The 31 HPBs related to the NLH framework goals determined women’s HPB outcomes. All HPBs were assessed using the NLHQ unless otherwise specified. For each woman, all HPBs were assessed as “achieved” or “not achieved.” Thus, each woman could achieve up to 31 HPBs at each time point. Definition and achievement criteria for the 31 HPBs are listed in Table 5. The 31 HPBs were associated with the six HPB categories: physical activity (n = 3), sleep (n = 6), nutrition (n = 10), eating behaviour (n = 5), self-care (n = 4) and stress management (n = 3). Achievement of most HPBs were assessed using the NLHQ. HPBs related to aerobic activity and sleep duration were assessed using the RPAQ and PSQI respectively.
Table 5
The 31 HPBs and Their Achievement Criteria
Category Health-Promoting Behaviour Achievement Criteria
PA Aerobic At least 150 minutes of moderate-to-vigorous physical
activity per week.
PA Muscle strengthening Exercise sessions (minimum 10 minutes) on at least one
to two days per week
PA Stretching Exercise sessions (minimum 10 minutes) on at least one
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SL Sleeping the recommended
hours
At least 7 hours for the majority of nights in the past month.
SL Consistent sleep/wake times At least three to four nights per week.
SL Wind-down routine At least three to four nights per week.
SL Limiting screen time At least 30 minutes before sleep on an average night.
SL Avoiding sleep stealers Less than three nights per week (alcohol, caffeine, naps
and sugar).
SL Limits eating and working in
bed
Less than three nights per week.
NU Vegetables At least three serves per day.
NU Fruit At least two serves per day.
NU Limiting sodium sources Reports “sometimes” or less for both salt and soy sauce.
NU Fibre sources At least two of the following: fruit and vegetables (five
servings or more), legumes (at least three times per week) or choosing wholegrain varieties (“often” or more)
NU Healthy fat sources At least two of the following: plant-based cooking oil;
fish intake at least one to two times per week; or intake of nuts and seeds reported as “often” or more.
NU Limiting less healthy fat
sources
No more than one of the following: fried fish, chips, takeaways more than two times per week each and animal-based cooking fat.
NU Limiting added sugar sources No more than one of the following: lollies, fizzy drinks,
fruit juices, energy drinks and alcohol less than three times per week each.
NU Calcium sources Consumes calcium sources more than four times per
week.
NU Iron sources Consumes iron sources more than four times per week.
NU Reading nutrition labels Report 'often' or 'always' reading three or more of the
following: sodium, fibre, fat, and added sugar.
EB Eating breakfast Every day
EB Eating three meals Every day
EB Meal preparation Reports preparing at least 60% of total meals reported.
EB Meal planning Reports planning at least 50% of total meals reported.
EB Water At least eight 250 mL glasses per day.
SC Personal goals/values Reports 'enough' time or more.
SC Self-appreciation Reports 'enough' time or more.
SC Relaxation Reports 'enough' time or more.
SC Personal development Reports 'enough' time or more.
SM Self-reflection Reports 'enough' time or more.
SM Reaching out to others ‘Agrees' or 'strongly agrees.'
SM Time management Reports 'most of the time' or 'always.'
Note. HPB = Health-promoting behaviour; PA = physical activity; SL = sleep; NU = nutrition; EB =
Physical activity
Three HPBs (i.e., aerobic, stretching, muscle strengthening) determined women’s frequency and variety of physical activity. Women achieved the aerobic HPB if they reported participating in at least 150 minutes of moderate- to vigorous-intensity physical activity (MVPA) per week as recommended by the national guidelines (Ministry of Health, 2015). Women’s duration of time spent in MVPA was assessed using the RPAQ, which has demonstrated significant association for self-reported physical activity and objectively criterion (r = .70, p < 0.001) and intra-class correlation of 0.76 for overall energy expenditure (p < 0.001; Besson et al., 2010). Women reported the type and duration of their usual activities across four domains (work, travel, recreation and domestic life) and all activities were assigned a metabolic equivalent (MET) obtained from the Compendium of Physical Activities (Ainsworth et al.). A MET is a measure of physical activity cost equal to the expenditure of 3.5 ml O2/kg/min at rest (Jetté, Sidney, &
Blümchen, 1990). Each activity was categorised by intensity level: sedentary (< 1.5 METs); light (1.5 to < 3 METs), moderate (3 to 6 METs); and vigorous (> 6 METs; Besson et al., 2010). Activity durations were summed to calculate the total amount of time (hours) women spent at each intensity level. Moderate and vigorous categories were combined to provide a MVPA category (> 3 METs; Golubic et al., 2014) that could be interpreted against national recommendations.
Women used a seven-point Likert scale (not at all, 1-3 times a month, 1-2 days per week, 3-4 days per week, 5-6 days per week, and every day) to report how often they completed at least 10 minutes of stretching and muscle strengthening exercises. Muscle strengthening and stretching
HPBs were individually accomplished if women reported participating in at least 10 minutes of the respected activities for a minimum of 1-2 days per week (American College of Sports Medicine, 2013; Ministry of Health, 2015).
Sleep
Six sleep HPBs evaluated women’s sleep routine consistency and management of sleep barriers: (1) sleeping the recommended hours, (2) consistent sleep/wake times, (3) wind-down
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routine, (4) limiting screen time, (5) avoiding sleep stealers and (6) limits eating and working in bed. In order to determine women’s sleep duration, women’s sleep hours were reported using the
PSQI, which identified the typical times that women went to sleep and woke up. Women achieved
sleeping the recommended hours if the reported amount of time between sleeping and waking was
at least seven hours (Hirshkowitz et al., 2015).
For limiting screen time, women reported the usual amount of elapsed time between
turning off backlit screens and going to sleep by selecting a response from six choices (none, less than 30 minutes, 30 minutes, 1 hour, 1.5 hours, 2 hours, or more than two hours). Women accomplished limiting screen time if there was at least a 30-minute window of time between when they turned off backlit screens and when they fell asleep (National Sleep Foundation, 2016).
Women reported all other sleep HPBs using a seven-point Likert scale (not at all, 1-3 times a month, 1-2 days per week, 3-4 days per week, 5-6 days per week, and every day). Women reported how often they adhered to similar times for going to bed and waking up. In order to achieve the consistent sleep/wake times HPB, both sleeping and waking scales had to show adherence of at least three to four nights per week (National Sleep Foundation, 2016).
Avoiding sleep stealers and limits eating and working in bed HPBs were determined by
multiple frequency items. HPBs based on multiple frequencies required all reported frequencies to less than three nights per week (National Sleep Foundation, 2016). Avoiding sleep stealers
included avoiding stimulants (i.e., nicotine and caffeine) within six hours of sleep, alcohol within three hours of sleep, sugar food/drinks within two hours of sleep and naps longer than 30 minutes (National Sleep Foundation, 2016). The limits eating and working in bed combined the reported frequencies of eating in bed and working in bed (National Sleep Foundation, 2016).
Nutrition
Ten HPBs accounted for the nutrition HPB category including intakes for (1) vegetables, (2) fruit, (3) sodium, (4) fibre sources, (5) healthy fat sources, (6) limiting less healthy fat sources, (7) limiting added sugar sources, (8) calcium sources, (9) iron sources and (10) reading nutrition
labels. Achievement criteria for each of the HPBs were largely guided by the Eating and Activity Guidelines for New Zealand Adults (Ministry of Health, 2015). Women reported daily servings for vegetable and fruit intakes. Frequencies reported as “don’t know” were assumed as more than “never” and thus corrected to “1 serving.” The vegetables HPB was achieved if women reported at least three servings per day and the fruit HPB was achieved if at least two servings were reported per day (Ministry of Health, 2015).
Limiting sodium, fibre sources, healthy fat sources, limiting less healthy fat sources and
limiting added sugar sources HPBs were each based upon multiple frequency items. Women’s
sodium sources were based on how frequently (never, rarely, sometimes, often, all of the time) women reported adding salt and soy sauce to their meals. The limiting sodium HPB was achieved if both salt and soy were reported as “sometimes” or less (Ministry of Health, 2015). Women’s
fibre sources were based upon women’s reported intakes of fruit, vegetables, legumes and
wholegrain foods. The fibre sources HPB was achieved if women reported at least two of the following three frequencies: at least five servings of fruit and vegetables per day, eating legumes at least three to four times per week, choosing wholegrain varieties “often” or more. Women achieved healthy fat sources if women reported at least two of the three frequencies: eating seafood at least one to two times per week, cooking with plant-based sources (e.g., olive oil, margarine) and/or adding nuts/seeds to their foods “often” or more. Women achieved limiting less
healthy fat sources by reporting no more than one of the following frequencies: intakes of fried
fish more than twice per week, chips more than twice per week, takeaways more than twice per week or usually cooking with animal-based sources (e.g., butter, lard). Limiting added sugar
sources was achieved if women reported no more than one of the following: fruit juice more than
twice per week, fizzy drinks more than twice per week, energy drinks more than twice per week, sweets more than twice per week or alcohol more than four times per month (equivalent to once per week).
In addition to NZANS items, questions regarding the sources of calcium and iron were reported as frequencies (never, less than once per week, 1-2 times per week, 3-4 times per week,
80 Chapter 4 – Methods for Evaluation 5-6 times per week, 7 or more times per week, don’t know). Frequencies reported as “don’t know” were corrected to “less than once per week” assuming women’s intake were more than “never.”
Calcium sources and iron sources HPBs were achieved if women reported an intake frequency of
at least five to six times per week (National Health and Medical Research Council, 2006).
Women reported how frequently (never, rarely, sometimes, often, all of the time) they looked at sodium, sugar, fat or fibre on nutrition labels. Since the (Ministry of Health, 2015) recommends using nutrition labels to inform food selection (e.g., compare labels of similar foods), women achieved the reading nutrition labels HPB if they reported looking at a minimum of three out of the four nutrients “often” or more.
Eating behaviour
Eating behaviour HPBs focused on behaviours that influenced meal frequency and content such as meal preparation and planning. Five HPBs were considered for the eating behaviour category including (1) eating breakfast, (2) eating three meals or equivalent, (3)
preparing meals, (4) planning meals and (5) water intake. A frequency scale (never to less than
once per week, 1-2 days per week, 3-4 days per week, 5-6 days per week, every day) was used to report how often women consumed three meals a day (or equivalent) or ate breakfast. Eating
breakfast and eating three meals or equivalent HPBs were achieved if women reported “every
day.”
In order to determine achievement for meal preparation, women reported how frequently (never, less than once per week, 1-2 days per week, 3-4 days per week, 5-6 days per week or every day) they prepared breakfast, lunch, dinner and snacks. Using the same style of frequency reporting, women also reported how frequently they bought meals (pre-prepared foods or takeaways) and how frequently others (e.g., family, flatmates) prepared meals for them (excluding bought meals). The proportion of meals prepared was calculated by dividing the number of meals women prepared by the total overall meals reported. The Ministry of Health (2015) recommends that adults “prepare meals at home as often as possible,” thus, women achieved meal preparation
if they reported preparing at least 60% of their meals. For meal planning, participants provided a weekly frequency of how often they planned each of their meals (breakfast, lunch, dinner, snacks). The total number of meals per week women reported planning was divided by the total number of overall meals. The meal planning HPB was achieved if women reported planning at least 50% of their meals.
Women reported their water intake by number of glasses (equivalent to 250 mL) they consumed on an average day (none, less than 1, 1-2, 3-4, 5-6, 7-8, 9-10, more than 10). Women achieved the water HPB if they reported drinking at least 7-8 glasses per day as per the national guidelines (Ministry of Health, 2015).
Self-care
Evaluation of self-care included four HPBs: (1) personal development, (2) relaxation, (3)
self-appreciation and(4) personal goal/values. Personal development involved women spending
time on positive stressors such as trying new activities (e.g., recipe, language, instrument, exercise) or challenging vulnerabilities (e.g., joining a new class, public speaking, speaking up).
Relaxation included activities that allowed women to wind down and find calmness (e.g., taking
a bath, yoga, meditation, going for a walk). Self-appreciation encompassed gratitude activities, such as reflecting daily on things they did well or things that went well during the day. Personal
goals/values focused on women’s ability to set time aside for activities that were meaningful to
them, such as spiritual development, professional development or spending time with friends and family. All self-care HPBs aligned with the Five Ways to Wellbeing(Mental Health Foundation, 2018). Since each of the self-care HPBs were highly individualised, outcomes were assessed on the women’s perceptions of the amount of time dedicated to each area (“not enough,” “a little, but needed more” “enough,” “a little more than needed,” or “too much”). Women achieved the self- care HPB’s if they reported spending at least “enough” time or more for each HPB.
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Stress management
Three HPBs were assessed for the stress management category: (1) self-reflection, (2)
reaching out to others and (3) time management. The self-reflection HPB encompassed women’s
observations and analysis of their stress patterns and triggers. The reaching out to others and time
management HPBs assessed women’s capacity to address identified stressors. Similar to self-care,
women reported their perception of the amount of time they spent on reflection and achieved the
self-reflection HPB if women reported “enough” time or more. Women reported how likely they
were to reach out to someone for support when needed by rating their level of agreement on a five-point Likert scale (strongly disagree to strongly agree). Women achieved the reaching out to
others HPB if women reported “agree” or “strongly agree.” Lastly, women described how well
they felt that they managed their time by general frequency (not at all, rarely, sometimes, most of the time, all of the time). Women achieved time management if they reported managing their time well at least “most of the time.”