Adherence_and_Well_Being_in_Obese_Patients_Referred_to_an_EoP_Scheme_resubmission

1 1Running head: SELF-DETERMINATION, EXERCISE ADHERENCE AND WELL-BEING Adherence and Well-Being in Overweight and Obese Patients Referred to an Exercise on Prescription Scheme: A Self-Determination Theory Perspective Original manuscript submitted: 9th January 2006 Revisions received: 27th March 2006 Revised manuscript submitted: **** 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Abstract 1Based on Self-Determination Theory (SDT; Deci & Ryan, 1985), this study examined 2reported differences in perceived autonomy support, psychological need satisfaction, self3determined motivation, exercise behaviour, exercise-related cognitions and general well4being, between overweight/obese individuals who demonstrated greater adherence to an 5exercise on prescription programme and those who adhered less In addition, this study 6explored the demographic and SDT constructs underpinning each of the aforementioned 7variables Before commencing, during, and upon terminating a 3-month exercise on 8prescription program, overweight/obese individuals (N = 49; M Body Mass Index = 38.75) 9completed a multi-section questionnaire packet tapping all relevant variables Participants’ 10adherence to the scheme was assessed using attendance records Multilevel regression 11analyses revealed that, at the end of the exercise prescription, those individuals who adhered 12more, versus less, reported more self-efficacy to overcome barriers to exercise In addition, 13those individuals who showed greater adherence to their 3-month exercise prescription 14demonstrated an increase in relatedness need satisfaction over time Examining the 15constructs underpinning each of the SDT and outcome variables, for the sample as a whole, 16showed that need satisfaction predicted self-determined regulation, and collectively, these 17constructs predicted adaptive exercise-related outcomes and general well-being throughout 18the program Exercise on prescription schemes would benefit from creating services that 19foster self determination by providing autonomy support and facilitating need satisfaction 20 21Keywords Autonomy support, psychological need satisfaction, self-determined motivational 22regulations, exercise, obesity 23 Adherence and Well-Being in Overweight and Obese Patients Referred to an Exercise on Prescription Scheme: A Self-Determination Theory Perspective Obesity now constitutes the second highest cause of preventable disability and death 4in the developed world (House of Commons Health Committee, 2004) Sedentary lifestyles 5contribute significantly to the prevalence of overweight and obesity (National Audit Office, 62001), and thus, increasing exercise engagement should represent one way in which to tackle 7these conditions To this successfully, the determinants of exercise participation need to 8be delineated Self-Determination Theory (SDT; Deci & Ryan, 1985; 2000) appears to hold 10considerable promise for elucidating the social psychological factors influencing exercise 11participation SDT (SDT; Deci & Ryan, 1985; 2000) postulates that an autonomy supportive 12context will foster the satisfaction of three basic psychological needs (i.e., autonomy, 13relatedness and competence) When the needs are satisfied, self-determined forms of 14motivational regulation guide behaviour (i.e., intrinsic motivation and integrated and 15identified regulation), and adaptive behavioural (e.g., behavioural engagement), cognitive 16(e.g., commitment) and affective (e.g., psychological well-being) outcomes are postulated to 17ensue In contrast, diminished need satisfaction elicits less self-determined motivation (i.e., 18amotivation, external and or introjected regulation), and non-optimal outcomes are 19hypothesized to accrue 20 In delineating the theoretical propositions of SDT, we should further elucidate the 21role of the psychological needs in promoting optimal experiences and well-being Notably, 22SDT postulates that satisfaction of the three needs in people’s immediate situations and in 23their developmental histories will lead to global well-being and psychological health (Ryan 24& Deci, 2000) Thus, if an individual’s needs for autonomy, relatedness and competence in 25exercise and physical activity settings are satisfied, a sense of global well-being (e.g., 1feelings of life satisfaction) or eudaimonia (e.g., subjective vitality) should be experienced 2(see Hagger & Chatzisarantis, this edition, for a more detailed overview of this theory) 3Support for SDT in the exercise domain Previous SDT-focused exercise research has revealed that autonomy support is 5positively associated with psychological need satisfaction and the self-determined regulation 6of exercise behaviour (e.g., Edmunds, Ntoumanis, & Duda, in press; Wilson & Rodgers, 72004) Competence need satisfaction has also emerged as a partial mediator of the 8relationship between autonomy support and self-determined regulation (Edmunds, et al., in 9press) Further, need satisfaction has been positively associated with self-determined 10motivation (e.g., Edmunds, et al., in press; Wilson, Rodgers & Fraser, 2002), and 11competence need satisfaction and self-determined regulation have been associated with 12various positive behavioural (e.g., Edmunds, et al., in press; Landry & Solmon, 2004; 13Mullan & Markland, 1997; Wilson et al., 2002), cognitive (e.g., Wilson & Rodgers, 2004), 14and affective (Edmunds, Duda, & Ntoumanis, 2005; Wilson & Rodgers, 2002) aspects of 15exercise 16 Previous SDT-focused exercise studies have been predominantly cross-sectional in 17design Consequently, they are restricted in the extent to which they can explicate the 18motivational mechanisms impacting exercise engagement For example, it has been 19suggested that between initial adoption and adherence to a regular exercise program, an 20individual’s motivational focus is likely to shift from less to more self-determined (Mullan & 21Markland, 1997) This suggests that variation in the degree to which individuals internalize 22exercise will be central in determining those who adhere to programmes over time (Wilson, 23Rodgers, Blanchard & Gessell, 2003) Longitudinal methodologies are required to examine 24this presumed internalization process 1 A number of SDT-focused studies in the physical domain have begun to attempt to 2rectify the aforementioned shortcoming For example, Pelletier, Fortier, Vallerand, and 3Briere (2001) examined, longitudinally, the importance of internalization to behavioural 4persistence among a sample of 369 competitive swimmers Supporting the internalization 5process, introjected regulation predicted persistence in the short-term (i.e., at 10-months), but 6only identified regulation and intrinsic motivation predicted persistence for the duration of 7the 22-month study Wilson et al (2003) also examined the internalization process among 53 8individuals volunteering to engage in an exercise program to increase cardiovascular fitness 9Again supporting the process of internalization, those participants who adhered (i.e., 70%) to 10their exercise reported modest-large changes in relatedness and competence need 11satisfaction, identified regulation and intrinsic motivation over time 12 In considering the SDT-focused exercise research reviewed thus far, it is important to 13note that previous studies have typically adopted a primary prevention perspective (i.e., 14activities that help avoid a given health care problem; U.S Preventative Services Task Force, 151996), sampling previously active populations, or volunteers, to garner a better 16understanding of the principles underpinning exercise and physical activity engagement 17Researchers have yet to test the utility of SDT in terms of exercise engagement from a 18secondary prevention perspective (i.e., activities for persons who have already developed 19risk factors or preclinical disease but in whom the condition is not clinically apparent; U.S 20Preventative Services Task Force, 1996), for example, individuals who are at risk of 21developing a variety of diseases as a consequence of being overweight or obese Whilst 22Williams, Grow, Freedman, Ryan and Deci (1996) did, longitudinally, consider the potential 23of SDT to explain successful weight loss attempts among severely or morbidly obese 24patients, this study only considered the promotion of a reduced caloric intake 25Aims and hypotheses 1 The main objective of the current study was to delineate whether the theoretical 2propositions of SDT contribute to our understanding of exercise adherence, exercise-related 3cognitions and associated general well-being, among a sample of overweight/obese 4individuals referred by their doctor to an Exercise on Prescription (EoP) scheme to aid 5weight loss Specifically, this study examined whether overweight/obese individuals who 6adhered more, versus less, to their exercise prescriptions reported greater levels of autonomy 7support, psychological need satisfaction and self-determined motivational regulations 8Moreover, given that motivation is postulated to causes a diverse array of consequences, 9which include a multitude of cognitive, affective and behavioural outcomes (Vallerand, 101997; 2001), this study also examined whether those individuals that adhered more, versus 11less, reported greater levels of exercise behaviour, exercise-related cognitions (i.e., self12efficacy, commitment and behavioural intention) and general well-being (i.e., positive and 13negative affect, subjective vitality and satisfaction with life) By distinguishing between 14‘behavioural, cognitive and affective consequences’ we aimed to garner a better 15understanding of how different facets of SDT impact upon different components of the 16exercise experience, and thus, identify how practitioners may more effectively facilitate each 17of these components in applied settings 18 Exercise behaviour was chosen as a dependent variable as this is considered the key 19outcome of the EoP scheme, as well as it being a health promotive behaviour of most 20concern to public health Barrier self efficacy was chosen as this construct has been 21repeatedly shown to predict exercise behaviour (e.g., McAuley & Jacobson, 1990) Given its 22conceptual links to competence need satisfaction, which has also been shown to be a 23significant predictor of exercise behaviour (e.g., Edmunds et al., in press) we felt that the 24inclusion of self-efficacy would allow us to distinguish the influence of these two variables 25Similarly, we examined behavioural intention as a dependent variable as previous research 1has also shown this construct to be a predictor of exercise behaviour (e.g., Hausenblas, 2Carron, and Mack, 1997) Thus, the impact of this variable, compared to those of SDT, could 3be assessed As our measure of behavioural intention related specifically to general exercise, 4we also chose to include a measure of commitment to the scheme per se Thus, we aimed to 5explore changes in participants’ cognitions about the scheme itself, as well as their wider 6exercise behaviour Finally, the inclusion of well-being was considered to be consistent with 7tenets of SDT (i.e., SDT research has shown that needs and regulations are related to 8different degrees of well-being) The variables of positive and negative affect, satisfaction 9with life and subjective vitality were chosen as these provide a comprehensive assessment of 10well-being in accordance with Diener, Emmons, Larson, & Griffin, (1985) and also the 11hedonic/eudaimonic aspects of well-being as advocated by Deci & Ryan (2001) 12 We hypothesized that those individuals who adhered more would report higher 13levels of the aforementioned variables at 3-months, as well as a greater increase in these 14constructs over time, compared to those who adhered less Secondly, we explored which 15demographic variables and SDT theorized psychological constructs contributed to the 16prediction of each of the variables under study It was hypothesized that, over time, 17perceived autonomy support would emerge as a positive predictor of psychological need 18satisfaction Autonomy support and psychological need satisfaction were hypothesized to 19predict self-determined motivation Further, autonomy support, need satisfaction and self20determined regulation were hypothesized to predict desirable behavioural and cognitive 21exercise related outcomes, as well as targeted indicators of well-being, over the course of the 223-month exercise prescription 23 24Participants Method 1 Participants (N = 49; 84% female) ranged in age from 16 – 73 years (M = 44.98, SD 2= 14.61) Thirty nine classified themselves as White, five as Black/Black British, and four as 3Asian/Asian British The majority were separated or divorced (53.1%) Participants’ weight 4ranged from 70 – 150kgs (M = 105.68, SD = 21.32) BMI’s ranged from 29 – 58 kg/m2 (M = 538.75, SD = 7.25) An individual with a BMI of 25 – 30 kg per m2 is considered as 6overweight, and an individual with a BMI >30kg per m2 as obese 7Procedures The current research was approved by the ethics subcommittee of a large British 9University Participants were patients referred by their General Practitioner (Physician) to an 10EoP scheme run in a large city in the West Midlands, UK EoP schemes are designed for 11individuals between 15 and 74 years of age who display specific Coronary Heart Disease 12risk factors Upon referral to the scheme, an EoP advisor (i.e., a health and fitness instructor 13who has received specialized training to deliver exercise prescriptions) develops a 3-month 14exercise routine to suit each patient/clients condition.1 15 All participants taking part in this study were referred to the scheme because they 16were overweight or obese During an ‘initial consultation’ with their EoP advisor, during 17which time the patients’ health status is assessed, the exercise prescription process explained 18and exercise modalities discussed (approximately 30 - 45 minutes), overweight/obese clients 19were asked if they would be willing to take part in a study being conducted at a local 20University It was stressed to clients that participation was voluntary, that they could drop out 21at any stage, and that refusal to take part/dropping out would not affect their treatment in any 22way All participants who participated in the study, and returned all required 23data, were entered into a prize draw for one of five £50 cash prizes 24(approximately $90 US) Clients agreeing to take part provided informed consent, which 25was returned to the principle investigator 1 Following their initial consultation, participants were booked in for their ‘fitness 2induction session’ Prior to this appointment, all participants who had consented to take part 3in the current study completed an initial (baseline) packet of questionnaires The assessments 4tapped basic demographic information (including weight and height, as measured the EoP 5instructor), perceived autonomy support, exercise-specific psychological need satisfaction, 6motivational regulations for exercise, general self-reported exercise behaviour, self-efficacy 7for exercise, and indicators of general well-being (i.e., positive and negative affect, 8subjective vitality and life satisfaction) At 1- and 3-month post entry to the scheme, participants were mailed an additional 10questionnaire packet which contained the same measures as those assessed at baseline, as 11well as a measure of commitment to the scheme, behavioural intention to continue 12exercising, and self-reported weight These measures were intended to assess each of the 13study variables during (i.e., 1-month) and at the end of (i.e., 3-month) the exercise 14prescription process, and thus, allow changes in these variables to be mapped across the 15course of the programme (from referral to the end of the prescription) The 1-, as opposed to 16a 1.5- (i.e., mid-scheme) or 2-month, measurement point was chosen on the basis of 17discussions with the EoP staff Talking to the staff it became evident that drop out from the 18scheme was highest in the initial month of the exercise referral Based on this information, 19we felt that the inclusion of a 1-month measurement point would optimize the number of 20respondents providing a second set of data That is, we felt that dropouts were more likely to 21respond to the questionnaire mail out if this correspondence took place close in time to their 22last attendance in the scheme 23 Based on the methodology utilised by Pelletier et al (2001), upon completing their 3- 24month exercise prescription, the relevant EoP advisor accessed each participants’ attendance 25log (stored at the leisure facility they attended) to rate, on a – scale, their adherence to the 10 1scheme (1 = dropped out during first month, = dropped out during second month, = 2dropped out during third month, = still exercising at months but not in accordance with 3prescription, and = still exercising at months in accordance with prescription) This 4interval scale methodology, which was simple for the EoP advisors to use, allowed us to 5easily distinguish between those who dropped out at different phases of the programme 6Measures Perceived autonomy support (PAS) PAS, provided by the EoP advisor, was measured 8using a six-item version of the Health Care Climate Questionnaire (e.g., My exercise on 9prescription advisor provided me with choices and options about how to exercise regularly; 10Williams et al., 1996) This scale has been shown to possess an alpha of 95 in previous 11research (Williams et al., 1996).3 12 Psychological need satisfaction Psychological need satisfaction was measured via a 13nine-item scale developed by Tobin (2003) Following the stem “Considering how you feel 14about exercise,” participants responded to items tapping autonomy (e.g., I exercise because I 15like to rather than because I feel I have to), relatedness (e.g., In exercise situations I feel 16supported) and competence (e.g., I think I am pretty good at the exercise that I do) need 17satisfaction Alpha values of 65, 81 and 80, for autonomy, relatedness and competence, 18have been reported in past work (Tobin, 2003) Scale items demonstrate a mean factor 19loading of 70 (Tobin, 2003) all fit indices are considered acceptable (Tobin, 2003) 20 Motivational regulations for exercise Participants’ motivation to engage in exercise 21was measured using the 19-item Behavioural Regulation in Exercise Questionnaire-2 22(BREQ-2; Markland & Tobin, 2004) Using a 0-4 scale, separate subscales of the BREQ-2 23tap amotivation (e.g., I don’t see the point in exercising), external (e.g., I exercise because 24other people have said I should), introjected (e.g., I feel guilty when I not exercise) and 25identified (e.g., I value the benefits of exercise) regulation, and intrinsic motivation (e.g., I 25 1focused exercise research should utilise objective measures of exercise and physical activity 2This suggestion also extends to measures of weight, and thus, weight loss In relation to 3aforementioned supposition, it should be noted that despite attempts to obtain an objective 4marker of exercise behaviour, the use of attendance records in the current study did not 5provide an indication of the intensity of exercise engaged in The use of objective measures 6would also help to rectify this shortcoming 7Conclusions With the exception of relatedness need satisfaction, the results of the current 9investigation suggest that those individuals who adhere more, versus less, to EoP schemes 10not derive higher levels of key SDT constructs within the exercise domain As a potential 11consequence, those who adhered more did not report greater levels of exercise behaviour, 12certain exercise related cognitions, or general well-being Nonetheless, the theoretical 13propositions of SDT were observed to underpin self-determined regulation and adaptive 14outcomes Collectively, these findings suggest that to increase their success, EoP schemes 15should attempt to ensure that service delivery pulls from the basic theoretical tenets of SDT 16and indicates the need for SDT-focused interventions in EoP schemes 1 26 References Baumeister, R., & Leary, M R (1995) The need to belong: Desire for interpersonal attachments as 3a fundamental human motivation Psychological Bulletin, 117, 497 - 529 Biddle,4 J H., & Mutrie, N (2001) Psychology of physical activity: Determinants, well-being and 5interventions London: Routledge Bostic,6 T J., Rubio, D M., & Hood, M (2000) A validation of the subjective vitality scale using 7structural equation modeling Social Indicators Research, 52, 313-324 Chirkov, V I., Ryan, R M., Kim, Y., & Kaplan, U (2003) Differentiating autonomy from 9individualism and independence: A self-determination theory perspective on internalization 10of cultural orientations and well-being Journal of Personality and Social Psychology, 8, 9711110 Cohen, 12 J., & Cohen, P (1983) Applied multiple regression/correlation analysis for the behavioural 13sciences (2nd ed.) Hillsdale, NJ: Erlbaum deCharms, 14 R (1968) Personal causation: The internal affective determinants of behavior New 15York, NY: Academic Press Deci,16 E L (1975) Intrinsic motivation New York: Plenum Deci,17 E L, Eghrari, H, Patrick, B C., & Leone, D (1994) Facilitating internalization: The self18determination theory perspective Journal of Personality, 62, 119 – 142 Deci,19 E L., & Ryan, R M., (1985) Intrinsic motivation and self-determination in human behavior 20New York, NY: Plenum Press Deci,21 E.L., & Ryan, R.M (2000) The ‘what’ and ‘why’ of goal pursuits: Human needs and the self22determination of behavior Psychological Inquiry, 11, 227 – 268 27 Department of Health (2004) Choosing Health? Choosing activity: A consultation on how to 2increase physical activity London: Department of Health/ Department of Culture Media and 3Sport Diener,4 E., Emmons, R.A., Larsen, R J., & Griffin, S (1985) The Satisfaction with Life Scale 5Journal of Personality Assessment, 49, 71–75 Edmunds, J.K., Duda, J.L., & Ntoumanis, N (2005) Psychological needs theories as predictors of 7exercise-related cognitions and affect among an ethnically diverse cohort of female exercise 8group participants Manuscript submitted for publication Edmunds, J.K., Ntoumanis, N., & Duda, J.L (in press) A test of self-determination theory in the 10exercise domain Journal of Applied Social Psychology Fox, 11 K R., Boutcher, S H., Faulkner, G E & Biddle, S J H (2000) The case for exercise in the 12promotion of mental health and psychological well-being In S.J.H Biddle, K.R Fox & S.H 13Boutcher (Eds.), Physical activity and psychological well-being (pp 1-9) London: 14Routledge Godin, 15G., & Shepard, R J (1985) A simple method to assess exercise behavior in the community 16Canadian Journal of Applied Sport Science, 10, 141 –146 Hausenblas, 17 H A.; Carron, A V.; Mack, D E (1997) Application of the theories of reasoned 18action and planned behavior to exercise behavior: A meta-analysis Journal of Sport and 19Exercise Psychology, 19, 36 – 41 Mulvihill, 20 C., & Quigley, R (2003) The management of obesity and overweight: An analysis of 21reviews of diet, physical activity and behavioural approaches London: Health Development 22Agency House 23of Commons Health Committee (2004) Obesity London: The Stationery Office 28 Hox, J.J & C.J.M Maas (2002) Sample sizes for multilevel modeling In J Blasius, J Hox , E de 2Leeuw & P Schmidt (Eds.) Social Science Methodology in the New Millennium 3Proceedings of the Fifth International Conference on Logic and Methodology Jacobs,4 D.R., Ainsworth, B.E., Hartman, T.J., & Leon, A.S (1993) A simultaneous evaluation of 10 5commonly used physical activity questionnaires Medicine and Science in Sports and 6Exercise, 25, 81 – 91 Koestner, R., & Losier, G.F (2002) Distinguishing three ways of being internally motivated: A 8closer look at Introjection, Identification, and Intrinsic motivation In E.L., Deci & R.M., 9Ryan (Eds.), Handbook of self-determination research Rochester, NY: University of 10Rochester Press Landry, 11 J.B., & Solmon, M (2004) African American women’s self-determination across the stages 12of change for exercise Journal of Sport and Exercise Psychology, 26, 457 – 469 Li, F.13 (1999) The exercise motivation scale: Its multifaceted structure and construct validity 14Journal of Applied Sport Psychology, 11, 97 – 115 Tobin, 15V.J (2003) Facilitating exercise behaviour change: A self-determination theory and 16motivational interviewing perspective Unpublished doctoral dissertation: University of 17Wales, Bangor Markland, 18 D., & Tobin, V (2004) A modification of the behavioural regulation in exercise 19questionnaire to include an assessment of Amotivation Journal of Sport and Exercise 20Psychology, 26, 191 – 196 McAuley, 21 E (1993) Self-efficacy and the maintenance of exercise participation in older adults 22Journal of Behavioral Medicine, 16, 103 – 113 McAuley, 23 E., & Jacobson, L.(1991) Self-efficacy and exercise particpation in sedentary adult 24females American Journal of Health Promotion, 5, 185-191 29 McAuley, E., & Mihalko, S (1998) Measuring exercise-related self–self-efficacy 2In J L Duda (Ed.), Advances in sport and exercise psychology measurement 3(pp 371–390) Morgantown, WV: Fitness Information Technology Mullan, E., & Markland, D (1997) Variations in self-determination across the stages of change for 5exercise in adults Motivation and Emotion, 21, 349 – 362 National Audit Office (2001) Tackling obesity in England The Stationary Office: London Noar, S.M., & Zimmerman, R.S (2005) Health behaviour theory and cumulative knowledge 8regarding health behaviours: are we moving in the right direction? Health Education 9Research, 20, 275 – 290 Pavot, 10W., & Diener, E (1993) Review of the Satisfaction With Life Scale Psychological 11Assessment, 5, 164-172 Pelletier, 12 L.G., Fortier, M.S., Vallerand, R.J., & Briere, N.M (2001) Associations among perceived 13autonomy support, forms of self-regulation, and persistence: A prospective study Motivation 14and Emotion, 25, 279 – 306 Perrin, 15B (1979) Survey of physical activity in the regional municipality of Waterloo Recreation 16Research Review, 6, 48 – 52 Raftery, 17 A E (1995) Bayesian model selection in social research Sociological Methodology, 25, 18111 – 163 Reeve, 19J (2002) Self-determination theory applied to educational settings In E.L Deci & R.M 20Ryan (Eds.), Handbook of self-determination research (pp 183 – 203) Rochester, NY: 21University of Rochester Press Ryan,22R.M., & Deci, E.L (2000) Self-determination theory and the facilitation of intrinsic 23motivation, social development, and well-being American Psychologist, 55, 68 – 78 Ryan,24R., & Frederick, C (1997) On energy, personality and health: Subjective vitality as a 25dynamic reflection of well-being Journal of Personality, 65, 529 – 565 30 Sallis, 1J.F., Hovell, M., Hofstetter, R, Barrington, E (1992) Explanation of vigorous physical 2activity during two years using social learning variables Social Science and Medicine, 34, 325 – 32 Sallis, 4J.F., & Owen, N (1998) Physical activity and behavioural medicine Newbury Park, CA: 5Sage Sallis J.F., Pinski R.B., Grossman R.M., Patterson T.L., & Nader P.R (1988) The development of 7self-efficacy scales for health-related diet and exercise behaviors Health Education 8Research, 3, 283 – 292 Scanlan, T.K., Carpenter, P.J., Schmidt, G.W., Simons, J.P., & Keeler, B (1993) An introduction to 10the sport commitment model Journal of Sport and Exercise Psychology, 15, – 15 Singer, 11 J.D., & Willett, J.B (2003) Applied longitudinal data analysis: Modeling change and event 12occurrence New York: Oxford University Press U.S 13 Department of Health and Human Services (1996) Physical Activity and health; A report of 14the Surgeon General Executive summary Pittsburgh, PA: Superintendent of documents U.S 15 Preventative Services Task Force (1996) Guide to clinical preventative services (2d edition) 16Baltimore: Williams & Wilkins Vallerand, 17 R.J (1997) Toward a hierarchical model of intrinsic and extrinsic motivation In M.P 18Zanna (Ed.), Advances in experimental social psychology (pp 271 – 360) New York: 19Academic Press Vallerand, 20 R.J (1999) Intrinsic and extrinsic motivation in sport: Toward a hierarchical model In 21I.R Lidor & M Bar-Eli (Eds.), Sport psychology: Linking theory to practice (pp 191 – 212) 22Morgantown, WV: Fitness Information Technology Vallerand, 23 R.J (2001) A hierarchical model of intrinsic and extrinsic motivation in sport and 24exercise In G.C Roberts (Ed.), Advances in motivation in sport and exercise (pp 263 25319) Champaign, IL: Human Kinetics 31 Watson, D., Tellegen, A., & Clark, L (1988) Development and validation of brief measures of 2positive and negative affect: The PANAS scales Journal of Personality and Social 3Psychology, 54, 1063 – 1070 WHO 4(1998) Obesity: Preventing and managing the global epidemic Report of WHO consultation 5on obesity Geneva: World Health Organization Williams, G.C., Grow, V.M., Freedman, Z.R., Ryan, R.M., & Deci, E.L (1996) Motivational 7predictors of weight loss and weight-loss maintenance Journal of Personality and Social 8Psychology, 30, 115 – 126 Wilson, P.M., & Rodgers, W.M (2002) The relationship between exercise motives and physical 10self-esteem in female exercise participants: An application of self-determination theory 11Journal of Applied Biobehavioral Research, 7, 30 – 43 Wilson, 12 P.M., & Rodgers, W.M (2004) The relationship between perceived autonomy support, 13exercise regulations and behavioural intentions in women Psychology of Sport and 14Exercise, 5, 229 – 242 Wilson, 15 P.M., Rodgers, W.M., Blanchard, C.M., & Gessell, J (2003) The relationship between 16psychological needs, self-determined motivation, exercise attitudes and physical fitness 17Journal of Applied Social Psychology, 33, 2373 – 2392 Wilson, 18 P.M., Rodgers, W.M., & Fraser, S.N (2002) Examining the psychometric properties of the 19behavioural regulation in exercise questionnaire Measurement in Physical Education and 20Exercise Science, 6, – 21 21 1 32 Author note 2We would like to thank the staff and clients of the Birmingham City Council Exercise on 3Prescription Service for their assistance and involvement in this study 1 33 Footnotes 21 Patients displaying Coronary Heart Disease risk factors, who are perceived by their General 3Practitioner (Physician) as being suitable for the EoP programme, are given a Prescription 4Card The patient then makes an appointment with a local EoP advisor (who will assess the 5patients’ eligibility/suitability for the scheme) Eligible patients then attend an initial 6consultation with the EoP advisor at their local Leisure Centre, which last up to an hour 7(typically 30 – 45 minutes), to discuss the aim of the scheme, the patients’ current medical 8condition and physical activity status and the activities on offer locally Height, weight and 9body composition are assessed and an exercise plan is then devised for the patient The 10patient/referral then attends an induction session with the EoP advisor, where they are shown 11how to follow their exercise prescription and use the facilities and fitness equipment 12appropriately The patient is then required to follow their 12-week prescribed exercise plan 13At the end of the 12-weeks, the patient/referral will meet with their EoP advisor again to 14discuss their progress, complete another fitness appraisal, if appropriate, and compare their 15pre/post fitness/physical activity levels A report is also sent to the patients/referrals General 16Practitioner 172 We also ran a series of models to discern whether those individuals who adhered for 318months and exercised in accordance to their prescriptions (coded as 1; 51% of the sample) 19differed to the rest of the sample (coded as 0) in terms of the means for each of the variables 20reported at 3-months, and the rate of change of their scores over time The results obtained 21were analogous to those reported in the text [i.e., as observed in Model (c)] 223 The range of scores for all the scales used in this study can be found in Table 234 In line with the theoretical propositions of Vallerand (1997) we also examined the 24mediating role of the psychological needs between autonomy support and the motivational 25regulations and the motivational regulations between psychological need satisfaction and the 34 1behavioural cognitive and affective outcomes None of the variables satisfied the conditions 2for mediation outlined by ******** 1Table 2Reliability Analyses (Cronbach’s Coefficient ) and Descriptive Statistics for Perceived Autonomy Support (PAS), Psychological Need 3Satisfaction, Motivational Regulations, Exercise-Related Behavioural and Cognitive Outcomes, and Indices of Well-being Baseline 1-month post entry 3-month post entry Range M SD M SD M SD    PAS 1–7 91 5.81 1.17 91 5.36 1.32 95 4.96 1.66 Autonomy 1–7 59 4.01 1.62 62 4.15 1.53 55 4.05 1.58 Relatedness 1–7 88 3.50 1.69 74 3.73 1.45 77 3.37 1.32 Competence 1–7 78 3.35 1.69 83 3.82 1.34 72 3.66 1.05 Amotivation 0–4 88 0.41 0.82 72 0.41 0.62 76 0.31 0.51 External regulation 0–4 74 1.03 0.97 81 1.30 1.05 79 0.83 0.89 Introjected regulation 0–4 84 1.63 1.23 81 2.29 1.11 84 2.01 1.04 Identified regulation 0–4 79 3.06 0.85 74 2.74 0.80 85 2.41 0.88 Integrated regulation 0–4 70 2.27 0.95 86 2.41 1.06 87 2.01 1.10 Intrinsic motivation 0–4 91 2.22 1.11 90 2.48 1.05 98 2.23 0.96 Total exercise 20.47 18.99 38.44 24.26 30.74 19.94 Self-efficacy – 100 89 52.84 20.40 92 53.11 23.07 88 47.56 20.10 Commitment 1–5 76 4.07 0.78 82 3.59 0.97 Behavioural intention 1–7 78 5.61 1.33 91 5.08 1.59 Positive affect 1–5 92 3.35 0.94 94 3.01 1.00 89 1.44 0.43 Negative affect 1–5 73 2.15 0.75 88 2.21 1.04 80 1.14 0.42 Subjective vitality 1–7 89 3.35 1.73 88 3.27 1.50 91 2.99 1.50 Satisfaction with life 1–7 96 3.45 1.62 94 3.34 1.51 95 3.54 1.63 4Note: No  values are provided for total exercise as this represents a global score drawn from the multiplicative function of weighted items 5Commitment and behavioural intention were not measured at baseline 35 1 36 37 1Table 2Correlations between Adherence and Measures of Perceived Autonomy Support, Psychological Need Satisfaction, Motivational Regulations, -.29* 06 -.00 31* 39* 16 40* 32 17 -.23 22 - 19 Satisfaction with life vitality 18 Subjective affect 17 Negative affect 16 Positive intention 15 Behavioural 14 Commitment 13 Self-efficacy exercise 12 General motivation 11 Intrinsic regulation 10 Integrated regulation Identified regulation Introjected -.22 11 Regulation External 36* 75** 31 -.06 23 Amotivation Autonomy 02 27 03 02 33 44* -.07 -.29 Competence -.37 -.02 -.17 -.15 31 -.08 -.22 10 34 -.09 -.05 16 16 -.21 Relatedness BL 1m 3m BL 1m 3m BL 1m 3m BL 1m 3m BL 1m 3m BL 1m Perceived autonomy support Adherence 3Exercise-Related Behavioural and Cognitive Outcomes, and Indices of Well-being at baseline (BL), 1-month (1m) and 3-months (3m) 3m BL 1m 3m BL 1m 3m BL 1m 3m 10 BL 1m 3m 11 BL 1m 3m 12 BL 1m 3m 13 BL 1m 3m 14 BL 1m 3m 15 BL 1m 3m 16 BL 1m 3m 17 BL 1m 3m 18 BL 27 14 -.25 22 -.02 -.21 -.01 13 28 23 06 25 13 -.07 18 29 -.07 -.08 03 -.08 08 39* N/A 12 23 N/A 33 03 -0.2 35* 14 -.07 -.34 -.38 -.13 38 -.01 29* 15 -.23 09 00 -.05 58** 10 -.11 53** 05 -.12 42** 28 04 08 13 -.25 26 28 -.12 N/A 37* 06 N/A 39* -.07 34* 28 -.08 -.18 -.19 16 20 -.25 -.36* -.41* -.42* 11 -.18 06 -.31 34* 44* -.22 37* 55** 12 59** 65** 20 13 42* 18 39* 27 N/A 44* 30 N/A 26* 17 07 56* 48* 02 -.46** -.40* 10 13 31* 40* 23 17 14 01 01 36* 20 08 30 06 27 60** 31 09 10 05 26 41* -.15 N/A 29 09 N/A 34* -.08 36* 63** 11 -.35* -.51** -.23 47** -.14 27 19 12 35* 21 11 47** 52** 43* 40** 38* 34 67** 67** 52** 34* 21 28 27 55** 16 N/A 43* 21 N/A 41* 23 21 57** 25 01 -.39* -.06 31* 30* -.47** 36 12 07 18 -.33* -.25 -.12 -.29* -.13 -.23 -.26 -.09 -.04 -.12 31 00 -.28 -.04 -.12 N/A -.13 -.21 N/A -.24 -.14 -.34* -.12 -.21 22 -.10 -.10 -.31* 38* 42* 27 15 -.00 19 21 06 05 13 -.05 10 14 18 -.12 -.16 10 02 N/A -.22 -.15 N/A -.19 19 -.07 04 -.09 05 04 22 10 16 49** 73** 23 25 59* 08 -.00 22 12 -.03 35 -.12 10 10 N/A -.21 -.06 N/A -.16 26 -.16 -.07 -.24 20 19 13 -.01 68** 74** 92** 48** 52** 58** -.01 01 32 20 53** 45* N/A 46** 16 N/A 45** 39* 17 41* 05 18 -.28 -.22 18 43** 43* 60** 22 21 44* 19 67** 53** N/A 37* 27 N/A 29 52** 34* 42* 24 -.16 -.39* -.30 33* 30* 38* 28 29 58** 27 N/A 64** 40* N/A 42* 43* 32* 72** 60** -.08 -.54** -.43* 13 37* 09 N/A 27 25 N/A -.01 27 29* 23 26 -.30* -.41* -.24 N/A 55** 30 N/A 46** 36 35* 50** 22 -.21 -.30 -.32 N/A 77** 63** N/A 48** 50** N/A -.44** -.53** N/A 45** 44* N/A -.26 -.26 44** -.66** -.42* - 1m 3m 19 BL 1m 3m 11 15 -.00 29 16 39 10 04 -.06 17 -.26 29 37 10 51** 34 -.45** 29 31* 44** 11 33 20 03 27 -.09 13 16 -.05 -.00 -.04 29 03 02 -.04 02 -.08 -.20 01 00 -.09 22 05 -.05 26 17 46** 06 00 18 29 21 40* 48** 26 -.06 02 2Note * p