LEISURE-TIME PHYSICAL ACTIVITY PERCEPTIONS, INFLUENCES, AND BEHAVIOR
DURING PREGNANCY
By
Christopher P. Connolly

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirement
for the degree of
Kinesiology – Doctor of Philosophy
2014

ABSTRACT
LEISURE-TIME PHYSICAL ACTIVITY PERCEPTIONS, INFLUENCES, AND BEHAVIOR
DURING PREGNANCY
By
Christopher P. Connolly
Psychosocial factors, which may facilitate or impede pregnancy leisure-time physical
activity (LTPA) have been identified by pregnant women. Although the influence of each factor
is unclear, some may be vital in enabling pregnant women to participate in sufficient levels of
LTPA. The Risk Perception Attitude Framework (RPA) suggests risk perceptions and efficacy
beliefs interact to predict self-protective behavior. Therefore, the first purpose of this
dissertation was to examine the joint influence of pregnancy risk perceptions and LTPA efficacy
beliefs on LTPA behavior among pregnant women. An additional factor which may impact
LTPA behavior, but which has not been examined thoroughly, is religion. Thus, the second
purpose of this dissertation was to examine the influence of religion (specifically the Latter-day
Saint (LDS) faith) on pregnancy LTPA and potential psychosocial factors which influence
pregnancy LTPA.
A convenience sample of pregnant women (n=302) was recruited via prenatal clinics and
word-of-mouth from mid-Michigan as well as Salt Lake City, Utah. Data were collected from a
15-minute survey (via iPad or paper copy) completed by all study participants. RPA defined
attitudinal groups were created via a median split of both pregnancy risk perceptions (high/low)
and LTPA efficacy beliefs (high/low) for both moderate and vigorous LTPA. Moderate LTPA
was dichotomized as meeting current LTPA guidelines [moderate LTPA ≥150 min/week] or not,
while vigorous LTPA was dichotomized as performing any [vigorous LTPA >0 min/week], or

not. Chi-square and logistic regression analyses were utilized to examine group differences for
both moderate and vigorous LTPA. Hierarchical logistic regression was utilized to examine
further the joint influence of pregnancy risk perceptions and LTPA efficacy beliefs on pregnancy
LTPA. Four religious groups were defined as LDS, and non-LDS high, moderate, and low
religiosity (as determined via tertiles). Group differences for LTPA as well as pregnancy risk,
LTPA efficacy, physical activity social support, and discussions with prenatal healthcare
providers were determined via chi-square analyses and logistic regression.
Responsive and proactive pregnant women (those with high efficacy beliefs) were most
likely to meet moderate LTPA guidelines and participate in any vigorous LTPA compared to the
other attitudinal groups. Hierarchical logistic regression did not reveal an interactive effect of
pregnancy risk perceptions and LTPA efficacy beliefs for meeting moderate LTPA guidelines or
any vigorous LTPA participation. LDS women were less likely to meet moderate LTPA
guidelines, but more likely to participate in vigorous LTPA compared to non-LDS women. LDS
women reported higher levels of moderate and vigorous LTPA efficacy.
The results suggest that high LTPA efficacy beliefs are important in facilitating greater
levels of pregnancy LTPA. Our findings partially extend the scope of the RPA, specifically to
classifying pregnant women with respect to LTPA behavior. Although this investigation did not
find a significant interactive effect between pregnancy risk perceptions and LTPA efficacy
beliefs, their joint consideration should not be discounted in future investigations. Interventions
aiming to increase pregnancy LTPA should focus on methods to heighten pregnant women’s
LTPA efficacy beliefs such that avoidant pregnant women become responsive and indifferent
pregnant women become proactive.

Copyright by
CHRISTOPHER P. CONNOLLY
2014

ACKNOWLEDGEMENTS

Successfully navigating my doctoral studies would not have been remotely possible
without several individuals who have been so selfless in their mentorship of me. I am indebted
in particular to my dissertation committee members. To Dr. Lanay Mudd, thank you for all the
time you spent teaching me to meticulously evaluate scientific literature and also for showing me
that statistical analyses really are “the fun part”. My only regret was that I did not have four
years at Michigan State to learn from you. To Dr. Deborah Feltz, thank you for sitting with me
on numerous occasions and teaching this exercise physiologist the importance of always
considering psychosocial factors in examining physical activity behavior. Because of you, an
exciting array of research opportunities has been introduced to me, of which I was previously
unaware. To Dr. Maria Lapinski, thank you for teaching me the value of basing research in wellrespected theoretical frameworks. Additionally, I must thank you for taking so much time to
help me design and implement my dissertation project.
I would like to acknowledge the incredible undergraduates who volunteered many hours
of their time to assist me with the data collection portion of this dissertation. Particularly, I am
indebted to Madeline Stahl and Ashley Triplett, who were truly invaluable to me in coordinating
various project tasks. I would also like to thank Dr. Karin Pfeiffer for her mentorship and
guidance over these last four years. I must also thank my fellow graduate students who have
provided me with friendship, advice, and perspective during my time at Michigan State.
Particularly, I would like to acknowledge Dr. Rebecca Schlaff, Catherine Gammon, Kimbo Yee,
Alicja Stannard, Dr. Mallory Marshall, and Joseph Warning. Most of all I would like to thank
Dr. Alexander Montoye and Samantha Danbert who have been such wonderful friends to me. I

v

look forward to us progressing together in our academic careers wherever we may be. I am
beyond grateful to my friend and former adviser, Dr. Dawn Coe at the University of Tennessee.
Thank you so much for helping me onto this wonderful path and opening the door for me be
successful at Michigan State University.
Finally, I must express my gratitude to family, both those who were before and those who
have become such during these last four years. To Dr. James and Linda Pivarnik, I could not
have been blessed with better people to guide me. Linda, you are so dear to me and my little
family and have blessed our lives immensely through your kindness and love. Chief, words
cannot express the respect I have for you and gratitude I feel for all you have done for me. Dawn
told me before I came to Michigan State that working with you would be one of the best
experiences of my life – she was correct. Thank you for your constant guidance, patience,
support, and friendship. To mom and dad, I would not have amounted to anything without your
love and support. You both have been and always will be my heroes. To Jedd and Karen, thank
you likewise for your support and being incredibly understanding as we have worked to
complete six years of graduate education over 1,500 miles away. Most importantly, to Erin,
Carly, John, and Quinn, I love you and cannot thank you enough for the love and confidence you
have given me. There were long days, late nights, and stressful times that we all felt. But
coming home to you has made and will continue to make every single day perfect. Thank you
for making me the most blessed of men.

vi

TABLE OF CONTENTS

LIST OF TABLES…………………………………………………………………………. x
LIST OF FIGURES……………………………………………………………………....... xii
CHAPTER 1
INTRODUCTION……………………………………………………………….………… 1
POTENTIAL PSYCHOSOCIAL INFLUENCES ON PREGNANCY LTPA.……. 3
Pregnancy Risk Perceptions and LTPA Efficacy Beliefs………………….. 3
Social Support and Discussions with Prenatal Healthcare Providers…….... 5
Religion…………………………………………………………………….. 6
RESEARCH AIMS….……………………………………………………………... 8
OVERVIEW OF DISSERTATION…………………………...…………………... 11
REFERENCES…………………………………………………………………….. 12
CHAPTER 2
REVIEW OF THE LITERATURE……………………………………..…………………. 18
INTRODUCTION….……………………………………………………………… 18
PHYSICAL ACTIVITY DURING PREGNANCY…...…………………………... 20
History of Recommendations…………………………………………….... 20
Health Benefits…………………………………………………………….. 21
LTPA Trends among Pregnant Women……………………………………. 22
OVERVIEW OF BARRIERS TO LTPA DURING PREGNANCY………...……. 23
PHYSICAL, ENVIRONMENTAL, AND LIFESTYLE INFLUENCES ON
LTPA DURING PREGNANCY…………………………………………………... 27
Fatigue and Lack of Energy……………………..…………………………. 27
Anthropometric Change and Musculoskeletal Discomforts……………….. 27
Pregnancy-Induced Nausea………………………………………………… 28
Work/Childcare…………………………………………………………….. 29
Family Access……………………………………………………………… 30
PSYCHOSOCIAL INFLUENCES ON LTPA DURING PREGNANCY……….... 30
Pregnancy Risk Perceptions………………………………………………... 31
LTPA Response Efficacy………………………………………………….. 33
LTPA Self-Efficacy………………………………………………………... 35
LTPA Risk Perceptions…………………………………………………......38
Physical Activity Discussions with Prenatal Healthcare Providers…...…… 40
Physical Activity Social Support…………………………………………... 44
UTILIZING THE RISK PERCEPTION ATTITUDE FRAMEWORK……….…... 47

vii

THE POTENTIAL INFLUENCE OF RELIGION ON LTPA DURING
PREGNANCY………………………………………………….…………..……… 51
The Case of Mormonism………………………………………………....... 52
SUMMARY…...…………………………………………………………………… 54
REFERENCES ……………………….………………………...…………………. 56
CHAPTER 3
METHODS…………………………………………..………….…………………………. 68
STUDY DESIGN………………………………………………………………….. 68
PARTICIPANT RECRUITMENT………………………………………………… 68
DATA COLLECTION…………………………………………………………….. 70
DATA MANAGEMENT…………………………….……………………………..71
THEORETICAL FRAMEWORK…………………………………………………. 72
SURVEY DEVELOPMENT………………………………………………………. 74
SURVEY OVERVIEW……………………………………………...…………….. 75
VARIABLES OF INTEREST……………………….…………………………….. 77
Leisure-Time Physical Activity……………………………………….…… 77
Pregnancy Risk Perceptions………………………...……………………… 78
LTPA Efficacy Beliefs……………………………………………….…….. 78
LTPA Risk Perceptions……………………………………………….…….79
Discussion and Satisfaction of Discussion with Prenatal HCP………........ 80
Physical Activity Social Support…………………………………………... 80
Religion and Religiosity……………………...……………………………. 81
STATISTICAL ANALYSES…………………...…………………………...…….. 82
APPENDICES……………...……………………………………………...………. 91
Appendix A: IRB Approval – Michigan State University…………………. 92
Appendix B: IRB Approval – University of Utah…………………………. 93
Appendix C: Informed Consent (Electronic)………………………………. 94
Appendix D: Informed Consent (Paper Copy)…………………………….. 95
Appendix E: Survey Instrument……………………………………….……96
Appendix F: Recruitment Flyer……………………………………………. 108
Appendix G: Dissertation Funding Sources……………………………….. 109
REFERENCES ………………...……….…………………………………………. 110
CHAPTER 4
RESULTS………………………………………………………………………………….. 113
REFERENCES ……………...……………………………………….……………. 142
CHAPTER 5
DISCUSSION…………………………………………...…………………………………. 144
PREGNANCY RISK PERCEPTIONS AND LTPA EFFICACY BELIEFS…...…. 146

viii

Descriptive Results………………………….……………….…………….. 146
Influence on LTPA Behavior during Pregnancy.………………………….. 148
Practical Significance of Findings…………………...…………………….. 155
RELIGION AND PREGNANCY LTPA………….………………………………..157
Practical Significance of Findings………….……………………………… 162
STUDY LIMITATIONS………………………….……………………………….. 163
STUDY STRENGTHS…………………………….………………………………. 165
FUTURE RESEARCH DIRECTIONS…………………………………………… 166
CONCLUSION……………………………………………………………………. 168
REFERENCES …….…………...…………………………………………………. 169

ix

LIST OF TABLES

Table 2.1. Perceived barriers to LTPA during pregnancy (quantitative investigations)....... 25
Table 2.2. Perceived barriers to LTPA during pregnancy (qualitative investigations)…..... 26
Table 3.1. Content overview for the study instrument (Appendix E)…………..………….. 76
Table 4.1. Participant characteristics for total sample……………………………….…….. 115
Table 4.2. LTPA descriptive statistics for total sample………..……….………………….. 118
Table 4.3. Participant characteristics of attitudinal groups (moderate LTPA)…………….. 119
Table 4.4. Odds of meeting moderate LTPA guidelines by attitudinal groups……………. 121
Table 4.5. Participant characteristics of attitudinal groups (vigorous LTPA)……...……… 122
Table 4.6. Odds of participating in and vigorous LTPA by attitudinal groups……………. 124
Table 4.7. Bivariate correlations among demographic and moderate LTPA variables……. 126
Table 4.8. Predictors of meeting moderate LTPA guidelines……………………………… 126
Table 4.9. Bivariate correlations among demographic and vigorous LTPA variables…….. 128
Table 4.10. Predictors of participating in vigorous LTPA………………..………………...128
Table 4.11. Demographic characteristics for religious groups…………………………….. 130
Table 4.12. LTPA behavior and perceptions of religious groups…………..……………… 131
Table 4.13. Odds of meeting moderate LTPA guidelines during pregnancy by
religious groups………………………………………………………………………….…. 133
Table 4.14. Odds of participating in any vigorous LTPA during pregnancy by
religious groups………………………………………………………………………….…. 134
Table 4.15. Odds of strong disagreement with pregnancy risk by religious groups…….…. 134

x

Table 4.16. Odds of strong agreement with moderate LTPA efficacy during
pregnancy by religious groups…………………………………………………….……….. 136
Table 4.17. Odds of some agreement with vigorous LTPA efficacy during
pregnancy by religious groups…………………………………………………….……….. 137
Table 4.18. LTPA social characteristics of religious groups…………………….………… 138
Table 4.19. Odds of discussing physical activity with HCP during pregnancy by
religious groups………………………………………………………………………..…… 139
Table 4.20. Odds of high satisfaction with HCP physical activity discussions during
pregnancy by religious groups……………………………………………………......……. 139
Table 4.21. Odds of perceiving higher levels of physical activity social support
(total) during pregnancy by religious groups……………………………………….……… 140
Table 4.22. Odds of perceiving high levels of physical activity social support
(family) during pregnancy by religious groups……………………………………………. 141
Table 4.23. Odds of perceiving higher levels of physical activity social support
(significant other) during pregnancy by religious groups………………………….………. 141

xi

LIST OF FIGURES

Figure 1.1. Psychosocial factors that potentially influence LTPA during pregnancy……... 2
Figure 2.1. Variables of interest in examining potential psychosocial influences on
LTPA during pregnancy………………………………………………………………...…. 19
Figure 2.2. Desciption of commonly-used categories for social support……………….…. 44
Figure 2.3. Risk percpetion and efficacy belief attitudinal groups created within
the RPA…………………………………………………………………………………..… 49
Figure 3.1. Risk perception and efficacy belief components as defined by the RPA…........ 73
Figure 3.2. Risk percpetion and efficacy belief attitudinal groups created within
the RPA…………………………………………………………………………………..… 74
Figure 3.3. Study IRB approval by Michigan State University………….………………… 92
Figure 3.4. Study IRB approval by University of Utah………..…………………………... 93
Figure 3.5. Study recruitment flyer………………………………………………………… 108
Figure 4.1. Participant flowchart for the total analytic sample………………………….…. 114
Figure 4.2. Histograms depicting the frequencies of (A) pregnancy risk perceptions,
(B) moderate LTPA efficacy beliefs, and (C) vigorous LTPA efficacy beliefs
(7=strongly agree, 1= strongly disagree)………………………………………………....... 117
Figure 4.3. Relative frequency of meeting moderate LTPA guidelines by
attitudinal groups………………………………………………………………….……….. 120
Figure 4.4. Relative frequency of participating in any vigorous LTPA by
attitudinal groups……………………………………………………………………..……. 123
Figure 4.5. Relative frequencies of meeting moderate LTPA guidelines and
participating in any vigorous LTPA by religious groups………………………...…………133

xii

Figure 4.6. Relative frequencies of participant agreement for vigorous
LTPA efficacy by religious groups………………………………………………………… 136

xiii

CHAPTER 1
INTRODUCTION
Physical activity during pregnancy provides a host of health benefits to both mother and
fetus. For the mother, these include a reduced risk of gestational diabetes,1-3 preeclampsia,4,5
unhealthy gestational weight gain,6 and prolonged labor.7,8 Fetal health benefits include
prevention of excessive fetal weight gain,9 as well as a reduced risk of adverse birth outcomes,
including preterm delivery10,11 and operative delivery.12 Therefore, the importance of physical
activity on maternal-fetal health cannot be overstated.
Despite the many beneficial effects of physical activity during pregnancy, volume and
intensity typically decrease as gestation progresses.13-15 Moreover, it is evident that many
pregnant women do not participate in sufficient amounts of leisure-time physical activity (LTPA)
throughout pregnancy, with only 14-29% meeting the minimum recommendation of at least 150
minutes of moderate-intensity activity per week.16,17 Furthermore, population-based
investigations have indicated that as many as 35-44% of pregnant women have not participated
in any moderate LTPA within the previous month.17,18
Various barriers to LTPA during a healthy pregnancy have been identified, including lack
of time,19-23 fatigue,19-21,23,24 physical discomfort,19-23,25 and childcare responsibilities.19,22,26
Additionally, pregnant women have reported a number of psychosocial factors limit LTPA.
These include unfavorable perceptions towards physical activity,25-28 lack of adequate healthcare
provider (HCP) advice,23,27 and insufficient levels of social support.27 Although preliminary
research suggests each of these psychosocial factors influences LTPA among pregnant women,

1

more thorough analyses of each variable, including the extent to which they affect various
subgroups of pregnant women, are needed.
This dissertation focused on psychosocial factors that may influence pregnancy LTPA,
including pregnancy risk perceptions, physical activity beliefs, physical activity discussions with
prenatal HCPs, and physical activity social support (Figure 1.1). The joint influence of
pregnancy risk perceptions and LTPA efficacy beliefs on pregnancy LTPA were explored. The
influence of physical activity social support and physical activity discussions with prenatal HCPs
on pregnancy LTPA were not directly investigated. However, a previously unconsidered
potential influence to pregnancy LTPA (religion) will be a central focus of this dissertation.
More specifically, differences among various religious groups with respect to LTPA and each of
these potential psychosocial influences will be examined.

Figure 1.1. Psychosocial factors that potentially influence LTPA during pregnancy.

Pregnancy
Risk
Perceptions

LTPA
Efficacy
Beliefs

LTPA
Discussions
w/ Prenatal
HCP

2

Social
Support

Religion?

POTENTIAL PSYCHOSOCIAL INFLUENCES ON PREGNANCY LTPA
Pregnancy Risk Perceptions and LTPA Efficacy Beliefs
A part of this dissertation will utilize the Risk Perception Attitude Framework (RPA),
which originates from the Extended Parallel Process Model (EPPM), and stipulates that
perceptions for a specific risk and efficacy beliefs for a health behavior to protect against that
risk, jointly determine the participation in that behavior.29 While the EPPM focuses on how
individuals process a given message about a threat, the RPA pertains to how individuals’ risk
perceptions lead to action. Within the RPA, four attitudinal groups are formed (responsive,
proactive, avoidant, indifferent), based on risk perceptions (high/low) and efficacy beliefs
(high/low). Theoretically, individuals with higher perceptions of the risk and higher efficacy
beliefs for the behavior (responsive group) will be most likely to engage in that behavior.29
Although this framework has not yet been applied within a physical activity context, it is an ideal
tool to use when studying pregnant women, given the protective feelings that an expectant
mother may feel for her unborn child. Utilizing the RPA may reveal the combinations of
pregnancy risk perceptions and physical activity efficacy beliefs that drive pregnancy LTPA.
Results from qualitative investigations indicate it is common for women to have some
level of concern or worry about the health and safety of their babies during pregnancy.25,30
Women with “high-risk” pregnancies or previous complications may perceive either their
personal health or that of their babies’ to be more at risk31,32 and expect more medical
interventions33 than do women with uncomplicated pregnancies. Among nulliparous women,
pregnancy risk perceptions may be higher among those with higher pregnancy-related anxiety as
well as those at lower gestational ages.34 Such feelings of risk can theoretically comprise

3

perceptions of how likely an adverse outcome is (perceived susceptibility) and how severe it
would be (perceived severity) if it occurred. The perception that LTPA is protective against
adverse prenatal health outcomes (response efficacy) may be a powerful motivator for pregnant
women to be physically active, particularly if women believe the risk of such outcomes to be
great. However, only a few investigations have attempted to assess these perceptions, and have
indicated that the majority of pregnant women believe moderate LTPA to be somewhat safe16,20
and beneficial.35 In contrast, fewer pregnant women believe in the safety16,20 and health benefit35
of vigorous LTPA despite evidence that it is not detrimental and may be protective to mother and
baby. Assessing the extent to which pregnant women perceive physical activity to be beneficial
and or safe is complex, as are the mechanisms by which these perceptions develop. There is a
need to more precisely examine risk perceptions during pregnancy and also response efficacy of
LTPA behavior in order to better understand their impact on LTPA among pregnant women.
The relationship between LTPA self-efficacy and LTPA behavior during pregnancy has been
studied more thoroughly, particularly over the past decade. Results suggest that LTPA selfefficacy may predict women’s LTPA during pregnancy as they transition from prepregnancy into
the first trimester.25,36 Moreover, researchers have shown that LTPA self-efficacy predicts LTPA
during the second trimester, while the self-efficacy to overcome physical activity barriers
predicts LTPA in the third trimester.21
Optimal combinations of pregnancy risk perceptions and LTPA efficacy beliefs in
influencing pregnancy LTPA are not well-studied. However, Gaston and Prapavessis37 recently
examined the influence of these individual perceptions on exercise behavior among 105 second
and third-trimester pregnant women. Results showed that perceived susceptibility, response
efficacy, and self-efficacy all are indirectly related to exercise behavior, with these relationships

4

mediated by goal intention and implementation intention. However, within this investigation,
the perception that physical activity is protective was considered generally for pregnancy health,
rather than the specific health and safety of the baby. Additionally, combinations of physical
activity efficacy beliefs and pregnancy risk perceptions were not assessed. Determining the joint
influence of LTPA efficacy beliefs (response efficacy and self-efficacy) and risk perceptions
specific to the safety of the baby (perceived severity and susceptibility) on LTPA behavior may
provide meaningful insight into how sufficient levels of physical activity can be achieved during
pregnancy.
Social Support and Discussions with Prenatal Healthcare Providers
Pregnancy has been described as a self-identifying experience, which introduces many
women to challenges and fears not previously experienced.38-40 The role of a pregnant woman’s
social network may be critical during such a time. Specifically in regards to LTPA, qualitative
research has shown that social support enables pregnant women to overcome barriers and be
more physically active.19,24 Melender41 indicated that talking about physical activity concerns
with trusted support sources is influential in minimizing perceptions of fear during pregnancy.
Although physical activity advice that pregnant women receive from family members may
outweigh that of other individuals,19 it is possible that various sources have influence on
pregnant women’s perceptions towards physical activity through either the encouragement or
discouragement of being physically active.42,43 Thus, there is a need to assess total physical
activity social support as well as social support from specific sources.
The prenatal healthcare provider (HCP) may also have tremendous impact on a pregnant
woman’s physical activity perception and behavior, given his/her regular personal interactions

5

with the woman as well as his/her expertise in maternal-fetal health. Of specific interest are the
discussions that prenatal HCPs may have with their patients, an avenue through which accurate
physical activity information, including the current LTPA recommendations, may be presented.
However, it appears prenatal HCPs do not discuss physical activity with pregnant women on a
regular basis.27,44,45 Additionally, unclear or out-of-date physical activity information may be
given during the discussions that do take place.44,46,47 Not surprisingly, some pregnant women
have reported uncertainty regarding LTPA participation due to a lack of guidance from their
prenatal HCP.23,27 Yet prenatal HCP discussions and social support are possible means by which
physical activity perceptions and behavior among pregnant women may be improved. How
these differ between subgroups of pregnant women has not yet been specifically investigated.
Religion
Given that individuals often identify and draw strength from spiritual beliefs when faced
with health challenges or significant life events,48 the influence of spirituality on perceptions and
behaviors may be unique during pregnancy. This may be especially pertinent for Latter-day
Saint (LDS) pregnant women (otherwise known as Mormons), who have had consistently higher
rates of childbearing compared to other religious denominations49,50 and report pregnancy and
childbirth to both be deeply personal and spiritual.51 The role of the family is deeply integrated
within LDS theology and many LDS women view having and raising children to be a sacred
responsibility and divine experience.52 Additionally, LDS members live by a strict health code,
which consists of abstaining from addictive substances and living a healthy lifestyle. Given
these unique doctrines, it is possible that LDS pregnant women differ in their physical activity
beliefs and behavior from non-LDS pregnant women. Likewise, these hypothetical differences
may be reflected in the physical activity social support received and prenatal HCP physical

6

activity discussions. It does not appear that previous investigations have explored the impact of
spirituality or religiosity during pregnancy on physical activity behavior, nor on psychosocial
influences of physical activity. However, investigating these differences may offer a unique and
important perspective with respect to the role of spirituality/religion in a healthy pregnancy.
Psychosocial factors that appear to influence physical activity behavior among pregnant
women are complex and difficult to assess. The overall purpose of this dissertation is to gain a
better understanding of the psychosocial factors that may influence LTPA during pregnancy.
This study will be a unique examination of pregnant women’s pregnancy risk perceptions, LTPA
efficacy beliefs, LTPA behavior, and the how these and social influences of physical activity
(social support and discussions with prenatal HCP) differ between LDS and non-LDS pregnant
women of different religiosity levels. Findings may encourage practitioners and researchers
working with pregnant women to more fully integrate psychosocial and religious factors into
interventions aiming to improve LTPA participation during pregnancy.

7

RESEARCH AIMS
Specific Aim 1: To develop a survey instrument to measure pregnant women’s pregnancy risk
perceptions, LTPA efficacy beliefs, and LTPA in order to utilize the Risk Perception Attitude
Framework (RPA).
Aim 1 is not hypothesis driven.
Specific Aim 2: To determine the pregnancy risk perceptions and LTPA efficacy beliefs in a
convenience sample of 300-400 pregnant women from mid-Michigan and Salt Lake City, Utah
regions.
Aim 2 is not hypothesis driven.
Specific Aim 3: To determine if differences exist in meeting the moderate LTPA guidelines
among pregnancy risk perception/moderate LTPA efficacy attitudinal groups as defined by the
RPA.
Hypothesis 3: Pregnant women with high pregnancy risk perceptions and high LTPA
efficacy beliefs (responsive group) as well as those low pregnancy risk perceptions and
high LTPA efficacy beliefs (proactive group) will be more likely to meet the moderate
LTPA guidelines than will women with high pregnancy risk perceptions and low LTPA
efficacy beliefs (avoidant group) as well as those with low pregnancy risk perceptions
and low LTPA efficacy beliefs (indifferent group).
Specific Aim 4: To determine if differences exist in vigorous LTPA participation among
pregnancy risk perception/vigorous LTPA efficacy attitudinal groups as defined by the RPA.

8

Hypothesis 4: Pregnant women with high pregnancy risk perceptions and high LTPA
efficacy beliefs (responsive group) will be more likely to participate in any vigorous
LTPA compared to a) women with low pregnancy risk perceptions and high LTPA
efficacy beliefs (proactive group), b) women with high pregnancy risk perceptions and
low LTPA efficacy beliefs (avoidant group), and c) women with low pregnancy risk
perceptions and low LTPA efficacy beliefs (indifferent group).
Specific Aim 5: To determine if the interaction of pregnancy risk perceptions and moderate
LTPA efficacy is associated with meeting moderate LTPA guidelines among pregnant women.
Hypothesis 5: The interaction of pregnancy risk perceptions and moderate LTPA efficacy
beliefs will be associated with meeting the moderate LTPA guidelines.
Specific Aim 6: To determine if the interaction of pregnancy risk perceptions and vigorous LTPA
efficacy is associated with participating in any vigorous LTPA among pregnant women.
Hypothesis 6: The interaction of pregnancy risk perceptions and vigorous LTPA efficacy
beliefs will be associated with participating in vigorous LTPA.
Specific Aim 7: To determine the relationship of religion (Latter-day Saints [LDS] vs. non-LDS
(high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with LTPA,
pregnancy risk perceptions, and LTPA efficacy beliefs among pregnant women.
Hypothesis 7.1: LDS pregnant women will be more likely to meet the moderate LTPA
guidelines and participate in any vigorous LTPA compared to non-LDS pregnant women
of high, moderate, and low religiosity.

9

Hypothesis 7.2: LDS pregnant women will not differ in pregnancy risk perceptions
compared to non-LDS pregnant women of high, moderate, and low religiosity.
Hypothesis 7.3: LDS pregnant women will have higher efficacy beliefs toward moderate
and vigorous LTPA compared to non-LDS pregnant women of high, moderate, and low
religiosity.
Specific Aim 8: To determine the relationship of religion (Latter-day Saints [LDS] vs. non-LDS
(high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with prenatal
HCP discussions, perceived satisfaction with these discussions, and perceived physical activity
social support among pregnant women.
Hypothesis 8.1: LDS pregnant women will be more likely to report discussing physical
activity with their prenatal HCPs compared to non-LDS pregnant women of high,
moderate, and low religiosity.
Hypothesis 8.2: LDS pregnant women who have physical activity discussions with their
prenatal HCPs will feel more satisfied with these discussions compared to non-LDS
pregnant women (of high, moderate, and low religiosity) who have physical activity
discussions with their prenatal HCPs.
Hypothesis 8.3: LDS pregnant women will perceive higher levels of total physical
activity social support compared to non-LDS pregnant women of high, moderate, and low
religiosity.

10

Hypothesis 8.4: LDS pregnant women will perceive higher levels of physical activity
social support from family compared to non-LDS pregnant women of high, moderate,
and low religiosity.
Hypothesis 8.5: LDS pregnant women will perceive higher levels of physical activity
social support from significant others compared to non-LDS pregnant women of high,
moderate, and low religiosity.

OVERVIEW OF DISSERTATION
This dissertation is presented in five chapters. Chapter one consists of the introduction,
aims, and hypotheses. Chapter two is a detailed review of the literature pertaining to each of the
research aims. Chapter three contains a comprehensive description of study procedures,
including survey instrument development, participant recruitment, variables of interest, and
statistical analyses. Chapter four details the results of this dissertation, specifically addressing
each research aim. The fifth and final chapter of this dissertation summarizes the overall
dissertation findings and includes recommendations for future research pertaining to the
relationships between LTPA perception and behavior among pregnant women, as well as the
influence of religiosity on LTPA-related variables during pregnancy.

11

REFERENCES

12

REFERENCES

1.

Dempsey JC, Sorensen TK, Williams MA, et al. Prospective study of gestational diabetes
mellitus risk in relation to maternal recreational physical activity before and during
pregnancy. Am J Epidemiol. Apr 1 2004;159(7):663-670.

2.

Dempsey JC, Butler CL, Sorensen TK, et al. A case-control study of maternal
recreational physical activity and risk of gestational diabetes mellitus. Diabetes Res Clin
Pract. Nov 2004;66(2):203-215.

3.

Oken E, Ning Y, Rifas-Shiman SL, Radesky JS, Rich-Edwards JW, Gillman MW.
Associations of physical activity and inactivity before and during pregnancy with glucose
tolerance. Obstet Gynecol. Nov 2006;108(5):1200-1207.

4.

Rudra CB, Sorensen TK, Luthy DA, Williams MA. A prospective analysis of recreational
physical activity and preeclampsia risk. Med Sci Sports Exerc. Sep 2008;40(9):15811588.

5.

Sorensen TK, Williams MA, Lee IM, Dashow EE, Thompson ML, Luthy DA.
Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension.
Jun 2003;41(6):1273-1280.

6.

Stuebe AM, Oken E, Gillman MW. Associations of diet and physical activity during
pregnancy with risk for excessive gestational weight gain. Am J Obstet Gynecol. Jul
2009;201(1):58 e51-58.

7.

Clapp JF, 3rd. The course of labor after endurance exercise during pregnancy. Am J
Obstet Gynecol. Dec 1990;163(6 Pt 1):1799-1805.

8.

Melzer K, Schutz Y, Soehnchen N, et al. Effects of recommended levels of physical
activity on pregnancy outcomes. American journal of obstetrics and gynecology. Mar
2010;202(3):266 e261-266.

9.

Pivarnik JM. Potential effects of maternal physical activity on birth weight: brief review.
Med Sci Sports Exerc. Mar 1998;30(3):400-406.

10.

Hegaard HK, Hedegaard M, Damm P, Ottesen B, Petersson K, Henriksen TB. Leisure
time physical activity is associated with a reduced risk of preterm delivery. Am J Obstet
Gynecol. Feb 2008;198(2):180 e181-185.

11.

Juhl M, Andersen PK, Olsen J, et al. Physical exercise during pregnancy and the risk of
preterm birth: a study within the Danish National Birth Cohort. Am J Epidemiol. Apr 1
2008;167(7):859-866.

13

12.
13.

Voldner N, Froslie KF, Haakstad LA, Bo K, Henriksen T. Birth complications,
overweight, and physical inactivity. Acta Obstet Gynecol Scand. 2009;88(5):550-555.
Fell DB, Joseph KS, Armson BA, Dodds L. The impact of pregnancy on physical activity
level. Matern Child Health J. Sep 2009;13(5):597-603.

14.

Mottola MF, Campbell MK. Activity patterns during pregnancy. Can J Appl Physiol.
Aug 2003;28(4):642-653.

15.

DiNallo JM, Le Masurier GC, Williams NI, Downs DS. Walking for health in pregnancy:
assessment by indirect calorimetry and accelerometry. Res Q Exerc Sport. Mar
2008;79(1):28-35.

16.

Mudd LM, Nechuta S, Pivarnik JM, Paneth N. Factors associated with women's
perceptions of physical activity safety during pregnancy. Prev Med. Aug-Sep 2009;49(23):194-199.

17.

Evenson KR, Wen F. National trends in self-reported physical activity and sedentary
behaviors among pregnant women: NHANES 1999-2006. Prev Med. Mar
2010;50(3):123-128.

18.

Evenson KR, Savitz DA, Huston SL. Leisure-time physical activity among pregnant
women in the US. Paediatr Perinat Epidemiol. Nov 2004;18(6):400-407.

19.

Evenson KR, Moos MK, Carrier K, Siega-Riz AM. Perceived barriers to physical activity
among pregnant women. Matern Child Health J. May 2009;13(3):364-375.

20.

Duncombe D, Wertheim EH, Skouteris H, Paxton SJ, Kelly L. Factors related to exercise
over the course of pregnancy including women's beliefs about the safety of exercise
during pregnancy. Midwifery. Aug 2009;25(4):430-438.

21.

Cramp AG, Bray SR. A prospective examination of exercise and barrier self-efficacy to
engage in leisure-time physical activity during pregnancy. Annals of behavioral
medicine: a publication of the Society of Behavioral Medicine. Jun 2009;37(3):325-334.

22.

Cioffi J, Schmied V, Dahlen H, et al. Physical activity in pregnancy: women's
perceptions, practices, and influencing factors. Journal of midwifery & women's health.
Sep-Oct 2010;55(5):455-461.

23.

Krans EE, Chang JC. A will without a way: barriers and facilitators to exercise during
pregnancy of low-income, African American women. Women & health. Nov 30
2011;51(8):777-794.

24.

Da Costa D, Ireland K. Perceived benefits and barriers to leisure-time physical activity
during pregnancy in previously inactive and active women. Women & health.
2013;53(2):185-202.

14

25.

Hegaard HK, Kjaergaard H, Damm PP, Petersson K, Dykes AK. Experiences of physical
activity during pregnancy in Danish nulliparous women with a physically active life
before pregnancy. A qualitative study. BMC Pregnancy Childbirth. 2010;10:33.

26.

Marshall ES, Bland H, Melton B. Perceived barriers to physical activity among pregnant
women living in a rural community. Public health nursing. Jul 2013;30(4):361-369.

27.

Clarke PE, Gross H. Women's behaviour, beliefs and information sources about physical
exercise in pregnancy. Midwifery. Jun 2004;20(2):133-141.

28.

Weir Z, Bush J, Robson SC, McParlin C, Rankin J, Bell R. Physical activity in
pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women.
BMC Pregnancy Childbirth. 2010;10:18.

29.

Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change: Use of
the risk perception attitude (RPA) framework to understand health behaviors. Hum
Commun Res. Jul 1 2003;29(3):370-399.

30.

Gibbins J, Thomson AM. Women's expectations and experiences of childbirth.
Midwifery. Dec 2001;17(4):302-313.

31.

Gupton A, Heaman M, Cheung LW. Complicated and uncomplicated pregnancies:
women's perception of risk. Journal of obstetric, gynecologic, and neonatal nursing :
JOGNN / NAACOG. Mar-Apr 2001;30(2):192-201.

32.

Lee S, Ayers S, Holden D. Risk perception of women during high risk pregnancy: A
systematic review. Health Risk Soc. 2012;14(6):511-531.

33.

Heaman M, Beaton J, Gupton A, Sloan J. A comparison of childbirth expectations in
high-risk and low-risk pregnant women. Clinical nursing research. Aug 1992;1(3):252265.

34.

Bayrampour H, Heaman M, Duncan KA, Tough S. Predictors of Perception of Pregnancy
Risk among Nulliparous Women. Jognn-J Obst Gyn Neo. Jul 2013;42(4):416-427.

35.

Evenson KR, Bradley CB. Beliefs about exercise and physical activity among pregnant
women. Patient Educ Couns. Apr 2010;79(1):124-129.

36.

Hinton PS, Olson CM. Predictors of pregnancy-associated change in physical activity in a
rural white population. Matern Child Health J. Mar 2001;5(1):7-14.

37.

Gaston A, Prapavessis H. Maternal-fetal disease information as a source of exercise
motivation during pregnancy. Health psychology : official journal of the Division of
Health Psychology, American Psychological Association. Nov 2009;28(6):726-733.

15

38.

Lundgren I, Dahlberg K. Women's experience of pain during childbirth. Midwifery. Jun
1998;14(2):105-110.

39.

Parratt J. The impact of childbirth experiences on women's sense of self: a review of the
literature. Aust J Midwifery. 2002;15(4):10-16.

40.

Melender HL, Lauri S. Fears associated with pregnancy and childbirth--experiences of
women who have recently given birth. Midwifery. Sep 1999;15(3):177-182.

41.

Melender HL. Fears and coping strategies associated with pregnancy and childbirth in
Finland. Journal of midwifery & women's health. Jul-Aug 2002;47(4):256-263.

42.

Bradley DE. Religious Involvement and Social Resources - Evidence from the Data Set
Americans Changing Lives. J Sci Stud Relig. Jun 1995;34(2):259-267.

43.

Ellison CG, George LK. Religious Involvement, Social Ties, and Social Support in a
Southeastern Community + a Study of a Theoretical-Model Linking Institutional Church
Participation and Social Network Relationships. J Sci Stud Relig. Mar 1994;33(1):46-61.

44.

Ferrari RM, Siega-Riz AM, Evenson KR, Moos MK, Carrier KS. A qualitative study of
women's perceptions of provider advice about diet and physical activity during
pregnancy. Patient Educ Couns. Feb 8 2013.

45.

Evenson KR, Pompeii LA. Obstetrician practice patterns and recommendations for
physical activity during pregnancy. J Womens Health (Larchmt). Sep 2010;19(9):17331740.

46.

Bauer PW, Broman CL, Pivarnik JM. Exercise and pregnancy knowledge among
healthcare providers. J Womens Health (Larchmt). Feb 2010;19(2):335-341.

47.

Entin PL, Munhall KM. Recommendations regarding exercise during pregnancy made by
private/small group practice obstetricians in the USA. J Sport Sci Med. Sep
2006;5(3):449-458.

48.

Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life.
The Gerontologist. Oct 2002;42 Spec No 3:24-33.

49.

Heaton TB. How Does Religion Influence Fertility, the Case of Mormons. J Sci Stud
Relig. Jun 1986;25(2):248-258.

50.

Thornton A. Religion and Fertility - Case of Mormonism. J Marriage Fam.
1979;41(1):131-142.

51.

Callister LC, Semenic S, Foster JC. Cultural and spiritual meanings of childbirth.
Orthodox Jewish and Mormon women. J Holist Nurs. Sep 1999;17(3):280-295.

16

52.

Asplund-Campbell. With child: Mormon women on mothering. Salt Lake City, UT:
Signature Books; 1998.

17

CHAPTER 2
REVIEW OF LITERATURE
INTRODUCTION
The health benefits of physical activity during pregnancy for both mother and child are
many and highlight the need for pregnant women to be physically active. However, recent
research suggests that few pregnant women are meeting the most current physical activity
recommendations.1 Pregnant women have reported a number of barriers which prevent them
from being physically active during this unique time, some of which concern how physical
activity is perceived.2-5 The extent to which, and underlying reasons why, psychosocial factors
influence gestational leisure-time physical activity (LTPA) is unclear, with the possibility of
notable variability between subgroups of pregnant women depending on cultural norms, support
systems, or past experiences.
Some potential psychosocial influences to pregnant women participating in LTPA
include the perceived risk of pregnancy, the perceived efficacy beliefs of LTPA, the physical
activity discussions with a prenatal healthcare provider (HCP), and the social support received
with respect to physical activity (Figure 2.1). It is important to more precisely assess these
factors in order to gain a comprehensive understanding of how they may influence pregnancy
LTPA. One method by which some of these psychosocial factors may be examined is the Risk
Perception Attitude Framework (RPA),6 which fundamentally involves a perceived risk (such as
harm to the baby during pregnancy) and perceived efficacy beliefs for a health behavior (such as
LTPA during pregnancy). This framework may provide a novel insight into the combined

18

influence of pregnancy risk perceptions and LTPA efficacy beliefs on LTPA among pregnant
women.
Religiosity may affect a pregnant woman's LTPA perception and behavior, given the
reported spiritual nature of pregnancy and childbirth. This may be especially true for pregnant
women who are members of the Church of Jesus Christ of Latter-day Saints (LDS), otherwise
known as the “Mormon” church. The role of the family is deeply essential in LDS theology, and
therefore many LDS members view having and raising children to be a sacred responsibility and
experience. Additionally, LDS members live by a health code, which doctrinally requires
members to abstain from addictive substances and to engage in healthy behaviors. However,
little is known about the influence of religious beliefs (including Mormonism), on physical
activity perception, psychosocial influences of physical activity, and LTPA during pregnancy.

Figure 2.1. Variables of interest in examining potential psychosocial influences on LTPA
during pregnancy.
Pregnancy LTPA

Discussion w/
Prenatal HCP

LTPA
Beliefs

Pregnancy Risk
Perceptions

*Response Efficacy
*Self-efficacy
*Risk Perception

*Susceptibility
*Severity

Religion

19

Social Support

PHYSICAL ACTIVITY DURING PREGNANCY
History of Recommendations
Exercise during pregnancy has not been encouraged for most of the 20th century. The
most notable initial physical activity recommendations for pregnant women were issued by the
American College of Obstetricians and Gynecologists (ACOG) in 1985.7 Although these
recommendations endorsed low-impact moderate intensity physical activity, multiple restrictions
were proposed including a maternal heart rate of no greater than 140 beats/min and strenuous
exercise not lasting more than 15 minutes. Since this time, an array of research investigations
have been conducted to evaluate the impact of gestational physical activity on maternal-fetal
health, many providing strong evidence in favor of pregnant women being physically active.
The result has been a 30-year evolution in physical activity recommendations for pregnant
women.8 The most recent ACOG recommendations are substantially less conservative and
suggest at least 30 minutes of moderate-intensity exercise on most days of the week for healthy
pregnant women.9 However, women are still cautioned about strenuous exercise, particularly
with respect to activities that may be associated with an increased risk of falling, physical
contact, or abdominal trauma. In 2008, the U.S. Department for Health and Human Services
released the first federal recommendations for physical activity during pregnancy.10 These
largely agree with the 2002 ACOG guidelines, and suggest pregnant women should participate in
at least 150 minutes of moderate-intensity aerobic activity per week, regardless of prepregnancy
activity level. Additionally, the 2008 guidelines10 suggest that pregnant women who have
participated consistently in vigorous-intensity physical activity may continue to be active at this
intensity throughout gestation, provided their activity program is developed with the knowledge
of the prenatal healthcare provider (HCP).

20

Health Benefits
An ample body of evidence suggests that physical activity during pregnancy provides
numerous health benefits to the maternal-fetal unit. For example, researchers have shown that
physical activity is associated with decreased risk of gestational diabetes and preeclampsia.11-16
Additionally, regular physical activity during pregnancy has also been shown to assist in healthy
levels of gestational weight gain,17-19 an extremely important protection considering the
numerous associations that gestational obesity has with adverse outcomes to the maternal-fetal
unit.20 There is also evidence of possible psychological benefit, including of lower levels of
anxiety21,22 and depressive symptoms,21,23 as well as higher levels of self-esteem24,25 and overall
psychological well-being.21 Moreover, regular physical activity may be an effective adjunctive
treatment for psychological disturbances and clinical depression during pregnancy, reducing
feelings of anxiety and depression, and also improving mood.26 Gestational physical activity
also yields notable health benefits for the child in-utero and upon delivery. Although there are
mixed results regarding the impact of physical activity during pregnancy on optimal fetal birth
weight,27 the general consensus is that maternal activity results in healthy decreases in birth
weight within the optimal, recommended range.28,29 Additionally, there is evidence that maternal
physical activity is inversely associated with a number of adverse birth outcomes including labor
duration30,31 as well as risk of preterm delivery32,33 and operative delivery.31,34 However, not all
studies investigating these birth outcomes have found significant relationships with maternal
physical activity during pregnancy.35-37

21

LTPA Trends among Pregnant Women
Leisure-time physical activity (LTPA) refers to activities that individuals participate in
that do not include occupational, transportation, or household responsibilities. Historically, most
research on pregnancy and exercise has focused on LTPA, the belief being that a) it is easier to
measure than occupational activity and b) most women studied do not participate in jobs
requiring large amounts of physical activity. Ning et al.38 reported that approximately 61% of
pregnant women participate in some form of LTPA, somewhat greater than the 48% reported by
Zhang and Savitz.39 However, Zhao et al.40 examined data from the Behavioral Risk Factor
Surveillance System (BRFSS) and found that participation in pregnancy LTPA increased from
67% in 2001 to 73% in 2009. Regardless of the true prevalence, the majority of this LTPA likely
involves walking, which is by far the most common choice of activity among pregnant
women.1,41,42
It is clear from nationally-representative studies that LTPA participation during
pregnancy appears to be largely insufficient, with only a fraction of pregnant women meeting the
most current physical activity recommendations. Evenson et al.42 examined BRFSS data from
the year 2000 with the intent to determine LTPA trends among a nationally-representative
sample of pregnant women. The investigators found that 15.8% met the then recommended
LTPA levels. Furthermore, Evenson and Wen1 analyzed self-reported data from the 1999-2006
National Health and Nutrition Examination Survey (NHANES) and found that only 14% of
pregnant women met the moderate-intensity LTPA recommendations (≥150 minutes/week).
However, when vigorous-intensity LTPA was included, approximately 23% met current
recommendations.

22

Studies examining pregnancy LTPA using self-reported instruments indicate a decrease
in participation as pregnancy progresses.43-45 Rousham et al.46 found via self-report and also
objective monitoring that physical activity among a small sample of pregnant women (n=57)
significantly decreased from the second to third trimester, suggesting that LTPA reduction may
be most prominent in the final stages of pregnancy. Further investigations have indicated that
both volume and intensity of LTPA (including walking) decrease during the second half of
pregnancy.47,48 Evenson and Wen49 expanded this research by examining nationallyrepresentative, free-living accelerometer data from 359 pregnant women. The investigators found
that moderate to vigorous intensity physical activity was significantly lower for the third
trimester (7.6 min/day) compared to the previous two trimesters, but that gestational activity was
actually higher in the second trimester (14.3 min/day) than the first trimester (11.5 min/day).
These trimester-specific physical activity trends may be partially a result of the dynamic
physiological changes and discomforts common throughout gestation, which possibly include
pregnancy-induced nausea in the first trimester and general physical discomfort and increased
weight in the third trimester.
OVERVIEW OF BARRIERS TO LTPA DURING PREGNANCY
Over the past decade, various investigations have attempted to identify and gain a more
comprehensive understanding of barriers to LTPA during pregnancy. Evenson et al.5 examined
perceived LTPA barriers quantitatively among 1,535 pregnant women using a socioecologic
framework. Nearly 85% of these women reported an intrapersonal barrier (an influence or
characteristic experienced specifically within oneself) to be the primary reason for their lack of
physical activity. These results (as well as those from other quantitative investigations) provide
evidence to suggest that a lack of time, lack of energy, and physical discomfort to be the three

23

most common reasons why pregnant women are not physically active.3,5,50 Although
quantitative investigations which have examined LTPA barriers during pregnancy (Table 2.1)
generally indicate both physical and environment/lifestyle barriers limit LTPA during pregnancy,
they provide little evidence of psychosocial influences. However, these investigations are
limited by their homogeneous samples (mostly white, affluent) and their study purposes, which
primarily involve only the identification of barriers, and only those that are considered to be most
prominent.
A number of qualitative investigations (Table 2.2) have also been performed to examine
barriers to LTPA. In contrast to the quantitative investigations, these studies have focused
number on specific subgroups of pregnant women including low income-African American
women,51 women living in a rural community,52 and women previously physically active prior to
pregnancy.4 The qualitative methodology has allowed for a deeper examination of barriers,
including how prominent each is among various populations. Findings from these qualitative
investigations confirm a number of physical and environment/lifestyle barriers which keep
pregnant women from being physically active. However, they also illuminate a myriad of
psychosocial influences not evident from the quantitative investigations. The literature
pertaining to each category of pregnancy LTPA barriers is described in tabular form below
(Table 2.1, Table 2.2). Given the focus of this dissertation, the psychosocial factors are reviewed
in upcoming sections of this chapter in slightly greater detail compared to the physical and
environment/lifestyle factors.

24

Table 2.1. Perceived barriers to LTPA during pregnancy (quantitative investigations).
STUDY

SAMPLE

BARRIERS
Physical

Environment/
Lifestyle

Psychosocial

Duncombe et al.
(2009)

n=158
2nd/3rd trimester
Affluent

• Fatigue
• Feel “unwell”

• Lack time

Evenson et al.
(2009)

n=1,535
2nd/3rd trimester
Affluent, mostly
white

• Fatigue
• Physical discomfort

• Lack time

• Concern for baby

Cramp & Bray
(2009)

n=160
2nd/3rd trimester
Affluent, white

• Fatigue
• Physical limitations

• Lack time
• Work
• Weather

• Lack motivation

DaCosta & Ireland
(2013)

n=84
1st/2nd trimester
Affluent, white

• Fatigue

• Lack time
• Facility access

25

Table 2.2. Perceived barriers to LTPA during pregnancy (qualitative investigations).
STUDY

SAMPLE

BARRIERS
Physical

Environment/
Lifestyle

Symons Downs &
Hausenblas
(2004)

n=74
Affluent, mostly
white

• Fatigue
• Physical limitations
• Body size

• Lack time
• Childcare
• Weather

Evenson et al.
(2009)

n=58
2nd/3rd trimester
Multi-racial

• Fatigue
• Physical discomforts

• Childcare
• Weather

Cioffi et al.
(2010)

n=19
All trimesters
Affluent

• Physical discomforts
• Body size

• Lack time
• Childcare
• Work

Weir et al.
(2010)

n=14
3rd trimester
Overweight, Obese

• Fatigue
• Physical discomforts
• Body size

• Work
• Facility Access

n=19
3rd trimester
Nulliparous, Active
prepregnancy
n=34
All trimesters,
Low SES, African
American

• Fatigue
• Physical discomforts
• Body size
• Fatigue
• Physical discomforts
• Body size

•
•
•
•

n=88
All trimesters
Rural community

• Fatigue
• Physical discomforts

• Lack time
• Childcare
• Work

Hegaard et al.
(2010)

Krans & Chang
(2011)

Marshall et al.
(2012)

26

Psychosocial

• Concern for baby
• Lack motivation
•
•
•
•
•
•
•
•
•
•
•

Concern for baby
Lack motivation
Conflicting advice
Lack support
Concern for baby
Lack motivation
Uncertainty about
physical activity
Concern for baby
Lack motivation
Lack support
Lack confidence

• Concern for baby
• Lack motivation
Lack time
Childcare
Facility access
Financial reasons

• Lack support
• Lack HCP
guidance
• Concern for baby
• Lack motivation
• Concern for self

PHYSICAL, ENVIRONMENTAL, AND LIFESTYLE INFLUENCES ON LTPA DURING
PREGNANCY
Fatigue and Lack of Energy
The most common physical barrier to pregnant women being physically active relates to
fatigue and lack of energy.5 This barrier is moderately high in more than 70% of pregnant
women.53 Various qualitative investigations examining barriers to pregnancy LTPA report that
women are overwhelmed by how fatigued they are and that it decreases their motivation to be
physically active.4,51,52 Additionally, the percentage of women who indicate pregnancy-related
fatigue as a barrier to physical activity remains fairly consistent throughout gestation, with
perhaps slightly elevated values during the first and third trimesters.3,50 During the first
trimester, fatigue and lack of energy may partially be a result of the hormonal changes or
increased metabolic demand common towards the beginning of pregnancy.54,55 However, during
the third trimester, it has been suggested that fatigue is most likely the result of general physical
discomforts which may disrupt sleeping periods.54,55
Anthropometric Change and Musculoskeletal Discomforts
Pregnancy is characterized by women as being physically demanding and includes
dynamic anthropometric changes that can make it difficult for pregnant women to manage even
everyday tasks.56 In addition to the notable cardiovascular and thermoregulatory adaptations to
pregnancy, women typically experience an increase in body weight and abdominal mass as
pregnancy progresses, as well as possible increases with joint laxity and lumbar lordosis.29,57
Often, these anatomical changes yield musculoskeletal discomforts such as back pain, leg pain,
or hip pain,57,58 particularly toward the end of pregnancy. This has been confirmed by
Duncombe et al.,3 who found that the percentage of women (n=158) experiencing physical

27

discomforts increases from the beginning of the second semester until well into the third
trimester. The prevalence of these discomforts was assessed at 16-23 weeks, 24-31 weeks, and
32-38 weeks gestation, and included body soreness (40%, 66%, 73%), leg cramps (25%, 57%,
63%), groin pain (14%, 31%, 42%) and shortness of breath (52%, 68%, 80%). Such discomforts
have been identified by pregnant women as a prominent barrier to being physically active and
may be a primary reason for significant LTPA decreases during the third trimester.48,59 Among a
sample of 1,535 pregnant women (27-30 weeks gestational age) from the central North Carolina
area, 17% reported physical discomfort or pain as their primary barrier to physical activity.5
Moreover, the percentage of both nulliparous and multiparous pregnant women who cite
musculoskeletal discomfort as a barrier to physical activity increases as gestation progresses.50
Women who regularly experience such discomforts may be concerned that being physically
active may be increase the risk of harm to her baby.60 Although the sample is small and
homogenous, a recent case study of five Danish pregnant women reported that the experience of
these physical discomforts resulted in feelings of fear for the health of the baby.61
Pregnancy-Induced Nausea
Pregnancy-induced nausea or vomiting are experienced by 75-80% of pregnant
women62,63 and may contribute to the discontinuance of certain modalities or intensities of LTPA
from a woman’s lifestyle.4 Researchers suggest this specific physical discomfort results from
both biological and psychosocial factors.64 Indeed, nausea and vomiting during pregnancy has
been shown to be related to depressive symptoms and inversely related to social support.65
Qualitative investigations seeking a deeper understanding of the barriers to pregnancy LTPA
have reported nausea and vomiting play a role in preventing pregnant women being physically
active.66-68 This may be particularly prominent during the first trimester.3 In contrast to other

28

investigations examining nausea and physical activity during pregnancy, Owe et al69 conducted a
large (n=34,908), population-based investigation which found that second-trimester pregnant
women who experience any level of nausea were 22% less likely to participate in regular
physical activity. However, physical activity levels did not differ between women who did and
did not experience nausea in the third trimester.
Work/Childcare
Results from a recent quantitative investigation (n=1,535), showed that 24.6% of
pregnant women believe a “lack of time” to be the primary reason for their lack of LTPA, more
than any other barrier.5 In the case of this investigation (and others), “lack of time” encompasses
work and or household responsibilities, given the time commitment both require. Pereira et al.44
examined individual lifestyle factors that influence change in levels of physical activity among
1,442 pregnant women in the Boston, Massachusetts area and found that 60% regularly worked
at a full-time occupation (≥35 hours/week). Although employment level during pregnancy did
not significantly predict the likelihood of achieving sufficient levels of pregnancy physical
activity, it did predict whether or not pregnant women became insufficiently active at 6 months
postpartum. Work-related responsibilities have been reported in qualitative investigations as a
prominent barrier to pregnancy LTPA;52,70,71 however, the frequency at which this is reported
appears to decrease towards the end of pregnancy (24 weeks, 13.3%; 30 weeks, 7.7%; 36 weeks,
4.2%).50 Like work-related barriers to pregnancy LTPA, childcare has often been reported by
pregnant women to limit their LTPA.5,51,52,68,70

Pereira et al.44 also examined the influence of

childcare and found that women with at least one child at home were 58% more likely to engage
in insufficient levels of physical activity (≥150 minutes/week) compared to women with no

29

children yet in their care. However, this relationship has not found elsewhere in the literature,
including a population-based investigation using BRFSS data.42
Facility Access
Access to exercise gyms and public recreational facilities are listed in quantitative
investigations by a small percentage of women as a main barrier to pregnancy LTPA. However,
as previously mentioned, these investigations are limited by their homogenous samples, namely
affluent, high SES, mostly white populations. Recently, Krans and Chang51 used a qualitative
design to assess barriers to 34 low SES, African American pregnant women from an urban
community. Their findings highlight the prominence of environmental barriers in this
population, with pregnant women reporting minimal public resources for physical activity,
limited space for recreation, and outdated facilities. Furthermore, many study participants
discussed how financial constraints preclude them from purchasing memberships to local gyms
or private wellness facilities.
PSYCHOSOCIAL INFLUENCES ON LTPA DURING PREGNANCY
The extent to which various psychosocial factors influence pregnant women’s LTPA
behavior is unclear and necessitates further investigation. Generally, how pregnant women
perceive the pregnancy experience and physical activity participation may dictate their behavior.
Likewise, prenatal social support and discussions with prenatal HCPs (which may act as a form
of informative support) may be effective mechanisms by which perceptions are formed or
reinforced, and pregnancy LTPA is influenced. By and large, prior investigations attempting to
investigate these influences among pregnant women are few and are limited by small,
homogeneous samples and imprecise means of assessment. Risk perceptions comprise both

30

perceived severity and perceived susceptibility. Perceived severity is how severe an individual
believes a specific risk to be, while perceived susceptibility is how susceptible the individual
believes they are to that specific risk.72 For the purposes of this dissertation, the specific risk was
defined as harm to the baby during pregnancy. Efficacy beliefs comprise both response efficacy
and self-efficacy. Response efficacy is how strongly the individual believes that engaging in a
specific behavior can protect against that specific aforementioned risk, and self-efficacy is how
confident the individual is that he/she can successfully engage in that specific behavior.72 This
dissertation defined the specific behavior as LTPA during pregnancy, and in accordance with
current recommendations for both moderate and vigorous-intensity physical activity.10 In
contrast to pregnant women who have high efficacy beliefs regarding LTPA during pregnancy
and also those who are undecided on their beliefs for the health benefits of LTPA, some women
may believe LTPA during pregnancy to be dangerous for their baby. For this purpose, risk
perceptions of physical activity were also assessed.
Pregnancy Risk Perceptions
In addition to anatomical and physiological discomforts experienced throughout
gestation, there is evidence that the experience of pregnancy is also psychologically challenging
for many women. However, this small body of evidence consists primarily of investigations
attempting to assess the complex emotions and feelings that expectant mothers have towards
childbirth, immediate postnatal recovery, and postpartum life-alteration among small,
homogeneous samples. While pregnancy and childbirth can be an empowering and selfidentifying experience,73,74 some pregnant women have reported high levels of anxiety,
depression, and stressful life events.75 However, results of qualitative investigations designed to
specifically examine barriers to pregnancy LTPA show it is not uncommon for pregnant women

31

to have feelings of uncertainty.2,51 Such feelings appear to be particularly common among firsttime mothers, who have no previous experience with pregnancy and childbirth.76
Risk perceptions with respect to pregnancy appear to be complex and multi-faceted.
Melender76 investigated feelings and experiences of fear during pregnancy via questionnaire
among 329 pregnant women (16-40 weeks gestational age) from Finland and showed that fears
regarding childbirth, cesarean section, postpartum family life as well as regarding health of
mother and baby were more common among nulliparous than multiparous women. For some
pregnant women, the fear they have during pregnancy is focused specifically on possible harm to
their babies.76 Not surprisingly, adverse outcomes that women have personally experienced or
vicariously experienced (most likely via a family member or close friend) from previous
pregnancies may exacerbate these fears.76
Eide et al.77 examined the relationship between mothers’ fear for babies’ health and their
experience of a specific traumatic experiences prior to and during pregnancy among a large
cohort of pregnant women (n=58,139) from Norway. Investigators found that the odds of having
strong worries about the babies health were significantly and substantially greater among
pregnant women who reported a negative experience for a previous pregnancy (OR=2.16,
CI=1.79-2.63) as compared to pregnant women who had only positive experiences previously.
However, “negative experience” was not defined by the study investigators. Additionally, the
odds of strong worries were significantly greater for pregnant women who felt distrust for
antenatal care (OR=1.75, CI=1.55-1.99), reported pelvic pain (OR=1.14, CI=1.04-1.25), and
experienced childhood physical abuse (OR=1.62, CI=1.26-2.08), sexual abuse (OR=1.30,
CI=1.03-1.64), and both (OR=2.10, CI=1.68-2.62), compared to those women who had not. A
possible limitation to these findings, however, is that “worry for the baby’s health” was assessed

32

via a single question asking the frequency that the mother worries. This result was then
dichotomized into “strong” and “less than strong” for the purposes of this investigation. While
few investigations assess risk perceptions specific to the baby’s health, perceived severity
appears to only have been examined generally. It appears that the susceptibility that a pregnant
woman feels that her baby could experience harm has not been assessed.
LTPA Response Efficacy
Pregnant women’s perceptions of whether LTPA specifically reduces the risk of harm to
the baby have not yet been investigated. Evenson and Bradley78 conducted a study assessing the
physical activity beliefs of 1,306 mostly white and well-educated pregnant women (27-30 weeks
gestational age). Approximately 73% of pregnant women believed moderate intensity physical
activity provided some benefit, but only 13% believed in the benefit of vigorous intensity
physical activity. However, this investigation did not specify what “benefit” referred to or ask
follow-up questions pertaining to whether physical activity is protective against specific health
risks.
Various qualitative investigations have evaluated how beneficial pregnant women believe
regular LTPA to be. One such investigation, which involved a small sample (n=19) of pregnant
women queried during all three trimesters, found that pregnant women believe LTPA provides
both physical and mental health benefits.70 Specifically, these women reported stress reduction,
increased energy, maintenance of fitness levels, and preparation for the difficulty of labor as
benefits. In another investigation, pregnant women who were active prepregnancy (n=19),
reported that physical activity during pregnancy increased energy levels, feelings of happiness
and relaxation, decreased gestational weight gain, and improved back pain and blood

33

circulation.4 Weir et al.71 examined LTPA beliefs of overweight and obese pregnant women
(n=14). Participants most frequently reported regaining prepregnancy body weight as a benefit
of physical activity; however, a generally easier pregnancy/labor and improved mood were also
cited as benefits. However, when discussing the health benefits of physical activity, pregnant
women in each of these investigations referred only to their own personal health (rather than the
health of the baby). Although pregnant women have reported the risks of pregnancy physical
activity as a part of various qualitative studies, it appears only one investigation exists in which
pregnant women (n=34, low-income, African American) openly discuss their beliefs that
physical activity is healthy for their baby.51 In many of these qualitative investigations, women
were encouraged to openly discuss or describe their beliefs, yet few voiced a belief in physical
activity health benefits for the baby. Thus, it is possible that pregnant women are more
convinced of the health benefits that LTPA provides to them personally compared to health
benefits provided to their babies.
Perceived health benefits of LTPA during pregnancy have also been assessed via survey
designs. Symons Downs and Hausenblaus79 utilized an Exercise Beliefs Questionnaire that asked
89 pregnant women (mostly-white, highly-educated) to list the health benefits that they believe
physical activity provides. Approximately 34% of pregnant women listed an improvement in
mood as a benefit to LTPA, compared to nearly 30% who believed in an increase in energy, and
21% who believed in the maintenance of fitness. Approximately 15% listed an improvement in
labor and delivery as a health benefit of LTPA. Duncombe et al.3 longitudinally assessed
reasons second and third trimester pregnant women (n=158, high SES) participated in LTPA.
For three different gestational age ranges (16-23 weeks, 24-31 weeks, 32-38 weeks) the
percentage of women who exercised for various reasons decreased. These included: to maintain

34

fitness (74.2%, 64.7%, 52.8%), lose weight (6.3%, 3.3%, 2.1%), relive stress (34.6%, 30.7%,
28.2%), and experience enjoyment (53.5%, 52.3%, 38.7%).
LTPA Self-Efficacy
Researchers have shown that physical activity self-efficacy plays a critical role in
determining pregnancy LTPA. Hinton and Olsen80 a prospective investigation among 622
pregnant women from upstate New York (mostly-white) and found that exercise self-efficacy
significantly predicted increased self-reported pregnancy LTPA compared to prepregnancy
levels (β=0.09). Hausenblas and Symons Downs81 used the theory of planned behavior to
investigate exercise behavior among first trimester pregnant women (n=104, mostly-white, highSES) and found that perceived behavioral control (which conceptually is similar to self-efficacy)
predicted exercise behavior. Symons Downs and Hausenblas79 used the same construct to
investigate exercise behavior among second trimester pregnant women (n=89, mostly-white,
high-SES). However, the investigators found the results somewhat contradicted the findings
among first trimester women, in that intention, rather than perceived behavioral control (β=0.17,
p=NS), predicted exercise behavior. Moreover, their investigation revealed that the strongest
predictor of exercise intention was not perceived behavioral control, but rather attitude. The
difference between the results of these two investigations possibly infers that first trimester
women have higher physical activity self-efficacy then do second trimester women. This is
plausible given that the second trimester is characterized by substantial fetal growth compared to
the first trimester. Physical changes and discomforts become more apparent, and the mother can
begin to feel the baby kick. It is possible that this could result in women feeling like they should
be more cautious with, or are unable to participate in LTPA, thereby decreasing LTPA efficacy

35

beliefs. If this is the case, it would be despite the improvement in fatigue and nausea levels
commonly experienced as women progress from the first to the second trimester.
Cramp et al.50 examined exercise self-efficacy and barrier self-efficacy (belief to be able
to overcome barriers to physical activity) via questionnaire among 160 pregnant women (18-30
weeks gestational age, mostly-white, high-SES, highly-educated) with the intent to determine
whether either predicts LTPA. Findings from this investigation showed that exercise selfefficacy predicted current LTPA from gestational weeks 18-24 (β=0.32, R2=0.26) and 30-36
(β=0.41, R2=0.37) and barrier self-efficacy from weeks 24-30 (β=0.40, R2=0.32). This
relationship is confirmed qualitatively by Hegaard et al.,4 who retrospectively (at 37 weeks GA)
assessed physical activity barriers and experiences throughout pregnancy of 20 pregnant women,
who were physically active prepregnancy. Findings revealed that all participants continued to be
active throughout pregnancy, the majority maintaining their LTPA levels by altering physical
activity modality and intensity as pregnancy progressed to lessen their concerns of possible harm
to the baby. The investigators suggest that study participants were able to accomplish this
because they had high levels of self-efficacy to overcome physical activity barriers by adopting a
slightly different exercise plan.
Da Costa and Ireland82 examined pregnancy LTPA influences among 84 first trimester
previously active and inactive women (mostly-white, high-SES). Questionnaires were provided
to participants, with the purpose of specifically assessing exercise social support, depressive
symptoms, physical activity beliefs and barriers, fatigue, and physical activity self-efficacy.
Investigators found overall that physical activity self-efficacy was associated with stronger
beliefs of LTPA benefits among both previously active (β=0.49, R2=0.24) and inactive women
(β=0.61, R2=0.36). Additionally, low physical activity-self efficacy was related to perceived

36

greater impact of LTPA barriers among both the previously active (β= -0.48, R2=0.64) and
inactive groups (β= -0.33, R2=0.35).
It appears only one investigation has examined specifically how pregnancy risk
perceptions (perceived vulnerability and severity) and LTPA efficacy beliefs (response and selfefficacy) predict LTPA behavior.83 The investigators utilized Protection Motivation Theory
(PMT)84 in assessing 208 pregnant women in their second or third trimester for each of these
variables, as well as goal intention, implementation intention, and physical activity. PMT posits
that in the face of a threat, an individual protects themselves based on the perceived severity and
vulnerability of the threat, as well as the response and self-efficacy they have towards a
protective behavior.85 The risk/efficacy variables are virtually the same for this theory and the
RPA; however, PMT focuses more on fear appraisal (risk and coping) in messaging and claims
that goal intention and implementation intention mediate the relationship between the four
risk/efficacy variables and the behavior. Furthermore, the RPA (an extremely young framework)
jointly considers the risk variables (perceived severity and susceptibility) as well as the efficacy
variables (response and self-efficacy), and contextualizes them as attributes of an individual
rather than the appraisal of a message. In this investigation (which utilized PMT), 83 a subgroup
of pregnant women (n=105) received an informational brochure regarding vulnerability and
severity of adverse pregnancy conditions as well as the response efficacy of physical activity in
reducing that risk and suggestions about how to increase exercise self-efficacy. The
investigators found that perceived susceptibility (r=0.26), response efficacy (r=0.66), and selfefficacy (r=0.55) were significantly related to goal intention, but that when examined via
multiple regression, only response efficacy and self-efficacy were significant predictors (β=0.48,
β=0.34, R2=0.51). Goal intention in turn predicted implementation intention, which then

37

predicted LTPA behavior. However, it should be mentioned that this investigation did not
specifically characterize the risk as harm to the baby, but rather as “developing health problems
during pregnancy.”
LTPA Risk Perceptions
Risk perceptions that pregnant women have towards LTPA has received attention
recently in the scientific literature. In a cross-sectional investigation conducted by Mudd et al.,86
safety perceptions of gestational physical activity were assessed in an ethnically diverse sample
of 296 pregnant women (12-36 weeks GA) from nine prenatal care practices in western
Michigan. Although perceived safety of physical activity was assessed via five-point Likert
scale, the data were dichotomized for analytic purposes into “safe” (safe and somewhat safe) and
“unsafe/unsure” (unsure, somewhat unsafe, very unsafe). Approximately 89% of the sample
believed that it was safe to perform moderate physical activity and 80% indicated their intent to
be active during pregnancy. In contrast, only 36% believed participating in vigorous physical
activity to be safe. Specifically, pregnant women with lower socioeconomic status (SES), less
than high school education, or who identified themselves as a race/ethnicity other than nonHispanic white, associated feelings of moderate-intensity activity with being unsafe. Similarly,
pregnant women who indicated less than high school education, nulliparity, or Hispanic
race/ethnicity had higher odds of unsafe perceptions about vigorous-intensity physical activity.
Duncombe et al.3 examined perceptions towards LTPA during pregnancy among 158
pregnant women and found somewhat different results. Specifically, 77% of women believed
participating in moderate activity three to five times a week to be somewhat or very safe,
whereas 11% believed it unsafe. For moderate activity participation greater than five days per

38

week, 53% believed moderate activity greater than five times per week to be somewhat or very
safe, whereas 27% believed it to be somewhat unsafe. For vigorous physical activity, 6% or the
sample believed three to five times per week was somewhat or very safe, whereas 82% believed
it to be unsafe. Pregnant women also believed greater than five days per week of vigorous
intensity activity to be extremely unsafe (2.5% somewhat safe, 85% unsafe. These findings
indicate that pregnant women perceive physical activity to be substantially less safe than what
Mudd et al.86 reported. This difference may be due to the assessment physical activity
perceptions. Specifically, Duncombe et al.3 framed questions regarding the safety of a physical
activity intensity with the frequency of such activity per week (i.e. number of days), whereas
Mudd et al.86 did not specify the frequency, but rather asked about participation at that intensity
in general. It is important to note that neither investigation assessed risk/safety perceptions of
physical activity specifically with respect to mother or the baby, but rather asked about
perceptions in general.
The perception of LTPA risk has been qualitatively assessed among pregnant women
who were physically active prepregnancy. Hegaard et a.l4 found that every pregnant women
assessed in their investigation (n=19) expressed at least some worry regarding the effects of
being physically active during pregnancy, regardless of their moderately high prepregnancy
LTPA. Rather than discontinuing physical activity participation, most participants in this
investigation, despite their feelings of concern, chose to continue to be physically active (rather
than discontinue) by modifying LTPA. More specifically, these women chose to switch activity
modalities. Most replaced those of vigorous intensity (such as jogging and strength training)
with those of moderate-intensity (such as swimming). Additionally, participants from this
investigation who had experienced fertility treatment, previous miscarriage, or who knew

39

someone who had experienced miscarriage expressed particular concern about harming their
baby. Likewise, Evenson et al.5 found that potential past pregnancy complications, such as
fertility issues, are prevalent among women (n=58) who cite fear of harming their unborn baby
as their primary barrier to LTPA.
Fear of harming the unborn child may be the most notable reason why pregnant women
are particularly avoidant of vigorous-intensity physical activity.4 Overall, it appears that
pregnant women do not perceive moderate physical activity to be risky as it pertains to them, but
may not be convinced regarding the health of their baby. It appears that vigorous physical
activity is not trusted by the majority of pregnant women who have been studied. Risk
perceptions and fears appear to stem, at least in part, from feelings of uncertainty regarding the
health effects of LTPA participation.70
Physical Activity Discussions with Prenatal Healthcare Providers
The extent to which LTPA behavior changes throughout pregnancy may be partially a
product of the physical activity information received from various sources.2,5,8 If true, the
providers of such information perhaps play a critical role in determining the LTPA among
pregnant women, given the possible influence that information has on beliefs and perceptions.
Prenatal HCPs are in the unique and influential position to advocate for recommended levels of
gestational physical activity and construct personalized activity plans for pregnant women.
However, for this potential influence to take effect, prenatal HCPs must be convinced of the
beneficial effects of gestational physical activity and also be committed to helping pregnant
women reach at least minimal levels of activity.

40

Preliminary findings indicate that physical activity discussions between prenatal HCP and
pregnant women do not occur frequently enough, and consist of outdated or inaccurate
information. Clarke and Gross2 found that approximately one in five pregnant women report
receiving confusing and or contradictory advice regarding physical activity at some point during
pregnancy. Moreover, Ferrari et al.87 found that pregnant women rarely received gestational
physical activity advice and recommendations from prenatal HCPs, confirming the findings of
Clarke and Gross2 as well as Evenson and Pompeii88 who found that only 18% and 23.5% of
pregnant women received such instruction. Slightly better results were reported by Krans et
al.,89 who found that 31% of pregnant women engaged in a physician-initiated physical activity
discussion at some point during gestation. However when assessed from the viewpoint of
obstetricians, 52% report discussing exercise with their patients.90 Moreover, Bauer et al.91
found that 66% of prenatal physician offices gave exercise advice to their patients, although such
information is less likely to occur among younger physicians. The possibility that HCPs who
typically prescribe pregnancy LTPA are more likely to participate in these investigations may
account for the patient-provider discrepancy in the reported nature of these discussions.
Ferrari et al87 qualitatively assessed pregnant women’s (n=58, multi-race) perceptions of
HCP physical activity via 13 race-stratified focus groups. Participants felt they were rarely given
physical activity advice from their prenatal HCP, and that when such discussions occurred, they
were dissatisfied with the advice given. More specifically, the findings indicated that pregnant
women often perceive physical activity advice from HCPs to be vague and somewhat unclear. In
certain cases among pregnant women, the physician or practitioner may be extremely
conservative with activity recommendations.92 It is also possible that the HCP does not have a
sufficient knowledge of the current physical activity research or familiarity with the most recent

41

physical activity recommendations. For example, the findings of Entin et al.90 show that 62% of
obstetricians still specify a maximum heart rate during prenatal exercise and more than 50%
suggest reduced activity during the third trimester for healthy pregnancies, neither of which is
part of the most recent guidelines. Likewise, Bauer et al.91 found that 64% of prenatal health
care providers caution pregnant women that heart rate during activity should not exceed 140
beats per minute, a recommendation that was removed from all guidelines after 1985. Thus,
prenatal HCPs’ expertise with respect to pregnancy LTPA is questionable.
It appears that obstetric healthcare professionals may not receive the training necessary to
advocate for gestational physical activity. Leiferman et al.93 recently administered a closed-item
survey to prenatal health care providers, including obstetricians, midwives, and family medicine
physicians providing obstetric care. The investigators found that 17% of these providers had
never received any professional training regarding gestational physical activity, and of the
providers that did, 69% believed the instruction to be “fair” or “poor”. Additionally, the
investigators found that only 43% of providers believed their patients followed the gestational
physical activity advice they provided.93 Therefore, provider-led physical activity discussions
with pregnant women may be insufficient or vague if the providers perceive their patients are not
accepting or implementing the recommendations given.
The impact of prenatal HCPs on physical activity behavior among pregnant women is not
well understood. However, the preliminary evidence reviewed above suggests the frequency and
quality of physical activity discussions between HCPs and pregnant women are less than
optimal. Despite this, prenatal care appointments remain a promising avenue for supportive
messages to be communicated by HCPs, possibly with the intent of increasing pregnant women’s
response and or self-efficacy of LTPA. In general, understanding how individuals respond or

42

will respond to supportive messages is extremely complex. Burleson94 suggests four critical
factors in determining the outcome of such communication: the actual message, the source of the
message, the interactional context, and the recipient of the message. Prenatal HCPs have at least
partial control over the first three factors if they choose to deliver supportive physical activity
messages to patients.
The actual HCP message should naturally be consistent with the most current physical
activity guidelines, but also may be most effective at improving pregnancy LTPA if highly
person-centered,95 meaning the message directly recognizes the feelings and challenges of the
pregnant woman. In other words, these discussions may be most effective if both provider and
patient participate, including the pregnant woman’s expression of concerns and difficulties
towards LTPA and the provider’s acknowledgement and understanding of these as well as the
provision of advice and personalized recommendations. HCPs are optimal suppliers of
supportive messages given their occupational position and the opportunity they often have to
communicate one-on-one with patients. MacGeorge et al.96 suggest that a messenger’s
credibility and expressed confidence in the message increase the recipient’s perception of the
message and also the possibility of adhering to the message content. Regarding the context in
which the supportive message is given, discussions between prenatal HCPs and pregnant women
will most often occur in a professional setting, where privacy and personal communication can
be ensured. Additionally, a pregnant woman may consider such discussions to be highly relevant
and more important than in non-pregnant situations, given the concern she may feel for the
health of her baby. In any event, a great deal is still unknown regarding the current quality of
these discussions as well as pregnant women’s perceptions of prenatal HCPs’ advice. These
discussions must be assessed more precisely to understand their true impact on pregnancy LTPA.

43

Furthermore, it is necessary to establish whether certain subgroups of pregnant women are more
likely to engage in physical activity discussions with prenatal HCPs and perceive those
discussions to be meaningful.
Physical Activity Social Support
The concept of social support is generally considered to be an act by one individual that
aides another in carrying out a certain task or goal successfully.97 Historically difficult to assess
given its complexity, social support is currently considered a multidimensional construct when
examining how it relates to certain health behaviors.98,99 Four broad categories are commonly
utilized in the assessment of social support: emotional social support, informational social
support, belonging social support, and tangible social support (Figure 2.2).100 However, it is
difficult to capture social support from each of these dimensions to determine how they
collectively influence the behavior. Regardless of social support’s operational breakdown, a
sizeable array of evidence has been provided that it is potentially a crucial element with respect
to to LTPA during pregnancy. More specifically, social support, as complex as it is to assess,
may act as the mechanism by which common barriers to gestational physical activity are
overcome.
Figure 2.2. Desciption of commonly-used categories for social support.
Emotional
•Providing concern,
trust, attachment,
encouragement, or
affection

Informational
•Providing adive,
direction, or
information

Belonging
•Providing
companionship or
affiliation with
others

44

Tangible
•Providing direct
aid, services, or
assistance

In general, social support significantly predicts quality of life among pregnant women.101
Prominent influences of social support also pertain to labor and delivery, including labor
difficulty, birth outcomes, and fetal development both prenatally and postnatally.102-106 From a
psychological perspective, social support during pregnancy has been shown to be closely related
to psychological well-being, including low levels of anxiety, stress, and depressive symptoms
prenatally and postnatally.107-109
Among 84 first-trimester pregnant women (mostly-white, high-SES), Da Costa and
Ireland82 found social support to be inversely related to reported barriers to gestational physical
activity among women who were the least active prepregnancy (β= -0.40, R2=0.35). However,
the authors suggest that low levels of social support may not significantly decrease LTPA
participation among women who were physically active prior to pregnancy. Furthermore,
qualitative investigations have reported that pregnant women believe social support from family
or friends to be critical in enabling them to overcome barriers to LTPA.5,70 Among pregnant
women who have childcare responsibilities, tangible social support from family or friends in the
form of babysitting is crucial. For low-income pregnant women who may struggle with
environmental barriers to physcial activity , social support provided via group exercise may be
particularly crucial to achieving sufficient physical activity levels. These women report that not
only does social support provide a safer environment in which women can be active, but also it
assists women in overcoming feelings of self-conciousness while increasing motivation to
particpate in physical activity.51
Informational social support from family or friends may have a critical impact on
minimizing perceptions of fear of harming the fetus as a result of gestational physical activity.
Clarke and Gross2 conducted prospective investigation among 57 pregnant women and found

45

that nearly all received some physical activity advice at one point during their pregnancy, with
approximately half of the women reporting on more than three occasions. However, often this
advice is contradictory to what pregnant women may have heard from other sources, which
could increase uncertainty towards the health benefit of physical activity. Although there is
evidence that pregnant women seek out physical activity information in books and magazines
early in pregnancy,60 family and friends are clearly the more preferred and constant source of
physical activity advice throughout pregnancy.60 Pregnant women also have reported that
talking about and gaining more knowledge about pregnancy-related concerns with their families
can help alleviate potential fears during pregnancy.76 In fact, pregnant women have suggested
that physical activity advice and information they receive from family outweighs the advice
received from prenatal HCPs.5 However, it must also be considered that the strong influence of
familial informational support towards pregnant women may be negative, if unconditional
avoidance of physical activity is suggested. For example, Clarke and Gross2 found that family
discouragement of LTPA at 25 weeks gestational age occurs among 59% of pregnant women.
At 34 weeks gestational age, such discouragement occurs with 85% of pregnant women. Such
discouragement of gestational physical activity from family members may be even more
prominent among less healthy subgroups of pregnant women, such as those who are overweight
or obese.71
Although more research is requried to understand the nature of physical activity social
support during pregnancy, the preliminary consensus highlights the important role it plays in
allowing pregnant women to be active. The importance of physical activity social support may
be best understood when assessed in relation to specific exercise barriers; however, it is clear that
all dimensions of social support play a role in overcoming their collective disabling influence.

46

Therefore researchers should attempt to assess social support from an emotional, informational,
tangeble, and esteem standpoint. Additionally, support that pregnant women receive from their
social network, including family, friends, and significant others, should be assessed individually
as well as collectively, in order to understand the most influential sources of physial activity
social support. This will allow for the examination social support differences between subgroups
of pregnant women, for each of these individual sources.
UTILIZING THE RISK PERCEPTION ATTITUDE FRAMEWORK
Various theoretical approaches have been utilized to evaluate to understanding risk and
efficacy as they pertain to preventative behavior, including Rosenstock’s Health Belief Model
(HBM),110 Roger’s Protection Motivation Theory (PMT),84 and Witte’s Extended Parallel
Process Model (EPPM).72 The HBM or the PMT individually consider the variables which make
up risk (perceived severity and susceptibility) and efficacy (response and self-efficacy) in the
EPPM and RPA. Further differences from the RPA include the HBM’s integration of external
influences (e.g. cues to action, barriers) and the PMT’s posit that intention mediates
perceptions/beliefs and behavior. The RPA6 is in actuality a derivation from the EPPM, which
focuses heavily on how a threat inherent in a message is processed by the individual and which
results in either danger-control or fear-control action.111 In contrast, the RPA centers on
perceived risk, an attribute of the individual (rather than a message). Efficacy is the other
essential component of the RPA in that it has also been shown to moderate the relationship
between risk perception and the preventative health behavior.
The RPA posits that an individual’s personal perception of a risk and efficacy beliefs for
a behavior jointly govern the intent to engage in a specific health behavior. Utilizing the RPA

47

allows for participants to be categorized into one of four distinct attitudinal groups, which are
created via combinations of risk perceptions (high/low) and efficacy beliefs (high/low).
Theoretically, the RPA should allow health interventions to target the needs of attitudinally
similar individuals.6 The EPPM posits that 1) those with high risk perceptions and high efficacy
beliefs will be more likely to engage in the behavior compared to those with high risk
perceptions and low efficacy beliefs and also that 2) for those with low risk perceptions, efficacy
beliefs will have minimal effect on the behavior.72,111 Likewise, the RPA adopts these
hypotheses, given the four attitudinal groups (responsive, proactive, avoidance, indifference) are
made up of high/low combinations of risk perceptions and efficacy beliefs (Figure 2.3) (these
will be further described in Chapter 3 of this dissertation). Thus, both the RPA and EPPM
suggest that the high risk/high efficacy group (responsive) should be more motivated and likely
to participate in the protective behavior than the other attitudinal groups. While the EPPM
theorizes the remaining three groups should not significantly differ, the RPA additionally
suggests the indifferent (low risk/low efficacy) group will be less motivated to participate in the
protective behavior compared to the proactive (low risk/high efficacy) and avoidant (high
risk/low efficacy) groups.

48

Figure 2.3. Risk percpetion and efficacy belief attitudinal groups created within the RPA.
EFFICACY
High

Low

High

“Responsive”

“Avoidant”

Low

“Proactive”

“Indifferent”

RISK

Compared to the comprehensive and well-researched EPPM literature base, RPA
research is in its infancy and has yet to provide a consistent trend regarding attitudinal group
differences across investigations. However, notable RPA investigations have been conducted
over the past decade, some with the intent to manipulate risk perceptions, and others not. Given
that this dissertation does not seek to alter perceptions through a prepared message, RPA
investigations that abstain from risk or efficacy manipulation are most relevant to be reviewed.
Rimal and Real6 conducted a telephone survey among 319 adults in the College Station, Texas
area with the purpose of determining whether the RPA was a useful tool with respect to skin
cancer (risk) and skin cancer-related protective behaviors. Investigators found that the
responsive group was significantly more likely to seek information on skin cancer preventative
49

behaviors and regularly use sunscreen than the avoidance group. Additionally, the proactive
group was significantly more likely to seek information, use sunscreen, and engage in skincancer self-inspections than the indifferent group.
Real112 investigated perceptions of workplace safety and information seeking among a
random sample of production workers (n=645) at a manufacturing facility utilizing the RPA.
Hierarchical regression analyses revealed the interaction between perceived risk and safety
beliefs, after controlling for prior worksite injury, were related to intention for and engaging in
safety behavior. The investigator also reported that the safety behavior (such as wearing
protective equipment), intention to engage in safety behavior, and intention to seek information
were greater for the responsive group compared to the avoidant group, and also the proactive
group as compared to the indifferent group.
Rimal et al.113 used the RPA to explore the joint influence of risk perception of
HIV/AIDS and the efficacy beliefs of preventative behaviors on the actual participating in those
behaviors among 890 Malawi residents. Findings from hierarchical regression revealed that the
interaction of HIV/AIDS risk and preventative behavior efficacy predicted the intention to
practice monogamy. Moreover, the responsive group had higher intentions to be monogamous
compared to all other attitudinal groups. Rimal and Juon114 sought to utilize the RPA to examine
breast cancer preventative behavior among 413 immigrant Indian women. Similar to previous
investigations, breast cancer risk perceptions and preventative behavior efficacy beliefs
significantly predicted the preventative behaviors of information seeking, breast selfexaminations, and clinical breast screenings. Information seeking was significantly greater and
self-examinations were significantly more frequent among responsive and proactive groups as
compared to avoidant and indifferent groups.
50

The RPA appears to be an optimal instrument for use within this dissertation given the
concern a pregnant woman may feel for the health of her unborn baby. This framework can
reveal the joint influence of pregnancy risk perceptions and physical activity efficacy beliefs on
LTPA among pregnant women and also provide useful information for future interventions
regarding prenatal attitudinal groups.
THE POTENTIAL INFLUENCE OF RELIGION ON LTPA DURING PREGNANCY
Another psychosocial factor which potentially influences LTPA behavior during
pregnancy is religion, or rather religious beliefs. Some women have reported pregnancy, labor,
and childbirth to be self-affirming events that may result in feelings of personal empowerment
and strength.73,115 For this reason, pregnancy has also been described as a time of spiritual
connectedness, some women specifically reporting that spirituality positively affects their
pregnancy via comfort, guidance, support, and increased confidence.116 Quantitative and
qualitative investigations with small samples have reported that women with high-risk
pregnancies seem to demonstrate a particularly great reliance on religious beliefs and
practices,117,118 given the uncertainty and worry they feel.
It appears that religious beliefs during pregnancy may have some impact on maternalfetal health. More specifically, spirituality and religiosity have been shown to be inversely
related to adverse health behaviors, such as smoking, drinking, and marijuana use among
pregnant women.119,120 Kim and Sobal121 found a significant relationship between religious
commitment and physical activity among non-pregnant women after controlling for
demographics including, age, race, marital status, employment, and education. However, in this
investigation, findings were only significant when religious commitment was conceptualized as

51

monetary donations, a variable which may be influenced by various other factors beyond
spirituality. The relationship between religiosity and physical activity during pregnancy has not
been evaluated specifically. However, some pregnant women report effects from physical
activity to be similar to those from spiritual experiences, including feelings of peace and
enlightenment.70 The influence of spirituality and religion on pregnancy health behaviors should
be assessed further, particularly as it pertains to dietary habits and LTPA.
The Case of Mormonism
Given that some religious denominations advocate for health behaviors and also a
traditional religious emphasis on having children, the question arises as to whether physical
activity participation and also psychosocial influences of physical activity are different between
religious subgroups of pregnant women. The Church of Jesus Christ of Latter-day Saints,
otherwise known as Mormons, is of particular interest. The Latter-day Saints (LDS) church is
currently the fourth largest religious denomination in United States with over 6 million members,
who comprise some 14 million members worldwide.122
For LDS members, the family unit is considered to be of divine origin. LDS leadership
has repeatedly reiterated that the supposed ancient commandment given to “multiply and
replenish the Earth” remains in effect today.123 Moreover, many within the LDS church believe
that within the family unit, the greatest satisfaction and feelings of happiness can be found.
Additionally, LDS doctrine teaches that family relationships, those between husbands, wives,
and children, endure in some existence after death. Because of this teaching that the family is
“eternal” and the source of ultimate happiness, LDS members view marriage, familial
relationships, and raising children as deeply sacred.124

52

Decisions pertaining to when LDS parents should begin a family or attempt to have a
child is considered extremely personal and something to be prayerfully considered between
husband and wife. Many LDS members believe they can receive revelation from God pertaining
to when to begin or extend their family. Because of the divine direction that many feel they
receive in this regard, motherhood is typically viewed by LDS women as one of the most
important roles they can have.125 Thus, the experience of pregnancy and childbirth is considered
an extremely spiritual and inherently sacred (although not an easy) experience by many LDS
women.126 Not surprisingly, LDS women have indicated the intention to have significantly more
children and consistently had higher rates of childbearing compared to other Judeo-Christian
faiths common in North America.127 It has also been shown that mean parity is higher for
religiously-active LDS women compared to LDS women with lower levels of religiosity, in
addition to non-LDS women.128
LDS members also fundamentally believe and live by a strict health code, known as the
“Word of Wisdom” which includes the abstinence to alcohol, tobacco, coffee, black tea, illegal
drugs, and other addictive substances. As a part of this health code, LDS members are expected
to make healthy dietary choices and be physically active. While adherence to this health code
has not be specifically examined, a recent investigation examining cancer risk factors and
religious practices among more than 800 Utah residents found that only 0.4% of religiously
active LDS members currently consume alcohol and 0% engage in smoking behavior.129
Consequently, LDS men and women have been found to have lower rates of cardiovascular
events and cancer, as well as an increased longevity compared to non-LDS members.130-132
While many non-LDS individuals certainly live by a similar health code, the LDS faith considers
the “Word of Wisdom” to be doctrine, acting literally as if a commandment from God. Thus,

53

given LDS members’ views on having children and on living a healthy lifestyle, it is plausible
that differences exist regarding LTPA, perceptions towards LTPA, and other potential influences
of LTPA between LDS pregnant women and non-LDS pregnant women.
SUMMARY
The health benefits of regular physical activity to women are many, and suggest a
protective effect during pregnancy. Despite this, many pregnant women do not engage in
sufficient levels of LTPA. In addition to the commonly reported reasons which keep nonpregnant women from being physically active, pregnancy overlays a number of additional
barriers, which include discomforts, fears, and lack of support. The influence of both pregnant
women’s pregnancy risk perceptions and physical activity efficacy beliefs on LTPA has received
some attention in the scientific literature over the past decade. However, more research, utilizing
more precise assessments of these beliefs, is clearly needed. Additionally, the combined
influence of pregnancy risk perceptions and physical activity efficacy beliefs has not yet been
explored. The impact of social support and prenatal HCPs has been considered as a part of
research investigations only recently. Before effective physical activity interventions can be
designed around these psychosocial factors of pregnancy LTPA, the influence of each should be
more thoroughly understood. Few investigations have attempted to do this systematically.
Religiosity is also a potential factor to be considered, given its potential psychosocial elements.
Although the relationship between religion and physical activity has not been explored among
pregnant women, specific religious beliefs (such as those found in the LDS church) may dictate
this health behavior as uniquely important. Differences in pregnancy LTPA and potential
psychosocial factors of pregnancy LTPA between various levels of religiosity may initiate an
understanding of its potential influence during the complex and sometimes spiritual experience

54

of pregnancy. Thus, two primary questions drive this dissertation: 1) whether pregnancy LTPA
is jointly influenced by pregnant women’s pregnancy risk perceptions and physical activity
efficacy beliefs, and also 2) whether religiosity (particularly LDS) affects LTPA participation as
well as the psychosocial influences on LTPA (such as pregnancy risk perceptions, LTPA beliefs,
physical activity discussions with prenatal HCP, and physical activity social support) during
pregnancy.

55

REFERENCES

56

REFERENCES

1.

Evenson KR, Wen F. National trends in self-reported physical activity and sedentary
behaviors among pregnant women: NHANES 1999-2006. Prev Med. Mar
2010;50(3):123-128.

2.

Clarke PE, Gross H. Women's behaviour, beliefs and information sources about physical
exercise in pregnancy. Midwifery. Jun 2004;20(2):133-141.

3.

Duncombe D, Wertheim EH, Skouteris H, Paxton SJ, Kelly L. Factors related to exercise
over the course of pregnancy including women's beliefs about the safety of exercise
during pregnancy. Midwifery. Aug 2009;25(4):430-438.

4.

Hegaard HK, Kjaergaard H, Damm PP, Petersson K, Dykes AK. Experiences of physical
activity during pregnancy in Danish nulliparous women with a physically active life
before pregnancy. A qualitative study. BMC Pregnancy Childbirth. 2010;10:33.

5.

Evenson KR, Moos MK, Carrier K, Siega-Riz AM. Perceived barriers to physical activity
among pregnant women. Matern Child Health J. May 2009;13(3):364-375.

6.

Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change: Use of
the risk perception attitude (RPA) framework to understand health behaviors. Hum
Commun Res. Jul 1 2003;29(3):370-399.

7.

ACOG. Exercise during pregnancy and the prenatal period. Washington, D.C.1985.

8.

Downs DS, Chasan-Taber L, Evenson KR, Leiferman J, Yeo S. Physical activity and
pregnancy: past and present evidence and future recommendations. Res Q Exerc Sport.
Dec 2012;83(4):485-502.

9.

ACOG committee opinion. Exercise during pregnancy and the postpartum period.
Number 267, January 2002. American College of Obstetricians and Gynecologists. Int J
Gynaecol Obstet. Apr 2002;77(1):79-81.

10.

United States. Dept. of Health and Human Services. 2008 physical activity guidelines for
Americans : be active, healthy, and happy! Washington, DC: U.S. Dept. of Health and
Human Services; 2008.

11.

Zhang C, Solomon CG, Manson JE, Hu FB. A prospective study of pregravid physical
activity and sedentary behaviors in relation to the risk for gestational diabetes mellitus.
Arch Intern Med. Mar 13 2006;166(5):543-548.

57

12.

13.

Rudra CB, Sorensen TK, Luthy DA, Williams MA. A prospective analysis of recreational
physical activity and preeclampsia risk. Med Sci Sports Exerc. Sep 2008;40(9):15811588.
Saftlas AF, Logsden-Sackett N, Wang W, Woolson R, Bracken MB. Work, leisure-time
physical activity, and risk of preeclampsia and gestational hypertension. Am J Epidemiol.
Oct 15 2004;160(8):758-765.

14.

Sorensen TK, Williams MA, Lee IM, Dashow EE, Thompson ML, Luthy DA.
Recreational physical activity during pregnancy and risk of preeclampsia. Hypertension.
Jun 2003;41(6):1273-1280.

15.

Oken E, Ning Y, Rifas-Shiman SL, Radesky JS, Rich-Edwards JW, Gillman MW.
Associations of physical activity and inactivity before and during pregnancy with glucose
tolerance. Obstet Gynecol. Nov 2006;108(5):1200-1207.

16.

Dempsey JC, Butler CL, Williams MA. No need for a pregnant pause: physical activity
may reduce the occurrence of gestational diabetes mellitus and preeclampsia. Exerc Sport
Sci Rev. Jul 2005;33(3):141-149.

17.

Stuebe AM, Oken E, Gillman MW. Associations of diet and physical activity during
pregnancy with risk for excessive gestational weight gain. Am J Obstet Gynecol. Jul
2009;201(1):58 e51-58.

18.

Giroux I, Inglis SD, Lander S, Gerrie S, Mottola MF. Dietary intake, weight gain, and
birth outcomes of physically active pregnant women: a pilot study. Appl Physiol Nutr
Metab. Oct 2006;31(5):483-489.

19.

Haakstad LA, Voldner N, Henriksen T, Bo K. Physical activity level and weight gain in a
cohort of pregnant Norwegian women. Acta Obstet Gynecol Scand. 2007;86(5):559-564.

20.

Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal
health. Reviews in obstetrics and gynecology. Fall 2008;1(4):170-178.

21.

Da Costa D, Rippen N, Dritsa M, Ring A. Self-reported leisure-time physical activity
during pregnancy and relationship to psychological well-being. J Psychosom Obstet
Gynaecol. Jun 2003;24(2):111-119.

22.

Goodwin A, Astbury J, McMeeken J. Body image and psychological well-being in
pregnancy. A comparison of exercisers and non-exercisers. Aust N Z J Obstet Gynaecol.
Nov 2000;40(4):442-447.

23.

Downs DS, DiNallo JM, Kirner TL. Determinants of pregnancy and postpartum
depression: prospective influences of depressive symptoms, body image satisfaction, and
exercise behavior. Ann Behav Med. Aug 2008;36(1):54-63.

58

24.

25.

Wallace AM, Boyer DB, Dan A, Holm K. Aerobic exercise, maternal self-esteem, and
physical discomforts during pregnancy. J Nurse Midwifery. Nov-Dec 1986;31(6):255262.
Koniak-Griffin D. Aerobic exercise, psychological well-being, and physical discomforts
during adolescent pregnancy. Res Nurs Health. Aug 1994;17(4):253-263.

26.

Davis K, Dimidjian S. The Relationship Between Physical Activity and Mood Across the
Perinatal Period: A Review of Naturalistic and Clinical Research to Guide Future
Investigation of Physical Activity-Based Interventions for Perinatal Depression. Clin
Psychol-Sci Pr. Mar 2012;19(1):27-48.

27.

Pivarnik JM. Potential effects of maternal physical activity on birth weight: brief review.
Med Sci Sports Exerc. Mar 1998;30(3):400-406.

28.

Pivarnik JM, Mudd L. Physical activity during pregnancy and postpartum: what have we
learned? Physical Activity and Fitness Research Digest. 2009.

29.

Pivarnik J, Chambliss HO, Clapp JF, et al. Impact of physical activity during pregnancy
and postpartum on chronic disease risk. Medicine and Science in Sports and Exercise.
May 2006;38(5):989-1006.

30.

Clapp JF. The course of labor after endurance exercise during pregnancy. Am J Obstet
Gynecol. Dec 1990;163(6 Pt 1):1799-1805.

31.

Melzer K, Schutz Y, Soehnchen N, et al. Effects of recommended levels of physical
activity on pregnancy outcomes. American journal of obstetrics and gynecology. Mar
2010;202(3):266 e261-266.

32.

Hegaard HK, Hedegaard M, Damm P, Ottesen B, Petersson K, Henriksen TB. Leisure
time physical activity is associated with a reduced risk of preterm delivery. Am J Obstet
Gynecol. Feb 2008;198(2):180 e181-185.

33.

Juhl M, Andersen PK, Olsen J, et al. Physical exercise during pregnancy and the risk of
preterm birth: a study within the Danish National Birth Cohort. Am J Epidemiol. Apr 1
2008;167(7):859-866.

34.

Voldner N, Froslie KF, Haakstad LA, Bo K, Henriksen T. Birth complications,
overweight, and physical inactivity. Acta Obstet Gyn Scan. 2009;88(5):550-555.

35.

Leiferman JA, Evenson KR. The effect of regular leisure physical activity on birth
outcomes. Matern Child Health J. Mar 2003;7(1):59-64.

36.

Collings CA, Curet LB, Mullin JP. Maternal and fetal responses to a maternal aerobic
exercise program. Am J Obstet Gynecol. Mar 15 1983;145(6):702-707.

59

37.

38.

Klebanoff MA, Shiono PH, Carey JC. The effect of physical activity during pregnancy on
preterm delivery and birth weight. Am J Obstet Gynecol. Nov 1990;163(5 Pt 1):14501456.
Ning Y, Williams MA, Dempsey JC, Sorensen TK, Frederick IO, Luthy DA. Correlates
of recreational physical activity in early pregnancy. J Matern Fetal Neonatal Med. Jun
2003;13(6):385-393.

39.

Zhang J, Savitz DA. Exercise during pregnancy among US women. Ann Epidemiol. Jan
1996;6(1):53-59.

40.

Zhao GX, Ford ES, Tsai J, et al. Trends in Health-Related Behavioral Risk Factors
Among Pregnant Women in the United States: 2001-2009. J Womens Health. Mar
2012;21(3):255-263.

41.

Petersen AM, Leet TL, Brownson RC. Correlates of physical activity among pregnant
women in the United States. Med Sci Sports Exerc. Oct 2005;37(10):1748-1753.

42.

Evenson KR, Savitz DA, Huston SL. Leisure-time physical activity among pregnant
women in the US. Paediatr Perinat Epidemiol. Nov 2004;18(6):400-407.

43.

Fell DB, Joseph KS, Armson BA, Dodds L. The impact of pregnancy on physical activity
level. Matern Child Health J. Sep 2009;13(5):597-603.

44.

Pereira MA, Rifas-Shiman SL, Kleinman KP, Rich-Edwards JW, Peterson KE, Gillman
MW. Predictors of change in physical activity during and after pregnancy: Project Viva.
Am J Prev Med. Apr 2007;32(4):312-319.

45.

Schmidt MD, Pekow P, Freedson PS, Markenson G, Chasan-Taber L. Physical activity
patterns during pregnancy in a diverse population of women. Journal of women's health.
Oct 2006;15(8):909-918.

46.

Rousham EK, Clarke PE, Gross H. Significant changes in physical activity among
pregnant women in the UK as assessed by accelerometry and self-reported activity. Eur J
Clin Nutr. Mar 2006;60(3):393-400.

47.

Downs DS, LeMasurier GC, DiNallo JM. Baby steps: pedometer-determined and selfreported leisure-time exercise behaviors of pregnant women. J Phys Act Health. Jan
2009;6(1):63-72.

48.

DiNallo JM, Le Masurier GC, Williams NI, Downs DS. Walking for health in pregnancy:
assessment by indirect calorimetry and accelerometry. Res Q Exerc Sport. Mar
2008;79(1):28-35.

49.

Evenson KR, Wen F. Prevalence and correlates of objectively measured physical activity
and sedentary behavior among US pregnant women. Prev Med. Jul-Aug 2011;53(1-2):3943.

60

50.

Cramp AG, Bray SR. A prospective examination of exercise and barrier self-efficacy to
engage in leisure-time physical activity during pregnancy. Ann Behav Med. Jun
2009;37(3):325-334.

51.

Krans EE, Chang JC. A will without a way: barriers and facilitators to exercise during
pregnancy of low-income, African American women. Women & health. Nov 30
2011;51(8):777-794.

52.

Marshall ES, Bland H, Melton B. Perceived barriers to physical activity among pregnant
women living in a rural community. Public health nursing. Jul 2013;30(4):361-369.

53.

Lee KA, Dejoseph JF. Sleep Disturbances, Vitality, and Fatigue among a Select Group of
Employed Childbearing Women. Birth-Iss Perinat C. Dec 1992;19(4):208-213.

54.

Chang JJ, Pien GW, Duntley SP, Macones GA. Sleep deprivation during pregnancy and
maternal and fetal outcomes: is there a relationship? Sleep Med Rev. Apr 2010;14(2):107114.

55.

Lee KA, Zaffke ME, McEnany G. Parity and sleep patterns during and after pregnancy.
Obstetrics and Gynecology. Jan 2000;95(1):14-18.

56.

Nicholls JA, Grieve DW. Performance of Physical Tasks in Pregnancy. Ergonomics. Mar
1992;35(3):301-311.

57.

Hartmann S, Bung P. Physical exercise during pregnancy--physiological considerations
and recommendations. J Perinat Med. 1999;27(3):204-215.

58.

Nicholls JA, Grieve DW. Posture, Performance and Discomfort in Pregnancy. Appl
Ergon. Apr 1992;23(2):128-132.

59.

Evenson KR. Towards an Understanding of Change in Physical Activity from Pregnancy
Through Postpartum. Psychol Sport Exerc. Jan 2011;12(1):36-45.

60.

Gross H, Bee PE. Perceptions of effective advice in pregnancy - The case of activity.
Clinical Effectiveness in Nursing. 2004;8:161-169.

61.

Hanghoj S. When it hurts I think: Now the baby dies. Risk perceptions of physical
activity during pregnancy. Women Birth. Sep 2013;26(3):190-194.

62.

Gadsby R, Barnie-Adshead AM, Jagger C. A prospective study of nausea and vomiting
during pregnancy. Br J Gen Pract. Jun 1993;43(371):245-248.

63.

Lacroix R, Eason E, Melzack R. Nausea and vomiting during pregnancy: A prospective
study of its frequency, intensity, and patterns of change. American journal of obstetrics
and gynecology. Apr 2000;182(4):931-937.

61

64.

Buckwalter JG, Simpson SW. Psychological factors in the etiology and treatment of
severe nausea and vomiting in pregnancy. American journal of obstetrics and
gynecology. May 2002;186(5 Suppl Understanding):S210-214.

65.

Chou FH, Lin LL, Cooney AT, Walker LO, Riggs MW. Psychosocial factors related to
nausea, vomiting, and fatigue in early pregnancy. J Nurs Scholarsh. 2003;35(2):119-125.

66.

Beilock SL, Feltz DL, Pivarnik JM. Training patterns of athletes during pregnancy and
postpartum. Res Q Exerc Sport. Mar 2001;72(1):39-46.

67.

Marshall NE, Spong CY. Obesity, pregnancy complications, and birth outcomes.
Seminars in reproductive medicine. Dec 2012;30(6):465-471.

68.

Downs DS, Hausenblas HA. Women's exercise beliefs and behaviors during their
pregnancy and postpartum. J Midwifery Wom Heal. Mar-Apr 2004;49(2):138-144.

69.

Owe KM, Nystad W, Bo K. Correlates of regular exercise during pregnancy: the
Norwegian Mother and Child Cohort Study. Scandinavian journal of medicine & science
in sports. Oct 2009;19(5):637-645.

70.

Cioffi J, Schmied V, Dahlen H, et al. Physical activity in pregnancy: women's
perceptions, practices, and influencing factors. J Midwifery Womens Health. Sep-Oct
2010;55(5):455-461.

71.

Weir Z, Bush J, Robson SC, McParlin C, Rankin J, Bell R. Physical activity in
pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women.
BMC Pregnancy Childbirth. 2010;10:18.

72.

Witte K. Putting the Fear Back into Fear Appeals - the Extended Parallel Process Model.
Commun Monogr. Dec 1992;59(4):329-349.

73.

Parratt J. The impact of childbirth experiences on women's sense of self: a review of the
literature. Aust J Midwifery. 2002;15(4):10-16.

74.

Larkin P, Begley CM, Devane D. Women's experiences of labour and birth: an
evolutionary concept analysis. Midwifery. Apr 2009;25(2):E49-E59.

75.

Whitehead NS, Brogan DJ, Blackmore-Prince C, Hill HA. Correlates of experiencing life
events just before or during pregnancy. J Psychosom Obstet Gynaecol. Jun
2003;24(2):77-86.

76.

Melender HL. Fears and coping strategies associated with pregnancy and childbirth in
Finland. J Midwifery Womens Health. Jul-Aug 2002;47(4):256-263.

77.

Eide J, Hovengen R, Nordhagen R. Childhood abuse and later worries about the baby's
health in pregnancy. Acta Obstet Gyn Scan. Dec 2010;89(12):1523-1531.

62

78.

Evenson KR, Bradley CB. Beliefs about exercise and physical activity among pregnant
women. Patient Educ Couns. Apr 2010;79(1):124-129.

79.

Downs DS, Hausenblas HA. Exercising for two: examining pregnant women's second
trimester exercise intention and behavior using the framework of the theory of planned
behavior. Women's health issues : official publication of the Jacobs Institute of Women's
Health. Nov-Dec 2003;13(6):222-228.

80.

Hinton PS, Olson CM. Predictors of pregnancy-associated change in physical activity in a
rural white population. Matern Child Health J. Mar 2001;5(1):7-14.

81.

Hausenblas HA, Downs DS. Prospective examination of the Theory of Planned Behavior
applied to exercise behavior during women's first trimester of pregnancy. J Reprod Infant
Psyc. Aug 2004;22(3):199-210.

82.

Da Costa D, Ireland K. Perceived benefits and barriers to leisure-time physical activity
during pregnancy in previously inactive and active women. Women & health.
2013;53(2):185-202.

83.

Gaston A, Prapavessis H. Maternal-fetal disease information as a source of exercise
motivation during pregnancy. Health psychology : official journal of the Division of
Health Psychology, American Psychological Association. Nov 2009;28(6):726-733.

84.

Rogers RW. A protection motivation theor of fear appeals and attitude change. The
Journal of Psychology. 1975;91:93-114.

85.

Rogers RW. Protection Motivation Theory of Fear Appeals and Attitude-Change. J
Psychol. 1975;91(1):93-114.

86.

Mudd LM, Nechuta S, Pivarnik JM, Paneth N. Factors associated with women's
perceptions of physical activity safety during pregnancy. Prev Med. Aug-Sep 2009;49(23):194-199.

87.

Ferrari RM, Siega-Riz AM, Evenson KR, Moos MK, Carrier KS. A qualitative study of
women's perceptions of provider advice about diet and physical activity during
pregnancy. Patient Educ Couns. Feb 8 2013.

88.

Evenson KR, Pompeii LA. Obstetrician practice patterns and recommendations for
physical activity during pregnancy. Journal of women's health. Sep 2010;19(9):17331740.

89.

Krans EE, Gearhart JG, Dubbert PM, Klar PM, Miller AL, Replogle WH. Pregnant
women's beliefs and influences regarding exercise during pregnancy. J Miss State Med
Assoc. Mar 2005;46(3):67-73.

63

90.

Entin PL, Munhall KM. Recommendations regarding exercise during pregnancy made by
private/small group practice obstetricians in the USA. J Sport Sci Med. Sep
2006;5(3):449-458.

91.

Bauer PW, Broman CL, Pivarnik JM. Exercise and pregnancy knowledge among
healthcare providers. Journal of women's health. Feb 2010;19(2):335-341.

92.

Doran F, Davis K. Factors that influence physical activity for pregnant and postpartum
women and implications for primary care. Aust J Prim Health. 2011;17(1):79-85.

93.

Leiferman J, Gutilla MJ, Paulson J, Pivarnik J. Antenatal physical activity counseling
among healthcare providers. Open Journal of Obstetrics and Gynecology. 2012;2:346355.

94.

Burleson BR. Understanding the outcomes of supportive communication: A dual-process
approach. J Soc Pers Relat. Feb 2009;26(1):21-38.

95.

Burleson BR. Emotional support skills. In: Greene JO, Burleson BR, eds. Handbook of
communication and social interaction skills. Mahwah, NJ: Erlbaum; 2003:551-594.

96.

MacGeorge EL, Feng B, Thompson ER. "Good" and "bad" advice: How to advise more
effectively. In: Motley MT, ed. Studies in applied interpersonal communication.
Thousand Oaks, CA: Sage; 2008:145-164.

97.

Cohen S, Syme SL. Social support and health. Orlando, Fla.: Academic Press; 1985.

98.

Rees T, Hardy L, Evans L. Construct validity of the social support survey in sport.
Psychol Sport Exerc. May 2007;8(3):355-368.

99.

Richman JM, Rosenfeld LB, Hardy CJ. The Social Support Survey - a Validation-Study
of a Clinical Measure of the Social Support Process. Res Social Work Prac. Jul
1993;3(3):288-311.

100.

Rees T, Hardy L, Ingledew DK, Evans L. Examination of the validity of the Social
Support Survey using confirmatory factor analysis. Res Q Exerc Sport. Dec
2000;71(4):322-330.

101.

Emmanuel E, St John W, Sun J. Relationship between social support and quality of life in
childbearing women during the perinatal period. Journal of obstetric, gynecologic, and
neonatal nursing : JOGNN / NAACOG. Nov-Dec 2012;41(6):E62-70.

102.

Collins NL, Dunkel-Schetter C, Lobel M, Scrimshaw SC. Social support in pregnancy:
psychosocial correlates of birth outcomes and postpartum depression. J Pers Soc Psychol.
Dec 1993;65(6):1243-1258.

64

103.

Feldman PJ, Dunkel-Schetter C, Sandman CA, Wadhwa PD. Maternal social support
predicts birth weight and fetal growth in human pregnancy. Psychosom Med. Sep-Oct
2000;62(5):715-725.

104.

Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support
during labor in a US hospital. A randomized controlled trial. Jama. May 1
1991;265(17):2197-2201.

105.

Norbeck JS, Tilden VP. Life stress, social support, and emotional disequilibrium in
complications of pregnancy: a prospective, multivariate study. J Health Soc Behav. Mar
1983;24(1):30-46.

106.

Orr ST. Social support and pregnancy outcome: a review of the literature. Clin Obstet
Gynecol. Dec 2004;47(4):842-855; discussion 881-842.

107.

Albrecht SA, Rankin M. Anxiety levels, health behaviors, and support systems of
pregnant women. Matern Child Nurs J. Spring 1989;18(1):49-60.

108.

Glazier RH, Elgar FJ, Goel V, Holzapfel S. Stress, social support, and emotional distress
in a community sample of pregnant women. Journal of psychosomatic obstetrics and
gynaecology. Sep-Dec 2004;25(3-4):247-255.

109.

Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for
depressive symptoms during pregnancy: a systematic review. American journal of
obstetrics and gynecology. Jan 2010;202(1):5-14.

110.

Rosensto.Im. Historical Origins of Health Belief Model. Health Educ Quart.
1974;2(4):328-335.

111.

Witte K, Allen M. A meta-analysis of fear appeals: Implications for effective public
health campaigns. Health Educ Behav. Oct 2000;27(5):591-615.

112.

Real K. Information seeking and workplace safety: A field application of the risk
perception attitude framework. J Appl Commun Res. 2008;36(3):339-359.

113.

Rimal RN, Bose K, Brown J, Mkandawire G, Folda L. Extending the Purview of the Risk
Perception Attitude Framework: Findings from HIV/AIDS Prevention Research in
Malawi. Health Commun. 2009;24(3):210-218.

114.

Rimal RN, Juon HS. Use of the Risk Perception Attitude Framework for Promoting
Breast Cancer Prevention. J Appl Soc Psychol. Feb 2010;40(2):287-310.

115.

Lundgren I, Dahlberg K. Women's experience of pain during childbirth. Midwifery. Jun
1998;14(2):105-110.

65

116.

Jesse DE, Schoneboom C, Blanchard A. The effect of faith or spirituality in pregnancy: a
content analysis. Journal of holistic nursing : official journal of the American Holistic
Nurses' Association. Sep 2007;25(3):151-158; discussion 159.

117.

Price S, Lake M, Breen G, Carson G, Quinn C, O'Connor T. The spiritual experience of
high-risk pregnancy. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN /
NAACOG. Jan-Feb 2007;36(1):63-70.

118.

Lobel M, Yali AM, Zhu W, DeVincent CJ, Meyer BA. Beneficial associations between
optimistic disposition and emotional distress in high-risk pregnancy. Psychol Health. Feb
2002;17(1):77-95.

119.

Page RL, Ellison CG, Lee J. Does religiosity affect health risk behaviors in pregnant and
postpartum women? Matern Child Health J. Sep 2009;13(5):621-632.

120.

Jesse DE, Reed PG. Effects of spirituality and psychosocial well-being on health risk
behaviors in Appalachian pregnant women. Journal of obstetric, gynecologic, and
neonatal nursing : JOGNN / NAACOG. Nov-Dec 2004;33(6):739-747.

121.

Kim KH, Sobal J. Religion, social support, fat intake and physical activity. Public Health
Nutr. Sep 2004;7(6):773-781.

122.

Yearbook of American & Canadian Churches. United States of America: The National
Council of the Churches of Christ in the United States of America; 2012.

123.

The Family: A Proclamation to the World: The Church of Jesus Christ of Latter-day
Saints; 1995.

124.

Heaton TB, Goodman KL. Religion and Family Formation. Rev Relig Res.
1985;26(4):343-359.

125.

Asplund-Campbell. With child: Mormon women on mothering. Salt Lake City, UT:
Signature Books; 1998.

126.

Callister LC, Semenic S, Foster JC. Cultural and spiritual meanings of childbirth.
Orthodox Jewish and Mormon women. Journal of holistic nursing : official journal of the
American Holistic Nurses' Association. Sep 1999;17(3):280-295.

127.

Thornton A. Religion and Fertility - Case of Mormonism. J Marriage Fam.
1979;41(1):131-142.

128.

Merrill RM, Lyon JL, Jensen WJ. Lack of a secularizing influence of education on
religious activity and parity among Mormons. J Sci Stud Relig. Mar 2003;42(1):113-124.

66

129.

Daniels M, Merrill RM, Lyon JL, Stanford JB, White GL. Associations between breast
cancer risk factors and religious practices in Utah. Preventive Medicine. Jan
2004;38(1):28-38.

130.

Lyon JL, Gardner JW, West DW. Cancer incidence in Mormons and non-Mormons in
Utah during 1967--75. J Natl Cancer Inst. Nov 1980;65(5):1055-1061.

131.

Lyon JL, Gardner K, Gress RE. Cancer incidence among Mormons and non-Mormons in
Utah (United States) 1971-85. Cancer Causes Control. Mar 1994;5(2):149-156.

132.

Lyon JL, Wetzler HP, Gardner JW, Klauber MR, Williams RR. Cardiovascular mortality
in Mormons and non-Mormons in Utah, 1969--1971. American journal of epidemiology.
Nov 1978;108(5):357-366.

67

CHAPTER 3
METHODS
STUDY DESIGN
This dissertation utilizes a survey-based methodology, with the purpose of assessing
pregnant women’s leisure-time physical activity (LTPA), pregnancy risk perceptions, and LTPA
efficacy beliefs. It was also the intent of this investigation to collect data on potentially
influential sources of physical activity information and support, including pregnant women’s
social support network and prenatal healthcare provider (HCP). Additionally, religiosity data
was collected for the purpose of determining if pregnant women of a particular religious
subgroup (Latter-day Saints (LDS)) differ in terms of LTPA behavior, perceptions, and potential
social influences, from three groups of non-LDS pregnant women, those of high, moderate, and
low religiosity. Prenatal clinics within the state of Michigan, as well as clinics within Salt Lake
City, UT were identified as the primary means of participant recruitment for this investigation.
Data collection for this dissertation occurred over a three month period (February-April 2014).
The procedures for this investigation were approved by Institutional Review Boards at Michigan
State University (IRB# x14-050e, January 2014, Appendix A) and the University of Utah (IRB#
00070835, February 2014, Appendix B) and given exempt status. Therefore, participants did not
sign a consent form.
PARTICIPANT RECRUITMENT
Those eligible for participation in this investigation included pregnant women of any
ethnic or educational background, socioeconomic status, or religious identification who were 1845 years of age. Pregnant women were excluded if carrying more than one baby, having
68

received prescribed bed rest from a prenatal HCP during the current pregnancy, or unable to
communicate fluently in either English or Spanish. Therefore, few physical criteria pertaining to
their pregnancies disqualified women from participating in this investigation. However, multiple
physical characteristics pertaining to past and current pregnancy were assessed to ensure
sufficient statistical control, if necessary.
Data collection for this investigation took place at multiple locations throughout the states
of Michigan and Utah. Specifically, pregnant women were recruited from clinics in the greater
Lansing community including, MSU Women’s Healthcare Clinic (Lansing, MI) and
Sparrow/MSU OBGYN Residency Clinic (Lansing, MI). In order to satisfy Specific Aims 7 and
8 of this study, it was necessary to obtain data from pregnant women of the LDS faith. Thus,
data collection also occurred at multiple clinics within the University of Utah’s Health Science
Center (Salt Lake City, UT), a general geographical location in the United States where LDS
population is high. At all prenatal clinics involved with this study (including those from midMichigan and Salt Lake Cit), convenience sampling was utilized to recruit pregnant women
either before a regularly scheduled appointment with their prenatal healthcare provider or
immediately following this appointment. Women were invited by a member of the prenatal
nursing staff to complete either a 15-minute electronic survey via iPad computer tablet (Lansing
clinics) or a paper copy survey (Salt Lake City clinics). Finally, pregnant women were recruited
via word-of-mouth in multiple locations, including the greater Lansing area (Michigan), Saginaw
County (Michigan), and the Lafayette/West Lafayette community (Indiana). At every data
collection site, potential participants were informed as to the study procedures, the content of the
survey, and the compensation they would receive as thanks for their participation.

69

DATA COLLECTION
Data collection at this study’s mid-Michigan site was conducted by a research team
consisting of the study coordinator (CPC) and 16 undergraduate research assistants, two of
whom served as supervisors of this research team. All participated in data collection and/or data
entry, and thus were considered “study investigators”. To ensure consistency in data collection
procedures among undergraduate research assistants, the study coordinator provided a detailed
set of written instructions and met regularly with the research team members both collectively
and individually. After each data collection session, the responsible undergraduate assistant
reported back to both the study coordinator (CPC) and undergraduate supervisors on the
effectiveness of the session and on whether data collection procedures were followed. Data
collection at the Salt Lake City clinics was conducted by research staff at the University of
Utah’s Health Science Center. The study coordinator (CPC) trained the research staff remotely
on all study protocols and communicated with the Salt Lake City site supervisor on a bi or triweekly basis to ensure consistency in data collection procedures.
For each study participant, a study investigator first explained the basic format and
components of the survey and reminded participants of their option to discontinue participation
at any point if desired. After agreeing to take the survey, participants were provided with an
iPad computer tablet (or paper survey) by the study investigator and asked to read through the
informed consent page. If they wished to continue, participants were asked to click “agree”
(iPad) or check “agree” (paper) at the bottom of the consent page (Appendix C/Appendix D).
The investigator informed the participant that they would be present to answer any questions the
participant may have regarding survey items or directions. Participants then completed the
survey (Appendix E) via iPad or paper copy at their self-selected pace. Following completion of

70

the survey, participants were thanked and given a $10 gift card to Target (no expiration date) for
assisting in the proposed investigation. In the rare instance when a participant was called in for
her appointment before survey completion, the study investigator collected the computer tablet
and informed the participant and prenatal nurse of the opportunity to finish their survey
immediately following the prenatal care appointment.
DATA MANAGEMENT
The electronic version of this survey was powered by the Qualtrics survey platform.
Specifically, the Qualtrics Offline App was utilized, which allowed the survey to be administered
without the need of a wireless internet connection. At the end of each data collection session, a
study investigator connected the iPad device to a wireless connection, tested the connection for
stability, and uploaded all completed electronic surveys to the password-protected online
database (through Qualtrics). The study investigator then informed the study coordinator (CPC)
of the number of surveys collected and uploaded during that session. Data from paper surveys
were entered into the Qualtrics Offline App by study investigators. For each data entry session,
the study coordinator observed the data entry for every tenth survey to ensure accuracy.
Furthermore at each session, after five surveys had been entered into the Qualtrics Offline App,
the iPad device was connected to a secure wireless internet signal, and data were uploaded to the
online database. Following each data collection or data entry session, the study coordinator
downloaded all data from the online database into a password-protected excel file to ensure
security of all information collected. Data from incomplete surveys were not included for
analysis in this investigation.

71

THEORETICAL FRAMEWORK
In order to more precisely understand how pregnant women perceive physical activity
and also how those perceptions predict physical activity behavior, the Risk Perception Attitude
Framework (RPA) was utilized.1 Utilizing the RPA as a theoretical framework in this
investigation is unprecedented for a variety of possible reasons. First, the risk being assessed
does not pertain to the woman herself, but rather her unborn baby. Second, the risk perceptions
and efficacy beliefs in this population may be recently-formed at the time of assessment given
that participants recently discovered they are pregnant. Furthermore, these perceptions may
rapidly evolve as pregnancy progresses and women experience its transient physical and
psychological challenges. Lastly, the RPA has not yet been used to assess perceived efficacy of
physical activity behavior in protecting against a health risk.
Risk perceptions comprise both perceived severity (how severe one believes the risk is)
and perceived susceptibility (how susceptible one believes they are to the risk) (Figure 3.1).2
Efficacy beliefs comprise both response efficacy (how strongly one believes the health behavior
can protect against the risk) and self-efficacy (how confident one is that s/he is able participate in
the health behavior) (Figure 3.1).2,3 Accordingly, four attitudinal groups can be created within
this framework, typically via a median split of both risk perceptions and efficacy beliefs (Figure
3.2). The responsive group comprises individuals with high levels of risk perception and
efficacy beliefs; this group is both highly motivated and able to participate in a given behavior.
Individuals in the proactive group are able to participate in the specific behavior but lack the
motivation, as their efficacy beliefs are high but their risk perceptions (thus, their incentives to
act) are low. The avoidance group includes individuals who have high levels of risk perception
but low levels of efficacy beliefs; theoretically resulting in minimal motivation to engage in a

72

behavior. Lastly, the indifferent group has the least motivation to participate in a specific
behavior, in that individuals in this group do not perceive great risk and have little efficacy
towards that behavior. A prominent advantage of this categorization schema is that interventions
can be designed with the purpose of targeting individuals placed within one of these four specific
groups, each having a distinct combination of risk perceptions and efficacy beliefs.

Figure 3.1. Risk perception and efficacy belief components as defined by the RPA.

RISK PERCEPTIONS

Perceived
Severity

EFFICACY BELIEFS

Perceived
Susceptibility

Response
Efficacy

73

Self-Efficacy

Figure 3.2. Risk percpetion and efficac belief attitudinal groups created within the RPA.

EFFICACY
High

Low

“Responsive”

“Avoidant”

High

RISK

Low

“Proactive”

“Indifferent”

The RPA has been used in previous investigations to assess risk perceptions and efficacy
beliefs in regards to skin cancer and information-seeking behavior,1 workplace accidents and
workplace safety behavior,4 cancer and dietary habits,5 HIV contraction and condom use,6 as
well as breast cancer and self-examination behavior.7 A purpose of this investigation is to
understand pregnant women’s perceptions of harmful risk to the unborn child and their efficacy
beliefs with respect to pregnancy LTPA as a protective mechanism against those harmful risks.
SURVEY DEVELOPMENT
The survey for this investigation (Appendix E) was developed by researchers at Michigan
State University with the intent of gaining a more precise understanding of the perceptions and

74

beliefs that pregnant women have with respect to LTPA, as well as the potential influences of
social support and the prenatal HCP. To ensure that our survey was ready for use as a part of
this investigation, a series of nine cognitive interviews were conducted among pregnant women
(two LDS, seven non-LDS) matching the inclusion criteria for this investigation. The cognitive
interviews consisted of a face-to-face, informal discussion through which all sections of the
survey were reviewed. Feedback was provided to investigators regarding the clarity of
individual survey items for each section. Additionally, investigators inquired as to whether any
survey item was perceived as too personal or invasive and also whether additional questions
should be added. Information obtained from these cognitive interview sessions allowed for final
revisions of the survey instrument to be made. No names, addresses, or other identifiable
information were collected, ensuring participant anonymity. Thus, exempt approval for this
investigation was sought and granted.
SURVEY OVERVIEW
The survey used for this investigation consisted of 77 survey items, categorized within
seven primary sections. Specific content of each section is detailed in Table 3.1, and reflects the
question and section order throughout the survey. This survey was designed with the intent for
participation to last no longer than 15 minutes. It was believed that a moderate length survey
would enable study participants to complete study procedures before being called into their
scheduled appointment with their prenatal HCP. In order to prevent fatigue effects among study
participants, survey questions considered to be most direct to comprehend and easiest for the
respondent to recall information were ordered towards the end of the survey (social support,
demographics, religious beliefs).

75

Table 3.1. Content overview for the study instrument (Appendix E).
SECTION

CONTENT

(1) LTPA Behavior






Moderate LTPA (current)
Vigorous LTPA (current)
Moderate LTPA (prepregnancy)
Vigorous LTPA (pregpregnancy)

(2) Pregnancy Risk/LTPA Beliefs







Pregnancy Risk Perceptions
LTPA Efficacy Beliefs (moderate PA)
LTPA Risk Perceptions (moderate PA)
LTPA Efficacy Beliefs (vigorous PA)
LTPA Risk Perceptions (vigorous PA)

(3) Pregnancy History











“High Risk” status
Parity
Miscarriage
Pre-term Birth
Operative Delivery
Fertility Treatment
Adverse Conditions (current)
Adverse Conditions (previous pregnancy)
Bedrest Prescription (previous pregnancy)

(4) Prenatal HCP/Patient Interaction









Physical Activity Discussion (current)
Physical Activity Discussion (previous pregnancy)
Physical Activity Recommendations
Perceived Satisfaction with Discussion
Perceived Expertise
Informational Sources
Prenatal HCP Encouragement of PA

(5) Physical Activity Social Support






Support from Significant Other
Support from Family
Support from Friends
Encouragement of physical activity

(6) Demographics









Age
Race
Gestational Age
Education
Household Income
Childcare Responsibilities
Significant Other

(7) Religious Beliefs





Belief in God
Religious Affiliation
Religiosity

76

VARIABLES OF INTEREST
Leisure-Time Physical Activity
Participants were asked to report LTPA prior to and during pregnancy (Appendix E;
Items 1-4, 5-8). Specifically, these survey items asked pregnant women to consider activities,
sports, or recreational activities that they participate in in their “leisure time,” rather than as a
part of their job or occupational or household responsibilities. Participants were asked how
many days per week and for approximately how many minutes per day they typically
participated in both moderate and vigorous-intensity LTPA. Moderate physical activity was
described as activities that cause small increases in breathing or heart rate. Vigorous physical
activity was described as activities that cause large increases in breathing or heart rate.
Examples of both moderate and vigorous physical activities were provided in the survey
directions to assist pregnant women in categorizing their LTPA participation. For both moderate
and vigorous LTPA, typical days per week and minutes per day of reported activity were
multiplied, providing total minutes per week at each intensity. These physical activity questions
were slightly adapted from items within the Global Physical Activity Questionnaire (GPAQ) and
from the 2013-2014 National Health and Nutrition Examination Survey (NHANES). Among
non-pregnant individuals, these questions have demonstrated excellent test-retest reliability
(ICC=0.90 (moderate); ICC=0.96(vigorous)) and acceptable criterion validity (r=0.36
(moderate); r=0.48(vigorous)) with respect to objective monitoring (Actigraph GTM1
accelerometer).8 However, the reliability and validity of these have not yet been assessed among
pregnant women.

77

Pregnancy Risk Perceptions
Pregnancy risk severity and susceptibility items were adapted from the Risk Behavior
Diagnosis Scale,9 with harm to a pregnant woman’s baby considered as the perceived risk
(Appendix E; Items 9-10). For each risk perception item, study participants reported how
strongly they agree or disagree with the given statement using a 7-point Likert-type scale
(1=Strongly Disagree; 7=Strongly Agree). For risk susceptibility, each participant indicated how
strongly she agrees or disagrees that her baby could experience a harmful effect during
pregnancy. For risk severity, each participant indicated how strongly she agrees or disagrees that
a harmful effect that her baby would experience is severe. For the purposes of this dissertation,
perceived pregnancy severity and susceptibility were averaged into a single risk perceptions
score.
LTPA Efficacy Beliefs
LTPA response and self-efficacy items were likewise adapted from the Risk Behavior
Diagnosis Scale,9 with LTPA participation as the recommended response (Appendix E; 11-12,
15-16). For each efficacy belief item, pregnant women reported how strongly they agree or
disagree with the given statement using a 7-point Likert-type scale (1=Strongly Disagree;
7=Strongly Agree). Response and self-efficacy for LTPA were assessed for both moderate and
vigorous intensity. In accordance with the most current recommendations of 150 of moderateintensity activity per week,10 each participant indicated for response efficacy how strongly she
agrees or disagrees that participating in 30 minutes of moderate physical activity, five times per
week will help protect her baby from harm. Likewise for self-efficacy, each participant indicated
how strongly she agrees or disagrees that she can participate in 30 minutes of moderate physical

78

activity, five times per week. The current vigorous physical activity guidelines stipulate that
pregnant women may exercise at high intensities if they have regularly done so previously
throughout their pregnancy.10 Given this guideline is only for pregnant women who are
consistently active at this intensity, the response efficacy item for vigorous physical activity has
been hypothetically framed. Therefore, each participant indicated how strongly she agreed or
disagreed with the belief that if a pregnant woman has been vigorously active prepregnancy, and
continues to be vigorously active during pregnancy, this activity will help protect her baby from
harm. For self-efficacy of vigorous LTPA, each participant indicated how strongly she agrees or
disagrees that she can participate in some vigorous physical activity during pregnancy. For the
purposes of this dissertation, response efficacy and self-efficacy were averaged into a single
efficacy beliefs score for both moderate and vigorous LTPA.
LTPA Risk Perceptions
Two survey items assessed risk perceptions that pregnant women have for LTPA
(Appendix E; Items 13, 17). Participants reported how strongly they agree or disagree with the
given statement using a 7-point Likert-point scale (1=Strongly Disagree; 7=Strongly Agree). For
moderate LTPA, each participant indicated how strongly she agrees or disagrees that
participating in 30 minutes of activity, five times per week is harmful to her baby. For vigorous
LTPA, each participant indicated how strongly she agrees or disagrees that if a woman was
vigorously active before and so far during pregnancy, that participating in vigorous LTPA could
harm her baby.

79

Discussion and Satisfaction of Discussion with Prenatal HCP
Pregnant women were queried whether or not they have discussed physical activity with
a prenatal health care provider (OBGYN, midwife, or prenatal nurse) (Appendix E; Item 30). In
order to gain an understanding of the quality and effectiveness of these discussions, participants
also indicated how satisfied or unsatisfied they feel with that discussion using a 7-point Likerttype scale (1=Very Unsatisfied; 7=Very Satisfied) (Appendix E; Item 32). These survey items
were not drawn from previous literature, but rather were developed by the researcher directing
this study.
Physical Activity Social Support
Survey items assessing physical activity social support are taken from the
Multidimensional Scale of Perceived Social Support (MSPSS) and framed within a physical
activity context (Appendix E; Items 40-54).11 The MSPSS allows for social support to be rated
via twelve items on a 7-point Likert-type scale (1=Strongly Disagree; 7=Strongly Agree).
Advantages of the MSPSS include the shortness of the scale, the consideration of multiple
dimensions of social support, and the assessment of social support from three different sources
via subscales (family, friends, and significant other). The total scale is internally reliable with a
Cronbach’s alpha of 0.88 and a test-retest reliability of 0.85.11 Confirmatory factor analysis has
shown that scale questions had high loading on the subscales for which they were intended
(family, friends, significant others) with minimal cross-loading, confirming these as functional
subscales. Zimet et al.11 additionally assessed internal reliability for the family (0.87), friends
(0.85), and significant other (0.91) subscales. Additionally, test-retest reliability was found to be
high for family (0.85), friends (0.75), and significant other (0.72) subscales.11 Moreover, the

80

MSPSS has been investigated among pregnant women,12 showing excellent reliability for the
total scale (0.92) and also the subscales for family (0.90), friends (0.94), and significant other
(0.90). Answers (7-point Likert-type scale) for the four items pertaining each to family, friends,
and significant other were averaged, providing a measure of physical activity social support
provided by each of the three social support sources. Answers from all twelve items were
averaged to generate the total physical activity social support score for each participant.
Religion and Religiosity
Participants were asked to what religious affiliation they belong to or most identify with
(Appendix E; Item 66). Given dissertation Aims 7 and 8, this allowed for the participants to
indicate whether they were a member of the LDS faith. In order to assess religiosity of all study
participants, a series of ten questions (Appendix E; Item 68-77) from the Santa Clara Strength of
Religious Faith Questionnaire (SCSORF) were utilized.13 These questions allow for religiosity
to be rated via a 4-point Likert-type scale (1=Strongly Disagree; 4=Strongly Agree). High
internal reliability has been found for the SCSORF among general university (Chronbach
alpha=0.94) and highly-religious university students (0.95),13,14 high school students (0.96),15
and medical/cancer patients (0.87-0.94).16,17 The SCSORF has also demonstrated exceptional
convergent validity with respect to other measures of religious faith.13,18,19 Furthermore, factor
analysis has revealed the SCSORF is comprised of a single factor.14,20 Answers from all ten
items (4-point Likert-type scale) were summed to generate the total religiosity score for each
participant (range 10-40). It was assumed that LDS pregnant women would report very high
religiosity scores, yet are culturally different from non-LDS pregnant women of higher
religiosities. As such, LDS pregnant women were grouped separate from non-LDS participants.
Religiosity score tertiles were calculated to categorize all non-LDS participants as high
81

religiosity (36-40 score), moderate religiosity (20-35 score), and low religiosity (10-19 score).
Thus, all study participants could be allocated into one of four religiosity groups: LDS, non-LDS
high religiosity, non-LDS moderate religiosity, or non-LDS low religiosity.
STATISTICAL ANALYSES
All statistical analyses were performed using IBM SPSS 22.0. An alpha level of p <0.05
was used to determine statistical significant for each analysis.
Specific Aim 1: To develop a survey instrument to measure pregnant women’s pregnancy risk
perceptions, LTPA efficacy beliefs, and LTPA in order to utilize the Risk Perception Attitude
Framework (RPA).
In order to determine internal consistency for pregnancy risk perceptions and LTPA
efficacy beliefs (for both moderate and vigorous intensity), Cronbach’s alpha coefficients
were calculated.
Specific Aim 2: To determine the pregnancy risk perceptions and LTPA efficacy beliefs in a
convenience sample of 300-400 pregnant women from mid-Michigan and Salt Lake City, Utah
regions.
The distribution for each variable was examined by calculating skewness and kurtosis.
Kolmogorov-Smirnov (K-S) tests were additionally performed to observe whether the
distribution for each variable significantly differed from a normal distribution. Nonnormal distributions were evident for pregnancy risk perceptions (skewness=1.12;
kurtosis=0.45; K-S test p<0.001) as well as LTPA efficacy beliefs for both moderate
(skewness=-0.70; kurtosis=0; K-S test p<0.001) and vigorous intensity (skewness=-0.20;

82

kurtosis=-0.63; K-S test p=0.002). Therefore, pregnancy risk perception and LTPA
efficacy belief scores were categorized as such: strong agreement (≥6.5), some agreement
(4.5-6.0), unsure or some disagreement (2.0-4.0), and strong disagreement (≤1.5).
Frequency and percentages were calculated for each, and histograms were also
constructed. The medians and ranges for these variables were also calculated.
Specific Aim 3: To determine if differences exist in meeting the moderate LTPA guidelines
among pregnancy risk perception/moderate LTPA efficacy attitudinal groups as defined by the
RPA.
A median split of both pregnancy risk perceptions (high/low) and moderate LTPA
efficacy beliefs (high/low) allowed for the creation of four attitudinal groups
(combinations of high/low risk and efficacy). Moderate LTPA, as defined by minutes per
week, was determined to be non-normally distributed (skewness=2.35, kurtosis=7.78, KS test p<0.001). Thus, moderate LTPA was dichotomized as “meeting moderate LTPA
guidelines” (≥150 minutes/week) and “not meeting moderate LTPA guidelines.” To
assess categorical participant characteristics, chi-square analyses were performed to
determine if relative frequency differed among attitudinal groups. Pairwise comparisons
with Bonferonni adjustments were examined specifically for meeting the moderate LTPA
guidelines. Kruskal-Wallis tests were performed to determine differences in continuous
participant characteristics among attitudinal groups. Logistic regression analysis was
utilized to examine the odds of meeting the moderate LTPA guidelines for each
attitudinal group. Therefore, odds ratios and 95% confidence intervals were calculated
for the responsive, proactive, and avoidant groups, with the avoidant group serving as the
referent category. Due to the lack of literature examining the relationship between
83

physical activity perceptions and LTPA behavior during pregnancy, no definitive variable
could be identified as a potentially important covariate to adjust for in this analysis.
However, results of the previously described chi-square and Kruskal-Wallis analyses
showed a number of variables to be significantly related (p<0.05) to our attitudinal
groupings. These variables were examined systematically via a forward stepwise method
(by examining Wald statistics) to determine whether they significantly entered (p<0.05)
the regression model. Those that did enter, were kept in the regression model for
analysis, while those that did not enter, were excluded.
Specific Aim 4: To determine if differences exist in vigorous LTPA participation among
pregnancy risk perception/vigorous LTPA efficacy attitudinal groups as defined by the RPA.
A median split of both pregnancy risk perceptions (high/low) and vigorous LTPA
efficacy beliefs (high/low) allowed for the creation of four attitudinal groups
(combinations of high/low risk and efficacy). Vigorous LTPA, as defined by minutes per
week, was determined to be non-normally distributed (skewness=2.86, kurtosis=10.5, KS test p<0.001). Thus, vigorous LTPA was dichotomized as “participating in any
vigorous LTPA” and “not participating in vigorous LTPA.” To assess categorical
participant characteristics, chi-square analyses were performed to determine if relative
frequency differed among attitudinal groups. Pairwise comparisons with Bonferonni
adjustments were examined specifically for participating in any vigorous LTPA.
Kruskal-Wallis tests were performed to determine differences in continuous participant
characteristics among attitudinal groups. Logistic regression analysis was utilized to
examine the odds of participating in vigorous-intensity LTPA for each attitudinal group.
Therefore, odds ratios and 95% confidence intervals were calculated for the responsive,
84

proactive, and avoidant groups, with the indifferent group serving as the referent
category. Due to the lack of literature examining the relationship between physical
activity perceptions and LTPA behavior during pregnancy, no definitive variable could
be identified as a potentially important covariate to adjust for in this analysis. However,
results of the previously described chi-square and Kruskal-Wallis analyses showed a
number of variables to be significantly related (p<0.05) to our attitudinal groupings.
These variables were examined systematically via a forward stepwise method (by
examining Wald statistics) to determine whether they significantly entered (p<0.05) the
regression model. Those that did enter, were kept in the regression model for analysis,
while those that did not enter, were excluded.
Specific Aim 5: To determine if the interaction of pregnancy risk perceptions and moderate
LTPA efficacy is associated with meeting moderate LTPA guidelines among pregnant women.
An interaction term for pregnancy risk perceptions and moderate LTPA efficacy beliefs
(pregnancy risk x LTPA efficacy) was first created. In order to reduce multicollinearity,
variables used to create this interaction term were mean centered and then standardized
prior to the formation of the interaction term, as recommended by Aiken and West.21
Pearson and Spearman correlation coefficients were calculated to determine the
relationships for potentially important covariates with the independent variables
(pregnancy risk perceptions, moderate LTPA efficacy beliefs, pregnancy risk x LTPA
efficacy interaction) as well as dependent variable (meeting moderate LTPA guidelines).
Hierarchical logistic regression was utilized to examine both the main and interaction
effects on meeting the moderate LTPA guidelines. First added to the model were the
demographic control variables (step 1) and psychosocial control variables (step 2). Next,
85

main effects were explored with the addition of pregnancy risk perceptions and moderate
LTPA efficacy beliefs (step 3). Finally, the pregnancy risk x LTPA efficacy interaction
term was added to the model (step 4). The statistical significance of change in variance
(∆R2) was explored for each step. Participant characteristics that were identified as
control variables through the statistical analyses for Aim 3 were controlled for as a part of
this analysis. Moderate LTPA risk perception (psychosocial control variable) was also
controlled for due to its theoretical rationale as a potential confounding factor and also its
significant bivariate correlation with pregnancy risk perceptions, moderate LTPA
efficacy beliefs, and meeting moderate LTPA guidelines during pregnancy (see Table
4.4, Chapter 4).
Specific Aim 6: To determine if the interaction of pregnancy risk perceptions and vigorous
LTPA efficacy is associated with participating in any vigorous LTPA among pregnant women.
An interaction term for pregnancy risk perceptions and vigorous LTPA efficacy beliefs
(pregnancy risk x LTPA efficacy) was first created. In order to reduce multicollinearity,
variables used to create this interaction term were mean centered and then standardized
prior to the formation of the interaction term, as recommended by Aiken and West.21
Pearson and Spearman correlation coefficients were calculated to determine the
relationships for potentially important covariates with the independent variables
(pregnancy risk perceptions, vigorous LTPA efficacy beliefs, pregnancy risk x LTPA
efficacy interaction) as well as dependent variable (meeting moderate LTPA guidelines).
Hierarchical logistic regression was utilized to examine both the main and interaction
effects on meeting the moderate LTPA guidelines. First added to the model were the
demographic control variables (step 1) and psychosocial control variables (step 2). Next,
86

the main effects were explored with the addition of pregnancy risk perceptions and
vigorous LTPA efficacy beliefs (step 3). Finally, the pregnancy risk x LTPA efficacy
interaction term was added to the model. The statistical significance of change in
variance (∆R2) was explored for each step. Participant characteristics that were identified
as control variables through the statistical analyses for Aim 4 were controlled for as a part
of this analysis. Vigorous LTPA risk perception (psychosocial control variable) was also
controlled for due to its theoretical rationale as a potential confounding factor and also its
significant bivariate correlation with pregnancy risk perceptions, vigorous LTPA efficacy
beliefs, and participating in vigorous LTPA during pregnancy (see Table 4.6, Chapter 4).
Specific Aim 7: To determine the relationship of religion (Latter-day Saints [LDS] vs. non-LDS
(high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with LTPA,
pregnancy risk perceptions, and LTPA efficacy beliefs among pregnant women.
Religious groups were formed as previously described in this chapter. Non-normal
distributions were found for the dependent variables: moderate LTPA (skewness=2.35,
kurtosis=7.78, K-S test p<0.001), vigorous LTPA (skewness=2.86, kurtosis=10.5, K-S
test p<0.001), pregnancy risk perceptions (skewness=1.08, kurtosis=0.28, K-S test
p<0.001), moderate LTPA efficacy beliefs (skewness=-0.70, kurtosis=0.13, K-S test
p<0.001), and vigorous LTPA efficacy beliefs (skewness=-0.11, kurtosis=-0.62, K-S test
p=0.002). Moderate LTPA was dichotomized as “meeting moderate LTPA guidelines”
(≥150 minutes/week) and “not meeting moderate LTPA guidelines.” Vigorous LTPA
was dichotomized as “participating in any vigorous LTPA” and “not participating in
vigorous LTPA.” Pregnancy risk perception score was dichotomized as “strong
disagreement” (≤1.5 for score) and “all else.” Moderate LTPA efficacy was

87

dichotomized as “strong agreement” (≥6.5 for score) and “all else.” Vigorous LTPA
efficacy was dichotomized as “some agreement” (≥4.5 for score) and “unsure or some
disagreement.” To assess categorical participant characteristics, chi-square analyses were
performed to determine if relative frequency differed among religious groups. KruskalWallis tests were performed to determine differences in continuous participant
characteristics among religious groups. Pairwise comparisons with Bonferonni
adjustments were examined for all dependent variables. Logistic regression analysis was
utilized to calculate odds ratios and 95% confidence intervals for the non-LDS religious
groups (high, moderate, and low). The LDS religious group served as the referent
category given the general interest of this Aim was to determine how LDS pregnant
women differ from each of the non-LDS groups. The relationship between religion and
LTPA behavior during pregnancy has rarely been investigated, and therefore no
definitive variable could be identified as a potentially important covariate to adjust for in
this analysis. However, the previously described chi-square and Kruskal-Wallis analyses
showed a number of variables to be related to the religious groups (p<0.05). These
variables were examined systematically via a forward stepwise method (by examining
Wald statistics) to determine whether they significantly entered (p<0.05) the regression
model. Variables that did significantly enter were kept in the adjusted model.

88

Specific Aim 8: To determine the relationship of religion (Latter-day Saints [LDS] vs. non-LDS
(high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with prenatal
HCP discussions, satisfaction with these discussions, and physical activity social support among
pregnant women.
Religious groups were formed as previously described in this chapter. Non-normal
distributions were found for the dependent variables: satisfaction of physical activity
discussion with prenatal HCP (skewness=-1.07, kurtosis=0.94, K-S test p<0.001), total
social support (skewness=-1.27, kurtosis=2.02, K-S test p<0.001), and social support
from family (skewness=-1.09, kurtosis=0.91, K-S test p<0.001), friends (skewness=-1.09,
kurtosis=0.83, K-S test p<0.001), and significant other (skewness=-1.90, kurtosis=3.18,
K-S test p<0.001). Median splits were utilized in order to dichotomize each variable as
“high” and “low.” Whether discussion of physical activity with prenatal HCP occurred (a
further dependent variable), was already dichotomized as “yes” or “no.” To assess
categorical participant characteristics, chi-square analyses were performed to determine if
relative frequency differed among religious groups. Kruskal-Wallis tests were
additionally performed to determine differences in continuous demographic
characteristics among religious groups. Pairwise comparisons with Bonferonni
adjustments were examined for all dependent variables. Logistic regression analysis was
utilized to calculate odds ratios and 95% confidence intervals for the non-LDS religious
groups (high, moderate, and low), with the LDS religious group serving as the referent
category. The relationship between religion and LTPA behavior during pregnancy has
not yet been investigated, and therefore no definitive variable could be identified from
previous literature as a potentially important covariate to adjust for in these analyses.

89

However, the previously described chi-square and Kruskal-Wallis analyses showed a
number of variables to be related to the religious groups (p<0.05). These variables were
examined systematically via a forward stepwise method (by examining Wald statistics) to
determine whether they significantly entered (p<0.05) the regression model. Variables
that did significantly enter were kept in the adjusted model.

90

APPENDICES

91

Appendix A: IRB Approval – Michigan State University
Figure 3.3. Study IRB approval by Michigan State University.

92

Appendix B: IRB Approval – University of Utah
Figure 3.4. Study IRB approval by University of Utah.

93

Appendix C: Informed Consent (Electronic)
LEISURE-TIME PHYSICAL ACTIVITY PERCEPTIONS, INFLUENCES, AND BEHAVIOR
DURING PREGNANCY
Participant Informed Consent Form (ELECTRONIC)
You are being asked to participate in a research study about how pregnant women feel about physical activity
during pregnancy.
Subjects must be women who are currently pregnant, can speak fluent English and/or Spanish, not be on bed
rest as prescribed by your OBGYN for your pregnancy status, and be 18 – 45 years of age.
This research project’s main objective is to determine how pregnant women feel about physical activity
during pregnancy and to see if their feelings lead to participation in physical activity.
Your participation will consist of taking a 15-minute online survey using a computer device while you wait for
your doctor appointment. The survey will ask you questions about your physical activity beliefs, current
exercise habits, pregnancy history, any support you receive to be physically active, and your religious beliefs.
Your participation in this survey will assist us in better understanding what pregnant women believe about
physical activity and how it relates the baby’s health.
Your participation in the research study is completely voluntary. You may choose not to participate and/or
you may withdraw at any point during the study if you change your mind. There will be no penalty for
choosing not to participate. All responses will be confidential. Also, no identifying information, such as name,
email address, or residential address will be collected. Additionally, we will not use your personal medical
records to collect any information.
As a thank you for participation, you will receive a $10 gift card to Target after completing the survey. If you
are not finished with the survey before getting called into your appointment with your doctor, you will be
able to complete it afterwards.
The researchers for this project are: Christopher Connolly, Dr. James Pivarnik, Dr. Lanay Mudd, Dr. Maria
Lapinski, and Dr. Deborah Feltz at Michigan State University, Dr. Rebecca Schlaff at Saginaw Valley State
University, and Dr. Robert Silver at the University of Utah. If you have any questions about the research
study, please contact Christopher Connolly at 765-418-1713, connol57@msu.edu.
If you have questions about your rights as a research participant, would like to obtain information or off
input, or would like to register a complaint about this study, you may contact the Michigan State University’s
Human Research Protection Program, 408 W. Circle Dr., Room 207 Olds Hall, Est Lansing, MI., 48823, (517355-2180 or irb@msu.edu).

By clicking on the button below, you indicate your voluntary agreement to participate in this online
survey.
______ Agree
(Agree will lead them to the survey)

94

Appendix D: Informed Consent (Paper Copy)
LEISURE-TIME PHYSICAL ACTIVITY PERCEPTIONS, INFLUENCES, AND BEHAVIOR
DURING PREGNANCY
Participant Informed Consent Form (PAPER COPY)
You are being asked to participate in a research study about how pregnant women feel about physical activity
during pregnancy.
Subjects must be women who are currently pregnant, can speak fluent English and/or Spanish, not be on bed
rest as prescribed by your OBGYN for your pregnancy status, and be 18 – 45 years of age.
This research project’s main objective is to determine how pregnant women feel about physical activity
during pregnancy and to see if their feelings lead to participation in physical activity.
Your participation will consist of taking a 15-minute survey while you wait for your doctor appointment. The
survey will ask you questions about your physical activity beliefs, current exercise habits, pregnancy history,
any support you receive to be physically active, and your religious beliefs. Your participation in this survey
will assist us in better understanding what pregnant women believe about physical activity and how it relates
the baby’s health.
Your participation in the research study is completely voluntary. You may choose not to participate and/or
you may withdraw at any point during the study if you change your mind. There will be no penalty for
choosing not to participate. All responses will be confidential. Also, no identifying information, such as name,
email address, or residential address will be collected. Additionally, we will not use your personal medical
records to collect any information.
As a thank you for participation, you will receive a $10 gift card to Target after completing the survey. If you
are not finished with the survey before getting called into your appointment with your doctor, you will be
able to complete it afterwards.
The researchers for this project are: Christopher Connolly, Dr. James Pivarnik, Dr. Lanay Mudd, Dr. Maria
Lapinski, and Dr. Deborah Feltz at Michigan State University, Dr. Rebecca Schlaff at Saginaw Valley State
University, and Dr. Robert Silver at the University of Utah. If you have any questions about the research
study, please contact Christopher Connolly at 765-418-1713, connol57@msu.edu.
If you have questions about your rights as a research participant, would like to obtain information or off
input, or would like to register a complaint about this study, you may contact the Michigan State University’s
Human Research Protection Program, 408 W. Circle Dr., Room 207 Olds Hall, Est Lansing, MI., 48823, (517355-2180 or irb@msu.edu).

By checking the space below, you indicate your voluntary agreement to participate in this survey.
______ Agree

95

Appendix E: Survey Instrument
PART 1 - PHYSICAL ACTIVITY DURING PREGNANCY
We would like to ask you about moderate and vigorous-intensity physical activities that you
perform in your leisure-time. Activities during “leisure-time” refer to exercise, sports, or
recreational activities that are not a part of your job or household responsibilities. “Moderate
physical activity” includes activities that cause small increases in breathing or heart rate such
as brisk walking, light swimming, or bicycling. “Vigorous physical activity” includes activities
that cause large increases in breathing or heart rate such as running, aerobic dance, or
intense swimming or bicycling. Please provide the response that most closely represents your
leisure-time physical activity that you participate in.
For the next four questions, we will ask you about your moderate and vigorous leisure-time
physical activity prior to this pregnancy.
1) Prior to this pregnancy, how many days per week did you typically participate in moderate
physical activity?
0 1
2
3
4
5
6
7
2) Prior to this pregnancy, how many minutes per day did you typically spend participating in
moderate physical activity (If you answered “0” for question 1, please skip this question)?
______
3) Prior to this pregnancy, how many days per week did you typically participate in vigorous
physical activity?
0
1
2
3
4
5
6
7
4) Prior to this pregnancy, how many minutes per day did you typically spend participating in
vigorous physical activity (If you answered “0” for question 3, please skip this question)?
______

For the next four questions, we will ask you about your moderate and vigorous leisure-time
physical activity during this pregnancy.
5) During this pregnancy, how many days per week do you typically participate in moderate
physical activity?
0 1
2
3
4
5
6
7
6) During this pregnancy, how many minutes per day do you typically spend participating in
moderate physical activity (if you answered “0” for question 5, please skip this question)?
______

96

7) During this pregnancy, how many days per week do you typically participate in vigorous
physical activity?
0 1
2
3
4
5
6
7
8) During this pregnancy, how many minutes per day do you typically spend participating in
vigorous physical activity (if you answered “0” for question 7, please skip this question)?
______

PART 2 - BELIEFS ABOUT PREGNANCY
We would like to first ask how at risk you feel your baby is during this pregnancy. For each
question, please mark the number on the scale that most accurately represents your feelings.
Marking “1” means you most strongly disagree with the statement. Marking “7” means you
most strongly agree with the statement.
9) It is possible that my baby will experience a harmful effect during pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
10) A harmful effect that my baby would experience during pregnancy is severe.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

For the next four questions, we will ask you about your beliefs that you have towards
moderate physical activity during this pregnancy.
Marking “1” means you most strongly disagree with the statement. Marking “7” means you
most strongly agree with the statement.
11) Participating in 30 minutes of moderate physical activity per day, five times per week helps
protect my baby from harm.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

97

12) I can participate in 30 minutes of moderate physical activity per day, five times per week
while pregnant.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
13) Participating in 30 minutes of moderate physical activity per day, five times per week is
harmful to my baby.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
14) Women who participated in moderate activities before pregnancy should participate in
moderate physical activity during pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

For the next questions, we would like to ask you about your beliefs that you have towards
vigorous physical activity during pregnancy.
15) If a pregnant woman was vigorously active before and so far during pregnancy (including
you), participation in vigorous physical activity during pregnancy would help protect her
baby from harm.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
16) I can participate in some vigorous physical activity while pregnant.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
17) If a pregnant woman was vigorously active before pregnancy (including you), participation
in vigorous physical activity during pregnancy could harm her baby.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

98

18) Women who participated in vigorous activities before pregnancy should participate in
vigorous physical activity during pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

PART 3 - PREGNANCY HISTORY
For these next questions, we would like to ask you about your personal pregnancy and
delivery history. Please mark the response that most closely represents your experiences.
Some questions will relate to your current pregnancy, and some will relate to a previous
pregnancy (if you have had one).
19) During this pregnancy, has your prenatal physician informed you that you are “high-risk”?
Yes
No
20) How many children have you given birth to?
None
One
Two
Three
More than three
21) Have you had a miscarriage?
Yes
No
22) If you answered “yes” for question 21, how many miscarriages have you had (if you
answered “No” for question 21, please skip this question)?
One
Two
Three
More than three
23) For a previous pregnancy, did you deliver your child pre-term?
Yes
No
Not applicable

99

24) For a previous pregnancy, did you deliver your child via C-section?
Yes
No
Not applicable
25) Have you ever sought help from a healthcare provider to get pregnant?
Yes
No
26) Select any of the conditions listed below that you have been diagnosed with during your
current pregnancy (select all that apply).
Gestational Diabetes (diabetes first diagnosed during pregnancy)
Pregnancy-Induced Hypertension (high blood pressure)
Major Depressive Disorder (clinical depression)
Hyperemesis Gravidarum (severe nausea)
None of the above
27) Select any of the conditions listed below that you were diagnosed with during a previous
pregnancy (select all that apply).
Gestational Diabetes (diabetes first diagnosed during pregnancy)
Pregnancy-Induced Hypertension (high blood pressure)
Major Depressive Disorder (clinical depression)
Hyperemesis Gravidarum (severe nausea)
None of the above
28) During a previous pregnancy, have you ever been prescribed bedrest?
Yes
No
Not applicable

PART 4 - PRENATAL HEALTH CARE PROVIDER
For these next questions, we would like to ask you about whether you have discussed
physical activity during pregnancy with your doctor or midwife and the nature of those
discussions. Please mark the response that most accurately represents your feelings.
29) During a previous pregnancy, did you and an OBGYN, midwife, or prenatal nurse discuss
physical activity during pregnancy?
Yes
No
Unsure
Not applicable

100

30) During this pregnancy, have you and an OBGYN, midwife, or prenatal nurse discussed
physical activity during pregnancy?
Yes
No
31) If you answered “Yes” for question 30, did you initiate this discussion of being physically
active during pregnancy or did an OBGYN, midwife, or prenatal nurse initiate the discussion
(if you answered “No” for question 30, please skip this question)?
You
Your OBGYN/midwife/prenatal nurse
32) If you answered “Yes” for question 30, please indicate on the scale below how satisfied you
feel regarding this physical activity discussion with an OBGYN, midwife, or prenatal nurse (if
you answered “No” for question 30, please skip this question)?
1
2
3
4
5
6
7
Very
Very
Unsatisfied
Satisfied
33) If you answered “Yes” for question 30, please indicate on the scale below what you believe
his/her expertise is regarding physical activity during pregnancy and the effects it has on
you and your baby (if you answered “No” for question 30, please skip this question).
1
2
3
4
5
6
7
Low
High
Expertise
Expertise
34) If you answered “No” for question 30, would you have the desire to discuss physical activity
during pregnancy with an OBGYN, midwife, or prenatal nurse (if you answered “Yes” for
question 30, please skip this question)?
Yes
No
35) During this pregnancy, has an OBGYN, midwife, or prenatal nurse discussed the current
physical activity recommendations for pregnant women with you (At least 150 minutes of
moderate physical activity per week)?
Yes
No

101

Marking “1” means you most strongly disagree with the statement. Marking “7” means you
most strongly agree with the statement.
36) During this pregnancy, an OBGYN, midwife, or prenatal nurse encourages me to be
physically active.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
37) I feel adequately informed regarding the benefits and risks of physical activity during
pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
38) Have you ever sought out information about physical activity during pregnancy from
another source besides from an OBGYN, midwife, or prenatal nurse?
Yes
No
39) Please select the means by which you would most prefer to receive accurate information on
physical activity during pregnancy (circle only one answer).
Discussion with your OBGYN or midwife
Pamphlet or Booklet
Video
Online Document
Informative Magazines
Family or Friends

102

PART 5 - SOCIAL SUPPORT
For these next questions, we would like to ask you about the support you currently receive
for you participating in physical activity. We will ask about the physical activity-support you
receive from family, friends, and your significant other during this pregnancy. For each
question, please circle the number on the scale that most accurately represents your feelings.
For the questions which pertain to a “significant other”, if you do not feel like you have such a
person in your life right now, please mark “Not applicable”.

Marking “1” means you most strongly disagree with the statement. Marking “7” means you
most strongly agree with the statement.
40) Regarding physical activity, my significant other is available when I am in need.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
41) I can share my successes and challenges about physical activity with my significant other.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree

42) My family really tries to help me be physically active.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree

Not applicable

43) I get the emotional help and support I need from my family so that I can be physically
active.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
44) My significant other is a real source of comfort to me when I am concerned or unsure about
physical activity.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
45) My friends really try to help me so that I can be physically active.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
103

Not applicable

46) Regarding physical activity, I can count on my friends when things are not going well.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
47) I can talk about the concerns I have towards physical activity with my family.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
48) I have friends with whom I can share my successes and challenges about physical activity.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
49) My significant other cares about my feelings towards physical activity.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
50) My family is willing to help me make decisions about physical activity.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
51) I can talk about the concerns I have towards physical activity with my friends.
1
2
3
4
5
6
7
Not applicable
Strongly
Strongly
Disagree
Agree
52) My family encourages me to be physically active during pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
53) My friends encourage me to be physically active during pregnancy.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
54) My significant other encourages me to be physically active.
1
2
3
4
5
6
7
Strongly
Strongly
Disagree
Agree
104

Not applicable

Not applicable

Not applicable

PART 6 - DEMOGRAPHICS
For these next questions we would like to ask about some of your basic demographic
information. Please provide the response that most closely represents you.
55) What is your age? _________
56) What is your race?
Caucasian
African American
Asian
Hispanic
Other______________
57) How many weeks pregnant are you (If you do not know, please write unsure)? _______
58) Are you currently carrying more than one baby (i.e. twins, triplets, etc.)?
Yes
No
Unsure
59) What is the highest level of education you have completed?
Less than High School
High School/GED
Associate Degree (2 year)
Bachelor Degree (4 year)
Graduate Degree
Other______________
60) What is your estimated annual household income?
Less than $10,000
$10,000-$30,000
$30,001-$50,000
$50,001-$70,000
Greater than $70,000
61) In what U.S. state do you currently reside?
Utah
Michigan
Other______________
62) How many children do you currently care for in your household? ___________

105

63) Do you currently have a “significant other”?
Yes
No

PART 7 - RELIGIOUS BELIEFS
For the next four questions we would like to ask about some of your basic religious beliefs.
Please provide the response that most closely represents you.
64) Do you believe in a God or some sort of higher power?
Yes
No
65) Do you regularly practice a religion?
Yes
No
66) To what religious affiliation do you belong or do you most identify with? __________
67) Do you feel that your faith actively promotes a healthy lifestyle?
Yes
No

For these last ten questions, please mark the number on the scale that most accurately
represents your feelings
Marking “1” means you strongly disagree with the statement. Marking “4” means you
strongly agree with the statement.
68) My religious faith is extremely important to me.
1
2
3
4
Strongly
Strongly
Disagree
Agree
69) I pray daily.
1
2
Strongly
Disagree

3

4
Strongly
Agree

70) I look to my faith as a source of inspiration.
1
2
3
4
Strongly
Strongly
Disagree
Agree
106

71) I look to my faith as providing meaning and purpose in my life.
1
2
3
4
Strongly
Strongly
Disagree
Agree
72) I consider myself active in my faith, church, or place of worship.
1
2
3
4
Strongly
Strongly
Disagree
Agree
73) My faith is an important part of who I am as a person.
1
2
3
4
Strongly
Strongly
Disagree
Agree

74) My relationship with God is extremely important to me.
1
2
3
4
Strongly
Strongly
Disagree
Agree
75) I enjoy being around others who share my faith.
1
2
3
4
Strongly
Strongly
Disagree
Agree
76) I look to my faith as a source of comfort.
1
2
3
4
Strongly
Strongly
Disagree
Agree
77) My faith impacts many of my decisions.
1
2
3
4
Strongly
Strongly
Disagree
Agree

107

Appendix F: Recruitment Flyer
Figure 3.5. Study Recruitment Flyer.

Participants Needed for Pregnancy
-Based Research!!!
Participants: Pregnant women (ages 18-45), not prescribed bedrest,
able to speak English or Spanish
Procedures: Completion of a 15-minute survey (iPad or paper copy)
Survey content includes:







Physical activity beliefs
Exercise behavior
Physical activity social support
Interactions with Healthcare Provider
Past pregnancy history
Basic religious beliefs

Participants will be compensated with a $10 gift card to Target as
thanks for their help with our study!!!

If interested, please contact:
Chris Connolly, M.S. (Study Coordinator)
Phone: 765-418-1713
Email: connol57@msu.edu

Study Title: Leisure-Time Physical Activity Perceptions, Influences, and Behavior during Pregnancy

108

Appendix G: Dissertation Funding Sources
Dissertation Funding Sources
(Participant compensation, iPad devices, travel, and supplies)
1. Research Practicum and Dissertation Fellowship
College of Education, Michigan State University
Funded - $3,355
2. Research and Professional Development Fellowship
Department of Kinesiology, Michigan State University
Funded - $700
3. Research Enhancement Award
The Graduate School, Michigan State University
Funded - $950
(Study investigator support – University of Utah)
4. The Center for Physical Activity and Health
Department of Kinesiology, Michigan State University
Funded - $6,000
(Study coordinator assistantship support)
5. College of Education Seed Grant
College of Education, Michigan State University
Funded - $4,089
6. Dissertation Completion Fellowship
College of Education/The Graduate School, Michigan State University
Funded - $6,000

Not Funded
1. Henry David Research Grant
American Psychological Foundation
Not Funded - $1,500
2. Dissertation Research Support Fellowship
College of Education, Michigan State University
Not Funded - $4,000

109

REFERENCES

110

REFERENCES

1.

Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change: Use of
the risk perception attitude (RPA) framework to understand health behaviors. Hum
Commun Res. Jul 1 2003;29(3):370-399.

2.

Witte K. Putting the Fear Back into Fear Appeals - the Extended Parallel Process Model.
Commun Monogr. Dec 1992;59(4):329-349.

3.

Rimal RN. Perceived risk and self-efficacy as motivators: Understanding individuals'
long-term use of health information. J Commun. Dec 2001;51(4):633-654.

4.

Real K. Information seeking and workplace safety: A field application of the risk
perception attitude framework. J Appl Commun Res. 2008;36(3):339-359.

5.

Sullivan HW, Burke Beckjord E, Finney Rutten LJ, Hesse BW. Nutrition-related cancer
prevention cognitions and behavioral intentions: testing the risk perception attitude
framework. Health Educ Behav. Dec 2008;35(6):866-879.

6.

Rimal RN, Bose K, Brown J, Mkandawire G, Folda L. Extending the Purview of the Risk
Perception Attitude Framework: Findings from HIV/AIDS Prevention Research in
Malawi. Health Commun. 2009;24(3):210-218.

7.

Rimal RN, Juon HS. Use of the Risk Perception Attitude Framework for Promoting
Breast Cancer Prevention. J Appl Soc Psychol. Feb 2010;40(2):287-310.

8.

Herrmann SD, Heumann KJ, Der Ananian CA, Ainsworth BE. Validity and reliability of
the Global Physical Activity Questionnaire (GPAQ). Measurement in Physical Education
and Exercise Science. 2013;17(3):221-235.

9.

Witte K, Cameron KA, McKeon JK, Berkowitz JM. Predicting risk behaviors:
development and validation of a diagnostic scale. Journal of health communication. OctDec 1996;1(4):317-341.

10.

United States. Dept. of Health and Human Services. 2008 physical activity guidelines for
Americans : be active, healthy, and happy! Washington, DC: U.S. Dept. of Health and
Human Services; 2008.

11.

Zimet GD, Dahlem NW, Zimet SG, Farley GK. The Multidimensional Scale of Perceived
Social Support. J Pers Assess. Spr 1988;52(1):30-41.

12.

Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric
Characteristics of the Multidimensional Scale of Perceived Social Support. J Pers Assess.
Win 1990;55(3-4):610-617.

111

13.

Plante TG, Boccaccini M. The Santa Clara Strength of Religious Faith Questionnaire.
Pastoral Psychology. 1997;45:375-387.

14.

Freiheit SR, Sonstegard K, Schmitt A, Vye C. A psychometric evaluation of the Santa
Clara Strength of Religious Faith Questionnaire. Pastoral Psychology. 2006;55:27-33.

15.

Plante TG, Boccaccini M. Reliability and validity of the Santa Clara Strength of
Religious Faith Questionnaire. Pastoral Psychology. 1997;45:429-437.

16.

Sherman AC, Plante TG, Simonton S, Adams DC, Burris K, Harbison C. Assessing
religious faith in medical patients: Cross-validation of the Santa Clara Strength of
Religious Faith Questionnaire. Pastoral Psychology. 1999;48:129-142.

17.

Sherman AC, Plante TG, Simonton S, Adams DC, Harbison C, Burris SK. A
multidimensional measure of religious involvement for cancer patients: the Duke
Religious Index. Supportive care in cancer : official journal of the Multinational
Association of Supportive Care in Cancer. Mar 2000;8(2):102-109.

18.

Plante TG, Yancey S, Sherman AC, Guertin M, Pardini D. Further validation for the
Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychology. 1999;48:1121.

19.

Plante TG. The Santa Clara Strength of Religious Faith Questionnaire: Assessing Faith
Engagement in a Brief and Nondenominational Manner. Religions. Dec 2010;1(1):3-8.

20.

Sherman AC, Simonton S, Adams DC, et al. Measuring religious faith in cancer patients:
Reliability and construct validity of the Santa Clara Strength of Religious Faith
Questionnaire. Psycho-Oncol. Sep-Oct 2001;10(5):436-443.

21.

Aiken LS, West SG, Reno RR. Multiple regression : testing and interpreting
interactions. Newbury Park, Calif.: Sage Publications; 1991.

112

CHAPTER 4
RESULTS
We planned to recruit at least 300 pregnant women who met the participant inclusion
criteria (18-45 years of age, fluent English or Spanish speaker, not on prescribed bedrest).
Although 360 pregnant women participated in this investigation, 18 women were excluded from
final analyses as a result of incomplete LTPA data, 20 as a result of incomplete psychosocial or
religious data, and 10 as a result of carrying more than one fetus. Furthermore, 10 women were
excluded as a result of self-reported LTPA ≥3 standard deviations above the mean. The final
analytic sample for this investigation was 302 participants, as shown in Figure 4.1. Data from
141 participants were provided by investigators from the University of Utah’s Health Science
Center in Salt Lake City, Utah. Data from the remaining 161 participants were provided by
study investigators located in the mid-Michigan area at Michigan State University.
Participant characteristics for the total analytic sample are displayed in Table 4.1. In
total, 27.2% (n=82) of the sample reported meeting the current moderate LTPA guidelines (≥150
minutes per week)1 as compared to 41.1% (n=124) of participants who achieved these guidelines
prior to pregnancy. Likewise, 30.1% (n=91) reported participating in any vigorous LTPA as
compared to 62.9% (n=190) who participated in any vigorous LTPA prior to pregnancy. The
total analytic sample for this investigation had a median age of 28 (range 18-45) and a median
gestational age of 27 weeks (range 5-40). Participants were primarily Caucasian (72.8%, n=220)
and multiparous (63.9%, n=193), with the majority having at least some college education
(59.3%, n=179). Nearly two-thirds of participants (n=199) reported having discussed LTPA
with their prenatal HCP sometime during the current pregnancy.

113

Figure 4.1. Participant flowchart for the total analytic sample.

Incomplete LTPA
data

MID-MICHIGAN SITE

SALT LAKE CITY SITE

Participants who completed
surveys (n=177)

Participants who completed
surveys (n=183)

n=7

n=11

Participants with LTPA data
(n=170)

Incomplete
psychosocial or
religious data

n=17

n=3

Participants with complete
data (n=167)

Carrying more
than one baby

Participants with complete
data (n=155)

n=1

n=9

Singleton participants with
complete data (n=166)

LTPA data >3 SD
above mean

Participants with LTPA data
(n=172)

Singleton participants with
complete data (n=146)

n=5

n=5

Total analytic sample
(n=302)

114

Table 4.1. Participant characteristics for total sample.
(n=302)
median (range)
Age (years)
Gestational Age (weeks)
frequency (percentage)
Parity
Nulliparous
Multiparous
Race
Caucasian
Non-Caucasian
Education
High School or less
Some College
Income
≤$30,000
>$30,000
Miscarriage
Preterm Birth
C-section
Previous Conditions†
Current Conditions†
Moderate LTPA Efficacy
Strong agreement
Vigorous LTPA Efficacy
Strong agreement
Pregnancy Risk
Strong disagreement
Moderate LTPA Risk
Strong disagreement
Vigorous LTPA Risk
Strong disagreement
Discussed LTPA w/ HCP
Pre Met LTPA Guidelines
Meet LTPA Guidelines
Pre Any Vigorous LTPA
Any Vigorous LTPA

28 (15, 45)
27 (5, 40)

109 (36.1)
193 (63.9)
220 (72.8)
82 (27.2)
123 (40.7)
179 (59.3)
136 (45.5)
163 (54.5)
91 (30.1)
40 (13.2)
54 (17.9)
36 (11.9)
38 (12.6)
71 (23.5)
25 (8.2)
148 (49.0)
205 (67.9)
68 (22.5)
199 (65.9)
124 (41.1)
82 (27.2)
190 (62.9)
90 (30.1)

†Gestational diabetes, pregnancy-induced hypertension, hyperemesis
gravidarum, or major depressive disorder.

115

Specific Aim 1: To develop a survey instrument to measure pregnant women’s pregnancy risk
perceptions, LTPA efficacy beliefs, and LTPA in order to utilize the Risk Perception Attitude
Framework (RPA).
General development procedures and content overview of the survey instrument utilized
for this dissertation are described in Chapter 3. Pregnancy risk perception (harm to the baby
during pregnancy) questions assessing perceived severity and perceived susceptibility
demonstrated acceptable internal consistency (Cronbach’s alpha (α) = 0.78). LTPA efficacy
beliefs questions assessed response and self-efficacy for both moderate and vigorous LTPA and
demonstrated acceptable internal consistency (α = 0.69, α = 0.67).

Specific Aim 2: To determine the pregnancy risk perceptions and LTPA efficacy beliefs in a
convenience sample of 300-400 pregnant women from mid-Michigan and Salt Lake City, Utah
regions.
Figure 4.2 demonstrates the non-normal distributions for pregnancy risk perceptions
(skewness=1.08, kurtosis=0.28, K-S test p<0.001) and moderate LTPA efficacy beliefs
(skewness=-0.70, kurtosis=0.13, K-S test p<0.001). Although less skew was evident for
vigorous LTPA efficacy beliefs, the distribution was still found to be non-normal (skewness=0.11, kurtosis=-0.62, K-S test p=0.002) (Figure 4.2). Approximately half of the sample (49.0%,
n=148) reported strong disagreement with the susceptibility/severity of a harmful effect their
babies could experience during pregnancy, and a further 40.7% (n=123) indicated some
disagreement. Just over 50% (n=152) of participants reported some agreement with
response/self-efficacy of moderate LTPA, and a further 23.5% (n=71) indicated strong

116

agreement. With respect to the vigorous LTPA efficacy, strong agreement was reported by only
8.2% (n=25); however, 41.1% (n=124) reported some agreement. As a point of interest, 68%
(n=205) of participants indicated strong disagreement that moderate LTPA participation has a
harmful effect on the baby as compared to approximately 23% (n=68) for vigorous LTPA. Table
4.2 provides the median and range for each of these variables (and also moderate and vigorous
LTPA in min/week) given the non-normal distribution of data.
Figure 4.2. Histograms depicting the frequencies of (A) pregnancy risk perceptions,
(B) moderate LTPA efficacy beliefs, and (C) vigorous LTPA efficacy beliefs (7=strongly
agree, 1= strongly disagree).
140

(A)

120

Frequency

100
80
60
40
20
0
1.0

2.0

3.0

4.0

5.0

6.0

7.0

Pregnancy Risk Perceptions

50

50

(C)

(B)
40

Frequency

Frequency

40
30
20
10

30
20
10

0

0
1.0

2.0

3.0

4.0

5.0

6.0

7.0

Moderate LTPA Efficacy

1.0

2.0

3.0

4.0

5.0

6.0

Vigorous LTPA Efficacy

117

7.0

Table 4.2. LTPA descriptive statistics for total sample.
(n=302)
median (range)
Moderate LTPA (min/week)
Vigorous LTPA (min/week)
Prepregnancy Moderate LTPA (min/week)
Prepregnancy Vigorous LTPA (min/week)
Pregnancy Risk†
Moderate LTPA Efficacy†
Vigorous LTPA Efficacy†

90 (0, 1080)
0 (0, 360)
120 (0, 1080)
37.5 (0, 450)
2.0 (1.0, 7.0)
5.5 (1.0, 7.0)
4.0 (1.0, 7.0)

†For all risk and efficacy variables; 7=strongly agree, 1=strongly disagree

Specific Aim 3: To determine if differences exist in meeting the moderate LTPA guidelines
among pregnancy risk perception/moderate LTPA efficacy attitudinal groups as defined by the
RPA.
Descriptive statistics for demographic characteristics of each attitudinal group are
displayed in Table 4.3. Chi-square analyses indicated differences among attitudinal groups for
race, education, income, preterm birth, adverse maternal conditions for a prior pregnancy,
moderate LTPA risk perception, total physical activity social support, as well as physical activity
social support from family and friends (p<0.05).

118

Table 4.3. Participant characteristics of attitudinal groups (moderate LTPA).

median (range)
Age (years)
Gestational Age (weeks)
frequency (percentage)
Parity
Nulliparous
Multiparous
Race
Caucasian
Non-Caucasian
Education
High School or less
Some College
Income
≤$30,000
>$30,000
Miscarriage
Preterm Birth
C-section
Previous Conditions†
Current Conditions†
LTPA Risk
Strong disagreement
All else
Total Social Support
High
Low
Family Social Support
High
Low
Friend Social Support
High
Low
Sig Other Social Support
High
Low
Discussed LTPA w/ HCP
Pre Met LTPA Guidelines
Meet LTPA Guidelines

Responsive
(n=87)

Proactive
(n=72)

Avoidant
(n=67)

Indifferent
(n=76)

p-value

28 (19, 39)
24 (8, 40)

28.5 (19, 40)
28 (5, 40)

28 (19, 40)
24.5 (8, 40)

26 (15, 45)
29.5 (6, 40)

0.191
0.062

33 (37.9)
54 (62.1)

21 (29.2)
51 (70.8)

29 (43.3)
38 (56.7)

26 (34.2)
50 (65.8)

78 (89.7)
9 (10.3)

51 (70.8)
21 (29.2)

48 (71.6)
19 (28.4)

43 (56.6)
33 (43.4)

21 (24.1)
66 (75.9)

28 (38.9)
44 (61.1)

26 (38.8)
41 (61.2)

48 (63.2)
28 (36.8)

31 (35.6)
56 (64.4)
23 (26.4)
13 (14.9)
13 (14.9)
5 (5.7)
10 (11.5)

31 (43.1)
41 (56.9)
23 (31.9)
5 (6.9)
14 (19.4)
6 (8.3)
6 (8.3)

27 (40.9)
39 (59.1)
22 (32.8)
13 (19.4)
11 (16.4)
12 (17.9)
13 (19.4)

47 (63.5)
27 (36.5)
23 (30.3)
9 (11.8)
16 (21.1)
13 (17.1)
9 (11.8)

68 (78.2)
19 (21.8)

65 (90.3)
7 (9.7)

24 (35.8)
43 (64.2)

48 (63.2)
28 (36.8)

0.356

<0.001*

<0.001*

0.003*

0.823
0.037*
0.841
0.016*
0.246
<0.001*

0.037*
46 (52.9)
41 (47.1)

45 (62.5)
27 (37.5)

28 (41.8)
39 (58.2)

32 (42.1)
44 (57.9)

51 (58.6)
36 (41.4)

44 (61.1)
28 (38.9)

25 (37.3)
42 (62.7)

34 (44.7)
42 (55.3)

0.011*

0.015*
49 (56.3)
38 (43.7)

46 (63.9)
26 (36.1)

29 (43.3)
38 (56.7)

31 (40.8)
45 (59.2)

49 (56.3)
38 (43.7)
58 (66.7)
43 (49.4)
33 (37.9)

45 (62.5)
27 (37.5)
46 (63.9)
34 (47.2)
24 (33.3)

32 (47.8)
35 (52.2)
47 (70.1)
20 (29.9)
13 (19.4)

40 (52.6)
36 (47.4)
48 (63.2)
27 (35.5)
12 (15.8)

0.349

0.815
0.044*
0.004*

*Significant differences comparing RPA groups (p <0.05).
†Gestational diabetes, pregnancy-induced hypertension, hyperemesis gravidarum, or major depressive disorder.

119

The frequency of participants meeting moderate LTPA guidelines during pregnancy
significantly differed among groups, χ2(3)=13.50, p=0.004. Pairwise comparisons with
Bonferonni adjustments were performed and revealed that the frequency of meeting moderate
LTPA guidelines was significantly greater for the responsive group compared to the indifferent
group (Figure 4.3). No other significant differences in meeting the moderate LTPA guidelines
were found.
Figure 4.3. Relative frequency of meeting moderate LTPA guidelines by attitudinal groups.
45

Relative Frequency (%)

40

*

35
30
25
20
15

10
5
0

Responsive

Proactive

Avoidant

Indifferent

*Significantly greater than the indifferent attitudinal group (p<0.008).

Logistic regression was performed to determine the odds of meeting moderate LTPA
guidelines during pregnancy for each attitudinal group. The overall unadjusted model was
statistically significant (χ2(3)=13.83, p=0.003), but explained only 6.5% of the variance in
meeting the guidelines. Table 4.4 shows the responsive group had 3.26 times the odds (CI=1.536.92) of achieving the moderate LTPA guidelines as compared to the indifferent group, whereas
the proactive group had 2.67 times the odds (CI=1.21-5.86). The avoidant group did not have
significantly greater odds than did the indifferent group of achieving these guidelines.

120

Of the demographic characteristics that differed significantly among attitudinal groups
(Table 4.3), only income level, moderate LTPA risk perception, and meeting LTPA guidelines
prior to pregnancy significantly entered the logistic regression model. The adjusted model was
also statistically significant (χ2(6)=70.84, p<0.001) and explained 30.5% of the variance in
meeting moderate LTPA guidelines. Further results of the adjusted model are displayed in Table
4.4 and show the responsive group had 3.23 times the odds (CI=1.35-7.74) of meeting the
guidelines as compared to the indifferent group. After controlling for potential confounding
variables, the difference between the proactive and indifferent groups bordered on statistical
significance. As with the unadjusted analyses, odds ratio differences were not apparent between
the avoidant group and indifferent group in the adjusted model.

Table 4.4. Odds of meeting moderate LTPA guidelines by attitudinal groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

Avoidant

1.28 [0.54-3.05]

0.571

1.94 [0.72-5.21]

0.188

Proactive

2.67 [1.21-5.86]

0.015*

2.44 [0.99-6.01]

0.052

Responsive

3.26 [1.53-6.92]

0.002*

3.23 [1.35-7.74]

0.008*

Indifferent

*Significantly different compared to indifferent group (p<0.05).
†Adjusted for income, moderate LTPA risk perception, and meeting moderate LTPA guidelines prior to pregnancy.

Specific Aim 4: To determine if differences exist in vigorous LTPA participation among
pregnancy risk perception/vigorous LTPA efficacy attitudinal groups as defined by the RPA.
Descriptive statistics for demographic characteristics of each attitudinal group are
displayed in Table 4.5. Kruskal-Wallis analyses suggested that age and gestational age differ
among attitudinal groups. Chi-square analyses indicated differences among attitudinal groups

121

for race, education, income, miscarriage, preterm birth, and vigorous LTPA risk perception
(p<0.05).

Table 4.5. Participant characteristics of attitudinal groups (vigorous LTPA).

median (range)
Age (years)
Gestational Age (weeks)
frequency (percentage)
Parity
Nulliparous
Multiparous
Race
Caucasian
Non-Caucasian
Education
High School or less
Some college
Income
≤$30,000
>$30,000
Miscarriage
Preterm Birth
C-section
Previous Conditions†
Current Conditions†
LTPA Risk
Strong disagreement
All else
Total Social Support
High
Low
Family Social Support
High
Low
Friend Social Support
High
Low
Sig Other Social Support
High
Low
Discussed LTPA w/ HCP
Pre Any Vigorous LTPA
Any Vigorous LTPA

Responsive
(n=81)

Proactive
(n=68)

Avoidant
(n=73)

Indifferent
(n=80)

p-value

27 (19, 39)
23 (8, 40)

29 (17, 40)
32 (5, 40)

29 (19, 40)
26 (8, 40)

25 (15, 45)
27.5 (6, 40)

0.006*
0.020*

0.161
31 (38.3)
50 (61.7)

17 (25.0)
51 (75.0)

31 (42.5)
42 (57.5)

30 (37.5)
50 (62.5)

69 (85.2)
12 (14.8)

51 (75.0)
17 (25.0)

57 (78.1)
16 (21.9)

43 (53.8)
37 (46.3)

26 (32.1)
55 (67.9)

25 (36.8)
43 (63.2)

21 (28.8)
52 (71.2)

51 (63.7)
29 (36.3)

32 (40.0)
48 (60.0)
15 (18.5)
10 (12.3)
13 (16.0)
9 (11.1)
8 (9.9)

28 (41.8)
39 (58.2)
25 (36.8)
5 (7.4)
14 (20.6)
8 (11.8)
7 (10.3)

26 (35.6)
47 (64.4)
30 (41.1)
16 (21.9)
11 (15.1)
8 (11.0)
15 (20.5)

50 (63.3)
29 (36.7)
21 (26.3)
9 (11.3)
16 (20.0)
11 (13.8)
8 (10.0)

16 (19.8)
65 (80.2)

31 (45.6)
37 (54.4)

3 (4.1)
70 (95.9)

18 (22.5)
62 (77.5)

43 (53.1)
38 (46.9)

38 (55.9)
30 (44.1)

31 (42.5)
42 (57.5)

39 (48.8)
41 (51.2)

46 (56.8)
35 (43.2)

39 (57.4)
29 (42.6)

30 (41.1)
43 (58.9)

39 (48.6)
41 (51.2)

46 (56.8)
35 (43.2)

37 (54.4)
31 (45.6)

32 (43.8)
41 (56.2)

40 (50.0)
40 (50.0)

46 (56.8)
35 (43.2)
54 (66.6)
62 (76.5)
41 (50.6)

41 (60.3)
27 (39.7)
41 (60.3)
45 (66.2)
26 (38.2)

35 (47.9)
38 (52.1)
51 (69.9)
37 (50.7)
4 (5.5)

44 (55.0)
36 (45.0)
53 (66.3)
46 (57.5)
20 (25.0)

<0.001*

<0.001*
0.003*

0.010*
0.009*
0.903
0.872
0.135
<0.001*

0.398

0.157

0.404

0.504

0.685
<0.006*
<0.001*

*Significant differences comparing RPA groups (p <0.05).
†Gestational diabetes, pregnancy-induced hypertension, hyperemesis gravidarum, or major depressive disorder

122

The frequency of participating in any vigorous LTPA during pregnancy significantly
differed among groups (χ2(3)=40.34, p<0.001). Pairwise comparisons with Bonferonni
corrections were performed and revealed that the frequency of participating in vigorous LTPA
was significantly greater for the responsive group compared to the avoidant and indifferent
groups (Figure 4.4). Additionally, both proactive and indifferent groups had a higher frequency
of participating in vigorous LTPA than did the avoidant group (Figure 4.4).
Figure 4.4. Relative frequency of participating in any vigorous LTPA by attitudinal groups.
60

Relative Frequency (%)

*
50
†
40
†

30

20
10
0

Responsive

Proactive

Avoidant

Indifferent

*Significantly greater than the avoidant and indifferent attitudinal groups (p<0.008).
†Significantly greater than the avoidant attitudinal group (p<0.008).

Logistic regression was performed to determine the odds of participating in any vigorous
LTPA during pregnancy for each attitudinal group. The overall unadjusted model was
statistically significant (χ2(3)=45.91, p<0.001) and explained only 20.0% of the variance in
meeting the guidelines. Table 4.6 shows the responsive group had 3.08 times the odds (CI=1.585.99) of participating in vigorous LTPA as compared to the indifferent group. However, the

123

avoidant group had significantly lower odds (OR=0.17, CI=0.06-0.54) compared to the
indifferent group. The proactive group approached significantly greater odds of achieving the
guidelines compared to the indifferent group.
Of the demographic characteristics that significantly differed among attitudinal groups
(Table 4.5), only education level, vigorous LTPA risk perception, and participating in vigorous
LTPA prior to pregnancy significantly entered the logistic regression model. The adjusted model
was also statistically significant (χ2(6)=116.86, p<0.001) and explained 45.5% of the variance in
vigorous LTPA participation. Further results of the adjusted model are displayed in Table 4.6
and show the responsive group had 3.65 times the odds (CI=1.60-8.36) of participating in
vigorous LTPA as compared to the indifferent group, with the avoidant group having had
significantly lower odds (aOR=0.25, CI=0.07-0.86). Like the unadjusted model, adjusted results
revealed the odds of participating in vigorous LTPA to be near statistically greater for the
proactive group than the indifferent group.

Table 4.6. Odds of participating in and vigorous LTPA by attitudinal groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

Avoidant

0.17 [0.06-0.54]

0.001*

0.25 [0.07-0.86]

0.028*

Proactive

1.86 [0.92-3.75]

0.080

2.24 [0.95-5.27]

0.064

Responsive

3.08 [1.58-5.99]

0.002*

3.65 [1.60-8.36]

0.002*

p-value

Indifferent

*Significantly different compared to indifferent group (p<0.05).
†Adjusted for education, vigorous LTPA risk perception, and participating in vigorous LTPA prior to pregnancy.

124

Specific Aim 5: To determine if the interaction of pregnancy risk perceptions and moderate
LTPA efficacy is associated with meeting moderate LTPA guidelines among pregnant women.
Correlations between demographic characteristics and the independent variables and
dependent variable are displayed in Table 4.7. Moderate LTPA risk perception and multiparity
were weakly inversely associated with the likelihood of meeting the moderate LTPA guidelines
(r= -0.12 and r= -0.13, p<0.05). Meeting moderate LTPA guidelines prior to pregnancy was
moderately associated with meeting moderate LTPA guidelines during the current pregnancy
(r=0.43, p<0.05).
Table 4.8 shows the results from the hierarchical logistic regression analyses. For step 1,
demographic control variables (income level, meeting moderate LTPA guidelines prior to
pregnancy) were entered into the model and explained 25.9% of the variance in meeting
moderate LTPA guidelines during pregnancy. Specifically, those who met these guidelines prior
to pregnancy were 8.20 times more likely (p<0.001) to meet them during pregnancy compared to
those who did not. For step 2, the single psychosocial control variable (moderate LTPA risk
perception) was entered into the model and explained an additional 1.6% of the variance. The
main effects of pregnancy risk perceptions and moderate LTPA efficacy beliefs were tested in
step 3. Results from this step explained an additional 6.4% of the variance in meeting moderate
LTPA guidelines. Those with higher pregnancy risk perceptions (per 0.5 increase on 1-7
agreement scale) had significantly greater odds (OR=1.37, p<0.05) of meeting the moderate
LTPA guidelines compared to those with lower risk perceptions. Likewise, those with higher
efficacy beliefs for moderate LTPA (per 0.5 increase on 1-7 agreement scale) had significantly
greater odds (OR=1.82, p<0.01). In the final step, the interaction term for pregnancy risk and

125

moderate LTPA efficacy was entered into the model but was not significant. In total, the model
explained 34% of the variance in meeting moderate LTPA guidelines during pregnancy.
Table 4.7. Bivariate correlations among demographic and moderate LTPA variables.
Variable
Age
Gestational Age
Total Social Support
Mod LTPA Risk Perception
Parity (multiparous)
Race (Caucasian)
Education (>High School)
Income (>$30,000)
Past Miscarriage
Past Preterm Birth
Past C-Section
Previous Conditions†
Current Conditions†
Discussed LTPA w/ HCP
Pre Met LTPA Guidelines

Pregnancy Risk
Perceptions
.100
-.156**
.049
.216**
-.117*
.196**
.219**
.168**
-.001
.148*
-.053
.019
.081
.085
.019

Mod LTPA
Efficacy Beliefs
.070
-.117*
.201**
-.364**
-.022
.227**
.269**
.156**
-.051
-.111
-.114
-.247**
-.126*
.016
.211**

Pregnancy Risk x
LTPA Efficacy
-.044
.013
.047
-.149**
-.012
-.010
-.108
-.091
-.108
-.024
.012
.003
-.055
-.034
.052

Met LTPA
Guidelines
-.046
-.015
.003
-.125*
-.115*
.071
-.009
-.071
.021
.081
.011
-.074
.038
.015
.429**

*Significant correlation (p<0.05).
**Significant correlation (p<0.01).
†Gestational diabetes, pregnancy-induced hypertension, hyperemesis gravidarum, or major depressive disorder.

Table 4.8. Predictors of meeting moderate LTPA guidelines.
Exp(β)

95% C.I.

Income

0.69

[0.39-1.21]

Pre Met LTPA Guidelines

8.20***

[4.56-14.88]

Step 1: Demographic Controls

.016*

Step 2: Psychosocial Controls
LTPA Risk Perception

0.74

[0.54-1.01]
.064***

Step 3: Risk and Efficacy Effects
Pregnancy Risk Perceptions†

1.37*

[1.02-1.84]

LTPA Efficacy Beliefs†

1.82**

[1.24-2.68]
NS

Step 4: Interaction
Pregnancy Risk x LTPA Efficacy†
Total R2

∆R2
.259***

0.94

[0.66-1.36]
.340***

*Significant correlation (p<0.05).
**Significant correlation (p<0.01).
***Significant correlation (P<0.001).
2
†Variables centered and standardized according to Aiken & West.

126

Specific Aim 6: To determine if the interaction of pregnancy risk perceptions and vigorous
LTPA efficacy is associated with participating in any vigorous LTPA among pregnant women.
Correlations among demographic characteristics and the independent variables and
dependent variable are displayed in Table 4.9. Vigorous LTPA risk perception and having
experienced preterm birth for a previous pregnancy were weakly inversely associated with
participating in vigorous LTPA (r= -0.16 and r= -0.14, p<0.05). Participating in vigorous LTPA
prior to pregnancy was moderately associated with vigorous LTPA participation during the
current pregnancy (r=0.44, p<0.05).
Table 4.10 shows the results from the hierarchical logistic regression analyses. For step
1, demographic control variables (education, participating in any vigorous LTPA prior to
pregnancy) were entered into the model and explained 32.8% of the variance in vigorous LTPA
participation during pregnancy. Specifically, those who participated in vigorous LTPA prior to
pregnancy had significantly greater odds (OR=25.29, p<0.001) to do so during pregnancy
compared to those who did not. However, pregnant women with some level of college education
had significantly lower odds (OR=0.48, p<0.05) of participating in vigorous LTPA compared to
those with lower education levels. For step 2, the single psychosocial control variable (vigorous
LTPA risk perception) was entered into the model and explained a further 2.1% of the variance.
The main effects of pregnancy risk perceptions and vigorous LTPA efficacy beliefs were tested
in step 3. Results from this step explain an additional 16.6% of the variance in vigorous LTPA
participation during pregnancy. The pregnancy risk perceptions score was not significantly
related to vigorous LTPA participation during pregnancy. However, those with higher vigorous
LTPA efficacy beliefs (per 0.5 increase on 1-7 agreement scale) had 4.09 times greater odds
(p<0.01) compared to those with lower vigorous LTPA efficacy. In the final step, the interaction

127

term for pregnancy risk and vigorous LTPA efficacy was entered into the model, but was not
significant. In total, the model explained 51.5% of the variance in vigorous LTPA participation.
Table 4.9. Bivariate correlations among demographic and vigorous LTPA variables.
Variable
Age
Gestational Age
Total Social Support
Vig LTPA Risk Perception
Parity (parous)
Race (Caucasian)
Education (>High School)
Income (>$30,000)
Past Miscarriage
Past Preterm Birth
Past C-Section
Previous Conditions†
Current Conditions†
Discussed LTPA w/ HCP
Pre Any Vigorous LTPA

Pregnancy Risk
Perceptions
.100
-.156**
.049
.202**
-.117*
.196**
.219**
.168**
-.001
.148*
-.053
.019
.081
.085
.044

Vig LTPA
Efficacy Beliefs
.089
.043
.165**
-.383**
.070
.222**
.126*
.104
-.102
-.140
-.028
-.031
-.068
-.022
.187**

Pregnancy Risk x
LTPA Efficacy
-.106
-.008
.087
-.093
-.041
-.102
-.139*
-.098
-.108
.016
.030
.040
-.071
-.010
.009

Any Vigorous
LTPA
-.097
.015
.087
-.156**
-.077
-.005
-.102
-.089
-.070
-.143*
-.099
-.001
.012
.122*
.444**

*Significant correlation (p<0.05).
**Significant correlation (p<0.01).
†Gestational diabetes, pregnancy-induced hypertension, hyperemesis gravidarum, or major depressive disorder.

Table 4.10. Predictors of participating in vigorous LTPA.
Exp(β)

95% C.I.

.328***

Step 1: Demographic Controls
Education

0.48*

[0.27-0.85]

Pre Any Vigorous LTPA

25.29***

[8.86-72.19]
.021*

Step 2: Psychosocial Controls
LTPA Risk Perception

0.79*

[0.65-0.96]
.166***

Step 3: Risk and Efficacy Effects
Pregnancy Risk Perceptions†

1.04

[0.75-1.46]

LTPA Efficacy Beliefs†

4.09***

[2.57-6.49]
NS

Step 4: Interaction
Pregnancy Risk x LTPA Efficacy†
Total R2

∆R2

1.41

[0.86-2.29]
.515***

*Significant correlation (p<0.05).
***Significant correlation (p<0.001).
2
†Variables centered and standardized according to Aiken & West.

128

Specific Aim 7: To determine the relationship of religion (Latter-day Saints [LDS] vs. nonLDS (high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with
LTPA, pregnancy risk perceptions, and LTPA efficacy beliefs among pregnant women.
Demographic characteristics of each religious group are displayed in Table 4.11.
Education and income level significantly differed among religious groups (χ2(3)=15.71, p=0.001;
χ2(3)=38.14, p<0.001) with LDS pregnant women more likely to have completed at least some
college education and have a higher income level compared to non-LDS high, moderate, and low
religiosity pregnant women. LDS pregnant women were also more likely to be Caucasian than
non-LDS pregnant women of low and moderate religiosity, who in turn were more likely to be
Caucasian than non-LDS high religiosity pregnant women (χ2(3)=42.25, p<0.001). Differences
were not seen among religious groups for the likelihood of experiencing miscarriage, preterm
birth, C-section, adverse maternal conditions during this pregnancy, and adverse maternal
conditions during a previous pregnancy. LDS pregnant women were more likely to be
multiparous than non-LDS pregnant women of moderate and low religiosity (χ2(3)=19.92,
p<0.001), but not more so than non-LDS high religiosity pregnant women. Furthermore, LDS
pregnant women were more likely to seek the help of a healthcare professional for the purpose of
becoming pregnant compared to non-LDS pregnant women of high, moderate, or low religiosity
(χ2(3)=10.80, p<0.013). LTPA behavior and perception variables for each religious group are
displayed in Table 4.12.

129

Table 4.11. Demographic characteristics for religious groups.
LDS

median (range)
Age (years)
Gestational Age (weeks)
Religiosity Score
frequency (percentage)
Parity
Nulliparous
Multiparous
Race
Caucasian
Non-Caucasian
Education
High School or less
Some College
Income
≤$30,000
>$30,000
Miscarriage
Preterm Birth
C-section
Previous Conditions†
Current Conditions†
Fertility Treatment

Non-LDS

Non-LDS

Non-LDS

(High Rel.)

(Mod Rel.)

(Low Rel.)

(n=94)

(n=75)

(n=68)

(n=65)

29 (20, 45)
27.5 (6, 40)
40 (11, 40)

27 (17, 36)
26 (10, 40)
39 (36, 40)

26.5 (18, 40)
27 (5, 40)
28 (20, 35)

28 (15, 38)
28 (20, 35)
12 (10, 19)

p-value

0.064
0.894
<0.001*

<0.001*
19 (20.2)
75 (79.8)

27 (36.0)
48 (64.0)

28 (41.2)
40 (58.8)

35 (53.8)
30 (46.2)

87 (92.5)
7 (7.4)

36 (48.0)
39 (52.0)

48 (70.6)
20 (29.4)

49 (75.4)
16 (24.6)

<0.001*

0.001*
24 (25.5)
70 (74.5)

41 (54.7)
34 (45.3)

31 (45.6)
37 (54.4)

27 (41.5)
38 (58.5)

19 (20.2)
75 (79.8)
29 (30.9)
18 (19.1)
19 (20.2)
11 (11.7)
9 (9.6)
19 (20.2)

44 (60.3)
29 (39.7)
20 (26.7)
5 (6.7)
10 (13.3)
11 (14.7)
11 (14.7)
5 (6.7)

42 (61.8)
26 (38.2)
24 (35.3)
8 (11.8)
13 (19.1)
10 (14.7)
9 (13.2)
4 (5.9)

31 (48.4)
33 (51.6)
18 (27.7)
9 (13.8)
12 (18.5)
4 (6.2)
9 (13.8)
7 (10.8)

<0.001*

*Significant differences comparing religious groups (p<0.05).
†Religiosity scores range from 10-40 (per the Santa Clara Strength of Religious Faith Questionnaire)

130

0.683
0.159
0.258
0.420
0.755
0.013*

Table 4.12. LTPA behavior and perceptions of religious groups.
LDS

frequency (percentage)
Pre Met LTPA Guidelines
Met LTPA Guidelines
Pre Any Vigorous LTPA
Any Vigorous LTPA
Pregnancy Risk
Strong disagreement
All else
Moderate LTPA Efficacy
Strong agreement
All else
Vigorous LTPA Efficacy
Agreement
Unsure or disagreement
Moderate LTPA Risk
Strong disagreement
All else
Vigorous LTPA Risk
Strong disagreement
All else

Non-LDS

Non-LDS

Non-LDS

(High Rel.)

(Mod Rel.)

(Low Rel.)

(n=94)

(n=75)

(n=68)

(n=65)

33 (35.1)
18 (19.1)
64 (68.1)
31 (33.0)

30 (40.0)
19 (25.3)
43 (57.3)
31 (41.3)

31 (45.6)
16 (23.5)
44 (64.7)
15 (22.1)

30 (46.2)
29 (44.6)
39 (60.0)
14 (21.5)

37 (39.4)
57 (60.6)

44 (58.7)
31 (41.3)

28 (41.2)
40 (58.8)

39 (60.0)
26 (40.0)

25 (26.6)
69 (73.4)

22 (29.3)
53 (70.7)

12 (17.6)
56 (82.4)

12 (18.5)
53 (81.5)

56 (59.6)
38 (40.4)

42 (56.0)
33 (44.0)

29 (42.6)
39 (57.4)

22 (33.8)
43 (66.2)

70 (74.5)
24 (25.5)

54 (72.0)
21 (28.0)

41 (60.3)
27 (39.7)

40 (61.5)
25 (38.5)

23 (24.5)
71 (75.5)

17 (22.7)
58 (77.3)

14 (20.6)
54 (79.4)

14 (21.5)
51 (78.5)

p-value

0.443
0.003*
0.492
0.027*
0.011*

0.247

0.005*

0.142

0.943

*Significant differences comparing religious groups (p<0.05).

The relative frequency of participants in each group meeting moderate LTPA guidelines
during pregnancy was examined via chi-square analysis with Bonferroni adjustments. Results
showed differences among religious groups (χ2(3)=13.64, p=0.003), with LDS pregnant women
being less likely to meet moderate LTPA guidelines compared to non-LDS low religiosity
pregnant women (Figure 4.5), but not the other religiosity groups. Logistic regression analyses
were performed, with the unadjusted model (χ2(3)=12.94 p=0.005) indicating that non-LDS low
religiosity pregnant women had higher odds (OR=3.43, CI=1.67-6.91) of meeting the moderate
LTPA guidelines compared to LDS pregnant women (Table 4.13). However, this explained only
6.1% percent of the variance. After controlling for potential confounding variables (pregnancy
risk perceptions and participating in any vigorous LTPA), the first adjusted model† remained

131

statistically significant (χ2(5)=25.28, p<0.001) and explained 11.6% percent of the variance. As
displayed in Table 4.13, adjusted findings† also show that non-LDS low religiosity pregnant
women had higher odds (aOR=4.17, CI=1.99-8.75) of meeting moderate LTPA guidelines
compared to LDS pregnant women. In a final adjusted analysis, moderate LTPA efficacy beliefs
and meeting moderate LTPA guidelines prior to pregnancy were additionally controlled for,
resulting in a significant model (χ2(7)=91.38, p<0.001) that explained 37.9% of the variance.
Adjusted findings indicated the same significant differences in odds of meeting the moderate
LTPA recommendations as the previous models, with non-LDS low religiosity pregnant women
having greater odds (aOR=5.43, CI=2.28-12.9) compared to LDS pregnant women (Table 4.13).
Non-LDS high and moderate religiosity pregnant women did not significantly differ from LDS
pregnant women for these analyses.
Chi-square analysis indicated the relative frequency of pregnant women who participated
in any vigorous LTPA during pregnancy significantly differed among religious groups
(χ2(3)=3.22, p=0.027). However, when Bonferroni adjustments were applied to the p value,
group differences were not observed. The unadjusted logistic regression model was statistically
significant (χ2(3)=9.24, p=0.026) but did not indicate that non-LDS pregnant women of any
religiosity level differed from LDS pregnant women with respect to the odds of vigorous LTPA
participation (Table 4.14). The first adjusted model† controlled for vigorous LTPA efficacy
beliefs and meeting moderate LTPA guidelines. This model significantly explained
(χ2(5)=65.22, p<0.001) 27.5% of the variance but again showed no differences in the odds of
vigorous LTPA participation between non-LDS pregnant women and LDS pregnant women. A
final adjusted model additionally controlled for education level and vigorous LTPA participation

132

prior to pregnancy and explained 53.7% of the variance (χ2(7)=143.89, p<0.001). Once again,
no significant differences in the odds of participating in vigorous LTPA were observed.
Figure 4.5. Relative frequencies of meeting moderate LTPA guidelines and participating in
any vigorous LTPA by religious groups.
50

Relative Frequency (%)

45
40
35
30

LDS
Non-LDS (High)

25
20

*

Non-LDS (Mod)
Non-LDS (Low)

15

10
5
0
Moderate LTPA Guidelines

Any Vigorous LTPA

*Significantly less than non-LDS (low religiosity) pregnant women (p<0.008).

Table 4.13. Odds of meeting moderate LTPA guidelines during pregnancy by religious
groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.43 [0.69-3.00]

0.335

1.42 [0.67-3.02]

0.357

Non-LDS Mod Religiosity

1.30 [0.61-2.80]

0.500

1.44 [0.66-3.15]

0.356

Non-LDS Low Religiosity

3.40 [1.67-6.91]

0.001*

4.17 [1.99-8.75]

0.001*

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†Adjusted for pregnancy risk perceptions and participating in any vigorous LTPA.

133

Table 4.14. Odds of participating in any vigorous LTPA during pregnancy by religious
groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.43 [0.76-2.69]

0.264

1.79 [0.88-3.63]

0.110

Non-LDS Mod Religiosity

0.58 [0.28-1.18]

0.130

0.73 [0.33-1.60]

0.431

Non-LDS Low Religiosity

0.56 [0.27-1.16]

0.118

0.72 [0.31-1.67]

0.447

LDS

* Significantly different compared to LDS religiosity group (p<0.05).
†Adjusted for vigorous LTPA efficacy beliefs and meeting moderate LTPA recommendations.

Chi-square analyses indicated religious groups differed in having strong disagreement
with pregnancy risk (χ2(3)=11.11, p=0.011). However, when Bonferroni adjustments were
applied, these differences were no longer apparent. The unadjusted logistic regression model
was statistically significant (χ2(3)=11.18, p=0.011) and indicated that non-LDS high and low
religiosity pregnant women were more likely (OR=2.19, CI=1.18-4.06; OR=2.31, CI=1.21-4.41)
to have strong disagreement compared to LDS pregnant women (Table 4.15). The adjusted
model† was significant (χ2(6)=22.57, p<0.001) and controlled for race, education, and preterm
birth from a previous pregnancy. Although adjusted analyses† explained 14.7% of the variance
in the odds of having strong disagreement with pregnancy risk, differences between LDS and
non-LDS pregnant women of any religiosity were not observed (Table 4.15).

Table 4.15. Odds of strong disagreement with pregnancy risk by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

2.19 [1.18-4.06]

0.013*

1.18 [0.51-2.75]

0.698

Non-LDS Mod Religiosity

1.08 [0.57-2.04]

0.816

0.98 [0.43-2.24]

0.965

Non-LDS Low Religiosity

2.31 [1.21-4.41]

0.011*

2.06 [0.82-5.18]

0.125

LDS

* Significantly different compared to LDS religiosity group (p<0.05).
†Adjusted for race, education, and preterm birth from a previous pregnancy.

134

The relative frequency of participants indicating strong agreement with response/selfefficacy of moderate LTPA during pregnancy did not significantly differ among religious groups
(χ2(3)=4.13, p=0.247) according to chi-square analysis with Bonferroni adjustments. The
unadjusted logistic regression model was additionally not significant (χ2(3)=4.19, p=0.242);
however, an adjusted model† (in which education, vigorous LTPA efficacy, and meeting
moderate LTPA guidelines were controlled for) was statistically significant (χ2(6)=60.58,
p<0.001). For both the unadjusted and adjusted models, the odds of pregnant women reporting
strong agreement with moderate LTPA efficacy did not differ between LDS pregnant women
and non-LDS pregnant women of any religiosity (Table 4.16).
Chi-square analysis with Bonferroni adjustments indicated the relative frequency of
participants reporting at least some agreement with the response/self-efficacy of vigorous LTPA
during pregnancy differed among religious groups (χ2(3)=12.73, p=0.005). Specifically, LDS
pregnant women were more likely to have some agreement with vigorous LTPA efficacy
compared non-LDS low religiosity pregnant women (Figure 4.6). Unadjusted results from
logistic regression analysis (χ2(3)=12.88, p=0.005) explained only 5.6% of the variance, but also
indicated that non-LDS moderate and low religiosity pregnant women had significantly lower
odds (OR=0.51, CI=0.27-0.95; OR=0.35, CI=0.18-0.67) of agreeing with vigorous LTPA efficacy
compared to LDS pregnant women (Table 4.17). After controlling for potential confounding
variables (race, education, and participating in any vigorous LTPA during pregnancy), the
adjusted model† remained significant (χ2(6)=54.88, p<0.001), but explained 22.2% of the
variance. As shown in table 4.17, adjusted results† indicated only non-LDS low religiosity
pregnant women significantly differ (aOR=0.44, CI=0.22-0.90) from LDS pregnant women in
having some agreement with vigorous LTPA efficacy.

135

Figure 4.6. Relative frequencies of participant agreement for vigorous LTPA efficacy by
religious groups.

Relative Frequency (%)

70
60

*

50
LDS

40

Non-LDS (High)

30

Non-LDS (Mod)

20

Non-LDS (Low)

10
0

Some Agreement
*Significantly greater than non-LDS (low religiosity) pregnant women (p<0.008).

Table 4.16. Odds of strong agreement with moderate LTPA efficacy during pregnancy
by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.15 [0.58-2.25]

0.693

1.64 [0.75-3.59]

0.215

Non-LDS Mod Religiosity

0.59 [0.27-1.28]

0.183

0.83 [0.35-1.96]

0.674

Non-LDS Low Religiosity

0.63 [0.29-1.36]

0.625

0.77 [0.32-1.89]

0.571

LDS

* Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for education, vigorous LTPA efficacy beliefs, and meeting moderate LTPA guidelines.

136

Table 4.17. Odds of some agreement with vigorous LTPA efficacy during pregnancy by
religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

0.86 [0.47-1.60]

0.640

1.24 [0.60-2.55]

0.568

Non-LDS Mod Religiosity

0.51 [0.27-0.95]

0.034*

0.72 [0.36-1.43]

0.345

Non-LDS Low Religiosity

0.35 [0.18-0.67]

0.002*

0.44 [0.22-0.90]

0.025*

LDS

* Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for race, education, and participating in vigorous LTPA.

Specific Aim 8: To determine the relationship of religion (Latter-day Saints [LDS] vs. nonLDS (high religiosity) vs. non-LDS (moderate religiosity) vs. non-LDS (low religiosity)) with
prenatal HCP discussions, satisfaction with these discussions, and physical activity social
support among pregnant women.
LTPA social characteristics for each religious group are displayed in Table 4.18.
Differences were not found among religious groups in discussing LTPA with a prenatal HCP
during pregnancy (χ2(3)=1.17, p=0.760). This was confirmed via results from logistic regression
analyses (Table 4.19). The unadjusted model was not significant (χ2(3)=1.16, p=0.762).
Although the second model† (adjusted for parity, total social support, and participation in
vigorous LTPA) was significant (χ2(6)=16.78, p=0.010) and explained 7.5% of the variance, it
did not show that the odds of discussing LTPA with a prenatal HCP differed between LDS and
non-LDS pregnant women of any religiosity (Table 4.19).

137

Table 4.18. LTPA social characteristics of religious groups.
LDS

frequency (percentage)
Discussed LTPA w/ HCP
Satisfaction w/ Discussion
High
Low
Total Social Support
High
Low
Family Social Support
High
Low
Friends Social Support
High
Low
Sig Other Social Support
High
Low

Non-LDS

Non-LDS

Non-LDS

(High Rel.)

(Mod Rel.)

(Low Rel.)

(n=94)

(n=75)

(n=68)

(n=65)

58 (61.7)

50 (66.7)

46 (67.6)

45 (69.2)

23 (24.5)
35 (37.2)

24 (32.0)
26 (34.7)

17 (25.0)
29 (42.6)

17 (26.2)
28 (43.1)

52 (55.3)
42 (44.7)

30 (40.0)
45 (60.0)

35 (51.5)
33 (48.5)

34 (52.3)
31 (47.7)

51 (54.3)
43 (45.7)

43 (57.3)
32 (42.7)

30 (44.1)
38 (55.9)

30 (46.2)
35 (53.8)

49 (52.1)
45 (47.9)

37 (49.3)
38 (50.7)

33 (48.5)
35 (51.5)

36 (55.4)
29 (44.6)

57 (60.6)
37 (39.4)

35 (46.7)
40 (53.3)

39 (57.4)
29 (42.6)

35 (53.8)
30 (46.2)

p-value

0.760
0.669

0.235

0.320

0.853

0.321

*Significant differences comparing religious groups (p<0.05).

Chi-square analysis with Bonferroni adjustments likewise did not indicate that religious
groups significantly differed in their satisfaction level with prenatal HCP discussions regarding
LTPA during pregnancy (χ2(3)=1.56, p=0.669). When examined via logistic regression, the
unadjusted model (χ2(3)=1.54, p=0.672) was not significant (Table 4.20). An adjusted model†
which controlled for meeting moderate LTPA guidelines was also not statistically significant
(χ2(4)=6.95 p=0.139). As shown in Table 4.20, differences were not observed among religious
groups for the odds of having high satisfaction with HCP physical activity discussion.

138

Table 4.19. Odds of discussing physical activity with HCP during pregnancy by religious
groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.24 [0.66-2.34]

0.505

1.24 [0.63-2.43]

0.533

Non-LDS Mod Religiosity

1.30 [0.67-2.50]

0.436

1.36 [0.68-2.74]

0.385

Non-LDS Low Religiosity

1.40 [0.71-2.73]

0.329

1.32 [0.64-2.71]

0.453

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for parity, total social support, and participating in vigorous LTPA.

Table 4.20. Odds of high satisfaction with HCP physical activity discussions during
pregnancy by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.41 [ 0.65-3.02]

0.384

1.38 [0.64-3.00]

0.412

Non-LDS Mod Religiosity

0.89 [0.40-1.98]

0.779

0.84 [0.37-1.89]

0.671

Non-LDS Low Religiosity

0.92 [0.41-2.06]

0.846

0.74 [0.32-1.70]

0.475

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for total social support and meeting moderate-LTPA guidelines.

Religious groups did not significantly differ in the relative frequency of pregnant women
reporting high physical activity social support received in total (χ2(3)=4.26, p=0.235), nor in
physical activity social support specifically from family (χ2(3)=3.50, p=0.320) and significant
others (χ2(3)=3.50, p=0.321). Logistic regression results for total social support produced in
unadjusted model that was not significant (χ2(3)=4.28, p=0.232), but indicated the odds of
perceiving higher total support were less (OR=0.53, CI=0.29-0.99) for non-LDS high religiosity
pregnant women compared to LDS pregnant women (Table 4.21). An adjusted model† (which
included race and participating in any vigorous LTPA) was significant (χ2(5)=16.97, p=0.005)

139

and explained 7.3% of the variance, but did not show odds ratio differences among religious
groups.
Logistic regression results for the odds of perceiving high levels of physical activity
social support from family and significant others are described in Tables 4.22 and 4.23.
Unadjusted models for each construct were not significant and did not reveal differences among
religious groups. Adjusted models revealed no significant differences among religious groups,
with the exception of physical activity social support from significant other. After adjusting for
the other social support sources (physical activity social support from family and friends), the
model (χ2(5)=86.94, p<0.001)† explained 33.5% of the variance. Adjusted results† shown in
Table 4.21 indicate that non-LDS high religiosity pregnant women had a significantly lower odds
(aOR=0.44, CI=0.21-0.92) than do LDS pregnant women in perceiving a high level of physical
activity social support from a significant other.
Table 4.21. Odds of perceiving higher levels of physical activity social support (total)
during pregnancy by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

0.53 [0.29-0.99]

0.049*

0.72 [0.37-1.41]

0.338

Non-LDS Mod Religiosity

0.86 [0.46-1.60]

0.628

1.08 [0.56-2.08]

0.809

Non-LDS Low Religiosity

0.89 [0.46-1.67]

0.708

1.08 [0.56-2.09]

0.814

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for race and participating in any vigorous LTPA.

140

Table 4.22. Odds of perceiving high levels of physical activity social support (family)
during pregnancy by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

1.13 [0.62-2.09]

0.689

1.76 [0.81-3.82]

0.154

Non-LDS Mod Religiosity

0.67 [0.36-1.25]

0.204

0.63 [0.29-1.36]

0.236

Non-LDS Low Religiosity

0.72 [0.38-1.36]

0.316

0.64 [0.29-1.41]

0.272

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for social support from friends and significant other.

Table 4.23. Odds of perceiving higher levels of physical activity social support
(significant other) during pregnancy by religious groups.
OR (95% C.I.)

p-value

aOR† (95% C.I.)

p-value

--

--

--

--

Non-LDS High Religiosity

0.57 [0.31-1.05]

0.071

0.44 [0.21-0.92]

0.029*

Non-LDS Mod Religiosity

0.87 [0.46-1.65]

0.675

1.06 [0.50-2.22]

0.889

Non-LDS Low Religiosity

0.76 [0.40-1.44]

0.394

0.76 [0.36-1.62]

0.482

LDS

*Significantly different compared to LDS religiosity group (p<0.05).
†
Adjusted for having a significant other and social support from family and friends.

141

REFERENCES

142

REFERENCES

1.

United States. Department of Health and Human Services. 2008 physical activity
guidelines for Americans : be active, healthy, and happy! Washington, DC: U.S. Dept. of
Health and Human Services; 2008.

2.

Aiken LS, West SG, Reno RR. Multiple regression : testing and interpreting
interactions. Newbury Park, Calif.: Sage Publications; 1991.

143

CHAPTER 5
DISCUSSION
The central purpose of this dissertation was to gain a more comprehensive understanding
of the psychosocial factors that may influence LTPA during pregnancy. Specifically, this study
examined the joint influence of pregnancy risk perceptions and LTPA efficacy beliefs on
pregnancy LTPA behavior at both moderate and vigorous intensities. This was accomplished by
utilizing the Risk Perception Attitude Framework (RPA). In addition, this study examined the
influence of religious beliefs on pregnancy LTPA and potential psychosocial factors that
influence pregnancy LTPA, including pregnancy risk perceptions, LTPA efficacy beliefs,
physical activity social support, and discussions pregnant women have with prenatal HCPs.
Just over 27% (n=82) of pregnant women who participated in this investigation reported
meeting the current moderate LTPA guidelines of at least 150 minutes of moderate physical
activity per week.1 Population-based investigations have shown noticeably lower prevalences.
Evenson et al.2 assessed data collected from the Behavioral Risk Factor Surveillance System
(BRFSS) in 2000 and found that 15.8% of pregnant women (n=1,979) met the moderate LTPA
guidelines most associated with pregnancy at that time, of five bouts per week of at least 30
minutes in duration. Evenson and Wen3 examined data from a different population-based
source, the 1999-2006 National Health and Nutrition Examination Surveys (NHANES). The
investigators found that the prevalence of meeting the most current moderate LTPA guidelines
throughout this time period to be 13.8% (n=1,280). The fact that these are population-based and
consist of substantially larger sample sizes may provide partial explanation why the prevalence
found in the current study (n=302) is higher. More specifically, the convenience sample in the

144

current investigation had higher gestational ages, was slightly more educated, and less ethnically
diverse. Evenson and Wen4 recently examined objective, population-based data (n=396,
NHANES) and found that Caucasian pregnant women were more physically active than pregnant
women of several other races and ethnicities. Thus, the vastly higher prevalence of Caucasian
participants in the current study (compared to those of population-based samples) may account
for the higher rate of meeting the moderate LTPA guidelines. Findings from the current study
appear to be more in line with other non-population-based investigations, such as that by Mudd
et al.,5 who utilized adapted BRFSS questions and found that 29% of pregnant women (n=296,
ethnically diverse) recruited from western-Michigan prenatal healthcare clinics were meeting
current guidelines. Similarities between the current study and Mudd et al.'s study include sample
size and recruitment from Michigan-based prenatal healthcare clinics. However Mudd et al.
defined meeting LTPA guidelines as performing at least 150 minutes per week of moderate or
vigorous activity, whereas the current study considered only moderate activity. This more liberal
definition utilized by these investigators might partially explain the slightly higher prevalence
found in their study.
Although many investigators have reported data from women who participated in “any”
LTPA, few have reported specifically on the frequency of pregnant women who participate in
any vigorous LTPA. Evenson et al.6 sought to understand the effect of vigorous LTPA on birth
outcomes and reported that 14% of pregnant women (n=1,699) participated in any vigorous
LTPA in the first trimester, compared to 8% in the second trimester. Our findings do not agree
with those of Evenson et al., in that 30.1% of our analytic sample typically participated in
vigorous LTPA. A possible reason for the discrepancy between these findings involves a
difference in the question format. While our participants were asked to self-report number of

145

days and minutes/per day that they typically participate in vigorous LTPA (as defined as LTPA
causing large increases in breathing and heart rate), Evenson et al. asked participants whether
they participated in such activities at least twice a week, sometime in the past three months. It is
possible that the higher prevalence of any vigorous LTPA participation found in the present
investigation is partially a result of not defining “any” as multiple bouts of activity per week.
However, it is also possible that vigorous LTPA participation has increased over the years
among pregnant women, given that the aforementioned investigation examined 1995-1998 data.
While these possibilities may contribute in some part, the higher prevalence for participating in
vigorous LTPA found in this study reflects a group that is simply more physically active than
pregnant women in general, which may be due in part to the high prevalence of Caucasian
participants.
PREGNANCY RISK PERCEPTIONS AND LTPA EFFICACY BELIEFS
Descriptive Results
For this dissertation, pregnancy risk perceptions were determined via a perceived severity
question and a perceived susceptibility question, which were averaged into a single pregnancy
risk perception score. Most participants indicated disagreement that pregnancy was risky, as
defined as a potential harmful pregnancy effect on the unborn baby. More specifically, nearly
90% of the analytic sample was categorized as perceiving “strong disagreement (1.0-1.5 risk
score)” or “unsure or some disagreement (2.0-4.0 risk score)” with the susceptibility and severity
of this specific risk. Only 1.3% of participants were categorized as perceiving “strong agreement
(6.5-7.0 risk score)” with the aforementioned pregnancy risk. Given the weak positive
relationship found in this study between pregnancy risk perceptions and education (r=0.22), such

146

low perceptions of risk may be partially due to a decent portion of study participants having
achieved some high school education as their highest level (40.7%). Eide et al.7 conducted a
large, population-based investigation utilizing the Mother and Child Cohort (Norway) and found
that only 3.9% of pregnant women (n=58,139) reported strong agreement regarding the
possibility of something adverse occurring to their baby. However, Eide et al. assessed
pregnancy risk with only a single question, which asked specifically about the frequency that
pregnant women felt worried about their babies being “healthy or normal.” Thus, the specific
magnitude of the perceived risk was not assessed. This dissertation examined both severity and
susceptibility of the pregnancy risk, and found that risk perceptions (as it pertains to the health of
the unborn baby) were generally low.
Similar to pregnancy risk perceptions, moderate and vigorous LTPA efficacy were each
determined via two questions, one pertaining to response efficacy and one to self-efficacy, which
were averaged into a single LTPA efficacy belief score for each activity intensity. For moderate
LTPA efficacy, just over half of pregnant women were categorized as having some agreement,
with an additional quarter being categorized as having strong agreement. For vigorous LTPA
efficacy, nearly half of this study’s sample had some agreement, with only a small fraction
having had strong agreement. It appears no investigation has jointly considered response and
self-efficacy in assessing efficacy beliefs during pregnancy. Additionally, no investigation has
specifically examined LTPA efficacy as it pertains to protecting the unborn baby from an
adverse health effect. However, general response efficacy beliefs have been examined recently
for both moderate and vigorous LTPA during pregnancy. Most notably, Evenson and Bradley8
found that 73% of pregnant women agreed with the benefits of moderate LTPA, whereas 13%
agreed with the benefits of vigorous LTPA.

147

At first glance, it appears study participants had slightly higher levels of moderate LTPA
efficacy and substantially higher levels of vigorous LTPA efficacy compared to women studied
by Evenson and Bradley. However, comparisons must be interpreted with caution given that
these previous investigators considered only response efficacy for LTPA (rather than response
AND self-efficacy). Additionally, the perceived risk was not specific to the health of either the
mother or the baby, but rather in general. Given that this investigation may be the first to assess
both perceived susceptibility and severity for pregnancy risk perceptions as well as both response
and self-efficacy for LTPA efficacy beliefs, these descriptive results are unique, so direct
comparisons to pregnancy risk and LTPA efficacy findings of previous investigations are not
possible. Within this context, the results of the current study indicate high LTPA efficacy beliefs
for moderate LTPA and somewhat moderate LTPA efficacy beliefs for vigorous LTPA among
pregnant women.
Influence on LTPA Behavior during Pregnancy
Utilizing the RP A is advantageous in that it enables a clear classification of the
population being studied, specifically by categorizing individuals into attitudinal groups as
described below.


Responsive -- High risk perceptions, High efficacy beliefs



Proactive -- Low risk perceptions, High efficacy beliefs



Avoidant -- High risk perceptions, Low efficacy beliefs



Indifferent -- Low risk perceptions, Low efficacy beliefs

Given the non-normal distribution of LTPA data, moderate LTPA (min/week) was dichotomized
into meeting moderate LTPA guidelines and not meeting these guidelines for analytic purposes.

148

This study examined group differences for the relative frequency of meeting these guidelines
during pregnancy. It was hypothesized that the responsive and proactive groups would be most
likely to participate in moderate LTPA, given that both are defined by having high efficacy
beliefs, which has been shown to strongly predict moderate LTPA behavior in previous
investigations. Findings clearly indicated the responsive and proactive groups to be more likely
to meet the moderate LTPA guidelines compared to the avoidant and indifferent groups, but a
statistically significant difference was apparent only between the responsive (highest likelihood)
and indifferent (lowest likelihood) groups.
These findings are partially consistent with RPA theory in that responsive pregnant
women appear more likely than pregnant women of other attitudinal groups to achieve moderate
LTPA guidelines. However, given statistical significance was not observed between the
responsive group and the proactive or avoidant groups, these results may somewhat vary from
theorized attitudinal group differences. Meta-analytic findings from Witte and Allen9 revealed
that the high threat-high efficacy group (analogous to responsive) was more likely to participate
in the recommended response (protective behavior) than high threat-low efficacy (analogous to
avoidant) and low threat-high efficacy (analogous to proactive). The investigators also found
that the low threat-low efficacy (analogous to indifferent) group was less likely to participate in
the recommended response compared to all other attitudinal groups. Although the current
study’s findings suggest the avoidant group was more likely to meet the moderate LTPA
guidelines compared to the indifferent group, this difference was not statistically significant.
The lack of difference between these two attitudinal groups may be a result of the low efficacy
beliefs consistent in both groups. Given the numerous barriers to regular LTPA during
pregnancy (discussed in Chapter 2), expectant mothers, particularly those with little exercise

149

history, may have little motivation to perform moderate physical activity if they do not perceive
a protective benefit for their babies. More specifically, avoidant pregnant women may not
participate in sufficient moderate LTPA if they do not believe in its positive impact, and if they
must simultaneously cope with other pregnancy-related difficulties (e.g., fatigue, discomfort,
lack of time).
This study additionally aimed to investigate attitudinal group differences for vigorous
LTPA. As with the moderate LTPA data, vigorous LTPA (min/week) was non-normally
distributed, so this variable was dichotomized into participating in any vigorous LTPA and not
participating in vigorous LTPA. It was hypothesized that the responsive group would be more
likely to participate in any vigorous LTPA compared to the other attitudinal groups, as suggested
by the RPA and EPPM. Indeed, findings suggest that responsive pregnant women were most
likely to participate in any vigorous LTPA, followed by proactive pregnant women. However, it
was also found that the avoidant group was less likely than all other groups to be vigorously
physically active, which was unexpected. This specific finding is not in agreement with results
from previous investigations, which have revealed the indifferent group to be the least likely to
act.9,10 With respect to vigorous LTPA, it seems plausible that high pregnancy risk perceptions
in the presence of low efficacy beliefs (found in the avoidant group) are associated with extreme
fear control responses, possibly including defensive avoidance or denial. Thus, the results of this
study indicate that pregnant women who worry about the health of their unborn babies and who
do not believe in the health benefit of vigorous LTPA likely avoid vigorous LTPA participation.
Moreover, high levels of anxiety found among avoidant individuals11 may prompt those who are
pregnant to seek out information regarding their concern for the health and safety of their baby.
This anxiety could possibly solidify their conviction to avoid vigorous LTPA. Interestingly, the

150

same high risk perceptions coupled with high efficacy beliefs appear to trigger high motivations
to participate in vigorous LTPA as a protective mechanism, as theorized by Rimal and Real.10
The impact of LTPA efficacy beliefs on pregnancy LTPA behavior (meeting the moderate LPTA
guidelines and participating in vigorous LTPA) appears to be considerable when examined via
attitudinal groups, particularly relative to the impact of pregnancy risk perceptions.
In addition to examining risk/efficacy via attitudinal groups, hierarchical regression was
also utilized to explore main and interactive effects. Main effects were shown for both
pregnancy risk and moderate LTPA efficacy on meeting the moderate LTPA guidelines. Also, a
main effect was shown for vigorous LTPA efficacy on participating in vigorous LTPA (although
not for pregnancy risk). After controlling for potential confounding variables, including
prepregnancy LTPA behavior, pregnancy risk and moderate LTPA efficacy explained a
relatively minor percent of the variance (6.4%) in meeting moderate LTPA guidelines during
pregnancy. Thus, the main effects with respect to moderate LTPA should be interpreted with
caution. Efficacy beliefs explained a more sizable amount (16.6%) of the variance for
participating in vigorous LTPA, which again suggests efficacy may play a somewhat larger role
than for vigorous LTPA participation than for moderate LTPA behavior. A notable strength to
this investigation pertains to the specific assessment of LTPA efficacy beliefs, namely regarding
the protective health effect for the unborn baby (rather than the general health effect considered
in other investigations). While this offers specificity in the interpretation of this study’s findings,
it may also be one reason why these results show LTPA efficacy does not explain a higher
percent of the variance for moderate and vigorous LTPA behavior. As discussed in Chapter 2 of
this dissertation, findings from qualitative investigations and a few non-population-based
quantitative investigations may indicate that pregnant women are more convinced of the health

151

benefits of LTPA for themselves then they are for their babies. If true, then an assessment of
LTPA efficacy specified towards the health of the mother may result in LTPA efficacy being a
stronger predictor of LTPA behavior.
An interesting finding within this study’s main effect results is that vigorous LTPA
efficacy has a greater effect on participating in vigorous LTPA than moderate LTPA efficacy on
meeting the moderate LTPA guidelines during pregnancy. This is plausible, given that pregnant
women may be more likely to regularly engage in moderate LTPA for reasons other than the
health of their babies compared to vigorous LTPA. Reasons may include social interaction with
other mothers, alleviation of minor physical discomforts, or improving psychological mood.
Whereas, vigorous LTPA, presumably perceived to be more difficult, may be performed if
expectant mothers are more firmly convinced that it offers a protective health benefit to their
babies. Thus, vigorous LTPA response efficacy would theoretically be a stronger predictor of
vigorous LTPA behavior compared to moderate LTPA response efficacy predicting moderate
LTPA behavior. In seeking to investigate this presumption, post-hoc logistic regression analyses
were performed examining the dimensions of risk (severity and susceptibility) and efficacy
(response and self) as individual predictors of LTPA. These analyses indicate self-efficacy
(OR=1.51, CI=1.17-1.96) to be the only significant predictor of meeting moderate LTPA
guidelines, but not response efficacy. In contrast, both self (OR=1.65, CI=1.31-2.09) and
response efficacy (OR=1.47, CI=1.16-1.88) have influence on participating in vigorous LTPA,
supporting this hypothesis.
Previous RPA investigations have shown risk/efficacy interactions for HIV and
remaining monogamous,12 workplace accidents and wearing protective equipment,13 and breast
cancer and self-examinations.14 Although these interactions accounted for a relatively minor
152

percentage of the overall variance explained, they were statistically significant. Thus, based on
these previous results, the current study hypothesized that interactive effects would be observed.
As discussed previously, LTPA differences among attitudinal groups (combinations of high/low
risk and efficacy) were apparent. This further suggested the possibility of an interaction between
pregnancy risk and LTPA efficacy for moderate and vigorous LTPA behavior. However, this
study’s hierarchical logistic regression results showed no interactive effect for pregnancy
risk/moderate LTPA efficacy on meeting moderate LTPA guidelines after controlling for
potential confounding variables. Similarly, an interactive effect was not found between
pregnancy risk perceptions and vigorous LTPA efficacy beliefs on participating in any vigorous
LTPA. Lack of interaction may be related to extremely low pregnancy risk perceptions overall
within the sample. Had there been more variability in perceived pregnancy risk (i.e., higher risk
perceptions), it is possible that an interaction would have been found. In summary, these crosssectional results indicate that pregnancy risk perceptions and LTPA efficacy beliefs have little
interdependence on one another in affecting LTPA behavior during pregnancy. These findings
are somewhat parallel to those of Witte and Allen9 who conducted a meta-analysis of 23 EPPM
investigations and did not find significant interaction between the perceived threat of the
message and the perceived efficacy of the recommended response. Similar to the current study’s
results, however, Witte and Allen's meta-analysis found main effects for perceived threat and
efficacy, or rather that the higher level of each led to higher levels of the recommended response.
The current study’s cross sectional findings distinctly suggest that efficacy beliefs have stronger
influence on LTPA behavior than do pregnancy risk perceptions, but especially with respect to
vigorous LTPA.

153

In examining main and interactive effects of pregnancy risk and LTPA efficacy on
moderate and vigorous LTPA, several possible confounding variables were controlled for.
Having met moderate LTPA guidelines prior to pregnancy explained a large amount of the
variance in meeting moderate LTPA guidelines during pregnancy. Similarly, vigorous LTPA
performed prior to pregnancy was related to LTPA performed during pregnancy. Most
investigations which have examined both prepregnancy LTPA and pregnancy LTPA, have found
that women who are active prior to pregnancy are more likely to remain active throughout
pregnancy.15 Owe et al.16 recently conducted a population-based investigation among more than
34,000 Norwegian pregnant women and found that exercise prior to pregnancy was associated
with exercise during pregnancy during the second (OR=18.4, CI=17.2-19.7) and third (OR=4.3,
CI=4.08-4.61) trimesters. These strong associations align with the current study’s findings. It
should be noted that Owe et al. evaluated exercise behavior via frequency (bouts/week) and did
not differentiate between moderate and vigorous exercise as in the current investigation.
Findings regarding prepregnancy LTPA appear congruent with Bandura’s Social
Cognitive Theory,17 specifically that past experience is a strong predictor of efficacy beliefs, and
in turn, behavior. Therefore, the influence of prepregnancy LTPA on a pregnant woman’s
LTPA efficacy beliefs (and therefore behavior) may depend on how similar she feels pregnancy
LTPA (from a difficulty standpoint) is to prepregnancy LTPA. Bandura has also suggested that
the influence of past experience depends on the perceived task difficulty.17 Given the many
barriers to LTPA that pregnant women experience, it is likely that some women perceive LTPA
to be more difficult to perform during pregnancy compared to prior to pregnancy. Theoretically,
pregnant women who successfully engaged in prepregnancy LTPA despite a number of barriers
(i.e., lack of time, work, childcare) will have greater efficacy beliefs to engage in LTPA during

154

pregnancy (with its many barriers), as compared to women who did not experience LTPA
barriers prior to pregnancy. Unfortunately, barriers to LTPA were not assessed, so their effect on
this study’s participants is speculative.
Practical Significance of Findings
This dissertation partially extends the scope of the RPA to LTPA during pregnancy and
suggests its potential utility in aiding those attempting to enhance physical activity behavior of
expectant mothers. The most commonly utilized physical activity intervention technique among
pregnant women has involved providing physical activity information, some investigations
resulting in effective behavior change and others not.18 In general, interventions aiming to
improve pregnancy LTPA may be most effective by targeting women who are attitudinally
similar.
To generate positive health behavior change, the RPA posits that researchers focus on
moving individuals from the indifferent, avoidant, and proactive groups to the responsive
group.11 The caveat in this theory is that messages should be designed with specific
consideration of which attitudinal group the study participants are moving from, given the
previously described group differences. This study’s cross sectional findings suggest that
efficacy beliefs play a major role in determining moderate and vigorous LTPA behavior, but that
pregnancy risk perceptions are of less importance. A possible reason for this is the overall low
risk pregnancy risk perceptions reported by this study’s participants. These findings suggest the
RPA attitudinal groupings to not be completely effective in predicting pregnancy LTPA.
However, it is clear that pregnancy LTPA interventions should aim to increase efficacy beliefs,
or within the RPA context, move pregnant women from the avoidant to the responsive group or

155

the indifferent to proactive group. The avoidant group, which has high-risk perceptions and low
efficacy beliefs, is perhaps most challenging. Individuals in this group are most likely to engage
in “fear control processes”, or behaviors that will control their fears (i.e., defensive avoidance,
denial, issue derogation) as opposed to behavior which will control the perceived risk (i.e.,
LTPA).19 For such individuals, messages designed to increase efficacy beliefs (without
increasing perceived risk) are essential.
Messages designed to increase efficacy beliefs may be most effective when incorporating
elements suggested within Social Cognitive Theory: performance accomplishments (past
experience), vicarious reinforcement (learning through observation/visualization), verbal
persuasion (attempting to convince by others), and affective arousal (receiving confidence from
feeling good). According to Bandura,16 performance accomplishments most strongly predict
efficacy beliefs, followed by vicarious reinforcement. Thus, given the findings with respect to
the influence of prepregnancy LTPA, researchers may consider designing interventions that
target less active, non-pregnant women of childbearing age with the purpose of establishing a
prepregnancy LTPA routine. Similarly, it may be advantageous to target first-time mothers as
they are more likely to become pregnant again as compared to women who have not been
pregnant. Another method by which pregnancy LTPA efficacy beliefs could be improved would
involve enlisting the assistance of postpartum women who regularly participated in pregnancy
LTPA to convey the message. This intervention would utilize vicarious reinforcement and
verbal persuasion in order to increase LTPA efficacy beliefs among less active pregnant women.
Real12 suggests keeping an efficacy message simple is essential for it to be effective, particularly
for individuals in the avoidant and indifferent groups. Given their low efficacy beliefs regarding
the protective behavior, an excessive amount of detail and advanced information may illicit a

156

“boomerang effect” by impeding efficacy improvement. Such messages may be most effective if
coupled with personalized goal setting and multiple assessments of performance, particularly
with the various additional barriers that may impede sufficient LTPA participation.
RELIGION AND PREGNANCY LTPA
A final general objective of this dissertation was to examine the influence of religion on
pregnancy LTPA behavior and potential psychosocial influences of pregnancy LTPA. These
influences include pregnancy risk perceptions, LTPA efficacy beliefs, physical activity social
support, and discussions that pregnant women have with prenatal healthcare providers (HCP).
Of particular interest to this project is the Latter-day Saint (LDS) or “Mormon” religion, which
teaches the importance of living by a strict health code. Additionally, LDS theology focuses
heavily on the family unit, including the importance of having and raising children. Given the
emphasis within the LDS church on healthy behaviors, this study investigated whether effects of
these religious beliefs are evident in LTPA behavior and psychosocial influences during
pregnancy.
It was hypothesized that LDS pregnant women would participate in more moderate and
vigorous LTPA compared to non-LDS pregnant women. As described previously, both
moderate and vigorous LTPA were dichotomized as a result of non-normal distributions. This
study’s findings show that LDS pregnant women were significantly less likely to meet the
moderate LTPA guidelines of at least 150 minutes of activity per week compared to non-LDS
low religiosity pregnant women, a result which did not support the proposed hypothesis.
Furthermore, relative frequencies and odds ratio calculations indicate that non-LDS high and
moderate religiosity pregnant women were also less likely to meet these guidelines compared to

157

non-LDS low religiosity participants, although these trends were not statistically significant. In
contrast, LDS pregnant women and non-LDS high religiosity pregnant women were more likely
to participate in vigorous LTPA compared to non-LDS low religiosity pregnant women. It
should be noted that logistic regression results showed that religious grouping explained only a
small portion of the variance in the prediction of meeting moderate LTPA guidelines and
participating in any vigorous LTPA.
In attempting to understand the relationships between religion and LTPA behavior among
pregnant women, it is necessary to review the findings with respect to the psychosocial
influences to LTPA and how each differs by this investigation’s religious grouping. LDS
pregnant women were less likely to have strong disagreement with pregnancy risk (indicating
higher risk perceptions) compared to non-LDS high and low religiosity pregnant women.
However, it appears these differences were somewhat related to previous preterm birth
experiences, given that after adjusting for this variable, significant differences between groups
were no longer evident. LTPA efficacy differences were also examined among religious groups.
LDS pregnant women were more likely to have strong agreement with moderate LTPA efficacy
and more likely to have some agreement with vigorous LTPA efficacy compared to non-LDS
moderate and low religiosity pregnant women (however, only significant for vigorous LTPA
efficacy). Increased levels of vigorous LTPA efficacy among LDS pregnant women may very
well be a result of the LDS health code, the “Word of Wisdom.” This is considered doctrine to
those in the LDS faith and strongly emphasizes the importance of regularly engaging in healthy
behaviors, promising physical and spiritual blessings to those who do.20
With seemingly higher risk perceptions and higher LTPA efficacy beliefs compared to
lower religiosity groups (although these were not significant except for vigorous LTPA efficacy),
158

it is plausible that LDS pregnant women would be more likely to meet the moderate LTPA
guidelines and participate in any vigorous LTPA. However, this is clearly not the case for
meeting the moderate LTPA guidelines given the LDS participants had the lowest rates of all
religious groups. In contrast, vigorous LTPA efficacy likely accounts in part for why LDS
women were more likely to participate in vigorous LTPA.
It can be speculated that meeting the moderate LTPA guidelines is impeded among LDS
pregnant women (and possibly non-LDS women of higher religiosity levels) by factors other
than the perceptions and social influences directly examined in this investigation. It has been
shown that LDS women have the highest parity rates compared to women of other major JudeoChristian religious denominations.21,22 Additionally, there is a clear relationship between
religiosity (in general) and parity.23 Given the inverse relationship between parity and levels of
pregnancy LTPA,24 it is plausible that this might account for lower levels of LTPA. However,
LTPA differences did not change among religious groups when parity was controlled for in
logistic regression analyses. As discussed in Chapter 2 of this dissertation, one of the more
prominent barriers to pregnancy LTPA is a lack of time. A possible explanation to this study’s
LTPA findings among religious groups could be that pregnant women of higher religiosities
(including LDS pregnant women) perceive themselves to be busier throughout the day than are
pregnant women of lower religiosity, but this is speculative. Additionally, higher religiosity
women may have more family obligations compared to lower religiosity women, possibly
resulting in more commitments, errands, and extracurricular activities. Specific to the LDS faith,
weekly religious commitments and “family time” are often integrated into the routine of life.
Commitments include Sunday services, daily scripture study, weekly church service
opportunities, and weekly family home evening (one night/week). Thus the time that LDS

159

pregnant women have to participate in LTPA may be more limited than non-LDS pregnant
women of lower religiosities, and they must choose whether to engage in moderate LTPA or
vigorous LTPA with the leisure-time they have.
This study additionally examined religious group differences with respect to physical
activity discussion with prenatal HCPs and physical activity social support. Prior to this
investigation, impact of religious beliefs on the perceived frequency or quality of HCP-patient
interactions has not been thoroughly explored. Thus, it was hypothesized that LDS pregnant
women would be more likely to discuss LTPA with their prenatal HCP and would feel more
satisfied with these discussions, are somewhat speculative. Contrary to this study’s hypotheses,
no religious group differences were seen when evaluating whether or not pregnant women
discussed LTPA with a prenatal HCP or in the satisfaction level with those discussions. This
finding suggests that LDS pregnant women are no more cognizant of pregnancy LTPA compared
to non-LDS pregnant women, and therefore do not initiate these discussions with pregnancy
HCPs any more so than do non-LDS pregnant women.
In contrast, the relationship between religiosity and social support has been previously
investigated, with findings showing a positive association.25,26 Accordingly, it was assumed and
found in the current study that LDS pregnant women would have a higher religiosity score
compared to non-LDS pregnant women, and therefore hypothesized that LDS pregnant women
would have higher levels of total social support. The finding that LDS participants were more
likely to perceive high levels of total social support compared to non-LDS high religiosity aligns
with the proposed hypothesis. However, after race was controlled for, this difference was no
longer apparent. In general, perceptions of social support during pregnancy may be greater
among Caucasian women compared to non-Caucasian women (particularly Latinas).27 With
160

respect to this study, greater levels of perceived physical activity social support among LDS
pregnant women appears to have been a result of a higher percentage of Caucasian participants
among the LDS group (92.5%) as compared to the non-LDS high religiosity group (48.0%).
Given the LDS religion’s strong emphasis on the family relationships, we additionally
hypothesized that LDS pregnant women would perceive higher levels of support specifically
from family and significant others, compared to non-LDS pregnant women of any religiosity
level. However, these findings revealed that LDS pregnant women did not differ in perceived
family social support from non-LDS pregnant women of any religiosity level. Physical activity
social support from family members can be minimal, particularly from past generations (i.e.,
mother/father, aunts/uncles, grandparents).28 Having lived during times when no guidelines for
pregnancy physical activity existed, these individuals may still believe the previous notion that
LTPA is dangerous for mother and baby. Despite over three decades of research revealing the
health benefits of physical activity during pregnancy as well as more liberal guidelines, recent
investigations have shown that immediate family members still try to convince pregnant women
of its adverse health effects.28-30 Thus all pregnant women, regardless of religious beliefs, may
be receiving similar amounts of “negative” physical activity social support from family
members.
The gender roles which exist in LDS families are generally considered to be more
conservative than those of non-LDS families. Heaton et al.31 found that LDS men and women
are significantly more likely to believe in the traditional roles (men should make the living,
women manage the home) compared to non-LDS mem and women. Despite LDS women
believing in their more traditional family role, Heaton et al. also found that LDS women were
particularly likely to feel overwhelmed, lonely, an d unsuccessful with respect to their roles.
161

Thus, the current study examined differences among religious groups in perceived social support
from significant others. After controlling for having a significant other as well as social support
from the family and friends subscales, LDS pregnant women were more likely to perceive higher
levels of significant other social support compared to non-LDS high religiosity pregnant women
(but not non-LDS moderate and low religiosity groups). The non-LDS high religiosity group
was substantially less educated and had lower income levels; therefore, it is possible that these
pregnant women are more likely to feel low levels of satisfaction with their significant other, as
found in non-pregnant populations.32,33 Such dissatisfaction could easily carry over to pregnant
women’s perceptions of significant other supportive behavior.
Practical Significance of Findings
This dissertation represents one of the first investigations to examine the relationship
between religion and LTPA during pregnancy. Study findings show an influence of religiosity,
although it accounted for very little of the variance in predicting LTPA behavior. Further study
is required to determine if pregnant women of higher religiosities are participating in less total
LTPA compared to lower religiosity levels. Assessing the amount of occupational physical
activity (for many as a homemaker) that pregnant women participate in may be essential to
understand LTPA behavior. Pregnant women with children in their care likely participate in
high amounts of moderate-intensity activity as a part of their daily routines as being mothers.
For such women, when the opportunity for LTPA presents itself, they may desire something
different than their occupational activity, and therefore be less inclined to participate in moderate
LTPA and more so in vigorous LTPA. Given the higher parity rates for LDS pregnant women
compared non-LDS women, this seems a possible explanation for this study’s findings regarding
LDS women meeting the moderate LTPA guidelines and participating in vigorous LTPA.
162

LDS pregnant women additionally have a unique combination of doctrinal beliefs, which
pertain to having children and general health behavior. Given these beliefs, interventions to
reduce the influence of physical and lifestyle related LTPA barriers may be needed among LDS
pregnant women. Researchers should additionally consider qualitative designs to better ascertain
the impact of spirituality/religiosity on LTPA and other health behaviors among specific
religious groups during pregnancy.
STUDY LIMITATIONS
Although this dissertation provides novel information with respect to the psychosocial
influences to LTPA during pregnancy, our findings are subject to a number of limitations. First,
a cross-sectional design was utilized, and collected data when the majority of pregnant women
were in the second or third trimesters. A longitudinal design following pregnant women from
their first trimester through delivery would have added strength to our findings. Our crosssectional design allowed for the collecting of significant amount of data on over 300 pregnant
women over a period of just three months. This sample size, while adequate, did not provide the
precision available to investigators who utilized significantly larger samples.
Another limitation to this investigation involves the assessment of moderate and vigorous
LTPA behavior via self-report. Survey questions assessing LTPA were adapted from items
within the Global Physical Activity Questionnaire (GPAQ). These questions have demonstrated
acceptable criterion validity and excellent test-retest reliability,34 and therefore have been
integrated into the National Health and Nutrition Examination Survey (NHANES), a highly cited
population-based initiative used to track LTPA and other health behaviors in the United States.

163

Despite this, self-reporting physical activity via questionnaire has its limitations,35 and has been
repeatedly shown to be less valid than objective methods of physical activity assessment.36,37
Our findings may be additionally limited by the specific timeframe in which LTPA data
were collected. Our survey instrument contained questions about participants’ current LTPA
behavior. Given data collection for this investigation occurred from the months of February to
April, it is possible that LTPA levels are different than those that would have been evaluated
during the summer months. This may be relevant, as over half our analytic sample were
recruited from mid-Michigan during one of the coldest winters and springs in recent years in this
geographical region.
It should also be acknowledged that this study’s findings with respect to perceived risk
and LTPA efficacy are limited by single-item assessments. Although these questions were
adapted from the often-cited Risk Behavior Diagnostic Scale, Witte et al. 19 recommends three
items for each of the risk (severity, susceptibility) and efficacy (response and self) dimensions.
This study aimed to create a survey instrument that could be completed within 15 minutes.
Given this and the variety of additional factors that were deemed important to assess, the survey
instrument for this investigation could not realistically include more than one item per
risk/efficacy dimension.
Finally, this study is limited by the generalizability of our study findings. Our analytic
sample was predominantly Caucasian and fairly well educated. It is not known if the findings
would be similar in ethnically diverse and low SES populations. Additionally, study
investigators neglected to ask pregnant women about perceived risks and LTPA efficacy as it
pertains to their own personal health. Given a pregnant woman may feel risk and or benefit for

164

both her personally and also her baby, such questions would have provided a more complete
understanding of how maternal perceptions facilitate LTPA behavior during pregnancy.
STUDY STRENGTHS
There were various strengths to this dissertation. First, this was a multi-site effort, which
involved data collection at multiple locations in the mid-Michigan area and Salt Lake City, Utah.
Our primary means of recruiting participants involved working directly with various prenatal
care clinics and many prenatal HCPs.
Another strength to this investigation is that this study utilized the RPA, a well-respected
theoretical framework in the health communication literature. Although relatively new and
therefore having a small literature base, the RPA originates from and is theoretically similar to
the EPPM, one of the leading fear appeal theories to date. A testament to its parsimony and
robust nature, the EPPM has remained unchanged over the years.38 Thus, the RPA is grounded in
exceptional health communication theory. To our knowledge this is the first investigation to
utilize the RPA within a physical activity or prenatal health context.
Finally, the pregnancy risk in this investigation was defined in a specific manner, namely
as a harmful pregnancy effect on the baby. Previous investigations examining pregnant women’s
perceptions of risk and benefits of physical activity have done so generally, and have not
specified whether the “risk” and “benefits” pertain to the mother or the baby.4,7,39 Thus, an
important and previously unaddressed issue, namely that of concern that a mother feels for her
baby, has been specifically applied to the methodological examination of LTPA behavior.

165

FUTURE RESEARCH DIRECTIONS
Findings from this dissertation introduce a number of future research directions with
respect to psychosocial influences of pregnancy LTPA. Now that this study has identified the
impact of pregnancy risk perceptions and LTPA efficacy with respect to pregnancy LTPA,
interventions should be designed to specifically increase efficacy beliefs among pregnant
women. Given its prominence in the message design literature and its many similarities with the
RPA, the EPPM should be utilized to create and present persuasive messages to pregnant women
regarding LTPA. Various techniques are available for use within such interventions. However,
the effectiveness of pregnancy risk and LTPA messages may be increased if prenatal HCPs are
integrated in the communication of these messages. Regardless, the overall goal of an
intervention should clearly be to help avoidant pregnant women to a more responsive attitude
and indifferent pregnant women to a more proactive attitude.
In order to design effective LTPA efficacy messages, a deeper understanding of how such
perceptions/beliefs are formed may be valuable. The influence of previous adverse birth
outcomes, including preterm birth, operative delivery, and prolonged maternal labor on
pregnancy risk perceptions is not well understood. Also unclear is the influence of potentially
traumatic pregnancy-related experiences, such as previous miscarriage or infertility. In
attempting to understand how these impact levels of perceived risk, researchers should consider
vicarious experiences (possibly through an immediate family member or close friend), and not
just those that are experienced personally.
Another important research step involves the simultaneous examination of pregnancy
risk/LTPA efficacy as it pertains to both the health of the baby AND also the health of the

166

mother. An advantage of this investigation is that the pregnancy risk was specified as a harmful
pregnancy effect on the baby. Therefore, LTPA efficacy (specifically response efficacy) was
assessed specifically for reducing that risk to the baby. To our knowledge, this dissertation
represents the first pregnancy LTPA investigation to have done this. However, a more complete
understanding of how pregnancy risk and LTPA efficacy affects pregnant women’s LTPA
behavior would be possible if risk and efficacy were assessed for both the mother and the baby,
separately. This is of particular importance given the pregnant women’s pregnancy risk
perceptions and LTPA efficacy beliefs may be very different with respect to the health of the
mother as compared to the baby.
A number of descriptive investigations would also provide meaningful insight. In order
to understand how perceptions change over the course of gestation, pregnant women should be
assessed longitudinally, with initial recruitment beginning as early as possible within the first
trimester. However, such an investigation would require lengthy time commitments given the
natural course of a health pregnancy. Additionally, pregnant women’s perceptions towards
specific modalities of moderate and vigorous LTPA should be explored, including brisk walking,
jogging, swimming, prenatal yoga, and resistance training. Investigations attempting to replicate
our findings should consider more diverse samples, particularly multiethnic and of low
SES/education, in order to determine whether our findings generalize beyond the specific
demographic of this study’s participants. According to the defined exclusion criteria of this
investigation, pregnant women carrying more than one baby and also high-risk pregnancies were
excluded from analysis. These populations need to be assessed in the future to see what
differences exist with respect to our sample.

167

CONCLUSION
This dissertation provides evidence that pregnancy risk perceptions and LTPA efficacy
beliefs are related to LTPA behavior during pregnancy. Results suggest that pregnancy LTPA
can be increased by altering how pregnant women perceive pregnancy and LTPA so they are
proactive or responsive (those with high LTPA efficacy beliefs). Given the substantial maternalfetal health benefits of regular LTPA during pregnancy, this is of utmost importance. This
investigation partially designates the RPA as an effective tool for characterizing LTPA behavior
among pregnant women. Furthermore, it suggests the EPPM as an optimal tool for pregnancy
LTPA interventions given its theoretical similarities with the RPA. The influence of religion on
pregnancy LTPA is less well understood. However, this study’s results suggest that higher
religiosity pregnancy women (including LDS pregnant women), despite higher levels of efficacy
beliefs, are less likely to meet the moderate LTPA guidelines during pregnancy, but are more
likely to participate in vigorous LTPA.

168

REFERENCES

169

REFERENCES

1.

United States. Department of Health and Human Services. 2008 physical activity
guidelines for Americans : be active, healthy, and happy! Washington, DC: U.S. Dept. of
Health and Human Services; 2008.

2.

Evenson KR, Savitz DA, Huston SL. Leisure-time physical activity among pregnant
women in the US. Paediatric and perinatal epidemiology. Nov 2004;18(6):400-407.

3.

Evenson KR, Wen F. National trends in self-reported physical activity and sedentary
behaviors among pregnant women: NHANES 1999-2006. Preventive medicine. Mar
2010;50(3):123-128.

4.

Evenson KR, Wen F. Prevalence and correlates of objectively measured physical activity
and sedentary behavior among US pregnant women. Preventive medicine. 2011;53:39-43.

5.

Mudd LM, Nechuta S, Pivarnik JM, Paneth N. Factors associated with women's
perceptions of physical activity safety during pregnancy. Preventive medicine. Aug-Sep
2009;49(2-3):194-199.

6.

Evenson KR, Siega-Riz AM, Savitz DA, Leiferman JA, Thorp JM, Jr. Vigorous leisure
activity and pregnancy outcome. Epidemiology. Nov 2002;13(6):653-659.

7.

Eide J, Hovengen R, Nordhagen R. Childhood abuse and later worries about the baby's
health in pregnancy. Acta obstetricia et gynecologica Scandinavica. Dec
2010;89(12):1523-1531.

8.

Evenson KR, Bradley CB. Beliefs about exercise and physical activity among pregnant
women. Patient education and counseling. Apr 2010;79(1):124-129.

9.

Witte K, Allen M. A meta-analysis of fear appeals: implications for effective public
health campaigns. Health education & behavior : the official publication of the Society
for Public Health Education. Oct 2000;27(5):591-615.

10.

Rimal RN, Real K. Perceived risk and efficacy beliefs as motivators of change: Use of
the risk perception attitude (RPA) framework to understand health behaviors. Hum
Commun Res. Jul 1 2003;29(3):370-399.

11.

Turner MM, Rimal RN, Morrison D, Kim H. The role of anxiety in seeking and retaining
risk information: Testing the risk perception attitude framework in two studies. Hum
Commun Res. Apr 2006;32(2):130-156.

170

12.

Rimal RN, Bose K, Brown J, Mkandawire G, Folda L. Extending the Purview of the Risk
Perception Attitude Framework: Findings from HIV/AIDS Prevention Research in
Malawi. Health Commun. 2009;24(3):210-218.

13.

Real K. Information seeking and workplace safety: A field application of the risk
perception attitude framework. J Appl Commun Res. 2008;36(3):339-359.

14.

Rimal RN, Juon HS. Use of the Risk Perception Attitude Framework for Promoting
Breast Cancer Prevention. J Appl Soc Psychol. Feb 2010;40(2):287-310.

15.

Gaston A, Cramp A. Exercise during pregnancy: a review of patterns and determinants.
Journal of science and medicine in sport / Sports Medicine Australia. Jul
2011;14(4):299-305.

16.

Owe KM, Nystad W, Bo K. Correlates of regular exercise during pregnancy: the
Norwegian Mother and Child Cohort Study. Scandinavian journal of medicine & science
in sports. Oct 2009;19(5):637-645.

17.

Bandura A. Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice-Hall; 1986.

18.

Pearce EE, Evenson KR, Downs DS, Steckler A. Strategies to Promote Physical Activity
During Pregnancy: A Systematic Review of Intervention Evidence. American journal of
lifestyle medicine. Jan 1 2013;7(1).

19.

Witte K, Cameron KA, McKeon JK, Berkowitz JM. Predicting risk behaviors:
development and validation of a diagnostic scale. Journal of health communication. OctDec 1996;1(4):317-341.

20.

Ford C. The origin of the Word of Wisdom. Journal of Mormon Histor. 1998;24(2):129154.

21.

Mosher WD, Williams LB, Johnson DP. Religion and fertility in the United States: new
patterns. Demography. May 1992;29(2):199-214.

22.

Thornton A. Religion and Fertility - Case of Mormonism. J Marriage Fam.
1979;41(1):131-142.

23.

Hayford SR, Morgan SP. Religiosity and Fertility in the United States: The Role of
Fertility Intentions. Social forces; a scientific medium of social study and interpretation.
2008;86(3):1163-1188.

24.

Pereira MA, Rifas-Shiman SL, Kleinman KP, Rich-Edwards JW, Peterson KE, Gillman
MW. Predictors of change in physical activity during and after pregnancy: Project Viva.
American journal of preventive medicine. Apr 2007;32(4):312-319.

171

25.
26.

Bradley DE. Religious Involvement and Social Resources - Evidence from the Data Set
Americans Changing Lives. J Sci Stud Relig. Jun 1995;34(2):259-267.
Ellison CG, George LK. Religious Involvement, Social Ties, and Social Support in a
Southeastern Community + a Study of a Theoretical-Model Linking Institutional Church
Participation and Social Network Relationships. J Sci Stud Relig. Mar 1994;33(1):46-61.

27.

Dunkel-Schetter C, Sagrestano LM, Feldman P, Killingsworth C. Social support and
pregnancy: A comprehensive review focusing on ethnicity and sulture. In: Pierce GR,
Sarason BR, Sarason IG, eds. Handbook of social support and the family. New
York:Plenum Press; 1994:375-412.

28.

Clarke PE, Gross H. Women's behaviour, beliefs and information sources about physical
exercise in pregnancy. Midwifery. Jun 2004;20(2):133-141.

29.

Evenson KR, Moos MK, Carrier K, Siega-Riz AM. Perceived barriers to physical activity
among pregnant women. Maternal and child health journal. May 2009;13(3):364-375.

30.

Thornton PL, Kieffer EC, Salabarria-Pena Y, et al. Weight, diet, and physical activityrelated beliefs and practices among pregnant and postpartum Latino women: the role of
social support. Maternal and child health journal. Jan 2006;10(1):95-104.

31.

Heaton TB, Goodman KL, Holman TB. In search of a pecular people: Are Mormon
familis really different. In:Cornwall M, Heaton TB, Young LA, eds. Contemporary
Mormonism: Social Science Perspectives. 1994;87-117.

32.

Conger RD, Conger KJ, Martin MJ. Socioeconomic Status, Family Processes, and
Individual Development. Journal of Marriage and Family. Jun 2010;72(3):685-704.

33.

Dakin J, Wampler R. Money doesn't buy happiness, but it helps: Marital satisfaction,
psychological distress, and demographic differences between low- and middle-income
clinic couples. Am J Fam Ther. 2008;36(4):300-311.

34.

Herrmann SD, Heumann K, J., Der Ananian CA, Ainsworth BE. Validity and reliability
of the Global Physical Activity Questionnaire (GPAQ). Measurement in Physical
Education and Exercise Science. 2013;17(3):221-235.

35.

Shephard RJ. Limits to the measurement of habitual physical activity by questionnaires.
British journal of sports medicine. Jun 2003;37(3):197-206; discussion 206.

36.

Westerterp KR. Assessment of physical activity: a critical appraisal. European journal of
applied physiology. Apr 2009;105(6):823-828.

37.

Schutz Y, Weinsier RL, Hunter GR. Assessment of free-living physical activity in
humans: an overview of currently available and proposed new measures. Obesity
research. Jun 2001;9(6):368-379.

172

38.

Maloney EK, Lapinski MK, Witte K. Fear appeals and persuasion: A review and update
of the Extended Parallel Process Model. Social and Personality Psychology Compass.
2011;5(4):207-219.

39.

Gaston A, Prapavessis H. Maternal-fetal disease information as a source of exercise
motivation during pregnancy. Health psychology : official journal of the Division of
Health Psychology, American Psychological Association. Nov 2009;28(6):726-733.

173