In Western Counties, such as Australia, there is a high and increasing prevalence of three inter-connected chronic conditions: T2DM, overweight, and depression (ABS, 2009), and women are more likely than men to report depression (AIHW, 2010). Additionally, despite the well known physical and psychological health benefits of PA (Pate et al., 1995), the number of individuals who do not do enough PA to gain health benefits remains high (ABS, 2009). People with chronic conditions (such as T2DM, overweight, and depression) who would benefit most from regular PA participation are even less likely than the general population to engage in regular PA. Furthermore, women are more likely than men to report low levels of PA (ABS, 2009). Researchers have identified an inverse reciprocal relationship between PA and depression. That is, PA participation can have psychological benefits (e.g., reduced depression), and such psychological benefits can assist people to sustain their participation in PA (Babyak et al., 2000). Ironically, however, depression has been
considered a major risk factor for poor adherence to regular PA participation (Mier, Medina, & Ory, 2007; Morrato et al., 2007). Taken together, it would be expected that overweight women with T2DM are at a much greater risk of depression and inactivity than those with one or no chronic conditions. Thus, it is predicted that there is a negative relationship
between depression and PA in women who are overweight and have T2DM. The purpose of this cross-sectional study, therefore, was to examine the relationship between depression and PA among overweight women with T2DM. This study provided valuable preliminary information for the development of an appropriate psychological intervention aimed at increasing regular PA participation among overweight women with T2DM and depression.
Method Participants
Power analysis indicated that at a significance level of .05, for a medium effect size of 0.5, and a power of .80, I required 68 participants (Cohen, 1988). Of the 981 questionnaire packs that were distributed (see procedure section of this chapter for further details), a total of 77 (7.85%) participants returned their completed pack, however, four were excluded from analysis because they did not meet the Body Mass Index (BMI) inclusion criteria (i.e., their BMI was less 25), and 12 participants were excluded from the analysis due to incomplete data. Therefore, data from a total of 61 participants were included in the analysis.
Participants were 61 women residing in Victoria, who were overweight (BMI ≥ 25; M = 31.50, SD = 9.87), aged between 30 and 70 years (M = 59.44 years, SD = 7.80), and had diagnosed T2DM. Of these participants, 11 (18%) had been diagnosed with T2DM for 4 years or less, 15 (24.6%) had been diagnosed for between 5 and 9 years, 29 (47.5%) had been diagnosed for 10 to 19 years, and 6 (9.8%) had been diagnosed for 20 years or more. A large proportion (41; 67.2%) of participants reported at least one health complication in addition to their T2DM. Nine (15%) participants acknowledged depression as an additional health complication. Other commonly reported health complications included, although were not limited to, high blood pressure (19; 32%) and cholesterol (6; 10%), arthritis (5; 8%) and osteoarthritis (4; 7%), asthma (4; 7%), and heart complications (4; 7%).
Multiculturalism was evident in this sample. A total of 32 participants were from an Australian background (52%). Among the remaining participants, 19 different birth places were recorded, including Sri Lanka (7%), India (5%), England (5%), Philippines (3%), and Vietnam (2%). Regardless of participants’ cultural background, an inclusion
criterion was the ability to comprehend English. The majority of participants (82%) stated English as their main language. All participants were able to comprehend English.
Materials
Demographic information form. See Appendix F. Demographic details were obtained through a short form devised for this study. Information collected included age, weight, height, birth country, time since diagnosis of T2DM, and any other (diabetes and non-diabetes related) health complications.
Hospital Anxiety and Depression Scale (HADS; Zigmond, & Snaith, 1983). See Appendix G. The HADS is a self-report measure consisting of 14 items, with two subscales measuring symptoms of depression (HADS-D) and symptoms of anxiety (HADS-A) during the past week. Each subscale consists of seven questions. For every item there are four possible responses, indicating the severity of the symptoms from 0 (not at all) to 3 (most of the time). Thus, the range is from a minimum of 0 to a
maximum score of 21 for each subscale. A typical question on the depression subscale is “I still enjoy the things I used to enjoy”. A typical question on the anxiety subscale is “I feel tense or wound up”. Scores below 8 on the HADS subscales indicate no
depressive or anxiety symptoms, scores between 8 and 10 on either subscale are most commonly used to indicate mild levels of depressive or anxiety symptoms, scores between 11 and 14 on either subscale are most commonly used to indicate moderate symptomatology, and scores of 15 or above reflect a severe level of depressive or anxiety symptoms. The HADS was chosen to measure depression in this study for two main reasons. First, because the HADS does not contain somatic items, symptoms of depression/anxiety are less likely to be confounded with the physical symptoms of diabetes. Thus, it can be used to measure depression and anxiety for both clinical and
general populations, including people with diabetes (Bjelland, Dahl, Haug, &
Neckelmann, 2002; McHale, Hendrikz, Dann, & Kenardy, 2008). Second, the HADS has been shown to have good psychometric properties. The factor structure has been confirmed in a number of studies (e.g., Cameron, Crawford, Lawton, & Reid, 2008). Cronbach’s alpha coefficients for HADS-A ranging from .68 - .93 (mean .83) and for the HADS-D between .67 - .90 (mean .82) are good (Bjelland et al., 2002). Similarly, in the present study, good internal consistency for sub-scale was demonstrated (Cronbach alpha for HADS-A .87 and HADS- D .77). Furthermore, in their review of 747 papers that used the HADS, Bjelland et al. (2002) reported good validity (sensitivity to change and specificity).
Scottish Physical Activity Questionnaire (SPAQ; Lowther, Mutrie, Loughlan, & McFarlane, 1999). See Appendix H. The SPAQ consists of four questions that assess the time participants spent in occupational and leisure PA during the previous week (minutes per week of at least moderate intensity PA). Occupational PA includes walking at work (e.g., walking to and from your desk, walking up or down stairs) and manual labour at work (e.g., lifting, climbing ladders). Leisure PA includes walking outside work (e.g., walking for pleasure, walking to the shops), manual labour outside work (e.g., digging, washing car), active housework (e.g., vacuuming, scrubbing floors), dancing, cycling for pleasure or to work, and participating in a sport, leisure activity or training (e.g., exercise class, swimming).
The SPAQ also measures current PA stage of behaviour change (a core construct of the transtheoretical model; Prochaska & DiClemente, 1982). The first three questions require a tick-the-appropriate-box response. Of these three questions, the first two questions assess whether people consider themselves to be currently regularly
third question lists five different categories. Each category represents one of the five stages of change: pre-contemplation, contemplation, preparation, action, and
maintenance. Respondents tick the box next to the category that best describes their PA level over the last 6 months. The fourth question requests an answer in a diary format. Specifically, the person is asked to record how many minutes they spent engaging in PA, each day, for seven consecutive days. The SPAQ was chosen to measure self- reported physical activity in this study for two main reasons: First, the SPAQ has been shown to be reliable (r = 0.998[32]; critical value 0.436, p<0.01) and to hold strong concurrent validity and limited criterion validity (Bauman, Phongsavan, Schoeppe, & Owen, 2006; Lowther et al., 1999). Second, as mentioned, the measure includes questions to assess participants’ stage of exercise behaviour change (Lowther et al., 1999), and thus provides another way to examine PA.
Study 1 supporting letter. See Appendix I. To enhance the likelihood that