Psychology of Sport and Exercise 26 (2016) 83e93

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Psychology of Sport and Exercise

journal homepage: www.elsevier.com/locate/psychsport

Motivational, volitional and multiple goal predictors of walking in

people with type 2 diabetes
Masoumeh Namadian a, c, Justin Presseau b, d, Margaret C. Watson c, *, Christine M. Bond c,
Falko F. Sniehotta b
a
Social Determinants of Health Research Centre, Zanjan University of Medical Sciences, Iran
b
Institute of Health and Society, Newcastle University, UK
c
Centre of Academic Primary Care, University of Aberdeen, UK
d
Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: Type 2 diabetes is a major public health problem. Effective diabetes self-management in-
Received 2 August 2015 volves people engaging in multiple health behaviours, including physical activity. Walking is an effective,
Received in revised form accessible and inexpensive form of physical activity, yet many people with Type 2 diabetes do not meet
16 June 2016
recommended levels. The present study aimed to: 1) identify demographic, motivational and volitional
Accepted 16 June 2016
factors predictive of walking in people with Type 2 diabetes mellitus, and 2) test whether accounting for
Available online 18 June 2016
the perceived impact of other goal pursuits (goal facilitation and goal conflict) improved the prediction of
walking.
Keywords:
Physical activity
Methods: A theory-based cross-sectional study using the Health Action Process Approach was conducted
Type 2 diabetes mellitus in adults with Type 2 diabetes across Scotland. Assuming a 50% response rate 1000 questionnaires were
Walking mailed to achieve the target sample size (N ¼ 500). Demographic information was collected, and
Motivation intentional (outcome expectations, social support, risk perceptions), motivational (intention, self-
Volition efficacy), volitional (action planning, action control) and multiple goal (goal conflict, goal facilitation)
Goal facilitation factors were assessed as predictors of physical activity in general and walking specifically.
Goal conflict Results: The final sample comprised 411 respondents. The majority (60%) were non-adherent to physical
Action control
activity recommendations. Of 411 respondents, 356 provided walking data. Body Mass Index and age
Health action process approach
were the only demographic and anthropometric factors predictive of walking (overall R2 ¼ 0.04). When
motivational factors were added, intention and self-efficacy added to the prediction (overall R2 ¼ 0.07).
When volitional factors were added, only action control was predictive of walking (overall R2 ¼ 0.08).
Finally, goal facilitation explained an additional 7% variance in walking when added to the model (final
overall R2 ¼ 0.15).
Conclusion: There was low adherence with physical activity recommendations in general and walking in
particular. When testing predictors of motivational, volitional and competing goal constructs together,
action control and goal facilitation emerged as predictors of walking. Future research should consider
how walking can be embedded synergistically alongside other goal pursuits and how action control may
help to ensure that they are pursued.
© 2017 Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/).

1. Background (IDF, 2013). In Scotland, the prevalence of diabetes is 4.7%, slightly

above the UK average (S.D.S.M. Group, 2012). Almost 90% of pa-
Diabetes is a common non-communicable chronic disease. The tients with diabetes have Type 2 diabetes (WHO, 2006) and their
global prevalence of 8.3% is expected to increase to 10.1% by 2030 life expectancy is up to 10 years less than people without Type 2
diabetes (Diabetes UK, 2012a, 2012b).
Diabetes is a chronic, metabolic disease characterized by
* Corresponding author. Health Services Research Unit, Health Sciences Building increased levels of blood sugar. Diabetes occurs either when the
3rd Floor, University of Aberdeen, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK. pancreas produces no or insufficient insulin, or when the body
E-mail address: m.c.watson@abdn.ac.uk (M.C. Watson).

http://dx.doi.org/10.1016/j.psychsport.2016.06.006
1469-0292/© 2017 Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
84 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93

improve an individual’s adherence to physical activity recommen-

List of abbreviations dations. These new approaches need to be acceptable, accessible
and inexpensive to increase the probability of adoption.
CSO Chief Scientist Office
DSME Diabetes Self-Management Education 1.1. Walking as a specific form of physical activity
HAPA Health Action Process Approach
IPAQ International Physical Activity questionnaire Walking is the most common form of physical activity and is an
IQR Interquartile range important component of total physical activity in adult populations
MET Metabolic Equivalent of Task (Monteiro et al., 2003; Morris & Hardman, 1997). Walking is
NRES North of Scotland Research Ethics Committee acceptable, accessible and inexpensive; it requires no specific fa-
SDRN The Scottish Diabetes Research Network cilities, can be integrated easily into a daily routine, and is generally
SIGN The Scottish Intercollegiate Guidelines Network safe (Monteiro et al., 2003; Morris & Hardman, 1997). The energy
SPSS Statistical Package for the Social Sciences expenditure of walking at a moderate pace of 5 km/h (3 miles/hour)
TDF Theory Domain Framework can meet the definition of moderate intensity physical activity
WHO World health Organization (Ainsworth et al., 2000). However, data from the National Health
and Nutrition Examination Survey on 2896 patients with Type 2
diabetes in the US showed that 46% of participants did not report
any walking for exercise (Gregg, Gerzoff, Caspersen, Williamson, &
cannot effectively use the insulin it produces. Type 2 diabetes re- Narayan, 2003). While the literature to date on behavioural de-
sults from the body’s insufficient production and/or ineffective use terminants of physical activity focuses on more generic de-
of insulin. Hyperglycaemia (an increased concentration of glucose scriptions of physical activity, given the above-mentioned benefits
in the blood) is a common effect of uncontrolled diabetes and over of walking, our aim was to focus specifically on understanding the
time leads to serious damage to the heart, blood vessels, eyes, factors associated with walking in people with Type 2 diabetes.
kidneys, and nerves (WHO, 2015).
Type 2 diabetes has non-modifiable (genetic) and modifiable 1.2. Behavioural determinants of physical activity
(environmental and behavioural) risk factors (Alberti, Zimmet, &
Shaw, 2007). Genetic predisposition is aggravated by behavioural There is a large body of evidence on the biological, sociological,
factors including smoking, being overweight, abdominal obesity psychological, and environmental factors that influence physical
and lack of physical activity (Stumvoll, Goldstein, & van Haeften, activity (Bonner, 2010). Non-modifiable factors (e.g., age, gender)
2005). Good management of these behavioural factors can pre- can help to identify sub-groups that are likely to be physically
vent or delay onset of diabetes, and many of its complications inactive, whereas modifiable factors (e.g., intention, self-efficacy)
(WHO & IDF, 2004). The recommended regimen for managing Type provide potential targets for increasing physical activity
2 diabetes includes eating healthily, being physically active (mod- (Schwarzer, 2008; Wing et al., 2001).
erate intensity) for at least 30 min on most days, smoking cessation, A number of theories summarise the relationship between
and taking medication (e.g., oral hypoglycaemic drugs, insulin, modifiable factors and behaviour to generate testable hypotheses.
antihypertensive and lipid lowering drugs) (D.P.P.R. Group, 2002; The Health Action Process Approach (HAPA) (Schwarzer, 1992) is a
Hallal et al., 2012; WHO, 2012; Zimmet, Alberti, & Shaw, 2001). comprehensive social cognition model which accounts for moti-
Evidence suggests that regular physical activity reduces the risk vational factors including outcome expectation, social support, risk
of coronary heart disease, stroke, diabetes, hypertension, colon perceptions, intention, and self-efficacy, and as well as contempo-
cancer, breast cancer and depression and is the main factor in rary theoretical development in volitional (post-intentional) pro-
weight control (WHO, 2010). For example, trials have demonstrated cesses including action planning and action control (Schwarzer,
the benefits of undertaking physical activity in preventing Type 2 2008).
diabetes, improving glycaemic control and aerobic fitness, as well The HAPA describes intention as a function of self-efficacy,
as decreasing the risk of cardiovascular disease and overall mor- outcome expectations and risk perceptions. Intentional processes
tality (Sigal, Kenny, Wasserman, Castaneda-Sceppa, & White, are then related to action via volitional processes involving plan-
2006). Physical inactivity is the fourth leading risk factor for mor- ning and action control, further supported by self-efficacy and
tality worldwide, accounting for 6% of deaths (WHO, 2010), and impacted by available barriers and facilitators such as social sup-
approximately 30% of the disease burden due to diabetes and port (Schwarzer et al., 2003). Self-efficacy is a main influential
ischemic heart disease (WHO, 2010). factor, referring to a person’s perceived capability of performing a
There is evidence to suggest that patients with Type 2 diabetes desired behaviour (Schwarzer et al., 2003). Outcome expectations
engage in even less physical activity than the general population refer to perceived positive and negative outcomes of engaging in
(39% versus 58%) (Morrato, Hill, Wyatt, Ghushchyan, & Sullivan, the health behaviour; the more the beneficial outcomes and the
2007), and the level of physical activity in those who do partici- fewer the negative outcomes that are perceived, the more likely it is
pate is low (Badenhop, 2006). However there is wide inter-country that an individual will intend to engage in the behaviour
variation, with recent studies showing that adherence to recom- (Schwarzer et al., 2003). Risk perceptions refer to the minimum
mended physical activity in Type 2 diabetes ranges between 9% and level of perceived risk, which must exist before an individual starts
69% (Broadbent, Donkin, & Stroh, 2011; Morrato et al., 2007; to consider the benefits of possible behaviour and their capability
Nelson, Reiber, & Boyko, 2002; Plotnikoff, Brez, & Hotz, 2000; to undertake those behaviours.
Serour, Alqhenaei, Al-Saqabi, Mustafa, & Ben-Nakhi, 2007; Shultz, Strong intention is an often necessary but rarely sufficient
Sprague, Branen, & Lambeth, 2001; Thomas, Alder, & Leese, 2004). precondition for action (Orbell & Sheeran, 1998). Post-intentional
A World Health Organization (WHO) report showed that adherence (volitional) processes such as action planning and action control
with physical activity recommendations by people with Type 2 can help to ensure intentions are translated into action. Action
diabetes ranged from 7.7% to 55% across different countries (WHO, planning involves linking goal-directed action to environmental
2003). The high prevalence of Type 2 diabetes, along with low level cues by specifying the when, where, whom, and how to enact a
of physical activity, highlights the need for new approaches to behaviour to help translate intention into action (Darker, French,
 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93 85

Eves, & Sniehotta, 2010; Gollwitzer, 1999). In addition, more active where the pursuit of other personal goals sets the stage or makes
self-regulatory efforts can further supplement the translation of it more likely that physical activity will take place (e.g. socialising
intention into action. Action control, i.e., self-monitoring of with friends that involves walking in the park), or inherently in-
behaviour, being aware of monitoring standards and expending volves physical activity (e.g. commuting to work can be facilitative
effort in goal pursuit, is a self-regulatory process for ensuring of physical activity when involving active travel). The presump-
intention enactment (Carver & Scheier, 1982; Sniehotta, Scholz, & tion is that the more one’s other personal goals are aligned with
Schwarzer, 2005). physical activity, the greater the physical activity. Goal facilitation
The HAPA has been applied to understand physical activity has been demonstrated to positively predict physical activity
across numerous studies. Some studies focus on the entire HAPA (Riediger & Freund, 2004), a relationship that is maintained even
model (Barg et al., 2012; Bonner, 2010; Caudroit, Stephan, & Le when controlling for intention and self-efficacy (Presseau et al.,
Scanff, 2011; Renner, Spivak, Kwon, & Schwarzer, 2007; Scholz, 2010). However, it is not clear whether these relationships
Schuz, Ziegelmann, Lippke, & Schwarzer, 2008; Scholz, Sniehotta, persist when accounting for volitional (planning, action control)
& Schwarzer, 2005, 2008; Schwarzer et al., 2007; Sniehotta, processes, which could in themselves involve managing
Scholz, et al., 2005; Sniehotta, Schwarzer, Scholz, & Schüz, 2005), competing goals. For instance, action planning may involve
whilst others focus on more specific components of the model describing other goals that facilitate engaging in physical activity,
(Barg et al., 2012; Lippke, Ziegelmann, & Schwarzer, 2005; whereas coping planning may involve identifying barriers that in
Schwarzer et al., 2007; Sniehotta, Scholz, & Schwarzer, 2006; themselves are actually competing goal pursuits (Presseau, Boyd,
Sniehotta, Schwarzer, et al., 2005). Few studies have applied the Francis, & Sniehotta, 2015). This conceptual overlap issue could be
HAPA to the behaviour of people with Type 2 diabetes. Bonner addressed empirically by investigating whether indicators of goal
(Bonner, 2010) used the HAPA in Type 2 diabetes and showed that conflict or goal facilitation remain predictive of physical activity
self-efficacy and outcome expectations were predictive of physical when controlling for volitional factors. Furthermore, it is not clear
activity intention, and intention (but not self-efficacy or action how either goal conflict or goal facilitation relate to walking
planning) predicted physical activity levels. No study has yet used behaviour specifically, which may have different levels of
the HAPA model to understand physical activity in people with perceived conflict and facilitation than other forms of more
Type 2 diabetes focusing specifically on walking as an inexpensive intensive physical activity.
and accessible form of physical activity (Lippke & Plotnikoff, 2014). The present study aimed to: 1) identify demographic, motiva-
tional and volitional factors predictive of walking in people with
1.3. Towards multiple behaviour approaches Type 2 diabetes, and 2) test whether accounting for the perceived
impact of goal pursuits (goal facilitation and goal conflict) improved
Most popular social cognition models of health behaviour focus the prediction of walking.
on understanding a single health behaviour at a time. The ecolog-
ical validity of such an approach has increasingly been questioned
2. Methods
(Presseau, Tait, Johnston, Francis, & Sniehotta, 2013). In everyday
life, individuals pursue multiple goals and perform multiple be-
This was a cross-sectional theory-informed postal questionnaire
haviours alongside the single health behaviour that is typically the
study undertaken with people with Type 2 diabetes from the
focus of tests of behavioural theory. These goal pursuits compete for
Grampian and Tayside regions of Scotland. All English-speaking
time and energy such that pursuit of some may help and/or hinder
adults (>18 years) diagnosed with Type 2 diabetes were eligible
the pursuit of a particular health behaviour, such as physical ac-
to participate. Patients with serious end stage illness and patients
tivity in general or walking specifically.
with mental disability were excluded.
The extant literature has predominantly managed the concept
of considering multiple goals by focusing on the impact of goal
conflict on health behaviour. Goal conflict can be described as 2.1. Questionnaire development
occurring when the pursuit of multiple personal goals leads to
situations where they interfere with one another. For instance, A qualitative study was initially conducted using the Theoretical
working, childcare, relaxing and socialising may be common Domains Framework (TDF) (Michie et al., 2005) to identify which
personal goals that have the potential to conflict with walking by theoretical domains and constructs were relevant to understanding
taking available leisure time, energy or other resources that the adherence of people with Type 2 diabetes to physical activity
might otherwise be used go for a walk. The evidence on the link recommendations in general and walking in particular. The results
between goal conflict on physical activity-related behaviour is were used to identify relevant items that were included in a draft
mixed. There is a lack of support for this relationship in between- questionnaire. The questionnaire explored physical activity in
subject predictive studies (Li & Chan, 2008; Presseau, Sniehotta, general, and walking in particular. Pre-piloting of the questionnaire
Francis, & Gebhardt, 2010; Riediger & Freund, 2004). However, was undertaken with five people using the “think aloud” method
a study investigating actual time spent pursuing goals that con- (Jones, 1989; Lundgren-Laine & Salantera, 2010) where participants
flict with physical activity within-subjects was negatively pre- verbalised their thoughts. Three participants with Type 2 diabetes
dictive of objectively assessed physical activity (Presseau et al., were recruited from the Scottish Diabetes Research Network
2013), and a study investigating goal conflict in more resource (SDRN) (see later) and three were colleagues with Type 2 diabetes
constrained contexts has also shown that goal conflict is nega- in the Centre of Academic Primary. Minor revisions were made
tively predictive of behaviour (Presseau, Francis, Campbell, & prior to the pilot study. The questionnaire was piloted with 50
Sniehotta, 2011). As people with Type 2 diabetes engage in self- people with Type 2 diabetes, selected randomly from the SDRN list,
management regimens that inherently involve pursuing multi- replicating the distribution process planned for the main survey
ple behaviours and goals, it is plausible that goal conflict may be a (pre-notification letter, questionnaire and covering letter, and a
useful additional construct in this population. reminder letter and replacement questionnaire after two weeks).
By comparison, goal facilitation has received less research than To assess test-retest reliability, respondents were sent a second
goal conflict, yet is recurrently shown to be predictive of physical copy of the questionnaire two weeks after returning their first
activity-related behaviours. Goal facilitation involves instances questionnaire.
86 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93

2.2. Sample and recruitment of interest given the wording of our predictors focused upon
walking. Walking was assessed using the total time or energy
The sample size for this study was influenced by two factors: 1) (150 min or >600 MET minutes/week) spent on walking measured
having acceptable precision for the estimation of adherence with by the IPAQ and served as the dependent variable in all predictive
physical activity (any precision within ±5% that would be clinically analyses. However we also aimed to describe overall adherence to
and statistically acceptable) and 2) the resources (time and money) physical activity recommendations.
available to undertake the research. To achieve a balance between Adherence to physical activity was assessed by comparison with
these two items, a sample size of 500 patients was required. As two different recommendations. Firstly it was assessed by com-
previous research has shown compliance with physical activity to parison with the Scottish Intercollegiate Guideline Network/WHO
range from 19 to 30% (midpoint: 25%) (Kamiya et al., 1995; Kravitz (SIGN, 2010; WHO, 2010) advice of at least 150 min of vigorous/
et al., 1993), this allowed estimation of adherence with physical moderate (no walking included) combined physical activity per
activity of 25% with precision within ±3.8% (95% CI 21.2%e28.8%). week (equal to at least 600 MET1). Secondly it was assessed
Previous research in community samples indicated a 50% response accordingly to the IPAQ criterion of 600 MET minutes/week of any
rate was likely, therefore 1000 questionnaires were mailed to combination of walking, moderate-intensity or vigorous-intensity
achieve the target of 500 evaluable responses. physical activities (IPAQ, 2002). According to IPAQ, <600 MET mi-
Participants were recruited from the Scottish Diabetes Research nutes/week, 600e2999 MET minutes/week, and >3000 MET mi-
Network (SDRN), a register of patients with diabetes in Scotland nutes/week are considered as low, moderate and vigorous physical
who have consented to be contacted about potential participation activity, respectively (IPAQ, 2002).
in research studies (SDRN, 2010). All SDRN registered patients in
Grampian (n ¼ 388) were identified and invited to participate, 2.3.2. Predictors of walking
supplemented by a random sample of 612 of the 1279 patients The questionnaire assessed a number of potential demographic
registered in Tayside exclusive of those who had taken part in the and theoretical predictors of walking: demographic variables, self-
pilot study. A pre-notification letter with a reply slip, that they efficacy, outcome expectations, risk perceptions, intention, action
could use if they did not want any further communication, was sent planning and control, social support, goal facilitation and goal
to these 1000 patients two weeks before the questionnaire and conflict. The demographic variables age, gender, education, and
accompanying invitation letter were mailed. Two weeks after the employment items were defined using the England household
first mailing, a reminder letter and another copy of the same version of the 2001 Census questionnaire (OFNS, 2002). All theo-
questionnaire were sent to non-respondents. The questionnaire retical items were worded according to the TACT principle (Target,
was piloted with 50 people with Type 2 diabetes, selected Action, Context, and Time), specifying the behaviour of interest as:
randomly from the SDRN list, replicating the distribution process “To increase (my) own walking level by 20% during the normal daily
planned for the main survey (pre-notification letter, questionnaire routine in the forthcoming month” and described in detail below.
and covering letter, and a reminder letter and replacement ques-
tionnaire after two weeks). To assess test-retest reliability, re- 2.3.2.1. Self-efficacy. Self-efficacy was assessed using six items
spondents were sent a second copy of the questionnaire two weeks ranging from 1 (strongly disagree) to 5 (strongly agree) in relation to
after returning their first questionnaire. perceived capability to increase walking despite the presence of
barriers (Schwarzer et al., 2003). The stem “I am confident that I can
2.3. Measures increase my walking by 20% in the next month even if ….” had
response options such as: “the weather is bad”, “it is hard for me
2.3.1. Physical activity and walking physically”, “I do not have much time”.
The questionnaire included items assessing time spent being
physically active in the last seven days based on the short version of
2.3.2.2. Outcome expectations. Two facets of outcome expectations
International Physical Activity Questionnaire (IPAQ) (IPAQ, 2002). It
were assessed (Schwarzer et al., 2003), with scores for each item
measures physical activity over a short time frame. The IPAQ was
ranging from 1 (not at all) to 4 (exactly true): there were six items to
developed by consensus in 1998e1999 with support from the WHO
assess positive outcome expectations, and three items to assess
to enable the cross-national assessment of physical activity in
negative outcome expectations. The stem “if I increase my walking
adults aged 18e65 years (Craig et al., 2003; Macfarlane, Lee, Ho,
by 20% in the next month ….” had response options such as: “I
Chan, & Chan, 2007; Papathanasiou et al., 2010). The short format
would feel better afterwards”, “it would take up a lot of time”.
of the IPAQ asks about three types of activity in the four domains.
Walking, moderate-intensity activities and vigorous-intensity ac-
tivities are the specific types of activity which are assessed by the 2.3.2.3. Risk perception. Risk perception refers to the respondent’s
IPAQ short form (IPAQ 2002). This version generates a total score by belief about their vulnerability to health problems, or specifically in
summation of the duration (in minutes per day) and frequency this patient group for their diabetes to worsen (Schwarzer et al.,
(days) of walking, moderate-intensity activities and vigorous- 2003). Absolute and relative vulnerability were assessed using six
intensity activities. The IPAQ measures energy as Metabolic items with response options ranging from 1 (strongly disagree) e 7
Equivalent of Task (MET). The IPAQ has been used in a number of (strongly agree). The items measuring absolute vulnerability had a
international studies (Craig et al., 2003; Guthold, Ono, Strong, stem “If I am not physically active … ” and response options such as:
Chatterji, & Morabia, 2008) and acceptable reliability and validity “ … I am concerned that my health in general will become worse”, “
has been reported (Craig et al., 2003; Hagstromer, Oja, & Sjostrom, … I am concerned that my diabetes in general will become worse”,
2006; Hallal et al., 2010; Macfarlane et al., 2007; Papathanasiou “ … I will worry about getting a serious medical condition”. The
et al., 2010). An international reliability and validity test of the
IPAQ was conducted in 14 centres in 12 countries and reported that
1
it has acceptable reliability and validity at least equal to other Metabolic equivalent of task (MET) is a concept frequently used to show the
amount of energy or oxygen the body uses during physical activity. One MET is
established self-report tools for physical activity in diverse pop- equivalent to the energy or oxygen that the body uses at rest, or consuming 3.5 mL
ulations of 18e65 years (Craig et al., 2003). We focused specifically of oxygen/kg of body weight/minute (1 MET ¼ 50 kcal/h/m2 body surface area)
upon understanding predictors of walking as the primary outcome (Davis & Wilbrn, 2003).
 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93 87

items measuring relative vulnerability had a stem “If I am not 2.4. Data management and analysis
physically active … ” comparing myself with an average person of
my age and sex, then I will be at higher risk of … and response Data were entered into SPSS version 20 and 10% of all data were
options such as: “ … my diabetes gets worse”, “… having a serious double entered and checked for quality assurance. Few errors
medical condition”. (n ¼ 11 or 0.1% of entered fields) were identified and corrected, with
no evidence of systematic errors.
2.3.2.4. Intention. Intention refers to a participant’s intention to The primary outcome measure was the IPAQ walking criterion
increase walking (Schwarzer et al., 2003) and was assessed by four (MET minutes/week). A sensitivity analysis was conducted using
items with response options ranging from 1 (completely disagree) to total MET minute/week. The extent of missing data varied across
5 (totally agree). Intention was measured by items such as “I intend variables. The variables with the greatest and smallest amount of
to walk more in the next month” and “I am motivated to walk more missing data were walking level (13.4%), and diabetes management
to improve my health in general”. method (2.1%). We used multiple imputation (Klebanoff & Cole,
2008) to account for missing data which addresses missing data
2.3.2.5. Action planning. Action planning consisted of items issues in the most robust manner possible. All model testing was
assessing the extent to which participants had a plan about when, conducted on multiple imputed data and results presented as
where, and how to increase their walking (Schwarzer et al., 2003). pooled estimates. Hierarchical multiple regression analyses were
Action planning was assessed using four items (Sniehotta, Scholz, conducted to test the sequential contribution of demographic,
et al., 2005; Sniehotta, Schwarzer, et al., 2005). All items had motivational, volitional and multiple goal constructs as predictors
response options ranging from 1 (completely disagree) to 4 (totally of walking.
agree). The stem “I have made a specific plan about ….” had
response options such as: “… when to increase my walking in the 2.5. Ethics approval
next month”, “ … where to increase my walking in the next month”,
“ … what to do if something interferes with my intention to in- Ethics approval for the study was granted by North of Scotland
crease my walking in the next month”. Research Ethics Committee (NRES) (Ref 10/S0802/4).

2.3.2.6. Action control. Action control refers to perceived self- 3. Results

monitoring, awareness of standards and effort (Sniehotta, Scholz,
et al., 2005; Sniehotta, Schwarzer, et al., 2005) to increase 3.1. Response rate
walking of participants. Action control was assessed using six items
and all items had response options ranging from 1 (strongly Of 1000 people contacted, 35 withdrew at the pre-notification
disagree) to 4 (strongly agree). The stem “During the last week I ….” letter stage. Of the 965 questionnaires mailed, 426 were returned
had response options such as:“… regularly thought about my (compared to the target sample size of 500). Of these fifteen were
intention to be regularly physically active”, “ … I have consistently excluded (five received after the agreed deadline (15/07/2012),
checked to see whether I am physically active enough”. seven with excessive (>90%) missing data, three because of
participation in the pilot study). Most questionnaires (373/426;
2.3.2.7. Social support. Social support items assessed support from 87.6%) were returned by people who had responded to the pre-
colleagues, friends and household members to increase walking notification letter. No significant difference was found between
using a modified version of the Molloy social support tool (Molloy, participating and non-participating respondents in terms of gender
Dixon, Hamer, & Sniehotta, 2010). All items (17 items) had response and age suggesting the final sample was representative. The final
options ranging from 1 (strongly disagree) to 7 (strongly agree). evaluable sample comprised 411 respondents.
Social support (friends/colleague) was measured by items such as “I
have a friend/colleague who thinks that I should increase my 3.2. Socio-demographic characteristics of respondents
walking”, and “I have a friend/colleague who encourages me to
increase my walking”. Social support (household) was measured by The mean age of respondents was 65.5 years (SD 9.7); 57.4%
items such as “I have somebody to encourage me to increase my (n ¼ 236) were men. Most were married (60.6%), did not live alone
walking on the regular basis”, and “I have somebody to walk with (63.3%) or were retired (62.3%). A quarter (26%) had no formal
me”. educational qualification. Most participants (92.7%) were either
overweight (BMI 25.0e29.9) or obese (BMI  30.0). The mean
2.3.2.8. Goal conflict and goal facilitation. Goal conflict (5 items) average BMI was 34.0 (SD 5.9) and 31.4 (SD 5.1) for women and
and goal facilitation (3 items) items focus on the extent that a men, respectively.
participant’s personal goals conflicted with physical activity and
were adapted from general goal conflict and facilitation scales 3.3. Descriptive statistics and bivariate correlations
(Riediger & Freund, 2004). All the items had response options
ranging from 1 (never, not at all, or completely disagree) to 5 (very As shown in Table 1, which presents findings across all 411 re-
often, a great deal, or completely agree). The items measuring goal spondents, the mean total physical activity measured as Metabolic
conflict consisted of a stem “How often does it happen that, because Equivalent of Task (METs) was 1732 min/week (Inter Quartile Range
of the pursuit of another personal goal, you do not invest ….” and (IQR) 485, 4398; median 200). Based on SIGN and WHO guidelines,
response options such as: “ … as much time in participating in which exclude walking, almost 60% (n ¼ 236) of patients did not
regular physical activity as you would like to?”, “ … as much energy adhere to physical activity recommendations (<600METs); how-
in participating in regular physical activity as you would like to?” ever this proportion was reduced to 28% using the IPAQ (Metabolic
Goal facilitation was measured by items such as “To what extent do Equivalent of Task (MET) minutes/week) measure which includes
other things you do in everyday life help you to participate in walking (Table 2). Men had higher median levels of physical activity
regular physical activity?”, and “How often does it happen that you than women. According to the IPAQ categories nearly 36% and 35%
do something in pursuit of a personal goal that is simultaneously of participants reported moderate and vigorous levels of physical
beneficial for participating in regular physical activity?” activity during the last week (Table 2), but the median time (hours/
88 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93

Table 1
Descriptive statistics for different type of physical Activity.

Characteristic n Median (IQR) Range

Total Physical activity (MET minute/week) 403 1732 (485, 4398) 0e29,460
Total time spent on each physical activity (Hours/week) 403 9 (3.2, 20) 0e112
Vigorous Physical activity 371 0 (0, 2) 0e49
Moderate physical activity 371 0 (0, 4) 0e57
Walking 356 5.25 (1.5, 12) 0e77

Note. IQR ¼ Interquartile range.

week) spent for both moderate and vigorous physical activity was behaviour (DR2 ¼ 0.07) whilst action control no longer significantly
zero (Table 1). The median duration of walking was 5.25 h per predicted behaviour.
week. The proportion of total physical activity reported as walking
was 65.6%.
As shown in Table 3, which presents findings for the 356 re- 4. Discussion
spondents providing walking data, BMI, action planning, action
control and goal facilitation were significantly associated with The study showed that the majority (60%) of Type 2 diabetic
walking behaviour, and outcome expectations, social support, risk patients were non-adherent to physical activity recommendations
perceptions, self-efficacy, action planning, action control, and goal as defined by SIGN/WHO. Most of the physical activity undertaken
conflict were significantly associated with walking intention. The by people with Type 2 diabetes was walking (65.6%). Action control
Cronbach’s alpha of different subscales of HAPA questionnaire are and goal facilitation were predictive of walking. Goal facilitation
presented in Table 3 indicating that most subscales of the ques- explained a further 7% of the walking variance.
tionnaire had a good internal consistency. The negative outcome Non-compliance of the majority of respondents with the SIGN
expectations scale was omitted from any analyses due to low recommendation (SIGN, 2010), for physical activity is consistent
observed internal consistency. with the Scottish Health Survey (The Scottish Government, 2012)
which showed that 61% of the general population aged 16 and over
did not meet physical activity recommendations. Other evidence
3.4. Predicting walking suggests that patients with Type 2 diabetes may be even less
physically active than the general population (Morrato et al., 2007).
The hierarchical multiple regression was conducted in four This was also the finding of a study in USA of 23,283 adults, which
steps. First, demographic factors and predictors of intention from showed that only 39% of individuals with Type 2 diabetes were
the HAPA were included. Next, motivational factors from HAPA physically active compared with 58% of those without diabetes
were added, then volitional, and finally multiple goal constructs. At (Morrato et al., 2007).
each step, we tested whether the added factors contributed to The median duration of walking reported in the current study
explaining additional variance in walking beyond factors in the was 5.25 h per week (IQR 1.5, 12). The proportion of walking as a
model from the previous steps, and which specific constructs percentage of total physical activity was 65.6% suggesting that in
explained this additional variance. In Step 1 of the hierarchical some cases walking was the main type of physical activity under-
multiple regression, walking was regressed against demographic taken by patients. This finding reflects the behaviour of the general
factors (BMI, age, sex) and HAPA theory-based predictors of adult population (Monteiro et al., 2003; Morris & Hardman, 1997);
intention (outcome expectations, social support and risk percep- therefore developing and evaluating interventions to increase and
tion). As shown in Table 4, only BMI and age predicted walking, maintain this behaviour are important. Walking is a common,
explaining 3.7% of the variance in walking. In Step 2, HAPA moti- accessible, inexpensive Type of physical activity. Walking provides
vational constructs (intention and self-efficacy) were added, with diverse health benefits of physical activity with few adverse effects.
intention and self-efficacy adding to the prediction (DR2 ¼ 0.03). In There is a large body of evidence about the positive effect of
Step 3, the volitional constructs of action planning and action walking to improve health in people with Type 2 diabetes. This
control were added, with only the latter adding significantly to the suggests that focusing on walking as a form of physical activity to
prediction (DR2 ¼ 0.01) and intention and self-efficacy no longer improve peoples’ adherence with physical activity recommenda-
significantly contributing to predicting behaviour. In Step 4, the tions is important and could be an effective way to improve phys-
multiple goal constructs of goal conflict and goal facilitation were ical activity.
added, with the latter significantly adding to the prediction of In terms of the existing literature one study conducted with

Table 2
Descriptive Statistics of Compliance with Physical Activity Based on IPAQ measure and SIGN/WHO guideline.

Characteristic Percentage (%) Frequency (n)

Physical activity (N ¼ 403)

Low physical activity (<600 MET min/week) 28.0 115
Moderate physical activity (600e3000 MET min/week) 35.8 147
Vigorous physical activity (>3000 MET min/week) 34.3 141
IPAQ (N ¼ 403)
Non-Compliant (<150 min any physical activity/week) 28.0 115
Compliant (>150 min any physical activity/week) 72 288
SIGN/WHO (N ¼ 392)
Non-Compliant (<150 min vigorous & moderate physical activity/week) 60.2 236
Compliant (>150 min vigorous, moderate physical activity/week) 39.8 156

Note. IPAQ ¼ International Physical Activity Questionnaire; SIGN ¼ The Scottish Intercollegiate Guidelines Network; WHO ¼ World Health Organization.
 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93 89

Table 3
Correlations and descriptive statistics of study variables for walking (N ¼ 356; pooled estimates).

Walking BMI Age Sex Outcome Social Risk Intention Self- Action Action Goal Goal
(sqrt) expectations support perceptions efficacy planning control facilitation conflict

BMI 0.13*
Age 0.06 0.29**
Sex 0.05 0.22** 0.06
Outcome 0.01 0.12* 0.15** 0.08
Expectations
Social Support 0.01 0.10 0.04 0.04 0.14*
Risk Perceptions 0.05 0.14** 0.18** 0.05 0.34** 0.16**
Intention 0.10 0.03 0.11* 0.06 0.55** 0.30** 0.27**
Self-efficacy 0.08 0.08 0.11* 0.01 0.09 0.04 0.23** 0.28**
Action Planning 0.11* 0.02 0.06 0.06 0.39** 0.30** 0.15** 0.65** 0.20**
Action Control 0.14** <0.01 0.06 0.06 0.23** 0.22** 0.21** 0.39** 0.04 0.44**
Goal Facilitation 0.29** 0.13* 0.06 0.05 0.06 0.13* 0.07 0.05 0.01 0.13* 0.34**
Goal Conflict 0.10 0.16** 0.22** 0.06 0.31** 0.13* 0.26** 0.21** 0.12* 0.07 0.05 0.11*

Mean 33.50 32.70 65.24 2.97 4.06 5.02 3.63 2.99 2.40 2.60 3.04 2.80
Cronbach’s alpha 0.88 0.83 0.92 0.92 0.68 0.88 0.86 0.67 0.84

Note. Sqrt ¼ Square root transformed; BMI ¼ Body Mass Index.

*p < 0.05. **p < 0.01.

Table 4
Pooled hierarchical multiple regression results on walking only (N ¼ 356).

Variables Med R2 Med DR2 Unstandardised Sig. 95% CI

coefficients

B SE LL UL

Step 1 e Demographics Factors& Predictors of Intention 0.04

BMI** 0.74 0.24 <0.01 1.20 0.27
Age* 0.28 0.13 0.04 0.53 0.02
Sex 3.86 2.50 0.12 1.05 8.77
Outcome Expectations 0.06 1.93 0.98 3.74 3.85
Social Support 0.02 0.88 0.98 1.79 1.74
Risk Perceptions 0.84 0.89 0.35 2.59 0.91

Step 2 e Predictors of Motivation 0.07 0.03

BMI** 0.70 0.23 <0.01 1.16 25
Age* 0.29 0.13 0.03 0.54 0.03
Sex 3.43 2.49 0.17 1.46 8.31
Outcome Expectations 3.06 2.23 0.17 7.43 1.32
Social Support 0.73 0.93 0.44 2.60 1.15
Risk Perceptions 0.67 0.90 0.46 2.44 1.10
Intention** 5.61 2.08 0.01 1.53 9.69
Self-efficacy* 3.59 1.83 0.05 7.17 0.01

Step 3 e Predictors of Volition 0.08 0.01

BMI** 0.72 0.23 <0.01 1.17 0.20
Age* 0.32 0.13 0.01 0.58 0.07
Sex 3.12 2.48 0.21 1.75 7.99
Outcome Expectations 3.20 2.22 0.15 7.56 1.16
Social Support 1.00 0.98 0.31 2.99 0.98
Risk Perceptions 0.87 0.91 0.34 2.65 0.91
Intention 3.18 2.40 0.19 1.54 7.91
Self-efficacy 3.42 1.84 0.06 7.02 0.18
Action Planning 2.38 2.61 0.36 2.75 7.50
Action Control* 4.97 2.37 0.04 0.33 9.62

Step 4- Multiple Goals 0.15 0.07

BMI* 0.57 0.22 0.01 1.01 0.12
Age** 0.34 0.13 0.01 0.59 0.09
Sex 3.62 2.40 0.13 1.08 8.32
Outcome Expectations 1.64 2.23 0.46 6.01 2.72
Social Support 1.17 0.99 0.25 3.20 0.86
Risk Perceptions 1.00 0.88 0.26 2.73 0.73
Intention 4.11 2.31 0.08 0.42 8.65
Self-efficacy 3.47 1.78 0.052 6.97 0.02
Action Planning 1.64 2.50 0.51 3.27 6.55
Action Control 0.81 2.42 0.74 3.93 5.55
Goal Facilitation** 7.78 1.57 <0.01 4.69 10.86
Goal Conflict 1.46 1.50 0.33 4.41 1.49

Note. CI ¼ .Confidence Interval; Med ¼ median across imputed samples; SE ¼ Standard Error; LL ¼ Lower Limit; UL ¼ Upper Limit; BMI ¼ Body Mass Index.
**p < 0.01; *p < 0.05.
90 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93

cardiac rehabilitation patients, was found that measured action when controlling for predominant theoretical constructs reported
control as a predictor of physical activity (Sniehotta, Scholz, et al., in the literature, the relationship between goal facilitation and
2005; Sniehotta, Schwarzer, et al., 2005). That study reported that walking robustly accounted for additional variability in walking.
each of the three factors of planning, self-efficacy and action control With increasing recognition of the importance of considering the
made unique contributions to translating intention into action wider context of multiple goal pursuit when understanding per-
(Sniehotta, Scholz, et al., 2005; Sniehotta, Schwarzer, et al., 2005). A formance of a given health behaviour, the present study further
study conducted in students confirmed associations specified by contributes evidence suggesting that goal facilitation may be a key
the HAPA at the intrapersonal level: outcome expectancies and self- indicator in the move towards developing models that explicitly
efficacy, but not risk awareness, were positively associated with account for the impact of multiple goal pursuit.
intentions for physical exercise. Physical activity was positively There is also mounting lack of support for the role of goal con-
associated with intentions, self-efficacy, action control, but not flict in understanding physical activity. There may be a range of
with action planning (Scholz, Keller, & Perren, 2009). These find- reasons for this. For instance, when considering the totality of an
ings are in accordance with the results of this current study. individual’s goal pursuits, individuals may be better able to
Another study conducted in Type 2 diabetic patients participating perceive helpful goal relationships than conflicting ones. In-
in a Diabetes Self-Management Education (DSME) (Bonner, 2010) dividuals may not be aware of the extent that their competing goals
showed that self-efficacy was the strongest predictor of behav- interfere with their physical activity. When using diaries to assess
ioural intention, followed by positive outcome expectancy. The actual time spent in pursuit of goals that conflict with physical
study (Bonner, 2010) revealed that behavioural intention, but not activity over time, goal conflict has been shown to be predictive of
self-efficacy and action planning could significantly increase initi- objectively assessed physical activity (Presseau et al., 2013). This
ation of a minimum level of physical activity. suggests that measures of perceived goal conflict may need to be
The current study showed some degree of support for the te- supplemented with behavioural assessments. This also presents
nets of the HAPA, whilst demonstrating the importance of opportunities for feedback interventions by showing individuals
considering multiple goal pursuit in people with Type 2 diabetes. which of their behaviours is most interfering with their physical
The majority of respondents did not engage in physical activity at activity. In addition, when focusing the goal pursuit context to a
recommended levels. Action control and goal facilitation were specific time and place rather than all of everyday life, both goal
shown to be predictors of physical activity when considered conflict and goal facilitation have been shown to predict behaviour
alongside other HAPA and demographic factors. Findings in rela- (Presseau et al., 2011).
tion to the HAPA with respect to intention (step 2 of the regres- The utility of the HAPA to explain and possibly predict adher-
sion) and action control (step 3) were consistent with previous ence with physical activity in addition to the demonstrated added
research (Sniehotta, Scholz, et al., 2005; Sniehotta, Schwarzer, contribution of considering goal facilitation suggests clear oppor-
et al., 2005) and extend these findings by demonstrating the tunities for developing and evaluating novel, theory-based in-
role for multiple goals constructs on physical activity (in this case, terventions for promoting walking in people with Type 2 diabetes.
goal facilitation). Conversely we did not show a predictive role for The present study extends the literature by demonstrating the role
action planning and in step two, there is an unexpected negative of multiple goal pursuit and goal facilitation in particular in a
predictive relationship between self-efficacy and walking behav- population sample of people with Type 2 diabetes. In addition, the
iour, although this becomes insignificant when the additional findings extend the theoretical literature by demonstrating that
predictors in steps three and four are added. Both findings are at goal facilitation predicts independent variability in health behav-
odds with the HAPA model and most of the literature investigating iour over and above all contemporary single-behaviour cognitions.
these relationships (Sniehotta, Scholz, et al., 2005; Sniehotta, This is important as it provides further evidence for moving beyond
Schwarzer, et al., 2005). Self-efficacy showed no significant on of health behaviours in isolation. This study is the first to spe-
bivariate relationships with walking which may be due to the fact cifically consider the role of goal facilitation in relation to walking
that the target behaviour was ‘increasing walking by 20%’ which by people with Type 2 diabetes.
equates to large absolute changes for more active respondents. The importance of goal facilitation as a key predictor of walking,
Moreover, self-efficacy was significantly correlated with inten- points to possible interventions to increase walking behaviour.
tion, so that the negative beta-coefficient in the second step of the Indeed, Darker et al. (Darker et al., 2010) used a variation of action
hierarchical regression analysis may be reflective of an artefact, a planning e facilitation planning e in their walking intervention,
statistical suppressor effect. Action planning showed a weak which was successful in increasing and maintaining the increased
bivariate correlation with walking and was significantly corre- walking behaviour. Planning when, where and how to perform
lated with action control so that when action control was simul- behaviours may facilitate action. To some extent, these may be
taneously controlled for, there was not a unique predictive preparatory behaviours, but goal facilitation encompasses the
relationship between action planning and walking. In the final broader spectrum of valued goals pursued in everyday life and may
model, neither of these variables was significant. not necessarily be preparatory in nature, whereas preparatory be-
Findings regarding multiple goal constructs are also consistent haviours may not have any intrinsic value to the actor. Neverthe-
with earlier research showing that perceived goal facilitation but less, the functional similarities between preparatory behaviours
not perceived goal conflict were predictive of physical activity and goal facilitation are noteworthy and future research should
(Presseau et al., 2010, 2013; Riediger & Freund, 2004). consider these two constructs in more detail.
There is now growing evidence across a range of studies with
diverse populations that particularly support the role of goal 4.1. Strengths and limitations
facilitation as a key factor in physical activity and, with the present
study’s findings, walking specifically. Goal facilitation is an indica- The present study is strengthened by its large sample size,
tor of the extent to which a target behaviour (in this case, walking) robust development and inclusion of theoretical factors as de-
“fits” synergistically alongside the other behaviours and goals that terminants of walking. Although the sample of 411 (356 for the
individuals pursue in daily life. Findings from this study continue to main analysis) was slightly short of the target of 500, this did not
support the role of goal facilitation and also underscore its potential impact substantially upon the precision of the estimates achieved:
importance in understanding health behaviours; indeed, even 40% with precision within ±4.7% (95% CI 35.3%e44.7%) of
 M. Namadian et al. / Psychology of Sport and Exercise 26 (2016) 83e93 91

respondents being categorised as adherent with physical activity Competing interests

recommendations compared with the original estimate of 25% with
precision within ±3.8% (95% CI 21.2%e28.8%). The authors declare that they have no competing interests.
The study also had limitations. Firstly, the cross-sectional study
design only allows association, and not causation, to be inferred. Author note
While there is no obvious suggestion of multicollinearity, the
modest bivariate correlations between predictors in the model Masoumeh Namadian (m.namadian@zums.ac.ir) Social De-
should be considered in interpreting the relative contribution of terminants of Health Research Centre, Zanjan University of Medical
predictors in the model, particularly with respect to factors which Sciences, Iran and Centre of Academic Primary Care, University of
were not zero-order correlations, and were not bivariately asso- Aberdeen, UK; Margaret C. Watson (m.c.watson@abdn.ac.uk) and
ciated with walking but which were associated with walking Christine M. Bond (c.m.bond@abdn.ac.uk) Centre of Academic Pri-
when included in the multivariate analyses (i.e. age and self- mary Care, University of Aberdeen, UK; Justin Presseau (jpresseau@
efficacy). Future research should aim to replicate findings using ohri.ca) Centre for Practice-Changing Research, Ottawa Hospital
a prospective design or by embedding such questionnaires in a Research Institute, Ottawa, Canada; Falko F. Sniehotta (falko.
theory-based process evaluation alongside a trial (Sedgwick, sniehotta@newcastle.ac.uk), Institute of Health and Society, New-
2014). castle University, UK. This article is based on data reported in the
A further limitation is that the study may have overestimated first author’s doctoral dissertation.
levels of physical activity in people with Type 2 diabetes. People
living in Grampian and Tayside have slightly better self-reported Acknowledgment
general health than the total population of Scotland (72% and
69.6% in Grampian and Tayside, respectively versus 67.9% in Scot- MN’s PhD scholarship was provided by Ministry of Health and
land) (The Scottish Census, 2011). Therefore, their self-reported Medical Education (Islamic Republic of Iran). This study was funded
physical activity, used as the main outcome in this study, may by the University of Aberdeen reference number: GP007RGC1618.
also be higher than the general national population. A further cause FFS is funded by Fuse, the UK Clinical Research Collaboration Centre
of over estimation could be that due to the patient population in the of Excellence for Translational Research in Public Health (grant
current study i.e. patients with Type 2 diabetic registered with the number: MR/K02325X/1). The researchers gratefully acknowledge
SDRN may be more engaged with their disease management all the Type 2 diabetic patients and their household members who
compared with patients not registered with the SDRN. Social participated in the study for their contribution to this study;
desirability bias could also contribute to any over-estimation of without them there would be no data. The researchers gratefully
self-reported physical activity. The IPAQ has in fact been shown to acknowledge the SDRN for providing the list of Type 2 diabetes and
overestimate self-reported time spent in physical activity helping for sampling.
compared with accelerometer measured activity (Ekelund et al.,
2006; Hallal et al., 2012).
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