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Colon cancer information as a source of

exercise motivation
a b a
Stacey P. Graham , Dr Harry Prapavessis & Linda D. Cameron
a
Department of Psychological Medicine, and Department of
Psychology , The University of Auckland
b
School of Kinesiology, The University of Western Ontario
Published online: 01 Feb 2007.

To cite this article: Stacey P. Graham , Dr Harry Prapavessis & Linda D. Cameron (2006) Colon
cancer information as a source of exercise motivation, Psychology & Health, 21:6, 739-755, DOI:
10.1080/14768320600603554

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 Psychology and Health
December, 2006; 21(6): 739–755

Colon cancer information as a source

of exercise motivation
Downloaded by [University of Birmingham] at 11:11 20 November 2014

STACEY P. GRAHAM1, HARRY PRAPAVESSIS2,

& LINDA D. CAMERON1
1
Department of Psychological Medicine, and Department of Psychology, The University of
Auckland and 2School of Kinesiology, The University of Western Ontario

(Received 17 March 2005; in final form 23 January 2006)

Abstract
Using a Protective Motivation Theory (PMT) framework, this study examined whether
colon cancer is a meaningful source of exercise motivation. Participants were (N ¼ 173)
teaching and school staff randomly assigned into one of three treatment conditions: PMT
present, PMT absent (attention control) and no information (non-contact control).
Two separate DVD videos were developed (one incorporating the four major components
of PMT; perceived vulnerability (PV), perceived severity (PS), response efficacy (RE)
and self-efficacy (SE) featured colon cancer and exercise information while the other
DVDs featured cancer and nutritional information). Following treatment, participants
completed questionnaires which assessed their beliefs towards colon cancer and exercise
as well as their intentions to do more exercise. Two weeks later (T1), self-reported
measures of exercise behaviour were assessed and then repeated at 1 month (T2).
Only physically inactive participants were used in subsequent analyses (n ¼ 72).
Results indicated that compared to the two control groups, the PMT present group
scored significantly higher on RE and intention to engage in more exercise
( p-values ¼ 0.001). A trend effect in the expected direction also was noted for
T1 exercise behaviour ( p ¼ 0.09). RE, SE and PV made significant and unique
contributions to exercise intention scores, explaining 44% of the response variance.
Intention was the only variable to show an association with T1 exercise behaviour,
explaining 10% of the response variance. Overall, these findings suggest that a single
exposure of media intervention grounded in theory can influence people’s beliefs,
motivation and initial behaviour.
Keywords: Health promotion, disease, message tailoring, intentions, physical activity

Correspondence: Dr Harry Prapavessis, School of Kinesiology, Faculty of Health Science,

The University of Western Ontario, London, Ontario, N6A 3K7 Canada. E-mail:
hprapave@uwo.ca

ISSN 0887-0446 print/ISSN 1476-8321 online ß 2006 Taylor & Francis

DOI: 10.1080/14768320600603554
 740 S. P. Graham et al.

Introduction
New Zealand has one of the highest rates of colon cancer in the world (American
Cancer Society, 2003) with colon (bowel) cancer being the second most common
cancer for both men and women (Ministry of Health, 2003). Evidence exists that
physical activity is consistently related to lower risk of colon cancer (Everson,
Stevens, Cai, Thomas, & Thomas, 2002; Lee, 2003; McTiernan, 2003).
The median relative risk overall studies comparing the most active with their
least active counterparts is 0.7 for males and 0.6 for females, indicating a 30–40%
reduction in risk. This inverse relationship between exercise and risk of colon
cancer holds after adjusting for potential confound factors such as diet, body mass
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index and smoking status. In a recent review article, Slattery and Potter (2002)
observed a dose-response effect of exercise on colon cancer risk, when
participation in activities was at least moderate in intensity (>4.5 estimated
metabolic equivalent – MET) and activities were expressed as MET hours
per week. Plausible mechanisms of protection include the positive effect of
physical exertion on (a) insulin, prostaglandin and bile acid levels, all of
which influence the growth and proliferation of colonic cells and (b) reducing
bowel transit time and contact between faecal carcinogens and colonic mucosa
(Batty, 2000).
An important practical question is whether information about the protective
benefits of exercise for colon cancer will have any impact on exercise motivation.
To date, one study has shed light on this issue. Courneya and Hellsten (2001)
examined whether cancer prevention is a meaningful source of exercise
motivation using Protection Motivation Theory (PMT), a theory that has been
successfully applied in many studies assessing determinants of exercise and
other health behaviours (Floyd, Prentice-Dunn, & Rogers, 2000; Milne, Sheeran,
& Orbell, 2000; Norman, Boer, & Seydel, 2005). Male and female undergraduate
students (N ¼ 427) were randomly assigned to read persuasive communications
that independently manipulated four cognitive beliefs that are central to PMT;
perceived vulnerability (PV) towards the threat, perceived severity (PS) of
the threat, response efficacy (RE) to effectively avert the threat and the ability
to perform the coping response to avert the threat (i.e., self-efficacy – SE).
Results showed that individuals who were led to believe that colon cancer
was a severe disease, and also believed that exercise was effective in reducing
the risk of colon cancer were more motivated to exercise than those who were
led to believe that colon cancer was not a severe disease and exercise
was only a minimally effective prevention. Despite these promising findings,
they are not generalized beyond physically active young undergraduate students.
In addition, exercise intention was the primary outcome measure and not actual
exercise behaviour.
The purpose of the proposed study is to extend the work of Courneya
and Hellsten (2001) and examine the effectiveness of an intervention
strategy grounded in PMT that seeks to modify exercise behaviour in physically
inactive middle-aged adults. Inactive individuals were targeted because some
 Colon cancer information as a source of exercise motivation 741

theorists have advocated a stage-matched intervention approach using the

Transtheoretical Model (TTM) to promote health behaviour change
(Prochaska & Marcus, 1993). The TTM provides a framework for identifying
the interventions that are most appropriate for a person at a particular stage of the
targeted behaviour. The Cancer Prevention Research Consortium (1995) has
exercise interventions for people in the various stages of the TTM. Research also
has demonstrated the benefits of matching self-help manuals and other
motivational materials to a person’s stage of change (e.g., Marcus et al., 1998a,
1998b).1
Hence, our research question was as follows: ‘Is colon cancer prevention
information effective for motivating inactive people to seriously consider initiating
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exercise?’ Within this general research question, the following specific hypotheses
were generated: (a) manipulation of the four PMT constructs (i.e., PV þ
PS ¼ Threat, RE þ SE ¼ Coping Resources) using persuasive communications
will influence people’s beliefs towards colon cancer and exercise. Specifically,
those exposed to the persuasive communications will view colon cancer as more
threatening as well as perceive they have greater coping resources to reduce the
threat compared to those not receiving the persuasive communications; (b) those
exposed to the persuasive communications will also show greater intention to
perform more exercise as well as demonstrate higher levels of exercise behaviour
compared to those not receiving persuasive communications and (c) beliefs
towards colon cancer and exercise will be positively associated with concomitant
increases exercise intention and exercise behaviour.

Method
Participants
A sample of 173 teaching and school staff (121 females and 52 males, whose ages
ranged from 22.58 to 66.50 years – M ¼ 43.81, SD
11.50), who engage in
varying levels of exercise were recruited from 13 different schools in the greater
Auckland area. Relevant demographic characteristics are presented in Table I.
Individuals of all exerciser levels were recruited to avoid singling out non-
exercisers and making them feel uncomfortable about taking part in the study.

Development of PMT and other material

Two separate DVD videos were produced for use in this study. The first was
designed to incorporate the four major components of PMT; PV, PS, RE and SE.
An oncologist and a gastroenterologist sourced from Auckland Hospital were
enlisted to feature on the intervention video. They presented factual information
regarding the susceptibility (e.g., ‘‘There are 2,200 new colon cancer patients
every year’’; ‘‘New Zealand has one of the highest rates of colon cancer in the
western world’’) and severity (e.g., ‘‘Treating colon cancer involves a major
operation which often is followed by chemotherapy, making one tired and weak
for many weeks’’; ‘‘50% of those who contract colon cancer will die from the
 742 S. P. Graham et al.
Table I. Demographic characteristics for the three treatment conditions.

Experimental Attention control Non-contact

Variable (n ¼ 58) (n ¼ 51) control (n ¼ 64) Statistic p-level

Age (years) 44.84 (11.20) 41.60 (10.31) 44.65 (12.54) F(2, 170) ¼ 1.35 0.26
Ethnicity
European 82.8% 86.3% 93.8% 2 (32) ¼ 10.48 0.11
Other 5.7% 3.2% 3.4%
(Indian Maori,
Pacific Islander)
Gender
Male 25.9% 23.5% 31.9% 2 (32) ¼ 3.99 0.14
Female 74.1% 76.5% 60.9%
BMI 25.27 (4.25) 24.93 (4.25) 26.66 (5.64) F(2, 170) ¼ 1.99 0.14
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Hours worked 47.82 (11.55) 48.35 (5.79) 47.29 (9.35) F(2, 170) ¼ 0.179 0.84
per week
Stage of Exercise 4.05 (1.09) 3.90 (1.10) 3.71 (1.12) F(2, 170) ¼ 1.34 0.26
Readinessa
a
1 ¼ Precontemplation; 2 ¼ Contemplation; 3 ¼ Preparation; 4 ¼ Action; 5 ¼ Maintenance.

disease’’) of colon cancer in New Zealand. A senior academic in Sports and

Exercise Science from the University of Auckland was also enlisted to present
information regarding evidence linking colon cancer and exercise (e.g., ‘‘Research
suggests that physical activity and exercise reduce colon cancer risk by as much
as 40%’’) and to give some common methods to help increase one’s SE for
engaging in more exercise (e.g., ‘‘There are many ways for you to integrate more
physical activity and exercise into your daily life to meet the recommended
guidelines of 30 min a day of moderate to vigorous activity. For example, instead
of taking the car to the dairy, walk or ride your bike . . . ’’; ‘‘Park your car further
away from where you are going and walk . . . ’’; ‘‘Write these activity goals out and
put reminders around the house . . . ’’). The viewing time for the intervention
video was approximately 18 min. Video was chosen as the primary method of
framing the PMT persuasive information because it is a popular form of media,
targets people with a broad range of literacy skills, and ensured that the content
was standardized for all participants (Meade, 1996).
The second video was designed as an attention control condition. This design
allowed the researchers to distinguish the specific effect of the intervention from
the non-specific effect of receiving comparable attention. It featured a nutritionist
giving information regarding the links between diet and cancer in general,
and then went on to discuss more specifically the links between diet and
colon cancer. The attention control video was approximately 15 min in length.

Measures
Stage of exercise readiness questionnaire (SERQ). The SERQ was adapted
by Marcus, Rakowski and Rossi (1992) from smoking literature. Five statements
are presented (one based on each stage of change) and the participants were asked
to mark (tick) the statement that best describes their current level of exercise
 Colon cancer information as a source of exercise motivation 743

(e.g., ‘‘I do not currently exercise and am not seriously thinking about changing
in the next 6 months’’; precontemplation). The Kappa index of reliability
for the SERQ, taken over a 2-week period was 0.78 (Marcus et al., 1992).
All statements pertained to leisure-time physical activity outside of school.
Leisure-time physical activity was defined as exercising 3 times per week
for 30 min or more at a moderate intensity or higher (at least some light sweating,
for example: fast walking, swimming, cycling, hockey, soccer and aerobics).

Beliefs towards colon cancer and exercise. Four seven-point items commonly used
in PMT literature and specifically used by Courneya and Hellsten (2001)
assessed each of the components; PV, PS and RE. Each item was anchored by the
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descriptors strongly disagree (1) and strongly agree (7). As an example, sample
items related to colon cancer are: ‘‘Personally, I feel vulnerable to developing
colon cancer at some point in my life’’ (PV); ‘‘I feel colon cancer would be a very
serious illness for me to develop’’ (PS); ‘‘I feel that increasing my current level
of exercise would assist me personally to reduce the risk of developing colon
cancer later on’’ (RE). In addition, SE was assessed by four seven-point items
often used by Ajzen (1991) to assess perceived behavioural control, a construct
conceptually similar to self-efficacy. A sample item is ‘‘If I wanted to, I could
easily do the recommended exercise necessary to reduce the risk of developing
colon cancer’’.
Responses from participants were submitted to principal components
analysis to identify sets of items likely to constitute internally consistent scales.
Multiple criteria were examined to determine an appropriate oblique solution
(Comrey, 1988). These selection criteria were as follows; (a) Factor eigen values
greater than one, factor item loadings greater than 0.45 on the primary factor and
(c) factor items loadings less than 0.20 on the other factors. Results showed
that the 16 items grouped into four factors readily interpretable as PS (4 items),
PV (4 items), RE (4 items) and SE (4 items). These four factors accounted
for approximately 68% of the total response variance. Internal consistency
Cronbach’s alpha values for all scales were good (PV,  ¼ 0.75; PS,  ¼ 0.91;
RE,  ¼ 0.88 and SE,  ¼ 0.86). In addition to the four individual components
of PMT, the PS and PV constructs were added to form a person’s threat appraisal
and the RE and SE constructs were summed to produce a person’s coping
appraisal.

Exercise intentions. Three seven-point items drawn from the PMT literature and
specifically used by Courneya and Hellsten (2001) assessed exercise intentions.
A sample item is: ‘‘How likely is it that colon cancer prevention would motivate
you to exercise?’’, with responses ranging between extremely unlikely (1) to
extremely likely (7). The reliability coefficient value for the scale in the present
study was 0.81.

Exercise behaviour. Exercise behaviour was assessed using the Leisure Score
Index (LSI) of the Godin and Shepard (1985) Leisure Time Exercise
 744 S. P. Graham et al.

Questionnaire. The LSI contains three questions covering the frequency of mild,
moderate and strenuous exercise performed during free time for at least 30 min
during a typical week. A total score can be derived by summing the reported
weekly frequency ( f ) of participation at each of the three intensity levels
multiplied by the corresponding estimated metabolic equivalents (METs) value
(e.g., ( f )3 (mild) þ ( f )5 (moderate) þ ( f )9 (strenuous)). A MET is unit that
represents the metabolic equivalent of an activity expressed in multiples of resting
rate of oxygen consumption. Jacobs, Ainsworth, Hartman and Leon (1993) have
shown the LSI to possess acceptable test–retest reliability and concurrent validity
(correlates with objective indicators of exercise such as CALTRAC accelerometer
and VO2 max).
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Design and procedure

Ethical approval was obtained from the University of Auckland Ethics
Committee. A three-group randomized controlled experimental design was
used. Participants were recruited by canvassing of schools and referrals
from principals whose staff had already participated in the study. The canvassing
was conducted via letter, phone and visits in person by the lead investigator.
First, a time was arranged to meet the principal. Once consent was secured,
staff from each school was approached directly to participate in this study.
Schools, once recruited, were randomly assigned to one of three treatment
conditions: PMT present (experimental) – receive persuasive communications
that focused on the PMT constructs threat (vulnerability and severity) and coping
(response efficacy and self-efficacy); PMT absent (attention control) – receive
non-PMT communication (diet and cancer) and no information (non-contact
control). The distribution of participants to conditions were as follows;
Experimental conditions consisted of five schools with a total of 58 participants,
the attention control condition consisted also of five schools and totalled to
51 participants and the non-contact control group was derived from three schools
supplying 64 participants to the study.
Baseline demographic (i.e., age, gender, height, weight, education, stage
of exercise readiness, ethnicity) data and self-reported measures of exercise
behaviour (LSI) were obtained from each participant. The intervention (DVD
viewing material) was presented to participants in groups that ranged in size from
4 to 26 participants. Immediately following treatment participants were then
asked to complete a post intervention questionnaire which assessed their beliefs
towards colon cancer and exercise. Finally, exercise intentions were assessed
immediately after completing the beliefs questionnaire. The non-contact control
condition participants completed beliefs and intention measures directly
following the questionnaire on general demographic information.
Two weeks later (T1), self-reported measures of exercise behaviour were
assessed and then repeated at one month (T2). All participants were given the
two follow-up exercise behaviour questionnaires (LIS) along with two stamped
self-addressed envelopes. As part of the general demographic questionnaire,
 Colon cancer information as a source of exercise motivation 745

participants were asked to supply an email address. This was used to remind
participants to fill out and send away their follow-up LIS questionnaires the day
they were due. Only physically inactive participants (those who reported being
at either the precontemplation, contemplation or preparation stage of exercise
readiness) were used in subsequent analyses (n ¼ 72) to test the three major
hypotheses generated for the present study. The rationale for this was that
there was no point in providing an intervention to influence exercise beliefs
and intentions as well as change exercise behaviour in people who are already
motivated and doing the targeted behaviour. The overall design of the study,
along with the attrition rate for each group at each follow-up can be seen in
Figure 1.
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Results
Group equivalency
Chi-square and one-way ANOVA procedures were used to test for group
equivalency between the three treatment groups on demographic characteristics
and other factors that could influence beliefs about exercise and colon cancer,
exercise intentions and subsequent exercise behaviour. As can be seen in Table I
there was group equivalency between groups across all these variables.2 Due to
equivalency between groups, it was deemed unnecessary to use demographic
variables as covariates in the subsequent group analyses.
Correlation and ANOVA procedures also were conducted to determine
relationships among the demographic variables (i.e., age, BMI, gender, ethnicity,
stage of exercise readiness) and the PMT variables, exercise intentions and
exercise behaviour. Results showed that age was moderately related to exercise
intentions (r ¼ 0.31, p < 0.001). Results also showed that stage of exercise
readiness was positively related to all three exercise behaviour end point scores
(r values ranged between 0.36 and 0.50) and SE scores (r ¼ 0.41, p < 0.001).
ANOVAs showed a trend effect for gender at baseline, F(1, 171) ¼ 3.63, p < 0.06,
and T2, F(1, 171) ¼ 3.20, p < 0.08, exercise behaviour (male LSI scores were
higher than female at both time points).3
An ANOVA also was made to determine whether there were true differences
between the ‘‘non-exercisers’’ (M ¼ 13.56, SD ¼ 11.42) and ‘‘exercisers’’
(M ¼ 35.71, SD ¼ 20.54) on baseline exercise behaviour (LIS) scores and the
result was significant, F(1, 173) ¼ 67.99, p < 0.001.

Beliefs towards colon cancer and exercise

One-way ANOVA was used to test for differences between treatment groups
on their beliefs towards colon cancer and exercise questionnaire scores (see
Table II). ANOVAs were followed by planned comparisons to determine if the
PMT present group differed from the other two control groups. Results show that
the PMT present group was significantly higher on coping appraisal than the
other two control groups, which was carried through to RE but not SE. For threat
 746 S. P. Graham et al.

173 participants obtained

through sampling process
and randomized by school

Experimental Attention control Non contact control

condition (non- condition (non- condition (non-
exercisers) n = 22 exercisers) exercisers) n = 30
n = 20
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Participants complete Participants complete Participants complete

demographic and demographic and demographic and
baseline measures baseline measures baseline measures

Participants view Participants view

educational program educational program
based on PMT, colon based on diet and
cancer and exercise cancer

Participants complete Participants complete Participants complete

post intervention post intervention post intervention
beliefs questionnaire beliefs questionnaire beliefs questionnaire

Participants complete Participants complete Participants complete

first follow-up first follow-up first follow-up
questionnaire (T1) questionnaire (T1) questionnaire (T1)
n = 20 n = 19 n = 21
91% 95% 70%

Participants complete Participants complete Participants complete

second follow-up second follow-up second follow-up
questionnaire (T2) questionnaire (T2) questionnaire (T2)
n = 15 n = 17 n = 18
68% 85% 60%

Figure 1. Flow diagram of design and overall procedure.

 Downloaded by [University of Birmingham] at 11:11 20 November 2014

Table II. Beliefs towards colon cancer and exercise data between treatment conditions for PMT constructs.

Experimental Attention Non-contact

(Expt) control (AC) control (NC) Effect Planned
Variables n ¼ 22 n ¼ 20 n ¼ 30 F (df ¼ 2, 69) Significance size (2) comparisons

Threat 10.55 (1.44) 10.09 (1.93) 9.37 (1.92) 2.86 0.06 0.08 Expt > AC & NC
( p ¼ 0.08)
Coping 11.01 (1.26) 9.34 (1.60) 8.24 (1.90) 18.36 0.001 0.34 Expt > AC & NC
( p < 0.001)
Vulnerability 4.32 (1.10) 3.86 (1.29) 3.53 (1.45) 2.33 0.10 0.06 Expt > AC & NC
( p ¼ 0.07)
Severity 6.23 (0.67) 6.23 (1.11) 5.84 (0.94) 1.57 0.22 0.04 Expt ¼ AC & NC
( p ¼ 0.41)
RE 5.99 (0.69) 5.05 (1.01) 3.77 (1.14) 33.90 0.001 0.49 Expt > AC & NC
( p < 0.001)
SE 5.02 (1.17) 4.29 (1.22) 4.48 (1.26) 2.13 0.13 0.05 Expt > AC & NC
( p < 0.05)

Notes: Expt ¼ PMT group (information on colon cancer and its relationship with exercise); AC ¼ Attention control group (information on cancer
and diet); NC ¼ Non-contact control group. Bonferroni adjustment to alpha for planned comparisons is 0.05/7 ¼ 0.007.
Colon cancer information as a source of exercise motivation
747
 748 S. P. Graham et al.
Table III. Descriptive statistics for exercise intentions and exercise behaviour.

Experimental Attention control Control

Mean SE Mean SE Mean SE

Intention 5.51 0.20 4.90 0.19 4.35 0.16

Exercise behaviour 11.68 2.24 14.85 2.79 14.30 2.10
(Baseline)
Exercise behaviour 24.20 5.80 17.89 5.96 9.42 2.28
(Time 1)
Exercise behaviour 15.26 4.21 15.35 4.40 12.83 2.55
(Time 2)

Exercise behavior – total weekly energy expenditure.

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SE – Standard error.
Notes: Experimental (PMT information); Attention control (non-PMT information);
Control (non-contact control).

appraisal, a trend effect in the expected direction was found which was not
carried through to PV or PS (see Table II).

Exercise intentions
A one-way ANOVA was used to test for differences between treatment groups
on their exercise intention scores (see Table III). The ANOVA was significant,
F(2, 69) ¼ 11.80, p < 0.001, 2 ¼ 0.26. Planned comparisons test showed that the
intention to engage in more exercise was significantly greater in the PMT present
group when compared with the other two control groups, t(1, 69) ¼ 4.59,
p < 0.001.

Exercise behaviour
Exercise behaviour (LIS) scores between treatment groups across time are
presented in Table III and illustrated in Figure 2. Our analysis plan involved
conducting a treatment condition ANCOVA on each follow-up exercise
behaviour time point. Pre intervention exercise behaviour served as a covariate
to remove the variance in post intervention exercise behaviour that is due to
pre intervention exercise behaviour thereby increasing the power and sensitivity
of the F-test (Stevens, 1996). Prior to conducting these analyses, the assumptions
underlying the use of ANCOVA (e.g., linearity, homogeneity of regression) were
tested and met (Tabachnick & Fidell, 2001). Results showed that after controlling
for baseline exercise behaviour scores, a condition trend effect was found in
exercise behaviour at T1 (2 weeks post intervention), F(1, 60) ¼ 2.51, p ¼ 0.09,
2 ¼ 0.08, but not at T2 (4 weeks post intervention), F(1, 50) ¼ 0.113, p ¼ 0.893,
2 ¼ 0.005. Planned comparisons test showed a trend effect, t(1, 57) ¼ 1.76,
p ¼ 0.08. Specifically, those in the PMT group reported higher levels of exercise
behaviour at T1 compared to their control counterparts (see Figure 2).
 Colon cancer information as a source of exercise motivation 749
35

30
Total weekly energy expenditure (METS)

25

20 Experimental
Attention control
15 Control

10
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0
Baseline Time 1 Time 2

Figure 2. Mean and SE scores in exercise behaviour (LIS) between treatment groups across time.
Notes: Experiment (PMI information); Attention control (non-PMT information); Control
(non-contact control).

Table IV. Inter-correlations of all PMT variables, exercise intentions and exercise behaviour.

Variable 1 2 3 4 5 6 7 8 9 10

1. Coping 0.18 0.19 0.09 0.79** 0.74** 0.61** 0.07 0.17 0.19
2. Threat 0.88** 0.73** 0.30** 0.04 0.15 0.07 0.08 0.04
3. Vulnerability 0.23 0.57** 0.02 0.04 0.05 0.05 0.10
4. Severity 0.27** 0.03 0.27** 0.05 0.02 0.00
5. RE 0.18 0.57** 0.20 0.17 0.16
6. SE 0.36** 0.11 0.09 0.13
7. Exercise intention 0.04 0.31* 0.26
8. Exercise behaviour 0.27* 0.56**
(Baseline)
9. Exercise behaviour T1 0.40**
10. Exercise behaviour T2

*p < 0.05; **p < 0.01 (2-tailed).

Relationships between PMT constructs, exercise intentions and exercise behaviour

The correlations between the PMT variables, exercise intentions and exercise
behaviour are presented in Table IV. If bivariate relations were found between the
predictor variables and the criterion variable of interest then they were put
into a regression analysis to determine their uncorrelated contribution. Intention
to engage in more exercise was significantly related to all PMT constructs
expect PV. Standard multiple regression analysis revealed that the remaining
three constructs explained 44% of the variance in exercise intentions,
F(4, 67) ¼ 13.02, p < 0.001, with all the three constructs making significant
 750 S. P. Graham et al.

unique contributions: RE ( ¼ 0.52, t ¼ 5.28, p < 0.001); SE ( ¼ 0.29, t ¼ 3.04,

p < 0.01); PS ( ¼ 019, t ¼ 1.93, p < 0.05).
Intention to engage in more exercise was the only variable related to exercise
behaviour (see Table IV). Regression analysis showed that intention accounted
for 10% of the variance in exercise behaviour at T1, ( ¼ 0.31, t ¼ 2.46, p < 0.01).
In light of intention’s contribution to exercise behaviour at T1, a hierarchical
regression was conducted entering baseline exercise behaviour at step 1 followed
by intentions at step 2. Results showed that after controlling for baseline exercise
behaviour, R2 ¼ 0.06, F(1, 58 ¼ 4.07, p < 0.05, intentions continued to make a
significant contribution to exercise behaviour, R2 change ¼ 0.09, F change
(1, 57) ¼ 6.46, p < 0.01.
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Discussion
Our data supports the notion that colon cancer prevention is a meaningful source
of exercise motivation. In general, the persuasive message framing developed for
the present study was effective in manipulating participants’ coping appraisal
(RE), which in turn influenced their intentions to perform more exercise, which
in turn influenced their behaviour to do more initial exercise. The failure to
strongly manipulate participants’ SE and threat appraisal (PS and PV) was
unfortunate because both the SE and PS component made a significant
and unique contributions to exercise intention scores. Response bias may be
one reason for which SE was manipulated to a lesser extent than RE. For
instance, the SE intervention was designed to encourage participants to get better
organized and start planning for ways to incorporate more physical activity into
their daily lives. Based on the post intervention belief items scores, it seems
participants in the two control groups felt just as confident in achieving this
goal (all three groups showed moderate levels of confidence – see Table II).
Perhaps participants in the control groups did not want to convey lower levels
of confidence in order to protect their self-worth and self-esteem. An equally
plausible reason, however, is that the intervention material was not strong enough
to positively influence SE beliefs.
There are a number of plausible reasons as to why the threat appr-
aisal components were not manipulated as successfully as the coping
appraisal components. First, our persuasive material was based on factual
information unlike the design of Courneya and Hellsten (2001), which focused
on using bogus written information to manipulate the four PMT constructs into
high versus low levels. For example, in their study, PS of colon cancer was
characterized by either limited treatment problems and an 80% five-year relative
survival rate (low PS), or by major treatment problems and a 20% five-year
relative survival rate (high PS). These design differences, in part, likely
contributed to why the Courneya and Hellsten study successfully manipulated
PS and we did not. Our failure to manipulate PS is not surprising. One would
expect middle-aged people to be aware of the seriousness of cancer in general,
and perhaps colon cancer specifically. This is reflected in the high mean score
 Colon cancer information as a source of exercise motivation 751

of PS between all treatment conditions. Clearly a ceiling effect was operating

which restricted the potential impact of PS information.
Second, of the four PMT constructs, PV scores were the lowest irrespective
of treatment condition (overall mean was 3.7 on the seven-point scale). This may
be due to defensive denial where participants discount themselves from the threat
in order to blunt its psychological impact (cf Wiebe & Korbel, 2003). On the
one hand, these moderate vulnerability rates may reflect rational appraisal of
personal risk. The average individual has a low-to-moderate risk of colon cancer
and so high vulnerability ratings would not be accurate. On the other hand,
high rating for colon cancer severity, SE and RE would be reasonable and
desirable from a health promotion perspective. The main reason Courneya
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and Hellsten (2001) offered for their inability to successfully manipulate PV was
that their sample population was made up of university undergraduate students
with an average age of 19.7 years and that an optimistic bias is naturally held
by young individuals when it comes to diseases such as cancer. Our findings
taken together with those of Courneya and Hellsten (2001) suggest that altering
perceptions of vulnerability to colon cancer remains a major challenged for cancer
prevention health professionals.
As predicted, significant differences in intention to do more exercise were
found between treatment conditions. Specifically, those in the PMT group
scored higher on this construct than their two control counterparts (see
Table III). A trend effect also was noted between treatment conditions in post
intervention exercise behaviour at T1 (2 weeks) but not T2 (4 weeks). Those
in the PMT group reported higher exercise behaviour scores at T1 compared to
those the two control groups. The eta-squared statistic (0.08) indicated a medium
effect size (Cohen, 1992) and that a significant finding would likely have occurred
with a larger sample and its accompanying smaller variability (standard error)
in exercise behaviour LIS scores (see Table III and Figure 2). Perhaps we might
have found a stronger effect if RE had shown an association with exercise
behaviour or intention’s association with exercise behaviour was more robust.
The large effect observed in both RE and intention suggested that these
two variables had the greatest potential to produce an exercise behaviour effect.
It is noteworthy that of the three treatment conditions, the PMT group
was the only one to show an increase in early exercise behaviour across time.
Also as predicted, three of the four PMT variables (PS, RE, SE) were
significantly related with intentions to engage in exercise (see Table IV). Standard
regression analysis showed that all three variables made unique contributions
to intention scores (i.e., explained 44% of the response variance). Of the three
PMT variables, RE had the strongest relationship with exercise intentions.
These findings are in line with the Milne et al. (2000) meta-analysis on PMT
research. They reported that overall, coping variables were more strongly
and consistently associated with intention than threat appraisal variables.
It appears that documenting reductions in colon cancer risk from exercise is
associated with concomitant increases in intention to engage in more exercise.
Intention was the only construct to show an association with exercise behaviour.
 752 S. P. Graham et al.

These findings are again in accordance with the Milne et al. (2000) meta-analysis
on PMT research. They found from reviewing twelve studies that intention
had the strongest, most robust and most consistent association with concurrent
behaviour.
As mentioned earlier, some theorists have suggested a stage-matched
intervention approach to health behaviour change (Prochaska & Marcus,
1993). In the present study the majority of participants (n ¼ 101) reported
being in the action/maintenance stage of exercise readiness and hence were
not included in subsequent analyses. This raises the question: ‘what would
happen to our findings if we included the full sample?’ To shed light
on this issue we re-analyzed our data using the entire sample (N ¼ 173).
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The following notable differences were found: (a) the effect found for exercise
intention between groups was substantially smaller (2 ¼ 0.11); (b) the PMT
variables explained much less variance in exercise intention scores (25%); (c) no
trend effect in the expected direction was found for exercise behaviour (LIS
scores) at T1 and (d) intention was no longer a significant predictor of exercise
behaviour.
These post hoc findings, together with the findings reported for the
‘‘non-exercise’’ sub sample, allow the following conclusions to be made.
Intention to do more exercise can result by framing video information that
influences people’s coping appraisal (i.e., RE – documenting the colon cancer
protective benefits of engaging in regular exercise). This video information can
also improve early exercise behaviour for those not currently engaged in exercise.
For this targeted subgroup, exercise intention is the most salient factor
influencing exercise behaviour. Overall, our findings support the potential
effectiveness of health interventions that focus on self-regulation processes
(i.e., coping resource appraisal, goal intentions) in enhancing coping appraisals,
intentions and behaviour.
Although the present findings are promising, there are a number of limitations
in this study that should be acknowledged. First, the failure to successfully
manipulate SE, PV and PS is problematic. To adequately test PMT in facilitating
exercise through colon cancer prevention, all components of the model
need to be manipulated. However, as previously mentioned, this presents
a challenge (especially framing vulnerability messages) for health professionals.
Second, the absence of a pre-test belief assessment period prevented conclusions
to be drawn about actual change in the PMT constructs. Third, the measure
of exercise behaviour was exclusively self-report, which depends on an
individual’s accurate recall of physical activity. The use of more objective
measures of exercise behaviour (e.g., accelerometer, heart rate, monitors)
are needed to strengthen conclusions about PMT constructs and exercise
behaviour. Fourth, the study would have been strengthened with a larger
sample of non-exercisers as it would have increased our power to detect small
to medium effects. A larger sample also would have allowed us to examine our
data across gender. Lastly, the sample used was teaching and administration
staff employed at primary, intermediate and secondary schools, and hence
 Colon cancer information as a source of exercise motivation 753

our findings may not be generalized beyond this generally well-educated

population.
There are a number of fruitful research avenues stemming from the findings of
the present study. For instance, self-regulation strategies such as planning or what
Gollwitzer (1999) referred to as ‘‘implementation intentions’’ may help bridge
the intention–behaviour (i.e., exercise) gap. It has been suggested that intention
goals do not trigger behaviour directly, but they likely lead to specific intention
plans which in turn trigger behaviour (Taylor, Pham, Rivkin, & Armor, 1998).
For example, Sniehaotta, Scholz and Schwarzer (2005) found that a measure
of planning mediated the goal intention–exercise behaviour relationship.
Furthermore, Milne, Orbell and Sheeran (2002) found that a PMT intervention
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was only successful in changing exercise behaviour when combined with an

implementation intention intervention. This issue deserves further research
attention.
The adoption of regular exercise requires that individuals’ progress through
three critical phases: (a) sufficient motivation and intention to exercise;
(b) successful initiation of exercise and (c) successful maintenance of the exercise
over time (Estabrooks & Gyurcsik, 2003). The present study was designed to
only address motivation, intention and initiation of exercise, hence future
intervention work is needed to determine whether cancer prevention can be used
as source of exercise adoption and maintenance. From other interventions such
as smoking cessation, it is known that the rate of recidivism is high and it is
unlikely that a relatively short period of activity would substantially decrease the
risk of colon cancer. Empirical based evidence showing that exercise can be
increased and maintained is essential before longitudinal prospective studies can
be conducted that evaluate the colon cancer protective benefits of exercise and
physical activity.
A final recommendation is to consider message tailoring that corres-
ponds with an individual’s style of processing health-relevant information (cf
Williams-Piehota et al., 2004; Salovey & Williams-Piehota, 2004). The premise
here is that matched messages will be more effective in promoting behaviour
change (i.e., exercise and physical activity) than mismatched messages. It is likely
that the messages used in the present experiment were not matched to all
participants’ processing styles.

Acknowledgements
The authors would like to acknowledge the valuable contribution of Drs Bryan
and Suzan Perry for their expert commentary on (a) the severity and vulnerability
of colon cancer and (b) the benefits of exercise in reducing the risk of colon
cancer. The authors would also like to acknowledge Ms Jenny Pearce for her
expert commentary on diet and its relationship to cancer in general. Finally, the
authors would like to thank Neil Morris and Richard Smith from the Education
 754 S. P. Graham et al.

Media centre for their assistance with filming and editing the intervention
material.
All participants were provided the results from the study and those in the
attention and non-contact control groups were provided the opportunity to view
the PMT intervention.

Notes
[1] A recent systematic review (Bridle et al., 2005) of the effectiveness of health behaviour
interventions (including physical activity) based on the transtheoretical model (TTM)
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showed limited evidence for the utility of stage-based interventions as a basis for behaviour
change or facilitating stage progression. The authors do acknowledge, however, that lack of
evidence may be due in part to poor model specification, and the inappropriate manner in
which interventions have been developed and delivered.
[2] Group equivalency between the three treatment conditions on the demographic factors also
was found for the ‘‘non-exercise’’ (n ¼ 72) subgroup.
[3] For the ‘‘non-exercise’’ subgroup, relations found among the demographic variables, PMT
variables, exercise intentions, and exercise behaviour parallel those reported for the entire
sample (N ¼ 173).

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