self-reported logged data (e.g. swimming or cycling), so unadjusted results are reported.
On average, mothers wore activity monitors with at least eight hours of wear time for 6.6
13
days (SD= 1.0). Mothers’ total wear time mean was 854.6 minutes (SD=76.9). The mean minutes mothers spent in MVPA per day was 30.1 (SD=18.5). Mothers’ total sitting time on a typical work day was 451 minutes (SD=201.7), and 356 (SD=159.0) minutes on a typical non-work day.
For daughters, 65 percent were healthy weight, and 30 percent overweight or obese.
Daughters’ mean accelerometer wear time was 6.6 days (SD=0.8). Total wear time mean was
737.1 minutes (SD=61.2). Daughters’ mean minutes spent in MVPA was 41.6 minutes
(SD=16.8).
Maternal correlates of daughters’ physical activity
Bivariate correlations for the maternal correlates of girls’ physical activity are presented in
Table 2. Significant positive correlations were found between daughters’ % MVPA and mothers’ beliefs, daughters’ total activity (CPM) and mothers’ logistic support, and mothers’ beliefs. Further details on bivariate correlations for the maternal correlates of girls’ physical activity are presented in Table 2.
Linear regression models were used to examine the variance explained and significant correlates of physical activity [% MVPA, CPM], % SED, screen time and BMI z-score
(Table 3). For daughters’ % MVPA, mothers’ beliefs about physical activity (P=0.01, beta=0.40) explained 14 percent of the variance. Significant correlates for daughters’ total activity (CPM) included mothers’ logistic support (P<0.05, beta=0.32), mothers’ CPM
(P<0.05, beta=0.37), and mothers’ outcome expectations (P=0.01, beta=0.40), and this model explained 24 percent of the variance. For the model daughters’ % SED, mothers’ logistic support for daughters’ physical activity was the sole correlate of daughters’ % SED, having a negative association with daughters’ % SED (P<0.05, beta=-0.37), (R2=0.11). For
14
daughters’ total screen time, mothers’ % SED was the sole correlate (P<0.001, beta=0.59);
(R2=0.33). Finally, for daughters’ BMI z-score, mothers’ BMI was the sole correlate
(P<0.001, beta=0.57) (R2=0.31).
Discussion
The study’s primary aim was to examine maternal correlates of objectively-measured physical activity in girls. A number of maternal parenting practices, cognitions and behaviors were found to be significant. In relation to girls’ % time in MVPA, data revealed mothers’ beliefs were significantly related.
To our knowledge, this is the first study to examine maternal correlates of objectively-measured physical activity using accelerometry in both the mothers and daughters. Mothers’ beliefs about girls’ physical activity were significantly related to daughters’ % time in MVPA. Mothers who believed physical activity was important for their daughters were more likely to have daughters who participated in health-enhancing levels of physical activity. It is likely that daughters would be supported and provided with more opportunities to engage in MVPA, if their mothers believed it was important and that this may influence behavior through provision of more physical activity opportunities. It is also possible that girls who are aware of their mother’s beliefs regarding physical activity seek opportunities to be involved in MVPA.
Our findings are supported by those of Trost and colleagues, who found that parents who believed in the importance of physical activity had more physically active children, compared to parents who did not report strong beliefs (Trost et al., 2003). However, in their study, physical activity was measured via self-report, and possible gender-specific intergenerational influences were not explored. Dempsey and colleagues (1993) found that 15
parental beliefs about their children’s self-reported MVPA explained only a small amount of variance (6%) (Dempsey, Kimiecik, & Horn, 1993) compared to our findings of 14 percent of variance explained. Our variance of 14 percent may be strengthened due to the use of an objective measure of physical activity.
For daughters’ CPM (total activity), mothers’ logistic support, outcome expectations, and mothers’ CPM were all significantly related. It is clear that beliefs of mothers appear to be key, whether it be their beliefs about physical activity benefits for themselves and/or their daughters. Logistic parental support is a form of support that involves practical tasks such as enrolling a child in sport, transporting them to/from sporting activities, and watching them participate in sporting activities (Davison et al., 2003). Our results suggest that mothers who provide high levels of physical activity-related logistic support to daughters have more active daughters. This association between daughters’ CPM and mothers’ logistic support could also reflect that daughters who are more active may prompt their mothers to provide such logistic support, i.e. positive reinforcement cycle (Davison et al., 2003). The recent review by Trost and Loprinzi (2011), on parental influences on physical activity in youth, found strong and consistent correlations between parental support for physical activity and children’s physical activity (Trost & Loprinzi, 2011). In addition, Sleddens et al. (2012) highlighted parental supporting behaviors, including role modeling, were positively correlated to children’s physical activity (Sleddens et al., 2012). Other reviews investigating parental correlates and youth physical activity have concluded that parental support (Gustafson & Rhodes, 2006) is correlated to physical activity.
Similar to the current study, mothers’ logistic support has been shown to be associated with girls’ activity (Davison et al., 2003), where maternal support explained 12 percent of the variance in girls’ self-reported activity (Davison et al., 2003). Our regression model for
16
daughters’ CPM explained 24 percent variance, and the individual contribution of mothers’ logistic support explained 10 percent of the variance. It has been found that mothers offer higher levels of logistic support for girls than boys (Edwardson & Gorely, 2010a). In a more recent study assessing parenting practices and physical activity in 10- to 11-year-old boys and girls, maternal logistic support was associated with girls’ CPM only (Jago et al., 2011).
Although in the current study we found maternal logistic support to be a correlate of daughters’ CPM, the parenting activity-related measure of support was not significant, which was adapted from Adkins and colleagues (2004) (Adkins et al., 2004). Our findings align with Adkins and colleagues (2004), with this support measure not revealing a significant association with daughters’ physical activity. Adkins and colleagues did, however, report parents’ self-efficacy for being active with their daughters significantly correlated with daughters’ activity.
Although we found a correlation between mother-daughter total activity (CPM), there was no significant relationship between mother-daughter % time in MVPA. A review focusing on parent-child physical activity correlations revealed that overall findings are largely varied, which could be owing to the lack of objective physical activity measures being adopted (Gustafson & Rhodes, 2006). It may be that our sample of daughters had more opportunity for engaging in MVPA, such as in the after-school period or on weekends, and their mothers are providing the logistic support for this engagement. For example, mothers who offer logistical support, i.e. by taking her daughter to sport, may be more sedentary while sitting on the sideline or waiting for her daughter to finish the physical activity.
Mothers may have had less time in their day for engaging in MVPA, as 50 percent of our mothers reported an office job as their occupation. A large proportion of mothers in the current study were categorized as overweight or obese (67.5%), which is much greater than
17
national averages (50%). This may also explain the lack of association between mothers’ % time in MVPA and daughters’ % time in MVPA.
Overall, it appears findings are varied regarding parental physical activity levels and the association with children’s physical activity levels. Further, very little is known about mother-daughter physical activity associations. In other reviews, Gustafson and Rhodes
(2006) found mothers’ physical activity correlated with daughters’ physical activity, although findings across individual studies are mixed and differences are exacerbated by the different methods used to assess physical activity (Gustafson & Rhodes, 2006).
Mothers’ outcome expectations were also a significant correlate of daughters’ CPM.
The outcome expectations scale asked mothers to report their beliefs surrounding the benefits of regular physical activity for themselves. The mean score for this scale was high, at 4.6/5, indicating that the mothers had high expectations about the effects of regular physical activity on their health, and this was associated with more active daughters. We also found that mothers’ total physical activity level (CPM) was a significant correlate of daughters’ total activity (CPM). This is a novel finding, which is strengthened by the study’s use of an objective measure of physical activity for both mothers and daughters. It may be that the daughters of mothers who have high outcome expectations model higher levels of physical activity due to their mother’s beliefs. Evidence from the review conducted by Trost and
Loprinzi (2011) revealed weak associations between parental and child physical activity.
However, only 31 percent of these studies used an objective measure of physical activity. In addition, only three out of nine studies reported a positive significant association between mothers’ and daughters’ physical activity, and these studies used self-report measures.
Our regression model for daughters’ sedentary time revealed mothers’ logistic support was significantly inversely associated with daughters’ sedentary time. Therefore, our results 18
suggest the more logistical support, i.e. physical activity-related support, mothers provide to their daughters, the less likely their daughter is to be involved in sedentary behaviors. This suggests that the logistic support may occur at a time when the daughters would otherwise be sedentary (e.g. taking daughters to sport in the after-school period or weekends). Through mothers providing this support for activity, this may displace daughters’ sedentary time.
Further studies are needed that adopt objective measures of physical activity. Furthermore, parents who are sedentary are likely to have daughters who are sedentary (Jago, Fox, Page,
Brockman, & Thompson, 2010).
In the final model for daughters’ screen time, mothers’ sedentary time was positively associated with daughters’ total screen time. Mothers who have higher levels of sedentary behavior were more likely to have daughters who engaged in higher levels of screen time.
This may be explained, as parents are important role models for their children. Sedentary behaviors of children may be learned from their parents (Jago et al., 2010). Jago et al. (2010) examined associations between objectively-measured physical activity, sedentary and screen time practices from a large sample of British children and parents, and found parental sedentary minutes predicted girls sedentary minutes (Jago et al., 2010). Of note, over 80 percent of the parent sample were mothers and they found that parents who watched two to four hours of television (TV) per day increased their daughters’ risk by over three times, of watching more than four hours of TV (Jago et al., 2010).
A unique aspect of the current study is the examination of maternal behaviors, social- cognitive and parenting-related correlates of girls’ physical activity. This is one of few studies that has examined maternal parenting correlates of girls’ objectively-measured physical activity. Moreover, a strength of this study is the comprehensive use of reliable parenting physical activity measures. Study limitations include the cross-sectional design,
19
which does not allow causality to be determined between the girls’ activity and maternal behaviors and cognitions, and the small sample size of participants who were a relatively homogenous sample of mothers and daughters, in terms of socio-economic status. Of note, mothers’ answers to the questionnaire may have socially desirable responses, as they had registered for a physical activity intervention.
Conclusion
This study extends the literature related to maternal correlates of objectively-measured physical activity and suggests that future interventions aiming to increase girls’ physical activity levels should include mothers. We have shown specific aspects of mothers’ parenting for physical activity that are significantly associated with daughters’ physical activity levels.
The current study indicates mothers’ beliefs about their daughters’ physical activity are key correlates of daughters’ health-enhancing physical activity. Mothers’ sedentary behavior and logistic support are also influential in terms of their daughters’ SSR and sedentary behavior, respectively. A potential strategy to increase girls’ physical activity may be to target improving mothers’ beliefs about girls’ physical activity. Providing mothers with logistic support strategies, to reduce their own and their daughters’ screen time, could lead to decreased sedentary behavior and increase total physical activity, and increased health- enhancing activity. These findings can be used to inform and tailor interventions targeting mothers and daughters.
20
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26
Table 1. Descriptive statistics of mothers’ and daughters’ demographic, anthropometric, physical activity variables, and maternal characteristics
Variables Mothers Daughters
Total (N=40) Total (N=40)
Mean (s.d.) Mean (s.d.)
Age (years) 39.1 4.8 8.8 1.6
Height (cm) 164.3 5.4 134.4 10.4
Weight (kg) 74.32 14.47 33.60 9.10
BMI (kg/m2) 27.58 5.45 18.33 2.99
BMI z-score N/A N/A 0.69 1.19
Waist (umbilicus) (cm) 93.60 11.74 66.09 9.21
Physical Activitya
Mean CPMb 320.69 116.75 421.97 169.55
% time in MVPA 3.49 2.08 5.26 2.12
% time in SED 58.44 8.03 62.78 7.14
Screen time
Total screen time (minutes) N/A N/A 1074.75 560.53
Mothers’ sitting time (minutes)
Work day 451.3 201.7 N/A N/A
Non-work day 355.9 159.0 N/A N/A
27
Parenting for physical activity c
Confidence 3.45 0.42 N/A N/A
General Support 2.74 0.55 N/A N/A
Logistic Support 3.25 0.60 N/A N/A
Explicit modeling 2.73 0.60 N/A N/A
Beliefs 3.52 0.43 N/A N/A
Physical activity cognition d
Self-efficacy 3.62 0.96 N/A N/A
Outcomes expectations 4.61 0.58 N/A N/A
Social support 3.40 1.35 N/A N/A
Intention 4.67 0.52 N/A N/A
n % n %
BMI category e f
Healthy weight 13 32.5 28 70
Overweight 15 37.5 8 20
Obese 12 30.0 4 10
Socio-Economic Statusg
1-2 (lowest) 1 2.50 - -
3-4 4 10.00 - -
5-6 11 27.50 - -
28
7-8 22 55.00 - -
9-10 (highest) 2 5.00 - -
Marital Status
Married 29 72.50 - -
De facto 4 10 - -
Separated 3 7.5 - -
Divorced 3 7.5 - -
Never married 1 2.5 - -
Abbreviations: s.d., standard deviation; cm. centimeters; BMI, body mass index; an=39; btransformed
(square root) & median and IQR presented; cRange 1-4; dRange 1-5; eRepresentations of BMI categories for daughters based on BMI z-score; fChild grade 1 thinness and healthy weight combined; gSocio- economic status by population decile for SEIFA Index of Relative Socioeconomic Advantage and
Disadvantage.
29
Table 2. Bivariate correlations between potential maternal correlates physical activity behavior
Daughters variables (N=40)
Maternal variables % MVPA CPM % SED Screen time BMI-z
Background
Mothers’ age -0.15 -0.18 0.24 0.04 0.17
Family Seifa decilea -0.05 -0.14 0.30 0.20 -0.07
Mothers’ BMI 0.08 -0.01 -0.05 -0.12 0.57**
Mothers’ physical activityb
% MVPA 0.17 0.24 -0.13 -0.16 0.05
CPMc 0.20 0.23 -0.24 -0.40* 0.07
% SED -0.27 -0.31 0.34* 0.56** -0.06
Mothers’ sitting time
Work day -0.17 -0.05 -0.13 -0.11 0.20
Non-work day -0.24 -0.23 0.09 -0.12 0.06
Parenting for physical activity
Confidence 0.20 0.06 -0.02 -0.07 -0.16
Support 0.14 0.15 -0.13 -0.12 0.13
Logistic support 0.31 0.36* -0.37* -0.22 0.04
Explicit modeling -0.02 0.05 -0.15 -0.23 0.04
30
Beliefs 0.40* 0.40* -0.27 -0.27 0.10
Physical activity cognitions
Self-efficacy 0.17 0.12 -0.05 0.03 0.21
Outcomes expectations 0.28 0.25 -0.16 -0.14 0.14
Social support 0.10 0.18 -0.16 0.07 0.07
Intention 0.19 0.26 -0.29 0.03 0.14
** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)
Abbreviations: SED, sedentary behavior; MVPA, moderate-to-vigorous intensity physical activity; CPM, counts per minute; a SEIFA Index of Relative Socioeconomic Advantage and Disadvantage bn=39; cTransformed
(square root).
31
1 Table 3. Linear regression analyses results of physical activity, % time spent in sedentary behavior, screen time, and BMI z-score in daughters (Daughters
2 n=40; Mothers n=40)
Variables in final model Standardized β P value Part R2 R2
Daughters’ % time in MVPA Model R2 = 0.14
Mothers’ beliefs about physical activity 0.40 0.01 0.40 0.16
F(1,38) =7.17P = 0.01
Daughters’ CPMa Model R2 = 0.24
Mothers’ logistic Support 0.32 <0.05 0.32 0.10
Mothers’ CPMa c 0.37 <0.05 0.33 0.11
Mothers’ outcome expectations 0.40 0.01 0.37 0.13
F(3,36) = 5.20 P = 0.004
Daughters’ % time in SED Model R2 = 0.11
Mothers’ logistic support -0.37 <0.05 -0.37 0.14
F(1,38) = 6.01 P = 0.019
Daughters’ total screen time Model R2 = 0.33
Mothers’ % time in SEDc 0.59 <0.001 0.59 0.34
F(1,38) = 19.74 P =0 .000
Daughters’ BMI z-score Model R2 = 0.31
Mothers’ BMI 0.57 <0.001 0.57 0.32
F(1,38) = 18.25 P = 0.000
Abbreviations: MVPA, moderate-to-vigorous intensity physical activity; CPM, counts per minute; SED, sedentary behavior;
aTransformed (square root); c n=39
3
4
Appendices
Appendix 2: JOURNAL ARTICLE ‘FEASIBILITY AND PRELIMINARY EFFICACY OF THE M.A.D.E (MOTHERS AND DAUGHTERS EXERCISING) 4 LIFE PROGRAM: A PILOT RANDOMIZED CONTROLLED TRIAL’, JOURNAL OF PHYSICAL ACTIVITY AND HEALTH. IN PRESS
269 Mother-daughter physical activity intervention
1 Feasibility and preliminary efficacy of the M.A.D.E (Mothers And Daughters Exercising) 4
2 Life program: a pilot randomized controlled trial.
3
4 Brief running head: Mother-daughter physical activity intervention
5
6 Manuscript type: Original Research
7 Keywords: Accelerometry, community-based research, exercise, gender, physical activity,
8 intervention study
9 Abstract word count: 200
10 Manuscript word count: 3895 (excluding tables)
11 Number of tables: 6
12 Number of figures: 1
13 Date of revised manuscript submission: 05/02/2014
14
15 Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12611000622909)
16
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17 Abstract
18 Background: The aim was to assess the feasibility and preliminary efficacy of a community-
19 based physical activity (PA) intervention targeting mothers and daughters.
20 Methods: A randomized controlled trial of 48 primary school-aged girls and their 40 mothers
21 were randomized to (i) Mothers And Daughters Exercising for Life (MADE4Life) (n=21 mothers,
22 n=25 daughters) or (ii) wait-list control (n=19 mothers, n=23 daughters). The 8-week program
23 involved 8 sessions; 25-minute separate mothers and daughters education sessions and 60-
24 minutes PA together. Assessments were at baseline, post-intervention and 3-month post-
25 intervention. Primary outcome measure was daughters’ moderate-to-vigorous physical activity
26 (MVPA) (accelerometer). Secondary outcomes included accelerometer-assessed
27 light/moderate/vigorous PA, BMI, waist circumference, body composition, blood pressure,
28 resting heart rate, sedentary behaviors and mothers’ self-reported PA, parenting measures and
29 cognitions. Intention-to-treat analysis used linear mixed models.
30 Results: Recruitment and retention goals were exceeded. Attendance rates, program acceptability
31 and satisfaction were high. There was no significant group-by-time effect for daughters’ %
32 MVPA (-0.08; 95%CI -1.49, 1.33, d=-0.03) or other secondary outcomes for girls (post-
33 intervention range d=0.01–-0.46). Significant intervention effects were found for mothers’
34 %VPA (P=0.04, d=0.25) and role modelling (P=0.02, d=0.66).
35 Conclusion: MADE4Life was both feasible and acceptable. Although very small effect sizes were
36 found for the daughters, significant changes were seen for mothers (d=0.25-0.66). Future fully
37 powered trials targeting PA in mothers and daughters is warranted.
38 39
40
41
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Mother-daughter physical activity intervention
42 INTRODUCTION
43 Physical inactivity in children and adults is a global public health concern and associated
44 with a number of chronic diseases1. Internationally, the prevalence of physical inactivity in youth
45 is high. For example, only 7% of children aged 6-19 years in Canada2; 15.3% aged 4-17 years
46 from Germany3 and 29% aged 11-18 years from the US4 meet physical activity (PA) guidelines.
47 Of particular concern, is the marked sex difference with girls consistently shown to be less active
48 than boys across all age groups1.
49 Many interventions have been designed and evaluated to increase PA in children through
50 settings including schools, family and communities but with limited success. A recent systematic
51 review of school-based PA programs that included objective measures of PA, found studies were
52 methodologically poor, programs were largely unsuccessful and led only to an increase in
53 MVPA of 4 minutes per day5. Further, a recent review of family-based PA interventions reported
54 a lack of effectiveness of family-based PA programs targeting children characterised by poor
55 study quality and a lack of objectively measured PA6.
56 Given the inconclusive evidence for generic approaches to PA promotion and the gender
57 disparity in PA levels, targeted interventions for girls may have particular potential7. However, a
58 recent review of interventions to promote PA among girls revealed mixed results. Only seven of
59 21 interventions successfully increased PA. The review reported only three interventions were
60 community-based, none having a follow-up assessment beyond post intervention assessment and
61 only one employed objectively measured PA. Importantly, the review called for further high-
62 quality, community-based interventions targeting girls and that use objective measures of PA7.
63 One novel approach to increase PA levels is the targeting of both mothers and daughters8.
64 This is particularly important as women are less active than men1,9 and maternal involvement in
65 PA has been positively associated with child PA levels, and is stronger for daughters10-12.
66 However, there have been limited RCTs conducted in mothers and daughters which have noted
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Mother-daughter physical activity intervention
67 limitations including small sample size, no true control group, lack of follow up assessment
68 beyond post intervention and only two RCTs13,14 utilized an objective measure of PA.
69 Therefore, the primary aim of this randomized control trial was to evaluate the feasibility
70 and preliminary efficacy of a mother-daughter program targeting improvements in PA levels.
71 METHODS
72 Participants
73 Mothers and their primary school-aged daughters (5-12 years) were recruited from an
74 Australian community through media releases, school newsletter advertisements, school
75 presentations to students and parents, local newspapers and local television news. Mothers were
76 screened for eligibility by telephone questionnaire. Eligibility criteria included mothers passing a
77 pre-exercise risk assessment screen, and obtaining a doctor’s clearance if >40 years. Approval
78 was obtained from the University of Newcastle Human Research Ethics Committee and mothers
79 provided written consent and daughter(s) providing assent. Mothers were ineligible if they
80 reported previous heart disease or diabetes, orthopedic or joint problems which would inhibit PA
81 or if they were pregnant.
82 Study design
83 This study was a pilot randomized controlled trial (RCT). Mothers and their daughter(s)
84 were stratified by BMI category (Healthy Weight; 18-24.99, Overweight; 25-29.99, Obese1; 30-
85 34.99, Obese2; 35-39.99, Obese3; >40) and randomly assigned to either the (i) MADE4Life
86 intervention or (ii) a six-month wait-list control. The allocation sequence was generated by a
87 computer-based random number-producing algorithm in block lengths of six to guarantee an
88 equal chance of allocation to each group. To ensure concealment, the sequence was generated by
89 a statistician, concealed in envelopes and given to a researcher who was not involved in the
90 assessment of participants. Researchers were blinded at the baseline assessment sessions.
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91 Outcome measures were collected from mothers and daughters at baseline (prior to
92 randomization; July, 2011), immediate post-intervention [post-intervention] (10-week follow-up;
93 September, 2011) and three-month follow-up [follow-up] (20-week-follow-up; December, 2011).
94 Measurements were taken after school University of Newcastle, Australia, using the same
95 instruments at each time point. The wait-list control received no intervention prior to attending
96 the post-intervention and follow-up assessment sessions. The primary endpoint for this study was
97 the post-intervention assessment. The Consolidated Standards of Reporting Trials (CONSORT)
98 guidelines were adhered to for this study15.
99 The MADE4Life intervention
100 The MADE4Life program involved mothers and daughters attending weekly after-school
101 90 minute sessions over 8-weeks. Mothers and daughters attended separate education sessions for
102 the first 25 minutes, with both participating in the final 60 minute PA sessions. Mothers’ and
103 daughters’ education and PA sessions were delivered by female researchers with qualifications in
104 physical education teaching. The major focus of the mother-daughter PA sessions were fun active
105 games, health-related fitness16, zumba, aerobics17, pilates, yoga18, rough and tumble play19 and
106 fundamental movement skills20.
107 The aim of the MADE4Life program was to encourage PA in girls and their mothers, and
108 to promote PA role modelling and parenting PA parenting practices in mothers. MADE4Life was
109 informed by Social Cognitive Theory21 and operationalized key constructs of self-efficacy, social
110 support and outcome expectations (Table 7) and adopted intervention components the ‘Healthy
111 Dads, Healthy Kids’ program22,23 while other components were based on teaching experiences of
112 the researchers. Moreover, MADE4Life activities were based upon fun, interactive games and
113 fitness activities developed by the research team, incorporating popular music. MADE4Life
114 encouraged reciprocal reinforcement between mothers and daughters24 of PA e.g. daughters
115 encouraging mothers to be active and vice versa.
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Mother-daughter physical activity intervention
116 Daughters’ education sessions focused on developing an active lifestyle, benefits of PA
117 and ways to reduce screen time. The ‘daughter’s booklet’ contained weekly worksheets for
118 daughters to complete with activities, e.g., the importance of PA, fun ways to be active, reducing
119 screen time. Daughters completed weekly ‘pink slip’ homework tasks that encouraged home PA
120 with their mothers, e.g., creating home-based fitness circuits. Pink slips were reviewed weekly by
121 facilitators and daughters were rewarded with a ‘scratch n smell’ sticker to attach to a sticker
122 chart.
123 Mothers’ education sessions consisted of evidence-based information on PA, behavior
124 change, role modelling and parenting strategies to support their daughter(s) PA. Sessions focused
125 on the importance of mothers being a positive and active female role model13. Mothers were
126 given a ‘mother’s handbook’ to file weekly session outlines and various resources that supported
127 mother-daughter PA (e.g., pedometers, skipping ropes). Mothers were encouraged to set SMART
128 goals and self-monitor their daily PA using pedometers.
129 MADE4Life Outcome measures
130 Assessment sessions were held one week prior to intervention commencement. Families
131 received a $10 voucher from a local supermarket chain on completing assessments. The primary
132 outcome was daughters’ % time spent in moderate to vigorous physical activity (MVPA) at post-
133 intervention. Actigraph GT3X and GT3X+ (ActiGraph, LLC, Fort Walton Beach, FL)
134 accelerometers, which are considered to be valid and reliable for both children25 and adults26,
135 were used to assess PA for seven consecutive days in all participants. Accelerometers were
136 initialised to collect data in 15 second epochs for daughters and 60 second epochs for mothers27.
137 Daughters’ data with ≥20 minutes28,29 and mothers’ data with ≥60 minutes of consecutive zeros
138 were considered non-wear time and excluded from analysis. Activity counts were calculated for
139 time spent in moderate (MPA) (4-5.9 METS) and vigorous (VPA) (≥6 METS) PA. Total counts
140 were divided by total minutes monitored to calculate mothers’ and daughters’ mean counts per
6
Mother-daughter physical activity intervention
141 minute (CPM). Separate cut-points were applied for daughters27,30 and mothers31 to determine the
142 amount of time spent in sedentary, light, moderate, and vigorous PA. To account for wear time
143 variation, values were calculated for percentage of monitored time spent in sedentary behavior (%
144 SED), LPA (%LPA), MPA (%MPA), VPA (%VPA) and MVPA (% MVPA). Participants’ data
145 were included in the analysis if accelerometers were worn for ≥480 minutes on ≥4 days29,32.
146 Participants were given an activity monitor sheet to log non-wear time activities such as
147 swimming and bike riding. To support retention rates of the primary outcome, families were sent
148 two reminder text messages throughout their 7-day wear time.
149 Feasibility, acceptability and satisfaction
150 Process measures including feasibility, acceptability and satisfaction were assessed via:
151 recruitment (40 mother-daughter dyads to be screened and randomized); retention (a minimum of
152 80% retention of primary outcome; calculated by summing the total number of daughters’
153 returning acceptable accelerometer data); and attendance (a minimum of 80% attendance over the
154 eight sessions; calculated by summing the total weekly attendance). Acceptability and satisfaction
155 were measured via a process evaluation questionnaire, using a 5-point Likert scale (‘strongly
156 disagree to strongly agree’) and for enjoyment of activities (‘really didn’t enjoy to really
157 enjoyed’) (Table 6). Mothers also completed three short-open-ended questions asking what they
158 did and did not like about MADE4Life and suggestions for improvement.
159 Secondary outcomes are reported in Table 1.
160 Data analysis
161 Analyses were performed using SPSS Statistics 20 (IBM Inc. Armonk, NY). Descriptive
162 analysis (percentages and frequency counts) were conducted to assess retention, recruitment,
163 attendance and satisfaction. Data are presented as means (SDs) for continuous variables and
164 counts (percentages) for categorical variables. Means and standard deviations were calculated for
165 all normally distributed variables. Characteristics of completers versus dropouts were tested using
7
Mother-daughter physical activity intervention
166 independent t tests for continuous variables and chi-squared (χ2) tests for categorical variables.
167 The significance level was set at .05 for all analyses. Analyses were performed separately for
168 mothers and daughters and included all randomized participants.
169 Linear mixed models (LMM) were used to assess all outcomes (primary and secondary)
170 for the impact of group (Intervention and Control), time (treated as categorical with levels
171 baseline and post-intervention and baseline and follow-up) and the group-by-time interaction,
172 with these three terms forming the base model. LMM were fitted with an unstructured covariance
173 structure for all primary and secondary outcomes. 95% confidence intervals (CIs) and differences
174 between means were determined via LMM. Analyses included all randomized participants. Age,
175 daughters age, SES and BMI were examined for mothers; for daughters, age and SES were
176 examined as pre-specified covariates to determine if they contributed significantly to the
177 models33. Significant covariates were then examined via two-way interactions with time and
178 treatment, with all significant terms added to the final model to adjust the results for these effects.
179 The MADE4Life study was designed as a pilot randomized controlled trial; hence it was not
180 deemed to be adequately powered from a statistical perspective. Therefore, to demonstrate effects
181 and trends, Cohen’s d34 was used to determine effect sizes by calculating mean differences from
182 the mixed models and the pooled standard deviation of the two groups at baseline (d=(M1-M2
183 )/pooled).
184 RESULTS
185 The baseline characteristics of daughters and mothers are summarised in Table 2 and
186 Table 3 respectively. Mean age of daughters was 8.5 years (1.7) and mean BMI z-score was 0.7
187 (1.2). After adjusting for non-wear time based on self-report accelerometer logs, no differences
188 were found, therefore the non-adjusted wear time is reported. Daughters’ accelerometer assessed
189 % time in MVPA was 5.7 (2.3). At baseline, 19% (n=9) of the daughters met the PA guidelines.
190 In comparison to children’s age-matched accelerometer data, 7% of children met the PA guidelines,
8
Mother-daughter physical activity intervention
191 therefore when comparing our sample of daughters to normative data, our daughters were a higher
192 active sample.
193 Mean age (SD) of mothers was 39.1 (4.8) and mean BMI was 27.6 (5.5). Mothers’
194 accelerometer assessed % time in MVPA was 3.5 (2.1). At baseline, 40% (n=16) of the mothers
195 met the PA guidelines. Recent self-report data from Australia report 44% of women aged 35-44 to be
196 sufficiently active .Therefore our sample of mothers are slightly less active compared to normative
197 data. For the primary outcome, all randomized daughters with baseline data (n=48) were analysed
198 at both follow-up time points.
199 Feasibility
200 The first aim was to determine program feasibility. Figure 1 illustrates the flow of
201 participants through the trial. In just over three weeks, a total of 122 families registered their
202 interest for the program and were screened for eligibility. The most successful recruitment
203 strategy was via local school newsletters with more than half of mothers reporting this as the
204 primary exposure, followed by local radio, school gate/school presentations, university website,
205 newspaper and television news. The target sample size was met with 40 mothers and 48
206 daughters attending baseline assessment sessions.
207 The 80% retention target was met for the primary outcome (accelerometer data) with
208 100%, 81% and 83% at baseline, post-intervention and follow-up respectively. Similarly,
209 retention rates for mothers were high with 98%, 85% and 83% at each assessment. The study had
210 excellent retention for assessments with 100% attending baseline assessments, 93% attended
211 post-intervention and 91% at follow-up. There were no significant differences in follow-up rates
212 between the MADE4Life and control group daughters at post-intervention (2=0.94, df=1, P=0.33
213 or follow-up (2=2.02, df=1, P=0.15), and for mothers post-intervention (2= 0.02, df=1,
214 P=0.894) and follow-up (2=1.129, df=1, P=0.270). Daughters lost at post-intervention had
215 higher average per day screen time (P=0.05) at baseline compared to daughters retained at follow-
9
Mother-daughter physical activity intervention
216 up. Mothers lost at post-intervention had a lower mean fat mass (P=0.05) at baseline than mothers
217 retained at follow-up.
218 Average attendance at program sessions was high (82%). Two families withdrew for
219 reasons not related to the MADE4Life program i.e., sickness and family commitments. Contact
220 was lost with one additional family, who attended only two sessions. For the remaining 18
221 families, average attendance was 93%, and median number of sessions attended was 8 (range=6-
222 8). The most common reasons for non-attendance were sickness (50%), family commitments
223 (30%) and work commitments (20%). All eight MADE4Life program sessions were implemented
224 as planned (100%).
225 Acceptability and satisfaction results are summarised in Table 6. Overall, mothers
226 reported MADE4Life was highly acceptable which is reflected by the high mean scores. Mothers’
227 qualitative answers indicated program highlights were spending quality time with their daughters
228 in PA in a fun, supportive environment with other mothers and daughters.
229 Preliminary efficacy
230 Tables 4 and 5 report the results of primary and secondary outcomes for daughters and
231 mothers respectively. There was no significant intervention effect (d=-0.03) for the primary
232 outcome of daughters’ % time in MVPA. Similarly, very small effect sizes were reported for
233 daughters secondary outcomes of %VPA; d=-0.09, %MPA; d=0.04 and CPM d=-0.09 post-
234 intervention. At follow-up, a small effect size was found for daughters’ CPM d=0.20, with a
235 significant within-group effect for the treatment group at follow-up (with a +75 counts per minute,
236 increase from pre to post; 95%CI 7.17, 144.68). A medium effect size for daughters’ % LPA; d=-
237 0.46 was revealed at both post-intervention and follow-up. Both the treatment and control daughters
238 showed within-group effects for % LPA at post-intervention and, in addition, the control daughters
239 showed a within-group difference at follow-up. Small-to-medium effect sizes were found in the
10
Mother-daughter physical activity intervention
240 intervention group for daughters’ %SED at both post-intervention (d=0.20) and follow-up
241 (d=0.38) and medium effect sizes were found for daughters’ blood pressure (d=0.32–0.40).
242 Intervention mothers’ % MVPA effect size was d=0.25 at post-intervention. Intervention
243 mothers increased their % MVPA by 0.4% at post-intervention compared to the control group
244 who decreased by 0.1%. A significant intervention effect was found for mothers %VPA (P=0.04,
245 d=0.25), with the overall group by time effect significant (P=0.04) with the mothers in the
246 MADE4Life group increasing their % VPA (+0.22%, 95% CI; 0.05, 0.39) compared to the control
247 group (+0.04% 95%CI; -0.15, 0.22). A large (d=0.66) and significant (P<0.04) treatment effect
248 size was found for mothers’ PA role modelling.
249 Medium effect sizes were found for mothers’ MET minutes at both post-intervention
250 (d=0.42) and follow-up (d=0.53), with a significant within group difference in favour of the
251 MADE4Life mothers. MADE4Life mothers’ also recorded a significant within group effect for
252 their parenting for PA beliefs, with medium effect sizes post-intervention (d=0.34) and follow-up
253 (d=0.44). A large effect size (d=-0.70) was found for mothers sitting time on a non-work day
254 post-intervention in favour of the MADE4Life group.
255 DISCUSSION
256 The aim of this pilot RCT was to evaluate the feasibility and preliminary efficacy of a
257 program targeting PA in pre-adolescent girls and their mothers. The MADE4Life program and
258 study methods were highly feasible as demonstrated by successful recruitment, retention, and
259 high levels of satisfaction and acceptability. The potential efficacy of the program was
260 demonstrated by the encouraging effect sizes for some of the targeted measures (maternal role
261 modelling, MET mins, maternal beliefs and sitting time). However, we did not see an effect on
262 our primary outcome, which would need to be tested in a fully powered trial.
263 Our feasibility metrics demonstrate the appeal of the program. Recruitment goals were
264 met promptly within three weeks, following a variety of promotion strategies. This may be
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Mother-daughter physical activity intervention
265 attributed to the novelty of the MADE4Life program i.e., new, engaging, girls only program
266 which appealed to mothers and daughters. In contrast, other studies have had difficulties in
267 recruitment35, particularly when using wait-list or no intervention control groups36.
268 Attendance levels were excellent (82%) and much higher than other mother-daughter
269 studies which report attendance ranging from 65%37 to 70–77% attendance35 . The high retention
270 in the current study for both mothers and daughters and complying to assessments studies is
271 similar to Ransdell et al, 200335 (85% compliance) and Ransdell et al, 2004 with a 93%
272 completion rate for the intervention group but only 43% for the control group13. The high
273 attendance for the MADE4Life may be attributed to the positive rapport built with the study leader
274 and program staff as the quality of facilitators rated very highly (average 4.8 out of 5). It may also
275 be due to the variety of fun and engaging program activities. Considering the difficulties of
276 accelerometer adherence38, our retention rates were high and likely facilitated by reminder text
277 messages sent during assessment weeks, rapport built with the program facilitators, and the
278 incentive of a store gift card given for assessment attendance.
279 Program Acceptability and Satisfaction was demonstrated through the very positive
280 ratings from mothers’ on program quality, impact, content and support. Mothers rated their
281 overall enjoyment of the program close to the maximum possible score. This could be attributed
282 in part to program alignment with SCT21, with an emphasis on self-efficacy, social support and
283 outcome expectations or the qualifications, teaching experience and teaching strategies employed
284 by the facilitators. In addition, high program satisfaction may have also been facilitated by the
285 content tailored specifically for females, pedagogically designed sessions, encouragement of
286 social support, and use of engaging mother-daughter home tasks that were appealing to the whole
287 family.
288 The preliminary efficacy of the MADE4Life program was assessed via the primary
289 outcome physical activity (%MVPA) in daughters. For daughters, only a very small effect size
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Mother-daughter physical activity intervention
290 was found, however, the study was underpowered and not designed to detect significant
291 differences. The small effect size may also be due to the study inclusion criteria. The study was
292 open to all girls, as opposed to a recruiting ‘low active’ girls or those not involved in organised
293 sports or activities, as has been the case in previous mother-daughter studies12,13,35 or focusing on
294 recruiting exclusively overweight or obese girls39,40 . Our baseline findings suggest the girls
295 recruited were more active than the general population, compared to objective data in boys and
296 girls41 . Therefore, both study arms may have had less potential for improvement due to a ‘ceiling
297 effect’42. The MADE4Life program may have been unable to increase daughters’ PA for other
298 reasons. For example, it is noteworthy that other areas of focus of the MADE4Life intervention
299 included rough and tumble play and fundamental movement skills for mothers and daughters, which
300 are problematic to measure with accelerometers and both have often distinct benefits 19,20. Although
301 these variables were not evaluated, the potential impact of the MADE4Life program might also be
302 further explored through assessing these aspects. Further, co-physical is important variable, however,
303 was not evaluated in this trial. The literature on the efficacy of mother-daughter/parent daughter
304 PA studies are mixed, with some studies reporting significant increases in daughters PA13,39,43
305 while others not14,37. Such variation in findings may be attributed no follow-up beyond post-
306 intervention assessment and not using objective PA measures. There has only been one mother-
307 daughter RCT which has assessed MVPA objectively (via accelerometer) in daughters and this study
308 did not find a significant difference between groups for MVPA or mean daily CPM 14. Notably, PA
309 assessment in this study was relatively short (i.e., 2 weekdays). Moreover, there has been only one
310 pre-post study which used accelerometry in daughters 39, however, data were only collected during the
311 intervention sessions, i.e. between 9am-5pm Monday to Friday during a summer camp. Results for
312 daughters’ MVPA indicated a significant increase in daily MVPA from Week 1 to Week 4 during the
313 intervention 39. This may have been due to the high retention rate 39 and because the daughter were a
314 captive audience, participating in structured daily exercise sessions at the organised camp, therefore
315 increasing MVPA. Limitations of this study included the absence of a control group and no 13
Mother-daughter physical activity intervention
316 assessment of PA at baseline and post-intervention. It is unknown whether the daughters’ MVPA was
317 increased outside the intervention period and whether increases in MVPA would be sustainable. In
318 addition, maternal PA was not assessed in this study 39.
319 A moderate effect size at immediate post-intervention was reported for mothers’
320 %MVPA and encouraging results were revealed for mothers’ %VPA, with a significant
321 intervention effect. Indeed, very few studies exclusively targeting mothers-daughters have used
322 objective measures of PA i.e., pedometers13 or accelerometers14,39. However, limitations of these
323 particular studies include no objective assessment for the study mothers, aggregating three day
324 step counts as a family average rather than reporting separately for daughters and mothers13 and
325 no follow-up beyond post-intervention assessment14,39. Given the decrease in PA levels from
326 post-intervention to follow-up in the current study, future interventions may need to increase the
327 intervention dose, for example, bi-weekly sessions) and/or include booster sessions during the
328 maintenance phase.
329 A large effect size was found for mothers’ PA ‘role modelling’ with mothers in the
330 MADE4Life group significantly improving their frequency of doing activity with their
331 daughter(s), organisation for family PA and using their own behavior to encourage daughters’
332 PA. This is a novel finding and there are no mother-daughter studies that have measured these or
333 similar constructs.
334 Study limitations and strengths
335 The sample size was small and hence not fully powered to detect significant differences
336 in outcomes. This is the first study focussing on intergenerational females, to objectively assess
337 PA in daughters and mothers. Further strengths include the randomized design, high retention
338 percentage, intention to treat analysis, follow-up assessments beyond immediate post-intervention
339 and a theoretically-grounded program.
340 Conclusion
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Mother-daughter physical activity intervention
341 This study aimed to assess the feasibility and preliminary efficacy of a novel mother-
342 daughter PA gender tailored program. It makes an important contribution to the paucity of studies
343 targeting mothers and daughters. Importantly, it was a RCT and used objectively measured PA.
344 Future trials could screen participants with low baseline PA levels as a way to target low active
345 mothers and daughters. Furthermore, future studies should continue to include objectively
346 measuring PA in both mothers and daughters, and target and assess co-physical activity and
347 fundamental movement skills. Overall, the MADE4Life program was highly feasible and
348 acceptable to mothers and daughters and larger statistically powered trials are warranted.
349 Funding source
350 MADE4Life was funded by the 2011 Seed Funding Grants from the Priority Research
351 Centre in Physical Activity & Nutrition, University of Newcastle. RCP is supported by a Senior
352 Research Fellowship Salary Award from the National Health and Medical Research Council
353 (NHMRC), Australia. This trial is registered with the Australian New Zealand Clinical Trials
354 Registry http://www.anzctr.org.au/ (ACTRN12611000622909).
355 Acknowledgements
356 We would like to thank the participating mothers and daughters, Erin Watts for assisting
357 with the MADE4Life PA sessions, student volunteers at assessment and program sessions; Joanne
358 Graham, Kayla Lawson, Siobhan Handley, Jessica Dunn, Brianne McCabe, Katie Sylvester,
359 Angela Humphrey, Amanda Williams, Myles Young, Sarah Costigan, The Forum Sports and
360 Aquatic Centre (NUSPORT) and the University of Newcastle.
361
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502 Author;2008. ABS catalogue 2033.0.55.001.
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504
505
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Table 1: Secondary measures assessed in the MADE4Life program Variables Description Scoring outcome BMI and BMI z-score Weight was measured in light clothing, without shoes and on a digital scale to 0.1kg (model CH-150kp, A&D n/a Mercury Pty, Adelaide, Australia). Height was measured to 0.1 cm using the stretch stature method (Mentone Educational Centre, Victoria, Australia) and the Biospace Stadiometer (BSM370, Seoul, Korea). Mothers’ BMI was calculated using the standard equation, weight kg/height m2. Daughters’ BMI z-score was calculated using age-adjusted standardized scores (z-scores) in reference to the UK 1990 reference population 44. Waist circumference Waist circumference was measured at the umbilicus level with non-extensible steel tape (KDSF10-02, KDS, n/a Osaka, Japan) to the nearest 0.1cm. Blood pressure and Blood pressure and resting heart rate were measured using NISSEI/DS-105E digital electronic blood pressure n/a resting heart rate monitors (Nihon Seimitsu Sokki Co. Ltd., Gunma, Japan) under standardised procedures. Body Composition Bioimpedance was used to assess body composition, including fat mass, fat free mass and total body water. n/a Body composition was assessed by the InBody720 (Biospace Co., Ltd, Seoul, Korea), a multi-frequency bioimpedance device featuring an eight-point tactile electrode system. This method has been shown to be valid and reliable 45. Self-report PA Mothers’ self-reported their PA via a modified version 46 of the validated Godin Leisure-time Exercise Total time spent in moderate intensity activity behaviors Questionnaire (GLETQ) 47 and reported the number of times per week (average week over the past month) and was multiplied by 4.5. minutes per session they spent in strenuous (rapid heartbeats, sweating), moderate (not exhausting, light Total time spent in strenuous activity was perspiration) and mild (minimal effort and no perspiration) for a minimum of 10 minutes per session. Calculation multiplied by 7. These variables were then of this variable has been explained in detailed elsewhere 22. MET scores (MET-minutes/week) were generated added. 48 and final MET mins were calculated using self-reported Strenuous and Moderate Mets (excluding mild) representing MVPA. Mothers’ sedentary Adapted from a valid and reliable sitting time questionnaire 49. Mothers reported typical sitting time on a work Time spent in each domain was added to behavior and non-work day for time spent sitting for transport, work, watching TV, using a computer at home, other determine overall work day sitting time and non- leisure activities and sleep time 49. work day sitting time Daughters’ Mothers proxy-reported their eldest participating daughter’s leisure activity over a typical week using the Screen recreation (SR) was calculated by sedentary behaviour previously validated Children’s Leisure Activities Study Survey (CLASS) 50. summing the three domains TV/Videos, and screen time PlayStation/Nintendo/Computer games and Computer/internet. Total sedentary behavior for each of Monday-Friday and Saturday-Sunday were calculated by converting reported values to minutes and summing the 15 domains. An average was then calculated. Maternal parenting Mothers’ parenting of PA was measured by adapting either full scales or selected items of previously validated Maternal scores for each domain was added to for PA scales on maternal logistic support for PA and maternal explicit modelling 51,52, maternal beliefs53, maternal self- determine an overall score for each maternal PA efficacy and general support 54. Details of the maternal parenting for PA scales have been reported in further subscale. detail elsewhere . 22
Mother-daughter physical activity intervention
Maternal social- Key SCT cognitions 21 related to mothers’ PA were adapted from validated measures of self-efficacy 55, Maternal scores for each domain was added to cognitive variables outcome expectations 56, social support , and intention 57. determine an overall score for each SCT cognition. Demographics Information regarding maternal demographics including mothers’ age, socioeconomic status (SES) postcode, SES was based on postal code of residence highest level of education, marital status, and weekly household income were collected. using the Index of Relative Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics census-based Socio-Economic Indexes for Areas (SEIFA) 58. 506
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507
Table 2: Baseline characteristics of Daughters randomized to the MADE4Life intervention and control groups Control MADE4Life program Total Characteristics (n = 23) (n = 25) (n = 48) Mean (SD) Mean (SD) Mean (SD) Age (years) 8.63 1.76 8.36 1.72 8.49 1.73 Weight (kg) 33.06 9.88 31.42 8.37 32.21 9.06 Height (m) 132.48 12.09 131.85 10.25 132.15 11.05 BMI (kg/m2) 18.49 3.06 17.80 2.69 18.13 2.87 BMI z-score 0.81 1.09 0.65 1.27 0.71 1.18 Waist [umb] (cm) 65.60 9.47 64.71 8.69 65.14 8.98 Waist z-score 2.12 1.63 2.10 1.89 2.11 1.75 Systolic blood pressure (mmHg) 94 6 94 13 94 10 Diastolic blood pressure (mmHg) 60 7 57 9 58 8 Resting heart rate (BPM) 84 13 83 10 83 12 Fat mass % 24.22 7.76 22.84 8.23 23.50 7.95 Physical activity Mean CPM 452.69 123.97 482.95 168.97 468.45 148.34 % time in MVPA 5.60 1.77 5.71 2.76 5.65 2.32 % time in MPA 3.83 1.00 3.93 1.62 3.88 1.35 % time in VPA 1.77 1.08 1.78 1.27 1.78 1.17 % time in LPA 31.12 5.50 34.02 5.97 32.67 5.86 % time in SED 63.18 6.79 60.27 7.90 61.66 7.46 Sitting time (minutes/day) a, b Sitting time daily average 382.00 187.03 363.30 143.20 372.16 163.55 Screen time (minutes) a, b Screen time (average minutes/day) 162.29 99.49 145.61 58.80 153.54 80.08 n % n % n % BMI Category Healthy weight c 14 60.8% 18 72% 32 66.6% Overweight 6 26.1% 3 12% 9 18.8% Obese 3 13.1% 4 16% 7 14.6% Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA = moderate/vigorous physical activity; MPA = moderate physical activity, VPA = vigorous physical activity; LPA = light physical activity; SED = sedentary activity; a Reported by mothers for eldest daughter only if more than one child enrolled; b n=19 (control); n= (21 intervention); N=40 (total); c Child grade 1 thinness included (n=2) 508
509
510
511
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Table 3: Baseline characteristics of Mothers randomized to the MADE4Life intervention and control group Control MADE4Life program Total Characteristics (n = 19) (n = 21) (n = 40) Mean (SD) Mean (SD) Mean (SD) Age (years) 39.53 5.26 38.71 4.41 39.10 4.79 Weight (kg) 73.99 15.2 74.63 14.16 74.33 14.47 Height (m) 164.58 6.78 163.98 4.01 164.27 5.44 BMI (kg/m²) 27.35 5.60 27.80 5.45 27.59 5.46 Waist [umb] (cm) 93.43 13.99 93.76 9.62 93.60 11.74 Systolic blood pressure (mmHg) 115 9 112 14 113 12 Diastolic blood pressure (mmHg) 76 7 74 11 75 10 Resting heart rate (BPM) 68 9 69 10 68 9 Fat mass % 34.93 8.42 36.61 6.73 35.81 7.53 Physical activity a Mean CPM 333.03 108.84 355.97 132.67 345.38 121.24 % time in MVPA 3.40 1.82 3.65 2.35 3.53 2.10 % time MPA 3.20 1.40 3.30 1.96 3.25 1.71 % time VPA 0.20 0.47 0.36 0.90 0.29 0.73 % time LPA 37.32 6.58 38.03 7.49 37.71 7.00 % time in SED 59.27 7.11 58.32 8.65 58.76 7.89 Godin Leisure Time (GLTEQ) Total Met Minutes exc mild 592.89 842.96 443.45 551.68 514.44 699.82 Sitting time (min) Work day b 358.81 172.85 529.21 194.77 451.31 201.69 Non-work day 324.74 125.18 345.95 186.95 335.88 158.97 Parenting for PAc,d Maternal role modelling 13.95 3.34 13.38 2.67 13.65 3.03 Maternal logistic support 9.32 2.08 10.14 1.42 9.75 1.79 Maternal beliefs 18.11 2.21 17.17 2.07 17.60 2.16 Maternal self-efficacy 16.95 2.27 17.52 1.94 17.25 2.10 Maternal support 14.00 3.51 13.48 1.89 13.73 2.75 Physical activity cognitionsc,e Self-efficacy 18.37 4.50 17.90 5.18 18.13 4.81 Outcomes expectations 14.42 1.12 13.33 2.03 13.85 1.73 Social support 3.42 1.42 3.38 1.32 3.40 1.35 Intention 4.53 0.61 4.80 0.40 4.67 0.52 n % n % n % BMI Category Healthy weight 7 36.8% 6 28.6% 13 32.5% Overweight 7 36.8% 8 31.1% 15 37.5% Obese 5 33.4% 7 33.4% 12 30% SESf 1-2 (lowest) 0 0% 0 0% 0 0% 3-4 1 2% 2 4% 3 3% 5-6 16 36% 17 35% 33 36% 7-8 28 62% 29 61% 57 61% 9-10 (highest) 0 0% 0 0% 0 0% Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA = moderate/vigorous physical activity; MPA = moderate physical activity, VPA = vigorous physical activity; LPA = light physical activity; SED = sedentary activity; a n=18 (control); n=21 (intervention) N=39; b n=16 (control); n=19 (intervention); N=35 (total); c mean score represented; d Range 1-4; e Range 1-5; f Socio-economic status by population decile for SEIFA Index of Relative Socioeconomic Advantage and Disadvantage. 512
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Table 4: Changes in outcome variables for daughters by treatment group from baseline to immediate post-intervention and 3-month post-intervention and differences in outcomes among the treatment groups at immediate post-intervention and 3-month post-intervention follow up (ITT analysis) (n= 48)
Treatment group Group * Time Effect Size Mean change from Baseline (95% CI) a (overall) Time point Outcome Control MADE4Life program Mean difference between groups P (Cohen’s d) (n =23 ) (n =25 ) (95% CI)a
Weight (kg) 1 0.88 (0.50, 1.27) 0.37 (-0.02, 0.76) -0.52 (-1.06, 0.03) -0.06 2 1.90 (1.38, 2.42) 1.69 (1.17, 2.22) -0.20 (-0.94, 0.54) 0.16 -0.02 BMI z-score 1 0.45 (-0.08, 0.17) -0.08 (-0.20, 0.05) -0.12 (-0.30, 0.06) -0.10 2 0.14 (0.02, 0.27) 0.08 (-0.05, 0.21) -0.06 (-0.24, 0.13) 0.39 -0.05 Waist z-score 1 0.17 (-0.03, 0.36) 0.34 (0.14, 0.54) 0.17 (-0.11, 0.45) 0.10 2 0.35 (0.16, 0.54) 0.42 (0.22, 0.61) 0.07 (-0.21, 0.34) 0.44 0.04 Systolic blood pressure (mmHg)b 1 -5.50 (-9.44, -1.56) -4.64 (-8.62, -0.66) 0.86 (-4.74, 6.46) 0.01 2 -8.02 (-11.56, -4.49) -3.84 (-7.60, -0.08) 4.18 (-0.98, 9.34) 0.24 0.40 Diastolic blood pressure (mmHg)b 1 -8.03 (-12.81, -3.24) -5.36 (-10.16, -0.56) 2.67 (-4.12, 9.46) 0.32 2 -9.25 (-12.49, -6.02) -6.50 (-9.83, -3.17) 2.75 (-1.90, 7.40) 0.49 0.33 Resting heart rate (BPM) 1 -7.50 (-15.47, 0.47) -5.43 (-13.36, 2.51) 2.07 (-9.17, 13.32) 0.17 2 -7.17 (-13.30, -1.05) -0.23 (-6.61, 6.15) 6.94 (-1.90, 15.78) 0.24 0.57 Fat mass (%) 1 0.34 (-0.30, 0.98) 0.74 (0.09, 1.40) 0.40 (-0.52, 1.32) 0.05 2 1.76 (0.90, 2.61) 3.23 (2.33, 4.14) 1.48 (0.23, 2.73) 0.07 0.19 Mean CPM b 1 111.39 (41.95, 180.83) 99.23 (28.08, 170.37) -12.17 (-111.58, 87.25) -0.09 2 45.72 (-20.39, 111.83) 75.92 (7.17, 144.68) 30.20 (-65.18, 125.58) 0.69 0.20 % time in SED b 1 -5.74 (-8.19, -3.29) -2.90 (-5.40, -0.40) 2.84 (-0.66, 6.34) 0.38 2 -4.28 (-6.35, -2.21) -1.56 (-3.70, 0.57) 2.72 (-0.25, 5.69) 0.14 0.36 % time in LPA b,c 1 4.84 (2.82, 6.85) 2.14 (0.09, 4.20) -2.69 (-5.57, 0.18) -0.46 2 3.99 (2.28, 5.70) 1.31 (-0.47, 3.07) -2.69 (-5.15, -0.22) 0.08 -0.46 % time in MPA b 1 0.58 (-0.06, 1.23) 0.63 (-0.00, 1.28) 0.05 (-0.87, 0.96) 0.04 2 0.35 (-0.013, 0.82) 0.11 (-0.38, 0.60) -0.24 (-0.92, 0.45) 0.73 -0.18 % time in VPA b 1 0.36 (-0.09, 0.81) 0.26 (-0.20, 0.72) -0.10 (-0.74, 0.54) -0.09 2 -0.05 (-0.05, 0.44) 0.16 (-0.34, 0.66) 0.21 (-0.49, 0.91) 0.67 0.18 % time in MVPA b 1 0.96 (-0.03, 1.95) 0.88 (-0.12, 1.88) -0.08 (-1.49, 1.33) -0.03 2 0.28 (-0.57, 1.13) 0.31 (-0.57, 1.19) 0.03 (-1.20, 1.25) 0.99 0.01 Daughters sitting time 7 day average (min/day) d 1 2.78 (-58.03, 63.60) -14.43 (-78.44, 49.58) -17.21 (-105.49, 71.07) -0.11 2 -27.59 (-100.27, 45.09) -25.81 (-99.76, 48.14) 1.78 (-101.90, 105.46) 0.87 0.01 Daughters mean screen time (min/day) d 1 -22.67 (-54.08, 8.74) -7.81 (-40.09, 24.48) 14.86 (-30.17, 59.89) 0.19 2 -24.00 (-51.92, 3.93) 2.99 (-25.76, 31.73) 26.98 (-13.09, 67.05) 0.40 0.34 Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; Time point 1 = immediate post-intervention Time point 2 = 3-month post-intervention; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA = moderate to vigorous physical activity; VPA = vigorous physical activity; MPA = moderate physical activity, LPA = light physical activity; SED = sedentary activity; a intervention minus control; b adjusted for AGE; c adjusted for SES; d reported by mother for eldest daughter if more than one child enrolled 513
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Table 5: Changes in outcome variables for mothers by treatment group from baseline to immediate post-intervention and 3-month post-intervention and differences in outcomes among the treatment groups at immediate post-intervention and 3-month post-intervention follow up (ITT analysis) (n= 40) Treatment group Group * Time Effect Size Mean change from Baseline (95% CI) a
Outcome Control MADE4Life program Mean difference between groups Time point P (Cohen’s d) (n =19) (n =23) (95% CI)a
Weight (kg) b 1 -0.49 (-1.48, 0.51) 0.45 (-0.57, 1.46) 0.93 (-0.49, 2.35) 0.06 2 0.17 (-0.10, 0.44) 0.49 (0.20, 0.77) 0.32 (-0.08, 0.71) 0.15 0.02 Waist [umb] (cm) b 1 -1.48 (-4.41, 1.46) 1.14 (-1.87, 4.15) 2.61 (-1.59, 6.82) 0.22 2 -0.57 (-2.41, 1.27) 0.95 (-0.96, 2.86) 1.52 (-1.13, 4.18) 0.40 0.13 BMI (kg/m2) 1 -0.04 (-0.55, 0.46) -0.17 (-0.69, 0.35) -0.13 (-0.85, 0.60) -0.02 2 -0.26 (-0.69, 0.18) 0.10 (0.36, -0.36.56) 0.36 (-0.28, 0.99) 0.34 0.07 Systolic blood pressure (mmHg) b 1 -4.35 (-8.45, -0.24) -2.59 (-6.79, 1.61) 1.76 (-4.11, 7.63) 0.14 2 -6.74 (-11.63, -1.85) -2.95 (-7.92, 2.01) 3.79 (-3.18, 10.76) 0.53 0.30 Diastolic blood pressure (mmHg) b 1 -4.50 (-7.80, -1.20) -2.15 (-5.51, 1.20) 2.34 (-2.36, 7.05) 0.23 2 -5.17 (-8.97, -1.37) -3.95 (-7.84, -0.06) 1.22 (-4.22, 6.66) 0.60 0.12 Resting heart rate (BPM) 1 -1.24 (-5.16, 2.69) -0.14 (-4.03, 3.76) 1.10 (-4.43, 6.63) 0.11 2 -1.94 (-5.03, 1.14) -1.82 (-5.09, 1.46) 0.13 (-4.37, 4.63) 0.91 0.01 Fat mass % b 1 -0.20 (-1.53, 1.14) -0.62 (-1.20, 0.75) -0.42 (-2.33, 1.49) -0.06 2 -0.90 (-2.38,0.59) 0.41 (-1.15, 1.98) 1.31 (-0.85, 3.47) 0.39 0.17 Mean CPMc 1 -7.07 (-47.39, 33.24) 16.75 (-20.92, 54.41) 23.82 (-31.35, 78.99) 0.20 2 -1.32 (-40.64, 38.00) -12.70 (-50.93, 25.52) -11.38 (-66.20, 43.45) 0.33 -0.09 % time in SEDc 1 0.36 (-2.20, 2.93) 0.91 (-1.50, 3.32) 0.54 (-2.97, 4.06) 0.07 2 -1.00 (-2.85, 2.66) -1.23 (-3.93, 1.51) -1.13 (-5.01, 2.75) 0.59 -0.14 % time in LPAc 1 -0.18 (-2.53, 2.18) -1.39 (-3.60, 0.84) -1.21 (-4.44, 2.03) -0.17 2 0.18 (-2.42, 2.78) 1.77 (-0.83, 4.38) 1.60 (-2.08, 5.28) 0.20 0.23 % time in MPAc 1 -0.19 (-0.88, 0.51) 0.20 (-0.44, 0.85) 0.39 (-0.56, 1.33) 0.23 2 -0.10 (-0.80, 0.61) -0.50 (-1.18, 0.19) -0.40 (-1.38, 0.58) 0.17 -0.23 % time in VPAc 1 0.04 (-0.15, 0.22) 0.22 (0.05, 0.39) 0.18 (-0.07, 0.43) 0.25 2 0.07 (-0.12, 0.25) -0.07 (-0.25, 0.11) -0.14 (-0.39, 0.12) 0.04 -0.19 % time in MVPAc 1 -0.14 (-0.93 0.65) 0.38(-0.35, 1.12) 0.53 (-0.55, 1.61) 0.25 2 -0.03 (-0.82, 0.76) -0.59 (-1.36, 0.18) -0.56 (-1.67, 0.54) 0.06 -0.27 Mothers sitting time work day (min/day) b 1 23.52 (-75.64, 122.67) -44.16 (-142.86, 54.54) -71.49 (-209.28, 66.27) -0.35 2 -53.32 (-228.23, 121.58) 71.30 (-111.60, 254.20) 124.62 (-128.44, 377.69) 0.24 0.62 Mothers siting time non-work day (min/day) 1 88.16 (-7.54, 183.86) -22.50 (-117.86, 72.86) -110.66 (-245.75, 24.43) -0.70 2 29.21 (-53.79, 112.22) 29.53 (-55.82, 114.89) 0.32 (-118.73, 119.38) 0.15 0.00 Mothers godin weekly met minutes_excMild 1 50.42 (-203.79, 304.64) 346.00 (90.61, 601.40) 295.58 (-64.76, 655.92) 0.42 2 71.33 (-302.95, 445.61) 438.76 (62.51, 815.01) 367.43 (-163.27, 898.13) 0.21 0.53 Parenting for PA Role modelling f 1 0.04 (-1.10, 1.19) 2.05 (0.89, 3.21) 2.00 (0.37, 3.63) 0.66 2 0.26 (-0.85, 1.38) 0.62 (-0.55, 1.79) 0.36 (-1.26, 1.97) 0.02 0.12 Parenting for PA beliefs f 1 0.32 (-0.73, 1.36) 1.06 (0.01, 2.11) 0.74 (-0.74, 2.23) 0.34 27
Mother-daughter physical activity intervention
2 0.21 (-0.78, 1.20) 1.17 (0.16, 2.19) 0.96 (-0.49, 2.38) 0.39 0.44 Parenting for PA Logistic Support f 1 -0.26 (-0.99, 0.47) -0.30 (-1.04, 0.45) -0.03 (-1.08, 1.01) -0.12 2 0.53 (-0.17, 1.22) 0.27 (-0.44, 0.99) -0.25 (-1.25, 0.74) 0.80 -0.14 Parenting for PA Self Efficacy e,f 1 0.53 (-0.54, 1.59) -0.42 (-1.49, 0.66) -0.94 (-2.46, 0.58) -0.45 2 -0.58 (-1.96, 0.80) -1.52 (-2.93, -0.11) -0.94 (-2.91, 1.04) 0.45 -0.45 Parenting for PA Support f 1 0.53 (-0.54, 1.60) -0.43 (-1.50, 0.65) 0.65 (-0.85, 2.16) 0.24 2 -0.58 (-1.96, 0.80) -1.54 (-2.96, -0.13) 0.96 (-2.94, 1.01) 0.43 0.35 (SCT) Self Efficacy 1 -1.74 (-4.10, 0.62) -0.41 (-2.78, 1.97) 1.33 (-2.01, 4.68) 0.28 2 -2.53 (-4.80, -0.29) -1.37 (-3.64, 0.89) 1.15 (-2.03, 4.33) 0.68 0.24 (SCT) Outcome Expectations d 1 -0.05 (-0.84, 0.74) -0.09 (-0.89, 0.72) -0.04 (-1.16, 1.09) -0.02 2 -0.68 (-1.99, 0.62) -1.22 (-2.54, 0.10) -0.54 (-2.39, 1.32) 0.83 -0.31 (SCT) Social Support b 1 -0.00 (-0.47, 0.47) -0.07 (-0.54, 0.41) -0.07 (-0.74, 0.61) -0.05 2 0.04 (-0.46, 0.53) 0.03 (-0.46, 0.54) -0.00 (-0.71, 0.71) 0.97 0.00 (SCT) Intention 1 0.16 (-0.41, 0.01) -0.24 (-0.49, 0.02) -0.08 (-0.44, 0.28) -0.15 2 -0.47 (-0.854, -0.09) -0.47 (-0.86, -0.08) 0.00 (-0.54, 0.55) 0.88 0.00 Abbreviations: MADE4Life = Mothers and Daughters Exercising for Life; kg = kilograms; Time point 1 = immediate post-intervention Time point 2 = 3-month post-intervention; BMI = body mass index; umb = umbilicus measurement; mmHg = millimetres of mercury; BPM = beats per minute; CPM = counts per minute; MVPA = moderate to vigorous physical activity; VPA = vigorous physical activity; MPA = moderate physical activity, LPA = light physical activity; SED = sedentary activity; a intervention minus control; b adjusted for BMI; c Intervention n=23, Control n=18; d adjusted for ses; e adjusted for age; f reported by mother for eldest daughter if more than one child enrolled 514
Table 6: Mothers’ process evaluation from the M.A.D.E 4 Life program Construct (n= number of items) Example of item Mean (SD) Quality of program a (n=4) The M.A.D.E 4 Life program was enjoyable 4.6 (0.5) The facilitators had a high level of knowledge and good Quality of facilitators a (n=4) 4.8 (0.4) communication skills PA session contentb (n=8) Rough & tumble play/Boxing/Pilates/Zumba 4.3 (0.2) The M.A.D.E 4 Life program had a positive impact on Impact on family members a (n=5) 3.7 (0.2) my families PA levels As a result of the M.A.D.E 4 Life program I spend more Behavior change a (n=3) 3.9 (0.1) time being active with my daughter The M.A.D.E 4 Life program taught me how to increase Program support a (n=2) 4.5 (0.1) my PA levels a 1=Strongly disagree to 5= Strongly agree; b 1=Really didn’t like to 5=Really liked;
PA = physical activity 515
28
Appendices
Appendix 3: SECONDARY PUBLICATION ‘THE ‘HEALTHY DADS, HEALTHY KIDS’ COMMUNITY RANDOMISED CONTROLLED TRIAL: A COMMUNITY-BASED HEALTHY LIFESTYLE PROGRAM FOR FATHERS AND THEIR CHILDREN’. PREVENTIVE MEDICINE
298 Appendices
Appendix 4: SECONDARY PUBLICATION ‘EFFICACY OF A WORKPLACE-BASED WEIGHT LOSS PROGRAM FOR OVERWEIGHT MALE SHIFT WORKERS: THE WORKPLACE POWER (PREVENTING OBESITY WITHOUT EATING LIKE A RABBIT) RANDOMIZED CONTROLLED TRIAL’. PREVENTIVE MEDICINE
309 Appendices
Appendix 5: SECONDARY PUBLICATION ‘THE IMPACT OF A WORKPLACE-BASED WEIGHT LOSS PROGRAM ON WORK-RELATED OUTCOMES IN OVERWEIGHT MALE SHIFT WORKERS’. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE.
319 Appendices
Appendix 6: MADE4LIFE RECRUITMENT FLYER
326
Are you a Mum who would like to participate in some fun physical activities such as ZUMBA, PILATES & FUN GAMES with your daughter?
Mothers and Daughters Exercising 4 Life is a physical activity program coming to your community. We are looking for Mums and Daughters to join in!
The program : Runs for 8 weeks after school and is 1 ½ hours per session Provide mums with the latest information about physical activity, fitness and health for them and their daughters Includes information about easy ways to help mums and their daughters have fun being active and getting fit together Teaches mums about how to be healthy role models for their daughters Allows mums and daughters to participate together in FUN physical activity sessions fun family activities and games such as Zumba, Pilates, Resistance Circuits and more!
Interested? For more information contact: Philip Morgan 4921 7265 or [email protected]
Appendices
Appendix 7: MADE4LIFE SCHOOL NEWSLETTER ENTRY
328
The M.A.D.E (Mothers and Daughters Exercising) 4 Life program comes to Newcastle!
Do you know a Mum who would like to participate in some fun physical activities such as ZUMBA, PILATES & FUN GAMES with her daughter? Tell her about the Mothers and Daughters Exercising for Life (M.A.D.E 4 Life) program. M.A.D.E 4 Life is for mums/step mums and primary school aged girls who would like to become fitter and have fun exercising together. M.A.D.E 4 Life teaches mums about how to be healthy role models for their daughters!
M.A.D.E 4 Life happens after school in the early evening. Mums and daughters come along for 8 weeks to ‘have A LOT of FUN, be active and spend quality time together’.
When: Term 3, 2011 Time: 4:00pm – 5:30pm 8 after-school sessions Where: University of Newcastle – HPE & The Forum Sports & Aquatic Centre
M.A.D.E 4 Life provides mums with the latest research about physical activity, fitness and health for them and their daughters. This program includes information about easy ways to help mums and their daughters have fun being active and getting fit together!
Show this to a mum you know and get her involved in M.A.D.E 4 Life. She can contact us at: Email: [email protected] Phone: 49216566 Appendices
Appendix 8: UNIVERSITY OF NEWCASTLE MEDIA RELEASE
330 MEDIA RELEASE Thursday 30 June 2011
Mothers and daughters team up to get fit
An Australian first study at the University of Newcastle will examine how mums can help their daughters to get more active by becoming more active themselves. MADE (Mothers And Daughters Exercising) 4 Life is a program designed to increase physical activity participation, fitness and health in both mothers and daughters by developing physical activity skills and confidence through fun activities performed together. “Previous studies have found that girls are less active than boys and women less active than men. We also know how important the mother is as a role model for her daughter, and this influence extends to the lifestyle a mother leads,” lead researcher Alyce Cook said. “There have been no Australian studies that focus on the mother-daughter combination to increase physical activity levels in the family. This research will test if the MADE 4 LIFE program is successful in improving the physical activity behaviours of mothers and daughters.” The after school community-based program will include a one and a half hour session per week over eight weeks. Researchers are inviting volunteers to participate in the study. The study will: • include the latest evidence and research about how active girls should be and strategies to increase their physical activity levels • include innovative ideas to help mums and their daughters have fun being active and getting fit together • allow mums and daughters to participate together in fun physical activity sessions including zumba, pilates, fun games, and resistance circuits. “It is important that parents and carers are armed with the appropriate knowledge and skills to teach their children about health. This study will examine whether a fun program made specifically for mothers and daughters helps them to become more active together.” MADE 4 Life joint researchers include Professor Philip Morgan, Professor Clare Collins and Professor Ron Plotnikoff from the Priority Research Centre in Physical Activity and Nutrition from the University of Newcastle. Newcastle and Hunter families interested in participating in the study can contact Alyce Cook on 02 4921 6566 or email [email protected].
Interview and photo opportunity: Alyce Cook is available for interview on 02 4921 6566 or 0409 075 779. A mother and daughter are available for a photo opportunity on request.
MEDIA AND PUBLIC RELATIONS I CARMEN SWADLING T + 61 2 4985 4276 F + 61 2 4921 6400 M 0428 038 477 E [email protected] Appendices
Appendix 9: MEDIA COVERAGE
332 HERALD NEWS Man, teen charged ‘Smear’ By NAOMI DAVIDSON
TWO men have been charged after an alleged break-in at a Clarence Town liquor store yester- day. A man walking past the cut cash store on Grey Street about 3am yesterday saw a num- ber of men carrying bot- tles of alcohol from it into a car parked nearby. Labor rang: developer Police officers spoke to a boy, 16, found in a car in A PUBLIC smear campaign Queen’s Street a short against a waterfront project on time later. Sydney’s northern beaches had He and a man, 18, both discouraged banks from lending from Newcastle, were to a developer, a company boss arrested and taken to has told a corruption hearing. Raymond Terrace police Eco Villages in late 2010 station. sought finance to buy the Cur- DISPUTE: The Currawong site They were charged ROLE MODEL: Study leader Alyce Cook, background, watches Narelle Eather work out rawong site at Pittwater from once owned by Unions NSW. with a number of offences yesterday with her daughters Emily, 8, and Chloe, 10. – Picture by Dean Osland Unions NSW and the deal was including aggravated meant to be have been com- had trouble securing finance break and enter. By JACQUI JONES Narelle Eather is already pleted by November last year. after a smear campaign. The man, 18, was getting active with daughters The Independent Commis- In early February, just days remanded and will BE it with an energetic gym Family ties Chloe, 10, and Emily, 8. sion Against Corruption (ICAC) after the land deal was com- appear in Maitland Local workout, hip-shaking aerobic The trio go running on the is investigating how the former pleted, LPMA chief executive Court today. dance moves or a strength beach, play netball and work NSW Labor government Warwick Watkins telephoned The youth, 16, was also and flexibility session, important out in the gym. bought the land in March from Mr Linz, offering to buy the land remanded and expected Newcastle researchers want ‘‘It’s fun,’’ Chloe said. Eco Villages, even though on behalf of the government. to appear in court yester- to get mothers and daughters ‘‘They get to try and beat caretaker conventions leading Mr Linz told the hearing his day. exercising. for fitness me,’’ Mrs Eather said. up to the March 26 state elec- company wanted $20 million ‘‘The reason I’m looking at Mrs Eather said the study tion banned governments from for the land. Mr Watkins was mums and daughters is activity decreases. would encourage women and entering into contracts. prepared to offer only between Road reopens because overall girls are ‘‘That’s another reason we girls to get active. The inquiry is examining $11 million and $12 million. less active than boys and thought we could target ‘‘Mums are always trying to why the Land and Property Eco Villages had incurred THUNDERBOLTS Way women are less active than mums and daughters to have do everything else around Management Authority (LPMA) hefty costs after taking Pitt- was reopened at Nowen- men,’’ MADE (Mothers and fun and spend quality time the house and forget about paid the developer $12.2 mil- water Council to the NSW doc, 50 kilometres north Daughters Exercising) 4 Life together and also get themselves,’’ she said. lion for land it had bought from Land and Environment Court. of Gloucester, yesterday. study leader Alyce Cook, of exercise.’’ ‘‘The kids need mum to say, Unions NSW only six weeks With the court case due to be The road had been the University of Newcastle, Researchers are seeking come and do it together.’’ earlier for $11 million. heard in June 2011, Mr Linz closed so that landslips said. participants for the after- The MADE project will Eco Villages director Allen took up the government’s land and fallen trees from last ‘‘There’s also evidence to school program, which will include 11⁄2-hour weekly Linz said its eventual deal with buy offer in March. month’s heavy rain and say as girls grow into begin soon. sessions over eight weeks. Unions NSW was postponed The hearing before ICAC flooding could be adolescence their physical Caves Beach resident Phone 4921 6566. from November 2010 until late Commissioner David Ipp con- cleared. January because his company tinues on Monday. AAP
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HERALD NEWS
NEXT week Lightening up for life Sharing a Australians falling short laugh is a on exercise LOAFING QUEENSLANDERS are health aid the laziest when it ABOUT comes to exercising, By JACQUI JONES while more than one in The rise of Health Reporter three Canberrans are getting their sourdough HUNTER researchers hope to recommended 30 hone their collective know- LIVING GREEN minutes a day. ledge in a new collaboration The Australian Bureau >> MONDAY aimed at inspiring mums, dads, of Statistics released its kids and students to fight the snapshot of physical battle of the bulge. fitness yesterday. The University of Newcastle The figures showed yesterday launched its Priority six out of 10 Australians Research Centre in Physical were not getting the Activity and Nutrition. recommended 30 The centre brings together minutes of exercise specialists from the fields of each day. education, nutrition, exercise The ACT had the physiology, public health and highest rate of people biomedical sciences. meeting the physical Co-director Ron Plotnikoff activity guidelines (37 said there was a public health per cent), while THE WRITE need to focus on physical activ- Queensland had the ity and nutrition. BOXING CLEVER: Taleisha Carter, 8, takes on mum Narelle. – Picture by Jonathan Carroll lowest at 28 per cent. STUFF The aim was to combat the Education and Meet our local rising burden of chronic dis- general practice and com- disease would be targeted. simple and fun activities income levels both ease, obesity and mental health munity settings. Co-director Philip Morgan together. influence exercise food bloggers problems. ‘‘Coming up with effective said three school and two com- Others were designed to help levels, the bureau said. ‘‘Because these behaviours programs that are going to work munity programs were under girls enjoy exercise. Fitness Australia GT >> WEDNESDAY are key factors to prevent these not only in the research envir- way, encouraging parents to be ‘‘Teenage girls are far less spokeswoman Lauretta health issues,’’ he said. onment, but in the real world,’’ good role models to their chil- active than teenage boys,’’ Pro- Stace said people Professor Plotnikoff said the he said. dren in exercise and eating fessor Morgan said. should start small and centre would undertake Groups such as children, habits. Another project built weight set aside 10 minutes a research and develop pro- adults, indigenous popula- Central to these programs loss programs for shift workers, day to go for a walk or a grams for school, workplace, tions or those with chronic was the enjoyment of doing tailored to their lifestyle. 20 minute cycle. AAP
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16 NEWCASTLE HERALD Saturday, September 10, 2011
Appendices
Appendix 10: PARTICIPANT TELEPHONE SCREEN
335 This participant telephone screener has been adapted from a Microsoft Excel spreadsheet
Read: Do you understand that you have a 50/50 chance of beginning the program immediately or in 6 months time?
How did you hear about study (Primary) Other?
How did you hear about study (other)
How did you hear about study (other)
Highest level of education
Are you currently employed? Full-time/part-time/casual
Mums Usual Occupation
Does your daughter attend primary school?
School daughter attends
Mums age
Daughter1 name Daughter 1 DOB Daughter1 age
Daughter2 name Daughter 2 DOB Daughter2 age
Does your daughter live with you?
Are you the biological mother?
Does your daughter have other siblings (brothers or sisters)
Sibling 1 Sex Sibling1 DOB Sibling1 age
Sibling 2 Sex Sibling2 DOB Sibling2 age
Read - "To participate in the program you and your daughter/s will be required to attend an assessment session where baseline measures of height, weight, waist circumference, body composition, blood pressure, & physical activity levels of yourself and your daughter will be taken. Following this you will be invited to attend 8 sessions of the M.A.D.E 4 Life program. We will ask you to bring your daughter/s to all 8 of these sessions. Are you agreeable to this?"
Read: “To participate in the program you and your daughter/s will be required to attend 8 sessions between July, August and September on Mondays 4.00-5.30pm at the University of Newcastle; Health & Physical Education Building & The Forum Sports & Aquatic Centre. Are you available to attend the study on these days?”
Read: “Assessment days will be held on the weeks beginning (Mon 18th July, Monday 19th September & Monday 5th December from 3:30pm - 6:30pm). Will you and your daughter/s be available during these periods?”
Are you pregnant?
Do you have heart disease? (diagnosed in past 5 years)
Orthopaedic or joint problems? If so what? Diabetes? Type?
Asthma?
Any other diseases?
Does your daughter have heart disease? (diagnosed in past 5 years)
Does your daughter have orthopaedic or joint problems? If so what?
Does your daughter have diabetes? Type?
Does your daughter have asthma?
Does your daughter have any other diseases?
Are you currently involved in a physical activity program? PA program
Do you currently administer medications that might be affected by weight loss? If yes -what?
Is there any other physical reason or medical condition that could prevent you or your daughter from undertaking physical activity or that you are concerned about? If yes -what?
Address Surburb Postcode State Email Home phone Mobile number Work phone
Best time to contact?
Read: We will be sending you an information pack which includes an information statement, consent form and a pre-exercise screening questionnaire. The sooner these forms are completed and returned, the greater your chance of gaining a place in the study. Once these are received, we will call you to arrange a convenient time for you and your daughter to attend pre-program screening.
Read: Would you prefer to be sent screening documents via email or post?
Read: If you have any friends that you think would like to participate in the program, please feel free to pass on our contact details. Would it be appropriate if we sent you a flyer to place on a notice board or on the lunch room table at work?
Address to use for work flyer? Appendices
Appendix 11: SPORTS MEDICINE AUSTRALIA PRE EXERCISE SCREENING QUESTIONNAIRE
338 Pre-exercise Screening Questionnaire
Name Date
Age (yrs) Gender M F
Height (cm) Weight (kg)
Occupation
PART 1
Have you ever had a heart attack or coronary revascularisation surgery? No Yes Have you ever had a stroke? No Yes Has your doctor ever told you that you have heart trouble or vascular No Yes disease? Has your doctor ever told you that you have a heart murmur? No Yes Do you suffer from pains in your chest, especially when you exercise? No Yes Do you ever get pains in your calves, buttocks or the backs of your legs No Yes during exercise, which are not due to soreness or stiffness? Do you ever feel faint or have spells of severe dizziness, particularly with No Yes exercise? Do you experience swelling or accumulation of fluid around the ankles? No Yes Do you ever get the feeling that your heart is suddenly beating faster, No Yes racing or skipping beats, either at rest or during exercise? Do you have chronic obstructive pulmonary disease, interstitial lung No Yes disease or cystic fibrosis? Have you ever had an attack of shortness of breath, which developed when No Yes you were not doing anything strenuous, in the last 12 months? Have you ever had an attack of shortness of breath, which developed No Yes after you stopped exercising, at any time in the last 12 months? Do you have diabetes (Type I or Type II)? No Yes If YES, do you have trouble controlling your diabetes? Do you have any ulcerated wounds or cuts on your feet that don’t seem to No Yes heal? Do you have any liver, kidney or thyroid disorders? No Yes Do you experience unusual fatigue or shortness of breath with usual No Yes activities? Is there any other physical reason or medical condition that could prevent No Yes you from undertaking exercise or that you are concerned about?
PART 2
Do you smoke tobacco or cannabis regularly OR have you quit No Yes smoking in the last 6 months? Do you have a close male relative (father, son, brother) who has No Yes Don’t had a heart attack, coronary bypass surgery or died suddenly due know to a heart attack before the age of 55 years? Do you have a close female relative (mother, daughter, sister) who No Yes Don’t has had a heart attack, coronary bypass surgery or died suddenly know due to a heart attack before the age of 65 years? Do you have impaired fasting blood glucose? No Yes Don’t know Do you have high resting blood pressure or do you take medication No Yes Don’t for blood pressure? know Do you have high serum cholesterol or low HDL levels or take lipid- No Yes Don’t lowering medication? know Do you have an occupation where you sit for long periods of time? No Yes Do you do LESS than 150 minutes of moderate physical activity per No Yes week?
PART 3
Do you currently use any medication for asthma? No Yes
Do you have any other medical condition that the people conducting this No Yes study need to be aware of for your safety during physical activity? If yes, please provide details below
Other medical conditions:
Developed from: Sports Medicine Australia (SMA) pre-exercise screening system 2005 Australian Government Department of Health and Ageing www.sma.org.au Appendices
Appendix 12: UNIVERSITY OF NEWCASTLE HUMAN RESEARCH ETHICS COMMITTEE (HREC) APPROVAL
341 HUMAN RESEARCH ETHICS COMMITTEE
Notification of Expedited Approval
To Chief Investigator or Project Supervisor: Associate Professor Philip Morgan Cc Co-investigators / Research Students: Professor Ronald Plotnikoff Professor Clare Collins Miss Alyce Cook Re Protocol: The M.A.D.E (Mothers and Daughters Exercising) 4 LIFE Pilot Randomised Control Trial: A theory-based physical activity intervention targeting mothers and their daughters. Date: 14-Apr-2011 Reference No: H-2011-0054 Date of Initial Approval: 13-Apr-2011
Thank you for your Response to Conditional Approval submission to the Human Research Ethics Committee (HREC) seeking approval in relation to the above protocol.
Your submission was considered under Expedited review by the Chair/Deputy Chair.
I am pleased to advise that the decision on your submission is Approved effective 13-Apr-2011.
In approving this protocol, the Human Research Ethics Committee (HREC) is of the opinion that the project complies with the provisions contained in the National Statement on Ethical Conduct in Human Research, 2007, and the requirements within this University relating to human research.
Approval will remain valid subject to the submission, and satisfactory assessment, of annual progress reports. If the approval of an External HREC has been "noted" the approval period is as determined by that HREC.
The full Committee will be asked to ratify this decision at its next scheduled meeting. A formal Certificate of Approval will be available upon request. Your approval number is H-2011-0054.
If the research requires the use of an Information Statement, ensure this number is inserted at the relevant point in the Complaints paragraph prior to distribution to potential participants You may then proceed with the research.
Conditions of Approval
file:///E|/PhD/Ethics Application/Approval 2011.htm[12/07/2014 11:53:24 AM] This approval has been granted subject to you complying with the requirements for Monitoring of Progress, Reporting of Adverse Events, and Variations to the Approved Protocol as detailed below.
PLEASE NOTE: In the case where the HREC has "noted" the approval of an External HREC, progress reports and reports of adverse events are to be submitted to the External HREC only. In the case of Variations to the approved protocol, or a Renewal of approval, you will apply to the External HREC for approval in the first instance and then Register that approval with the University's HREC.
Monitoring of Progress
Other than above, the University is obliged to monitor the progress of research projects involving human participants to ensure that they are conducted according to the protocol as approved by the HREC. A progress report is required on an annual basis. Continuation of your HREC approval for this project is conditional upon receipt, and satisfactory assessment, of annual progress reports. You will be advised when a report is due.
Reporting of Adverse Events
1. It is the responsibility of the person first named on this Approval Advice to report adverse events. 2. Adverse events, however minor, must be recorded by the investigator as observed by the investigator or as volunteered by a participant in the research. Full details are to be documented, whether or not the investigator, or his/her deputies, consider the event to be related to the research substance or procedure. 3. Serious or unforeseen adverse events that occur during the research or within six (6) months of completion of the research, must be reported by the person first named on the Approval Advice to the (HREC) by way of the Adverse Event Report form within 72 hours of the occurrence of the event or the investigator receiving advice of the event. 4. Serious adverse events are defined as: Causing death, life threatening or serious disability. Causing or prolonging hospitalisation. Overdoses, cancers, congenital abnormalities, tissue damage, whether or not they are judged to be caused by the investigational agent or procedure. Causing psycho-social and/or financial harm. This covers everything from perceived invasion of privacy, breach of confidentiality, or the diminution of social reputation, to the creation of psychological fears and trauma. Any other event which might affect the continued ethical acceptability of the project.
5. Reports of adverse events must include: Participant's study identification number; date of birth; date of entry into the study; treatment arm (if applicable); date of event; details of event; the investigator's opinion as to whether the event is related to the research procedures; and action taken in response to the event.
6. Adverse events which do not fall within the definition of serious or unexpected, including those reported from other sites involved in the research, are to be reported in detail at the time of the annual progress report to the HREC.
Variations to approved protocol
If you wish to change, or deviate from, the approved protocol, you will need to submit an Application for Variation to Approved Human Research. Variations may include, but are not limited to, changes or additions to investigators, study design, study population, number of participants, methods of recruitment, or participant information/consent documentation. Variations must be approved by the (HREC) before they are implemented except when Registering an approval of a variation from an external HREC which has been designated the lead HREC, in which case you may file:///E|/PhD/Ethics Application/Approval 2011.htm[12/07/2014 11:53:24 AM] proceed as soon as you receive an acknowledgement of your Registration.
Linkage of ethics approval to a new Grant
HREC approvals cannot be assigned to a new grant or award (ie those that were not identified on the application for ethics approval) without confirmation of the approval from the Human Research Ethics Officer on behalf of the HREC.
Best wishes for a successful project.
Professor Alison Ferguson Chair, Human Research Ethics Committee
For communications and enquiries: Human Research Ethics Administration
Research Services Research Integrity Unit HA148, Hunter Building The University of Newcastle Callaghan NSW 2308 T +61 2 492 18999 F +61 2 492 17164 [email protected]
Linked University of Newcastle administered funding:
Funding body Funding project title First named investigator Grant Ref
file:///E|/PhD/Ethics Application/Approval 2011.htm[12/07/2014 11:53:24 AM] Appendices
Appendix 13: PARTICIPANT INFORMATION STATEMENT AND CONSENT FORMS
345 M.A.D.E 4 Life – Information sheet and Consent form
Professor Philip Morgan School of Education Faculty of Education and Arts University of Newcastle Callaghan NSW 2308 4921 7265 (PH) 4921 7407 (Fax) [email protected]
Information Statement for the Research Project:
The ‘M.A.D.E (Mothers and Daughters Exercising) 4 Life’ Project
Document Version 4: dated 20/06/2011 You and your daughter/s are invited to participate in the research project identified above which is being conducted by the following researchers; Professor Philip Morgan, Professor Clare Collins and Professor Ron Plotnikoff and Miss Alyce Cook from the University of Newcastle. This project is part of the research studies of Miss Alyce Cook who is supervised by Prof Morgan, Prof Plotnikoff and Prof Collins.
Why is the research being done?
Our research group is developing programs to help women and girls participate in regular physical activity. The major aim of this project is to evaluate the effectiveness of a program designed to increase physical activity participation, and to improve self efficacy, health and lifestyle behaviours in both mothers and their daughters. M.A.D.E 4 Life program is specifically designed to unite mothers and daughters in a fun, educational setting where both parties can experience positive behaviour change the improvements in self-efficacy and overall health and wellbeing.
A secondary aim of our project is to determine whether having a mother participate in a physical activity program has an effect on their daughters health and lifestyle behaviours. Parents influence the physical activity behaviours in the home environment through their behaviours, attitudes, and approach to physical activity and by being a role model. Parents of primary school children, in particular, play a pivotal role in changing a child’s environment to facilitate healthy physical activity behaviours.
Who can participate in the research?
You can participate in this project if you are: Female Aged 21-60 years Have a daughter aged 5 to 12 years (primary school age) Wanting to increase your physical activity levels Able to pass a health-screening questionnaire Available for assessment and intervention sessions (see below for details) You will not be eligible to participate if you have: a history of major medical problems such as heart disease or diabetes orthopaedic or joint problems that would be a barrier to completing physical activities such as walking a daughter who is extensively involved in competitive sport are pregnant
Page 1 of 5
M.A.D.E 4 Life – Information sheet and Consent form
What choice do you have? Participation in this research is entirely your choice. You will only be included in the project if you have given your informed consent. If you do decide to participate, you may withdraw from the project at any time without giving a reason. This decision will not disadvantage you in any way.
What would you be asked to do? M.A.D.E 4 Life will run twice; in Term 3, 2011 and in Term 1, 2012. If you agree to participate in the study, you will be randomly allocated to one of these groups:
(i) the ‘Mothers and Daughters Exercising for Life (M.A.D.E 4 Life)’ Program in Term 3, 2011 or (ii) a group that commences in Term 1, 2012
You will have an equal chance of allocation to each group but we cannot place you in the group of your choice. If you are randomised to the M.A.D.E 4 Life program you and your daughter/s will be required to complete the following:
(a) Attend eight information and physical activity sessions held during Term 3, 2011 during after- school hours on a Monday at the University of Newcastle; Health & Physical Education Building and The Forum Sports & Aquatic Centre (mothers and daughters attend all 8 sessions). (b) A range of measurements taken on 3 occasions: at the beginning of the study, after 10-weeks and 20-weeks (see below). (c) Give your permission for photographs taken during the program to be used in the preparation of future training materials and promotional material. Participants will be shown photographs to seek approval to use them prior to researchers using them for research purposes. (see consent form)
If you are randomised to the waiting list control group, you and your daughter/s will be required to complete the same assessment sessions at the beginning of the study and then after 10 and 20-weeks. The information sessions will then be delivered in early 2012 and you and your daughter/s will be invited to attend these.
Table 1: Assessment items and method of measurement
Mothers Daughters Demographics – Background Demographics – Background questionnaire questionnaire Height – using a portable Height – using a portable stadiometer stadiometer Weight – using a calibrated Weight – using a calibrated scale scale Waist circumference – using Waist circumference – using non-extensible steel tapes non-extensible steel tapes Body composition – using the Body composition – using the InBody720 body composition InBody720 composition analysis analysis Blood Pressure - using an Blood Pressure - using an automated blood pressure automated blood pressure monitor monitor Physical activity intensity –an Physical activity intensity –an accelerometer is worn for 7 accelerometer is worn for 7 consecutive days consecutive days Physical activity beliefs Sitting time questionnaire – questionnaire completed by mother for their Sitting time questionnaire – daughter adults Girls perception of physical Parenting Questionnaire activity – answered verbally by daughter An accelerometer is a small device that is worn around the waistband and is used to measure exercise intensity.
Page 2 of 5
M.A.D.E 4 Life – Information sheet and Consent form
Mothers and Daughters Exercising (M.A.D.E) 4 Life Program
There are eight sessions that you and your daughter will attend. Sessions will be delivered by student researcher Miss Alyce Cook who is a fully qualified PD/H/PE teacher, having completed her Bachelor of Teaching/Bachelor of Health and Physical Education at the University of Newcastle in 2008. Miss Cook has taught as a specialist PD/H/PE teacher in a Primary school and is qualified and experienced in physical education. Each session will last approximately 90 minutes. The sessions will involve educational information and physical activity fun. The information sessions will focus on physical activity and behaviours to support and achieve physical activity and fitness goals for mothers and promote physical activity and healthy lifestyles for their daughters. The physical activity sessions will involve the mother and daughter engaging in a variety of fun physical activities. A healthy afternoon tea will be provided at the beginning of each of the eight sessions for mothers and their daughters.
Session 1: The importance of mothers and physical activity, Games using innovative teaching strategies Session 2: The importance of raising physically active daughters Zumba dance fitness Session 3: Role modelling mothers, Pilates and yoga Session 4: Successful mother and daughter teams, Resistance training fun Session 5: Fundamentals for Women, Muscular and cardiovascular fitness Session 6: Healthy lifestyles, Skipping with ropes Session 7: Active families, Rough and tumble play Session 8: Sustainable change, The amazing race
How much time will it take?
Each assessment session should take approximately 30-40 minutes to complete. You will be able to select a day and time that suits your schedule and you will be given a $10 voucher valid at a national supermarket chain to cover any travel or parking costs. Each M.A.D.E 4 Life session will take 90 minutes
What are the risks and benefits of participating?
The program aims to help you achieve increased physical activity levels to reduce the risks associated with several physical and psychological health issues such as unhealthy weight gain leading to overweight and obesity, cardiovascular disease, diabetes, depression and low beliefs about your confidence. The study is designed to give you skills and knowledge to increase levels of physical activity, which can, in turn, be passed onto your daughter/s to improve their lifestyle habits, which it is hoped will have a long-term benefit on their health and wellbeing. The program does involve you and your daughter participating in physical activity, some of which may be moderate-to-vigorous in intensity for a short period of time. As such there are some risks such as asthma or bronchoconstriction, joint and muscular discomfort and elevated blood pressure. The structure of the physical activity program will minimise these risks by including appropriate warm-up, cool-down and stretching activities, and providing frequent rest and drink breaks. In the demographics questionnaire you are asked to provide information including your income, education and marital status. If in the unlikely event that you find this nature of the question distressing you do not have to answer this particular question. If you injure yourself during the physical activity sessions, first aid will be provided. If the injury is severe, we will recommend you contact your local Doctor or nearest hospital: John Hunter Hospital (02) 4921 3000. If you are allocated to the intervention group, you will be provided full access to the program in Term 3, 2011. If you are allocated to the control group you will be provided with access to the full program offered in Term 1, 2012.
Page 3 of 5
M.A.D.E 4 Life – Information sheet and Consent form
How will your privacy be protected?
Initially, all personal information data will be stored in a locked filing cabinet in the chief investigator’s office to ensure its security and the confidentiality of any identified data. Only the student researcher and the chief investigators will have access to the raw data. The student researcher will then enter raw data into a statistics program. As there is a need to be able to identify individual data as it is collected due to multiple data entry points, the identifiers will be removed and replaced with a code. Data used for analysis will be de-identified before entry into a statistical program. Once the information is entered on the data file, all paper data records will be shredded and no person will be identifiable in the data files or in any published report. The results of the study will be published in general terms and will not allow the identification of individuals. The data file will be kept for at least five years beyond the completion of the project.
How will the information collected be used?
The results of the research will be reported and disseminated via national and international conferences and scientific publications. You will not be identified in any reports arising from the study. At the conclusion of the study, you will receive an email from the chief investigator summarising the results of the study.
What do you need to do to participate?
Please read this Information Statement carefully and be sure you understand its contents. Please also discuss the project with your daughter to ensure they are willing to participate and understand they can withdraw from the project at any time and do not need to give any reason for withdrawing. If there is anything you do not understand, or you have questions, contact Associate Professor Philip Morgan (details below). If you and your daughter are willing to participate in this study, please complete the accompanying consent form and return it to the researchers in the reply paid envelope provided. You will then be contacted to confirm which group you are in and when the assessments session will be.
Further information - If you would like further information please contact:
- Professor Philip Morgan on 4921 7265 or [email protected]
Thank you for considering this invitation.
______
Philip Morgan Clare Collins Ron Plotnikoff Alyce Cook Prof Philip Morgan Prof Clare Collins Prof Ron Plotnikoff Alyce Cook Faculty of Education & Arts Faculty of Health Faculty of Education & Arts Faculty of Education & Arts School of Education School of Health School of Education School of Education University of Newcastle University of Newcastle University of Newcastle University of Newcastle Phone: (02) 4921 7265 Phone: (02) 4921 5646 Phone: (02) 4985 4465 Phone: (02) 49 216566 [email protected] [email protected] [email protected] [email protected]
Complaints about this research This project has been approved by the University’s Human Research Ethics Committee, Approval No H-2011-0054 Should you have concerns about your rights as a participant in this research, or you have a complaint about the manner in which the research is conducted, it may be given to the researcher, or, if an independent person is preferred, to the Human Research Ethics Officer, Research Office, The Chancellery, The University of Newcastle, University Drive, Callaghan NSW 2308, Australia, telephone (02) 49216333, email [email protected].
Page 4 of 5 M.A.D.E 4 Life – Information sheet and Consent form
Professor Philip Morgan School of Education Faculty of Education and Arts University of Newcastle Callaghan NSW 2308 4921 7265 (PH) 4921 7407 (Fax) [email protected]
Consent Form for the Research Project: The ‘M.A.D.E (Mothers and Daughters Exercising) 4 Life’ Project Professor Philip Morgan, Professor Clare Collins and Professor Ron Plotnikoff and Miss Alyce Cook from the University of Newcastle.
I have discussed the project described above with my daughter and we give our consent to participate in the project. We understand that the project will be conducted as described in the Information Statement, a copy of which I have retained. We understand that we can withdraw from the project at any time and do not need to give any reason for withdrawing. I consent to completing the measurements outlined in the Information Statement; attending eight information sessions with my daughter/s. YES NO
I further consent to photographs of myself and my daughter being used to promote M.A.D.E 4 Life (Participants will be shown photographs to seek approval to use them prior to researchers using them for research purposes).
YES NO
I understand that my personal information will remain confidential to the researchers and that data collected from my participation will be used in journal publications and conference presentations. If I decide not to participate or withdraw from the study, it will not affect my relationship with the University of Newcastle. I have had the opportunity to have questions answered to my satisfaction. By signing below I am indicating my consent and that of my child to participate in the research project.
Your name: ______
Your daughter/s name: ______
Signature: ______
Date: ______
Contact Details: Phone (Home) ______(Mobile)______
E-mail ______
Best time to contact: ______
Please return the completed consent in the prepaid envelope enclosed.
Page 5 of 5 Appendices
Appendix 14: PARTICIPANT RANDOMISATION OUTCOME LETTER
351
WHERE TO FROM HERE?
1. You and your daughter/s have been allocated to the group that starts the M.A.D.E 4 Life Program immediately
2. We ask that you and your daughter/s complete your 7 day accelerometer assessment from tomorrow and return the accelerometer & log sheet to the M.A.D.E 4 Life drop box (in the corridor) in the Health & Physical Education Building on day 8.
3. Follow up assessments with be around the 19th September and 5th December. I’ll provide further information during the M.A.D.E 4 Life sessions
4. You and your daughter/s will begin the program from next Monday 25th July at 4:00pm-5:30pm.
Sessions continue each Monday at 4:00pm-5:30pm for 8 weeks with the final session on Monday 12th September. What to wear: Please come dressed in comfortable exercise clothes, with enclosed shoes and don’t forget to bring a drink bottle to keep hydrated during the physical activity sessions. Where to meet: Health & Physical Education Building in Room HPE 2.02. Please ensure you and your daughter/s arrive before 4:00pm as we will be starting the sessions right on 4:00pm.
If you have any questions, please contact: Alyce Cook on 4921 6566
WHERE TO FROM HERE?
You and your daughter/s have been allocated to the group that begins the M.A.D.E 4 Life Program in 6 months time Regardless of the delay in starting your program, we ask that you continue to participate in the research components of the study. These are: o Please complete your 7 day accelerometer assessment from tomorrow and return the accelerometer & log sheet to the M.A.D.E 4 Life drop box (in the corridor) in the HPE building on day 8. o Your 10-week re-assessment will be around the 19th of September o Your 20-weeks re-assessment will be around the 5th of December We will contact you prior to re-assessments to book you and your daughter in at a convenient time On Mondays during Term 1, 2012 you will commence the M.A.D.E 4 Life Program and will receive all materials and support Meanwhile, please continue on with your usual lifestyle, without changing anything
If you have any questions, please contact: Alyce Cook on 4921 6566
Appendices
Appendix 15: DAUGHTERS’ BOOKLET/WEEKLY WORKSHEETS
354 SESSION ONE Draw a picture of a FUN activity you would like to do at M.A.D.E 4 Life with your MUM
WHY SHOULD WE BE ACTIVE? SESSION TWO
Children should participate in at least ______minutes
(and up to several hours) of ______- to ______- intensity physical activity ______.
List 5 ways you can be active with your mum 1. ______2. ______3. ______4. ______5. ______
1. Cardio-respiratory fitness
2. Muscular fitness
3. Flexibility
SESSION THREE
Key □ □ □ □ □ □
______should not spend more than ______hours per day using electronic media for entertainment
(e.g.______) particularly during daylight hours
______
______
______
______
______
______SESSION FOUR
Create a map of the FMS skills and in the middle draw your favourite skill.
SESSION FIVE
Create a game that you will play with MUM to be active! REMEMBER …. It’s your game pick a theme that YOU like!
Name of game: ______Theme: ______Equipment: ______Rules: ______
Skills you use: ______
Where you can play: ______
Time played: ______
On the next page draw a picture of what your game looks like
SESSION SIX
Brainstorm ways you and your family can be MORE active before school, during school, after school, on weekends and holidays.
Design a poster advertisement to influence girls and their MUMS to participate in physical activity. SESSION SEVEN In your workgroups, brainstorm as many ways you can help the characters be MORE active! SCENARIOS … 1. Couch Potato If you were Hayley, what could you do to be more active?? ______
______2. Rainy weekend If you were Katie and Billy, what could you do to be more active?? ______
3. Busy MUM What could you do if you were Ali to be more active with her mum?? ______Appendices
Appendix 16: DAUGHTERS’ PINK SLIP TASKS
367 PiNK SLiP ACTIVITY WEEK ONE
Choose two of your favourite games from Session 1 and play them for 15 minutes with MUM. (e.g. Knee taps, tootsies, Chinese wrestle, mirrors, steal the tail, dodge walk) Choose a favourite song and create a ‘follow the leader’ dance with MUM. Write down the name of your favourite song here.
Favourite song:______
PiNK SLiP ACTIVITY WEEK TWO
Complete a home based fitness circuit twice this week to music. Create a 5 station circuit, spend 3 minutes at each station and perform 2 laps of your circuit. (e.g. squats, lunges, funky dance move, running man, skipping, jumping jacks, push ups, triceps dips, crunches)
Wear your pedometer for 4 days this week. Record your pedometer steps on your chart.
MUMS set 3 SMART Goals (2 for you, 1 for your Daughter/s).
PiNK SLiP ACTIVITY WEEK THREE
Perform 4 yoga/pilates poses and perform your signature dance move when you swap between poses. (bridge, toe taps, happy/angry cat, downward dog, child pose, swimming, box balance) Wear your pedometer and go for a 30 minute powerwalk with MUM. Record your pedometer steps on your chart. Complete a home based abdominal fitness circuit twice this week to music. Create a 5 station circuit, spend 3 minutes at each station and perform 2 laps of your circuit. (e.g. crunches passing a ball/balloon, twists holding ball/balloon, football pass with ball/balloon, static hold with ball/balloon, arm extensions with ball/balloon )
PiNK SLiP ACTIVITY WEEK FOUR
Perform 4 yoga/pilates poses and perform your signature dance move when you swap between poses. (warrior, tree, happy/angry cat, downward dog, child pose, swimming, box balance) Wear your pedometer 4 days this week and record your pedometer steps on your chart.
Challenge MUM to playing 3 wrestling games this week. (You’re so strong, Chinese wrestle, push up tips, arm pull, stand challenge, shoulder slaps, itchy fingers).
PiNK SLiP ACTIVITY WEEK FIVE
Use the Family ACTIVation pack twice this week for 30 minutes each time.
Wear your pedometer 4 days this week and record your pedometer steps on your chart.
Go for a powerwalk with your MUM and focus on increasing your VPA (vigorous physical activity) for 10 minutes. (e.g. run up sets of stairs, play chase games, step ups, hill walk/run) Take your heart rate at the end of the 10 minutes and write it on your session print out.
PiNK SLiP ACTIVITY WEEK SIX
Complete a home based skipping circuit twice this week to music (using the skipping rope). Create a
5 station circuit, spend 40 seconds at each station and perform 2 laps of your circuit.
(double bounce, backward jump, skier, bell, twist, scissors, side swing, toe-to-toe, heel-to-heel, criss cross, straddle, can-can, peek-a-boo)
Wear your pedometer 4 days this week and record your pedometer steps on your chart.
Have a 40 second on the spot skipping challenge against MUM to increase your VPA (vigorous physical activity) everyday this week. Take it in turns with mum to compare your pedometer steps after each 30 second interval.
PiNK SLiP ACTIVITY WEEK SEVEN
Complete your own backyard games session twice this week. Choose your favourite games and play for 20
minutes with your whole family/neighbours/friends. (tails, pizza tag, rats & rabbits, beat the ball, numbers, french cricket, golden
child, rounders)
Wear your pedometer 4 days this week and record your pedometer steps on your chart.
Put your favourite music on and play musical skipping on the spot or moving around. When the music stops FREEZE! Continue playing for the duration of the song. Take it in turns with mum to start & stop the music. Compare your pedometer steps after each song.
MUMS set 3 SMART Goals (2 for you, 1 for your Daughter/s).
Appendices
Appendix 17: MADE4LIFE STICKER CHART
371 PiNK SLiP chart
NaME: ______Appendices
Appendix 18: DAUGHTERS’ CARD
373 M.A.D.E 4 YOU WITH SMILES & HAPPINESS BY ...... Hey MUM! I had a fantastic time with you at M.A.D.E 4 Life. The thing I liked best was …………………...... ………………………………………….. ……………...... Things to keep doing with MUM: 1.
2.
3.
Appendices
Appendix 19: MADE4LIFE CERTIFICATE
376 presents
Certificate of Participation presented to
for involvement in the Mothers and Daughters Exercising for Life program
______Alyce Cook Professor Philip Morgan M.A.D.E 4 Life Facilitator Co-Director of Priority Research Centre for Physical Activity & Nutrition University of Newcastle University of Newcastle Appendices
Appendix 20: MOTHERS’ MANUAL
378
Appendices
Appendix 21: MOTHERS’ SMART GOAL SETTING SHEETS
380 YOUR SMART GOALS Achieved? Goals Weeks 1-3 (please tick)
Goal 1:
Goal 2:
Daughter Goal:
RE WARD
Goals Weeks 4-6
Goal 1:
Goal 2:
Daughter Goal:
REWARD
Goals Weeks 7-9
2nd Month Goals Goal 1:
Goal 2:
Daughter Goal:
REWARD
Appendices
Appendix 22: MOTHERS’ PEDOMETER CHART
382 DAILY PEDOMETER RECORD CHART
No. of No. of No. of No. of Week Average steps/day steps/day steps/day steps/day
8425 7291 5893 9732 7835 Example 1
2
3
4
5
6
7
8
Remember:
1) Calculate the average step count over 4 days:
2) Plot the average on the at the appropriate week
WEEKLY STEP COUNT CHART
1 2 3 4 5 6 7 8 9 10 11 12
WEEK 1 2 3 4 5 6 7 8
WEEK
Appendices
Appendix 23: MADE4LIFE PATHWAYS AND POSSIBILITIES RESOURCE
385
WHERE YOU CAN FIND PHYSICAL ACTIVITIES IN YOUR COMMUNITY FOR YOU AND YOUR DAUGHTER! This pathways document has been created for M.A.D.E 4 Life participants to continue being physically active!
Activities you will find in this totally RAD resource: Walking paths, cycling and scooting tracks Parks & playgrounds Zumba & Dance centres Pilates & Yoga Family fun activities SPORTS Workout DVDs
Use this totally RAD resource for both you and your daughter to find activities to do together, and with your whole family!
Remember; think of movement as an opportunity, not an inconvenience children should aim for at least 60-90 minutes of moderate to vigorous physical activity (MVPA) everyday adults should aim for a minimum of 30mins to 60 minutes of MVPA everyday
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WHAT WHERE WHO WEB LINK Bathers way Nobbys Mums & http://www.newcastle.nsw.gov.au/recreation/walks_and_cycling/walking_tracks Headland to Daughters Glenrock Reserve (5 km coastal walk) Blackbutt Approximately Mums & http://www.newcastle.nsw.gov.au/recreation/blackbutt_reserve Reserve 10km of Daughters scenic walking trails Fernleigh Approximately Mums & http://svc066.bookeasy.com/images/newcastle/fernleigh_track.pdf Track 16km from Daughters Adamstown to Belmont Shipwreck Approximately Mums & http://www.newcastle.nsw.gov.au/recreation/walks_and_cycling/heritage_walks walk 2km along the Daughters Stockton Breakwater Glenrock Mums & http://www.environment.nsw.gov.au/nationalparks/parkCycling.aspx?id=N0616 State Daughters Conservation Area Yeularbah Section of the Mums & http://www.wildwalks.com/bushwalking-and-hiking-in-nsw/hunter-region/charelstown-park- walking Great North Daughters track-head-to-newcastle-station.html track walk – various tracks totally http://www.aussiehiking.com.au/hike/dir/8/NSW up to approximately 12.8km Lake This car-free Mums & http://treadly.com/bikeride/newcastle.html 2 | P a g e Macquarie cycling and Daughters
Elebana to walking track Booragul runs from Elebana via Warners Bay and Speers Point to Booragul. 10km This car-free http://treadly.com/bikeride/newcastle.html Newcastle cycling and Bike Ride - walking track Islington - links Newcastle Newcastle to Islington. 3km Learner Bike http://www.lakemac.com.au/page.aspx?&pid=62&vid=1&nid=1059&npt=details Cycle Circuit Track for Zone- Speers Variety point Park Playground
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WHAT WHERE WHO DETAILS CONTACT & WEB LINK ZUMBA® Newcastle Mums & The Forum Sports and Aquatic Centre @The University & Daughters University Drive Forum Harbourside 10+ Callaghan NSW 2308 Australia Phone: +61 2 4921 7001 Email: [email protected] http://control.visionscape.com.au/SiteFiles/theforum2010orgau/University_timetable_Aug_20 11.pdf
Zumba + Adamstown Mums & Lift Dance Lift Dance Fitness Toning @ Daughters Fitness is a 44 Park Ave Lift Dance casual Adamstown NSW 2289, AU Fitness based dance http://www.liftdancefitness.com.au/classes/ studio. Zumba + Newcastle Girls Zumba Pivot Studio Zumba Atomic 22 Newcomen Street, Newcastle New South Wales 2290 Atomic @ (kids) Atalie Wilmoth – 0416314105 Pivot Mums Zumba Studio http://www.pivotstudio.new/index.html
Zumba Newcastle Mums & Zumba Atomic @ daughters Atomic La Fiesta Fitness Studio La Fiesta (kids) 189 King Street Fitness Newcastle New South Wales 2300, AU Studio Linda Pichardo 0438468050
Zumba Newcastle Mums & Zumba Howzat Health Club @Howzat Daughters Corner Tooke & Brooks Streets Heath Newcastle New South Wales 2300, AU Club Alicia Broughton-Rouse http://www.howzatnewcastle.com.au 4 | P a g e
Aqua The Junction Mums & Aqua Arnold’s Swim Center Zumba @ Daughters Zumba 3 Jenner Pde Arnold’s The Junction NSW 2291, AU swim Keffa Heaney - (02) 4961 5282 Zumba @ Merewether Mums & Zumba Impact Boxing and Personal Training Impact Daughters 8/10 Mitchell Street Boxing Merewether New South Wales 2291, AU and PT Emma Thomson- 0421256863 http://www.impactstudio.com.au/ Zumba @ Hamilton Mums & Zumba Hamilton Public School hall Hamilton Public Daughters Tudor Street Public School hall Hamilton - Newcastle NSW 2303, AU School Jarrod Tucker- Tuesday 7-8pm Zumba + Balance Mums Zumba Balance Health Club Zumba Health Club, CNR of William St and Industrial Dr Atomic @ Mayfield Girls Zumba Mayfield New South Wales 2304, AU Balance Atomic Melissa Kemp http://www.balancehealth.com.au/mayfield/services-programs/group-fitness Zumba Curves, Mums Zumba Curves Broadmeadow circuit @ Broadmead 43 Belford Street Curves ow Broadmeadow Newcastle New South Wales 2292, AU http://www.curvesbroadmeadow.com/ Zumba + Active Mums Zumba Active Dance Mayfield Zumba Dance, Church St Atomic @ Mayfield Girls Zumba Mayfield Newcastle New South Wales 2304, AU Active Atomic Megan Sutton- 0410679482 Dance Zumba @ Planet Mums & Zumba Planet Fitness- Lambton Planet Fitness, Daughters Energy Australia Stadium, Turton Road, Lambton Fitness Lambton Newcastle New South Wales 2299, AU Aleisha Bailey- 0432525766 http://www.planetfitness.com.au/home
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WHAT WHERE WHO DETAILS CONTACT & WEB LINK Body Balance University Mums Yoga, Tai The Forum Sports & Aquatic Centre @ The Forum & Harbourside Chi and The University of Newcastle, University Drive, Callaghan Pilates. www.theforum.org.au Yoga @ The Meditatio P 02 4921 7001 E [email protected] Forum n & http://www.theforum.org.au/page11847/Home.aspx Harbourside relaxation Positive Energy Mums & Pilates Positive Energy Studio 4926 5446 Studio - Pilates Newcastle Girls 10yrs+ Mat Cnr Merewether & Wharf Road, Honeysuckle, Newcastle, Australia 2300 Yoga & classes & http://www.positivenrg.com.au/ Personal reformer Training classes Pilates for Life The Junction Mums Pilates 1/15 Kenrick st, The Junction, NSW 2291 49 622 177 Mat http://www.pilatesforlife.com.au/index.html classes & reformer classes, fitball classes Genetics Warners Bay Mums Pilates 314 Hillsborough Road Warners Bay NSW 2285 Fitness Club Mat 4956 6557 [email protected] classes http://www.geneticsfitness.com.au/groupfitness.htm Fitness First Westfield Kotara Mums Pilates Shop 1067/ Cnr Park Ave & Lexington Parade Kotara 2289 PH: 4016 3000 Mat http://www.fitnessfirst.com.au/clubs/timetable/index_html?club_id=77 classes Embody Arts Vitality Junction Mums Pilates Located at Vitality Junction Health Centre Health Centre Mat Level 1, 179 Union Street, The Junction, NSW Phone:4969 1965 Mobile: 0423 436 554 classes http://embodyarts.com.au/yogalates/timetables/
Newcastle Hot Newcastle Mums Bikrim Level 1/285 Hunter Street or 204 King St (between Darby and Crown Streets) 4929 6791 Power Yoga Yoga http://www.hotpoweryoga.com.au/ (30)
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Focus Pilates Charlestown, Mums Charlestown Studio Studio Warners Bay 1/193 Pacific Highway Charlestown NSW 2290 4947 8838 Warners Bay Studio 2/4 King St Warners Bay NSW 2282 4947 4801 http://www.focuspilates.com.au/classes Fitness Lake Macquarie Mums Pilates 26 Oakdale Road, Gateshead NSW 2290 Revolution Mat 4943 5855 [email protected] classes http://www.fitnessrevolution.com.au/pilates.htm Pilates Fitness Belmont Mums Pilates 22 Patrick Street, Belmont North NSW 2280 0404 037 622 for Life Mat http://www.truelocal.com.au/business/pilates-fitness-for-life/belmont-north classes Pilates & Cooks Hill Mums Pilates Pilates & Physiotherapy Newcastle Physiotherapy Mat 1/235 Darby Street, Cooks Hill NSW 2300 4926 2279 Newcastle classes Pilates Mums Pilates Pilates Evolution Now Evolution Now Mat 93 High Street, East Maitland NSW 2323 0411 836 153 classes http://www.pilatesevolutionnow.com.au/ Body Logic @ Mums Pilates 1 Skyline Way, Gateshead NSW 2290 4942 1322 Macquarie Mat Physiotherapy classes Tania Dunning Mums Pilates Ms Tania Dunning Phone: 0404 037 622 Pilates Mat 22 Patrick Street, Belmont North, NSW, 2280 classes http://www.pilatessource.com.au/studio/tania-dunning-pilates Seechange Hamilton Mums Pilates Ms Laurianne Gwilliam Phone: 02 4962 1491 Pilates Mat 8 Veda Street, Hamilton, NSW, 2303 classes
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WHAT WHERE WHO CONTACT & WEB LINK Tree Tops Wyong Creek Mums & Adventure park TreeTop Adventure Park Central Coast Adventure or Minmi Daughters consisting of 105 Ourimbah State Forest Park challenges in the 1 Red Hill Road tree tops, where Wyong Creek 2259 participants can slide 02 4025 1008 down flying foxes, OR move from tree to TreeTop Adventure Park Newcastle tree on suspension Blue Gum Hills Regional Park bridges and enjoy Minmi Rd many other exciting Minmi 2287 activities up to 20m 02 4026 7617 above the forest floor! Rock Climbing The Forum Mums & A great place to start The Forum Sports and Aquatic Centre Wall Sports & Daughters adventure climbing, University Drive Aquatic (8yrs+) the wall allows Callaghan NSW 2308 Australia Centre climbers to Phone: +61 2 4921 7001 concentrate on Email: [email protected] correct movement Web: http://www.theforum.org.au/page11716/Activities-For- and technique under Adventure.aspx controlled conditions without having to worry about weather or outdoor climbing hazards. Pulse Adamstown Mums and Facilities cater for all Pulse Climbing Climbing Daughters levels of climbing 122 Garden Grove Pde (6yrs+) from beginners just Adamstown starting out, right up Phone: (02) 4023 4743 to elite climbers who Email: [email protected] are after a high class training facility.
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Rock up Varying Mums & Abseiling – for all Rock up adventures Adventures – locations Daughters ages, no experience Phone: 02 49308375 abseiling, necessary, all Mob: 0419 814 786 rock climbing, equipment provided Email: [email protected] bush walking Rock climbing- for Web: www.rockupadventures.com.au beginners or experts! Bush walking- varying lengths and and difficulties. Ice Skating Hunter Ice Mums & Enter a whole new Hunter Ice Skating Stadium Skating Daughters frozen world of fun. 230 Macquarie Road Warners Bay Stadium, Public skating Phone: (02) 4954 4499 Warners Bay sessions available as Email: [email protected] well as kids birthday Web: http://www.huntericeskating.com.au/ parties Zone Empire Wallsend Mums & Laser Skirmish- a Zone Empire Daughters multi-level 8 Council St fluorescent room for Wallsend laser tagging fun! Phone: (02) 4951 2753 Web: http://www.zone-empire.com.au
Splash Zone The Forum Mums & The most fun you The Forum Sports and Aquatic Centre Sports & Daughters can have on the University Drive Aquatic water is on The Callaghan NSW 2308 Australia Centre Forum's two Phone: +61 2 4921 7001 awesome pool Email: [email protected] floats. Web: http://www.theforum.org.au/page11694/SplashZone.aspx
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WHAT WHERE WHO DETAILS CONTACT & WEB LINK Touch Wallsend Junior Juniors Wallsend Touch Football , Wallsend Park Football Touch competition Thursday nights Julie Andrews 02 4968 8938 Email: [email protected] Football for girls & http://www.sportingpulse.com/assoc_page.cgi?c=0-473-0-0-0&sID=68510 Association boys
Ladies/Mixed Ladies; Wednesday nights competition Mixed; Friday nights for Mums
Newcastle Junior Juniors Newcastle Harness Racing Club (behind Ausgrid Stadium) City Touch competition Friday nights October- Kerry Campbell [email protected] 0249465877 Football for girls & December http://www.sportingpulse.com/assoc_page.cgi?c=14-465-0-0-0 Association boys
Ladies/Mixed Ladies Tuesday nights; competition Mixed Thursday nights. for Mums
Gibbs Oval, Rowan Crescent, Merewether Mereweth Junior Juniors Billie-Joe Edmonds: email- [email protected] or er Carlton competition Tuesday afternoons Term 4 [email protected] Junior for girls & http://www.mcjr.rugbynet.com.au/default.asp?id=171278 Touch boys Football
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Soccer Quick Kicks Primary School Thursdays 5.30pm Charlestown Oval GIRLS ONLY October 13th - December (Lincoln St) from 15th Year 3-Year 9 Wednesdays 5.30pm National Park, Cooks Hill October 12th - December 14th http://www.sportingpulse.com/assoc_page.cgi?client=1-8558-0-0-0
New U/6’s & U/10’s Saturday’s Contact: http://www.nlfc.org.au/contact/ Lambton (small-sided Web: http://www.nlfc.org.au/home/ Football local) U/11’s (Inter-district)
Cardiff Juniors Saturday’s Cardiff Junior Soccer Club Junior Email: [email protected] Soccer Club Website: http://www.sportingpulse.com/club_info.cgi?c=1-8218-110115-0-0 Phone number : 0425 300 393
Valentine All junior ages Saturday’s (Sunday’s for Valentine Eleebana Football Club Eleebana girl’s only competition) Parklea Avenue, Croudace Bay NSW Australia Football Phone: (02) 4946 9750 Club Web: http://www.vefc.com.au/
Kotara South All junior ages Saturday’s Kotara South Junior Football Club Junior + girls only Web: http://ksjfc.org/ Football teams Club
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Futsal Hunter Juniors Under Broadmeadow, Gateshead Indoor Sports Centre, Howzat Darby St Newcastle Futsal 6 to Under 8 www.hfss.com.au Soccer & Juniors Under Sports 9 to Under 16 Mixed Women and Youth Netball Newcastle Girls: Saturdays NEWCASTLE NETBALL ASSOCIATION Sub Junior Venue Address: Union St, Newcastle Junior Contact Name: Aileen Shutt Contact Phone: (02) 4955 6653 Contact Mobile: 0409 327 257 Association Email: [email protected] Association Website: www.newcastle.netball.asn.au Clubhouse Phone: (02) 4929 4200 Clubhouse Hours: Saturdays (during the season)
Charlestown CHARLESTOWN NETBALL ASSOCIATION Venue Address: Bula St Charlestown NSW 2290 Contact Name: Marie Caddies Contact Phone: (02) 4943 2805 Contact Mobile: 0447 432 805 Association Email: [email protected] Association Website: www.charlestownnetball.com.au Clubhouse Phone: (02) 4943 1389 Clubhouse Hours: Saturday 10am - 5pm
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Belmont LAKESIDE NETBALL ASSOCIATION Venue Address: Merleview St, Belmont Contact Name: Shirley Fitzgerald Contact Phone: (02) 4945 0907 Association Email: [email protected] Association Website: www.lakeside.netball.asn.au Clubhouse Phone: (02) 4945 9244 Clubhouse Hours: Saturdays 6am - 6pm
Valentine/ Valentine Eleebana Netball Club Eleebana Parklea Avenue, Valentine (02) 4942 8345 Waratah Waratah Netball Club, Newcastle, NSW
44 Buruda St, Mayfield
(02) 4967 4972 Westlakes Westlakes District Netball Association Dobell Dr, Wangi Wangi New (02) 4975 2368 Lambton West Leagues Netball Club Inc. - Home Tyrone Street, New Lambton Jenny Herringe 49 622 867 http://www.westleaguesnetballclub.com/
.
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Basketball Newcastle U8’s, U/10’s Thursdays Corner of Young & Curley Road, Broadmeadow Basketball 4:00– 6:30 4961 3185 Assoc U/12’s Wednesdays http://www.newcastlebasketball.com.au/page10663/PlayBasketball.aspx 4:00 - 6:30 Learn to Play Mon-Tue 4:00-5:30 City Limits Juniors Lisa Stanton 0401 062 209 www.citylimits.org.au Keith Paton 4948 8114
Port Hunter Garry Craig 0422 259 200 Gateshead www.porthunter.basketball.net.au
United Robyn Connet 4943 5869
Wests Libby Herington 4952 6137 Hockey Newcastle Girls: 20 Lois Crescent, Cardiff Tigers Juniors 0414 771 849 Hockey Club
Newcastle Juniors Turton Road, Broadmeadow Hockey (02) 4952 8899 Association
Little Athletics Newcastle Mums & Monday 5:30pm Sue Kenny [email protected] 0402 100 441 City Daughters Newcastle Athletics Field www.nlac.org.au
Adamstown/ Friday 5pm David Priestley [email protected] 0419 655 811 New Alder Park, New Lambton www.anllac.org.au Lambton
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Kotara South Monday 6pm Shannyn Robards [email protected] 0406 774 888 Nesbitt Park www.kotarasouthathletics.org.au
Wallsend Monica Kumar [email protected] 4950 2880 Monday 5.30pm Federal Park www.wallsendathletics.org.au
Glendale Friday 5.30pm Yvonne Webster [email protected] 0438 599 877 Hunter Sports Centre, Glendale www.machunter.com.au
Cardiff Friday 5.30pm Greg Jones [email protected] 0431 066 725 Neegulbah Park, Macquarie Hills www.cardifflittleathletics.com
Edgeworth Friday 6pm Sharon Studley [email protected] 0438 585 788 Edgeworth Oval #3
Tennis Newcastle Mums & Social bookings, adult National Park Tennis Courts at Hamilton East 49 612190 City Tennis Daughters lessons, private coaching, http://www.newcastlecitytennis.com.au/ Centre junior
District Park Pee Wee Tennis Richard Nicholls 0412 089 777 Tennis Girls & Boys 5-7 years Corner of Lambton and Curley Roads Broadmeadow 49 610 806 Junior – intermediate http://www.topspintennis.com.au/tst_public/tst_public_webpage.aspx?pageA 7 - 17 years bbrev=Home Holiday camps, Ladies fun & fitness (females only +childcare avail.) Newcastle King Edward Park 0418 264 551 Hill
Kotara Park Park Avenue Kotara 0412 006 150
Lambton Lambton & Curley Rds Broadmeadow 4961 0806 Elder Street, Lambton 4952 4130 15 | P a g e
40 Ada Street, Cardiff 4954 9877
Lake Adult coaching, junior Parklea Avenue, Croudace Bay 4946 8014 Macquarie coaching
Usk Street ,Mayfield 4951 1492 Valentine Tennis Club
Hillcrest Tennis AFL AUS KICK Girls & Boys 5-12 years NEWCASTLE CITY AUSKICK CENTRE No. 1 SPORTSGROUND, Parry Street, March-August Newcastle Simon McCauley 4926 3731 0408 474847 [email protected] http://www.aflauskick.com.au/parents/coaching-for-parents/
CARDIFF AFL Club Percy Street Oval, Percy Street, Hillsborough 2290 Debbie King Email: [email protected]
WALLSEND AFL CLUB Bill Elliott Oval, Maryland Rd, Maryland 2287 Terese Drane 02 49502352 http://www.wallsendswans.org.au/cms/
WARNERS BAY AFL CLUB Gary Ryan 0417121316 http://www.sportingpulse.com/team_info.cgi?c=1-916- 15237-50031-3001971&sID=23750
EASTLAKES AFL CLUB Barton Oval, Glover Street, Belmont Scott Ferguson [email protected] http://www.eastlakesafl.com.au
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Cricket Charlestown Girls & Boys http://www.newcric.org.au/ Junior CC Juniors 5+ , girls only, http://www.newcric.org.au/ Glendale mixed Edgeworth JCC http://www.newcric.org.au/
Newcastle City CC Juniors http://www.newcric.org.au/
Southern Lakes http://www.newcric.org.au/
Swansea- Caves http://www.newcric.org.au/ Cricket Club Tigers JCC(Adamsto wn, New Lambton South, Kotara South http://www.newcric.org.au/ Junior Cricket) http://www.newcric.org.au/ Valentine Eleebana CC http://www.newcric.org.au/ Wallsend, Waratah, Warners Bay
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OzTag Newcastle U/8, U/10, Monday afternoons at Smith Liberty Watters 0412704221 [email protected] Junior Oztag U/12, U/14 & Park. Smith Park, Newcastle U/16 mixed Lake boys and girls Barton Oval Belmont Macquarie Peter on 0401794903 Junior Oztag [email protected]
Gymnastics Newcastle Girls & Boys Mon-Fri 3:30 – 8:00 http://www.pcycnsw.org/club_newc_act_gymnast PCYC Cnr Young & Melbourne Roads Broadmeadow 49614493 Kindy Gym Howzat Girls & Boys Tuesday s Corner of Tooke and Darby Streets Newcastle 4926 4488 Newcastle 3yrs-6yrs 4:00 – 5:00 http://www.howzatnewcastle.com.au/sports/gymnastics.htm or 49264488 7Yrs – 12yrs 5:00 – 6:00
Hunter Girls & Boys Kindergym http://www.hsc.org.au/services.php. Sports 5yrs & under Mon-Fri Centre 9:30-12:30
Girls & Boys Recreational Gymnastics 4 - 18yrs Girls & Boys 5 - 18yrs Trampoline
Cheerleading Hunter Girls All ages Tumble classes, recreational 5/7 Friesian Close, Sandgate, Australia 2304 Cheerleading cheerleading, acrobatic [email protected] Academy gymnastics
East Coast Kassi or Derrick 0413 218 963 AllStars, 7/30 Metro Court Gateshead 2290 Gateshead [email protected]
Bodyrock Michelle Flemming 4954 4300 Warners Bay NSW 2282
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Judo Martial Lake Mums Basic Conditioning & Self Ken McKenzie Arts Macquarie Defence for Women 0249 512530 0421343626 PCYC & Newcastle PCYC, Cnr Young & Melbourne St, BROADMEADOW, NSW 2292 Newcastle Girls& Boys Mini Samurai 4-7 yrs Lake Macquarie PCYC, Cnr Lake Rd and Pacific Hwy, Windale NSW PCYC 4-7 Junior Samarai 8-12 yrs http://www.samuraijudoacademy.com/st.php?uv=376I0I1I0I0I0 Girls & Boys 8-12 Swimming NuSwim All ages Club Nights Friday 6pm http://www.nuswim.org/site/index.cfm Swimmers The Forum, Newcastle University
Central Mon/Tue/Wed 4:30-5:45 Newcastle Thurs 6:30-7:30 Lambton Swimming Pool Swimming Club http://www.centralnewcastle.nswswimming.com.au/ Lambton www.ncc.nsw.gov.au Swimming Centre Durham Road, Lambton - 02 4904 3366
Mayfield Swimming Centre Ingall Street, Mayfield - 02 4974 6635 Wallsend Swimming Centre Frances Street, Wallsend - 02 4985 665 Stockton Swimming Pitt Street, Stockton - 02 4928 1589 Centre
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WHAT WHERE TO PURCHASE WHO DETAILS ZUMBA ® Rebel Sport MUMS & DAUGHTERS Target
Fitball Workouts http://www.fitball.com.au/ MUMS & DAUGHTERS Fun fitball exercises in your home. All you need is a DVD player, TV & a fitball. Windsor Pilates http://www.guthy-renker.com.au/products/Fitness/Mari-Winsor-Slimming-Pilates/Mari-Winsor- MUMS & DAUGHTERS Sculpting pilates Slimming-Pilates-Basic-Kit?cguid=4fe5fad0-fadc-427c-b15e-2729dea30b49 workout with equipment included in the comfort of your own lounge room. Activ8 Kidz Fitness http://activekidz.com.au/index.php?area=shop&PHPSESSID=7c92e56c7fc6734cfb4a2a64f423a4bc MUMS & DAUGHTERS Awesome fun for the kids to perform on rainy days or when you feel like jumping about like an Activ8 kid! Bindy Irwin http://www.myshopping.com.au/ZM--1068321684_Movies MUMS & DAUGHTERS Fun aerobic & fitness with Bindy Irwin herself!
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Appendices
Appendix 24: TABLE A1: EDUCATION CONTENT, PHYSICAL ACTIVITIES, PINK SLIP TASKS AND ALIGNMENT WITH SCT
406 Table A1: Intervention content and alignment with SCT
Session Theory Component Physical Activity Component Pink Slip task Behaviour Change (25-30 minutes) (55-60 minutes) SCT construct 1 Mums Fun games 1. Choose two of your favourite * Outcome expectations: Provide information Why are you here? * Dodge & walk games from Session 1 and play about importance of PA Aims of program * Mirrors them for 15 minutes with MUM. NSW SPANS report *Tails * Social support: Provide social support & Benefits of being physically active * Cone flip 2. Choose a favourite song and encouragement for mums and daughters Importance of mothers and physical create a ‘follow the leader’ activity Rough & tumble play dance with MUM. * Self-efficacy: Develop skills in a range of * Knee taps PA Daughters * Tootsies Aims of program * Chinese wrestle * Self-efficacy: Provide opportunities to Discussion of what they like doing with develop self-confidence in a variety of PA their mums Zumba™ skills PA interests * Alexis Jordan: Happiness * Soca Boyz: Follow the leader * Shakira Waka Waka * Jessie J: Money
2 Mums Aerobics 1. Complete a home based * Outcome expectations: Provide information Physical activity recommendations – *Eye of the Tiger fitness circuit twice this week to about inactivity consequences adults & children music. Create a 5 station Why are children inactive? Fitness Circuit circuit, spend 3 minutes at each * Goal setting: Prompt goal setting Health-related fitness * Step ups station and perform 2 laps of Mums as role-models & facilitators * Modified push ups your circuit. * Self-efficacy: Develop skills in a range of SMART GOALS * Sit ups PA * Jump rope 2. Wear your pedometer for 4 Daughters * Tricep drips days this week. Record your * Self-efficacy: Provide opportunities to Physical activity recommendations (5- * Shoulder rotations pedometer steps on your chart. develop self-confidence in a variety of PA 12 years) * Develop PA behaviours ladder runs skills Health-related fitness * Lunges 3. MUMS set 3 SMART Goals * Heel touches (2 for you, 1 for your * Social support: Provide opportunities for * Hula hoops Daughter/s). mother and daughter to develop PA behaviours Signature Dance Move * 30 seconds at each dance station
3 Mums Pilates & Yoga 1. Perform 4 yoga/pilates poses * Outcome expectations: Provide information Review SMART GOALS *Roll down and perform your signature about sedentary behaviour consequences Screen time recommendations *Bridge dance move when you swap Reducing sedentary behaviour *Toe taps between poses. * Goal setting: Self-monitoring skills by Incorporating incidental PA into *Single leg stretch setting goals everyday *Double leg stretch 2. Wear your pedometer and go *Scissors for a 30 minute powerwalk with * Self-efficacy: Develop skills in a range of Daughters *Box balance MUM. Record your pedometer PA A balanced lifestyle *Points of contact steps on your chart. Screen time recommendations *Swimming * Self-efficacy: Provide opportunities to Imagine life without TV or computers *Crane 3. Complete a home based develop self-confidence in a variety of PA *Downward facing dog abdominal fitness circuit twice skills *Childs pose this week to music. Create a 5
Resistance training station circuit, spend 3 minutes * Social support: Provide opportunities for Fitballs at each station and perform 2 mother and daughter to develop PA *Core balance laps of your circuit. behaviours * Knee balance *Single leg lift *Hip extension *Hamstring curl *Supine feet extension *Russian upper twist *Lateral ball roll *Prone feet hold *Ball push up
Medicine/soft volley balls *Mediball twists *Football pass *Partner sit-ups Fit Boxing *Cross jab *Upper cuts * Hook * Speed ball * Waterfall
Gymstick (mums only) *Biceps *Upright row *Military press *Chest press *Tricep
4 Mums Games 1. Use the Family ACTIVation * Outcome expectations: Provide information 100 ways to unplug & play *Tails pack twice this week for 30 about sedentary behaviour consequences Fundamental Movement Skills *Cars minutes each time. FMS & girls * Goal setting: Prompt goal setting Vigorous Physical Activity Fundamental Movement Skills 2. Wear your pedometer 4 days Setting new SMART GOALS *Overarm throw this week and record your * Self-efficacy: Develop skills in to decrease *Kick pedometer steps on your chart. screen time Daughters *Basketball dribble Fundamental movement skills *One-handed strike 3. Go for a powerwalk with your * Self-efficacy: Provide opportunities to Importance of FMS being FUN *Catching MUM and focus on increasing develop self-confidence in a variety of PA *One-two handed strike your VPA (vigorous physical skills activity) for 10 minutes. (e.g. run up sets of stairs, play chase * Social support: Provide opportunities for games, step ups, hill walk/run) mother and daughter to develop PA behaviours 4. Take your heart rate at the end of the 10 minutes and write it on your session print out.
5. MUMS set 3 new SMART Goals (2 for you, 1 for your Daughter/s).
5 Mums Games 1. Create your own version of a * Outcome expectations: Provide Baseline results (weight, BMI, BP, HR, *Ship Deck Shore game played at M.A.D.E 4 Life personalised information about BMI MVPA) * Pizza and play twice this week with category, BP, HR and MVPA minutes and Get in ‘their’ world MUM. compare to recommendations Rough & tumble play for MUMS Rough and tumble play * Knee taps 2. Wear your pedometer 4 days * Goal setting: Prompt goal setting in Daughters * Tootsies this week and record your relation to their baseline results What is important in ‘their world’ * Itchy fingers pedometer steps on your chart. Creation of unique game to play with * Stand challenge 3. Have a sock wrestle with * Self-efficacy: Develop skills to engage in Mum for homework *Shoulder slaps MUM EVERY night this week. daughter’s world *Push up tips * Self-efficacy: Provide opportunities to *You’re so strong 4. Challenge MUM to playing 3 develop self-confidence in a variety of PA *Chinese wrestle wrestling games this week. skills
* Social support: Provide opportunities for mother and daughter to develop PA behaviours
6 Mums Skipping with ropes 1. Complete a home based * Outcome expectations: Brainstorm Brainstorming barriers to physical * Basic jump skipping circuit twice this week perceived barriers to PA activity * Bell to music (using the skipping Brainstorming solutions to the barriers * Skier rope). Create a 5 station circuit, *Self-efficacy: Barrier identification of other Keeping on track * Side straddle spend 40 seconds at each mothers in group * Jogging step station and perform 2 laps of Daughters * High knees your circuit. * Social support: Discuss barriers and Brainstorm ways to be more active with * Peek-a-boo brainstorm solutions to PA with other MUM * Can-can 2. Wear your pedometer 4 days mothers in similar situations Design a poster to influence other girls * Double under this week and record your & their mums to be active * Criss cross pedometer steps on your chart. *Social support: encourage PA strategies * Backward that involve support of mum-daughter * Backward criss cross 3. Have a 40 second on the spot skipping challenge against Partner drills MUM to increase your VPA *Goal setting: Increase knowledge and skills * Mirror jump (vigorous physical activity) relating to PA behaviours, * Partner jump everyday this week. * Partner twist * Partner switch 4. Take it in turns with mum to compare your pedometer steps Skipping Circuit & choreograph skipping after each 30 second interval. to music
7 Mums Backyard games 1.Complete your own backyard * Outcome expectations: Provide solutions Defining realistic solutions to physical * Rats & rabbits games session twice this week. to perceived barriers activity barriers * Cone flip Choose your favourite games Group support discussion * Rob the nest and play for 20 minutes with * Goal setting: Prompt goal setting * Golden child your whole Daughters * Rounders family/neighbours/friends. * Self-efficacy: Develop skills in to decrease
Scenarios: couch potato, rainy weather, * French cricket 2. Wear your pedometer 4 days screen time mum is busy this week and record your Brainstorm solutions to the barriers pedometer steps on your chart. * Self-efficacy: Provide opportunities to Role play solutions develop self-confidence in a variety of PA 3. Play musical skipping on the skills spot or moving around. When the music stops FREEZE! Take * Social support: Provide opportunities for it in turns with mum to start & mother and daughter to develop PA stop the music. Compare your behaviours pedometer steps after each song.
4. MUMS set 3 SMART Goals (2 for you, 1 for your Daughter). 8 Mums The Amazing Race N/A * Goal setting: Set goals for post program Where to from here? * Gymsticks & fitballs Recap of all resources & equipment to * Hovers, push up tips * Social support: Review opportunities for continue to use to stay active for life * Hula hooping PA and resources available * Hurdles & SAQ ladder Daughters * Boxing *Self-efficacy: Reflect on achievements Recap of favourite activities with Mum * Cone flip & tails since beginning of program Create a thank you card for Mum * FMS – kicking * Rough & tumble play * Social support: Encourage known * Skipping opportunities for mother and daughter to * Funky dance move develop PA behaviours
Appendices
Appendix 25: MADE4LIFE ASSESSMENT MEASUREMENT SHEETS
412
MADE 4 LIFE DAUGHTER 10-Week Data Collection
Daughter’s Name: ______Mum’s Name: ______
DOB: ______Time: ______
Clothing: ______Date:______
Accelerometer Type (circle): G3TX G3TX+
Accelerometer ID Number: ______
Measurements 1 2 3 4 Assessor Record to .1 cm Tolerance of .3 cm Height (cm) Record to . 01 kg Tolerance of .1 kg Weight (kg)
BMI (kg/m2)
InBody BIA :
Fat Mass (Kg) ______Fat Free Mass (Kg) ______
TBW (L) ______ICW (L)______ECW (L)______
Waist Circumference: Record to .1cm Tolerance of .5 cm (large people) and .3 cm (small children) Umbilicus (cm)
Resting (Right Arm): Cuff Size (S/M/L) Colour: Arm: R L Tolerance of 10mmHg (ideally 5mm Hg). Within 5 heart beats Blood Pressure / / / / (mmHg) (S/D) Resting Heat
Rate (bpm) Check all questionnaires are complete All measurements are complete Accelerometer distributed/protocol explained Where to from here envelope distributed
______(Assessor sign off)
MADE 4 LIFE MOTHER 20-Week Data Collection
Mum’s Name: ______Daughter’s Name: ______
DOB: ______Time: ______
Clothing: ______Date:______
Accelerometer Type (circle): G3TX G3TX+
Accelerometer ID Number: ______
Measurements 1 2 3 4 Assessor Record to .1 cm Tolerance of .3 cm Height (cm) Record to . 01 kg Tolerance of .1 kg Weight (kg)
BMI (kg/m2)
InBody BIA :
Fat Mass (Kg) ______Fat Free Mass (Kg) ______
TBW (L) ______ICW (L)______ECW (L)______
Waist Circumference: Record to .1cm Tolerance of .5 cm (large people) and .3 cm (small children) Umbilicus (cm)
Resting (Right Arm): Cuff Size (S/M/L) Colour: Arm: R L Tolerance of 10mmHg (ideally 5mm Hg). Within 5 heart beats Blood Pressure / / / / (mmHg) (S/D) Resting Heat
Rate (bpm) Check all questionnaires are complete All measurements are complete Accelerometer distributed/protocol explained Where to from here envelope distributed
______(Assessor sign off)
Appendices
Appendix 26: MADE4LIFE ASSESSMENT PROTOCOL
415 M.A.D.E 4 Life Assessment Protocol 2011
HEIGHT o Turn the machine on using black switch at back of the machine at the base plate. o Ask the participant to remove shoes and socks.
o Automatic arm will move up and down to calibrate. Once arm has returned to the top position, ask participant to stand on feet plate with their back facing the pole (back doesn’t necessarily need to touch the pole).
o Ask participant to stand straight and tall. Observe participant from side on to ensure participant is standing in true vertical position.
o Once standing in correct position, the machine will beep to confirm it is ready.
o Once you hear the beep, ask participant to take a deep breath in and stretch neck upwards (this can make a 0.5cm difference). Ensure heels stay on the ground and that the headboard is contacting the head. Instruct the participant to keep their head in a vertical position, looking straight ahead (Frankfort plane).
o The machine arm will move down and tap participant on their head and return to top once measured. o Measurement can be read from digital screen on side of machine. Record the measurement to one decimal place eg 175.2 cm o Ask the participant to step off the stadiometer o Take a second measure. Check the two values, and if the difference is greater than 0.3 cm, take a third measure. o Write your initials in the Height Assessor box
M.A.D.E 4 Life Assessment Protocol 2011
WEIGHT o Ensure that the weight scales are switched on (battery case inserted and press ‘ON’ button). It will take a few moments until ready (scale displays 0.00 kg) o Ask participant to remove shoes, socks and all unnecessary clothing (i.e. coat, jacket, belts, cardigans, heavy jewellery, etc). Empty pockets (mobile phone, wallets, keys etc) o Have participant stand in the middle of the scales, balanced evenly on both feet o Record weight to 2 decimal places eg 75.26 kg o Ask the participant to step off the scale. o Take a second measure. o Check the two values, if difference is more than 0.1 kg then take a third measure o Use Calculator to work out BMI [weight (kg) / height(m)2] o Write your initials in the Weight Assessor box
BMI ranges (Caucasians) Underweight - <18.5 Healthy 18.5 – 24.9 (for older Australians, acceptable weight range BMI – 22.0 – 27.0) Overweight - >25 Overweight – 25 – 29.9 Obese 1 – 30 – 34.9 Obese 2 – 35 – 39.9 Obese 3 - >40.0
* Source DAA – Best Practice Guidelines for the treatment of overweight and obesity in adults 2004
M.A.D.E 4 Life Assessment Protocol 2011
WAIST CIRCUMFERENCE o Inform the participant that you will be taking measurements of torso circumference, at the level of the umbilicus (belly button). Tell them that you need to make this measurement against their bare skin. o Ask participants to stand on the wooden box (so that their waist is at the assessor’s eye level). Instruct the participant to lift their shirt so that the measurement can be taken against bare skin. If you need to palpate for iliac crest or bottom rib, warn them what you are about to do. o The first assessor will then slide the tape around the participant’s waist in line with the umbilicus. The second assessor should ensure that the tape is horizontal at the back and sides of the participant. o Ask the participant to breathe normally with the arms relaxed at the sides. The measurement will be taken at the end of a normal expiration. Record to the nearest millimetre eg 75.1 cm o The first assessor will then repeat the umbilicus waist measurements. If the difference between measurements is greater that 0.5 cm at a location, take a third measure. o Write your and second assessors initials in the waist circumference assessor box.
NORMAL RANGES
Female Normal Healthy = <80 cm Increased risk of CV and metabolic complications = > 80 cm Substantially increased risk of CV and metabolic complications = > 88 cm
* Source DAA – Best Practice Guidelines for the treatment of overweight and obesity in adults 2004
M.A.D.E 4 Life Assessment Protocol 2011
BLOOD PRESSURE o Ask the subject to be seated in an upright posture with legs uncrossed. The participant should rest for 5 min prior to the first measurement. o Ask subject to raise their right arm at shoulder height with the palm facing up. Measure circumference of upper arm to determine the need for paediatric (black/blue) medium (brown) or large (grey) cuff. Brown cuff - arm size 24-32 cm, Grey cuff - arm size 32-42 cm. On the data sheet, record the cuff size (paediatric, medium or large), colour (black, blue, brown or grey) and arm used. o Attach the cuff 2-3 cm (two fingers) above the crease of the elbow, with the tubing at the distal end of the upper arm (near elbow crease). Ensure the tubing (or artery marker) is placed over the brachial artery (slightly to the left of centre of the upper arm). o Ask subject to rest their right arm on the table. Flick the air release switch to the closed position. Turn BP monitor on and wait for it to beep and read 0, with the arrow flashing up. In general, pump the cuff to 170-180 mmHg (for children only pump to 120-130 mmHg) and then leave to deflate automatically. Once it detects a pulse, it will start to beep and count down. If you have not inflated the cuff sufficiently (30-40mm Hg) above the participants systolic BP the monitor will beep three times and prompt you to inflate the cuff further (arrow flashes up). Inflate the cuff to 200mmHg. Ensure the participant’s right arm remains still and that they do not talk during measurement. o Once the readings have appeared on the monitor, flick the air release switch to open, then record BP and resting heart rate on data sheet. Eg 120/80 and 60. Turn monitor off and then back on to reset. o The participant should rest for 2 minutes between measurements. Repeat BP measurement, this time inflating the cuff 30-40 mmHg above the previous resting value. Eg maybe only need 150 mmHg the second time. o You will need 3 measurements within the accuracy ranges – 10 mmHg for Systolic and Diastolic (preferably 5 mmHg for Dias) and 5 bpm for heart rate Eg 127/85, 125/83, 123/81 and 64, 60, 62. You can take a maximum of 5 measurements. If you cannot obtain a satisfactory set of readings discuss with Elroy, Ashlee or Robin if available. o Write your initials in the weight assessor box.
ADULT NORMAL RANGES
Normal BP ~ <120/80 High Normal - Systolic: 121-140; Diastolic: 81-90
Mild Hypertension - Systolic: 141-160; Diastolic: 91-100 Moderate Hypertension - Systolic: 161-180; Diastolic: 101-110 Severe Hypertension - Systolic: > 160; Diastolic: >110
If BP > 140/90, advise participant to raise this issue with their GP.
NORMAL CHILD RANGES Normal BP ~ <100/60 *Source – Australian Heart Foundation (Guide to management of hypertension 2008)
M.A.D.E 4 Life Assessment Protocol 2011
INBODY BODY COMP ANALYSER
Cover the screen on the InBody machine so participants can’t see the data Bioimpedance measurements should ideally be taken when fasted, or at least 2 hours after last meal. The subject should refrain from caffeinated drinks and moderate-vigorous exercise on the day of the measurement. Measurements should be taken with minimal clothing (also remove jewellery and other items contacting skin if possible) Turn on InBody device (black button at back of machine). It needs 8 minutes to warm up and calibrate itself, make sure nothing is touching/resting on the standing platform of the device as this will affect calibration. Set up research laptop (green tag on bag). Ask Carolyn or Elroy for this. User: Biomed Pass: Student Connect the InBody to the laptop using the serial-to-usb cable. This cable should be on the ground behind the InBody device. The Windows taskbar (bottom right hand corner of screen) should display a symbol (computer and person) that shows when the device is connected to the computer. If you open the software prior to connecting the device to the computer, an InBody program will launch automatically to prompt you to connect the device. Place the HASP key into a USB slot (Blue USB device, kept in blue Look InBody box). The program will not open without this key. Open Look InBody 3.0 software (icon on desktop). Click on the profile button to create a new profile (or add a new measurement to an existing profile) For a new subject, click the “New” button (orange) at bottom of screen). Enter in the subject’s details. For the registration No. field, enter the subjects name. Then add name, DOB (American date format), height and gender. Press the ‘Save’ button (orange) at bottom of screen. A pop up will be displayed saying “Input ID…”. For an existing profile, use the search function on the right hand side of the screen. Enter the subjects name and click search, then select their profile. Instruct the participant to stand on the InBody platform. Heels must be placed directly over the gold plates (heel on the circle). If the subject is wearing long pants, ensure they roll up their pants so the fabric is not touching the platform. Remove the handles of the device from the rack. Place your thumb over the gold plate. Fingers should wrap around the handle and contact the gold plates at the back. Ensure that the subject’s limbs are not touching any other part of their body, eg hold their arms away from their body slightly and make sure insides of the thighs are not touching. Instruct the subject to remain as still as possible and not talk during the test. To start the test, click on the InBody test button (blue, top corner of screen). A message will pop up instructing the assessor “do you want to start InBody...” click yes The test will begin. Information entered on computer will be sent to InBody and populate the fields at the top of the InBody LCD screen. You will hear a beeping sound which tells you the test has started. The test takes roughly 1.5 minutes. Once the measurement is complete, the InBody will show results on the screen as well on the computer. The data is automatically saved. To export information to excel, see handbook or Elroy.
NORMAL RANGES Classification Women (% fat) Essential Fat 10-12% Athletes 14-20% Fitness 21-24% Acceptable 25-31% Obese >31% * Source – From the American Council of Exercise
M.A.D.E 4 Life Assessment Protocol 2011
MOTHER QUESTIONNAIRE
Request participants PLEASE answer all questionnaires honestly and emphasise that their questionnaire booklet will be de-identified and answers to questionnaires will be kept confidential
Show participants that questions are on the front and back of each sheet and reinforce that both sides should be completed i.e. all questions
Flip the page to SECTION E straight away (pg 13) and ask mum if she undertakes any paid work. If the answer is NO, cross out the first column “sitting time last typical paid work day” and tell her she does not need to answer the first column. However, she MUST answer the second column.
Advise participants it will take approximately 20 minutes to complete the questionnaire
Go through booklet when participant has finished and ensure they have all completed every question and have not left any blanks – particularly in SECTION B and SECTION E – they must write a 0 (ZERO) if the answer is nil and not leave any blanks
DAUGHTER QUESTIONNAIRE
Emphasise to daughters that this is not a test
M.A.D.E 4 Life staff member must sit with daughters and read each question as it is written. For the younger girls, show them the smiley face chart when you read the answer options and get them to point to their answer. E.g.
Almost Sometimes Almost never always a) I enjoy walking in the rain 1 2 3 When asking the girls and reading the word ‘almost always’ point to the smiley face card to help prompt their answer.
Ensure daughter is 100% sure they understand what the question is asking (don’t hesitate to re-read question)
If there are any comments or questions asked for any of the questions, please write down these on paper supplied to give to Alyce at end of session
This should take the daughters <5 minutes to complete the 1 page of questions
M.A.D.E 4 Life Assessment Protocol 2011
Accelerometer Protocol
VISIT ONE
Checklist:
Accelerometers Accelerometer Master spread sheet Activity Monitor Information Sheet (1 for each mother and each daughter) Accelerometer Log (1 for each mother and each daughter)
Introduction Script Thank you for helping us in the MADE 4 Life program. Mothers and Daughters in the program will be doing the same thing as you to help us find ways of keeping active, skilled and healthy. Today we’re going to show you how to put on an accelerometer, how it works and when you should and should not wear it. Next week, we will need you to return your accelerometers to us at uni (in the MADE 4 Life drop box – HPE building). You will be provided with a reward for bringing it back on time.
Instructions:
1. Distribute the Activity Monitor Information Sheet (see below, page 7). Point out Alyce’s phone number on the on this sheet in case they have any problems or questions regarding their accelerometer (02 49216566). 2. “Alyce” will go through the Activity Monitor Information Sheet with the Mothers and Daughters. 3. Tell Mothers and Daughters that they should behave normally and not do things just because they are wearing the monitor. 4. Explain that it is very important for Mothers and Daughters who wear their monitor for the whole week to return it on time. 5. Explain to Mothers and Daughters that they will receive a text message during the week to encourage them to wear their accelerometer and again the day before they need to return their accelerometer to school so researchers can collect them back. Alyce will go through the Accelerometer Log instructions (see below, page 9) with the Mothers and Daughters and get them to fill in their name, and dates for the next 8 days (starting from today). Ask Mothers and Daughters to fill in when they put on their accelerometer on their Activity Log (eg ON 7am). 6. Have accelerometers set up beforehand in separate bags according to their belt size. 7. Mothers and Daughters line up and are given a monitor and belt based on what looks like a good fit.
M.A.D.E 4 Life Assessment Protocol 2011
8. Ask each Mother and Daughter to put on their own accelerometer outside their clothes, and pull it firmly. Explain that once it is fitted correctly they should put it underneath their clothes (ie on their skin). 9. Ask girls to check the accelerometer is: a. firm (does not bounce but shouldn’t be uncomfortably tight) b. sticker facing upwards (pointing towards the sky) c. on the right hip (in line with the middle of their right knee) 10. M.A.D.E 4 Life staff then check each mother and daughter’s accelerometer to make sure it is on properly using the above criteria. If the belt is the wrong size then the girl should be given a different size. M.A.D.E 4 Life staff should also double-back the belt through the buckle to ensure the belt does not become loose. 11. Once M.A.D.E 4 Life staff have checked that each mother and daughter’s monitor is on correctly, ask them to take out their monitor log. The M.A.D.E 4 Life staff write down each mum’s mobile number on the Master Sheet (see below) and their accelerometer number on their master sheet as well as the girl’s accelerometer log. The date and type of monitor (OLD/NEW) need to also be recorded on the master sheet. If the Mother and Daughter does not have a mobile then ask for their home phone number. On the old monitors the number is located on the bottom of the monitor and on the new monitors the number is located on the back of the monitor. Sometimes there will be two numbers visible on the new monitors. If this is the case please use the number starting with ‘LYN’. Be careful when writing down these numbers as one incorrect number makes it extremely difficult to track that monitor. 12. Ask the Mothers and Daughters if they have any questions. 13. Finally, ask Mothers and Daughters some prompt questions regarding their accelerometer such as: a. When do you wear it? b. When don’t we wear it? c. What do we write on the log? Have you gone through the following with the mums & daughters:
Sticker facing up On the left or right (preferred) hip in line with the middle of right or left knee Firm On the skin Off – bed and water Maintain normal activities Filling in log Text messages Check each accelerometer Record mobile no. and accelerometer no. carefully on assessment recording sheet
M.A.D.E 4 Life Assessment Protocol 2011
ACTIVITY MONITOR INFORMATION SHEET
Please do not hesitate to call Alyce Cook on (02) 4921 6566, please leave a message at this number if you have any questions or concerns about your monitor.
What does the monitor do? The monitor records all movement, so that when you watch television, play outside, or eat dinner, it records how much and how often you move your body.
Does the monitor hurt? No. The monitor is attached to a soft elastic belt and worn under your clothes. You may be aware of the monitor when you first start to wear it, but it will not hurt.
When do you put your monitor ON? - The monitor is to be put on as soon as you wake up each morning. - You are to wear the monitor under your clothes over the right hip (not in the middle near their belly- button), making sure that it is the correct way up (The sticker on the top of the monitor should be facing upwards i.e. pointing towards the sky). The monitor should fit firmly so that the elastic belt can not bounce, but should not be uncomfortably tight. - Write the time when the monitor is put on (see activity monitor log). - The monitors are not water-proof, so please remember that the monitor is not to be worn in the shower, bath or when swimming or playing in aquatic areas.
When do you take OFF the monitor? - The monitor should be taken off when you go to bed, or if there is a chance that the monitor could get wet (eg playing near water). Please note on the monitor diary any specific time periods that the monitor is taken off and why (eg 3.30-4.30pm on Wednesday – Swimming at the beach). - The monitor is to be worn for all waking hours for all 8 days. At the end of each day please write the time the monitor is taken OFF (see activity monitor log).
What do I do at the end of the 8 days? Please keep wearing your monitor for 7 days in a row. On day 8 please return to the HPE building in the M.A.D.E 4 Life Drop Box (in corridor).
What if I damage or lose the monitor? You will NOT have to pay for the monitor if you damage or lose it.
The monitors are expensive, so please take care of them. It is quite a sturdy piece of equipment, but will be damaged if thrown or forcefully dropped. You should not lose the monitor because it is securely fitted to a belt, and should not be removed except for during aquatic activities and sleeping.
M.A.D.E 4 Life Assessment Protocol 2011
ACCELEROMETER LOG SHEET
Full Name …………………………………. Monitor ID Number ……………….…. Mother / Daughter (circle) INSTRUCTIONS: 1. Please shade in the times that the activity monitor was ON 2. During the times the monitor was OFF please indicate what you were doing and the time the monitor was OFF. 3. Please indicate any time spent swimming, riding a bike, or playing on a trampoline. 4. See the example on the left hand side of the page for how to complete the log.
EXAMPLE:
Date Monday 20/5 Date
12-1 Sleep 12-1
1-2 Sleep 1-2
2-3 Sleep 2-3
3-4 Sleep 3-4
4-5 Sleep 4-5 AM 5-6 Sleep AM 5-6
6-7 Sleep 6-7
7-8 ON 7-8
8-9 BIKE RIDING 8-9
9-10 9-10
10-11 10-11
11-12 11-12
12-1 12-1
1-2 1-2
2-3 2-3
SWIMMING 3-4 OFF 3-4 SHOWER 4-5 OFF 4-5 PM 5-6 ON PM 5-6
6-7 6-7
7-8 7-8
8-9 8-9
9-10 BED 9-10 OFF
10-11 Sleep 10-11
11-12 Sleep 11-12
Total time swimming for the day: Total time riding a bike for the day: Total time using a trampoline for the day:
M.A.D.E 4 Life Assessment Protocol 2011
Date
12-1
1-2
2-3
3-4
4-5
AM 5-6
6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
PM 5-6
6-7
7-8
8-9
9-10
10-11
11-12
Total time swimming for the day: Total time riding a bike for the day: Total time using a trampoline for the day:
M.A.D.E 4 Life Assessment Protocol 2011
Master spreadsheet - Accelerometer tracking
Group: ______Date: ______
Assessment (circle): Baseline 10–week 20–week
Study ID Name Accel. Accel. No. Mobile no. Date Date Log Returned Type Distributed Returned
M.A.D.E 4 Life Assessment Protocol 2011
Master spreadsheet - Accelerometer tracking
Group: ______Date: ______
Assessment (circle): Baseline 10–week 20–week
Study ID Name Accel. Accel. No. Mobile no. Date Date Log Returned Type Distributed Returned
Appendices
Appendix 27: MADE4LIFE MOTHER’S QUESTIONNAIRE BOOKLET
429 MOTHER QUESTIONNAIRE
BOOKLET
Name: ______
To protect your privacy this cover sheet will be removed and destroyed once you have been allocated a study number.
This questionnaire booklet is about your background information, behaviours and thoughts regarding physical activity.
Please answer every question you can as honestly as you can. If you are unsure about how to answer a question, mark the response for the closest answer to how you feel.
Please read the instructions above each question carefully. Some require you to only answer those options which are applicable to you. Other questions require you to mark one answer on each line.
This questionnaire contains the following sections:
SECTION A – Background Information
SECTION B – Physical Activity Behaviours
SECTION C – Parenting for Physical Activity
SECTION D – Physical Activity Beliefs
SECTION E – Sitting Time
SECTION F – Oldest Daughter’s Sitting Time
1 Study ID______
This page is blank
2 Study ID______
SECTION A – Background Information
The following questions are about you: These questions will help us to find out which mothers find the M.A.D.E 4 Life program helpful.
For Question 1: Please write neatly For questions 2 onwards, please tick the box. Please tick
1. What is your age? ______
2. How old were you when you left school? Please include both full and part time schooling. Never attended school 14 years or less 15-16 years 17-18 years 19 years or older
3. Are you currently attending an education institution? No Yes, part-time student Yes, full-time student
4. What is the highest qualification you have completed? No formal qualifications School certificate (Year 10 or equivalent) Higher school certificate (Year 12 or equivalent) Trade/Apprenticeship (e.g. Hairdresser/Chef) Certificate/Diploma (e.g. childcare, technician) University Degree Higher University Degree (e.g. Grad Dip, Masters, PhD)
5. Are you of Aboriginal or Torres Strait Islander origin? No Aboriginal Torres Strait Islander
6. In which country were you born? Australia - Go to Question 8 United Kingdom Italy Greece Vietnam Other (Which one?)
3 Study ID______
7. If you were not born here, when did you first arrive in Australia with the intention of living here for one year or more? 1987 or earlier 1989-1993 1994-1998 1999- 2003 2004 or later
8. What language do you usually speak at home? Tick one box only
I speak only English at home. (Go to Question 10)
Italian Greek Cantonese Mandarin German Arabic Another language (Which one?)
9. How well do you speak English? Very well Well Not well Not at all
10. What is your PRESENT marital status? Married Defacto Separated Divorced Widowed Never married
11. What is your postcode?
4 Study ID______
12. What is your average gross (before tax) income? Tick one box
No income $1-$119 per week ($1-$6,239 annually) $120-$299 per week ($6,240-$15,999 annually) $300-$499 per week ($16,000-$25,999 annually) $500-$699 per week ($26,000-$36,999 annually) $700-$999 per week ($37,000-$51,999 annually) $1,000-$1,499 per week ($52,000-$77,999 annually) $1,500 or more per week ($78,000 or more annually) Don't know Don't want to answer
13. What is the average gross (before tax) income of your household (e.g. you and your partner, or you and your parents sharing a house)? No income $1-$119 per week ($1-$6,239 per year) $120-$299 per week ($6,240-$15,999 per year) $300-$499 per week ($16,000-$25,999 per year) $500-$699 per week ($26,000-$36,999 per year) $700-$999 per week ($37,000-$51,999 per year) $1,000-$1,499 per week ($52,000-$77,999 per year) $1,500 or more per week ($78,000 or more per year) Don't know Don't want to answer I live alone
5 Study ID______
SECTION B – Physical Activity Behaviours
This section is about your usual leisure-time exercise habits.
For this question, we would like you to recall your average weekly participation in physical activity over the past month. How many times per week on average did you do the following kinds of physical activity during your free time over the past month?
When answering these questions please:
. Consider your average over the past month.
. Only count physical activity sessions that lasted 10 minutes or longer in duration.
. Do not count physical activity that was done as part of your employment or household chores.
. Note that the main difference between the three categories below is the intensity of the physical activity.
. Please write the average amount of times per week in the first column and the average time in the second column for strenuous, moderate, and mild physical activity.
. Please write ZERO (0) where you have no times per week or no average session times
Times Per Average Time Week Per Session (minutes)
A. Strenuous physical activity (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 physical activity (not exhausting, light perspiration)
(e.g., fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, popular and folk dancing)
C. Mild physical activity (minimal effort, no perspiration)
(e.g., easy walking, yoga, archery, fishing, bowling, lawn bowling, shuffleboard, horseshoes, golf, snowmobiling)
Is the amount of activity you did in the past month less, more, or about the same as your usual physical activity habits?
I am now much I am now less I am now about I am now I am now much less active active the same more active more active 1 2 3 4 5
6 Study ID______
NOTE: Please use your oldest daughter participating in M.A.D.E4LIFE as the reference point for answering SECTION C.
Name of oldest daughter participating in M.A.D.E4LIFE
……………………………......
Name of person completing the survey
……………………………………......
7 Study ID______
SECTION C – Parenting for PA
The following question is about your Intention to do family physical activity
1. Over the next two months, how committed are you to participating in mother-daughter physical activity?
Tick one box Extremely uncommitted Very uncommitted Uncommitted Somewhat committed Committed Very committed Extremely committed
2. Prior to hearing about M.A.D.E 4 Life, how committed were you to participate regularly (at least for the next month) in mother-daughter physical activity?
Tick one box Extremely uncommitted Very uncommitted Uncommitted Somewhat committed Committed Very committed Extremely committed
3. In the past 7 days, how many days did you do any physical activities with your daughter, including things like active games, sports, or other physical activities, and so forth? Please include only activities where both you and your daughter were active.
______Days (answer 0 to 7)
4. Based on the last 30 days;
How often did you... Never Rarely Sometimes Frequently Always a) Play a game outdoors or exercise together
8 Study ID______
5. The following 2 questions are about your confidence. Tick the box that best describes your level of confidence relating to your daughter/s Physical Activity
How confident are you that you Not at all Slightly Somewhat Quite Extremely could: confident confident confident confident confident a) get your daughter to do something physically active, like dancing, skipping, playing outside when they want to watch TV/DVD or videos? b) prevent your daughter from becoming overweight?
6. The following 8 questions relate to role modelling and support
Strongly Strongly Disagree Agree Physical Activity disagree agree a) I go out of my way to enrol my daughter in sports and other activities that get her to be physically active. b) I often drive or take my daughter to places where she can be active (e.g., parks, playgrounds, sport games or practices) c) I often watch my daughter participate in sporting activities (e.g., watch your daughter perform at netball, soccer or a dance recital) d) I often organise family outings that involve physical activity (e.g. going for a walk or a bike ride) e) I frequently do something active with my daughter. f) I use my behaviour to encourage my daughter to be physically active. g) I encourage my daughter to be physically active by leading by example (by role modelling). h) I exercise or am physically active on a regular basis.
7. My daughter has a TV in her room Yes No
9 Study ID______
8. The following 5 questions relate to parental beliefs about physical activity Strongly Strongly Disagree Agree disagree agree a) Girls who do regular physical activity have more self-confidence. b) Girls who do regular physical activities are healthy. c) Girls who do regular physical activities will be healthier adults. d) All girls should be physically active every day e) Parents play an important role in whether their girls are physically active when they grow up.
9. The following 5 questions relate to your self-confidence to do physical activity with your daughter
How hard would it be to . . . Not Very ------hard at hard all a) Get your daughter to be physically active 1 2 3 4 instead of watching TV b) Get your daughter to go for a walk with you? 1 2 3 4 c) Be physically active with your daughter each 1 2 3 4 week? d) Take your daughter to the park? 1 2 3 4 e) Go for a walk with your daughter? 1 2 3 4
10. The following 6 questions relate to your support of your daughter’s physical activity level
Almost Almost ------never always a) I try to get my daughter to play outside 1 2 3 4 b) I try to get my daughter to be active instead of 1 2 3 4 watching TV c) I do physical activity with my daughter each 1 2 3 4 week d) I take my daughter to practice, dance, or other 1 2 3 4 physical activity programs e) I take my daughter to the park 1 2 3 4 f) I go for a walk with my daughter 1 2 3 4
10 Study ID______
SECTION D - Physical Activity Beliefs
PHYSICAL ACTIVITY
‘Regular physical activity’ is defined as doing activities such as brisk walking, recreation, and sporting activities all at a moderate intensity of a brisk walking pace. Moderate intensity does not have to mean huffing and puffing and sweating. These free-time activities do not include household chores or physical labour on the job.
For moderate activity to be regular, your activity must: Add up to a total of 30 minutes or more per day Be done at least 5 days per week Add up to a total of 150 minutes or more per week
There are a number of ways that you could reach your 30 minute total. You could, for example: Take a half-hour brisk walk or bicycle ride Or Take three, 10-minute periods of activities; such as a brisk walk for 10 minutes, swimming for 10 minutes and climbing stairs for exercise for 10 minutes, all in the same day.
Self Efficacy
These questions are about your confidence. Please tick the box that best describes your level of confidence.
Over the next two months, how confident are you that you can:
Completely Quite Somewhat Slightly Not at all confident confident confident confident confident
a) participate in ‘regular physical activity’ when you feel tired?
b) participate in ‘regular physical activity’ when you are in a bad mood?
c) participate in ‘regular physical activity’ when the weather is bad?
d) Add ‘regular physical activity’ into your daily routine?
e) Arrange your schedule to include ‘regular physical activity’?
11 Study ID______
Outcome Expectations:
These questions are about your beliefs about the effects of regular physical activity on your health. Please tick the box that best describes your beliefs.
If you complete ‘regular physical activity’ daily for the next two months, how likely is it that you will:
Extremely Very Somewhat A little Not at likely likely likely likely all likely
a) Increase your fitness? b) Improve your health? c) Experience weight loss or get control of your weight?
Social Support:
How much support do you receive to participate in ‘regular physical activity’ from the people closest to you?
Please tick one box No support A little bit of support Some support Quite a lot of support A great deal of support
Intention:
Please indicate how strongly you agree or disagree with the statement, “I intend to participate in ‘regular physical activity’ over the next two months?”
Please tick one box Strongly Agree Agree Neither agree nor disagree Disagree Strongly disagree
12 Study ID______
SECTION E – Sitting time
These questions are about time you spend sitting during your typical work days (considered as paid work) and non-work days.
Please estimate how much time you spent SITTING in each of the following activities on your last typical WORKING day (considered as paid work) and your last typical NON-WORKING day (ie weekend day or day off paid work). Please write an answer in every box, even if it is 0.
For these Questions: Please write neatly
SITTING TIME SITTING TIME LAST LAST TYPICAL TYPICAL PAID NON-WORK WORK DAY DAY hours mins hours mins For TRANSPORT (eg in car, bus, train etc)
At WORK (eg sitting at a desk or using a computer)
Watching TV
Using a computer at home (eg email, games, information, chatting)
Other leisure activities (socialising, movies, etc, but NOT including TV or computer use)
How much time did you spend SLEEPING on each of these days?
1. In a typical week do you undertake paid work (Please circle)? YES NO (Go to questions on next page)
2. If YES to Q1, how many hours do you work on a typical paid work day?
______
3. If YES to Q1, how many days do you work in a typical paid working week?
______
13 Study ID______
NOTE: Please use your oldest daughter participating in M.A.D.E4LIFE as the reference point for answering SECTION F.
Name of oldest daughter participating in M.A.D.E4LIFE
……………………………......
Name of person completing the survey
……………………………………......
14 Study ID______
SECTION F – Oldest Eligible Daughter Sitting Time
Which of the following LEISURE activities does your daughter USUALLY do during a typical WEEK? (since the start of the school year, do NOT include school holidays)
Notice that this question asks you how many hours/minutes your daughter does each particular activity for the whole week or weekend.
During a typical WEEK what Does your Total hours/minutes Total hours/minutes leisure activities does your daughter usually Monday-Friday Saturday & Sunday DAUGHTER usually do? do this activity?
EG. TV No1 Yes2 15hrs 6hrs 30mins
TV / videos No1 Yes2
Playstation / Nintendo / No1 Yes2 computer games Computer / Internet No1 Yes2
Homework No1 Yes2
Play indoors with toys No1 Yes2
Sitting talking No1 Yes2
Talk on the phone No1 Yes2
Listen to music No1 Yes2
Musical instrument No1 Yes2
Board games/cards No1 Yes2
Reading No1 Yes2
Art & craft (eg. pottery, sewing, No1 Yes2 drawing Imaginary play No1 Yes2
Travel by car / bus No1 Yes2 (to and from school) Other (please state) No1 Yes2 ______
------End of Questionnaire------
Thank you for taking the time to complete the M.A D.E 4 Life Questionnaire. 15 Study ID______
Appendices
Appendix 28: MADE4LIFE ACTIVITY INFORMATION SHEET & MONITOR LOG
445 ACTIVITY MONITOR INFORMATION SHEET Please do not hesitate to call Alyce Cook on (02) 4921 6566, please leave a message at this number if you have any questions or concerns about your monitor.
What does the monitor do? The monitor records all movement, so that when you watch television, play outside, or eat dinner, it records how much and how often you move your body.
Does the monitor hurt? No. The monitor is attached to a soft elastic belt and worn under your clothes. You may be aware of the monitor when you first start to wear it, but it will not hurt.
When do you put your monitor ON?
- The monitor is to be put on as soon as you wake up each morning. - You are to wear the monitor under your clothes over the right hip (not in the middle near their belly-button), making sure that it is the correct way up (The sticker on the top of the monitor should be facing upwards i.e. pointing towards the sky). The monitor should fit firmly so that the elastic belt can not bounce, but should not be uncomfortably tight. - Write the time when the monitor is put on (see activity monitor log). - The monitors are not water-proof, so please remember that the monitor is not to be worn in the shower, bath or when swimming or playing in aquatic areas.
When do you take OFF the monitor? - The monitor should be taken off when you go to bed, or if there is a chance that the monitor could get wet (eg playing near water). Please note on the monitor diary any specific time periods that the monitor is taken off and why (eg 3.30-4.30pm on Wednesday – Swimming at the beach). - The monitor is to be worn for all waking hours for all 8 days. At the end of each day please write the time the monitor is taken OFF (see activity monitor log).
What do I do at the end of the 8 days? Please keep wearing your monitor for 7 days in a row. On day 8 please return to the HPE building in the M.A.D.E 4 Life Drop Box (in corridor).
What if I damage or lose the monitor? You will NOT have to pay for the monitor if you damage or lose it.
The monitors are expensive, so please take care of them. It is quite a sturdy piece of equipment, but will be damaged if thrown or forcefully dropped. You should not lose the monitor because it is securely fitted to a belt, and should not be removed except for during aquatic activities and sleeping.
BASELINE ACCELEROMETER LOG SHEET Full Name …………………………………. Monitor ID Number.....……………….…...... Mother /
Daughter (circle) INSTRUCTIONS: 1. Please shade in the times that the activity monitor was ON 2. During the times the monitor was OFF please indicate what you were doing and the time the monitor was OFF. 3. Please indicate any time spent swimming, riding a bike, or playing on a trampoline. 4. See the example on the left hand side of the page for how to complete the log. EXAMPLE:
Date Monday 20/5 Date
12-1 Sleep 12-1
1-2 Sleep 1-2
2-3 Sleep 2-3
3-4 Sleep 3-4
4-5 Sleep 4-5 AM 5-6 Sleep AM 5-6
6-7 Sleep 6-7
7-8 ON 7-8
8-9 BIKE RIDING 8-9
9-10 9-10
10-11 10-11
11-12 11-12
12-1 12-1
1-2 1-2
2-3 2-3
SWIMMING 3-4 OFF 3-4
4-5 SHOWER 4-5 OFF PM 5-6 ON PM 5-6
6-7 6-7
7-8 7-8
8-9 8-9
BED 9-10 OFF 9-10
10-11 Sleep 10-11
11-12 Sleep 11-12
Total time swimming for the day: Total time riding a bike for the day: Total time using a trampoline for the day:
Date DAY 8 12-1
1-2
PLEASE RETURN LIFE TOPLEASE 4 DROP CORR M.A.D.E IN BOX
2-3
3-4
4-5
AM 5-6
6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
PM 5-6
IDOR BUILDING HPE OF
6-7
7-8
8-9
9-10
10-11
11-12
Total time swimming for the day: Total time riding a bike for the day: Total time using a trampoline for the day:
Appendices
Appendix 29: MADE4LIFE TEACHER INFORMATION SHEET
449 Miss Alyce Cook School of Education University of Newcastle Callaghan NSW 2308 P 49216566 F 49217005 [email protected]
Dear Teacher
______is participating in the M.A.D.E. (Mothers and Daughters Exercising) 4 Life research program at the University of Newcastle. Over the next week she will be wearing an accelerometer (a small activity monitor that is worn on the waist that measures activity intensity) to school which will collect data on her activity. The accelerometer is an expensive piece of equipment ($400) that cannot get wet. If she is involved in any activities where she may get wet can you please ask her to remove the accelerometer. Once the activity is complete she will need to put the accelerometer back on. The accelerometer is to be worn just above her hip. I have asked her not to share it with any of her classmates.
If you have any queries about the research please feel to contact me. I have also included a copy of the Activity Monitor Information Sheet for your information.
Thank you for your cooperation.
Kind regards,
ACTIVITY MONITOR INFORMATION SHEET
Please do not hesitate to call Alyce Cook on (02) 4921 6566, please leave a message at this number if you have any questions or concerns about your monitor. What does the monitor do? The monitor records all movement, so that when you watch television, play outside, or eat dinner, it records how much and how often you move your body. Does the monitor hurt? No. The monitor is attached to a soft elastic belt and worn under your clothes. You may be aware of the monitor when you first start to wear it, but it will not hurt. When do you put your monitor ON?
- The monitor is to be put on as soon as you wake up each morning.
- You are to wear the monitor under your clothes over the right hip (not in the middle near their belly-button), making sure that it is the correct way up (The sticker on the top of the monitor should be facing upwards i.e. pointing towards the sky). The monitor should fit firmly so that the elastic belt can not bounce, but should not be uncomfortably tight.
- Write the time when the monitor is put on (see activity monitor log).
- The monitors are not water-proof, so please remember that the monitor is not to be worn in the shower, bath or when swimming or playing in aquatic areas. When do you take OFF the monitor?
- The monitor should be taken off when you go to bed, or if there is a chance that the monitor could get wet (eg playing near water). Please note on the monitor diary any specific time periods that the monitor is taken off and why (eg 3.30-4.30pm on Wednesday – Swimming at the beach).
- The monitor is to be worn for all waking hours for all 8 days. At the end of each day please write the time the monitor is taken OFF (see activity monitor log). What do I do at the end of the 8 days? Please keep wearing your monitor for 7 days in a row. On day 8 please return to the HPE building in the M.A.D.E 4 Life Drop Box (in corridor). What if I damage or lose the monitor? You will NOT have to pay for the monitor if you damage or lose it. The monitors are expensive, so please take care of them. It is quite a sturdy piece of equipment, but will be damaged if thrown or forcefully dropped. You should not lose the monitor because it is securely fitted to a belt, and should not be removed except for during aquatic activities and sleeping.
Appendices
Appendix 30: MADE4LIFE PROCESS EVALUATION QUESTIONNAIRE
452 MADE 4 LIFE Mother end of program evaluation_v1
M.A.D.E 4 LIFE Program Evaluation – 10 Weeks
Name: ______
Date of Birth: ______
To protect your privacy this cover sheet will be removed and destroyed once your study number has been checked and placed on each page.
We would like to know what you thought of the M.A.D.E 4 LIFE program and would be grateful if you could complete the following questions. Your responses will help us improve the program for the future. Please answer every question you can as honestly as you can. If you are unsure about how to answer a question, mark the response for the closest answer to how you feel.
1 MADE 4 LIFE Mother end of program evaluation_v1
General feedback questions
1. What did you like about the M.A.D.E 4 LIFE program?
2. Please tell us if there was anything about the M.A.D.E 4 LIFE program you didn’t like.
3. Do you have any other comments about the M.A.D.E 4 LIFE program you think might be useful to the researchers?
2 MADE 4 LIFE Mother end of program evaluation_v1
Your thoughts before you started the program
4. Why did you decide to join up for the M.A.D.E 4 LIFE program? (Rank those that apply starting with 1 – most important reason) I wanted to be more active
I wanted to spend more time with my daughter(s)
I wanted to learn about improving my daughter(s) health
My daughter(s) encouraged me to sign up
My husband/partner encouraged me to sign up
Other ……………………………………………… ……………………………………………………… ………………………………………………………
5. Have you tried to increase your physical activity levels before?
No (go to next page – “The Program”)
Yes
6. How did you try to increase your physical activity? (Tick all that apply)
Gym membership
Boot camp/outdoor fitness
Dance/Zumba classes
Walking dates with friends
Personal trainer
Social sport competition
Other physical activity program/s (Please tell us) …………………………………………………………………. …………………………………………………………………. …………………………………………………………………. ………………………………………………………………….
3 MADE 4 LIFE Mother end of program evaluation_v1
The program
Agree Agree
Neutral
Strongly Strongly
Disagree Disagree
7. The program
a. The M.A.D.E 4 LIFE program was enjoyable SD D N A SA b. The program taught me how to increase my physical SD D N A SA activity levels c. The content of the program was relevant to my life SD D N A SA d. The games/activities were appropriate for myself and my SD D N A SA daughter(s) e. The session content was explained in a way that was SD D N A SA easy to understand f. The M.A.D.E 4 LIFE program provided me with the support I needed to help me increase my physical activity SD D N A SA levels g. I would recommend the M.A.D.E 4 LIFE program to my SD D N A SA friends h. The timing of the program (4:00- 5:30pm) was convenient SD D N A SA
If there is a time you would have preferred please state: …………………………………….
Right
Too long Too Too short Too
i. The weekly session length (approx 90 minutes) was
j. The overall number of sessions (8) was
k. I would have liked more interactive sessions with my
daughter
Agree Agree
Neutral
Strongly Strongly
Disagree Disagree SD D N A SA If so, please state how many sessions you would have ……………………………………. liked:
l. Enjoyment of each Physical Activity session
Ok like
liked
Liked
Didn’t Didn’t
Really Really didn’t didn’t like ZUMBA RDL DL O L RL MOTHER & DAUGHTER GAMES RDL DL O L RL
BOXING RDL DL O L RL
FITNESS CIRCUIT RDL DL O L RL
GYMSTICKS RDL DL O L RL
FITBALLS RDL DL O L RL
PILATES & YOGA RDL DL O L RL
4 MADE 4 LIFE Mother end of program evaluation_v1
ROUGH & TUMBLE PLAY RDL DL O L RL
SKIPPING RDL DL O L RL
BACKYARD GAMES RDL DL O L RL
THE AMAZING RACE RDL DL O L RL
m. Which of the information session topics did you use to
help you increase your physical activity levels? (please tick)
Physical activity recommendations Reduce your sitting time
Data shown from the NSW Schools SMART GOALS Physical Activity Nutrition Survey
Mums as role models & facilitators Pedometer chart record
Health related components of Screen time recreation fitness
Fundamental Movement Unplug & Play resources Skills
Family ACTIVation Pack Get in ‘their’ world
Barriers to Physical Activity Rough & Tumble Play & Solutions
Pathways & Possibilities for
Physical Activity
Agree Agree
Neutral
Strongly Strongly
Disagree Disagree
8. The facilitators
a. The facilitators had a high level of knowledge SD D N A SA
b. The facilitators had good communication skills SD D N A SA
c. The facilitators were approachable SD D N A SA d. The facilitators motivated me to apply the principles SD D N A SA presented in the program
Poor Fair Average Good Excellent
e. Overall, I would rate the facilitators
5 MADE 4 LIFE Mother end of program evaluation_v1
9. Pink Slips a. The Pink Slip activities were valuable because they (tick as many as apply):
- helped me increase my level of physical activity
- helped increase my daughters level of physical activity
- helped me increase my active time with my daughters
- gave me more ideas about how to be active
- helped keep me on track for my SMART goals
- Other (please tell us)……………………………………………………
Too Too Too
little little
Right much
b. The time commitment required to complete Pink Slip
activities was
Agree Agree
Neutral
Strongly Strongly
Disagree Disagree
c. My daughter(s) enjoyed using the SD D N A SA completing the weekly worksheet d. The weekly worksheet were a valuable SD D N A SA resource for my daughter(s) e. The activities in the weekly worksheet SD D N A SA were appropriate for my daughter’s age f. The weekly worksheet activities encouraged my daughter(s) and I to do SD D N A SA
things together
Too Too Too
little
Right much
g. The number of activities in the weekly
worksheet was
6 MADE 4 LIFE Mother end of program evaluation_v1
10. The M.A.D.E 4 LIFE Program and my husband/partner
a. My husband/partner believed that the M.A.D.E 4 Life SD D N A SA Program was a positive experience for the family b. The M.A.D.E 4 Life program had a positive impact on my SD D N A SA husband’s/partner’s physical activity levels
c. The M.A.D.E 4 Life program had a positive impact on my SD D N A SA husband’s/partner’s dietary behaviours
d. The M.A.D.E 4 LIFE program changed my husband's/partner’s parenting practices in relation to SD D N A SA healthy lifestyles (i.e. role modelling, support)
Please add any comments about your husband/partner’s perceptions of the program:
After the M.A.D.E 4 LIFE program
1. Changes in behaviour
As a result of attending the M.A.D.E 4 LIFE program: a. My family is more active together SD D N A SA
b. I spend more time being active with my daughter(s) SD D N A SA
c. My role as a mother has changed for the better SD D N A SA
d. My family’s eating habits have changed for the better SD D N A SA
e. What are your family doing differently? (Tick as many as
apply)
We are more active together
We spend more time together
We use ‘active toys’ more than before the program began
Other (please tell us…………………………………………………………………………………)
7 MADE 4 LIFE Mother end of program evaluation_v1
f. Have you changed any of your dietary No intake as a result of the M.A.D.E 4 Life program? Yes
If so, in what way? (please tell us …………………………………………………………………)
2. Do you think people would be willing to pay for the
M.A.D.E 4 LIFE program? No (Skip to Q.14)
Yes
3. How much do you think people would be willing to
pay for the M.A.D.E 4 LIFE program?
$
4. Would you be willing to be interviewed about the M.A.D.E 4 LIFE program? (This would be a brief phone interview focussing on your thoughts about the program, its strengths/weaknesses and improvements that might be needed) Yes
No If Yes, please add your name and contact details here Note: this page will be removed to leave your evaluation
information((this page anonymous will be removed from your
Name:…………………………………………………………..
Best phone contact:………………………………………….
Best time to contact you……………………………………..
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE. YOUR COOPERATION IS GREATLY APPRECIATED.
8 Appendices
Appendix 31: TABLE A2: MADE4LIFE EXTENDED OPEN ENDED QUESTIONS
461 Table A2: MADE4Life Extended Open Ended Questions MADE4Life Wait-list Control Item (n=18) (n=13) Program start time
4:15 5 pm 5 5 pm If there is a time you would have preferred 4:30 3 pm 5 please state: 5 pm 4:30 5 pm 4:30 Number of program sessions
2/week 2/week Please state how many sessions you would 2/week 2/week 2/week have liked: 2/week 2/week Husband/partner perspective on MADE4Life
My husband was supportive My husband thought it was great that the girls and I were doing the program as he is a triathlete and He thought it was positive for us to do. He is is very physically active already quite physically active so it didn't later his My husband has also started jogging with the dogs practises/diet instead of strolling and we all play netball together Please add any comments about your He thought it was a good idea 2 on 2 husband/partner’s perceptions of the Husband already does active games with kids He thought it was a great thing and strongly when time permits. Hence no change. Usually only encouraged us program: time to do pink slips were when he wasn't home, My husband is very active with the kids and joined hence no impact on his activity levels in on a couple of the backyard games and family He was delighted that we were involved. He'd like activation a\pact activities to be involved in a Dads & Daughters program! I loved the program-I was disappointed one of my daughters found it a challenge and appreciated the help of Alyce with that. I would have enjoyed it more if my eldest daughter had Other child(ren) perspective on
MADE4Life
Enjoyed it, we both felt calm & relaxed on the They thought it was fair and good that I got to way home spend time with my daughter for special time My other daughter is only 4, didn't really know My children really enjoyed the program and it a lot about what we did encouraged them to be more physically active My daughter and I loved this program and She loved it and wants it to go for longer. She really has made us aware of our lack of activity also said she liked the Zumba and skipping Please add any comments about your other and gave us great ideas to increase it best. 'I loved it' thankyou for taking me! Other children have joined in pink slip activities children’s perceptions of the program: The girls looked forward to MADE each week when appropriate, but they were already and were motivated by the pink slips encouraged to be active My eldest daughter really enjoyed the time Son was jealous & made it very hard to come with me. My other two daughters were upset to weekly as well as doing any activities be left out and not have me around for an Son was quite jealous and wants to be extra 2 hours each week involved in something similar! Friends/other school mothers’ perspective on MADE4Life The think it was great and wished they had enrolled in it It seemed to them that it was a long time They were interested and thought it sounded Other mums thought it was a good idea, but like a good idea depended on their other time commitments Many want to know why there is not a similar Lots of mums were very interested and said fitness program running for not just mums and they would love to take part daughters but mum & children because Please add any comments about your Positive otherwise it's difficult for mums to find time to friends/other school mothers perceptions of Concerns about adding extra task into a busy exercise - especially single mums schedule. Care of siblings. Made them think the program: Sounds great, wanted to join. Asked where about how they play with their children. found it They love the idea and would like to be Most people I have spoken to about this involved in future programs program have been very interested They have all been very interested and Interested to find out the results of the supportive. School staff were also interested research. Great to spend quality girl time particularly in outcomes together
Changes in behaviour as a result of
MADE4Life What are your family doing differently? We have purchased some outdoor activities We talk about healthy food & the sorts of Other (please tell us) scoop ball/egg & spoon/beanbags/hoops games we can play together Changes in dietary behaviour as a result
of MADE4Life cut out on non-nutritional snacks More water & trying to reduce junk food More healthy snacks after school Eat more vegetables & fruit Healthier options different eating habits More fruit instead of sweet snacks How have you changed your dietary intake? This was in conjunction with MEND through Tried, but a diet plant along with the program Hunter Health would be good More conscious of healthy snacks We try to eat better
MADE4Life Wait-list Control Item (n=18) (n=13) Program start time
4:15 5 pm 5 5 pm If there is a time you would have preferred 4:30 3 pm 5 please state: 5 pm 4:30 5 pm 4:30 Number of program sessions
2/week 2/week Please state how many sessions you would 2/week 2/week 2/week have liked: 2/week 2/week
Husband/partner perspective on MADE4Life
My husband was supportive My husband thought it was great that the girls and I were doing the program as he is a triathlete and is He thought it was positive for us to do. He is already very physically active quite physically active so it didn't later his My husband has also started jogging with the dogs practises/diet instead of strolling and we all play netball together Please add any comments about your He thought it was a good idea 2 on 2 husband/partner’s perceptions of the Husband already does active games with kids when He thought it was a great thing and strongly time permits. Hence no change. Usually only time to encouraged us program: do pink slips were when he wasn't home, hence no My husband is very active with the kids and joined impact on his activity levels in on a couple of the backyard games and family He was delighted that we were involved. He'd like to activation a\pact activities be involved in a Dads & Daughters program! I loved the program-I was disappointed one of my daughters found it a challenge and appreciated the help of Alyce with that. I would have enjoyed it more if my eldest daughter had Other child(ren) perspective on
MADE4Life
Enjoyed it, we both felt calm & relaxed on the way They thought it was fair and good that I got to home spend time with my daughter for special time My other daughter is only 4, didn't really know a My children really enjoyed the program and it lot about what we did encouraged them to be more physically active My daughter and I loved this program and really She loved it and wants it to go for longer. She has made us aware of our lack of activity and also said she liked the Zumba and skipping Please add any comments about your other gave us great ideas to increase it best. 'I loved it' thankyou for taking me! Other children have joined in pink slip activities children’s perceptions of the program: The girls looked forward to MADE each week when appropriate, but they were already and were motivated by the pink slips encouraged to be active My eldest daughter really enjoyed the time with Son was jealous & made it very hard to come me. My other two daughters were upset to be weekly as well as doing any activities left out and not have me around for an extra 2 Son was quite jealous and wants to be involved in hours each week something similar! Friends/other school mothers’
perspective on MADE4Life The think it was great and wished they had It seemed to them that it was a long time enrolled in it Other mums thought it was a good idea, but They were interested and thought it sounded depended on their other time commitments like a good idea Lots of mums were very interested and said they Many want to know why there is not a similar would love to take part fitness program running for not just mums and Please add any comments about your Positive daughters but mum & children because friends/other school mothers perceptions of Concerns about adding extra task into a busy otherwise it's difficult for mums to find time to schedule. Care of siblings. Made them think exercise - especially single mums the program: about how they play with their children. Sounds great, wanted to join. Asked where They love the idea and would like to be involved found it in future programs Most people I have spoken to about this They have all been very interested and program have been very interested supportive. School staff were also interested Interested to find out the results of the particularly in outcomes research. Great to spend quality girl time together Changes in behaviour as a result of
MADE4Life What are your family doing differently? We have purchased some outdoor activities We talk about healthy food & the sorts of Other (please tell us) scoop ball/egg & spoon/beanbags/hoops games we can play together Changes in dietary behaviour as a result
of MADE4Life cut out on non-nutritional snacks More water & trying to reduce junk food More healthy snacks after school Eat more vegetables & fruit Healthier options different eating habits More fruit instead of sweet snacks How have you changed your dietary intake? This was in conjunction with MEND through Tried, but a diet plant along with the program Hunter Health would be good More conscious of healthy snacks We try to eat better
Appendices
Appendix 32: MADE4LIFE AMAZING RACE RESOURCE
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Gymsticks & Fitballs
1. Mums pick a gymstick and Daughters pick a fitball
2. Mums check the gymstick cards & spend 60 seconds on each exercise
3. Daughters check the fitball cards & spend 60 seconds on each exercise
Push up tips Hover challenge Situp twist
1. Kneel on the mat Mothers & Daughters facing each other. Play push up tips for 60 seconds 2. Hover on your knees OR your toes for 60 seconds – Daughters – can you beat mum? 3. Sit on your mat with bent knees holding the ball and twist from side to side for 30 seconds 4. Daughters sit opposite mum holding ball & perform a sit up, meeting in the middle to pass the ball x 20
Hula Hoop challenge
1. Hula the hoop around your waist for 60 seconds 2. Hula the hoop around your ankle for 60 seconds 3. Hold your hoop next to you & jump through from side to side for 30 seconds 4. Mums & Daughters link arms to form a chain, aiming to get the hoop from one end to the other as quick as you can …. don’t let go!
Hurdles and Quick Step Ladder sprint
1. Quick step ladder – one foot in each, 2 feet in each, 1 in – 1 out, icky shuffle! 2. Race mum over the hurdles then race her in the quick step ladder 3. Run through the hurdles 5 times and the quick step ladder 5 times. 4. Try the ICKY SHUFFLE ------E V E R Y D A Y I M S H U F F L I N G
Eye of the Tiger Boxing
30 sec cross jab 30 sec hook 30 sec upper cut 30 second speedball 60 second random jumping around – 6 jabs Swap gloves and focus pads
Cone flip Tails
1. Mums vs Daughters 2. 90 seconds on each game!
Fundamental Movement Skills Soccer dribble between cones & goal shooting. 1. Daughter has 3 attempts to dribble ball and kick for goal, Mum tries to save the goal. 2. SWAP positions!
Rough & Tumble play 1. Pick your ‘safety’ word 2. On the mat play the following R&T games for 30 seconds each: Itchy fingers Shoulder slaps Chinese wrestle You’re so strong Sock wrestle
Skipping 1. Pick 2 flash cards for individual rope skipping & 2 flash cards for partner skipping. 2. Practise your skipping to the beat of the music. 3. Put it all together – spend 8 counts on each skipping skill. E.g 8 basic jumps 8 skier 8 partner loop 8 partner turns
Funky Dance Move 1. Mum and Daughter create your signature dance move to the tunes on the iPod for 8 counts each. 2. Put both moves together & break it down on the D-Floor for 60 seconds. 3. The M.A.D.E 4 Life team member will teach you a third move to add to your dance – put it all together & boogie girl for another 60 seconds!