i A COUPLES BASED APPROACH F OR INCREASING PHYSIC AL ACTIVITY AMONG COUPLES WITH T YPE 2 DIABETES by JENNALEE SHEA WOOLDR IDGE B.A., University of Colorado, Boulder, 2009 M.A., San Diego State University, 2012 A dissertation submitted to the Faculty of t he College of Liberal Arts and Sciences of the University of Colorado Denver in partial fulfillment of the requirements for the degree of Doctor of Philosophy Clinical Health Psychology 2017
ii This dissertation for the Doctor of Philosophy degree b y Jennalee Shea Wooldridge h as been approved for the Clinical Health Psychology Program b y Kevin S. Ma s ters, Chair Krista W. Ranby, Advisor Jonathan Sha f f er Amy Hueb schman n Date : December 16, 2017
iii Wooldridge, Jennalee Shea (PhD, Clinical Health P s ychology Program) A Couples Based Approach for Increasing Physical Activity among Couples with Type 2 Diabetes Dissertation Directed by Assistant Professor Krista W. Ranby ABSTRACT Engaging in physical activity lessens the effects of diabetes, yet many pa tients fail to meet recommended guidelines (Morrato et al., 2007). Forming plans for when and where to engage in physical activity (individual implementation intentions; individual IIs) has been shown to increase physical activity ( Prestwhich et al., 2012 ) A recently developed strategy has people form these plans with a partner (collaborative implementation intentions; collaborative IIs ; Prestwich et al., 2005 ) to engage the interpersonal context in which behavior occurs. The current study examine d whether collaborative IIs improve outcomes (e.g., partner investment in diabetes self management patient 's self efficacy for physical activity patient 's phys ical activity) over individual IIs and an education only control condition among couples in which one partner had been diagnosed with type 2 diabetes ( T2D ) We examine d aims using a prospective, longitudinal experimental design. The aims were 1) to examin e implementation outcomes (i.e. feasibility, acceptability, intervention fidelity) of a collaborative IIs intervention within a T2D population, 2) examine whether collaborative IIs as compared to individual IIs and control would be related to an increase i n patient perceived partner investment in diabetes self management, patient self efficacy for physical activity, patient perceived physical activity related social support, patient perceived physical activity related social control, and patient physical ac tivity intentions,
iv and 3) examine whether collaborative IIs as compared to individual IIs and control would be related to an increase in patient physical activity The collaborative IIs condition had a significantly greater self reported increase in recrea tional physical activity at 6 weeks compared to individual IIs and control conditions. However being assigned to the collaborative II condition did not predict an increase in physical activity as measured by accelerometer compared to the individual IIs an d control conditions. The collaborative IIs condition reported a greater increase in physical activity related social support at 6 weeks than those in the individual IIs and control conditions. Change in partner investment in diabetes self management and s elf efficacy for physical activity between baseline and 6 weeks did not differ between participants in the collaborative IIs condition and those assigned to individual II and control conditions. Future direction s and implications for interventions are disc ussed. The form and content of this abstract are approved. I recommend its publication. Approved: Krista W. Ranby
v ACKNOWLEDGEMENTS I am forever grateful to my mentor, Krista Ranby for believing in me and accepting me into her lab. Thank you for being so generous with your time and energy on all aspects of this project and throughout my time in the CHP program as a whole. I would also like to thank Kevin Masters for his guidance throughout the program. Thank you for helping me to think critically and grow as a researcher. Thank you to Amy Huebschman for helping with recruitment and for sharing your knowledge as a clinician and implementation scientist. Your expertise helped to improve the quality of my project. Thank you to Jonathan Shafer for also serving on my committee and providing valuable input. I would also like to thank Beth Allen as her research methods class was critical for developing the initial idea for this project and providing an outlet to obtain valuable feedback. Thank you to all the resear ch assistants for your hours of help and the manager of the Healthy Couples Lab, Sydneyjane Varner, who also put in a lot of time and effort into this project. Thank you to the students who came before me in the CHP program for setting the bar high and giv ing me someone to look up to. Thank you to all of my fellow students in the program that went through graduate school with me. We have had so much fun together and I cherish our friendship. Thank you to my parents teaching me to value education and pursue my goals. I wouldn't have been able to get through 6 years (and counting) of graduate school with out you. Lastly, thank you to my husband Rob for moving across the country with me twice, making me the best excel spreadsheets and making me dinner often. Yo ur love, support, and encouragement means the world to me.
vi TABLE OF CONTENTS CHAPTER I INTRODUCTION ................................ ................................ ................................ ......... 10 Diabetes ................................ ................................ ................................ ................. 10 Physical Activity and Diabetes ................................ ................................ ............. 11 Implementation intentions and physical activity ................................ .................. 13 Couple level processes and T2D ................................ ................................ .......... 14 Collaborative implementation intentions ................................ .............................. 16 Partner Investment ................................ ................................ ................................ 17 Other psychosocial constructs ................................ ................................ ............... 19 Successful Implementation ................................ ................................ ................... 19 The current study ................................ ................................ ................................ .. 20 Aims ................................ ................................ ................................ ...................... 20 II. METHOD ................................ ................................ ................................ ..................... 22 Participants ................................ ................................ ................................ ............ 22 Procedure ................................ ................................ ................................ .............. 24 Study Sample ................................ ................................ ................................ ........ 29 Measures ................................ ................................ ................................ ............... 33 Primary outcomes ................................ ................................ ................................ 33 Second ary Outcomes ................................ ................................ ............................ 36 Covariates ................................ ................................ ................................ ............. 38 Implementation outcomes ................................ ................................ ..................... 40
vii Data Analyses ................................ ................................ ................................ ....... 43 III. RESULTS ................................ ................................ ................................ ................... 44 Descriptive statistic s ................................ ................................ ............................. 44 Correlations of study variables at baseline ................................ ........................... 59 Correlations of study variables with covariates ................................ .................... 61 Implementation Outcomes ................................ ................................ .................... 64 Primar y Outcomes ................................ ................................ ................................ 68 Secondary Outcomes ................................ ................................ ............................ 69 IV. DISCUSSION ................................ ................................ ................................ ............. 73 Research Feasibility ................................ ................................ .............................. 73 Implementation Outcomes ................................ ................................ .................... 74 Prima ry and Secondary Outcomes ................................ ................................ ........ 76 Limitations ................................ ................................ ................................ ............ 80 Future Directions ................................ ................................ ................................ .. 82 APPENDIX A: ................................ ................................ ................................ .................. 98 PHYSICAL ACTIVITY PL ANS ................................ ................................ ..................... 98 APPENDIX B ................................ ................................ ................................ ................. 105 SELF REPORT AND PARTNER REPORT MEASURES ................................ ........... 105
viii LIST OF TABLES Table 1 Eligibility Criteria... 22 2 Timeline of Assessments, Compensation, and Particip ant contact.....24 3 Instructions for each Experimental Condition ....28 4 Demographics of the Sample ..32 5 Internal Consistency Reliabilities of Self Report Scales 42 6 Means and Standard Deviations of Study Measures at Baseline.46 7 Means and Standard Deviations of Study Measures at 3 Weeks.47 8 Means and Standard Deviations of Study Measures at 6 Weeks.48 9 Descriptive Statistics for Physical Activity Measures.49 10 Means and Standard Deviations of Physical Activity Outcome Measures by Condition and Time.57 11 Means and Standard Deviations of Study Measures by Condition and Time.58 12 Correlations among Primary and Secondary Outcomes at Bas eline...61 13 Correlations among Physical Activity Outcomes and Covariates at Baseline....63 14 Correlations among Secondary Outcomes and Covariates at Baseline...64 15 Physical Activity Plans: Collaborative Implementation Intentions Condition ..103 16 Physical Activity Plans: Individual Implementation Intentions Condition...105 17 Regression Summary: IPAQ Recreational METs at 6 Weeks ...72 18 Regression Summary: Physical Activity Related Support at 6 Weeks....73
ix LIST OF FI GURES Figure 1 CONSORT Flow Diagram ...30 2 Physical Activity Outcomes over Time by Condition...51 3 Self Efficacy for Physical Activity over time by Condition ....52 4 Diabetes Partner Investment over time by Cond ition53 5 Physical Activity Related Social Support over time by Condition...54 6 Physical Activity Related Social Control over time by Condition55 7 Physical Activity Intentions over time by Condition56 8 Acceptability of Intervention Conditions .68 9 Commitment to Activity Planning by Condition...67
10 CHAPTER I I NTRODUCTION Diabetes Diabetes mellitus, is a group of metabolic diseases in which the body's use of insulin to regulate blood gluc ose levels is impaired causing chronically high levels of blood glucose Type 1 diabetes refers to a condition where the body is unable to produce insulin. For people with Type 2 diabetes (T2 D), their body produces insulin; however their cells becom e r esistant to insulin, and therefore their body's ability to transport glucose from the blood stream to the cells is impaired T2D is the most common form of diabetes; lifestyle factors such as poor diet and physical inactivity are considered to be main con tributors to its development (Aizawa, Shoemaker, Overend, & Petrella, 2009; Centers for Disease Control and Prevention [CDC] 2014) The prevalence of diabetes is high and is increasing. In 2014, 9.3 % of the US adult popul ation had diabetes (CDC, 201 4 ), with T2D accounting for 90 95% of cases (Colberg et al., 2010) Each year approximately 1.5 million pe ople in the US are newly diagnosed with diabetes (C DC 2008) Diabetes is the seventh leading cause of death in the United States, and the leading cause of kidney failure, nontraumatic lower limb amputations, and new cases of blindness. People with diabetes are two to four times more likely than people without diabetes to die of heart disease or stroke and about 70% of people with diabetes have high blood pr essure (CDC, 2014 ) In addition, the prevalence of depression is almost twice as high in people with diabetes as compared to the general population (Ali, Stone, Peters, Davies, & Khunti, 2006)
11 Physical Activity and D iabetes Complications rela ted to T2D can be reduced through adherence to self management behaviors such as physica l activity (Warburton, Nicol, & Bredin, 2006) Physical activity is central to the management of T2D beca use it can delay or p revent diabetes complications and comorbid cardiovascular problems through multiple mechanisms. These mechanisms include lowering blood pressure, improving cholesterol levels, lowering body fat, improving joint function, i ncreasing sk eletal muscle mass, improving mental health and reducing stress (Colberg et al., 2010) In addition, regular physical activity can directly aid in the management of T2D by lowering blood glucose and decreasing insulin resistance (Awad, Gagnon, & Messier, 2004; Colberg et al., 2010) Both animal (Matos et al., 2010; Touati et al., 2011) and human research ( Duncan et al., 2003; Awad et al., 2004; Colberg et al., 2010) indicate that exercis e leads to increased insulin stimulated glucose uptake in skeletal muscle, a mechanism that is impaired at rest for people with T2D ( Colberg et al., 2010 ). A 2011 meta analysis indicated that a erobic exercise alone or in combination with resistance traini ng at least two times per week at moderate intensity is related to declines in glycated hemoglobin (HbA1c) triglyceride levels, waist circumference, and systolic blood pressure among people with T2D (Chudyk & Petrella, 2011) One study found tha t men with T2D who report about 130 minutes per week of moderate intensity walking or 90 minutes of jogging had an all cause and cardiovascular mortality risk that was 1.7 6.6 times lower than those who reported less physical activity (Church, LaMonte, Barlow, & Blair, 2005) Few rando mized trials have had sufficiently long follow up to ass ess changes in health outcomes; however, the Japan Diabetes Complications Study compared
12 a treatment arm of lifestyle counseling that included physical activity counseling as compared to usual care an d found a significant decrease in the rate of strokes for patients randomized to lifestyle after 8 years of follow up (S one et al., 2010) Physical activity can also contribute to weight loss, which leads to decreased fat tissue, and therefore better glucose absorption (Awad et al., 2004) W eight loss may be more difficult among people with T 2D than among the general population (Guare, Wing, & Grant, 1995) ; however, there is evidence that physical activity can improve glucose tolerance and insulin sensitivity regardless of weigh t loss and diet modification (Duncan et al., 2003 ; Chudyk & Petre lla, 2011; Touati et al., 2011) For example, Touati et al. (2011) found that among obese rats with metabolic syndrome exercise improved glucose, insulin, lipid profiles, and decr eased hypertension with or without diet modification. Similarly, Duncan e t al. (2003) found that among sedentary individuals physical activity improve d glucose tolerance and insulin sensitivity in the absence of weight loss. Despite the evidence for benefits of physical activity the majority of people with T2D do not engage in regular physical activity (Morrato, Hill, Wyatt, Ghushchyan, & Sullivan, 2007) It has been reported that only 23 37% of adults with T2D meet the recomme nded level of physical activity an estimate below that of the general population (Nwasuruba, Khan, & Egede, 2007) Individuals with T2D face barriers to physical activity including: lack of self efficacy not knowing what behaviors are appropriate for them, not knowing how to incorporate physical activity into their daily lives, perceived difficulty of exercise, fear of injury, and lack of social support ( Korkiakangas, Alahuhta, & Laitinen, 2009; Lim & Taylor, 2005 ; Huebschmann et al., 2011, 2015 ) As a result of
13 these barriers, individual des ires or intentions to engage in physical activity do not always translate into actual physical activity engagement ( Luszczynska & Aleksandra, 2006 ; De Vet, Oenema, Sheeran, & Brug, 2009; SkÂŒr, Sniehotta, Molloy, Prestwich, & AraÂœjo Soares, 2011) In t he general population, research on individual health behavior change suggests that there is an intention behavior gap, meaning that even strong intentions for positive behavior changes do not always result in actual behavior change (Sheeran, 2002; Webb & Sheeran, 2008) Implementation intentions and physical activity Implementation intentions, that is, specific plans an individual makes for when and where he or she will perform a particular behavior begin to bridge this intention behavior gap (G ollwitzer 1999) Making implementation intentions requires individuals to think through the barriers in their own life and create a plan that is most likely to succeed in that environment. In this way, implementation intentions combine reflective and au tomatic process es because an individual can exhibit conscious control over a behavior as well as pre select environmental cues to trigger the goal behavior (Rothman, Sheeran, & Wood, 2009) Individual implementation intentions (i ndividual IIs ) have been shown to be more predictive of behavior than general intention to perform the be havior ( Gollwitzer 1999; Luszczynska & Aleksandra, 2006) For physical activity specifically, f ormin g individual IIs have been shown to increase behavior (Gollwitzer, 1999; Luszczynska, 2006) ; yet, not all studies of ind ividual IIs to be beneficial ( Luszczynska & Aleksandra, 2006 ; De Vet et al., 2009; SkÂŒr et al., 2011) One explanation for this is that e nga ging in a regular physical activity routine can involve complex barriers including
14 personal and situational contexts as well as short term cost ( e.g. fatigue and soreness) that are not addressed by i ndividual IIs (Belanger Gravel, Godin, & Amireault, 2013) Couple level processes and T2D Given the inconsistent effects of individual IIs and the likelihood that different strategies are needed to impact different groups of people, alternative planning manipulations should be considered. One way in which individual IIs manipulations may be strengthened is through consideration of the individual's social environment ( O'Reilly & Emerson Thomas, 1989 ; Wallace, Raglin, & Jastremski, 1995 ; Hays & Clark, 1999; Korkiakangas et al., 2009 ) For married people, their romantic partner serves as an important source of support and influence on their behavior (Gottlieb, 2000) Fur ther, partner support is related to self efficacy (Robinson, Stapleton, & Turrisi, 2008) which is an established predictor of physica l activity C onsidering the interpersonal context of behavior change and the establishment of long term healthy lifestyle maintenance, couple level health processes are one promising area to incorporate into behavior change interventions Research has in dicated that there is a high concordance between partners' health behaviors (Meyler, Stimpson, & Peek, 2007) including physical activity (Li, Cardinal, & Acock, 2013) Fo r example, Pettee et al. ( 2006) found that among married older adults, approximately 65% of couples reported concordant levels of physical activity Further, romantic partners are highly interdependent; thus any significant lifestyle change made by one partner impacts the other. This relationship may be especially important for people wit h chronic illness as there is evidence that m anagement of chronic illnesses is often shared with a person's
15 spouse (Revenson, 2003; Berg & Upchurch, 2007; Searle, Norman, Thompson, & Vedhara, 2007) A study examining spousal support and physical activity in people with a chronic illness indicated that couples based interventions should focus on both partners as well as strategies for incre asing spousal support (Martire, 2013) It has also been demonstrated among people with knee osteoarthritis that spousal support relates to patient perceiv ed efficacy for exercising as well as actual energy expenditure from physical activity (Martire et al., 2013) Specific to people with T2D, s everal studies indicate that spousal interaction relates to patient's health behaviors and outcomes (Henry, Rook, Stephens, & Franks, 2013; Johnson et al., 2013; Khan, Stephens, Franks, Rook, & Salem, 2013) F or example, in a dyadic study of couples with T2D spousal involvement was related to higher levels of physical activity, energy expenditure, and efficacy to exercise (Khan et al., 2013) Similarl y, a focus group of 30 couples where at least one partner had a diagnos i s of diabetes, revealed that couples who felt they were "in this together" were better able to communicate and support each other and were more likely to engage in regular physical act ivity (Beverly, Penrod, & Wray, 2007) There is also evidence that a partner's illness representations (or beliefs about the cause, control, timeline, consequences, and symptoms of a condition) are related to ph ysical activity in people with T2D (Searle et al., 2007) Couples based i nterventions may also be particularly relevant for people with T2D because of the high prevalence of couples in which both partners have a diagnosis of diabetes. A spousal history of diabetes is associated with a 26% increased risk of diabetes compared to the general population (Leong, Rahme, & Dasgupta, 2014) So, not
16 only do partners have similar experiences with physical activity they are likely to both be in a po sition in which an increase in physical activity would benefit their own health. Further, a meta analysis of couple oriented interventions for people with chronic illness revealed that intervention effects could be strengthened by targeting partners' influences on patients' health behaviors and indicat ed a need for dyadic research specifically in the area of T2D (Martire, Schulz, Helgeson, Small, & Saghafi, 2010) Trief et al. ( 2016) found that a collaborative, couples based telephone intervention among individuals with poorly controlled diabetes produced better health outcomes (e.g. weight loss, HbA1c) tha n an individual based telephone intervention or an education only control condition Collaborative implementation intentions Taken together, these data suggest that it may be helpful for couples where at least one partner has T2D to engage in physical ac tivity planning and behavior together. C ollaborative implement ation intentions ( collaborative IIs ) are joint self regulatory strateg ies that involve a couple planning when and where they will perform a specific physical activity behavior (A Prestwich et al., 2005) Collaborative IIs have been shown to be more effective than individual IIs for health behaviors including breast self examination among undergraduate women (Prestw ich et al., 2005) and physical activity among working adults (A Prestwich et al., 2012) ; however they have not been tested in a patient population. C ollaborative IIs provide a feasible way to address several intervention components that have been associated with increased effectiveness in physical activity interventions. For example, in a systematic review Greaves et al. ( 2011) found that social support, goal setting, and self monitoring we re among intervention components
17 found to be most effective for increasing physical activity In a review of interventions to increase physical activity among people with T2D, informatio n on where and when to perform physical activity social support, goa l setting, time management and barrier identification/problem solving were identified among components most strongly related to improved glycemic control (Avery, Flynn, van Wersch, Sniehotta, & Trenell, 2012) Similarly, t he Canadian Diabetes Association (CDA) rec ommends that people with diabetes set specific physical activity goals, anticipate likely barriers to PA develop strategies to overcome these barriers and monitor their physical activity (Sigal et al., 2013) Jointly i dentifying barriers and planning ways the patient can be more physically active should increase partner involvement and increase physical activity self efficacy through modeling and social influence (Prestwich et al., 2012) That is, forming collaborative IIs may help individuals with T2D increase physical activity by increasing their self efficacy for engaging in physical activity and by increasing the partner 's involvement in the physical activity goal Partner Investment As discussed, collaborative IIs may lead to an improvement of partner involvement. A main construct designed to capture this positive involvement is partner investment ( a construct related to communal coping and dyadic coping). Partner investment refers to the degree to which one's partner has a shared responsibility and takes action to support the goal of the patient being physically active If partner s feel a sense of personal investment in the goal, they should provide more support for that goal. Lyons, Mickelson, Sullivan, and Coyne ( 1998) define this construct as the process of 1) one or both couple members holding beliefs that joint effort is advantageous, needed, or
18 useful, 2) couple members communicating about the situation, and 3) the couple engaging in cooperative action to sol ve problems. Partner investment relates to better smoking cessation rates and improved health outcomes following congestive heart failure (Rohrbaugh et al., 2002; Rohrbaugh, Mehl, Shoham, Reilly, & Ewy, 2008) Additionally, among women treated for breast cancer and their partners, more partner investment perceived by the patient was related to higher relationship quality and lower levels of depression for both patients and their partners (Rottmann et al., 2015) Self Efficacy for Physical Activity Collaborative IIs may also improve patient self efficacy for physical activity (PA self efficacy) As noted earlier, increased partner support relates to greater self efficacy. In addition, a plan made collaboratively to reduce barriers to physical activity should result in improved feelings of physical activity se lf efficacy. For partners who chose to engage in physical activity together, observing the partner model the behavior should also increase self efficacy. Self efficacy refers to the belief a person has about his or her personal capabilities to accomplish a task (Bandura, 1977) Self e fficacy for physical activity is an established predictor of physical activity For example physical activity related self efficacy has been related to increase d physical activity among older adults (Resnick & Spellbring, 2000) African American and Caucasian women enrolled in a home based walking program (Resnick & Spellbring, 2000), and overweight sedentary adults (Steptoe, Rink, & Kerry, 2000) Further, physical activity self efficacy has been related to the long term maintenance of physical activity (McAuley, Jerome, Marquez, Elavsky, & Blissmer, 2003) Among people with T2D, physical activity self efficacy has also been predictive of calor ies expended from physical activity (King et al., 2010) and
19 has med iated the relationship between a physical activity intervention and increases in physical activity (Dutton et al., 2009) Other p sychosocial constructs In addition to PA self efficacy and partner investment, the experimental manipulation may affect other psychosocial variables employed in physical activity research. Specifically, intentions, physical activity related spousal suppor t, and physical activity related spousal control will be assessed. Intentions, or the degree to which an individual is willing to try to perform a particular behavior, has been shown to account for 25% to 30% of the variance in behavior (Sheeran, 2002) Health related spousal support refers to partn er's availability to provide aid to the recipient with a variety of life stressors (Franks et al., 2006) Health related spousal control refers to a partner's direct attempt to influence or regulate the person's behavior (Franks et al., 2006). Among people with chronic illness, spousal support has bee n related to better health behavior and mental health of patients, whereas spousal control has been related to poor health behaviors and poor mental health of patients (Franks et al., 2006). Among couples where one member has type 2 diabetes, when a spouse engage s in both support and control actions, patients have higher physical activity self efficacy and energy expenditure the following day (Khan et al., 2013) Successful Implementation While pervious research has examined collaborative implementation intention interventions ( e.g. Andrew Prestwich et al., 2005a, 2012) co uples based interventions ( e.g. Martire et al., 2010) and physical activity interve n tions for those with T2D ( e.g. Avery, Flynn, Van Wersch, Sniehotta, & Trenell, 2012) there is a little information
20 provided about the feasibility and acceptability of implementing these interventions into a clinical setting. Reporting these implementati on outcomes in addition to treatment outcomes is important for understanding the potential translation on interventions into a clinical health care setting (Proctor et al., 2011) The current study The purpose of the current study was to extend previous research on collaborative IIs for physical activity with couples where at least one partner does not currently meet American Diabetes Associa tion ( ADA ) / American College of Sports Medicine ( ACSM ) guidelines for physical activity (Colberg et al., 2010) and has been diagnosed with T2D. In a 6 week experimental design, adult coupl es were randomly assigned to the collaborative IIs condition the individual IIs condition or the control condition and assessed a t baseline 3 weeks, and 6 weeks Further, patients wore Actigraph (Pensacola, FL) accelerometers at baseline and 6 weeks to provide an objective measure of physical activity. Aims Aim 1 Examine implementation outcomes ( i.e. feasibility, acceptability intervention fidelity ) of a collaborative IIs intervention with in a T2D population. Aim 2 Examine whether collaborative IIs as compared to individual IIs and control would be related to an increase in patient perceived partner investment in diabetes se lf management patient self efficacy for physical activity, patient perceived physical activity related social support patient perceived physical activity related social control and patient physical activity intentions.
21 Aim 3 Examine whether collaborati ve IIs as compared to individual IIs and control would be related to an increase in patient physical activity
22 CHAPTER II M ETHOD Participants Participants were screened for eligibility to participate. The eligibility criter ia (Table 1 ) defined a sample of sedentary adults who ha d been diagnosed with T2D and their romantic partners. Table 1. Eligibility Criteria Inclusion criteria for both partners At least 18 years of age Able to read and understand English Not currently meeting Physical Activity gui delines (< 60 minutes of moderate vigorous exercise per week) for the last 3 months (only required of one partner) Diagnosed with type 2 diabetes (only required of one partner) Married or living with a romantic partner Willing to participate in physic al activity Both relationship partner s must be willing to participate in the study Exclusion Criteria Neuropathy Other medical or physical contraindications to participate in physical activity Over the age of 69 (without physician clearance) Pregnant w omen Participants had to have been interested and ready to increase their physical activity and be physically able to do more physical activity than they were currently doing. We included adults who read and underst oo d English because the majority of the measures ha d only b een validated in English. It was required that study participants did not meet ACSM guidelines for physical activity a t baseline because the study was designed to examine the process of physical activity adoption. Participants with seve re neuropathy, cardiovascular disease, high risk of cardiovascular disease or other medical/physical
23 contraindications to participate in physical activity were excluded. Participants were between the ages of 18 69 to form a representative sample of adults In addition, our physical activity readiness screening measures we re not considered valid for individuals over the age of 69 (ACSM) and it is recommend ed that a more extensive screen be conducted for an older adult population (ACSM). One exception was made for a 71 year old patient whose physician provided clearance. For safety reasons and to limit the heterogeneity of our sample we excluded women who were currently pregnant or planning a pregnan cy during the study duration Participants were required t o live with their romantic partner because we were examining a process within committed relationships Romantic part ners were not excluded based on their current physical activity habits; they w ere not required to engage in physical activity below the ACSM guidelines at the start of the study but their baseline physical activity was measured Initial participant recruitment involved contact ing individuals who participated in an online pilot study for this project. Specifically, we obtained contact informati on from 463 individuals who were willing to be contacted to be invited to participate in the current study ; all were married and either had T2D or were the partner of a person with T2D as of July 2015 Not all were eligible due to physi cal limitations or i nterest in physical activity engagement. Some were unable to be reached following multiple attempts. Further, not all agree d to participate. Next, p articipants were recruited from primary care offices in Denver, CO including University of Colorado School o f Medicine affiliated clinics ( AF Williams Family Medicine and two Internal Medicine offices ) a safety net health system that primarily serves a low income urban population ( Denver Health ) and through flyers and advertisements. We also post ed an ad for t his
24 project on the University of Colorado Denver 's research participant listserv which reaches over 15,000 people. Participants were also recruited through Facebook advertisements and health fairs in the Denver area. Interested participants called or emai led the research team A research assistant called potential participants to screen for study participation. Eligible participants were invited to participate and receive d up to $50.00 compensation (for each member of the couple ) to take part in all parts of the study (see Table 4) Table 2 Timeline of assessments, compensation, and participant contact Procedure Research assistants contacted potential participants to determine their eligibility as well as the eligibility of their partner. At this time parti cipants were screened using the Initial Contact Baseline 3 weeks 6 weeks Phone call from research assistant Email/mail baseline survey Email/mail Follow up survey Email/mail Follow up survey Determine eligibility Phone reminder to wear accelerometer and complete assessment Phone reminder to wear accelerometer and complete assessment Phone reminder to wear accelerometer and complete assessment Mail accelerometer $20 per participa nt for returning baseline survey $10 per participant for returning 6 week follow up survey $10 per participant for returning 12 week follow up survey Phone reminder to wear accelerometer Additional $10 if both partners return follow up surveys
25 Physical Activity Readiness Questionnaire (PAR Q ; Appendix B, p. 100 ) as well as symptoms and history from the Health/Fitness Facility Preparation Screening Questionnaire (Appendix B, p. 101 ) Theses measures assess ed whether participants were healthy enough to engage in physical activity without physician supervisio n. The PAR Q is a seven item measure in which respondents indicate "yes" or "no" to each of the questions. An example item is "Do you feel pain in your chest when you do physical activity?" The PAR Q is considered valid for individuals aged 18 69 years (A CSM). Participants who indicated, "Yes" to any questions were not eligible to participant in the current study without physician clearance. As an extra layer of precaution to screen for severe cardiovascular symptoms, participants were also administered the history and symptoms questions from American Heart Association (AHA)/ACSM Fitness Facility Preparation Screen Questionnaire. The history questions include a checklist of 9 cardiovascular conditions (e.g. heart failure, heart transplant) and the sympto ms questions include a checklist of 6 cardiovascular symptoms (e.g. you experience chest discomfort with exertion). If participants checked any of the items from the history or symptoms items they were not eligible for the study without physician clearanc e. Eligible p articipants w ere then ema iled a link to an online Qualtrics survey. Both members of the couple complete d the baseline self report measures. They were instructed to complete these individually without consulting their partner. After both pa rtners completed the baseline survey, e ach patient was mailed an Actigraph accelerometer (GT9X Link; Pensacola, FL) to wear for seven days to obtain an objective baseline measure of their physical activity As recommended in previous
26 research (Chase, 2013) r esearch assistants called participants to make sure they knew how to use accelerometers properly before their first day of use at baseline and at 6 weeks Participants were also provided with an accelerometer log to indicate the date and time they put the accelerometer on and took it off. After returning the accelerometer couples were randomized to either the collaborative IIs condit ion, individual IIs condition, or the control condition (2:2:1 randomization). Participants in all conditions received a worksheet for overc oming barriers to physical activity, and an information sheet about the benefits of physical activity for people with T2D. Participants also received the ADA and ACSM joint guidelines for physical activity for people with T2D (Colberg et al., 2010) Parti cipants w ere not instructed to meet the full public health guidelines for physical activity immediately however they were encouraged to work toward the goal of accumulating at least 30 minutes of moderate intensity physical activity on most, preferably a ll, days of the week Encouraging moving toward the goal in a way that is consistent with their lifestyle has been effective in previous research with sedentary adults (Dunn et al., 1999) and among overweight and obese adults (Williams et al., 2015) Based on their assigned condition, participants were emailed instructions for an activity to complete. These instructions serve d as the experimental manipulation and differ ed based on the couple's random assignment to one of the t hree conditions Table 3 provides details of the experimental manipulation s In the individual IIs condition, patients were instructed to make a plan for increasing their physical activity for the next 6 weeks Patients were instructed to make thes e plans on their own without consulting their partner. In the collaborative IIs condition, patients and partners were instructed to
27 do the planning activity together. Their plan was made jointly, and when possible, partners were encouraged to plan an act ivity that can be carried out together. Some couples were not able to engage in physical activity together because of a medical condition, different interest in physical activity, or different ability levels. Thus, participants were given the option of m aking a plan in which the patient engage d in physical activity and the partner d id something to support this goal. For example, t his support activity could be taking over some household responsibility so that the patient can engage in physical activity We collected records on what plans the participants generated in both conditions to explore any themes that emerged. Participants in both conditions were provided with a template, checklist, and examples to complete their plans. Research assistants emaile d participants if their plans did not meet the requirements stated in the instructions and asked them to form new plans. Again, participants were instructed to plan for physical activity for the next 6 weeks Participants randomized to the control conditi on were provided with the ADA and ACSM joint guidelines for physical activity as well as a barriers planning worksheet. Participants in the control condition were not explicitly instructed to increase physical activity. At the 3 week time point, participan ts in both the i ndividual IIs and c ollaborative IIs were mailed a copy of their plan as a reminder to continue engaging in physical activity. At this time participants were also given the option of modifying their plan.
28 Table 3 Instructions for each ex perimental condition Individual Implementation Intentions Collaborative Implementation Intentions Instructions I will do X in place Y at time Z WE will do X (specific physical activity) in place Y at time Z OR "Partner will do X ( supportive ac tion ) so that Patient will do X(specific PA) in place Y at time Z Check list Does your plan 1) Contain the activity, time, and place ; contain the word I 2) Identify enough situations for you to increase physical activity as suggested in the guidel ines provided? 3) Identify how you will undertake physical activity in the situations identified in your plans? Does your plan 1)Contain the activity, time, and place, and specify actions both you and your partner will perform 2) Identify enough situatio ns for you to increase physical activity as suggested in the guidelines provided? 3a) Identify how you will undertake physical activity with your partner in the situations identified in your plans? Or 3b) Identify how your partner will support you in und ertaking physical activity in the situations identified in your plans? Example I will go to the gym straight from work on Monday and walk on the treadmill for 20 minutes" We will go to the gym straight from work on Monday and walk on the treadmill fo r 20 minutes" OR "My partner will pick up our children on Monday evening while I am at the gym walking on the treadmill for 20 minutes"
29 Following the experimental manipulation, couples were assessed through Qualtrics online self reports at 3 week and 6 week follow ups. Patient participants were also asked to wear their accelerometer for a 7 day period again at 6 weeks. This study was approved by the Colorado Multiple Institution Review Board (COMIRB; Protocol #: 15 0601) and is registered at clinicaltr ials.gov. Study Sample At baseline 74 participants (37 couples) completed study measures. Out of these couples, the majority (3 3 ) were recruited from a pilot study using Qualtrics participant panels. The other three couples were recruited through a Faceb ook advertisement, a flyer, and a diabetes support group and from a provider at a diabetes related clinic visit A C on solidated Standards of Reporting Trials ( CONSORT ; Schulz, Altman, Moher, & Group, 2010) flow diagram is presented in Figure 1. In total, 162 couples were screened for eligibility. Of those couples, 116 were excluded. Of these couples 57 did not meet inclusion criteria, with the most common reason being a diagnosis of a medical condition that prevents engaging in physical activity without physician clearance. An additional, 59 couples were either not interested in participating or their partner was not interested in participating. Afte r baseline assessment, 9 couples were excluded for not complet ing the baseline survey or not returning a valid accelerometer. The remaining 37 couples were randomized into at 2: 2:1 ratio into either the c ollaborative IIs, i ndividual IIs, or control conditi on.
30 A ssessed for eligibility (n = 162 couples ) Excluded (n = 116 couples ) Participant or partner not meeting inclusion criteria (n =57) Medical condition (n = 26) Too active (n = 19) Other reason (n = 12) Participant or partner refused to participate (n = 59) Patient refused (n= 37) Partner refused (n = 22) R andomized (n = 37 couples ) Note. Participants ra ndomized to either an implementation intentions condition (collaborative or individual) or to the control group at a 2: 2:1 ratio. Allocation Enrollment Follow up Did not complete 3 week follow up (n = 4 couples) Did not complete 6 week follow up (n = 5 couples) Did not complete 3 week follow up (n = 3) Did not complete 6 week follow up (n = 1) Completed Study (n = 19 Couples) Collaborative IIs (n = 15 couples) Received allocated i ntervention (n = 15) Control (n = 7 couples ) Received allocated intervention (n = 7) Individual IIs (n = 15 couples ) Received allocated intervention (n = 12) zz Did not complete 3 week follow up (n = 3 couples) Did not complete 6 week follow up (n = 2 couples) (n = 13 Couples) Lost at baseline (n = 9 couples) One partner did not complete baseline survey Patient did not r eturn valid accelerometer Potential Participants (n = 470) Qualtrics Database (n = 463 individuals) Unable to reach (n = 284) Invalid contact Information (n = 24) Other Recruitment Sources (n = 7 individuals) Facebook ad vertisement (n = 2) Local clinics (n = 5) Local diabete s support group (n = 1) Figure 1. CONSORT Flow Diagram Note. Either one or both partners. Participants could complete 6 week assessments if they missed 3 week assessments.
31 Demographics of patients and partners who comprised the sam ple are presented in Table 4 On average pa tients were approximately 54 years old ( SD = 9. 4 ) and 56.8 % were fe male Approximately 81% of participants identified as White and 16% identified as Black. Across all races, approximately 7% of participants reported identifying as Hispanic and 65 % of pa tients reported knowing their most recent HbA1c value. Participants tended to be well educated 75% of participants with T2D had a college degree and over 90% of participants with T2D had at least some college education. On average, these participants reported relatively well controlled HbA1c ( M = 7. 34 SD = 1.06 ). Two participants reported HbA1c values above 12 % which were considered outliers within this sample and thus were removed from analyses involving that varia b l e P articipants reported being diagnosed with T2D for an average of 11 years ( SD = 8.2 0 ). Both partners were diagnosed with T2D in approximately 20% of the sample which closely resemble s United States population estimates (Leong et al., 2014 ; Al Sharbatti Abed, Al Heety, & Basha, 2016 )
32 Table 4 Demographics of the Sample Patient Partner Age (years) M = 53.9 ( SD = 9.4) 53.5 ( SD = 10.13) Gender Female Male 56.8 % 43.2% 40.5 59.5 Race/Ethnicity White Black Native American Multiracial Hispanic* 81.1% 18.9% 0.0% 0.0% 8.1% 80.6% 13.9 % 2.8% 2.8% 4.57% Employment status Employed Not Employed 56.8% 43.2% 61.1% 38.9% Education Less than High School High School Diploma or GED Some College College Degree or higher 2.8 % 2.8% 19.4% 75.0% 2.9 0.0% 34.3% 62.9% Household Income < $40,000 $40,000 $74,999 $75,000 $99,000 > $1 00,000 21.2% 21.2% 24.2% 33.3% Know HbA1c 64.9% Comorbidity Index M = 1.50 ( SD = 1.07) BMI M = 34.1 ( SD = 7.0 ) HbA1c % M = 7.34 ( SD = 1.06 ) Length since diagnosis (years) M = 11.0 ( SD = 8.2) Length of marriage (years) M = 19.2 ( SD = 11.6) Length of cohabitation (years) M = 20.9 ( SD = 10.9) Both partners diagnosed with T2D 18.9% Note. Refers to the percent of individuals who identify as Hispanic across all races N = 74 individuals, 37 couples Data contain s one male same sex couple
33 Measure s All measures were assessed from participants through online surveys. Physical activity was also collected from patient participants through the use of accelerometers. Primary o utcomes Physical a ctivity. Self report, partner report, and objective measures of physical activity were collected Patient report of patient physical activity The International Physical Activity Questionnaire self report (IPAQ ; Appendix B, p. 105 ) a ssesses the duration (number of days X hour s/minutes per day) that an individual has engaged in job related physical activity, transportation physical activity, housework, house maintenance, caring for family, recreation, sport and leisure time physical activity as well as time spent sitting over t he last 7 days. A metabolic equivalent (MET) score was calculated using IPAQ scores by weigh t ing each reported activity by its MET energy requirements (3.3 X walking duration) + (4 X moderate activity duration) + (8 X vigorous activity duration). The test retest reliability within the same week of the IPAQ is acceptable (Spearman's r ranging from .32 .88 with 75% a bove .65; Craig et al., 2003) However, the IPAQ may overestimate physical activity levels in sedentary ind ividuals (Fogelholm et al., 2006) As compared to accelerometer data, however, the IPAQ has the ability to capture some additional activities (e.g., swimming weight l ifting, bodyweight movements ). For the current analyses, patient physical activity was measured as total METS from recreation, sport and leisure time physical activity (total REC MET s ). The total REC MET s measure of physical activity was chosen for analys es because it most closely resembled the type of
34 physical activity that was targeted by the intervention Objective measures of patient physical activity. ActiGraph GT 9 X Link (Actigraph LLC Pensacola, FL) accelerometers w ere used to mea sure steps, activ ity time and vector magnitude (not wearing, standing, sitting, and lying down) in order to compute subsequent variables The Actigraph GT 9 X Link uses a triaxial capacitive accelerometer to detect change in movement by measuring variation in the sensor's electric charge storage potential (John & Freedson, 2012) Actigraph accelerometers are widely used and are among the most validated objective measures of physical activity (Cain, Conway, Adams, Husak, & Salli s, 2013) Participants w ere instructed to wear accelerometers with a belt provided on their non dominant hip (Tudor Locke et al., 2015) during waking hours (besides swimming and bathing) for seven days at ba seline, and again at the 6 week follow up. Participants recorded the times the monitor was worn each day on a paper log for the purpose of verifying device wear and non wear time Data w ere analyzed using ActiLife software version 6 .11.8 (Actigraph, Pensa cola, FL) Participants with at least 10 hours of wear time on at lea st two week days and one weekend day were retained for analyses (Troiano e t al., 2008) Variables were calculated by dividing the total values by the number of valid days. Variables produced by the accelerometer that w ere included in the current analyses include mean steps per day, the mean percent of time spent engaged in mo derate or vigorous activity ( % MVPA) per day, and mean percent of sedentary time per day (% SED) Thus, including these 4 ( Patient IPAQ Rec METs mean steps per day, % MVPA, and % SED) measures of physical activity will allow for tests of whether different aspects of physical activity were affected by the experimental manipulation.
35 Patient self e fficacy for p hysica l a ctivity S elf efficacy for physical activity ( PA self efficacy ; Appendix B, p. 1 1 6 ) was measured using a 4 item, self report scale that asses se d participant's confidence that they could plan a physical activity routine and exercise on a regular basis. Respondents rate d items on a 6 point scale Since existing self efficacy measures do not capture the planning aspect of the current study, we dev eloped this measure in line with recommendations of Bandura ( 2006) In the current sample, the PA self efficacy items exhibited good reliability at all three time p oints (alpha s range from .84 .88 ; see T able 5 ). The mean of the 5 items was calculated to form a PA self efficacy scale score. Partner i nvestment in diabetes self m anagement The Partner Investment in Diabetes Self Management (partner investment ; Appendix B, p. 119 ) Scale assesses the degree to which the partner in a couple defines the management of the patient 's diabetes as a shared responsibility as well as the degree to which they are taking action to address barriers to diabetes self managemen t The 5 items selected were modified to be specific to management of diabetes Participants we re asked to rate their agreement to each item on a scale from 1 (strongly disagree) to 7 (strongly agree). Example items include The responsibility of managing my dia betes is mine alone," My partner and I have useful discussions about how to manage my diabetes", and "My partner and I are able to work together toward helping me manage diabetes." This scale was adapted from four scales used to measure partner investmen t in smoking cessation: individual responsibility, shared responsibility, communal action, and communal orientation (Rohrbaugh et al., 2008) and from the dyadic coping inventory ( DCI; Bodenmann, 20 08) a mea s ure used to assess dyadic coping among couples in which one or both partners are experiencing
36 stress Th e scales used to measure partner investment in smoking cessation had satisfactory internal reliability among couples (alphas > .50 ; Grinbe rg et al., 2012). The DCI subscales have demonstrated adequate to high internal consistency among clos e relationship partners (alphas range from .71 .92; Bodenmann, 2008). In this sample the scale had adequate reliability at all 3 time points (alphas rang e from .70 to .78 ; see table 5 ). The mean of the 5 investment items was calculated to form an investment scale score. These items were collected from both patients and partners at baseline, and from patients only at 3 weeks and 6 weeks The scores from pat ients were included in analyses. Secondary Outcomes Physical a ctivity r elated s ocial s upport To measure physical activity re la ted social support ( PA social support ; Appendix B, p. 1 22 ), 7 self report items were adapted from Khan et al.'s (2013) measur e of exercise related support by replacing the word "exercise" with "physical activity the word "husband" to "partner" and the word "today" with "in the past month." I n addition, the items were modified to create a patient report version in addition to the partner report version. Pa tients rated on a Likert type scale from 1 (Not at A ll ) to 4 ( Very Much ) how frequently in the past month partners provided them with PA social support An example item was, Listened to my concerns about maintaining a physica l activity routine Partners rated on the same scale how frequently in the past month they provided patients with PA social support An e xample item answered by partners was, Listened to your partner's concerns about maintaining a physical activity routi ne In the current sample, the support items exhibited good to excellent internal consistency reliability at all 3 time points (alpha s range from .85 .91 ; see T able 5 ). The mean of the 7 support items was calculated to form a support scale
37 score These i tems were collected from both patients and partners at baseline, and from patients only at 3 weeks and 6 weeks Analyses include patient reported scores. Physical activity related social c ontrol. To measure physical activity related social control ( PA so cial control ; Appendix B, p.122 ), 7 self report items were adapted from Khan et al.'s (2013) measure of exercise related control by replacing the word "exercise" with "physical activity," the word "husband" to "partner" and the word "today" with "in the pa st month." In addition, the items were modified to create a patient report version in addition to the partner report version. Patients rated on a Likert type scale from 1 (Not at All) to 4 (Very Much) how frequently in the past month partners provided the m with PA social control An example item was, "Prompted or reminded me to engage in physical activity more often Partners rated on the same scale how frequently in the past month they provided patients with PA social control An example item was, "Promp ted or reminded my partner to engage in physical activity more often. In the current sample, the control items exhibited good internal consistency reliability (alpha s ranged from .87 .92 ; see Table 5 ). The mean of the 7 control items was calculated to for m a control scale score. This measure was collected from patients at baseline, 3 weeks and 6 weeks and collected for partners at baseline. These items were collected from both patients and partners at baseline, and from patients only at 3 weeks and 6 week s. Analyses include patient reported scores. Patient Physical Activity Intentions. Intentions to engage in physical activity (intentions ; Appendix B, p. 118 ) were assessed using five self report items developed by Prestwich et al. (2012). Items used var ious 7 point Likert type scales (i.e. 1 = Strongly Disagree to 7 = Strongly Agree; 1 = Definitely Will N ot to 7 = Definitely Will; and 1 =
38 Unlikely to 7 = Likely). Example items include "I intend to engage in physical activity in the next month" and "How likely is it that you will engage in physical activity in the next month?" These items have demonstrated internal consistency reliability among a sample of working adults (Prestwich et al., 2012). In the current sample, the intention items exhibited good to excellent internal consistency reliability at all 3 time points (alphas ranged from .85 .92; see Table 5). The mean of the 5 intention items was calculated to form an intention scale score Covariates Demographics. At baseline, demographic information was collected from both partners including age, gender, diabetes diagnosis, relationship length. See Appendix B (p. 102 ). Health information. S elf reported health measures ( glycated hem oglobin [HbA1C], height, weight ) and comorbidities (Charlson Comorbid ity Index; Charlson, Szatrowski, Peterson, & Gold 1994) were collected at baseline. See Appendix B (p. 104 ). Depressive Symptoms. The 8 item Patient Health Questionnaire 8 ( PHQ 8; Kroenke & Spitzer, 2002 ; Appendix B, p. 125 ) was used to measure depressive symptoms. Respondents rate d the extent to which they ha d been bothered by a seri es of eight problems (e.g., "little interest or pleasure in doing things" ) over the past 2 weeks on a scale ranging from 0 ( not at all ) to 3 ( nearly every day ). If they ha d experienced any of the eight problems, they we re asked to rate how difficult tho se problems ha d been for them from 0 ( not difficult at all ) to 3 ( extremely difficult ) The PHQ 8 is derived from the PHQ 9, but the ninth item assessing suicidal ideation w as omitted as per
39 recommendations from the authors because this study (1) uses a sel f administered survey; and (2) depression is being assessed as a secondary measure (Kroenke & Spitzer, 2002). H igher scores on the PHQ are related to greater likelihood of being diagnosed with any depressive disorder (Kroenke & Spitzer, 2002) T he P HQ 9 has also been validated among outpatients with T2D and demonstrated a sensitivity of 75.7% and a specificity of 80.0% ( van Steenbergen Weijenburg 2010). In the current sample, the depression items exhibited good internal consistency reliability at bot h b aseline and 6 week follow up (alpha s = .87 and .83, respectively ; see Table 5 ). The sum of the 8 depression items was calculated to form a depression scale score. Diabetes Distress Diabetes distress was assessed using the Diabetes Distress Scale ( DDS; Polonsky et al., 2005 ; Appendix B, P. 1 27 ) The DDS is a 17 item self report measure, which assess es pat ient's emotional responses to diabetes and includes four subscales: emotional burden (EB) physician related distress (PD) regimen related distress (RD) and diabetes related interpersonal distress (ID) Respondents are asked to indicate on a Likert type scale the degree to which they consider ed each item to be a problem from 1 ( no problem ) to 6 (a very serious problem ). Example items include Feeling that diabetes is taking up too much of my mental and physical energy every day and Feeling that I will end up with long term complications, no matter what I do ." The DDS has demonstrated excellent internal consistency reliability as a total scale (alpha = .93) and for each subscale (alphas .88 .90; Polonsky et al., 2005). H igher scores on the DDS are relat ed to more depressive symptomology, poorer adherence to meal planning recommendations, lower levels of exercise and higher levels of total cholesterol (Polonsky et al., 2005). In the current sample, the diabetes distress items exhibited
40 excellent internal consistency reliability at all 3 time points (alpha s ranged from .94 to .96 ; see Table 5 ) The mean of the 17 distress items was calculated to form a total diabetes distress scale score. Relationship Satisfaction. Relationship satisfaction as perceiv ed by both partners was measured using the 10 item satisfaction subscale from the Investment Model Scale (Rusbult, Martz, & Agnew, 1998 ; Appendix B, p. 1 30 ) This measure assesses the positive versus negative affect experi enced in a relationship as well as the extent to which a partner fulfills the individual's most important needs. Example items include, I feel satisfied with our relationship ," and My relationship is close to ideal ." This measure has been deemed reliab le and valid for assessing relationship satisfaction in ongoing close relationships (Rusbult et al., 1998). In the current sample, the relationship satisfaction items exhibited excellent internal consistency reliability at all time points (alphas ranged f rom .9 6 to .9 8 ; see Table 5). The mean of the 10 items forms the relationship satisfaction scale score. Implementation o utcomes Participant f easibility. Participant f easibility was a ssessed from the perspective of the patient and partner by measures of l ength of time to complete the intervention recruitment, r efusal rates retention and follow up rates. Plans to increase physical activity were also examined to assess whether participants were able to understand the instructions and develop plans. Prov ider and organizational feasibility. Provider and organizational feasibility was assessed by the amount time research assistants sp ent delivering the intervention.
41 Participant a cceptability Acceptability of the intervention was evaluated using the Attitu des about P lanning scale (Appendix B, p. 1 31 ) This scale was developed by Prestwich et al. (2012) to assess participant attitudes toward their collaborative implemen tation intention manipulation. The scale contains self report items which respondents rate on various 7 point Likert type scales. Example items include My study partner and I discussed the plan together" (Not at all to A great extent ) and Keeping the plan to undertake regular physical activity will be" (Difficult to Easy). Each item was exami ned individually to assess different aspects of acceptability. Intervention fidelity. Intervention fidelity was assessed by examining participant's perceived commitment to their plans. Plans to increase physical activity were examined to assess whether p articipants w hether participants completed the intervention as it was intended. All measures can be found in Appendix B.
42 Table 5. Internal Consistency Reliabilities of Self Report Scales Coefficient Alpha (!) Scale Baseline 3 Weeks 6 weeks Secon dary Outcomes PA Self Efficacy .84 .87 .88 Partner Investment 1 .71 .78 .75 Partner Investment 2 .70 ----PA Social Support 1 .89 .88 .85 PA Social Support 2 .91 ----PA Social Control 1 .87 .88 .91 PA Social Control 2 .92 ----Intentions 1 .91 .92 .93 Intentions 2 .85 ----Covariates PHQ8 .87 --.83 Diabetes Distress .95 .96 .94 Relationship Satisfaction 1 .96 .98 .97 Relationship Satisfaction 2 .96 .96 .97 Note. PA= Physical Activity 1 = patient report 2 =Partner Report
43 Data Analyse s Data screening procedures were carri ed out to assess distributions and screen for outliers on all variables. Bivariate correlations between variables were examined to understand relationships among primary outcomes, secondary outcomes, and potential cov ariates (Tables 12 and 13) Patterns of change over time in constructs were also examined separately for the 3 conditions. To examine a im 1, feasibility and acceptability of the intervention, means and standard deviations from the attitudes about planning scale were examined. In addition, qualitative themes were extracted from physical activity plans developed by participants in the collaborative IIs and individual IIs conditions. T o examine whether collaborative IIs increase d patient's PA self efficacy, patient reported partner investment in diabetes self management, patient's p hysical activity, patient's PA social support and control, and patients intentions more than individual IIs and the control condition, hierarchical linear regression s w ere used ( ai ms 2 3 ) The first step of each analysis predicted outcomes using the corresponding baseline measures and covariates as predictors. Only significantly correlated covariates were included to improve the precision Of note, intervention effects were examined with and without covariates and the significance of the intervention effects did not differ. There fore results w ith covariates are discussed
44 CHAPTER III RESULTS Descriptive statistics Means and standard deviations of secondary outcomes and covariat es at baseline are presented in Table 6. At baseline, pa rticipants reported a mean PA self efficacy score around the high end of the scale ( M = 5.50, SD = .88). As indicated by a t test, partners ( M = 4.97, SD = 1.24) reported significantly higher levels o f partner investment in diabetes self management than patients ( M = 3.73, SD = 1.25). Patients and partners did not significantly differ on their reports of PA social support, PA social control, or PA intentions. Overall, participants repor ted relatively h igh levels of intentions (approximately 6 on a 7 point scale). On average, patients ( M = 3.46, SD = .67) and partners ( M = 3.31, SD = .72) reported relationship satisfaction at the high end of the scale. The sample exhibited moderate levels of depression ( M = 11.97, SD = 3.83) and mild levels of diabetes distress ( M = 1.96, SD = .97) on average. Means and standard deviations of study variables at 3 weeks and 6 weeks are presented in Tables 7 and 8, respectively. Descriptive statistics for physical activit y variables as measured by the IPAQ and accelerometer at baseline and at 6 weeks are presented in Table 9. After examining frequencies of IPAQ recreation METs, one outlier at both baseline and at 6 weeks was identified. Th ese participant's value s (4914.00 and 8524.80, respectively) were removed because they did not fall within the distribution of the sample and are not reasonable values. Because of the non normal distribution of energy expenditure, it is often recommended to present the median IPAQ METs per week (IPAQ Research Committee;
45 2005 ). At baseline, patients reported a median weekly energy expenditure on the IPAQ of 260 METs. For reference, it is recommended that individuals engage in 500 1000 METs of physical activity per week (Physical Activity Guidelines Advisory Committee, 2008) As measure d by accelerometer, participants' average daily steps at baseline were 5028 ( SD = 1885). As measured by accelerometer, patients spent 1.76 ( SD = 1.44) percent of their time in moderate or vigorous activity, and 66.7 ( SD = 8.38) percent of their time in sed entary behavior at baseline.
46 Table 6. Means and Standard Deviations of Study Measures at Baseline Variable Scale Range Mean (Standard Deviation) Patient Partner Primary Outcomes PA Self Efficacy 1 10 5.04 (.81) --Diabetes Partner Investment 1 7 3.73 (1.25) 4.97 (1.24)** Secondary Outcomes PA Social Support 1 4 2.59 (.98) 2.91 (.85) PA Social Control 1 4 2.19 (.90) 2.40 (.91) PA Intentions 1 7 6.0 (1.06) 6.32 (.73) Covariates Depression 0 24 11.97 (3.83) --Diabetes Distress 1 5 1.96 ( .97) --Relationship Satisfaction 1 4 3.46 (.67) 3.31 (.72) Note. N = 74 individuals, 37 couples PA, Physical Activity Physical Activity measures presented separately **Paired T test indicate significant difference between patient and partner p < .001
47 Table 7. Means and Standard Deviations of Study Measures at 3 Weeks Variable Scale Range Mean (Standard Deviation) Patient Partner Primary Outcomes* PA Self Efficacy 1 10 5.07 (.85) --Diabetes Partner Investment 1 7 4.97 (1.08) --Second ary Outcomes PA Social Support 1 4 2.90 (.88) --PA Social Control 1 4 2.50 (.92) --PA Intentions 1 7 6.20 (.86) 6.11 (.91) Covariates Diabetes Distress 1 5 1.86 (1.01) --Relationship Satisfaction 1 4 3.42 (.82) 3.37 (.71) Physical Activity mea sures presented separately PA, Physical Activity Paired T test indicate significant difference between patient and partner p < .001
48 Table 8. Means and Standard Deviations of Study Measures at 6 Weeks Variable Scale Range Mean (Standard Deviation ) Patient Partner Primary Outcomes* PA Self Efficacy 1 10 4.99 (.84) --Diabetes Partner Investment 1 7 3.93 (1.33) --Secondary Outcomes PA Social Support 1 4 2.80 (.87) --PA Social Control 1 4 2.34 (.90) --PA Intentions 1 7 5.84 (1.01) 5. 90 (.78) Covariates Depressive Symptoms 0 24 11.82 (3.88) --Diabetes Distress 1 5 1.87 (.88) --Relationship Satisfaction 1 4 3.45 (.71) 3.41 (.74) Note N = 66 individuals, 33 couples Physical Activity measures presented separately PA, Physical A ctivity ** Paired T test indicate significant difference between patient and partner p < .001
49 Table 9. Descriptive Statics for Physical Activity Measures Variable Baseline 6 Weeks N Min Max Mean (SD) Median N Min Max Mean (SD) Median Patient IPAQ Rec METs 3 6 0 4514.00 683.04 (1000.06 ) 2 6 0 33 0 7200.00 1621.45 (1857.20) 899.00 Average Daily Steps 25 2557 8954 5028 ( 1885 ) 4583 18 1368 757 6 4419.59 ( 180 2) 3961 % spent in MV Activity 25 .24 5.69 1.76 (1.44) 1.54 22 .13 3.09 1.33 (.76) 1.23 % spe nt in Sedentary Activity 25 45.65 77.67 66.7 (8.38) 70.48 23 51.36 89.14 70.29 (8.83) 71.85 Note. MV, Moderate Vigorous ; SD, Standard Deviation ; MET, Metabolic Equivalent
50 Examination of Primary and Secondary Variables by Condition Figures 2 throu gh 7 present graphs of primary and secondary outcomes over time by assigned study condition. Means and standard deviations of study variables by con dition are presented in Table s 10 and 11 Condition was not significantly correlated with any of the study variables at baseline. For physical activity variables measured by accelerometer, 10 participants did not have enough valid wear time at 6 weeks to include in analyses. Of these 10 participants, 2 were from the control group, 3 were from the individual II s condition, and 5 were from the collaborative IIs condition. Notable patterns include that those in the individual IIs and control conditions appears to decrease the amount of time they spend in MVPA over time, whereas % MVPA remains stable for those in the collaborative IIs condition. There appears to be an increase in sedentary activity across all conditions, although this increase is less severe for the collaborative IIs condition. PA Self efficacy decreases for all three conditions over time, with a less steep decrease for the collaborative II condition. Regarding partner investment in diabetes self management, all three conditions demonstrated a pattern of increasing from baseline to 3 weeks and then decreasing from 3 weeks to 6 weeks. A similar pat tern was observed for PA social support and PA social control in which there was an increase from baseline to 3 weeks followed by a decrease from 3 weeks to 6 weeks. PA Social support and PA social control remained relatively stable for the control conditi on. Depression fell within the moderate range and diabetes distress fell within the mild range for all three conditions B ecause of the limited sample size, later analyses compared the collaborative IIs condition with the combined individual II and control conditions.
51 Figure 2 Physical Activity Variables over time by Condition Note. Total Steps, %MVPA, % Sedentary were assessed using accerlerometry
52 Figure 3 Self Efficacy for Physical Activity over time by Condition 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 Baseline 3 Weeks 6 Weeks Self-Efficacy for Physical Activity Collaborative II Individual II Control
53 Figure 4 Partner Investmen t for diabetes self management over time by Condition 1 2 3 4 5 6 7 Baseline 3 Weeks 6 Weeks Patner Investment in Diabetes self-management Collaborative II Individual II Control
54 Figure 5 Physical Activity Related Social Support over time by Condition !" !#$" %" %#$" &" $" '" '#$" (" Baseline 3 Weeks 6 Weeks Physical Activity Social Support Collaborative II Individual II Control
55 Figure 6 Physical Activity Related Social Control over time by Condition 0 0.5 1 1.5 2 2.5 3 Baseline 3 Weeks 6 Weeks Physical Activity Social Control Collaborative II Individual II Control
56 Figure 7 Physical Activity Intentions over time by Condition 1 2 3 4 5 6 7 Baseline 3 Weeks 6 Weeks Physical Activity Intentions Collaborative II Individual II Control
57 Table 10. Means and Standard Deviations of Physical Activity Outcome Measures by Condition and Time Variable Mean (SD) Baseline 6 Weeks IPAQ Control (n = 6) Individual IIs (n = 15) Collaborative IIs (n = 15) Control (n = 6) In dividual IIs (n = 13) Collaborative IIs (n = 14) Recreational METs 700.50 (602.19) 716.20 (1253.93) 642.90 (731.19) 983.67 (969.66) 1137.85 (1370.71) 2343.86 (2326.11) Actigraph Accelerometer Control (n = 4) Individual IIs (n = 9) Collaborative I Is (n = 12) Control (n = 4) Individual IIs (n = 10) Collaborative IIs (n = 9) Average Daily Steps 5667.74 (1934.08) 4585.60 (1659.31) 5146.22 (2022.26) 3633.09 (478.56) 5116.52 (1613.16) 4104.72 (2173.02) % Time in MVPA 2.53 (2.15) 1.72 (1.59) 1.54 (1. 08) 1.14 (.54) 1.19 (.68) 1.56 (.92) % Sedentary time 67.33 (6.88) 68.85 (7.65) 64.92 (9.50) 72.27 (3.10) 72.44 (7.43) 67.03 (11.36)
58 Table 11. Means and Standard Deviations Study Measures by Condition and Time Variable Mean (SD) Primary Outcomes Baseline 3 Weeks 6 Weeks Control (n = 7) Individual IIs (n = 13) Collaborative IIs (n = 15 ) Control (n = 7) Individual IIs (n = 13) Collaborative IIs (n = 15) Control (n = 7) Individual IIs (n = 13) Collabora tive IIs (n = 15) PA Self Efficacy 5.71 (.22) 5.02 (.75) 4.75 (.89) 5.64 (.48) 5.13 (.70) 4.73 (1.00) 5.46 (.46) 4.92 (.86) 4.85 (.92) Diabetes Partner Investment 3.91 (1.27) 3.80 (1.46) 3.57 (1.07) 5.23 (1.01) 5.18 (.96) 4.61 (1.20) 4.30 (1.44) 3.69 (1.41) 4.00 (1.26) Secondary Outcomes Baseline 3 Weeks 6 Weeks PA Social Support 3.04 (.98) 3.70 (1.46) 2.34 (.99) 2.92 (1.01) 2.96 (.80) 2.82 (.95) 3.10 (.91) 2.69 (.98) 2.78 (.76) PA Social Control 2.37 (.81) 2.17 (1.12) 2.11 (.73) 2.50 (.98) 2.45 (.96) 2.56 (.93) 2.57 (.89) 2.27 ( 1.05) 2.30 (.81) PA Intentions 6.31(. 82) 6.00 (1.07) 5.85 (1.17) 6.57 (.42) 6.17 (.80) 6.04 (1.05) 6.37 (.71) 5.82 (.88) 5.64 (1.18) Covariates Baseline 3 Weeks 6 Weeks Depression 11.00 (2.52) 11.87 (4.09) 13.93 (5.27) ------11.17 (3.12) 11.3 1 (4.01) 12.57 (4.16) Diabetes Distress 1.60 (2.52) 1.96 (1.20) 2.13 (.87) 1.60 (.77) 1.78 (.86) 2.08 (1.24) 1.56 (.78) 1.73 (.85) 2.13 (.94) Relationship Satisfaction 3.66 (.41) 3.55 (.52) 3.27 (.73) 3.64 (.65) 3.47 (.70) 3.26 (1.00) 3.68 (.48) 3. 54 (.54) 3.28 (.89) Note. SD, Standard Deviation; PA, Physical Activity
59 Correlations of study variables at baseline Correlations of primary and secondary outcomes at baseline are presented in Table 12 Significant associations are discussed. Physical a ctivity. IPAQ recreational METs was negative ly correlated with % SED as measured by accelerometer and positively correlated to % MVPA as measured by accelerometer as well as partner reported partner investment Less sedentary time as measured by accelerometer was related to greater % MVPA patient reported control and patient reported partner investment Higher a verage daily steps as measured by accelerometer was related to higher % MVPA and partner reported PA intentions. Self efficacy for ph ysical activity. P atient reported PA self efficacy was positively re lated to patient reported intentions. P artner investment in diabetes self management Partner Investment was positively re lated to PA support (as reported by patients and partners), PA c ontrol (as reported by patients and partners), and intentions as reported by patients Partner investment as reported by partners was positively related to PA social support ( as reported by both patients and partners ) and PA social control (as reported by both patients and partners). Physical activity intentions. Patient reported intentions were not related to any physical activity outcomes as baseline.
60 Table 12 Correlations among Primary and Secondary Outcomes at Baseline Construct 1 2 3 4 5 6 7 8 9 10 11 12 13 1. PA Self Efficacy 1 .30 .32 .34* .03 .34 .27 .29 .20 .13 .19 .75** .01 2. Diabetes Partner Investment 1 .24 .29 .48* .19 .30 .63** .51** .56** .56** .33* .02 3. Diabetes Partner Investment 2 .40* .02 .16 .30 .40* .46** .22 .48* .27 .01 4. IPAQ REC METS 1 .45* .41* .27 .30 .04 .29 .03 .27 .22 5. Actigraph SED .47* .73** .35 .25 .46* .32 .17 .34 6.Actigprah MVPA .79** .16 .05 .16 .04 .39 .28 7.Actigraph Steps .12 .09 .17 .07 .32 .47* 8. PA Social Support 1 .67** .88** .62** .31 .07 9. PA Social Support 2 .63** .91** .33 .08 10. PA Social Control 1 .62** .21 .10 11. PA Social Control 2 .24 .13 12. Intentions 1 .11 13. Intentions 2 Note. 1 Patient Report 2 Partner Report p < 05. ** p < .001 Condition is coded as 1= Collaborative II, 0= Individual II and Control
61 Correlations of study variables with covariates Correlations of study variables with potential covariates at b aseline are shown in Tables 11 and 12. Significantly correlated variables are discussed below and were included as covariates in later analyses. IPAQ Rec METs. Depression was negatively related to IPAQ Rec METs. Self efficacy for physical activity. Self efficacy was negatively related to depression and comorbidity index. Male patients had higher self efficacy than female patients. Partner investment in diabetes self management. Partner investment as reported by patients was negatively related to dep ression and comorbidity index as well as positively related to patient male gender and partner female gender. Social support for physical activity. PA Social support was negatively correlated with depression, diabetes distress, and was positively relate d to patient male gender Social control for physical activity. PA Social control was negatively related to diabetes distress and partner age Intentions for physical activity. Intentions were negatively related to partner age and comorbidity index. In a ddition, intentions were positively related to patient male gender, and HbA1C.
62 Table 13 Correlations among Physical Activity Outcomes and Covariates at Baseline Depression Diabetes Distress Age 1 Age 2 Gender 1 Gender 2 BMI 1 Comorbidity Index HbA1C Cohabi tation Length Marriage Length IPAQ REC METS 1 37* .29 .03 .12 .24 .20 .08 .03 .03 .28 .21 Actigraph SED .04 .24 .21 .30 .02 .01 .07 .36 .31 .003 .90 Actigprah MVPA .15 .21 .26 .35 .04 .05 .08 .22 .03 .39 .43 Actigraph Steps .1 2 .19 .20 .26 .02 .14 .22 .30 .20 .24 .33 Note. 1 Patient Report 2 Partner Report p < 05. ** p < .001, N = 37
63 Table 1 4 Correlations among Primary and Secondary Outcomes and Covariates at Baseline Depression Diabetes Distress Age 1 Age 2 Gender 1 Gender 2 BMI 1 Comorbidity Index HbA1C Cohabitation Length Marriage Length PA Self Efficacy 1 .37* .07 .08 .0 4 .52** .15 .18 .42** .18 .03 .003 Diabetes Partner Investment 1 .37* .2 6 .20 .2 4 .38* .38* .1 3 .39* .28 .11 .11 P A Social Support 1 .34* .44** .25 .27 .36* .17 .06 .28 .06 .12 .20 P A Social Control 1 .24 .40* .30 .34* .26 .16 .07 .29 .06 .07 .15 PA Intentions 1 .2 9 .0 8 .20 .37* .42* .03 .1 3 .34* .41* .28 .28 Note. 1 Patient Report 2 Partner Report p < 0 5. ** p < .001, N = 37 Gender is coded as 1 = Male 2 = Female
64 Implementation Outcomes Participant feasibility. On average it took participants in the collaborative IIs condition ( M = 28.59, SD = 15.76) about twice as many minutes as those in the indiv idual IIs condition ( M = 13.64, SD = 4.8) to complete the planning task. Provider and organizational feasibility. Research assistants spent approximately 10 minutes per participant to email participants the online planning template and follow up with a rem inder of their of plans at 3 weeks. Participant acceptability. Participants in both experimental conditions reported they believed the intervention was acceptable, rating the intervention highly in the categories of "beneficial", "pleasant," "good", "valu able", and "enjoyable" (see Figure 8 ). There were no significant differences as examined by t test between ratings by participants in the c ollaborative IIs condition and ratings by participants in the individual II condition on the above variables. With th e notable exception of finding the intervention to be enjoyable, all group means were in the positive direction in favor of collaborative IIs. Intervention fidelity. Participants in both conditions reported being highly committed to the PA pl ans they devel oped (see Figure 9 ). Participant Plans Plans developed by participants in the collaborative IIs and individual IIs conditions were examined to assess participant feasibility and intervention fidelity and are presented in Tables 1 5 and 1 6 respectively (Se e Appendix A) Of the 15 couples who completed the collaborative II condition, all couples included at least one plan in the 3 to 5 they developed that involved engaging in physical activity together. Three couples (20%) included at least one plan that inv olved supporting the other partner
65 to engage in PA. About half of couples (53%) included at least one plan that involved an activity that could not be easily captured by accelerometer (e.g. kayaking, swimming, water aerobics). Three couples (20%) included at least one plan with a problematic aspect ("if fin ances allow," "if the weather is decent"). In total, 12 participants completed plans as part of the individual IIs condition. Of these 12 participants, 50% included at least one plan that could not be captured by accelerometer (e.g. swimming, water walking). One participant included a plan with an as pect that is not a direct violation of the instructions but undermines the purpose of implementation intentions (i.e. "I could go running" rather than "I wi ll go running ).
66 Figure 9 Commitment to Activity Planning by Condition Note. Scale is from 1 7 1 2 3 4 5 6 7 Times planned Places planned Type of activity planned I am commited to the... Individual IIs Collaborative IIs
67 Figure 8 Acceptability of Intervention Conditions Note. Scale is from 1 7, Figure reflects patient and partner perspective 6.42 5.42 5.83 6.08 5.25 6.25 5.19 5.81 5.94 3.8 %" &" '" (" $" )" *" Individual IIs Collaborative IIs Harmful Beneficial Unpleasant Pleasant Good Bad Worthless Valuable Not Enjoyable Enjoyable
68 Primary Outcomes Phy sical Activity A hierarchical linear regression controlling for b aseline IPAQ recreational METs and b aseline d epres sion revealed that condition significantly predicted IPAQ recreational METs at 6 weeks [ M CollaborativeII = 2275.72, SD = 436.96 ; M Individua lII+Control = 880.84 SD = 369.77; B condition = 1394.89 p = .02 ; see T able 1 7 ] ; that is, patients in the collaborative IIs condition showed a greater increase in METs expended during recreation than the other two conditions In addition, g reater baseline depression ( B Depression = 181.64, p = .04) predicted fewer IP AQ recreational METs at 6 weeks. The full model explained approximately 30% of the variance in IPAQ recreational METs [ F (2, 15) = .56, p = .58, R 2 = .31] Adding study condition in the second s tep significantly improved prediction of IPAQ rec reational METs ( # R 2 = .16, F = 5.79, p = .02). H ierarchical linear regression s controlling for baseline values indicated that condition did not predict average daily steps at 6 weeks [ B condition = 533.44 p = .55; F (2, 15) = .48, p = .627 # R 2 = .0 2 ], average percent of time spent in moderate and vigorous activity per day [ B condition = .16, p = .67 ; F (2, 15) = .56, p = .58 # R 2 = .0 1 ] or average percent of sedentary time per day [ B condition = 2.60, p = .22 ; F (2, 14) = 33.17 p < .001 # R 2 = .02 ]. Baseline average pe rcent of sedentary time per day significantly predicted average percent of sedentary time per day at 6 weeks ( B Sedentary = .87, p < .001) Post hoc power analyses were conducted using G Power version 3.1 (Faul, Erdfelder, Lang, & Buchner, 2007) a nd revealed this analysis was powered at .13. Based on the number of predictors and effect size observed (d = .02), an n of approximately 395 would be ne eded to obtain statistical power at the recommended .80 level (Cohen, 1992)
69 Self e fficacy for p hysical a ctivity A hierarchical linear regression controlling for baseline PA self efficacy for physical activity, baseline depression, gender of patient, and comorbidity index indicated that baseline self efficacy ( B PAself efficacy = 51 p = .0 2 ), but not condition ( B Condition = .20, p = 49 ) significantly predicted PA self efficacy at 6 weeks [ F ( 5 2 7 ) = 3. 96 p < .05 # R 2 = .01 ] No other predictors were significant. The overall model explained 43% of the variance in PA self efficacy at 6 weeks ( R 2 = .42). Partner investment in diabetes self m an a gement A hierarchical linear regress ion controlling for baseline partner investment baseline depression, gender of patient, gender of partner, and comorbidity index revealed that baseline partner investment ( B Partner Investment = 73 p < .05 ), but not condition ( B Condition = .2 4 p = 61 ) significantly predicted partner investment at 6 weeks [ F ( 6, 25 ) = 3. 63 p = .01, # R 2 = .01 ]. No other predictors were significant. The full model explained 68 percent of the variance in patient reported partner investment at 6 weeks ( R 2 = .68). Secondary Outcomes Patient reported physical activity related social s upport A hierarchica l linear regression controlling for baseline PA social support, diabetes distress, d epression and patient gender revealed that condition significantly predicted PA social support at 6 weeks [ M CollaborativeII = 3.12, SD = 1.3 ; M IndividualII+Control = 2 .57 SD = .11 ; B condition = 1394.89 p = 02 ; see T able 1 8 ]. That is, collaborative IIs led to a greater increase in perceived social support between baseline and 6 weeks. Greater baseline social support ( B support = .72 p = <.001 ) also predicted great er so cial support at 6 weeks. The full model explained approximately 79 % of the variance in social support [ F ( 5, 26 ) = 19.91 p
70 <.001 R 2 = .79 ]. Adding study condition in the second step significantly improved prediction of PA social support ( # R 2 = 07 F = 9 .12 p < .05 ). Patient reported p hysical activity related social control. A hierarchical linear regression controlling for baseline PA social control, gender of patient, and baseline diabetes dist ress revealed that baseline PA social control ( B = 74 p < 001 s ), but not condition ( B Condition = .29, p = 21 ) significantly predicted PA social control at 6 weeks [ F ( 4, 28 ) = 16.92 p <.001 # R 2 = 02 ]. No other predictors were significant. The full model explained 70 percent of the variance in patient reported PA social control at 6 weeks ( R 2 = .70) Physical activity i ntentions. A hierarchical linear regression controlling for baseline inten tions partner age, patient gender, comorbidity index, and HbA1C revealed that baseline intentions ( B Intentions = 57 p < .0 2 ), but not condition ( B Condition = .46, p = 25 ) significantly predicted intentions at 6 weeks [ F (6, 12 ) = 3.63, p = .1 2 # R 2 = .0 6 ]. No other predictors were significant. The full model explained 52 percent of the variance in patient reported intentions ( R 2 = .52).
71 Table 1 7 Hierarchical Linear Regression Summary: IPAQ Recreational METs at 6 Weeks Steps Variable Unstandardized Coefficient F B SE 1 __ __ 2.66 Constant 2829.98 1208.35 __ Baseline IPAQ Rec METs .32* .32 __ Baseline Depression .135.14 90.11 __ 2 __ __ __ 4.00* Constant 2831.50* 1116.61 __ Baseline IPAQ Rec METs .26 .29 __ Baseline Depression 181.64* 85.48 __ Condition 1394.89* 579.71 __ Note. B SE, Standard Error; Unstandardized Beta R2, Variance, #R2, Change in Variance Condition is coded as 1, Collaborative II; 0, Individual II and Control ** p < 0.01 p < .05 N = 32
72 Table 1 8 Hier archical Linear Regression Summary : Physical Activity Related Partner Social Support at 6 Weeks Steps Variable Unstandardized Coefficient F B SE 1 __ __ 17.38* Constant .77 .65 __ Baseline PA Support .72 .12* __ Baseline Depression .05 .04 __ Baseline Diabetes Distress .15 .19 __ Patient Gender .08 .20 __ 2 __ __ __ 19.91* Constant 1.03 .59 __ Baseline PA Support .72* .11 __ Baseline Depression .05 .03 __ Baseline Diabetes Distress .23 .16 __ Patient Gender .28 .20 __ Cond ition .55* .18 __ Note. SE, Standard Error; B Unstandardized Beta; R 2 Variance; #R 2 Change in Variance PA Support, Physical Activity Related Social Support Condition is coded as 1, Collaborative II; 0, Individual II and Control ; Gender is coded as 1, Male; 2, Female ** p < 0.01 p < .05 N = 32
73 CHAPTER IV DISCUSSION A need for understanding the circumstances and for whom implementation based interventions are most effective has been identified in the implementation intention literature ( Prestwich & Kellar, 2014) Th e current study addressed this by being the first study to test collaborative IIs within a patient population as well as by testing PA self efficacy and diabetes related partner investment for diabetes self management as secondary outcomes of the intervent ion. This study was the first to examine partner investment for diabetes self management in patients with T2D and their partners. Additionally, t he current study contributes to the limited couples based intervention research for people with T2D. Research Feasibility While not planned outcomes, there are some aspects related to research feasibility worth noting. Recruitment rates indicated that only a small number of potential participants contacted were eligible and willing to participate. Online recrui tment (i.e. Qualtrics and Facebook ) allowed us to reach a large number of geographically diverse people; however, the majority of these participants did not provide contact information, were unable to be reached and/or were not interested in participating. Conversely, in person recruitment methods such as through clinic visits and a diabetes support group meeting reached very few individuals, but yielded a much higher percenta ge of interested participants. Thus, it appears in person recruiting in a clinical setting may be a more effective means of finding participants who are appropriate and willing to participate ; however, it requires more resources to recruit in this manner Similar studies may benefit
74 from having a member of the research team available to regularly recruit from local diabetes clinics with a consistent stream of potential participants While accelerometers are considered to more accurately assess physical activity than self report measures (Westerterp, 2009) they are resource intensive and not without limitations. A s noted in the results, some participants in the study were not compliant with t he accelerometer instructions and had to be excluded from some analyses I n person lab visits with a demonstration may have helped participants better understand how to properl y wear accelerometers and the importance of wearing the devices consistently. Individualized problem solving could also be provided This problem solving may include tips for wearing accelerometers with various articles of clothing or for remembering to pu t on the accelerometer at the beginning of the day. It is also possible that some participants were wearing t heir accelerometers but were too sedentary for the devices wear time validation to recognize they were wearing the device. A less conservative cut off for wear time validation may be more appropriate for this less active population. Implementation Outcomes The most common reason interest ed participants were excluded f r o m the study was having a comorbid medical condition such as neuropathy or cardio vascular disease that prevented them from safely participating in physical activity without medical clearance or supervision. Thus, this brief intervention was designed to be appropriate for relatively healthy patients or those who were newly diagnosed. Ho wever, for participants with a more complex medical history, a more intensive intervention with additional components and more medical supervision may be required. Further, almost half of
75 ineligible participants ( approximately 45% of those excluded) did no t participate because their partner was not willing to participate. Thus, couples that are more supportive of each other or have higher levels of relationship satisfaction m ay have self select ed into the study. Similarly, in a study recruiting breast cance r survivors and their caregivers (usually romantic partners), 69% of participants refused to provide caregiver information, and dyads higher in cohesion were more likely to participate as a couple (Bazzi, Cla rk, Winter, Tripodis, & Boehmer, 2016) Also in the area of breast cancer, a review indicated successful engagement of both dyad members is estimated to be about 58%, highlighting the difficulty of recruiting couples (Dagan & Hagedoorn, 2013) It is possible that many couples do not want to participate in physical activity together and that some individuals may benefit from an individual intervention. Future work in the area of couples based research should examine factors participants consider in choosing whe ther to p articipate as couple. Examinat ion of participant s plans is one way to determine intervention fidelity, and is a step often not included in implementation intention interventions (Hagger & Luszczynska, 2014) Based on the physical activity plans participants developed, it appeared patients u nderstood the instructions. The majority (93%) of participants were able to develop acceptable plans for increasing physical activity. However, s ome participants did not follow the "IF, THEN" format correctly (approximately 15% across both conditions) Pre vious research has indicated that forming plans using an "if then" format (Gollwitzer, 1999) lead s to more behavior change than a global, or free response form at. In addition, forming plans that include cues to behavior that are highly salient to the indiv idual is related to better behavioral outcomes (Hagger & Luszczynska, 2014)
76 Most participants included appropriate cues with the "IF statement;" however, some participants included less relevant cues (e.g. "if fin ances allow"). Overall the intervention appeared be feasible and acceptable from a clinical standpoint. On average, participants in the collaborative IIs condition completed the task in just under a half hour. Thus, the intervention is relatively brief a nd may be easily incorporated as "homework" following a medical appointment In addition, r esearch assistants spent relatively little time (approximately 10 minutes per participant over 6 weeks) delivering the clinical aspects of the intervention. Particip ants in both e xperimental conditions reported generally enjoying the study and f inding it beneficial although the collaborative IIs group appeared to consider it less enjoyable than individual IIs group. P articipants reported a high level of confidence in their abilities to carry out the plans Primary and Secondary O utcomes Re sults of the study indicated that the c ollaborative IIs condition had a significantly greater increase in recreational physical activity as reported on the IPAQ at 6 weeks compare d to individual IIs and control condition s These results are consistent with previous research on increasing physical activity in working adults (Prestwich at al., 2012 ) and increasing breast self examination among female college students (Prestwich et al ., 2005 ). However being assigned to the collaborative II condition did not predict an increase in physical activity as measured by accelerometer compared to the individual IIs and control condition. One possible reason for this finding is that, based on p articipant reported plans, many participants reported plans for increasing activity that could not be captured by accelerometer measurement such as swimming and water aerobics.
77 Participants also included plans that could not be captured well by acceleromet ers such as sit ups and push ups. These activities may have been better captured by the IPAQ as this instrument assesses the number of minutes spent doing activities at different intensity levels. Results indicated a non significant trend for participants in the c ollaborative IIS condition to engage in less sedentary time than participants in the i ndividual IIs or control conditions. Another possible reason that more significant effects were not detected is that group differences were too small to detect w ith the current sample size particularly for variables measured via accelerometer. Participant plans indicate several participants created at least one plan for increasing light physical activity such as gardening or walking. In addition the study sampl e was generally sedentary per the study 's inclusion criteria. These sedentary p articipants were asked to work toward the goal of engaging in 150 minutes of moderate physical activity per week. Thus, forming c ollaborative IIs in this sample may not have inc rease d moderate or vigorous activity to a large extent. Another possibility is that collaborative IIs were not effective for increasing p hysical activity and those in the collaborative IIs condition self reported higher levels of physical activity at 6 w eeks as a result of demand characteristics (Orne, 1996) Research assistants were not blinded to experimental condition and may have unintentionally interacted differently with those in the collaborative IIs condition. However, ass essments were conducted online and interaction with participants was minimal. Further participants were unaware of the three possible condition assignments. Thus, it is unclear how demand characteristics may have specifically influenced participants in th is study. When considering secondary outcomes p articipants in the collaborative IIs condition reported a greater increase in PA social support at 6 weeks than those in the
78 individual IIs condition and control conditions It is possible that communicatin g about physical activity and agreeing on a ph ysical activity routine increased how much support patients perceived from their partners. It is interesting that participants in the collaborative IIs group increased in social support but not objectively meas ured physical activity. It is possible the intervention helped increase perceived support from partners by involving them in the planning process but that this support did not translate into actual physical activity behavior change. Knoll and colleagues (2017) found that following dyadic planning intervention participants increased in perceived support from partners more so than the control group post intervention ; h owever, perceived social support did not mediate the e ffects of a dyadic planning intervention on physical activity Collaborative physical activity planning may be more effective in combination with other tools such as tracking physical activity and reducing additional barriers to physical activity engagemen t. There were no differences in patient reported PA social control at 6 weeks among experimental conditions. This may be because the intervention instructions focused on ways to support a partner's physical activity but did not emphasi ze social control b e haviors such as watching spouse s to make sure they engage in physical activity, or criticizing a spouse for not engaging in physical activity. A meta analysis on health related social control indicates there is mixed evidence regarding whether social contr ol items are positively or negatively related to health behavior outcomes (Craddock, vanDellen, Novak, & Ranby, 2015) Craddock et al calls for more work on moderators of the effects of social control such as affec t experienced by the recipient.
79 PA self efficacy was at the high end of the scale in our sample at baseline and similar to that of patients with coronary heart disease in another study (Sniehotta, Scholz, & Schwarzer, 2005) Change in PA s elf efficacy between baseline and 6 weeks did not differ between participants assigned to the collaborative IIs condition and those assigned to individual II and control conditions. Several studies testing individual planning interventions (Milne, Orbell, & Sheeran, 2002 ; Andrew Prestwich, Lawton, & Conner, 2003 ; Andrew Prestwich et al., 2005b ; Luszczynska, 2006 ; Arbour & Martin Ginis, 2009; Barg et al., 2012; Gellert, Ziegelma nn, Lippke, & Schwarzer, 2012 ) and one examining coll aborative IIs (Prestwich et al., 2012) have found that the intervention had no effect on self efficacy. One explanation for this finding is that PA self efficacy that pertains to beliefs about ones ability to execute behavior in the future, such as the mea sure used in the current study, is related to the decision to engage in PA and that planning occurs post decision making (Hagger & Luszczynska, 2014) S elf efficacy related to over coming barriers to engaging in physical activity may be likely to be influence d by implementation intentions as it is more relevant after making the decision to engage in physical activity Thus, future work should assess multiple types of self efficacy for physical activity. Change in p atient perceived p artner i nvestment in diabetes self management did not diffe r b etween intervention condition s between baseline and 6 weeks. Research in the area of type 1 diabetes indicates that communal coping, a similar construct is generally lower among couples facing diabetes than other chronic conditions (Helgeson, 2017) In addition, high levels of partner investment may not be ideal as partner over involvement has been related to poor outcomes among patients with diabetes ( Wiebe,
80 Helgeson, & Berg, 2016; Helgeson, 2017) However, more research is needed in regard to the ideal level of partner investment as it related to health outcomes, such as physical activity. When e xamining mean partner investment in diabetes self management over time (as displayed in Table 5), it appears that partner investment in diabetes self management increases from baseline to 3 week s then decreases in all three conditions. Participating in a couples based intervention may ha ve initially increased partner investment for all participants; however, additional intervention components may be needed to sustain a long term increase in partner investment. Lastly change in patient's i ntentions for engaging in phys ical activity did not differ among study conditions between baseline and 6 weeks. This makes sense, as the intervention was not designed to increase intentions for physical activity, but rather to bridge the intention behavior gap Of note, participants in this study report ed a h igh level of intentions for physical activity and p revious work indicates that implementation intentions may be more effective when intentions are low (Hagger & Luszczynska, 2014) Limitations While the current study is novel and is the first to test collaborative IIs in a T2D populati on, several limitations should be noted First, the study included a small sample size and was underpowered to detect group differences. Also, t he maj ority of the study outcomes were measured using self report instruments. Therefore the usual limitations of self report measures such as recall bias and social desirability bias may have influenced the results. We did include accelerometers to objectively measure physical activity; however, some participants included plans that could not be assessed by acce lerometry.
81 Also, challenges were experienced in getting participants to wear the accelerometers for the necessary amount of time. Future work using accelerometers to measure activity may include requirements to develop plans for activities such as walking and running and exclude swimming and water aerobics. In addition, a "run in" accelerometer phase may alleviate any tendency for participants to be more active than usual during their first accelerometer baseline measure, the so called "reactivity bias" (Clemes & Deans, 2012) Because of limited resources we were unable to measure partner physical activity as measured by accelerometer in this study. This study was not designed to increase partner physical activity specifically but it is possible that partners could change behavior along with patients. Furth er, d iabetes patients are a heterogeneous patient population and differences in comorbidities and disease severity could influence results; although, we examine d these characteristics (i.e. comorbidity index, HbA1c ) a s they relate d to physical activity in our sample. Specific to our sample, a pproximately 40% of participants did not know their most recent HbA1c value and the remaining participants self reported this information. It is possible that participants did not accurately report HbA1c and those part icipants who did not know their most recent value have less well controlled T2D. Similarly participant's self reported diabetes status is not as ideal as having clinical data; however, several studies have shown that self reported diabetes status is highl y accurate when compared to fasting blood glucose and Hb A1c (Margolis et al., 2008 ; Espelt, Goday, Franch, & Borrell, 2012; Schneider, Pankow, Heiss, & Selvin, 2012) In addition, our sample was generally highly educa ted (at least some college), reported household income
82 above $40,000 and identified as white; therefore results may not generalizable to the T2D population as whole. Future Directions Future research would benefit from testing this collaborative IIs intervention with a larger sample size that is powered to test po tential mediators such as social support. A larger sample size may allow for examining differences between couples where both partners have been diagnosed with T2D versus couples that are not concordant on diabetes status. If collaborative IIs were found to be effective at increasing physical activity in a larger sample, it would be important to extend the follow up period to 6 months or longer to test whether collaborative IIs lead to long term maintenance of physical activity and be able to detect chang es in patient's HbA1b levels. In addition, combining collaborative IIs with additional intervention components may strengthen the intervention. For example, in our sample participants were already willing to increase physical activity; however, for patie nts with who are currently ambivalent about physical activity may benefit from a component which addresses the motivational phase (Hagger & Luszczynska, 2014) Supporting this notion a counseling intervention by Di Loret o and colleagues ( 2003) involving motivational, tracking, planning, family support, and problem solving components was identified in a systematic review as both effective for increasing physical activity among patients with T2D and pragmatic for implement ing in a clinical setting (Luoma et al., 2016) Further, future work in this area may consider testin g collaborative IIs in patients who are newly diagnosed with T2D to capitalize on a transitional period when motivation to increase physical activity may be high. Another future direction is to examine whether
83 change in patient's physical activity relates to change in the physical activity of their partner. Research regarding collaborative IIs may also translate to other self management behaviors important for people with T2D. Given the importance of assessing implementation outcomes, future work should inc lude more measures to assess successful implementation from the provider/organizational point of view as well as the cost effectiveness of the intervention (Proctor et al., 2011) Conclusion Collaborative IIs appeared to be feasible and acceptable among patients in our small sample. Continued work with a larger sample is needed to understand the mechanisms related to collaborative IIs. However, r ecruitment of couples within a patient population is a particularly difficult research endeavor and strategies for obtaining an adequate and generalizable sample are needed in order to move the field forward. Further similar studies should carefully cons ider physical activity assessment by considering the population being studies, the intervention instructions, and the resources available. As a stand alone intervention, collaborative IIs are relatively easy to administer, are a low burden on patients, and are low cost. However, collaborative IIs may also be strengthened when combined with other intervention components. More research is needed to understand the populations and health behaviors for which collaborative IIs may be beneficial either as a brief intervention or as part of a larger multiple component intervention.
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96 SkÂŒr S., Sniehotta, F. F., Molloy, G. J., Prestwich, A., & AraÂœjo Soares, V. (2011). Do brief online planning interventions increase physical activity amongst university students? A randomised controlled trial. Psychology & Health 26 (4), 399 417. http://doi. org/10.1080/08870440903456877 Sniehotta, F. F., Scholz, U., & Schwarzer, R. (2005). Bridging the intention behaviour gap: Planning, self efficacy, and action control in the adoption and maintenance of physical exercise. Psychology & Health 20 (2), 143 16 0. http://doi.org/10.1080/08870440512331317670 Sone, H., Tanaka, S., Iimuro, S., Tanaka, S., Oida, K., Yamasaki, Y., Yamada, N. (2010). Long term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: A nationw ide multicentre randomised controlled trial (the Japan Diabetes Complications Study). Diabetologia 53 (3), 419 428. http://doi.org/10.1007/s00125 009 1622 2 Steptoe, A., Rink, E., & Kerry, S. (2000). Psychosocial Predictors of Changes in Physical Activit y in Overweight Sedentary Adults Following Counseling in Primary Care. Preventive Medicine 31 (2), 183 194. http://doi.org/10.1006/pmed.2000.0688 Touati, S., Meziri, F., Devaux, S., Berthelot, A., Touyz, R. M., & Laurant, P. (2011). Exercise reverses met abolic syndrome in high fat diet induced obese rats. Medicine and Science in Sports and Exercise 43 (3), 398 407. http://doi.org/10.1249/MSS.0b013e3181eeb12d Trief, P. M., Fisher, L., Sandberg, J., Cibula, D. A., Dimmock, J., Hessler, D. M., Weinstock, R. S. (2016). Health and psychosocial outcomes of a telephonic couples behavior change intervention in patients with poorly controlled type 2 diabetes: A randomized clinical trial. Diabetes Care 39 (12), 2165 2173. http://doi.org/10.2337/dc16 0035 Troia no, R. P., Berrigan, D., Dodd, K. W., MÂ‰sse, L. C., Tilert, T., & Mcdowell, M. (2008). Physical activity in the United States measured by accelerometer. Medicine and Science in Sports and Exercise 40 (1), 181 188. http://doi.org/10.1249/mss.0b013e31815a51b 3 Tudor Locke, C., Barreira, T. V, Schuna, J. M., Mire, E. F., Chaput, J. P., Fogelholm,
97 M., ISCOLE Research Group. (2015). Improving wear time compliance with a 24 hour waist worn accelerometer protocol in the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE). International Journal of Behavioral Nutrition and Physical Activity 12 (1), 11. http://doi.org/10.1186/s12966 015 0172 x Wallace, J. P., Raglin, J. S., & Jastremski, C. A. (1995). Twelve month adherence of adults who joined a fitness program with a spouse vs without a spouse. The Journal of Sports Medicine and Physical Fitness 35 (3), 206 13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8775648 Warburton, D. E. R., Nicol, C. W., & Bredin, S. S. D. (2006). He alth benefits of physical activity: the evidence. CMAJ!: Canadian Medical Association Journal = Journal de l'Association Medicale Canadienne 174 (6), 801 9. http://doi.org/10.1503/cmaj.051351 Webb, T. L., & Sheeran, P. (2008). Mechanisms of implementatio n intention effects: The role of goal intentions, self efficacy, and accessibility of plan components. British Journal of Social Psychology 47 (3), 373 395. http://doi.org/10.1348/014466607X267010 Westerterp, K. R. (2009). Assessment of physical activity : A critical appraisal. European Journal of Applied Physiology http://doi.org/10.1007/s00421 009 1000 2 Wiebe, D. J., Helgeson, V., & Berg, C. A. (2016). The social context of managing diabetes across the life span. American Psychologist 71 (7), 526 538 http://doi.org/10.1037/a0040355 Williams, D. M., Dunsiger, S., Miranda, R., Gwaltney, C. J., Emerson, J. A., Monti, P. M., & Parisi, A. F. (2015). Recommending Self Paced Exercise among Overweight and Obese Adults: a Randomized Pilot Study. Annals of B ehavioral Medicine 49 (2), 280 285. http://doi.org/10.1007/s12160 014 9642 7
98 APPENDIX A: PHYSICAL ACTIVITY PL ANS Table 15 Physical Activity Plans: Collaborative Implementation Intentions Condition IF THEN I t is Monday We can work together to ge t dishes done and walk our dogs I t is Tuesday We can do push ups and sit ups while watching TV It is Wednesday We c an walk the dogs again which we need to do anyway and /or go swimming at my Sisters house I t is Thursday We can do exercise s like sit u ps and push ups to help us with strength training while watching TV or listening to music I t is Friday We can walk our 7 dogs again and work in the yard F inances allow We will do water aerobics twice a week Finances do not allow for a gym membership W e will ride the stationary bike 2 3 miles for 3 days a week Fi nances allow W e will walk the track 7 laps (1/2 mile) 2 times a week W e both need the treadmill at the same time in the morning Joe will use it on Monday, W ednesday, and F riday at 6:00 AM in the basement. Jane will use it on Sunday, Tu esday and Sat urday at 6:00 AM in the basement W e're at home and it's a Monday, Wednesday, or Friday when our favorite show is on television We w ill do sit ups, push ups and other body weight exercises together while watching the television Someone needs to watch the kids after school We will t ake turns running or weight lifting in the basement D oing treadmill and Bowflex is scheduled at same time We will share and rotate I t is the end of the work day on Monda y through Friday We will briskly walk home together There are after work appointments Monday through Friday W e will walk the dog together before/after eating dinner for at least 15 minutes I t's Saturday We will kayak before starting our week end errands for at least an hour It 's Saturday and we can't kayak We will go bowling for at least 2 games
99 I t's Monday through Friday J oe will get Jane up at 4:30 so she can go to the gym for 45 minutes before work I t's Sunday We will honor God by resting Jane come s ho me from work We will walk briskly from the bus stop to home Jane has to go to the market We walk briskly to the market Jane is running errands I will do household chores While Jane is doing female push ups Joe will do weight training with milk car tons T he weather is decent on Sunday and Monday plus one other day during the week W e will go golfing 2 to 3 times a week and will walk when we play nine holes W e cant get outside for the 3 times a week We will walk at the mall W e are camping We will walk the campgrounds at least 2 times an evening T he weather is permitting We w ill walk our dogs for 20 30 minutes every other day Jane can get Joe to do it, Tuesday, Thursday, and S at urday We w ill do an exercise routine with hand weights stretches and would love to try some yoga since we both have bad backs W e get up earlier on Monday and Tuesday We can work out for 30 minutes at home We come home early Wednesday and T hursday We can work out for 30 minutes at home W e come home for a long lunch We ca n work out for 30 minutes at home W e miss a day We will, m ake it up by exercising during our favorite show at home W e need to make up a workout W e will do so on the weekend It is Tuesday W e will walk 30 minutes together and do the evening chores togeth er for 30 more minutes It is Wednesday W e will go swimming in the pool with the grandkids for 45 minutes It is Thursday Joe and I will do yard work together f or 30 minutes It is Monday W e will walk together for one hour and Jane will do sit ups for 10 minutes while Joe does weights It is Friday after work W e will go to the gym for one hour and a half Joe gets off work at 4 PM on Monday through Friday We will walk through our neighborhood for 30 minutes each night It is Tuesday, Thursday, or Saturday and our favorite show comes on We will do simple resistance training during the show
100 The weather gets too warm We will go down to the pool and swim It is Tuesday morning at 8:30 AM We will walk the sea wall at Port Aransas for 45 minutes It is Frida y afternoon at 1:30 PM We will walk 2 laps of Indian Point Pier It is Saturday morning at 8:30 A M We w ill walk to Violet Andrews Park and walk 2 laps of the trail It is Monday after 12:30 PM Joe will clean up from lunch so Jane can walk the mall It is W ednesday before lunch We will walk to and from the library I am watching TV on Monday Tuesday and Thursday W e will do 10 repetitions of leg lifts It is Saturday W e will go to the Gym and do water aerobics I t is not raining and every other day We will wa lk 1/2 mile T here is a commercial on TV on Tuesday and Wednesday We will do free weights arm curls 10 reps of 5 times It is Sunday and during laundry We will walk up and down 12 steps for 10 repetitions It is at the end of the work day on Monday thru Fr iday We will do sit ups and walk on the treadmill for 180 minutes Saturday or Sunday morning We will do stretching and exercise (jumping jacks and sit ups) for 80 minutes in the living room Monday thru Friday at bedtime We will do stretching exercises be fore bed for 60 minutes Monday, Wednesday or Saturday before work We will walk around the track for 2 miles or 45 minutes It is night time and we are sitting down, watching TV We will do arm exercise and sit ups while watching TV for 180 minutes It is M onday at 5 PM We will take 1 $ hour walks around our neighborhood It is Tuesday and Friday at 5 PM I will ride my bike for an hour in my home If it is Saturday at 9 AM We will exercise to stretch our muscles It is Tuesday at 5 PM We will sign up to t ake classes at a gym on close by It is Saturday at 5 PM We will ride our bikes through a bike path close to our home We are home Monday and Wednesday early afternoon We will work out together with the 21 day fix workout DVDs at home We are home Tuesday and Thursday early We will work out together with the 21 day fix
101 afternoon work out DVDs at home We are home Friday and Sunday at bedtime before dark We will take a brisk walk around the neighborhood We are watching TV We can do stretching and sit ups I t is after dinner We can walk around the block It is before breakfast We can stretch and walk in place It is bedtime We can do stretches and push ups It is lunchtime We can walk vigorously on the treadmill Note. Spelling errors, typos and sentence str ucture were corrected in all plans. Identical or redundant plans listed by the same couple were not included. Changes in shading reflect grouping of plans made by each couple. Names were changed to "Joe" and "Jane" for participant confidentiality.
102 Tab le 16 Physical Activity Plans: Individual Implementation Intentions Condition IF THEN I I can't get a ride home from work Will walk the 4 miles home. It's enjoyable weather is good and it's flat all the way home. I'm doing laundry W ill put my timer on and walk on my treadmill and than put my c lothes in the dryer and walk until the laundry is done ( about 45 min ) It is Friday, Sunday or Tuesday morning W ill play the Wii Walk It Out Game for 30 minutes It is afternoon W ill get up every 15 minutes an d use the stairs before returning to my desk I'm watching television at night W ill use my hand weights during commercials It is time to wake up in the morning Will do 15 sit ups I'm shopping Will park as far from the building as possible It is Monday Wednesday or Friday Will take a water walking class It is Tuesday or Thursday Ride my stationary bike I t is during the work week when I get home in the evening Will walk briskly while listening to music or watching TV It is on the weekend and I'm not on duty W ill start doing yard work I t is during the work week and I get home early enough W ill get the treadmill out and listen to music on the treadmill If it is on the weekend and I'm off Will get up early and briskly walk around the small loop in t he neighborhood I'm home on the weekends off duty Will start using the treadmill while watching football The weather is good (almost always here) W ill go swimming If it is after supper W ill go for a walk at least 3 times a week, and if it's raining I could walk up and down the stairs in my building I am watching TV C an workout and watch at the same time, to make exercise less boring. I go for a swim at my condo I can also use the gym at the condo for resistance exercise If I am walking I could run part of the way It is Monday, Wednesday or Friday at 10 AM Will ride the stationary bike for 30 minutes at home
103 It is Tuesday or Thursday at 7 PM Will ride the st ationary bike for 30 minutes at home It is Saturday at 2 PM W ill work in the yard for 30 mi n at home If it is Monday Wednesday or Friday at 10 AM and the pollen is gone W ill walk at the Vaal for 30 minutes It is Tuesday or Thursday and the weather is nice Will w alk in the neighborhood for 30 min I t is Monday evening at 6 PM after work Will g o to the gym, walk 2 miles on the tr ack then play basketball for 1 hour, then stretch to finish things off I t is Wednesday morning at 7AM W ill get up and take a walk around my neighborhood then come home and do some weightlifting before I go to work at 9 AM I t is Saturday at 9 AM will go to the gym by 9am Will go to the gym, then play basketball with my friends for an hour or so the n I will ride a bike for 1 hour to finish up The dog wants to go out after breakfast Will take a brisk wa lk with the do g down to Walnut R oa d and back The dog wants to go out after dinner Will take a brisk walk with the do g down to Walnut Road and back It is any day and not raining Will do general gardening in the back yard If it is Tuesday or Thursday Will do heavy gard ening in the back yard It is afternoon Will go outside and play with the dog I am cutting the grass Will use the push mower and not use the riding mower It is Tuesday or Thursday morning Will g o on brisk walks or will use the treadmill in the house (wea ther dependent) I am watching TV in the evenings Will d o stretching exercises I am working at my job every day Will get up and move around more often, walk up and down steps or walk briskly around the area I let the dog outside to play each day Will be active with her, by playing with a ball and chasing her around We are at home I will get on the treadmill for 2 minutes each day t his week and try to increase 1 minute per day until I am up to 150 minutes per week. If that seems like too big a goal star ting out I will stick with my 2 minutes or 10, 15 or 20 minutes like my Dr said until I am comfortable to move on to 30 minutes per day. If I feel like doing more it's ok, if I don't that is ok too, no matter if I
104 move backwards one day or skip a day. T his is the only way I know how to start and this is ok per my Dr. Some movement is better than no movement. We are shopping Will park the car farthe r from the store and walk to it We are at the big box store I will take time to walk all the way around i t once We go out to eat I will go walk the Kroger store on the way home I can kick my booty I will tackle de cluttering the basement like I did the upstairs of my house. Less st uff is easier to clean weekly It is Monday through Friday during the day W i ll walk the concourses in the airport and let someone else have my golf cart. If I am at home in the evenings W ill walk the one mile round trip to the mailbox and back It is the weekend or a holiday W ill increase my walking and increase my heart rate wh ile walking at the state park. If I am not able to get out because of the weather W ill do floor exercise at home I f I am watching my favorite TV show Will exercise with my free weights at home I t is Monday, Wednesday or Friday W ill start doing a walk aerobics tape at home and use this as a starting point for my exercise plan. Will start out on one of t hese days w orking up to three days a week I t is Monday and Wednesday I will work out in the garden to get it ready to plant veggies. If it rains I wi ll do on next day. Getting a garden ready for plants is heavy gardening...digging, hoeing, pulling up old weeds, getting rid of old leaves, working the soil I ts Tuesday and Thursday I will hike up our steep road up to our house first without a backpack then once conditioned with one Note. Spelling errors, typos and sentence structure were corrected in all plans. Identical or redundant plans listed by the same couple were not included. Changes in shading reflect grouping of plans made by each couple. Na mes were changed to "Joe" and "Jane" for participant confidentiality.
105 APPENDIX B SELF REPORT AND PARTNER REPORT MEASURES The Physical Activity Readiness Questionnaire (PAR Q) Please read the questions below carefully, and answer each one honestly. P lease check YES or NO. 1. Has your healthcare provider ever said that you have a heart condition and that you should only do physical activity recommended by a healthcare provider? 2. Do you feel pain in your chest when you do physical activity? 3. In t he past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be ma de worse by a change in your physical activity? 6. Is your doctor currently prescribing you drugs for your blood pressure or a heart condition? 7. Do you know of any other reason why you should not do physical activity?
106 AHA/ ACSM Health/Fitness Facility Preparation Screening Questionnaire Please mark all true statements: History Have you had: __ A heart attack __Heart Surgery __Cardiac Catheterization __Coronary angioplasty __Pacemaker/implantable cardiac defibrillator/rhythm disturbance __Heart valve di sease __Heart failure __Heart transplantation __Congenital heart disease Symptoms __You experience chest discomfort with exertion __You experience unreasonable breathlessness __You experience dizziness, fainting, or blackouts __You experience ankle swell ing __You experience unpleasant awareness of a forceful or rapid heart rate. __You take heart medications Demographic Information
107 We are surveying people who have been diagnosed with Type 2 Diabetes and their relationship partners. What is your relatio nship status with your current partner ? (Married, living with a partner, other________) Have you or your partner been diagnosed with Type 2 Diabetes? (I have My partner has We both have Neither of us have been diagnosed) If yes: How long ago were you diagnosed with Type 2 Diabetes? (years + months) If yes: How long ago was your partner diagnosed with Type 2 Diabetes? (years + months) Date of Birth Gender (male/female/transgender/prefer not to answer) Ethnicity (do you identify as Hispanic; yes, no) Race (Black or African American, White, Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaskan Native More than one race other)
108 Household Income (< $15, 000; $15,000 $24,999; $25, 000 $34,999, $35,000 to $74,999; $75,000 $99,999; $100,000 and above) How long have you been living with your partner/spouse? (years + months) How long have you been married to your current spouse? (years + months) How many children do you have? If 1: How old is your child ( years + months) If > 1: Please indicate the age of each of your children ( years + months) Health Information What is your most recent HbA1c level? (option for don't know) When was your HbA1c last tested? (option for don't know) What is your current weight? What is your current height?
109 Charlson Comorbidity Index Have you been diagnosed with any of the following conditions? (check all that apply ) 1. Myocardial Infarction 2. Congestive Heart Failure 3. Peripheral Vascular Disease 4. Cerebrovascular Disease 5. Dementia 6. COPD 7. Connective Tissue Disease 8. Peptic Ulcer Disease 10. Moderate to Severe Chronic Kidney Disease 11. Hemiplegia 12. Leukemia 13. Malignant Lymphoma 14. Solid Tumor (metastatic vs non metastatic) 15. Liver Disease (mild versus moderate to severe) 16. HIV/AIDS 17. Depression
110 The International Physical Activity Questionnaire short form (IPAQ) We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport. Think about all the vigorous and moderate activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Part 1: Job Related Physical Activity The first section is about your work. This includes paid jobs, farmin g, volunteer work, course work, and any other unpaid work that you did outside your home. Do not include unpaid work you might do around your home, like housework, yard work, general maintenance, and caring for your family. These are asked in Part 3. Do yo u currently have a job or do any unpaid work outside your home? (Circle one) Yes No If circled, skip to Part 2: Transportation The next questions are about all the physical activity you did in the last 7 days as part of your paid or unpaid work. This do es not include traveling to and from work.
111 During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, heavy construction, or climbing up stairs as part of your work? Think about only those physical activit ies that you did for at least 10 minutes at a time. Circle corresponding answer below: None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip t he question below about hours/minutes per day. How much time did you usually spend on one of those days doing vigorous physical activities as part of your work? Hours per day:________ Minutes per day:_______ Again, think about only those physical activitie s that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads as part of your work? Circle answer and please do not include walking. None 1 day per week 2 days p er week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day.
112 How much time did you usually spend on one of those days doing modera te physical activities as part of your work? Hours per day:________ Minutes per day:________ During the last 7 days, on how many days did you walk for at least 10 minutes at a time as part of your work? Please do not count any walking you did to travel to or from work. None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usua lly spend on one of those days walking as part of your work? Hours per day:________ Minutes per day:________ PART 2: TRANSPORTATION PHYSICAL ACTIVITY These questions are about how you traveled from place to place, including to places like work, stores, mo vies, and so on. During the last 7 days, on how many days did you travel in a motor vehicle like a train, bus, car, or tram?
113 None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had pr eviously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days traveling in a train, bus, car, tram, or other kind of motor vehicle? Hours per day:________ Minutes per day:______ __ Now think only about the bicycling and walking you might have done to travel to and from work, to do errands, or to go from place to place. During the last 7 days, on how many days did you bicycle for at least 10 minutes at a time to gofrom place to pl ace? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days to bicycle from place to place? Hours per day:________ Minutes per day:________
114 During the last 7 days, on how many days did you walk for at least 10 minutes at a time to go from place to place? None 1 day per week 2 days per week 3 d ays per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days walking from place to p lace? Hours per day:________ Minutes per day:________ PART 3: HOUSEWORK, HOUSE MAINTENANCE, AND CARING FOR FAMILY This section is about some of the physical activities you might have done in the last 7 days in and around your home, like housework, gardeni ng, yard work, general maintenance work, and caring for your family. Think about only those physical activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do vigorous physical activities like heavy lif ting, chopping wood, shoveling snow, or digging in the garden or yard? None 1 day 2 days 3 days 4 days 5 days 6 days 7 days
115 per week per week per week per week per week per week per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days doing vigorous physical activities in the garden or yard? Hours per day:________ Minutes per day:________ Again, think about only those physical activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do moderate activities like carrying light loads, sweeping, washing windows, and raking in the garden or yard? None 1 day per week 2 days per week 3 days per week 4 days p er week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days doing moderate physical activities in the ga rden or yard? Hours per day:________ Minutes per day:________
116 Once again, think about only those physical activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do moderate activities like carrying ligh t loads, washing windows, scrubbing floors and sweeping inside your home? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question be low about hours/minutes per day. How much time did you usually spend on one of those days doing moderate physical activities inside your home? Hours per day:________ Minutes per day:________ PART 4: RECREATION, SPORT, AND LEISURE TIME PHYSICAL ACTIVITY Th is section is about all the physical activities that you did in the last 7 days solely for recreation, sport, exercise or leisure. Please do not include any activities you have already mentioned. Not counting any walking you have already mentioned, durin g the last 7 days, on how many days did you walk for at least 10 minutes at a time in your leisure time? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week
117 If you had previously selected "n one," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days walking in your leisure time? Hours per day:________ Minutes per day:________ Think about only those physical activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do vigorous physical activities like aerobics, running, fast bicycling, or fast swimming in your leisure time? None 1 day per week 2 days per week 3 days per week 4 days pe r week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip the question below about hours/minutes per day. How much time did you usually spend on one of those days doing vigorous physical activities in your le isure time? Hours per day:________ Minutes per day:________ Again, think about only those physical activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do moderate physical activities
118 like bicycling at a regular pace, swimming at a regular pace, and doubles tennis in your leisure time? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week If you had previously selected "none," then skip t he question below about hours/minutes per day. How much time did you usually spend on one of those days doing moderate physical activities in your leisure time? Hours per day:________ Minutes per day:________ PART 5: TIME SPENT SITTING The last questions are about the time you spend sitting while at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading or sitting or lying down to watch television. Do not include any time spe nt sitting in a motor vehicle that you have already mentioned. During the last 7 days, how much time did you usually spend sitting on a weekday? Hours per day:________ Minutes per day:________ During the last 7 days, how much time did you usually spend si tting on a weekend day? Hours per day:________
119 Minutes per day:________ Partner physical activity This section is about the physical activities that your partner did in the last 7 days. During the last 7 days, on how many days did your partner walk for a t least 10 minutes at a time? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week Not Sure If you had previously selected "none" or "not sure," then skip the question below about hours/minut es per day. How much time did he or she usually spend on one of those days walking? Hours per day:________ Minutes per day:________ Think about only those physical activities that your partner did for at least 10 minutes at a time. During the last 7 days, on how many days did he or she engage in vigorous physical activities like aerobics, running, fast bicycling, or fast swimming? None 1 day per 2 days per 3 days per 4 days per 5 days per 6 days per 7 days per Not Sure
120 week week week week week week week If you had previously selected "none" or "not sure," then skip the question below about hours/minutes per day. How much time did he or she usually spend on one of those days doing vigorous physical activities in your leisure time? Hours per day:________ M inutes per day:________ Again, think about only those physical activities that he or she did for at least 10 minutes at a time. During the last 7 days, on how many days did he or she do moderate physical activities like bicycling at a regular pace, swimmi ng at a regular pace, and doubles tennis? None 1 day per week 2 days per week 3 days per week 4 days per week 5 days per week 6 days per week 7 days per week Not Sure If you had previously selected "none" or "not sure," then skip the question below about hours/minutes per day. How much time did he or she usually spend on one of those days doing moderate physical activities? Hours per day:________
121 Minutes per day:________
122 Self Efficacy for Physical Activity How much confidence do you have in your abilit y to plan an exercise routine? 1 2 3 4 5 6 None A great Deal I know how to engage in physical activities. 1 2 3 4 5 6 Strongly Disagree Strongly Agree How much confidence do you have in your ability to engage in regular exercise? 1 2 3 4 5 6 None A great Deal How prepared or ready are you to exercise on a regular basis in the next few months?
123 1 2 3 4 5 6 Not at all Prepared Very Prepared
124 Physical Activity Intentions Strongly Disagree Strongly agree I intend to e ngage in physical activity in the next month 1 2 3 4 5 6 7 I want to engage in physical activity in the next month 1 2 3 4 5 6 7 I expect to engage in physical activity in the next month 1 2 3 4 5 6 7 Definitely Will Not Definitely Will I will e ngage in physical activity next month 1 2 3 4 5 6 7 Unlikely Likely How likely is it that you will engage in physical activity in the next month 1 2 3 4 5 6 7
125 Partner Investment in Diabetes Self Management Patient Report Please choose a numb er to indicate how much you agree or disagree with each statement: Strongly Disagree Strongly Agree 1. The responsibility of managing my diabetes is mine alone 1 2 3 4 5 6 7 2. When I think about the negative consequences of not following the recommended diabetes management treatment (diet, medication, blood sugar testing, exercise), I view this as "our" problem (shared by my partner and me equally) rather than just my problem. 1 2 3 4 5 6 7 3. Ultimately, I must face the challenges of managing my diabete s, as an individual rather than depending on my partner. 1 2 3 4 5 6 7 4. My partner and I have useful discussions 1 2 3 4 5 6 7
126 about how to manage my diabetes. 5. My partner and I are able to work together toward helping me manage diabetes. 1 2 3 4 5 6 7 Partner Report Please choose a number to indicate how much you agree or disagree with each statement: Strongly Disagree Strongly Agree 1. The responsibility of managing my partner's diabetes is his or hers alone. 1 2 3 4 5 6 7 2. When I think about the negative consequences of my partner not following the recommended diabetes management treatment (diet, medication, blood sugar testing, exercise), I view this as "our" problem (shared by my partner and me equally) rather than just his or her problem. 1 2 3 4 5 6 7
127 3. Ultimately, my partner must face the challenges of managing his or her diabetes, as an individual, rather than depending on me. 1 2 3 4 5 6 7 4. My partner and I have useful discussions about how to manage his or her diabetes. 1 2 3 4 5 6 7 5. My partner and I are able to work together toward helping my partner manage diabetes. 1 2 3 4 5 6 7
128 Physical Activity Related Support and Control Patient Report How much did your partner do each of the following regarding your physical activity routin e: In the past month, my partner Not at all A Little Somewhat Very Much 6. Listened to my concerns about engaging in physical activity 1 2 3 4 7. Tried to influence me to engage in more physical activity 1 2 3 4 8. Congratulated me for participating in phys ical activity 1 2 3 4 9. Watched me to make sure that I participated in physical activity? 1 2 3 4 10. Agreed with my decisions about participating in physical activity 1 2 3 4 11. Told me to engage in physical activity more often because others are depending on m e 1 2 3 4 12. Assisted me in carrying out my physical activity routine 1 2 3 4 13. Prompted or reminded me to engage in physical activity more often 1 2 3 4
129 14. Helped me maintain my physical activity routine 1 2 3 4 15. Gave me advice about improving my physical act ivity routine that I did not ask for 1 2 3 4 16. Encouraged me to continue participating in physical activity 1 2 3 4 17. Criticized me for not engaging in physical activity more often 1 2 3 4 18. Told me that I was doing a good job maintaining a physical activity routine 1 2 3 4 19. Tried to make decisions for me regarding my physical activity routine 1 2 3 4 Pa rtner Report How much did you do each of the following regarding your partner's physical activity routine: In the past month, I Not at all A Little Somew hat Very Much 1. Listened to my partner's concerns about engaging in physical activity 1 2 3 4 2. Tried to influence my partner to engage in more physical activity 1 2 3 4 3. Congratulated m y partner for participating in physical activity 1 2 3 4
130 4. Watched my p artner to make sure that he/she participated in physical activity? 1 2 3 4 5. Agreed with my partner's decisions about participating in physical activity 1 2 3 4 6. Told my partner to engage in physical activity more often because others are depending on him/h er 1 2 3 4 7. Assisted m y partner in carrying out his/her physical activity routine 1 2 3 4 8. Prompted or reminded m y partner to engage in physical activity more often 1 2 3 4 9. Helped m y partner maintain his/her physical activity routine 1 2 3 4 10. Gave my par tner advice about improving his/her physical activity routine that he/she did not ask for 1 2 3 4 11. Encouraged my partner to continue participating in physical activity 1 2 3 4 12. Criti cized my partner for not engaging in physical activity more often 1 2 3 4 13. Told my partner th at he/she was doing a good job maintaining a physical activity routine 1 2 3 4 14. Tried to make decisions for my partner regarding his/her physical activity routine 1 2 3 4 Items 1, 3, 5, 7, 9, 11, and 13 reflect physical activity relate d support Items 2, 4, 6, 8, 10, 12, and 14 reflect physical activity related control
131 PHQ 8 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several Days More than half the days Nearly Every Day Littl e interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3 Feeling tired or having little energy 0 1 2 3 Poor appetite or overeating 0 1 2 3 Feeling bad about yourself or that you a failure or have let yourself or your family down 0 1 2 3 Trouble concentrating on things such as reading the newspaper or watching television 0 1 2 3 Moving or speaking so slowly that other people could have noticed? Or 0 1 2 3
132 the opposite being so fidgety or restless that you have been moving around a lot more than usual
133 Diabetes Distress DIRECTIONS: Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 17 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 17 items may have distressed or bothe red you DURING THE PAST MONTH and circle the appropriate number. Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular ite m is not a bother or a problem for you, you would circle "1". If it is very bothersome to you, you might circle "6". Not a Problem A Slight Problem A Moderate Problem Somewhat Serious Problem A Serious Problem A Very Serious Problem
134 Feeling that diabetes is taking up too much of my mental and physical energy every day. 1 2 3 4 5 6 Feeling that my doctor doesn't know enough about diabetes and diabetes care. 1 2 3 4 5 6 Ultimately, my partner and I must face the challenges of living a physically active li festyle, as individuals, rather than depending on each other. 1 2 3 4 5 6 Feeling angry, scared, and/or depressed when I think about living 1 2 3 4 5 6
135 with diabetes. Feeling that my doctor doesn't give me clear enough directions on how to manage my diab etes. 1 2 3 4 5 6 F eeling that I am not testing my blood sugars frequently enough. 1 2 3 4 5 6 Feeling that I am often failing with my diabetes routine. 1 2 3 4 5 6 Feeling that friends or family are not supportive enough of s elf care efforts (e.g. plan ning activities that conflict with my schedule, encouraging me to 1 2 3 4 5 6
136 eat the "wrong" foods). Feeling that diabetes controls my life. 1 2 3 4 5 6
137 Relationship Satisfaction Please indicate the degree to which you agree with each of the follow ing statements regarding your current relationship, Don't Agree at All Slightly Agree Moderately Agree Completely Agree My Partner fulfills my needs for intimacy (sharing personal thoughts, secrets, etc.) 1 2 3 4 My partner fulfills my needs for c ompanionship (doing things together, enjoying each others company, etc.) 1 2 3 4 My partner fulfills my sexual needs (holding hands, kissing, etc.) 1 2 3 4 My partner fulfills my needs for security (feeling trusting, comfortable, in a stable relationship etc.) 1 2 3 4 My partner fulfills my needs for emotional involvement (feeling emotionally attached, feeling good when another feels god, etc.) 1 2 3 4 I feel satisfied with our relationship. 1 2 3 4 My relationship is much better than others. 1 2 3 4 My relationship is close to ideal. 1 2 3 4 Our relationship makes me very happy. Our relationship does a good job of fulfilling my needs for intimacy, companionship, etc.
138 Attitudes about Planning This section concerns your fe elings about the plans you have developed with your study partner to increase your level of regular physical activity. Please indicate your response by selecting the appropriate number: 1. My study partner and I came up with ideas and suggestions for the plan together
139 Not at all 1 2 3 4 5 6 7 To a great extent 2. My study partner and I discussed the plan together Not at all 1 2 3 4 5 6 7 To a great extent 3. My study partner and I were both involved in the planning process Not at all 1 2 3 4 5 6 7 To a great extent 4. I am committed to undertaking regular physical activity at the times planned in the planning task Strongly disagree 1 2 3 4 5 6 7 Strongly agree 5. I am committed to undertaking regular physical activity in the places plann ed in the planning task Strongly disagree 1 2 3 4 5 6 7 Strongly agree 6. I am committed to doing the type of regular physical activity planned in the planning task
140 Strongly disagree 1 2 3 4 5 6 7 Strongly agree 7. Keeping to the plan to undert ake regular physical activity will be: Difficult 1 2 3 4 5 6 7 Easy 8. For me, developing the plan to undertake regular physical activity was: Harmful 1 2 3 4 5 6 7 Beneficial Pleasant 1 2 3 4 5 6 7 Unpleasant Good 1 2 3 4 5 6 7 Bad Worthless 1 2 3 4 5 6 7 Valuable Enjoyable 1 2 3 4 5 6 7 Not enjoyable 9. How long did it tak e to complete the planning task? ___________________ minutes